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Witness Testimony of Robert L. Jesse, M.D., Principal Deputy Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs

­ STATEMENT OF
DR. ROBERT L. JESSE, M.D.
PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION (VHA)
DEPARTMENT OF VETERANS AFFAIRS (VA)
BEFORE THE
U.S. hOUSE OF rEPRESENTATIVES COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON HEALTH
October 10, 2013

Good morning, Chairman Benishek, Ranking Member Brownley and Members of the Committee.  Thank you for the opportunity to participate in this oversight hearing and to discuss the Department of Veterans Affairs’ (VA) pain management programs and the use of medications, particularly opioids, to treat Veterans experiencing acute and chronic pain.  I am accompanied today by Dr. Robert Kerns, VA National Director for Pain Research, Veterans Health Administration.

The issues related to pain and pain management are by no means exclusive to VA.  As described in the 2011 Institute of Medicine (IOM) report, “Relieving Pain in America:  A Blueprint for Transforming Prevention, Care, Education, and Research”[1], pain is a public health challenge that affects millions of Americans and is rising in prevalence.  Pain contributes to national rates of morbidity, mortality, and disability and there are costs of pain both on the toll it takes on people’s lives and economically.  The IOM estimated that chronic pain alone affects 100 million United States citizens and that the cost of pain in the United States is at least $560-635 billion each year, which is the combined cost of lost productivity and the incremental cost of healthcare.

Studies show more than 50 percent of all Veterans enrolled and receiving care at VHA are affected by chronic pain, which is a much higher rate than in the general adult population.  That makes pain management a very important clinical issue for VA.  My testimony today will focus on how VA is providing comprehensive and patient-centered pain management services to improve the health of Veterans.  The statement will highlight VA’s current pain management strategies, the prevalence and use of opioid therapy to manage chronic pain in high risk veterans, the challenges of prescription drug diversion[2] and abuse among Veterans, and the actions VA is taking to improve the management of chronic pain, including the safe use of opioid analgesics, and the use of best practices across the VA health care system.

Prescription Drug Diversion and Abuse Challenges

Opioid analgesics may help many patients manage their severe pain when other medications and modalities are ineffective or are only partially effective.  However, there may be risks to both individual patients as well as to the surrounding community when these agents are not prescribed or used appropriately.  VA has embarked on a two pronged approach to addressing the challenge of prescription drug diversion and abuse among Veteran patients.

One approach is to improve the education and training in pain management and safe opioid prescribing for clinicians and the interdisciplinary teams that provide pain management care for Veterans.  A complementary approach involves improving risk management through two systems initiatives.  The first system initiative, the Opioid Safety Initiative, employs the tremendous advantages of VHA’s electronic health record. This system-wide initiative identifies patients with one or a combination of risk factors, for example, high doses of opioids and opioids combined with sedatives to identify providers whose prescribing practices are misaligned with medical evidence/strong practices and to provide counseling, education and support for them to improve their care of Veterans with pain.

The second system-wide risk management approach to support the Veterans’ and public’s safety is promulgation of new regulations that enable VHA to participate in state Prescription Drug Monitoring Programs (PDMP).  These programs, featuring appropriate health privacy protections, allow for the interaction between VA and state databases, so that providers in either can view electronic information about opioid prescriptions and be able to identify potentially vulnerable at-risk individuals.  PDMPs can provide information to VA on prescribing and dispensing of controlled substances to Veterans outside the VA health care system.  Participation in PDMPs will enable providers to identify patients who have received non-VA prescriptions for controlled substances, which in turn offers greater opportunity to discuss the effectiveness of these non-VA prescriptions in treating their pain or symptoms.  More importantly, information that can be gathered through these programs will help both VA and private providers  to prevent harm to patients that could occur if the provider was unaware that a controlled substance medication had been prescribed elsewhere already.

 

 

Current VA Pain Management Strategies

Chronic Pain in Veterans

            The burden of pain on the Veteran population is considerable.  We know that Veterans have much higher rates of chronic pain than the general population.[3]  Chronic pain is the most common medical problem in Veterans returning from the last decade of conflict (almost 60 percent).[4]  Many of these Veterans have survived serious, even extreme, injuries often associated with road-side bombs and other blast injuries.  These events can cause damage to multiple bodily sites including amputations and spinal cord injuries.  These Veterans also survived severe psychological trauma associated with exposure to the horrors of war on the battlefield.  Many Veterans require a combination of strategies for the effective management of pain, including treatment with opioid analgesics, which are known to be effective for at least partially relieving pain caused by many different medical conditions and injuries.  In 2010, VA and the Department of Defense (DoD) published evidence-based Clinical Practice Guidelines for the use of chronic opioid therapy in chronic pain. The guidelines reserve the use of chronic opioids for patients with moderate to severe pain who have not responded to, or responded only partially to, clinically indicated, evidence-based pain management strategies of lower risk, and who also may benefit from a trial of opioids to improve pain control in the service of improving function and quality of life.

