Starting a Primary Care Pain Management Clinic in a Military Treatment Facility

Abstract

Pain is an ever-present challenge in military medicine. Our war-fighter is a high intensity professional. Through multiple trainings and deployments, they push their bodies, which can lead to injury, trauma, and chronic pain.''^ Opioid use for chronic non-malignant pain among U.S. patients is rising.^'' Recent estimates show that 3% of the population use opioids 30 days or more.'-' Among U.S. military soldiers, studies suggests an even higher prevalence, with 4.5% opioid prevalence in young veterans.*' A recent Department of Defense survey showed that one-fourth of active duty soldiers reported abusing prescribed drugs over a 12-month period and an increase of 4 times the amount of prescription pain medications written by military physicians over the last 7 years.* These are alarming figures. Our soldiers are highly skilled professionals, but their skills can become dulled and their decision making compromised when using opioids.' A reliable pain-management physician is needed to help guide and educate these soldiers and their family members for their best care. As the U.S. military is spread worldwide, we often do not have access to specialists who are utilized at large medical centers. As a result, primary care physicians often take on expanded roles at their military treatment facilities (MTF). To meet the increased need for the treatment of chronic pain, the Army has called for establishing a pain management clinic within primary care in the Pain Management Task Force report by the Office of the Army Surgeon General.' I was tasked with starting our Primary Care Pain Management Clinic (PCPMC) at my MTF. My MTF provides primary care services to approximately 7,500 beneficiaries. I have a primary care patient panel of 950 patients and see about 300 to 325 patients per month. The PCPMC sees about 70 chronic pain patients per month, which includes approximately 25 to 30 continuous sole provider patients on chronic daily opioids. The vast majority of pain complaints are musculoskeletal, with back pain (44%) being the most predominate followed by knee pain (15%) and shoulder pain (11%). The start of the PCPMC was hectic. Questions and patient encounters were coming from multiple angles, including calls, emails, front desk, and walk-ins. To assist me with the PCPMC and to manage my patients, we implemented a Team Care approach to include a strong dedicated pain clinic medic and a front desk clerk. The Team-based care allows me to maintain good therapeutic boundaries and to utilize