Advances in pain management for Veterans: Current status of research and future directions.

Military Veterans have been identified as being particularly vulnerable to the development and perpetuation of pain [1]. Among the 23 million U.S. military Veterans, it has been estimated that as many as 50 percent of male Veterans and as many as 75 percent of female Veterans experience chronic pain [2]. Painful musculoskeletal conditions are the most common disorders among Veterans returning from the recent conflicts in Iraq and Afghanistan, surpassing the rates of all mental health conditions combined [3]. Pain among these Veterans is highly comorbid with the "signature injuries" of these conflicts, namely posttraumatic stress disorder (PTSD) and traumatic brain injury [4]. Although not unique to Veterans, compounding the challenges associated with successful management of chronic pain is continued evidence of a provider workforce that is ill-prepared to assess and manage common pain conditions [5], limited effectiveness of analgesic medications and other nonpharmacological approaches [6], and growing concerns about harms associated with long-term opioid therapy [7]. In 2011, the Institute of Medicine (IOM) published its seminal report, "Relieving pain in America: A blueprint for transforming prevention, care, education, and research," and called on the Department of Veterans Affairs (VA) and other Government and stakeholder groups to renew their commitment to this national transformational effort [1]. Research on pain among Veterans is not new. In fact, some of the early pioneering work to advance the multidimensional assessment of chronic pain and establish the efficacy of psychological approaches for pain management was conducted in the VA [8-9]. By 1998, former VA Undersecretary for Health Kenneth Kizer, MD, identified the need for more pain research as one of the objectives of a VA Pain Management Strategy [10]. A special topic issue of the Journal of Rehabilitation Research and Development (JRRD) in 2007 highlighted sustained growth in the VA pain research portfolio [11], and annual reports since that time provide evidence of yearly growth in terms of the number, scope, and financial expenditures in support of the VA's pain research portfolio. This special topic issue of JRRD presents results from pain research projects taking place in the VA healthcare system, with a focus on innovative research and its practice and policy implications. The specific objectives of the issue are to educate readers about (1) special issues faced by Veterans with pain, especially Veterans of the recent wars in Iraq and Afghanistan; (2) potential sources of inequities in pain care that may have special relevance for Veterans; and (3) novel approaches to the assessment and treatment of pain and comorbid conditions for Veterans with pain. As such, contributions to this special issue come from the VA clinical, rehabilitation, and health services research communities as opposed to investigators conducting basic laboratory science and preclinical research. Ultimately, we hope that the series of original articles that comprise this special issue will convey a sense of the robust pain-relevant research program in the VA and inform an agenda for further research addressing the management of pain in Veterans and other groups. Contributions to this special topic issue offer a window into the exciting, innovative, and important pain-relevant research being conducted in the VA that directly informs the VA's efforts to address the challenge of the IOM. As just one example, a key finding of the IOM was the lack of consistent data that document the incidence and prevalence of pain and its effects on activities of daily living and work, use of healthcare and social services, and costs of pain and pain care and the recommendation to "improve the collection and reporting of data on pain" [1]. The VA is ideally positioned to address this recommendation because it has one of the most comprehensive electronic health record (EHR) systems in the United States, which includes longitudinal clinical assessments (e. …