Pain. It’s a four-letter word with powerful implications for those suffering from long-term, chronic medical conditions. Today the single most common reason patients seek medical care in the United States is for treatment for pain.
Pain for military personnel has its own unique set of issues, including the reality that their duties are much more likely to cause injury than the jobs of their civilian counterparts. The realities of military life in the early 21st century have only highlighted that fact. Along with the dangers of being wounded or killed on the battlefields of the world since 9/11, there are the physical consequences of getting ready for multiple deployments to some of the most rugged places on the planet.
High-impact physical activities repeated daily for months at a time take a toll on joints and muscles, and with ever increasing loads being carried, back injuries are becoming more common all the time. Trauma caused by wounds and accidents are also generating their share of pain, as are the effects of stress, improvised explosive devices (IEDs), and even vehicle accidents. There is physical pain as a result of stress, depression, and, of course, the concussions that are among the signature wounds of America’s present conflicts overseas.
This is why the U.S. Army Pain Management Task Force was chartered to recommend some solutions to the pain problem. One of the members of the Pain Management Task Force was Col. Kevin T. Galloway of the U.S. Army Nursing Corps. A lifetime Army medical professional, he is well qualified to talk about the task force, along with some of the discoveries and conclusions from their final report.
The Year in Veterans Affairs & Military Medicine: Can you tell us a little about your project?
Col. Kevin Galloway: All right. Be careful what you ask for. I can tell you this is a very exciting thing. This is a very proactive initiative on behalf of the Army and DoD [Department of Defense]. It started … a couple of years ago when the Office of the Surgeon General, the Army surgeon general, began to connect the dots of several issues that were out there that affect military medicine, but more importantly, these are things that are out there in what I call the big “M”: civilian medicine.
Pain was something that started to pop up on the radar. It’s the primary reason that Americans seek appointments with medial providers. It affects more Americans than several diseases that everybody’s familiar with – diabetes, heart disease, and cancer – combined. There are issues globally with abuse and diversion of prescription pain medicine, as well as poly pharmacy shopping, that are indicative of just the way our medical model delivers care and pain care in particular – the “pill for every ill” approach – and specifically to the military health model. I mean, we certainly are a subset of medicine. And to complicate things for the Army and military medicine, we’ve got similar challenges but some heightened things that focus it for us.
We’ve got the number of severely injured soldiers that are returning from operational theaters in Iraq and Afghanistan and have been coming in for years. We’re concerned about the reports of prescription drug diversion and abuse in our own force, and asking ourselves some very tough questions. Is our treatment and structure minimizing and mitigating these issues that, like I said, are not limited to the military? What are we doing differently based on the fact we have a specific population of patients? We have a moral and ethical obligation to take care of the soldiers that we put in harm’s way and the nation has entrusted to us for their medical care. I think that our surgeon general has taken it very seriously, and … event after event came up, whether it was issues of diversion in the news or questions that he couldn’t answer when he talked about the increases of soldier suicides. What is the pain component of that? And he asked his staff to look at it, because we didn’t have the kinds of information that we would have liked to bring to him, which was a comprehensive pain strategy in place. He then decided to take a very serious step for an organization like the U.S. Army, and chartered a task force to look at the problem of pain.
Now, when we talk “pain,” we’re not just talking about pain from wounds, but about twisted ankles, orthopedic injuries, bad backs, and all sorts of other things?
That is correct. You know, the actual wounded population, size-wise, is a relatively small part of the pain problem for Department of Defense medicine. The majority of the people medically evacuated from theater are not wounded. They are injured. They have back pain. They have ankle injuries, almost sports medicine types of issues. And so the things that plague us pain-wise … are a tremendous workload on our system. The real challenge that we have is for the folks that have chronic pain conditions that are not combat related.
Does this include the pains from stress and other mental problems?
Well, there’s something emerging called P3 Syndrome, which is a combination of the symptom overlap between post-traumatic stress [PTS], post-concussive brain injury [TBI], and pain. And so, there’s so much symptom overlap between these three conditions, which are prevalent with the high operations tempos in theater, and, you know, the war going on for eight years, that it’s really hard sometimes to separate just what is what. Several of the treatments are very similar, and so we’ve taken a hard look at ourselves, and we’re going to start really looking at the whole patient as opposed to dividing them up into individual symptoms or diagnoses. A patient is a patient, and we are all about patient-centered care. Whether it’s pain or TBI or PTS, it’s very much related, and so it’s going to take an integrated team approach, and I think that that’s the conclusion the pain task force came to.