We also know that the long-term use of opioids is associated with significant risks, particularly in vulnerable individuals, such as Veterans with Post-Traumatic Stress Disorder (PTSD), depression, Traumatic Brain Injury (TBI) and family stress – all common in Veterans returning from the battlefield, and in Veterans with addiction disorders.  Chronic pain in Veterans is often accompanied by co-morbid mental health conditions (up to 50 percent in some cohorts) caused by the psychological trauma of war, as well as neurological disorders, such as TBI caused by blast and concussion injuries.  In fact, one study documented that more that 40 percent of Veterans admitted to a polytrauma unit in VHA suffered all three conditions together – chronic pain, PTSD, and post-concussive syndrome.[5]

In addition to these newly injured Veterans suffering from chronic pain conditions and neuropsychological conditions, VA cares for millions of Veterans from earlier conflicts, who along with chronic pain and psychological conditions resulting from their earlier war injuries, are now developing the many diseases of aging, such as cancer, neuropathies, spinal disease, and arthritis, which cause chronic, often terrible pain.  All these Veterans also deserve appropriate pain care, including, when indicated, the safe use of opioid analgesics.

VA cares for a Veteran population that suffers much higher rates of chronic pain than the civilian population, and also experiences much higher rates of co‑morbidities (PTSD, depression, TBI) and socioeconomic dynamics (family stress, disability, joblessness) that contribute to the complexity and challenges of pain management with opioids.[6]  Because more Veterans have the kind of severe and disabling pain conditions that require stronger treatments such as opioids, more of them have risks for overdose due to depression, PTSD and addiction.

In recognition of the seriousness of the impact of chronic pain on our Veterans’ health and quality of life, VHA was among one of the first health systems in the country to establish a strong policy on chronic pain management and to implement a system-wide approach to addressing the risks of opioid analgesia.  Our approach is outlined below.

VA National Pain Management Strategy and VHA Pain Management Directive

As part of the VA’s National Pain Management Strategy,[7] VHA Pain Management Directive 2009‑053[8] was published in October 2009 to provide uniform guidelines and procedures for providing pain management care.  These include standards for pain assessment and treatment, including use of opioid therapy when appropriate, for evaluation of outcomes and quality of pain management, and for clinician competence and expertise in pain management.  Since publication of the Pain Management Directive, a dissemination and implementation plan has been enacted that supports the following:

  • Comprehensive staffing and training plans for providers and staff;
  • Comprehensive patient/family education plans to empower Veterans in pain management;
  • Development of new tools and resources to support the pain management strategy, and
  • Enhanced efforts to strengthen communication between VA’s Central Office (VACO) and leadership from facilities[9] and Veterans Integrated Service Networks (VISNs).

      Following the guidance of the VHA National Pain Management Strategy, and in compliance with generally accepted pain management standards of care, the Directive provides policy and procedures for the improvement of pain management through implementation of the Stepped Care Model for Pain Management (SCM-PM), the single standard of pain care for VHA, central to ensuring Veterans receive appropriate pain management services.  The Directive also requires tracking opioid use and implementing strong practices in risk management to improve Veterans’ safety.

Consistent with this model, a key objective is to expand capacity for specialty pain care services.  Present data demonstrates an increase in this capacity over the past year, continuing this yearly trend since data were first analyzed in fiscal year (FY) 2005. Specifically, we know that:

