VHA National Pain Management VHA National Pain Management Strategy: Update and Future Strategy: Update and Future

DirectionsDirections

Robert D. Kerns, Ph.D.Robert D. Kerns, Ph.D.Chief, Psychology ServiceChief, Psychology Service

VA Connecticut Healthcare SystemVA Connecticut Healthcare SystemAndAnd

Professor of Psychiatry, Neurology and PsychologyProfessor of Psychiatry, Neurology and PsychologyYale UniversityYale University

Pain management is a Pain management is a national priority for VHAnational priority for VHA

As many as 50% of male VA patients in As many as 50% of male VA patients in primary care report chronic pain. primary care report chronic pain. (Kerns et al., 2003; Clark, (Kerns et al., 2003; Clark, 2002)2002)

The prevalence may be as high as 75% in The prevalence may be as high as 75% in female veterans. female veterans. (Haskell et al., 2006)(Haskell et al., 2006)

Pain is among the most frequent presenting Pain is among the most frequent presenting complaints of returning OEF/OIF soldiers; complaints of returning OEF/OIF soldiers; particularly in patients with polytrauma particularly in patients with polytrauma (Clark, (Clark, 2004; Gironda et al., 2006)2004; Gironda et al., 2006)

Pain is among the most costly disorders Pain is among the most costly disorders treated in VHA settings; total estimated costs treated in VHA settings; total estimated costs attributable to low back pain was $2.2 billion attributable to low back pain was $2.2 billion in FY99 in FY99 (Yu et al., 2003)(Yu et al., 2003)

Concomitants of persistent Concomitants of persistent painpain

Pain is associated with:Pain is associated with: poorer self-rating of health status,poorer self-rating of health status, greater use of healthcare resources,greater use of healthcare resources, more tobacco use, alcohol use, diet/weight more tobacco use, alcohol use, diet/weight

concerns,concerns, decreased social and physical activities,decreased social and physical activities, lower social support,lower social support, higher levels of emotional distress, andhigher levels of emotional distress, and among women, high rates of military sexual among women, high rates of military sexual

trauma. trauma. (Haskell et al, in press; Kerns et al., 2003; Mantyselka et al., (Haskell et al, in press; Kerns et al., 2003; Mantyselka et al., 2003)2003)

VHA National Pain VHA National Pain Management StrategyManagement Strategy

Informed by study demonstrating Informed by study demonstrating inconsistencies in VHA pain careinconsistencies in VHA pain care

Strategy initiated by the Strategy initiated by the Undersecretary for Health in 1998Undersecretary for Health in 1998

Pain Management Directive Pain Management Directive published in 2003published in 2003

VHA Directive 2003-021: VHA Directive 2003-021: Pain Management Pain Management

Provides policy and implementation guidance for Provides policy and implementation guidance for the improvement of pain management consistent the improvement of pain management consistent with the VHA National Pain Management Strategy with the VHA National Pain Management Strategy and compliance with generally accepted Pain and compliance with generally accepted Pain Management Standards of Care. Management Standards of Care.

Overall objective of the national strategy is to Overall objective of the national strategy is to develop a comprehensive, multicultural, develop a comprehensive, multicultural, integrated, system-wide approach to pain integrated, system-wide approach to pain management that reduces pain and suffering for management that reduces pain and suffering for veterans experiencing acute and chronic pain veterans experiencing acute and chronic pain associated with a wide range of illnesses, associated with a wide range of illnesses, including terminal illness. including terminal illness.

Goals of the VHA National Pain Goals of the VHA National Pain Management StrategyManagement Strategy

Provide a system-wide VHA standard of Provide a system-wide VHA standard of care for pain management that will reduce care for pain management that will reduce suffering from preventable painsuffering from preventable pain

Assure that pain assessment is performed Assure that pain assessment is performed in a consistent manner.in a consistent manner.

Assure that pain treatment is prompt and Assure that pain treatment is prompt and appropriate.appropriate.

