Tools, Time, Training, and Team—Military Primary Care Providers’ Perspectives on Improving Chronic Pain Assessment and Management

ABSTRACT

Introduction

Primary care providers are on the front lines of chronic pain management, with many reporting frustration, low confidence, and dissatisfaction in handling the complex issues associated with chronic pain care. Given the importance of their role and reported inadequacies and dissatisfaction in managing this challenging population, it is important to understand the perspectives of primary care providers when considering approaches to chronic pain management. This qualitative descriptive study aimed to comprehensively summarize the provider challenges and suggestions to improve chronic pain care in military primary care settings.

Materials and Methods

Semi-structured interviews with 12 military primary care providers were conducted in a single U.S. Army medical center. All interviews were audio-recorded and lasted between 30 and 60 minutes. Interview transcripts were analyzed using ATLAS 9.0 software. Narratives were analyzed using a general inductive approach to content analysis. The Framework Method was used to organize the codes and emergent categories. All study procedures were approved by the Institutional Review Board of the University of Washington.

Results

Four categories captured providers’ challenges and suggestions for improving chronic pain care: (1) tools for comprehensive pain assessment and patient education, (2) time available for each chronic pain appointment, (3) provider training and education, and (4) team-based approach to chronic pain management. Providers suggested use of the Pain Assessment Screening Tool and Outcomes Registry, more time per visit, incorporation of chronic pain care in health sciences curriculum, consistent provider training across the board, insurance coverage for complementary and integrative therapies, patient education, and improved access to interdisciplinary chronic pain care.

Conclusions

Lack of standardized multifaceted tools, time constraints on chronic pain appointments, inadequate provider education, and limited access to complementary and integrative health therapies are significant provider challenges. Insurance coverage for complementary and integrative health therapies needs to be expanded. The Stepped Care Model of Pain Management is a positive and definite stride toward addressing many of these challenges. Future studies should examine the extent of improvement in guidelines-concordant chronic pain care, patient outcomes, and provider satisfaction following the implementation of the Stepped Care Model of Pain Management in military health settings.

INTRODUCTION

Approximately 100 million adults in the USA report chronic pain, and chronic pain complaints are the second most common reason for outpatient primary care visits.¹ The U.S. Department of Health and Human Services’ National Pain Strategy and the military healthcare system recognize primary care as the hub of chronic pain management in the USA, with primary care providers (PCPs) serving at the forefront of this health care challenge.^2,3 Despite the prevalence of chronic pain, many PCPs receive inadequate training in pain management and report frustration, unpreparedness, low confidence, and dissatisfaction in treating chronic pain and handling the complex issues inherent in caring for this challenging population.^1,2,4 The safety and benefit concerns associated with opioid treatment within this population have only worsened these challenges.⁵ Particularly, fear of risks and liability associated with opioid misuse among this population could discourage practitioner willingness to accept and manage patients with chronic pain.⁶

Given the reported provider inadequacies and dissatisfaction in addressing this challenging population and the important role of PCPs in chronic pain care, it is important to understand their perspectives on improving chronic pain management. This article presents PCP suggestions on improving chronic pain care in military primary care settings.

METHODS

Setting and Participants

PCPs were recruited at the Madigan Army Medical Center (MAMC) in Tacoma, Washington, a teaching hospital and referral center serving all surrounding military instillations for the Pacific Northwest region of the country. The interviews with military PCPs were part of a larger telehealth intervention study that evaluated patient- and provider-reported outcomes associated with pain management telementoring participation.⁷ Due to predesignated Pain Champions and clinics with policies in place to promote telementoring participation, the researchers were logistically limited in their ability to randomly assign study providers (n = 25) to the intervention or control arm of the study. Hence, a nonrandomized group assignment was used. The intervention group (n = 14) comprised of (1) primary care “Pain Champions,” designated by their family medicine and internal medicine clinics based on an interest in learning about pain management, who had protected time on their clinical schedules for required participation in telementoring; (2) providers assigned to a special clinic established to care for active duty service members with complex medical conditions requiring limitations of military duties. Providers assigned to this clinic were encouraged but not required by their clinic leadership to participate in telementoring sessions; and (3) providers recruited from internal medicine clinical staff who were not Pain Champions. Control group PCPs (n = 13) were non–Pain Champions, recruited from family and internal medicine clinics at the study site. Two PCPs participated in both groups, first as a control provider and then as an intervention provider. The purposive sample for qualitative interviews included 12 PCPs who participated in the larger study (8 from the intervention group and 4 from the control group). All study procedures were approved by the Institutional Review Boards of the University of Washington and MAMC.

