Julie Franklin, M.D. Pain Medicine, Practitioner White River Junction, VT VA Medical Center
DR. JULIE FRANKLIN
MEDICAL DIRECTOR OF THE WHITE RIVER JUNCTION PAIN SERVICE
VETERANS HEALTH ADMINISTRATION (VHA)
DEPARTMENT OF VETERANS AFFAIRS (VA)
HOUSE COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
U. S. HOUSE OF REPRESENTATIVES
CONCORD, NEW HAMPSHIRE
March 4, 2016
Good morning, Chairman Coffman, Ranking Member Kuster, and Members of the Subcommittee. Thank you for the opportunity to participate in this hearing and to discuss VA’s pain management programs and the use of medications, particularly opioids, to treat Veterans experiencing acute and chronic pain. I am accompanied today by Dr. Grigory Chernyak, Chief of Anesthesia and Pain Service, at the Manchester, New Hampshire VAMC.
Chronic Pain Across the Nation
Chronic pain affects the Veteran population, with almost 60 percent of returning Veterans from the Middle East and more than 50 percent of older Veterans in the VA health care system living with some form of chronic pain. The treatment of Veterans’ pain is often very complex. Many of our Veterans have survived severe battlefield injuries, some repeated, resulting in life-long moderate to severe pain related to damage to their musculoskeletal system and permanent nerve damage, which can impact their physical abilities, emotional health, and central nervous system. It is important to note as well that there is limited clinical trial data supporting the use of opioids for chronic pain[i] and so VHA is committed to reducing overreliance on opioid medicines especially in light of the severe negative consequences many patients on opioids risk.
Current VHA Pain Management Collaboration
To implement effective management of pain, VHA’s National Pain Program oversees several work groups and a National Pain Management Strategy Coordinating Committee representing the VHA offices of nursing, pharmacy, mental health, primary care, anesthesia, education, integrative health, and physical medicine and rehabilitation. Working with the field, these groups develop, review and communicate strong pain management practices to VHA clinicians and clinical teams.
For example, the VHA Pain Leadership Group, consisting of Pain Points of Contact for the Veterans Integrated Service Networks (VISNs) and facilities, meets monthly with the National Pain Program to discuss policy, programs, and clinical issues and disseminate information to the field as well as to provide feedback to VACO leadership about these programs. Several of these groups are chartered to promote the transformation of pain care in VHA at all levels of the Stepped Care Model: the Pain Patient Aligned Care Team (PACT) Initiative Tactical Advisory Group focuses on primary care issues; the Pain Medicine Specialty Team (PMST) Workgroup coordinates and provides standards for specialty pain services; the Interdisciplinary Pain Management Workgroup focuses on developing Commission on Accreditation of Rehabilitation Facilities (CARF) certified tertiary care pain management programs for complex patients.
The Opioid Safety Initiative (OSI) Toolkit Task Force has published and promoted 16 evidenced-based documents and presentations to support the Academic Detailing model of the OSI. More information on the OSI Toolkit can be found at the following link: (http://vaww.va.gov/PAINMANAGEMENT/index.asp).
The Department of Defense (DoD)-VA Health Executive Council’s Pain Management Workgroup (PMWG) oversees joint projects with DoD including the two Joint Investment Fund (JIF) projects, the Joint Pain Education and Training Project and the Tiered Acupuncture Training Across Clinical Settings, and other projects that aim to standardize good pain care across DoD and VHA.
In Manchester, VA offers an Interventional Pain Program, Acupuncture Program, Physical and Occupational therapies, and is in the process of creating Chiropractic and other Complementary and Integrative Medicine programs to meet the needs of Veterans. We closely collaborate with VHA pharmacy on opioid prescribing to monitor prescribing to our Veterans. We hold Interdisciplinary Pain Team meetings weekly to collaborate on the treatment we provide to the 488 patients currently in our program. The process lends itself to frank and open discussions which focus on real time issues and improvements to the program. Manchester outcomes include: working as a multimodal team to cultivate change with the culture of prescribing. Interdisciplinary team prescribers include: Surgical, SPRS (Sensory and Physical Rehabilitation Services), Primary Care, Mental Health, Pharmacy, QM, Medical, CLC (Long term care, rehabilitation Palliative care), and Urgent Care. This Interdisciplinary team has allowed Manchester providers to decrease opioid dispensing from FY 2011 to 2014 by 6 percent.
