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Rethinking pain management within the MHS

Nurse wearing gloves, putting acupuncture needle in patient's ear Ashley Blake, an acupuncture nurse at Naval Hospital Pensacola’s Pain Management Clinic, treats a patient with Battlefield Acupuncture (BFA) Dec. 13. BFA consists of inserting five tiny and sterile 2 mm needles into specific points of the ear, where they can remain for up to three days. (Photo by Petty Officer 1st Class Brannon Deugan.)

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“Over the past decade there has been growing awareness of the limitations of pharmacological approaches to pain management and the risks associated with opioid pharmacotherapy in particular,” said Dr. Diane Flynn, a primary care pain management adviser at the Interdisciplinary Pain Management Center at Madigan Army Medical Center aboard Joint Base Lewis-McChord in Washington. Aligning to this awareness, the Military Health System is also changing the conversation on treating and managing pain among beneficiaries.

As a result, within the Military Health System pain management is shifting – and improving. By implementing the Stepped Care Model of pain management first adopted by the U.S. Department of Veterans Affairs, the MHS is exploring nondrug interventions such as acupuncture, chiropractic, massage, physical therapy, occupational therapy, yoga, nutrition, and behavioral health management. “We’re trying to reorient our culture away from the idea that pain equals pills,” said Dr. Chester Buckenmaier, director of the Uniformed Services University’s Defense & Veterans Center for Integrative Pain Management.

Part of that change includes the introduction of behavioral health consultants or BHCs in the primary care clinic to provide evidence-based behavioral health treatments and brief cognitive behavioral therapy for pain, said U.S. Public Health Service Capt. Anne Dobmeyer, Ph.D., a clinical health psychologist. Cognitive-behavioral therapy for pain helps patients develop coping strategies for managing pain that could include stress management and mood management. BHCs also work with patients on pacing physical activity, developing skills in relaxation, and altering thought patterns that can worsen the pain experience.

“Sometimes the way we think about our situation or about our pain can really turn the dial up on pain by increasing the stress that we’re feeling and magnifying the experience of pain,” said Dobmeyer. “Being able to change the way we are looking at or thinking about our pain or experience can help turn the dial down on the pain level, and help improve quality of life, despite the presence of an ongoing chronic pain condition.”

Pain management involves a mind-body and social connection; cognitive coping strategies can help address the whole patient in treating pain.

“We’re not asking people to put on rose-colored glasses and just think positive thoughts,” Dobmeyer said. “But we want patients to evaluate whether the way they are thinking about pain or their situation is really helping them get where they want to be in life, or whether it’s getting in the way.”

In a pioneering move, the Defense Health Agency issued guidelines and regulations in January 2020 on the use of acupuncture for beneficiaries. Buckenmaier called the guidelines historic and an example of federal medicine providing leadership in the health care community.

“Oftentimes people will say, well, acupuncture is alternative medicine, but what’s really being made clear in these documents is it’s not alternative,” he said. “[Acupuncture] is medicine and it’s an equal partner with the things we’ve been using.”

That’s not to say integrative interventions such as acupuncture can or should replace medication, including opioids, said Buckenmaier. “I don’t mind saying to you opioids aren’t bad,” he added. “If you’ve been in a war zone and just been blown up, you’re not screaming for acupuncture. In that situation, opioids can be very useful.”

The problem is how the health care community has relied on opioids to treat pain. “Opioid pain medications can have a role in helping manage acute pain, but they are less effective at helping treat chronic pain problems,” said Dobmeyer.

Still, patients want simple, fast relief. “There is usually no one treatment that will eliminate chronic pain,” said Dr. Flynn. “The best approach to chronic pain involves a variety of approaches.”

The DoD’s new pain scale implemented last year is helping better define a patient’s pain and, as a result, better treat it through a variety of approaches. Using the new pain scale, Buckenmaier treated a patient suffering from chronic pain after he had been severely wounded. The patient commented his pain level was a 6 out of 10 and fully expected it to remain so into the following week. Through the pain scale, he revealed he was sleeping and happy to be reunited with his wife. “He said, ‘My pain is a 6, but I’m OK,’” Buckenmaier recalled. “When you ask that sort of detailed information, that’s not a patient who needs another prescription; that’s a patient who may want to double down on other successes like acupuncture, physical therapy, or behavioral health modification.”

People living with chronic pain don’t need to suffer. “Comprehensive pain management focuses on helping people with pain live active, meaningful lives despite pain,” said Flynn. “With a willingness to try different pain management approaches and a commitment to a daily pain management practice, it is possible to lead a satisfying, productive life despite pain.”

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