Senate Veterans’ Affairs Committee Hearing

Good morning, Chairman Sanders, Ranking Member Burr, and Members of the Committee. Thank you for the opportunity to participate in this hearing and to discuss the Department of Veterans Affairs' (VA) pain management programs and the use of complementary and alternative medicine. I am accompanied today by Dr. Tracy Gaudet, Director of Office of Patient Centered Care & Cultural Transformation, and Dr. Peter Marshall, Director of Primary Care Pain Management.

The challenges related to living with chronic pain and providing safe and effective pain care are by no means unique to Veterans and the VA health care system. As described in the 2011 Institute of Medicine (IOM) report, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" n1, pain is a public health challenge that affects millions of Americans and is increasing in prevalence. Pain contributes to morbidity, mortality, and disability across our Nation and the costs of pain can be measured both in terms of human suffering as well as economic impact. The IOM estimated that chronic pain alone affects 100 million United States citizens and that the cost of pain in the United States is at least $560-$635 billion each year, which is the combined cost of lost productivity and the incremental cost of health care.

Chronic Pain in Veterans

The burden of pain on the Veteran population is considerable. We know that Veterans have much higher rates of chronic pain than the general population, with more than 50 percent of all Veterans enrolled and receiving care at VA affected by chronic pain. n2 Chronic pain is the most common medical problem in Veterans returning from the last decade of conflict (almost 60 percent). n3 Many of these Veterans have survived serious and at times catastrophic injuries frequently a result of road-side bombs and other blast injuries. These events can result in multiple physical traumas including amputations and spinal cord injuries as well as concomitant psychological trauma which can compound chronic pain concerns. Often these Veterans require a combination of strategies for the effective management of pain, which may include treatment with opioid analgesics. That makes pain management a very important clinical issue for VA. Further, the treatment of pain is highly complex, and in the recent past, health care providers have often been accused of undertreating the pain that patients suffer. Getting the balance right is a challenge that we continue to work towards.

In 2010, VA and the Department of Defense (DoD) published evidence-based Clinical Practice Guidelines for the use of chronic opioid therapy in chronic pain. The guidelines reserve the use of chronic opioids for patients with moderate to severe pain who have not responded to, or responded only partially to, clinically indicated, evidence-based pain management strategies of lower risk, and who also may benefit from a trial of opioids to improve pain control in the service of improving function and quality of life.

We also know that the long-term use of opioids is associated with significant risks, and can complicate health care for Veterans with Posttraumatic Stress Disorder (PTSD), depression, Traumatic Brain Injury (TBI) and family stress - all common in Veterans returning from the battlefield, and in Veterans with substance use disorders. Chronic pain in Veterans is often accompanied by co-morbid mental health conditions (up to 50 percent in some cohorts) caused by the psychological trauma of war, as well as neurological disorders, such as TBI caused by blast and concussion injuries. In fact, one study documented that more that 40 percent of Veterans admitted to a polytrauma unit in VHA suffered all three conditions together - chronic pain, PTSD, and post-concussive syndrome. n4 posttraumatic stress disorder, and post-concussive syndrome in OEF/OIF veterans: The polytrauma clinical triad. Journal of Rehabilitation Research and Development, 46, 697-702.

In addition to these newly injured Veterans suffering from chronic pain conditions and neuropsychological conditions, VA cares for millions of Veterans from prior conflicts, who along with chronic pain and psychological conditions resulting from their earlier combat experiences, are now developing health concerns related to aging, such as cancer, neuropathies, spinal disease, and arthritis, all of which may be accompanied by chronic and at times debilitating pain. All of these Veterans deserve safe and effective pain care that may include the use of opioid analgesics when clinically appropriate.

Thus, VA cares for a population that suffers much higher rates of chronic pain than the civilian population, and also experiences much higher rates of co-morbidities (PTSD, depression, TBI) and socioeconomic dynamics (family stress, disability, joblessness) that contribute to the complexity and challenges of pain management with opioids. n5 So even as more Veterans have the kind of severe and disabling pain conditions that require stronger treatments such as opioids, so do more of them have increased risk for overdose complicated by depression, PTSD and substance use disorders.

In recognition of the seriousness of the impact of chronic pain on our Veterans' health and quality of life, VHA was among one of the first health systems in the country to establish a robust policy on chronic pain management and to implement a system-wide approach to addressing the risks of opioid analgesia.

