Changing the Paradigm
Gallagher noted that the new policies aim not just to use opioids less, but to focus more on improving veterans’ functionality. “Opioids don’t treat chronic pain itself; they just put a wet blanket on pain in the brain. They do help patients feel better temporarily,” he said.
In some instances, even brief relief can make a significant difference. “The goal is to use them only when necessary. That might be to help a veteran get back to work or get into physical therapy until they don’t need them anymore, or to alleviate pain from a terrible nerve injury where they can’t think because the pain is so bad,” Gallagher said.
The real goal, though, is to shift the paradigm for pain care, again. As Gallagher noted, the medical profession went from largely ignoring pain to recognizing it as a serious condition that affected 30% of adults. At the same time, economic pressures reduced the amount of time physicians could spend with patients, so giving patients a pill that could relieve pain at least temporarily became very appealing.
“But if you have spine disease and poor flexibility and just take a pill for the pain, you’ll lose your conditioning and gain weight, and that will make the back pain worse,” he said. “What’s needed is a package of psychological and lifestyle and coping skills interventions that improve physical and mental functioning while avoiding depression and other issues.”
The challenge has been making alternatives available to a very large and widely spread population, with many patients challenged to come to VA medical centers on a regular basis. The wait time for care can be daunting, and some patients cannot travel.
To address some of these issues, the VA uses the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) to reach veterans in rural and other medically underserved areas. The video teleconferencing system has proved a particularly effective way to deliver cognitive-behavioral therapy (CBT), which has strong evidence of effectiveness in reducing chronic pain.
For veterans with osteoarthritis pain, who may be demoralized, have limited activity and find that their pain pills make them sleepy, CBT can help them think differently. They might put themselves on a schedule or initiate a meditative sequence when pain starts so they don’t stress out, said Gallagher. If they start moving more, that will strengthen their legs and change the physiology of the knee. They may lose weight with the increased exercise and rebuild the muscle support structures around the knee. All these changes can reduce pain for the long term.
The VA also has trained 1,700 practitioners in auricular acupuncture, also known as battlefield acupuncture, which uses needles in specific locations in the ear to relieve pain. Medical acupuncturists have also been hired to train even more therapists in the technique, so that acupuncture is now available in primary care programs at most VA facilities.
“The message is pretty clear from the top of the VA down through the clinics that we’ve made a large investment in addressing substance abuse and developing new treatments for pain,” Gallagher said. “The focus is not just on using medications but improving quality of life for the wounded warriors and heroes who have come to us for care.”
1 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, et.al. National Analysis of Opioid Use Among Veterans. Poster session presented at: the 30th Annual Meeting of the American Academic of Pain Medicine; 2014 March 6-9, Phoenix.
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