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Military Workshop, National Rx Drug Abuse Summit, April 2-4, 2013. Lessons Learned from the U.S. Military's Pain Management Task Force presentation by Robert Kerns

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Military2 robert kerns

  1. 1. VHA   N ATIONAL   PAIN   M ANAGEMENT   STRATEGY   Implementa8on   o f   a   stepped   care   m odel   o f   pain   m anagement   ROBERT  D.  KERNS,  PH.D,  NATIONAL  PROGRAM  DIRECTOR  FOR  PAIN  MANAGEMENT  February 2012
  2. 2. Learning  Objec8ves  1.  Tell  an  overview  of  Pain  Management  Task   Force.  2.  Outline  similari8es  and  differences  with  pain   management  challenges  facing  Department   of  Defense  and  Veterans  Health   Administra8on.  3.  Iden8fy  best  prac8ces  of  pain  management   alterna8ves  from  the  Pain  Management  Task   Force.  
  3. 3. Disclosure  Statement  •  Robert  Kerns  has  no  financial  rela8onships   with  proprietary  en88es  that  produce  health   care  goods  and  services.    •  Kevin  Galloway  has  no  financial  rela8onships   with  proprietary  en88es  that  produce  health   care  goods  and  services.  
  4. 4. Pain  Management  is  a  priority    •  As  many  as  50%  of  male  VHA  pa8ents  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  se]ngs;  total  es8mated  cost  a^ributable   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  (Sinno^  &  Wagner,  2009)   4  
  5. 5. Frequency of Diagnoses1 among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans Diagnosis  (Broad  ICD-­‐9  Categories)a   Frequency   Percentb   Infec8ous  and  Parasi8c  Diseases  (001-­‐139)   144,167     16.0     Malignant  Neoplasms  (140-­‐209)   13,016     1.4     Benign  Neoplasms  (210-­‐239)   64,424     7.2     Diseases  of  Endocrine/Nutri8onal/  Metabolic  Systems  (240-­‐279)   302,719     33.6     Diseases  of  Blood  and  Blood  Forming  Organs  (280-­‐289)   36,899     4.1     Mental  Disorders  (290-­‐319)   486,015     54.0     Diseases  of  Nervous  System/  Sense  Organs  (320-­‐389)   415,543     46.2     Diseases  of  Circulatory  System  (390-­‐459)   198,140     22.0     Disease  of  Respiratory  System  (460-­‐519)   241,229     26.8     Disease  of  Diges8ve  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/ConnecBve  System  (710-­‐739)   519,721     57.8     Symptoms,  Signs  and  Ill  Defined  Condi8ons  (780-­‐799)   478,267     53.2     Injury/Poisonings  (800-­‐999)   267,407     29.7    1Includes  both  provisional  and  confirmed  diagnoses.  aThese  are  cumula8ve  data  since  FY  2002,  with  data  on  hospitaliza8ons  and  outpa8ent  visits  as  of  September  30,  2011;  Veterans  can  have  mul8ple    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.    bPercentages  reported  are  approximate  due  to  rounding.   5   Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2013  
  6. 6. Prevalence  of  Chronic  Pain,  PTSD  and   TBI:  sample  of  340  OEF/OIF  veterans   Chronic Pain PTSD N=277 N=232 81.5% 16.5% 68.2% 2.9% 10.3% 42.1% 6.8% 12.6% TBI 5.3% 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.
