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a. Understand the prevalence and nature of pain concerns in returning combat veterans. ...

a. Understand the prevalence and nature of pain concerns in returning combat veterans.
b. Understand that pain issues are part of a complex group of co-occurring and inter-related issues.
c. Describe a collaborative, bio-psycho-social approach to address pain issues.
d. Understand the stepped-care, collaborative approach in VA.
e. Understand how to implement collaborative pain care on PACT teams - a nuts and bolts approach
This two-part class will begin by highlighting collaborative pain care in Primary Care using real-life scenarios that address the complex issues and needs of returning Veterans and then move on to address how to apply a nuts-and-bolts approach within a Patient Aligned Care Team in the VA.

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  • IOM reportPain represents a challenge not only for our Veterans but nationally. A cultural transformation is necessary to better prevent, assess, treat, and understand pain of all types. Last summer the IOM issued this report offering a blueprint for action in transforming prevention, care, education, and research recommending that we adopt a population-level prevention and management strategy. Better data are needed and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. IOM recommends that providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted and thateducation programs be better designed to bridge these gaps. Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority
  • 20-40% of adults report chronic painIn primary care settings up to 20% of visits generate and opioid prescriptionIn the US overall 4 million adults are prescribed a long acting opioid each yearAs prescriptions have increased so have the consequences such as impairment, diversion, overdose and dependenceThere is little evidence that long term opioid therapy is effective in reducing pain much less in restoring function , the ultimate goal of treatment yet continues to be the backbone of our therapy The few randomized trials that support opioid therapy were of only of a few months duration and not of high qualityWe have an evidence base for non opioid based alternatives such as CBT targeting factors that influence a patients ability to cope with pain symptomsKroenke demonstrated that treating depression in patients with chronic pain who were not previously recognized as depressed led to improvement in pain scores equal the opioids. Recent work using exercise and telephone CBT is promising and represents self management strategies that puts the patient in charge. These skills are available after hours and don’t require monthly refills Cognitive Behavior Therapy, Exercise, or Both for Treating Chronic Widespread PainJohn McBeth, MA, PhD et al ; Arch Intern Med. 2012;172(1):48-57. doi:10.1001/archinternmed.2011.555
  • The figure above shows rates of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold in the United States during 1999-2010. During 1999-2008, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially.Figure from CDCMMWR Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008WeeklyNovember 4, 2011 / 60(43);1487-1492
  • 20-40% of adults report chronic painIn primary care settings up to 20% of visits generate and opioid prescriptionIn the US overall 4 million adults are prescribed a long acting opioid each yearAs prescriptions have increased so have the consequences such as impairment, diversion, overdose and dependenceThere is little evidence that long term opioid therapy is effective in reducing pain much less in restoring function , the ultimate goal of treatment yet continues to be the backbone of our therapy The few randomized trials that support opioid therapy were of only of a few months duration and not of high qualityWe have an evidence base for non opioid based alternatives such as CBT targeting factors that influence a patients ability to cope with pain symptomsKroenke demonstrated that treating depression in patients with chronic pain who were not previously recognized as depressed led to improvement in pain scores equal the opioids. Recent work using exercise and telephone CBT is promising and represents self management strategies that puts the patient in charge. These skills are available after hours and don’t require monthly refills Cognitive Behavior Therapy, Exercise, or Both for Treating Chronic Widespread PainJohn McBeth, MA, PhD et al ; Arch Intern Med. 2012;172(1):48-57. doi:10.1001/archinternmed.2011.555
  • Lets take a look at what is happening here Karl is one of the soldiers carrying the litter lets hear Karl’s story
  • Would like to have audio
  • For women and men Veterans who use VA, the prevalence of painful musculoskeletal conditions including back problems, musculoskeletal problems and joint problems increases every year after deployment…But, it increases more for women than men, so by 7 years after deployment20% of women and 17% of men have back problems12% of women and 10% of men have musculoskeletal conditions19% of women and 17% of men have joint problems
  • Wounding PatternsSurvivable extremity traumaIED’sBody ArmorIncreased survival ratesRelative increase in extremity traumaLow back painTime in vehiclesImprovements in Medical CareMEDEVAC/CCATT (Critical Care Air Transport Teams)Combat medicine and in-theater hospitalsMason, Eadie, & Holder, 2008; Hicks et al., 2010; Champion et al., 2010; Belmont et al., 2010; Nevin & Means, 2009Slide prepared by: Don McGeary, Ph.D.
  • Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 JRR&DSample = 340 OEF/OIF outpatients at Boston VAOverall prevalence in Polytrauma population: -Pain 81.5% -TBI 68.2% -PTSD 66.8% -CLARK- 2009
  • Pain and PTSD coexist 60-80% of veterans (Lew et al, 2009; Beckham et al, 1997; White et al, 1989)
  • Recent research suggests that individuals suffering from comorbid chronic pain and traumatic stress may respond poorly to treatment targeting only one diagnosisThe co-occurrence of chronic pain and PTSD is becoming more widely recognizedConcurrent use of opiates and benzodiazepines in the treatment of this population is a concern For people with chronic pain, the pain may actually serve as a reminder of the traumatic event, which will tend to exacerbate the PTSD.Recently a Retrospective cohort study of 141,029 Veterans with non-cancer pain diagnosisComorbid PTSD and Pain Significantly More Likely:Highest quintile for dose; More than one opioid prescribed concurrently; Concurrent sedative hypnotics; Early refillsHave more Opioid related accidents, Overdoses, Alcohol and Non-opioid related accidents and overdoes, Self-inflicted injuries and Violence related injuriesSeal, K.H., Shi, Y., Cohen, G. et al. Veterans with PTSD were more likely to receive higher dose opioids, 2 or more opioids, sedative hypnotics and get early refillsBohnert 2011Pain and depression frequently co-exist (30-50% co-occurrence) and have additive effect on adverse health outcomes and treatment responsiveness of one another *The presence of depressive symptoms is a strong, independent, and highly prevalent risk factor for the occurrence of disabling back pain *** Bair, MJ, Robinson RL, Katon W, Kroenke K. Depression and Pain Co-morbidity: a literature review. Arch Intern Med 2003;163:2433-2455** Reid MC, Depressive symptoms as a risk factor for disabling back pain Am Geriatr Soc. 2000 Dec;51(12):1710-7.
  • Urgent and complete relief is an expectation of patients and taught in medical schools as the biomedical model Unfortunately opioids became equated with managing pain Pain as 5th VS in 1998 moved us to try to do a better job at fixing pain and opioids at the time seemed to be the answer
  • Elicit examples of each component from group. Not just the Biomedical model is inadequateBiopsychosocial model best describes the chronic pain experienceComplex interaction among biological, psychological, and social factorsBiomedical ModelDualism: “mind” and “body" are separatePain is a symptom of an underlying physical problemDisease resides in the individualIndependent of psychological and social experienceObjective evidence is valued more than subjective reportpain, or the “chronic pain patient”.
  • VHA is innovating the way health care is delivered by moving the current system which is reactive “find it, fix it,” disease care to one that is personalized, proactive and patient-driven. This approach is Informed by chronic illness model where we move from a provider centric system to one that is team based and centered around what is important to the Veteran in their livesEmpowering Veterans through reassurance, encouragement and education Conservative safe use of analgesics and adjuvant medicationsPromotion of regular exercise and healthy and active lifestyleDevelopment of adaptive strategies for managing painA system that is centered around the patient will help us better assist with the management of chronic disease and chronic painThis cloud tag emphasizes that Self Management skills are key to managing and improving any chronic pain condition involving a multitude of modalities promoting an active and healthy life style that is personalized proactive This can be can be supported by a Veteran-centered healthcare system that involves patient education, conservative management of acute pain and prevention of chronic pain, overall wellness and healthy living, conservative and safe use of medications, including over the counter medications, and use of adaptive strategies for managing pain
  • Universal precautions originally to prevent transmission of infection but the principal can be generalized to any practice that applied universally to all as standard protocol improves the safety of patients. As an example in diabetes we have standardized approaches around the use of insulin Periodic Reassessment of Pain Diagnosis and Comorbid Conditions, Including Addictive behaviorsUniversal Precautions in Pain Medicine: A Rational Approach to theTreatment of Chronic PainDouglas L. Gourlay, MD, MSc, FRCPC, FASAM,* Howard A. Heit, MD, FACP, FASAM,† andAbdulazizAlmahrezi, MD, CCFP‡*The Wasser Pain Management Center, Mount Sinai Hospital, Toronto, Ontario, Canada; †Assistant Clinical Professor ofMedicine, Georgetown University School of Medicine, Washington DC; ‡Clinical Fellow, Center for Addiction and MentalHealth, Toronto, Ontario, Canada
  • Welcome. We are very pleased that you are here. You have come to the right place and we have many resources and services that will be very useful to you. I personally want to acknowledge your service, and the sacrifices that have resulted from that service. We will discuss your pain medications, but I will start by saying that you will be getting the best pain care possible here at the VA. Our approach to pain care has been proven to be the best approach possible. You will have a team and we all will work together to insure that all of your health concerns are addressed in the most effective way possible, including your pain care. Medications may be a part of your pain care, but there will be many other things we will be doing to insure that pain impacts your life as little as possible. Our mission in VA is to support you in having the healthiest and most successful, satisfying life possible. Your team will work with you to make that happen. So let’s get started!”
  • What do we do in Step 1
  • Bullet out the key pointsPACT/Medical Home, the non-VA community is looking to VA  to lead the way in figuring out how to do these things…and accomplishing true interdisciplinary, collaborative, team function is the key….we have the plan, we have the staff, we have educational materials, we have the sense of mission…we just have to show teams how to “put it all together” and then support them in that process, just as we did with PDICITo do his well we need to emphasize patient education, focus on promoting adaptive self-management and empowerment and improve provider patient communication
  • Plan Implementation of the directive which emphasizes need to standardize our approaches , follow guidelines Come visit us in our booth and pick up a summary summary of the guidelinesWe have guideline for opioid use but the truth is that we overuse opioids and need to use other evidence based approaches in the management of chronic pain EffectivenessMore than reduction of pain intensity Improved overall function and quality of life Progress toward individual goalsHarmsCommon symptoms (constipation, nausea, somnolence) Long-term harms (sleep disordered breathing, hypogonadism)Psychosocial harms (role interference, dependence concerns) Addiction AdherenceAppropriate medication taking Safe storage and disposalNo sharing, borrowing, or selling Informed ConsentProvide written and verbal educationDiscuss specific goals of treatmentReview opioid agreement (consider signature) Obtain consent for UDT (can be verbal)Visit Frequency Reassess at least every 1-6 monthsEffectiveness Discuss progress toward individualized treatment goalsHarmsEvaluate adverse effects and tolerabilityAdherenceDiscuss how and when patient is taking medicationPerform UDT periodicallyAssess adherence to verall treatment plan
  • Opioid Risk Mitigation EffectivenessMore than reduction of pain intensity Improved overall function and quality of life Progress toward individual goalsHarmsCommon symptoms (constipation, nausea, somnolence) Long-term harms (sleep disordered breathing, hypogonadism)Psychosocial harms (role interference, dependence concerns) Addiction AdherenceAppropriate medication taking Safe storage and disposalNo sharing, borrowing, or selling Informed ConsentProvide written and verbal educationDiscuss specific goals of treatmentReview opioid agreement (consider signature) Obtain consent for UDT (can be verbal)Visit Frequency Reassess at least every 1-6 monthsEffectiveness Discuss progress toward individualized treatment goalsHarmsEvaluate adverse effects and tolerabilityAdherenceDiscuss how and when patient is taking medicationPerform UDT periodicallyAssess adherence to verall treatment plan
  • emphasize the interdisciplinary and collaborative nature of pain management at every level, including primary care.  At the same time, I think that there is still value in using the term tertiary, interdisciplinary pain centers to further emphasize the concept of a coordinated, integrated “program” that serves as a resource for Veterans with particularly high complexity and risk, and who have been less than optimally responsive to prior interventions. CollaborationConsultationWarm Hand-offs: early on to avoid the “rule-out train”Opioid AgreementAssessment including risk for opioid misuseMonitoring high risk populationHelping to determine when opioid therapy is not appropriateCo-visitsTreatment/functional goalsCoaching for self-management2) Promoting Self-ManagementInformed by chronic illness modelReassurance, encouragement, educationConservative use of analgesics and adjuvant medicationsPromotion of regular exercise and healthy and active lifestyleDevelopment of adaptive strategies for managing pain3) Pain School (Self-Management Groups)Promote self-managementInterdisciplinary: primary care provider, psychologist, clinical pharmacist, rehab medicine (PT/OT), dietitianTopics: biopsychosocial model, mind-body connection, SMART goals, CBT, relaxation training, stress management, assertive communication, pacing, energy conservation, thermal modalities, exercise, CAM, sleep, sexual functioning, medication, nutrition4) Group Medical Visits: CHCC Can discuss the TAMPA model and the Lovell Shared Medical apts)Focus on patient population (high risk or high utilization behavior, i.e. management of chronic pain, diabetes, CHF, hypertension)Goal to increase access while delivering quality of careGroups are co-led by primary care and behavioral health specialistOutcome: Improve provider and patient satisfaction Improve patient outcomesReduce service (utilization of hospital, ER, and nursing facilities)Lower costs 5) Care management of pain and depressionDobschaKroenke6) Working with health coaches/health behavior coordinator7) Shared decision making
  • Primary Care Providers and PACT TeamsWhat can VA SCAN provide as “added value” to Primary Care Providers and PACT Teams? Specialty Care Practice Guidance Build Competency and Confidence CME, CUE, CE credit Improve patient outcomes Enhance Provider and Patient satisfactionPatients and their familiesWhat can VA SCAN provide as “added value” to patients and family members?1. Continue care with their PCP2. Consult a specialist when needed3. Avoid travel to “distant” medical centers4. Avoid delays in diagnosis and treatment5. Become an “educated consumer” and part of your own healthcare5. Obtain tertiary care if needed
  • Virtual VisitThe National Telemental Health Center (NTMHC) is designed to provide consultation from panels of designated expert clinicians to Veterans anywhere in the country using telehealth technologies. The NTMHC portfolio includes the National Tele-Behavioral Pain Program, which provides extensive psychosocial evaluation and cognitive behavioral treatment for patients referred with refractory pain management.  Expert psychologists deliver care remotely using tele-video conferencing technologies. These evaluations provide recommendations for the patient’s treating clinicians along with enrollment into 6-10 sessions of specialized pain cognitive behavioral therapy (CBT) for pain management.  Referrals generally originate from mental health and primary care services or directly from pain programs which benefit from a specialized cognitive-behavioral component. The tele-pain expert provides consultation and adjunctive specialty CBT services. From October 1, 2011 through June 30, 2012, 338 tele-behavioral pain management encounters for 70 individual Veterans were documented. Thirteen sites in six States have thus far been engaged in this program.
  •   E-Consult is an alternative to face-to-face visits, and it is expected to improve access, communication, and coordination of care. E-Consult aims to provide clinical support from provider to provider.  Through a formal consult request, processed and documented in the CPRS a provider requests a specialist to address a clinical problem or to answer a clinical question for a specific patient.  Utilizing information provided in the consult request and/or review of the patient’s electronic medical record, the consultant provides a documented response that addresses the request without a face-to-face visit. This method of consultation supports Veteran-centric care, reduces the burden of travel to the Veteran, and reduces overall travel and fee basis costs
  • TAUGHT and reinforced by all team members IN PAIN SCHOOLGroup VISTS SHARED MEDICAL APPOINTMENTSPCP VISITSPCMHI WARM HAND OFFSNURSING VISITS PHARM D VISITSPATIENT EDUCATION MATERIALSMHVAFTERDEPLOYMENTREINFORCED BY ALL
  • Consider non-pharmacological approaches including: physical therapy (TENS unit), occupational therapy, behavioral modification, cognitive behavioral therapy (with relaxation training), mindfulness-based therapies (Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy, mindfulness meditation), biofeedback, chiropractic care, acupuncture, yoga nidra and yoga with movement, and massage. Non Pharmacological – Leverage Expanded team(PCMHI, RN Care manager, case manager) May include steps 1, 2, 3Rehab: PT/OT/KT/chiro/Rec therapy, exercise Behavioral: pain psychology/psychiatry/social workCAM yoga MBSR outpatient and inpatient pain rehab, advanced diagnostics and interventionsSubstance abuse treatment
  • Consider non-pharmacological approaches including: physical therapy (TENS unit), occupational therapy, behavioral modification, cognitive behavioral therapy (with relaxation training), mindfulness-based therapies (Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy, mindfulness meditation), biofeedback, chiropractic care, acupuncture, yoga nidra and yoga with movement, and massage. Non Pharmacological – Leverage Expanded team(PCMHI, RN Care manager, case manager) May include steps 1, 2, 3Rehab: PT/OT/KT/chiro/Rec therapy, exercise Behavioral: pain psychology/psychiatry/social workCAM yoga MBSR outpatient and inpatient pain rehab, advanced diagnostics and interventionsSubstance abuse treatment
  • Remember MHVAfterdeploymentSmart phone apps
  • GOAL SETTING NEED TO BE SMARTAn example of attainable and measureable goals to Anyone on opioids for chronic pain has an Opioid Care AgreementUrine Drug Screens on all starts and q6monthsChronic pain on the problem list All understand and agree on stepped care model usinga biopyschosocial approachInclude Pain Management as a standing agenda item in all team meetings Informed by Chronic Illness Model: 1) Self efficacy 2) Self managementCommunication: Reassurance, Encouragement, Education
  • T2 collaborated with the VA's National Center for PTSD to develop this app to assist Veterans and Active Duty personnel (and civilians) who are experiencing symptoms of PTSD. It is intended to be used as an adjunct to psychological treatment but can also serve as a stand-alone education tool. Features: Self-assessment of PTSD Symptoms Tracking of changes in symptoms Manage symptoms with coping tools Assistance in finding immediate support Customized support information
  • How would you work with your team to accomplish that?Be sure to say this is not a real case but the goal of what we are working towardINSTEAD OF HEARING THE AUDIO OF THE IDEAL VISIT I CAN DESCRIBE DEPENDS ON TIME Called the VA, got an appointment ion 2 weeks in a clinic near my homeOne week before my apt a nurse called and asked what I wanted out of the visit asked about my health concerns and how I was doingShe told me about MHV and that it would be good to sign up and told me to check out the VA on MHV and facebookThe Clinic was bright and friendly Welcomed by clerk, thanked for service An assistant checked my BP amd weight and told me that a team would be taking care of me and gave me the card with all their names and contact infoThe doc then came in and pulled up my record, already knew a lot about me but asked me about my military service and seemed really interested . He was very concerned about my PAIN he gave me a head to toe exam and talked to me about how difficult it is to have pain but there are other things that can make pain worse such as depression PTSD and stress He said we would work together to figure out the best care plan for my pain.He then introduced me to the psychologist who talked to me about my experiences and combat stress. She seemed to understand an I was comfortable with her. Before I left I met a social worker on a video screen who could help me with any questions I had about managing my benefits and my life in general. I also got signed up to go to Pain School via VA SCAN Very cool course with Veterans at other sitesI left with a plan – there were instructions on how to take the pain meds and the pills to help me sleep, medication, , when to return to see the psychologist, a follow up visit in one month with my primary care team and something to help me sleep , another visit to meet with the psychologist, a follow visit with my team in 3 months to see how I am doing and all the contact information I needed to reach my primary team and the OEF/OIF program I was impressed, and they are actually going to call me next week to see how I am doing, I got what I needed

401 vehu pccpain_burgo_hunt-8.5 401 vehu pccpain_burgo_hunt-8.5 Presentation Transcript

  • Integrated Pain Care:A Nuts and Bolts Approach Dr. Lucille Burgo and Dr. Stephen Hunt
  • Part 1:Pain Concerns in Veterans
  • 73.36 million High Blood Pressure17.0 million Diabetes16.8 million Coronary Heart Disease11.7 million Cases of Cancer100+ million Pain Sufferers
  • Poll QuestionWhat percentage of outpatient clinic visits are related to pain? A. 10% B. 20% C. 30% D. 40%
  • Rates of opioid pain reliever(OPR) overdose death, OPRtreatment admissions, andkilograms of OPR sold --- UnitedStates, 1999--2010
  • Poll Results 40%
  • The bulk of pain care is provided in the primary care setting < 5% of chronic pain patients will be managed by a pain specialist40% of all outpatient visits are related to pain
  • Pain in Veterans• 50% of male Veterans report chronic pain• Pain in women Veterans may be as high as 75%• Pain is among the most costly disorders treated in VHA settings
  • How do pain concerns impact our returning combat Veterans?
  • Karl• 26 y/o; deployed once to Iraq and once to Afghanistan• infantryman; convoy security• exposed to frequent direct and indirect fire,• saw many casualties, lost several close friends• multiple IED exposures;• screens positive for TBI, PTSD and depression.• chronic back pain; taking hydrocodone.• initial PACT assessment; desires refill of his hydrocodone and a refill of his clonazepam (for sleep)• no mental health treatment in the past year How can we best help Karl?
