Office of The Army Surgeon General 

Providing a Standardized DoD and VHA Vision and 

Approach to Pain Management to Optimize the Care for 

Warriors and their Families

Pain Management Task Force

Final Report 

 May 2010 

Public 
PAIN MANAGEMENT TASK FORCE 

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Pain Management Task Force Report 

Providing a Standardized DoD and VHA Vision and 

Approach to Pain Management to Optimize the Care 

for Warriors and their Families
TABLE OF CONTENTS

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ............................................................................................................................ E-1 

I. PRELUDE TO THE PAIN MANAGEMENT TASK FORCE .................................................................... 1 

II. TASK FORCE ORGANIZATION AND LIMITATIONS ............................................................................ 2 

 Charter ................................................................................................................................................... 2 

 Structure and Member Selection ......................................................................................................... 2 

 Methodology .......................................................................................................................................... 3 

 Task Force Activities ............................................................................................................................ 4 

 Limitations and Caveats for the TF Report ......................................................................................... 6 

III. PAIN MANAGEMENT OVERVIEW ........................................................................................................ 7 

 Introduction ........................................................................................................................................... 7 

 Pain in the MEDCOM, MHS, and VHA .................................................................................................. 8 

 Health Administration Pain Management Initiative ............................................................................ 9

 Pain Care Legislation .......................................................................................................................... 10 

IV. FINDINGS AND RECOMMENDATIONS .............................................................................................. 11 

 4.1 Provide Tools and Infrastructure that Support and Encourage Practice and Research 

 Advancements in Pain Management ....................................................................................... 11 

 Standards and System Improvements ................................................................................................... 12 

 4.1.1 Standardized Pain Taxonomy ...................................................................................................... 12 

 4.1.2 Standardized Pain Assessment Tool ........................................................................................... 13 

 4.1.3 Pain Management Survey ............................................................................................................ 16 

 4.1.4 Nursing Role in Pain Management .............................................................................................. 17 

 4.1.5 Standardized Credentialing .......................................................................................................... 18 

 4.1.6 Productivity Measures .................................................................................................................. 19 

 4.1.7 DoD and VHA Pain Care Standardization .................................................................................... 20 

 4.1.8 DoD and VHA Joint Formulary ..................................................................................................... 22 

 Infrastructure and Tools .......................................................................................................................... 24 

 4.1.9 Pain Assessment and Outcome Registry..................................................................................... 24 

 4.1.10 Battlefield Pain Care Continuum .................................................................................................. 26 

 4.1.11 Tele Pain ...................................................................................................................................... 27 

 4.1.12 Joint Theater Trauma Registry .................................................................................................... 28 

 4.1.13 Electronic Pain Order Set ............................................................................................................ 29 

 4.1.14 Standardized Medical Equipment and Personnel in the Deployed Setting .................................. 30 

 4.1.15 Joint Regional Anesthesia and Analgesia Tracking System ........................................................ 31 

 4.1.16 Standardize Identification of Substance Abuse Patients .............................................................. 32 

 4.1.17 Risk Management in Chronic Pain Medical Management ........................................................... 34

 Research ................................................................................................................................................... 36 

 4.1.18 DoD and VHA Pain Research Strategy........................................................................................ 36 

 4.1.19 Research Strategic Communications ........................................................................................... 38 

 4.1.20 Clinical Practice Guidelines for Pain Management ...................................................................... 39 
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 4.2 Build a Full Spectrum of Best Practices for the Continuum of Acute and Chronic Pain, 

 Based on a Foundation of Best Available Evidence .............................................................. 41 

 An Integrative and Interdisciplinary Approach ...................................................................................... 42 

 4.2.1 Complementary and Integrative Pain Treatment Medicine .......................................................... 42 

 4.2.2 Osteopathic Manipulation ............................................................................................................ 45 

 4.2.3 Primary Care Pain Management .................................................................................................. 48 

 4.2.4 Stepped Care Model .................................................................................................................... 51 

 4.2.5 Musculoskeletal Action Plan ........................................................................................................ 54 

 4.3 Focus on the Warrior and Family - Sustaining the Force ...................................................... 57 

 Warrior and Family Care .......................................................................................................................... 57 

 4.3.1 The Safe Use of Opioids .............................................................................................................. 57 

 4.3.2 Embed Pain and Pharmacy Resources ....................................................................................... 60 

 4.3.3 WTC Pain Survey Collaboration .................................................................................................. 61 

 4.4 Synchronize a Culture of Pain Awareness, Education, and Proactive Intervention ............ 63 

 A Unified Approach to Content, Education, and Training .................................................................... 64 

 4.4.1 Pain Curriculum Transformation .................................................................................................. 64 

 4.4.2 Integration of Pain Management Recommendations ................................................................... 66 

 4.4.3 Pain Education Campaign Plan ................................................................................................... 66 

 Pain Management and Leadership ......................................................................................................... 68 

 4.4.4 Standardize Pain Management Capabilities ................................................................................ 68 

 4.4.5 Interdisciplinary Pain Management Departments ........................................................................ 70 

 4.4.6 Pain Medicine Consultants to Military Leadership ....................................................................... 71 

 4.4.7 Central Pain Management Advisory Board for DoD and VHA ..................................................... 73 

V. THE WAY AHEAD ................................................................................................................................ 76 

APPENDICES 

Appendix A: Task Force Recommendations ...................................................................................................... A-1 

Appendix B: Supplement to Findings and Recommendations ....................................................................... A-12

Appendix C: Task Force Charter ....................................................................................................................... A-52 

Appendix D: Task Force Stakeholders .............................................................................................................. A-55 

Appendix E: MTF Pain Data Call ........................................................................................................................ A-56 

Appendix F: Sites Visited by Task Force .......................................................................................................... A-59 

Appendix G: Subject Matter Expert Briefings ................................................................................................... A-66 

Appendix H: Acronyms ...................................................................................................................................... A-67 

Appendix I: References ..................................................................................................................................... A-70 
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EXECUTIVE SUMMARY 

Introduction

The Army Surgeon General LTG Eric B. Schoomaker chartered the Army Pain Management Task Force (TF) in 

August 2009 to make recommendations for a MEDCOM comprehensive pain management strategy that was 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. TSG appointed BG 

Richard Thomas, Assistant Surgeon General for Force Projection, as the TF Chairperson. Task Force membership 

included a variety of medical specialties and disciplines from the Army, as well as representatives from the Navy, Air 

Force, TRICARE Management Activity, and Veterans Health Administration (VHA). 

The Task Force conducted its review and analysis utilizing site visits, interviews with clinical subject matter experts 

and medical staff, and data collection through Regional Medical Commands, as well as through a review of medical 

literature, and policies and regulations of U.S. Army Medical Command (MEDCOM) and the Department of Defense 

(DoD). 

The Task Force conducted 28 site visits from October 2009 through January 2010 at Army, Navy, and Air Force 

Medical Centers, Hospitals and Health Clinics, as well as VHA and civilian hospitals. Visits outside of Army Medical 

Treatment Facilities (MTFs) were scheduled based on recommendations from Service representatives, while also 

taking into account the facilities’ reputations for innovative and state of the art approaches to pain medicine. During 

site visits, leadership and staff were asked to assess pain management capabilities, strengths, weaknesses, and best 

practices at their respective facilities. 

National Defense Authorization Act for 2010 

Section 711 of the National Defense Authorization Act for fiscal year 2010 tasked the Secretary of Defense to 

develop and implement a comprehensive policy on pain management by the military health care system, no later 

than March 31, 2011. 

Overview of Pain in the United States and the Military Health System 

Pain is the most frequent reason patients seek physician care in the United States, and more than 50 million 

Americans suffer from chronic pain. The annual cost of chronic pain in the U.S. is estimated at $100 billion, including 

health care expenses, lost income, and lost productivity. Back pain alone is the leading cause of disability in 

Americans under 45 years of age. The failure to adequately address pain in the health care system continues to 

result in unnecessary suffering, exacerbation of other medical conditions, and huge financial and personnel costs. 

The variability that characterizes the practice of pain management in the U.S. health care system is a result of 

several factors. To begin with, each medical provider's understanding and approach to pain management is unique 

and variable, as it is significantly influenced by each physician’s academic medical training, mentors, cultural beliefs, 

and personal experiences with pain. In addition, there is a lack of clear ownership of pain medicine by any one 

medical specialty. According to the American Academy of Pain Medicine, “pain medicine” is a relatively new medical 

specialty that is evolving along with its place in the medical hierarchy. 
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Although there are many treatment modalities for pain management, one of the major components for the treatment 

of pain continues to be the use of Over-The-Counter and prescription medications. The use of medications is 

appropriate, required, and often an effective way to treat pain. However, the possible overreliance on medications to 

treat pain has other unintended consequences, such as the increased prevalence of prescription medication abuse 

and diversion throughout the United States. According to the Office of National Drug Control Policy, prescription 

opioid analgesics are the most commonly abused prescription drugs in the U.S., with the highest rate of abuse 

occurring among those ages 18-25. 

For patients interested in treatments other than, or in addition to, medication, Complementary Alternative Medicine 

(CAM) is a popular option. Though CAM is increasing in popularity among patients, this popularity has yet to result in 

a parallel increase in acceptance and use within traditional medicine. There is a wide range of these therapies and 

treatments, such as acupuncture and yoga therapy, that have proven valuable in reducing an overreliance on use of 

medications to treat pain. 

Many of the Military Health System’s (MHS) challenges with pain management are very similar to those faced by 

other medical systems, but the MHS also faces some unique issues because of its distinctive mission, structure and 

patient population. For example: 

The nation expects the MHS to provide the highest level of care to those carrying wars’ heaviest burdens. 

The transient nature of the military population, including patients and providers, makes continuity of care a 

challenge for military medicine. 

Pain management challenges associated with combat polytrauma patients require integrated approaches to 

clinical care that cross traditional medical specialties, not all of which are universally available across the 

MHS. 

MEDCOM and MHS lack a comprehensive pain management strategy that addresses current deficiencies. As a 

result, pain management initiatives are fragmented - often driven by local champions and subject to retirements, 

changes of command, and annual budget priorities for their continued existence. 

Finally, the MHS care for Warriors is rooted in a military culture that praises selflessness, toughness, and willingness 

to accept pain. “No pain, no gain” is a philosophy embraced by much of the Active Duty force and their leadership. 

This attitude often causes delays in seeking treatment, as Soldiers, Sailors, Airmen, and Marines attempt to work 

through their pain and “tough it out.” This frequently results in relatively minor acute issues later becoming harder-tomanage chronic conditions. 

Pain Management Task Force Recommendations 

The Pain Management Task Force developed 109 recommendations that lead to a 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 recommendations rely heavily on an education and communication plan that crosses DoD and VHA medical staff 

and patients. The Task Force also placed an emphasis on linking to existing Service and MHS initiatives (e.g. 

Patient Centered Medical Home, Comprehensive Soldier Fitness) that support the pain management strategy. The 

requirement to synchronize both effort and approach to pain management across the MHS and VHA is an essential 

first step in combating the variability that plagues pain management across the MHS. This requirement was the 

driving force behind many of the other TF recommendations. 
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Recommendations are divided into four areas: 

1. Provide Tools and Infrastructure that Support and Encourage Practice and Research Advancements in Pain 

Management 

2. Build a Full Spectrum of Best Practices for the Continuum of Acute and Chronic Pain, Based on a Foundation of 

Best Available Evidence 

3. Focus on the Warrior and Family - Sustaining the Force 

4. Synchronize a Culture of Pain Awareness, Education, and Proactive Intervention 

All recommendations support the TF vision statement of “Providing a Standardized DoD and VHA Vision and 

Approach to Pain Management to Optimize the Care for Warriors and their Families.” 

The Way Ahead 

Improving pain management across the DoD will require a significant reorganization, education, and training effort 

that will be most effective if pursued as a part of a DoD and VHA partnership. 

The Uniformed Services boast an impressive group of pain medicine physician subspecialist but they are relatively 

few in number when compared with the mission. In addition to ensuring there are continued efforts to grow and 

retain pain medicine specialists, the MHS must develop a supporting team of clinicians and staff to assist specialists 

in addressing the pain management needs of their patients and staff. 

Pain medicine should be managed by integrated care teams which employ a biopsychosocial model of care. The 

standard of care should have objectives to decrease overreliance on medication driven solutions and create an 

interdisciplinary approach that encourages collaboration among providers from differing specialties. 

The DoD should continue to responsibly explore safe and effective use of advanced and non-traditional approaches 

to pain management and support efforts to make these modalities covered benefits once they prove safe, effective 

and cost efficient. 

MHS Leadership must establish pain as a priority, with an urgency that leads to practice changes. The focus should 

be on prevention, followed by prompt and appropriate treatment that seeks to relieve acute pain and eliminate 

progression to chronic pain when possible. 

Including the VHA in this strategy is essential. DoD and VA should cooperate and share common educational 

materials, venues, protocols, and formularies. A common standard would demonstrate the power of a unified effort 

and expedite achievement of the common goal: providing a standardized DoD and VHA vision and approach to pain 

management to optimize the care for Warriors and their Families. 
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Task Force Recommendation Objectives 

Provide Tools and Infrastructure that Support and Encourage Practice and Research 

Advancements in Pain Management

Establish common pain taxonomy across the DoD and VHA.

Describe a common language DoD and VHA pain assessment tool with visual cues and a common set of 

measurement questions.

Establish a common baseline of pain care capabilities across DoD and VHA by creating a modified version of the 

2009 VHA Pain Management Survey to distribute to all DoD MTFs.

Evaluate the utilization, potential roles, and certification requirements for Nurses in the DoD pain management 

strategy.

Establish a process to standardize a Military Health System credentialing process for pain medicine.

Reexamine the use of productivity measures (Relative Value Units) in evaluating primary care.

Develop a patient-centric approach to recovery, rehabilitation, satisfaction, and pain control, with greater attention 

to opioid control and minimizing abuse.

Establish a joint formulary to facilitate smoother transitions and minimize pain throughout the continuum of care.

Adopt a clinical information data system that provides pain assessment screening with an outcomes registry to 

promote consistency in pain care delivery.

Incorporate scientific advances in battlefield surgery and medical technology to improve the delivery of pain care 

across the continuum.

Expand telemedicine capabilities to incorporate pain management initiatives.

Add a Joint Theater Trauma Registry module to capture, define, and characterize Wounded Warrior pain issues 

throughout the care continuum, from the battlefield to MTFs.

Develop an electronic pain order set to assist health care providers in selecting evidence-based, individually 

tailored pain management plans.

Standardize medical equipment, personnel support, and training across the continuum of pain care.

Leverage advances in regional anesthesia techniques by integrating the data through an existing, sanctioned joint 

tracking data system.

Identify substance abuse patients in Warrior Transition Units by embedding the necessary resources to develop 

and implement a coordinated care and monitoring plan.

Mitigate the risk of prescription drug abuse and dependence in pain patients, with a focus on those receiving 

controlled substances for the treatment of chronic pain.

Develop collaborative pain research strategies that advance Warrior pain care and rapidly translate effective 

findings into practice.

Improve military pain research strategic communications.

Standardize the practice of pain medicine with pain management clinical practice and clinical management 

guidelines.
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Build a Full Spectrum of Best Practices for the Continuum of Acute and Chronic Pain, Based on a 

Foundation of Best Available Evidence

Incorporate integrative and alternative therapeutic modalities into a patient centered plan of care.

Leverage embedded osteopathic and physical therapy resources in the provision of manipulation therapies for 

musculoskeletal pain.

Integrate pain management into primary care, consistent with the Patient Centered Medical Home Model.

Adopt the VHA Stepped Care Model to ensure timely access to collaborative care, reduce pain and suffering, and 

improve quality of life for Warriors and their Families.

Integrate the prevention, early identification, and treatment of injuries as a component of the comprehensive pain 

management strategy.

Focus on the Warrior and Family - Sustaining the Force

Implement a drug abuse assessment strategy to ensure the efficacy of pain treatment and reduce aberrant 

behavior, abuse and addiction with opioids.

Provide appropriate pain management and clinical pharmacy oversight in Warrior Transition Units.

Collaborate with the Warrior Transition Command to revise the satisfaction survey to incorporate pain metrics. 

Synchronize a Culture of Pain Awareness, Education, and Proactive Intervention

Transform the pain curriculum at all levels of medical education and care delivery.

Integrate TF recommendations and STRATCOM with other related DoD and VHA programs.

Develop a pain management education plan that addresses the full spectrum of stakeholders and issues.

Establish enterprise-wide tiered pain management requirements to standardize patient care services.

Establish interdisciplinary pain management services to oversee optimum patient-centered, integrated pain care.

Develop requirements for Service pain consultants to reflect an interdisciplinary, integrative approach to pain 

management.

Establish an effective pain management advisory board for DoD and VHA.
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TASK FORCE REPORT 

 
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I. PRELUDE TO THE PAIN MANAGEMENT TASK FORCE 

In May 2008 the Health Policy and Services (HP&S) Proponency Office for Rehabilitation and Reintegration (PR&R) 

at Office of The Army Surgeon General (OTSG) began an examination of “Pain” as a distinctive issue for the U.S. 

Army Medical Command (MEDCOM). Around the same time, Congress proposed a “Military Pain Care Act” in the 

House and Senate versions of the National Defense Authorization Act (NDAA) for 2009. The legislative language 

included an assessment that stated: 

“Comprehensive pain care is not consistently provided on a uniform basis 

throughout the systems to all patients in need of such care.” 

Although the Military Pain Care Act was not included in the NDAA for 2009, the Services were informed by Congress 

that the issue would be revisited in the NDAA for 2010. Subsequently, PR&R formed the MEDCOM Pain 

Management Work Group, consisting of local military pain management specialists from Army, Navy and Air Force, 

as well as a few OTSG staff officers. The group concluded that MEDCOM’s pain management strategy was focused 

on complying with the Joint Commission (JC) pain standards. Although this was a worthy objective and MEDCOM 

appeared to be successful in meeting the JC standards for pain management, the work group was convinced that 

this goal was not sufficiently ambitious. 

During a PR&R-sponsored strategic summit in December 2008, participants shared information about local pain care 

initiatives, including the Walter Reed-based Military Advanced Regional Anesthesia & Analgesia (MARAA) program 

that focuses primarily on the analysis of: 

Acute pain management techniques for the battlefield, and ways to make improvements. 

Pain management clinics that utilize a wide variety of integrated medicine approaches. 

The Veterans Administration’s (VA) very mature pain management initiative. 

At the 2009 Army Family Action Plan (AFAP) Conference, one of the four new medical issues presented to Army 

Senior leadership was “overmedication of Service Members and Families.” Senior leaders at the MEDCOM 

Behavioral Health Summit singled out pain management as a priority for the organization. Several months later, the 

Army Suicide Prevention Task Force (ASPTF) tasked MEDCOM to develop recommendations to provide alternate 

approaches to pain management. The ASPTF concluded there was a possible overreliance on pain management 

medications, while certain complementary approaches for pain management were being underutilized. Although the 

Pain Management Work Group members concurred with the need to expand available treatment modalities, they 

were also convinced that no new approach would have the desired effect unless it was part of a comprehensive pain 

management strategy for MEDCOM. 

Despite some successes, such as establishing a requirement for a Pain Consultant to The Surgeon General (TSG) 

and increased recognition of the ongoing efforts of many local pain management champions around MEDCOM, there 

continued to be insufficient progress toward the development of an effective comprehensive pain management 

strategy. The Pain Management Work Group determined that: 

Significant improvement in pain management would require a course correction for the organization. 

Pain management would need to be redefined for MEDCOM. 

MEDCOM would require a reorientation and an updated approach to a new definition of pain management. 

The PR&R and HP&S leadership supported the assessment that an increased amount of command attention and 

resources would be required to develop and implement an effective strategy for an organization as large as 

MEDCOM. Following a briefing from the MEDCOM Chief of Staff, TSG elected to charter a Task Force (TF) to 

address the pain management challenge under his command.
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II. TASK FORCE ORGANIZATION AND LIMITATIONS 

Charter

Army Surgeon General LTG Eric B. Schoomaker established the Pain Management Task Force in August 2009 to 

make recommendations for improving clinical, administrative, and research processes for the provision of pain 

management care and services at MEDCOM facilities. The primary objective of the TF was to develop a template for 

a MEDCOM 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. A copy of the signed Charter is attached as Appendix C. 

LTG Schoomaker appointed BG Richard Thomas, Assistant Surgeon General for Force Projection, as the TF 

Chairperson and later appointed the remainder of MEDCOM TF members, ensuring representation from the 

continuum of clinical specialties involved in pain management. 

Because pain management challenges are not unique to MEDCOM, and a joint solution is required to ensure a 

uniform continuum of care is provided for Warriors and other Beneficiaries, TSG invited the Assistant Secretary of the 

Army for Manpower and Reserve Affairs (M&RA); Acting Under Secretary for Health for the Veterans Health 

Administration (VHA); Surgeons General of the Air Force and Navy; Deputy Director, TRICARE Management Activity 

(TMA); and United States Army Reserve (USAR) and United States Army National Guard (USNG) to nominate 

representatives for the TF. All of these organizations nominated individuals who were subsequently appointed to the 

Task Force. 

Structure and Member Selection

Because relieving pain and suffering is an objective that is organic to all specialties across the health care continuum, 

there was an extensive list of stakeholders to be considered for inclusion on the TF. MEDCOM Regional Medical 

Commands submitted nominations for the TF with the understanding that TF activities would require an estimated 

25% of representatives’ duty time. The TF Chairperson selected the number of members as well as the cross 

section of specialties required to adequately represent this complex issue, while ensuring a manageable TF size. 

The TF member list follows in Figure 1. 

Chairperson BG Thomas requested that those specialties not specifically represented on the Task Force be provided 

the opportunity to offer feedback on the TF recommendations prior to release of the Final TF Report. Their feedback 

has been solicited and integrated, as directed. A list of the medical specialties and stakeholders is attached as 

Appendix D. 
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Figure 1: Task Force Member List 

Role Person Organization

Chairperson BG Richard. W. Thomas Army ASG, (FP) 

Senior Medical Officer COL MC AFRRI 

Acute Pain: Anesthesia COL MC MEDCOM-WRAMC 

Chronic Pain: Anesthesia MAJ MC MEDCOM-WRAMC 

Behavioral Health (Addiction) COL MC MEDCOM-GAHC 

Pharmacy LTC MS MEDCOM-CRDAMC 

Primary Care PA, Pharm MEDCOM-MAMC 

PM&R (Integrative Medicine) COL MC MEDCOM-WBAMC 

Research Dr COL (Ret) MRMC 

IM IT: Primary Care LTC MC OTSG 

Physical Medicine and Rehab MAJ MC OTSG 

WTC: Primary Care COL AN WTC 

Reserve Component: Primary Care MAJ SP ARNG 

Orthopedic Surgeon COL MC USAR 

Nursing LTC (P) AN M&RA 

Primary Care Dr. COL (Ret) M&RA 

TF Operations Specialist M&RA 

Pain Management: Anesthesia CDR MC NAVY 

Pain Management: Anesthesia Maj. MC AIR FORCE 

TMA: Primary Care CDR MC TMA 

VHA: Pain Medicine Dr. MD Veterans Health Administration 

TF Chief of Staff: Nursing LTC (P) AN OTSG 

Methodology

The Task Force conducted its review and analysis utilizing site visits, interviews with clinical subject matter experts 

and medical staff, and data collection through Regional Medical Commands, as well as through a review of medical 

literature, and policies and regulations of MEDCOM and the Department of Defense (DoD). 

The large amount of information collected during the TF operations was managed through a Web portal developed 

on Army Knowledge Online (AKO). Access to the AKO Web portal was limited to TF members and select invited 

guests. Capabilities of the Web portal included document sharing, editing, and scheduling, as well as an extensive 

library of pain-related information links, news stories, medical literature, and educational materials. 

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The TF focused on developing actionable information to meet the major deliverables identified in the Charter, 

including the following: 

1. Assessment of current pain management clinical and administrative processes, capabilities, best practices, and 

research; 

2. Identification of safe and effective complementary and alternative approaches to pain management; and 

3. Recommendations for improvements to clinical and administrative processes, capabilities, best practices, and 

research. 

Task Force Activities

Data call 

The first activity of the Task Force was a pain management data call sent to MEDCOM Military Treatment Facilities 

(MTFs). Regional Medical Centers (RMCs) responded with a 100% return rate, providing the TF with qualitative 

baseline summaries of MTF pain management activities, initiatives, resources and perceived deficiencies. This data 

provided the TF visibility of locations with unique approaches to pain care and the identity of local champions. 

Information from the data call helped further focus TF areas of exploration and analysis. 

The data revealed a wide variation in approaches to treating acute and chronic pain across MEDCOM, specifically in 

coordination, collaboration, standardized measurement, tracking, and resource availability. MTFs of similar size and 

mission reported significant variations in pain management structure, staffing and available treatment modalities. 

Many promising local initiatives were Unfinanced Requirements (UFR). There were neither standards for patientcentered, outcomes-based care nor actionable pain metrics across the enterprise. In summary, there was no 

common understanding of pain management responsibilities, approaches or resourcing across commands. A copy 

of the MTF distribution list and data call template can be found in Appendix E. 

Meetings 

The Pain Management Task Force held its first meeting 24-27 August 2009. In addition to TF Chairperson BG 

Thomas, and the appointed members of the TF, attendees included: 

ASA (M&RA) 

Acting DASA-MHA 

RADM Thomas J. McGinnis, TMA 

BG (Ret) Stephen Xenakis, M.D. 

The meeting also included invited representatives from: 

MEDCOM 

Warrior Transition Command (WTC) 

Headquarters Department of the Army (HQDA) 

Defense Centers of Excellence (DCoE) 

Veterans Health Administration (VHA) 

The first day consisted of an orientation to the Pain Management Task Force goals followed by presentations from 

MEDCOM, Army, DoD, and VHA programs and initiatives. These briefings were organized to: 

Educate the TF membership about the wide variety of ongoing initiatives related to the TF mission; 

Educate the representatives on initiatives and programs related to TF objectives; and 

Initiate collaboration and communication among TF participants to ensure activities complement existing 

efforts. 

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The second day TF members were divided into three facilitated breakout sessions focused on identifying Policy and 

Performance Management, Service Delivery, Warriors in Transition, and Program Integration issues related to pain 

management. The TF focused on these tasks in its initial evaluation of MEDCOM pain management and began to 

develop a comprehensive pain management strategy. TF members decided to invite representatives from Air Force 

(USAF), Navy (USN), and Army Guard and Reserve to ensure full representation. 

Following the initial meeting, the TF held monthly in-person meetings and weekly or biweekly telephone conferences 

to provide updates, conduct issue discussions, and coordinate future TF activities. Additionally, ad hoc meetings 

were held among TF members while working on their assigned issues. 

Site Visits 

The Task Force conducted 28 site visits from October 2009 through January 2010. The TF visited Army, Navy, Air 

Force, and VA MEDCENS, MEDDACS and Health Clinics as well as civilian facilities, which were chosen based on 

their reputations for innovative and state of the art approaches to pain medicine. Civilian facilities outside of 

MEDCOM were selected based on input from TF representatives. 

The TF developed a standardized site visit template that was used to conduct interviews and report findings on the 

site visits (Appendix F). Interview questions asked leadership and staff to assess pain management capabilities, 

strengths, weaknesses, and best practices at their respective facilities. The TF found a variety of best practices and 

confirmed the wide variation in existing practices and available resources, further substantiating information provided 

through the MTF data call. Findings from the site visits, and other activities of the Task Force, are presented in this 

Task Force Report. 

Figure 2: Task Force Site Visit Map 
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Limitations and Caveats for the TF Report

The Army Surgeon General chartered the Army Pain Management Task Force to evaluate MEDCOM pain 

management, and although the TF membership and charter were naturally “Army-centric,” The Surgeon General 

recognized the importance of including Navy, Air Force, and Veterans Health Administration in this effort. At the start 

of the process, all TF members concluded that achieving significant pain management improvements in their 

respective organizations would require developing recommendations that could be applied to a larger DoD and VHA 

approach to pain care. As such, all recommendations in this report were developed with the intent of being part of a 

DoD and VHA comprehensive pain management strategy. 

Representations in this TF Report were made as part of the TF mandate to provide recommendations regarding the 

DoD and VHA programs, initiatives, and projects. The Task Force understands that the Services and the Veteran’s 

Health Administration, while having representation on the TF, have not had the opportunity to officially review and 

staff the recommendations within their organizations. 

While the TF Report appears to focus on the inadequacies of pain medicine in the military and VHA health care 

systems, there was no intention to leave an impression that standards of care are not currently being met. In fact, 

the DoD and VA facilities continue to deliver exceptional health care within accepted standards of care. During the 

site visits and interviews, the TF identified numerous best practices for pain management that were later used to 

develop the recommendations in this report. The TF members determined that there was both a need and an 

opportunity to push the MHS and VHA beyond meeting the current standards of care. 

The Pain Task Force conducted its evaluation and analysis over the course of six months. With the exception of 

scheduled monthly meetings and site visits, the appointed members continued working at their regularly assigned 

places of duty and positions. The Task Force leadership continually balanced the desire to leverage the synergy of 

gathering TF members with the competing reality that these were leaders in military medicine with clinical 

responsibilities. 

Lastly, with the limited time available, the Task Force was not able to fully evaluate and make specific 

recommendations for Pediatric and Palliative Care pain management. The consensus from the Task Force members 

was that a thorough evaluation of these areas would require further expertise and time, neither of which were 

available to the TF. 
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III. PAIN MANAGEMENT OVERVIEW 

Introduction

Treating pain is one of medicine’s oldest and most fundamental responsibilities. Yet modern medicine continues to 

be challenged in its efforts to understand pain mechanisms and to relieve pain and suffering. Pain is an enigmatic 

issue that places significant burdens on patients, families, medical providers, and employers. 

Pain is the most frequent reason patients seek physician care in the United States and it affects more Americans 

than diabetes, heart disease and cancer combined (Centers for Disease Control and Prevention and American 

Academy of Pain Medicine). When including health care expenses, lost income, and lost productivity, the annual 

cost of chronic pain in the U.S. is estimated at $100 billion (National Institutes for Health). Back pain alone is the 

leading cause of disability in Americans under 45 years of age. 

The variability in pain management practice throughout medicine is partially due to the lack of a congruent pain 

curriculum in the academic preparation of various medical professionals. The topic of pain management is often 

poorly presented and inadequately developed in the curricula of many U.S. medical, nursing, pharmacy, and other 

medical professional schools, as well as in their respective continuing education. 

A medical provider's understanding and approach to pain management is unique and variable. It is significantly 

influenced by academic medical training, currency of pain curriculum, medical mentors, cultural beliefs, and personal 

experiences with pain. Considerable variation in the management of pain currently exists also, in part, due to a lack 

of clear ownership of pain medicine by any one medical specialty. This has resulted in medical turf-wars as diverse 

specialties battle for reimbursement and workload credit. The failure to adequately address pain in the health care 

systems continues to result in unnecessary suffering, exacerbation of other medical conditions and huge financial 

and personnel costs. 

According to the American Academy of Pain Medicine, “pain medicine” is a relatively new medical specialty that is 

evolving in conjunction with advances in pharmacology and interventional procedures. Its place in the medical 

hierarchy is still developing. There is much variability in what constitutes a “Pain Specialist” or “Pain Clinic.” This 

creates uncertainty for patients and providers. The perception of many patients and providers is that pain 

management specialists fall within one of two categories: intervention-centered (e.g., needles) or medicationcentered (e.g., pills). Neither of these unitary approaches to pain management completely meets the needs of 

patients, who often present complicated causes and reasons for their pain. Therefore, a comprehensive and 

integrated approach to pain management across several medical specialties is required. 

Although there are many treatment modalities for pain management, one of the major components for the treatment 

of pain, whether in primary care or by “pain specialists,” continues to be the use of Over-the-Counter (OTC) and 

prescription medications. Using medications to treat pain is appropriate, required, and often effective. In some 

cases, an increased reliance on prescription medications for pain treatment appears to be influenced by the fact that 

most pain medications are relatively inexpensive, patients readily accept their use, and they require minimum time 

expenditure on behalf of the provider and patient. The possible overreliance on medications to treat pain has other 

unintended consequences, however, such as an increase in prescription medication abuse and diversion throughout 

the United States. According to the Office of National Drug Policy, prescription opioid analgesics are the most 

commonly abused prescription drugs in the U.S., with the highest rates of abuse occurring among those between the 

ages of 18 and 25 (Wilson, 2006). These medications are often diverted from family members or friends and are 

viewed as “legal,” less shameful to use, and safer than illegal drugs (NIDA, 2008). 
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For patients seeking a treatment plan that includes more than just medication, Complementary Alternative Medicine 

(CAM) is gaining popularity, though this has yet to result in a parallel increase in the acceptance and use of these 

complementary modalities within traditional medicine. There is a wide range of these therapies and treatments, such 

as acupuncture and yoga therapy, that have proven valuable in reducing an overreliance on use of medications to 

treat pain. There are many reasons individuals may seek the option to use CAM, not the least of which is the failure 

of current treatment to relieve their pain. Current research indicates that part of the appeal of CAM includes the 

opportunity for greater personal involvement in health maintenance, holistic health beliefs and, for those with chronic 

conditions, an active coping mechanism (Bishop, Yardley and Lewith, 2007; Sollner et al., 2000). 

Understanding that pain is not just a symptom of disease but at times, is a disease process in itself, is a fundamental 

change occurring in modern medicine, explaining the new emphasis on effective pain control. Regardless of the 

treatment setting, inadequate acute pain control is associated with a myriad of physiologic changes that can 

significantly increase patient morbidity and possibly mortality (Dubois, 2009). Evidence suggests that untreated or 

poorly treated acute pain, and the pro-inflammatory and immunosuppressive responses associated with it, may result 

in deleterious health effects for months or even years after the initial onset of pain (Meiler, 2006). Pain is a disease 

state of the nervous system and deserves the same management attention given to any other disease states. 

Pain in MEDCOM, MHS, and VHA

The Military Health System’s (MHS) challenges with pain management are very similar to those faced by other 

medical systems. However, there are some unique issues faced by the MHS because of its distinctive mission, 

structure and patient population. 

The MHS’s mission to take care of Service Members and their Families extends beyond the usual relationship 

between a health care system and its patients. Providing world-class medical care is always an imperative, but 

during a time of war, its importance is heightened. The nation expects and demands that the MHS provide the 

highest level of care possible for those carrying the heaviest burdens. Doing any less than this is unacceptable to the 

military leadership, Congress, and the American people. 

The likelihood that patients have their medical care coordinated by a single Primary Care Manager (PCM) remains 

very low in the MEDCOM. The transient nature of the military population, including both patients and providers, 

creates extraordinary challenges to providing continuity of care, something very important to pain management. 

Ongoing access to a PCM is often limited because of provider deployments, Temporary Duty (TDY) for training, or 

Permanent Change of Station (PCS) moves. Patients are also subject to many of these same variables. The 

inability to provide continuity of care is extremely problematic when attempting to develop and implement long-term 

treatment plans for pain management and other chronic medical conditions. This often exposes patients to 

duplicative appointments, laboratory tests, and medical procedures, along with inconsistent treatment approaches 

that can cause confusion, frustration and in some cases unnecessary suffering. 

Modern military medicine is unparalleled in its ability to save Wounded Warriors. Body armor and improved delivery 

of battlefield medicine have increased patient survival from wounds that were fatal in previous conflicts. This, 

however, has resulted in pain management challenges for combat polytrauma patients. One such challenge is the 

need to provide pain control for potentially medically unstable Warriors immediately following injury and then 

continuously during transport to secondary and tertiary care facilities. Other challenges include the management of 

comorbid conditions, such as post concussive syndrome, mild-Traumatic Brain Injury (TBI) and PTSD. These latter 

conditions require integrated approaches to clinical care that cross traditional medical specialties, not all of which are 

universally available across the MHS. 

Overall, both MEDCOM and MHS lack a comprehensive pain management strategy, exacerbating several patientprovider continuity challenges. The MEDCOM and MHS are responsible for patient care throughout the world. 
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However, no widely disseminated pain management philosophy is currently in place and specialty care services, 

personnel, and treatment modalities are neither standardized nor predictable across MTFs. The MEDCOM and MHS 

have no published standards for pain management structure, capabilities, or personnel for their clinics, hospitals, or 

medical centers. 

As a result, MEDCOM and MHS pain management initiatives are fragmented, driven by local champions and subject 

to retirements, changes of command, and annual budget priorities for their continued existence. A PCS move for a 

Service or Family Member can result in loss of access to certain treatment modalities that have proven successful for 

pain management. Losing access to multimodal treatment options frequently results in an overreliance on 

medications, associated complications, decreased quality of life and, eventually unnecessary burdens on both the 

health care system and Families. 

Another complication is that the MHS care for Warriors is rooted 

in a military culture that praises selflessness, toughness, and a 

willingness to accept pain. “No pain, no gain” is a philosophy 

embraced by much of the Active Duty force and their leadership. 

This attitude often results in delays in seeking treatment as 

Soldiers, Sailors, Airmen, and Marines attempt to work through 

their pain and “tough it out.” This frequently results in relatively minor acute issues becoming harder-to-manage 

chronic conditions. Additionally, the military faces complex pain management challenges during a time of war when 

the patient population is sustaining levels of physical and emotional trauma unparalleled in civilian medicine. 

Veterans Health Administration Pain Management Initiative

The Veterans Health Administration initiated a national pain strategy in 1998 in an effort to develop a systemwide approach to pain management, with an ultimate goal of reducing suffering among Veterans with acute and 

chronic pain. The strategy aimed to establish consistent pain management understanding and expectations 

among the patients, providers, and support staff in a medical system that cares for more than 5.8 Million patients 

in 153 Medical Centers, 134 Community Living Centers (NH Care), 6 independent outpatient clinics, and 783 

Community Based Outpatient Clinics across the U.S. “Pain as the 5th Vital Sign” was promoted in all inpatient 

and outpatient clinical settings in order to ensure consistency of pain assessments throughout the VHA. 

One of the elements the plan addressed was the complexity of chronic pain management, which is often beyond 

the expertise of a single practitioner, especially for patients whose pain problems are complicated by PTSD, 

combat injuries, and substance abuse. Primary care providers’ ability to effectively deal with pain management 

challenges requires additional education and access to resources, such as pain medicine specialists and 

behavioral specialists, as well as interdisciplinary pain clinics in order to effectively evaluate and manage these 

complex patients. 

The VHA pain management strategy was strengthened in October 2009 with the publication of VHA Directive 

2009-053 for Pain Management (Appendix B-9). This directive provides policy and implementation procedures 

for the improvement of pain management consistent with the VHA National Pain Management Strategy and in 

compliance with generally accepted pain management standards of care. It also defined the “Stepped Care” 

model for pain management. 

This model serves as the framework for developing organizational capabilities that support timely access to 

providers, treatment modalities, and specialty referrals commensurate with patient pain management needs. 

Stepped Care balances a focus on managing pain as early as possible in a primary care setting while providing 

access to pain medicine specialty consultation, and interdisciplinary and multimodal pain management resources 

when required. It also emphasizes optimal pain control, improved function, and increased quality of life. 

“No pain, no gain” is a philosophy embraced 

by much of the Active Duty force and their 

leadership and this frequently results in 

relatively minor acute issues becoming 

harder-to-manage chronic conditions 
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Patients and Families are encouraged to be active participants in their pain management plans of care. Lastly, 

the national strategy promotes standardized education and training of medical staff appropriate to their clinical 

settings and role. 

Pain Care Legislation

Section 711 of the National Defense Authorization Act for Fiscal Year 2010 (FY10 NDAA) tasked the Secretary of 

Defense to develop and implement a comprehensive policy on pain management by the MHS, no later than March 

31, 2011. This policy will cover: 

1. The management of acute and chronic pain. 

2. The standard of care for pain management to be used throughout the Department of Defense. 

3. The consistent application of pain assessments throughout the Department of Defense. 

4. The assurance of prompt and appropriate pain care treatment and management by the Department when 

medically necessary. 

5. Programs of research related to acute and chronic pain, including pain attributable to central and peripheral 

nervous system damage characteristic of injuries incurred in modern warfare, brain injuries, and chronic 

migraine headache. 

6. Programs of pain care education and training for health care personnel of the Department of Defense. 

7. Programs of patient education for Members suffering from acute or chronic pain and their Families. 

The Secretary of Defense was also directed to revise the policy on a periodic basis in accordance with experience 

and evolving best practice guidelines. Not later than 180 days after the implementation date of the policy and on 

October 1 each year thereafter through 2018, the Secretary shall submit to the Committee on Armed Services of the 

Senate and the Committee on Armed Services of the House of Representatives a report on the policy that will 

include: 

1. A description of the policy implemented, and any revisions to such policy. 

2. A description of the performance measures used to determine the effectiveness of the policy in improving pain 

care for Beneficiaries enrolled in the military health care system. 