Data Collection

The interviews were conducted either in person in a private setting or over the phone at a time convenient for the provider. All interviews were audio-recorded and lasted between 30 and 60 minutes. A semi-structured interview guide, containing open-ended questions focused on domains of interest to the main study, was used. These domains were as follows: views on pain management, assessments and treatment plans, and patient and provider interactions. The focus of this study is on the analysis of provider challenges and suggestions for improvement in chronic pain management. Interview questions that produced the dataset for this analysis are shown in Table I.

TABLE I.

Semi-structured Interview Guide

Questions	Probes
1. How often do you generally have appointments with patients seeking chronic pain care?	Those patients with chronic pain, how often do you see them?
2. What is the cause of your patients’ chronic pain conditions generally?	Do you see it as being related to their military service or do you see more family members?
3. What tools do you use to help patients communicate their pain to you?	Do you use any additional assessments for evaluating or helping to understand their pain story?
4. And what areas of life have you identified as affected by pain?
5. What have you found to be the most helpful treatments or remedies that you’ve used with your patients?
6. Have you tried treatments or remedies that did not help or that made the patient’s pain worse?
7. Are there any treatments that you’re interested in trying with your patients?
8. What is the one thing about pain management you would like to see improved in the future?
9. And what do you see as the best part of the visit?
10. How do you feel the visit can be improved?

Data Analysis

Interviews were transcribed verbatim and verified by the interviewer (HM) for accuracy. The transcribed interviews were imported into ATLAS.ti 9.0 qualitative analysis software program.⁸ Narratives were analyzed using a general inductive approach to content analysis.⁹ The Framework Method was used to organize the codes and emergent categories.¹⁰ After familiarizing with the data, two researchers (AM and AZD) independently read five transcripts and coded significant meaning units. The various codes were compared based on differences and similarities and collated into categories. This formed the initial analytical framework. The initial framework was discussed by two researchers (AM and AZD). Following consensus, the final analytical framework was applied to all the transcripts. In an iterative process, categories were continually redefined, revised, and collapsed. Four researchers (HM, DMF, JCR, and AZD) with expertise in qualitative analysis independently reviewed the narratives and verified the final categories.

Trustworthiness

Several strategies were used to improve the trustworthiness of findings.^9,11 Peer debriefing with the research team at various stages of data abstraction established credibility. Rich and thick verbatim extracts from multiple PCPs enhanced transferability and confirmability. The iterative coding process was accompanied with analytical memos. The transcripts were read multiple times before abstracting categories, to ensure that all relevant data have been included. The data were continually compared with the research findings and interpretations, to ensure that the categories accurately reflected the meanings evident in the dataset as a whole.

RESULTS

Twelve PCPs participated in the study, of which eight were primary care physicians and four were nurse practitioners (NPs) (Table II). Their median experience with chronic pain management was 10.5 years, and 58% of them (7/12 providers; 5 physicians, 2 NPs) had received formal chronic pain management training (Table II). Providers reported that patients who were stable and satisfied with their prescribed treatment regimen were typically seen once every 2-3 months. However, for patients who were new, on higher opioid doses, had not achieved satisfactory pain relief or had co-existing issues complicating chronic pain, the visit interval was 1 month or sooner. Additionally, opioid informed consent and urine drug screens were routinely completed once a year, unless greater frequency was indicated. PCPs typically reported seeing three to five patients with chronic pain per week, with one PCP reporting 5-10 patients per week on average.

TABLE II.

Demographic Characteristics of Primary Care Providers (n = 12)

Variable	Number (%) or median, range
Gender
Male	6 (50)
Female	6 (50)
Provider type
Physician	8 (67)
Nurse practitioner	4 (33)
Personal military experience
Yes	8 (67)
No	4 (33)
Chronic pain management training received
Formal traininga	7 (58)
Informal trainingb	5 (42)
Years of experience as a healthcare provider	18.5 years, 5-25 years
Years of experience in the military setting	12.25 years, 4-22 years
Years of experience with chronic pain care	10.5 years, 3-25 years
Primary care pain champion
Yes	6 (50)
No	6 (50)

^aCourse for suboxone prescribing, online training for chronic pain management, telepain/ECHO training, pain management training conducted by VA/Madigan.