I would like to at this time outline our approach to this pain care transformation. I will highlight VA's current pain management strategies as well as actions being taken to improve the management of chronic pain, including the safe use of opioid analgesics, the prevalence and use of opioid therapy to manage chronic pain in high risk Veterans, the challenges of prescription drug diversion n6 and substance use disorders among Veterans, and efforts being made to broaden non-pharmacological approaches to pain care. I will also describe some of the best pain care practices across the VA health care system.

VA's Pain Care Mission

VA's mission relative to pain care is simple: safe and effective pain care to enhance the quality of life and satisfaction of all Veterans living with chronic pain.

VA's concept of safe and effective pain care includes the following six essential elements:

1. Education of Veterans and family members about good pain care;

2. Education of the treatment teams about good pain care;

3. Developing non-pharmacological and self-management approaches;

4. Safe and evidence-based use of all interventions and medications, including opioids;

5. Developing effective modalities for bringing pain care specialty expertise to the Veteran; and

6. Monitoring pain care efficacy at the individual and system level.

As a blueprint for implementing these principles throughout the system, n7 VHA Pain Management Directive 2009-053 n8 was published in October 2009 to provide uniform guidelines and procedures for providing pain management care. These include standards for pain assessment and treatment, including use of opioid therapy when clinically appropriate, for evaluation of outcomes and quality of pain management, and for clinician competence and expertise in pain management. Since publication of the Pain Management Directive, a dissemination and implementation plan has been enacted that supports the following:

. Comprehensive staffing and training plans for providers and staff;

. Comprehensive patient/family education plans to empower Veterans in pain management;

. Development of new tools and resources to support the pain management strategy; and

. Enhanced efforts to strengthen communication between VA's Central Office (VACO) and leadership from facilities n9 and Veterans Integrated Service Networks (VISN).

Following the guidance of the VHA National Pain Management Strategy, and in compliance with generally accepted pain management standards of care, the Directive provides policy and procedures for the improvement of pain management through implementation of the Stepped Care Model for Pain Management (SCM-PM), the single standard of pain care for VHA, central to ensuring Veterans receive appropriate pain management services. The Directive also requires tracking opioid use and implementing strong practices in risk management to improve Veterans' safety.

To establish the six essential elements of good pain care listed above, numerous modalities have been recently implemented or are in the process of implementation throughout the VHA, including: pain schools, tele-pain schools, apps and web based modules for patient and family education; case based audio conferences, Rural Health Initiative and VeHU trainings, nation-wide community of practice calls and numerous other training initiatives to educate and train teams; developing Cognitive Behavioral Therapy (CBT) in primary care, tele-CBT, self-management strategies and complementary and integrative medicine modalities; a number of initiatives to address opioid prescribing which I will discuss shortly; e-consultation, Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), and telemedicine to bring pain care expertise to all settings; and pain dashboards to monitor care at the individual and populations levels.

VA facilities9 are now increasingly leveraging their video conferencing capabilities to reach Veterans in the community based outpatient clinics (CBOC) both rural and highly rural to provide group and individual visits for pain schools, evidence based CBT, smoking cessation, and weight loss through the MOVE program all important for the self-care and self-management skills needed as part of a chronic pain care plan.

A particularly exciting initiative is the development of a pain management application for smart phones that will be used by Veterans and their care partners to develop pain self-management skills. This tool, called VA Pain Coach, will eventually interface with VHA's Electronic Health Record (EHR), with appropriate privacy protections, allowing Veteran-reported information about pain, functioning, and other key elements in a secure mobile application environment to be securely stored and accessible to clinicians. VA Pain Coach, which is part of a suite of VA applications called "Clinic in Hand", has just finished a one-year pilot test phase with 1150 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans and their caregivers and is now being converted to HTML 5 and will be available for smart phones, tablets and as a web based application. In the future, a complementary initiative will build a clinician-facing application that will enhance the capacity of clinicians and Veterans to share in monitoring, decision making, treatment planning, and reassessment of pain management interventions.