3. An assessment of the adequacy of Department pain management services based on a current survey of patients 

managed in Department clinics. 

4. An assessment of the research projects of the Department relevant to the treatment of the types of acute and 

chronic pain suffered by Members of the Armed Forces and their Families. 

5. An assessment of the training provided to Department health care personnel with respect to the diagnosis, 

treatment, and management of acute and chronic pain. 

6. An assessment of the pain care education programs of the Department of Defense. 

7. An assessment of the dissemination of information on pain management to Beneficiaries enrolled in the military 

health care system. 

The Pain Task Force was nearly half-way into its evaluation of pain management in the MEDCOM, MHS, and VHA 

when this legislation was signed in October 2009. At that time, a comparison between the NDAA language and the 

Task Force’s charter, ongoing analysis, and the pain management strategy under development validated the current 

direction of the Task Force.
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IV. FINDINGS AND RECOMMENDATIONS 

4.1 Provide Tools and Infrastructure that Support and Encourage Practice and 

Research Advancements in Pain Management 

One of the major observations realized during the Pain Task Force site visits was a general feeling among medical 

providers that they were ill-prepared to manage the full continuum of pain management responsibilities for their 

patients. With the exception of those with advanced training in pain management, providers almost universally 

communicated that they did not have the necessary training, time, support staff, modalities, or available consultative 

services in their “pain toolkit”. Pain care tools, clinical orientation, and capabilities varied greatly between MTFs, 

even those with a similar size and mission. There was also significant variation in the orientation, documentation, 

and understanding of pain management responsibilities within individual MTFs. It was difficult to find consistency in 

either the MTF capabilities or the expectations of their clinical staffs. 

Although most primary care providers felt they could adequately provide pain care for their acute pain patients, most 

would qualify this statement by adding that the available modalities were largely limited to medication and possibly 

Physical Therapy (PT). MTFs with pain management specialty care are frequently only able to provide that care to 

small segments of the facilities’ patients, many times for Warriors in Transition (WT) or Active Duty only. Patients 

unable to access specialty care at the MTFs are referred to network care of varying perceived quality and value. 

It is clear that any first step in improving pain care should consist of developing a system of tools and capabilities for 

provider “toolkits.” Developing and deploying a uniform approach to pain care that includes common taxonomy, 

tools, technologies, medical capabilities, and data collection across DoD and VHA will have wide appeal and the 

potential to make significant improvements in the practice of pain medicine. The tools, education and pain structure 

will create a common language, standardize measurement of pain, and facilitate enhanced data collection, treatment 

outcomes reporting and analysis. 

After establishing each Service and MTF baseline, the pain management infrastructure and tools must be integrated 

into the medical practice, pain care must be optimized across the continuum, and a valid and strategically informed 

research agenda must be developed and resourced. The MHS should build on lessons learned from the VHA pain 

initiative. Finally, initial priorities should focus on Wounded Warriors and their Families by ensuring that future pilot 

projects target areas with large WT and Veteran populations. 
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Standards and System Improvements

Figure 3: A Summary of Categories for Standards and System Improvements 

Provide Tools and Infrastructure that Support and Encourage Practice and Research 

Advancements in Pain Management 

Standards and 

System 

Improvements

Standardized Pain Taxonomy 

Standardized Pain Assessment Tool 

Pain Management Survey 

Nursing Role in Pain Management

Standardized Credentialing 

Productivity Measures 

DoD and VHA Pain Care Standardization 

DoD and VHA Joint Formulary 

4.1.1 Standardized Pain Taxonomy 

Objective: Establish common pain taxonomy across the DoD and VHA. 

The Joint Commission’s 2001 pain management standards state that every patient has a right to have their pain 

assessed and treated (Joint Commission Web site). Any effective pain assessment is predicated on a clinician’s 

understanding of “pain” and pain-related terms, yet there is no standardized DoD, much less DoD and VHA, pain 

taxonomy to use as a foundation for this assessment. Even among clinical experts in the field of pain medicine, it is 

challenging to come to a consensus on the exact definition of pain, let alone the many subsets and types of pain. A 

common pain vocabulary is fundamental to the creation and proliferation of a common understanding and approach 

to pain management among providers and patients throughout DoD and VHA. 

Figure 4: Fundamental Pain Words 

Pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue 

damage or described in terms of such damage. Pain is always subjective. Pain can be acute or 

chronic. 

Acute

Pain

Acute pain is a normal physiologic response, usually time-limited, to a noxious stimulus that 

enhances survival by warning the individual of impending or potential injury or progression of 

disease. If the noxious stimulus persists, changes in the peripheral tissues and both the central and 

peripheral nervous systems can lead to sensitization that worsens and prolongs the pain from 

noxious stimulation. Appropriate management of acute pain may prevent the onset of the 

pathophysiologic processes that change the spinal cord and brain and lead to chronic pain. 

Chronic

Pain

Chronic pain continues beyond the normal time expected for healing and is associated with the 

onset of pathophysiologic changes in the central nervous system that may adversely affect an 

individual’s emotional and physical well-being, cognition, level of function, and quality of life. 

Chronic pain serves no apparent useful purpose for the individual and may be diagnostically and 

therapeutically approached as a chronic disease process. 
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The military and VHA deliver care around the world to a population of providers and patients that is constantly on the 

move. Standardization across the DoD and VHA is necessary to ensure continuity of care across the continuum, as 

well as a common understanding and framework for providers and patients. Standardization allows for improved 

Provider-Provider and Patient-Provider communication, better interpretation and implementation of practice 

guidelines, and higher quality of data. 

As an example, the Traumatic Brain Injury (TBI) Task Force developed a list of DoD and VHA TBI related terms and 

definitions. This proved to be a key step for further development of DoD and VHA benefits, care coordination, and 

transition between the variety of DoD and VHA health care settings, from in-theater to stateside. Furthermore, it 

helped establish and synchronize a uniform language for TBI-related research coming from both the DoD and VHA. 

A common pain taxonomy must be defined and integrated into the organization. The TF reached consensus on a list 

of definitions, including three fundamental words – pain, acute pain, and chronic pain – in the pain taxonomy. These 

definitions were developed using accepted resources (International Association for the Study of Pain - IASP) and are 

recommended for integration into MHS policies and regulations. 

The entire list of pain taxonomy is included in Appendix B-1. The list should be distributed to all DoD and VHA health 

care sites, posted internally, and made available to providers and patients online. A readily available list of 

standardized pain terms will not only enhance user satisfaction but also promote uniformity when discussing pain 

care throughout the DoD and VHA. 

Recommendation 4.1.1.1

Establish a uniform understanding and use of key pain-related terms in the vocabulary of the DoD and VHA 

health care systems. 

Recommendation 4.1.1.2

Identify a process to Review, Revise, and Approve DoD and VHA definitions for pain, acute pain, and chronic 

pain. 

Recommendation 4.1.1.3

Integrate DoD and VHA definitions for pain, acute pain, and chronic pain into existing training, policies and 

regulations, and standards throughout DoD and VHA. 

4.1.2 Standardized Pain Assessment Tool 

Objective: Describe a common language DoD and VHA pain assessment tool with 

visual cues and a common set of measurement questions.

The most commonly used tool to measure pain in both civilian and military medicine settings is an 11-point, 0-10 

Visual Analog Scale (VAS). During site visits, the TF received a great deal of negative feedback regarding the use 

and perceived value of the VAS Pain Scale. A majority of the doctors, nurses, physical therapists, medics and other 

clinicians who were interviewed reported similar negative feelings about the VAS Pain Scale, including: 

The VAS Pain Scale is inconsistently administered. 

The VAS Pain Scale is regarded as very subjective and had no functional anchors. 

The VAS Pain Scale assessments recorded in patient medical records are considered to have little value by 

clinicians at all levels. 

These findings were of great concern to the Task Force. In the MEDCOM alone, there are approximately 42,000 

outpatient visits per day, the majority of which include a pain assessment (Army Medicine Web site). These pain 
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assessments are subsequently recorded in the patients’ medical records. TF findings indicate that because of the 

noted VAS Pain Scale failings, this information is of little value and 

represents a missed opportunity to capture useful, consistent, and actionable 

information about a patient’s pain. When factoring in the impact of these 

shortcomings across the rest of DoD, the imperative to improve and 

standardize this pain assessment is clear. 

The Pain Task Force determined that a new DoD and VHA Pain Assessment Tool was needed to obtain actionable 

information at every patient encounter across the MHS. The new Pain Assessment Tool must be: 

1. Validated: 

A. Able to measure pain intensity, mood, stress, biopsychosocial impact, and functional impact; 

2. Objective and useful in evaluating treatment effectiveness: 

A. Practical and adaptable to multiple clinical settings and scenarios throughout the continuum of care (e.g. 

battlefield, transport, combat support hospital, primary care, medical center, pain medicine specialty 

services); 

B. Easily adapted and integrated into DoD and VHA computer medical databases; 

C. Standardized into all levels of medical training across all roles of care (e.g. useful for the medic, the ward 

nurse, the primary care provider, the pain researcher, and the pain management specialist); and 

3. Consistent with current validated pain research tools. 

Using these attributes as a guide and pairing them with the best available pain scale research, the Task Force 

selected references and expert opinion, to develop a new Pain Assessment Tool for testing and refinement with the 

goal of achieving its widespread use in the DoD and VHA (Appendix B-2). 

Figure 5: Defense and Veterans Pain Rating Scale 

In the MEDCOM alone, there are 

approximately 42,000 outpatient 

visits per day, the majority of 

which include a pain assessment
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This new tool combines the validated 11-point pain scale used by clinical researchers with a simple green, yellow, 

and red scale suitable for combat medical conditions. Furthermore, this tool anchors each numeral on the 11-point 

scale with standardized ‘experiential’ and ‘functional’ language, greatly enhancing clarity for both patients and 

providers when discussing pain levels and treatment effectiveness throughout the care continuum. 

The new Pain Assessment Tool requires additional resources, including: 

Linguistic and graphic support; 

AHLTA / VISTA / Essentris integration: 

– Enterprise-wide patient and provider re-education efforts in both DoD and VHA, 

– DoD and VHA multicenter research study to validate the tool (see Appendix B-2), 

– Establish metrics for training success and practice that are evaluated annually, driven by research from 

a central pain management advisory board, and used to update and continuously improve the Pain 

Assessment Tool. 

The tool also includes four supplemental questions for clinicians at all levels to evaluate the biopsychosocial impact 

of pain. Questions include the impact of pain on general activity, mood, level of stress and sleep. These 

supplemental questions, when combined with the functionally anchored 11-point scale, will provide a potentially 

powerful clinical tool in evaluating a patient’s pain, considering treatment goals, and establishing the most 

appropriate treatment plan. 

Figure 6: Defense and Veterans Pain Supplemental Questions 

The impact of this tool on patient care is likely to be very significant. By approving, validating, and implementing this 

tool, the DoD and VHA health care systems should improve both the quality and quantity of objective pain data in 

what is currently considered to be a mostly subjective and difficult to interpret part of medicine. This tool will impact 

every aspect of clinical medicine and increase the quality and consistency of pain evaluation and outcomes 
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measurement. The reduction in variability of pain evaluations should greatly enhance patient care and exceed the 

spirit and intent of the Joint Commission’s 2001 pain standard. 

The current lack of standardized pain assessments, pain data collection, and pain coding throughout DoD and VHA 

adversely impacts pain management along the entire care continuum and impedes the effort of military, VHA and 

civilian research to identify the most effective pain management strategies. As a result, DoD still does not possess 

large databases that would enable medicine, through large prospective blinded clinical trials, to test the effectiveness 

of many of the pain medicine interventions used routinely today, particularly the effectiveness of combined 

treatments. Without actionable data, it is more difficult to determine best practices or the most effective treatments 

for reducing specific types of acute and chronic pain. Any movement toward a common DoD and VHA pain strategy 

should begin with a common pain assessment and the eventual development of a de-identified data registry.

Recommendation 4.1.2.1

Review and approve the new DoD and VHA common Pain Assessment Tool validation plan. 

Recommendation 4.1.2.2

Validate Pain Assessment Tool in DoD and VHA facilities. 

Recommendation 4.1.2.3

Integrate the Pain Assessment Tool, upon validation, into training, clinical practice, and data collection of pain 

management in DoD and VHA. 

4.1.3 Pain Management Survey 

Objective: Establish a common baseline of pain care capabilities across DoD and VHA 

by creating a modified version of the 2009 VHA Pain Management Survey to 

distribute to all DoD MTFs. 

It is very difficult to make accurate comparisons between MEDCOM MTF pain management capabilities. The MTF 

data call survey conducted by the Task Force at the start of its evaluation indicated that there was no common 

baseline for understanding pain management concepts, approaches, and capabilities. It is even more complicated to 

attempt to compare MTFs across DoD, and another level of complexity is added when making comparisons with the 

VHA. Collaborating on future pain management priorities and initiatives will require common assessments of pain 

management capabilities. 

The VHA administered a pain management capability survey to 100% of its MTFs in 2009. The creation of a 

modified version of this survey for DoD facilities would leverage the data already collected by the VHA and 

standardize measurement across the DoD and VHA continuum, enabling the identification of best practices across 

care settings and identifying future research topics. 

Representatives from each of the Services reviewed the VHA survey and assisted with revisions to make it more 

applicable to DoD, replacing VHA-specific data elements with DoD data elements. Each Service representative will 

be provided the opportunity to include Service-specific questions. This approach will help identify common 

capabilities across DoD and VHA and assist with the measurement of progress when implementing pain 

management strategies. Task Force-recommended definitions should be incorporated into the survey to ensure its 

future validity following implementation of TF recommendations on standardizing DoD and VHA orientation to pain. 
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Recommendation 4.1.3.1

Administer a modified VHA pain survey across DoD MTFs to establish a baseline of pain care capabilities. 

Recommendation 4.1.3.2

Continue to periodically administer the survey to track improvements at DoD MTFs to ensure a standardized 

measurement of pain longitudinally and across organizations. 

4.1.4 Nursing Role in Pain Management 

Objective: Evaluate the utilization, potential roles, and certification requirements for 

Nurses in the DoD pain management strategy. 

The American Nursing Association defines Nursing as: “The protection, promotion, and optimization of health and 

abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human 

response, and advocacy in the care of individuals, families, communities, and populations.” 

Nurses comprise the largest health care profession and have been the traditional 

bearers of the patient advocacy torch. Pain is the most frequently used nursing 

diagnosis in all delivery of care models, and the assessment and management of pain 

is significant to every professional registered nurse. Their unique qualifications and 

relationships with patients make nurses an essential component of any pain management strategy. Nurses provide 

hospitals and patients with a capable, professional workforce adept at measuring, monitoring, evaluating, and 

documenting pain interventions and outcomes. 

Nursing staff interviewed during TF site visits included Registered Nurses, Licensed Practical Nurses, Nurse 

Practitioners, Advanced Practice Nurses, and Nursing Assistants. Their responses to the interview questions 

paralleled those from other health care professionals. The most common observation made by nurses concerned 

their inability to identify any rationale behind the variability in pain management practices among providers. Nurses are 

most often the ones responsible for assessing pain, administering pain medications, and communicating pain 

management issues to a patient’s provider. They frequently expressed an inability to understand the underlying 

principles that would explain the lack of a standardized approach to pain care amongst providers. There were similar 

percentages of nurses concerned about the over- and under- medication of patients. 

Pain is only one of many areas where the use of Nursing Case Management would be very appropriate and beneficial. 

Warrior Transition Unit (WTU) case managers have demonstrated their value in locations with integrated pain 

management teams. The Task Force recommendation to adapt a disease management approach to pain care will 

require a corresponding assessment of the impact on nursing education, staffing, and utilization. As with other 

advanced-practice nursing specialties, the scope of practice may be broadened to provide a wider approach to optimal 

care and outcomes in pain management, with increasing levels of education, certification, and licensure. 

The MHS executes its health care mission with a combination of military and civilian nursing professionals, and they 

are present in virtually every patient care setting. A revision for the utilization of advanced-practice pain nurses, 

Clinical Nurse Specialists, Nurse Practitioners and in some cases, Certified Registered Nurse Anesthetists needs to be 

part of the DoD pain management strategy. The TF members concurred with the need to refer this issue to the Senior 

Nursing Executives in DoD and VHA for comments and recommendations on the expanded and redefined roles and 

utilization of nurses in pain management across the health care continuum. Additionally, these recommendations 

should be referred to the DoD multidisciplinary advisory board for evaluation and integration into the DoD pain 

management strategy. 

Pain is the most frequently 

used nursing diagnosis in 

all delivery of care models
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Recommendation 4.1.4.1

Request that the Federal Nurse Advisory Board evaluate the impact of certified pain nurses on patient outcomes 

and satisfaction. 

Recommendation 4.1.4.2

Request that the DoD and VHA Nurse Executives evaluate the role of certified pain nurses in patient care delivery 

(military and civilian). 

Recommendation 4.1.4.3

Determine the future role and potential use of certified pain nurses across the care continuum. 

Recommendation 4.1.4.4

Build the population of certified pain advanced-practice nurses (graduate education, board certification, short 

courses, and career field designation) to maximize the value and utilization of their critical skill sets. 

Recommendation 4.1.4.5

Integrate approved TF recommendations into Core Nursing Competencies, Clinical Transition Program (CTP), 

and other Nursing training programs. 

Recommendation 4.1.4.6

Utilize the DoD multidisciplinary pain management advisory board to evaluate and integrate recommendations 

from the Federal Nurse Advisory Board into the DoD pain management strategy. 

4.1.5 Standardized Credentialing 

Objective: Establish a process to standardize a Military Health System credentialing 

process for pain medicine. 

The Task Force found that minimum training, certification, and skill requirements for providers delivering procedural pain 

care were not consistent between MTFs or across health care professions. Examples of procedural pain care include, but 

are not limited to, fluoroscopically-guided epidural steroid injections, fluoroscopically-guided invasive treatments of spinal 

arthritis, spinal manipulation, and acupuncture. The expansion of treatment modalities, to include integrative medicine 

approaches to pain management, necessitate an MHS-wide process for standardizing the credentialing for these 

modalities. Establishing MHS-wide credentialing guidance for these treatment modalities and providers would provide a 

uniform standard of quality across the MHS and eliminate the burden on local commands to develop these credentialing 

standards. 

A credentialing document that features a three-tiered certification scheme is currently used in credentialing some 

physicians to match training and skill levels to the complexity and risk of approved procedures. This document or a system 

with similar detail should be used for all professionals offering procedural pain care, including physicians not currently 

credentialed under the tiered document. Training and skill of providers should be confirmed or measured. 

Examples of measurement would include documented completion of an approved fellowship, Accreditation Council for 

Graduate Medical Education (ACGME) board certification, or experience and skill as confirmed by observation of a 

provider credentialed at that level or higher. Standards regarding minimum training, certification, skill requirements, and 

scope of practice for providers delivering procedural pain care should be consistent across the MHS and developed with 

assistance from both the physician and non-physician Subject Matter Experts (SMEs) for these areas, usually the 

Consultants to the Uniformed Service Surgeons General. 
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Support for the TF recommendations regarding expanded availability of multimodal and interdisciplinary pain care will 

require additional credentialing by MHS facilities. Standards need to be developed in order to ensure the growing number 

of acupuncturists, massage therapists, and other integrative medicine practitioners are safe, effective, and qualified 

to practice in hospitals and clinics. 

It is impractical to place the burden on individual commands to develop credentialing criteria for this expanding 

number of integrative medicine practitioners and procedures. The MHS needs to develop standards for credentialing 

integrative medicine providers and procedures for use at local MTFs. This standardization would support the 

recommendations to decrease variation between MTFs and Services. 

Recommendation 4.1.5.1

Use specialty consultants to determine procedures to standardize MHS pain credentialing. 

Recommendation 4.1.5.2

Standardize minimum training, certification, skill requirements, and scope of practice requirements for providers 

delivering procedural pain care across MHS. Develop requirements with assistance from both physician and nonphysician subject matter experts. 

Recommendation 4.1.5.3

Consolidate specialty consultant recommendations into standard credentialing documents and approve DoDwide. 

4.1.6 Productivity Measures 

Objective: Reexamine the use of productivity measures (Relative Value Units) in 

evaluating primary care. 

A common contention among clinicians in the MHS is the perceived “disconnect” between what they are asked to do 

and how they are assessed on performance. Clinicians feel process-oriented measures of their “productivity” are not 

compatible with the highest quality of patient care espoused by leadership. In fact, the resource-based Relative Value 

Unit (RVU) is a reimbursement tool that does not consider outcomes. Clinicians are convinced that this process-based 

approach to productivity measurement is a barrier to the integrated, multimodal, interdisciplinary models that will yield 

the best outcomes in complex chronic diseases, such as chronic pain. 

The barrier to quality presented by RVU-based productivity metrics is most 

visible in the primary care setting. RVU metrics reward high throughput of 

acute minor illnesses but punish the holistic approach needed to sort out the 

complex and nuanced needs of chronic disease patients, particularly chronic 

pain patients with biopsychosocial complexity, including comorbidities. The 

critical outcomes of quality chronic pain management – return to work; 

improved quality of life; satisfaction with care; decreased Emergency Room visits; decreased unscheduled 

admissions; decreased medication misuse, abuse, and diversion; decreased adverse domestic issues – play no role in 

assessing the quality and effectiveness of the MHS primary care practice. Moreover, an integrated team approach to 

chronic disease management in primary care that includes appropriately trained nurse case managers, behavioral 

health providers, and clinical pharmacologists generally fails to generate the RVUs necessary to justify their use of 

resources. For example, a group of clinicians acting as part of an integrated care team to evaluate a patient’s 

treatment plan can only claim workload credit for one of the team members. This is a huge disincentive to providing 

integrated patient care. 

A common contention among 

clinicians in the MHS is the 

perceived “disconnect” between 

what they are asked to do and how 

they are assessed on performance
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Another area of RVU ‘disconnect’ is in pain medicine specialty practice. Selective integrated biopsyschosocial 

rehabilitation, which has a comparatively strong evidence basis in terms of outcomes effectiveness amongst all 

treatments for chronic pain, is given little value, where as interventional procedures are accorded very high RVUs. 

Thus, pain medicine specialists and institutions are incentivized (consciously or unconsciously) to perform procedures 

while indirectly discouraged from using other effective clinical modalities. This will likely not change unless a greater 

emphasis is placed on outcomes. 

One approach to fixing this issue is to de-emphasize the role of RVUs in favor of adopting outcomes-based metrics in 

assessing a clinical practice. Forward thinking commands within the MHS have already suspended the use of the 

RVU metric of productivity while transitioning to a patient-centered medical home model of delivering health care. 

Evidence-based models can be used to resource primary care practices and drive delivery of safe, integrated 

coordinated care to yield the best patient-oriented clinical outcomes. 

The TF believes a patient-centric, outcome-based measure of productivity can decrease resource utilization and 

improve patient and provider satisfaction. 

Recommendation 4.1.6.1

Establish patient-centric clinical outcome measures of productivity.

Recommendation 4.1.6.2

Modify the Relative Value Units metric to include a patient-centric outcome standard. 

4.1.7 DoD and VHA Pain Care Standardization 

Objective: Develop a patient-centric approach to recovery, rehabilitation, satisfaction, 

and pain control, with greater attention to opioid control and minimizing 

abuse. 

Enhancing standardization of pain care between the DoD and VHA has the potential to revolutionize the way patients 

perceive and receive their health care. Pain permeates every discipline of medical care and is a complaint of many 

patients. There is currently a lack of coordination between DoD and VHA pain services at both the inpatient and 

outpatient levels of care. Better institutional patient coordination may lead to decreased medication use (particularly 

opioids) and transition to an effective pain treatment plan. The majority (>52%) of Operation Iraqi Freedom (OIF) and 

Operation Enduring Freedom (OEF) Service Members report experiencing a myriad of pain symptoms as they move 

between the DoD and VHA or retire into the VHA system for care (Office of Public Health and Environmental 

Hazards, 2010) 

Presently there is no mechanism to communicate patient pain issues throughout the care continuum. An electronic 

pain record of care is essential to provide DoD and VHA providers with a common communication tool that would 

assist physicians in the care of patients during the transition from the DoD system into the VHA health care system. 

One possible solution in development is the Joint Regional Anesthesia and Analgesia Tracking System (JRAATS -

see section 4.1.15). The JRAATS electronic pain record would provide DoD and VHA clinicians with a detailed pain 

management history of the patient while that patient was under the Federal health care system. This database would 

also provide a powerful tool to evaluate treatment trends and outcome measures. 

One example of the existing disconnect involves DoD patients who have had to discontinue an effective regimen of 

acute regional anesthesia to maintain pain control prior to air evacuation to a VHA site. Instead of continuing the 

proven and effective treatment method, patients are often forced to rely on “as needed” IV morphine or short-acting 

oral opioids for the flight. It is difficult to gauge the onset of pain and the need for these medications during transfer. 
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Most patients end up taking higher doses of opioids than they need, when greater benefit would have been derived 

from continuing their peripheral pain catheters of local anesthetic. 

Similarly, patients transitioning from one inpatient facility to another may be forced to change their oral medications 

because the new facility does not have the same medications available on formulary. This may cause an 

unnecessary wait time, resulting in an undue spike in pain. Then the patient must adapt to a different pain 

medication, resulting in pain, potential complications, and new side effects throughout the transition. 

Finally, individuals transitioning from the outpatient DoD facility to the outpatient VHA upon retirement may have to 

wait for an examination prior to obtaining refills at the VHA. Once again, justification for a medication that is not on 

the VHA formulary may be required and the patient may experience unnecessary wait times, resulting in undue pain. 

Differences in DoD and VHA formularies and pain management capabilities make the transition of these patients 

especially difficult from a pain perspective. Better discharge planning and care coordination would optimize the 

adjustment of pain medication regimens and outpatient recovery. An individual who has been medically retired from 

DoD may face special challenges, including inconsistencies in follow-ups, pain care coordination, management, 

transition, and prescription renewals. 

Standardizing pain care between the DoD and VHA will require project management along with policy and process 

decisions coordinated through a central pain management advisory board, and must address: 

Coordinated discharge pain care planning for those patients with documented pain management issues, 

those with polypharmacy combinations requiring pharmacist consultation, and those identified as “at risk.” 

This is necessary for inpatient-to-inpatient transfers, inpatient-to-outpatient discharges, and outpatient-tooutpatient transfers. This will require case managers and better provider-to-provider communication. 

Establishing DoD and VHA joint formularies to maintain effective treatment plans during transitions to a new 

facility. 

Ensuring availability of successful therapies (physical therapy, occupational therapy, behavioral health, 

medication, regional anesthesia) at the new facility. 

Developing acute pain service capabilities at the Polytrauma VHA sites. This ensures that patients with 

effective regional pain control are able to air evacuate with their pain under control, enabling earlier transfers 

with significantly less patient anxiety. 

Establishing a pain medications transition policy for individuals on pain medications transitioning from Active 

Duty to Retired. 

By implementing a standardized line of pain care for the DoD and VHA, patient rehabilitation, recovery, satisfaction, 

and pain control will likely be enhanced. Improved care standardization will lead to better opioid control and will 

minimize abuse. Improved care standardization will also lead to higher provider satisfaction. 

Pilot projects should be established at DoD and VA facilities that share a high flow of Active Duty and Retirees, such 

as Tampa or Richmond and Walter Reed Army Medical Center (WRAMC), or Palo Alto and Balboa. 

An outstanding example of policy changing to meet Warrior needs has already been developed. As a result of 

inadequate pain control during transfers, patients transitioning from inpatient DoD sites on the east coast to the Palo 

Alto VA Medical Center on the west coast now air evacuate through Travis Air Force Base. Based on patient and 

Family complaints about poor pain control throughout the transfer, and the difficulty regaining pain control upon 

arrival to the VHA, the patients are now required to spend the night at Travis AFB to regain and maintain pain control. 

These transfers are now coordinated via video teleconferences, phone calls, and emails. Since the change in policy, 

there have not been any serious complaints about pain care or management during transfer. 
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Recommendation 4.1.7.1

Establish a uniform DoD and VHA formulary.

Recommendation 4.1.7.2

Integrate specific pain management "at risk" criteria into existing discharge planning coordination for transitioning 

patients. 

Recommendation 4.1.7.3

Establish similar pain care capabilities at DoD and VHA sites of similar size. 

Recommendation 4.1.7.4

Conduct pain management pilots to measure improvements in transfers. 

4.1.8 DoD and VHA Joint Formulary 

Objective: Establish a joint formulary to facilitate smoother transitions and minimize 

pain throughout the continuum of care. 

One specific area of standardization between the DoD and VHA is the formulary. About 90-95% of pain medications are 

formulary to both the military and VHA. Pain management issues arise with restricted drugs and those with criteria for 

approval. When pain regimens are properly titrated to the patient’s satisfaction, the outcome is optimal. Sub-optimal care 

occurs when the regimens are changed and providers and systems do not communicate and coordinate, resulting in 

increased pain, dissatisfaction, poor continuity of care, increased opportunity for drug diversion, misuse or abuse, increased 

patient safety risk, and excessive costs. 

Both the VHA and the DoD have formulary decision-making committees. They operate independently of each other and 

sometimes drugs approved for DoD will not be found on the VHA formulary for continued therapy. Both decision-making 

committees may have drugs in non-formulary status with criteria that must be approved prior to a patient receiving the drug. 

The problem has been that the criteria for approval was different in each system, which resulted in a Service Member who 

was already approved for the drug in the DoD system having a delay in continuing the drug in the VHA system because a 

subsequent approval in the VHA system was required. 

Formulary findings identified during site visits: 

Service Members incurred at least a 2-3 month wait time between leaving the military and their first 

appointment within the VA medical system. As a result, Service Members and Veterans may run out of their 

maintenance pain medications. Military MTFs do not have consistent medication discharge planning 

practices nor do they communicate with VHA liaisons to create care transition plans. 

Service Members stabilized on pain medications within the military MTFs sometimes have their pain regimen 

changed due to formulary inconsistencies between the VHA and the military. The VHA has criteria for use of 

medications such as fentanyl, buprenorphine, sustained-action oxycodone, gabapentin, pregabalin, 

duloxetine and others. 

Service Members who have gone through the “medical necessity” or “prior authorization” approval 

requirement within the MTF system and are transferred to the VHA system are required to re-submit 

paperwork for the approval of the same drug or drugs (e.g., duloxetine and pregabalin). 

Service Members admitted to the VA Polytrauma Centers are discharged on pain medications that are nonformulary under the Uniform Formulary system. A Medical Necessity Form requesting continuation of the 

medication can be submitted to the MHS, but there are inconsistencies among MTFs. Service Members 

have had their pain regimen changed to conform to the formulary agent(s) available, medical necessity 

aside. 
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Service Members have been transferred from military MTFs to VA medical centers on epidurals, PCAs or 

pain balls and have been unable to continue their pain regimen because of a lack of medications, staff 

education on the devices, and equipment. 

The lack of uniformity in pain practice exists throughout the DoD health care system and into the VHA. Pain 

plans established at one facility are often changed for no other reason than lack of familiarity with the pain 

medication or technology used at the transfer facility, resulting in unnecessary patient discomfort. This issue 

is exacerbated by the lack of a clear understanding of who is responsible for managing pain at each node of 

care. For example, it is very common for continuous peripheral nerve block catheters to be removed during 

evacuation because providers at the next treatment node are either unfamiliar with the technology or do not 

have personnel responsible for pain management. 

There are several groups coordinating on DoD and VHA joint formulary issues: 

Pain Management Task Force 

DoD Pharmacoeconomic Center 

DoD Pharmacy & Therapeutics Committee 

Defense and Veterans Pain Management Institute (DVPMI) 

Healthcare Executive Committee (HEC) Pharmacy Workgroup 

VHA and DoD Chronic Opioid Therapy Clinical Practice Guidelines Panel 

VA Pharmacy Benefits Management (PBM) 

VA Medical Advisory Panel (VA MAP) 

VA National Formulary (VANF) 

The TRICARE system allows Service Members with prior authorization or medical necessity approval to continue their 

pharmacy care wherever they go, in any of the three points of service – MTF, retail or mail order – enabling continuity of 

care. When patients transfer to the VA system, VA policy that stable pain regimens for military members should not be 

changed unless medically necessary. 

Recommendation 4.1.8.1

Standardize pharmacy benefits between DoD and VHA, and make them reciprocal, without delay or challenge.

Recommendation 4.1.8.2

Evaluate the safety and effectiveness of prescriptions renewals process for Service Members transitioning to VHA 

care.

Recommendation 4.1.8.3

Establish a common DoD and VHA policy to support state of the art and science practices, such as the use of 

non-narcotic pain balls, PCA pumps, and epidurals, with associated common education content. 
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Infrastructure and Tools

Figure 7: A Summary of Categories for Infrastructure and Tools 

Provide Tools and Infrastructure that Support and Encourage Practice and Research 

Advancements in Pain Management 

Infrastructure and 

Tools

Pain Assessment and Outcome Registry 

Battlefield Pain Care Continuum 

Tele Pain 

Joint Theater Trauma Registry 

Electronic Pain Order Set

Standardized Medical Equipment and Personnel in the Deployed Setting 

Joint Regional Anesthesia and Analgesia Tracking System 

Standardize Identification of Substance Abuse Patients 

Risk Management in Chronic Pain Medical Management 

4.1.9 Pain Assessment and Outcome Registry 

Objective: Adopt a clinical information data system that provides pain assessment 

screening with an outcomes registry to promote consistency in pain care 

delivery.

There is a lack of data within the United States health care system concerning the appropriateness and effectiveness 

of many pain management procedures and techniques. Additionally, the exceedingly complex nature of the pain 

disease process requires pain medicine providers to delve into all the biopsychosocial aspects of a patient’s pain 

issues. This can be remarkably difficult in the limited time allotted for provider and patient interaction that is 

characteristic of modern medicine. 

The lack of a DoD and VHA pain data screening and outcomes repository causes difficulty in making responsible 

decisions on the myriad of possible treatment modalities. This lack of pain data makes counseling patients on pain 

procedure efficacy a challenge. It also presents barriers to greater patient involvement in decisions about care, 

makes longitudinal comparison of changes in pain difficult, and may limit availability of optional pain management 

techniques and medications. This situation inhibits DoD and VHA pain specialists from providing outcomes- and 

evidence-based clinical pain medicine solutions to Warriors and Families. At its core, the lack of a shared 

interagency pain data repository impacts patient safety and pain care quality, and contributes to variability throughout 

the care continuum. 

The Task Force has determined that the DoD and VHA health care systems require a Pain Assessment Screening 

Tool and Outcomes Registry (PASTOR) clinical information and data system. This information technology solution 

will gather information from patients and provide summaries for providers, leaders, and researchers to use for 

decision support. This information will be vital in minimizing clinical variation in pain care delivery among providers 

and medical treatment facilities. 

The University of Washington (UW) health care system has developed a computer-based patient pain information 

and diagnostic system called “My Pain Profile” (MPP). The UW computer system guides pain patients through a 

series of questions concerning patient demographics, pain characteristics, medication use, substance abuse, and 

other pain variables. Information is provided by the patient prior to the clinical visit and is summarized for the 
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provider in a computerized form. Efficient for both patient and provider, the system generates information that can 

assist the provider in enhancing care by providing indicators of real or potential pain-related health problems. 

Traditionally, this level of patient information could only be obtained after a long series of clinical visits using 

inefficient paper-based surveys. MPP has also provided UW a unique tool for outcomes assessment, research, and 

program self-assessment. The UW solution will be one system that guides the development of the DoD and VHA 

PASTOR system. 

PASTOR will incorporate military-specific demographic and diagnostic information to enhance the value of the 

information for Warrior and Beneficiary pain issues. The PASTOR system will also integrate with other Task Force 

recommendations, such as the DoD and VHA Pain Assessment Tool, Pain Centers of Excellence, and the 

establishment of a central pain management advisory board. 

Additional resource requirements: 

A computer-based system that facilitates self-reported patient data entry from both the clinic and the 

patient’s home using the Internet. 

Full integration with the Medical Home concept of care. 

Full-time IT personnel and equipment support. 

Full integration with existing and future DoD and VHA medical information systems (within a year, or an 

interim standalone system will be adopted). 

A central pain management advisory board to define and develop PASTOR content and maintain data 

repository. 

Large educational component for use by primary care providers and pain specialists throughout the DoD 

and VHA health care systems. 

The DoD and VHA PASTOR will serve as the primary source and an international model for outcomes-driven pain 

research and resource allocation decision support. PASTOR will collect and provide the necessary data for 

determining best pain practices, determining DoD and VHA pain care standards, and enhancing patient pain care. 

The opportunities for population-based research on pain treatments and safety-related issues are enormous and hold 

great potential for improving pain medicine. 

Recommendation 4.1.9.1

Jointly fund the development of a Pain Assessment Screening Tool and Outcome Registry under the direction of 

a central pain management advisory board.

Recommendation 4.1.9.2

Integrate and mandate a Pain Assessment Screening Tool and Outcome Registry with DoD and VHA IT systems.

Recommendation 4.1.9.3

Implement and mandate a Pain Assessment Screening Tool and Outcome Registry across DoD and VHA. 
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4.1.10 Battlefield Pain Care Continuum 

Objective: Incorporate scientific advances in battlefield surgery and medical 

technology to improve the delivery of pain care across the continuum. 

The TF did not conduct any interviews or site visits in Iraq or Afghanistan. The following findings and 

recommendations were developed with assistance from TF members with recent deployment experience, as well as 

from interviews with returning providers and clinicians from the current theater of operation.

While battlefield medicine has experienced significant advances and outcome 

improvements over the last 20 years, these have not always been accompanied 

by equivalent advances in battlefield pain management. The variation in 

practice and capabilities that is evident in the care provided in MTFs is 

mirrored, to some extent, on the battlefield. Many Warriors do not receive the 

most advanced pain care due to a lack of equipment and inadequate provider 

training in pain management. There is no “Theater Pain Management Practice Guideline,” resulting in an 

overreliance on opioid-based pain solutions, from point of injury throughout the care continuum. This emphasis on 

opioid pain therapy at all levels has likely factored into the improper use of these medications among Wounded 

Warriors. Military medicine prides itself on investing in the prevention and treatment of many combat injuries, as well 

as disease and non-battle injury conditions. The recent increase in the number of behavioral health providers 

deployed to Iraq and Afghanistan was planned after an assessment by senior leadership indicated that behavioral 

health issues on the battlefield were better handled by specialty providers further forward. Similarly, pain should be 

recognized as a disease process that, if poorly managed, adversely impacts every aspect of a Warrior’s recovery and 

rehabilitation. Successful pain management on the battlefield demands a pain medicine champion far forward. 

Figure 8: Consequences of Unrelieved Pain (Joshi and Ogunnaike, 2005)

Organ Systems Physiologic Responses 

Cardiovascular Increased heart rate, peripheral vascular resistance, arterial blood pressure, and myocardial 

contractility resulting in increased cardiac work, myocardial ischemia and infarction. 

Pulmonary

Respiratory and abdominal muscle spasm (splinting), diaphragmatic dysfunction, decreased 

vital capacity, impaired ventilation and ability to cough, atelectasis, increased 

ventilation/perfusion mismatch, hypoventilation, hypoxemia, hypercarbia, increased 

postoperative pulmonary infection. 

Gastrointestinal Increased gastrointestinal secretions and smooth muscle sphincter tone, reduced intestinal 

motility, ileus, nausea, and vomiting. 

Renal Oliguria, increased urinary sphincter tone, urinary retention. 

Coagulation Increased platelet aggregation, venostasis, increased deep vein thrombosis, 

thromboembolism. 

Immunologic Impaired immune function, increased infection, tumor spread or recurrence. 

Muscular Muscle weakness, limitation of movement, muscle atrophy, fatigue. 

Psychological Anxiety, fear, anger, depression, reduced patient satisfaction. 

Overall Recovery Delayed recovery, increased need for hospitalization, delayed return to normal daily living, 

increased health care resource. 

Pain should be recognized as a 

disease process that, if poorly 

managed, adversely impacts 

every aspect of a Warrior’s 

recovery and rehabilitation
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Additional resource requirements: 

A physician trained in pain management at all Level III facilities. 

Pain Equipment Set at all Level III facilities. 

Pain Nursing. 

Joint Theater Trauma Registry pain questions. 

Joint Theater Trauma System Clinical Practice Guideline for Pain Management (Appendix B-3). 

Renewed pre-deployment emphasis on pain management at all medical training levels. 

Recommendation 4.1.10.1

Adopt the Joint Theater Trauma System Clinical Practice Guideline as policy for pain management. 