^bSeminars, workshops, conferences, and continuing education sessions.

Analyses resulted in four categories, which captured providers’ challenges and suggestions for improving chronic pain care. These suggestions, presented along with the context of respective challenges, were as follows: (1) tools for comprehensive pain assessment and patient education, (2) time available for each chronic pain appointment, (3) provider training and education, and (4) team-based approach to chronic pain management.

Tools for Comprehensive Pain Assessment and Patient Education

Providers reported that chronic pain visits could be improved by having standardized tools for comprehensive pain assessment. They reported using screening tools such as the Defense and Veterans Pain Rating Scale (DVPRS), Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and the Opioid Risk Tool for comprehensively evaluating chronic pain. However, they placed heavy emphasis on open-ended questions to get an accurate picture of patients’ chronic pain stories. These open-ended questions were centered on areas in patients’ lives affected by chronic pain, as identified by providers during their experiences of managing chronic pain. Approximately 75% of the PCPs reported that chronic pain affected patients’ family lives, and 66% of them reported that chronic pain affected patients’ mood. Half of the providers responded that pain also impacted sleep, and 33% to 42% reported pain affecting physical function, social life, work, and finances.

How’s your sleep? What’s your emotions? Those types of questions are asked…we ask questions that I think they want to expand on. You know, so we let them expand on it and give us an idea of where we’re at. Makes a big difference. (PCP6, intervention group)

In lieu of using multiple tools and open-ended questions, PCPs verbalized the need for a single standardized multifaceted tool that would cover these commonly affected areas, which would facilitate conversations on these topics. They suggested that visits could also be improved if there were means to assess patient adherence to sleep, activity, and nutrition recommendations. PCPs expressed the desire for expanded access to tools like the Pain Assessment Screening Tool and Outcomes Registry (PASTOR), which could improve provider adherence to mandated regulations for chronic pain management.

More standardized tools that could be applied across the board…would be really nice to have, like a multi-faceted…just one thing that would cover, like, the PASTOR and have something that would gauge just for that over and over again. (PCP10, intervention group)

So, the government regulations are necessary and important for the health of the patient. But if they’re requiring that, they need to give us the tools to do it. (PCP2, control group)

Another aspect described by the providers was educating patients to do self-assessments and to reduce reliance on opioids. Providers reported that patients’ involvement in decision-making involved teaching the latter “to discuss their progress…and do more self-assessments” (PCP6, intervention group). In order to get patients’ buy-in for recommended pain management treatment and therapies, providers spent time in educating patients on alternative modalities and “alerting patients at the very beginning” (PCP3, control group) on the potential adverse impact of opioids. Providers reported that patient education on risks associated with opioids and availability of alternative modalities can have a tremendous effect on improving chronic pain management and help “rechannel their efforts from being a medication oriented treatment to a more comprehensive biopsychosocial approach” (PCP12, intervention group). However, none of the PCPs reported using any specific patient education tools, which implied that tools designed to facilitate patient education on these aspects were unavailable at the time of this analysis. One PCP suggested that a motivational interviewing tool would facilitate patient engagement and acceptance of nonpharmacological therapies. Another PCP described using “principles of responsible opioid prescribing”, intended for providers, as a patient handout tool “because it helps patients understand, ‘Here’s what experts all over are acknowledging as safe practice’” (PCP7, intervention group). Another PCP reported using “RelayHealth,” a secured messaging system, to answer patient queries.

Time Available for Each Chronic Pain Appointment

Around 83% of the providers (10/12 providers) reported that the short time frame allowed for primary care visits was a significant challenge in assessing chronic pain and creating patient-centered treatment plans. They spent considerable time in assessing chronic pain and its impact on the “whole” patient because they relied on responses to open-ended questions. Additionally, due to the complexities of chronic pain conditions and the prevalence of co-occurring conditions, addressing these patients in relatively short visits was challenging. They reported that prioritizing and sorting out the issues to get an accurate picture of the pain story and understanding the subjective pain perception of each individual required considerable time. In addition, providers and patients often had conflicting goals and methods for chronic pain management, requiring considerable time in re-setting realistic goals. Due to these concerns, a typical 20-minute appointment was characterized as “kind of a mish-mash (PCP8, control group), feeling rushed to get to the next patient” (PCP10, intervention group), “and thinking on our feet most of the time” (PCP8, control group). In this context, providers suggested longer appointment times for chronic pain visits.

