A website specializing in Lifestyle Modification of Chronic Non-Cancer Pain

Background

In 2011 I took a vacation from http://www.chronicpaindoctor.net to go work at Naval Hospital Camp Pendleton (NHCP) with Marines returning from Afghanistan. Camp Pendleton is the Marines main base an hour’s drive up I-5 from San Diego. NHCP is where the Navy implements its duty to provide the care Marines need as a result of their combat responsibilities. I took the job for 3 reasons: 1) to add to my knowledge about pain, to see what the Navy had learned from a heavy concentration of pain cases about how to restore optimal functioning; 2) to treat Marines with chronic pain the “Navy way” and learn how to implement their rehab approach for chronic pain; and, 3) to give wounded Marines my personal “thanks” for their bravery in Afghanistan by extending to each one in pain a credentialed pain specialist’s best efforts to help restore function.

What follows are my observations extracted specifically from my experience with Marines who had diagnosable chronic pain disorders – often in combination with other combat-related disorders – and which I personally treated during 2011.

Functioning As An HMO, Is NHCP Structured to Treat Chronic Pain? 

The quick answer is “No” because only if the structures are in place for a hospital to be enabled to effectively treat, manage and rehabilitate chronic pain and restore function is it possible to rehabilitate chronic pain. Simply put, the extent to which you ski is determined by the investment you make in developing the skill-knowledge needed to ski. Since NHCP made no investment in developing chronic pain rehab capabilities, it has none to offer.

Problems of All Non-Pain Specialty Approaches to Treating Chronic Pain

The problem for those with chronic pain is that NHCP operates like any other HMO in the country and so it concentrates on offering only a narrow range of primary care services in general, family and internal medicine. A few additional services in specialty medicine, like Ob/Gyn and Pediatrics, exist which, in combination with the primary care services, are available to anyone who is a beneficiary of Tricare, the military’s health insurance. Medical needs that fall outside the hospital’s primary care area of practice ar simply not acknowledged and that is why they are never treated. Therefore, those chronic complex disorders that do not “fit” the primary care acute care model, referrals to “out-of-network” providers who are qualified to treat these disorders are rarely made. If as far as primary care providers a disorder is not acknowledged then no need exists to make a referral to someone who specializes in that disorder. Again, the services needed to treat the chronic complex pain disorders that many Marines develop were never adequately treated for 18-24 months, do not exist at NHCP.  The fact a Marine could be exposed to primary care or specialty care treatment at NHCP for 18-24 with no objective change in the Marine’s chronic pain condition provides evidence of the absence of qualified pain treatment at NHCP. Clearly engaging a pain patient in 18-24 months of inept, failed treatment does nothing to provide stable enough pain relief, restored function, and a return to full-duty status, all of which are the explicit duty of Navy doctors to provide wounded Marines. That the Naval Hospital at Camp Pendleton has chosen to administratively limit itself to functioning as a primary care hospital that does not offer a qualified chronic pain rehab program does not exculpate it and its doctors from its duty to treat wounded Marines according to the needs of their symptoms.

How Navy medicine manages a Marine with chronic complex pain reveals the same negligence seen in how civilian providers manage chronic complex pain – by either under treating or not treating it at all, which leads to worsening of condition and a complex chain of further costly healthcare services in all pain patients. Marines are harmed further by terminating their careers without a solidly grounded differential diagnosis or proof of the failure of a demonstrably competent chronic pain rehab program. My experience in running a chronic pain rehab program is that ~70 percent of musculoskeletal pain cases could be restored to optimal functioning with that 12 months, or about half the time that Marines in chronic pain are exposed to failed or inept acute approaches to chronic pain.

The Steps NHCP Uses to Evaluate Chronic Pain Complaints

The steps that Marines went through who I treated for chronic pain were as follows:

– All Marines are first evaluated by their BAS MOs (Battalion Aid Station Medical Officers), family medicine residents not yet licensed to practice as independent physicians. Since BAS MOs work and live with and are deployed with the battalion, they know individual Marines best and the likely conditions of their symptoms occurrence. Most complaints at the BAS level are acute and are resolved by usual care from a family medicine approach. However, many Marine complaints surface once Marines are no long “in theater” where most believe they have “no time or stomach” for severe pain.  So once some Marines return to base, chronic pain issues will emerge. When issues develop that require repeated visits over a period of 6-9 months to their BAS MOs for treatment to which the Marine fails to respond, referral is then made further up the ladder;

– Primary care (physicians licensed in general medicine, family practice or internal medicine) now evaluates the complaints  and starts a medication regimen that fits the acute care model of the primary care doctor and has nothing to do with the end objective of restoring function and a return to full-duty status.  This treatment usually shows no response within 4 weeks, but it may be extended, or literally forgotten, for another 6-9 months. As with the BAS MO, this is a similar treatment to which a Marine with an under or untreated pain disorder will fail to respond. Referral is now made to specialty medicine;

– Specialty medicine now evaluates the Marine’s complaints, usually orthopedics, neurology or psychiatry, to rule out objective causes from the perspective of the particular specialty. More modifications to treatment are made over a period of another 9-15 months, often with multiple prescription drugs to which the Marine with an inappropriately treated pain disorder will again fail to respond, often with side effects that further exacerbate the pain condition and decrease his/her ability to function as a Marine.