Recommendation 4.1.10.2

Establish acute pain medicine services across the continuum of care, consisting of pain-trained providers who are 

responsible for pain consultation and management within the MTF.

Recommendation 4.1.10.3

Establish a DoD central pain management advisory board as the battlefield pain management proponent and 

consultant organization. 

4.1.11 Tele Pain 

Objective: Expand telemedicine capabilities to incorporate pain management 

initiatives.

Advanced pain management expertise is often limited on the battlefield and in remote MTFs. Patients being treated 

for chronic pain conditions often travel long distances to be seen, at a considerable expense. Many pain follow-up 

visits do not necessarily require the physician and the patient to be in the same physical space to check on treatment 

plan progress, answer patient questions or concerns, and plan for future physician-patient interactions. 

Telecommunication technology is available and would enhance patient and health care provider access to pain 

consultation regardless of geographic location. Pain consults can be performed by pain management experts using 

video conferencing technology. With the establishment of Tele Pain clinics as part of Regional Pain Centers of 

Excellence (RPCoE – see section 4.4.4), distant sites within the TRICARE region would have routine access to 

specialty pain consultation. 

Primary care physicians could conduct initial consultations without having to send the patient to the RPCoE, 

enhancing communication between primary care and pain specialists, increasing efficiency, and potentially reducing 

the number of unnecessary or improper patient specialty visits. From a personnel perspective, Active Duty pain 

patients using this service will be absent from their mission for shorter periods of time and travel costs should be less 

for the command. 

Several VA hospitals have ongoing telemedicine initiatives to assist with the management of patients with chronic 

diseases. The VHA has been able to use technology to improve the remote management of patients with diabetes, 

hypertension, congestive heart failure, or chronic obstructive lung disease. The VA Medical Center (VAMC) in 

Salisbury, North Carolina uses telemonitors to monitor patient blood pressures and oxygen levels. Patients are also 

able to communicate how they are feeling or if they are having problems with medication via an electronic device. 

Without the patient having to come into the hospital, Primary care and specialty providers are often able to adjust 

patient appointments, alter treatments, and communicate with the patients. This technology has great potential for 

the management of chronic pain or complex acute pain. 
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Additional resources would be required: 

Establish RPCoEs within each TRICARE region and Pain Departments at medical centers throughout the 

DoD. 

Create Tele Pain sites within the RPCoE and participating MTFs. 

Resolve issues from Health Insurance Portability and Accountability Act (HIPAA). 

Leadership commitment to develop new policies governing primary care support and productivity metrics 

Reallocate personnel and resources. 

Commit information technology support and expand DoD Internet bandwidth infrastructure. 

Leverage existing DoD and VHA telemedicine infrastructure to include pain management programs. 

This approach will likely improve pain consultant access, reduce physical patient clinic visits, reduce health care 

costs, and improve patient satisfaction. 

Recommendation 4.1.11.1

Establish Tele Pain sites at Regional Pain Centers of Excellence and MTFs throughout DoD and VHA. 

Recommendation 4.1.11.2

Develop an enterprise strategic communications plan on the availability and benefits of telemedicine. 

Recommendation 4.1.11.3

Develop metrics to evaluate the effectiveness and costs of providing enhanced telemedicine for pain medicine.

Recommendation 4.1.11.4

Develop new telemedicine technology applications for pain management uses.

4.1.12 Joint Theater Trauma Registry 

Objective: Add a Joint Theater Trauma Registry module to capture, define, and 

characterize Wounded Warrior pain issues throughout the care continuum, 

from the battlefield to MTFs. 

The Joint Theater Trauma Registry (JTTR) is the primary military combat casualty care data collection repository. 

Currently, the registry does not collect any information on casualty pain. After eight years of conflict, this has been a 

tremendous missed opportunity to define and characterize Wounded Warrior pain issues throughout the care 

continuum. 

Theater-specific and longitudinal information would improve the understanding of the pain care needs of Wounded 

Warriors. It would enable the measurement of treatment effectiveness across facilities and settings, the development 

of pain care policy, and the identification of pain care resource gaps, as well as offer the opportunity to establish pain 

research priorities. 

The new DoD and VHA Pain Assessment Tool will provide a unique way of defining a patient’s pain in terms of 

function. Combined with the four supplemental questions on activity, mood, stress, and sleep, the Pain Assessment 

Tool will provide a powerful research and outcomes measurement tool when incorporated into the JTTR system. 

Additional resource requirements: 

Inclusion of the 11-point DoD and VHA Pain Assessment Tool into the JTTR database. 

A central pain management advisory board to be responsible for routine analysis and trend modeling. 
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This database will serve as the source for objective, population-based information on pain management outcomes 

and will guide pain management decision making and resource allocation for the battlefield and evacuation chain. 

The database will be important in evaluating the success of new pain medications, Task Force recommendations, 

and technologies deployed far forward. 

Recommendation 4.1.12.1

Establish the Standardized Pain Assessment Tool as an integral part of the Joint Theater Trauma Registry 

database.

Recommendation 4.1.12.2

Maintain routine analysis, management, and reporting of pain data through a central pain management advisory 

board.

4.1.13 Electronic Pain Order Set 

Objective: Develop an electronic pain order set to assist health care providers in 

selecting evidence-based, individually tailored pain management plans. 

The majority of patient pain issues are handled by primary care providers. As discussed earlier, there is wide 

variability in health care provider pain management training based on the health care provider’s specialty and 

experience, leading to variability in pain management. Because pain is not a main focus for the primary physician 

writing the orders, medications are often based on the physician’s residency experience and not on the latest 

evidenced-based pain recommendations. 

The DoD and VHA need to establish guidelines to assist health care providers in delivering a more consistent 

approach to pain management for their patients. The guidelines should be integrated into the DoD and VHA medical 

information systems. Such guidelines are not intended to prevent or replace physician judgment in developing 

patient pain orders, but rather to influence provider practice patterns with DoD- and VHA-wide guidance based on 

best current evidence on pain management. 

Additional resource requirements: 

Development and inclusion of pain order sets in all DoD and VHA medical information systems (AHLTA, 

Essentris and VISTA). 

A central pain management advisory board to be responsible for development and maintenance of all pain 

order sets and policies. 

Annual review of pain guidelines. 

Upon completion of the pain order set, the physician or prescriber will have created an effective plan for each patient 

that is consistent with the best DoD and VHA evidence-based data for pain treatment. While these recommendations 

do not preclude a provider from exercising his or her own clinical judgment, they do ensure that all prescribers of pain 

medications at least consider DoD and VHA recommendations for best pain prescribing. It is likely that this policy will 

result in a de-emphasis on opioids in pain management plans. Electronic pain order sets will also prompt primary 

care physicians when specialty pain management consultation is needed. Additionally, commanders should be able 

to monitor providers who consistently practicing outside of the recommended guidelines. 

An example of pain medication orders developed for the WRAMC Essentris system is provided in Appendix B-4. 

Variations of this theme could be developed through a central pain management advisory board for all levels of MTFs 

within the DoD and VHA systems. 
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Recommendation 4.1.13.1

Establish DoD and VHA electronic pain order sets in all electronic medical records.

Recommendation 4.1.13.2

Conduct an annual review and update electronic pain guidelines.

4.1.14 Standardized Medical Equipment and Personnel in the Deployed Setting 

Objective: Standardize medical equipment, personnel support, and training across the 

continuum of pain care. 

There is no current standard equipment or personnel requirement for pain management throughout the continuum of 

care. Wounded Warriors are often not given advanced pain management technologies far forward due to 

unavailability of advanced pain management medications and equipment. Battlefield pain control is euphemistically 

discounted as a non-issue because pain management is considered to be everyone’s responsibility. In actuality, 

responsibility for pain management is highly uncertain. 

This issue is presently most conspicuous at OIF and OEF Level III facilities. Level III equipment lists do not include 

standard supplies needed for routine pain management procedures. Personnel are often willing and available to 

manage trauma pain but are ill equipped to do so unless the medical officer brings his or her own supply. Wounded 

Warrior care depends on who is present and what supplies are available at the Combat Support Hospital (CSH). 

Therefore, MEDCOM must deploy a uniform set of advanced pain management medications and equipment. A 

proposed CSH pain medication set is included in Appendix B-5. 

Beyond having the appropriate supplies and equipment, successful pain management on the battlefield requires 

dedicated personnel assigned to the unit pain mission. A Level III facility, for example, would have a medical officer 

assigned the duty of pain consultation and management within the facility. This officer, usually an anesthesiologist, 

would coordinate pain management plans with assigned pain nurse representatives from each CSH ward. The 

number of personnel required for acute pain services will be dictated by the size and scope of a facility’s health care 

mission. 

The establishment of an acute pain service at every Level III facility and also throughout the care continuum will 

greatly enhance Warrior pain care. Pilot programs in Iraq and Afghanistan have demonstrated the success of Level 

III acute pain services.

Additional resources requirements: 

Development of acute pain services and inclusion of pain equipment sets in all Level III facilities. 

Adoption of the tier system of pain care throughout the care continuum that defines medical officer 

responsibilities, resource requirements, and equipment for pain management at all levels of care. 

Extensive education and training effort and policy generation at all levels of care. 

Warrior and Beneficiary care will be positively influenced throughout the care continuum. A standardized equipment 

set is required to deliver uniform pain management throughout the care continuum. 
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Recommendation 4.1.14.1

Establish comprehensive acute pain services in the deployed setting.

Recommendation 4.1.14.2

Standardize equipment sets for the deployed setting.

Recommendation 4.1.14.3

Establish requirements and authorizations for pain management specialists across DoD to identify and implement 

best practices from the VHA.

Recommendation 4.1.14.4

Develop training program modules to support pain management in the deployed setting. 

4.1.15 Joint Regional Anesthesia and Analgesia Tracking System 

Objective: Leverage advances in regional anesthesia techniques by integrating the data 

through an existing, sanctioned joint tracking data system. 

During the course of OEF and OIF, many Service Members have been severely wounded and their pain care has 

been a challenge. The military anesthesiology community developed regional anesthesia techniques and other 

advanced pain care technologies that have revolutionized pain management. Advanced pain care technologies, 

such as continuous peripheral nerve blocks, epidurals, patient-controlled analgesia, and ketamine infusions require 

close management at all times, whether the patient is in a hospital bed or in the evacuation system. Leadership 

quickly recognized that an electronic system for following patients and transmitting vital pain information to their 

accepting physicians was needed if these important techniques were to be used safely throughout the care 

continuum. 

In response to this need, Army anesthesia specialists working through the DVPMI developed a Regional Anesthesia 

Tracking System (RATS) to monitor patients using advanced pain technologies as they traveled through the military 

health care system. RATS is a stand-alone information system that allows medical providers to document pain 

management notes on a central server and notify receiving providers about patients in transit with regional 

anesthesia. It does not connect to or share data with any of the MHS electronic health record systems, such as the 

Theater Medical Data Store (TMDS) or AHLTA. The military medical community has recognized the importance of 

the data collected in RATS and has requested that RATS functionality be incorporated into a MHS electronic health 

record system. 

The Joint Regional Anesthesia and Analgesia Tracking System (JRAATS) is under development to meet this medical 

information requirement. Once integrated into the TMDS, this system will give pain medicine providers at all Levels 

of care a key communication tool for the safe and effective implementation of advanced pain care throughout the 

care continuum. The JRAATS Concept of Operations (CONOPS) document is provided in Appendix B-6. 

Additional resource requirements: 

Complete integration of MEDCOM and TMDS with JRAATS. 

Adopt the JRAATS information system throughout the care continuum. 

Extensive education, training effort, and policy generation at all Levels of care. 
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This approach will maintain the advantages of RATS and focus on the three most important and basic sets of pain 

notes: procedure, clinical, and transfer. The integration of the JRAATS into the DoD sanctioned TMDS will improve 

the safety and pain care of Wounded Warriors. This approach will enhance opioid management across the pain care 

continuum to include the VHA system, and provide a tremendous data source for pain outcomes research. 

Recommendation 4.1.15.1

Complete the Joint Regional Anesthesia and Analgesia Tracking System.

Recommendation 4.1.15.2

Implement the Joint Regional Anesthesia and Analgesia Tracking System.

Recommendation 4.1.15.3

Assign program, data, and content responsibility for the Joint Regional Anesthesia and Analgesia Tracking 

System to a central pain management advisory board. 

4.1.16 Standardize Identification of Substance Abuse Patients 

Objective: Identify substance abuse patients in Warrior Transition Units by embedding 

the necessary resources to develop and implement a coordinated care and 

monitoring plan. 

Substance abuse disorders are not uncommon in society or the military. According to the Substance Abuse and 

Mental Health Services Administration (SAMSHA), an estimated 20.1 million Americans aged 12 or older were 

illicit drug users in 2008 (SAMSHA National Survey on Drug Use and Health Report, 2008). The National 

Institute of Drug Abuse 2008 study, “Monitoring the Future,” found that 9.7% of 12th graders in the U.S. abused 

Vicodin in the past year and 4.7% abused Oxycontin. Drug abuse in the military has paralleled the civilian 

sector. The 2005 Pentagon Health Survey found that 15% of Service Members admitted to prescription drug 

abuse in the previous year, with 4% in the past month. The 2008 survey reported 22% admitting use in the 

previous year and 13% in the previous month. 

Prescription drug abuse is increasing. The risk of opioid abuse and dependence increases for those who are 

receiving controlled substances for the treatment of chronic pain. Opioid dependence in chronic pain patients is 

often associated with poor outcomes, including occupational difficulties, disciplinary problems, social problems, 

disability, and death. 

OIF and OEF have placed tremendous strains on military personnel and their Families. The number of 

prescriptions written for pain medications has increased and the correlation between suicide and prescription 

pain medication abuse is of deep concern to DoD. As such, a two-day meeting with the National Institute on 

Drug Abuse (NIDA) and VA was held in January 2009. The meeting focused on addressing substance abuse 

and associated mental health problems in military personnel, Veterans and their Families. 

More than 20 years of research has identified many of the biological variables and social circumstances that 

foster or protect against drug abuse and addiction. NIDA is actively supporting research that strives to help 

people, across the lifespan, develop and apply the skills and resources they need to stop problem behaviors 

before and after they begin. 

The issue is two-fold for military medicine. While there is an increased risk of addiction in pain patients who are 

receiving controlled substances for the management of pain (or not receiving controlled drugs and instead selftreating with illicit drugs), there is no routine or standardized screening for those at risk, nor is there a system to 
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share this information, when known, throughout the health care continuum. In other words, there is no reliable 

means of connecting the dots. 

Many barriers make it difficult or impossible to share information among health care providers: 

Systems do not communicate. 

Within the military, there are intra- and inter-Service restrictions on the release of certain information. 

Under a new test program in select locations, soldiers can, without the commander’s knowledge, selfrefer to Army Substance Abuse Program (ASAP). 

Some Soldiers seek treatment outside of the military establishment and some deliberately seek to not 

disclose this information, making it difficult for health care providers to be fully informed. 

For these reasons, screening is critical, as it represents a fail-safe way to identify those with, or at risk for, 

substance abuse disorders and initiate early intervention efforts. 

Currently, the Drug and Alcohol Management Information System (DAMIS) tracks those enrolled in ASAP, but 

the system is closed to military medical providers. It is estimated that 45% of patients who are present for care 

are affected by substance abuse disorders that are routinely unrecognized by health care providers (Military 

Health System, 2009). It is imperative that addiction risk be assessed as early as possible, preferably at the very 

first encounter with the health care system, irrespective of whether controlled substances are being considered 

or not. This is the proverbial “golden time” for substance abuse prevention and/or detection. 

Undoubtedly, the best approach to reducing substance abuse is prevention. Early and effective screening for 

substance abuse patients would save untold direct and indirect costs and suffering. It is a proven fact that 

research-based drug abuse prevention programs are cost-effective. Each dollar invested in prevention achieves 

a savings of up to $7 in areas such as substance abuse treatment and criminal justice system costs (NIDA, 

2007), not to mention their wider impact on the trajectory of young lives and their Families. Each year, drug 

abuse and addiction cost taxpayers nearly $534 billion in preventable health 

care, law enforcement, crime, and other costs (NIDA, 2007). Early detection 

and intervention would reduce societal costs and prevent the adverse 

personal consequences of substance abuse. 

WTU patients often have complex pain issues that require pain specialty consultation and close pharmacologic 

monitoring. Many have co-existing disorders, such as PTSD, TBI, depression, insomnia, and substance abuse. 

Obtaining an appropriate history and understanding the impact of these co-existing disorders is necessary to 

formulating an appropriate treatment plan. Evaluating these patients in close collaboration with the primary care 

physician allows for a coordinated care plan that can reduce the length of time a patient is held in the WTU, reduce 

the risks inherent in fragmented care, and facilitate the early detection of aberrant pain behavior in this high risk 

population. 

The Task Force recommends that a tri-service and VHA working group, representing subject matter experts from 

primary care, behavioral health, and pain management, make a recommendation for a standardized substance 

abuse screening tool. The tool would monitor the development of problems for individuals and identify those 

individuals who are either with, or at risk for, substance abuse. This tool should allow for initial intake evaluation 

and periodic follow-up rescreening in both a paper form (that can be quickly implemented) and Web-based. 

This tool, when added to pain assessment and outcome registry tool, would give providers a comprehensive 

view of the individual, including their proclivities. Knowing this information from the outset would enhance care 

and management. After analysis, the working group would make a recommendation that would then go to the 

VHA and the Service Surgeons General for final review. 

The best approach to reducing 

substance abuse is prevention
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A standardized screening tool for substance abuse along with a standardized informed consent that explains risks, 

benefits, and alternatives to chronic opioid therapy for the treatment of chronic pain conditions are necessary. Poor 

access to pain subspecialty care and lack of a widely accepted tiered or stepped model of pain care has resulted in 

an overreliance on opioid medication which contributes to the increase in opioid abuse and dependence. 

Recommendation 4.1.16.1

Establish a tri-service and VHA working group that will recommend a paper form and Web-based interactive tool, 

designed for general medical settings, as the standardized tool to identify substance abuse patients. 

Recommendation 4.1.16.2

Incorporate the screening tool into the Pain Assessment Screening Tool and Outcome Registry. 

Recommendation 4.1.16.3

Implement use of the tool during the initial patient visit to obtain a baseline assessment. 

Recommendation 4.1.16.4

Enhance the communication of the patient's plan of care among primary care, specialty care, and substance 

abuse providers.

Recommendation 4.1.16.5

Develop a strategic communications plan on the use of a standardized substance abuse screening tool. 

4.1.17 Risk Management in Chronic Pain Medical Management 

Objective: Mitigate the risk of prescription drug abuse and dependence in pain 

patients, with a focus on those receiving controlled substances for the 

treatment of chronic pain. 

Current accepted treatment for opioid dependence includes both an abstinence-based approach and a 

pharmacologic approach. While an abstinence-based approach is clearly ideal, there is a significant relapse rate with 

the abstinence-based approach that is associated with increased morbidity and mortality. Early recognition of 

patients with risk factors for abuse and dependence will lead to closer monitoring and consultation with a pain 

specialist and behavioral health specialist when considering the use of opioids for the treatment of chronic pain. 

Once opioid dependence has been identified, appropriate treatment can be arranged. 

There has been limited success with the use of naltrexone in patients who have completed detoxification, but the 

long term compliance rate is low, much as compliance with Antabuse is low among patients with alcohol 

dependence. Until the Drug Abuse Treatment Act of 2000 (DATA 2000), the only opioid agonist treatment available 

for opioid dependence was methadone. When used for opioid dependence, methadone can only be obtained from a 

licensed methadone clinic. Opioid agonist therapy is associated with increased compliance, reduced criminal 

behavior, increased social and occupational functioning, and reduced morbidity and mortality. 

DATA 2000 allowed for office-based opioid agonist treatment using the medication buprenorphine/naltrexone 

(Suboxone) in a tightly regulated manner. Although buprenorphine/naltrexone is being used in the treatment of 

patients with opioid dependence within several military medical treatment centers and is prescribed for some patients 

receiving treatment in the network, buprenorphine/naltrexone is not a covered benefit under TRICARE. Thus, it is 

extremely difficult for patients to continue therapy following discharge from the network treatment facility. The 

patients referred to civilian inpatient treatment programs and started on buprenorphine/naltrexone are often the 
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patients with the most severe forms of opioid dependence and are at the highest risk of relapse. Failure to continue 

the therapy used to stabilize their opioid dependence increases their likelihood of relapse after discharge. 

In addition, there are some high functioning patients who have been on opioids for the treatment of chronic pain for a 

long period of time but for whom the medication has ceased to provide benefit. Some of these patients have trouble 

stopping secondary to withdrawal symptoms that result in protracted discomfort, difficulty sleeping, difficulty with 

concentration, and irritability. These patients often have a stable home life, function well at work, do not experience 

disciplinary problems, and may not need a formal substance dependence treatment program. It is acceptable to treat 

these patients in an office-based setting with close monitoring and appropriate pain medicine, behavioral health, and 

primary care support. Over time, these patients may be successfully tapered off the opioid agonist therapy. 

The TF recommends implementing standardized screening tools, using a stepped care approach to pain 

management, increasing access to specialized pain care, offering alternatives to chronic opioid therapy, and 

implementing pain education programs to address and reduce the reliance on opioid medications. For patients who 

have developed prescription opioid dependence, there should be ready referral for appropriate substance abuse 

treatment and the use of office-based opioid agonist treatment should be available as an option for selected patients 

who would benefit. 

Recommendation 4.1.17.1

Implement a stepped care model for pain care. 

Recommendation 4.1.17.2

Develop a strategic communications plan on DoD and VHA guidelines for chronic opioid therapy and the VHA 

Opioid Pain Care Agreement. 

Recommendation 4.1.17.3

Educate providers and chronic pain patients on the signs and symptoms of opioid dependence, addiction 

treatment options, and stigma issues.

Recommendation 4.1.17.4

Ensure that appropriate treatment for opioid dependence, including the use of office-based opioid agonist therapy, 

is available for those patients who have developed an opioid dependence as a result of pain treatment.

Recommendation 4.1.17.5

Ensure that patients with chronic pain who demonstrate, or are deemed at risk for, aberrant behavior have access 

to structured pharmacy management programs that support opioid and medication pain management. 
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Research

Figure 9: A Summary of Categories for Research 

Provide Tools and Infrastructure that Support and Encourage Practice and Research 

Advancements in Pain Management 

Research

DoD and VHA Pain Research Strategy 

Research Strategic Communications 

Clinical Practice Guidelines for Pain Management 

4.1.18 DoD and VHA Pain Research Strategy 

Objective: Develop collaborative pain research strategies that advance Warrior pain 

care and rapidly translate effective findings into practice. 

The theoretical criteria for selecting analgesics for pain procedures and other treatment include 

Efficacy 

Overall effectiveness 

Side effects and complications 

Onset of symptoms 

Drug interactions 

Abuse potential 

Practical issues such as cost and availability of the drug, as well as the severity and type of pain 

Social and cultural issues, such as the time and location of the provider’s training, mentor preferences, and the 

influence of pharmaceutical marketing and advertising also play a role. There are still other factors relating to 

prescribing medication, including availability of the compound and cost. At any given time, the order of choice in the 

decision-making process can change. Wide variation in the treatment of pain is the result. 

Qualitative and quantitative evidence-based research is the best way to inform the pain management process and 

translate new information (e.g., techniques) into clinical practice. Data analysis yields the most unbiased results and 

informs the selection of future lines of research. This is the best way to advance pain care and standardize clinical 

variation, while minimizing patient pain and suffering. Research can inform pain treatment modalities, decrease cost, 

identify ways to prevent addiction, and ensure the research priorities match the actual need. 

Currently, research information outcomes are not widely available and there are inadequate processes for the 

implementation of knowledge in the form of transfer to clinical practice. There is insufficient funding for pain 

Research, Development, Test & Evaluation (RDTE). Research productivity must be increased, with a goal of higher 

quality, improved patient care. Battlefield pain care drives the DVPMI agenda. The field of pain care would be 

advanced if the same need-based approach were adopted across the enterprise and sufficient resources provided. 

It is critical to communicate issues of systematic evaluation and ongoing care of chronic or persistent pain, and 

provide information about the scientific basis of recommended procedures in order to eliminate variation and improve 

care. Research and guidelines could be expected to increase patient compliance, dispel miscommunications among 

providers and patients, manage reasonable patient expectations, and form the basis of a therapeutic partnership 

between the patient and the provider. 
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The MHS must leverage TF discoveries to ensure research in pain management addresses current medical 

knowledge and the technology needs of the MEDCENs and VA hospitals to care for Wounded Warriors. Pain 

management is one of the most costly medical care functions MEDCENs perform. Developing better medicines and 

techniques to manage pain more effectively has the potential to significantly decrease costs and result in better 

health care overall. 

The Surgeon General’s lead for conducting medical research and development under the Army’s RDTE program, 

United States Army Medical Research and Materiel Command (MRMC), maintains organizations and core funding for 

pain management. In 2008, MRMC established the Clinical and Rehabilitative Medicine Research Program 

(CRMRP) to focus investments on Wounded Warrior care. Pain management RDTE is assigned to CRMRP. 

CRMRP identifies objectives and priorities for pain management research through a joint, interdisciplinary clinical 

panel – the Pain Management Scientific Steering Committee (SSC) – of stakeholders from all Services, appropriate 

DoD elements, National Institute of Health (NIH), and VHA. The Pain Management SSC established research 

objectives and priorities in April 2009 but discoveries of the TF regarding technologies, techniques, and guidelines 

applied to pain management indicate a need to reexamine those issues and communicate revisions to CRMRP for 

incorporation into its RDTE strategic plan. 

CRMRP accomplishes research objectives by leveraging other research programs, laboratories, and the global 

medical science base, including academia and industry. Once objectives and priorities are known, CRMRP issues 

solicitations. CRMRP uses an interdisciplinary team to review proposals from these solicitations for scientific merit, 

programmatic compliance, and affordability. Selections are then funded by CRMRP. 

Beginning in Fiscal Year 2010, the RDTE Core Program 

includes funding for the DVPMI’s science programs. This 

core funding establishes the first organization solely 

focused on pain management and enhances DoD’s 

capability and capacity to conduct RDTE specifically for 

pain management. Pain Management RDTE competes 

with all other research and science needs for the medical care of Wounded Warriors. The Pain TF found that of all 

DoD Medical RDTE investments over the next 5 years, pain management research is programmed to receive < 2%, 

or $54.6M. However, in CRMRP’s portfolio, pain management is presently ranked second, behind musculoskeletal 

injury rehabilitation. 

Pain management investments are seriously underrepresented in DoD’s research investment strategy, given the high 

cost of pain management in Wounded Warriors, and the ubiquitous nature of acute and chronic pain in trauma 

patients. Widespread patient dissatisfaction with pain control and other outcomes measures suggest an urgent need 

for a change in strategy. 

The organization must leverage TF recommendations and the core RDTE organizations to validate pain 

management research objectives, recommend priorities, and reset as needed. The DVPMI is assembling the best 

pain management expertise available in the DoD and VHA. This body of expertise appears tailor-made to enable 

CRMRP to establish strategic objectives and priorities for pain management RDTE. Next, the organization must 

widely disseminate knowledge and technology objectives through the Research Strategic Communications initiative 

and resource the implementation of strategic communications (STRATCOM). CRMRP will evaluate risks in meeting 

critical pain management research outcomes and propose right-size funding for Fiscal Year 2012 and beyond. Pain 

management RDTE priorities are established at high levels within DoD and Army. Significantly increasing 

investments in pain management will require approval at the Assistant Secretary of Defense for Health Affairs and 

Assistant Secretary of the Army Acquisition, Logistics, and Technology level. Thus, a strong statement by the 

Services Surgeons General will be important in right-sizing investments in pain management RDTE. 

Pain management investments are seriously 

underrepresented in DoD’s research investment 

strategy, given the high cost of pain management 

in Wounded Warriors, and the ubiquitous nature 

of acute and chronic pain in trauma patients
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Recommendation 4.1.18.1

Develop a pain medicine research strategy to ensure evidence-based medicine guides clinical decisions. 

Recommendation 4.1.18.2

Ensure research in pain management incorporates emerging medical knowledge and technology needs to care 

for Wounded Warriors. 

Recommendation 4.1.18.3

Implement proposed solutions to ensure pain management research objectives, priorities, and resources enable 

MRMC to satisfy current, validated medical technology and information needs. 

4.1.19 Research Strategic Communications 

Objective: Improve military pain research strategic communications. 

The MHS can improve STRATCOM related to military pain research opportunities and research outcomes to improve 

translation of innovative pain management practices and technologies into clinical practice. 

The DoD’s research and development (R&D) businesses use a formal process (prescribed by Department of 

Defense Instruction 5000) to develop and then communicate and translate new materiel innovations into Table of 

Organization and Equipment (TO&E) (i.e., battlefield) military operations. DoD’s Medical R&D businesses follow 

these same processes to translate new medicines and medical equipment onto the battlefield. Processes used to 

broadcast progress and outcomes (i.e., technologies and knowledge) to battlefield military medical users are 

managed by the United States Army Medical Department (AMEDD) Center and School or other Service Combat 

Developers and Logisticians. 

Historically, medical R&D businesses within DoD have focused on battlefield technology development. In 2008, the 

MRMC established CRMRP to focus R&D specifically on “resetting” care for severely Wounded Warriors to enable 

their reintegration into society or reintroduction into service. CRMRP is responsible for developing new technologies, 

including pain management technologies, to treat Wounded Warriors. The CRMRP differs from other medical R&D 

programs by having, as its principal customers, clinicians within the Table of Distribution and Allowances (TDA) (i.e., 

sustainment base) MEDCENS and VHA, instead of those in TO&E MTFs. From a military medical R&D perspective, 

this difference is a game changer. Many of the established TO&E processes for preparing the users and then 

translating innovations into practice do not apply to the TDA base. Therefore, future pain management innovations 

that focus on MEDCEN and VHA care for Wounded Warriors may not reach the right audience(s) unless a new 

STRATCOM plan is developed and implemented. 

New pain management knowledge and technologies are acquired by CRMRP using a formal process that includes 

an objectives definition, solicitation for proposals, and awarding funds to perform scientific work. To enable CRMRP 

to satisfy its objectives, pain management researchers must be aware both of the unmet needs (i.e., objectives) and 

of funding opportunities (i.e., solicitations). They must then have the ability and resources to prepare high quality 

proposals judged through a competitive, formal process. When solicitations fail to reach the best researchers, or if 

the best researchers are not able to prepare a high-quality proposal, then advancement of knowledge and 

technologies in pain management will falter. 

Formal mechanisms for communicating pain-related research opportunities and outcomes (i.e., technologies and 

knowledge) to researchers, care providers, and policy-makers in the military health care sustaining base and in the 

VHA are needed. Mechanisms must be created that ensure awareness and action by MEDCEN and VHA care 

providers in defining requirements, assist in relevant research, and translate research innovations into practice. 
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Creating an Army and Joint Forces approval process for acquiring, translating, and sustaining new technologies for 

TDA use would greatly enhance opportunities for success. 

Recommendation 4.1.19.1

Encourage collaboration among MRMC, CRMRP, and the AMEDD Center and School to institutionalize strategic 

communications and dissemination of innovation in pain management technologies and knowledge.

Recommendation 4.1.19.2

Secure funding to support the acquisition of information system technologies.

Recommendation 4.1.19.3

Secure funding for a central pain management advisory board.

Recommendation 4.1.19.4

Task MRMC and CRMRP to provide a central pain management advisory board access to shared information 

platforms acquired by MRMC to fill research information needs. 

4.1.20 Clinical Practice Guidelines for Pain Management 

Objective: Standardize the practice of pain medicine with pain management clinical 

practice and clinical management guidelines. 

Clinical Practice Guidelines (CPGs) are documents developed to guide the diagnosis, treatment, and management of 

specific diseases and conditions. Based on best available evidence, CPGs are educational tools and can be used to 

align medical practice patterns with the available evidence. Many CPGs have been developed through collaborative 

efforts between DoD and VHA. Three out of the twenty-three CPGs available on the VHA Web site are pain-related 

CPGs (http://www.healthquality.va.gov/): 

Chronic Opioid Therapy 

Lower Pack Pain 

Post-Operative Pain 

Providers interviewed during site visits consistently expressed a need for improved clinical guidelines for pain 

management. It was often explained that providers would be less likely to refer pain patients for specialty care if they 

felt more comfortable that they were doing the right thing for these patients in their respective clinics. Additionally, 

they further explained that it is difficult to determine what “right” looks like when evaluating the wide variance in 

treatment plans used by other providers across the medical continuum. There are pain management guidelines 

available for providers but the Task Force analysis indicated several variables limiting their influence and use within 

the current practice of pain management in the MHS and VHA: 

Lack of provider awareness of CPGs related to pain management. 

Current format of CPGs not easily used or integrated into provider practice. 

Need for new CPGs developed to specifically address requirement to standardize practice of pain 

medicine in DoD and VHA health care systems. 

A majority of the providers interviewed were unaware of the existence of these CPGs. This is regrettable because 

these VA and DoD CPGs were developed through an extremely resource-intensive process involving multiple senior 

clinicians and researchers and a rigorous examination of the medical evidence. Additional efforts are required to 

expand their visibility and use throughout the MHS and VHA and should be a focus of the DoD comprehensive pain 

strategy. 
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Of the providers who stated that they were aware of CPGs, specifically the VHA and DoD CPGs, many felt that in 

their current format, they were too long, cumbersome, and difficult to integrate into their daily practice. For example, 

the length of the CPG for chronic opioid therapy is 111 pages for the full document, 32 pages for the summary, and 4 

pages for the “pocket card.” In addition to expanding provider awareness of CPGs, current and future CPGs should 

be evaluated for ease of use for providers. Where possible, they should be integrated into the computerized patient 

medical record to provide an automated decision support tool to providers and ultimately an increased 

standardization of pain management practice across the enterprise. 

New CPGs should be developed to incorporate the best available medical evidence in pain medicine that will address 

the unique needs of military patients. The triad of comorbid pain, post-concussive syndrome (mTBI), and PTSD 

require additional clinical guidance and support for providers. A central pain management advisory board should 

develop a list of priorities for pain related CPG development. As stated earlier, these new CPGs should be 

developed in a format that encourages provider utilization and is integrated into the computerized medical record. All 

future CPGs should be developed as a part of the larger DoD comprehensive pain management strategy. 

Recommendation 4.1.20.1

Incorporate Clinical Practice Guidelines into STRATCOM plan to ensure maximum awareness of pain related 

Clinical Practice Guidelines by DoD and VHA providers.

Recommendation 4.1.20.2

Integrate Clinical Practice Guidelines into computerized medical record.

Recommendation 4.1.20.3

Utilize a central pain management advisory board to develop priorities for future pain-related Clinical Practice 

Guideline development. 
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4.2 Build a Full Spectrum of Best Practices for the Continuum of Acute and 

Chronic Pain, Based on a Foundation of Best Available Evidence 

The second objective calls for building a full spectrum of best practices for the continuum of pain care, from acute to 

chronic, which is based on a foundation of the best available evidence. This can be accomplished through the adoption of 

an integrative and interdisciplinary approach to managing pain. 

Despite the best intentions of clinicians, pain and symptom control is often sub-optimal because the entire health 

care system has been designed around cure of disease rather than palliation (Max, 1990). There have been many 

demonstrations of major improvements in pain treatment within health care organizations, but programs that institute 

such improvements must redesign many aspects of the way care is delivered (Jacox et al., 1994). Essential 

ingredients in such improved programs include the following: 

Physicians, nurses, patients, and Families must be educated about pain treatment, and materials to guide 

treatment must be readily available to assist clinicians in writing orders. 

The organization and all of its professionals must make themselves accountable to all of their patients – 

ranging from newborns to the elderly – for attentive treatment of pain. 

Pain must be made “visible” in the organization – routinely charted as a “fifth vital sign" so that unrelieved 

pain triggers a prompt response. 

Quality improvement activities should be used to encourage steady improvement in the treatment of pain in 

the organization. 

Expert consultants and “high technology" pain treatment interventions, such as patient-controlled analgesia 

and epidural catheters, must be available (either within the health care organization or by referral) for the 

minority of cases in which simpler measures do not suffice. 

Policies on reimbursement for health professionals, medications, and other palliative treatments (e.g., 

counseling, cognitive treatment for symptoms, and other supportive care), and controlled substance 

regulations must be designed so that they do not create barriers to symptom treatment. 

Patients' and Families' values and preferences regarding care must be respected. 

Implementation of program components such as these will require an organizational commitment to identify 

opportunities for improvement and offer guidance to close organizational gaps across the enterprise, including 

deficiencies in: 

Interdisciplinary staffing, training, and education 

Space and workflow organization 

Coordination of care and support services 

Clinical practice standardization 

Technology 

Communication barriers to effective and efficient service 

Such an organizational reset will require an examination of program capacity, effective non-traditional services, and 

resources needed for enhanced pain management services. 
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An Integrative and Interdisciplinary Approach

Figure 10: A Summary of Categories for an Integrative and Interdisciplinary Approach 

Build a Full Spectrum of Best Practices for the Continuum of Acute and Chronic Pain, Based on 

a Foundation of Best Available Evidence 

An Integrative and 

Interdisciplinary

Approach

Complementary and Integrative Pain Treatment Medicine 

Osteopathic Manipulation 

Primary Care Pain Management 

Stepped Care Model 

Musculoskeletal Action Plan

4.2.1 Complementary and Integrative Pain Treatment Medicine 

Objective: Incorporate integrative and alternative therapeutic modalities into a patient 

centered plan of care. 

The etiology of pain is multimodal and complicated, affecting every aspect of the individual: physical, emotional, and 

spiritual, as well the Family and community. There is no simple solution to this complex problem. Thus, the 

treatment needs to be interdisciplinary and multimodal in its approach. But more than that, it needs to incorporate all 

the aspects of the individual, Family, and community and not just focus on the etiology itself. 

One way to achieve an interdisciplinary, multimodal and holistic approach to pain 

management is by incorporating complementary and alternative therapies into an 

individualized pain management plan of care. The current medical model is a 

provider-to-patient relationship. This is known as provider-based care where the 

team leader is the provider. This model is often one of “doing something to the 

patient” instead of having the patient participating in his or her own care. In the case of pain management, the 

patient presents a complaint of pain to the provider. Many times the treatment is a prescription for a medication and 

a brief description of precautions, limits, and possibly some exercises. Rarely does the patient do anything other 

than take the medication and return for a refill. The patients become devoid of ownership of the condition when they 

are a passive participant in their own care. This leads to recurrent cases of poor outcomes, problems with multiple 

prescriptions, and some patients’ disillusion with the medical system. 

Stress is a significant contributor to pain conditions. In fact, by definition, pain has an emotional component. Further, 

chronic pain leads to increased stress which leads to a vicious cycle. Therefore, pain cannot be managed without 

addressing its relationship to stress. Research is showing that our thoughts and perceptions influence our ability to 

heal. Mindfulness or the ability to be in the moment brings a greater awareness to the unconscious and its affect on 

emotional, physical, and spiritual health. Mindfulness focuses the mind’s ability to heal the body. This interaction is 

often missed in the disease based treatment model. 

The terms complementary medicine and alternative medicine are often used interchangeably, but they do in fact 

differ from each other. Complementary medicine is used together with conventional medicine. An example of a 

complementary therapy is using aromatherapy (the scent of essential oils from flowers, herbs or trees) to help lessen 

a patient's discomfort following surgery. Alternative medicine is used in place of conventional medicine. An example 

of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or 

chemotherapy that has been recommended by a conventional doctor. 

The patients become devoid 

of ownership of the condition 

when they are a passive 

participant in their own care
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The Integrative model emphasizes the patient-centered care model of treatment. In this model, the patient is the 

team leader with the providers acting as consultants and guides to the patient. Taking this a step further, Integrative 

Health and Healing teaches the importance of self: self-care, self-responsibility, and self-awareness. In February 

2009, the Institute of Medicine (IOM) acknowledged patient-centered care as one of the five critical dimensions of 

high-quality care. Further, research shows that focusing the health care system around the patient can improve 

patients' satisfaction with care, as well as their clinical outcomes. Patient-centered care empowers the patient to be 

responsible and participatory in his or her health and healing process. 

However, the change from the current model will require a significant paradigm shift. Over the past twenty years, 

patients have led this shift. They are seeking out “alternative medicine” to help address their individual needs. They 

often do this without the guidance of professionals. In fact, sometimes the patients withhold the fact they are using 

other treatments from their conventional health care providers. The medical community needs to be part of the 

patient’s journey, promoting each patient’s individual health goals. To best address the goal of patient-centered care, 

providers must work in partnership with patients and Families in providing health promotion options while maintaining 

efficacy and safety standards. This integration needs to be methodical, appropriate, and evaluated throughout the 

process to ensure the best potential outcomes. 

