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In his 2001 book, Good to Great, James Collins
describes characteristics that distinguish a merely "good" company from a competitor
who moves beyond "good" to become a "great" market leader. VA efforts to advance our understanding and management of pain over the past 15 years are well-articulated by Kerns in the lead commentary article for this issue of FORUM. At the same time, actions that might further solidify and strengthen clinical care and research related to pain management
warrant our attention.
Since launching its National Pain Management Strategy in 1998, the VA has witnessed substantial
strides in pain clinical care and research. The Pain Research Working Group, Pain Management
Program Office, and PRIME Center have all played pivotal roles in advancing VA's pain research agenda through special topic issues in scientific journals, a monthly webinar series on pain management, and other initiatives. Numerous
projects centered on pain have been funded by the Office of Research & Development. The VA Pain Management Directive issued in 2009 provides comprehensive policy and implementation
procedures for elevating the standards of care for pain management across all VA facilities.
The 2011 Institute of Medicine report was a milestone in bringing national attention to the importance of pain and, moreover, in highlighting
the potential role of the VA as a lead agent.
According to Kerns, the 1998 VA National Pain Management Strategy "has served to elevate pain management as a top priority within the VA." However, as of 2011, pain had not yet risen to being one of the official HSR&D Priorities for Investigator-Initiated Research.
Ascending to this top tier would signify that pain has truly "arrived" as an HSR&D research priority. A second step would be to provide targeted money for pain research, similar to the request for application issued by the NIH when it identifies areas of particular importance. Congress passed the National Pain Care Policy Act in 2003, which declared the first decade of the 21st century as the "Decade of Pain Control and Research." However, from 2003 to 2007, NIH funding for pain research declined sharply—an average
of 9 percent per year.1 Thus, the lip-service
Congress paid to pain research was not heeded by the NIH. While VA ORD has been more supportive of pain research according to Kern's figures, pain-targeted research announcements
would further accelerate the research agenda. Other steps might include funding of a pain QUERI and support of multi-center pain trials through the Cooperative
Nowadays, quality gaps in the care of specific diseases are often identified and targeted for quality improvement initiatives as well as clinical
research. Until the past few decades, pain has been sufficiently ignored that some of the gaps are more like chasms. The appropriate use of opioid analgesics remains one of the great divides. The pendulum swings between highly restrictive and more liberal usage. While we await the results from currently funded studies, disparate guidelines from various organizations complicate practice.2 Even the universal vs. selective use of opioid contracts and urine drug screens are debated by experts. A second major gap is measurement
which, paradoxically, is not resolved by VA's Pain as the 5th Vital Sign initiative.3 First, it is unclear the single 0 to 10 rating of current
pain initially developed for acute pain, often in hospitalized patients, performs as well in assessing and monitoring chronic pain. Second, frequent feedback of pain scores to busy clinicians without having systems-based interventions in place is analogous to the inadequacy of depression screening in the absence of systems in place to provide adequate monitoring, treatment adjustments, and specialty support. Integration of pain care constitutes a third chasm. Because pain is ubiquitous across diseases and central to many specialties, pain care can be coordinated by primary care clinicians and Patient Aligned Care Teams (PACTs), but cannot be disarticulated
from multiple other practice settings. Also, pain management relies more on patient report and less on laboratory testing than many other medical disorders, making pain particularly well-suited to tele-care management.
Other important gaps include Veterans' acceptance of and access to behavioral treatments
for pain; the appropriate and efficient use of highly-specialized pain programs; effective provider-patient communication regarding
pain; and reduction in excessive imaging
and other diagnostic testing, and disability determinations in Veterans with chronic pain.
In the past 15 years, the clinical care and research
in Veterans with chronic pain has advanced
considerably. For the VA to move from "good" to "great" and assume the mantle of leadership encouraged by the Institute of Medicine
report, parity of pain with other medical and mental disorders will be paramount.
Bradshaw, H. et al. "Trends in Funding for Research on Pain: A Report on the National Institutes of Health Grant Awards Over the Years 2003 to 2007," Journal of Pain 2008; 9:1077-87.
- Von Korff, M. et al. "Long-term Opioid Therapy Reconsidered,"
Annals of Internal Medicine 2011; 155:325-8.
- Lorenz, K.A. et al. "How Reliable is Pain as the Fifth Vital Sign?" Journal American Board of Family Medicine 2009; 22:291-8.