Transforming Pain Care for Veterans

By Gail Gourley

MANY VETERANS ARE IN PAIN. It affects their lives, and their families, every day.

Recognizing the needs of its patients, the Veterans Health Administration (VHA) continues to take a system-wide proactive role in managing pain. Moreover, recent years have seen a shift in pain management techniques and approaches in the context of the ongoing opioid crisis, emphasizing reduced reliance on medication and increased utilization of a variety of alternative pain therapies. This shift also incorporates a holistic, team-based approach to patient care.

“Talking about the current state of pain management in the VA [Department of Veterans Affairs], clearly we are in the process of transforming our health care approach to pain management,” explained Friedhelm Sandbrink, MD, national program director for pain management, VHA, and director, Pain Management Program, Department of Neurology, Washington DC VA Medical Center.

Pain is a significant and complex issue in the veteran population. “In veterans, it’s often in the context of significant mental health and often medical comorbidities, which really contribute to the challenge,” Sandbrink said. “If it’s in the setting of somebody, for example, with PTSD [post-traumatic stress disorder], you have to really coordinate the mental health [aspect] with the medical and the pain approach. It requires coordination of care.”

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Sandbrink said that, in general, chronic pain is more common in veterans than in non-veterans, and more often severe, citing data from a National Health Interview Survey published in 2017 that compared veterans to non-veterans in the United States. Survey results indicated severe pain in veterans is 40 percent more common than in non-veterans, 9.1 percent of respondents versus 6.4 percent respectively, and especially in veterans who served in recent conflicts.

Charles Brill, a physician’s assistant at the Fort Campbell Intrepid Spirit Center, uses acupuncture to relieve a patient’s pain March 20, 2017. The Department of Veterans Affairs is in the process of transforming its health care approach to pain management, moving away from reliance on opioid medication to incorporating complementary and integrative health approaches that include, for example, acupuncture, yoga, and cognitive behavioral therapy.

Additionally, of veterans enrolled in VA primary care, Sandbrink said 1 in 3 has a chronic pain diagnosis, 1 in 5 has persistent pain, and 1 in 10 has severe persistent pain. “And we know also from data comparing 2008 to 2015 that both pain diagnoses as well as mental health diagnoses actually have increased in prevalence,” he added.

The trend away from medication reliance, especially opioid medication, began more than five years ago, Sandbrink said. “We initiated our Opioid Safety Initiative [OSI] as a pilot in 2012 and took it nationally in 2013. The [OSI] supports our approach of implementing pain care transformation, moving away from relying on medication itself, but including and providing additional access to nonpharmacological strategies – approaches that include complementary and integrative health [CIH] modalities,” he said, including, for example, cognitive behavioral therapy (CBT), yoga, and acupuncture.

Sandbrink added that the VA approach aligns very well with the findings of the Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force report, released in May 2019. “It truly supports our approach to pain care, which is an integrated, collaborative approach to pain management that relies on these different modalities and relies on teams working together so that the best pain care can be brought to the individual patient," he said.

"In many ways, the VA is really spearheading this effort," Sandbrink continued, adding, "We are, I think, a good example of how to do it, and are being used as a role model for the nation of how to bring the different partners together so that the best practices can be applied to an individual patient."

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The VA's efforts to combat the opioid crisis and reduce opioid use are reflected in components of the OSI. In addition to increasing transparency of opioid prescribing regarding providers, patients, and facilities. Sandbrink explained that intiative is an effort to educate providers about the best pain care appraoch, reducing reliance on opioid medication and implementing better, safer, multimodal pain care.

Sandbrink provided numbers that indicate significant reduction in opioid prescribing in the VCA. Comparing most recent figures of the third quarter fiscal year 2019 to baseline figures of the fourth quarter 2012, Sandbrink said, "We reduced overall opioid prescribing by 53 percent – so we are prescribing less than half of what we did in 2012. We are especially proud of our efforts to reduce prescribing that is a particularly high risk for overdose," referring to the combination of opioid and benzodiazepine medications. "Co-prescribing numbers actually have been reduced by 81 percent. We had about 123,000 veterans on a combination of opioids and benzodiazepines in 2012, and the most recent number is about 23,000," he said. "So we truly have been managing our patients in a much safer way by guiding them to better alternatives – better pharmacological strategies and non-pharmacological strategies."

