Transforming Pain Management Services for Veterans
In a recent report, "Relieving Pain in America: A Blueprint for Transforming Pain Prevention, Care, Education, and Research," the Institute of Medicine (IOM) asserted that pain is a significant public health problem and estimated that as many as 100 million Americans experience persistent pain at a cost of as much as $635 billion in treatment costs and lost productivity.1 The report invites the Department of Veterans Affairs (VA) to join with other agencies to transform care of persons with pain, to educate and train providers and consumers of pain management services, and to conduct more pain research. The IOM specifically calls on agencies such as VA to improve its collection and use of data to support this transformation. Among its recommendations for research, the report encourages increased support for interdisciplinary research, longitudinal research, and training of pain researchers. The report emphasizes the development of strategies to minimize disparities in pain care, and it identifies Veterans of military service as one of several vulnerable groups. The VA provides a unique laboratory in which to conduct effectiveness and implementation research required for this transformation.
Pain Management – A Top Priority
In late 1998, the former Under Secretary for Health, Kenneth Kizer, launched the VA National Pain Management Strategy to provide a system-wide standard of care to reduce suffering from preventable pain. Support for the Strategy has served to elevate pain management as a top priority within VA, and to spark innovation in the planning and provision of high quality pain care. Among the several primary goals of this initiative is an explicit emphasis on promoting pain-relevant research. Data document a strong and growing commitment to funding pain-relevant research through the intramural research program of the Office of Research & Development (ORD). In Fiscal Year 2011, ORD invested $11.4 million in support of 56 investigator-initiated research projects and career development awards for early career investigators. The Health Services Research & Development Service (HSR&D), in particular, continues to invest in and strengthen its pain research portfolio with particular attention to research that promotes improvement in the organization, delivery, safety, and equity of pain management services. A national Pain Research Working Group (PRWG), comprised of over 75 scientists and scholars, plays a key role in advancing VA's pain research agenda and in promoting its impact. Special topic issues of leading scientific journals including the Journal of Rehabilitation Research and Development, Pain Medicine, Translational Behavioral Medicine, and Clinical Journal of Pain highlight some of the important contributions of PRWG members. A monthly "Spotlight on Pain Management" webinar series offered through a partnership among the Pain Management Program Office, the HSR&D's Pain Research, Infomatics, Medical comorbidities, and Education (PRIME) Center, and the Center for Information Dissemination and Educational Resources (CIDER) supports the shared interests of VA's research, practice, and policy communities in advancing National Pain Management Strategy.
The Role of Health Services Investigators
VA health services investigators have played instrumental roles in advancing the theoretical and empirical foundations for core pain management policies and clinical practice guidance as established in VA's Pain Management Directive (2009-053).2 For example, investigators have published empirical tests of integrated and collaborative care models in the primary care setting that support the establishment of a Stepped Care Model of Pain Management (SCM-PM) as the single standard of pain care for VA. The SCM-PM provides the ability to assess and treat pain in primary care settings by integrated Patient Aligned Care Teams (PACTs), while maintaining the capacity to escalate treatment options to include specialized care and interdisciplinary approaches to pain care, if necessary. The SCM-PM can similarly be applied for pain management in other settings, including management of acute pain in inpatient settings, management of pain in specialty mental health and substance use disorders treatment settings, and management of pain in the context of palliative and hospice care. VA health services investigators continue to conduct high-impact work in each of these settings.3
Other high priority areas in which health services research has already had considerable impact on policy and practice can be cited. Promoting equitable access, safety, and effectiveness of opioid therapy for the management of chronic pain has emerged as a particularly important challenge. Several teams of VA investigators collaborate with VA patient care and operations partners to ensure that policies and practice guidance are informed by strong science. Development and evaluation of alternative treatment approaches such as behavioral interventions that promote adaptive pain self-management is another area of interest and importance.
As emphasized in the IOM report, VA is uniquely positioned to provide leadership in the development of comprehensive registries, databases, and quality improvement efforts that can have widespread impact on pain management within and outside VA. Particularly important are efforts targeting highly prevalent conditions such as musculoskeletal disorders and headache; high cost conditions such as low back pain and trauma-related pain; chronic pain and mental health comorbidities, especially post-traumatic stress disorder, substance use disorder, and depression; and conditions known to be associated with disparities and differences associated with age, gender (including gender specific disorders), and race/ethnicity. Finally, the use of these databases to identify explanatory and causal factors associated with the transition from acute to chronic pain and to develop interventions to reduce this likelihood is another particularly high priority.