PAIN and VETERANS HEALTH ADMINISTRATION(VHA)

by Clyde H. Stagner

VETERANS ADMINISTRATION(VA) – In an effort to improve pain management, the VHA began the “Pain as the 5th Vital Sign” initiative in 1999 which required a pain intensity rating of 0 to 10 at all VA clinical encounters. The first four vital signs are pulse(time repetitions), blood pressure(force/area), temperature(degree),and breathing rate(time repetitions) : the first four vital signs are objective with unit dimensions scientifically calibrated to the unit standard at the U.S. National Institute of Standards and Technology (NIST).

Tagging subjective pain as a fifth vital sign is psychologically misleading when referenced to the objective first four vital signs:

1. SUBJECTIVE: Is that which exists in the mind of the observer in contradistinction to existing in the object being evaluated. This emphasizes the observers own interpretive judgment whether expert or novice.

2. OBJECTIVE: Evaluations are not affected by personnel impressions or predisposition judgments in contradistinction to conclusions based on fact and reality.

As a disabled veteran experiencing various modes and intensities of pain, my responses to VA clinicians at VA primary care appointments has been a subjective number designating pain rather than defining pain which requires objective measurement calibrated to NIST. The clinicians have never asked for a description of the pain such as point, area, volume, stabs, jolts ,flashes, et al.

The VHA has conducted clinical evaluations of the 5th Vital Sign involving disabled military veterans. At the Health Service Research and Development Service (HSRD)National Meeting in 2005,3033- Pain as the 5th Vital Sign :No Detectable Impact on the Quality of Pain Management in a VHA Clinic was presented with the Implications: routine measurement of pain mandated by the P5th VSI was not associated with increased quality of care. For veterans with pain levels of four, or greater, we discovered performance below the initiative objective across all measured indicators.

At the HRSD National Meeting in 2006,3073-Implementation of pain as the Vital Sign Initiative and Trends in Analgesic Prescription. Of 25,789 veteran patients, those with moderate pain score were likely to be prescribed an opioid and those with severe pain were more likely to be prescribed an opioid. These results, described in terms other than the 5th Vital Sign, confirm the primary care provider’s excellence in judgment. A factual scientific relationship to the 5th Vital Sign is lacking in the findings of this study.

In the above two studies, data for medical manpower, funds, and facilities are not included to enable determination of responsibility and accountability.

After ten years of failure to scientifically relate the subjective 5th Vital Sign for pain to a scientifically calibrated numerical value(s). the VA issued VHA Directive 2009-053,dated October 28,2009,providing policy and implementation procedure for the improvement of pain management consistent with the pain 5th Vital Sign protocol contained in VHA National Pain Management Strategy initiated November 12, 1998 which established Pain Management as a national priority(for the VA). This latest effort is supported by consultation from pain medicine, behavioral health, physical medicine and rehabilitation, specialty consultation, and care by palliative care, tertiary care, advanced diagnostic and medical management, and rehabilitative service for complex cases which requires family and patient education programs, collaboration with integrative mental health-primary care team.

The latter VHA effort involving mental health represents an effort to transfer the existence of pain from the wound/injury/disease source to the mental capacity of the disabled veteran. VHA, at the VA Michael E. De Bakey Medical Center, Houston, Tx, has tested cranial electrotherapy stimulation(electrical shock treatment) to treat pain with the conclusion: Findings of study support the use of CES as a practical and effective treatment for particular type of SCI-individual pain. What were the scientific findings? What were the the side effects: temporary and permanent?

Several VHA studies used statistics in pain evaluations. Statistic results are considered scientific for results designating groups or individual groups from a larger group. An individuals identification in statistics evaluation remains unknown, Life, health, auto, house, et al insurance are based on statistical data(facts) for future frequency occurrence without individual identification among the group total prior to an occurrence.

The National Academy of Science(NAS) has studied pain from its scientific objective parameters. The use of a Scalar value affecting the brain was successful in the assessment of neurological status. The subjective entity(Scalar) was measured by the direction and distance expansion(objective) in the pupil of a human eye.

DR. Phillip Needleman determined that cycloxygenae was responsible for inflammatory pain suffered by arthritic patients. As a result celebrex was developed and used with pleasure by this disabled veteran for over a year.

To obtain possible medical treatment parameters as a result of patient studies, the NAS scientist’s qualifications and investigative results indicate the VA, and more importantly, the disabled veteran, would benefit from a scientific, objective relationship between pain presence, type, and intensity determined by a collaborative effort between the VA and NAS. Past NAS study results indicate the objective NAS scientists are best qualified to establish specifications and parameters of any given pain study to include responsibility and accountability. NAS is science. Medicine consists of art and science.

In 2009,after arthritic treatment of pain with tylenol, motrin, voltaren, celebrex, naproxen, and resultant anemia, my VA primary care physician prescribed Tylenol 3 which is taken three times daily supplemented with 500mg of Tylenol as needed below a maximum of 2400 mg of tylenol daily. This daily maximum narcotic boundary dosage for treatment of pain can be increased by my VA primary care provider for increased experienced pain. The latter iteration(s) require patient/primary care provider contact which is extremely difficult ,if not impossible, within the VA modus operands: clerks, answering telephone calls, evaluate medical conditions rendered by the veteran patient.

In September,2009,my broken knee cap required surgery by an orthopaedic surgeon at the Tucson Orthopaedic Institute,P.C.. Subsequent to surgery, the surgeon prescribed forty Hydrocodone-APAP 5-500 tablets with instructions to take 1-2 tablets every six hours as needed. The Hydrocodone contained/controlled my pain throughout surgical recovery with some of the tablets remaining after surgical recovery.

On January 11,2010, another knee cap surgery was conducted with the same pain treatment protocol. Results in the treatment of pain were identical to that previously experienced. These three experiences indicate that primary care physicians and medical surgeons, through instruction, training, and experience, possess the intellect and wisdom to prescribe a boundary quantity of pain control medication with the subsequent wisdom of observation for reductions or increases in dosage as necessary. Initial boundary prescriptions of pain medication for the various known medical diseases and conditions would best be initially indicated by the appropriate medical group/association/board /et al with publication as recommended rather than binding in implementation.

Until the VA obtains objectivity in assessing and treating pain ,disability claims of disabled veterans involving pain should be determined by Disability Evaluation under Social Security, Part II-Evidentiary Requirements, Medical Evidence which is SSA PUB. No. 64-039,ICN 468600,September,2008, in accordance with the Fourth Circuit Court decision, July 11,2006 obtained by class action suit.

For the Veteran