What Would Bonica Say? A Word on the DVPRS Validation Study

Authors


The wars in Afghanistan and Iraq have challenged pain medicine and health care like no previous conflict. Saving lives from injuries that would previously been deemed unsalvageable is now tempered by the challenges of restoring to survivors a meaningful and productive life [1]. Tragically, we are failing, and everyday, a soldier commits suicide [2] and every other day unintentionally dies from a prescription opioid overdose [3]. These deaths are added to the long list of warriors who have sacrificed their life in our defense, while leaving behind survivors who continue to burden the Military and Veteran Health Care programs, now staggering at a cost of $51 billion [4]. This is not sustainable, and something needs to be done.

Collaboration in pain management between the Veteran Health Administration (VHA) and the Department of Defense (DoD) began soon after the onset of the current wars. The 2009 VHA Pain Management Directive and the Defense Veterans Center for Integrated Pain Management led by the authors Drs. Gallagher and Buckenmaier created the necessary common platform to conceptualize a standardized approach for pain management. In 2010, the National Defense Authorization Act charted the Secretary of Defense and the Army Surgeon General to create the Army Pain Task Force (APTF), followed by the formation of the conjoint Veterans Administration-Department of Defense (VA-DoD) Health Executive Council Pain Management Working Group, to ensure that the task force recommendations are operationalized and disseminated in the military and veterans’ health systems.

This brief historical account and context is important for the reader. The creation of Defense and Veterans Pain Rating Scale (DVPRS) is not an intellectual exercise in pain assessment, born in the thought lab of outcome aficionados. DVPRS came to life after multiple deliberations of dozens of providers, leaders, and commanders devising an acute response to a medical crisis. The authors are to be recognized for this validation study, but even more for their Herculean effort to ensure that standardization and accountability will be the first recommendation from the APTF to be followed. Multiple recent reports (the Institute of Medicine, the Office of National Drug Control Policy, US Government Accountability Office, Food and Drug Administration, Risk Evaluation and Mitigation Strategy [REMS] blueprint) have all offered some guidance on how to improve appropriate, effective, and safe care for pain patients. But none have been so bold and explicit like the APTF, in mandating measurement with a standardized tool, from injury, through recovery and rehabilitation, to everyone, everywhere, in every clinical encounter.

The complexity of creating a tool to be accurate, objective, and used across all roles of care cannot be understated. It is clear that the authors were extremely prudent and thorough in their approach to validate DVPRS; they have been able to complete a preliminary study that suggests that the tool is practical and adaptable to both inpatient and outpatient clinical settings, and indicate that further testing in multiple settings and scenarios throughout the continuum of care is necessary. The authors cautioned, rightfully so, that accumulation of psychometric data is necessary before DVPRS is ready for general use, but the idea that this tool already exists and that data will be housed in a Pain Assessment Tool and Outcome Registry is very exciting.

Noteworthy is the author's statement that “the revised Face Rating Scale (FSR-R) was removed from DVPRS due to copyright restrictions and that a new faces scale was redesigned.” It is unclear why this was necessary, and I find it hard to believe that International Association for the Study of Pain (IASP), who holds the copyright, would decide to decline to preform a validation study with the military, using the FRS-R scale. If indeed this happened, and IASP prohibited the use of FRS-R, one can only lament this decision which clearly contraries their mission statement: IASP brings together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.

Finally, the validation of DVPRS is a seminal event for Pain Medicine not because it introduces into clinical practice “the best” tool for pain assessment. It is groundbreaking because it is the first time measurement-based care has been seriously embraced by any health care system in the United States. This will not be the first time the military has catalyzed change. To quote Secretary of Defense Leon Panetta: “Just as we helped foster the jet age, the space race and the internet, now we will break ground in understanding the human mind” [5]. In that vein, I dare presume that John Bonica, chief of Anesthesiology at Army Base McChord prior to the University of Washington and founder of IASP, would probably be proud of the Western Region Military-Veteran-Civilian Pain collaborative led by Major GeneralRichard (Tom) Thomas and be “satisficed” (combining satisfied and suffice) with the development and validation of DVPRS as a solid step forward in helping our health systems establish measurement-based care for our warriors and veterans.