The VHA National Pain Management Strategy outlines a stepped care model for managing pain across the VHA system. This involves establishing an infrastructure with defined roles and responsibilities at the national, VISN, and facility levels to coordinate a comprehensive, multidisciplinary approach to pain care. The goal is to provide timely access to evidence-based pain assessment, treatment, and follow-up utilizing primary care and specialty-level services tailored to patients' needs.

1. VHA
N ATIONAL
PAIN
M ANAGEMENT
STRATEGY
Implementa8on
o f
a
stepped
care
m odel
o f
pain
m anagement
ROBERT
D.
KERNS,
PH.D,
NATIONAL
PROGRAM
DIRECTOR
FOR
PAIN
MANAGEMENT
February 2012

2. Learning
Objec8ves
1.
Tell
an
overview
of
Pain
Management
Task
Force.
2.
Outline
similari8es
and
differences
with
pain
management
challenges
facing
Department
of
Defense
and
Veterans
Health
Administra8on.
3.
Iden8fy
best
prac8ces
of
pain
management
alterna8ves
from
the
Pain
Management
Task
Force.

3. Disclosure
Statement
• Robert
Kerns
has
no
financial
rela8onships
with
proprietary
en88es
that
produce
health
care
goods
and
services.
• Kevin
Galloway
has
no
financial
rela8onships
with
proprietary
en88es
that
produce
health
care
goods
and
services.

4. Pain
Management
is
a
priority
• As
many
as
50%
of
male
VHA
pa8ents
in
primary
care
report
chronic
pain
(Kerns
et
al.,
2003;
Clark,
2002)
• The
prevalence
may
be
as
high
as
75%
in
female
Veterans
(Haskell
et
al.,
2006)
• Pain
is
among
the
most
costly
disorders
treated
in
VHA
se]ngs;
total
es8mated
cost
a^ributable
to
Veterans
with
low
back
pain
was
$2.2
billion
in
FY99
(Yu
et
al.,
2003)
• Number
of
Veterans
with
chronic
low
back
pain
is
growing
steadily
(Sinno^
&
Wagner,
2009)
4

5. Frequency of Diagnoses1 among
Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn (OEF/OIF/OND)
Veterans
Diagnosis
(Broad
ICD-­‐9
Categories)a
Frequency
Percentb
Infec8ous
and
Parasi8c
Diseases
(001-­‐139)
144,167
16.0
Malignant
Neoplasms
(140-­‐209)
13,016
1.4
Benign
Neoplasms
(210-­‐239)
64,424
7.2
Diseases
of
Endocrine/Nutri8onal/
Metabolic
Systems
(240-­‐279)
302,719
33.6
Diseases
of
Blood
and
Blood
Forming
Organs
(280-­‐289)
36,899
4.1
Mental
Disorders
(290-­‐319)
486,015
54.0
Diseases
of
Nervous
System/
Sense
Organs
(320-­‐389)
415,543
46.2
Diseases
of
Circulatory
System
(390-­‐459)
198,140
22.0
Disease
of
Respiratory
System
(460-­‐519)
241,229
26.8
Disease
of
Diges8ve
System
(520-­‐579)
326,338
36.3
Diseases
of
Genitourinary
System
(580-­‐629)
142,687
15.9
Diseases
of
Skin
(680-­‐709)
199,803
22.2
Diseases
of
Musculoskeletal
System/ConnecBve
System
(710-­‐739)
519,721
57.8
Symptoms,
Signs
and
Ill
Defined
Condi8ons
(780-­‐799)
478,267
53.2
Injury/Poisonings
(800-­‐999)
267,407
29.7
1Includes
both
provisional
and
confirmed
diagnoses.
aThese
are
cumula8ve
data
since
FY
2002,
with
data
on
hospitaliza8ons
and
outpa8ent
visits
as
of
September
30,
2011;
Veterans
can
have
mul8ple
diagnoses
with
each
health
care
encounter.
The
total
may
be
higher
than
899,752
unique
Veterans
because
a
Veteran
can
have
more
than
one
diagnosis
and
each
is
entered
separately
in
this
table.
bPercentages
reported
are
approximate
due
to
rounding.
5
Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2013

6. Prevalence
of
Chronic
Pain,
PTSD
and
TBI:
sample
of
340
OEF/OIF
veterans
Chronic Pain PTSD
N=277 N=232
81.5% 16.5% 68.2%
2.9%
10.3%
42.1%
6.8%
12.6%
TBI
5.3% N=227
66.8%
Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in OEF/
OIF Veterans: The Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development, 46, 697-702.

