Witness Testimony of Steven G. Scott, M.D., Chief of Physical Medicine and Rehabilitation Service, Veterans Health Administration, U.S. Department of Veterans Affairs
DR. STEVEN G. SCOTT, M.D.
CHIEF OF PHYSICAL MEDICINE & REHABILITATION SERVICE
VETERANS HEALTH ADMINISTRATION (VHA)
DEPARTMENT OF VETERANS AFFAIRS (VA)
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 specifically the Department of Veterans Affairs’ (VA) James A. Haley Veterans’ Hospital’s Chronic Pain Rehabilitation Program (CPRP) that treats Veterans experiencing acute and chronic pain.
For many individuals, chronic pain is much more than a lingering medical problem. It is instead a pervasive, unrelenting, and serious condition that affects every area of an individual’s life including their mental health, physical health, family life, vocation, friendships, and even sleep. For these individuals, chronic pain is an unending daily battle where pain assumes command. Even the most rudimentary daily decisions - whether to go shopping; attend a medical appointment; see a friend - are based not on the individual’s preferences, but instead on their level of pain. We call this constellation of pain related problems a “Chronic Pain Syndrome” or CPS. Estimates are that more than 25 percent of adults with chronic pain also have symptoms of CPS, and while pain may have been the cause of these problems, there is evidence that once established, these related problems linger even if the underlying pain is substantially reduced.
Unfortunately, many individuals with CPS attempt to fight these problems using increasing amounts of opioid analgesics. But, these efforts are rarely successful. Due to the complexity of CPS, no single treatment approach is the answer. A multi-disciplinary and multi-modality approach is almost always necessary.
CHRONIC PAIN REHABILITIATION PROGRAM OVERVIEW
The James A. Haley Veterans’ Hospital and Clinics in Tampa, Florida have both an inpatient and outpatient Chronic Pain Rehabilitation Program (CPRP). The Haley Veterans’ Hospital has the only VA inpatient CPRP. The CPRP was designed to specifically treat Veterans and active duty military personnel with chronic pain syndrome (CPS). The CPRP is an evidence-based, intensive, interdisciplinary, 19-day inpatient chronic pain treatment program that targets not only pain intensity, but also all of the accompanying symptoms of CPS. The core philosophy of the CPRP recognizes the complex interactions between pathophysiological, emotional, social, perceptual, cultural, and situational components of chronic pain.
The CPRP teaches pain self-management practices where participants assume responsibility for their daily functioning and learn to actively manage their pain. For most participants this includes increasing their level of independent functioning, increasing activity levels, reducing the emotional distress associated with chronic pain, eliminating reliance on opioid analgesics and/or muscle relaxants, reducing pain intensity, improving marital, familial and social relationships, increasing vocational and recreational opportunities, and improving overall quality of life.
One of the unique aspects of the program is that all participants taking opioid analgesics at admission are tapered off these medications during the course of treatment. This practice began in 1988 when CPRP was established, and continues today. We do this because opioids essentially have no positive effects for this group of patients. Eliminating opioids for this group of individuals does not increase their pain nor increase their daily impairment. In fact, we have found that eliminating opioid reliance has virtually no effect on treatment outcomes. Individuals who discontinue these medications during treatment improve, as much or more than those who were not using opioid analgesics at admission.
CPRP TREATMENT COMPONENTS
The CPRP uses a variety of strategies to enhance self-management skills, increase activity, and reduce pain. These include daily goal-directed programs of individualized exercises, walking, pool therapy, occupational therapy, relaxation training, medical management, recreational therapy, and educational classes. Much of the skill enhancement and self-management training is provided by pain psychologists who serve as rehabilitation coaches and use individual cognitive and behavioral therapy techniques to reduce emotional distress, encourage self-reliance, enhance pain management skills and promote healthy lifestyles. Family members are involved in treatment when available and prior to discharge participants develop a plan of continued rehabilitation that can be implemented at home.
The typical participant in the CPRP is a male or female Veteran in their late 40s who has been fighting pain constantly for the last 15 years on average. They have tried virtually every known treatment, ranging from surgery to multiple medications or injections, and out of desperation may have become victims of a variety of pseudo treatments promising total pain relief at substantial individual cost. They are depressed, irritable, anxious and often angry with the medical establishment that they feel has failed them. Marital and family problems abound, separation or divorce is common, and friendships have dissolved. Typically they are unemployed or disabled and face a variety of financial challenges or crises. Many may misuse prescribed medications, alcohol, or other substances to try to cope. Although this cycle began with a single distinct pain, they now experience multiple pain problems many of which can develop or intensify due to their sedentary lifestyle and prolonged stress.
These same individuals, when offered hope, compassionate treatment, and the camaraderie of others in similar circumstances typically demonstrate remarkable improvements and resiliency during this 19-day inpatient program. When we used standardized measures to asses these changes, we see the following outcomes: reductions in pain severity, improvements in mood and sleep; increased strength, flexibility, and endurance; enhanced engagement with life and families; significant weight loss; and, increased confidence in their abilities to manage their lives despite elimination of opioid analgesics and other potentially harmful medications. What we find after this treatment are individuals who are now laughing instead of frowning, seeking out contact with others instead of avoiding, and who are proud about their accomplishments. It is not rare to observe individuals who entered the program reliant on wheelchairs, walk out the door unaided at discharge.
In the CPRP’s 25 years of existence, the program and its staff have received numerous accolades and awards. The CPRP has been recognized as a two-time Clinical Center of Excellence by the American Pain Society. The CPRP is one of only two programs that has twice won this prestigious award, the other being a program at Stanford University. The program has also received the prestigious Secretary of Veterans Affairs Olin E. Teague Award for clinical excellence and been accredited six times by the Commission on Accreditation of Rehabilitation Facilities (CARF). CPRP leaders have been actively involved in promoting system-wide enhancements in VA pain care, particularly for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans suffering from chronic pain in combination with other significant physical and emotional co-morbidities. As the most specialized chronic inpatient pain treatment option in the VA health care system, the program accepts referrals from all 50 states, Puerto Rico and the US Virgin Islands.
In 2009, the CPRP was selected to serve as the VA’s national training site for interdisciplinary pain programs. Thirty teams from across the country have visited the James A. Haley Veterans’ Hospital to observe the model system and learn how to enhance pain treatment services at their facilities. The training program has focused on helping these teams develop tertiary level, CARF-accredited pain programs in order to help meet the 2009 Veterans Health Administration Pain Management Directive 2009-053 mandating an interdisciplinary CARF option in each Veterans Integrated Support Network. The positive effects of these trainings are manifest by the increase from 2 CARF-accredited programs in 2009, both in the same VISN, to 8 CARF accredited programs in the VHA in 2013; 14 other VHA facilities are presently applying for CARF accreditation for a developed program or in the process of developing a CPRP with the intention of applying for CARF accreditation.
Mr. Chairman, VA is committed to providing the high quality of care that our Veterans have earned and deserve. I appreciate the opportunity to appear before you today to discuss the James A. Haley Veterans’ Hospital’s Chronic Pain Rehabilitation Program, and I am grateful for your support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans. I am prepared to respond to any questions you may have.
 Murphy J, Clark M, Banou E,. Opioid Cessation and Multidimensional Outcomes After Interdisciplinary Chronic Pain Treatment. Clin J Pain 2013;29:109–117.
 Murphy J, et al (2013)