The Patient Aligned Care Team (PACT): The Core of the Stepped Care Model

The VA approach to pain care mirrors its approaches to all health care concerns: care is increasingly personalized, proactive and patient driven. Chronic pain, as is the case with all chronic health conditions, is most safely and effectively addressed using a biopsychosocial model in which all aspect of the Veterans health and well-being are included in both the assessment and management of the condition: physical health, psychological health and social health. The basic platform for providing such care is the Veteran's PACT, or patient aligned care team, supported by pain and other specialists. PACT is a partnership between the Veteran and the health care team, which emphasizes prevention, health promotion, and self-management. Veterans are the center of the care team and the PACT teamlet, which includes at its core a primary care provider, nurse care manager, clinical associate, and clerical associate. Core pain teams in PACT often add a behavioral health clinician and pharmacist to help address the complexity of pain management.

The Pain Medicine Specialty Team: Specialty Care Access Supporting PACT

PACT access to consultation and collaborative care with interdisciplinary pain specialty teams is critical. VHA's Pain Medicine Specialty Team Workgroup, chartered on January 26, 2012, provides standards for pain specialty care services and support of PACT pain management in the Stepped Care Model. Key areas of focus include the development of collaborative care models and participation in provider and team education through telehealth, e-consults, and SCAN-ECHO. VA SCAN-ECHO pain experts provide didactics and case-based learning to PACT members using videoconferencing technologies to strengthen the competencies of providers in pain management. More than 95 percent of VHA facilities have specialty pain clinics with documented yearly increases in use and capacity.

VHA Pain Management Centers: Developing and Promulgating Strong Practices

The complexity of managing chronic pain may require a more intensive and structured approach to care than can be provided in the primary care or specialty pain medicine clinics. To address the need for tertiary care pain services, on December 15, 2010, the VHA charted the Interdisciplinary Pain Management Workgroup to assist Veterans Integrated Service Network (VISN) Directors in determining the need for tertiary pain care and pain rehabilitation services. As of January 2014, VA has ten sites in seven VISNs with Commission on Accreditation of Rehabilitation Facilities (CARF)-accredited tertiary care pain rehabilitation programs, an increase from only 2 programs in 2009, with 11 more sites in active preparation or actually applying for CARF status. These Centers have the capacity for providing advanced pain medicine diagnostics, surgical and interventional procedures, and in addition provide intensive, integrated chronic pain rehabilitation for Veterans with complex, co-morbid, or treatment refractory conditions.

VHA is in process of greatly expanding access to such Chronic Pain Rehabilitation Centers. Pursuant to the expectation that every VISN shall have at least one CARF-accredited tertiary, interdisciplinary pain care program no later than September 30, 2014, the long-standing CARF Center at the James Haley Veterans Hospital in Tampa, one of only two multidisciplinary pain management centers that has been twice recognized by the American Pain Society as a Clinical Center of Excellence (the other being a program at Stanford University), has provided direct training to VISN teams from across VHA who wish to start CARF programs. Some VISNs may eventually have 2 or more such programs. In addition, there is an ongoing system-wide education effort, using the expertise at these Centers and in other facilities, to educate physicians in Primary Care PACT and other providers taking care of Veterans with chronic pain conditions about Chronic Pain Rehabilitation approaches.

Implementing the Stepped Care Model in VHA

To help manage the implementation of the Stepped Care Model, VHA's National Pain Management Program Office (NPMPO) works closely with other VHA national offices such as pharmacy, mental health, and primary care. Other collaborations include NPMPO's partnership with Women's Health Services to develop a strategic plan to strengthen the capacity for women Veteran pain management services. NPMPO also relies on consultation with the interdisciplinary National Pain Management Strategy Coordinating Committee, consisting of members of all relevant clinical offices/programs in VHA, and meets regularly with all VISN Pain Points of Contact (POC). VISN POCs in turn meet regularly with Facility POCs in their VISN.

The role of the Pain POCs, at the VISN and at the facility level, is primarily to coordinate efforts in regard to pain management from an administrative side. The Pain POCs are expected to work closely with the Pain specialists at each facility within the facility Pain Management Committee. This structure creates a two-way communication of successful 'best practices' in the field, which are then communicated nationally, as well as advice and support on policy implementation. The Pain POCs are not the point of contact for clinical issues regarding individual patients. With regards to evaluation and treatment, a Veteran's clinical point of contact for their individual pain needs is their primary care provider within the PACT. As necessary, the pain medicine specialty team at the facility would work in collaboration.

Stepped Care Model for Pain Management

As mentioned earlier, SCM-PM is the single standard of pain care for VHA to ensure Veterans receive appropriate pain management services. Specifically, SCM-PM provides for assessment and management of pain conditions in the primary care setting. This is supported by timely access to secondary consultation from pain medicine, behavioral health, physical medicine and rehabilitation, specialty consultation, and care by 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 TBI.

In FY 2012, VHA made several important investments in implementing the SCM-PM. Major transformational initiatives support the objectives of building capacity for enhanced pain management in the primary care setting, including education of Veterans and caregivers in self-management, as well as promoting equitable and timely access to specialty pain care services.

There are other important efforts contributing to the implementation of SCM-PM in VHA facilities. Current initiatives focus on empowering Veterans in their pain management, and expanding capacity for Veterans to receive evidence-based psychological services as a component of a comprehensive and integrated plan for pain management. For example, during FY 2012, the VHA National Telemental Health Center expanded its capacity to deliver face-to-face, psychological services to Veterans remotely via high-speed videoconferencing links. This initiative not only emphasizes the delivery of cognitive behavior therapy for Veterans with chronic pain, but also promotes pain self-management, leading to reductions in pain and improvements in physical functioning and emotional well-being.

Additionally, a Primary Care and Pain Management Task Force is developing a comprehensive strategic and tactical plan for promoting full implementation of the SCM-PM in the Primary Care setting, and it continues to work on several products in support of this effort. For instance, the Task Force is continuing to expand its network of facility- level Primary Care Pain Management points of contact (Pain Champions) who meet monthly, via teleconference, to identity and share strong practices that have led to improved pain care in primary care settings.

VA's pain management initiatives are designed to optimize timely sharing of new policies and guidance related to pain management standards of care. Of particular importance are VHA's continuing efforts to promote safe and effective use of opioid therapy for pain management, particularly those initiatives designed to mitigate risk for prescription pain medication misuse, abuse, addiction, and diversion.

Opioid Prescribing

While opioid medications, due to their high risk to benefit ratio in chronic pain, will be playing a less prominent role in chronic pain management in the future, they are a primary focus currently due to the attendant risk of their use, particularly in individuals with some of the co-morbid conditions mentioned above.

To monitor the use of opioids by patients in the VA health care system, VA tracks multi-drug therapy for pain in patients receiving chronic or long-acting opioid therapy for safety and effectiveness. This includes tracking of use of guideline recommended medications for chronic pain (i.e., certain anticonvulsants, tricyclic antidepressants (TCA), and serotonin and norepinephrine reuptake inhibitors (SNRI) which have been shown to be effective for treatment of some chronic pain conditions), and tracking of concurrent prescribing of opioids and certain sedative medications (e.g., benzodiazepines and barbiturates) which can contribute to over sedation and overdose risk when taken with opioids and the other medications for pain listed above.

The prevalence of Veterans using opioids has been measured for Veterans using VHA health care services. For FY 2012, of the 5,779,668 patients seen in VA, 433,136 (7.5 percent) received prescriptions for more than 90 days supply of short-acting opioid medications and 92,297 (1.6 percent) received at least one prescription for a long-acting opioid medication in the year. Thus, since more than 50 percent of Veterans enrolled in VHA suffer from chronic pain, the most common condition in all Veterans, a relatively small percentage of those Veterans are receiving chronic opioid therapy, consistent with the DoD-VA Clinical Practice Guidelines which limit their use to patients with moderate to severe persistent pain that has not responded to other safer alternatives that are clinically appropriate. Of these 525,433 patients that received chronic or long-acting opioid therapy, 79,025 (15 percent) were also prescribed a TCA, 90,066 (17 percent) were also prescribed an SNRI, and 178,361 (34 percent) were also prescribed an anticonvulsant some time in FY 2012.

The co-prescription of either TCAs and SNRIs with opioids is first line therapy for the more severe cases of pain related to nerve damage from disease (e.g., diabetes, cancer) or from injuries (e.g., battlefield blast and projectile injuries with or without limb amputation and spinal cord injury). The numbers above suggest that clinical teams are using medically indicated combinations of medications that are specifically needed for these more severe conditions, which themselves are often co-morbid with musculoskeletal pain such as injuries to joints, spine and muscles. Of note, these prescriptions may or may not have overlapped with the opioid prescription during the year.

Notably, 272,719 (52 percent) of patients on chronic or long-acting opioid therapy received non-medication-based rehabilitative treatments as part of their treatment plan (e.g., physical therapy (32 percent), chiropractic care (1 percent), programs to encourage physical activity (9 percent) or occupational therapy (17 percent), and 241,465 (46 percent) also received behavioral or psychosocial treatment for chronic pain or co-morbid mental health conditions.

These data, showing the use of non-medication treatments, suggest that Veterans are benefitting from VHA's efforts to create access to additional pain treatment modalities besides medication. This is consistent with VA's commitment to transform pain care to a biopsychosocial model n10 that addresses all the factors that by research are demonstrated to affect Veterans' success in chronic pain treatment. Pursuant to this aim, a multimodality, team-based, stepped care model, per VHA Directive 2009-053, is being implemented widely throughout VHA, and in coordination with DoD.

Opioid analgesics may help many patients manage their severe pain when other medications and modalities are ineffective or are only partially effective. However, there may be risks to both individual patients as well as to the surrounding community when these agents are not prescribed or used appropriately. VA has embarked on a two pronged approach to addressing the challenge of prescription drug diversion and substance use disorders among Veteran patients. One approach is to improve the education and training in pain management and safe opioid prescribing for clinicians and the interdisciplinary teams that provide pain management care for Veterans. A complementary approach involves improving risk management through two systems initiatives.

Opioid Safety Initiative

VA recently developed and implemented an Opioid Safety Initiative (OSI) program to ensure opioid pain medications are used safely, effectively and judiciously. The Opioid Safety Initiative Requirements were issued to the VISN's on April 2, 2014. The purpose of the initiative is to ensure pain management is addressed thoughtfully, compassionately and safely. The nine goals are summarized below:

. Goal One: Educate prescribers of opioid medication regarding effective use of urine drug screening

. Goal Two: Increase the use of urine drug screening

. Goal Three: Facilitate use of state prescription databases

. Goal Four: Establish safe and effective tapering programs for the combination of benzodiazepines and opioids

. Goal Five: Develop tools to identify higher risk patients

. Goal Six: Improve prescribing practices around long-acting opioid formulations

. Goal Seven: Review treatment plans for patients on high doses of opioids

. Goal Eight: Offer Complementary and Alternative Medicine (CAM) modalities for chronic pain at all facilities

. Goal Nine: Develop new models of mental health and primary care collaboration to manage opioid and benzodiazepine prescribing in patients with chronic pain

To do this, the initiative leverages the VHA's Electronic Health Record, making visible the totality of opioid use at all levels, patient, provider and facility, in order to identify high-risk situations. The OSI includes key clinical indicators such as the number of unique pharmacy patients dispensed an opioid, unique patients on long-term opioids who receive a urine drug screen, the number of patients receiving an opioid and a benzodiazepine (which puts them at a higher risk of adverse events) and the average dosage per day of opioids such as hydromorphone, methadone, morphine, oxycodone, and oxymorphone. Patients at risk for adverse events from use of opioids are identified through the use of administrative and clinical databases using pre-determined parameters based on published evidence and expert opinion. Providers whose prescribing practices are not aligned with medical evidence/strong practices are provided with counseling, education and support for to improve their care of Veterans with pain. Several aspects to measure the implementation of the Opioid Safety Initiative upon opioid use were underway at the time of the October 10, 2013 hearing and suggested positive impacts:

. Despite an increase in the number of Veterans who were dispensed any medication from a VA pharmacy, (i.e., all pharmacy users) in October 2012 compared to November 2013, 39,088 fewer Veterans received an opioid prescription from VA during that time period.

. Performing urine drug screens is a useful tool to assist in the clinical management of patients receiving long-term opioid therapy. As of November 2013, urine drug screens were performed on 80,294 more patients than in October 2012.

. Whenever clinically feasible, the concomitant use of opioid and benzodiazepine medications should be avoided. In November 2013, 9,609 fewer patients were receiving these drugs at the same time than in October 2012.

. Lastly, the average dose of selected opioids has begun to decline slightly in VA, demonstrating that prescribing and consumption behaviors are changing.

While these changes may appear to be modest given the size of the VA patient population, they signal an important trend in VA's use of opioids. VA expects this trend to continue as it renews its efforts to promote safe and effective pharmacologic and non-pharmacologic pain management therapies. Very effective programs yielding significant results have been identified (e.g. Minneapolis, Tampa, Columbus), and are being studied as strong practice leaders.

The second system-wide risk management approach to support the Veterans' and public's safety is promulgation of new regulations that enable VHA to participate in state Prescription Drug Monitoring Programs (PDMPs). VA providers can now access the state PDMP for information on prescribing and dispensing of controlled substances to Veterans outside the VA health care system. Participation in PDMPs will enable providers to identify patients who have received non-VA prescriptions for controlled substances, which in turn offers greater opportunity to discuss the effectiveness of these non-VA prescriptions in treating their pain or symptoms. More importantly, information that can be gathered through these programs will help both VA and non-VA providers to prevent harm to patients that could occur if the provider was unaware that a controlled substance medication had been prescribed elsewhere already.

Leveraging Strong Practices to Change Opioid Prescribing: The Minneapolis VA Medical Center (VAMC)

In summary, there is growing evidence of the successful implementation of a Stepped Care Model for Pain Management in VHA. Importantly, Veterans receiving long term opioid therapy for management of chronic pain are increasingly likely to be receiving this therapy in the context of multidisciplinary and multimodal care that often incorporates physical and occupational therapy and mental health services. All VISNs provide specialty pain clinic services, and the number of Veterans who receive these services has grown steadily for the past five years. Ten facilities now provide CARF accredited pain rehabilitation services, a rapid increase in the availability of these higher specialized pain rehabilitation services for our most complex Veterans with debilitating chronic pain and comorbid mental health disorders.

VA learns from VISNs and VAMCs that are early adopters of implementing evidence-based guidelines and best practices. The Minneapolis VAMC has had great success with decreasing over utilization of opioid pain medications and developing a full range of pain management services. These efforts began with the Minneapolis VA Opioid Safety Initiative in 2011. Strong medical center leadership support led to the development of systems to identify patients on high risk opioids and provide team-based support from pharmacy, primary care, and mental health to develop individualized care plans to decrease high risk opioid use and improve patient safety. Implementing this best practices approach, Minneapolis has seen a nearly 70 percent decrease in high-dose opioid prescribing for chronic non-cancer pain patients. This early success lead to a coordinated effort between Minneapolis VAMC and VISN 23 to expand support for PACT team-based pain management, Step 2 pain consultation services, and rehabilitation focused multidisciplinary pain specialty services. The Minneapolis pain specialty services are now developing state-of-the-art, evidence-based interdisciplinary pain management programs and services, and also providing leadership, guidance, and support for primary care pain management throughout VISN 23 and VHA.

VA is working aggressively to promote the safe and effective use of long-term opioid therapy for Veterans with chronic pain for whom this important therapy is indicated. VA's Opioid Safety Initiative holds considerable promise for mitigating risk for harms among Veterans receiving this therapy, for promoting provider competence in safe prescribing of opioids, and in promoting Veteran-centered, evidence-based, and coordinated multidisciplinary pain care for Veterans with chronic pain. VA's Opioid Safety Initiative Tool provides monthly reports to all VISNs and facilities as to overall opioid prescribing an average dose per day of opioid therapy, which informs facilities of Veterans who are at risk for adverse outcomes and enables remedial steps to reduce those risks as described earlier by the Minneapolis VAMC. Interventions include VISN level, facility level and committees that provide support and education to improve the appropriate opioid risk mitigation for individual providers and facilities. Early evidence of success in reducing overall opioid prescribing and average dose per day of opioid therapy is encouraging.

Complementary and Integrative Medicine

VHA leadership has identified as its number one strategic goal "to provide Veterans personalized, proactive, patient-driven health care." Integrative Health (IH), which includes CAM approaches, provides a framework that aligns with personalized, proactive, patient-driven care. There is growing evidence for effectiveness of non-pharmacological approaches as part of a comprehensive care plan for chronic pain which includes acupuncture, massage, yoga and spinal manipulation. These are all being increasingly made available to Veterans.

In 2011, VA's Healthcare Analysis and Information Group published a report on Complementary and Alternative Medicine in VA. At that time, 89 percent of VHA facilities offered some form of CAM/IH; however, there was extensive variability regarding the degree, level, and spectrum of services being offered in VHA. The top reasons for offering CAM/IH included the following:

. Promotion of wellness;

. Patient preferences; and

. Adjunct to chronic disease management.

The most commonly offered CAM/IH modalities in VHA facilities were: Meditation, Stress Management/Relaxation Therapy, Progressive Muscle Relaxation, Biofeedback, and Guided Imagery. The conditions most commonly treated with CAM/IH include: Stress management, Anxiety Disorders, PTSD, Depression, and Back Pain.