There’s a huge issue that we are looking at. I mean, we look at the pain continuum from “no pain” to “resolution” to folks that end up living with some level of chronic pain. It’s a huge group that we’re looking at, and there’s a huge continuum of initiatives that need to focus on prevention, early identification, and treatment that need to be integrated into our entire medical care system. This is a huge effort! This is something that, when I did my research in the beginning of this effort with the other members of the pain task force, we saw long-term failure. We’ve seen organizations, both inside and outside the military, in medicine with “the big M” look at this, begin to address it and back off occasionally because it was always in the “too hard to do” box. It is a very complex problem, but I think for us, we don’t see an alternative to looking at it dead in the face and attacking the problem.
In terms of the size of this patient population, what kind of numbers are we talking about? Tens of thousands? Hundreds of thousands? Looking over the 10 years roughly since 9/11 that we’ve been putting people in harm’s way, what kind of population size are we realistically talking about here?
Well, I think the studies all show that virtually 75 percent of an average population is going to have some issue with acute and chronic pain. And for us it’s all a matter of, do we have a system in place to optimize the treatment for all those individuals? So the folks that have what can be called “minor acute pain” issues don’t continue in the chronically affected ranks? So that systems are in place to identify them early, treat them early and prevent it? But it’s huge, and it’s something that exists in and outside of the military. No.1: Pain is a subjective experience. I think we all agree. It means whatever it means to you as an individual. Medicine has traditionally looked at pain and sort of made it a given that it’s subjective, and so we’ve never worked real hard at making pain measurement an objective assessment by the patient and the provider, something that we can actually work on. That subjectivity has plagued us in our ability to quantify it and to quantify the success of the modalities that we’ve thrown at pain to fight it.
When you say that, are you talking about having good metrics to be able to actually measure pain in individual patients?
Oh, absolutely! I know the joint commission years ago had an initiative to raise awareness of pain in the medical community, and it was largely successful. And if you’ve ever been a patient, when you go see your provider in an acute pain setting, a primary care setting, they’re going to ask you about pain. The question is, as large organizations, is it like a blood pressure that we can take, and I as an Army nursing officer know what 120 over 80 is, across the population. Because we don’t have a standard way of assessing the pain, even if we use the traditional 11-point, “0 through 10” pain scale, because we’re not administering it in a very structured and standardized fashion, it’s very difficult from person to person, from appointment to appointment, from facility to facility, to compare patients and groups across time. This is because everybody’s accepted both the way that the question is asked and the answers that we get from the question as subjective.
And, of course, different people have different experiences with pain. Obviously women who’ve had kids and men who have passed kidney stones have a pretty good idea of what a “10” is, right?
Again, it’s orientation. If I ask you how much pain are you in on a scale of 0 to 10 and I reference a scale that “10” is the worst pain you ever had, and “0” is no pain whatsoever, frequently that’s what we do. Well, if you’ve been very lucky and haven’t had significant pain in your life, and the pain you are having now is bad, … it is the worst you’ve ever had, worst you can remember, … you are going to think [that] is a “10.” “It’s the worst I’ve ever had!” But sometimes we need to develop a better way, which we’re doing as a result of the task force, in assigning anchors to that “10” scale, that make it a more objective finding, putting functional components to that 0 through 10 score that allow the patient to more fully express what sort of pain they’re in, and for the providers, over time, to address and assess, along with addressing the success of what modalities we’re throwing at the pain. Is it working? Is it not working? And this allows us to orient the patient.
You know, if you ask me the same question weeks apart, I may not be oriented the same way in how my day is going and the way I answer it. We have to make this as objective as possible while acknowledging the fact that pain is a subjective thing. It’s a product of our experiences in life. It’s a product for the providers of their own personal experience, how they were trained, what they’ve seen work as far as effective treatment. But there’s a wide variance out there. And so we’re committed to tightening that up a little bit as much as possible on something as subjective as pain.