  • All VISNs are providing dedicated Pain Clinic services with dedicated Pain Clinics in about 95 percent of facilities.
  • Through the third quarter of FY 2013, VHA provided Pain Clinic services to 104,388 unique Veterans (including both inpatient and outpatient pain clinic services).  Compared to the same time period in FY 2012, this represents a 3.6 percent increase in the number of Veterans served in these specialty clinics.
  • Total Pain Clinic encounters increased to 316,204 through the third quarter of FY 2013; up 2.6 percent over this same time period in FY 2012.
  • Of the 95 percent of facilities with Pain Clinic Services, 84 percent have dedicated physician staff through the second quarter of FY 2013 (includes all physician specialty areas delivering Pain Clinic services by both VHA and In-House Contract Physician staff).
  • Through the second quarter of FY 2013, 59 percent of facilities have physicians who specialize in Pain Medicine, and 44 percent of physician-delivered services VHA wide are provided by those who specialize in Pain Medicine.  In the same period, 95 percent of Pain Clinic services were provided by VHA physicians, 3 percent by contract, and 2 percent by in-house fee physicians.
  • Physician pain specialist staffing has increased slightly from 113 full-time equivalent employees in FY 2012 to 115 through the second quarter of FY 2013.
  • The current supply of physicians providing specialty Pain Clinic services per 100,000 unique patients, is 1.93, with an average of 2.22 support staff per physician (including administrative staff, advanced-practice providers, and other clinical staff).

Oversight and Accountability

Several key responsibilities are articulated in the Pain Management Directive.  The Directive establishes a National Pain Management Program Office (NPMPO) in VACO that has the responsibility for policy development, coordination, oversight, and monitoring of VHA’s National Pain Management Strategy.  The Directive further authorizes the establishment of a multidisciplinary VHA National Pain Management Strategy Coordinating Committee that supports the Program Office in achieving its strategic goals and objectives.  The Committee is comprised of 15 members to include:  anesthesiology, employee education, geriatrics and extended care, mental health, neurology, nursing, pain management, patient education, pharmacy benefits management, primary care/internal medicine, quality performance, rehabilitation medicine, research, and women Veterans’ health.

The Directive requires VISN Directors to ensure that all facilities establish and implement current pain management policies consistent with this Directive.  VISN and facility pain management points of contact serve key roles as links between the NPMPO and VHA health care facilities.  Facility directors are responsible for ensuring that accepted standards of pain care are met.  The facilities establish multidisciplinary pain management committees to provide oversight, coordination, and monitoring of pain management activities and processes to facilitate the implementation of VA’s Pain Management Strategy.

The NPMPO maintains records of VISN and facility compliance, along with other key organizational requirements contained in the Directive.  All VISNs and facilities have appointed National Pain Office pain management points of contact, established multidisciplinary committees, and implemented pain management policies as required by the Directive.

Stepped Care Model for Pain Management

As mentioned earlier, SCM-PM is the single standard of pain care for VHA to ensure Veterans receive appropriate pain management services.  Specifically, SCM-PM provides for assessment and management of pain conditions in the primary care setting.  This is supported by timely access to secondary consultation from pain medicine, behavioral health, physical medicine and rehabilitation, specialty consultation, and care by coordination with palliative care, tertiary care, advanced diagnostic and medical management, and rehabilitation services for complex cases involving co-morbidities such as mental health disorders and TBI.

In FY 2012, VHA made several important investments in implementing the SCM-PM.  Major transformational initiatives support the objectives of building capacity for enhanced pain management in the primary care setting, including education of Veterans and caregivers in self-management, as well as promoting equitable and timely access to specialty pain care services.

      There are other important efforts contributing to the implementation of SCM-PM in VHA facilities.  Current initiatives focus on empowering Veterans in their pain management, and expanding capacity for Veterans to receive evidence-based psychological services as a component of a comprehensive and integrated plan for pain management.  For example, during FY 2012, the VHA National Telemental Health Center expanded its capacity to deliver face-to-face, psychological services to Veterans remotely via high-speed videoconferencing links.  This initiative not only emphasizes the delivery of cognitive behavior therapy for Veterans with chronic pain, but also promotes pain self-management, leading to reductions in pain and improvements in physical functioning and emotional well being.

Additionally, a Primary Care and Pain Management Task Force is developing a comprehensive strategic and tactical plan for promoting full implementation of the SCM-PM in the Primary Care setting, and it continues to work on several products in support of this effort.  For instance, the Task Force is continuing to expand its network of facility- level Primary Care Pain Management points of contact (Pain Champions) who meet monthly, via teleconference, to identity and share strong practices that have led to improved pain care in primary care settings.

VA’s pain management initiatives are designed to optimize timely sharing of new policies and guidance related to pain management standards of care.  Of particular importance are VHA’s continuing efforts to promote safe and effective use of opioid therapy for pain management, particularly those initiatives designed to mitigate risk for prescription pain medication misuse, abuse, addiction, and diversion.

