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Pain and Addiction Care: VA’S TRANSFORMATION & ITS IMPACT ON NON-VA

CLINICIANS

Charlotte Bailey, DPT

Acknowledgements and Disclosures

I do not have any financial relationships to disclose.

I do not authorize commitments for government purchases.

This presentation was prepared as an individual acting in a personal capacity. The opinions expressed in this continuing education session are the author's own and do not reflect the view of the Iowa City VA Health Care System, the Department of Veterans Affairs, or the United States government.

Some graphs/graphics included here are elements provided through national VA resources including Pharmacy Benefits Management.

One VA

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With Implementation of the Mission Act

High Risk Veterans have more options

to choose Care in the Community

Your Clinic/Health Care System may become their medical home.

You May Be Their Lifeline!

Veterans Crisis Line 1-800-273-8255 Press 1,

send a text message to 838255,

or chat online

Everything ChangedJune 2019

VHA Directive 2009-053

Stepped Care Update

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Supporting Primary CareWork as a team to address pain-perpetuating comorbidities.

Image of non-pharmacologic treatments from PBM Academic Detailing (2017)11

Understanding Complex Pain:Neurophysiology Education, Inter-professional Care Planning, and Multimodal Pain Treatments can help.

Paced rehabilitation activities to improve capacity for movement in the home and in the community.

Engaging in personal goal-setting, prioritizing and planning for a better quality of life.

Transition toward more effective and ACTIVE self-management of multiple health conditions including chronic pain.

Interdisciplinary Care:Complex Conditions rarely have Simple Solutions

Six Essential Elements of Good Pain Care

1. Educate Veterans/families to promote self-efficacy and shared decision

making; provide access to all relevant resources

2. Educate/train all team members to their discipline specific competencies,

including team based care

3. Develop and integrate non-pharmacological modalities into care plans

4. Institute evidence based medication prescribing, use of pain

procedures and safe opioid use (universal precautions)

5. Implement approaches for bringing the Veteran’s whole team together

such as virtual pain consulting (SCAN-ECHO, e-consults, tele-health,

clinical video tele-consultation and education) and for maintaining ongoing

communication between team members

6. Establish metrics to monitor pain care and outcomes at both the

individual level and the population level

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Explain Pain Supercharged

VA Whole Health

https://www.va.gov/patientcenteredcare/about.asp

US Military Model of Health

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It’s Complicated!

Treat Pain By (almost)Any Means Necessary

Image of non-pharmacologic treatments from PBM Academic Detailing (2017)

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Transforming VA Pain Care

• VA has taken strong steps to improve the quality of pain care for Veterans

• They have invested resources in moving toward multimodal evidence-based care– Expanded access to interdisciplinary care teams

– Increased availability of integrative health services and non-pharmacologic therapies

– Developed resources for clinicians with a major emphasis on opioid safety

• PACT PAIN ROADMAPhttp://vaww.va.gov/PRIMARYCARE/components/Welcome_to_the_PACT_Roadmap.asp

More Care Isn’t Enough

• Health Care Spending is Rising– Added services, more referrals per capita cost

– Options without guidance on how to match treatment strategies to the nature of the pain problem increase variability in care

• Patients are Still In Pain and

They Don’t Understand Why– Beliefs influence care-seeking behaviors

– Some of our patients struggle to shift to active lifestyle-based care for pain or any health issues

Our Messages/Their Pain Story

• Explaining pathology and procedures can worsen pain

– May leave patients with more fear, anxiety, stress

– Can worsen catastrophization

• The three most common and influential factors predicting progression from acute to chronic pain – Catastrophizing (viewing pain as a serious threat

to health and functioning)

– Fear Avoidance

– Depressed Mood (associated with increased pain, lower pain tolerance, & reduction in QoL)