7. VHA
Pain
Management
Direc8ve
(2009-­‐053)
• Objec8ves
of
Na8onal
Pain
Management
Strategy
• Pain
Management
Infrastructure
– Roles
and
responsibili8es
• Stepped
Pain
Care
Model
• Pain
Management
Standards
– Pain
assessment
and
treatment
– Evalua8on
of
outcomes
and
quality
– Clinician
competence
and
exper8se
7

8. Na8onal
Pain
Management
Strategy
Objec8ve
is
to
develop
a
comprehensive,
mul8cultural,
integrated,
system-­‐wide
approach
to
pain
management
that
reduces
pain
and
suffering
for
Veterans
experiencing
acute
and
chronic
pain
associated
with
a
wide
range
of
illnesses,
including
terminal
illness.
8

9. VHA
Na8onal
Pain
Management
Strategy
Infrastructure
• Pain
Management
Program
Office
– Specialty
Care
Services;
Pa8ent
Care
Services;
DUSH
for
Policy
and
Services
• Na8onal
Pain
Management
Strategy
Coordina8ng
Commi^ee
– Coordina8ng
Commi^ee
Working
Groups
• VISN
Pain
Points
of
Contact
• Facility
Pain
Points
of
Contact
• Primary
Care
Pain
Champions
• Pain
Resource
Nurses
• VISN
and
Facility
Pain
Management
Commi^ees
9

10. VHA
Stepped
Care
Model
for
Pain
Management
• Single
standard
of
pain
care
for
VHA
– Popula8on
based
approach
– Timely
access
to
pain
assessment
– State
of
the
art
treatment
and
follow-­‐up
– Reliable
communica8on
and
care
management
– Pa8ent
and
family
par8cipa8on
• Empirically
supported
model
– Von
Korff
et
al.
(2001).
Stepped
care
for
back
pain:
Ac8va8ng
approaches
for
primary
care.
Annals
of
Internal
Medicine,
134,
911-­‐917.
– Dobscha
et
al.
(2009).
Collabora8ve
care
for
chronic
pain
in
primary
care.
Journal
of
the
American
Medical
Associa9on,
301,
1242-­‐1252.
– Kroenke
et
al.
(2009).
Op8mized
an8depressant
therapy
and
pain
self-­‐
management
in
primary
care
pa8ents
with
depression
and
musculoskeletal
pain:
A
randomized
controlled
trial.
Journal
of
the
American
Medical
Associa9on,
301,
2099-­‐2110.
10

11. Veteran-­‐Centered
Pain
Management
• Informed
by
chronic
illness
model
• Empowering
Veterans
through
reassurance,
encouragement
and
educa8on
• Conserva8ve
use
of
analgesics
and
adjuvant
medica8ons
• Promo8on
of
regular
exercise
and
healthy
and
ac8ve
lifestyle
• Development
of
adap8ve
strategies
for
managing
pain
11

12. Pa8ent
Educa8on
Ini8a8ves
•
Veterans
Health
Library
•
“ Taking
Opioids
Responsibly”
•
Krames
resources
•
Pa8ent/Family
Pain
Management
Educa8on
Toolkit
•
MyHealtheVet
• Pa8ent
Educa8on
Management
System
(PEMS)
• VISN
20
Chronic
Pain
Educa8on
for
Veterans
• Veterans
Pain
Management
Resource
Program
•
Pain
Coach
(Mobile
Pain
App)
12

13. Stepped
Care
Model
for
Pain
Management
Ter8ary
Interdisciplinary
Pain
Centers
Advanced
diagnos8cs
&
interven8ons
RISK
Commission
on
Accredita8on
of
Rehabilita8on
Facili8es
accredited
pain
rehabilita8on
Integrated
chronic
pain
and
Substance
Use
STEP
ComorbidiBes
Disorder
treatment
3
Treatment
Refractory
STEP
2
Primary
Care/Pa8ent
Aligned
Care
Teams
(PACTs)
Rou8ne
screening
for
presence
&
intensity
of
pain
Comprehensive
pain
assessment
STEP
Complexity
Management
of
common
acute
and
chronic
pain
condi8ons
1
Primary
Care-­‐Mental
Health
Integra8on,
Health
Behavior
Coordinators,
OEF/OIF/OND
&
Post-­‐Deployment
Teams
Expanded
nurse
care
management
Clinical
Pharmacy
Pain
Medica8on
Management
13
Opioid
Pain
Care
and
Renewal
Clinics