Now, what is it that pain makes your population do that concerns you? You’re doing this because people have behaviors as a result of pain that are counterproductive and potentially dangerous to them and the force. Correct?
Well, I would phrase it this way: Pain is a significant problem, as I stated up front. It’s the primary reason people seek medical care. They’re uncomfortable. They can’t tolerate their current level of pain, and they want us to do something about it. The current medical model supports that as the patient experience folks are most likely to have. If I have pain, I come in, I see my provider, and they do something to me. They give me something, and they fix me. I have no role in it. I don’t normally participate in the process. Folks aren’t usually interested in my opinion on things. And right now, our patients are driving us to a shift in providing patient-centered care that starts with how pain is affecting the patient. When you talk about pain, what is the goal? Is it to eliminate pain? One of the issues with medicine, with the big M we’re talking about, is that if we focus on eliminating the pain, we can do that with medication relatively easily. We can bring your pain to a “0” level, but sometimes that results in a parent who’s lying on the couch in the morning when the kids go to school, unable to do anything else. They’ve got chronic pain. They’re taking their medications, but they’re on the couch sedated, basically, just with the pain.
And they’re non-functional?
Exactly! They are not functioning and their quality of life isn’t real great. And when the kids get home from school, and when the bus comes home in the afternoon, what if Mom or Dad is still on the couch, not interacting? Their pain is controlled, but is that our definition of success? Well, in big M medicine, frequently they assign that outcome as a “success.” The person is in no pain, but what else is wrong with their life now? So we need to re-orient to a care model where the first question is, “what is the patient interested in?” Their optimum quality of life under the circumstance, optimizing function. And that’s a shift for medicine with the big M, and military medicine is a subset of that. It’s going to be a shift for us.
Our providers are mostly trained in the civilian community. So we’ve taken on this mission of moving toward patient-centered care with several initiatives in the Army Medical Department with a patient-centered medical home and a behavioral health system of care, and promoting a culture of trust. These things are no accident. We’re moving an entire organization as large as the Army Medical Department within a paradigm shift toward starting with the patient – what’s important to the patient – and that’s the commonsense thing to do. But it requires a culture shift, both on the part of our providers, who are oriented to a different model of care most of the time in medical schools and nursing schools, and also on the part of our patients, who are now accountable in a patient-centered medical system to be active, informed participants and have some responsibility. Let me digress for one second. When we looked at how people in the medical world are trained for providing pain treatment, we talked to folks at top medical schools like Johns Hopkins University. So we asked, “What’s your pain curriculum?” And these are schools that have documented, published experts in their medical schools that are actually writing on the new ways of training doctors to treat pain. They told us several shocking things. I’ll tell you that medical schools in general have about 10 hours of focused pain training in their curriculum. By comparison, veterinary schools have an average of 50 hours of training for dealing with pain.
Are you saying that the average veterinarian gets more training on pain treatment and management than a doctor who is going to be treating human beings?
In terms of the average medical curriculum on pain treatment, yes. Now, there are pieces of it that are separate. But if you’re a medical training provider, whether it’s nursing school, physical therapy, or medical school, your students are “drinking through that fire hose,” and the assessment from the experts both outside the military and inside our task force was that our training programs don’t do a great job of connecting the dots in a way that is meaningful to a provider to see the connection between these things. It’s an important step, and so, when we looked at the DoD training programs, the most important question for us was where the most impressive curriculum for pain management was. It turned out to be in the physical therapy doctorate program in the Army Medical Department Center and School. And initially we asked, “Why is this?” Well, when you go see a physical therapist, is it your expectation that you will walk in, be passive, and have something done to you? No! You’re probably going to expect work. You are probably going to expect a treatment regimen, an exercise regimen, and activity program that as a patient you’re a part of – that you have to do something to make yourself get better. The physical therapists just don’t do stuff to you, and so the model that they support places a huge amount of importance on provider training, and orienting them to a patient-centered treatment model that puts equal amounts of responsibility on the provider and patient participation in the process. And without full partnership and ownership of the issue with both of those, in something like pain management you are probably not going to have a lot of success.
OK, now let me just clarify a couple of quick points. First, you’re serious that your average veterinarian is getting more focused curriculum on pain than a medical doctor that’s going to work on the human population?
