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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