14. Implementa8on
ini8a8ves
• OEF/OIF
Pain
Care
Enhancement
Ini8a8ve
• Communica8on/educa8on
infrastructure
– VA
Pain
List
Serve,
– Na8onal
Pain
Management
Website
(www.va.gov/painmanagement)
– Monthly
Pain
Management
Leadership
Teleconference
– Monthly
“Spotlight
on
Pain
Management”
webinar
(collabora8on
with
HSR&D
Center
for
Informa8on
Dissemina8on
and
Educa8onal
Resources
[CIDER]
– Na8onal
Pain
Management
Leadership
Conferences
– VA
Pharmacy
Pain
Management
Mentors
(VAPPMM)
Outlook
exchange
• Clinical
Prac8ce
Guidelines
– Opioid
Therapy
for
Management
of
Chronic
Pain
– Peri-­‐opera8ve
pain
management
– Dissemina8on
of
American
Pain
Society/American
Academy
of
Pain
Management
guidelines
14

15. Implementa8on
Ini8a8ves
• Web-­‐based
educa8on
– General,
opioid
therapy
for
acute
and
chronic
pain,
polytrauma
– Primary
Care
Rural
Health
Ini8a8ve
pain
management
courses
• Post-­‐Deployment
and
Integrated
Care
Ini8a8ves
– Pos^rauma8c
Stress
Disorder-­‐Trauma8c
Brain
Injury-­‐Pain
Prac8ce
Recommenda8ons
Consensus
Conference
– PC-­‐MHI/HBC
ini8a8ves
• Nursing
– Veteran
Affairs
Nursing
Outcome
Database
Nursing
Assessment
and
Reassessment
Ini8a8ve
(ini8al
focus
on
management
of
acute
pain
in
inpa8ent
se]ngs)
– Pain
Resource
Nursing
(PRN)
Ini8a8ve
• Pharmacy
– Na8onal
Clinical
Pharmacy
Pain
Management
Training
– Opioid
Pain
Care
Clinics
Central
Repository
15

16. Implementa8on
Ini8a8ves
• Telehealth
– Telebehavioral
Pain
Management
– Mobile
Pain
App
• Pain
Medicine
– Capacity
for
specialty
pain
medicine
diagnos8cs
and
interven8ons
• Mental
Health
– Evidence-­‐Based
Psychotherapy
– Capacity
for
pain
management
in
Substance
Use
Disorders
programs
– Capacity
for
pain
management
in
PTSD
treatment
se]ngs
•
Externship
training
at
James
Haley
Veterans
Hospital
– Interdisciplinary
pain
management
– CARF
accredited
pain
rehabilita8on
16

17. Promo8ng
safe
and
effec8ve
use
of
opioids
• Opioid
–
High
Alert
Medica8on
Ini8a8ve
• CPG
on
Management
of
Opioid
Therapy
for
Chronic
Pain
• TMS:
Opioid
Therapy
for
Acute
and
Chronic
Pain
• Pharmacy
Benefits
Management
Ini8a8ves
and
Clinical
Guidances
• Direc8ve
and
Clinical
Considera8ons
regarding
state-­‐authorized
use
of
marijuana
• Implementa8on
of
Na8onal
Prescrip8on
Drug
Control
Policy
• Opioid
Safety
Ini8a8ve
• Par8cipa8on
in
State
Prescrip8on
Drug
Monitoring
Programs
• Signature
Informed
Consent
17

18. VA
Specialty
Care
Access
Network
–
Extension
of
Community
Healthcare
Outcomes
(VA
SCAN-­‐
ECHO)
The
mission
of
VA
SCAN-­‐ECHO
is
to:
• Meet
the
needs
of
primary
care
providers
and
PACT
teams
for
access
to
specialist
consulta8on
services
and
support
• Provide
case-­‐based
learning
modules
to
improve
core
competencies
and
provider
sa8sfac8on
• Facilitate
referrals
to
ter8ary
care
centers
when
indicated
• Ul8mately
to
improve
veteran
access
to
specialty
care
and
treatment
outcomes
18

19. HEC
PMWG:
Objec8ves/Ini8a8ves
• DoD/VHA Core Pain Curriculum / • PASTOR/PROMIS
Training • DVPRS
• Collaboration with NiH CoEPES • CREATE
• ECHO / SCAN-ECHO
• Phone Apps for patient & for
provider Standardize Deliver
• Tiered acupuncture training Education and Measurement
and treatment Training Based Care
Function
Readiness
• Opioid Risk Strategy
• COT – CPG
Ensure Patient Establish • Stepped Care Model
• Opioid Risk Tools Consistent • Interdisciplinary PC / PACT
Safety
• Urine Drug Screening / Model of Care Pain Champions & Teams
Reporting • Pain Medicine Specialty
• Integration of non-medication support for Primary Care
modalities (PCMH)
• Patient Safety Videos • Pain Rehabilitation
• Joint Suicide Prevention Initiative