Since 2011, our Pain Clinic has seen its monthly patient clinic visits increase from an average of 40 visits per month to over 160. We have increased our availability to see patients on an ongoing basis and have added services for patients including a Chronic Opioid Therapy Clinic and acupuncture. Our Interventional Pain Procedures volumes have increased during the same time period from 20 procedures per month to over 60. We offer evidence-based psychotherapy for chronic pain. White River Junction is also the lead site for the VISN 1 Pain Mini Residency program. One of the patients treated with acupuncture started driving again, as well as taking care of her family after years of disability.
Since our Chronic Opioid Therapy Clinic opened in May 2014 through December 31, 2015, we have seen a 50 percent decrease in the number of Veterans treated with the highest doses of opioids (greater than 400 morphine equivalent daily dose). We have seen a 41 percent decrease in the number of patients treated with high dose opioids (greater than 200 morphine equivalent daily dose) during the same time period. Many of our patients have expressed that they are feeling much better since reducing their doses of medications.
Our VISN also takes Pain Management seriously. VISN 1 declared Pain Management as one of its five top priorities in 2015. The VISN committed to improving opioid safety and increasing access to other modes of treating pain. We will have an acupuncture clinic at each facility, four Commission on Accreditation of Rehabilitation Facilities (CARF)-accredited Pain Rehabilitation programs, and increased access to, iRest, and evidence-based psychotherapy for pain as a result of this commitment.
Approximately 4-5 years ago, Dr. Chernyak initiated acupuncture services and established an acupuncture clinic at the Oklahoma City VAMC. This clinic turned out to be very successful in helping Veterans. During this period, many Veterans contacted the administration with testimonial letters and with requests to expand this service to make it more accessible for Veterans. As a result, the Oklahoma City VAMC hired a dedicated Acupuncture specialist, and today this clinic sees approximately 50 patient visits per week.
Acupuncture has been used in the treatment of different kinds of acute and chronic pain, chronic headaches, migraines, various addiction problems, psychological issues such as PTSD, depression, anxiety, and in many other health disorders. This mode of treatment has withstood the test of time, as it has successfully survived several thousand years of clinical practice in various forms and in many different cultures. It is not unusual to see instances when very difficult health conditions, especially those resistant to conventional treatment modalities, are successfully treated with acupuncture.
Currently, new, high tech methods of acupuncture point stimulation are clinically available, such as the use of low level laser therapy (i.e., cold laser therapy). This method allows the clinician to achieve an effect without actually penetrating the skin with a needle and, without causing the pain sometimes associated with needle insertion. Cold laser therapy, or photobiomodulation therapy, is a non-invasive treatment modality that we are working to implement in our Integrative Pain clinic.
Both Dr. Chernyak and my goal is to build a robust Integrative Pain Center with a strong emphasis on Complementary and Integrative Medicine approaches to the treatment of pain at all our facilities. This approach would also address the issue of opioid overuse. Usually, health care providers tend to refer their patents for Complementary and Integrative Medicine therapies for chronic pain issues only after all other treatment modalities have failed. Therefore, Complementary and Integrative Medicine therapies are often considered as a last resort or a therapy of despair. Dr. Chernyak believes that this practice should be reversed and that Complementary and Integrative Medicine therapies should be offered at a much earlier stage in the treatment process along with physical therapy. Complementary and Integrative Medicine modalities, to include acupuncture, should be considered before more invasive treatment options are sought and most certainly before chronic opioid pain management is prescribed. Acupuncture has the added benefit of being inexpensive, and in our experience has virtually no side effects when performed by properly trained personnel.
Both Manchester and White River Junction have added positions to ensure that we have the expertise to provide interventional pain injections or even surgical help. Furthermore, it is our desire that both of our facilities will be able to initiate and conduct a number of research projects and possibly a pain fellowship program in collaboration with one of the teaching institutions.
