Supporting Veterans With Chronic Pain: Utilizing an Evidence-Based Self-Care Model

Sunday, 30 July 2017: 10:35 AM

Joseph F. Burkard, DNSc, MSNA, BSN
Hahn School of Nursing, University of San Diego, San Diego, CA, USA

Purpose: The purpose of this EB study was to determine the effectiveness of promoting self-care on pain levels and quality of life among veterans with chronic pain. A review of current chronic pain management policies for veterans in southern California was also conducted. Military veterans with chronic pain are frequently more complex in their presentation than the general population due to challenges of returning to civilian life and the influence of past military service on their pain. National veterans chronic pain levels have been noted to be on average 7.13. Quality of Life noted at 3.7. Conventional pain management methods have been largely dependent on the use of prescriptions, over-the-counter medications, and opioids, which are often ineffective for the management of chronic pain. A biopsychosocial model that has been shown to benefit chronic pain patients is the evidence based self-care model. Buckenmaier and Schoomaker (2014) noted that these initiatives recognize the important role the patient plays in maintaining his or her own health and promote practices that have few side effects compared to pain medications and are relatively easy to implement. Active self-management initiatives allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. The 2010 VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain states that more then 50% of male VA patients in primary care report chronic pain, which may even be higher in female veterans. Standardizing treatment for those with chronic pain using a multitude of complementary and alternative medicine (CAM) modalities has not occurred. Standardized CAM tools need to be established for all providers in the VHA system to use whether in a pain clinic or a primary care clinic. The VHA has a multitude of resources available to their patients but without a guide and protocol these modalities will be underutilized and chronic pain rates will increase.

Methods: Twenty-one veterans with chronic pain were seen in a primary care setting and received a standardized protocol for addressing chronic pain. This IRB approved standardized protocol included the Pain Medication Questionnaire (PMQ), the Numeric Pain Rating Scale, a self-care chart, and a personal action plan contract. Following the assessment, the provider implemented an educational intervention using a self-care model chart addressing alternative treatments to pain beyond controlled medications that promote self-management. At this time, patients were provided with referrals to appropriate resources offered by the VA. Self-care management was assessed at each visit. QOL data, Numeric Pain Rating Scale scores, and the number of pain medications were collected and tracked over time. Patients were seen monthly over a 6-month period. The PMQ score and the Numeric Pain rating scale were used to evaluate project effectiveness in controlling pain. VA Pain and QOL Benchmark was set at 5.0. SPSS version 23 was used to analyze the results. The paired t-test and ANOVA was used to determine if there was a difference in means from baseline out to six months.

Results: Evaluation of pre/post project implementation data: The Self-Care Model for veterans with chronic pain moderately decreased the veterans pain and increased QOL. The veterans pain decreased on average 1.33 (95% confidence interval, .52, 2.71) and was not statistically significant at p = .057. The veterans QOL increased on average 1.63 (95% confidence interval, .96, 3.17) and was statistically significant at p < .039. Twenty-one veterans started the program and at six months sixteen were still enrolled (76%). Sixty-one percent were diagnosed with PTSD. Seventy-six percent were enrolled in physical therapy and sixty-one percent started CBT. On average, each patient was on 2.5 medications although the program was able to limit narcotic use to seven patients (43%).

Conclusion: Healthcare providers who are effective in providing self-management can help enable patients to take responsibility for their health, decrease their pain, and improve their quality of life over time. Primary care providers are in a significant position to lead self-management programs. Research shows that self-management is highly recommended in the management of patients with chronic pain. Our program has demonstrated that you can decrease narcotic use and still achieve a higher QOL and decreased pain levels. Future Studies should include phone and text follow-up to improve compliance and encourage follow-up visits.