  • Poll QuestionWhat percentage OIF/OEF/OND veteransreported chronic pain after deployment? A. 14% B. 33% C. 47% D. 96%
  • What are the health concerns of OEF/OIF/OND veterans seen in the VA?• Musculoskeletal 56.7%• Mental disorders 52.8%• Symptoms/signs 51.9%• Nervous system (hearing) 44.8%• GI (dental) 36.0%• Endocrine/Nutrition 32.4%• Injury/Poisoning 28.8%• Respiratory 26.3%VHA Office of Public Health and Environmental Hazards March 2012
  • Pain is the primary physical problem afflicting service members
  • Poll answer 47%
  • • 47% OIF/OEF/OND veterans reported chronic pain after deployment – 80% have musculoskeletal concerns – 28% report moderate to severe pain• Pain is the primary physical problem afflicting soldiers – often begins in basic training (25% of male and 50% of female recruits experience at least one pain-related injury during Basic Combat Training) – #1 complaint of OEF/OIF/OND Vets 16
  • Factors Contributing to Rise in Pain  Wounding Patterns  IED’s Poll Results  Body Armor  Time in vehicles  Improvements in Medical Care
  • How do pain concerns impact our returning combat Veterans?
  • Poll QuestionChronic pain is present in what percentage of patients with PTSD? A. 12-29% B. 21-36% C. 38-48% D. 45-87%
  • Co-morbid Concerns in Combat Veterans TBI/Pain 12.6% 5.3% 10.3% P3 Multi-symptom Disorder 6.8% 42.1% 16.5% PTSD 2.9%
  • Poll Results 45-87%
  • • Pain and depressive disorder co-occur 30-60% of the time• Anxiety disorders occur in 35% of persons with chronic pain• 20-34% of persons with chronic pain meet criteria for PTSD• Chronic pain occurs in 45-87% of persons with PTSD• 37-61% of patients seeking substance use treatment have chronic pain• Pain undermines treatment for depression, anxiety disorders, PTSD, and substance use disorders
  • Depression Pain PTSD Loss of Stress Function
  • 71% of Primary Care Providersreport chronic pain management to be challenging (VHA PC Survey, 2008)
  • Culture of “Cure” • Urgent and absolute relief: appropriate in acute and cancer pain • Inappropriate in chronic pain  Rehabilitation  Restoring and preserving function • Acute strategies are inappropriate for chronic pain
  • Inadequacies in education and trainingLack of consultant supportPsychosocial complexityTime pressuresSkepticismSystems limitations Lincoln et al Survey, VA Connecticut HCS
  • Monitoring opioid use in primary care 100 76.6 90 80% of patients 70 48.8 60 50 40 30 8.0 20 10 0 Urine Drug Regular Office <1 Early Refill Testing Visits Becker, WC Ann Fam Med 2011
  • So how are we going to help Karl? What is our mission? What is our plan? Who is on our team? What tools do we have to help us? How are we going to make it happen?
  • Factors that influence pain experience• Biological Factors – Severity of injury/damage – Presence of source of nociception.• Psychological Factors – Mood – Anxiety (PTSD) – Stress/Anger – Cognitions/attention• Social Factors – Activity – Occupational status – Social interactions (+ and 29 –Social role -)
  • Social Biological PsychologicalWe must understand the “whole person with pain”.
  • Veteran Centered Pain Management
  • Collaborative Care requires a new Communication style Engage Find It Empathize Educate Fix It Enlist (Keller VF, Carroll JG, Patient Education and Counseling, 1994)
  • PACTCreating the Veteran’s team
  • Part 2: The Mission The Plan The Team The TrainingMaking It Happen
  • Highest quality,evidence based pain care for all Veterans.
  • VA Stepped Pain Care Directive
  • VA Stepped Pain Care RISK RISK Tertiary Interdisciplinary Pain Centers 3 Comorbidities Secondary ConsultationTreatment Refractory 2 Complexity Patient Aligned Clinical Team (PACT) 1
  • “Universal” Precautions in Pain Medicine• Diagnosis /Differential• Mental Health Assessment• Informed Consent /OpioidAgreement• Pre/Post Assessment of Pain Level/Function• Appropriate Trial of Pharmacotherapy +/- opioids• Regularly Assess the “Four A’s” of Pain Medicine • Analgesia, Activity, Adverse reactions, Aberrant behavior• Periodically Reassesing• Baseline/periodic UDS with opioid
  • Expanded Patient Aligned Care Team
  • PACT PACT teamlet MH Pharmacy Behavioral Health SUD PT/RCS/CAM Polytrauma SW/CM Chiropractic Pain SpecialistCreating the Veteran’s team
  • I need you to refill my painmedications, because I am almost outHow do you start?What do you say?