  7. 7. VHA  Pain  Management  Direc8ve   (2009-­‐053)  •  Objec8ves  of  Na8onal  Pain  Management  Strategy  •  Pain  Management  Infrastructure   –  Roles  and  responsibili8es  •  Stepped  Pain  Care  Model  •  Pain  Management  Standards   –  Pain  assessment  and  treatment   –  Evalua8on  of  outcomes  and  quality   –  Clinician  competence  and  exper8se   7  
  8. 8. Na8onal  Pain  Management  Strategy  Objec8ve  is  to  develop  a  comprehensive,  mul8cultural,   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.    8  
  9. 9. VHA  Na8onal  Pain  Management  Strategy   Infrastructure  •  Pain  Management  Program  Office   –  Specialty  Care  Services;  Pa8ent  Care  Services;  DUSH  for   Policy  and  Services  •  Na8onal  Pain  Management  Strategy  Coordina8ng  Commi^ee     –  Coordina8ng  Commi^ee  Working  Groups  •  VISN  Pain  Points  of  Contact  •  Facility  Pain  Points  of  Contact  •  Primary  Care  Pain  Champions  •  Pain  Resource  Nurses  •  VISN  and  Facility  Pain  Management  Commi^ees  9  
  10. 10. VHA  Stepped  Care  Model  for  Pain  Management  •  Single  standard  of  pain  care  for  VHA   –  Popula8on  based  approach   –  Timely  access  to  pain  assessment   –  State  of  the  art  treatment  and  follow-­‐up   –  Reliable  communica8on  and  care  management   –  Pa8ent  and  family  par8cipa8on    •  Empirically  supported  model   –  Von  Korff  et  al.  (2001).  Stepped  care  for  back  pain:  Ac8va8ng  approaches   for  primary  care.    Annals  of  Internal  Medicine,  134,  911-­‐917.   –  Dobscha  et  al.  (2009).  Collabora8ve  care  for  chronic  pain  in  primary  care.     Journal  of  the  American  Medical  Associa9on,  301,  1242-­‐1252.   –  Kroenke  et  al.  (2009).  Op8mized  an8depressant  therapy  and  pain  self-­‐ management  in  primary  care  pa8ents  with  depression  and   musculoskeletal  pain:  A  randomized  controlled  trial.    Journal  of  the   American  Medical  Associa9on,  301,  2099-­‐2110.  10  
  11. 11. Veteran-­‐Centered  Pain  Management  •  Informed  by  chronic  illness   model  •  Empowering  Veterans   through  reassurance,   encouragement  and   educa8on    •  Conserva8ve  use  of   analgesics  and  adjuvant   medica8ons  •  Promo8on  of  regular   exercise  and  healthy  and   ac8ve  lifestyle  •  Development  of  adap8ve   strategies  for  managing  pain  11  
  12. 12. Pa8ent  Educa8on  Ini8a8ves  •   Veterans  Health  Library   •   “ Taking  Opioids  Responsibly”   •   Krames  resources     •   Pa8ent/Family  Pain  Management    Educa8on  Toolkit  •   MyHealtheVet   • Pa8ent  Educa8on  Management    System  (PEMS)   • VISN  20  Chronic  Pain    Educa8on  for  Veterans   • Veterans  Pain  Management    Resource  Program  •   Pain  Coach  (Mobile  Pain  App)  12  
  13. 13.  Stepped  Care  Model  for  Pain  Management   Ter8ary  Interdisciplinary  Pain  Centers   Advanced  diagnos8cs  &  interven8ons   RISK   Commission  on  Accredita8on  of  Rehabilita8on   Facili8es  accredited  pain  rehabilita8on   Integrated  chronic  pain  and  Substance  Use   STEP   ComorbidiBes   Disorder  treatment   3  Treatment  Refractory   STEP   2   Primary  Care/Pa8ent  Aligned  Care  Teams  (PACTs)   Rou8ne  screening  for  presence  &  intensity  of  pain   Comprehensive  pain  assessment   STEP   Complexity   Management  of  common  acute  and  chronic  pain  condi8ons   1   Primary  Care-­‐Mental  Health  Integra8on,  Health  Behavior   Coordinators,  OEF/OIF/OND  &  Post-­‐Deployment  Teams   Expanded  nurse  care  management     Clinical  Pharmacy  Pain  Medica8on  Management   13   Opioid  Pain  Care  and  Renewal  Clinics