Created in 2011, VA’s Specialty Care Access Network–Extension of Community Healthcare Outcome (SCAN-ECHO) initiative allows pain specialists to train primary care providers in community based outpatient clinics (CBOCs) closer to Veterans’ homes, particularly in rural and underserved geographic areas.  Benefits of this program include reduced travel costs, improved quality of care, and increased provider and Veteran satisfaction.  Multiple modules are available on VA’s on-line Talent Management System (TMS), based on VA/DoD pain guidelines and approved for continuing education credits for physicians, nurses, pharmacists, and psychologists, thereby ensuring a standardized level of knowledge across pain care delivery.  This initiative supports the implementation and evaluation of seven pain SCAN‑ECHO regional training hubs.  Each hub, designed to provide support for up to twenty Patient-Aligned Care Teams (PACT), is staffed by experts in pain management, and linked by real-time videoconferencing to PACT teams away from the medical center.

VHA has also implemented the Consult Management initiative, which uses E‑Consults and phone consults, to change how specialty care services are delivered throughout VHA.  E-Consult provides clinical support from provider to provider.  E‑Consult is an alternative to face-to-face visits, and is expected to improve access, communication, and coordination of care.  Through a formal consult request, a provider requests a specialist to address a clinical problem or to answer a clinical question for a specific patient.  Using information provided in the consult request and/or review of the patient’s electronic health record (EHR), the consultant provides a documented response that addresses the request without a face-to-face visit.  This method of consultation supports patient-centric care, reduces the burden of travel for the Veteran, and reduces overall travel and non-VA costs.

            A particularly exciting initiative in its pilot phase of development is the pain management application for smart phones that will be used by Veterans and their care partners to develop pain self-management skills.  This tool, called VA Pain Coach, will eventually interface with VHA’s EHR, with appropriate privacy protections in a secure mobile application environment, allowing Veteran-reported information about pain, functioning, and other key elements to be securely stored and accessible to clinicians.  VA Pain Coach, which is part of a suite of VA applications called “Clinic in Hand”, is in the third month of a one-year pilot test with 1150 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans and their caregivers.  In the future, a complementary initiative will build a clinician-facing application that will enhance the capacity of clinicians and Veterans to share in monitoring, decision making, treatment planning, and reassessment of pain management interventions.

            VHA continues to work to strengthen its ability to meet the pain management needs of Veterans with complex chronic pain conditions with co-morbidities.  Of particular importance are continued efforts to promote access to integrated care services for Veterans experiencing chronic pain and symptoms of PTSD, mild TBI, sleep disorders, and other common co-morbid conditions.  In partnership with VHA’s Mental Health Services, the ongoing Evidence-Based Psychotherapy initiative has been expanded to include an initiative on cognitive behavior therapy for chronic pain.

            VHA’s NPMPO also partners with Primary Care Services in support of its Post-Deployment Integrative Care Initiative.  This field-based initiative, developed in 2008, supports integrated care clinical platforms for providing post-deployment services in VAMCs nationally.  An example of this initiative is the PACT-based collaborative for post-deployment pain care.  This initiative focuses on PACT and pain specialists in interdisciplinary collaborative care based on the Step Care Model of pain management.  An additional monthly community of practice discussion, as well as a monthly call for a network of PACT Primary Care Pain Champions, were recently added focusing specifically on pain care in PACT settings to further the implementation of good pain care and rational opioid use.

            VHA’s capacity to provide Veterans with equitable access to specialty care services is strengthened by integrating other services important for pain management.  For example, a partnership with Rehabilitation Services plans to build capacity for rehabilitation medicine services, including chiropractic services.  Recently, the NPMPO contributed to a national educational conference, focusing on rehabilitation services, to promote models of integrated care that emphasize the role of rehabilitation specialists for pain management.

            Further, the NPMPO continues to partner with Women Health Services to develop a strategic plan that will strengthen the capacity for women Veteran centered pain management services.  In April 2012, VHA sponsored a Women’s Health National audio conference on pain management for Women Veterans.

