Operation Enduring Freedom/Operation
I i Freedom
Iraqi
F d
Returning
R t i Veteran
V t
Issues:
I
VHA National Pain Management
g
Strategy
gy
Robert D. Kerns, Ph.D.
Director, Pain Research, Informatics, Medical comorbidities, and Education Center,
VA Connecticut Healthcare System
National Program Director for Pain Management, Veterans Health Administration
Professor of Psychiatry, Neurology and Psychology, Yale University
VHA National Pain Management
Strategy
gy
Objective is to develop a
comprehensive,
comprehensive
multicultural, integrated,
system--wide
system
syste
de approach
app oac to
pain management that
reduces pain and
suffering for veterans
experiencing acute and
chronic pain associated
with a wide range of
illnesses,, including
g
terminal illness.
VHA National Pain Management
g
Strategy
gy
Research as a priority




Pain Research Working Group
Theme based cluster groups
600% increase in pain research portfolio since 2000
Special issues:





Journal of Rehabilitation Research and Development
Pain
P i Medicine
M di i
Psychological Services
Pain Research Summits (2007, 2009)
Pain Research,, Informatics,, Medical comorbidities
and Education (PRIME) Center
Frequency of Possible Diagnoses Among
OEF and OIF Veterans
Diagnosis
(Broad ICD
ICD--9 Categories)
(n = 400,304)
Frequency *
%
Infectious and Parasitic Diseases (001(001-139)
Malignant
g
Neoplasms
p
(140--208))
((140
Benign Neoplasms (210
(210--239)
Diseases of Endocrine/Nutritional/ Metabolic Systems (240(240-279)
Diseases of Blood and Blood Forming Organs (280(280-289)
Mental Disorders (290(290-319)
Diseases of Nervous System/ Sense Organs (320
(320--389)
Diseases of Circulatory System (390(390-459)
Disease of Respiratory System (460(460-519)
Disease of Digestive System (520(520-579)
Diseases of Genitourinary System (580(580-629)
Diseases off Skin
S
(680-709)
(68009)
Diseases of Musculoskeletal System/Connective System (710(710-739)
Symptoms, Signs and Ill Defined Conditions (780(780-799)
Injury/Poisonings (800(800-999)
49,272
3,988
,
17,274
93,028
9,677
178,483
146 611
146,611
68,295
83,771
129,656
44,812
67,384
6 38
197,078
167,959
92,023
12.3
1.0
4.3
23.2
2.4
44.6
36
36.6
6
17.1
20.9
20.9
32.4
11.2
16
16.8
8
49.2
49.2
42.0
23.0
*These are cumulative data since FY 2002, with data on h
hospitalizations
ospitalizations and outpatient visits as of September 30, 2008;
veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single
diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 400,304.
Cumulative thru 4th Quarter FY2008
Pain Assessment and Pain
Characteristics byy Sex
Female
n=18,481
Male
n=134,731
P value
Pain Assessment
60.1%
59.6%
0.247
Any pain
38.1%
44.0%
<0.0001
Moderate pain
68.0%
62.6%
<0.0001
Persistent pain
18.0%
21.2%
<0.0001
Haskell SG, Brandt C, Krebs EE, Skanderson M, Kerns R,
Goulet JL.
JL Pain among Veterans of Operations Enduring
Freedom and Iraqi Freedom: Do Women and Men Differ? Pain
Med. 2009 Oct;10(7):1167-73.
Prevalence of Chronic Pain, PTSD and TBI in a sample of
340 OEF/OIF veterans
Chronic
Pain
N=277
81 5%
81.5%
16.5%
10.3%
2.9%
PTSD
N=232
68.2%
42.1%
12.6%
TBI
N=227
66.8%
6.8%
5.3%
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.
VA Stepped Pain
Care RISK
RISK
Advanced diagnostics &
interventions
CARF accredited pain
rehabilitation
STEP
3
Comorbidities
Treatment
Refractory
Complexity
Pain Medicine
Rehabilitation Medicine
Behavioral Pain Management
Multidisciplinary Pain Clinics
SUD Programs
Mental Health Programs
Routine screening for presence & intensity of pain
Comprehensive pain assessment
Management of common pain conditions
Support from MH-PC Integration, OEF/OIF, &
Post Deployment Teams
Post-Deployment
Expanded care management
Opioid Renewal Clinics
STEP
2
STEP
1
Donaghue/Mayday
Donaghue/Mayday
Program
g
for Research Leadership
p
Study Tasks
Intervention Development
Implementing a VA SCM-PM