20. Joint
Educa8on/Training
Program
(JPEP)
VA/DoD
HEC
Pain
Management
Working
Group
VHA
Pain
Management
(PACT)
VHA/DOD
DOD
Pain
Strategic
Oversight
CommiTee
HEC
Management
JIF
Joint
VA/
Pain
EducaBon
DOD
Pain
Advisory
Team
EducaBon
Community
of
PracBce
Pain
Management
CoordinaBng
EducaBon
and
Workgroup
Training
Facility
Pain
Workgroup
Champions
CoordinaBng
Workgroup
Training
Program
Community
of
Facility
Pain
PracBce
Champions
i.e.
PCP/RNCM
Facility/VISN
Monthly
Calls
Team,
facility
SME
Pain
Team
PACT

21. Healthcare
Analysis
Informa8on
Group
2010
VHA
Pain
Management
Survey
Results
• 100%
of
facili8es
have
pain
management
policies
• 100%
of
Veterans
Integrated
Service
Network
(VISN)
and
95%
of
facili8es
have
iden8fied
Pain
Points
of
Contacts
(POCs)
• 54%
of
facili8es
iden8fied
a
primary
care
pain
champion
• 96%
of
facili8es
have
mul8disciplinary
pain
commi^ees
21

22. Healthcare
Analysis
Informa8on
Group
2010
VHA
Pain
Management
Survey
Results
100%
80%
60%
40%
20%
0%
22

23. Specialty
Pain
Care
Capacity
• 100
%
of
VISNs
have
specialty
pain
clinics
• 91%
of
facili8es
have
dedicated
pain
clinics
FY
2010
FY
2011
FY
2011
FY
2012
%
Change
%
Change
(thru
2nd
(thru
2nd
FY11
Q2
FY
2010
quarter)
quarter)
–
-­‐
FY12
Q2
FY
2011
Encounters
333,447
374,880
179,352
199,485
11.2%
12.4%
Unique
Pa8ents
100,833
108,874
71,575
78,209
9.3%
8.0%
23

24. Building
Capacity
for
Ter8ary,
Interdisciplinary
Pain
Centers
• VHA
Pain
Direc8ve
requires
every
VISN
to
have
a
ter8ary
interdisciplinary
pain
center
by
September
2014
• VISN
Directors
survey
in
December
2011
– 19
VISNS
report
mee8ng
standard
for
advanced
pain
medicine
diagnos8cs
and
interven8ons;
2
have
yet
to
iden8fy
site
• Most
recent
data
on
Commission
for
Accredita8on
of
Rehabilita8on
Facili8es
(CARF)
– 7
VISNs
report
having
CARF-­‐accredited
pain
rehabilita8on
programs;
10
have
applica8ons
pending
24

25. Pain
Research
–
FY
2012
• 61
pain-­‐related
Office
of
Research
• Basic
mechanisms
underlying
pain
and
Development
funded
research
• Pain
diagnosis
projects
• Preclinical
studies
• $11.9
million
for
pain-­‐relevant
• Pain
management
(medica8ons;
research
psychosocial
interven8ons)
• Pain
Research
Working
Group
• Co-­‐morbidi8es
• Health
Services
Research
and
• Quality
of
Life
(QOL),
compara8ve
Development
Pain
Research
Center
effec8veness;
bioinforma8cs;
funded
(PRIME
Center)
dispari8es
• Partnerships
with
Na8onal
Ins8tute
• Training
(career
development)
of
Health/Department
of
Defense
25

26. FY
2013
Priori8es
• Opioid
Safety
Ini8a8ve,
and
other
opioid
therapy
ini8a8ves
• Pain
and
Primary
Care
ini8a8ves;
Joint
Incen8ve
Fund
Ini8a8ve
• Specialty
Care
Services
Transforma8on
Ini8a8ves,
especially
SCAN-­‐ECHO
• Guidance
for
Ter8ary,
Interdisciplinary
Pain
Centers
• Publica8on
of
acute,
peri-­‐opera8ve
pain
management
guideline
• Capacity
for
behavioral
services
in
PACT
• Pa8ent
Educa8on
Ini8a8ves
• Provider
Educa8on
Ini8a8ves
• Nursing
ini8a8ves
• Health
Execu8ve
Council
Pain
Management
and
VA-­‐DoD
ini8a8ves
26