Pain Care Coalition
Washington, DC.
June 4, 2008

Pain Care Coalition—A National Coalition for Responsible Pain Care
American Academy of Pain Medicine, American Headache Society, American Pain Society, American Society of Anesthesiologists

The Honorable Michael H. Michaud
Chairman, Health Subcommittee
Committee on Veterans’ Affairs
United States House of Representatives
335 Cannon House Office Building
Washington, DC 20515

Re: H.R. 6122—Veterans Pain Care Act of 2008

Dear Chairman Michaud:

The Pain Care Coalition enthusiastically supports H.R.6122, a bill to improve pain care and research for the benefit of America’s veterans. I submit the enclosed statement of the Pain Care Coalition outlining the need for and benefits of this important legislation, and request that it be included in the record of the Subcommittee’s June 5th hearing.

Mr. Chairman, virtually every wounded soldier returning from the current conflicts will experience acute pain attributable to their battlefield injuries. Far too many will go on to live a life burdened with chronic pain, frequently so severe as to affect their function, their relationships with their families, their ability to work productively, and often their self esteem. With prompt and aggressive treatment, much of that pain can be managed and alleviated, but without substantial research efforts leading to improved treatment options, much of it will never be truly cured.

The VA is doing much to promote good pain care within its health system, but much, much more remains to be done. Please ensure that pain care and research are, and continue to be, national priorities on which the country’s veterans can rely.

Respectfully submitted,

Richard Rosenquist, M.D.
Chair

Enclosure

 STATEMENT OF PAIN CARE COALITION 
IN SUPPORT OF H.R. 6122—VETERANS PAIN CARE ACT OF 2008

The Pain Care Coalition is pleased to support H.R. 6122, the Veterans Pain Care Act of 2008. The Pain Care Coalition is a national advocacy effort of the American Academy of Pain Medicine, American Pain Society, American Headache Society and American Society of Anesthesiologists. Collectively, these organizations represent more than 50,000 physicians and other clinicians, researchers, and educators who provide clinical leadership in the increasingly specialized field of pain management. Some of these individuals work directly in the VA health system, and many others are involved in collaborative relationships with research and clinical care programs throughout the VA system.

As professionals in the pain care field, members of these organizations are committed to assuring that those who serve the country in times of war get the very best pain care possible during all stages of their service, and in all settings of the military and veteran health and medical systems. These settings range from the battlefield to the clinics, hospitals, rehabilitation centers and long term care facilities of the VA. As a complement to these clinical care responsibilities, members of the Coalition have a continuing interest and responsibility in pain care research within the VA’s Medical and Prosthetic Research Program, as well as other public and private research efforts with which the VA collaborates.

THE SCOPE OF THE PAIN PROBLEM

Pain is a very large public health problem in this country. It is the most common reason people access the medical care system, a major cause of lost productivity in the workplace, and a substantial contributor to short and long term disability. It affects Americans at all stages of life and in all walks of life. For example, 26 million Americans of working age have frequent back pain, and chronic back pain is the leading cause of disability for those under 45 years of age. 25 million suffer from migraine headaches. 4 million, mostly women, suffer from a complex pain syndrome known as fibromyalgia.40 million have arthritis pain.

Pain imposes a terrible burden on those who suffer and on their families, and it imposes large costs on the health care and disability income systems. Medical costs and lost productivity alone are estimated to top $100 Billion annually. Pain is often poorly understood by those who suffer and by those around them. It is often undiagnosed or misdiagnosed, and under-treated or mistreated. Sometimes pain is the symptom of other diseases as in the case of cancer, arthritis, heart disease, and diabetes. Other times, pain is the disease itself as with migraine, chronic back pain and various diseases associated with damage to the nervous system, such as post-herpetic neuralgia, diabetic neuropathy, or injuries to the nervous system such as commonly occur in combat, including phantom limb pain, post-injury or post-surgery neuralgias, and traumatic brain injury.