Additionally, Sandbrink identified that high-dose opioid prescribing, associated with higher risk of overdose and death, in this case tracking as 100 or more morphine milligram equivalents per day, saw a 74 percent reduction from 2012 to currently. “So we still have about 15,000 patients on a high-dose regimen, but we used to have close to 60,000,” he said.

Another component of the OSI is the Overdose Education and Naloxone Distribution program, which educates veterans, families, and caregivers about overdose and aims to prevent death by treating and reversing a life-threatening opioid overdose with naloxone administration. Naloxone is provided to veterans identified as being at risk for opioid overdose. “They may be patients on high-dose opioid medication, or who maybe stopped opioid medication recently, or are on an opioidbenzodiazepine combination,” said Sandbrink. “We have now issued naloxone to more than 200,000 veterans at no cost to the veteran, and we have had over 700 successful reversals of an overdose with this medication. So, I think in many ways, the VA is a leader in naloxone distribution.”

The VA’s whole health approach incorporates complementary and integrative health practices – including non-pharmacological ways to manage pain – in its effort to provide veterans with more patient-centered, holistic care.

Concurrently with the VA moving away from reliance on opioid medication to treat pain, greater emphasis has been directed toward non-pharmacological CIH approaches. In 2016, the VHA Office of Health Services Research and Development held a state-of-the-art (SOTA) conference titled “Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management.” At this VA-sponsored research conference, Sandbrink said, “We looked at what is the best evidence that we have for non-pharmacological pain treatments for musculoskeletal pain, which is the most common pain conditions that veterans have.” He added that they determined there’s “good evidence” for the effectiveness of behavioral and psychological therapies such as CBT; exercise and movement therapies such as yoga and tai chi; and manual therapies such as acupuncture and massage.

The evidence-based findings and recommendations from this SOTA conference were published in a 2018 article in the Journal of General Internal Medicine. The article stated that participants recommended the following nine non-pharmacological therapies “be implemented across the VHA system as part of pain care: cognitive behavioral therapy; acceptance and commitment therapy; mindfulness-based stress reduction; exercise therapy; tai chi; yoga; acupuncture; manipulation; and massage.”

The article continued, “Integration of these non-pharmacological approaches into primary care, pain care, and mental health settings should be a policy priority, and these treatments should be offered early in the course of pain treatment.”

Sandbrink said, “We now make these treatment approaches available to our veterans whenever it’s clinically indicated. And if we can’t do it at the VA facility itself, then we make that information available through the community care program.”

Sandbrink reflected on the significance of the VA’s emphasis on the whole health approach, which he characterized as “a reorientation of how the VA engages with veterans.”

“The VA is moving towards a more patient-centered care approach – a more holistic, whole health approach,” Sandbrink explained. “It’s being rolled out nationwide, supported by the Comprehensive Addiction and Recovery Act, the CARA legislation from 2016, that not only supported the [OSI] in the VA, but also actually mandated that VA expand the use and the research and the education about integrative health modalities. The VA has taken this further and has implemented a whole health approach that is integrated into our health care at all facilities. In 2018, we actually established 18 flagship sites for [CIH] and whole health in the VA. Every VISN [Veterans Integrated Service Network] has a dedicated flagship site. By 2020, we expect to bring on two more sites in each VISN, so another 36 that have the whole health approach will be added.

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“What we mean by that is that not only do we build an integration of CIH modalities into our clinical care, and we have whole health clinicians and teach all providers about that, but we also include a much greater effort to educate and train veterans and their families in self-care and self-management,” Sandbrink continued.

“This is really about empowering the veteran,” he said. “What is really important for you in your situation in your life, and how can we as a health care system support you to reach your goals and be as functional as possible?”

