VHA NATIONAL PAIN MANAGEMENT STRATEGY Implementation of the Stepped Care Model ROBERT D. KERNS, PH.D. NATIONAL PROGRAM DIRECTOR FOR PAIN MANAGEMENT Director, Pain Research, Informatics, Medical comorbidities and Education Center Professor of Psychiatry, Neurology and Psychology, Yale University October 2012 Disclosures I have the following financial relationships to disclose: Employee of: VA Connecticut Healthcare System Yale University Research support Department of Veterans Affairs The Patrick and Catherine Weldon Donaghue Medical Research Foundation Mayday Fund National Institutes of Health I will not discuss off label use and/or investigational use Otherwise, nothing to disclose VETERANS HEALTH ADMINISTRATION

Outcomes and Objectives Outcomes/Objectives: At the conclusion of this educational program, learners will be able to: Discuss why pain management is a priority for VHA Describe the VHA Stepped Care Model for Pain Management Describe some of the key initiatives that have supported implementation of the Strategy VETERANS HEALTH ADMINISTRATION 3 IOM Committee for Advancing Pain Research, Care and Education Address the current state of the science with respect to pain research, care, and education; and explore approaches to advance the field. Review and quantify the public health significance of pain. Identify barriers to appropriate pain care and strategies to reduce such barriers. Identify demographic groups and special populations, and discuss related research needs, barriers, and opportunities to reduce such barriers. Identify and discuss what scientific tools and technologies are available. Discuss opportunities for public-private partnerships in the support and conduct of pain

research, care, and education. VETERANS HEALTH ADMINISTRATION 4 Pain as a Public Health Challenge: Findings Pain is a public health problem Affects at least 100 million American adults Reduces quality of life Costs society $560$635 billion annually Federal and state costs almost $100 billion annually More consistent data on pain are needed to: Monitor changes in incidence and prevalence Document rates of treatment and undertreatment Assess health and societal consequences Evaluate impact of changes in policy, payment, and care A population-based strategy is needed to reduce pain and its consequences. It should: Heighten national concern about pain Use public health strategies to foster patient self-management Inform public about nature of pain Focus on pain prevention VETERANS HEALTH ADMINISTRATION Trends in pain prevalence, United States, 1999-2004 SOURCE: Unpublished data from the National Health and Nutrition Examination Survey, 1999-2004.

NHANES 1999-2000 (%) NHANES 2001-2002 (%) NHANES 2003-2004 (%) 22.2 25.7 27.7 Ages 20 to 44 15.7 19.5 19.6 Ages 45 to 64 28.5 31.7

35.6 Age 65 and over 33.1 34.2 36.3 Men 19.4 23.8 24.8 Women 24.8 27.4 30.4 26.3 28.6

29.0 25.4 30.7 29.0 20.0 23.6 27.9 People Who Reported Pain in Previous Month Age 20 and over Below 100% of poverty level 100% to <200% of poverty level 200% of poverty level VETERANS HEALTH ADMINISTRATION Populations disparately undertreated for pain African Americans

Military veterans Hispanics People with cognitive impairments Asian Americans American Indians and Alaska Natives Surgical patients Cancer patients Women People at the end of life Children Non-English speakers The elderly VETERANS HEALTH ADMINISTRATION Care of People with Pain VETERANS HEALTH ADMINISTRATION

Care of People with Pain: Findings Pain care must be tailored to each persons experience Financing, referrals, records management need support this flexibility Significant barriers to adequate pain care exist Gaps in knowledge and competencies for providers Magnitude of problem Half of primary care providers report feeling only somewhat prepared, 27% report feeling somewhat unprepared or unprepared Inadequacies in subspecialty training Systems and organizational barriers VETERANS HEALTH ADMINISTRATION BARRIERS TO EFFECTIVE PAIN CARE System-level barriers Institutional Educational Organizational Reimbursement-related Clinician-level barriers Evidence-based guidelines on assessment and treatment Adequate pain education