Include patients and families as active Include patients and families as active participants in pain management.participants in pain management.

Goals of the VHA National Pain Goals of the VHA National Pain Management StrategyManagement Strategy

Provide for continual monitoring and Provide for continual monitoring and improvement in outcomes of pain improvement in outcomes of pain treatment.treatment.

Provide for an interdisciplinary, multi-Provide for an interdisciplinary, multi-modal approach to pain management.modal approach to pain management.

Assure that clinicians practicing in the VA Assure that clinicians practicing in the VA healthcare system are adequately healthcare system are adequately prepared to assess and manage pain prepared to assess and manage pain effectively.effectively.

Organization of National Organization of National StrategyStrategy

National Program Director National Program Director Pain Strategy Coordinating CommitteePain Strategy Coordinating Committee Coordinating Committee Working Coordinating Committee Working

GroupsGroups VISN Points-of-Contact/VISN Pain VISN Points-of-Contact/VISN Pain

CommitteesCommittees Local Facility Oversight CommitteesLocal Facility Oversight Committees

Coordinating Committee Coordinating Committee MembersMembers

Bob Kerns – VACO/VACHS (Psychology)Bob Kerns – VACO/VACHS (Psychology)

Matthew Bair – Indianapolis (Primary Care)Matthew Bair – Indianapolis (Primary Care) Martha Bryan – VACO (ORD)Martha Bryan – VACO (ORD) Michael Clark – Tampa (Psychology)Michael Clark – Tampa (Psychology) Audrey Drake – VACO (Nursing)Audrey Drake – VACO (Nursing) Rollin “Mac” Gallagher – Philadelphia (Pain Rollin “Mac” Gallagher – Philadelphia (Pain

Medicine/ Psychiatry)Medicine/ Psychiatry) Francine Goodman – VACO (PBM)Francine Goodman – VACO (PBM) Mitchell Nazario – West Palm Beach (Pharmacy)Mitchell Nazario – West Palm Beach (Pharmacy) Beverly Green-Rashad – Houston (Nursing)Beverly Green-Rashad – Houston (Nursing) Jack Rosenberg – Ann Arbor (Pain Medicine/ Jack Rosenberg – Ann Arbor (Pain Medicine/

Anesthesiology)Anesthesiology) Anne Turner – Birmingham (EES)Anne Turner – Birmingham (EES)

Working GroupsWorking Groups Acute Pain Management (Rosenberg)Acute Pain Management (Rosenberg) Education (Turner)Education (Turner) Guidelines (Rosenberg)Guidelines (Rosenberg) Nursing (Rashad)Nursing (Rashad) Outcomes Measurement (Lawler)Outcomes Measurement (Lawler) Performance Improvement (Czarnecki)Performance Improvement (Czarnecki) Pharmacy (Goodman/Nazario)Pharmacy (Goodman/Nazario) Polytrauma (Clark)Polytrauma (Clark) Primary Care (Bair/Gallagher)Primary Care (Bair/Gallagher) Research (Kerns/Bryan)Research (Kerns/Bryan)

Coordinating Committee Coordinating Committee ResponsibilitiesResponsibilities

Coordinating system-wide implementation Coordinating system-wide implementation of of StrategyStrategy

Disseminating state-of-the-art treatment Disseminating state-of-the-art treatment protocolsprotocols

Assure access to pain care throughout VHAAssure access to pain care throughout VHA Assure employee educationAssure employee education Assure pain-relevant research agendaAssure pain-relevant research agenda Integrate pain education into professional Integrate pain education into professional

training curriculatraining curricula Assure performance improvementAssure performance improvement Assure internal and external communicationAssure internal and external communication

VISN ResponsibilitiesVISN Responsibilities

Identify VISN Pain Point of ContactIdentify VISN Pain Point of Contact VISN 4 Pain POC – Nancy Wiedemer, VISN 4 Pain POC – Nancy Wiedemer,