– In several cases, specialty medicine referred the Marine for evaluation by pain anesthesiologists at the Naval Medical Center at Balboa in San Diego where a competent differential diagnosis was obtained and medications to which the Marine finally began to respond well and to get some pain relief. However, a solid diagnosis and some initial pain relief are not chronic pain rehabilitation by a qualified integrated interdisciplinary team where the primary responsibility of each of its members is chronic pain rehab alone. The problem was that there was no continuity of care by the pain anesthesiologists who knew how to best manage the pain; that responsibility fell back onto the BAS MO who, once the prescription ended, s/he might or might not renew, completely change the treatment, or be deployed and the Marine require transfer to a temporary BAS MO who would start this entire process all over again.

– By this time, specialty medicine would usually begin to discuss preparation of the Marine’s Medical Board, terminating his/her career in the Marine Corps. This without the chronic complex and disabling pain disorder ever being competently diagnosed, effectively treated (and confirming the diagnosis) and having this entered in the Marine’s AHLTA medical chart to document, once s/he went to request treatment from a civilian provider that the Marine was a legitimate chronic pain patient as evidenced in a credible military document by a qualified physician who treated the Marine’s pain and could attest to it if the civilian physician felt the need to do so.

With the Marine’s career ended thanks to a chronic pain disorder that the Marine has no awareness of what its causes are, how to relieve the pain, manage the conditions of its occurrence, what to do to return to optimal functioning (allowing for regular employment), and to enjoy increased quantity of life within his/her unique life situation.

The Result of “Business As Usual” At NHCP

In other words, the outcome of a military medicine approach to chronic complex pain is no different from that seen in the private sector when chronic pain patients are seen by independent practitioners and left with the same disabling conditions that will lead to unending high frequency use of medical visits, prescription medications, diagnostic and laboratory studies, the ER, hospitalization and unnecessary surgery. To this must be added becoming totally disabled, unemployed, divorced, with loss of children, in medical bankruptcy, living alone, being highly prone to developing multiple chronic diseases, intractable pain (see http://intractablepaindisease.com), along with a likely addiction to alcohol and prescription or street drugs.

Finally, my experience included a clear case of no leadership on the part of the psychiatrist who was in charge of the Wounded Warrior Battalion who knew I was credentialed in pain management and was bound to practice based on the ethical standards of my diplomate with the American Academy of Pain Management (AAPM) and who told me to “do less pain management and something more psychological.”  Ultimately he demanded I become credentialed in health psychology – which is not an evidence-based procedure for rehabilitating chronic complex pain – or not have my contract renewed. I chose to stick by the ethical standards of the AAPM and did leave.

Marine Myths about NHCP

NHCP knows and treats everything. No it doesn’t. NHCP only has the evidence-based skill-knowledge set for primary care – or the perspective of general, family or internal medicine plus a few specialty medical services. That’s it. Marines should not expect more. For Marines with pain that has lasted more than 3 months and for whom the usual medical care offered at NHCP has done nothing to restore their ability to function, NHCP lacks the MOS to treat, manage or rehab a Marine’s chronic pain disorders. The likelihood is that a Med Board will be the outcome for those with chronic pain.

Specialized rehab programs for chronic pain exist at NHCP.  They do not. There are many rehab programs in hospitals around the country. The classic ones are Cardiac Rehab, and Diabetes Rehab, and they all have the same characteristics: an integrated interdisciplinary team who are all knowledgeable about chronic pain with the single minded objective being to: (a) restore optimal behavioral and molecular to the patient as evidenced by objective behavioral and molecular markers, and (b) turning over to the patient the responsibility of self-managing the conditions of their pain’s occurrence.

If one has chronic pain, one can quickly get to see a pain specialist at NHCP. Not possible. A chronic pain specialty requires special education, training, experience and credentialing. There are no such providers at NHCP. Pain specialists are available at Balboa but it takes a long time to go through the steps to get a referral to Balboa. And then it’s just for a “differential diagnosis” that will probably be the basis for your Med Board rather than for ongoing treatment, relief of pain and restored ability to function (especially in “full-duty status”).

