By Sandra Basu
WASHINGTON—A pilot program integrating complementary and integrative health approaches in pain management and mental health services at 15 VA facilities has the potential to help facilitate the understanding of nonpharmacological approaches to treating pain.
Benjamin Kligler, MD, MPH, national director of the VHA Coordinating Center for Integrative Health, described the program at a forum last month.
Calling it an “exciting development on the legislative side,” Kligler explained that the pilot program was one of the provisions in the Comprehensive Addiction and Recovery Act of 2016, which was signed into law in July to help address the opioid epidemic in the United States.
“This will be a three-year pilot program and geographically diverse around the country,” he said. “Hopefully, with a very good measurement system in place to figure out what works and what is effective and cost-effective in bringing this whole-person approach to veterans with pain.”
The pilot program fits well with VA’s whole-health approach that the agency is pursuing at 18 pilot sites that will also focus on pain treatment, mental health treatment and reducing opioid use, he said.
“This congressional mandate to really push forward this more-progressive, whole-person, whole-health, nonpharmacological approach to pain puts us in a strong position to test out some models,” Kligler emphasized.
The goal is to build a learning community that brings together participating VA facilities in the pilot program mandated by law as well as DoD colleagues and facilities “to share the knowledge of what is working and the right measurement strategies,” he said.
The presentation where Kligler made his comments was coordinated by the Uniformed Services University of the Health Sciences through the Defense and Veterans Center for Integrative Pain Management (DVCIPM) at the 2016 AMSUS conference.
Kligler explained that one important way VA has responded to the opioid epidemic in the United States has been through its Opioid Safety Initiative. He said that opioid prescribing has been reduced in the VA in recent years by about 33%.
“We have to offer more proactive, full spectrum of approaches to pain early on in the course of treatment and really equip people to ultimately not need the opioids or only need them very short term if they do,” he said.
VA’s efforts to provide effective pain management is being conducted with the DoD through DVCIPM and other partners.
“We have to do this in collaboration with DoD and other federal agencies. The problem is too big,” Kligler noted. “We have to find a way to address the soldiers’ and veterans’ needs together, way up front in terms of preparing people to deal with pain and preventing the development of opioid use disorders.”
Instrumental in those efforts is DVCIPM, which has been at the forefront of addressing pain management issues through research and coordination of education and resources for providers and patients.
“We have been working very closely together. … We really have been working hand in glove, the VA and DoD,” explained retired Lt. Gen. Eric Schoomaker, MD, PhD, the former Army Surgeon General who serves as the USU director of Special Programs.
Schoomaker, who was instrumental in chartering the Pain Management Task Force in 2009, said that pain is the most-common reason that patients seek care. He said that what is needed is a change in focus “to a patient-centered team based, multidisciplinary approach that uses evidence-based practices to include complementary practices that can be integrated with conventional practices.”
Schoomaker added that the “evidence behind the use of many of these complementary practices exceeds the evidence behind a large number of conventional practices.”
“There is a lot of stuff out there that we need to be suspicious of, just as we need to be suspicious of conventional therapies that are not evidence-based,” he explained. “But, the emerging science and the trials that are designed to test these have been very successful and not to be frightened of. The problem is, how do we harness the very best of them and place them in the mainstream?”
Schoomaker said that he foresees the complementary practices in the early part of the 21st century are “the harbinger of high-tech practices that will be complementary in the next 10 years.”
“We will see things emerge that will be the next generation of complementary that we just can’t envision today, and many of these will be mainstream medicine for all of us,” he pointed out.
At the same time, Schoomaker said during the forum that they do not want to “demonize” the use of opioids.
“If we are not careful, we are going to swing the pendulum back again where we so demonize opioids that we are not going to use them for the indications. Believe me, if I am on the battlefield and I get shot, I want an opioid,” he said.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.