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National Pain Medicine 1st Edition May 2018

National Pain Newsletter - Content


Leaders Letter: Friedhelm Sandbrink, MD

Welcome from the VA Pain Program Office

When I assumed the role as Acting Program Director in Pain Management in November 2016, it was reassuring to know that I would be working with committed colleagues from many different programs in VHA. So many have contributed to our successes over the years. I want to thank in particular Dr. Rollin ‘Mac’ Gallagher and Dr. Bob Kerns as my predecessors in leading VHA Pain Management who have provided us with the very best guidance possible - biopsychosocial pain care within the Stepped Care Model for Pain Management that emphasizes functional improvement of Veterans by well-trained primary care teams supported by ready access to pain specialty, as well as mental health, rehabilitation services, behavioral treatment approaches and integrative health, just to name some of the many programs working together. We plan to introduce members and groups within our pain community in future editions; today, we include the names of the Pain Point of Contacts at the VISNs.

As we initiate this newsletter, we owe thanks to our colleagues who have contributed to this first edition for their commitment and enthusiasm. I am in particular grateful to Dr. Jen Murphy for her leadership in putting the newsletter together. We hope it will serve as a means of communication across the many different services and programs who are part of our community, and in conjunction with our newly revised national pain website. It is our desire to offer tips for our often-difficult tasks, communicate and problem solve about our challenges, and in particular share our successes and best practices. If you want to contribute to the newsletter in the future, please do not hesitate to contact us, as we want to hear from you! We are looking forward to learning your best practices and you sharing your perspectives. Many look to us in the VA as a model of excellence in pain care that is exemplary for its integration across programs and services, and for our leadership in opioid safety. Reflecting the importance of our work and what we have achieved so far, Pain Management and Opioid Safety are now included in the listing of VHA’s Foundational Services for Veterans. Our Pain Management Program i under Specialty Care Services (SPS) in VACO, and Dr. Laurence Meyer as the Chief Consultant for SPS has greatly supported pain care and opioid safety across the VHA. Our sincerest thanks to him and his team! While we strive to provide timely pain care at all facilities, we realize that coordination with community providers will be important when services are not available in house, as we aim to provide safe and effective pain care everywhere that is consistent with guidelines. The journey continues with many exciting opportunities awaiting broader implementation to enhance our ability to provide high quality care that is centered around the Veteran, whether at VA Medical Centers, CBOCs, or in Veterans’ homes. The Opioid Risk Reviews by interdisciplinary pain teams to assess and guide the care of the Veterans at highest risk for suicide or overdose by using the STORM dashboard is one example (see Opioid Section below); integration of Whole Health approaches in pain care is becoming a reality; greater inclusion of telehealth modalities is another approach that will broaden access to pain specialty expertise, behavioral pain therapies, integrative care such as Yoga classes, and for patients with opioid use disorder access to medication assisted therapy. It is a great privilege to walk this journey with you. Thank you all for your service to Veterans and to the VA

Education Corner: Lauren Hollrah,PsyD & Aram Mardian, MD

Help for Self-Management

Evidence supports a long-term recovery process for the treatment of chronic pain that highlights various self-management techniques addressing the mind and the body. Active therapies such as movement, stretching, relaxation, and mindfulness help those with chronic pain respond in the most helpful way. The VA has a number of mobile apps that are free, facilitate development of these strategies, and can be recommended to patients during their next visit. These include relaxation options such as Breathe2Relax and Tactical Breather, Virtual Hope Box, Mindfulness Coach and the forthcoming VA Pain Coach: http://t2health.dcoe.mil/products/mobile-apps

Opioid Safety Initiative Corner: Robert Sproul, PharmD

Risk Reviews for Suicide and Overdose Prevention

This month, VACO issued directions that outline new requirements for Opioid Risk Review at all facilities. The Comprehensive Addiction Recovery Act (CARA) from July 2016 has several mandates for VHA, including the designation of a Pain Management Team at all facilities, full implementation of the Stepped Care Model for Pain Management, and expansion of integrative health modalities. It also mandates that each VHA health care provider, before initiating opioid therapy to treat a patient, use the a data-driven tool to assess the risk for adverse outcomes of opioid therapy for the patient, and VHA has adopted the Stratification Tool for Opioid Risk Mitigation (STORM) for this purpose. There are key foundational considerations necessary for successful implementation.