I don’t think a twenty-minute visit at a primary care, when you’re taking care of other issues, that you really have an in-depth pain evaluation. (PCP9, control group)

I think it would be great if we had more time, especially with complex patients. That would allow us to feel a little less rushed and be able to focus on all the areas of health. (PCP1, intervention group)

Provider Training and Education

PCPs placed heavy emphasis on better provider education and training. One PCP reported that longer appointments combined with “better education and better tools” would help providers assess and manage chronic pain “a little more intelligently” (PCP8, control group). They also reported that provider education on opioid prescribing is inconsistent across the board. This leads to situations where providers “often dig holes for other providers that they then have to recover from” (PCP4, intervention group), making reduced reliance on opioids very difficult when patients move from one provider to another.

I don’t feel like it’s communicated well amongst providers… I would like to see that it’s a little more consistent across the board where these are some scenarios where the pain medications can be very appropriate, so that when those patients see a different provider, it’s not like—they don’t feel like that have to start all over again. (PCP4, intervention group)

One provider termed provider inconsistency on opioid prescribing as “the right hand doing one thing and the left hand doing something completely different” (PCP7, intervention group). Providers reported that they often inherit poorly managed legacy patients due to prior provider practices.

Often they’ll come in and they’re already on a ton of pain meds because we inherit them. If they come in from another [military] base….that’s assigned to me as a panel, it’s a can of worms sometimes. (PCP8, control group)

Another issue arising out of inadequate provider training was unrestricted opioid prescribing in acute care and inpatient settings. One provider wished “that acute care settings didn’t pass out Dilaudid like candy” (PCP7, intervention group).

…people go into an acute setting, like a hospitalization or ER visit, even if it is for a chronic condition, and get treated as though it were acute, and that undermines everything we’re trying to do…it just sets us back every time it happens. (PCP7, intervention group)

Among the providers, 42% (5/12 providers; 3 physicians, 2 NPs) had received only informal training through seminars or continuing education sessions. An important solution provided by the PCPs to improve provider education was to integrate chronic pain management in health science curricula, which could then be supplemented with ongoing in-service education. This solution was echoed by both physicians and NPs. Education content on opioid prescribing and opioid management was deemed important. Another educational topic suggested was communication techniques on how to introduce alternative options for chronic pain management to patients.

I just think it would be very helpful for nurse practitioner students and physicians and their residents to have a more integrated chronic pain management in the academic curriculum because that would spare many headaches for both patients and providers later because there would be some baseline knowledge that could grow with continued reference reading and collaboration. (PCP10, intervention group)

Another suggestion was spending time in the pain management clinic, especially for providers who do not have recent pain education and background, to get a better understanding of available treatment and therapy options.

Having to see 20-30 patients a day, you know, every day you lose your focus, and I’d really like to get … a week of—what did they used to call it in medical school—the clinicals. A week of clinicals to go watch. (PCP12, intervention group)

Team-Based Interdisciplinary Approach to Chronic Pain Management

The providers reported that they manage chronic pain using a “multifaceted approach” (PCP1, intervention group) and “focus on lifestyle management” (PCP 9, control group; PCP10, intervention group) by relying on interdisciplinary services at their medical facility. They collaborated with complementary and integrative health (CIH) therapists, primary care pain champions (PCPCs), the Army Wellness Center (which provides programs and services to sustain health and readiness for soldiers), Extension for Community Health Outcomes (ECHO) program (which provides education and multidisciplinary consultation from pain experts), and the Veterans Affairs PCPs. Yet, sometimes, they felt that the “resources available were disjointed” (PCP4, intervention group) and emphasized on the need for further improvement in availability and access to CIH therapies. All the providers reported that they referred patients for nonpharmacological therapies such as physical therapy, sleep, nutrition, and massage but were interested in offering additional resources such as behavioral health, group therapy, acupuncture, and chiropractic in managing chronic pain. Further, they reported that the presence of services in the same primary care facility would facilitate referrals and use of a broader spectrum of pain management resources.