In VA, chiropractic care is part of the standard medical benefits and is administratively aligned under Rehabilitation and Prosthetic Services. The number of Veterans receiving chiropractic services in VA has expanded form under 4,000 in FY2004, to over 26,000 in FY2013. In addition to clinical services, Rehabilitation and Prosthetic Services is working to develop innovative approaches to foster chiropractic inter-professional education strategies and research projects.

VA recognizes the importance and benefits of recreational therapy in the rehabilitation of Veterans with disabilities. Currently, over 30 VA medical centers across the country participate in therapeutic riding programs. These programs use equine assisted therapeutic activities to promote healing and rehabilitation of Veterans with a variety of disabilities and medical conditions (e.g. traumatic brain injury, polytrauma). VA facilities participating in such programs utilize their locally appropriated funds to support their participation. Facilities can also request supplemental support through the VA Secretary's General Post Fund, a trust fund administered by the Department to support a variety of recreational and religious projects and national rehabilitation special events.

A monthly Integrative Health (IH) community of practice conference call provides VHA facilities national updates, strong practices, and new developments in the field and research findings related to IH.

A key development is a Joint Incentive Fund DoD-VA project to improve Veterans' and Servicemembers' access to CAM, the "Tiered Acupuncture Training Across Clinical Settings" (ATACS) project. ATACS represents VHA's initiative to make evidence-based complementary and alternative medicine therapies widely available to our Veterans throughout VHA. A VHA and DoD network of medical acupuncturists are being identified and trained in Battlefield (auricular) Acupuncture by regional training conferences organized jointly by VHA and DoD. The goal of the project is for them to return to their facilities and VISNs with the skills to train local providers in Battlefield Acupuncture, which has been used successfully in DoD front-line clinics around the world. This initiative ultimately aims to provide all Veterans with access to this intervention, and a wider array of pain management choices generally, when they present with chronic pain.

Integrative Health - The Way Forward

In late 2012, the Under Secretary for Health appointed a Team to review the organizational structure to support implementation of integrative health strategies in VHA. The Team recommended the expansion of the VHA Office of Patient Centered Care and Cultural Transformation's (OPCC&CT) capacity to develop and implement integrative health strategies in clinical activities, education, and research. OPCC&CT is now serving as the lead office in this work, expanding on existing efforts and with active partnerships across the organization. An Acting Director of VHA's Integrative Health Coordinating Center (IHCC) has been named and recruitment for core staff is in process. Additional staffing is being vetted now and that will continue until the program is fully developed.

OPCC&CT has deployed a number of clinical, research, and education strategies to begin developing a more coordinated approach. This includes clinical pilots, work within the existing Centers of Innovations, and close alignment with the Office of Research and Development, as well as creating curricula and expanding education in these areas. VA's Evidence Synthesis program, in conjunction with OPCC&CT and Patient Care Services, is examining the scientific literature on various CAM modalities and presenting the findings in the form of an evidence map. At the present time, reviews are being done on Yoga, Tai Chi, and mindfulness meditation and a review was recently completed on acupuncture. The evidence map on acupuncture showed a positive effect of acupuncture on headaches, migraines, and chronic pain as well as a potential positive effect in multiple domains including depression and insomnia. The information from these reviews will help guide decision on how to best use CAM modalities within VA.

The Whole Health Clinical Education Program, which includes an integrative health focus, launched last year, has received outstanding evaluation feedback from the clinicians and leadership who have taken the course. An online curriculum is under development and will have greater than 40 modules. These have been co-created with VA and the University of Wisconsin, leaders in the field of Integrative Medicine.

Finally, the DoD-VA Health Executive Council (HEC) Pain Management Work Group (PMWG) was chartered to develop a model system of integrated, timely, continuous, and expert pain management for Servicemembers and Veterans. The Work Group participates in VA/DoD Joint Strategic Planning (JSP) process to develop and implement the strategies and performance measures, as outlined in the JSP guidance, and shares responsibility in fostering increased communication regarding functional area between Departments. The Group also identifies and assesses further opportunities for the coordination and sharing of health related services and resource between the Departments. A key development is the HEC PMWG's sponsoring of two Joint Incentive Fund projects to improve Veterans' and Servicemembers' access to competent pain care in the SCM-PM: the Joint Pain and Education Project (JPEP), and the "Tiered Acupuncture Training Across Clinical Settings" (ATACS) projects.

