VHA Directive:

National Pain Management Strategy

Courtesy of C. Buckenmaier, MD

The Beginning: Battlefield trauma

THE END

CRPS in artist: Injury Vietnam

Courtesy of N. Wiedemer, CRNP

Pain Hurts

Pain affects the whole person

What is pain? THE END

CRPS in artist: Injury Vietnam

Mismanaged chronic pain is often a

personal, biopsychosocial catastrophe!

….and is a huge public health problem.

• Quality of life

– Physical functioning

– Ability to perform activities of daily living (ADLs)

– Work

• Social consequences

– Marital/family relations

– Intimacy/sexual activity

– Social role and friendships

• Psychological / CNS

morbidity

– Fear, anger, suffering

– Sleep disorders

– Loss of self-esteem

• Medical comorbidites &

consequences

– Accidents

– Medication effects

– Immune function

– Clinical depression

– Neuroplasticity to pain disease

• Societal consequences- Health care costs

- Disability

- Lost workdays

- Business failures

- Higher taxes

Established (by research) effects of chronic pain

Beginning to End: The Chronic Pain Cycle Pathology:-Muscle atrophy,

weakness;

-Bone loss;

-Immunocomprimise

-Depression / Suicide

Less active

Kinesophobia

Decreased

motivation

Increased

isolation

Role loss

Disability

Pathophysiology of Maintenance:-Radiculopathy

-Neuroma traction

-Myofascial sensitization

-Brain, SC pathology (atrophy, reorganization)

Psychopathology

of maintenance:-Encoded anxiety

dysregulation

- PTSD

-Emotional

allodynia

-Mood disorder Neurogenic

Inflammation:- Glial activation

- Pro-inflammatory

cytokines

- blood-nerve barrier

dysruption

Acute injury

and pain

Peripheral

Sensitization:New Na+ channels

cause lower

threshold

Central

Sensitization-Neuroplastic

changes

Gallagher RM, in Ebert & Kerns, 2010)

If chronic pain is often a personal catastrophe and

is a huge public cost,

how do you deliver clinical care that is driven by

performance based, biopsychosocial outcomes?

1) Start by understanding:

- the causal models of disease

- the mechanisms underlying these models

- the biopsychosocial formulation of these models for each

unique disease population

- the evidence basis for treatment

2) Then develop chronic disease management programs:

- address salient biopsychosocial factors for each disease

population (e.g., low back pain, headache, fibromyalgia)

- guide formulating each individual patient’s chronic pain

- develop a goal-oriented management plan for each patient

How do we deliver clinical care driven by

performance based, biopsychosocial outcomes?

1) Apply evidence-based treatment approaches at a level appropriate to your clinical setting (primary care, pain medicine).

2) Apply chronic disease management principles in a community by utilizing clinical skills cost effectively in a performance based, integrated treatment network that:

- Reduces risk for complications and chronicity

- Relies on a sustainable patient /provider / community

network of support and responsibility

Self-care - meditation

- exercise

- web-training

- social modeling

-social supports

Primary care-Mech. Based Drug Algorithms

-Stepped Behavioral Care

-Physical Therapy

-Office procedures

-CAM

Secondary care: Pain Medicine - Biopsychosocial assessment

** pain generators, mechanisms

** perpetuating factors

- - - peripheral, CNS, psychosocial

- Biopsychosocial Formulation

Tertiary care: PM Subspecialties - Neuroremodeling

- Gene therapies

- Neurostimulation

- Rehabilitation Centers

POPULATION OF PATIENTS IN PAIN

Relative proportion of

pain care, by setting

Primary Care

Specialty, Primary /

secondary prevention

Secondary Care

Specialty, Subspecialty,

Secondary / tertiary

prevention

PAIN

SPECIALTY

-Practice

-Training

- Research

Tertiary Care

Subspecialty, tertiary

prevention

Evidence-based Continuum of Care

Self Care, Community

CarePrimary/secondary

Prevention

Disease Management

(Dubois , Gallagher,

Lippe Pain Med 2009

REQUIRES COMPETENCY

• System competency

– Redesign elements of system to support :

• Case recognition

• Early, evidence-based, integrated intervention

• Adequate workforce numbers, organization and

rewards

• Data based, continuous quality improvement

• Clinician competency

– Adequate training at all levels:

• primary care, pain medicine, rehabilitation

– Integrated teams for disease management

– Continuing education, monitored outcomes

RESEARCH CHALLENGES

Developing causal illness models: Epidemiology research

Developing cost-effective interventions :

Observational studies

Clinical efficacy trials

Comparator studies

Establishing clinical cost-effectiveness

Observational studies

Health services research

VHA Pain Management Strategy

• To develop a comprehensive, integrated

system-wide approach to pain

management.