…acupuncture, massage, mindfulness support… So, having those resources a little bit more available. (PCP1, intervention group)

Acupuncture, behavior modification, massage, chiropractor. I wish we had all of those for our patients. (PCP2, control group)

I think if I had better interdisciplinary pain management options that I could refer directly to. For example, rather than having somebody have to see the IPMC as a global package, if I could just say, “Wow, this sounds like maybe you would like to try some acupuncture. Let’s see if we can get just that.” You know, do referrals for some of the other modalities that are helpful. (PCP7, intervention group)

I think the biggest area we’re lacking up here is the behavioral health piece… or something similar where we can really engage that psychological piece. (PCP4, intervention group)

I think if I could have this great comprehensive program for my patient…. and get a more holistic approach…. (PCP9, control group)

In order to improve patient access, PCPs felt that insurance policies should cover more CIH pain management resources, which would greatly improve patient access and use of these therapies.

It would be helpful to have more resources that are covered by insurance policies. Complementary resources such as acupuncture and massage, which some patients seem to respond to. A lot of these things aren’t necessarily available for non-active duty. Can’t afford them or insurance doesn’t cover. (PCP1, intervention group)

Providers also suggested that a team-based approach would require a change in existing clinical protocols and guidelines for chronic pain management. They also reported that because specific opioid-weaning steps were unavailable, they made such decisions after consulting with pain specialists. Incorporating new evidence such as CDC guidelines into clinical practice would “improve consistency in guidelines” (PCP1, intervention group) and bridge the evidence–practice gap in pain management.

I think we need to change the protocols and formats we use…change the clinical focus from treating the disease. to support the healing process. (PCP6, intervention group).

DISCUSSION

PCPs in our study reported that their typical weekly schedule involved evaluating three to five patients with chronic pain. While this finding is not a true prevalence estimate, it does indicate that providers in military settings encounter a significant number of patients with chronic pain. Although the PCPs used different tools and instruments to understand patients’ pain stories, they relied mainly on open-ended patient–provider conversations around impact areas of chronic pain. Their suggestion to incorporate assessment tools such as PASTOR is explicable because this tool offers a comprehensive view of a patient’s pain.¹² PASTOR is a web-based battery of assessments developed as a result of the Army Pain Management Task Force and incorporates demographics; the DVPRS, an anatomical map for locating pain areas; military-specific pain-related questions; information on depression, anxiety, and opioid misuse; and information about the impact of pain on activities.^12,13 Since these data are stored over time, using this tool would allow the clinician to track patients’ progress across multiple measures. PASTOR is currently the standard pain assessment tool for use in military pain specialty clinics, but the PCPs in this study suggest its utility in the primary care setting.¹⁴

Next, the PCPs were spending considerable time on patient education regarding realistic expectations and goal re-setting. Patient educational tools and resources that cover opioid long-term effects and benefits of alternative modalities will facilitate provider communication during chronic pain visits. In light of the National Academy of Medicine’s recommendations on patient education, educating the person who is in pain and transforming their perception and beliefs about pain can substantially affect outcomes.^15,16 Expanding access to tools and resources for patient education will enhance patients’ understanding of pain and its consequences, while subsequently enabling them to play a more active role in managing their own pain.¹⁵

A significant challenge faced by the providers in our study was short duration of chronic pain appointments. In keeping with the revised definition of pain as an “unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”, providers need to pay greater attention to the phenomenology of pain and the social intersubjective space in which pain occurs.¹⁷ Considering that biological, psychological, and social factors influence perception and chronification of pain, a typical 20-minute appointment would not suffice to assess and manage each of these factors.⁵ One way to address this concern is to encourage PCPs to leverage other members of the patient-centered medical home, such as nurses, behavioral health providers, and clinical pharmacists to manage patient education, medication safety, goal setting, and overcoming barriers to progress toward treatment goals.

With 42% of providers in our study receiving only informal training through seminars and continuing education sessions, there was a strong emphasis on better provider education and training for managing this challenging population. Poor training and preparation of PCPs in managing chronic pain reported in our study is not a new concern.^15,18 But considering that this concern remains unchanged since its recognition two decades ago, the time is long overdue for a change in what is taught to health professionals about chronic pain and how to compassionately deal with this patient population.^19,20 This is especially important in primary care because PCPs care for a complicated group of patients with chronic pain that rivals the complexity of those seen in specialized tertiary care pain management facilities.²¹ Chronic pain is one of the most common reasons for seeking healthcare, but the providers making pain management decisions receive inadequate and fragmented chronic pain education during their training period.^22–24 With only 3% of medical schools in the USA having a part of their curriculum specifically devoted to pain education and inadequate pain management training in undergraduate and prelicensure nursing curricula, chronic pain remains an orphan disease in professional education.^25,26 Additionally, medical education literature generally focuses on opioids and gives less attention to education in nonpharmacological approaches.²⁷ Hence, it is not surprising that PCPs in our study, who did not have pain education during their training period, strongly emphasized the inclusion of chronic pain management in academic curricula. They equipped themselves by learning on the job and underscored the importance of ongoing in-service education as well. The educational content deemed important by PCPs was similar to previous recommendations; however, in addition to opioid-prescribing education (opioid selection, management, and end-organ effects), providers in our study suggested having training on communication techniques and clinical experience in pain clinics.²⁸ Actions such as Interprofessional Education Collaborative and NIH-initiated Centers of Excellence in Pain Education hold significant potential to develop, collaborate, and promote pain management curriculum resources, thus improving chronic pain education for healthcare professionals.^29,30