Clinician collaboration Policies on appropriate use of opioids Insurance coverage Patient-level barriers Awareness of pain Insurance coverage Concern of opioids use and addiction VETERANS HEALTH ADMINISTRATION 10 Care of People with Pain Recommendations 3-1. Health care provider organizations should promote and enable self-management of pain as the starting point of management Develop educational approaches and culturally and linguistically appropriate materials to promote and enable self-management 3-2. Population strategy described in Recommendation 2-2 should include developing strategies to overcome barriers to care Strategies should focus on ways to improve care for populations disproportionately affected by and undertreated for pain 3-3. Health professions education and training programs, professional associations, and other groups should provide educational opportunities in pain assessment and treatment in primary care Education should improve knowledge and skills in pain assessment and treatment VETERANS HEALTH ADMINISTRATION Care of People with Pain Recommendations (continued)

3-4. Pain specialty professional organizations and primary care professional associations should support collaboration between pain specialists and primary care clinicians, including greater proficiency by primary care providers along with referral to pain centers when appropriate 3-5. Payers and health care organizations should revise reimbursement policies to foster coordinated and evidence-based pain care 3-6. Health care providers should provide consistent and complete pain assessments VETERANS HEALTH ADMINISTRATION Pain Management is a priority for VHA As many as 50% of male VHA patients in primary care report chronic pain (Kerns et al., 2003; Clark, 2002) The prevalence may be as high as 75% in female Veterans (Haskell et al., 2006) Pain is among the most costly disorders treated in VHA settings; total estimated cost attributable to Veterans with low back pain was $2.2 billion in FY99 (Yu et al., 2003) Number of Veterans with chronic low back pain is growing steadily (Sinnott & Wagner, 2009) VETERANS HEALTH ADMINISTRATION 13 Concomitants of persistent pain

Pain is associated with: poorer self-rating of health status, greater use of healthcare resources, more tobacco use, alcohol use, diet/weight concerns, decreased social and physical activities, lower social support, higher levels of emotional distress, and among women, high rates of military sexual trauma. (Kerns, Otis, & Rosenberg, 2003; Haskell, Papas, Heapy, Reid, & Kerns, 2008) VETERANS HEALTH ADMINISTRATION 14 Frequency of Diagnoses1 among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans Diagnosis (Broad ICD-9 Categories)a

Frequency 144,167 Percentb 16.0 Malignant Neoplasms (140-209) 13,016 1.4 Benign Neoplasms (210-239) 64,424 7.2 302,719 33.6 36,899 4.1 486,015 54.0

Diseases of Circulatory System (390-459) 415,543 198,140 46.2 22.0 Disease of Respiratory System (460-519) 241,229 26.8 Disease of Digestive System (520-579) 326,338 36.3 Diseases of Genitourinary System (580-629) 142,687 15.9 Diseases of Skin (680-709) 199,803

22.2 Diseases of Musculoskeletal System/Connective System (710-739) 519,721 57.8 Symptoms, Signs and Ill Defined Conditions (780-799) 478,267 53.2 Injury/Poisonings (800-999) 267,407 29.7 Infectious and Parasitic Diseases (001-139) Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) Diseases of Blood and Blood Forming Organs (280-289) Mental Disorders (290-319) Diseases of Nervous System/ Sense Organs (320-389) Includes both provisional and confirmed diagnoses. These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2011; Veterans can have multiple diagnoses with each health care encounter. The total may be higher than 899,752 unique Veterans because a Veteran can have more than one

diagnosis and each is entered separately in this table. b Percentages reported are approximate due to rounding. 1 a VETERANS HEALTH ADMINISTRATION Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2013 15 Haskell et al (2012). The prevalence of painful musculoskeletal conditions in female and male Veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clinical Journal of Pain, 28, 163-167. Year Female Male OR (95% CI) P value Adjusted OR

(95%CI) P value 1 3.89 4.27 0.91(0.87,0.95) <.001 1.06(1.01,1.11) 0.01 2 8.25 8.7 0.94(0.91,0.98) 0.001 1.10(1.06,1.14)

<.001 3 13.07 13.3 0.98(0.95,1.01) 0.23 1.15(1.11,1.19) <.001 4 16.9 16.92 1.00(0.96,1.03) 0.91 1.17(1.13,1.21) <.001

5 19.43 18.77 1.04(1.00,1.09) 0.04 1.22(1.17,1.28) <.001 6 20.53 19.59 1.06(1.01,1.12) 0.03 1.25(1.18,1.32) <.001 7

19.63 17.19 1.18(1.05,1.31) .0004 1.38(1.23,1.55) <.001 VETERANS HEALTH ADMINISTRATION Prevalence of Chronic Pain, PTSD and TBI: sample of 340 OEF/OIF veterans Chronic Pain N=277 81.5% 10.3% 16.5% 2.9% PTSD N=232 68.2%

42.1% 6.8% 12.6% 5.3% TBI N=227 66.8% Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in OEF/ OIF Veterans: The Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development, 46, 697-702. VETERANS HEALTH ADMINISTRATION VHA Pain Management Directive (2009-053) Objectives of National Pain Management Strategy Pain Management Infrastructure Roles and responsibilities Stepped Pain Care Model Pain Management Standards Pain assessment and treatment Evaluation of outcomes and quality Clinician competence and expertise VETERANS HEALTH ADMINISTRATION 18 National Pain Management Strategy

Objective is to develop a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain and suffering for Veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness. VETERANS HEALTH ADMINISTRATION 19 Empirical foundations Cleeland, C.S., Schall, M., Nolan, K., Reyes-Gibby, C.C., Paice, J., Rosenberg, J.M., Tollett, J.H., & Kerns, R.D. (2003). Rapid improvement in pain management: The Veterans Health Administration and the Institute for Healthcare Improvement Collaborative. Clinical Journal of Pain, 19, 298-305. Kerns, R.D. (2003). Clinical research as a foundation for the Veterans Health Administration Pain Management Strategy. Journal of Rehabilitation Research and Development, 40, ix-xi. Kerns, R.D. (2007). Research on pain and pain management in the Veterans Health Administration: Promoting improved pain care for veterans through science and scholarship. Journal of Rehabilitation Research and Development, 44, vii-x. Kerns, R.D. & Dobscha, S.K. (2009). Pain among Veterans returning from deployment in Iraq and Afghanistan: Update on the Veterans Health Administration pain research program. Pain Medicine, 10, 1161-1164. Kerns, R.D., Philip, E.J., Lee, A., & Rosenberger, P.R. (2011). Implementation of the Veterans Health Administration National Pain Management Strategy. Translational Behavioral Medicine, 1, 635-643. VETERANS HEALTH ADMINISTRATION

20 VHA National Pain Management Strategy Infrastructure Pain Management Program Office Specialty Care Services; Patient Care Services; DUSH for Policy and Services National Pain Management Strategy Coordinating Committee Coordinating Committee Working Groups VISN Pain Points of Contact Facility Pain Points of Contact Primary Care Pain Champions Pain Resource Nurses VISN and Facility Pain Management Committees VETERANS HEALTH ADMINISTRATION 21 National Pain Management Strategy Coordinating Committee (FAC) and Working Groups Rollin Gallagher (Chair) Jack Rosenberg Pain Medicine/Clinical Practice Guidelines Joel Scholten Rehabilitation Sally Haskell Women Veterans Health Robert Ruff Neurology

Heidi Klingbell Geriatrics and Extended Care Anne Turner/Anne Sanford Employee Education Elliott/ Pamela Cremo (Program Specialist) VETERANS HEALTH ADMINISTRATION Andrew Pomerantz Mental Health Carla Cassidy Clinical Practice Guidelines Matthew Bair Primary Care Anthony Mariano Patient Education Michael Clark Performance Measurement Francine Goodman/Robert Sproul Pharmacy Christine Engstrom/Janette Susan Hagan Nursing 22

VHA Stepped Care Model for Pain Management Single standard of pain care for VHA Population based approach Timely access to pain assessment State of the art treatment and follow-up Reliable communication and care management Patient and family participation Empirically supported model Von Korff et al. (2001). Stepped care for back pain: Activating approaches for primary care. Annals of Internal Medicine, 134, 911-917. Dobscha et al. (2009). Collaborative care for chronic pain in primary care. Journal of the American Medical Association, 301, 1242-1252. Kroenke et al. (2009). Optimized antidepressant therapy and pain selfmanagement in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. Journal of the American Medical Association, 301, 2099-2110. VETERANS HEALTH ADMINISTRATION 23 Veteran-Centered Pain Management Informed by chronic illness

model Empowering Veterans through reassurance, encouragement and education Conservative use of analgesics and adjuvant medications Promotion of regular exercise and healthy and active lifestyle Development of adaptive strategies for managing pain VETERANS HEALTH ADMINISTRATION 24 Patient Education Initiatives Veterans Health Library Taking Opioids Responsibly Krames resources Patient/Family Pain Management Education Toolkit MyHealtheVet Patient Education Management System (PEMS) VISN 20 Chronic Pain Education for Veterans Veterans Pain Management Resource Program Pain Coach (Mobile Pain App) VETERANS HEALTH ADMINISTRATION

25 Stepped Care Model for Pain Management RISK Comorbidities Treatment Refractory Complexity Tertiary Interdisciplinary Pain Centers Advanced diagnostics & interventions Commission on Accreditation of Rehabilitation Facilities accredited pain rehabilitation Integrated chronic pain and Substance Use Disorder treatment Secondary Consultation Pain Medicine Rehabilitation Medicine Behavioral Pain Management Interdisciplinary Pain Clinics Substance Use Disorders Programs Mental Health Programs Primary Care/Patient Aligned Care Teams (PACTs) Routine screening for presence & intensity of pain Comprehensive pain assessment Management of common acute and chronic pain conditions

Primary Care-Mental Health Integration, Health Behavior Coordinators, OEF/OIF/OND & Post-Deployment Teams Expanded nurse care management Clinical Pharmacy Pain Medication Management Opioid Pain Care and Renewal Clinics STEP 3 STEP 2 STEP 1 26 Implementation initiatives OEF/OIF Pain Care Enhancement Initiative Communication/education infrastructure VA Pain List Serve, National Pain Management Website (www.va.gov/painmanagement) Monthly Pain Management Leadership Teleconference Monthly Spotlight on Pain Management webinar (collaboration with HSR&D Center for Information Dissemination and Educational

Resources [CIDER] National Pain Management Leadership Conferences VA Pharmacy Pain Management Mentors (VAPPMM) Outlook exchange Clinica l Practice Guidelines Opioid Therapy for Management of Chronic Pain Peri-operative pain management Dissemination of American Pain Society/American Academy of Pain Management guidelines VETERANS HEALTH ADMINISTRATION 27 Opioids for chronic pain management: Concerns about benefits, misuse and abuse, and other adverse outcomes Bohnert, A. et al. (2011). Association between opioid prescribing patterns and opioid overdose-related deaths. Journal of the American Medical Association, 305, 1315-1321.

Krebs, E.E. (2011). Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Medicine, 12, 740-746. Macey, T.A. et al. (2011). Patterns and correlates of prescription opioid use in OEF/ OIF Veterans with chronic non-cancer pain. Pain Medicine, 12, 1502-1509. Martel, B. et al. (2007). Opioid treatment for chronic back pain: a systematic review and meta-analysis of their prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127. Midboe, A.M. et al. (in press). Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain. Translational Behavioral Medicine. Morasco, B.J. et al. (2010). Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain, 151, 625-632. Naliboff, B.D. et al (2011). A randomized trial of 2 prescription strategies for opioid treatment of chronic non-malignant pain. Journal of Pain, 12, 288-296. VETERANS HEALTH ADMINISTRATION 28 Promoting safe and effective use of opioids

Opioid High Alert Medication Initiative CPG on Management of Opioid Therapy for Chronic Pain TMS: Opioid Therapy for Acute and Chronic Pain Pharmacy Benefits Management Initiatives and Clinical Guidances Directive and Clinical Considerations regarding state-authorized use of marijuana Implementation of National Prescription Drug Control Policy Participation in State Prescription Drug Monitoring Programs Signature Informed Consent Opioid Safety Initiative VETERANS HEALTH ADMINISTRATION 29 Opioid Safety Initiative A comprehensive education/training/ implementation plan aims to promote use of a Business Intelligence tool to: (1) identify Veterans who are at immediate, short term and long term risk of harms associated with high dose opioid therapy and to develop an individualized clinical action plan to mitigate risks, (2) offer providers education and training to enhance competencies and to promote clinical practice guideline concordant opioid therapy for the management of chronic pain, and (3) encourage utilization of existing tools and resources to promote organizational/system improvements to support providers in the delivery of safe and effective opioid therapy in the context of

integrated, team based pain management . VETERANS HEALTH ADMINISTRATION Opioid Safety Initiative Business Intelligence Tool VETERANS HEALTH ADMINISTRATION 31 VA Specialty Care Access Network Extension of Community Healthcare Outcomes (VA SCAN-ECHO) The mission of VA SCAN-ECHO is to: Meet the needs of primary care providers and PACT teams for access to specialist consultation services and support Provide case-based learning modules to improve core competencies and provider satisfaction Facilitate referrals to tertiary care centers when indicated Ultimately to improve veteran access to specialty care and treatment outcomes VETERANS HEALTH ADMINISTRATION 32

CBT for Chronic Pain Training Program National VA CBT-CP competency-based training program developed by the VA Office of Mental Health Services and National Pain Management Program Office focus on licensed VA mental health providers training program developed through expert consensus process Therapy protocol and training resources developed specifically for the application of CBT-CP with Veterans Second training workshop and training cohort recently completed in September 2012; remaining scheduled for FY 2013 Clinician training consultants to participate in weekly consultation with session tape review over 6-month period VETERANS HEALTH ADMINISTRATION HEC PMWG: Objectives/Initiatives DoD/VHA Core Pain Curriculum / Training Collaboration with NiH CoEPES ECHO / SCAN-ECHO Phone Apps for patient & for provider Standardize Tiered acupuncture training Education and treatment and Training PASTOR/PROMIS

DVPRS CREATE Deliver Measuremen t Based Care Function Readines s Opioid Risk Strategy Ensure COT CPG Patient Opioid Risk Tools Safety Urine Drug Screening / Reporting Integration of non-medication modalities Patient Safety Videos Joint Suicide Prevention VETERANS Initiative HEALTH ADMINISTRATION Establish Consistent Model of Care

Stepped Care Model Interdisciplinary PC / PACT Pain Champions & Teams Pain Medicine Specialty support for Primary Care(PCMH) Pain Rehabilitation Joint Education/Training Program (JPEP) VA/DoD HEC Pain Management Working Group VHA Pain Management (PACT) Strategic Oversight Committee VHA/DOD HEC JIF Joint VA/ DOD Pain Education Pain Education Advisory Team Community of Practice Coordinating Workgroup

Facility Pain Champions Coordinating Workgroup Pain Management Education and Training Workgroup Training Program Community of Practice Monthly Calls Facility Pain Champions i.e. PCP/RNCM Team, facility SME PACT VETERANS HEALTH ADMINISTRATION DOD Pain Management Facility/VISN Pain Team Healthcare Analysis Information Group 2010 VHA Pain

