Chronic pain is three times more prevalent in veterans than in the non-veteran population, with a link to trauma and mental health conditions. At the 45th International Committee of Military Medicine (ICMM) World Congress, the Department of Veterans’ Affairs (DVA) hosted a pre-congress workshop to address the barriers that both veterans and healthcare providers face in managing chronic and persistent pain. This commentary aims to summarise the learnings from the pre-congress workshop and discuss further strategies to support providers and veterans in accessing best-practice care.
Introduction
Chronic pain continues to be managed inadequately and remains a cause of increasing morbidity within the veteran population, with close to 90% of transitioned and regular ADF (Australian Defence Force) members reporting some degree of pain intensity and disability.1 The pathways for providing care for chronic pain are complex, and the barriers are multifactorial. Chronic pain often presents with or is compounded by mental health conditions such as post-traumatic stress disorder, anxiety and depression in up to 85% of veterans.2 The ICMM workshop aimed to consider the barriers that both veterans and healthcare providers face in accessing and providing high-quality care for chronic and persistent pain, and to identify actions that the DVA can take to support best-practice care in the Australian healthcare system.
Background
Despite the recent introduction of a national strategy for health practitioner pain management education,3 it remains challenging to translate education into the effective real-world management of complex chronic pain. In the military subgroup in particular, a complex management issue remains for many healthcare providers. While a recent randomised controlled trial looking at long-term outcomes has shown that an interdisciplinary pain management program can produce significant and sustained improvements in pain-related disability in veterans compared to standard care,4 these can be difficult to access.
In recent years, guidelines have reinforced an emphasis on non-opioid treatments as first-line for chronic pain.5 While opioids are effective for short-term pain management, they are not recommended for long-term use due to the effects of tolerance, dependence, addiction and opioid induced hyperalgesia. Education and self-management techniques, such as relaxation, acupuncture, massage, nutrition and exercise, have been an important part of treatment. Encouraging patients to independently manage their symptoms by promoting their own self-efficacy through lifestyle changes has been shown to reduce healthcare costs and medication use.6
The impact of mental health conditions on the development and perpetuation of chronic pain is also of critical importance in veterans. The recently published Monash report reviewed the association between chronic pain and mental health and found ‘consistent data suggesting an increased prevalence of chronic pain among ex-serving personnel and overlap of chronic pain with mild traumatic brain injury, post-traumatic stress disorder, depression and anxiety’.7 DVA already provide veterans with access to fully funded treatment for all mental health conditions regardless of the link to service through Non-Liability Health Care (NLHC).
Workshop design
Session 1
The workshop was attended by 73 participants, providing DVA with an opportunity to gain insights and expertise from health providers worldwide. Session 1 welcomed a panel of expert speakers comprising a Pain Specialist, Specialist Pain Physiotherapist and a Psychiatrist to lead the discussion through a fictitious case study of a veteran’s journey through chronic pain and coexisting mental health conditions. Participants were able to respond to an interactive platform on personal devices.
Outcomes of Session 1
The understanding of the definition of chronic pain, also known as persistent pain, between health providers varied. However, there was a consensus around the International Association for the Study of Pain (IASP) definition of ‘ pain that persists or recurs for longer than 3 months and can last for several years’ also noting their recently revised definition as either primary (main presenting problem) or secondary (due to an identifiable underlying cause).8
Chronic pain was acknowledged to require treatment in its own right and should go beyond direct treatment of the underlying condition. The complex interplay with the military compensation system, which addresses pain as a symptom, was noted. Additional biopsychosocial factors which can influence the perception of pain and treatment outcomes include a loss of identity, loss of camaraderie, financial stress and relationship pressures; treatment of chronic pain was deemed to incorporate all these factors.
The panel reiterated that a multidisciplinary evaluation, including a psychological assessment, was crucial, and participants agreed that a patient-centred approach should be adopted, encouraging the formation of a ‘therapeutic alliance’ and helping veterans accept mental health support early in the treatment plan. The panel discussed how other forms of psychological counselling, such as cognitive-behavioural therapy (CBT), should be utilised to ‘cope with the emotional strain and break the cycle of pain amplification through stress and fear’.
