Page 97 - Journal of Special Operations Medicine - Summer 2016

and context on measuring and reporting pain and pro- Table 1 Requirements Put Forward by the Pain Management
vide a brief overview of self-management techniques. Task Force as Critical for a New Metric for Assessing Pain
This updated approach is aligned with promoting func- Validated
tion and intended to identify treatments and actions • Able to measure pain intensity, mood, stress,
aimed at functional improvement and performance fac- biopsychosocial impact, and functional impact
tors rather than only a decreased intensity of pain. Objective and useful in evaluating treatment effectiveness
• Practical and adaptable to multiple clinical settings
Military leaders note that pain in Servicemembers re- and scenarios throughout the continuum of care (e.g.,
turning from deployments negatively affects readiness battlefield, transport, combat support hospital, primary
care, medical center, pain medicine specialty services)
and significantly hampers the recovery and rehabilita- • Easily adapted and integrated into DoD and VHA
tion of combat wounded and injured Servicemembers. computer medical databases
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Further, chronic pain, traumatic brain injury (TBI), and • Standardized into all levels of medical training across all
posttraumatic stress disorder (PTSD) have emerged as roles of care (e.g., useful for the medic, the ward nurse,
a common constellation of symptoms associated with the primary care provider, the pain researcher, and the
pain management specialist)
blast injuries and are termed the “polytrauma triad.”
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The detrimental synergism of these conditions de- Consistent with current validated pain research tools 13
grades the physical, emotional, and social health of the
force. 27,28 Additionally, the increasing morbidity in Ser- effort was deemed particularly important because the
vicemembers being treated with prolonged courses of inconsistent administration and known subjectivity of
opioid medications for chronic pain issues may reflect patient response to the NRS: the data being obtained
the sole focus on pain intensity, rather than on function were of questionable value (outside of a controlled clini-
and performance. 29 cal research projects) beyond a single provider–patient
interaction. After nearly a decade of ongoing military
30
combat operations, the actual impact of pain battlefield
Background casualties remains ill defined. PMTF members firmly be-
In response to the growing health concerns associated lieved that standardizing and optimizing the “pain ques-
with pain and its management within the military, a tion” throughout all roles of care would provide the
comprehensive evaluation of pain management practices first reasonably objective and actionable pain data from
was performed by a designated team of clinical experts a modern battlefield, during evacuation, and through-
from the Army, Navy, Air Force, and Veterans Health out all the roles of care. 30
Administration (VHA). The subsequently released Pain
Management Task Force (PMTF) report, published in Closer to the tactical level, another important driver
May 2010, contained 109 recommendations to improve for changing the way patients were being queried about
pain care throughout the Department of Defense (DoD) pain is the growing problem across the nation regard-
and VHA healthcare systems. A major finding from ing the overuse, abuse, and diversion of prescription
30
the PMTF was the consistent negative feedback regard- pain medications, particularly opioids. 31-34 The Centers
ing the value of the visual analog scale (VAS) and the for Disease Control and Prevention (CDC) designated
11-point numeric rating scale (NRS) (0 = no pain, 10 = this problem as an “epidemic” in the United States.
31
worst pain imagined) as a tool for discussing and man- The Presidential Memorandum: Addressing Prescrip-
aging pain. Clinicians at all levels noted the inconsistent tion Drug Abuse and Heroin Use, published in October
administration of the VAS scale, subjective nature of the 2015, directs federal medicine to develop innovative so-
information, and the lack of functional anchors to the lutions to combat what is likely an unintended conse-
numeric responses. Overall VAS assessments were of low quence of focusing on pain intensity. Military medicine
35
value in guiding pain therapy. The PMTF determined is not immune to these issues and challenges.
that a new pain assessment tool capable of providing
consistent and actionable data throughout all the roles The Defense and Veterans Pain Rating Scale
of care was needed. Table 1 outlines the requirements PMTF members recognized the utility and advantages
put forward by the PMTF for the proposed new tool. of working with the existing NRS scale, which was well
recognized by patients and providers. Development of
Armed with these requirements, the PMTF used the the new scale focused on enhancing the NRS with visual
best available pain scale research and clinical experts cues and functional word descriptors that would pro-
to develop the Defense and Veterans Pain Rating Scale vide patients with a more objective method of selecting a
(DVPRS) with the objective of validating the scale number representing their pain level based on perceptual
within the military and VHA healthcare systems. experiences and the functional limitations imposed by
27
Eventually, the new scale would be integrated as the the pain. Other issues considered included language,
36
federal medicine standard. At the enterprise level, this age and cultural barriers to effective communication

Pain as a Barrier to Human Performance 83