In the formalized curriculum addressment of pain? That’s what I’ve been told. I can’t cite the chapter and verse on it, but that’s been cited in more than one presentation I’ve seen on it. And I’ve spent a lot of time listening to the “painiacs” that our professionals teach about this.
You talked about potentially a successful engagement with pain in the civilian sector where the patient is in no pain but they’re non-functional. In the case of the U.S. Army, a non-functional soldier does you no good. So by definition, does the Army have higher expectations of your patient base and in their recovery, so you can keep them as soldiers and do other things with them afterwards?
I agree that we have an interest in personnel readiness. Readiness is definitely a focus for us, but pain treatment for soldiers should be no different than that of the “normal” patient population. In that regard, quality of life and restoration of normal patient functions should be behind every medical outcome. That should be what you’re shooting for. So, I would hope that my spouse who gets care in the military health system and out in the purchase health care system is involved with issues that are related to her functioning, and having a high quality of life. Her “readiness” may mean something different to a soldier, but medically we should be doing the same things for both of them. Our goal for military health care, while we may have some specific objectives militarily, we like it to look more like the sports medicine model – you know, where you need to keep the guy healthy and fit and trained, and rehab those with injuries so that they can get back on the field and be active members of the team. There really should be no difference.
Which takes us to the next question about the population you’re serving. In general, are they well motivated to want to be part of the engagement, managing and dealing with their pain? I mean, do they generally want to be more involved in their treatment and recovery than, say, a similar sized patient base from the civilian community?
I think they’re no different from the average patient population that’s been conditioned to be part of a medical model that requires a little participation from the patient. And so, we’ve got patient-soldiers that are very engaged, and ones that are very passive. And some of the ones that are very engaged are leading us in the direction of … movement toward including … complementary and alternative [therapies] … for pain. It was driven partially by medical providers, both in civilian medicine, that big M, and by our military providers who embraced it. But a lot of our patients are ahead of medicine in that they’ve been searching it out for themselves.
They’ve been the ones saying, “You know, acupuncture is working for me. I don’t need the medications or the amount of medications if I can just get access to the acupuncture.” And so, they’ve led us down this pathway. They’ve shown us the value of yoga. You know, “who would have ever have thunk it?” I did an interview with [the] Korean broadcasting system, and their question to us was, “You work in western medicine, and we hear that you’re embracing acupuncture. What’s up with that?” Well, you know, our patients have embraced it. A lot of our providers have investigated it, and found it to be extremely effective in certain populations, and so we have to take that seriously. We have to bring it “inside the wire,” and put it alongside our normal traditional medicine modalities and make it available to our patients.
We’re committed to looking at outcomes-based care, and making our decisions on what we can resource, and how we structure the modalities that will be available to our patients accordingly. We heavily embrace the traditional medical with the big M availability of medications and some interventions for pain. And then, when we look at these other integrated medicine approaches, whether it’s yoga or massage or acupuncture, we tend to put them in a separate “alternative” category. What we need to do is bring them right alongside “traditional” medicine, have them be part of the “tool kits” so our providers have options that are consistent across the whole military medical organization. Our goal is that our PAs and our nurse practitioners and our doctors, our family practitioners and our surgeons, will have access to a standard tool kit that is more varietal than traditional medicine usually presents them with. We want them to have options, and use combinations of tools and techniques to drive out the over reliance on a medication-only solution for pain. Not that we are against a medication-only solution for other problems, but we think these complementary, integrated approaches will drive down that behavior in our providers and increase the acceptance for treatment in our patient population.
So what I hear you saying is that your goal is not so much the elimination of, or shall we say, the absence of pain as the elimination and mitigation of pain? That this may mean teaching people that maybe there’s going to be a level of pain they live with for the rest of their lives, and that they need to learn to live with and manage it? Is that a fair statement?
You know, it’s very difficult. I hate to be the one that says that a patient has got to live with pain. I think that some people in certain situations will have a level of discomfort or pain chronically, and so our job is to make sure they’re able to function. There’s this scale where you have quality of life and function and both are going up. That’s the way we want to look at it. And pain, we want to minimize it. And so there’s somewhere on those continuums that you’re going to find the optimum care strategy that you can provide, and it’s different for everybody. And it’s not that we accept pain, or accept the discomfort. For example, I’ve got ankle pain as a result of a high school ankle sprain that is occasionally something I have to deal with. So if my expectation were to be pain-free in that ankle forever, I would constantly be in search of an answer that probably is never going to come. So, I have to learn how to deal with it, and how to make sure I do the preventive measures which keep me from aggravating it – using a splint, resting it when I need to rest it.