Although PCPs in our study relied on the existing interdisciplinary pain care services at their medical facility, they suggested an improved access and availability of CIH therapies through a team-based approach. The PCPs are experts in chronic disease management and are uniquely positioned as frontline professionals to deliver the biopsychosocial pain care promoted in the National Pain Strategy, but the burden of chronic pain management is not the responsibility of the PCPs alone.² To prevent provider burnout, PCPs require the support of interdisciplinary pain care services.¹ Our study supports previous recommendations of team-based care and collaborative care management protocols.³¹ Guidelines on how nurses and other professionals can partner with physicians to deliver effective multimodal chronic pain care would distribute the actions required for comprehensive pain care in the clinic. Team-based approach would also help employ a sociopsychobiological model of pain care that would close the current evidence–practice gap.³² Initiatives of the Defense Health Agency (DHA) and Veterans Health Administration to implement an interdisciplinary pain program integrated in primary care to address stakeholder-identified gaps and deliver biopsychosocial chronic pain care are promising.^33,34 On the other hand, it would be difficult for PCPs to implement guidelines that call for CIH therapies when most of these therapies cannot be provided to DoD beneficiaries through TRICARE or military treatment facilities.³⁵ Hence, some nonopioid therapies could still be inaccessible for a significant portion of the military population.³⁵

Suggestions given by providers in this study support recommendations of reframing of chronic pain as a distinct disease in its own right and not simply a symptom of injury or illness.^36,37 Developing a systematic approach of the Chronic Care Model (CCM) to proactively manage patients with chronic pain could prove useful to address provider challenges.³⁸ The Stepped Care Model of Pain Management (SCM-PM), articulated in the DHA Procedural Instruction 6025.04 Pain Management and Opioid Safety in the Military Health System, incorporates many aspects of the CCM.^33,39 Many of the needs identified by PCPs in our study were addressed by the SCM-PM workgroup. The workgroup created a series of trainings for PCPCs and was rolled out to military treatment facilities in each region in 2019.⁴⁰ Each PCPC is provided with 90 minutes per week to participate in ECHO education. The PCPCs were also given the responsibility for providing the SCM training to other PCPs. In addition, the SCM training included role-specific training for other members of the Patient-Centered Medical Home, including nurses, psychologists, and clinical pharmacists. Behavioral health providers were provided with training in brief cognitive behavioral therapy for acute and chronic pain. In addition, standardized patient education handouts were developed by the DHA that emphasized the importance of self-management and a multimodal treatment approach. For patients taking opioids for more than a few days, an opioid informed consent was developed by the DHA to communicate to patients the risks and limited benefits of opioids as well as alternatives to opioids.

LIMITATIONS

Findings from this qualitative study were limited to one Army medical center and may not be generalizable to other settings. In addition, the small sample of military PCPs consisted of physicians and NPs only and may not be representative of a wider provider population. Nevertheless, the study participants were experienced in chronic pain management in military health settings, and the open-ended questions facilitated an in-depth understanding of their perspectives on improving chronic pain care.

CONCLUSION

Lack of standardized multifaceted tools, time constraints, inadequate provider education, and disjointed CIH therapies are significant provider challenges. Insurance coverage for CIH therapies needs to be expanded. The Stepped Care Model of Pain Management is a positive and definite stride toward addressing many of these challenges. Future studies should examine the extent of improvement in guidelines-concordant chronic pain care, patient outcomes, and provider satisfaction following the implementation of the Stepped Care Model of Pain Management in military health settings.

FUNDING

Funding sources include National Institute of Nursing Research of the National Institutes of Health under award numbers R01 NR012450 and K24NR015340.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to report.