Just as patients can be active or passive participants in their treatment, that treatment can be active or passive as 

well. The difficulty with all treatment, regardless of whether the treatment is conventional or integrative, is that it can 

allow the patient to remain a passive participant. For example, weekly acupuncture performed on a patient can allow 

the patient to return each week without taking ownership and responsibility for the pain. Thus, it is imperative that 

one of the end goals of any treatment is patient participation. Clearly a patient with significant diabetes needs 

medications for control; however, evidence shows that the patient also needs to maintain a proper diet, exercise 

regimen and self-care. If the patient only takes medications for the diabetes, the outcome will not be optimal. 

Likewise, teaching the patient the points for self-directed acupressure, while performing acupuncture for a pain 

condition, incorporates the patient into the treatment. This changes the treatment from passive to active and 

improves the outcome, decreases provider dependent care, and empowers the patient with a sense of control over 

his or her condition. 

The Task Force site visits included an assessment of the scope of CAM modalities offered at each MTF. CAM 

experts, if they existed, were interviewed, as were providers and, where practical, patients and/or Family members. 

The literature on Complementary and Alternative Medicine was reviewed, along with the MHS policies and 

procedures. Various experts in the field of Mind Body and Complementary and Alternative Medicine were also 

visited or interviewed. Additionally, the Task Force consulted with the Samueli Institute, a non-profit research 

organization that supports the scientific investigation of healing and its role in medicine and health care. The Samueli 

Institute has been working on several research projects related to military and Veterans’ pain management. 

In 2005 the DoD Survey of Health Related Behaviors among Active Duty Military included questions on CAM usage 

among Service Members. These data, reflecting 19 CAM types in the five recognized CAM treatment categories are 

reported in a manuscript currently under review for publication (Samueli communication). The CAM subgroup of the 

TF studied the issues surrounding credentialing and licensing of CAM providers. 

The tiered structure represents a hierarchy of implementation based on current accepted literature supporting 

efficacy, safety, and widespread use or acceptability. Additionally, licensing and credentialing concerns were taken 

into consideration in the development of the recommendations. Within the tiers, active and passive treatments are 

identified to allow for an understanding of how passive treatments can become active treatments to avoid the pitfalls 

of passive patient participation. Most passive treatments require a provider to perform the treatment or guide the 

participant in the activity. On the other hand, active treatments typically require some level of patient education up 

front to ensure patients are using the modalities correctly and safely; only then should the treatment become patient 

self-directed. Some active treatments are portable with individualized equipment. The TF recommends adopting a 

tiered approach for the effective integration of Integrative Modalities to augment pain management. 
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Figure 11: Tier I Modalities

Modality Passive Active

Acupuncture Clinic based Acupuncture Self directed acupressure 

Yoga / Yoga Nidra Facility based yoga classes Self directed with video, exercising 

Non-allopathic Chiropractic Care Clinic based manipulations Self-correcting exercises 

Therapeutic Medical Massage Clinic based treatments Partner or self treatment 

Biofeedback Clinic based biofeedback 

techniques 

Self directed biofeedback with video, 

heart rate variability monitors, meditative 

practices 

Mind-body Therapies 

(Meditation, Mindfulness) Facility based classes Self directed 

Figure 12: Tier II Modalities

Modality Passive Active

Movement therapy (Qi Gong, Tai 

Chi, Marital Arts) Facility based classes Self directed with video, exercising 

Art Therapy Facility based classes Self expression through journaling, art, 

dance, etc. 

Music Therapy Facility based classes Self directed with iPods, etc. 

Aroma Therapy Facility based treatment Self directed 

Cold Laser Facility based treatments N/A 

Monochromatic Near Infrared 

Energy (MIRE) Treatments Clinic based treatments Self directed with MIRE personal equipment 

Cranial Electrical Stimulation Clinic based treatments Self directed with CES personal 

equipment 

While scientific evidence exists regarding some CAM therapies, for most, there are key questions that have yet to be 

answered through well-designed scientific studies – questions, such as whether these therapies are safe and 

whether they work for the purposes for which they are used. Medical science acknowledges that there are many 

accepted practices that are utilized without evidence from well-designed research and data in both complementary 

and traditional western medicine. CAM practices, in particular, are often debunked as ineffective or merely effective 

due to the placebo effect. Exciting research in neurobiological imaging is showing that the placebo effect is indeed a 

“real” one to be clinically exploited, given its efficacy and safety margin. Many of these gaps in evidence for CAM 

therapies remain since funded research on these therapies is one of the newest areas recognized by National 

Institutes for Health. The National Center for Complementary and Alternative Medicine (NCCAM) started as an 

Office of Alternative Medicine (OAM) in 1992 and expanded to a center in 1998 with a current budget of $122 million 

(NCCAM Web site). 
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Recommendation 4.2.1.1

Adopt a tiered approach for the effective integration of integrative modalities to augment pain management for 

military and Veteran populations. 

Recommendation 4.2.1.2

Establish integrative pain medicine capabilities at RPCoE's and DoD sites (Army, Navy, and Air Force) to 

champion integrative pain care with a focus on the best clinical practices, education, and research. 

Recommendation 4.2.1.3

Establish baseline data on the clinical integrative practices being used, along with provider and patient 

perspectives, through a comprehensive DoD survey, utilizing existing survey models (if appropriate). 

Recommendation 4.2.1.4

Develop an advisory board, with scholarly leaders in various integrative medicine fields, to assist in the 

development of appropriate programs, ensure proper credentialing of providers, and establish necessary 

guidelines for outcome measures and uniformed quality of care. 

Recommendation 4.2.1.5

Establish standardized and appropriate strategic communication plans on integrative health care methods for pain 

medicine. 

Recommendation 4.2.1.6

Develop and fund pilot programs across DoD in the delivery of integrative pain. 

Recommendation 4.2.1.7

Request Health Affairs undertake the evaluation of integrative medicine modalities in Tier I for inclusion as 

covered TRICARE benefits. 

4.2.2 Osteopathic Manipulation 

Objective: Leverage embedded osteopathic and physical therapy resources in the 

provision of manipulation therapies for musculoskeletal pain. 

Manual medicine or manipulation is well accepted by patients, has proven successful for treating many 

musculoskeletal pain syndromes, and is well suited for integration into the primary care and physiatry workflows. The 

goal of manual medicine is to restore the entire body to a state of homeostasis. Manual medicine employs palpation 

using the providers’ hands to detect sources of pain and dysfunction within the skin, fascia, muscles, ligaments, and 

tendons. Once these areas of dysfunction are identified, manual medicine should be used to decrease muscle 

spasms, neural facilitation, improve local circulation of blood and lymph, improve range of motion, and decrease pain. 

There are several barriers to widespread adoption of manual therapies; however most of these barriers can be 

overcome with adequate command support: 

Inadequate clinic set up: 

– requires flat treatment tables, not lithotomy tables 

– preferably two rooms per provider to improve patient flow 

– inability of the RVUs (productivity metrics) to track success of manual therapies 

– inability to have flexible appointment lengths 
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The AMEDD has a significant number of Osteopathic physicians on staff and in Graduate Medical Education (GME) 

training programs. However, there is inconsistent application of osteopathic modalities and continuing training at the GME 

and Continuing Medical Education (CME) level. Physical therapists are also trained to perform manual therapies and 

could provide them under a structure similar to what the TF is suggesting for Osteopathic Manipulative Treatment (OMT). 

The Army should take the initiative to use and continue training their embedded (wearing the uniform) resources. 

Many Active Duty Medical Corps Officers and Physical Therapist in the Medical Specialty Corps have been previously 

trained to provide manual medicine. These Active Duty assets are able to provide comprehensive medical care in 

addition to their manual manipulation skills. The TF recommends using these organic resources, rather than 

outsourcing and spending money, amongst other resources, on hiring chiropractors who are only trained to provide 

manipulation. 

GME training and program implementation policies will be required to implement manual manipulation programs at the 

MTF level. A GME level training program must be developed and implemented. This will enable residents to continue 

using and improving upon the skills they learned in medical school and increase their efficiency with treatment. Once these 

residents become staff, they will be able to successfully incorporate manual medicine into their daily clinic flow. A GME 

OMT training program should include a GME Manipulation Clinic with staff oversight, an education series on OMT, and a 

“hands-on” review of manipulative therapies. For non-osteopathic residents and staff, the GME program will serve to teach 

them improved diagnostic skills, educate them on which patients are appropriate for referrals for manual medicine, and 

teach them hands-on manual medicine they can use in their own clinics. A GME manual medicine program will also 

enhance the comprehensive care that all participating physicians provide to their patients. Additionally, GME OMT clinics 

would need longer appointment slots to encourage education and oversight by staff physicians. 

Staff physicians who have training in manual therapy will usually be able to see their patients in the course of their normal 

appointment slot lengths when indicated. On occasion, they may need to bring a patient back for a longer appointment slot 

to address more complicated and involved pathology. Staff physicians should be encouraged to use manual therapies as 

part of their comprehensive care process. Their success has the potential to be measured in patient satisfaction, 

decreased medications dispensed, decreased profiles written, improved return to duty, less referrals for musculoskeletal 

complaints, and decreased office visits for the same complaint. The main resource requirement for a staff physician to 

employ manual medicine skills is a flat exam table. 

There are some relevant best practices within the Army and these should be studied as possible best practices to 

replicate in other facilities. There are scattered training programs with various successes across the AMEDD. 

Figure 13: OMT Practices

Training Programs Selected Best Practices 

GME Ft. Belvoir Family Medicine Residency Program 

Skill Sustainment 

Physical Medicine and Rehabilitation at Walter Reed Army Medical Center 

Family Medicine at Grafenwoehr Army Health Clinic 

Ft. Belvoir Family Medicine Clinic 

Physical Therapy use of 

Manual Therapies 

AMEDD Center and School Physical Therapy Manipulation Residency 

Program at BAMC 

Amputee Physical Therapy at Walter Reed 

Continuing OMT Education Ft. Belvoir Family Medicine Residency Program 

Walter Reed Physical Medicine and Rehabilitation Service 
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CME should be available at MTFs for providers who have been trained in manual medicine. The resource requirement for 

this is minimal. Essentially, any individual provider with manual therapy knowledge would be able to provide presentations 

and hands-on demonstrations and review of the manual therapy techniques. In addition to these presentations, a room in 

which to provide the training is necessary. Providers should be encouraged to attend annual CME training provided by 

professional organizations to enhance their knowledge and skill sets. 

An example is a young Active Duty patient who has mid and low back pain who is seen for back pain after wearing 

gear and carrying large loads. 

Figure 14: OMT Options for Active Duty Patients 

Option 1 Option 2 

The patient receives a profile, a referral to 

physical therapy, quarters or convalescent 

leave, medication, and possibly, consults for 

more invasive procedures. These all lead to 

decreased productivity for the military from this 

active duty patient (lost work days, decreased 

productivity when at work, potential interaction 

of medications with ability to work). In addition, 

resources are needed to track this patient’s 

profile and medical care. 

The patient has an appointment with a primary care provider 

for the back pain and receives OMT during his visit. The 

treatment takes less than twenty minutes. The patient then 

leaves and returns to duty, without a profile, no medications, 

and no referrals. This option costs less money initially and 

subsequently less money is lost in productivity and use of 

assets. When you look at the many brigades full of young 

active duty soldiers only experiencing back pain, using OMT 

to treat musculoskeletal conditions could result in a significant 

cost savings to the military in addition to improved satisfaction 

and function for the patients. 

Resource requirements are minimal and include use of existing space for training clinics, two patient exam rooms per 

provider with OMT (simply flat or adjustable) tables. IT requirements include documentation and coding solutions 

(recommended AHLTA AIM forms, SOAP templates (Subjective, Objective, Assessment, Plan), Common Procedural 

Terminology (CPT) encounter templates, and Evaluation & Management (E&M) dispositions documentation) and training 

and use of MAPS (MEDCOM AHLTA Provider Satisfaction) tools (such as Dragon and As-U-Type). An extended list of 

OMT related issues can be found in Appendix B-7. 

Potential research pilot projects might include: 

OMT Clinic (GME) which tracks the residents to see which residents continue to use OMT in their 

comprehensive practice once they are staff physician and tracks the number of residents. 

Survey of Osteopathic Physicians and Physical Therapists who are Active Duty to establish those who use 

manipulative therapies in clinic /hospital / deployed setting, what the barriers to use are, amount of CME in 

manipulative therapies available at their site, interest in participating in a clinic specific for manipulation with 

other providers or why they chose not to use their unique skill set. 

Auricular (battlefield) acupuncture pilot program in the WTU clinics. 

Improved clinic resources with an adapted workflow – to accommodate in-clinic OMT visits: 

– Two rooms per provider for patient flow. 

– Manipulation tables. 

AHLTA business processes. 

Qualitative and Quantitative examination of the impact of OMT on acute and chronic pain syndromes. 

Down range use of OMT down range to prevent chronic complications from acute problems. 

It is ideal for the military to facilitate beneficiaries having their musculoskeletal concerns addressed by OMT during the 

course of an office visit. Referrals to other providers (either civilian network care or to other military providers) have 

their costs, such as time for providers and patients, lost patient work productivity in their military jobs, and availability of 
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appointment slots for other patients. By facilitating osteopathic manipulation in primary care clinics, some of these 

costs could be minimized and recouped (especially if the civilian network referrals are decreased). 

Validation and measurement should focus on reduction of acute and chronic musculoskeletal pain, as measured on 

the 0-10 point Pain Assessment Screening Tool, and prevention of chronic pain syndromes through the routine 

application of osteopathic manipulative therapies. Patient satisfaction could be measured using the new Pain 

Assessment Tool and analyzing for trends, reduced medication utilization, prevention of chronic pain syndromes, and 

improvement in the provider utilization rate. 

Reduction of acute and chronic musculoskeletal pain and prevention of chronic pain syndromes through the 

routine application of osteopathic manipulative therapies are achievable goals. 

Recommendation 4.2.2.1

Support osteopathic manipulation in staff clinics. 

Recommendation 4.2.2.2 

Survey Active Duty Osteopathic Physicians and manually trained Physical Therapists to understand the uses, 

practices, and barriers of manual medicine. 

Recommendation 4.2.2.3 

Implement and support Osteopathic Manipulation Graduate Medical Education during primary care and physiatry 

residency programs to utilize and continue developing current Army resources. 

Recommendation 4.2.2.4

Implement and encourage the use of osteopathic manipulation (or manual medicine) in theater. 

Recommendation 4.2.2.5

Incorporate osteopathic manipulation therapy referrals into case management in WTUs. 

Recommendation 4.2.2.6

Improve metrics, such as RVUs, which are used to measure the success of providers in treating patients but do 

not actually measure patient improvement. 

4.2.3 Primary Care Pain Management 

Objective: Integrate pain management into primary care, consistent with the Patient 

Centered Medical Home Model. 

According to the American Academy of Pain Management (AAPM) Web site, pain is the number one reason patients seek 

medical care. One out of two Americans is in pain and one in four has persistent or chronic pain with the leading cause 

being low back pain. One hundred billion dollars is spent annually on pain care, yet very little progress has been made in 

treating pain and suffering. In managed organizations, pain affects more people than heart disease, hypertension, 

diabetes, or cancer. 

The majority of pain care is delivered by primary care practitioners because they are often the first point of contact. Further,

there are insufficient numbers of pain specialists to manage the millions of people suffering from chronic pain. Primary care 

providers are experienced in providing comfort and disease management for conditions that have no cure. Primary care 

providers have a strong, sustaining patient relationship. With the proper training and system support, primary care 
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providers are in the best position to longitudinally coordinate pain management from early intervention to long-term 

continuity of care, on to end-of-life care. 

A patient-centered approach to pain management with an integrated pain 

team or clinic in primary care will impact the greatest number of patients. 

Utilizing both medications and non-drug therapies within a biopsychosocial 

model that emphasizes self-management will lead to the best results. Both 

chronic pain as a disease and the suffering of the patient must be 

addressed. Early education, early risk stratification, and early interventions 

to improve outcomes and safety will result in a greater relief from pain, a decrease in suffering, increased function, and safe

prescribing of opioids for a greater number of patients. The goal is to prevent pain from becoming a disabling disease. 

The demand for effective pain treatment is growing among patients in the United States. Despite advances in the 

treatment of pain, the quality of pain care remains far below the potential for optimal care. Fragmentation of pain care 

is perpetuated by the consecutive, and even concurrent, lack of integrated evaluation and management of complex 

pain disorders. Primary care often promotes fragmented care for patients with chronic pain conditions by utilizing a 

succession of referrals to specialists and subspecialists rather than implementing the biopsychosocial model of bestpractice pain management. Multiple physicians may contribute to a patient’s “pain management” with limited focus or 

goals, duplication of testing or unnecessary invasive testing, and with either limited interventions, or large variance of 

interventions available. This compartmentalized approach makes it difficult to identify a single provider to advocate for 

the patient’s overall care by treating the patient as a whole human being with often multiple chronic conditions – all 

affecting each other. 

The overall quality of treatment of pain is unacceptable for patients with acute and persistent pain leading to suffering, 

abuse, addiction and sometimes even more serious consequences. For example, abuse of prescription drugs is now 

the second leading cause of accidental death. Death caused by prescription pain drugs is higher than deaths caused 

by cocaine, heroin, and methamphetamine combined and health care costs are eight times higher for opioid abusers 

than non-abusers (SAMSHA, 2008). 

Clinicians are faced with a dilemma – how to safely incorporate opioids into treatment plans that maximize the 

possibility of successful pain control while minimizing the risk of misuse or abuse. The dilemma is heightened for 

primary care providers who shoulder most of the burden of pain management, despite having received little specific 

training in pain medicine or substance abuse, and generally being constrained to brief visits for evaluating and 

managing complex problems. Opioids are not the only answer to treatment of moderate or severe pain, but in the 

current system, often this is all that is offered. Providers find it much quicker to write a prescription than to manage the 

pain appropriately. The opposite may also occur, as pain may be undertreated due to provider’s discomfort, or even 

fear, of using opioids because of possible legal sanctions. Also of concern is the practice of providing opioids for 

chronic pain without following standard practice guidelines regarding assessment and monitoring, which can lead to 

negative outcomes. There are other barriers for providers to practice good pain care: 

Lack of training for primary care providers to manage pain 

The wide variance of provider beliefs about pain treatment 

Lack of timely access to comprehensive pain medicine consultation 

Poor monitoring of care for patients with chronic pain, who may receive treatment from multiple providers, 

without a coordinated care plan, including multiple prescribers of opioids 

Providers who prescribe opioids to treat pain are often caught between their professional obligation to relieve suffering 

and their desire to avoid contributing to the public health problem of non-medical consumption of controlled 

substances (i.e., prescription drug abuse). The challenge is to curtail the abuse and diversion of prescription opioids 

while ensuring their availability for patients who benefit from their use. The key to managing a patient’s opioid intake 

lies in screening for abuse potential and carefully monitoring the progress of treatment. In the mobile military 

Pain is the number one reason 

patients seek medical care and there 

are insufficient numbers of pain 

specialists to manage the millions of 

people suffering from chronic pain
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population, strategies for optimizing pain management need to address military medicine’s challenges with continuity 

of care, oversight of medication, enhanced physical functioning, and promotion of return to duty (see section 4.3.1). 

The solution to this issue begins with a health care organization that is designed to provide a comprehensive, 

integrated, patient-centric approach to the full spectrum of primary care, including – and most especially – care of 

patients with chronic disease, such as chronic pain. In addition to the Primary Care Manager and appropriate support 

staff, it seems clear that a successful organizational design will include, at a minimum, organic behavioral health 

providers and clinical pharmacologists, with additional assets based on population needs. The MHS is currently 

piloting the Patient Centered Medical Home (PCMH), which provides a comprehensive, integrated approach to 

primary care. PCMH incorporates a number of principles that facilitate a holistic approach to patients with simple and 

complex medical needs and also facilitates partnerships among individual patients, their personal physicians, and 

when appropriate, the patient’s Family. These principles, adapted from Patient Centered Primary Care Collaborative 

(PCPCC), can be found in Appendix B-8. 

Interdisciplinary pain clinics have the strongest evidence for improved pain outcomes. This is best implemented into 

pain management by developing a pain team or clinic integrated into primary care that is accessible and provides faceto-face coordination and communication with the primary care managers. Interdisciplinary pain team members may 

include: 

Primary Care Provider 

Medical Director 

Mental Health Clinicians (psychologists, social workers, chemical dependency) 

Rehabilitation Clinicians (physical therapists, occupational therapists, exercise physiologists) 

Nurses 

Case Manager 

Pain Educator 

Vocational Rehabilitation Counselors 

Pharmacist Consultant, and access to consultant specialty physicians in pain medicine and other specialties 

as indicated (neurology, physiatry, psychiatry, addiction medicine) 

This primary care pain clinic would benefit all involved, especially the patient. 

The goals of the clinic: 

Reduced pain intensity and suffering 

Enhanced physical functioning 

Improved access to pain treatment 

Controlled medication usage (safe use) 

Improved psychological functioning 

Pain education for patient and Family 

Promotion of meaningful life such as return to work 

Most patients with chronic pain should have a clinical evaluation that would include establishing their functional status, 

identifying comorbid conditions, evaluating psychosocial factors, setting goals, developing a goal-oriented 

management plan, and determining when to consult or refer. Before initiating long-term opioid therapy, a 

psychological evaluation should also be completed, which would include an opioid risk assessment, screening for 

potential drug abuse or addiction, identification of comorbid mental health issues, and determination of the patient’s 

readiness to engage in self-care behaviors. The benefits of increased integration and coordination between the pain 

clinic and primary care will enhance patient and provider satisfaction, improve patient outcomes, and decrease health 

care costs. It would also provide an opportunity to identify and intervene in many problems to prevent development of 

significant pathology. 
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Using the chronic care model as a framework, optimal pain care requires an interdisciplinary pain care clinic integrated 

in primary care with a stepped-care pain treatment approach similar to the VHA program (see section 4.2.4). In an 

integrated pain clinic the patient will feel like someone is listening to him, his symptoms are explainable and 

controllable, and someone cares. The primary care model will provide timely and appropriate access to pain 

management services for all Beneficiaries. The clinic will provide early intervention, including educational programs 

that may reduce the likelihood of disability, improve the under-treatment of pain, provide individual tailoring of 

treatment plans, and serve as a liaison for patients transfers between MTFs or VA facilities. It will also provide access 

to pain-trained medical expertise and deliver a safe, effective, and evidence-based continuum of care. 

The MHS should move forward briskly with implementing a Patient Centered Medical Home, fully resourced with 

adequate support staff and IT, with embedded Behavioral Health and Clinical Pharmacology. The MHS should 

simultaneously move to outcomes-based performance metrics that recognize and capture the quality and safety 

benefits of a holistic, patient-centric approach to health care. The next step is to establish interdisciplinary pain care 

clinics, integrated in primary care, with a stepped-care pain treatment approach similar to the VHA program. 

Recommendation 4.2.3.1

Implement a fully resourced Patient Centered Medical Home.

Recommendation 4.2.3.2

Develop outcomes-based performance metrics that recognize and capture the quality and safety benefits of a 

holistic, patient-centric approach to health care.

Recommendation 4.2.3.3

Identify a workgroup from DoD and VHA to ensure that DoD interdisciplinary pain care clinics, integrated with 

primary care, correctly adopt a stepped care pain treatment approach. 

4.2.4 Stepped Care Model 

Objective: Adopt the VHA Stepped Care Model to ensure timely access to collaborative 

care, reduce pain and suffering, and improve quality of life for Warriors and 

their Families. 

A continuum of effective pain care for Warriors, from the moment of injury on the battlefield or the onset of disease, to 

recovery or chronic pain management back home, is a core principle of the military’s pain management strategy. 

Effective implementation of this strategy presumes competent care at every level of need, regardless of the setting, 

whether emergency management far forward on the battlefield and during transport, definitive treatment at military 

medical facilities, or an open-ended commitment to provide continuity of care in military and VA facilities back home 

as Service Members and Veterans reintegrate with their Families and communities. 

Establishing competency of care at each level of need in this continuum and in each setting presents the following 

organizational challenges for the MHS and VA: 

Establishing an organized and systematic process of care with clearly delineated responsibilities and a 

chain of command 

Assuring a systematic method of monitoring and continuously improving quality of care through outcomes 

measurement and patient feedback 

Providing appropriate staffing at each level with adequately trained and skilled personnel to meet the needs 

of Service Members, Veterans and their Families 
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Lessons can be learned from organizational models in both civilian and Veterans’ health systems. As previously 

discussed, the Veterans Health Administration initiated a National Pain Management Strategy in 1998 to establish 

Pain Management as a priority in the VHA’s national health system. 

The overall objective of the national strategy was to develop a comprehensive, multicultural, integrated, system-wide 

approach to pain management that reduces pain and suffering and improves quality of life for Veterans experiencing 

acute and chronic pain associated with a wide range of injuries and illnesses, including terminal illness. Quality of life 

is now accepted by the medical field as a standard outcome measure of effectiveness of treatment, including 

treatment of pain, and includes such factors as level of physical and psychosocial functioning (e.g., in roles at work 

and home) and treatment satisfaction. However, implementing such a strategy to improve pain management in a 

large health system proved challenging due to the way health care is organized to manage pain. 

A new model for the VHA was proposed that emphasizes early, evidence-based biopsychosocial treatment in primary 

care, supported by pain medicine specialty treatment and community support (Gallagher, 2008; Gallagher, 1999). 

Support for implementing such a model increased with documentation of the high rates of pain in returning OIF and 

OEF veterans entering the VHA (43% in 2007; 52% in 2009); the increasing rates of chronic pain (>50%) and 

increasing pain-related costs and disability in older Veterans’ cohorts, as they accrue risk for diseases and conditions 

causing chronic pain; and the high rates of comorbidities, such as PTSD, depression, substance abuse and 

persistent post-concussive syndrome (Kang et al., 2007; Gironda et al., 2006; Schneiderman et al., 2008; Clark et al., 

2007; Kerns et al., 2003; Lew et al., 2009). 

Figure 15: VHA Stepped Pain Care Model
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On October 28, 2009, the VHA published a Directive (VHA DIRECTIVE 2009-053; Appendix B-9), which directs the 

medical treatment facilities and Veterans Integrated Service Network (VISNs - regional health systems) of the VHA to 

establish an integrated, biopsychosocial Stepped Care Model of Pain Management that provides for the care of most 

pain conditions in the primary care setting. The Biopsychosocial Model in pain takes the position that the causes and 

outcomes of many illnesses, including pain, often involve the interaction of physical and pathophysiologic factors, 

psychological traits and states, and social-environmental factors (Engel, 1980; Gallagher, 2004). Effective treatment 

planning accounts for the salience of these factors in the precipitation and perpetuation of illness and illness-related 

disability (Gallagher, 1999). 

This model includes, and is supported by, timely access to secondary consultation and collaborative care from pain 

medicine and when indicated, mental health, physical medicine and rehabilitation, and other specialties (Dubois, 

2009). Access to palliative care may ultimately be needed; access to tertiary care advanced diagnostic, medical 

management and rehabilitation services might also be required for complex cases involving comorbidities, such as 

mental health disorders and traumatic brain injury (Lew et al., 2009). 

The Pain Task Force believes the principles of Stepped Care apply to the military’s pain management challenges, 

beginning in the field. Evidence from studies of trauma indicates that early and aggressive pain intervention in 

animal models and in emergency room patients reduces the incidence and morbidity of chronic pain (Gallagher, 

2006; Castillo et al., 2005), and experience in the current OIF and OEF conflict indicates that aggressive pain 

management in the theatre, after injury, lessens care burden and stress (Stojadinovic et al., 2008, Buckenmaier et 

al., 2009). Thus, the military should implement a Stepped Care model that incorporates field-based management 

added to the primary care and secondary and tertiary care consultation model in the medical home. 

Figure 16: VHA Continuum of Stepped Care
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Stepped Care is instituted as a strategy to provide a continuum of effective treatment to a population of patients 

suffering from acute pain caused by injuries or diseases to longitudinal management of chronic pain diseases and 

disorders that may be expected to persist for more than 90 days, and in some instances, for the patient’s lifetime 

(Dubois, 2009). Components of Stepped Care have been implemented in VA settings for several populations in 

primary care including chronic low back pain with and without depression and patients with chronic pain at risk for 

substance abuse (Dobscha et al, 2008; Dobscha et al, 2009; Ang et al., 2009; Kroenke et al., 2009; Wiedemer et al., 

2007; Meghani et al., 2009; Trafton et al., 2010). The challenge for any health care system, including the military and 

VHA, is the development of standardized, cost-effective care through a competent provider workforce and effective 

health care system support. 

The First Step in implementing an adapted model of Stepped Care in the MEDCOM and MHS is appropriate 

Emergency Care and primary care. This calls for embedding the resources to provide pain care far forward in the 

war zone and potentially remote sites where military personnel are operating, and transport to medical facilities 

appropriate for the level of need is contingent. The care destination might be a field hospital or clinic, and in some 

cases a tertiary care facility in the Unites States. This requires: 

1. The development of competent field-based emergency care (including behavioral health and primary care 

provider workforce to manage injuries and common pain conditions); 

2. Consultation with pain medicine with competency in managing complexity, severity and risk, as well as other 

specialties as needed; and 

3. Advanced pain medicine diagnostics and procedures and severe comorbidities requiring interdisciplinary, 

intensive pain rehabilitation services, including inpatient settings as required. 

Recommendation 4.2.4.1

Implement the VHA Stepped Pain Care model. 

Recommendation 4.2.4.2

Leverage the VHA Directive Action Plan as a template for better coordination between MEDCOM and MHS. 

4.2.5 Musculoskeletal Action Plan 

Objective: Integrate the prevention, early identification, and treatment of injuries as a 

component of the comprehensive pain management strategy. 

Effective pain management will require efforts across the vast and complex pain continuum. The importance of injury 

prevention and early intervention efforts to minimize the adverse effects of pain on the Armed Forces is difficult to 

overstate. The TF recognizes the Musculoskeletal Action Plan (MAP) as another critical piece of a comprehensive 

pain management strategy. 

In 2008, there were 2,697,597 medical encounters, including hospitalizations and outpatient visits but excluding any 

visits to the Battalion Aid Stations. Of those, injuries accounted for 30.6% of all medical encounters (n=825,429), 

more than twice as many encounters as the second leading cause, mental disorders (n=370,233 or 10.8%). 

Furthermore, injuries affected 242,478 Soldiers (21.7%), over two times more individuals than the second leading 

diagnosis group, ill-defined signs and symptoms (n=121, 078) (OTSG Decision Support Cell). 

According to the Brigade Combat Team Physical Therapy Guide, six of the top ten reasons for a medical evaluation 

board are musculoskeletal, with the top one being degenerative arthritis. In a deployed setting, musculoskeletal nonbattle injuries account for 87% of all combat injuries. Non-combat related musculoskeletal injuries are estimated to 

occur 6.5 to 7 times more frequently than combat related injuries. More than 75% of all medical evacuations from the 
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OIF and OEF Theater of operations were due to non-combat musculoskeletal injuries associated with back, knee, 

foot, ankle, shoulder, hand, wrist, and neck pain. The typical Soldier medically evacuated from OIF and OEF was a 

29-year-old Soldier in need of additional musculoskeletal care, resulting in a negative impact on operational 

capabilities. 

Injuries not only place an enormous drain on the medical system, but adversely impact the operational readiness of 

the force. Without an increased emphasis on prevention, early identification and management, and proper 

rehabilitation and reintegration, the Army and DoD will continue to expend enormous amounts of money on Service 

Members with acute and chronic musculoskeletal injuries and related pain. 

Leadership within PR&R at OTSG, in collaboration with partners 

inside and outside of DoD, developed the Musculoskeletal Action 

Plan (MAP). The MAP consists of three initiatives: injury prevention, 

early identification & management, and rehabilitation & reintegration. 

Over the course of the last year, the MAP working group developed 

several products to mitigate the impact of injury on Soldiers. In a 

move very similar to that seen with behavioral health providers, the 

Army has decided to move physical therapists into the brigade 

combat teams in order to ensure that injury prevention and treatment 

capabilities are forward on the battlefield. To support the Brigade Combat Team Physical Therapists (BCT PT), the 

group developed the Building the Soldier Athlete (BSA) program, as well as a reconditioning program designed for 

Soldiers on profile. In addition, the group developed a BCT PT short course that provides information on how to 

conduct injury prevention, along with human performance optimization programs and information on how to collect 

meaningful metrics or outcomes that commanders can use to assess the fitness level of their unit. 

Other products include development of a functional capacity evaluation that better correlates to the Soldier’s military 

occupational specialty. This is an ongoing project between PR&R and those involved with the disability system. The 

ongoing Aquatic Pilot program standardizes aquatic rehabilitation and Warrior exercise and will provide valuable 

feedback on pain and function of Soldiers enrolled in these programs as part of their rehabilitation and recovery from 

injury. The outcome of this program evaluation will determine the funding required for these programs across the 

enterprise. 

Future initiatives include a project with Training and Doctrine Command (TRADOC) on the best utilization of either 

athletic trainers or the Musculoskeletal Action Team (MAT) to decrease injuries, optimize performance, and ultimately 

decrease attrition in initial military training. Another initiative between Forces Command (FORSCOM) and MEDCOM 

looks at how augmenting the BCT PT with a MAT impacts readiness and deployability by decreasing injuries and 

optimizing performance in garrison, and how that carries over into the deployed environment. 

The paradigm shift from a disease model health care system to one centered on wellness and prevention is no small 

matter. It requires hard work and proper resourcing. 

Without an increased emphasis on 

prevention, early identification and 

management, and proper rehabilitation 

and reintegration, the Army and DoD 

will continue to expend enormous 

amounts of money on Service Members 

with acute and chronic musculoskeletal 

injuries and related pain
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Recommendation 4.2.5.1

Develop an education and STRATCOM program focused on musculoskeletal injury prevention and human 

performance optimization, early identification, and management, rehabilitation, and reintegration. 

Recommendation 4.2.5.2

Integrate the Musculoskeletal Action Plan education program and concepts into the pain education and training 

program. 

Recommendation 4.2.5.3

Create an organizational structure, culture, and climate for awareness and execution of the Musculoskeletal 

Action Plan by collaborating with DoD and stakeholders within the Army (includes FORSCOM, TRADOC, 

MEDCOM, USUHS, AMEDD C&S, etc). 

Recommendation 4.2.5.4

Resource prevention and treatment programs that emphasize evidence-based practices. Capture relevant and 

available data to identify trends, cost, and return on investment. Utilize data to assist in the prioritization of 

resources. 
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4.3 Focus on the Warrior and Family - Sustaining the Force 

The third objective requires a renewed emphasis on sustaining the Force by focusing on Warrior and Family Member pain 

care and management. This is at the heart of the wartime medical mission and it must be a primary objective to which all 

necessary resources are applied. In fact, it’s understood in all the other objectives that taking care of the Warrior is the 

primary mission of military medicine. The organization must serve Active Duty military, their Beneficiaries, and Veterans 

with acute and chronic pain due to injury through state of the art clinical care, innovative clinical research initiatives, and

educational programs. 

It is easy to make the connection between improving care to Warriors and sustaining the force. However, the connection 

between improving care for Families and sustaining the force is not as universally understood. Family Members with 

significant pain management issues can be a constant source of stress and distraction for a Soldier and can interfere with 

duty performance while at home station or while deployed. Providing improved care to Family Members can be the 

difference between a Service Member deciding to separate from the military or to reenlist. 

Healthcare professionals need to monitor and assess each patient for opioid compliance to ensure the safety and 

efficacy of the pain treatment. The focus should be on pain relief and improving physical function and quality of life. 

Regional pain centers of excellence, a standardized pain care approach throughout DoD, and educational programs will 

improve pain care to Soldiers, Sailors, Airmen, and Marines. Those in the WTU often have complex medical issues, are 

taking multiple medications, and experience pain management challenges. Embedding or co-locating pain management 

specialty care and support services and collaborating with the Warrior Transition Command should be priorities. Pain 

management plans should be incorporated into the Comprehensive Transition Plans. 

Warrior and Family Care

Figure 17: A Summary of Categories for Warrior and Family Care 

Focus on the Warrior and Family - Sustaining the Force 

Warrior and Family Care

The Safe Use of Opioids 

Embed Pain and Pharmacy Resources 

WTC Pain Survey Collaboration 

4.3.1 The Safe Use of Opioids 

Objective: Implement a drug abuse assessment strategy to ensure the efficacy of pain 

treatment and reduce aberrant behavior, abuse and addiction with opioids. 

In the early 1980’s opioids began to be used in the treatment of nonmalignant chronic pain, not just cancer pain. By 

the 2000’s, increased prescribing, the availability of new opioids, and the failure to teach about chronic pain and 

addiction, along with a zeal to do good, created a backdrop for the growing problem of prescription drug abuse. The 

increase in the illegal diversion of prescription pain medication is a threat to public and personal health that must not 

be ignored. It is necessary to take any and all steps to help block the flow of opioid painkillers into the hands of 

nonmedical users, many of whom are young people and first-time abusers. 
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Trauma-induced anxiety, whether conscious or unconscious, is a powerful stimulus to seek relief from disturbing 

memories and often may lead to abuse of drugs and alcohol. The highest risk patients for unsafe behaviors have a 

“trio diagnosis” of psychiatric disease, substance abuse, and pain. These factors are interrelated and mutually 

reinforcing. This often describes many of our Soldiers returning from Iraq and Afghanistan. In some studies, the 

prevalence of comorbid PTSD, TBI and pain exceeds 40% in the VA (Clinical Practice Guideline for Management of 

Opioid Therapy for Chronic Pain, 2010). When a trio diagnosis is present, all three conditions must be treated 

simultaneously. These patients are complex and need multidisciplinary evaluations. 

People living with chronic pain have increased rates of attempted and completed suicides, especially during times of 

stress and loss. Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which 

underscores the need for close supervision of these patients (Unintentional and undetermined poisoning deaths, 

2004). Often patients, especially with a history of impulsivity or medication misuse, will choose to use lethal 

medication as a means of suicide. Suicides may be caused by poorly treated severe pain, intentional or unintentional 

overdose of opioids usually in combination with alcohol, benzodiazepines, or other pain medications. 

Misuse of opioids may be classified as aberrant behavior, abuse or addiction: 

1. A behavior is considered aberrant if it deviates from the accepted medical treatment plan. Forty percent of the 

general population may exhibit aberrant behaviors (Webster and Dove, 2007). 

2. Abuse is the use of any substance for a non-therapeutic purpose or the use of medication for purposes other 

than those for which the agent is prescribed. Approximately 50% of patients with at least one aberrant behavior 

can be classified as abusers (Webster and Dove, 2007). 

3. Addiction is a primary chronic neurobiologic disease influenced by genetic, psychosocial and environmental 

factors. The development of addiction requires a predetermined genetic framework with repeated exposures. 

This leads to impaired control over drug use, compulsive drug use, and continued drug use despite harm and 

because of craving. Only 1-2% of patients who abuse opioids are addicted to the drug and will engage in 

multiple aberrant behaviors (Webster and Dove, 2007). Failure to treat addiction when it is present can 

encourage a person to continue destructive and potentially deadly behavior. Abuse can usually be managed 

and addiction can usually be predicted. 

Knowing in advance whether a patient possesses these risk factors can assist a 

clinician in monitoring the progress of treatment and prevent abuse. The early 

recognition and treatment of mental disease are vital to the prevention of 

prescription opioid abuse. However, physicians, nurses, psychologists and others 

frequently report that they had little formal teaching about pain and even less 

teaching about addiction. Training on pain and addiction is almost non-existent. Medical providers need two sets of 

skills to use opioids safely and effectively - prescribing opioids and minimizing the risk of abuse. 

Most problematic opioid use does not stem from the disease of addiction but from several other causes including 

uncontrolled pain, fear of withdrawal symptoms, an untreated mental disorder, or recreational use to achieve a ‘high.’ 

Figure 18: Risk Factors for Misuse 

Biological Psychiatric Social

Age 45 years 

Male gender 

Family history of 

prescriptions 

Cigarette smoking

Substance disorder 

Preadolescent sexual abuse (in women) 

Major psychiatric disorder (e.g., 

personality disorder, anxiety or 

depressive disorder, bipolar) 

Prior legal problems 

History of motor vehicle accidents 

Poor Family support 

Involvement in a problematic 

subculture 

The early recognition and 

treatment of mental disease 

are vital to the prevention of 

prescription opioid abuse
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Healthcare professionals need the tools to assess their patients for opioid compliance to ensure the efficacy of pain 

treatment and to diagnose and treat any possible complicating disorders. Each patient must be monitored and 

reassessed at each visit for his or her response to opioid treatment, including meeting goals that are personal to the 

patient. The focus should be on: 

Physical function 

Pain relief 

Quality of life 

A full list of safety proposals can be found in Appendix B-10. 