• To reduce pain and suffering, and improve

quality of life for veterans suffering acute

and chronic pain.

• Stepped Care Model: continuum of

treatment from acute pain to longitundial

management of chronic pain.

Electronic transfer of

information from military to VA

VA screening to identify risk level and needs

Moderate to severe risk

Immediate engagement

and interventionRoutine Scheduling

Minimal risk

Restoration: pain control; community network; physical and

psychosocial function

Pain medicine

clinic consultation

Core primary care pain

management team: PCP,

behavioral medicine, mental

health, social work

Primary

care visit

Pain medicine

specialty

treatment

Continuum of stepped care

PC Stepped

Programs:

- pain school

- pain coping skills

(CBT) groups,

- opioid renewal

clinic

Mental Health

Specialty Programs

Pain and P3 Rehabilitation Programs

1

2

3

Steps

CHALLENGES

TRANSFER OF CLINICAL INFORMATION

TO VHA

- Diagnosis

- History of Pain Condition

- Nature and circumstances of injury

- Co-morbidities

- Prior Treatment

- Adequacy of trial

- Effectiveness

Stepped Care Model: The Steps

Step One: Primary Care

Must develop competent primary care workforce.

Requires availability of system supports:

Family and patient education programs

Collaboration with integrative mental health primary care teams.

Post deployment programs.

HEALTH SERVICES CHALLENGES

Developing adequate workforce:

Primary Care

• Competency through training redesign

• Biopsychosocial pain management

• Integrated teams

• Chronic disease management interventions (e.g.,

Dobscha et al JAMA 2009; Kroenke et al JAMA 2009)

• Re-design RVUs to reward competent longitudinal

care

• Provide systems support for chronic disease

management.

Primary Care

1. Routine screening, assessment,

management, reassessment

Primary Care Competencies

1. Conduct of comprehensive pain assessment

2. Negotiating behaviorally specific and feasible goals

3. Knowledge/use of common metrics for measuring function

4. Optimal patient communication

1. How to provide reassurance

2. How to foster pain self-management

Primary Care Competencies

5. Conduct of routine physical/neurological examinations

6. Judicious use of diagnostic tests/procedures and secondary consultation

7. Assessment of psychiatric/behavioral comorbidities

8. Knowledge of accepted clinical practice guidelines

9. Rational, algorithmic based polypharmacy

10. Opioid management

Numerical Rating Scale:

Monitoring Patient Progress

• Improvement can be monitored

• Gives clinician and patient a consistent

understandable measure with intra-rater

reliability that facilitates discussion regarding:

changes in pain, response to treatment

• Reduction of 2 points represents a clinically

important

0 1 2 3 4 5 6 7 8 9 10No pain Worst possible

pain

Adapted from Farrar JT et al. Pain. 2001;94:149-158.

SevereCan’t

function

Excruciating, ER time

ModerateBothersome

Mild, in backgroundJust

Noticeable

Intolerable,

Recognizing Neuropathic Pain

• Persistent burning sensation

• Paroxysmal lancinating pains

• Paresthesias

• Dysesthesias

• Hyperalgesias

• Allodynias

Common signs and symptoms

Galer BS. Neurology. 1995;45(suppl 9):S17-S25; Backonja M-M et al. Neurol Clin.

1998;16:775-789.

Pain Drawing & Neuropathy Types

Boulton AJM et al. Med Clin North Am. 1998;82:909-929; Portenoy RK. Pain Management: Theory and

Practice. 1996:108-113; Katz N. Clin J Pain. 2000;16:S41-S48

Nociceptivepain

Neuropathicpain

Pain condition +depression

Secondary sleepdisturbance

Secondary depression Primary D.

Short-termNSAIDs,

Cox-II (?),opioids

Persists afteradequateanalgesia

Persists afteradequateanalgesia

Evaluate risks

Evaluate risks

Antihistamine,zolpidem,low-dose

benzodiazepine

Trazodone

Low-doseTCA

Lidocaine patch;gabapentin & other AED (Ca+ & Na+

channels); alpha 2 agonists (tizanidine,

clonidine);opioids

Titrate TCAs (Na+ channels and SNRI) : desipramine,

nortriptyline,

SSRI trial

Evaluate risks

SNRIs: venlafaxine, duloxetine

Algorithm for Medication Selection in Chronic Pain

with and without Co-Morbid Depression

Gallagher RM, Verma S. Semin Clin Neurosurgery. 2004This information concerns uses that have not been approved by the US FDA.

