On September 8, 1854, acting on the advice of Dr. John Snow, London municipal authorities removed the pump handle from the Broad Street well in an effort to halt a major outbreak of cholera. Although an anesthesiologist by profession, Snow had methodically mapped the homes of new cases of cholera. He found that many clustered around the Broad Street pump.
Snow’s findings, still regarded as a classic example of epidemiology, established the principle: “that the most important information to have about any communicable disease is its mode of communication.” Dr. Snow did not establish the biologic mechanism of cholera or devise an effective treatment for those stricken with the disease; instead, his research indicated that the disease was transmitted through contaminated water. His methods demonstrated how the root cause of an emerging public health problem could be determined through epidemiological observation. It was later determined that a cholera-contaminated diaper had been washed near the pump.
We Need to Change How We Manage Pain
Today, our nation faces a different kind of epidemic — a rising toll of hospitalizations and deaths from opioid abuse. The Department of Defense (DoD) and Veterans Health Administration (VA) have been aware of problems with excessive use of opioids in patient management for more than a decade. This recognition, in part, was driven by the last 17 years of armed conflict and the health care challenges this has wrought on injured Service Members and their families.
In 2009, the Army Surgeon General and commander of the U.S. Army Medical Command (USAMEDCOM) commissioned the Pain Management Task Force (PMTF), “to make recommendations for a USAMEDCOM comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain.” The PMTF members embarked on their work noting that while American innovations in battlefield medicine had reduced death rates from combat to a historic low, too many wounded Service Members were struggling with their rehabilitation and recovery due to chronic pain and opioid-related dependence and addiction. An even larger number of warriors were dealing with chronic pain caused by the intense training and heavy physical work associated with frequent and long deployments. Even senior officers were not immune from the destructive side-effects of opioid dependence, as evidenced by the struggle of Lt. Gen. David Fridovich, Deputy Commander of U.S. Special Operations forces, who battled dependence on narcotics he had been prescribed for chronic back pain.
Military leaders and the Pain Management Task Force (PMTF) understood that the opioid problem is a symptom of a much larger problem — how American physicians inside and outside the federal government manage pain. Since the Civil War, opioid medications, particularly morphine, have been important tools in the acute care of injured and combat wounded warriors. The issue was the ongoing application of this opioid-based pain management regimen throughout a Service Members’ rehabilitation and recovery to the exclusion of almost anything else that might work.
Through the PMTF process, federal medicine learned that while opioids have a role in acute pain management, our recovering warriors wanted other options to help them deal with the long-term effects of chronic pain. It quickly became clear that major enhancements to the military and veterans’ health care systems were needed to address this challenge. Steps included, for the first time, a serious look at non-pharmacologic pain therapies like acupuncture, massage, mindfulness, yoga, and manipulation therapies that traditionally had been discounted over concerns of poor therapeutic evidence. When the PMTF undertook its review of the literature and consulted with leading pain and integrative health experts, it quickly realized that the evidence base for these underutilized therapies is more robust than many think. Furthermore, the risks of side-effects from these treatments are orders of magnitude smaller than the risks associated with long-term reliance on pharmaceutical-based treatments.
The initial findings of the Army’s Pain Management Task Force were validated less than a year later by a landmark Institute of Medicine report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” Both documents informed the recently released National Pain Strategy. Together, these three reports recognize that we cannot solve the prescription opioid crisis in the U.S. unless we address the underlying epidemic of poorly managed pain.
How the Military is Changing its Approach
To develop better options for pain management and coordinate Department of Defense and VA pain policy development, the DoD established the Defense and Veterans Center for Integrative Pain Management (DVCIPM) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Working in concert with the Centers for Disease Control and Prevention (CDC), the National Center for Complementary and Integrative Health (NCCIH), and National Institute for Drug Abuse (NIDA) at the National Institutes of Health, the Department of Veterans Affairs and a wide range of nongovernmental partners, the DVCIPM strives to coordinate and synchronize efforts to advance a national pain control strategy, while conducting research and developing evidence-based tools to help health care providers in a wide range of settings do a better job of managing acute and chronic pain. This approach can serve as a model for the country as the health care culture adjusts from a system that financially incentivizes medications and procedures to manage pain towards a system that focuses on rewarding patient reported outcomes. When outcomes are the primary driver of health care finance, non-pharmacologic approaches to pain management will become commercially viable.
We are both heartened and frustrated by the recent explosion in attention to opioid misuse, abuse, and diversion. One can hardly pick up a newspaper or watch the evening news without hearing another tragic story about the opioid crisis. Unfortunately, the attention is overwhelmingly directed towards the consequences of opioid abuse, addiction, and overdose. Little attention is being focused on the underlying cause of epidemic — excessive reliance on opiates to manage pain. In our view, urging doctors to “Just say no” to prescribing opiates is no more likely to succeed than when this approach was directed towards would-be drug users. Both providers and patients need healthier, safer alternatives to treat pain.
The current approach to the opioid epidemic is just as ineffective as managing a cholera outbreak by treating victims without ever bothering to find the source of contaminated water and provide access to safe alternatives. If the health care community continues to address opiate abuse and addiction without addressing their underlying cause, this will only drive more patients to illicit sources to relieve their physical and psychic pain. Emergency room visits, hospitalizations, and deaths from heroin and illicit fentanyl are already surging across the country and these increases have been linked to the prescription opioid epidemic.
Fortunately, there is hope. Road maps for better pain management exist, and they are being promoted with increasing vigor by federal and civilian pain organizations and experts. We can turn the tide on this devastating epidemic.
The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy of the Uniformed Services University, the Department of Defense, or the United States Government.