            The NPMPO also partners with Pharmacy Benefits Management Services (PBM) and others in development of a comprehensive approach to promote the safe and effective use of long-term opioid therapy for Veterans.  Of particular note was the promulgation of regulations permitting VA to participate with a growing number of states that have state Prescription Drug Monitoring Programs (PDMP).   Thus, following state laws, VA providers can query PDMP databases about prescriptions from providers outside the VA, and can respond to queries from outside the VA about Veterans receiving controlled medications from the VA, leading to better communications with Veterans and all their caregivers about safe practices.  The NPMPO also collaborates with PBM on the Opioid Safety Initiative which involves providing facility feedback on provider prescribing and facility utilization of opioids.  This program was piloted in 4 VISNs and was implemented system-wide in August and September 2013.

VHA Pain Management Centers

            The Under Secretary for Health chartered an Interdisciplinary Pain Management Center Work Group to provide guidance and oversight for VHA’s efforts to develop VISN level tertiary care Pain Management Centers.  These Centers have the capacity for providing advanced pain medicine diagnostics, surgical and interventional procedures, subspecialty pain care, and intensive, integrated chronic pain rehabilitation for Veterans with complex, co-morbid, or treatment refractory conditions.  There are currently nine Commission for the Accreditation of Healthcare Facilities, or CARF, accredited pain rehabilitation centers in VHA.  This includes one Center at the James Haley Veterans Hospital in Tampa, which is one of only two multidisciplinary pain management centers to be twice recognized by the American Pain Society as a Clinical Center of Excellence.  The other is a program at Stanford University.

            Finally, the DoD-VA Health Executive Council (HEC) Pain Management Work Group (PMWG) was chartered to develop a model system of integrated, timely, continuous, and expert pain management for Servicemembers and Veterans.  The Work Group participates in VA/DoD Joint Strategic Planning (JSP) process to develop and implement the strategies and performance measures, as outlined in the JSP guidance, and shares responsibility in fostering increased communication regarding functional area between Departments.  The Group also identifies and assesses further opportunities for the coordination and sharing of health related services and resource between the Departments.  A key development is the HEC PMWG’s sponsoring of two Joint Incentive Fund projects to improve Veterans’ and Servicemembers’ access to competent pain care in the SCM-PM: the Joint Pain and Education Project (JPEP), and the “Tiered Acupuncture Training Across Clinical Settings” (ATACS) projects.  The latter project, ATACS, represents VHA’s initiative to make evidence-based complementary and alternative medicine therapies widely available to our Veterans throughout VHA.  A VHA and DoD network of medical acupuncturists are being identified and trained in Battlefield (auricular) Acupuncture by regional training conferences organized jointly by VHA and DoD.  The goal of the project is for them to return to their facilities and VISNs with the skills to train local providers in Battlefield Acupuncture, which has been used successfully in DoD front-line clinics around the world.  This initiative will provide Veterans with a wider array of pain management choices when they present with chronic pain.

Prevalence and Use of Opioid Therapy for the Management of Chronic Pain in Veterans

To monitor the use of opioids by patients in the VA health care system, VA tracks multi-drug therapy for pain in patients receiving chronic or long-acting opioid therapy for safety and effectiveness. This includes tracking of use of guideline recommended medications for chronic pain (i.e., certain anticonvulsants, tricyclic antidepressants (TCA), and serotonin and norepinephrine reuptake inhibitors (SNRI) which have been shown to be effective for treatment of some chronic pain conditions), and tracking of concurrent prescribing of opioids and certain sedative medications (e.g., benzodiazepines and barbiturates) which can contribute to oversedation and overdose risk when taken with opioids and the other medications for pain listed above.

The prevalence of Veterans using opioids has been measured for Veterans using VHA health care services.  For FY 2012, of the 5,779,668 patients seen in VA, 433,136 (7.5 percent) received prescriptions for more than 90 days supply of short acting opioid medications and 92,297 (1.6 percent) received at least one prescription for a long-acting opioid medication in the year.  Thus, since chronic pain is the most common condition in all Veterans enrolled in VHA, more than 50 percent, a relatively small percentage of those Veterans are receiving opioid therapy, consistent with the DoD-VA Clinical Practice Guidelines which limit their use to patients with moderate to severe persistent pain that has not responded to other safer alternatives that are clinically appropriate.  Of these 525,433 patients that received chronic or long-acting opioid therapy, 79,025 (15 percent) were also prescribed a TCA, 90,066 (17 percent) were also prescribed an SNRI, and 178,361 (34 percent) were also prescribed an anticonvulsant some time in FY 2012.

