Pain Treatment and Medication Abuse in the Veterans Healthcare Administration

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Pain Treatment and Medication Abuse in the
Veterans Healthcare Administration
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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.
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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.
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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.
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VHA Directive 2009-053 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).
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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
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The following chart shows the number of
encounters ( contacts with providersvisits) 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.
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• 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

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• 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
  Veterans 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)

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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.
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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 Centers 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.
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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 veteranpersonally,
his family, his employment environment and his
recreational/social environment.
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What are some of your ideas?