Figure 19: Increasing the Safe Use of Opioids 

Early

Intervention

Appropriate early intervention in the treatment of acute pain, such as physical therapy, will 

help decrease the need for narcotics. Utilizing physical therapy in troop medical clinics, 

primary care clinics, and the emergency room will improve the treatment of acute pain and 

decrease its translation to chronic pain. Research is needed to determine the risk factors 

that influence this transition from acute to chronic pain, such as genetics, environment and 

behaviors. 

Screening 

Complete an assessment of drug-abuse risk in all patients on chronic opioids or preferably 

before initiating opioids. Knowing in advance whether a patient possesses risk factors can 

assist a clinician in monitoring the progress of treatment. Awareness will result in better 

clinical outcomes and fewer instances of drug abuse. The goal is not to deny pain 

treatment to any patient but to set and maintain a level for monitoring that is proportionate 

to the individual’s risk. 

Recognize and 

Treat Substanceuse Disorders

Currently, the poor continuity of care is a barrier to identification of problematic drug use. 

The visibility of patients with aberrant behaviors or previous history needs to be 

documented longitudinally. The number and persistence of aberrant behaviors is likely to 

be indicative of greater problems with managing opioid intake. If pain treatment with 

opioids is to be successful, prescription misuses must be managed. To accomplish this, it 

is necessary to monitor, chart over time, and address a patent’s aberrant drug-related 

behaviors. 

Prescription

Monitoring

Programs

Approximately seventy percent of DoD prescriptions are now filled in the civilian community 

(Joint Forces Pharmacy Seminar, 2009). Military Medical Facilities and VAs should utilize 

state prescription monitoring programs for additional safety monitoring. DoD needs to 

encourage states to provide this information to practitioners to help identify high-risk 

patients, “doctor shopping,” and compliance. 

Urine Drug 

Screening 

Urine drug testing is part of the effort to monitor the clinical efficacy of treatment, determine 

compliance, evidence of unsafe illicit drug use, and to serve as a deterrent to inappropriate 

drug taking. An abuser of street drugs is at increased risk for abusing prescription 

medications. As a clinical monitoring tool, urine drug screenings confer significant benefits 

as long as the limitations in interpreting results are well understood. Screening is 

recommended when aberrant behavior is suspected or confirmed, when changes in 

treatment are being made, and when pain persists despite aggressive treatment. 
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Recommendation 4.3.1.1

Implement a drug abuse assessment strategy in primary care as part of routine practice to set a level of 

monitoring proportionate to the individual’s risk.

Recommendation 4.3.1.2

Use a written opioid treatment agreement that outlines patients’ rights, expectations, and specifies the 

consequences of noncompliance, and informed consent for all chronic opioid patients. 

Recommendation 4.3.1.3

Mandate that only one provider and his or her surrogate may prescribe for patients on chronic daily opioids and 

that the program is supported by the pharmacy department (Sole Provider Program). 

Recommendation 4.3.1.4

Mandate that all MTFs and VA Hospitals become active in the state prescription-monitoring programs to facilitate 

medication reconciliation and the safe prescribing of opioids (standard of care).

Recommendation 4.3.1.5

Educate providers on pain and addiction, contraindications to opioid therapy, and the goals of a treatment plan.

4.3.2 Embed Pain and Pharmacy Resources 

Objective: Provide appropriate pain management and clinical pharmacy oversight in 

Warrior Transition Units. 

Pain management is a primary issue for the Warrior Transition Unit patient population. WTU patients often have complex 

pain issues that require pain specialty consultation and close pharmacologic monitoring. Many of these patients have coexisting disorders, such as PTSD, TBI, depression, insomnia, and substance abuse. Obtaining an appropriate history and 

understanding the impact of these co-existing disorders is critical to formulating an appropriate treatment plan. 

Evaluating these patients in close collaboration with the primary care physician allows for a coordinated care plan that can 

reduce the length of time that a patient is held in the WTU, reduce the risks inherent in fragmented care, and facilitate the 

early detection of aberrant pain behavior in this high risk population. Embedding pain and pharmacy resources in the WTU 

on a periodic basis will also lead to improved pain management skills among primary care physicians in the WTU as a 

result of close collaboration over time. Pain patients who would benefit from interventional pain management or other 

techniques can be referred directly for that care by the embedded pain physician. 

WTU patients, especially those with other co-existing disorders (PTSD, TBI, 

etc), are at higher-than-average risk for adverse outcomes, including 

accidental overdose and death. Pain is the primary issue for many patients in 

the WTU. It is critically important to address pain issues quickly, which can in 

turn facilitate return to duty or transition to the VHA system for care. 

Embedding pain and pharmacy resources can be expected to result in faster 

delivery of pain care, early identification of aberrant pain behavior, and reduced length of stay in the WTU. Pharmacists’ 

value to the health care delivery team is evidenced throughout the literature by the wide variety of innovative Medication 

Therapy Management Services (MTMS) currently being delivered at both local and regional levels. It has been 

demonstrated that MTMS, appropriately employed, can lead to a reduction in overall health care expenditures through 

optimizing therapeutic outcomes, reducing adverse medication events and reducing emergency room visits and hospital 

stays. Medication Therapy Management (MTM) is a partnership of the pharmacist, the patient or their caregiver, and other 

WTU patients, especially those with 

other co-existing disorders (PTSD, 

TBI, etc), are at higher-than-average 

risk for adverse outcomes, including 

accidental overdose and death
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health professionals that promotes the safe and effective use of medications and helps patients achieve the targeted 

outcomes from medication therapy. 

If a pain physician and a pharmacist were embedded in the WTU on a periodic basis they could see patients referred by 

primary care physicians. The schedule frequency of working in the WTU would be determined by the number and 

complexity of patients to be seen. Patients with urgent pain issues that could not wait until the next scheduled WTU pain 

clinic would be seen in the regular pain clinic. For facilities that do not have a pain medicine subspecialty trained physician, 

a primary care physician or other specialist with an interest in pain and additional training in evaluating pain patients may 

serve this purpose. That physician should have readily available consultation from a Regional Pain Center of Excellence. 

MTM encompasses a broad range of professional activities and responsibilities within the licensed pharmacist’s scope of 

practice. These services include, but are not limited to, the following, according to the individual needs of the patient: 

Performing or obtaining necessary assessments of the patient’s health status 

Formulating a medication treatment plan 

Selecting, initiating, modifying, or administering medication therapy 

Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness 

Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, 

including adverse drug events 

Documenting the care delivered and communicating essential information to the patient’s other primary care 

providers 

Providing verbal education and training designed to enhance patient understanding and appropriate use of their 

medications 

Providing information, support services and resources designed to enhance patient adherence with their 

therapeutic regimens 

Coordinating and integrating medication therapy management services within the broader health caremanagement services being provided to the patient 

Recommendation 4.3.2.1

Provide access to a Pain Management Provider at all WTU clinics.

Recommendation 4.3.2.2

Provide a clinical pharmacist capability to all WTUs based on each WTU's individual need for clinical consultation 

and medication reconciliation. 

4.3.3 WTC Pain Survey Collaboration 

Objective: Collaborate with the Warrior Transition Command to revise the satisfaction 

survey to incorporate pain metrics. 

The Army’s Medical Holdover (MHO) Satisfaction Survey Program began in August 2006. In February 2007, issues 

at WRAMC resulted in a modification and expansion of this survey instrument. In June 2007, the MHO survey 

transitioned to the WTU Survey, with the goal of providing current, actionable data to leadership. The survey 

included questions about the Case Manager, Provider and Platoon Sergeant, as well as detailed questions about 

Medical Care, the Medical Evaluation Boards (MEB) and Physical Evaluation Boards (PEB) process, and living 

quarters. One of the trends in these surveys has been relatively low satisfaction among the WTs with their “pain 

control.” No other details about pain control or pain management were available from these surveys. 
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The WTC is revising the WTU survey. Task Force members met with representatives from the WTC and developed 

some additional questions regarding pain management. These additional questions (Appendix B-11) will provide 

WTC leadership and MEDCOM with an increased amount of actionable information to improve delivery of pain 

management services to the Warrior population and will assist the TF with measuring impact of implementation of 

Task Force recommendations. 

Recommendation 4.3.3.1

Incorporate recommended Task Force pain questions into the WTU Satisfaction Survey. 
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4.4 Synchronize a Culture of Pain Awareness, Education, and Proactive 

Intervention

The organization must synchronize a culture of pain awareness, education, and proactive intervention. This requires a 

unified approach to content, education, and training, as well as leadership and organizational adaption on issues of pain 

management into the future. Patients and providers do not typically stay in one place for their careers. In the course of 

receiving their medical care, patients are treated in a variety of clinics and hospitals that cross regional, Service, and 

network boundaries. Likewise, many providers are as mobile as their patients. To the extent possible, the military should 

aim to standardize the orientation to and understanding of pain and pain management in order to manage the expectations 

of patients, providers, and leaders. 

The resources involved in synchronizing the pain orientation of providers and patients will likely be significant. Realigning 

existing efforts into one larger and more effective education program under a STRATCOM plan is a logical first step in this 

process. The likelihood that this would transform the DoD and VHA into a model organization for pain management that 

influences the practice of medicine, decreases unnecessary suffering, and improves overall readiness makes this a worthy 

investment. 

Strong leadership is required to develop a new vision of organizational pain management with new goals. The organization 

must examine all viable options for improving acute and chronic pain care, implement proven treatment modalities and 

process changes, measure results – learning from both successes and failures – and communicate the mission’s new 

priorities through the chain of command across the enterprise. A major organizational reset with regards to acute and 

chronic pain care will require the following: 

Standardization of pain management capabilities at every level, as well as care from medical education to pain 

care delivery 

High level integration and prioritization of pain management recommendations that complement issues identified 

in other Task Force reports and initiatives 

Development of an interagency pain management educational campaign that comprehensively addresses pain 

care issues among a wide variety of stakeholders 

Establishment of integrated, interdisciplinary and appropriately resourced pain medicine departments across the 

enterprise 

Standardization of requirements for Pain Medicine Consultants to the Surgeons General at the highest level 

Creation of a DoD and VHA central pain management advisory board to drive policy and curricula development, 

analyze data and coordinate research, as well as inform practice and establish future lines of inquiry to advance 

the field of pain medicine. 

The importance of this last recommendation – creation of a central pain management advisory board – cannot be 

understated. An evidence-based, analytical approach to measuring treatment efficacy that leverages standardized pain 

assessment tools, patient registries and a wealth of longitudinal patient data, holds the potential to advance pain research 

and unify pain care well into the 21st century. 
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A Unified Approach to Content, Education, and Training

Figure 20: A Summary of Categories for a Unified Approach to Content, Education, and Training 

Synchronize a Culture of Pain Awareness, Education, and Proactive Intervention 

A Unified Approach to 

Content, Education, and 

Training

Pain Curriculum Transformation 

Integration of Pain Management Recommendations 

Pain Education Campaign Plan 

4.4.1 Pain Curriculum Transformation 

Objective: Transform the pain curriculum at all levels of medical education and care 

delivery.

Pain management receives very little attention and is inadequately developed in the curricula of many U.S. 

medical and allied health professions schools. TF members met with Dr. Director of Pain 

Education, Johns Hopkins University School of Medicine, to discuss current trends in medical school pain 

curricula. Dr. stated that the typical medical school may provide four hours of pain content on the 

topics of basic pain physiology, opioids, non-opioid therapies, and back pain. While some of the components 

necessary for an adequate pain curriculum are available, the content is seldom organized in a manner that 

makes it possible for students to successfully integrate the knowledge acquired in a classroom into clinical 

practice. There is little evidence that medical schools have specific mechanisms to foster competence in 

providing comprehensive care for patients, which includes clinical skills, such as assessing a patient's emotional 

state. The lack of a congruent approach to pain management education results in a variation in pain 

management understanding and practice that is evident in all of the medical professions. The military medical 

training programs consistently mirror these deficiencies. 

Health care professional programs at most major medical educational and training sites do not include a 

dedicated pain management curriculum. Many health care professionals have little or no training in pain 

management and are unable to effectively respond to patients’ reports of pain. Undertreated pain, failure to 

prevent development of chronic pain, and unsafe use of opioids may lead to: 

Unnecessary suffering 

Duplicative or ineffective treatments 

Increased economic costs or loss of productivity 

Poor quality of life 

Development of comorbid disease such as depression 

Increased caregiver burden 

Increased physician visits 

Costly health care utilization in the form of Emergency Room visits, specialty care, and prolonged 

hospital stays 

Unintentional death 

New methods of teaching health care professionals about pain care are required to provide the most effective 

acute pain, chronic pain, and end-of-life pain care to patients. Currently, most clinicians’ knowledge about pain 

assessment and management is derived from clinical experience rather than medical schooling, but effective 

and standardized treatment requires that pain medicine become part of a core curriculum on chronic disease. 

(b) (6)

(b) (6)
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This requires leadership, including deans of medical and other health professional schools, directors of 

residency training programs in specialties and subspecialties that provide primary care, professional societies, 

and other stakeholders to ensure every trainee and health practitioner has the skills to assess and treat pain 

effectively, including chronic pain. 

Pain permeates many aspects of patient care and every medical discipline including medics, nurses, 

anesthesiologists, neurologists, emergency physicians, physiatrists, pediatric and adult primary care providers, 

pharmacists, psychologists, physical therapists, social workers and others. As health professionals graduate 

and treat patients of their own, they should know how to assess, diagnose, triage, and treat pain. This education 

should start in the health professionals’ schools and continue through their post-graduate training (residencies 

and fellowships) into clinical practice with ongoing, staff educational opportunities. 

The DoD and VHA are involved in the medical training of 

many of those providing the patient care in DoD and 

VHA medical facilities. The Uniformed Services 

University of Health Sciences (USUHS), AMEDD Center 

and School, and DoD GME programs are responsible 

for training everyone from combat medics to battlefield 

surgeons. Upon completion in 2011, the Medical 

Education and Training Campus (METC) led by tri-service leadership will centralize all Army, Navy and Air Force 

basic and specialty enlisted medical training. The VHA trains health professionals in many different specialties, 

both at undergraduate and post-graduate (GME) levels. These trainees may end up in the VHA, DoD, or civilian 

sectors as employees. In addition, the VHA routinely develops educational CME programs to advance the 

medical and clinical knowledge of their providers. 

The TF determined that existing DoD-controlled education and training programs lacked a consistent approach 

and orientation to teaching our providers about pain. The education curricula fell short in structuring the didactic 

content in a manner that allowed the students to integrate a comprehensive understanding of pain into their 

clinical practice. One exception noted by the TF was the U.S. Army-Baylor University Doctoral Program in 

Physical Therapy. This program’s curricula exemplified several of the concepts recommended by the TF. The 

Army-Baylor PT program successfully relates the pain-related content in its didactic training (e.g. 

pathophysiology, anatomy, and pharmacology) to its clinical practicums. In addition to “connecting the dots” for 

in their pain-related curriculum, the PT doctoral program placed a special emphasis on patient involvement in the 

effective management of pain. 

Synchronizing the pain education and training within DoD- and VHA-managed institutions is an essential step in 

implementing a comprehensive pain management strategy. The pain-related curricula for all of the DoD and 

VHA education and training programs should be structured to create an enterprise-wide group of providers and 

staff with a similar vision, orientation, and understanding of pain. This common orientation should be reinforced 

at every level of medical training and at every point on the vast continuum of medical care managed by the 

military and the Veterans Administration. 

Recommendation 4.4.1.1 

Establish a core curriculum specific to pain management to be integrated into all DoD graduate medical education 

and advanced medical training programs.

Recommendation 4.4.1.2

Integrate core pain education and training content into AMEDD training courses (68W, Office Basic Course, 

Combat Casualty Care Course). 

Pain permeates many aspects of patient care and 

every medical discipline including medics, nurses, 

anesthesiologists, neurologists, emergency 

physicians, physiatrists, pediatric and adult primary 

care providers, pharmacists, psychologists, physical 

therapists, social workers and others
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4.4.2 Integration of Pain Management Recommendations 

Objective: Integrate TF recommendations and STRATCOM with other related DoD and 

VHA programs. 

The Pain Task Force is only one of the many programs or initiatives undertaken to improve quality of life and 

maintain readiness of the Armed Forces. Examples of the programs and initiatives that appear to share a common 

interest with the Pain TF are: 

Comprehensive Soldier Fitness 

Behavioral Health Task Force 

Army Suicide Prevention Task Force 

Traumatic Brain Injury Task Force 

Behavioral Health Campaign Plan 

Musculoskeletal Action Plan 

Patient Centered Medical Home 

The Pain TF invited representatives from these initiatives to its working meetings and/or consulted with their 

representatives when developing recommendations. Continued collaboration and coordination between these very 

complementary processes are paramount to reducing duplication of effort, minimizing conflicting messages, and 

maximizing effectiveness of the Pain TF recommendations. 

The Pain TF recognizes the synergy involved in synchronizing related messages across a continuum of programs. 

For example, the Army’s Comprehensive Soldier Fitness (CSF) program’s mission is to “develop and institute a 

holistic fitness program for Soldiers, Families, and Army civilians in order to enhance performance and build 

resilience.” The Pain TF evaluated pain management along a continuum of care from prevention to early 

identification and treatment to resolution. Resilience certainly plays a role in successful pain management, therefore 

the prevention components in the education and training plans developed for the comprehensive pain management 

strategy should echo the messages from CSF. The effort to “connect the dots” between programs with similar 

interests should lead to more effective and efficient communication of the respective program messages. 

Recommendation 4.4.2.1

Develop pain management STRATCOM in collaboration with DoD and VHA programs with related interests.

4.4.3 Pain Education Campaign Plan 

Objective: Develop a pain management education plan that addresses the full spectrum 

of stakeholders and issues. 

The sweeping changes recommended in this report will require the MHS and VHA to undertake an extensive reeducation and training initiative for medical staff, patients, leaders, and Family Members. The current variation in 

orientation, understanding, and practice of pain management throughout DoD and VHA will not easily be corrected. 

In fact, the TF members have described the required action as essentially performing a massive “re-boot” on the 

military and VHA health care system’s orientation to pain management. While certainly a challenge, it is well within 

the capabilities of these organizations to make this happen. 

The first step in this process will require the Uniformed Services and VHA to agree on a series of common core 

approaches, standards, and messages that will become the key to standardization across DoD and VHA. Ideally, the 

Task Force recommendations will be the template for this strategy. The starting point is the Task Force’s goal of 
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providing a standardized DoD and VHA vision and approach to pain management to optimize the care for Warriors 

and their Families. 

The core components of the pain management strategy should support, reinforce, and complement the existing painrelated strategies and initiatives in DoD and VHA (e.g., Comprehensive Soldier Fitness and Army Suicide Prevention 

Task Force). This will require a complex series of continuing coordination and staffing among the Uniformed 

Services and VHA. Careful attention should be made to ensuring proper “handoffs” and continuity of messages and 

strategies that are related but external to medical commands (e.g. resilience, safety, addiction). Conversely, these 

non-medical but related initiatives should complement and reinforce the core messages from the pain strategy. 

Standardizing the core messages and organizational orientation to pain management across DoD and VHA will not 

only better manage the expectations of patients and staff, but also drive improvements in satisfaction and outcomes. 

Because of the overwhelming amount of variance in the understanding, approach, and practice of pain management 

across DoD and VHA, the “re-boot” necessitates an aggressive and highly visible campaign and education plan. This 

will require resource-intensive STRATCOM, marketing, and education efforts that cross all organizations. Again, 

while efforts are undertaken to reorient and educate medical staff to this strategy and approach, a simultaneous effort 

must occur to educate patients, Families and leaders. This will involve more than dissemination of new policies or 

presentations and should be given the attention and emphasis commensurate with the seriousness of the issue to 

DoD and VHA. 

As organizations implement this new strategy, it will need to be supported and sustained by a robust education and 

training program. Under the guidance of a central pain management advisory board, a curriculum should be 

developed that addresses the full scope of pain-related education and training needs of patients, staff, Family 

Members, and leaders. The minimal requirements for the Pain curriculum are outlined in Figure 21 and a detailed 

curriculum can be found in Appendix B-12. 

Figure 21: Notional Pain Management Curriculum 

100 - General Information about Pain / Pain Management 

101: Introduction to Pain Management (Audience: General Military Population) 

102: Pain Management for Leaders/Supervisors (Audience: Military Leaders) 

103: Understanding a Family Member with Pain Management Issues (Audience: Family Member of those with 

pain management issues) 

104: Patients with pain and co-existing disorders of TBI, PTSD, Depression, Substance Abuse, etc. (Audience: 

All of the above) 

200 - Pain Management for Healthcare Staff 

201: Introduction to Pain Management for Healthcare Personnel (Audience: All health care personnel) 

202: Pain Management in Primary Care (Audience: Primary Care Providers) 

203: Pain Management in the WTU (Audience: Providers and Staff in Warrior Transition Units) 

204: Pain Management for Pharmacist (Audience: Pharmacists) 

(continued on next page) 
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300 - Deployed / Battlefield Pain Management 

301: Medic Management of Battlefield Pain (Audience: Medics, Hospital Corpsmen, Airmen)

302: Pain Management at Level III (Audience: Deploying health care personnel)

303: Evacuation Pain Medicine (Audience: Deploying health care personnel)

304: Acute Pain Medicine Service (Audience: Pain medicine physicians (anesthesiologists) and nurses)

400 - Pain Care by Specialty 

401: Pain Medicine Specialty Care (Audience: Pain Medicine Specialists)

402: Perioperative pain management (Audience: Surgical personnel)

Recommendation 4.4.3.1

Further educate all DoD and VHA medical personnel on the disease process of pain and its management. 

Recommendation 4.4.3.2

Provide standard curriculum of pain education that is formed on the best available medical evidence. 

Pain Management and Leadership

Figure 22: A Summary of Categories for Pain Management and Leadership 

Synchronize a Culture of Pain Awareness, Education, and Proactive Intervention 

Pain Management and 

Leadership 

Standardize Pain Management Capabilities 

Interdisciplinary Pain Management Departments 

Pain Medicine Consultants to Military Leadership 

Central Pain Management Advisory Board for DoD and VHA 

4.4.4 Standardize Pain Management Capabilities 

Objective: Establish enterprise-wide tiered pain management requirements to 

standardize patient care services. 

While there is variability in pain services between the DoD and VHA health care systems, there is also no 

consistency in pain management from MTF to MTF. This lack of consistency results in considerable patient and 

provider frustration and a disruption of pain care plans as the highly mobile patient population moves from facility to 

facility. MTF commanders are given no guidance on what pain services they should be providing or what resources 

they should be obtaining. Many pain providers believe this lack of a consistent approach to pain care at all levels 

within the DoD and VHA systems has negatively impacted many Soldier health issues, such as opioid abuse and 

misuse, patient suicide, PTSD, and TBI, among others. 
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A consistent approach to pain management throughout the continuum of care is vital to the health and safety of the 

Beneficiary population. This pain policy must start at point of injury, continue throughout the levels of care, and 

persist at all Contiguous United States (CONUS) MTFs. The policy must also extend into the VHA and community 

health systems to enable continuity of care as patients move outside the MHS. 

To begin the process of developing this consistent approach, issues in battlefield pain management should be 

prioritized. Next, CONUS MTFs should implement a tiered system of pain medicine. In support of the proposed 

tiered system, each TRICARE region will have at least one Regional Pain Center of Excellence (RPCoE) to serve as 

the pain consultation center for the region. Each RPCoE will work with the central pain management advisory board 

on coordination of pain care policy among TRICARE regions. RPCoE services are outlined in Appendix B-13. 

The creation of pain departments in MEDCENs will 

support a coordinated system of pain management 

services, including most of the RPCoE services except 

the Pain Rehabilitation Center. Tier I and II services are 

outlined in Figure 23. The Tier System corresponds to 

the VHA Stepped Care Model (see section 4.2.4), which 

conceptualizes the process of care based upon patient need for intensity and additional expertise. By providing a 

consistent structure linked to the VHA Stepped Care Model, the tiered system will ensure consistent delivery of pain 

medicine services throughout the DoD and serve as a model for integrated pain care in the nation. 

Figure 23: Tier System of Pain Care 

Tier MTF Pain Services 

I Outpatient health clinics and troop medical clinics. 

MTFs with no routine surgical capability. Pain Champion and initial pain education 

II Small MTF or large multidisciplinary clinics with 

routine surgical capability 

On site behavioral health support plus a 

combination of pain pharmacology, other pain 

management modalities and case management 

III Large MTF or community hospital Acute and chronic interdisciplinary pain services 

IV Medical Center Pain Department 

V TRICARE Region Pain Consultation Center Regional Pain Center of Excellence 

Additional resource requirements: 

Adoption of the pain tier system. 

Adoption of related Pain Task Force recommendations, including a central pain management advisory 

board, battlefield pain recommendations, and creation of an interdisciplinary pain management department. 

Extensive re-training effort and policy generation at all Levels of care. 

Fundamental change in organizational attitudes and policies towards the disease process of pain. 

This issue is central to the success of all other Task Force recommendations. Change of this magnitude will be 

difficult but DoD and VHA commitment to and leadership in this endeavor will likely be the benchmark for pain 

management in the United States for the rest of this century. 

Recommendation 4.4.4.1

Adopt the tiered system of pain care. 

Many pain providers believe this lack of a consistent 

approach to pain care at all levels within the DoD and 

VHA systems has negatively impacted many Soldier 

health issues, such as opioid abuse and misuse, 

patient suicide, PTSD, and TBI, among others
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4.4.5 Interdisciplinary Pain Management Departments 

Objective: Establish interdisciplinary pain management services to oversee optimum 

patient-centered, integrated pain care. 

The field of pain medicine encompasses patients with acute, chronic, cancer-related, and other forms of pain. Pain 

treatment services are provided by clinicians from various specialties including primary care physicians, 

anesthesiologists, physical medicine and rehabilitation physicians, pain medicine subspecialists, neurologists, 

psychiatrists, psychologists, pharmacists, physical therapists, occupational therapists, complementary and alternative 

medicine practitioners, and other allied pain-related specialties. The body of medical knowledge representing the 

field of pain medicine is beyond the focus of any one of these contributing specialties alone. Fragmentation of pain 

care is common without interdisciplinary collaboration and care coordination, and was a common theme reported to 

the Pain Task Force during site surveys. 

Many sites were attempting to address pain needs in a subset of pain patients through a multidisciplinary pain 

committee. Such committees typically meet periodically to review care plans for high risk patients who came to 

command attention as a result of difficult-to-treat pain, high utilization of health care resources, and/or high risk painrelated behavior. These multidisciplinary committees serve an important function by identifying and tracking high risk 

patients and making a concerted effort to treat and refer them appropriately. Many members of these 

multidisciplinary committees expressed disappointment with the quality of pain care resources available for referrals 

within their respective TRICARE region. Only a small minority of sites had co-located pain care clinicians providing 

interdisciplinary pain care. 

MEDCENs are tertiary referral medical centers resourced to provide advanced medical services above the services 

provided at the MTF level. Effective pain management within the MEDCEN requires an interdisciplinary Pain 

Medicine Service that draws from multiple specialties but is philosophically independent and works collaboratively to 

provide integrated pain care. Co-location of these services in an Interdisciplinary Pain Center facilitates better 

communication and provides optimum patient-centered, integrated pain care. 

Poorly integrated pain services and fragmentation of care was a primary and consistent finding of the Pain Task 

Force. The risks inherent in not having pain providers co-located include the following: 

Delays in establishing treatment plans 

Increased risk that aberrant pain behavior will not be detected in a timely manner 

Increased risk of losing patients to follow-up 

Unnecessary variation in care provided 

Decreased efficiency of pain specialists 

Individually and collectively, these risks lead to a decreased total number of pain patients treated within the MEDCEN 

and an increased overall cost to the MHS. 

Command leadership must be responsible for ensuring that the Interdisciplinary Pain Medicine Service is 

appropriately resourced to meet its vital mission. This requires balancing inter-specialty competition for resources 

that may arise as the MEDCEN is tasked to meet the dual tertiary medical care and operational medical missions 

inherent in the MHS. The integration afforded by this consolidation and co-location of pain assets will allow for 

improved outcomes-based metrics for determining best practices. Development of a consistent pain clinical structure 

will reduce variability between DoD facilities and improve patient transitions into the VHA or community health 

systems. This approach will improve provider satisfaction, expand outcomes data collection, enhance patient safety 

and, most importantly, improve patient care and satisfaction. Failure to appropriately address and resource these 

requirements will increase fragmentation of pain care and risk of adverse outcomes in patients. 
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The TDA for each MTF should recognize the need for pain care appropriate to facility size, with each MEDCEN 

resourced for an Interdisciplinary Pain Medicine Service. One medical center in each TRICARE region should be 

designated a TRICARE Regional Pain Center of Excellence (RPCoE). The RPCoE will represent the fullest 

expression of the Interdisciplinary Pain Medicine Service concept (including co-location of pain care specialists into 

an Interdisciplinary Pain Medicine Center), serve as the regional pain consulting activity (Appendix B-13), and 

provide telemedicine pain support for the entire TRICARE region. Each RPCoE will coordinate with the central pain 

management advisory board on DoD- and VHA-wide pain issues and research activities. 

Additional resource requirements: 

Creation of a new Interdisciplinary Pain Medicine Service within each MEDCEN. 

Designation of one Interdisciplinary Pain Medicine Service within each TRICARE Region as the RPCoE. 

Establishing an interdisciplinary pain committee at each MTF and establishing a telemedicine link to the 

RPCoE for that TRICARE region. 

Standardized credentialing. 

Updated productivity metrics that support the integrated model for delivery of pain care. 

Reallocation of personnel and resources to staff pain RPCoE. 

Recommendation 4.4.5.1

Establish TRICARE Regional Pain Centers of Excellence networked to every MTF in that region.

Recommendation 4.4.5.2

Establish an Interdisciplinary Pain Medicine Service at each major DoD MEDCEN.

Recommendation 4.4.5.3

Define local capability requirements in establishing the tiered system of pain care delivery. 

4.4.6 Pain Medicine Consultants to Military Leadership 

Objective: Develop requirements for Service pain consultants to reflect an 

interdisciplinary, integrative approach to pain management. 

Army, Navy, and Air Force Surgeons General have consultants from the wide spectrum of medical specialties to 

assist them in making informed decisions. MTF commanders rely on subject matter experts within their commands 

for advice. Most recently, Army and Navy have added the position of Pain Consultant to their respective Surgeons 

General and the Air Force is considering a similar addition to their group of Surgeons General Consultants. The 

current Army and Navy Pain Consultants are Anesthesiologists and graduates of pain medicine fellowships. The TF 

recommends transforming pain management in the MEDCOM and MHS into an interdisciplinary and integrated 

specialty. It is essential to transform the current selection criterion of the Service pain consultants to reflect this 

expanded perspective of pain management. This recommendation should not be interpreted as an attempt to dilute 

the qualifications of this essential consultant position. 

Pain Medicine is currently a recognized medical subspecialty with board certification through the American Board of 

Medical Specialties (ABMS). Board certification requires successful completion of an Accreditation Council for 

Graduate Medical Education (ACGME) interdisciplinary pain medicine fellowship, demonstrated expertise in the 

evaluation and treatment of acute, chronic, and cancer pain, and the achievement of a passing score on the board 

examination. Although the intellectual background and clinical practice of pain medicine is derived from several 

traditional specialties (e.g., anesthesiology, neurology, psychiatry, Physical Medicine and Rehabilitation (PM&R), and 

neurosurgery), entrance into pain fellowships was initially restricted to anesthesiologists. As a result, these 
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fellowships have traditionally been focused on training in pain procedures and the vast majority of fellowship-trained 

specialists are anesthesiologists. 

The American Board of Pain Medicine (ABPM) was formed in 1993 to provide a standardized credential, and has 

credentialed more than 2,000 physicians who now practice pain medicine. The standardized credential for pain 

medicine specialists with ABMS board certification from these other specialties was based on a broader examination 

that was more representative of the practice of comprehensive pain medicine. Beginning in 2001, ACGME 

fellowships began opening to Neurologists, Psychiatrists, and Physiatrists. More recently, in recognition of the 

weaknesses of the current training emphasis on procedures, fellowships have attempted to become even more 

comprehensive and integrated in their approach to pain medicine, despite the limitations of a one-year experience. 

Recently, at an American Medical Association-sponsored Summit on Pain Medicine Practice and Training, 

representatives from all medical specialties reached the consensus that training was inadequate and that in order to 

provide more uniform standards in pain medicine care, training needed to be lengthened to at least two years with 

eventual development of separate residency training as a specialty. 

Pain Medicine Consultants should represent the integration concepts identified by the TF as critical to the success of 

pain management. The Pain Medicine Consultant should: 

Practice comprehensive pain care 

Have up-to-date knowledge of the expansive field of pain medicine 

Be involved in and/or knowledgeable about current pain research 

Have experience leading an interdisciplinary pain team 

Completion of a Pain Fellowship is a significant accomplishment in the field of pain medicine, but it should not be the 

sole discriminator for pain consultant selection. The Pain Medicine Consultant should be Board Certified in their 

primary medical specialty and be the most qualified person for that position. 

The VHA has established a National Program Director for Pain Management, and a Deputy National Program 

Director for Pain Management, in the VHA National Pain Management Program Office at the VA’s Central Office 

(similar to the Service Surgeons Generals Offices). Illustrating the diverse nature of the field of pain medicine, the 

National Program Director is a clinical Psychologist (PhD) and the Deputy National Program Director is a certified 

Pain Medicine Specialist by both the ABMS and the ABPM from a background of primary care and Psychiatry (MD). 

The American Academy of Pain Medicine, American Pain Society, and the International Association for the Study of 

Pain are all examples of large professional organizations dedicated to the practice, education, and research of 

interdisciplinary pain medicine. All of these organizations choose their leadership from a variety of the disciplines 

involved in comprehensive pain medicine. 

The formation of a Pain Medicine Department (as discussed in Section 4.4.5) will ensure that the comprehensive and 

interdisciplinary nature of Pain Medicine maintains the ultimate goal of effective patient care. It will encourage Pain 

Medicine specialists to focus on goals of the Pain Medicine Department and not be obligated to the departmental 

needs of their individual parent specialties. The Chief of each medical facility’s Pain Medicine Department will not be 

from the same specialty, but will be a strong leader in the field of pain medicine. This variability is secondary to the 

diverse field of pain medicine but also to the diverse nature of the military. Given the tiered structure of military 

medical facilities, not every facility will have the same specialties represented. For example, the Chief at one facility 

might be a fellowship trained interventionalist while at another facility the Chief might be from Behavioral Health. 

Recommendation 4.4.6.1

Develop pain medicine consultant selection criteria to identify the candidates who best represent the integrative 

and comprehensive nature of pain medicine. 
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4.4.7 Central Pain Management Advisory Board for DoD and VHA

Objective: Establish an effective pain management advisory board for DoD and VHA. 

The scope and magnitude of changes recommended by the DoD Pain Task Force require a central pain 

management advisory board to ensure effective implementation and stewardship of all pain care improvements 

throughout the care continuum. The TF identified numerous critical tasks that should be managed by a central pain 

management advisory board (see Figure 25). The board will provide the necessary policy development, research, 

and curriculum development to move pain care for all DoD and VHA Beneficiaries forward to a new, more patientcentric level. It will also establish a pain continuum of care from onset of pain (battlefield or at home) through DoD 

health care centers to VHA centers and the community. 

The central pain management advisory board will operate as a center of excellence and will provide a “central point 

of contact” for establishing and maintaining pain care clinical standards, managing pain provider education programs, 

and providing recommendations for pain research priorities. No current DoD program is tasked with this 

responsibility despite the correlation of pain with PTSD, suicide, and other mental and physical health issues 

identified in virtually every task force report since the beginning of OIF and OEF. 

Figure 24: Proposed Central Pain Management Advisory Board Structure 

The Defense and Veterans Pain Management Initiative (DVPMI) currently exists as a Congressionally-sponsored 

program that has historically focused on battlefield anesthesiology-related acute pain issues. Formally known as the 

Military Advanced Regional Anesthesia & Analgesia (MARAA) program, DVPMI has functioned as a tri-service 

collaborative group of anesthesia providers focused on battlefield pain management. They have spearheaded many 

recent battlefield advances in pain care, such as the military pain infusion pump, epidurals and continuous peripheral 
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nerve blocks in theater and on military evacuation aircraft, as well as the use of novel battlefield pain infusions such 

as ketamine. 

The Pain Task Force recommends that the DVPMI, after expanding its membership to reflect the interdisciplinary and 

integrated nature of pain medicine, becomes the DoD and VHA central pain management advisory board. Based on 

recommendations of the Task Force, the DVPMI will have a greatly expanded mission for the Services and the VHA 

in representing all medical specialties involved in acute and chronic pain management for Warriors and other DoD 

Beneficiaries. 

Figure 25: Responsibilities of a Central Pain Management Advisory Board 

Establish metrics for training success and practice impact that are evaluated annually and used to update and 

continuously improve the Pain Assessment Tool, driven by research

Validate the Pain Assessment Tool

Make policy and process decisions for Standardizing Pain Care

Develop PASTOR content and maintain data repository

Serve as the Battlefield pain management proponent and consultant organization

Maintain responsibility for routine analysis, trend modeling, and the management and reporting of the Joint 

Theater Trauma Registry (JTTR) 

Develop and maintain all electronic pain order sets and policies 

Develop variations of the pain medication orders for all levels of MTFs within the DoD and VHA systems 

Maintain responsibility for program, data, and content responsibility for the Joint Regional Anesthesia and 

Analgesia Tracking System (JRAATS) 

Fill research information needs by using shared information platforms from MRMC and CRMRP 

Develop priorities for future pain-related Clinical Practice Guideline development 

Ensure that any recommendations complement existing initiatives and collaborate with all relevant organizations 

and initiatives on development of future recommendations 

Develop a curriculum that addresses the full scope of pain-related education and training needs of patients, staff, 

Family Members, and leaders 

Coordinate with the RCPoE on DoD- and VHA-wide pain issues and research activities

Ensure effective implementation and stewardship of all pain care improvements throughout the care continuum

Provide the necessary policy development, research, and curriculum development to move pain care for all DoD 

and VHA Beneficiaries forward to a new, more patient-centric level

Ensure that clinical interventions are well-aimed and based upon proven methodology, and that current research 

findings can be rapidly translated into clinical practice

Implement, monitor, measure outcomes, and sustain Pain Research STRATCOM initiative as part of its 

Operations and Maintenance responsibilities

Review and update all electronic pain guidelines annually
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The reorganized DVPMI will serve as clinical advisor on the best integrated pain medicine practice, the foremost pain 

medicine educational resource, and the DoD and VHA pain research and outcomes evaluation focal point. As the 

Defense Pain Center of Excellence (DPCoE), the DVPMI will be responsible for assessing the effectiveness and 

safety of pain care. This initiative will seek to improve pain care communication among health care providers 

throughout the care continuum, particularly as it relates to the control of opioid use and prevention of abuse. 

The DVPMI will provide a research foundation to study how current and future pain care technologies and 

medications impact Soldiers from battlefield injury to evacuation and throughout recovery and rehabilitation. The 

interdisciplinary program will examine the influence of pain on PTSD, Soldier suicide, social re-integration, trauma 

rehabilitation, disease progression, and other interrelated issues. The DVPMI will provide an administrative structure 

for a Military Pain Medicine Board of Directors (MPMBD) consisting of Air Force, Army, Navy and VHA senior expert 

clinicians and researchers experienced in the management of acute and chronic pain. The proposed DVPMI charter 

is provided in Appendix B-14. 

Additional resource requirements: 

The DVPMI will require an annual budget to support its DoD-wide clinical, educational, and research 

mission. Personnel requirements for the DVPMI are outlined in the DVPMI Charter. DVPMI goals are 

consistent with established goals of the DCoE. 

The strategic pain mission of the DVPMI, which encompasses both the DoD and VHA health care systems, 

necessitates placement of the DVPMI at the level of the MHS. The Services Surgeons General would have 

to recommend placement of the DVPMI through the Senior Military Medical Advisory Council. 

Possible “homes” for the DVPMI include: Uniformed Services University; Defense Centers of 

Excellence, Institute for Surgical Research. 

Establishing the updated DVPMI will greatly enhance pain care throughout the continuum and help break down 

inconsistencies in pain care delivery between the Services and MTFs. Partnership with the VHA in pain 

management will contribute to a seamless transition of patients from DoD facilities to VA hospitals and back into their 

community. The DVPMI will reinforce the DoD Medical Services’ leadership role in clinical pain management, 

education, and research and will ensure that Pain Task Force recommendations result in lasting improvements in 

pain care. The DVPMI will continue to advance the care that DoD Beneficiaries are receiving, ensuring adoption of 

the latest and best pain management techniques and modalities from military and VHA health care facilities. This 

effort will positively impact all aspects of a patient’s care, recovery, rehabilitation and return to a productive life. 