CRNPCRNP

Oversight and monitoring of facility Oversight and monitoring of facility performanceperformance

Facility ResponsibilitiesFacility Responsibilities

Provider and staff competencies assuredProvider and staff competencies assured Orientation regarding pain assessment and managementOrientation regarding pain assessment and management Annual educationAnnual education

Assessment and treatment standards metAssessment and treatment standards met Pain as the 5Pain as the 5thth Vital Sign Vital Sign Comprehensive pain assessmentComprehensive pain assessment Patient and family educationPatient and family education Pain management protocols established and implementedPain management protocols established and implemented Pain management is integral component of palliative and Pain management is integral component of palliative and

end-of-life careend-of-life care

Ongoing evaluation of outcomes and Ongoing evaluation of outcomes and quality quality Pain management committee establishedPain management committee established Processes for continuous improvement are in placeProcesses for continuous improvement are in place Monitoring of outcomesMonitoring of outcomes Assure adequate documentationAssure adequate documentation

VISN 4 Facility Pain POCsVISN 4 Facility Pain POCs Altoona – Altoona – Rodolpho Medina, MDRodolpho Medina, MD

Butler – Butler – Timothy McNulty, MDTimothy McNulty, MD

Clarksburg – Clarksburg – Tracy Oldaker, RN, MSNTracy Oldaker, RN, MSN

Coatesville – Coatesville – Pat O’Rourke, RN, CHPNPat O’Rourke, RN, CHPN

Erie – Erie – Harry Haus, MDHarry Haus, MD

Lebanon - Lebanon - Jean Royal, RNJean Royal, RN

PhiladelphiaPhiladelphia - Nancy Wiedemer, CRNP - Nancy Wiedemer, CRNP

Pittsburgh - Pittsburgh - Michael Mangione MD; Mary Lou Bossio CRNPMichael Mangione MD; Mary Lou Bossio CRNP

Wilkes-Barre -Wilkes-Barre -Joseph Casagrande, Ph.D., Nabeela Mian, M.D.Joseph Casagrande, Ph.D., Nabeela Mian, M.D.

Wilmington - Wilmington - Mary Mackenzie CRNPMary Mackenzie CRNP

National Pain Management National Pain Management StrategyStrategy

AccomplishmentsAccomplishments Implementation of “Pain as the 5Implementation of “Pain as the 5thth

Vital Sign” initiativeVital Sign” initiative Pain as the 5Pain as the 5thth Vital Sign Toolkit Vital Sign Toolkit EPRP supportive measuresEPRP supportive measures

Successful VHA/IHI Pain Management Successful VHA/IHI Pain Management CollaborativeCollaborative

Development of web-based opioid Development of web-based opioid trainingtraining

AccomplishmentsAccomplishments Provider educationProvider education

Four national leadership conferencesFour national leadership conferences ““Evolving Paradigms” conferenceEvolving Paradigms” conference Participation in multiple other conferences Participation in multiple other conferences

(primary care, polytrauma)(primary care, polytrauma) Several satellite broadcastsSeveral satellite broadcasts National pain management website National pain management website

(www.va.gov/pain_management)(www.va.gov/pain_management) Monthly provider education teleconferencesMonthly provider education teleconferences VA Pain List ServeVA Pain List Serve VISN library resources VISN library resources

Patient educationPatient education Patient infomercialPatient infomercial MyHealthMyHealtheeVet information, self-assessment, Vet information, self-assessment,

and linksand links

AccomplishmentsAccomplishments

Pain medicine fellowship training Pain medicine fellowship training establishedestablished

Pain management guideline Pain management guideline developmentdevelopment Low back painLow back pain Acute post-operative painAcute post-operative pain Chronic opioid therapyChronic opioid therapy

AccomplishmentsAccomplishments

Outcome Measures Outcome Measures CPRS Clinical Reminders/Pain CPRS Clinical Reminders/Pain

assessment and treatment planning assessment and treatment planning templatetemplate

