Veteran’s Health Administration
A Whole Person Approach to Lifting the Burden of Chronic Pain Among Service Members and Veterans
Posted on by Helene M. Langevin, M.D., National Center for Complementary and Integrative Health
Chronic pain and its companion crisis of opioid misuse have taken a terrible toll on Americans. But the impact has been even greater on U.S. service members and veterans, who often deal with the compounded factors of service-related injuries and traumatic stress.
For example, among soldiers in a leading U.S. Army unit, 44 percent had chronic pain and 15 percent used opioids after a combat deployment. That compares to 26 percent and 4 percent, respectively, in the general population [1,2].
This disproportionate burden of chronic pain among veterans [3] and service members led NIH’s National Center for Complementary and Integrative Health (NCCIH) to act. We forged a collaboration in 2017 across NIH, U.S. Department of Defense (DOD), and U.S. Department of Veteran’s Affairs (VA) to establish the Pain Management Collaboratory (PMC).
The PMC’s research focusing on the implementation and evaluation of nondrug approaches for the management of pain is urgently needed in the military and across our entire country. Nondrug approaches require a shift in thinking. Rather than focusing solely on blocking pain temporarily using analgesics, nondrug approaches work with the mind and body to promote the resolution of chronic pain and the long-term restoration of health through techniques and practices such as manual therapy, yoga, and mindfulness-based interventions.
Addressing chronic pain in ways that don’t only rely on drugs means addressing underlying issues, such as joints and connective tissue that lack adequate movement or training our brains to “turn down the volume” on pain signals. Using mind and body practices to reduce pain can help promote health in other ways. Possible “fringe benefits” include better sleep, more energy for physical activity, a better mindset for making good nutritional choices, and/or improved mood.
Indeed, there is a growing body of research on the benefits of nondrug approaches to address chronic pain. What is so powerful about PMC is it puts this knowledge to work by embedding research within military health care settings.
The PMC supports a shared resource center and 11 large-scale pragmatic clinical trials. Within this real-world health care setting, the clinical trials have enrolled more than 8,200 participants across 42 veteran and military health systems. These studies offer both strength in numbers and insights into what happens when learnings from controlled clinical trials collide with the realities of health care delivery and the complexities of daily life. [4]
Central to the PMC partnership is whole person health. Too often, we see health through the prism of separate parts—for example, a person’s cardiovascular, digestive, and mental health problems are viewed as co-occurring rather than as interrelated conditions. A whole person framework—a central focus of NCCIH’s current Strategic Plan—brings the parts back together and recognizes that health exists across multiple interconnected body systems and domains: biological, behavioral, social, and environmental.
The VA’s implementation of a whole health model [5] and their unique closed-loop health care system offers an opportunity to deliver care, conduct research, and illustrate what happens when people receive coordinated care that treats the whole person. In fact, VA’s leadership in this area was the impetus for a recent report by the National Academies of Sciences, Engineering, and Medicine. The report underscored the importance of implementing whole person health care in all settings and for every American.
There are many opportunities ahead for this interagency collaboration. It will help to achieve an important shift, from treating problems one at a time to promoting overall military readiness, resilience, and well-being for U.S. service members and veterans.
Congress appropriated $5 million to NCCIH in fiscal year 2023 to enhance pain research with a special emphasis on military populations. These additional resources will allow NCCIH to support more complex studies in understanding how multiple therapeutic approaches that impact multiple body systems can impact chronic pain.
Meanwhile, programs like the DOD’s Consortium for Health and Military Performance (CHAMP) will continue to translate these lessons learned into accessible pain management information that service members can use in promoting and maintaining their health.
While the PMC’s research program specifically targets the military community, this growing body of knowledge will benefit us all. Understanding how to better manage chronic pain and offering more treatment options for those who want to avoid the risks of opioids will help us all build resilience and restore health of the whole person.
References:
[1] Chronic pain and opioid use in US soldiers after combat deployment. Toblin RL, Quartana PJ, Riviere LA, Walper KC, Hoge CW. JAMA Intern. Med. 2014 Aug;174(8):1400-1401.
[2] Pain and opioids in the military: We must do better. Jonas WB, Schoomaker EB. JAMA Intern. Med. 2014 Aug;174(8):1402-1403
[3] Severe pain in veterans: The effect of age and sex, and comparisons with the general population. Nahin RL. J Pain. 2017 Mar; 18(3):247-254.
[4] Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems. Ali J, Davis AF, Burgess DJ, Rhon DI, Vining R, Young-McCaughan S, Green S, Kerns RD. Learn Health Sys. 2021 Oct 19;6(2): e10291
[5] The APPROACH trial: Assessing pain, patient-reported outcomes, and complementary and integrative health. Zeliadt S, Coggeshall S, Thomas E, Gelman H, Taylor S. Clin. Trials. 2020 Aug;17(4):351-359.
Links:
National Center for Complementary and Integrative Health (NIH)
NCCIH Strategic Plan FY 2021-2025: Mapping a Pathway to Research on Whole Person Health (NIH)
Pain Management Collaboratory (Yale University, New Haven, CT)
Whole Health (U.S Department of Veteran’s Affairs, Washington, D.C.)