Our approach needs to incorporate all these things so we optimize the care that we provide and optimize the results on the patient side. And the patient orientation has to be, “I’m going to ‘be all you can be,’” as the Army used to say. “I’m going to optimize my care in a partnership with the medical community, and it is going to be what it is.” And sometimes we’re going to do that really well and we’ll eliminate the pain. Then sometimes we’ll be minimizing it. But I think we’re going to get the patient where they’re comfortable both understanding and re-orienting their expectations of what their new reality is, and it’s going to be different for each individual. And we talked about pain tolerance before. You know, some people are not that tolerant of any pain, and so we have to work with them in a very integrated fashion. We have to give them frequently some assistance with that, especially if there’s a strong behavioral health component with chronic pain. A pain doctor I talked with yesterday said, “Show me a patient with chronic pain who’s not depressed!” It is a depressing thing to be in chronic pain, and so, why aren’t we routinely providing them with behavioral health support? That’s what we need to do. We need to be very aggressive. We don’t need for them to ask for it. We need to assume, based on the medical evidence, that chronic pain conditions make patients depressed and we need to be aggressively treating that and optimizing their care. That way, when you treat the depression, the pain score gets better, and the patient feels better.
Which takes us to that P3 situation you were talking about earlier. Can you talk a little about the emergence of some of the signature injuries of the wars of this decade including TBI, PTSD, and such, and how your new strategy fits into helping deal with those conditions?
I will tell you as an organization I don’t think we’re vested in “signature” injuries unless we look at it as sort of a signature combination of injuries, and by my recent recollection of listening to [Lt.] Gen. [Eric] Schoomaker [Surgeon General of the U.S. Army], it’s been much more than just TBI. It’s the PTS and TBI, and the pain combination that the Department of Veterans Affairs (VA) has a long history of identifying, and I’d be remiss if I didn’t say this. One of the benefits of this task force that I have to get on record was that this was an Army task force chartered by the Army Surgeon General. And the first thing we did was go to the Navy and the Air Force and say, “come, come help us with this because it isn’t just an Army problem.” As we’ve discussed, it’s a big medicine with an M problem, and the solutions are going to be something that we require all the services to participate in.
In addition to that, we went to the VA. The VA’s been looking at this for 10 years, so they’re 10 years ahead of us in moving down this road and had a wealth of experience. So we had VA, Air Force, Navy, and Army people all working together on this, and a variety of folks from different commands, for the obvious reasons. There’s a huge research component to this that we need to right-size with the issue of pain, that includes finding the connections, marking the outcomes of those P3 conditions.
We also had the Reserves and National Guard components on there because we talked about what are our challenges with their populations. It’s hugely different with the Reserves and National Guard in that we have ownership and visibility of our active duty force downrange in theater. But when they go back home, the Reserves and National Guard personnel and units are frequently not next to a military medical facility. How do we optimize their care? How do we make sure we have oversight and we’re being as effective in managing their expectations, and in providing the interventions that they require?
It is a big challenge and is a huge issue, requiring a multi-disciplinary and interdisciplinary approach. It also is going to require all the services to buy in, along with the VA. Our patients no longer just end up at the VA at the end of their careers after they leave the military. We have patients coming from theater directly to stateside polytrauma centers, and are going back and forth between DoD and VA hospitals. Our partnership is very important, so when we finished the task force [we] came up with recommendations that said, you know, overall our vision is a standardized approach to pain care for warriors, for families across the DoD and VA. Because if we don’t standardize it, the issue of managing the expectations of our patients is going to be very difficult if every time they go to a different facility, they are not receiving the same sort of approach. And once they go to the VA, we want them to receive the same standard of care. We want them to receive the same look and feel everywhere and every time, and we’re investing a lot of time and effort in synchronizing the efforts from all these areas. Because it’s that important!
This article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition.