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This Issue: Chronic Disease Care | Table of Contents: Spring 2016 |

A Chat with Our Experts

How VA is combating pain

Dr. Robert Kerns
Dr. Robert Kerns

Dr. Robert Kerns

Dr. Robert D. (Bob) Kerns is a research psychologist at the VA Connecticut Healthcare System's Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, and a professor of psychiatry, neurology, and psychology at Yale University.

Kerns is the recipient of numerous awards, including the 2006 Leadership Award from the Association of VA Psychologist Leaders; the 2006 David M. Worthen Award for Academic Excellence; and the 2006 Mark Wolcott Award for Clinical Excellence, all from VA. He also received the John and Emma Bonic Public Service Award in 2010 from the American Pain Society.

From 2006 to 2013, Kerns was VA's national program director for pain management. He served as special adviser for pain research from 2013 until early 2016. He was the first director of the PRIME Center, the only federally funded pain research center in the United States, from 2008 through 2016.

He co-edited, along with Dr. Alicia Heapy, associate director of the PRIME Center and assistant professor of psychiatry at Yale University, a 2016 special issue (Vol. 53, No. 1) of the Journal of Rehabilitation Research and Development (JRRD) dedicated to pain management issues. VARQU spoke with him about this new publication, and about his and VA's accomplishments in pain management research.

VARQU: Why is pain management a significant issue for Veterans and VA research?

Kerns: I was privileged to serve on an Institute of Medicine/National Academy of Sciences committee that was legislated to take a look at the problem of pain management in this country. We published our report in 2011, and it said that one-third of all Americans have pain, at a cost of about half a trillion dollars—so it's a huge public health concern.

In addition, the report mentioned Veterans, among several other groups, as particularly vulnerable to pain—and more specifically chronic pain—for many reasons. They are partly related to combat exposure or the experience of being in the military, which is a highly demanding occupation. There are other factors, including combat- or service-related physical injuries, as well. Pain is a problem that should concern all of us, but Veterans and VA in particular.

VA's singular contribution to pain management research is the stepped-care approach to pain care. What is that approach, and why is it an advance over previous models of pain care?

Historically, pain was a problem that was "owned" by everyone, and hence no one. Pain is ubiquitous to the human experience, and is the number one reason people seek health care attention from a provider. They tend to use any number of different providers depending on the site of their pain, and the expected cause of their pain.

Among medical providers, if anyone could be said to have owned pain, it was anesthesiology, because of their role in suppressing pain in the operating room. By extension, they took on the development of what was essentially a specialty within the discipline to address problems related to acute and chronic pain.

Over time that situation evolved into a specialty within medicine called pain medicine, which is now a recognized, board-certified specialty. VA started to address the question of pain in a systematic way beginning in 1998, and has worked hard to expand its capacity for specialty pain care.

However, the data that indicate such a high prevalence of pain in America—which may be as high as 50 percent of male Veterans and 75 percent of female Veterans—makes it obvious we can't leave addressing the challenge of pain to specialists. We have to realize that this is a population-level problem that needs to be addressed in the primary care setting.

The idea of the stepped-care model VA has adopted as its standard of care is that most common pain conditions should be adequately and timely assessed in the primary care setting—and that treatment should be the most conservative possible to provide relief from the experience of pain.

For low back pain, for example, that equates to providing education about management of that kind of pain; reassurance that, for the most part, the pain is not likely to be a significant problem in the patient's life, and is likely to resolve over time; and the judicious use of over-the-counter pain medication.

For some people, however, that's not enough. And so the stepped care model is a way of considering more interventions, even within primary care.

For example, in the presence of comorbidities of pain, such as mood and anxiety disorders, substance use disorders or posttraumatic stress disorder, mental health providers might become involved in treatment of the Veteran's pain. Providers might also consider stepping up a level in terms of the use of medication to other non-opioids [coanalgesics] commonly used for the medication of specific kinds of pain conditions.

These can include non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants or anticonvulsant medications that have been found to be effective for some kinds of pain conditions for some people.

Increasing numbers of VA physicians and other providers are learning to deliver acupuncture to ease pain.
Increasing numbers of VA physicians and other providers are learning to deliver acupuncture to ease pain. (Photo: ©iStock/Diana Lundin)

Increasing numbers of VA physicians and other providers are learning to deliver acupuncture to ease pain. (Photo: ©iStock/Diana Lundin)

We might also think about other behavioral, rehabilitation and complementary and integrative approaches that may be delivered in a primary care setting. More and more in VA, primary care providers are learning to deliver acupuncture, for example, or to provide educational materials to support Veterans in pain self-management.

There are additional steps a primary care physician can take, of course, such as referrals to physical therapists, other clinicians and even pain management specialists. Ultimately, in VA's stepped-care model, we think about the importance of having timely access to the highest level of advanced and sophisticated pain diagnostics and intervention, as well as the "gold standard" of management of chronic pain, which is interdisciplinary rehabilitation.

You mentioned 1998 as a time when things changed. What happened at that time?

In 1998, our former under secretary for health, Dr. Kenneth W. Kizer, went before Congress along with colleagues from other federal agencies to tout a new National Pain Management Strategy.

The main driver of this initiative was a nurse anesthetist from the VA Puget Sound Health Care System, who had written a white paper based on a survey of the current state of pain care in the United States that identified gaps in care and inconsistencies across VA in terms of the availability of resources to support Veterans' pain care.

It was Kizer's vision to create the national strategy. VA chartered a multidisciplinary pain management committee, and the first coordinator of that committee was hired soon afterward.

VA then partnered with the Institute for Healthcare Improvement (IHI) to launch a major initiative to promote the concept of routine screening for the presence and intensity of pain, followed by a comprehensive pain management assessment, the development of an integrated treatment plan, and then ongoing reassessment of the effectiveness of that plan, with modifications made to the plan as needed.

So, back then, we had some of the core principles in place, and it was the job of the coordinating committee to enact them. I got in on the ground floor and provided some leadership around the IHI initiative. We published a paper in the Clinical Journal of Pain in 2003 about that IHI collaboration, and then we were off and running.

Also in 2003, we published the first VHA pain directive, which was revised in 2009, and which continues to serve us today.

Part of Kizer's vision, right from the beginning, was an objective specifically dedicated to advancing pain research. It was part of the foundational charter for the National Pain Management Strategy that VA would invest in pain research. One of my roles on the coordinating committee was developing a National Pain Research Working Group to support the committee.

I chaired that working group, and am proud to say that 16 years later, it's still a thriving entity that meets monthly by teleconference and has developed several important products, including the recent JRRD issue on pain management.

How is VA research helping to reduce dependence on opioid use for Veterans?

VA's Opioid Safety Initiative and other measures have led to downward trends in the use of opioids to treat pain—especially in high doses, and over extended periods. <em>(Photo: ©iStock/Juanmonino)</em>
VA's Opioid Safety Initiative and other measures have led to downward trends in the use of opioids to treat pain—especially in high doses, and over extended periods. (Photo: ©iStock/Juanmonino)

VA's Opioid Safety Initiative and other measures have led to downward trends in the use of opioids to treat pain—especially in high doses, and over extended periods. (Photo: ©iStock/Juanmonino)

VA has always been a leader in promoting the safe and effective use of opioids in several important ways. VA partnered with the Department of Defense (DoD) in 2003, and published a very important clinical practice guideline for the management of chronic pain. It was updated in 2010.

In 2008, VA, in the context of its "high alert medication initiative," identified opioids as one of a small number of classes of medications specifically known to be associated with harms, and made a major effort to address and promote risk-mitigating strategies in both inpatient and outpatient settings.

Of course, none of this quelled the rapid growth of opioid prescribing [at the time], and the associated risks of harm. In light of this, and the [emergence of ] prescription drug abuse and opioids in particular as a national public health crisis, VA was ready to take important next steps.

By 2013, VA had formally launched its Opioid Safety Initiative—and even before that, as early as 2010 and 2011, we were starting to see a downward trend in incident prescribing of opioids.

A paper by Dr. Hilary Mosher has documented that downward trend. All the while, the prevalence of opioid prescribing continued to rise within VA, but incident prescribing [the percentage of Veterans for whom opioids were prescribed for the first time] stopped increasing. I'm currently reviewing a paper, of which I am a co-author, which further documents the significance of the Opioid Safety Initiative, in terms of [reducing] high-dose opioid prescribing.

VA's role in developing the National Action Plan for Adverse Drug Event Prevention was quite important. That action plan was published in 2014, and is being enacted now. And VA researchers had a role in developing the recently released (March 2016) Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain.

What information does the special supplement of JRRD provide on the state of VA pain research?

Let me point to our editorial, which I wrote along with my colleague Dr. Alicia Heapy, who collaborated with me in co-editing this special issue. There are also two other editorials that are important for people to read and understand, written from the perspective of VA Central Office Policy and Planning.

One is by Dr. Rollin Gallagher, who's the current national program director for pain management. The other is by Dr. Audrey Kusiak of the Office of Research and Development, who is VA's representative to the Interagency Pain Research Coordinating Committee, which is a very important intergovernmental entity established at the same time that the Institute of Medicine Pain Committee was established.

In terms of content, we have an interesting blend of papers about some special issues faced by Veterans, especially Iraq and Afghanistan Veterans. The papers also speak to important concerns about inequities in pain care, and about important subgroups of Veterans with pain, including patients with comorbid pain, substance use disorders, and PTSD. All too often, Veterans have all of these problems.

