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MHS Leader Davison Reflects on New Path for Pain Management

Image of A U.S. service member gets treated for chronic knee pain. A U.S. service member gets treated with elector acupuncture as adjunctive treatment of chronic knee pain and to assist with rehabilitation that is part of the larger DHA effort to change how it manages pain. Photo credit: Rebecca Westfall, U.S. Army Medical Command.

The Defense Health Agency is changing its approach to pain management to provide quicker and more precise, evidence-based care for injured service members and their families.

John Davison, acting chief of DHA Integrated Clinical Operations Policy Support, discussed how DHA is approaching this new reality.

MHS Communications: How is DHA changing its approach to pain management? Specifically, could you address the Stepped Care Model and education on it for clinicians?

John Davison: The SCM is a tiered approach to provide consistent, quality, and safe care for patients with an emphasis on multidisciplinary, multi-modal, and non-drug pain management, such as acupuncture.

Each military hospital and clinic has at least one primary pain care champion who has been trained in the use of the SCM. The role of the champion is to ensure that all other pain care professionals in the patient-centered medical home are trained on the SCM.

The policy, developed by the Department of Defense and Department of Veterans Affairs, will require that all patient-centered medical home staffers take the SCM training within 90 days of their assignment to a military hospital or clinic, so that the approach to pain management is consistent across patient care.

When a provider team is familiar with a service member or family member's medical history, it's good for the patient to see the same provider team again and again, especially if they have more complex medical issues.

MHS Communications: How important is patient education on pain management?

John Davison: Patient education is a key component because the DHA aims to educate patients in effective self-management of pain and injury rehabilitation.

These ECHO sessions occur weekly and provide a continuing education learning activity followed by a case presentation of a patient who would benefit from pain management subject matter expert guidance.

MHS Communications: How does DHA lead in moving away from a medication approach, such as opioids, to a more holistic pain management approach?

John Davison: With the adoption of the holistic SCM for treating pain, DHA is committed to providing complementary and integrative pain treatments, previously referred to as "alternative" treatments. These include yoga, meditation, acupuncture, dry needling, and other non-drug treatments and activities.

Many DOD providers have experience and training with non-opioid, non-drug, pain therapies.

In conjunction with increasing medical evidence, the DOD has been expanding our experience and use of complementary and integrative health treatments as part of our pain management and opioids safety strategy.

The MHS has shown a significant decline in opioid prescriptions for opioids as a primary tool for pain management across the entire MHS, with the most dramatic decline in recent years among active-duty service members.

The decline in prescriptions for opioid medications–like morphine and oxycodone–highlights the success of DHA's training and education programs aimed at reducing the risks linked to opioid medications.

MHS Communications: What has been the response to the new pain scale and how many military hospitals and clinics now use this scale within the Military Health System?

John Davison: The DOD developed the Defense and Veterans Pain Rating Scale, or DVPRS, as a result of feedback from DOD clinicians and patients that the traditional ways of assessing and discussing pain were not telling the whole story. The pain scale expands patients' ability to define their pain levels beyond the traditional 0-10 and facial expression models.

It's a very important part of the DHA's comprehensive approach to pain management.

The DHA has been integrating the DVPRS into its policies and in the electronic health record, through the MHS GENESIS platform, for several years. We continue to work on ensuring that it is integrated into clinical practice in all of our military hospitals and clinics.

The response from our providers and patients who have been using the DVPRS has been extremely positive.

In fact, many of our patients who have been exposed to the DVPRS during their treatment in our hospitals and clinics have taken it upon themselves to share the DVPRS with providers outside of DHA.

This has resulted in a growing number of inquiries from civilian providers and health care organizations requesting information about the DVPRS as well as permission to use the scale in their practices. This is an indication that we are moving in the right direction.

MHS Communications: What kinds of teams are available for new pain management treatments?

John Davison: Interdisciplinary Pain Management Centers are another component of the MHS pain management transformation. There are 29 such centers throughout the MHS, including overseas in Germany, England, and Japan. One center is located in Hawaii at the Tripler Army Medical Center.

Staffing is variable at the centers, but typically, each one has at least one pain physician who has been trained as part of a pain management fellowship, physical and occupational therapists and technicians, behavioral health providers, acupuncturists, chiropractors, pharmacists, and several support staff.

Overall, the goal of the pain management paradigm is to enable clinical care communities to effectively treat acute and chronic pain, promote non-pharmacologic pain treatment, prevent acute pain from becoming chronic, and when appropriate, limit opioid prescribing to the minimal effective dose, for the shortest duration necessary.

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