Recommendation 4.4.7.1

Establish the Defense and Veterans Pain Management Initiative (DVPMI) as the DoD and VHA central pain 

management advisory board for pain medicine issues. 

Recommendation 4.4.7.2

Task the DVPMI with the responsibility to establish pain care clinical standards, manage pain provider education 

programs, and provide recommendations for pain research priorities. 
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V. THE WAY AHEAD 

Pain management has essentially changed very little since the discovery of morphine in 1805. Morphine remains the 

battlefield pain management standard, despite identification of significant side effects in the most advanced medical 

setting, much less a field environment. The military should continue to focus on improving the delivery of pain 

medicine by increasing the support and investment in research and technology efforts. 

It is imperative to minimize the current variation in pain management structure, practice, and orientation across the 

MEDCOM, MHS, and VHA. Overcoming these challenges will require a significant reorganization, education, and 

training effort that will be most effective if pursued as a part of a DoD and VHA partnership. 

The Uniformed Services boast an impressive group of pain 

medicine physicians who received training in a variety of pain 

fellowships and training programs, both inside and outside of 

the military. These pain subject matter experts have been 

integral in ensuring that military pain medicine keeps pace with 

advances in practice and technology. Unfortunately, there are 

relatively small numbers of these specialists in the MHS 

therefore demand for their services will likely continue to exceed supply. In addition to ensuring there are continued 

efforts to grow and retain pain medicine specialists, the MHS must develop a supporting team of clinicians and staff 

to assist specialists in addressing the pain management needs of their patients and staff. 

Pain medicine should be managed by integrated care teams which employ a biopsychosocial model of care. The 

standard of care should have objectives to decrease overreliance on medication driven solutions and create an 

interdisciplinary approach that encourages collaboration among providers from differing specialties. Efforts should be 

undertaken to eliminate stove-piping of pain care. 

The DoD should continue to responsibly explore safe and effective use of advanced and non-traditional approaches 

to pain management, conduct ongoing research, and provide ongoing education for providers and patients. Once 

integrative medicine approaches to pain have been piloted and documented as safe, effective, and cost efficient, they 

should become covered benefits for beneficiaries. 

There has been a systemic failure to establish pain as a priority beyond the narrow scope of the JC 2001 directive. 

The MHS and VHA are in a position to exceed the standard. Leadership must establish pain as a priority, with an 

urgency that leads to practice changes. The lack of a common understanding of, and orientation to, pain among 

providers and medical staff prevents a unity of effort, resulting in suboptimal care as well as lost synergies and 

missed savings. 

The focus should be on prevention, followed by prompt and appropriate treatment that seeks to relieve acute pain 

and eliminate progression to chronic pain when possible. The MHS can never keep up with the demand for specialty 

pain care unless it optimizes the pain management in primary care. 

Although there are many recommendations specifically targeting pain, the TF is convinced that one of most effective 

ways to improve pain management care and outcomes would be to improve health care delivery in the primary care 

setting. The medical home model allows for improvements in primary care, diagnosis and treatment management, 

early identification of injuries and disease, rapid and appropriate follow up, and specialty referrals. The VHA Stepped 

Care model should be adapted for use in DoD. 

Pain management has essentially changed very 

little since the discovery of morphine in 1805, 

and morphine remains the battlefield pain 

management standard, despite identification of 

significant side effects in the most advanced 

medical setting, much less a field environment
FINDINGS AND RECOMMENDATIONS 

PAIN MANAGEMENT TASK FORCE 77 

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Finally, the TF believes multiple synergies can be realized with the incorporation of a joint DoD and VHA strategy. 

Warriors and Beneficiaries need and deserve a unity of effort across MHS and VHA. A synergistic approach 

provides for practice improvement and outcome management research, which uses data to inform best practices and 

create the next generation of clinical practice guidelines. With this approach, there is no Army, Navy, or Air Force 

pain. 

Including the VHA in this strategy is essential and obvious. In addition to the number of MHS patients who eventually 

qualify and elect to receive care at VA facilities, there are many active duty Service Members who are in and out of 

the VHA system prior to separating from the military. The two organizations should cooperate and share common 

educational materials, venues, protocols, and formularies. A common standard would demonstrate the power of a 

unified effort and expedite achievement of the common goal: providing a standardized DoD and VHA vision and 

approach to pain management to optimize the care for Warriors and their Families. This goal can be realized.
Public

APPENDICES
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Appendix A: Task Force Recommendations 

4.1 Provide Tools and Infrastructure that Support and Encourage Research 

Advancements in Pain Management 

Standards and System Improvements

4.1.1 Standardized Pain Taxonomy 

Establish common pain taxonomy across the DoD and VHA. 

4.1.1.1 Establish a uniform understanding and use of key pain-related terms in the vocabulary of the DoD 

and VHA health care systems. 

4.1.1.2 Identify a process to Review, Revise, and Approve DoD and VHA definitions for pain, acute pain, and 

chronic pain. 

4.1.1.3 Integrate DoD and VHA definitions for pain, acute pain, and chronic pain into existing training, 

policies and regulations, and standards throughout DoD and VHA. 

4.1.2 Standardized Pain Assessment Tool 

Describe a common language DoD and VHA pain assessment tool with visual cues and a common set of 

measurement questions. 

4.1.2.1 Review and approve the new DoD and VHA common Pain Assessment Tool validation plan. 

4.1.2.2 Validate Pain Assessment Tool in DoD and VHA facilities. 

4.1.2.3 Integrate the Pain Assessment Tool, upon validation, into training, clinical practice, and data 

collection of pain management in DoD and VHA. 

4.1.3 Pain Management Survey 

Establish a common baseline of pain care capabilities across DoD and VHA by creating a modified version of the 

2009 VHA Pain Management Survey to distribute to all DoD MTFs. 

4.1.3.1 Administer a modified VHA pain survey across DoD MTFs to establish a baseline of pain care 

capabilities. 

4.1.3.2 Continue to periodically administer the survey to track improvements at DoD MTFs to ensure a 

standardized measurement of pain longitudinally and across organizations. 
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4.1.4 Nursing Role in Pain Management 

Evaluate the utilization, potential roles, and certification requirements for Nurses in the DoD pain management 

strategy. 

4.1.4.1 Request that the Federal Nurse Advisory Board evaluate the impact of certified pain nurses on 

patient outcomes and satisfaction. 

4.1.4.2 Request that the DoD and VHA Nurse Executives evaluate the role of certified pain nurses in patient 

care delivery (military and civilian). 

4.1.4.3 Determine the future role and potential use of certified pain nurses across the care continuum. 

4.1.4.4 

Build the population of certified pain advanced-practice nurses (graduate education, board 

certification, short courses, and career field designation) to maximize the value and utilization of their 

critical skill sets. 

4.1.4.5 Integrate approved TF recommendations into Core Nursing Competencies, Clinical Transition 

Program (CTP), and other Nursing training programs. 

4.1.4.6 Utilize the DoD multidisciplinary pain management advisory board to evaluate and integrate 

recommendations from the Federal Nurse Advisory Board into the DoD pain management strategy. 

4.1.5 Standardized Credentialing 

Establish a process to standardize a Military Health System credentialing process for pain medicine. 

4.1.5.1 Use specialty consultants to determine procedures to standardize MHS pain credentialing. 

4.1.5.2 

Standardize minimum training, certification, skill requirements, and scope of practice requirements 

for providers delivering procedural pain care across MHS. Develop requirements with assistance 

from both physician and non-physician subject matter experts. 

4.1.5.3 Consolidate specialty consultant recommendations into standard credentialing documents and 

approve DoD-wide. 

4.1.6 Productivity Measures 

Reexamine the use of productivity measures (Relative Value Units) in evaluating primary care. 

4.1.6.1 Establish patient-centric clinical outcome measures of productivity. 

4.1.6.2 Modify the Relative Value Units metric to include a patient-centric outcome standard. 

4.1.7 DoD and VHA Pain Care Standardization 

Develop a patient-centric approach to recovery, rehabilitation, satisfaction, and pain control, with greater attention 

to opioid control and minimizing abuse. 

4.1.7.1 Establish a uniform DoD and VHA formulary. 

4.1.7.2 Integrate specific pain management "at risk" criteria into existing discharge planning coordination for 

transitioning patients. 

4.1.7.3 Establish similar pain care capabilities at DoD and VHA sites of similar size. 

4.1.7.4 Conduct pain management pilots to measure improvements in transfers. 
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4.1.8 DoD and VHA Joint Formulary 

Establish a joint formulary to facilitate smoother transitions and minimize pain throughout the continuum of care. 

4.1.8.1 Standardize pharmacy benefits between DoD and VHA, and make them reciprocal, without delay or 

challenge. 

4.1.8.2 Evaluate the safety and effectiveness of prescriptions renewals process for Service Members 

transitioning to VHA care. 

4.1.8.3 

Establish a common DoD and VHA policy to support state of the art and science practices, such as 

the use of non-narcotic pain balls, PCA pumps, and epidurals, with associated common education 

content. 

Infrastructure and Tools

4.1.9 Pain Assessment and Outcome Registry 

Adopt a clinical information data system that provides pain assessment screening with an outcomes registry to 

promote consistency in pain care delivery. 

4.1.9.1 Jointly fund the development of a Pain Assessment Screening Tool and Outcome Registry under the 

direction of a central pain management advisory board. 

4.1.9.2 Integrate and mandate a Pain Assessment Screening Tool and Outcome Registry with DoD and 

VHA IT systems. 

4.1.9.3 Implement and mandate a Pain Assessment Screening Tool and Outcome Registry across DoD and 

VHA. 

4.1.10 Battlefield Pain Care Continuum 

Incorporate scientific advances in battlefield surgery and medical technology to improve the delivery of pain care 

across the continuum. 

4.1.10.1 Adopt the Joint Theater Trauma System Clinical Practice Guideline as policy for pain management. 

4.1.10.2 Establish acute pain medicine services across the continuum of care, consisting of pain-trained 

providers who are responsible for pain consultation and management within the MTF. 

4.1.10.3 Establish a DoD central pain management advisory board as the battlefield pain management 

proponent and consultant organization. 

4.1.11 Tele Pain 

Expand telemedicine capabilities to incorporate pain management initiatives. 

4.1.11.1 Establish Tele Pain sites at Regional Pain Centers of Excellence and MTFs throughout DoD and 

VHA. 

4.1.11.2 Develop an enterprise strategic communications plan on the availability and benefits of telemedicine. 

4.1.11.3 Develop metrics to evaluate the effectiveness and costs of providing enhanced telemedicine for pain 

medicine. 

4.1.11.4 Develop new telemedicine technology applications for pain management uses. 
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4.1.12 Joint Theater Trauma Registry 

Add a Joint Theater Trauma Registry module to capture, define, and characterize Wounded Warrior pain issues 

throughout the care continuum, from the battlefield to MTFs. 

4.1.12.1 Establish the Standardized Pain Assessment Tool as an integral part of the Joint Theater Trauma 

Registry database. 

4.1.12.2 Maintain routine analysis, management, and reporting of pain data through a central pain 

management advisory board. 

4.1.13 Electronic Pain Order Set 

Develop an electronic pain order set to assist health care providers in selecting evidence-based, individually 

tailored pain management plans. 

4.1.13.1 Establish DoD and VHA electronic pain order sets in all electronic medical records. 

4.1.13.2 Conduct an annual review and update electronic pain guidelines. 

4.1.14 Standardized Medical Equipment and Personnel in the Deployed Setting 

Standardize medical equipment, personnel support, and training across the continuum of pain care. 

4.1.14.1 Establish comprehensive acute pain services in the deployed setting. 

4.1.14.2 Standardize equipment sets for the deployed setting. 

4.1.14.3 Establish requirements and authorizations for pain management specialists across DoD to identify 

and implement best practices from the VHA. 

4.1.14.4 Develop training program modules to support pain management in the deployed setting. 

4.1.15 Joint Regional Anesthesia and Analgesia Tracking System 

Leverage advances in regional anesthesia techniques by integrating the data through an existing, sanctioned joint 

tracking data system. 

4.1.15.1 Complete the Joint Regional Anesthesia and Analgesia Tracking System. 

4.1.15.2 Implement the Joint Regional Anesthesia and Analgesia Tracking System. 

4.1.15.3 Assign program, data, and content responsibility for the Joint Regional Anesthesia and Analgesia 

Tracking System to a central pain management advisory board. 
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4.1.16 Standardize Identification of Substance Abuse Patients 

Identify substance abuse patients in Warrior Transition Units by embedding the necessary resources to develop 

and implement a coordinated care and monitoring plan. 

4.1.16.1 

Establish a tri-service and VHA working group that will recommend a paper form and web-based 

interactive tool, designed for general medical settings, as the standardized tool to identify substance 

abuse patients. 

4.1.16.2 Incorporate the screening tool into the Pain Assessment Screening Tool and Outcome Registry. 

4.1.16.3 Implement use of the tool during the initial patient visit to obtain a baseline assessment. 

4.1.16.4 Enhance the communication of the patient's plan of care among primary care, specialty care, and 

substance abuse providers. 

4.1.16.5 Develop a strategic communications plan on the use of a standardized substance abuse screening 

tool. 

4.1.17 Risk Management in Chronic Pain Medical Management 

Mitigate the risk of prescription drug abuse and dependence in pain patients, with a focus on those receiving 

controlled substances for the treatment of chronic pain. 

4.1.17.1 Implement a stepped care model for pain care. 

4.1.17.2 Develop a strategic communications plan on DoD and VHA guidelines for chronic opioid therapy and 

the VHA Opioid Pain Care Agreement. 

4.1.17.3 Educate providers and chronic pain patients on the signs and symptoms of opioid dependence, 

addiction treatment options, and stigma issues. 

4.1.17.4 

Ensure that appropriate treatment for opioid dependence, including the use of office-based opioid 

agonist therapy, is available for those patients who have developed an opioid dependence as a 

result of pain treatment. 

4.1.17.5 

Ensure that patients with chronic pain who demonstrate, or are deemed at risk for, aberrant behavior 

have access to structured pharmacy management programs that support opioid and medication pain 

management. 

Research

4.1.18 DoD and VHA Pain Research Strategy 

Develop collaborative pain research strategies that advance Warrior pain care and rapidly translate effective 

findings into practice. 

4.1.18.1 Develop a pain medicine research strategy to ensure evidence-based medicine guides clinical 

decisions. 

4.1.18.2 Ensure research in pain management incorporates emerging medical knowledge and technology 

needs to care for Wounded Warriors. 

4.1.18.3 Implement proposed solutions to ensure pain management research objectives, priorities, and 

resources enable MRMC to satisfy current, validated medical technology and information needs. 
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4.1.19 Research Strategic Communications 

Improve military pain research strategic communications. 

4.1.19.1 

Encourage collaboration among MRMC, CRMRP, and the AMEDD Center and School to 

institutionalize strategic communications and dissemination of innovation in pain management 

technologies and knowledge. 

4.1.19.2 Secure funding to support the acquisition of information system technologies. 

4.1.19.3 Secure funding for a central pain management advisory board. 

4.1.19.4 Task MRMC and CRMRP to provide a central pain management advisory board access to shared 

information platforms acquired by MRMC to fill research information needs. 

4.1.20 Clinical Practice Guidelines for Pain Management 

Standardize the practice of pain medicine with pain management clinical practice and clinical management 

guidelines. 

4.1.20.1 Incorporate Clinical Practice Guidelines into STRATCOM plan to ensure maximum awareness of 

pain related Clinical Practice Guidelines by DoD and VHA providers. 

4.1.20.2 Integrate Clinical Practice Guidelines into computerized medical record. 

4.1.20.3 Utilize a central pain management advisory board to develop priorities for future pain-related Clinical 

Practice Guideline development. 
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4.2 Build a Full Spectrum of Best Practices for the Continuum of Acute and 

Chronic Pain, Based on a Foundation of Best Available Evidence

An Integrative and Interdisciplinary Approach

4.2.1 Complementary and Integrative Pain Treatment Medicine 

Incorporate integrative and alternative therapeutic modalities into a patient centered plan of care. 

4.2.1.1 Adopt a tiered approach for the effective integration of integrative modalities to augment pain 

management for military and Veteran populations. 

4.2.1.2 

Establish integrative pain medicine capabilities at RPCoE's and DoD sites (Army, Navy, and Air 

Force) to champion integrative pain care with a focus on the best clinical practices, education, and 

research. 

4.2.1.3 

Establish baseline data on the clinical integrative practices being used, along with provider and 

patient perspectives, through a comprehensive DoD survey, utilizing existing survey models (if 

appropriate). 

4.2.1.4 

Develop an advisory board, with scholarly leaders in various integrative medicine fields, to assist in 

the development of appropriate programs, ensure proper credentialing of providers, and establish 

necessary guidelines for outcome measures and uniformed quality of care. 

4.2.1.5 Establish standardized and appropriate strategic communication plans on integrative health care 

methods for pain medicine. 

4.2.1.6 Develop and fund pilot programs across DoD in the delivery of integrative pain. 

4.2.1.7 Request Health Affairs undertake the evaluation of integrative medicine modalities in Tier I for 

inclusion as covered TRICARE benefits. 

4.2.2 Osteopathic Manipulation 

Leverage embedded osteopathic and physical therapy resources in the provision of manipulation therapies for 

musculoskeletal pain. 

4.2.2.1 Support osteopathic manipulation in staff clinics. 

4.2.2.2 Survey Active Duty Osteopathic Physicians and manually trained Physical Therapists to understand 

the uses, practices, and barriers of manual medicine. 

4.2.2.3 Implement and support Osteopathic Manipulation Graduate Medical Education during primary care 

and physiatry residency programs to utilize and continue developing current Army resources. 

4.2.2.4 Implement and encourage the use of osteopathic manipulation (or manual medicine) in theater. 

4.2.2.5 Incorporate osteopathic manipulation therapy referrals into case management in WTUs. 

4.2.2.6 Improve metrics, such as RVUs, which are used to measure the success of providers in treating 

patients but do not actually measure patient improvement. 
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4.2.3 Primary Care Pain Management 

Integrate pain management into primary care, consistent with the Patient Centered Medical Home Model. 

4.2.3.1 Implement a fully resourced Patient Centered Medical Home. 

4.2.3.2 Develop outcomes-based performance metrics that recognize and capture the quality and safety 

benefits of a holistic, patient-centric approach to health care. 

4.2.3.3 Identify a workgroup from DoD and VHA to ensure that DoD interdisciplinary pain care clinics, 

integrated with primary care, correctly adopt a stepped care pain treatment approach. 

4.2.4 Stepped Care Model 

Adopt the VHA Stepped Care Model to ensure timely access to collaborative care, reduce pain and suffering, and 

improve quality of life for Warriors and their Families. 

4.2.4.1 Implement the VHA Stepped Pain Care model. 

4.2.4.2 Leverage the VHA Directive Action Plan as a template for better coordination between MEDCOM 

and MHS. 

4.2.5 Musculoskeletal Action Plan 

Integrate the prevention, early identification, and treatment of injuries as a component of the comprehensive pain 

management strategy. 

4.2.5.1 

Develop an education and STRATCOM program focused on musculoskeletal injury prevention and 

human performance optimization, early identification, and management, rehabilitation, and 

reintegration. 

4.2.5.2 Integrate the Musculoskeletal Action Plan education program and concepts into the pain education 

and training program. 

4.2.5.3 

Create an organizational structure, culture, and climate for awareness and execution of the 

Musculoskeletal Action Plan by collaborating with DoD and stakeholders within the Army (includes 

FORSCOM, TRADOC, MEDCOM, USUHS, AMEDD C&S, etc). 

4.2.5.4 

Resource prevention and treatment programs that emphasize evidence-based practices. Capture 

relevant and available data to identify trends, cost, and return on investment. Utilize data to assist in 

the prioritization of resources. 
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4.3 Focus on the Warrior and Family - Sustaining the Force

Warrior and Family Care

4.3.1 The Safe Use of Opioids 

Implement a drug abuse assessment strategy to ensure the efficacy of pain treatment and reduce aberrant 

behavior, abuse and addiction with opioids. 

4.3.1.1 Implement a drug abuse assessment strategy in primary care as part of routine practice to set a level 

of monitoring proportionate to the individual’s risk. 

4.3.1.2 Use a written opioid treatment agreement that outlines patients’ rights, expectations, and specifies 

the consequences of noncompliance, and informed consent for all chronic opioid patients. 

4.3.1.3 Mandate that only one provider and his or her surrogate may prescribe for patients on chronic daily 

opioids and that the program is supported by the pharmacy department (Sole Provider Program). 

4.3.1.4 Mandate that all MTFs and VA Hospitals become active in the state prescription-monitoring 

programs to facilitate medication reconciliation and the safe prescribing of opioids (standard of care). 

4.3.1.5 Educate providers on pain and addiction, contraindications to opioid therapy, and the goals of a 

treatment plan. 

4.3.2 Embed Pain and Pharmacy Resources 

Provide appropriate pain management and clinical pharmacy oversight in Warrior Transition Units. 

4.3.2.1 Provide access to a Pain Management Provider at all WTU clinics. 

4.3.2.2 Provide a clinical pharmacist capability to all WTUs based on each WTU's individual need for clinical 

consultation and medication reconciliation. 

4.3.3 WTC Pain Survey Collaboration 

Collaborate with the Warrior Transition Command to revise the satisfaction survey to incorporate pain metrics. 

4.3.3.1 Incorporate recommended Task Force pain questions into the WTU Satisfaction Survey. 
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4.4 Synchronize a Culture of Pain Awareness, Education, and Proactive 

Intervention

A Unified Approach to Content, Education, and Training

4.4.1 Pain Curriculum Transformation 

Transform the pain curriculum at all levels of medical education and care delivery. 

4.4.1.1 Establish a core curriculum specific to pain management to be integrated into all DoD graduate 

medical education and advanced medical training programs. 

4.4.1.2 Integrate core pain education and training content into AMEDD training courses (68W, Office Basic 

Course, Combat Casualty Care Course). 

4.4.2 Integration of Pain Management Recommendations 

Integrate TF recommendations and STRATCOM with other related DoD and VHA programs. 

4.4.2.1 Develop pain management STRATCOM in collaboration with DoD and VHA programs with related 

interests. 

4.4.3 Pain Education Campaign Plan 

Develop a pain management education plan that addresses the full spectrum of stakeholders and issues. 

4.4.3.1 Further educate all DoD and VHA medical personnel on the disease process of pain and its 

management. 

4.4.3.2 Provide standard curriculum of pain education that is formed on the best available medical evidence. 

Pain Management and Leadership 

4.4.4 Standardize Pain Management Capabilities 

Establish enterprise-wide tiered pain management requirements to standardize patient care services. 

4.4.4.1 Adopt the tiered system of pain care. 

4.4.5 Interdisciplinary Pain Management Departments 

Establish interdisciplinary pain management services to oversee optimum patient-centered, integrated pain care. 

4.4.5.1 Establish TRICARE Regional Pain Center of Excellence networked to every MTF in that region. 

4.4.5.2 Establish an Interdisciplinary Pain Medicine Service at each major DoD MEDCEN. 

4.4.5.3 Define local capability requirements in establishing the tiered system of pain care delivery. 
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4.4.6 Pain Medicine Consultants to Military Leadership 

Develop requirements for Service pain consultants to reflect an interdisciplinary, integrative approach to pain 

management. 

4.4.6.1 Develop pain medicine consultant selection criteria to identify the candidates who best represent the 

integrative and comprehensive nature of pain medicine. 

4.4.7 Central Pain Management Advisory Board for DoD and VHA 

Establish an effective pain management advisory board for DoD and VHA. 

4.4.7.1 Establish the Defense and Veterans Pain Management Initiative (DVPMI) as the DoD and VHA 

central pain management advisory board for pain medicine issues. 

4.4.7.2 Task the DVPMI with the responsibility to establish pain care clinical standards, manage pain 

provider education programs, and provide recommendations for pain research priorities. 
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Appendix B: Supplement to Findings and Recommendations

B-1 Standardized Pain Taxonomy

Figure B-1.1: Pain Definitions

Pain

Pain is an unpleasant sensory and emotional experience associated with actual or 

potential tissue damage or described in terms of such damage. Pain is always subjective. 

Pain can be acute or chronic. 

Acute Pain 

Acute pain is a normal physiologic response, usually time-limited, to a noxious stimulus 

that enhances survival by warning the individual of impending or potential injury or 

progression of disease. If the noxious stimulus persists, changes in the peripheral tissues 

and both the central and peripheral nervous systems can lead to sensitization that worsens 

and prolongs the pain from noxious stimulation. Appropriate management of acute pain 

may prevent the onset of the pathophysiologic processes that change the spinal cord and 

brain and lead to chronic pain. 

Chronic Pain 

Chronic pain continues beyond the normal time expected for healing and is associated with 

the onset of pathophysiologic changes in the central nervous system that may adversely 

affect an individual’s emotional and physical well-being, cognition, level of function, and 

quality of life. Chronic pain serves no apparent useful purpose for the individual and may 

be diagnostically and therapeutically approached as a chronic disease process. 

Figure B-1.2: Extended Taxonomy List

Addiction

Addiction in the context of pain treatment with opioids is characterized by a persistent 

pattern of dysfunctional opioid use that may involve any or all of the following: 

Loss of control over the use of opioids. 

Preoccupation with obtaining opioids, despite the presence of adequate 

analgesia. 

Continued use despite physical, psychological, or social adverse consequences. 

Central

Central pain is a result of a primary lesion or dysfunction in the central nervous system 

(brain or spinal cord). Examples include pain from stroke, spinal cord injury, multiple 

sclerosis, or fibromyalgia. 

Dependence

Physical dependence on an opioid is a physiologic state in which abrupt cessation of the 

opioid, rapid tapering (e.g. when a patient forgets to take the medication), or administration 

of an opioid antagonist results in a withdrawal syndrome. Physical dependency on opioids 

is an expected occurrence in all individuals in the presence of continuous use of opioids for 

therapeutic or for non-therapeutic purposes. It does not, in and of itself, imply addiction. 

Neuropathic

Neuropathic pain is a result of a primary lesion or dysfunction in the peripheral and/or 

central nervous system(s). Symptoms may include numbness, tingling, burning, sharp, 

shooting, and/or aching. 

(continued on next page) 
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Peripheral

Peripheral pain is a result of a primary lesion or dysfunction in the peripheral nervous 

system (peripheral nerves – nerves outside the brain or spinal cord). Examples include 

direct nerve trauma, post herpetic neuralgia, carpal tunnel syndrome, or diabetic 

neuropathy. 

Phantom 

Phantom pain may be categorized as phantom pain or phantom sensations. Phantom pain 

is experienced as pain, tingling, itching, or numbness in the place where the amputated 

part used to be. Phantom sensation is the feeling that the amputated part is still there, but 

the sensations felt in the amputated part are not uncomfortable or painful for the individual. 

Pseudoaddiction

Pseudoaddiction describes patient behaviors that may occur when pain is undertreated. 

Patients with unrelieved pain may become focused on obtaining medications, may "clock 

watch," and may otherwise seem inappropriately "drug seeking." Even behaviors, such as 

illicit drug use and deception, can occur in the patient's efforts to obtain relief. In contrast 

to true addiction, in pseudoaddiction, the behaviors resolve when the pain is effectively 

treated. 

Misunderstanding of this phenomenon may lead the clinician to inappropriately stigmatize 

the patient with the label 'addict.' In the setting of unrelieved pain, the request for 

increases in drug dose requires careful assessment, renewed efforts to manage pain, and 

avoidance of stigmatizing labels. 

Pseudotolerance 

Pseudotolerance is defined as a need to increase dosage due to factors other than 

tolerance (a diagnosis of exclusion), such as disease progression, new disease process, 

increased physical activity, lack of compliance, change in medication, drug interaction, or 

deviant behavior. 

Radicular

Radicular pain is radiating pain and paresthesias (neuropathic pain) in the distribution of a 

specific nerve root. It may be associated with sensory loss or motor dysfunction in the 

distribution of the same nerve and paraspinal muscle spasms. 

Referred

Referred pain is pain that is felt at a location different than that of the injured or diseased 

part. The area where the pain is felt is usually innervated from the same spinal segment 

as that of the injured or diseased structure. Examples include angina (felt as left shoulder, 

arm, or jaw) or gallbladder (felt as right shoulder pain). 

Somatic

Somatic pain is a well localized pain (“pin point”) which results from activation of 

nociceptors located in the skin, deep soft tissues, muscles, bones, and joints. This pain is 

often described as aching or nagging and examples include pain associated with bruises, 

fractures, or wounds. 

Tolerance

Tolerance is a form of neuroadaptation to the effects of chronically administered opioids (or 

other medications), which is manifested by the need for increasing or more frequent doses 

of the medication to achieve the initial effects of the drug. Tolerance may occur both to the 

analgesic effects of opioids and to some of the unwanted adverse effects, such as 

respiratory depression, sedation, or nausea. The appearance of tolerance is variable in 

occurrence, but it does not, in and of itself, imply addiction. 

Visceral

Visceral pain is a poorly localized pain which results from activation of nociceptors located 

in the thoracic, abdominal, or pelvic viscera. This pain is usually poorly localized aching or 

cramping, which may be referred to cutaneous sites, increasing the difficulty of localization. 

Sources
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The Pain TF collaborated on the definitions listed above and used the following sources during the discussion: 

American Chronic Pain Association 

American Pain Society 

Braddom Physical Medicine and Rehabilitation 

Dorland's Medical Dictionary for Health Consumers 

Gale Encyclopedia of Medicine 

Heathline 

Institute for Clinical Systems Improvement 

International Association for the Study of Pain 

McGraw-Hill Concise Dictionary of Modern Medicine 

Medicine Net 

Medline - U.S. National Library of Medicine 

Mosby's Medical Dictionary 

National Pain Foundation 

National VA Pain Outcomes Working Group 

The American Heritage Medical Dictionary 

The British Pain Society 

VA and DoD Clinical Practice Guideline for the Management of Chronic Opioid Therapy (COT) 

Web MD
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B-2 Standardized Pain Assessment Tool

Figure B-2.1: Defense and Veterans Pain Rating Scale 
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Figure B-2.2: Defense and Veterans Pain Supplemental Questions 
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Summary for Internal Validation of the Standardized Pain Assessment Tool 

1. Sample

A total of 400 patients would be a good target. Eligibility criteria should include: 1) ability to read and understand 

English, 2) newly combat injured Soldiers, 3) older Veterans who have military-related injuries or other pain 

issues (e.g., chronic nonmalignant pain including a range of conditions [e.g., peripheral neuropathies, lower 

extremity arthritis, non-specific LBP], cancer-related pain, post-surgical pain, and other acute pain), 4) inpatients, 

and 5) outpatients. The sample should include a balance of those with acute pain and chronic pain and inpatient 

and outpatients. Of these patients, every 10th patient should be asked to participate in the descriptor validation 

(need about 40). 

2. Setting

Walter Reed Army Medical Center and selected VA Medical Centers (if willing to participate). 

3. Design

Cross sectional, one-time pain assessment. Patients will be asked to complete the DoD and VHA Pain 

Assessment Tool and the Brief Pain Inventory (BPI) 7 interference items. Items 1, 2, and 4 are duplicative of the 

BPI. Written instructions on completing the tools should be provided to participants. Every 10th patient (forms 

should be numbered) should be given the DoD and VHA pain intensity scale without the descriptors and be 

asked to select the number corresponding to their pain, and then match scrambled descriptors to the numbers. 

4. Demographic Data 

Age, gender, ethnicity, war veteran (e.g., OIF / OEF, Gulf War, Korean War, WWII), military status (e.g., active 

duty, retried, honorable discharge), type of pain (acute, chronic), cancer-related pain, inpatient vs. outpatient, 

length of hospitalization at the time of the interview, and duration of pain, as well as occupational status and 

marital status. 

5. Statistical Analyses 

Measures of central tendency (mean, median and mode) will be calculated for subgroups (e.g., acute pain, 

chronic nonmalignant pain, cancer-related pain, newly injured OIF and OEF, inpatient vs. outpatient. 

Correlational statistics will be used to demonstrate the magnitude of the relation between the mean BPI 

interference subscale score and pain intensity for the entire sample and selected variables. Independent rater 

content validation methods (qualitative analysis) will be used to validate the ability for respondents to correctly 

match the intensity descriptors to the pain intensity rating or Adult Faces Rating Scale. 
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B-3 Joint Theater Trauma System Clinical Practice Guideline

1. Goal

Provide standardization of pain care for Wounded Warriors evacuating from Level III facilities. Establishment of 

a physician pain consultant at all Level III facilities in Theater. 

2. Background

The physiologic response to battlefield trauma and surgery involves a “sympathetic surge” or stress response. 

The stress response involves a well-established sequence of physiologic and molecular events that include 

fever, tachycardia, tachypnea, hypertension, gastrointestinal ileus, hypercoagulability, protein catabolism, and 

immunosuppression, among other undesirable consequences that delay or prevent a Wounded Warrior’s full 

rehabilitation and recovery. 

Effective pain management requires coordination of all medical providers throughout the evacuation system to 

provide a multimodal approach to analgesia. The multimodal approach to analgesia involves using several 

different drug mechanisms of action and pain technologies which facilitates dose reductions of all pain 

medications used and therefore increases patient safety.3 This approach to pain care requires the 

establishment of an Acute Pain Service (APS) at all Level III (and above) health care facilities directed by a 

physician trained in pain management. 

3. Evaluation and Treatment

A. The Level III facility Commander will appoint a physician (usually an anesthesiologist) to head the facility 

APS who is trained in pain management. This officer is responsible for managing APS activities, delegation 

of APS responsibilities, and maintenance of APS equipment. The APS physician will serve as the 

Commander’s consultant on all facility issues related to pain management. 

B. All patients should have their pain assessed upon arrival and reassessed frequently using the DoD and VHA 

Pain Assessment Screen Tool. 

C. All patients should have a pain care plan established as part of their routine care. 

D. The patient’s primary physician should consult the guidelines when developing a pharmacologic plan for 

managing pain. 

E. The patient’s primary physician should consult the APS for complex pain issues or when advanced pain 

care technology or procedures are indicated (e.g. continuous peripheral nerve block, epidurals, pain drug 

infusions). 

F. Pain nursing is a vital component of every APS. Each health care facility patient ward will assign a member 

of the nursing staff to service as the ward pain nurse. The ward pain nurse will coordinate with the APS 

physician on all ward pain related issues. 

G. Effective pain management using multimodal techniques should not inhibit the timely diagnosis of 

compartment syndrome. In the case of combat trauma patients, if the surgeon is concerned about the 

possibility of compartment syndrome complicating a wound, the compartment should be surgically opened. 

The APS will work with the patient’s primary physician to develop a pain management plan that facilitates 

early recognition of compartment syndrome. There is no evidence that supports the exclusion of any pain 

management technique due to concerns of compartment syndrome. 
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H. Use of advanced pain management techniques should be encouraged, including, but not limited to, 

continuous peripheral nerve block, epidurals, pain medication infusions, and patient controlled analgesia. 

The APS physician is responsible for coordinating patient pain care issues and plans with the evacuation 

flight surgeon and receiving APS physician at the next receiving health care facility. Documentation of all 

advanced patient pain care techniques into the patient’s electronic medical record is mandatory. 

I. The Military Advanced Regional Anesthesia and Analgesia handbook will serve as the APS reference text 

for pain care standards and issues (www.bordeninstitute.army.mil or www.DVPMI.org). 

J. Tri-service policies for pain management can be found at www.DVPMI.org. Strategic issues on evacuation 

pain management should be referred by the health care facility APS physician to the Defense and Veterans 

Pain Management Initiative organization (www.DVPMI.org). 

4. Responsibilities

The health care facility Commander is responsible for establishing the APS and effective patient pain care 

services. 
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B-4 Electronic Pain Order Set

Pain Medication Orders 

1. PURPOSE 

To provide established guidelines for the safe and effective administration of pain medications at WRAMC and to 

educate and remind physicians and nurses of the appropriate pharmacological interventions to best manage the 

different types and levels of pain. Upon completion of the order set, the physician will have created an effective 

plan for each individual and particular patient. This appendix is meant to accompany and not override any 

previous guidelines on medication administration and does not preclude the use of clinical judgment when 

ordering pain medications.

2. APPLICABILITY 

This is applicable to all providers ordering and administering medications at WRAMC.

3. RESPONSIBILITIES 

A. Physician: 

1) Identify candidates for Pain Medications. Responsibility lies with the attending physician. 

2) Complete orders. 

3) Evaluate orders every 72 hours to determine if changes are necessary. 

4) Counsel patient and family or significant others on the purpose of the medication. 

B. Registered Nurses: 

1) Provide patient education for selected patients using established patient teaching guidelines and 

document accordingly. 

2) Initiate, maintain, change, and discontinue the medication therapy according to physician orders. 

C. Pharmacy Service: 

3) Provide educational resources for patients, Families, and health care providers. 

4) Ensure proper accountability, procurement, and wastage of pain medications, including providing a 

mechanism to restrict medications for individuals designated as using pain medications inappropriately. 

5) Alert physicians and providers to potential drug-drug and drug-food interactions. 

6) Ensure appropriate analgesics, including opioids, are maintained on nursing units/wards, as required. 

7) Monitor physician orders to ensure that only one long-acting or delayed release opioid is prescribed at 

one time and the use of meperidine (Demerol) is limited and appropriate (precautions about meperidine 

are necessary due to the toxic central nervous system effects of its active metabolite, normeperidine). 

4. PROCEDURE 

A. Opioids

Orders for Surgical or Injury Site Pain / Breakthrough Pain Orders

Physicians should consider these recommendations for the initial pain management for all routine inpatients. 

For the purposes of this document, mild pain is considered to be a visual analogue scale (VAS – zero = no 

pain; 10 = worst pain imagined) score of 1-4, moderate pain is a VAS of 5-7, and severe pain is a VAS of 8-

10. This does not preclude the use of clinical judgment when ordering pain medications. 
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FOR MILD TO MODERATE POST SURGICAL PAIN 

Consider Non-Steroidal Anti-Inflammatories (Listed Below) 

_____ VicodIn (5 mg hydocodone 500 mg acetaminophen) 1-2 tabs Q 6hrs prn 

_____ Percocet (5 mg oxycodone, 325 mg acetaminophen) 1-2 tabs oral q4hrs prn for VAS 7 or less 

OR

_____ OxyIR (oxycodone immediate release)___mg oral q4hrs prn for VAS 7 or less (5 mg tab) - USE IF 

PATIENT IS ON TYLENOL) 

_____ Dilaudid (2mg tab) 1-2 q4 hrs prn for VAS 7 or less 

FOR MODERATE-SEVERE PAIN CONTINOUS PAIN 

_____ Morphine sulfate PCA (use standard PCA order set) 

 OR 

_____ Dilaudid PCA (hydromorphone – use standard PCA order set) 

FOR MODERATE-SEVERE PAIN INCIDENTAL OR BREAKTHROUGH PAIN 

_____ Morphine sulfate___mg IV bolus q2hrs prn for VAS >5 

 OR

_____ Dilaudid (hydromorphone) ___mg IV bolus q3-6 hrs prn for VAS >5 

B. Non-Steroidal Anti-Inflammatories – Consider use in all patients to augment opioid based therapies or for 

mild to moderate pain. 

_____ Celebrex (celecoxib)___mg oral q12hrs (100, 200mg cap) 

 OR

_____ Motrin (ibuprofen)___mg oral q8hrs (400, 600, 800mg tab) 

 OR

_____ Toradol (ketorolac) 30 mg IV q6hrs, end date______(max 5 days) 

_____ Tylenol (acetaminophen)___mg oral q6hrs, end date_____(max 5 days) (325 mg tab, max 4000 

mg/day - Account for Tylenol dose if ordering Percocet )

_____ Naprosen/Aleve (Naproxen)___mg oral q12 hrs prn(250,375,500 mg tab) 

C. Opioid Orders for Opioid Tolerant Patients – Physicians should consider these long-acting opioids in 

patients requiring prolonged pain management. 

_____ Methadone___mg oral q8hrs (5 mg tab – mild NMDA receptor antagonism) 

 OR

_____ MS Contin (sustained release morphine)___mg oral q8hrs (15, 30, 60, 100 mg tab) 

 OR 

_____ Oxycontin (sustained release oxycodone)___mg oral q12hrs (10, 20, 40, mg tab)

 OR 

_____ Duragesic Patch (sustained release Fentanyl)___mcg Transdermal ( 25, 50 75 0r 100 mcg patch) 

change every 72 hours, allow 24 hors to work when applying the first patch.