The most recent complete study of soldiers enrolled in VA Polytrauma Centers show that more than 90 % have chronic pain that most have pain from more than one part of the body, and that pain is the most common symptom in returning soldiers. Advances in neuroscience, such as neuroimaging, now demonstrate that unrelieved pain, regardless of its initial cause, can be an aggressive disease that damages the nervous system, causing permanent pathological changes in sensory neurons and in the tissues of the spinal cord and brain.

Pain can be acute and effectively treated by short term interventions, or it can be chronic, often without effective “cures,” and sometimes without consistent and effective means of alleviation. Those who suffer severe chronic pain see their daily lives disrupted—sometimes forever. Their pain and their constant search for relief affects their function, their relationships with those they love, their ability to do their work effectively, and often their self esteem. Chronic pain is often accompanied by or leads to sleep disorders, emotional distress, anxiety, depression, and even suicide.

Pain is a major health problem in the military and veteran populations. The physical and emotional stresses of military service make inevitable the disproportionate incidence of both acute and chronic pain among active duty personnel. The incidence of acute pain among those injured in the current conflicts will be virtually 100%, and for far too many, the original short term trauma will be followed by chronic pain of significant dimension and duration. For example, virtually all who lose limbs as a result of combat injury will suffer from phantom limb pain. While this can be managed with varying degrees of effectiveness, there is no known “cure.” Virtually all veterans fitted with prostheses will suffer pain at the device/body “interface.” This can also be managed to some degree, but rarely eliminated.

Far less visible, but even more prevalent, is the extensive damage to the central and peripheral nervous systems resulting from the horrific explosive devices deployed in the current conflicts. Unlike broken bones, flesh wounds and burns, many of which will eventually heal after aggressive treatment, extensive nerve damage may only be manageable, not curable, given the current state of science and clinical practice. Most returning veterans with extensive nerve damage will be chronic pain sufferers and will require long term pain management, with varying prognoses for success. Ironically, the proportion of these chronic pain sufferers among returning wounded servicemen and women will be far greater in the current conflicts than in previous wars because of the remarkable successes of military medicine which now keep so many of the very severely injured alive.

THE STATE OF PAIN CARE AND RESEARCH AT THE VA 

Perhaps more than any other federal agency, the VA has been a leader in focusing institutional resources on the assessment and treatment of pain. Under a “National Pain Management Strategy” initiated in November of 1998 (“Strategy”), and pursuant to VHA Directive 2003-021, the Veterans Health Administration has made pain management a national priority. Among the specific objectives of the Strategy are:

• providing a system-wide standard of care to reduce suffering from “preventable” pain;
• ensuring consistency in the assessment of pain;
• ensuring prompt and appropriate treatment for pain;
• promoting an inter-disciplinary approach to pain management; and
• providing adequate training to and resources for clinicians in VA healthcare to achieve these objectives.

The Pain Care Coalition applauds the Strategy and generally supports its specific goals and objectives. At the same time, the Coalition has significant concerns with the current VA effort:

• Directive 2003-021 was only a five year plan. It needs revision and renewal this year;
• there has been, to the Coalition’s knowledge, no comprehensive assessment of the Strategy’s strengths, weaknesses and accomplishments; and
• reports from the field suggest that implementation has been far from consistent. Some VA facilities have made great strides in improving pain care, while for others it is more an aspirational goal than an operating reality. As a result, veterans get widely different treatment for pain depending on the expertise and resources of the particular VA facility at which they receive their care.

The Pain Care Coalition believes that, in order to ensure effectiveness, the VA’s pain management Strategy must be accompanied by and integrated with a significant research and training commitment to advancing the science of pain care, and to translating developments in the science to improved clinical care throughout the system.

On the one hand, the VA has had a long and continuing research interest in the phenomenon of phantom limb pain, with current work focused at the molecular level. It also has current research efforts in neural repair, which might some day lead to improvements in therapy for those veterans currently returning with significant damage to the nervous system. And it recently completed a successful study of the effectiveness of a shingles vaccine in older veterans which validated research findings elsewhere, and will improve care in the general population. Other important pain research initiatives are scattered amongst NIH research institutes.