  14. 14. Implementa8on  ini8a8ves  •  OEF/OIF  Pain  Care  Enhancement  Ini8a8ve  •  Communica8on/educa8on  infrastructure   –  VA  Pain  List  Serve,     –  Na8onal  Pain  Management  Website  (   –  Monthly  Pain  Management  Leadership  Teleconference   –  Monthly  “Spotlight  on  Pain  Management”  webinar  (collabora8on  with   HSR&D  Center  for  Informa8on  Dissemina8on  and  Educa8onal   Resources  [CIDER]   –  Na8onal  Pain  Management  Leadership  Conferences   –  VA  Pharmacy  Pain  Management  Mentors    (VAPPMM)  Outlook   exchange    •  Clinical  Prac8ce  Guidelines   –  Opioid  Therapy  for  Management  of  Chronic  Pain   –  Peri-­‐opera8ve  pain  management   –  Dissemina8on  of  American  Pain  Society/American  Academy  of  Pain   Management  guidelines   14  
  15. 15. Implementa8on  Ini8a8ves  •  Web-­‐based  educa8on   –  General,  opioid  therapy  for  acute  and  chronic  pain,  polytrauma   –  Primary  Care  Rural  Health  Ini8a8ve  pain  management  courses  •  Post-­‐Deployment  and  Integrated  Care  Ini8a8ves   –  Pos^rauma8c  Stress  Disorder-­‐Trauma8c  Brain  Injury-­‐Pain  Prac8ce   Recommenda8ons  Consensus  Conference   –  PC-­‐MHI/HBC  ini8a8ves  •  Nursing   –  Veteran  Affairs  Nursing  Outcome  Database  Nursing  Assessment  and   Reassessment  Ini8a8ve  (ini8al  focus  on  management  of  acute  pain  in   inpa8ent  se]ngs)   –  Pain  Resource  Nursing  (PRN)  Ini8a8ve  •  Pharmacy   –  Na8onal  Clinical  Pharmacy  Pain  Management  Training   –  Opioid  Pain  Care  Clinics  Central  Repository  15  
  16. 16. Implementa8on  Ini8a8ves  •  Telehealth   –  Telebehavioral  Pain  Management   –  Mobile  Pain  App  •  Pain  Medicine     –  Capacity  for  specialty  pain  medicine  diagnos8cs  and  interven8ons  •  Mental  Health     –  Evidence-­‐Based  Psychotherapy   –  Capacity  for  pain  management  in  Substance  Use  Disorders  programs   –  Capacity  for  pain  management  in  PTSD  treatment  se]ngs  •   Externship  training  at  James  Haley  Veterans  Hospital   –  Interdisciplinary  pain  management     –  CARF  accredited  pain  rehabilita8on  16  
  17. 17. Promo8ng  safe  and  effec8ve  use  of  opioids  •  Opioid  –  High  Alert  Medica8on  Ini8a8ve    •  CPG  on  Management  of  Opioid  Therapy  for  Chronic   Pain  •  TMS:  Opioid  Therapy  for  Acute  and  Chronic  Pain      •  Pharmacy  Benefits  Management  Ini8a8ves  and   Clinical  Guidances  •  Direc8ve  and  Clinical  Considera8ons  regarding   state-­‐authorized  use  of  marijuana  •  Implementa8on  of  Na8onal  Prescrip8on  Drug   Control  Policy  •  Opioid  Safety  Ini8a8ve  •  Par8cipa8on  in  State  Prescrip8on  Drug  Monitoring   Programs  •  Signature  Informed  Consent   17  
  18. 18. 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  consulta8on  services   and    support   •  Provide  case-­‐based  learning   modules  to  improve  core   competencies  and  provider   sa8sfac8on   •  Facilitate  referrals  to  ter8ary  care   centers  when  indicated   •  Ul8mately  to  improve  veteran   access  to  specialty  care  and   treatment  outcomes   18  
  19. 19. HEC  PMWG:  Objec8ves/Ini8a8ves  •  DoD/VHA Core Pain Curriculum / •  PASTOR/PROMIS Training •  DVPRS•  Collaboration with NiH CoEPES •  CREATE•  ECHO / SCAN-ECHO•  Phone Apps for patient & for provider Standardize Deliver•  Tiered acupuncture training Education and Measurement and treatment Training Based Care Function Readiness•  Opioid Risk Strategy •  COT – CPG Ensure Patient Establish •  Stepped Care Model •  Opioid Risk Tools Consistent •  Interdisciplinary PC / PACT Safety •  Urine Drug Screening / Model of Care Pain Champions & Teams Reporting •  Pain Medicine Specialty•  Integration of non-medication support for Primary Care modalities (PCMH)•  Patient Safety Videos •  Pain Rehabilitation•  Joint Suicide Prevention Initiative
