For the Relief of Suffering

Journal of General Internal Medicine, Apr 2018

Eric B. Schoomaker, Chester C. Buckenmaier

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For the Relief of Suffering

For the Relief of Suffering Eric B. Schoomaker 0 1 Chester C. Buckenmaier III 0 1 0 Defense and Veterans Center for Integrative Pain Management , Rockville, MD , USA 1 Department of Military & Emergency Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences , Bethesda, MD , USA pain; opioids; epidemic; Department of Defense - T ious and erosive health epidemics in its history—an he nation currently struggles with one of the most insidepidemic of poorly managed pain that has spawned an opioid crisis. In fact, the health system in this country is immersed in an epidemic of epidemics with each issue spawning other new health crises. This complex emergency involves the misuse and abuse of chronic prescription opioids and opiates, as well as heroin and other illegal street drugs. The crisis has had second-order effects including hepatitis C from needle sharing, in addition to destroyed families and the staggering loss of human potential derived from the increasing prevalence of addiction or the criminal consequences of addiction and chronic use. It is critically important to retrace the causes of this blossoming Bperfect storm^ of destructive social and health trends. The Centers of Disease Control and Prevention (CDC) have attributed them to poorly managed chronic pain.1, 2The magnitude of the national problems emanating from poorly managed chronic pain cannot be understated. Accidental deaths from drug overdoses, half of which now are from prescription opioids, are staggering in number. Between 1999 and 2015 over 183,000 people died from overdoses of these prescription opioids.3, 4 Prescription opioid deaths are approaching 20,000 a year; in 2016, combined prescription and illicit drug deaths—many of which can be attributed to gateway use of prescription opioids—topped 64,000. Just a few years of these ghastly losses exceed the number of American combat deaths in 15 years of fighting in Iraq and Afghanistan, the U.S. toll from the ten-year war in Vietnam and all of the American non-combat deaths in World War I when the most lethal modern epidemic—the Spanish Flu—was the leading killer. We are fast approaching the peak deaths from the HIV/ AIDS epidemic that occurred in the mid-1990s. These facts had not gone unrecognized by the Departments of Defense (DoD) and Veterans Affairs (VA). For over a decade, close cooperation between the DoD and VA communities in medical research, medical practice, and policy development have resulted in a shared perspective of the centrality of effective acute and chronic pain management and the need to combine efforts to find best practices and co-develop tools to address pain. This institutional insight began in the mid2000s during the peak of fighting in Iraq and Afghanistan when unprecedented survival from combat wounds, training and other injuries, and serious illnesses was being realized through a concerted effort to improve the protection, lifesaving measures, and recovery and rehabilitation of uniformed service members and veterans.5 Attending these improvements in survival and recovery of patients was the development of persistence of often crippling chronic pain—pain too often managed with potent psychotropic drugs and narcotics alone. A variety of internal reports and media stories made clear that many untoward effects of drug treatment were occurring, including accidental overdoses—even deaths—suicides, long-term addictions, and disability. The VA was the first to begin a comprehensive campaign to improve pain management. The DoD followed soon thereafter. In 2009–2010, the Office of the Army Surgeon General, united with the Navy and Air Force medical services, partnered with the VA in reviewing the extent of problems in managing pain and to adopt a more Bwhole-person^ approach that examined all existing evidence-based approaches and modalities that could be applied. The focus was on the wellbeing of the patient and return to optimal function. The result was the publication in 2010 of a Pain Management Task Force Report and the creation of a DoD pain management strategy to implement the report’s 109 recommendations.6 The recommendations fell into four broad categories: tools and infrastructure for advancing pain management—including a robust research program; a full spectrum of best practices—including complementary and integrative approaches—to address the continuum of acute and chronic pain; a patient and provider focus to manage pain with the goal of improve function; and synchronizing a culture of pain awareness, education, and proactive intervention. The PMTF Report was followed within a year by a landmark Institute of Medicine Report, Relieving Pain in America—A Blueprint for Transforming Prevention, Care, Education and Research.7 It closely mirrored the DoD report and called for a major cultural shift in how pain was understood, prevented, mitigated, and managed. The past decade since these collective efforts wer (...truncated)


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Eric B. Schoomaker, Chester C. Buckenmaier. For the Relief of Suffering, Journal of General Internal Medicine, 2018, pp. 1-2, DOI: 10.1007/s11606-018-4364-3