Outcomes Measures ToolkitOutcomes Measures Toolkit Consensus statement on assessment of Consensus statement on assessment of

pain in the cognitively impaired personpain in the cognitively impaired person Review of opioid use dataReview of opioid use data

AccomplishmentsAccomplishments ResearchResearch

Rehabilitation R&D solicitation Rehabilitation R&D solicitation Collaboration with HSRD QuERI programsCollaboration with HSRD QuERI programs Special issue of Special issue of Journal of Rehabilitation Journal of Rehabilitation

Research and DevelopmentResearch and Development JRRDJRRD, Volume 44, Number 2, 2007, Volume 44, Number 2, 2007

Working group establishedWorking group established Over 50 VA pain-relevant investigators identifiedOver 50 VA pain-relevant investigators identified

Cluster groups developedCluster groups developed Pain in the cognitively-impairedPain in the cognitively-impaired Pain, opioids, and substance abusePain, opioids, and substance abuse Diversity and health disparitiesDiversity and health disparities Chronic pain and comorbid psychiatric disordersChronic pain and comorbid psychiatric disorders Health servicesHealth services Post-deployment healthPost-deployment health

AccomplishmentsAccomplishments

Performance measuresPerformance measures EPRP EPRP ORYXORYX SHEPSHEP

Current ProjectsCurrent Projects Performance MeasuresPerformance Measures

Cancer pain management pilot projectCancer pain management pilot project Documented pain plan of careDocumented pain plan of care If opioid therapy, is there constipation prophylaxisIf opioid therapy, is there constipation prophylaxis

Evidence Synthesis Projects (ESP)Evidence Synthesis Projects (ESP) Management of pain in inpatient medical settingsManagement of pain in inpatient medical settings Pain and polytraumaPain and polytrauma

Outcomes measuresOutcomes measures Revised CPRS pain assessment and Revised CPRS pain assessment and

treatment planning template/reminder treatment planning template/reminder systemsystem

Revised Outcomes Measures ToolkitRevised Outcomes Measures Toolkit

Current ProjectsCurrent Projects

GuidelinesGuidelines Revise post-operative pain guidelineRevise post-operative pain guideline More broadly disseminate guidelines, including More broadly disseminate guidelines, including

guidelines developed by other groups (e.g., APS)guidelines developed by other groups (e.g., APS) EducationEducation

Revise opioid web-based courseRevise opioid web-based course Publish Information Letters on spinal cord Publish Information Letters on spinal cord

stimulators and intrathecal pumpsstimulators and intrathecal pumps Continued collaboration with MyHealthContinued collaboration with MyHealtheeVet Vet

initiativesinitiatives Identify and disseminate model web-based Identify and disseminate model web-based

training training Continuing update of national pain management Continuing update of national pain management

websitewebsite

Current ProjectsCurrent Projects PharmacyPharmacy

National opioid data “dashboard” projectNational opioid data “dashboard” project PBM publications related to opioidsPBM publications related to opioids Development and dissemination of model Development and dissemination of model

“opioid agreement”“opioid agreement” Evaluation of regulations related to C-II Evaluation of regulations related to C-II

prescriptionsprescriptions

Pain and PolytraumaPain and Polytrauma HSRD/QuERI pain assessment formative HSRD/QuERI pain assessment formative

evaluation and implementation projectevaluation and implementation project PT/BrI QuERI Executive CommitteePT/BrI QuERI Executive Committee Representation at National Polytrauma Representation at National Polytrauma

Conference and upcoming TBI SOTAConference and upcoming TBI SOTA

Current ProjectsCurrent Projects Pain and primary carePain and primary care

Identify and disseminate best practicesIdentify and disseminate best practices Cyberseminar on pain and primary careCyberseminar on pain and primary care Recently established pain and primary care Recently established pain and primary care

task force within Primary Care SHGtask force within Primary Care SHG

ResearchResearch Developing proposal for multisite Cooperative Developing proposal for multisite Cooperative

