Pain Treatment and Medication Abuse in the Veterans Healthcare Administration

As the topic of this conference addresses, Traumatic Brain Injury is perhaps the signature injury associated with the different battlegrounds of the War on Terror. However, as most of you associated with the treatment of veterans realize, the co-morbid conditions that frequently accompany TBI is Post Traumatic Stress Disorder and substance abuse. Less well discussed, though just as prevalent as TBI, is acute and chronic pain among OEF/OIF veterans. These three conditions are unique in that their close association involves the same etiology for TBI and PTSD, while the substance abuse, particularly medication abuse and addiction, has a different etiology.

The experience of chronic pain is intensified by the symptoms of TBI and PTSD and may be a major contributor to depression among veterans. All three have the effect of limiting the recreational, vocational and social activities of veterans who prior to their combat experience had a significantly greater range of life experiences and options in each area.

There is in the civilian arena on-going debate of the efficacy of opiate pain medication as an effective treatment modality for chronic pain. This is also a very poignant topic within the Department of Defense and the Veterans Administration. The Veterans Healthcare Administration is committed to the wellbeing of the “whole Veteran”, including effective treatment of chronic pain issues.

VHA Directive provides direction for the Veterans Medical Centers to provide effective and clinically appropriate pain management services to all veterans with legitimate pain issues. This directive states: “ The overall objective of the national strategy is to create a comprehensive, multi-cultural, integrated, system wide approach to pain management that reduces pain and suffering and improves the quality of life for Veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness. The VHA employs a wide range of stepped-care model of pain care that provides for the management of most pain conditions in a Primary Care setting. This is supported by timely access to secondary consultation from pain medicine, behavioral medicine, physical medicine and rehabilitation, specialty consultation, and care coordination with palliative care, tertiary care, advanced diagnostic and medical management and rehabilitation services for complex cases involving co- morbidities such as mental health disorders and traumatic brain injury (TBI).”

The use of addictive pain medication, particularly opioid pain medication has been the primary means of pain management for a significant period of time, particularly on the battlefield where it is perhaps the most effective, immediate and most easily administered form of pain medication. Opioid pain medication is also the least costly and remains the primary pain medication modality with in the Department of Defense health care arena. Many OEF/OIF veterans are discharging from the armed services and enrolling with the VA already having been put on an opioid pain medication regimen for some period of time. As should be evident from this seminar already, the symptomology of TBI and PTSD make adhering to a strict prescribed pain medication regimen difficult for many Veterans and perhaps even unlikely if they experience significant mental health, social and economic challenges and hardships upon their return to civilian life. Part of the problem resides in the confusion of how to treat acute pain versus chronic pain. Opiates are a first line in treating acute pain but are only one of multiple options for chronic pain. The lack of understanding of the difference in acute pain versus chronic pain is a large part of how we got here and why opiate prescription is so high. Physicians are trained in acute pain but not necessarily in chronic pain. The goals of treatment of acute pain is to make the pain go away but the goals of treatment of chronic pain is to improve quality of life, better physical functioning

The following chart shows the number of encounters ( contacts with providers— visits) and the number of unique Veteran patients treated for active pain problems at the main Muskogee VA Medical Center, as well as the Outpatient Clinics in Tulsa, Vinita and Hartshorne. The most startling statistic is the percentage of all individual veterans seen at each facility that have active pain problems. These percentages are for all veterans, not just OEF/OIF Veterans. The higher percentages at Muskogee and Tulsa are due to the availability of specialty services available there which are not available at this time at Vinita and Hartshorne.

ACTIVE PATIENTS (SEEN IN PAST 24 MONTHS) Division# Unique Encounters McAlester2299 Muskogee46681 Tulsa28514 VINITA CBOC1873 UNIQUE PATIENTS WITH ACTIVE PAIN PROBLEMS WITHIN LAST 12 MONTHS Division #Unique Patients # OF Pain Problems Pain Problems per Unique Pt McAlester Muskogee Tulsa VINITA CBOC

The Jack C. Montgomery VA Medical Center has undertaken an initiative to address these significant pain issues of our veterans. The establishment of a comprehensive Pain Management Clinic composed of a multi-disciplinary team is one of the FY 11 strategic goals for the Medical Center. The initial proposal by an existing Pain Management Committee includes the following: A Multidisciplinary Team composed of: Anesthesiologist for specialized injections Physician or Nurse Practitioner with Pain Management training Pain Psychologist RN Physical Therapist Medical Social Worker Clinical Pharmacist Occupational Therapist Recreational Therapist Administrative Support Assistant

A comprehensive program that is focused on patient centered care and patient goals and would potentially include such treatments as: Comprehensive pain and physical evaluations in a timely manner Coordination of needed tests or studies Development of a comprehensive treatment plan Education of primary care providers on the Veteran’s Treatment Plan Development of monitoring outcomes of the pain treatment plan Documentation of pain control/management Pain Medication Management Reiki therapy Acupuncture MOVE Program for weight control and fitness Biofeedback Injection Clinic Pain Psychology Therapy Group Therapy: Cognitive Behavioral Pain therapy; Relaxation Group; Problem Solving and Goal Setting Group; ACT for pain group; Yoga for pain Group. Physical Therapy Occupational Therapy Hydro Therapy( whirlpool and endless pool-swimming) Substance (Medication included) Abuse/Addiction education, therapy and Relapse Preventions

This model represents the Biopsychosocial Model and it is different in that it changes the emphasis from simply alleviating pain and focuses on eliminating suffering. The pain is not ignored, rather the other factors influencing the experience suffering versus a quality of life are addressed, i. e.: fear of pain or re- injury; physical de-conditioning; fatigue; adverse effects of medication; the influence of other and the unwillingness of the workplace to help with accommodations for disability; the loss of income; reduction of pleasant activities; social isolation; fears of physical incapacitation; fears of or experience of strain/loss of relationships; fears of loss of productivity and fear of being incapacitated psychologically.

The imperative for an active pain management program to alleviate Veterans suffering is further intensified by the fact that the in the last two Annual Suicide Aggregate Root Cause Analysis Reviews conducted by the Jack C. Montgomery VAMC have clearly revealed that the number one method of suicide attempt by Veterans in our catchment area was by overdose on prescribed pain medication. Also, the number of suicide attempts for the Jack C. Montgomery VA Medical Center’s catchment area was second in our VISN (Region) to Houston VAMC by only a few attempts. Furthermore, a recent national study revealed that Oklahoma led the nation in prescription medication abuse. These facts clearly indicate a problem of major significance that impacts all Oklahoma communities. To think that the VA alone can meet the needs of Veterans with these issues lacks understanding since the Veterans are residing in a local social environment that is experiencing the same issues as the Veterans. To meet the needs of Veterans and to truly effect a positive readjustment to civilian life, we must have available treatment for the veterans, their families and social relationships.

The VA is committed to the development of collaborative efforts with state and local agencies to address these issues. While the VA is currently beginning to reverse the past policies of treating veterans only by beginning to offer services to the families of veterans, the process of gearing to do that effectively is slow. There seems to be great opportunity for the VA to collaborate with community agencies and programs in addressing the supplemental needs of Veterans (i.e. peer support mentors) and in serving the families of veterans. There are some community resources that perhaps have not been fully developed, but who have a history of past collaboration, examples are Veterans Service Organizations, local pastors and Pastor Alliances. There are many new collaborative relationships that can be developed that will enable us to serve the “whole” veteran—personally, his family, his employment environment and his recreational/social environment.

What are some of your ideas?