Strengthening Collaborations With the U.S. Department of Defense and U.S. Department of Veterans Affairs: Effectiveness Research on Mind and Body Interventions | NCCIH

Strengthening Collaborations With the U.S. Department of Defense and U.S. Department of Veterans Affairs: Effectiveness Research on Mind and Body Interventions | NCCIH

A National Advisory Council on Complementary and Integrative Health (NACCIH) Working Group Report

February 2015

Table of Contents

• Executive Summary
• Working Group Charge and Study Process
  • The Charge
  • The Process
• General Introduction
  • The Problem of Pain in Military and Veteran Populations
  • Mind and Body Practices and Pain Management
  • Changing Perspectives on Health and Health Care
• Research on Pain Management and Integrative Medicine at NCCIH, the DoD, and the VA
  • NCCIH
  • The DoD
  • The VA
• Key Issues To Consider
  • Challenges to Research in Military and Veterans’ Settings
  • Pain Research Questions That Are Important to Military Personnel and Veterans
  • Examples of Current Research Projects
  • Complementary and Integrative Approaches in the VA and DoD.
  • Can Research Be Embedded Into the Delivery of Care?
  • Resources for Research
  • Study Design Considerations
• Recommendations for Study Design and Project Structure
  1. Comparing Integrative Approaches to Standard Pharmacotherapy
  2. Evaluating Process and Content Changes
  3. Working With the DHA To Facilitate Collaborative Larger-Scale Research Studies
• Conclusions
• References
• Appendix A: Working Group Members, Staff, and Speakers
• Appendix B: Agendas for the Working Group Meetings

Executive Summary

The National Advisory Council on Complementary and Integrative Health (NACCIH) convened a working group to advise the full Council on the potential for development of a large-scale initiative to examine the effectiveness of mind and body practices in military and Veterans’ health care settings. The working group was also asked to provide advice on strategies for collaboration with the Department of Defense (DoD) and Department of Veterans Affairs (VA) health systems and on implementation of any proposed initiatives.

The National Center for Complementary and Integrative Health (NCCIH), formerly the National Center for Complementary and Alternative Medicine (NCCAM), has used a phased approach over the past several years to promote research on complementary and integrative practices for pain and symptom management in military and Veteran populations. In cooperation with other agencies, NCCIH published several funding opportunity announcements in 2012–2014 for collaborative activities and relatively small-scale projects. The working group was convened to discuss potential future initiatives to build on these efforts.

The working group chose to focus on chronic pain. Chronic pain is a major societal problem, estimated to affect about 100 million U.S. adults, but it may disproportionately affect those who are serving or have served in the military. Data on the high prevalences of chronic pain and opioid use in the military and Veteran populations are alarming to policymakers. The current interest in the use of integrative approaches serves as an impetus to plan studies now so that widespread implementation of new interventions will benefit from concurrent research on outcomes. Pain research is a priority for NCCIH. About 30 percent of NCCIH’s research budget is devoted to pain research, and the role of the brain in perceiving, modifying, and managing pain is the main emphasis of NCCIH’s intramural research program.

The working group held five meetings that featured presentations from experts on pain research, study design, complementary and integrative approaches, and DoD and VA initiatives, practices, and priorities. Speakers also included a representative of a Veterans advocacy group and an Army Veteran who struggled with chronic pain after being injured during his service.

Presentations and discussions emphasized the strong commitment of the DoD and VA to pain research and improved management of pain and comorbid conditions, the ongoing shift toward an aspirational approach to health and healing, the role of innovative study designs in addition to individually randomized controlled trials, the value of pragmatic studies in real world settings where care is usually delivered, DoD and VA resources that could be leveraged for research, and the special considerations involved in working within a military environment.

Speakers agreed that, in general, pain is poorly managed, and better strategies are needed. Much emphasis was placed on concerns about opioids, which are widely used for chronic pain but lack compelling evidence for their effectiveness for chronic vs. acute pain and have risks and side effects that may exceed benefits when opioids are used chronically. Working group members noted that the evidence of efficacy for complementary approaches for chronic pain is incomplete, and many studies suggest effects are modest; nonetheless, conventional techniques for managing chronic pain, including opioids and surgical and epidural interventions, also have limited efficacy. The balance of risk and benefit suggests that integrative approaches that utilize complementary techniques are promising and deserve more study.

Several speakers, including the patient and advocate, emphasized the importance of promptly translating research findings into clinical practice. However, implementing new approaches in a health care system is challenging. The VA and DoD settings, each of which has unique attributes, are settings in which innovative changes can be rigorously assessed. The development of a learning health care system, in which research is embedded into the delivery of care, is an important goal of many health policy leaders. It may help to overcome the translational challenges, but creating this type of system is not easy. Research and patient care were traditionally considered separate activities, and scientists who are now trying to bring them together have encountered a variety of challenges.

At the group’s final meeting, the potential benefits of working cooperatively with the Defense Health Agency (DHA) to facilitate research were discussed. The DHA, now in its second year, is responsible for increasing the integration of health care provided by the individual armed services and may be interested in leveraging its resources for pain research. The DHA oversees shared services in enhanced multi-service markets (eMSMs), which include some of the largest military health care facilities, and has direct responsibility over military health care facilities in the National Capital Region. The involvement of the DHA in the proposed research initiative would be invaluable, but input from the health care leadership of all three armed services and the VA would also be needed for potential projects to be designed and implemented successfully.

Based on all these considerations, the working group recommends that NCCIH further assess the feasibility of undertaking one or more large-scale studies in cooperation with the VA and the DoD/DHA to answer important policy and patient care questions about the use of integrative approaches in pain management. The working group agreed that:

• The primary outcome measures should assess the impact of pain on patient function and quality of life, with changes in the use of opioids and other drugs as a secondary outcome.
• Instead of focusing on a single complementary modality, the research could focus on:
  
  • An integrated package of nonpharmacologic modalities that could be individualized;
  • An integrative model of care that could include complementary health approaches; and/or
  • A holistic or personalized approach to health care.
• Patients who are in the early stages of chronic pain may be the most appropriate population to study.
• Natural experiments and existing resources should be leveraged whenever possible.
• Studies should be pragmatic and research should be embedded in the delivery of care.

The proposed initiative could help the DoD and the VA achieve the goals presented in the DoD/VA Pain Management Task Force Final Report and recently outlined in the VA’s Blueprint for Excellence. New knowledge gained through collaborative larger-scale studies may improve pain management in the general public as well as in military and Veteran populations.

Top

Working Group Charge and Study Process

General Introduction

Research on Pain Management and Integrative Medicine at NCCIH, the DoD, and the VA

Key Issues To Consider

Recommendations for Study Design and Project Structure

Conclusions

References

Appendix A: Working Group Members, Staff, and Speakers

Appendix B: Agendas for the Working Group Meetings

[*] Congress recently changed the name of the National Center for Complementary and Alternative Medicine (NCCAM) to the National Center for Complementary and Integrative Health (NCCIH).

[†] The concept of health homes (or patient-centered medical homes) does not refer to care provided in the patient’s home. Instead, it is a team-based model of care in which care is provided primarily in a clinic or hospital-based setting.

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