Consortium for Health and Military Performance (Department of Defense, Bethesda, MD)
Achieving Whole Health: A New Approach for Veterans and the Nation. (National Academies of Sciences, Engineering, and Medicine, Washington, D.C.)
Note: Dr. Lawrence Tabak, who performs the duties of the NIH Director, has asked the heads of NIH’s Institutes, Centers, and Offices to contribute occasional guest posts to the blog to highlight some of the interesting science that they support and conduct. This is the 26th in the series of NIH guest posts that will run until a new permanent NIH director is in place.
Study Shows Benefits of COVID-19 Vaccines and Boosters
Posted on by Lawrence Tabak, D.D.S., Ph.D.
As colder temperatures settle in and people spend more time gathered indoors, cases of COVID-19 and other respiratory illnesses almost certainly will rise. That’s why, along with scheduling your annual flu shot, it’s now recommended that those age 5 and up should get an updated COVID-19 booster shot [1,2]. Not only will these new boosters guard against the original strain of the coronavirus that started the pandemic, they will heighten your immunity to the Omicron variant and several of the subvariants that continue to circulate in the U.S. with devastating effects.
At last count, about 14.8 million people in the U.S.—including me—have rolled up their sleeves to receive an updated booster shot [3]. It’s a good start, but it also means that most Americans aren’t fully up to date on their COVID-19 vaccines. If you or your loved ones are among them, a new study may provide some needed encouragement to make an appointment at a nearby pharmacy or clinic to get boosted [4].
A team of NIH-supported researchers found a remarkably low incidence of severe COVID-19 illness last fall, winter, and spring among more than 1.6 million veterans who’d been vaccinated and boosted. Severe illness was also quite low in individuals without immune-compromising conditions.
These latest findings, published in the journal JAMA, come from a research group led by Dan Kelly, University of California, San Francisco. He and his team conducted their study drawing on existing health data from the Veterans Health Administration (VA) within a time window of July 2021 and May 2022.
They identified 1.6 million people who’d had a primary-care visit within the last two years and were fully vaccinated for COVID-19, which included receiving a booster shot. Almost three-quarters of those identified were 65 and older. Nearly all were male, and more than 70 percent had another pre-existing health condition that put them at greater risk of becoming seriously ill from a COVID-19 infection.
Over a 24-week follow-up period for each fully vaccinated individual, 125 per 10,000 people had a breakthrough infection. That’s about 1 percent. Just 8.9 in 10,000 fully vaccinated people—less than 0.1 percent—died or were hospitalized from COVID-19 pneumonia. Drilling down deeper into the data:
• Individuals with an immune-compromising condition had a very low rate of hospitalization or death. In this group, 39.6 per 10,000 people had a serious breakthrough infection. That translates to 0.3 percent.
• For people with other preexisting health conditions, including diabetes and heart disease, hospitalization or death totaled 0.07 percent, or 6.7 per 10,000 people.
• For otherwise healthy adults aged 65 and older, the incidence of hospitalization or death was 1.9 per 10,000 people, or 0.02 percent.
• For boosted participants 65 or younger with no high-risk conditions, hospitalization or death came to less than 1 per 10,000 people. That comes to less than 0.01 percent.
It’s worth noting that these results reflect a period when the Delta and Omicron variants were circulating, and available boosters still were based solely on the original variant. Heading into this winter, the hope is that the updated “bivalent” boosters from Pfizer and Moderna will offer even broader protection as this terrible virus continues to evolve.
The Centers for Disease Control and Prevention continues to recommend that everyone stay up to date with their COVID-19 vaccines. That means all adults and kids 5 and older are encouraged to get boosted if it has been at least two months since their last COVID-19 vaccine dose. For older people and those with other health conditions, it’s even more important given their elevated risk for severe illness.
What if you’ve had a COVID-19 infection recently? Getting vaccinated or boosted a few months after you’ve had a COVID-19 infection will offer you even better protection in the future.
So, if you are among the millions of Americans who’ve been vaccinated for COVID-19 but are now due for a booster, don’t delay. Get yourself boosted to protect your own health and the health of your loved ones as the holidays approach.
References:
[1] CDC recommends the first updated COVID-19 booster. Centers for Disease Control and Prevention. September 1, 2022.
[2] CDC expands updated COVID-19 vaccines to include children ages 5 through 11. Centers for Disease Control and Prevention, October 12, 2022.
[3] COVID-19 vaccinations in the United States. Centers for Disease Control and Prevention.
[4] Incidence of severe COVID-19 illness following vaccination and booster with BNT162b2, mRNA-1273, and Ad26.COV2.S vaccines. Kelly JD, Leonard S, Hoggatt KJ, Boscardin WJ, Lum EN, Moss-Vazquez TA, Andino R, Wong JK, Byers A, Bravata DM, Tien PC, Keyhani S. JAMA. 2022 Oct 11;328(14):1427-1437.
Links:
COVID-19 Research (NIH)
Dan Kelly (University of California, San Francisco)
NIH Support: National Institute of Allergy and Infectious Diseases
Creative Minds: Building a Better Electronic Health Record
Posted on by Dr. Francis Collins
Stock photo
Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.
Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.