 The co-prescription of TCAs and/or SNRIs with opioids is first line therapy for the more severe cases of pain related to nerve damage from disease (e.g., diabetes, cancer) or from injuries (e.g., battlefield blast and projectile injuries with or without limb amputation and spinal cord injury).  The numbers above suggest that clinical teams are using medically indicated combinations of medications that are specifically needed for these more severe conditions, which themselves are often co-morbid with musculoskeletal pain such as injuries to joints, spine and muscles.  Of note, these prescriptions may or may not have overlapped with the opioid prescription during the year.

In FY 2012, 193,644 (37 percent) of the patients prescribed chronic or long-acting opioid therapy received an overlapping prescription for a sedative medication.  Notably, 272,719 (52 percent) of patients on chronic or long-acting opioid therapy also received non-medication-based rehabilitative treatments as part of their treatment plan (e.g., physical therapy (32 percent), chiropractic care (1 percent), programs to encourage physical activity (9 percent) or occupational therapy (17 percent), and 241,465 (46 percent) also received behavioral or psychosocial treatment for chronic pain or co-morbid mental health conditions.

These data, showing the use of non-medication treatments, suggest that Veterans are benefitting from VHA’s efforts to create access to additional pain treatment modalities besides medication.  This is consistent with VA’s commitment to transform pain care to a biopsychosocial model[10] that addresses all the factors that by research are demonstrated to affect Veterans’ success in chronic pain treatment.  Pursuant to this aim, a multi-modality, team-based, stepped care model, per VHA Directive 2009-053, is being implemented widely throughout VHA, and in coordination with DoD.

Improving Chronic Pain Management and Use of Best Practices in VHA

The strategies outlined earlier regarding VHA Pain Management Directive were developed and are being implemented to improve pain management outcomes for our patients.  To achieve successful transformation of pain care in VHA several strategic goals must be met.

Health Care Provider Education and Training

First, as recognized by the IOM in its extensive 2011 review, “Pain in America” and the American Medical Association in its 2010 Report on Pain Medicine[11], and as articulated in VHA’s Pain Management Directive in 2009-053, a formal commitment to pain management education and training for students and trainees in all clinical disciplines is required.  For example, VHA, which provides training for a large proportion of medical students and residents, has the opportunity to establish a system-wide requirement for education and training of physicians in pain management, as recommended in the Directive.

The Joint Pain and Education Project, JPEP, mentioned earlier, has proposed training faculty in all VA training sites to pursue the implementation of such a curriculum, so that new generations of providers and other clinicians will themselves become the new teachers of good pain care.  JPEP will target all levels of learner: the Veteran and his/her family and caregiver; the public; clinicians from all disciplines; specific providers and clinicians in practicing at each level of the SCM-PM: primary care, pain medicine specialty care, and other specialty care. VA is providing national leadership in developing interdisciplinary and discipline-specific competencies for pain management, in developing a system-wide approach to trainings, and in providing leadership roles in national projects to improve pain education and training.

Outcomes and Best Practices

In summary, there is growing evidence of the successful implementation of a Stepped Care Model for Pain Management in VHA.  Importantly, Veterans receiving long term opioid therapy for management of chronic pain are increasingly likely to be receiving this therapy in the context of multidisciplinary and multimodal care that often incorporates physical and occupational therapy and mental health services.  All VISNs provide specialty pain clinic services, and the number of Veterans who receive these services has grown steadily for the past five years.  Nine facilities now provide CARF accredited pain rehabilitation services, a rapid increase in the availability of these higher specialized pain rehabilitation services for our most complex Veterans with debilitating chronic pain and comorbid mental health disorders.

VA learns from VISN and VA medical centers that are early adopters of implementing evidence based guidelines and best practices.  The Minneapolis VAMC has had great success after their VISN leadership and Medical Center leadership organized multi-disciplinary team with pain providers, clinical pharmacist, psychologist, psychiatry, patient advocates and toxicologists. Interdisciplinary approaches were identified to address patients on the higher doses of opioid medications.  The PACTs were encouraged to offer trials of non-opioid care and increase access to behavioral pain management resources as alternatives.  Patients were assessed frequently to evaluate the trials of lower doses of medication and success of non-opioid alternative care.  After implementing best practices, this medical center saw over a fifty percent decrease in the need to prescribe opioids for chronic pain management, in higher doses.  The facilities’ practices were shared nationally through educational teleconferences.  VA applauds the work by this medical center and others like it to progress toward a standard of care for safer opioid prescribing

VA is working aggressively to promote the safe and effective use of long-term opioid therapy for Veterans with chronic pain for whom this important therapy is indicated.  VA’s Opioid Safety Initiative holds considerable promise for mitigating risk for harms among Veterans receiving this therapy, for promoting provider competence in safe prescribing of opioids, and in promoting Veteran-centered, evidence-based, and coordinated multidisciplinary pain care for Veterans with chronic pain.  Early evidence of success in reducing overall opioid prescribing and average dose per day of opioid therapy is encouraging.