The Med Board process is no big deal. Not really. Most wounded Marines who I saw at Camp Pendleton ended up being “med boarded” out of the Marines – at great harm to the Marine – not because the Marine had a specific, diagnosable condition that made him/her “unfitting” for duty. That their disorder rendered them “unfitting” never could be confirmed because they were never exposed to the appropriate treatment for chronic pain, which when done right, could have confirmed if their pain disorder really rendered them “unfit” by disappearing. Instead, Marines with chronic pain were summarily “med boarded” out of the Marines because the Marine’s pain disorder did not respond to general medicine’s acute perceptions, treatment and management approach to pain and your chronic pain failed to respond to their mistaken expectations.

If a provider at NHCP says I don’t have chronic pain it’s so.  Not so, not today when evidence-based pain management is what we practice, rather than philosophy and the unsupported use of words. Scientific pain management exposes the patient to the evidence-based treatment for the specific pain condition that is implemented by an integrated interdisciplinary team qualified in providing chronic pain rehab. If the Marine’s chronic pain responds to the qualified version of chronic pain treatment within the expected period of time, there is confirmation of the pain condition and the primary care doctor’s diagnosis is therefore false. If there is no response to the chronic pain treatment, there is no confirmation of the pain condition and the chronic pain specialist’s diagnosis is therefore false.

It’s easy for a neurologist to see the real causes of pain. No so. Take the case of a 20 y/o Lance Corporal “mortar man” who was on patrol in enemy territory carrying a heavy mortar barrel by wrapping both his arms around the mortar barrel and resting it over his traps as one might hold a heavy barbell prior to doing squats. As the patrol came over a rise, enemy rocket fire started coming in over the Marines, and the Lance Corporal started running down a hill that was inclined to the right. As he ran he stumbled on a rock and as gravity took him towards the right, still with the mortar barrel over his shoulders, he fell hard with all his weight. As he fell he put out his right elbow to break the fall and, in so doing, the barrel was forced towards the right front and tightly against his right trap which he fell against with all his weight. When he was able to get up the pain was sharp and throbbing over his right shoulder and neck. He reported to the BAS MO, was given rest and mild analgesics. The pain subsided slightly but within a week he reported having “bad migraines.” He was returned to base but was unable to perform his duties due to the “bad migraines” so he was air-evac’d back to Camp Pendleton for evaluation and treatment. After a period of unsuccessful treatment by his BAS MO he was referred him for primary care evaluation and more treatment with analgesics which again did nothing to relieve his headaches. At 12 weeks post-injury the Marine was referred to a neurologist for evaluation who prescribed the standard medication for migraines to which the Marine faithfully adhered for a further 4 months; however the migraines persisted while his marriage, work, and social life got worse. Another 8 months went by with relief in his migraines; he also was treated with psych meds because he couldn’t stand the side effects. He couldn’t do any exercise, he had no appetite and he lost 15 pounds. The neurologist told him he was going to be “med boarded” since his symptoms didn’t improve, he couldn’t qualify for any of his Marine required activities, and his Command was ready to support his being med boarded.

Since NHCP can provide no qualified treatments for chronic pain, all his Navy doctors could say concretely was that this young Marine did not have the neurological, psychiatric, or orthopedic conditions they hypothesized he might have. There is no way of confirming with hard evidence of either Navy physicians’ impression of the condition or provide no qualified treatment, only assertions that the condition is something that it is not – and for which there is no confirming response to treatment – rather than what it is – and for which the confirming response to treatment does exist.

CONCLUSION – THE EMPEROR HAS NO CLOTHES 

My original impression before I came to work with wounded Marines at NHCP was that Navy medicine at NHCP was at the same level of expertise that military medicine was at in their work amputees. This was not the case at NHCP on closer inspection:

– There is no qualified pain treatment at NHCP;

– There are no qualified full-time pain specialists available to Marines at NHCP;

– There are no continuing education courses on chronic pain for providers at NHCP;

– There is no integrated interdisciplinary chronic pain program at NHCP;

– Med Board diagnoses for those with chronic pain are probably in error

– Med Board diagnoses for those with chronic pain are often trivial (“neuritis” was given as a diagnosis rather than the disabling Complex Regional Pain Syndrome that it was based on a second round work-up by pain anesthesiologists at Balboa);

– There is no credentialed chronic pain specialty leadership for the Wounded Warrior Battalion.

The Marines I worked with were a wonderful group of men I got to know and appreciated enormously. They deserve a more than the “business-as-usual” primary care effort they have been given. All Marines should be returned to the high level of behavioral and molecular functioning they had shortly after finishing boot camp at their physical best. Hopefully, legislators in Washington will implement the urgently needed chronic pain rehab programs these brave young Americans deserve.

 

Dr. Henry Adams

AAPM Diplomate in Pain Management

Pain patients should read this to be aware of how major food manufacturers make decisions about what to put to the market. Click here to download the article (PDF, 2.2MB)