Treatment should also focus on substance addiction, weaning of opioid use and augmentation with other pharmacological or non-pharmacological modalities of pain management, including psychotherapy, nerve blocks and neuromodulation. Physical rehabilitation with an emphasis on graded exposure to activity should be utilised to overcome fear-avoidant behaviours and movement-related anxiety.
A new concept introduced was ‘clinical yarning’, a culturally sensitive communication framework utilised in healthcare for Aboriginal and Torres Strait Islander Peoples, which employs a ‘yarning’ approach (an informal two-way exchange of information via storytelling) to engage with the patient’s background and health concerns.9 Workshop participants discussed how this could be easily adapted for use between healthcare clinicians and the veteran population to establish trust, improve communication and engagement of veterans with self-management plans.
Session 2
Participants engaged in round table discussions to generate insights around three main questions from a veteran, provider and mental health lens:
1: What are the barriers to accessing best-practice pain management?
2: What are the solutions to address these barriers?
3: How should DVA prioritise these solutions?
Outcomes of Session 2
The major barriers for veterans in accessing chronic pain management were noted to be awareness of programs/services in place, limited access in the community to non-pharmacological treatment modalities, and a perception that these treatment options are less effective. Financial limitations, inadequate social support and a lack of transportation can be added challenges, particularly for those living in rural or remote locations. Participants raised the issue of cultural norms within the defence force, treatment avoidance due to a perceived risk to one’s career and the stigma attached to having a mental health diagnosis. Figure 1 below represents responses from participants and highlights the complexity of the issue.
For providers, a major barrier faced is the limited understanding of DVA processes and knowledge of support services. Health workforce shortages have impacted the availability of multidisciplinary facilities and care coordinators. The biggest challenge faced in the Australian population is providing integrated multimodal care across broad geographical regions with differing demographics, as well as the funding and resources required to develop and maintain such programs.
Solutions suggested by participants centred around the following themes:
Access and availability of multidisciplinary team (MDT) care
Funding
Veteran education
– Promotion of health literacy programs and support services
– Utilisation of avenues such as ex-service organisations and veteran-specific peersupport group
Provider training
– Access to evidence-based programs for GPs specific to veterans’ health
Promote early intervention
– Triage and care co-ordination
– Transition support for veterans with chronic pain
– Engage community support services
Improvements in DVA administrative burden
– Streamlined, simplified processes
– Appropriate remuneration and invoice processing
Figure 1. Barriers for veterans in accessing pain management – participant responses
The consensus among participants was that DVA’s focus should be on improving healthcare access and providing education on available support services for veterans. The launch of the Veterans Healthcare eLearning Platform ‘VetsHelp’, a DVA-initiated support service in collaboration with Medcast®, was very well received. Education for GPs to improve their understanding of the interplay between chronic pain and mental health issues in veterans, as well as increased support during transition, could assist in veteran engagement. DVA should also prioritise improvements in administrative workload for veterans and providers.
Conclusion
The ICMM workshop commentary emphasised the importance of a holistic approach to the management of chronic pain and the importance of addressing mental health and other co-morbidities in the veteran population. There was general agreement on what constitutes best-practice care, with the priority being the early identification of at-risk individuals, a patient-centred approach to care and the involvement of a multidisciplinary team. Unfortunately, significant barriers to optimal care still exist. While acknowledging funding limitations, solutions focused on the need for education of both veterans and healthcare providers as a key step in ensuring that the proper care is accessed. Participants suggested that DVA could further support these initiatives by improving the funding and administrative framework to better support optional models of care.