Management Survey Results 100% of facilities have pain management policies 100% of Veterans Integrated Service Network (VISN) and 95% of facilities have identified Pain Points of Contacts (POCs) 54% of facilities identified a primary care pain champion 96% of facilities have multidisciplinary pain committees VETERANS HEALTH ADMINISTRATION 36 Healthcare Analysis Information Group 2010 VHA Pain Management Survey Results 100% 80% 60% 40% 20% 0% VETERANS HEALTH ADMINISTRATION 37 Specialty Pain Care Capacity 100 % of VISNs have specialty pain clinics 91% of facilities have dedicated pain clinics FY 2010

Encounters FY 2011 FY 2011 (thru 2nd quarter) FY 2012 (thru 2nd quarter) % Change FY11 Q2 FY12 Q2 333,447 374,880 179,352 199,485 11.2% Unique Patients 100,833 108,874 71,575 78,209 9.3% % Change FY 2010 FY 2011

12.4% 8.0% VETERANS HEALTH ADMINISTRATION 38 Building Capacity for Tertiary, Interdisciplinary Pain Centers VHA Pain Directive requires every VISN to have a tertiary interdisciplinary pain center by September 2014 Advanced pain medicine diagnostics and interventions CARF accredited chronic pain rehabilitation VISN Directors survey in December 2011 19 VISNS report meeting standard for advanced pain medicine diagnostics and interventions; 2 have yet to identify site Most recent data on Commission for Accreditation of Rehabilitation Facilities (CARF) 7 VISNs report having CARF-accredited pain rehabilitation programs; 10 have applications pending VETERANS HEALTH ADMINISTRATION 39 Pain Research FY 2011

56 pain-related Office of Research and Development funded research projects $11.4 million for pain-relevant research Increase of $1.57 million over FY10 Pain Research Working Group Health Services Research and Development Pain Research Center funded (PRIME Center) Partnerships with National Institute of Health/Department of Defense VETERANS HEALTH ADMINISTRATION

Basic mechanisms underlying pain (n=18); Pain diagnosis (n=3); Preclinical studies (n=2); Pain management (medications; psychosocial interventions) (n=18); Co-morbidities (n=7); Quality of Life (QOL), comparative effectiveness; bioinformatics; disparities (n=5); and Training (career development) (n=5). 40 The PRIME Center Pain Research, Informatics, Medical comorbidities, and Education Enhancing Pain Care for Veterans Mission and Focused Area of Research To study the interactions between pain and associated chronic conditions and behavioral health factors to develop and implement effective interventions that can reduce pain, its negative impacts on emotional and physical functioning, and overall disease burden by employing principles of medical informatics, behavioral science, and health

services research. 41 Enhancing PACT Delivered Pain Management Collaborative Research to Enhance and Advance Transformational Excellence (CREATE) Three specific goals for the CREATE are: To enhance Veterans access to empirically validated and guideline concordant pain care To leverage health information technology to promote better pain care for Veterans To build sustainable improvements in pain care that are applicable beyond CREATE Three projects have the following specific aims: Create a musculoskeletal diagnoses cohort to address the lack of information on the natural history of pain and its treatment in primary care settings (MSD Cohort) Implement a pain screening and assessment tool that addresses empirically observed gaps in these processes (ESP) Coordinate a multimodal and interdisciplinary pain management program supported by health information technology to promote safe and effective chronic opioid therapy (COMPACT) VETERANS HEALTH ADMINISTRATION 42 FY 2012 Priorities

Performance metrics/dashboard Specialty Care Services Transformation Initiatives, especially SCAN-ECHO Guidance for Tertiary, Interdisciplinary Pain Centers Safe and effective use of opioids for pain management Publication of acute, peri-operative pain management guideline Capacity for behavioral services in PACT Patient Education Initiatives Provider Education Initiatives Primary Care/PACT Pain Initiatives Nursing initiatives Health Executive Council Pain Management and VA-DoD initiatives VETERANS HEALTH ADMINISTRATION 43

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