VA’s Progress in Pain Management
Chronic pain management is challenging for Veterans and clinicians – VA continues to focus on identifying Veteran-centric approaches that can be tailored to individual needs using medication and other modalities. Opioids are an effective treatment, but their use requires constant vigilance to minimize risks and adverse effects. VA launched a system-wide OSI in October 2013, and has seen significant improvement in the use of opioids. The Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) and the OSI, have been designed to integrate into the Academic Detailing model. Academic Detailing is a proven method in changing clinicians’ behavior when addressing a difficult medical problem in a population. Academic Detailing combines longitudinal monitoring of clinical practices, regular feedback to providers on performance, and education and training in safer and more effective pain management.
Most recently, in March 2015, we launched the new Opioid Therapy Risk Report tool which provides detailed information on the risk status of Veterans taking opioids to assist VA primary care clinicians with pain management treatment plans. This tool is a core component of our reinvigorated focus on patient safety and effectiveness.
VA’s own data, as well as the peer-reviewed medical literature, suggest that VA is making progress relative to the rest of the Nation. In December 2014, an independent study by RTI International health services researcher, Mark Edlund, MD, PhD and colleagues, supported by a grant from the National Institute of Drug Abuse, was published in the journal PAIN. This study, using VHA pharmacy and administrative data, reviewed the duration of opioid therapy, the median daily dose of opioids, and the use of opioids in Veterans with substance use disorders and co-morbid chronic non-cancer pain.
Dr. Edlund and his colleagues found that:
- About 50 percent of veteran with chronic non-cancer pain in this cohort received an opioid as part of treatment.
- Half of all Veterans receiving opioids for chronic non-cancer pain, are receiving them short-term (i.e.: for less than 90 days per year);
- The daily opioid dose in VA is generally modest, with a median of 20 Morphine Equivalent Daily Dose (MEDD),
- And the use of high-volume opioids (in terms of total annual dose) is not increased in VA patients with substance use disorders as has been found to be the case in non-VA patients.
Although it is good to have this information, a confirmation of our efforts for several years, starting with the “high alert” opioid initiative in 2008 and multiple educational offerings, by no means is VA’s work finished. By virtue of VA’s central national role in medical student education and residency training of primary care physicians and providers, VA will be playing a major role in this transformation effort. But we have already started with our robust education and training programs for primary care, such as SCAN-ECHO, Mini-residency, Community of Practice calls, two JIF training programs with DoD, and dissemination of the OSI Toolkit.
A key development is a Joint Incentive Fund DoD-VA project to improve Veterans’ and Servicemembers’ access to Complementary and Integrative Medicine, the “Tiered Acupuncture Training Across Clinical Settings” (ATACS) project. ATACS represents VHA’s initiative to make evidence-based Complementary and Integrative 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 ultimately aims to provide all Veterans with access to this intervention, and a wider array of pain management choices generally, when they present with chronic pain. Many providers in VISN 1 have received this training either through the ATACS program or through the Pain Mini-Residency program.
Complementary and Integrative Medicine
VHA leadership has identified as its number one strategic goal “to provide Veterans personalized, proactive, patient-driven health care.” Integrated Health Care (IH), which includes Complementary and Integrative Medicine approaches, provides a framework that aligns with personalized, proactive, patient-driven care. There is growing evidence for effectiveness of non-pharmacological approaches as part of a comprehensive care plan for chronic pain which includes acupuncture, massage and spinal manipulation. As I have described, these are all being made available to Veterans.
In 2011, VA’s Healthcare Analysis and Information Group published a report on Complementary and Integrative Medicine in VA. At that time, 89 percent of VHA facilities offered some form of Complementary and Integrative Medicine however, there was extensive variability regarding the degree, level, and spectrum of services being offered in VHA. The top reasons for offering Complementary and Integrative Medicine included promotion of wellness, patient preferences; and adjunct to chronic disease management. The conditions most commonly treated with Complementary and Integrative Medicine include: stress management, anxiety disorders, PTSD, depression, and back pain.