Evaluate risks

Opioid Renewal Clinic: A risk management

approach to aberrant behavior in primary care

Wiedemer, et al. Pain Med. 2007;8:573-584.

Negative

UDT

4%

Self-discharged

38%

Referred

13%

Resolved

45%

Aberrant

Behavior

51%

At risk, No

Aberrant

Behavior

49%

ONE YEAR

OUTCOMES,

ABERRANT

BEHAVIOR

N = 171TOTAL REFERRED

Stepped Care Model: The Steps

• Step Two: Secondary Consultation and

collaborative care

• Requires collaboration with community supports and

societal resources (e.g., voc rehab, college education,

etc)

• Requires timely access to competent specialty

consultation / collaboration from:

• Pain medicine and palliative care

• Physical medicine and rehabilitation

• Polytrauma programs, mental health and pain psychology

• Inpatient pain medicine consultations

HEALTH SERVICES CHALLENGES

Developing adequate workforce:

Pain Medicine

• Competency through training redesign• Lengthen and strengthen pain medicine training to establish

standardized skills: 2 year fellowships, residencies (Dubois,

Gallagher, Lippe. Pain Med 2009 10(6)

• Biopsychosocial medicine

• Integrated, interdisciplinary teams

• Chronic disease management / collaborative care

• Re-design RVUs to reward competent

longitudinal care not just procedures

Stepped Care Model: The Steps

• Step Three: Tertiary, Interdisciplinary

Care

–Requires advanced pain medicine

diagnostics and interventions.

–Requires Pain Rehabilitation Facilities

(CARF) for severity / complexity

–Requires collaboration with community

supports and societal resources (e.g.,

voc rehab, college education, etc)

Clinical Competence and Expertise in Pain

Management

• Initial and ongoing education and training of all

clinical staff on principles of pain assessment

and management

– Clearly delineated, specific pain management

responsibilities of each clinician

– Relevant education and training

• VHA standards for pain management will be

communicated by training faculty to all clinical

trainees: medical students and residents, allied

health professional students and interns.

VHA National Pain Management Program Office

• Coordinate system-wide implementation of

the Strategy at facility- and VISN-levels.

• Coordinate system-wide performance

improvement plan.

• Coordinate development and

dissemination of treatment protocols for

pain management.

VHA National Pain Management Program Office

• Identifying pain management expertise and

resources at facilities and VISNs.

• Assuring timely and appropriate access to

pain management services for veterans.

• Collaborating with relevant program offices

to develop, implement, and disseminate

education and training tools to assist

clinicians in acquiring necessary skills.

• Collaborating with:

– Office of R&D - To identify pain research

opportunities, and facilitate collaborative research

efforts.

– Office of Academic Affiliations – To assess

current state of pain management education in

health professional training programs and

develop enhancing educational interventions.

• Establishing plan for internal and external

communications of the Strategy.

VHA National Pain Management Program Office

VHA National Pain Management

Strategy Coordinating Committee

• A multi-disciplinary committee to support

the National Pain Management Program

Office in meeting responsibilities.

• Comprised of representatives from key

clinical disciplines.

• Includes representatives from other VHA

offices.

Veteran Integrated Service Network

(VISN ) Director

• VISN Director is responsible for:

– All facilities in VISN carrying out current pain

management policies.

– Appointing a pain management POC to

support at VISN level.

– Assuring tertiary inter-disciplinary pain care

services on VISN level.

– Evaluating implementation of the Strategy

according to NPMPO-established

performance measures.

Facility Director

• Facility Director is responsible for:

–Ensuring that objectives of strategy are

met

–Fully implementing Stepped Care Model

–Assuring that standards of pain care are

met, including standards for early pain

recognition, assessment, and treatment

Evaluation of Outcomes and Quality of

Pain Management

• Multidisciplinary pain management committee

must be established at each VHA facility:

– To provide oversight, coordination, and monitoring of

pain management activities and processes to ensure

compliance with standards

• Quality of pain assessments and effectiveness

of pain management must be monitored.

CHALLENGES in the System

• Establishing importance of mission

– WRISC data

– Observational and clinical studies

• Evaluating operational steps of implementation

– Establish baseline resources: Haig survey completed

with 100% participation

• Getting buy-in at VISN level

– Population-based approach: shared responsibility

• Getting buy-in at Facility level

– Change attitudes: primary focus vs “step-child”

– Change procedures: product line vs. fragmented

approach

VISN and Facility Models