The two populations identified for review are addressed in two different manners as follows:
1. The facility OSI Review Team systematically reviews high risk patients at the facility to monitor their clinical care and provide recommendations and coordination to optimize their care. The interdisciplinary team must review all patients that STORM identifies as very high risk for an overdose or suicide-related event.
2. Clinical providers must review STORM before initiating opioid therapy to individually determine risk.
3. All case reviews must be documented in the medical records per VA National Note Title that includes“Data-based” and“Opioid Risk Review.”
4. Keep in mind that STORM is a tool and should be considered one component of a comprehensive biopsychosocial risk assessment and treatment approach. Utilization of universal precautions/ best clinical practices continue to apply; the STORM risk reviews allow targeted stepped-up and coordinated interventions in the most vulnerable, highest risk patients.

For More Information:
◦Detailed background, implementation instructions, and monitoring plans regarding this requirement are available at VA National Stratification Tool for Opioid Risk Mitigation (STORM) Implementation SharePoint Site:
- https://vaww.portal2.va.gov/sites/mentalhealth/OEND/default.aspx mentalhealth/OEND/default.aspx
◦VA STORM FAQs: https://spsites.cdw.va.gov/sites/OMHO_PsychPharm/Pages/FAQ/STORM_FAQs.aspx_ PsychPharm/Pages/FAQ/STORM_FAQs.aspx
◦VA STORM Listserv - Email Amy.O’Donnell@va.gov if you would like to be added
◦Accredited EES Monthly Calls (accreditation offered: ACCME, ACCME-NP, ACPE, ANCC, ASWB, and APA)
- Overview of VHA Notice to Conduct Data-Based Case Reviews
- Three introductory sessions scheduled for May 9th (3 pm EST), May 17th (11 am EST), and May 22nd (2 pm EST) and then Monthly STORM Implementation Calls every 2nd Wednesday of the month at 3 pm EST starting June 13th.
- Location: Adobe Connect: https://va-eerc-ees.adobeconnect.com/_a1089657440/storm/. Audio through VANTS, 1-800-767-1750, Access Code: 55055

Practical Pearls: Heidi Klingbeil, MD

Patient-Led Weaning

In response to the opioid epidemic most medical providers nowadays avoid initiating long-term opioid therapy in patients with chronic pain. But the process of decreasing opioids in patients who have been on them for some time is difficult for providers and patients alike. Most patients have read enough in the news to realize that opioids are potentially dangerous, and that there is a national trend to decrease their use but many just don’t want that trend to affect them, and what they feel is their legitimate need for them! Many have occasionally run out of a prescribed pain medication before securing a refill and know it is a very unpleasant feeling. What I have found most useful is the practice of “patient led weaning. ”That is, discuss the need to decrease pain medication dosages with your patients who are on high doses, or perhaps unnecessary pain meds, and motivate and engage them to develop a plan to gradually reduce dosages over time. This is best started when the patient feels ready to do so, and you man not want to start at this same visit if the patient is not on-board. Then, promise them this will be done in a slow, and planned manner. For a patient that has been on for years but who is willing to begin a reduction in medication, we find that going down just 5%-20% at a time is usually well tolerated, with little impact on how they feel, and yet make steady progress. This can even be done on an every other month basis, and either stepped up if the patient feels they can handle it-or slowed down and a month skipped if needed. For instance, one of my patients lost her son, and had a very bad month, and we thought this was not the time to change anything. The next month she presented and announced she was ready to step down again. Even for patients on large doses, over a year’s time significant decreases are realized this way-and the patient is a partner in the process, with some control over the situation; hence the term patient led,patient-centered, or consensual tapering. This emphasizes shared-decision making during the process.

Of course, there will be the few patients that aggressively and angrily protest. Keep in mind that the patient may just not be ready at  his time; patients may be scared, or fear that the proposed opioid dosage reduction exceeds their ability to cope and adjust. We have to take the patient’s concerns seriously and individualize the care plan to the specific needs of each Veteran. It is OK to go slow, especially if the patient is doing well. As a prescribing provider, we may be sometimes too eager to reduce the opioid dosage and may want to go faster than what the patient considers acceptable. Dr. Sandbrink often warns against involuntary dosage reductions that may exceed the ability of the Veteran to cope and even increases risk. Many Veterans with chronic pain and on opioid therapy have MH comorbidities and psychological stressors that greatly contribute to risk. The goal is to improve function – we must avoid destabilization! Thus, in such patients, it is particularly important to coordinate closely with MH. Always assess for evidence of opioid use disorder (OUD): if OUD is present, a warm hand-off into an OUD treatment that provides evidence-based medication-assisted therapy (MAT) is mandatory. The Pain Management teams (PMT) are legislatively mandated for all VA facilities to provide help in such difficult situations. Seek their input early in patients with complex pain conditions and work collaboratively with your PMT to implement the pain care plan that is right for the patient. All PMTs should have integrated access to OUD treatment. Generally, however, many patients will come to declare that they feel better as they have decreased their pain meds. And from a medicolegal perspective, providers can satisfy the need to show they are tapering their patients, while closely monitoring them.

Pain Happenings: Stacey Sandusky, PhD

Recent or Upcoming Noteworthy Events

American Pain Society, Scientific Summit, Anaheim. CA, March 4-6, “Understanding Pain Mechanisms” American Academy of Pain Medicine, 34th Annual Meeting, Vancouver, BC, Canada. Highlights and more information can be found at http://americanpainsociety.org/meetings-and-events/2018-scientific-summit/2018-scientific-summit.
Upcoming pain meetings in the months of April and May include:
• 34th Annual Meeting of the American Academy of Pain Medicine, April 25-29: “Managing Acute and High-Impact Chronic Pain Through Multidisciplinary Care” http://annualmeeting.painmed.org/.
• Cleveland Pain Management Conference, May 10-11: “Pain Management and the Opioid Crisis: Balancing Quality and Patient Safety” http://clevelandpainconference.com/- landPainConference.com
• NIH’s Annual Pain Symposium, May 31-June 1: “From Science to Society: At the Intersection of Pain Management and the Opioid Crisis” Attend in person or join through the NIH Web cast:
https://www.painconsortium.nih.gov/Meetings_ Events/Annual_Symposium/2018-NIH-Pain-Consortium-Symposium

Research Reads: Alicia Heapy, PhD

Expanding the Evidence Base

The SPACE Trial, a VA -funded study conducted by Erin Krebs, MD, found that opioid treatment did not result in better pain related functioning when compared to non-opioid medication treatment in patients with chronic back, hip and knee pain. Pain intensity was worse and more medication-related adverse events occurred in the opioid therapy group versus the non-opioid medication group. A collaborative care model was used for both groups that included symptom monitoring and a treat-to-target approach for medication management. https://jamanetwork.com/journals/ jama/fullarticle/2673971

A Team Sport: Sanjog Pangarkar, MD

This Month: From the Pain Physician’s Desk…

Ketamine has now been in clinical use for over 50 years and is seeing a renascence in the fields of pain management and mental health. This medication
is similar in structure to PCP and acts on multiple targets in the human body. Ketamine is classified as  a dissociative anesthetic with pain effects related to N-methyl-D-aspartate (NMDA) receptor inhibition. As
interest in this medication has grown, the VA Office of Research and Development has started a trial on the use of Ketamine for treatment resistant depression.
Ketamine’s benefit for neuropathic and cancer pain is still being studied but appears promising.

Pain Is Primary: Lucille Burgo, MD & Stephen Hunt, MD

Tools to Ease the Burden

Are you having trouble with planning your clinic day? Are you able to easily collect all the information you need to provide patient centered, safe and effective care prior to the visit? God News! With the Primary Care Almanac tool, get a quick snapshot of all the opioid safety measures without having to access each individually. The new clinic pre-planning tool can also provide useful information on clinic patients over a specified time range. Check out the new VSSC tool here:https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fPACTFutureApptClinicList&rs:Command=Render

Bright Spots: Jennifer Murphy, PhD

Women’s Overdose Prevention Campaign

Women’s Health Services are leading the way with their campaign to help prevent opioid-related overdoses and encourage the safe use of medications among female Veterans. They focus
on providing clear and concrete educational information for Veterans and their treatment teams with links to helpful social media options. This coordinated effort reinforces the both the importance of opioid safety and the service of our women who have served. https://www.womenshealth.va.gov/ WOMENSHEALTH/OutreachMaterials/General- HealthandWellness/PrescriptionOpioids.asp

New VA/DOD Guidelines for Low Back Pain Released

Updated VA/DoD guidelines for the treatment of LBP were released in late 2017 and many were surprised by the recommendation changes. There was a lack of robust evidence for many commonly used interventions for chronic LBP such as epidural injections and limited evidence for the use of many pain medications including opioids. Integrating a mental health screening was suggested as part of standard LBP evaluation and options such NSAIDs and Cognitive Behavioral Therapy were evidence-based treatment recommendations. More information can be found here, including helpful a pocket card with summary: https://www.healthquality. va.gov/guidelines/Pain/lbp/

Group Think - Leading the Way

National Pain Management Strategic Coordinating Committee.

There are many groups of pain leaders across the VA that help Veterans with pain live better lives. We will highlight some of them in this newsletter to acknowledge their dedication.

Name .... Location
Lucille Burgo, MD.... VA Connecticut HCS, West Haven, CT
Pamela Cremo.... VA Connecticut HCS, West Haven, CT
Karen Drexler, MD.... VA Central Office, Atlanta, GA
Sally Haskell, MD.... VA Connecticut HCS, West Haven, CT
Alicia Heapy, PhD.... VA Connecticut HCS, West Haven, CT
Julianne Himstreet, PharmD.... Roseburg VAMC, Eugene, OR
Stephen Hunt, MD, MPH.... VA Puget Sound HCS, Seattle, WA
Benjamin Kligler, MD.... VA Central Office, New York, NY
Heidi Klingbeil, MD.... VA Hudson Valley HCS, Bronx, NY
Audrey Kusiak, PhD.... VA Central Office, Washington, DC
Anthony Mariano, PhD.... VA Puget Sound HCS, Seattle, WA
Jennifer Murphy, PhD.... James A. Haley VAMC, Tampa FL
Mitchell Nazario, PharmD, CPE.... Hines VA, Hines, IL
Sanjog Pangarkar, MD.... Greater Los Angeles HCS, Los Angeles, CA
Andrew Pomerantz, MD.... White River Junction VAMC, White River Junction, VT
Pooya Pouralifazel, MD.... Dallas VAMC, Dallas, TX
Eric Rodgers, PhD, FNP, BC.... VA Central Office, Glendale, CO
Jack Rosenberg, MD.... Ann Arbor VAMC, Ann Arbor, MI
Friedhelm Sandbrink, MD.... VA Central Office/Washington VAMC, Washington, DC
Joel Scholten, MD.... VA Central Office, Washington, DC
Robert Sproul, PharmD.... Orlando VAMC, Orlando, FL
Andy Tracy, PhD, CRNA.... Lovell Federal HCS, North Chicago, IL
Anne Turner.... Employee Education Resource Center, Birmingham, AL