In 2006, through an initial grant funded privately, the VA brought together research investigators with interests in pain as part of a VA sponsored conference on pain and palliative care. That meeting identified several research interest groups including post-deployment pain, primary care pain programs, and opioid analgesics. These groups generated a number of new research projects, several of which have earned Merit Award funding through the peer-review process of the VA’s Office of Research Development (“ORD”). Work from these groups also spawned important articles in major journals and a special issue of the Journal of Rehabilitation Research and Development devoted to pain research. Based on this success, the VA’s ORD funded a second meeting of pain researchers just held in September of 2007. At this meeting, researchers identified other important projects which demonstrated the breadth and depth of research that is possible if a focused effort is made to organize and promote a VA research agenda dedicated to the basic and clinical sciences of pain medicine.

It is imperative that pain research be placed high on the list of current VA research priorities. While recent developments suggest an increasing awareness among VA researchers of the importance of pain in the veteran populations, the resources to make a significant difference have not yet been committed. The proportion of the VA research budget devoted to pain is unknown, or at least not systematically reported. A significant internally generated proposal to expand research, training and care in a coordinated fashion was apparently tabled for lack of funding.

Pain is not an area where the VA’s leveraged research approach can rely on leadership from research partners at the NIH or in private industry. For example, despite documentation that chronic pain is one of the most costly of all health problems to the U.S. economy, a review of the NIH pain research portfolio in the early years of this decade showed that only 1% of NIH’s annual research funding was devoted to projects with a primary focus on pain. When projects with pain as a secondary concern were added, it only rose to 2%. There is no Institute or Center at NIH to provide a central home for pain research, and efforts to coordinate pain research across the various institutes and centers are in the very early stages of development.

While private industry has significantly advanced drug and device therapies for particular types of pain or classes of pain patients, industry alone can not be expected to carry the load of long term basic science research needed to better understand the mechanisms of pain, and in particular how chronic pain syndromes develop despite successful treatment of the original trauma.

HOW H. R. 6122 WOULD HELP THE COUNTRY’S VETERANS

The Pain Care Coalition applauds Cong. Walz for his leadership in introducing H.R. 6122 in the House and urges the Subcommittee to act favorably on the bill at the earliest opportunity. The legislation is a companion to bi-partisan legislation developed in the Senate by Senators Akaka and Burr which is now awaits Senate passage as Title II of S. 2162. While not a complete solution to all shortcomings in pain care in the VA health system, the bill represents an important and manageable first step in moving the VA towards more effective—and particularly more consistent—pain care assessment, diagnosis and treatment. The bill:

• requires “fast track” development and implementation of a comprehensive system-wide policy on pain management in VA facilities;
• specifies the essential elements of such a policy, including among others, standards of assessment and treatment, assurance of prompt treatment when medically necessary, research, education and training for health professionals, and patient education for veterans and their families;
• requires consultation with both VSOs and professional experts outside the VA in developing the policy; and
• requires annual reporting to the VA Committees of the Congress on the key elements of the policy, ensuring ongoing oversight.

The Pain Care Coalition believes that these features will provide the building blocks upon which major improvements in pain care for veterans will ultimately be constructed.

CONCLUSION

Pain is often characterized as an invisible disease—we can not see it, and unlike such diseases as cancer, diabetes, and heart disease, there are no affordable and widely available lab or imaging tests to confirm its presence and quantify its severity. But that’s no excuse for letting research and treatment efforts lag behind those of other priorities.

The Pain Care Coalition is committed to advancing the practice of pain management to ensure that the brave men and women returning from combat receive the best pain care possible. The Coalition, along with each of the organizations it represents, stands ready to work with the House and Senate Committees on Veterans’ Affairs and the Department of Veterans Affairs toward that end.

For Further Information Contact: Richard Rosenquist, M.D. Chair, Pain Care Coalition, Richard-Rosenquist@uiowa.edu, (319) 353-7783, Or Robert Saner, Washington Counsel, Pain Care Coalition, rsaner@ppsv.com, (202) 466-6550 .