VA also has the opportunity to measure the impact of new policies and programs systematically and in a way that enhances the outcomes of interdisciplinary pain care for Veterans.  VA’s Office of Research and Development Pain Portfolio for FY 2013 consisted of 82 projects relevant to the treatment, diagnosis, and mechanisms underlying painful conditions experienced by Veterans, totaling approximately $16.4 million (an increase of $4.5 million from 2012).

VA recently funded a new research project that identifies a cohort of all Veterans in care in VHA with diagnosed painful musculoskeletal disorders.  This database provides an important opportunity to examine pain care in VHA, including multidisciplinary pain care consistent with the SCM-PM, costs of care, and outcomes.  VA is currently exploring the development of a prospective electronic system for supplementing this system by collection of Veteran reported outcomes.  VA Pain Coach already described may provide an initial secure platform for this important initiative. Another opportunity is to partner with our DoD and National Institutes of Health colleagues to develop a registry of Veterans with painful conditions that can link with a similar system, called PASTOR Patient Reported Outcomes Measurement Information System (PROMIS), being developed in DoD military treatment facilities.

In addition to interagency collaborations mentioned earlier, VHA pain experts serve on the Interagency Pain Research Coordinating Committee (IPRCC).  The IPRCC was tasked by the Undersecretary for Health at the Department of Health and Human Services to create a comprehensive population health-level strategy for pain prevention, treatment, management, and research.

Finally, on February 25, 2013, VHA submitted a notice in the Federal Register (FR Doc. 2013-04248) outlining a Pain Public Private Collaboration for the development of novel therapies to treat painful conditions.  The goal is to partner VHA investigators with industry sponsors to develop or test new therapies for chronic pain

Conclusion

Mr. Chairman, we know our work to improve pain management programs and the use of medications will never be truly finished.  However, we are confident that we are building more accessible, safe and effective programs and opportunities that will be responsive to the needs of our Veterans.  We appreciate your support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans.  VA is committed to providing the high quality of care that our Veterans have earned and deserve, and we appreciate the opportunity to appear before you today.  My colleagues and I are prepared to respond to any questions you may have.



[1] Institute of Medicine. 2011. Relieving Pain in America:  A Blueprint for Transforming Pain Prevention, Care, Education and Research. Washington, D.C.: The National Academies Press.

[2] Diversion is the use of prescription drugs for recreational purposes.

 

[3] Gironda, R.J., Clark, M.E., Massengale, J.P., & Walker, R.L. (2006). Pain among veterans of Operations Enduring Freedom and Iraqi Freedom. Pain Medicine, 7, 339–343.

 

[4] Veterans Health Administration (2013). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans.  Washington, DC: Department of Veterans Affairs.

[5] Lew, H.L., Otis, J.D., Tun, C., Kerns, R.D., Clark, M.E., & Cifu, D.X. (2009).  Prevalence of chronic pain, posttraumatic stress disorder, and post-concussive syndrome in OEF/OIF veterans:  The polytrauma clinical triad.  Journal of Rehabilitation Research and Development, 46, 697-702.

 

[6] See citations 3 and 4.

[7] The overall objective of the national strategy is to develop a comprehensive, multicultural, integrated, system-wide approach pain management that reduces pain and suffering and improves quality of life for Veterans experiencing acute and chronic pain associated with a wide range of injuries and illnesses, including terminal illness.

[9] The term “facilities” or “facility” refers to VA’s 151 medical centers, hospitals, or healthcare systems.

 

[10] The Biopsychosocial Model takes the position that the causes and outcomes of many illnesses often involve the interaction of physical and pathophysiologic factors, psychological traits and states, and social-environmental factors. Effective treatment planning accounts for the salience of these factors in the precipitation and perpetuation of illness and illness-related disability.

[11] Lippe PM, Brock C, David JJ, Crossno R, Gitlow S. The First National Pain Medicine Summit – Final Summary Report. Pain Med 2010;11(10):1447–68.