VA recognizes the importance and benefits of recreational therapy in the rehabilitation of Veterans with disabilities. Currently, over 30 VA medical centers across the country participate in therapeutic riding programs. These programs use equine assisted therapeutic activities to promote healing and rehabilitation of Veterans with a variety of disabilities and medical conditions (e.g. traumatic brain injury, polytrauma). VA facilities participating in such programs utilize their local appropriated funds to contract for these services. Facilities may also be able to use money in the General Post Fund, a trust fund administered by the Department, to pay for these services.
A monthly IH community of practice conference call provides VHA facilities national updates, strong practices, and new developments in the field and research findings related to IH.
The Opioid Safety Initiative (OSI)
The OSI was chartered by the Under Secretary for Health in August 2012. The OSI was piloted in several VISNs. Based on the results of these pilot programs, OSI was implemented nationwide in August 2013. The OSI objective is to make the totality of opioid use visible at all levels in the organization. It includes key clinical indicators such as the number of unique pharmacy patients dispensed an opioid, unique patients on long-term opioids who receive a urine drug screen, the number of patients receiving an opioid and a benzodiazepine (which puts them at a higher risk of adverse events), and the average MEDD of opioids. Results of key clinical metrics for VHA measured by the OSI from Quarter 4 Fiscal Year 2012 (beginning in July 2012) to Quarter 4 Fiscal Year 2015 (ending in September 2015) there are:
- 125,307 fewer patients receiving opioids (679,376 patients to 554,069 patients, an 18.44 percent reduction);
- 42,141 fewer patients receiving opioids and benzodiazepines together (122,633 patients to 80,492 patients, a 34.36 percent reduction);
- 94,507 more patients on opioids that have had a urine drug screen to help guide treatment decisions (160,601 patients to 255,108, a 58.84 percent increase);
- 105,543 fewer patients on long-term opioid therapy (438,329 to 332,786, a 24.08 percent reduction);
- The overall dosage of opioids is decreasing in the VA system as 15,172 fewer patients (59,499 patients to 44,327 patients, a 25.5percent reduction) are receiving greater than or equal to 100 Morphine Equivalent Daily Dosing.
The changes in prescribing and consumption are occurring at a modest pace, and the OSI dashboard metrics indicate the overall trends are moving in the desired direction. OSI will be implemented in a cautious and measured way to give VA time to build the infrastructure and processes necessary to allow VA clinicians to incorporate new pain management strategies into their treatment approaches. A measured process will also give VA patients time to adjust to new treatment options and to mitigate any patient dissatisfaction that may accompany these changes.
While these changes may appear to be modest given the size of the VA patient population, they signal an important trend in VA’s use of opioids. VA expects this trend to continue as it renews its efforts to promote safe and effective pharmacologic and non-pharmacologic pain management therapies. Very effective programs yielding significant results have been identified and are being studied as strong practice leaders. VA intends to implement safe opioid prescribing training for all prescribers in response to the Presidential Memorandum Addressing Prescription Drug Abuse and Heroin Use[ii].
In conclusion, VA continues to research pain treatment, Complementary and Integrative Medicine and opioid abuse. While we know our work to improve pain management programs and the use of medications will never truly be finished, VA has been at the forefront in dealing with pain management, and we will continue to do so to better serve the needs of Veterans.
Mr. Chairman, we appreciate this Subcommittee’s support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans. My colleague and I are prepared to respond to any questions you may have.
 Edlund MJ et al, Patterns of opioid use for chronic noncancer pain in the Veterans Health Administration from 2009 to 2011. PAIN 155(2014) 2337-2343
[i] Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014. Available at https://www.effectivehealthcare.ahrq.gov/ehc/products/557/1988/chronic-pain-opioid-treatment-executive-141022.pdf downloaded 2-24-2016
[ii] The white House Office of the Press Secretary. October 21, 2015. Presidential Memorandum Addressing Prescription Drug Abuse and Heroin Use-Available at https://www.whitehouse.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-and-heroin downloaded 2-24-2016