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VA Nebraska-Western Iowa Health Care System

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VA program helps Veterans learn to manage lives with pain

A Veteran recieves accupuncture at the Grand Island CBOC

Dr. Kathy Amoyt, primary care physician at the Grand Island CBOC, test the use of accupuncture on Jonathan Pfeiffer, U.S. Army Veteran, to relieve his back pain.

By Will Ackerman
Thursday, March 7, 2013

Deborah Hansen has a goal – to be a volunteer in the community. One thing prevents her from achieving that goal – chronic pain in her abdomen.

“I have pain all of the time,” Hansen said. The U.S. Army Veteran had a hysterectomy about 10 years ago. Five years ago during an exploratory surgery, doctors determined about five inches of her small intestine adhered to her abdominal wall in the years since her hysterectomy. Although doctors tried to fix the problem, it didn’t work. She now lives with chronic pain.

“Pain medications don’t do a lot for me,” she said.

Some days her pain is a three on a scale of one to 10; other days it’s in the eight to nine range, she said.

“Some days I can barely get out of bed,” Hansen said.

Although she thinks her pain will never go away, Hansen has found a better way to manage it through a program at VA Nebraska-Western Iowa Health Care System. The Pain Treatment Program is a collaborative, interdisciplinary approach to helping Veterans learn to live with and manage chronic pain.

The three main components include a Chronic Pain 101 class, a Managing Chronic Pain cognitive therapy group and a pain clinic.

In Chronic Pain 101 Veterans learn about different types of pain and medications. The instructors describe the Gate Control Theory, which suggests the spinal cord contains a neurological “gate” that controls signals to the brain. What’s often a surprise to Veterans is there’s more to pain than just the physical aspect.

“We tell Veterans that often when the mind is hurting, the body can hurt, too. Consequently, we explain how we can do behavioral intervention,” said Tabitha Carlson, a psychologist at the Grand Island Community-Based Outpatient Clinic.

Behavioral intervention can include helping Veterans reframe negative or distorted thoughts to positive ones, or how to overcome depression brought on by their chronic pain.

The class is offered from 1 to 4 p.m. the second Tuesday of every month. Although it is led by the team in Grand Island, Veterans can attend via video conference at all NWIHCS sites.

Veterans learn relaxation techniques in the cognitive pain therapy group. Therapists teach techniques including muscle relaxation and diaphragmatic breathing.

“This is not a support group where people can come to complain about pain,” said Lori Armstrong, a psychologist at the Omaha VA Medical Center program. “We talk about things that can help and learn behavioral skills and techniques.”

The pain 101 class and the therapy group are helpful, Hansen said.

“I learned alternate ways, other than with medications, to ease the pain and make my life a bit easier. I learned deep-breathing exercises that I can do anytime and anywhere,” Hansen said.

A more intensive piece of the program is a multidisciplinary pain treatment clinic, which is a consultation service to provide recommendations to the Veteran and his or her primary care provider.

At the NWIHCS clinic in Grand Island, Neb., on a recent Friday morning, U.S. Army Veteran Jonathan Pfeiffer met with the pain clinic team, which includes a psychologist, primary care physician, nurse, pharmacist and a physical therapist. Rather than individually evaluating Pfeiffer’s pain, the team worked together to provide him the best recommendation to help him manage his pain.

Each team member meets with the Veteran individually, then meets with the team to discuss recommendations. The team then finally presents an interdisciplinary plan to the Veteran.

“Our focus is on behavioral interventions to manage chronic pain,” Carlson said. “We want to help increase Veterans’ understanding of what they can do to best manage their pain, and how to integrate this into their daily lives.”

Dr. Kathy Amyot evaluated Pfeiffer through questions and a physical exam. Pfeiffer’s main pain complaint on this visit was due to a degenerative disc disease in his lower back. He cringed as he bent at the waist and returned to an upright position during part of the exam.

“Talk to me about your pain,” Amyot said. “What makes your back feel better?”

After evaluating his physical ailments, Paula Carlson, a pharmacist at Grand Island, and Pfeiffer discussed his current medications and how they affect his pain.

One of the key components she talks to patients about when they are dealing with chronic pain is the use of opioids, which are pain relievers. They reduce the intensity of the pain signals reaching the brain. Although the use of opioids in some patients with chronic pain is appropriate, Carlson and the patient discuss the purpose for using the medication and whether the benefits of using them outweigh the risks.

The danger for misuse and overuse of opioids has increased significantly, according to a March 2012 study conducted at the San Francisco VA Medical Center. Not only has the use of prescription opioids nearly doubled since 1994, they are also a leading cause of death in the United States.

Consequently, the pain treatment team collaborates to help Veterans like Pfeiffer and Hansen manage their pain through behavioral therapy and physical therapy in addition to ensuring any medicines they are taking are appropriate for their specific health issues.

“We present the information to the Veteran together so they have all of the pieces of the health care puzzle,” Amyot said.

Pfeiffer said he learned 10 percent of managing his pain can come from the pain medications, but the other 90 percent is behavioral.

“My goal is that this will help me to be more active with my children. That’s important to me. I want to find ways to live well and make a better quality of life,” Pfeiffer said.


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