Sandbrink also highlighted the VA’s efforts to fully implement a 2017 VA mandate that every facility have an interdisciplinary pain team – including a medical provider, an addiction specialist, a rehabilitation professional, and a provider who can deliver evidence-based behavioral approaches – at their site.

A counselor meets with a veteran. The VA’s patient-centered, whole health approach entails that a veteran and care providers work together to form a personal care plan, which guides not only a strategy to manage pain but the veteran’s health care altogether.

“This demonstrates how seriously we take this as a system to make sure that we not only provide medication but a truly comprehensive team approach,” he said.

Furthermore, Sandbrink emphasized, “One of the things that we do in the VA is truly target our resources to the veterans who need it most. So we need to have a population-based approach that makes sure that every veteran has access to the pain care they need. We also realize that there are veterans who are at particularly high risk for an opioid overdose or for suicide, and we know that chronic pain is one of the most commonly identified risk factors for suicide.”

In an effort that is both from mental health as well as from pain management, Sandbrink explained, information about veterans identified at highest risk is provided to the facility, and every facility now has a risk review team consisting of primary care, pain clinic providers, and mental health providers. “They discuss the care of these patients who are at highest risk in order to coordinate their care and make sure they get engaged by the right providers,” he said. “They may, for instance, see that a patient who is on opioid medication hasn’t been seen yet by the pain clinic, but may benefit from that, or they see that a patient may have a high risk for a mental health concern, and they proactively reach out to the veteran to engage them. The goal is really to integrate across our different stakeholders so that the teams who work with a veteran all work together to develop one care plan that includes pain care and mental health.”

As part of the ongoing effort to provide the best pain care for veterans, Sandbrink said the VA has a large pain research effort. “A lot of it is in regard to understanding the impact of opioid medication, and the impact of our non-opioid approach to pain care in regard to patient satisfaction and outcomes. We also have a lot of efforts to increase understanding of how we can better engage the veteran in this transformation of pain care, and for veterans who have opioid use disorder, how we can better actively engage them with the treatment program for that.”

For example, Sandbrink said the VA recently held a SOTA research conference specifically regarding opioid medication and opioid use disorder, bringing in external stakeholders, subject matter experts from all over the nation, and VA leaders to enhance research and understanding regarding patients who are on long-term opioid therapy; improving access to opioid use disorder treatment; and examining challenges for patients who have both pain conditions as well as substance use disorder.

Asked about the biggest challenges in addressing pain management for veterans, Sandbrink identified “moving away from reliance on opioid medication to multimodal pain care” and emphasized the need to engage veterans, their families, and their caregivers.

“It’s reflective of our whole health effort,” he said. “We’re transforming our approach to care, which is really a huge endeavor, but we are not changing pain care alone. We’re actually changing our entire health care approach. And one of the challenges is for everyone involved to work together collaboratively, speaking the same language and developing a care plan together.”

While pointing to “huge strides” made to date in opioid prescribing, he acknowledged, “Some patients are still on highdose long-term opioid therapy, and we realize the challenges that come with making that pain care transformation. We also realize that a significant number of the veterans who have been on opioid medication long term may have developed opioid dependence or opioid use disorder. Across the United States, we have more than 2 million people who are believed to have opioid use disorder. And we know that many veterans are affected by that.”

He continued, “One thing that we need to make sure [of] is that we adjust the care of those veterans that takes the whole person into account. And that means not just thinking about what is the safest from a pain care standpoint, but also possible addiction treatment.

“There’s a lot of stigma associated with opioid use disorder or receiving the medication for that,” he summarized. “So that needs to be considered as well.”

Sandbrink emphasized, “We want to make sure that veterans know that we are here to listen to them and that we offer a truly comprehensive pain care approach with multiple modalities. We want to encourage veterans to make use of what we offer, to make use of our behavioral therapies, our rehabilitation approaches, our integrative health modalities, because the best pain care can only happen if the patients are actively engaged with implementing it.

“This is something where the providers and the patients work in collaboration as a team,” he said. “And the most important team member is the veteran.”