The issue also discusses significant comorbidities in Gulf War Veterans with chronic multisymptom illness, an illness of which pain is an important part. A current issue affecting VA, and one still to be substantially addressed, is the relationship between pain and being overweight or obese, or having eating disorders. That's the subject of another paper.

There are papers in this issue of JRRD that really demonstrate the importance of VA in the pain research world. We have the benefit of our incredible electronic health record and other data that have allowed VA investigators to take the lead in learning how to use these kinds of data bases to study problems like chronic pain—not only to understand the characteristics of Veterans that have pain in a way that others haven't been able to do, but also to be able to look at what is effective care and the costs of care.

Other papers use more traditional survey approaches to these problems—using, for example, VA's MOVE! database to study obesity. There are several papers that are on the cutting edge of new assessment and treatment approaches that showcase VA's strengths. For example, there's a paper focusing on complementary and integrative approaches to pain management, and another that focuses on the development of a potentially important new tool for use in primary care settings to screen for opioid-related benefits, risks, misuse and harms.

Still another paper reports on VA's SCAN-ECHO initiative, which is designed to improve access to specialty care, and finally, there's a paper that talks specifically about the stepped-care model for pain management—one in a series of papers from the group that has worked on implementing the model and evaluating its implementation.

What does the future hold for VA pain management research, and for you personally?

VA's pain research portfolio continues to grow every year, and the last few years in particular have seen substantial investment in pain research, from basic laboratory science to clinical science and rehabilitation research to health services research and even dissemination and implementation research. Dr. Kusiak's JRRD editorial specifically highlights that investment.

Some of the most important issues right now relate to our efforts to provide effective pain care for Veterans and to promote equitable access to pain care—and the interface of those efforts with the prescription drug abuse and prescription opioid public health crisis.

VA is taking the lead on a White House initiative promoting research on complementary and integrative health approaches to pain management. These include a wide array of strategies, including acupuncture, yoga, tai chi, massage, and meditation, just to name a very few.

VA is also conducting a number of evidence synthesis reviews that will inform a state-of-the-art conference that's being planned for later this calendar year to better develop a targeted research agenda related to the role of complementary and integrative health as effective strategies for pain relief, and also to address the burden of opioid prescribing. [See "New Initiatives" in this issue of VARQU.]

Beyond that, VA is working hard to study dissemination and implementation methods to build our capacity to provide and promote equitable access to the kinds of evidence-based interventions and strategies VA and others have developed.

Access is a hugely important and timely issue and challenge for VA. VA is working hard to take the lead in developing strategies that take advantage of innovative technologies to improve access. These include smartphones, the Internet, and other phone-based strategies. We are studying and evaluating the development of tools that can help Veterans manage their pain regardless of where they are geographically.

We're also working to develop new pain self-management interventions [such as a recent study demonstrating how peers can help Veterans manage their own pain] , which I'm particularly interested in. I think that's an important VA effort.

As for me personally, I was fortunate to receive a grant through a VA HSR&D-National Institutes of Health (NIH) partnership. I had previously worked through private foundation funding to develop strategies to extract information from unstructured progress notes of primary care providers documenting Veterans' pain care and to put that data into quantifiable bits of information in structured data fields.

We're now partnering with medical informatics specialists to use natural language processing and machine learning to teach computers how to do that same extraction in order to reliably extract, for example, information on complementary and integrative health approaches that aren't otherwise coded in the record.

Learning how to use these tools will help us develop a systematic tool to better code dimensions of pain care quality. We can also think about using this tool in a broad array of performance improvement initiatives in VA, in the service of improving pain care.

Kerns and other VA researchers are studying a cohort of more than 5 million Veterans with musculoskeletal pain. <em>(Photo: ©iStock/Wavebreak)</em>
Kerns and other VA researchers are studying a cohort of more than 5 million Veterans with musculoskeletal pain. (Photo: ©iStock/Wavebreak)

Kerns and other VA researchers are studying a cohort of more than 5 million Veterans with musculoskeletal pain. (Photo: ©iStock/Wavebreak)

I'm also finding strategies for using our existing health record data. We are now studying 5.4 million Veterans with diagnosed musculoskeletal conditions. We're putting our arms around all of VA's data, and even some Center for Medicare and Medicaid Services data, in hopes of being able to characterize better than ever before the nature of these musculoskeletal conditions, the prevalence of these conditions, and the comorbidities of Veterans with these conditions.

We're studying the kinds of care they are provided and the effectiveness of different strategies, such as spinal cord stimulators and other interventions such as opioids, for example. Ultimately, we'll look at the costs of care in VA in ways we've been unable to before.

I'm excited about my work in using technology to provide different platforms to provide psychological interventions and pain self-management interventions that I've spent my entire career developing. I'm also excited about the tool we're developing for extracting information from electronic health record and other research using our different databases to better study pain.

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