D. Anticonvulsants (Membrane stabilizers) – Physicians should consider these medications in patients at 

increased risk for neuropathic pain such as crush/amputation trauma patients. 

_____ Neurontin (gabapentin)___mg oral q8hrs (300, 400, 600, 800 mg tab) 

_____ Lyrica (pregabalin)___mg oral q12hrs (25, 50, 100, 150, 225 mg cap – SPP required! 

E. Antidepressants – Physicians should consider these medications for chronic pain, neuropathic pain, and 

sleep/mood disorders. 

_____ Pamelor (nortriptyline)___mg oral qhs (10, 25, 50 mg cap) 

 OR

_____ Elavil (amitriptyline)___mg oral qhs (10, 25, 50, 75 mg tab) 
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 OR

_____ Cymbalta (duloxetine)___mg oral daily (20,30,60 mg) SPP required! 

F. Sleep Meds – Physicians should consider these medications for sleep disorders. 

_____ Ambien (zolpidem)___mg oral qhs prn (5-10 mg) 

_____ Seroquel (quetiapine)___mg oral qhs prn for nightmares (25-50 mg) 

G. Bowel Regimen – Physicians should consider in all patients subjected to long-term opioid therapy. 

_____ Colace (docusate sodium) 100 mg oral BID 

_____ Senna (8.6 mg tab) 1-2 tabs oral qhs as needed for patient complaint of constipation 

_____ Miralax (polyethylene glycol) 17 g (one cap) oral daily, adjust for bowel movement 

 OR 

_____ Milk of Magnesia 30 ml as needed for patient complaint of constipation 

H. Other Adjuncts – Physicians should consider for management of specific symptoms. 

_____ Benadryl (diphenhydramine)___mg oral q6hrs as needed patient complaint of difficulty 

sleeping or pruritus (25, 50 mg cap) 

_____ Zofran (ondansetron) 8 mg oral q12hrs as needed patient complaint of nausea/pruritus (4, 8 

mg tab) 

_____ Clonidine patch___mg/24hr, for neuropathic or phantom pain, apply to skin, change q week 

(0.1, 0.2, 0.3 mg/day patch) 

_____ Ativan (lorazepam)___mg oral q12hrs anxiety (1, 2 mg tab) 

_____ Ativan (lorazepam)___mg IV q4hrs as needed for patient complaint of anxiety 

_____ Lidoderm 5% patch. Apply topically to painful area for 12 hours on 12 hours off 

_____ Intranasal Calcitonin __200 Units QD X 2 Weeks 

_____ Clonodine 0.1 mg __ QD 

Acute Pain Medicine Consult 

Physicians should consider consulting the Acute Pain Service when standard treatments fail or for complicated acute 

pain issues that may require more advanced technology. 

_____ ESSENTRIS Acute Pain Consult (please call the acute pain service beeper at #108-6876) 

Figure B-4.1: World Health Organization Analgesic Ladder
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B-5 Standardized Medical Equipment and Personnel in the Deployed Setting

Figure B-5.1: Medical Equipment Template 
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B-6 Joint Regional Anesthesia and Analgesia Tracking System (JRAATS)

Appendix to Theater Integration CONOPS 

1. Purpose

During the course of Operations Enduring Freedom and Iraqi Freedom (OEF and OIF), many Service Members 

have been severely wounded. Pain management for the severely Wounded Warriors has been a challenge. 

However, the military anesthesiology community developed regional anesthesia techniques that have 

revolutionized pain management of the Wounded Warriors. These regional anesthesia techniques require close 

management at all times, whether the patient is in a hospital bed or being transported to another hospital. This 

appendix to the Theater Integration CONOPS describes requirements for a Regional Anesthesia Tracking 

System to allow for the required monitoring of Wounded Warriors who are benefiting from the advanced regional 

anesthesia pain management techniques. 

2. Current Status

The Army anesthesia specialists recognized the need to closely monitor Wounded Warriors who were receiving 

specialized regional anesthesia for pain control, especially during transportation. Therefore, they developed a 

Regional Anesthesia Tracking System (RATS) to monitor regional anesthesia patients as they traveled through 

the military health care system. RATS is a small, ad hoc information system. It allows medical providers to 

document pain management notes on a central server and notify receiving providers concerning patients with 

regional anesthesia that are being transported. RATS is a stand-alone system. It does not connect to or share 

data with any of the Military Health System (MHS) electronic health record systems, such as the Theater Medical 

Data Store (TMDS) or AHLTA. The anesthesia community has recognized the importance of the data collected 

in RATS. They have requested that RATS functionality be incorporated into a MHS electronic health record 

system. 

3. Planned Improvements

This Appendix includes requirements for incorporating the RATS functionality into TMDS. When included in 

TMDS, it will be renamed JRATS. 

4. Scenario. 

A. An airman working at a Forward Operating Base (FOB) is injured during a blast caused by a mortar round. 

The blast severs the airman’s left leg at his knee level. The airman is quickly stabilized at the scene and 

evacuated to the local Expeditionary Medical Support (EMEDS) hospital. 

B. Surgeons at the EMEDS stop the bleeding and stabilize the wound. While in the Operating Room, the 

anesthesiologist installs a Continuous Peripheral Nerve Block (CPNB) catheter in the left leg to stop the pain 

from the traumatic amputation. The CPNB is connected to a Patient Controlled Bolus (PCB) device so that 

when the airman begins to feel pain, he can add more medication to the CPNB. 

C. After the surgery and installation of the CPNB, the anesthesiologist logs on to JRATS. The anesthesiologist 

searches for the airman in JRATS using the airman’s last name and Social Security Number (SSN). After 

finding the airman, the anesthesiologist completes a Peripheral Nerve Block Procedure note. 

D. The EMEDS surgeon determines the airman needs to be evacuated to Landstuhl Regional Medical Center 

(LRMC) for more definitive treatment. The evacuation clerk logs on to TRAC2ES and completes a Patient 

Movement Request (PMR). In a few hours, the EMDS surgeon learns (through TRAC2ES) the airman will 

be evacuated in two days. 
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E. The next day, after evaluating the airman’s condition, the anesthesiologist determines the pain is well 

controlled with the CPNB. The anesthesiologist then logs in to JRATS, finds the airman’s record and 

documents a Clinical Note. When the anesthesiologist opens the Clinical Note, information from the 

anesthesiologist’s procedure note is “copy forwarded” into the Clinical Note. The anesthesiologist 

completes the clinical note with any changes to the airman’s status. 

F. On the day of the airman’s evacuation, the anesthesiologist logs on to JRATS, finds the airman’s record and 

documents a Transfer Note. When the anesthesiologist opens the Transfer Note, the previous day’s Clinical 

Note is “copy forwarded” into the Transfer Note. The anesthesiologist documents any changes in the 

Transfer Note. Within the Transfer Note, the surgeon clicks the “New Location” button which populates the 

Transfer Note with the airman’s receiving location (LRMC). The “New Location” button also triggers an 

email to be sent to the LRMC Pain Management Team notifying them of the impending arrival of the airman 

with advanced pain management technologies on board. 

G. The designated member of the LRMC Pain Management Team logs on to JRATS, finds the airman’s record, 

and reviews the pain management notes entered by the EMEDS anesthesiologist and surgeon. LRMC Pain 

Management Team uses the JRATS pain management notes to prepare for continuing care for the airman. 

H. After evaluating the airman at LRMC, the LRMC surgeon determines the airman needs to go to Walter 

Reed Army Medical Center (WRAMC) for further treatment and rehabilitation. The LRMC surgeon and Pain 

Management Team further determine the CPNB should remain during transport of the patient. 

I. The LRMC anesthesiologist logs on to JRATS, finds the airman’s record and documents a Transfer Note. 

When the LRMC Pain Management Team clicks the “New Location” button, an email is sent to the WRAMC 

Pain Management Team alerting them to the airman’s impending arrival. 

J. The designated member of the WRAMC Pain Management Team logs on to JRATS, finds the airman’s 

record, and reviews the pain management notes. The pain management notes assist the WRAMC Pain 

Management Team to prepare for continuing care for the airman. 

K. Two days after arriving at WRAMC, the surgeon determines the CPNB can be discontinued. When the Pain 

Management Team member discontinues the CPNB, a clinical note is documented in JRATS with this 

information. 

L. The WRAMC surgeon determines the airman should be transferred to a VA Poly Trauma Center for 

rehabilitative care. The receiving VHA provider is able to view (via Bidirectional Health Information 

Exchange) all of the theater notes documented on the airman, including the pain management notes 

entered through JRATS. Using these notes, the VHA provider is able to establish a continuing pain 

management plan during the airman’s rehabilitation. 

5. Requirements

The full list of requirements can be found at the TDMS shop. 
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B-7 Facilitate Osteopathic Manipulation Clinics and Education

Related Issues 

1. OMT visit logistics 

A. Separate clinic vs. embedded in primary care clinic setting for non-teaching visits 

B. OMT GME teaching clinics 

2. Concern for access to care

A. Held accountable for same throughput (#patients)? 

1) How to measure value as measured by and, in addition, to RVU? 

2) Improvements in coding (E&M/CPT) 

B. Expanded novel appointment templates–variable time slots (20/30 for OMT for non-GME settings) 

C. Limit the number of appointments for a certain diagnosis 

D. Handouts for patients describing what the clinic does, how many visits a patient may expect, process for 

referral, process for completion of care (resolution of problem vs. non-response to treatment and referral 

back to provider) 

3. OMT referral process (e.g. for non-DO, WTU, specialty providers) 

A. Consult-based only: 

1) GME OMT clinics are consult-based only 

2) Staff providers will see assigned patients, in addition to consults 

3) Consults will be seen for a set number of appointments and must follow up with assigned Primary Care 

Manager 

4. Applicability to inpatient setting 

A. GME training programs may implement inpatient OMT rounds: 

1) Analysis of staffing needs and applicability to each facility is needed 

B. Staff inpatient OMT consults: 

1) Based on availability and interest of OMT trained providers and command support 

5. Command Support / consultant support 

6. Coordinate with Chiropractic care 

A. Chiropractors provide similar, and sometimes identical, manual therapies to treat musculoskeletal 

complaints 

B. Coordination of manual medicine consults and clinics should be done at individual facilities for all providers 

using manual medicine to treat musculoskeletal complaints (OMT, Physical Therapy manual medicine, and 

Chiropractors) 

7. OMT Education 

A. Education for both MD and DO staff physicians 

B. GME education for both MD and DO resident physicians 

C. Integrated with allied health care providers (e.g. Physical Therapy) 

D. CME for staff 
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8. Staffing for residents 

A. Establish the optimal recommended ratio 

B. Concern for continuity of staff 

C. Ability to maintain recommended ratio for DO staff physicians to residents at GME training sites 

D. Contingency plan for when staff is not available 

9. Appointment templates 

A. GME 

1) 1 hour new visits 

2) 30 minute follow up visits 

B. Staff 

1) Integrated into routine appointment visits 

2) Follow up appointments for OMT for more complicated conditions with 20 or 30 minute slots 

10. Availability of resources 

A. Space 

1) GME Clinics 

a. One room per resident 

b. Room to review cases with staff 

c. Another option is to use a Physical Therapy Clinic (multiple treatment bays with individual 

treatment tables) for the GME OMT Clinic 

2) Staff Clinics 

a. Standard exam rooms 

i. Two rooms per provider is ideal 

B. Tables 

1) Flat, full length 

C. Staffing for GME programs 

11. Priority

A. OMT should not displaced in favor of other activities 

12. Competency Evaluation Standards Development 

13. Training module development 
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B-8 Primary Care Pain Management

Patient Centered Primary Care Collaborative (PCPCC) Principles 

1. Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and 

comprehensive care. 

2. The personal physician leads a team of individuals, at the practice level, who collectively take responsibility for the 

ongoing care of patients. 

3. The personal physician is responsible for providing for all of the patient’s health care needs or taking responsibility for 

appropriately arranging care with other qualified professionals. This includes care for all stages of pain care: 

preventive care, acute care, chronic care, and end of life care. 

4. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, 

hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private 

community-based services). Care is facilitated by registries, information technology, health information exchange and 

other means to assure that patients get the indicated care in a culturally and linguistically appropriate manner when 

and where they want and need it. 

5. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for 

communication between patients, their personal physician, and practice staff. 

6. Quality and safety are hallmarks of the medical home: 

A. Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are 

defined by a care planning process driven by a compassionate, robust partnership between physicians, 

patients, and the patient’s Family. 

B. Evidence-based medicine and clinical decision-support tools guide decision making. 

C. Physicians in the practice accept accountability for continuous quality improvement through voluntary 

engagement in performance measurement and improvement. 

D. Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are 

being met. 

E. Information technology is utilized appropriately to support optimal patient care, performance measurement, 

patient education, and enhanced communication. 

F. Practices go through a voluntary recognition process by an appropriate non-governmental entity to 

demonstrate that they have the capabilities to provide patient centered services consistent with the medical 

home model. 

G. Patients and Families participate in quality improvement activities at the practice level. 

7. Assessment of practice success appropriately recognizes the added value provided to patients who have a patientcentered medical home. The productivity metric structure should encompass the following in its framework: 

A. Reflect the value of physician and non-physician staff patient-centered care management work that falls 

outside of the face-to-face visit. 

B. Account for services associated with coordination of care both within a given practice and between 

consultants, ancillary providers, and community resources. 

C. Support adoption and use of health information technology for quality improvement. 

D. Support provision of enhanced communication access, such as secure e-mail and telephone consultation. 

E. Recognize the value of physician work associated with remote monitoring of clinical data using technology. 

F. Recognize case mix differences in the patient population being treated within the practice. 

G. Recognize and quantify savings from reduced hospitalizations and emergency services associated with 

physician-guided care management in the office setting. 

H. Recognize and reward achieving measurable and continuous quality improvements. 
APPENDICES

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B-9 Stepped Care Model and VHA Directive

VHA DIRECTIVE 2009-053 

Pain Management 

1. PURPOSE 

This Veterans Health Administration (VHA) Directive provides policy and implementation procedures for the 

improvement of pain management consistent with the VHA National Pain Management Strategy and compliance 

with generally accepted pain management standards of care. 

2. BACKGROUND 

A. The VHA National Pain Management Strategy, initiated November 12, 1998, established Pain Management 

as a national priority. The overall objective of the national strategy is to develop a comprehensive, 

multicultural, integrated, system-wide approach to pain management that reduces pain and suffering and 

improves quality of life for Veterans experiencing acute and chronic pain associated with a wide range of 

injuries and illnesses, including terminal illness. VHA employs a stepped-care model of pain care that 

provides for management of most pain conditions in the primary care setting. This is supported by timely 

access to secondary consultation from pain medicine, behavioral health, physical medicine and 

rehabilitation, specialty consultation, and care by coordination with palliative care, tertiary care, advanced 

diagnostic and medical management, and rehabilitation services for complex cases involving comorbidities 

such as mental health disorders and traumatic brain injury (TBI). 

B. Definitions 

1) Stepped Care. Stepped care is instituted as a strategy to provide a continuum of effective treatment to 

a population of patients from acute pain caused by injuries or diseases to longitudinal management of 

chronic pain diseases and disorders that may be expected to persist for more than 90 days, and in 

some instances, the patient’s lifetime. 

i. Step One, Primary Care. Requires the development of a competent primary care provider 

workforce (including behavioral health) to manage common pain conditions. To accomplish this, 

primary care requires the availability of system supports, family and patient education programs, 

collaboration with integrative mental health-primary care teams, and post-deployment programs. 

ii. Step Two, Secondary Consultation. Requires timely access to specialty consultation in pain 

medicine, physical medicine and rehabilitation, Polytrauma programs and teams, and pain 

psychology; occasional short-term co-management; inpatient pain medicine consultation; and 

the collaboration of pain medicine and palliative care teams. 

iii. Step Three, Tertiary, Interdisciplinary Care. Requires advanced pain medicine diagnostics and 

pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation 

Facilities (CARF). 

2) Quality of Life. Quality of life is now accepted by the medical field as a standard outcome measure of 

effectiveness of treatment, including treatment of pain. The concept includes such factors as level of 

physical and psychosocial functioning (e.g., in roles at work and home) and treatment satisfaction. 

3) The Biopsychosocial Model. The Biopsychosocial Model takes the position that the causes and 

outcomes of many illnesses often involve the interaction of physical and pathophysiologic factors, 

psychological traits and states, and social-environmental factors. Effective treatment planning accounts 

for the salience of these factors in the precipitation and perpetuation of illness and illness-related 

disability. 
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4) VHA National Pain Management Strategy Coordinating Committee. The VHA National Pain 

Management Strategy Coordinating Committee, a multidisciplinary Field Advisory Committee, was 

established to support the National Pain Management Program Office in meeting its responsibilities. 

The Committee is comprised of representatives from key clinical disciplines involved in provision of 

quality pain care as well as representatives from other VHA offices, including, but not limited to, the 

Employee Education System (EES), Office of Research and Development (ORD), Mental Health, 

Geriatrics and Extended Care, Primary Care, Nursing, Rehabilitation, and Pharmacy Benefits 

Management. 

C. Specific Objectives 

The updated VHA National Pain Management Strategy aims to: 

1) Establish expectations for attitudes, knowledge, and skills in pain management in primary, secondary, 

and tertiary care. 

2) Create system-wide VHA care standards for pain management, appropriate to setting and professional 

roles that reduces suffering and improves quality of life. 

3) Ensure that pain assessment is performed in an appropriately timely, regular, and consistent manner 

along the continuum of care from acute to chronic pain in all VHA settings. 

4) Ensure that pain treatment is prompt and strives to achieve pain management objectives along the 

continuum of care from acute to chronic pain in all VHA settings. 

5) Include patients and families as active participants in pain management. 

6) Provide for appropriate level and frequency of monitoring for improvement in outcomes of pain 

management including pain control, physical and psychosocial function, quality of life, and 

complications. 

7) Provide for an interdisciplinary, multimodal approach to pain management that emphasizes optimal pain 

control, improved function, and quality of life. 

3. POLICY 

It is VHA policy that VHA’s National Pain Management Strategy and the on-going work of the VHA National Pain 

Management Program Office and Coordinating Committee is to be used to guide the development of local 

policies related to pain management. 

4. ACTION

A. VHA National Pain Management Program Office. The VHA National Pain Management Program Office, in 

VA Central Office, has the responsibility for policy development, coordination, oversight, and monitoring of 

the VHA National Pain Management Strategy. Specifically, the National Pain Management Program office is 

charged with: 

1) Coordinating the system-wide implementation of the Strategy, including full implementation of a 

stepped care model of pain care at the facility and Veterans Integrated Service Network (VISN) levels. 

2) Coordinating a system-wide performance improvement plan. This plan evaluates the effectiveness of 

the VHA in meeting the objectives of the Strategy; it includes working with the appropriate VHA offices 

to establish target goals, mechanisms for accountability, and a timeline for implementation for a 

comprehensive, integrated VHA National Pain Management Strategy. 
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3) Coordinating the development and dissemination of state-of-the-art treatment protocols for pain 

management that are appropriate for different facility types (e.g., neuropsychiatry facility, teaching 

facility, and community based outpatient clinic). 

4) Identifying VHA pain management expertise and resources at each facility and VISN. 

5) Facilitating a national and regional referral system to ensure that all eligible Veterans have timely and 

appropriate access to pain management services. 

6) Collaborating with the EES, Primary Care Program Office, and the several other relevant program 

offices, as appropriate, to develop, implement, and disseminate education and training tools to assist 

VHA clinicians in acquiring the skills necessary to provide high-quality pain assessment and treatment. 

This includes funding to: 

i. Establish performance expectations; 

ii. Develop facility and VISN self-assessment tools; 

iii. Develop effective educational programs and tools including distance learning; 

iv. Evaluate the performance of these programs and tools in improving clinical care; and 

v. Establish feedback mechanisms for clinical improvement. 

7) Collaborating with ORD in identifying pain research opportunities and priorities and facilitating 

collaborative research efforts. 

8) Collaborating with the Office of Academic Affiliations in assessing the current state of pain management 

education in health professional training programs (“gap analysis”) and in exploring the development of 

innovative educational interventions for enhancing pain management. 

9) Establishing a plan for both 

B. Veterans Integrated Service Network (VISN) Director. The VISN Director is responsible for ensuring that: 

1) All facilities within the VISN establish and implement current pain management policies consistent with 

this Directive. 

2) A pain management Point of Contact (POC) is appointed and supported at the VISN level who is an 

appropriately trained and experienced clinician credentialed in pain medicine, pain management, or 

another credential appropriate to the clinical discipline. 

3) Tertiary interdisciplinary pain care services are available at the VISN level that include the capacity for 

advanced diagnostics and advanced integrated and interventional pain medicine, as well as functional 

rehabilitation for complex cases (e.g., chronic pain with comorbidities, such as post-traumatic stress 

disorder (PTSD), TBI, and substance abuse). NOTE: Each VISN is expected to have at least one 

CARF-accredited tertiary, interdisciplinary pain care program no later than September 30, 2014. 

4) The implementation of the VHA Pain Management Strategy is evaluated according to performance 

measures established by the National Pain Management Program Office. 

C. VISN POC. The VISN POC is responsible for: 

1) Reporting to the VISN Director annually to describe progress in implementing the Pain Management 

Strategy throughout the VISN; 
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2) Establishing a VISN pain committee to develop timelines for achieving and maintaining pain 

management standards; 

3) Partnering with VISN primary care leadership to develop a shared implementation strategy; 

4) Collaborating with VISN leadership in preparing responses to formal inquiries from the National Pain 

Management Program Office; 

5) Maintaining a reliable contact list of facility Pain POCs; and 

6) Serving as a link in communication 

D. Facility Director. The Facility Director, in consultation with the Chief of Staff and Associate Director for 

Patient Care Nursing Services, is responsible for ensuring that: 

1) The objectives of the VHA National Pain Management Strategy are met, including establishing a 

multidisciplinary pain management committee. 

2) A stepped care model of pain care is fully implemented. 

3) Accepted standards of pain care are met. These standards are: 

i. Pain assessment and treatment; 

ii. Evaluation of outcomes and quality of pain management; and 

iii. Clinical competence and expertise in pain management. 

5. REFERENCE 

Veterans’ Mental Health and Other Care Improvements Act of 2008, Public Law 110-387 § 501. 

6. FOLLOW-UP RESPONSIBILITY 

The Office of Patient Care Services (11), Medical-Surgical Services (111) is responsible for the contents of this 

Directive. Questions may be referred to the National Program Director for Pain Management at (203) 937-3841. 

7. RESCISSIONS 

VHA Directive 2003-021 dated May 3, 2003, is rescinded. This VHA Directive expires October 31, 2014.

STANDARDS OF PAIN MANAGEMENT 

The accepted standards of pain management are: 

1. PAIN ASSESSMENT AND TREATMENT 

Procedures for early recognition of acute and persistent pain and the design of prompt, longitudinal, and 

effective treatment must be implemented at each medical facility. 

A. VHA has implemented “Pain as the 5th Vital Sign” in all inpatient and outpatient clinical settings to ensure 

consistent recognition and assessment of pain intensity and pain's effects on function and quality of life. 

NOTE: A toolkit for implementation of this standard is available at the VHA pain management Web site at: 

www.va.gov/pain_management. 
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B. Routine assessment for the presence of pain is required for non-communicative patients, as well as for 

patients who communicate well. Assessment in this circumstance requires an approach that involves a 

range of methods including: direct observation by clinical staff, input from family members, and close 

monitoring of the effects of pain management interventions. 

NOTE: A consensus statement that provides additional guidance for pain screening in the noncommunicative patient is available at the VHA pain management Web site at: www.va.gov/pain_ 

management. 

C. Once pain symptoms are recognized, a timely and appropriate comprehensive pain assessment is 

performed, a pain treatment plan is developed and implemented, and reassessment of the effectiveness of 

the plan is completed. Each of these parameters must be documented. 

 

NOTE: To ensure consistency of documentation and to facilitate pain outcomes monitoring, all facilities are 

strongly encouraged to use the pain reminders and dialogs sponsored by the VHA National Pain 

Management Strategy Coordinating Committee. These reminders and dialogs can be downloaded from the 

Clinical Reminders Web page at: vista.med.va.gov/reminders. 

D. Patient and family education regarding pain and pain management is included in the treatment plan. 

NOTE: Patients are encouraged to be active participants in pain management. 

E. Evidence-based, to the degree possible, pain management protocols are implemented in all clinical settings. 

1) Using guidelines. Published clinical practice guidelines and related resources providing information 

regarding these pain management protocols are available on the VHA pain management Web site at: 

www.va.gov/pain_management and at: www.healthquality.va.gov. 

2) Patient participation in decision-making. Most uncomplicated pain conditions, for which the 

responsibility for assessment and management rests with the primary care provider or team (trained to 

implement a stepped care approach, as needed), respond best to one or more of several therapies 

readily available and coordinated in primary care settings. These therapies emphasize continuing 

patient participation in decision-making and clinical planning, patient instruction in self-management, 

and appropriate levels of family participation. 

NOTE: Standards for training in the use of these therapies in a primary care and other settings is 

available on the VHA pain management Web site at: www.va.gov/pain_management. 

3) Implementing stepped, consultative care 

i. Integrating behavioral health in primary care of chronic pain is essential to optimize clinical 

outcomes and provide essential support to the medical care of patients. Chronic pain can be a 

complex, biopsychosocial condition involving cognitive, psychosocial, and substance abuse issues 

as well as medical and mental health comorbidities. The complexity of chronic pain management 

is often beyond the expertise of a single practitioner, especially for patients whose pain problems 

are complicated by homelessness, PTSD, cognitive impairment from TBI and other conditions, 

including depression, combat injuries, Polytrauma, substance abuse, and other complex 

psychosocial issues. The experience of pain both impacts and is affected by social and family 

functioning. Veterans with complex chronic pain conditions are best served by a comprehensive, 

interdisciplinary approach within a continuum of care that is informed by a biopsychosocial model. 
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NOTE: The VHA Pain Management Program is presently developing models of pain care through 

inter-program collaboration with various VHA program offices, as listed below. Educational 

programs are being planned and executed through Employee Education System (EES) to present 

such collaborative clinical planning. New program models to achieve the objectives of this 

Directive will be found on the VHA pain management Web site at www.va.gov/pain_ management

as they are implemented. 

ii. Primary care providers must have access to pain consultative and treatment sources to effectively 

evaluate and manage these complexities. Access must be timely to the needs of the Veteran. 

These sources include Pain Medicine specialists, interdisciplinary pain clinics and centers, Hospice 

and Palliative Care Services, Mental Health services, Social Work services, and Clinical 

Chaplaincy services, among others. If such consultative services are not readily available at a 

specific facility, the facility Director, or designee, is responsible for arranging with the VISN Director 

reasonable and timely access to these consultative services through inter-facility collaborations 

within the VISN or through community resources, as appropriate. 

iii. At least one tertiary, interdisciplinary pain rehabilitation program must be available in each VISN to 

manage more complex cases. 

iv. Acute pain management is expected in every environment, including provision for seamless pain 

management during transportation from primary care and secondary care facilities to tertiary care. 

F. Effective pain management often requires consideration of the use of one or more of several different 

classes of medications and other treatment modalities prescribed simultaneously. Treatment may become 

particularly complex in the context of several causal or perpetuating mechanisms and comorbidities. The 

potential for each modality for improving pain treatment outcomes is weighed against the potential for drugdrug and drug-disease interactions, side effects, and toxicities. Patients with cognitive deficits from disease 

or TBI are particularly vulnerable when drug regimens increase in their complexity. Evidence-based 

stepped care treatment algorithms for managing different types and complexities of chronic pain and its 

comorbidities is readily available to providers as is training appropriate to their practice setting. 

G. The safe and effective use of opioid analgesics for the management of pain, particularly complex chronic 

pain conditions, requires special attention to personal and public health risks. 

1) Risks include adverse side effects of these medications, development of addiction, and risks to the 

public through diversion of prescribed medications. 

2) The potential for fatal overdose either by accident or in a suicidal attempt in patients suffering from 

multiple disorders or with polypharmacy must be considered in prescribing opioids and other 

medications, including prescribing for pain patients on opioid substitution programs. 

NOTE: Published guidelines for chronic opioid therapy, pain polypharmacy, and management of pain 

in the post-operative setting are available to guide the use of these medications. These guidelines are 

available at www.healthquality.va.gov and on the VHA pain management Web site at 

www.va.gov/pain_management . Completion of a written opioid pain care agreement is strongly 

encouraged to document provider-patient discussion of potential risks and benefits of opioids, provider 

and patient responsibilities related to their use, and the parameters for continued use. In this context, 

other methods such as random urine drug monitoring, frequent clinic visits and opioid renewal clinics 

may be useful to ensure adherence and safety. Further information about how to manage opioid 

treatment agreements can be found at www.healthquality.va.gov and on the VHA pain management 

Web site, www.va.gov/pain_management. 
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H. As pain management is an integral part of palliative and end-of-life care, the expertise of hospice and 

palliative care clinicians needs to be available to all patients with a serious, life-limiting illness. 

I. Patient satisfaction with pain management is monitored on an on-going basis. 

2. EVALUATION OF OUTCOMES AND QUALITY OF PAIN MANAGEMENT 

A. A multidisciplinary pain management committee must be established at each VHA facility to provide 

oversight, coordination, and monitoring of pain management activities and processes to facilitate the 

implementation of the VHA Pain Management Strategy in compliance with evidence-based standards of 

pain care and adherence to requirements of external accrediting bodies. In some facilities, this function may 

be the responsibility of an overarching clinical practice committee. In each facility, processes will be 

developed and implemented to evaluate the success of meeting the goals of the VHA National Pain 

Management Strategy on a regular basis, at least yearly. 

B. The quality of pain assessment and the effectiveness of pain management interventions must be monitored. 

Measures may include: adherence to published clinical practice guidelines, timeliness of pain treatment, 

adequacy of pain control, medication safety, appropriate use of stepped care treatment including behavioral 

health and pain medicine consultation and treatment, and clinical outcomes such as improvements in pain 

control, patient satisfaction, physical and psychosocial functioning, and quality of life. 

NOTE: A VHA Pain Outcomes Toolkit is available at www.va.gov/pain_management/docs/outcomes.doc. 

C. All elements of pain management must be documented in the patient record, often in the initial visit or in 

subsequent visits as clinically indicated over time. 

NOTE: For clinical tips, clinicians may want to consult www.va.gov/pain_management/docs/outcomes.doc

and www.va.gov/pain_management. Elements of pain management include: 

1) Medical History. The patient's prior experience of pain and pain-related diseases, disorders, injuries 

and comorbidities. 

2) Routine Screening for Pain. Routine screening for the presence and intensity of pain using "Pain as the 

5th Vital Sign," or a validated alternative tool for special populations, must be documented. This must 

be accomplished in association with outpatient or home visits and in residential and inpatient settings at 

a frequency that is appropriate to the specific clinical setting and problem. Screening for pain in noncommunicative patients must be documented by the use of the code "99," which indicates the pain 

assessment occurred in lieu of a verbal assessment. 

NOTE: It is important to appreciate that the goals of this method include the timely monitoring of pain 

treatment effectiveness, and the identification of new or previously undetected pain concerns. 

3) Comprehensive Pain Assessment. NOTE: Use of pain reminders and dialogs is encouraged. 

4) Individualized Plan of Care. An individualized goal-oriented, prioritized pain management plan of care 

that may include, but is not limited to: 

i. Pharmacologic interventions, including: 

a. The use of mechanism-specific and condition-specific treatment algorithms, 
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b. Appropriate trials of individual medications to determine effectiveness (pain control and 

function), and 

c. Cessation of medication without effectiveness. 

ii. Prescribing opioid analgesics for regular use, documentation of: 

a. An opioid pain care agreement, which is strongly encouraged, if not mandated (according to 

local facility policy), 

b. Effectiveness, including pain control, function, and quality of life, and 

c. Safe storage and management in the home. 

iii. Non-pharmacologic interventions, to include: 

a. Educational interventions to improve self-management; 

b. Psychological interventions, including established psychotherapies for chronic pain and 

associated sequelae (e.g., Cognitive-Behavioral Therapy), in conjunction with other 

treatments as appropriate, particularly for patients with unremitting chronic pain that 

demonstrate limited response to other treatment approaches; 

c. Family interventions and community supports; 

d. Rehabilitation therapies; 

e. Complementary therapies as available; and 

f. Pain medicine specialty procedures, such as injections, nerve blocks, ablations, and 

neuromodulation. 

5) Evaluation. Periodic evaluation of adherence, response to interventions, and achievement of timelimited therapeutic goals in the pain management plan, should include: 

i. Moderation or alleviation of pain; 

ii. Satisfaction with current treatment plan; 

iii. Stabilization or improvement in physical and psychosocial function; 

iv. Stabilization or improvement in salient comorbidities and overall health status; 

v. Adherence to opioid pain care agreement, if used; and 

vi. Adherence to pain management plan of care. 
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6) Education. Pain education for family and patient that may include the availability of pain specific 

programs, such as: formal pain school; pain relevant Web sites; printed pain management patient 

education materials at or below the ninth grade literacy level; and hospital video networks. Veterans' 

learning needs, readiness, preferences and barriers should be considered to ensure that messages are 

presented in an understandable format which the Veteran finds helpful. This education needs to occur: 

i. During hospitalization, as soon as clinically appropriate and acceptable to the patient. 

ii. At discharge from hospital or facility. 

iii. In all outpatient treatment settings when pain is assessed or treated. 

3. CLINICIAN COMPETENCE AND EXPERTISE IN PAIN MANAGEMENT 

A. All clinical staff (e.g., physicians, psychologists, nurses, pharmacists, therapists, and chaplains), should 

have orientation related to the principles of pain assessment and management upon being hired, as well as 

ongoing education and training. While general principles of pain management apply to all VHA clinicians, 

each staffing group must clearly delineate its specific pain management responsibilities and abilities and 

ensure that all its members receive training adequate to meet these responsibilities and to maintain these 

abilities. Education and training must be relevant to the specific needs of the patient population and clinical 

setting that provider groups serve, and should include, as appropriate, pharmacologic (especially opiates 

and including education regarding physical dependency, pseudoaddiction, tolerance, and potential for 

addiction, overdose and/or suicide; appropriate titration; side effects and benefits) and non-pharmacologic 

(including psychological, physical, complementary, and spiritual) treatment modalities. 

NOTE: Annual pain management education for clinical staff is highly recommended. Such education 

should include: for physicians, PAs, CRNPs, and nurses, 5 hours of continuing education in pain 

management, which can be obtained by attending continuing medical education (CME) and continuing 

education unit (CEU) offerings, completing online self-studies for CME and CEUs, or earning the credits in 

other ways and submitting evidence of the credits to the education staff at their facility. When feasible, 

facilities are encouraged to provide interactive "workshop" formats for learning specific cognitive and 

behavioral skills. Courses and educational tools for facilities can be found on the VHA pain management 

Web site at www.va.gov/pain_management. It is highly recommended that Pain Medicine Physician 

specialists obtain and maintain one or more of the following certifications: Pain Medicine specialty board 

certification by the American Board of Pain Medicine; Pain Management subspecialty board certification by 

the American Board of Anesthesiology, the American Board of Physical Medicine and Rehabilitation, or the 

American Board of Psychiatry and Neurology; Hospice and Palliative Care Medicine subspecialty board 

certification by one of the various ABMS boards granting this certification. It is recommended that they 

should also obtain yearly pain-relevant continuing medical education. In addition, innovative training 

programs are being developed and evaluated to ensure the adequacy of the pain management workforce 

for providing quality pain management to all Veterans regardless of location. 

B. VHA standards for pain management will be communicated by training faculty to all medical students, allied 

health professional students, residents, and interns who provide patient care; appropriate education in pain 

assessment and management will also be provided to these students and trainees. 
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THERAPIES EMPHASIZING CONTINUING PATIENT PARTICIPATION 

Most uncomplicated pain conditions, for which the responsibility for assessment and management rests with the 

primary care provider or team (trained to implement a stepped care approach, as needed), respond best to one or 

more of several therapies readily available and coordinated in primary care settings. These therapies emphasize 

continuing patient participation in decision-making and clinical planning, patient instruction in self-management, and 

appropriate levels of family participation. 

NOTE: Standards for training in the use of these therapies in a primary care and other settings is available on the 

VHA pain management Web site at: www.va.gov/pain_management. Therapies may include, as medically 

appropriate and indicated: 

1. Medication management through evidence-based algorithms; 

2. Office-based procedures (e.g., myofascial injections); 

3. Behavioral therapies (e.g., pain school, behavioral groups, support groups); 

4. Physical therapy interventions (e.g., stretching, posture, exercise, ice, and electronic stimulation), occupational 

therapy interventions (e.g., splinting, positioning, and adaptive equipment for modified activity, and chiropractic 

interventions (e.g., spinal manipulation); and 

5. Complementary and alternative therapies based on availability (e.g., acupuncture, massage, tai chi) may be 

considered. 

Figure B-9.1: Continuum of Stepped Care 
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Figure B-9.2: VHA Stepped Care Model 
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B-10 The Safe Use of Opioids

Safety Proposals 

1. Improve assessments of pain with function, pain level and quality of life to determine if pain is 

undertreated or over-treated and what are patients’ barriers to good treatment 

A. Need primary care pain team or clinic 

B. Need Assessment tools 

2. Psychological assessment of each patient 

A. Identify patients in pain with substance abuse, mental disease, PTSD, mTBI 

B. Determine suicide risk 

C. Risk Stratification of patients with chronic pain – low, moderate, high 

3. Profiles provided for Soldiers on chronic opioids 

A. Notifies command of safety issues 

B. May effect deployability or need for change of military occupational specialty 

4. Identify addiction and provide treatment 

A. Visibility of Army Substance Abuse Program referrals and assessments 

B. Medical is notified of command directed hot UAs for safe use of pain meds 

5. PCMs able to identify their chronic pain patients 

A. Providers need a quarterly list of their chronic pain patients 

B. Providers should have available calculated daily morphine equivalents, and the number of prescribers for 

past quarter for each patient 

6. Improve documentation of pain visits and opioid refills 

A. Separate appointments with PCM for only pain management 

B. Document analgesia level, ADLs-function, adverse effects and aberrant behaviors (4A’s) for both visits and 

telephone consults 

C. Document longitudinally aberrant drug-related behaviors 

D. Determine effectiveness of pain treatment 

E. Set Treatment Goals 

7. Clinical Guidelines for Opioid Therapy at MTFs and VA Hospitals with measurable metrics 

A. Chronic pain patient should have PCM and sole prescriber 

B. All chronic pain patients have Opioid Treatment Agreement and Informed Consent (should be standardized) 

C. Chronic pain patient must see PCM at least every six months 

D. High Risk chronic pain patients must see pain specialist every 2 years 

E. Documented drug screening for illegal drugs and compliance 

8. Provide Opioid Return Program for unused prescriptions of opioids to decrease doses available for 

misuse and abuse 

A. Prescribe smaller quantities 

B. Limit number of tablets (provide multiple dated Rxs) 

C. Ceiling limit mg of morphine/day prescribed in primary care 
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9. Launch Safety Education Program to educate teens, providers, Soldiers and Families 

A. Educating about the dangers of drugs leads to a decrease in abuse 

B. Proper disposal of opioids 

C. Dangers of using someone else’s prescriptions 

10. Provide non-drug pain therapies at both inpatient and outpatient clinics 

A. Consider OMT teams 

B. Acupuncture 

C. Provide a resource list to all providers in each MTF and VA Hospital 

11. Improve communication between civilian and VA, and MTF pharmacies for all beneficiaries 

A. Poly-pharmacy is a problem (example: methadone at VA and opioids at MTF) 

B. Outside mental health provider prescribing benzos and MTF giving opioids 

12. System to flag patients 

A. ER “frequent fliers” and list the sole prescriber 

B. History of addiction 

C. Suicidal risk 

D. High risk due to medication regimens-multiple psychoactive drugs with opioids 

E. Misuse/Abuse behaviors who require closer monitoring 

F. Notify ER of drug seeking behaviors, opioid treatment agreement, medication management plan 

G. Identify patients who need safety restrictions 

1) TRICARE limit controlled drugs or prescribers (MTF only or one prescriber) 

2) Limit 1:1:1 one prescriber, one pharmacy, and one ER 
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B-11 WTC Pain Survey Collaboration

Figure B-11.1: Pain Survey Questions Provide to WTC 
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B-12 Pain Education Campaign Plan

Figure B-12.1: Notional Pain Management Curriculum (extended list) 

100 - General Information about Pain / Pain Management 

101: Introduction to Pain Management (Audience: General Military Population) 

Core knowledge and message about pain/pain management for patients, medical staff, Family members, and 

leaders. It should describe an approach to pain and pain management within our health care systems. 

Definition in non-clinical terms, describe the problem to nation and the military.

