PHILADELPHIA — While VHA must face the challenge of meeting the needs both of aging veterans and recently deployed servicemembers returning from Afghanistan and Iraq, the two groups have at least one problem in common: a high incidence of chronic pain.
In fact, chronic pain plagues more than 50% of all veterans served by the VA. Among incoming veterans to the VHA, 56% report chronic musculoskeletal discomfort.
|Rollin “Mac” Gallagher, MD, MPH, deputy national program director for Pain management, VA Central Office, and co-chair, VA-DoD Health Executive Council Pain Management Work Group|
That makes pain management “a huge clinical issue for the VA,” according to Rollin “Mac” Gallagher, MD, MPH, deputy national program director for Pain Management, VA Central Office, and co-chair, VA-DoD Health Executive Council Pain Management Work Group.
“One of the biggest challenges is that, as last year’s Institute of Medicine (IOM) report on pain said over and over again, very clearly, our workforce is generally not well-trained in pain medicine — not just at the VA and DoD, but everywhere,” Gallagher told US Medicine.
More than 100 million Americans experience chronic pain, excluding children and patients in nursing homes, chronic-care facilities, prisons and the military, according to the IOM report “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.”
“Given the prevalence of chronic pain, it is not realistic or desirable to relegate pain management to pain specialists alone. There are fewer than 4,000 such specialists in the U.S., with limited geographic coverage. Ideally, primary-care physicians would coordinate pain management, but such a change cannot be achieved without significant improvements in education and training,” said Philip Pizzo, MD, chair of the IOM committee that wrote the report in a presentation earlier this year to the U.S. Senate Committee on Health, Education, Labor & Pensions.
A year after the report’s release and well ahead of the suggested schedule, the VA and DoD have implemented many of its recommendations. These include:
- Creating a comprehensive, population-level strategy for pain prevention, treatment, management and research;
- Reducing barriers to the care of pain;
- Supporting collaboration between pain specialists and primary-care clinicians;
- Enhancing patient education and self-management; and
- Expanding pain education and training opportunities for health professionals.
Two other goals addressed the collection and reporting of data on pain and facilitating research.
“The VA has the only electronic medical record that covers a very, very large population and is available for investigators to use for research and to make policy decisions that move the field forward,” Gallagher said. “In addition, the VA has built an infrastructure for health systems research that no one else has in the country, the Health Services Research & Development group.”
VA Ahead of Schedule in Improving Chronic Pain Care
Step One: Support and Training for Primary Care
Having the infrastructure for research and analysis in place has allowed the VA to rapidly implement the Stepped Care Model for pain management by developing several training programs for primary care and increasing the number of specialty-care clinics for pain medicine. One such program, the VA/DoD collaborative Specialty Care Access Networks — Extension for Community Healthcare Outcomes (SCAN ECHO) project, simulates residency training using video technology to remotely supervise patient care and follow cases longitudinally. Rolled out in the summer of 2011, in the model of the ECHO Program established by the University of New Mexico, SCAN ECHO now has nine VA participating regional tertiary centers (Albuquerque; Ann Arbor, MI; Denver; Cleveland; Los Angeles; San Francisco; Richmond, VA; Tampa, FL and West Haven, CT. )
By the fall, several more centers will be online in various locations around the country. In addition, the military is planning deployment of this model to connect primary-care providers to specialists throughout its system’s many remote sites.
“A pain-specialty team that might include a pain-medicine specialist, a psychologist, physical therapist, psychiatrist or addictionologist, social worker and others gathers in a conference room with video capability. Several practitioners from various distant locations network into the teaching center and present their cases to the team and are then supervised on the management of cases, just like in a residency training program,” said Gallagher.
In addition, short lectures are given so that primary-care providers receive didactic training related to the actual cases being presented.
This spring, a group of VA and DoD experts held the first conference focused on developing a national library of peer-reviewed, referenced, evidence-based lectures that will support the SCAN ECHO program.
SCAN ECHO “is a transformational project for the VA, because it really focuses on bringing specialty skills to the veteran where they are, rather than having them travel long distances to get these kinds of services. For veterans who are in pain, traveling is often a very difficult thing. For the DoD, this technology can be used to bring specialty care to outposts all over the world,” Gallagher said.
The VA uses technology to support primary care and leverage the network’s resources in other ways, as well. Using the electronic medical record, for instance, a pain specialist anywhere can do an e-consultation to advise a primary-care provider, without ever seeing the patient.
The West Haven VAMC provides cognitive behavioral therapy (CBT) for pain by telephone, and a network in Florida has weekly phone calls run by a pharmacist and a primary care pain specialist, a “pain champion,” where people call in to talk about their cases and hear a short lecture. The Tampa VAMC, which has a rehabilitation program accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), brings in leaders from other centers to learn how to establish their own pain rehabilitation programs. The VA also is considering establishing mini-residencies in pain medicine.
VA Ahead of Schedule in Improving Chronic Pain Care
Step Two: Expanding and Collaborating with Specialty-Care Clinics
“We want to have at least one ‘pain champion’ in every primary-care clinic who takes responsibility for developing collaborative-care models with specialists at the center and pain management nurses in that setting who do chronic-disease management. Today, we have that in about 90% of facilities,” said Gallagher. “Most of the chronic-pain patients do fine if managed by a confident primary-care provider, as long as you’re able to identify those who need more structure or additional specialty consultation like addictionology.”
In Philadelphia, the VA operates the Pharmacy Pain Management Clinic (formerly known as the Opioid Renewal Clinic), where a clinical pharmacist who specializes in pain pharmacology sees patients who are not managing their opiates responsibly, possibly have addiction issues or pose complex pharmacology challenges due to the interaction of pain medications with other diseases and their treatments. The program combines opioid treatment agreements and regular visits with weekly or bi-weekly prescriptions and monitoring, when necessary.
“Our research shows that about 50% of the cases who would not be taken care of by providers outside the VA because of aberrant behavior actually settle right down in the clinic, get their care and become responsible patients,” Gallagher noted.
“The clinic helps identify those patients who can’t manage themselves, even with structure, and then those patients are referred to the pain-medicine specialist and/or the addictionology clinic. The system efficiently sorts out which patients really do need a pain specialist from those who can manage well with some structure, because they are just having problems organizing and managing their medicines appropriately,” he added.
Comorbidities like depression, anxiety or PTSD complicate the management of chronic pain and may require the services of a pain specialist and/or mental-health specialist. Through the collaborative-care arrangement, a patient who is complex or having difficulties does not have to go on a waiting list but can be seen or have a consultation right away at the facility level or, using SCAN ECHO, over video technology.
Step Three: Offering Rehabilitation Services
By the end of 2014, each VISN will have a rehabilitation program that incorporates advanced pain-medicine specialties to treat the most complex cases, those that cannot be managed with a specialty consultation or temporary specialty care. These tertiary clinics focus on helping patients manage chronic pain while improving function and quality of life. Therapy addresses psychosocial functioning, including family relationships, as well as specific symptoms and diagnoses.
“Patients with polytrauma, for instance, may have traumatic brain injury or PTSD and severe pain problems. They may require a really structured program to organize their medicines, plus day-to-day rehabilitation that integrates CBT, physical therapy and other rehabilitation services,” said Gallagher. “This intensive rehabilitation approach has been proven effective for complex chronic pain, although few exist outside of federal medicine today because of restrictive reimbursement systems.”
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