  • What’s in your toolbox?Know your tools and have them handy.
  • Start at the beginning… . Your most important tool is yourrelationship with the Veteran and your commitment to the best pain care.
  • VA/DoD opioid monitoring guidelines• Informed Consent• Visit Frequency• Effectiveness• Harms• Adherence
  • The expanded PACT works together to manage chronic pain• Collaboration of PCP, Pharm D, RN, PCMHI, PT/Rehab• All promoting self-management, goal setting• Pain school (self-management groups)• Group Medical Visits, Shared Medical Appointments(SMA)• Care management of pain and depression• Health Coaches/Health Behavior Coordinator
  • New Age of TelemedicineVA SCANat work
  • TELE PAIN
  • E-consults and phone consults
  • Pain Self-Management• Education – pain; vocabulary; red flags;• Identifying /modifying fears and beliefs• Goal-setting and problem-solving• Exercise – strengthening; aerobic; etc.• Relaxation; deep-breathing;• Handling pain flare-ups• Working with clinicians and employers
  • Staff Education and Tools
  • Standardization of Opioid Prescribing for PACT• Opioid pain agreement/informed consent/risk discussion• Chronic Pain on problem list• Risk evaluation tool• Random UDS(Urine Drug Screen)• 4 A’s on every visit• Opioid Renewal/Refill Clinics 53
  • Communication Tools• TEACH for Success• Motivational Interviewing
  • Stepped Care Approach to Musculoskeletal PainMedications • NSAIDS, topical analgesics • TCAs or gabapentin for neuropathic pain • muscle relaxants for spasm • Appropriate medications for co-morbid conditions such as PTSD/depression
  • Stepped Care Approach to Musculoskeletal PainEarly utilization of self management and non-pharmacological modalities • Pain school • Health psychology for relaxation training, biofeedback, cognitive behavioral therapy • Chiropractor • Acupuncture • PT/OT/KT for TENS, massage, exercise • CAM with MBSR, yoga nidra, yoga with movement, mindfulness meditation
  • Staff Education/Resources on Pain• Rural Health Series on PAIN TMS classes…Four 30 min trainings……• VISN 20 online education• Wiki• E-consult pilot• National Pain Meeting archives• OEF/OIF/OND National Sharepoint Archives• VA Pain site:http://www1.va.gov/painmanagement/
  • Patient Education and Tools
  • Action Plan1. Goals: Something you WANT to do Begin Exercise2. Describe How Walking Where Neighborhood What 20 min Frequency 3x/week When After dinner3. Barriers - Dishes, safety (no sidewalks)4. Plans to overcome barriers - get kids to clean up, ask neighbor or husband to join me, wear reflective vest5. Conviction and Confidence ratings (0-10) - 9/86. Follow-Up: Will keep log and bring to next visit in 1 month
  • Exercise Taking medications Physical TherapyDiet/Weight Loss Depression Psychological Strategies  Mindfulness Massage (RI Dept of Health Chronic Care Collaborative)
  • Pain School Schedule• Non-Opioid medications for pain• How to cope when you can’t cure• Health and healing through leisure/ living with pain• Opioids and pain management• Physical therapy: improving your pain and function• Pain management techniques to break the cycle of pain
  • But what if our PACT is a smallCBOC and we don’t have a painschool?• VTEL it in from your main facility or how about showing a YouTube!• Provide the Veteran tools to build self efficacy
  • 5 minute Patient Education
  • Mobile Applications
  • AFTERDEPLOYMENT.ORG
  • Karl and his Team have a Mission: the best pain careKarl and his Team have a PlanKarl and his Team are all trained to do their partsKarl and his Team work together and by doing so carry out the plan …and succeed in the mission!
  • Ask the Presenter
  • References and useful websites VA Pain site: http://www1.va.gov/painmanagement/ VISN 20 LMS: http://vhapugweb3/pain/ChronicPain/index.html www.painedu.org www.painedu.com www.globalrph.com www.jpain.org www.ampainsoc.org Dobscha SK et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA.2009;301(12):1242-1252 Kroenke K et al. Optimized antidepressant therapy and pain self- management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009;301(20):2099-2110