Corresponding Author: Seema Menon, seema.menon@dva.gov.au Authors: S Menon1, F Davies1, A Colwell1, J Firman1 Author Affiliations: 1 Department of Veterans Affair
Chronic Pain in Veterans – A Way Forward
By Seema Menon , Fletcher Davies , Anna Colwell and Jenny Firman In Commentary Issue Volume 33 Number 4 Doi No https://doi-ds.org/doilink/07.2025-68538542/JMVH
Abstract
Chronic pain is three times more prevalent in veterans than in the non-veteran population, with a link to trauma and mental health conditions. At the 45th International Committee of Military Medicine (ICMM) World Congress, the Department of Veterans’ Affairs (DVA) hosted a pre-congress workshop to address the barriers that both veterans and healthcare providers face in managing chronic and persistent pain. This commentary aims to summarise the learnings from the pre-congress workshop and discuss further strategies to support providers and veterans in accessing best-practice care.
Introduction
Chronic pain continues to be managed inadequately and remains a cause of increasing morbidity within the veteran population, with close to 90% of transitioned and regular ADF (Australian Defence Force) members reporting some degree of pain intensity and disability.1 The pathways for providing care for chronic pain are complex, and the barriers are multifactorial. Chronic pain often presents with or is compounded by mental health conditions such as post-traumatic stress disorder, anxiety and depression in up to 85% of veterans.2 The ICMM workshop aimed to consider the barriers that both veterans and healthcare providers face in accessing and providing high-quality care for chronic and persistent pain, and to identify actions that the DVA can take to support best-practice care in the Australian healthcare system.
Background
Despite the recent introduction of a national strategy for health practitioner pain management education,3 it remains challenging to translate education into the effective real-world management of complex chronic pain. In the military subgroup in particular, a complex management issue remains for many healthcare providers. While a recent randomised controlled trial looking at long-term outcomes has shown that an interdisciplinary pain management program can produce significant and sustained improvements in pain-related disability in veterans compared to standard care,4 these can be difficult to access.
In recent years, guidelines have reinforced an emphasis on non-opioid treatments as first-line for chronic pain.5 While opioids are effective for short-term pain management, they are not recommended for long-term use due to the effects of tolerance, dependence, addiction and opioid induced hyperalgesia. Education and self-management techniques, such as relaxation, acupuncture, massage, nutrition and exercise, have been an important part of treatment. Encouraging patients to independently manage their symptoms by promoting their own self-efficacy through lifestyle changes has been shown to reduce healthcare costs and medication use.6
The impact of mental health conditions on the development and perpetuation of chronic pain is also of critical importance in veterans. The recently published Monash report reviewed the association between chronic pain and mental health and found ‘consistent data suggesting an increased prevalence of chronic pain among ex-serving personnel and overlap of chronic pain with mild traumatic brain injury, post-traumatic stress disorder, depression and anxiety’.7 DVA already provide veterans with access to fully funded treatment for all mental health conditions regardless of the link to service through Non-Liability Health Care (NLHC).
Workshop design
Session 1
The workshop was attended by 73 participants, providing DVA with an opportunity to gain insights and expertise from health providers worldwide. Session 1 welcomed a panel of expert speakers comprising a Pain Specialist, Specialist Pain Physiotherapist and a Psychiatrist to lead the discussion through a fictitious case study of a veteran’s journey through chronic pain and coexisting mental health conditions. Participants were able to respond to an interactive platform on personal devices.
Outcomes of Session 1
The understanding of the definition of chronic pain, also known as persistent pain, between health providers varied. However, there was a consensus around the International Association for the Study of Pain (IASP) definition of ‘ pain that persists or recurs for longer than 3 months and can last for several years’ also noting their recently revised definition as either primary (main presenting problem) or secondary (due to an identifiable underlying cause).8
Chronic pain was acknowledged to require treatment in its own right and should go beyond direct treatment of the underlying condition. The complex interplay with the military compensation system, which addresses pain as a symptom, was noted. Additional biopsychosocial factors which can influence the perception of pain and treatment outcomes include a loss of identity, loss of camaraderie, financial stress and relationship pressures; treatment of chronic pain was deemed to incorporate all these factors.