  20. 20. Joint  Educa8on/Training  Program  (JPEP)   VA/DoD  HEC  Pain  Management  Working  Group   VHA  Pain   Management  (PACT)   VHA/DOD   DOD  Pain   Strategic  Oversight   CommiTee   HEC   Management   JIF  Joint  VA/ Pain  EducaBon   DOD  Pain   Advisory  Team   EducaBon  Community  of   PracBce   Pain  Management   CoordinaBng   EducaBon  and   Workgroup   Training     Facility  Pain   Workgroup   Champions   CoordinaBng   Workgroup   Training  Program  Community  of   Facility  Pain   PracBce   Champions   i.e.  PCP/RNCM   Facility/VISN  Monthly  Calls   Team,  facility  SME   Pain  Team   PACT  
  21. 21. Healthcare  Analysis  Informa8on  Group  2010   VHA  Pain  Management  Survey  Results  •  100%  of  facili8es  have  pain  management  policies  •  100%  of  Veterans  Integrated  Service  Network  (VISN)  and  95%   of  facili8es  have  iden8fied  Pain  Points  of  Contacts  (POCs)  •  54%  of  facili8es  iden8fied  a  primary  care  pain  champion  •  96%  of  facili8es  have  mul8disciplinary  pain  commi^ees   21  
  22. 22. Healthcare  Analysis  Informa8on  Group  2010  VHA   Pain  Management  Survey  Results   100%   80%   60%   40%   20%   0%   22  
  23. 23. Specialty  Pain  Care  Capacity  •  100  %  of  VISNs  have  specialty  pain  clinics  •  91%  of  facili8es  have  dedicated  pain  clinics   FY  2010   FY  2011   FY  2011   FY  2012   %  Change   %  Change   (thru  2nd   (thru  2nd   FY11  Q2     FY  2010   quarter)   quarter)   –                -­‐   FY12  Q2   FY  2011  Encounters      333,447   374,880   179,352   199,485   11.2%   12.4%  Unique  Pa8ents   100,833   108,874   71,575   78,209   9.3%   8.0%   23  
  24. 24. Building  Capacity  for  Ter8ary,  Interdisciplinary  Pain   Centers  •  VHA  Pain  Direc8ve  requires  every  VISN  to  have  a  ter8ary   interdisciplinary  pain  center  by  September  2014  •  VISN  Directors  survey  in  December  2011   –  19  VISNS  report  mee8ng  standard  for  advanced  pain  medicine   diagnos8cs  and  interven8ons;  2  have  yet  to  iden8fy  site  •  Most  recent  data  on  Commission  for  Accredita8on  of   Rehabilita8on  Facili8es  (CARF)   –  7  VISNs  report  having  CARF-­‐accredited  pain  rehabilita8on   programs;  10  have  applica8ons  pending  24  
  25. 25. Pain  Research  –  FY  2012  •  61  pain-­‐related  Office  of  Research   •  Basic  mechanisms  underlying  pain   and  Development  funded  research   •  Pain  diagnosis     projects   •  Preclinical  studies    •  $11.9  million  for  pain-­‐relevant   •  Pain  management  (medica8ons;   research   psychosocial  interven8ons)    •  Pain  Research  Working  Group   •  Co-­‐morbidi8es    •  Health  Services  Research  and   •  Quality  of  Life  (QOL),  compara8ve   Development  Pain  Research  Center   effec8veness;  bioinforma8cs;   funded  (PRIME  Center)   dispari8es    •  Partnerships  with  Na8onal  Ins8tute   •  Training  (career  development)   of  Health/Department  of  Defense   25  
  26. 26. FY  2013  Priori8es  •  Opioid  Safety  Ini8a8ve,  and  other  opioid  therapy  ini8a8ves  •  Pain  and  Primary  Care  ini8a8ves;  Joint  Incen8ve  Fund  Ini8a8ve  •  Specialty  Care  Services  Transforma8on  Ini8a8ves,  especially  SCAN-­‐ECHO  •  Guidance  for  Ter8ary,  Interdisciplinary  Pain  Centers  •  Publica8on  of  acute,  peri-­‐opera8ve  pain  management  guideline    •  Capacity  for  behavioral  services  in  PACT  •  Pa8ent  Educa8on  Ini8a8ves  •  Provider  Educa8on  Ini8a8ves  •  Nursing  ini8a8ves  •  Health  Execu8ve  Council  Pain  Management  and  VA-­‐DoD    ini8a8ves   26