"Very good, that's a great description of the vicious cycle we know happens when you have pain," says Ngo, who heads the pain program at the Bedford VA Medical Center. "Pain is a stress response, it’s a signal to the brain saying, 'Hey, there’s something wrong.' "

A man who's sitting near the door, in case his PTSD flares up and he needs to leave, is ready with an answer. "Stress may increase your anxiety, the anxiety may increase your feeling of pain," says Tom Schatz, "the feeling of pain may increase depression, etc. etc."

Today's topic: stress. Psychologist Tu Ngo looks out at a small group of veterans seated around a classroom table. "Why would we be talking about stress when we’re here because of your pain?" she asks seriously, then smiles. "Lil’ pop quiz now."

“Pain is a stress response, it’s a signal to the brain saying, ‘Hey, there’s something wrong.’ ”

This is Pain School -- a five-week, 15-hour course that covers more than a dozen parts of daily life that can make pain better or worse. The classes cover nutrition, sleep, exercise, breathing, visualizations, relaxation and, yes, stress.

"What happens in your body normally when you get stressed?" Ngo asks, urging her students to think about the specific ways stress may increase pain.

"Your muscles tense up," answers Jasmine Navarrete, a disabled Navy veteran, "your respiratory rate has to increase."

Other veterans mention a hike in temperature or blood pressure. "Right, yes," Ngo says. "Then in usually about 20 to 30 minutes, your body comes back down again to what we call baseline." But many of these veterans never can get down from the feeling of being on guard or ready to flee.

"If you have chronic pain, your system is in overdrive all the time," Ngo says.

Constant pain can impair memory or concentration and make a veteran more anxious or irritable.

"But," she offers, "there is something you can do to try and turn that stress response off."

Ngo hands off to Kalin Clark, who outlines the antidote to stress: the relaxation response.

It begins, Clark says, with slow, deep breathing "and learning to control our heart rate with our breath." Clark asks for a volunteer, someone willing to demonstrate the connection.

Navarrete’s hand shoots up. The Navy veteran — who deals with nearly constant back, knee and other joint pain -- walks to the front of the room and sits down in front of a computer.

Clark slides a monitor onto Navarrete’s left index finger. That's her dominant hand.

"See if you can follow this pacer. Take a slow inhale and slow exhale, and let’s see what that does to your heart rate," Clark says, watching the computer monitor.

Navarrete’s belly rises and falls. Her shoulders drop. But waves on the screen jump. They're not smooth. Clark looks at Navarrete's hands, lingering on her shiny pink nails.

"It could be a nail polish issue," Clark says, somewhat under her breath, "because I turned it on me and it was..." Her voice trails off.

While someone else takes a turn, Ngo tells the class that regulated breathing is one of many tools veterans will be introduced to in Pain School. It's part of a pain management program the VA has been developing for almost two decades. It assumes patients will need help at many stages of coping with pain.

Losing That 'Security Blanket'

One goal is to help veterans reduce or stop using opioids and other drugs to control pain. Ngo says Bedford currently has the third-lowest opioid prescribing rate among VA medical facilities in the country.

"We’re not curing your pain, we are not taking it away, but it’s a way of helping you to manage your pain and live your life and function better," Ngo says.

Many veterans don’t buy it. Each time Ngo offers the Pain School, about half of the students drop out before it ends. We tried to reach some of the veterans who did not find this approach worthwhile, but no one would comment for this story.

Ngo says many veterans are scared to try something besides pain medications. "People are afraid to lose their security blanket as much as they know it isn’t working for them," she says.

Research shows opioids relieve acute pain, but the Centers for Disease Control says there's little evidence that they ease chronic pain, defined as pain that continues three months after an initial injury or ailment.

Some veterans who stay in Bedford's Pain School know the limitations of opioids firsthand.

"The side effects were just too much for me to deal with, I couldn’t function at work," says Robert, who asked that we not use his last name to avoid consequences on the job.

Robert injured his back several times during a dozen years in the Navy. When the pain is bad, he wakes up 10 to 20 times a night and can’t walk short distances — like from the car to the grocery store. Robert reached what he calls a breaking point a few years ago.

"You know, the thoughts that this is never going to go away," he recalls with a deep sigh, "that this is my life from this point forward. That’s a pretty devastating realization."

For Robert, it was time to try something other than opioids.

"The VA has been great about accepting that and not saying, 'Here’s a pill, this is our only solution for you,' " Robert says.

At Pain School, Robert and the other students set weekly goals, activities to both manage their pain and push past it. Robert has pledged to take yoga classes and use an app that tracks calories to control his weight. He goes to physical therapy. He’d like to try acupuncture or one of the martial arts, all of which are offered through the Bedford VA.

"So far everything’s been really good," Robert says. "The only thing that didn’t work was the medications."

Pain Management Programs 'Few And Far Between'

Bedford is one of 67 VA Pain Schools across the country, up from 33 in 2010. Through the schools and options such as hypnosis, chiropractic services, massage and tai chi, the VA is trying to shift the way patients think about pain.

"Right now, many patients feel like it’s a mechanical model of pain, where if you just take the part out and replace it or suppress the pain in the brain, that takes care of it. But it doesn’t," says Dr. Rollin Gallagher, the national pain management director for the Veterans Health Administration

A better strategy, according to Gallagher, is pulling together a team that includes the patient, their primary care doctor and specialists to craft a plan that puts the patient in charge of managing their pain.

"Once you sit down and explain what pain is and how it works, what makes it worse and better, and how an individual can manage that interaction between mind, body and brain, I think it really does help them," Gallagher says.

Gallagher says the consequences of ineffective pain treatment can be devastating: depression, disability, addiction and sometimes suicide. Veterans are even more at risk. Veterans report chronic pain at nearly twice the rate of Americans overall.

Gallagher says there's some proof the VA's approach is working. He points to opioid use, which is down 7 percent among all veterans in the latest three-year period.

Structured pain schools and the range of non-medical pain management options available through the VA are not available to most Americans.

“Pain management programs like the VA’s are pretty few and far between,” says Mara Laderman, senior research associate at the Institute for Healthcare Improvement. She says there are several reasons why. “Physicians have been trained to prescribe opioids for chronic pain, they’re slammed with packed schedules, and there aren’t a lot of physicians who are trained in pain management.”

But Laderman and others agree: Money may be the main reason most doctors, clinics and hospitals focus on medicine to relieve pain.

"We typically reimburse for the things we do to patients, and that means prescribing a medication, doing a procedure or surgery," says Dr. Sean Mackey, professor of pain medicine at Stanford University. "We don’t reimburse for these types of programs. I provide a large number of these at Stanford, quite a large number of them, but I give them away for free."

Mackey co-chaired work on a National Pain Strategy released earlier this year that calls for more research and education on the different types of chronic pain and effective treatments.

At the Bedford VA, nutritionist Joanne Maddock wraps up Bedford's Pain School class with information about foods that provoke headaches or constipation. She says fish, dark chocolate and ginger protect against inflammation.

And remember, Maddock says, excess weight can increase pain.

"If we’re carrying around too much weight it’s a lot of stress on our joints, so if you can get to a good healthy weight you might feel better," Maddock says. Veterans, she reminds the students, have higher obesity rates than do Americans as a whole.

A pharmacist will be in for the last class, to talk about how to balance pain medicine with all the other techniques students have learned. Some veterans will take more in-depth classes on stress or meditation, realizing there's a lot to learn about pain.