The panel reiterated that a multidisciplinary evaluation, including a psychological assessment, was crucial, and participants agreed that a patient-centred approach should be adopted, encouraging the formation of a ‘therapeutic alliance’ and helping veterans accept mental health support early in the treatment plan. The panel discussed how other forms of psychological counselling, such as cognitive-behavioural therapy (CBT), should be utilised to ‘cope with the emotional strain and break the cycle of pain amplification through stress and fear’.
Treatment should also focus on substance addiction, weaning of opioid use and augmentation with other pharmacological or non-pharmacological modalities of pain management, including psychotherapy, nerve blocks and neuromodulation. Physical rehabilitation with an emphasis on graded exposure to activity should be utilised to overcome fear-avoidant behaviours and movement-related anxiety.
A new concept introduced was ‘clinical yarning’, a culturally sensitive communication framework utilised in healthcare for Aboriginal and Torres Strait Islander Peoples, which employs a ‘yarning’ approach (an informal two-way exchange of information via storytelling) to engage with the patient’s background and health concerns.9 Workshop participants discussed how this could be easily adapted for use between healthcare clinicians and the veteran population to establish trust, improve communication and engagement of veterans with self-management plans.
Session 2
Participants engaged in round table discussions to generate insights around three main questions from a veteran, provider and mental health lens:
1: What are the barriers to accessing best-practice pain management?
2: What are the solutions to address these barriers?
3: How should DVA prioritise these solutions?
Outcomes of Session 2
The major barriers for veterans in accessing chronic pain management were noted to be awareness of programs/services in place, limited access in the community to non-pharmacological treatment modalities, and a perception that these treatment options are less effective. Financial limitations, inadequate social support and a lack of transportation can be added challenges, particularly for those living in rural or remote locations. Participants raised the issue of cultural norms within the defence force, treatment avoidance due to a perceived risk to one’s career and the stigma attached to having a mental health diagnosis. Figure 1 below represents responses from participants and highlights the complexity of the issue.
For providers, a major barrier faced is the limited understanding of DVA processes and knowledge of support services. Health workforce shortages have impacted the availability of multidisciplinary facilities and care coordinators. The biggest challenge faced in the Australian population is providing integrated multimodal care across broad geographical regions with differing demographics, as well as the funding and resources required to develop and maintain such programs.
Solutions suggested by participants centred around the following themes:
– Promotion of health literacy programs and support services
– Utilisation of avenues such as ex-service organisations and veteran-specific peersupport group
– Access to evidence-based programs for GPs specific to veterans’ health
– Triage and care co-ordination
– Transition support for veterans with chronic pain
– Engage community support services
– Streamlined, simplified processes
– Appropriate remuneration and invoice processing
Figure 1. Barriers for veterans in accessing pain management – participant responses
The consensus among participants was that DVA’s focus should be on improving healthcare access and providing education on available support services for veterans. The launch of the Veterans Healthcare eLearning Platform ‘VetsHelp’, a DVA-initiated support service in collaboration with Medcast®, was very well received. Education for GPs to improve their understanding of the interplay between chronic pain and mental health issues in veterans, as well as increased support during transition, could assist in veteran engagement. DVA should also prioritise improvements in administrative workload for veterans and providers.
Conclusion
The ICMM workshop commentary emphasised the importance of a holistic approach to the management of chronic pain and the importance of addressing mental health and other co-morbidities in the veteran population. There was general agreement on what constitutes best-practice care, with the priority being the early identification of at-risk individuals, a patient-centred approach to care and the involvement of a multidisciplinary team. Unfortunately, significant barriers to optimal care still exist. While acknowledging funding limitations, solutions focused on the need for education of both veterans and healthcare providers as a key step in ensuring that the proper care is accessed. Participants suggested that DVA could further support these initiatives by improving the funding and administrative framework to better support optional models of care.
Corresponding Author: Seema Menon, seema.menon@dva.gov.au
Authors: S Menon1, F Davies1, A Colwell1, J Firman1
Author Affiliations:
1 Department of Veterans Affair
Author Information