StudiesStudies TBI State-of-the-Art ConferenceTBI State-of-the-Art Conference Continued advocacy within ORD for increased Continued advocacy within ORD for increased

pain relevant research fundingpain relevant research funding Special issue of Special issue of Pain MedicinePain Medicine on pain and on pain and

OEF/OIF veteransOEF/OIF veterans Advocating for establishment of Pain Research Advocating for establishment of Pain Research

and Education Center and Education Center

Current ProjectsCurrent Projects

Nursing Working GroupNursing Working Group Support Coordinating CommitteeSupport Coordinating Committee Encourage collaborationEncourage collaboration Develop specific nursing initiativesDevelop specific nursing initiatives Promote involvement of nurses in existing Promote involvement of nurses in existing

projectsprojects Foster nursing initiated research and Foster nursing initiated research and

dissemination of evidence-based practicesdissemination of evidence-based practices Increased acknowledgement of nursing Increased acknowledgement of nursing

contributionscontributions

Current ProjectsCurrent Projects

Proposal for enhanced funding for Proposal for enhanced funding for musculoskeletal disorders among musculoskeletal disorders among OEF/OIF veteransOEF/OIF veterans Objective: Improved access to careObjective: Improved access to care

Increased medical and psychological providersIncreased medical and psychological providers Provider educationProvider education Telehealth technologiesTelehealth technologies Creation of additional multidisciplinary pain Creation of additional multidisciplinary pain

centerscenters

Current ProjectsCurrent Projects Opioid – High Alert Medications ProjectOpioid – High Alert Medications Project

Objective: Enhance safe and effective use of Objective: Enhance safe and effective use of opioidsopioids

Aims:Aims: Increased use of CPRS pain assessment and Increased use of CPRS pain assessment and

reassessment templatesreassessment templates Increased use of opioid agreementsIncreased use of opioid agreements Increased percent of prescribers who have completed Increased percent of prescribers who have completed

opioid web-based courseopioid web-based course Increased percent of facilities that have successfully Increased percent of facilities that have successfully

implemented accepted protocols/guidelines for opioid implemented accepted protocols/guidelines for opioid use (oral and PCA) in inpatient settings use (oral and PCA) in inpatient settings

Reduction in opioid related AEsReduction in opioid related AEs Increased availability of pain specialists, including pain Increased availability of pain specialists, including pain

medicine specialists, pain resource nurses, clinical medicine specialists, pain resource nurses, clinical pharmacists, and pain psychologists pharmacists, and pain psychologists

Opioid – High Alert Opioid – High Alert MedicationsMedications Standardize pain management protocolsStandardize pain management protocols

Use appropriate monitoring for side Use appropriate monitoring for side effectseffects

Increase use of non-pharmacologic Increase use of non-pharmacologic interventionsinterventions

Double checks on pumpsDouble checks on pumps Reversal protocolsReversal protocols Opioid agreements/treatment goalsOpioid agreements/treatment goals Medication reconciliationMedication reconciliation Availability of pain specialty consultAvailability of pain specialty consult

% PAIN POLICY/PAIN COMMITTEES

90.0

72.3

0.010.020.030.040.050.060.070.080.090.0

100.0

PM Policy PM Committee

%

PAIN STAFF

51.5 46.935.4 34.6 34.6 33.9 33.9

25.4 22.315.4

0.010.020.030.040.050.060.0

%

PAIN SERVICES

0102030405060708090

100

%

% SERVICES/SPECIALISTS

63.9

25.4 24.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Palliative Care Svc(PCS)