Studyy Goal: To studyy the adoption
p and implementation
p
of SCM-PM at VACHS and disseminate findings nationally
Study Aim 1: To evaluate the implementation of the
SCM-PM at VACHS using qualitative and quantitative
methods (process).
(process)



Aim 1a: To evaluate implementation of SCM-PM through
documentation of changes in pain management policies and
procedures.
Aim 1b: To evaluate the experience of organizational change and
acceptability of the new model to VACHS pain management
providers through qualitative interviews and organizational
assessments.
Study Aim 2: To test the effectiveness of the SCM
SCM-PM
PM
at VACHS
Retrospective Baseline
Assessment
Phase 1
SCM step 1: Primary Care
Phase 1
Evaluation/Dissemination
Phase 2
SCM steps 2 & 3:
secondary and tertiary
consultation and referral
services
Phase 2
Evaluation/Dissemination
Phase 3:
Model integration and
sustainability
i bili
Phase 3:
Evaluation/Dissemination
y
Data Analysis
Knowledge Uptake
Processes
Year 1
Year 2
Year 3
Year 4
Pain Management: Exploring Primary Care Providers
Attitudes, Knowledge, and Practices

Research questions:



1) What are primary care providers’ attitudes, beliefs, and knowledge about pain
management?
2) Is
I there
th
a relationship
l ti
hi between
b t
provider
id characteristics,
h
t i ti
knowledge
k
l d and
d beliefs
b li f regarding
di
pain management and their patterns of opioid use and adherence to practice guidelines
Methods: mixed methods using survey tools and administrative data sets
K
Knowledge
l d
Provider demographics
Beliefs/attitudes
F
Frequency
off opioid
i id use
Cohort of
pts with
chronic
pain
Adherence to practice
standards
d d
Pain scores
Promoting safe and effective
use of opioids
p


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Opioid – High Alert Medication
Initiative
 Opioid Renewal Clinic
 Collaborative Addiction and
Pain (CAP) Program
 Opioid Decision Support
System
Chronic Opioid Therapy –
Clinical Practice Guideline
O
Opioid
d Therapy
h
Web
b Course
C
Standardized Opioid Pain Care
Agreement
g ee e t
Behavioral Health Lab: Clinical Process
Veteran Identification
Screens/ Direct referral
Pain
Education
provided
BHL Initial
Assessment
Provider
Recommendations
Referral to
MHC or pain
clinic
Referral
Management
Care Management
(&/or pain school)
Pain, Depression,
Anxiety, Alcohol misuse
No treatment
&
Refusal of care
Dobscha et al. Collaborative care for chronic pain in primary care.
JAMA 2009;301:1242
2009;301:1242--1252.
1252



Assistance with Pain Treatment
(APT) vs Treatment as Usual
(TAU)
42 primary care clinicians/401
patients
Measures:


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
Roland Morris Disabilityy Questionnaire
Chronic Pain Grade – Pain Intensity
Patient Health Questionnaire - 9
APT:
 Clinician education
 Pt assessment, education &
activation
 Symptom monitoring
 Feedback and
recommendations
 Facilitation of specialty care
Change from baseline to 12 mo f.u.
0
‐1
RMDQ CPG‐ PI PHQ‐9
‐2
‐3
3
TAU
‐4
APT
‐5
SCAMP Trial
Kroenke K,
K Bair MJ
MJ, Damush TM et al
al. Optimized antidepressant
treatment and pain selfself-management in primary care patients with
depression and musculoskeletal pain: A randomized controlled trial.
JAMA 2009;301:2099
2009;301:2099--2110.
Intervention
Usual Care
SCL-20 Depressio
on
2.5
2
1.5
1
0.5
0
Baseline
1 month
3 months 6 months 12 months
Time Period
Summary



Pain-relevant research is a high priority for
VHA (and DoD)
Specific focus on ‘P3+’
P3+ comorbidities
among OEF/OIF Veterans
I l
Implementation
i and
d formative
f
i evaluation
l i
of stepped
pp pain
p
care model
Thanks!
robert.kerns@va.gov