Oversight and Accountability

Several key responsibilities are articulated in the Pain Management Directive. The Directive establishes a National Pain Management Program Office (NPMPO) in VACO that has the responsibility for policy development, coordination, oversight, and monitoring of VHA's National Pain Strategy. The Directive further authorizes the establishment of a multidisciplinary VHA National Pain Management Strategy Coordinating Committee that supports the Program Office in achieving its strategic goals and objectives. The Committee is comprised of 15 members to include: anesthesiology, employee education, geriatrics and extended care, mental health, neurology, nursing, pain management, patient education, pharmacy benefits management, primary care/internal medicine, quality performance, rehabilitation medicine, research, and women Veterans' health.

The Directive requires VISN Directors to ensure that all facilities establish and implement current pain management policies consistent with this Directive. The NPMPO maintains records of VISN and facility compliance, along with other key organizational requirements contained in the Directive. All VISNs and facilities have appointed National Pain Office pain management points of contact, established multidisciplinary committees, and implemented pain management policies as required by the Directive. Health Care Provider Education and Training

First, as recognized by the IOM in its extensive 2011 review, "Pain in America" and the American Medical Association in its 2010 Report on Pain Medicine n11, and as articulated in VHA's Pain Management Directive in 2009-053, a formal commitment to pain management education and training for all appropriate clinical staff is required.

The Joint Pain and Education Project, JPEP, mentioned earlier, has proposed training faculty in all VA training sites to pursue the implementation of such a curriculum; new generations of providers and other clinicians will themselves ultimately become the practitioners and teachers of good pain care. JPEP will target all levels of learner: the

Veteran and his/her family and caregiver; the public; clinicians from all disciplines; specific providers and clinicians in practicing at each level of the SCM-PM: primary care, pain medicine specialty care, and other specialty care. VA is providing national leadership in developing interdisciplinary and discipline-specific competencies for pain management, in developing a system-wide approach to trainings, and in providing leadership roles in national projects to improve pain education and training.

Conclusion

Mr. Chairman, I would be the last person to say that we are now right where we want to be with our pain care in VA, but I will be the first person to say that we are well along in the process of getting there. I am confident that we will be setting standards for pain care nationally in the coming years. We are confident that we are building more accessible, safe and effective pain care that will be responsive to the needs of our Veterans and will better serve to enhance the quality of their lives. VA is committed to providing the high quality of care that our Veterans have earned and deserve, and we appreciate the opportunity to appear before you today. My colleagues and I are prepared to respond to any questions you may have.

n1 Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Pain Prevention, Care, Education and Research. Washington, DC: The National Academies Press.

n2 Gironda, R.J., Clark, M.E., Massengale, J.P., & Walker, R.L. (2006).. Pain among Veterans of Operations Enduring Freedom and Iraqi Freedom. Pain Medicine, 7, 339-343.

n3 Veterans Health Administration (2013). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. Washington, DC: Department of Veterans Affairs.

n4 Lew, H.L., Otis, J.D., Tun, C., Kerns, R.D., Clark, M.E., & Cifu, D.X. (2009). Prevalence of chronic pain,

n5 See citations 3 and 4.

n6 Diversion is the use of prescription drugs for recreational purposes.

n7 The overall objective of the national strategy is to develop a comprehensive, multicultural, integrated, system-wide approach pain management that reduces pain and suffering and improves quality of life for Veterans experiencing acute and chronic pain associated with a wide range of injuries and illnesses, including terminal illness.

n8 www.va.gov/vhapublications/viewpublication.asp?pub_id=2781

n9 The term "facilities" or "facility" refers to VA's 151 medical centers, hospitals, or health care systems.

n10 The Biopsychosocial Model takes the position that the causes and outcomes of many illnesses often involve the interaction of physical and pathophysiologic factors, psychological traits and states, and social-environmental factors. Effective treatment planning accounts for the salience of these factors in the precipitation and perpetuation of illness and illness-related disability.

n11 Lippe PM, Brock C, David JJ, Crossno R, Gitlow S. The First National Pain Medicine Summit - Final Summary Report. Pain Med 2010;11(10):1447-68.

Read this original document at: http://www.veterans.senate.gov/download/?id=db50e14c-a307-44b5-a00e-851d164c3a95&download=1