Pain Specialist inPCS

Post-OP Epidural

%

PAIN TREATMENT FACILITIES

33.930.8

17.7

9.2

0.05.0

10.0

15.020.025.030.0

35.040.0

Pain clinic Multidisciplinarypain clinic

Modalityoriented clinic

Multidisciplinarypain center

%

OPIOID SAFETY INPATIENT

21.5

30.8

37.7

46.9

47.7

72.3

72.3

0 10 20 30 40 50 60 70 80

Protocols and reversal agents availablew ithout MD order

Protocols for AE monitoring

Protocol/algorithms for opioidinitiation/continuation

Routine double checks for PCAs

Performance improvement program

Pain specialty consultation available

Routine medication reconcilliation

%

OPIOID SAFETY OUTPATIENT

37.7

68.5

80.8

0 20 40 60 80 100

Performance improvement program

Routine use of random uring drugscreens

Routine use of opioid agreements

%

Recommendations for Recommendations for enhanced pain care at the enhanced pain care at the

facility levelfacility level Pain Management CommitteePain Management Committee

Assure provider competenceAssure provider competence Promote patient/family educationPromote patient/family education Promote safe and effective use of analgesics, Promote safe and effective use of analgesics,

particularly opioidsparticularly opioids Promote access to effective pain carePromote access to effective pain care

Emphasize optimal pain care in primary care Emphasize optimal pain care in primary care Expand interdisciplinary focusExpand interdisciplinary focus Assure access to cost-effective careAssure access to cost-effective care

Pain Management Pain Management CommitteeCommittee

Facility pain management policyFacility pain management policy

““The Pain Management Committee provides The Pain Management Committee provides oversight, coordination, and organization-oversight, coordination, and organization-wide monitoring of pain management wide monitoring of pain management activities and processes to ensure activities and processes to ensure consistency with the VHA National Pain consistency with the VHA National Pain Management Strategy”Management Strategy”

Report to Chief of Staff and Medical Staff Report to Chief of Staff and Medical Staff Executive CommitteeExecutive Committee

Reports to VISN Pain CommitteeReports to VISN Pain Committee

Pain Management CommitteePain Management Committee Active performance improvement effortActive performance improvement effort

Ongoing monitoring of performance in Ongoing monitoring of performance in all settings of careall settings of care

Collaboration in establishing pain-relevant policies and Collaboration in establishing pain-relevant policies and proceduresprocedures

Pain report cardPain report card Setting specific performance improvement projectsSetting specific performance improvement projects IHI type projectsIHI type projects

Establish minimal competencies and Establish minimal competencies and provide ongoing provider education provide ongoing provider education

Orientation of new employeesOrientation of new employees Annual mandatory trainingAnnual mandatory training Case based and setting/specialty specific provider trainingCase based and setting/specialty specific provider training

Provide ongoing patient/family educationProvide ongoing patient/family education Pain fairsPain fairs Promote access to MyHealthPromote access to MyHealtheeVetVet ““Living with pain class”Living with pain class”

Highlights from VISN 4Highlights from VISN 4

Philadelphia Philadelphia Opioid Renewal ClinicOpioid Renewal Clinic Chronic Pain SchoolChronic Pain School

Pittsburgh Pittsburgh Successful Pain Resource Nurse (PRN) Successful Pain Resource Nurse (PRN)

ProgramProgram Upcoming two day training programUpcoming two day training program

SummarySummary Support VISN Pain POCSupport VISN Pain POC

Develop mechanisms to assure bidirectional Develop mechanisms to assure bidirectional communication with National Pain Management communication with National Pain Management Strategy Coordinating CommitteeStrategy Coordinating Committee

Establish high functioning facility Pain Establish high functioning facility Pain CommitteeCommittee Performance improvement Performance improvement Provider competenceProvider competence Educated consumersEducated consumers

Use existing resourcesUse existing resources Pain Management website – Pain Management website –

www.va.gov/pain_managementwww.va.gov/pain_management VA Pain List ServeVA Pain List Serve Monthly national teleconferencesMonthly national teleconferences

Identify and nurture “painiacs”; get involvedIdentify and nurture “painiacs”; get involved

Thanks!Thanks!robert.kerns@va.govrobert.kerns@va.gov