Introduction to the new DoD/VA pain scale. How it will be used and what it will mean for patients. 

Introduction to the new DoD Tier structure for pain management.

Pain and the Patient – expectations and responsibilities. What care should patients expect, what are 

reasonable goals for pain treatment, and what responsibilities do patients have in the management of their 

pain?

Pain medications – good, bad, and ugly. What are substance abuse, misuse, and dependence? What is 

drug addiction? What about alcohol and tobacco?

102: Pain Management for Leaders/Supervisors (Audience: Military Leaders) 

Understanding pain, effects on readiness, deployment, medications, profiles, communication with Medical 

Providers.

Basic pain pharmacology. What are the risks and benefits of broad categories of drugs, such as opioids, 

NSAIDs, antidepressants, anti-seizure, sleep aids, and others?

What are the pain resources throughout the Levels of care?

103: Understanding a Family Member with Pain Management Issues (Audience: Family Member of 

those with pain management issues) 

Coping skills, support.

Resources (military and civilian) available for assistance.

Warning signs that alert to self-destructive behavior. How do I intervene?

104: Patients with pain and co-existing disorders of TBI, PTSD, Depression, Substance Abuse, etc. 

(Audience: All of the above) 

What is the relationship between these issues and pain?

Strategies and resources for minimizing the impact of pain on patients with co-existing disease.

200 - Pain Management for Healthcare Staff 

201: Introduction to Pain Management for Healthcare Personnel (Audience: All health care personnel) 

Medical overview, definitions, mechanisms, pathophysiology, identification, assessment and basic 

management.

Overview of pain care throughout the continuum. Introduction of the Tier system of pain care.

Introduction of the new DoD/VA pain scale. How is it administered and how is the information used clinically?

(continued on next page) 
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202: Pain Management in Primary Care (Audience: Primary Care Providers) 

Information on proper assessment, management, and referral of pain management conditions for the primary 

care provider.

PASTOR – an introduction to the tool and how it can be used.

Treating patients with headaches.

Managing patients with pain and co-existing disease (PTSD, TBI, Substance abuse).

Pain pharmacology – best pain medication resources. Non-pharmacologic approaches to pain management. 

What are the pain resources throughout the Levels of care?

203: Pain Management in the WTU (Audience: Providers and Staff in Warrior Transition Units) 

Pain and the combat casualty. What makes this population unique?

Strategies for tapering pain medications.

What resources are available to manage pain and/or refer patients?

PASTOR – an introduction to the tool and how it can be used.

204: Pain Management for Pharmacist (Audience: Pharmacists) 

Medication treatment algorithms

Pharmacy pain care clinics

Opioid pain care agreements

300 - Deployed / Battlefield Pain Management 

301: Medic Management of Battlefield Pain (Audience: Medics, Hospital Corpsmen, Airmen) 

Field Management Guidelines, assessment, documentation, pre-hospital treatment.

Future medications and technologies

302: Pain Management at Level III (Audience: Deploying health care personnel) 

Military Advanced Regional Anesthesia and Analgesia (www.DVPMI.org).

Use of the new DoD/VA pain scale in the deployed environment.

Why is far forward pain management important?

Opioids for pain on the battlefield – blessing or curse?

Multimodal analgesic techniques for the battlefield.

CSH Pain Consultant and pain nursing – What is there role?

Future medications and technologies for pain.

303: Evacuation Pain Medicine (Audience: Deploying health care personnel) 

Air evacuation and pain management – what are the challenges

Preparing a patient for evacuation from a pain perspective.

304: Acute Pain Medicine Service (Audience: Pain medicine physicians (anesthesiologists) and 

nurses) 

Military Advanced Regional Anesthesia and Analgesia (www.DVPMI.org).

CSH pain physician mission and responsibilities.

Pain nursing at the CSH.

Introduction to the pain equipment set.

Future pain medications and technologies.

(continued on next page) 
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400 - Pain Care by Specialty 

401: Pain Medicine Specialty Care (Audience: Pain Medicine Specialists) 

Core principles of biopsychosocial pain assessment, prioritized goal-oriented pain management planning, and 

time-dependent treatment outcomes assessment.

Operational management of a continuum of integrated stepped pain care from injury-related acute pain to 

chronic pain management within the Tiered System, including an interdisciplinary pain medicine clinic or 

service, and, when appropriate, a pain medicine department. Tasks would include the following: 

o Appropriate setting-specific clinical duties in the stepped model of care.

o A system of clinical service outcomes assessment, such as patient/provider satisfaction, pain control 

and quality of life measures.

o How to develop and manage collaborative care models between primary care, pain medicine, 

behavioral medicine/psychiatry, pharmacy, rehabilitation, and other medical and integrative medicine 

services.

o Risk management processes for patients, including procedures, medications especially opioids, and 

suicide. 

Medical supervision of a pain rehabilitation program.

How to contribute to training of front line and primary care providers and other providers and clinicians in pain 

management.

Medical overview, Definitions, Mechanisms, Pathophysiology, Identification, Assessment and basic 

Management.

402: Perioperative pain management (Audience: Surgical personnel) 

Why is perioperative pain management important? What are the consequences to my patients when acute 

pain in poorly managed?

The advantages of multimodal analgesia vs. opioid monotherapy for pain.

The role of regional anesthesia on the battlefield – what are the advantages and the risks (compartment 

syndrome)?

The role of the Acute Pain Service in the care of the patient.
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B-13 Standardize Pain Management Capabilities

TRICARE Regional Pain Center of Excellence Future Directions 

1. Pain Medicine Service (interdisciplinary) 

A. Acute & Chronic Pain Services 

1) Inpatient 

2) Outpatient 

3) Perioperative 

2. Pain PT 

3. Pain OT 

4. PM&R

A. Physical Rehabilitation 

5. Behavioral Health – Pain 

A. Co-existing Psychiatric Diseases 

B. Cognitive Therapy 

C. Substance Abuse and Addiction Medicine 

6. Pediatric Pain Service 

7. Cancer Pain & Palliative Care 

A. Pain Treatment 

B. Quality of Life 

C. Hospice 

8. Complementary and Alternative Medicine Techniques 

A. Acupuncture 

B. Yoga / Yoga Nidra 

C. Non-allopathic Chiropractic Care 

D. Therapeutic Medical Massage 

E. Biofeedback 

9. Family Education and Support 

10. Pain Rehabilitation Center 

A. Focus on patients with refractory maladaptive pain coping behavior: 

1) Inpatient Hospitalization 

2) Intensive Outpatient Program 

3) Outpatient Program 

Within each TRICARE region, pain services will be distributed by a Tier system based on the facility 

size, mission, and local patient pain care needs.

Figure B-13.1: RPCoE Tiers 

Tier Facility 

I Outpatient Health Clinics 

II Small MTF 

Large Multidisciplinary Clinics 

III MTF 

IV Medical Center 
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B-14 Central Pain Management Advisory Board for DoD and VHA

Figure B-14.1: Proposed Central Pain Management Advisory Board Structure 
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DVPMI Charter 

CHARTER OF THE DEFENSE & VETERANS PAIN MANAGEMENT INITIATIVE (DVPMI) 

ARTICLE I: NAME, OBJECTIVE, PURPOSE, and HISTORY 

1. Name

The Defense and Veterans Pain Management Initiative (DVPMI). Defense represents all United States Armed 

Forces personnel and dependents. Veterans represent the organization’s commitment to enhancing the 

continuity of effective pain care of Veterans and retirees into the health care systems of the Veterans Health 

Administration (VHA) and the community. 

2. Objective 

The DVPMI will serve the DoD and VHA as a clinical advisor of best integrated pain medicine practice, a pain 

medicine educational resource, and a pain research and outcomes evaluation focal point. As the Defense Pain 

Center of Excellence (DPCoE), the DVPMI will be responsible for assessing the effectiveness and safety of pain 

care for DoD and VHA Beneficiaries. The DVPMI will provide an administrative structure for a Military Pain 

Medicine Board of Directors (MPMBD) consisting of Air Force, Army, Navy and VHA senior expert clinicians and 

researchers experienced in the management of acute and chronic pain on the battlefield, at sea, in the air, and 

at home through recovery, rehabilitation and reintegration. 

3. Purpose

Based on the best available evidence, the DVPMI will develop consensus recommendations for the Air Force, 

Army, Navy, and VHA integrated pain management communities for improvements in pain medicine practice, 

education, and research. The DVPMI will be the proponent of world class pain management services for military 

and VHA Beneficiaries. The organization will serve as an advisory board (MPMBD) to the individual service pain 

consultants to the Surgeons General and VA’s Undersecretary for Health Director. 

The DVPMI will contribute directly to pain-related research, development, tests, and evaluations (RDT&E) 

sponsored by the Services or the Defense Health Program, or by other Federal organizations that sponsor 

research, such as the Department of Veterans Affairs and the National Institutes of Health. Direct contributions 

include proposing and executing clinical and nonclinical trials as a Principal Investigator and establishing clinical 

trial resources (e.g., clinical sites, subject recruitment, protocol development and execution, Institutional Review 

Board coordination, and analytical and report-writing capabilities). The DVPMI will support the compilation, 

organization, assessment, and dissemination of pain-related research information and outcomes. 

4. History 

The DVPMI began as a congressionally directed program called the Army Regional Anesthesia and Pain 

Management Initiative in 2000. Upon recognition that pain issues required a tri-service approach, the 

organization was re-named the Military Advanced Regional Anesthesia and Analgesia (MARAA) in 2005 to 

include Air Force and Navy partners in military pain medicine recommendations. Finally, the acknowledgment 

that military and VHA Beneficiaries require an integrated response to acute and chronic pain issues throughout 

the patient care continuum, led to the current DVPMI structure. The establishment year for the organization 

remains 2005 when it first became tri-service. 
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PAIN MANAGEMENT TASK FORCE A-49 Public

ARTICLE II: MANAGEMENT 

1. DVPMI Executive Administration 

The DVPMI Executive Administration serves as the non-voting administrative core of employees for the 

organization. The Chief Executive Officer will be appointed. The Chief Executive Officer serves with the 

approval of the MPMDB and is responsible for the supervision and staffing of administration employees. The 

Executive Administration is responsible for the dissemination of MPMDB recommendations to the DoD and VHA. 

The Executive Administration will ensure that the DVPMI organization is in compliance with all pertinent DoD and 

VHA regulations and policies. 

The Executive Administration will include, but is not limited to, the following positions: 

Chief Executive Officer (Appointed Position) 

Operations/Projects Officer 

Program Manager/Budget 

Clinical Pain Medicine Policy Coordinator 

Pain Medicine Education Coordinator 

Pain Medicine Research Coordinator 

Medical Writer 

Statistician 

Information Technologist 

Legal Assistant 

Project personnel (as required) 

2. DVPMI Military Pain Medicine Board of Directors (MPMBD) 

The DVPMI MPMBD group serves as an expert military and VHA advisory board on pain medicine clinical, 

educational, and research issues. The MPMBD will have four permanent members consisting of the Air Force, 

Army, and Navy Pain Consultants to the Surgeons General and a National Pain Director from the VHA. In 

consultation with their respective Surgeons General and VA Director, the four permanent members will appoint 

three additional members from their respective services. Consultants can nominate members outside of their 

respective service. At least one of the appointed members must come from the Medical Research and Material 

Command (MRMC). Appointed members must represent the following medical specialties (no particular ranking 

or order) with an interest and expertise in pain medicine:

Primary Care 

Pain Medicine 

Anesthesiologist 

PM&R 

Neurologist 

Pharmacist 

Physical Therapy 

Occupational Therapy 

Integrative Medicine / Complementary and Alternative Medicine 

Behavioral Health 

Addiction Psychiatry 

Nursing 

Pain Research 

Patient Advocate 

Combat Medic 

Other pain specialists 
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The permanent members will coordinate MPMBD appointments to ensure maximum representation of the listed 

pain medicine related specialties. All appointments will be reviewed by the permanent members on an annual 

basis with member adjustments made at the annual spring meeting. 

Each member of the organization has one vote on issues that require agreement and collaboration between 

services and VHA. All decisions will be made by a simple two thirds majority vote of the MPMBD. Issues that 

fail to obtain a two thirds majority will be tabled and re-addressed at the next meeting called by the DVPMI Chief 

Executive Officer. 

ARTICLE III: MPMBD and CHIEF EXECUTIVE OFFICER RESPONSIBILITIES

The Chief Executive Officer will be responsible for soliciting meeting issues from MPMBD members, setting 

meeting agendas, conducting meetings, keeping meeting minutes, and maintaining all meeting documents. The 

Chief Executive Officer never votes on MPMBD decisions. The Chief Executive Officer will be responsible for 

generating organization position white papers on decisions made by the MPMBD. The position white papers will 

provide each service Pain Consultant with collaborative recommendations for issues addressed by the 

organization. The Chief Executive Officer can assign the writing of decision papers to MPMBD members. The 

permanent Pain Consultant MPMBD members will have final editorial authority over any white paper 

recommendations submitted to their primary service Surgeon General and VA Director. 

ARTICLE IV: MEETINGS 

1. Meetings 

The organization will meet (at a minimum) twice yearly. Meeting locations and times will be set by the Chief 

Executive Officer to facilitate maximum participation of MPMBD members. Meetings will be coordinated by the 

Executive Administration. MPMBD members can send proxies to attend meetings in their place (proxy voting is 

allowed) if approved by that member’s service Pain Consultant. Teleconferencing is an acceptable means of 

attending a meeting. Meetings will only be held when a quorum of members (or their proxies) is available. A 

quorum will be defined as a majority of voting members with representation from each service and VHA. 

2. Special Meetings 

The Chief Executive Officer can call a special meeting by MPMBD members on issues requiring prompt 

attention. Special meetings can be conducted via teleconferencing with votes documented by email. 

3. Conduct of Meetings 

Meetings will be presided over by the Chief Executive Officer or, in the absence of the Chief Executive Officer, a 

member of the Executive Administration appointed by the Chief Executive Officer. 

4. Meeting Agenda 

The Chief Executive Officer will provide members with the meeting agenda one week prior to the scheduled 

meetings. MPMBD members may add new items to the agenda during meetings with the Chief Executive 

Officer’s request for new business. Meetings will be concluded with a review of unresolved issues. Meetings will 

be conducted by the Chief Executive Officer using Robert’s Rules of Order as a guide. 

ARTICLE V: ORGANIZATION SEAL 

The organization seal is represented at the head of this document. 

ARTICLE VII: AMENDMENTS 

Amendments to this charter can be made with two-thirds majority vote of the MPMBD. 
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PAIN MANAGEMENT TASK FORCE A-51 Public

B-15 Theater Hospitalization (FM 4-02.10)

Figure B-15.1: Army Levels of Care 

Level Description and Location Care 

I

Service - The first medical care a 

Soldier receives:

Divisions 

Corps 

Echelons Above Corps Units 

Life Saving Measures 

Emergency Medical 

Treatment (EMT) 

Advanced Trauma 

Management (ATM) 

Disease Prevention 

Stress Prevention 

Casualty Collection 

Evacuation from Supported 

United to Supporting MTF 

II

Service - Capabilities duplicate 

Level I and are expanded:

Combat Zone 

Echelons Above Corps Units 

Dental Care 

Laboratory 

X-Ray 

Patient Holding Capabilities 

Mental Health* 

Preventative Medicine* 

III 

Service - Capabilities duplicate 

Level II and are expanded:

Offshore Support Facilities 

Third Country Support Basis 

Other Hospital Locations 

Hospital (Command, 

Control, Communications) 

Patient Administration 

Nutritional Care 

Supply and Services 

Triage 

Emergency Medical 

Equipment 

Preoperative Care 

Orthopedics 

General Surgery 

Operating Rooms and 

Central Material and 

Supply Services 

Anesthesia 

Nursing Services 

Pharmacy 

Clinical Laboratory and 

Blood Banking 

Radiology Services 

Hospital Ministry Team 

Services 

IV

Service - Capabilities duplicate 

Level III and are expanded:

Echelons Above Corps Units 

Combat Support Hospital 

Third Country Support Basis 

Specialized Medical Capabilities 

Specialized Surgical Capabilities 

V

Service - Capabilities duplicate 

Level IV and are expanded:

CONUS Support Base 

Other Service, VA, and 

Civilian Hospitals 

Provide the most definitive care available 
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PAIN MANAGEMENT TASK FORCE A-52 Public

Appendix C: Task Force Charter 

Figure C-1: Army Pain Management task Force Charter (signed August 21, 2009) 

(continued on next page) 
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PAIN MANAGEMENT TASK FORCE A-53 Public

(continued on next page) 
APPENDICES

PAIN MANAGEMENT TASK FORCE A-54 Public
APPENDICES

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Appendix D: Task Force Stakeholders 

Figure D-1: Medical Specialties and Stakeholders paramount to the Task Force 

Behavioral Health* Warrior Transition Command*

Case Management Patients and Family Members

Chaplain Military Line Commanders

Integrated Medicine* DoD Leadership

Nursing* Air Force*

Pain Management* Navy*

Pharmacy* Reserve*

Physical Medicine and Rehabilitation* National Guard*

Primary Care* Veterans Administration*

Physical Therapy* TMA / Health Affairs*

Occupational Therapy Defense Center of Excellence*

Social Work M&RA*

* Designated TF member / invitee 
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PAIN MANAGEMENT TASK FORCE A-56 Public

Appendix E: MTF Pain Data Call 

Figure E-1: MTF Pain Data Call - Survey Distribution 

Region Facilities 

Europe Regional Medical 

Command 

Bavaria MEDDAC

Landstuhl Regional Medical Center

Heidelberg MEDDAC

Vicenza Army Health Clinic

Great Plains Regional 

Medical Command 

BAMC (Fort Sam Houston)

CRDAMC (Fort Hood)

GLWACH (Fort Leonard Wood)

MAHC (Fort Leavenworth)

RWBAHC (Fort Huachuca)

BJACH (Fort Polk)

EACH (Fort Carson)

IACH (Fort Riley)

RACH (Fort Sill)

WBAMC (Fort Bliss)

North Atlantic Regional 

Medical Command 

BAHC (Fort Detrick) 

DHCN (Fort Belvoir) 

GAHC (Fort Drum) 

KACC (Fort Meade) 

KAHC (Fort Lee) 

MCAHC (Fort Eustis) 

WAMC (Fort Bragg) 

DAHC (Carlisle Barracks) 

DTHC (Pentagon) 

IACH (Fort Knox) 

KACH (West Point) 

KUSAHC (Aberdeen MD) 

PAHC (Fort Monmouth) 

WRAMC (Washington DC) 

Pacific Regional Medical 

Command 

TAMC, Hawaii 

BG Sams USAHC, Camp Zama, 

Japan

USA MEDDAC Korea

Schofield Barracks Health Clinic, 

Hawaii

Southern Regional 

Medical Command 

BACH (Fort Campbell)

FAHC (Redstone Arsenal, AL)

MACH (Fort Jackson)

LAHC (Fort Rucker)

DDEAMC (Fort Gordon)

MACH (Fort Benning)

LJAH (Fort McPherson)

WACH (Fort Stewart)

Western Regional 

Medical Command 

BACH (Fort Wainwright)

MAMC (Fort Lewis)

WACH (Fort Irwin)

MTF Pain Data Call Questions 

Introduction: This data call is related to The Surgeon General's decision to charter a Pain Task Force to examine the 

delivery of pain care and services across the MEDCOM and make recommendations for a comprehensive pain 

management strategy. Your response will ensure that the Pain Task Force has visibility of the pain-related best 

practices and initiatives at your MTF. 

Additional Documentation: Please provide copies of any local policies related to pain management at your MTF and 

return with this completed spreadsheet. On a separate document, provide summary on any Pain-Related "Best 

Practices" or Initiatives ongoing or planned at your MTF. Please include POCs for these Best Practices and 

Initiatives and return with this completed spreadsheet. This includes any programs that provide alternate or 
APPENDICES

PAIN MANAGEMENT TASK FORCE A-57 Public

complementary therapies, treatments, and activities that might have impact on pain management, such as Rehab, 

R&R programs, Animal Therapy, and CAM. 

Figure E-2: Data Call Survey Questions 

# Question

1 MTF (enter name): 

2 Region (select from dropdown at right): 

3 MTF POC for this data call: 

4 Email address: 

5 Duty Phone: 

6 Do you have a Warrior Transition Unit at your location? 

7 If you have a Warrior Transition Unit at your location, what is the average number of WTs? 

8 Does your MTF have a designated pain management clinic / service? If no, please proceed to next 

section (question 24) 

9 What service is responsible for the pain management clinic / service? 

(Anesthesia, psychology, PM&R, etc.) 

10 What is the emphasis of your program? 

(acute pain, chronic pain, BOTH) 

11 How long has your pain clinic / program been in existence? 

12 List the number of personnel in the Pain Clinic / Service by specialty; indicate what percentage of their time 

is dedicated to Pain Management duties and responsibilities. 

13 What percentage of your patients are WT's, other Active Duty, Res / NG, Family Members of AD, RET and 

RET Family members? 

14 What is your program’s capacity? 

(e.g., # of appointments available per day) 

15 What is the average # of patient visits per month? 

16 What is the average # of NEW patients per month? 

17 Are you able to offer interventional pain management procedures for your patients? If so, please detail. 

18 What service provides the majority of your referrals? 

19 Can patients self-refer? 

20 

Do you offer any Complementary and Alternative Medicine (CAM) approaches to pain management within 

your Pain Management Clinic / Service? If so, please describe. 

(e.g. Acupuncture, Aromatherapy, BioFeedback, Heart Rate Variability Training Transcutaneous Electrical 

Stimulation, Relaxation techniques, Therapeutic Massages (dry/hydro), others) 

(continued on next page) 
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21 Outcome measures: How do you measure the effectiveness of your services? 

(metrics, outcomes measures, etc.) 

22 

If you do not have an MTF Pain Management Clinic / program within your MTF, where do you refer your 

patients with pain management issues? (PM&R, Anesthesia or other clinics within your MTF, network pain 

clinics, other military treatment facility, VA facility) 

23 

Outside of any Pain Clinic / Service, does your MTF provide any Complementary and Alternative Medicine 

(CAM) approaches to pain management? If so, please describe. 

(e.g. Acupuncture, Aromatherapy, BioFeedback, Heart Rate Variability Training Transcutaneous Electrical 

Stimulation, Relaxation techniques, Therapeutic Massages (dry/hydro), others) 

24 If you are providing alternate approaches to pain management outside of any pain clinic, how do you 

measure the effectiveness of these services? (metrics, outcomes measures) 

25 If not using integrative medicine (CAM) why not? 

(no expertise, privileging issues, other (please explain)) 

26 Is your facility involved in pain research? If yes, include completed studies, references. 

(may attached separate document if that would be easier) 

27 

What recommendations, proposals, and comments would you like to make available to the Pain 

Management Task Force? What do you need at your MTF to improve the delivery of pain management to 

your patients and families? 

(may attach separate sheet if necessary) 
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Appendix F: Sites Visited by Task Force 

Figure F-1: Site Visit Facilities 

Fort Lewis (MAMC) 

Puget Sound VA 

University of Washington 

Swedish Hospital 

Fort Sam Houston (BAMC) 

San Antonio VA 

Wilford Hall

Fort Bliss (WBAMC) 

Fort Hood (CRDAMC) 

Tampa VA 

University of Florida 

Balboa Naval Hospital 

Travis AFB (DG USAF) 

Scripps Center 

Fort Bragg (WAMC) 

Camp Lejeune 

Duke University 

Fort Gordon (DDEAMC) 

Fort Stewart (WACH) Fort Campbell (BACH) 

Fort Carson (EACH) Walter Reed (WRAMC) 

Fort Drum (GAHC) White River Junction VA 

Tripler Army Medical Center (TAMC) 

Schofield Barracks 

Landstuhl Regional Medical Center (LRMC) 

Baumholder AHC 

Site Visit Interview 

General Interview Questions 

Introduction: On behalf of BG Richard Thomas, Chairperson of the TSG chartered Pain Management Task Force, I 

am requesting your approval for the Pain TF to visit Medical Facility. As you might already be aware, we are 

evaluating pain management across the MEDCOM in order to provide recommendations for a MEDCOM 

comprehensive pain management strategy. We have a limited time to conduct our evaluation of current pain 

management models and best practices across MEDCOM. Part of the evaluation process involves visits to MTFs 

across MEDCOM, Air Force, Navy, VA, and civilian medicine. Site visit team will consist of 4-5 TF members. 

Purpose is to conduct interviews with leadership and clinical staff. 

Site Visits: This is not an inspection. Our intent is to meet with clinical leaders and providers to evaluate "What's 

working?", "What's not working?", "What additional resources are required?", and "What's going on at your facility 

that should be replicated across MEDCOM?" Begin trip with Command Inbrief. Followed by separate interviews with 

DCCS, DCN, and CSM. Additionally, we'd like to schedule interviews with representatives from Behavioral Health, 

Medic(s), Nursing Staff (in and outpatient), Pain Service, Pharmacy, Primary Care, Warrior Transition Unit, 

Anesthesiology, Emergency Department, Orthopedics / Sports Med, PM&R, Physical Therapy, and Surgery. We 

estimate approx. 30-45mins per interview. Only need a place to sit and chat with these folks. We can also move 

from place to place if that is easier. There is no intent to provide interview summaries to the command on departure. 

However, we will do a short out brief with DCCS to provide an overview of the visit. 
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Figure F-2: Site Visit Survey Questions 

# Question

A Date: 

B Facility: 

C Name: 

D Specialty: 

E Contact Info: 

F Outpatient (Yes/No): 

G Inpatient (Yes/No): 

H WTU (Yes/No): 

1 What is the biggest challenge in pain management at your facility? 

(For Inpatient, Outpatient, and WTU) 

2 Who is the primary consultant for your organization on clinical pain issues? 

3 Who is responsible for pain training in your facility? 

4 What routine training in pain management does your clinical staff receive? 

5 Are you aware of Clinical Practice Guidelines (CPGs) for pain management? 

6 If you answered yes to previous question, which pain management CPG(s) do you use? 

7 How do you determine your patient’s expectations for pain management? 

8 How do you manage your patient’s expectations for pain management? 

9 Do you use a standard strategy or ladder model when treating pain? Which model / strategy? 

10 What questions about a patient’s pain are a routine part of all clinical examinations / visits? 

(For Inpatient, Outpatient, and WTU) 

11 How is pain measured and documented in your clinic / facility? 

(For Inpatient, Outpatient, and WTU) 

12 How do you evaluate your patient’s pain or validate the pain assessment that was done by support staff? 

(For Inpatient, Outpatient, and WTU) 

13 How valuable is that pain assessment to you? 

(For Inpatient, Outpatient, and WTU) 

14 How do you assess the effectiveness of your interventions in pain treatment? 

(For Inpatient, Outpatient, and WTU) 

15 What clinical practice guidelines (if any) are used to assist providers in prescriptions for pain medications? 

(continued on next page) 
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16 What local policies or initiatives are used to assist providers in prescriptions for pain medications? 

17 How are opioid medications controlled in your patient population? Who can write for opioid medications? 

(For Inpatient, Outpatient, and WTU) 

18 Other than Opioids, what medications are used clinically for pain care? 

(For Inpatient, Outpatient, and WTU) 

19 What adjunctive therapies are available for you for pain care? Which of these do you use? 

(For Inpatient, Outpatient, and WTU) 

20 

 What Complementary or Alternative Medicine (CAM) therapies are available for you to treat pain? Which 

of these do you routinely use or request for pain treatment? 

(For Inpatient, Outpatient, and WTU) 

21 How is pain clinically managed and pain care documented in your inpatient population? 

22 How are patients transitioned from inpatient pain medications to outpatient pain medications? 

23 How are pain medications monitored in outpatients? 

24 What pain ‘best practices’ in your facility do you think should be replicated across the DoD? 

25 Where / How do you refer patients whose pain you cannot adequately treat? 

26 

Do you feel as though you are adequately resourced to manage ACUTE pain in your patients? If not, what 

tools or capabilities for pain assessment or management are you or your institution lacking that might be 

valuable in your practice? 

(For Inpatient, Outpatient, and WTU) 

27 

Do you feel as though you are adequately resourced to manage CHRONIC pain in your patients? If not, 

what tools or capabilities for pain assessment or management are you or your institution lacking that might 

be valuable in your practice? 

For Inpatient, Outpatient, and WTU) 

28 In an ideal world for treating pain at your facility, what would you ask for? 

29 What are the key components you feel should be part of any MEDCOM Comprehensive pain management 

strategy? 

30 Initial thoughts on the proposed Pain Assessment Tool? 

31 Additional Notes: 
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Figure F-3: Pharmacy Interview Questions 

# Question

A Date 

B Facility: 

C Name: 

D Contact Info: 

1 Is a clinical pharmacist involved in pain management decisions? Does that involvement include comanagement of chronic pain conditions? 

2 Who in Pharmacy is the primary pain management "go to" person? 

3 How does your MTF respond with the growing demand of non-formulary pain medication prescriptions for 

patients referred to network providers? Examples? 

4

How prevalent is 'off label' use of medications in the treatment of pain? How important is 'off label' use of 

medications to managing pain? Does your MTF have a culture of encouraging or discouraging 'off label' 

use of medications for managing pain? 

5 Do clinicians typically use multimodal therapy (therapeutic classes) for pain management? Examples? 

6 How does your MTF execute its sole-prescriber program? 

7 Have you experienced barriers in providing care to pain patients related to DOD P&T decisions (e.g., nonformulary, medical necessity, or prior authorizations)? 

8 How responsive is your P&T committee in addressing new drug requests from clinicians? 

9 Does your MTF's MUE Subcommittee monitor prescribing habits for pain medications? What interventions 

has your MTF provided to effect prescribing habits? 

10 Are pharmacists in your MTF involved in staff and patient education programs in pain management? 

11 Are you aware of clinical practice guidelines in pain management? What is pharmacy’s use of such CPGs? 

12 What controls are in place at your MTF to prevent prescriber’s medication errors for pain medications? 

(information technology, policy and procedures, education, etc)? 

13 How does your MTF use pharmacy monitoring of medication errors and pharmacy interventions to change 

prescribing behaviors? 

14 What is Pharmacy's biggest challenge in managing pain in your MTF? 

15 Are there differences in pharmacy standard of practice in providing pain medications for Active Duty, family 

members and Warrior in Transition Soldiers? 

16 Is your facility involved in any VA and DOD collaboration on P&T issues / Joint Formulary issues to support 

the transition of Soldiers from active duty to VA status? 

17 Additional Notes: 
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Figure F-4: Pain Service Questions 

# Question

A Facility: 

B Pain Service POC: 

C Specialty: 

D Contact Info: 

PATIENTS

1 How many pain patients are deferred to the network by your MTF each month on average? 

2 How was this data obtained? 

OUTCOMES

3

Which clinics in your MTF see patients for pain and how many visits per month based on an annual 

average does each clinic provide? (Can be gathered from ALTHA by searching pain diagnostic codes for 

clinics that do not do pain management exclusively, do not forget inpatient and regional anesthesia). 

Providing this data should probably be tasked to the DBO (budget office): 

Primary care 

Physical Medicine 

Pain Clinic 

Acute pain service / Regional anesthesia 

Complementary and Alternative Medicine visits 

Warrior Transition Unit Pain Services 

Surgery clinics 

OT / PT 

Other (specify) 

PAIN DATA QUESTIONS

4 What pain data (VAS scores, return to work, etc.) are you collecting? 

5 How are you collecting pain data / outcomes? 

6 How has collected pain data influenced clinical practice? 

7 How are you measuring effectiveness of your pain interventions? 

(continued on next page) 
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EDUCATION

8 What programs exist at your MTF for pain management education for (this includes all pain related 

education with emphasis on opioid related education)? 

9 Providers and support staff? 

10 Patients and families? 

11 Commanders and unit leaders? 

12 What additional pain education needs do you have? 

TECHNOLOGY

13 What technology used in pain management is available at your MTF? 

14 Dedicated clinic space with treatment and fluoroscopically equipped procedure rooms? 

15 Do you feel your ratio of clinical support staff to FTE pain provider adequate? What is your ratio? 

16 An acute pain service and a regional anesthesia section? Do you have a dedicated block area? 

17 Do you have acute and/or chronic pain nurses? 

18 Do your nurses have specialized pain nursing education? 

19 Implantable pain systems (and board certified pain specialists to implant and use them)? 

20 Ultrasound? 

21 How do you track and acquire new pain technology / systems? 

RESEARCH

22 What non-clinical research (if any) is being done? 

23 What clinical trials are being conducted (if any) to improve pain control for patients? Do the studies involve 

therapeutics? If so, what are they? 

24 What research budget (if any) supports these projects and the research staff? 

25 Who are your personnel conducting this research (AD, GS, Contract, Clinician v. Dedicated Researcher)? 

26 What research collaborations (civilian, federal, corporate) do you have? 

(continued on next page) 
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OUTCOMES (NEGATIVE)

27 How do you track negative outcomes? 

28 What process is used for tracking and follow-up of negative outcomes? 

29 

Interventions? 

Epidurals (separate out OB) – Dural puncture, nerve injury, infection? 

Peripheral Nerve Blocks? 

30 Single injection? 

31 

Continuous peripheral nerve block? 

Facet procedures 

Implantable pain systems 

Vertebroplasty / kyphoplasty 

Other pain related procedures (percutaneous fusion, etc.) 

EDUCATION COMPLICATIONS

32 How do you provide education about pain treatment complications for? 

33 Providers and support staff? 

34 Patients and families? 

35 Leaders? 

OTHER COMPLICATIONS

36 What technology do you use to limit complications? 

37 What research is your MTF participating in aimed at identifying or decreasing complications? 

WAY FORWARD & CPG

38 What pain CPGs would you like to see developed to assist you in your clinical practice? 

39 Do you use any pain CPGs in your clinical practice? 

40 

The Pain TF will be producing a recommendation for CPS to TSG, based on this, what would be essential 

components/ to be included to assist you in your practice and improve deliver of pain mgt in your 

population? 
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Appendix G: Subject Matter Expert Briefings 

Figure G-1: Task Force briefings with Subject Matter Experts 

Date Purpose SME Attendees (Non-Task Force) 

12/1/2009 MPP overview and discussion Dr. 

1/15/2010 Collaboration on pain management care and 

treatment Dr. 

1/19/2010 Current State of Medical Education and 

USUHS Pain-Related Curriculum 

Dr. 

Associate Dean, Dr. 

Vice Dean, Dr. 

Assistant Dean of Curriculum 

1/19/2010

USUHS discussion for the establishment of a 

Department of Defense/Veterans Health 

Administration pain center of excellence 

Dr. USUHS Vice President 

1/20/2010 Samueli Institute overview and discussion Samueli Institute 

Samueli Institute 

1/21/2010 Warrior Transition Command Pain Survey Warrior Transition 

Command 

2/3/2010 Joint Formulary discussion with the VA and 

TMA on current joint formulary practices 

Col, OASD(HA)/TMA 

DOD Pharmacoeconomic 

Center/ HEC Pharmacy Workgroup 

CTR, OASD(HA)/TMA 

VA 

(PBM) 

(VACO) 

2/17/2010

PASTOR meeting reviewing various electronic 

registry technologies for use for improving 

both patient care and satisfaction, in addition 

to being a wealth of knowledge for future 

research 

PhD; New Haven VA and 

Yale 

MSN, PhD; 

University of Pennsylvania 

MSN, MPH, PhD, 

epidemiologist; Drexel University 

3/1/2010 Pain-Related Curricula 

COL (IPAP) 

LTC (neurosci faculty DPT) 

LTC (GPAN) 

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)

(b) (6)
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Appendix H: Acronyms 

Figure H-1: Acronyms Used 

Acronym Name 

AAPM American Academy of Pain Management 

ABMS American Board of Medical Specialties 

ABPM American Board of Pain Medicine 

ACGME Accreditation Council for Graduate Medical Education 

AFAP Army Family Action Plan 

AKO Army Knowledge Online 

AMEDD United States Army Medical Department 

APS Acute Pain Service 

ASAM American Society of Addiction Medicine 

ASAP Army Substance Abuse Program 

ASPTF Army Suicide Prevention Task Force 

ATM Advanced Trauma Management 

BCT PT Brigade Combat Team Physical Therapists 

BPI Brief Pain Inventory 

BSA Building the Soldier Athlete 

CAM Complementary Alternative Medicine 

CARF Commission on Accreditation of Rehabilitation Facilities 

CME Continuing Medical Education 

CONOPS Concept of Operations 

CONUS Contiguous United States 

CPG Clinical Practice Guidelines 

CPNB Continuous Peripheral Nerve Block 

CPT Common Procedural Terminology 

CRMRP Clinical and Rehabilitative Medicine Research Program 

CSF Army’s Comprehensive Soldier Fitness 

CSH Combat Support Hospital 

CTP Clinical Transition Program 

DAMIS Drug and Alcohol Management Information System 

DATA 2000 Drug Abuse Treatment Act of 2000 

DCoE Defense Centers of Excellence 

DoD Department of Defense 

DPCoE Defense Pain Center of Excellence 

DVPMI Defense and Veterans Pain Management Institute 

E&M Evaluation & Management 

EES Employee Education System 

EMEDS Expeditionary Medical Support 

EMT Emergency Medical Treatment 

FOB Forward Operating Base 

(continued on next page) 
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FORSCOM Forces Command 

GME Graduate Medical Education 

HEC Healthcare Executive Committee 

HIPAA Health Insurance Portability and Accountability Act 

HP&S Health Policy and Services 

HQDA Headquarters Department of the Army 

IASP International Association for the Study of Pain 

IOM Institute of Medicine 

JC Joint Commission 

JRAATS Joint Regional Anesthesia and Analgesia Tracking System 

M&RA Manpower and Reserve Affairs 

MAP Musculoskeletal Action Plan 

MAPS MEDCOM AHLTA Provider Satisfaction 

MARAA Military Advanced Regional Anesthesia & Analgesia 

MAT Musculoskeletal Action Team 

MEB Medical Evaluation Boards 

MEDCOM US Army Medical Command 

METC Medical Education and Training Campus 

MHO Army’s Medical Holdover 

MHS Military Health System’s 

MPMBD Military Pain Medicine Board of Directors 

MPP My Pain Profile 

MRMC United States Army Medical Research and Materiel Command 

mTBI mild-Traumatic Brain Injury 

MTFs Military Treatment Facilities 

MTM Medication Therapy Management 

MTMS Medication Therapy Management Services 

NCCAM National Center for Complementary and Alternative Medicine 

NDAA National Defense Authorization Act 

NIDA National Institute on Drug Abuse 

NIH National Institute of Health 

OAM Office of Alternative Medicine 

OEF Operation Enduring Freedom 

OIF Operation Iraqi Freedom 

OMT Osteopathic Manipulative Treatment 

ORD Office of Research and Development 

OT Occupational Therapy 

OTC Over the Counter 

OTSG Office of The Surgeon General 

PASTOR Pain Assessment Screening Tool and Outcomes Registry 

PBM VA Pharmacy Benefits Management 

PCB Patient Controlled Bolus 

PCM Primary Care Manager 

PCMH Patient Centered Medical Home 

(continued on next page) 
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PCPCC Patient Centered Primary Care Collaborative 

PCS Permanent Change of Station 

PEB Physical Evaluation Boards 

PM&R Physical Medicine and Rehabilitation 

PMR Patient Movement Request 

POC Point of Contact 

PR&R Proponency Office for Rehabilitation and Reintegration 

PT Physical Therapy 

PTSD Post Traumatic Stress Disorder 

R&D Research and Development 

RATS Regional Anesthesia Tracking System 

RDTE Research, Development, Test & Evaluation 

RMCs Regional Medical Centers 

RPCoE Regional Pain Centers of Excellence 

RVU Relative Value Unit 

SME Subject Matter Expert 

SOAP Subjective, Objective, Assessment, Plan 

SSC Pain Management Scientific Steering Committee 

SSN Social Security Number 

STRATCOM Strategic Communications 

TBI Traumatic Brain Injury 

TDA Table of Distribution and Allowances 

TDY Temporary Duty 

TF Task Force 

TMA TRICARE Management Activity 

TMDS Theater Medical Data Store 

TO&E Table of Organization and Equipment 

TRADOC Training and Doctrine Command 

TSG The Surgeon General 

UFR Unfinanced Requirements 

USANG United States Army National Guard 

USAR United States Army Reserve 

USUHS Uniformed Services University of the Health Sciences 

UW University of Washington 

VA Veterans Administration 

VA MAP VA Medical Advisory Panel 

VAMC VA Medical Center 

VANF VA National Formulary 

VAS Visual Analog Scale 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

WRAMC Walter Reed Army Medical Center 

WT Warriors in Transition 

WTC Warrior Transition Command 

WTU Warrior Transition Unit 
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