Acute Pain Management: Meeting the Challenges

VA Pharmacy Benefits Management

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Explain Pain Supercharged

Saenger, APA PCSS-O Webinar Series, Evidence CAM LBP, 2013

Integrated Care in the Pain Crisis:

http://vaww.va.gov/PAINMANAGEMENT/docs/CIM_CAM_MH_INNOVATIONS_Pain_4_23_13.pdf

Towards therapies:Safe andModerately effective andActive / Self-Care:

Away from therapies:Dangerous orIneffective orPassive:

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Adapted from: Saenger, APA PCSS-O Webinar Series, Evidence CAM LBP, 2013

Thriving Veteran viaACTIVE SELF-CAREDeep BreathingProgressive RelaxationSelf MassageProgressive Exercise“Mindful Movement”:- Alexander Technique- Yoga / Tai Chi / Qi Gong- PT Neuromuscular Rehabilitation

& Therapeutic ExerciseMindfulness Training Mindfulness-Based Stress ReductionCBT or ACT for Pain

AWAY FROM:

High Dose OpioidsBenzodiazepinesChronic “Muscle Relaxants”Chronic “Sleep Medications”Some InjectionsSome Surgery

Image from Pain Neuroscience Education, Louw (2018)

Every Knee Has a Brain• A significant portion of patients with OA have central

(processing) mechanisms contributing significantly to their pain.

• Consider how that difference in mechanism might impact surgical outcomes… your PT outcomes– Is “slow movement” an option?

– More Complex & Mindful Movement!

– Plan to improve “Body Sense”, position sense, laterality, localization

– https://www.psychologytoday.com/us/blog/body-sense/201007/slow-movement-awareness-better-exercise

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EncouragingMultimodal Care

Biofeedback

Guided imagery

Meditation

Group Therapies and Socialization

Adapted from Explain Pain Supercharged

Science Brings Hope

• For Veterans in Pain

• For Frustrated Clinicians

• For Health Care Systems– To improve patient satisfaction

– Preventing harm with well-prepared teams

– Reduce unnecessary variation in care• Identify and treat patients with “red flags”

• Recognize and address “yellow flags”

• Better matched/stratified care reduces waste

• Standardizing best practices to improve outcomes

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Room To ImproveDistress is still driving prescribing & referralsImage from Seal (2012)

Transforming the Treatment of Chronic Pain: Moving Beyond Opioids;

VA Pharmacy Benefits Management

What’s NextCloser Looks at Suicide Risk, Addiction, and

Stepped Care for Opioid Use Disorder

• Almost 4 out of every 5 patients who died from overdose/suicide were prescribed doses < 90 MEDD• Almost 3 out of every 4 overdose/suicide deaths were among patients with MH/SUD diagnoses• More than 1 out of every 2 deaths were among patients with MH/SUD diagnoses prescribed < 90 MEDD

CARA and Access toMedication Assisted Therapy

University of Iowa College of Medicine Newsletter

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Resources for Suicide Prevention

• “Never Worry Alone” introduces VA’s free risk management consultation: 3 minute video https://youtu.be/JUA91AICGyA

• American Academy of Addiction Psychiatry

https://www.aaap.org/va-offers-free-suicide-risk-management-to-providers/

• VA REACH VET Initiative Helps Save Veterans Lives– Recovery Engagement and Coordination for Health –

Veterans Enhanced Treatment (REACH VET).

– Using a new predictive model, REACH VET analyzes existing data from Veterans’ health records to identify those at a statistically elevated risk for suicide, hospitalization, illness or other adverse outcomes.

• Veterans Crisis Line website: VeteransCrisisLine.net/BeThere

Suicide prevention outreach toolkit: VeteransCrisisLine.net/SpreadTheWord

“Be There” public service announcement: http://bit.ly/BeTherePSA

Suicide prevention fact sheet: http://bit.ly/2axW88D

Make the Connection website: http://MakeTheConnection.net

VA Mental Health website: http://www.mentalhealth.va.gov

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Back to the Mission Act

• Nationally mandated Standard Episodes of Care– For PT

– For OT

– For Pain