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VHA Pain Management


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VHA Pain Management Strategy


The purpose of the VHA National Pain Management Strategy is to develop a system-wide approach to pain management that will reduce pain and suffering for veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness.


Pain is a significant health care problem in the United States; a substantial portion of the population is afflicted with pain each year. Recent surveys and studies have determined that 20% to 30% of the population annually suffers from acute pain and/or chronic pain syndromes. Further, the incidence and severity of pain increase with increasing age, resulting in a disproportionately large amount of chronic pain occurring in individuals over 60 years of age. Control of cancer pain remains a substantial, unresolved problem with 75% of advanced cancer patients experiencing 'moderate' to 'very severe' pain. The knowledge and techniques to control most pain are known, but they are often not applied effectively. Proactive, aggressive management of both acute and chronic pain is universally recognized as an essential component of health care; however, substantial evidence indicates that neither acute nor chronic pain is managed adequately within most U.S. healthcare systems. It is essential that VHA develop a systematic approach to pain management that assures that pain is recognized and treated promptly and effectively.


The overall objective of this policy is to prevent suffering from pain in persons using the veterans healthcare system. The specific objectives of this policy are to:
  -Provide a system-wide VHA standard of care for pain management that will reduce suffering from preventable pain.      
  -Assure that pain assessment is performed in a consistent manner.      
  -Assure that pain treatment is prompt and appropriate.      
  -Include patients and families as active participants in pain management.      
  -Provide for continual monitoring and improvement in outcomes of pain treatment.      
  -Provide for an interdisciplinary, multi-modal approach to pain management.      
  -Assure that clinicians practicing in the VA healthcare system are adequately prepared to assess and manage pain effectively.


  -Pain Assessment and Treatment. Procedures for early recognition of pain and prompt effective treatment shall be implemented by all VA medical treatment facilities. VHA will implement "pain as the 5th vital sign" in all clinical settings to assure consistent assessment of pain. Pain management protocols will also be established and implemented in all clinical settings. The complexity of chronic pain management is often beyond the expertise of a single practitioner, especially for patients whose pain problems are complicated by homelessness, posttraumatic stress disorder, combat injuries, and substance abuse. Primary care providers should have ready access to resources such as pain specialists and multidisciplinary pain clinics and centers to effectively evaluate and manage these complex patients. Pain management is an integral part of palliative and end-of-life care. The expertise of hospice and palliative care clinicians should be available to all patients with a serious, life-limiting illness. Patient and family education about pain and its management should be included in the treatment plan and patients should be encouraged to be active participants in pain management.
  -Evaluation of Outcomes and Quality of Pain Management. All VHA medical facilities will implement processes for measuring outcomes and quality of pain management with the goal of continuous improvement. Electronic data monitoring of pain assessment and effectiveness of pain management interventions will be implemented. Patient satisfaction will be monitored on an ongoing basis.
  -Clinician Competence and Expertise in Pain Management. All VHA medical facilities will assure that appropriate clinical staff (e.g. physicians, nurses and therapists) have appropriate orientation and employee education related to pain assessment and pain management. VHA standards for pain management will be communicated to all medical students, allied health professional students, residents and interns providing patient care in VHA medical facilities. VHA education programs will be developed that include principles of pain assessment and management.
  -Research. VHA will expand its basic and applied research on management of acute and chronic pain, emphasizing conditions that are most prevalent among veterans. Research funded by the Health Services Research and Development Service (HSR&D) will encourage a systematic approach to identifying research priorities and providing scientific evidence on which to base pain management protocols throughout VHA and for evaluating and monitoring the quality of care.
  -Coordination of National VHA Pain Management Strategy.
The consistent and effective management of pain for all veterans cared for by VHA requires a coordinated national approach. A interdisciplinary committee will be established to oversee the development and implementation of a VHA National Pain Management System.
The Committee will be charged with the following responsibilities:
  1.Coordinating the system-wide implementation of "pain as the 5th vital sign."      
  2.Coordinating the development and dissemination of state-of-the-art treatment protocols for pain management.      
  3.Identifying VHA pain management expertise and resources and facilitating a national referral system to assure that veterans in every network have access to pain management services.      
  4.Coordinating a national employee education initiative to assure that VHA clinicians have the expertise to provide high quality pain assessment and treatment.      
  5.Identifying research opportunities and priorities in pain management and facilitating collaborative research efforts.      
  6.Integrating VHA pain management standards into the curricula and clinical learning experiences of medical students, allied health professional students, interns and resident trainees.      
  7.Establishing target goals, mechanisms for accountability and a timeline for implementation for a comprehensive, integrated VHA Pain Management Strategy.      
  8.Establishing a communication plan for both the internal and external communication of VHA's National Pain Management Strategy.

VHA NATIONAL PAIN MANAGEMENT STRATEGY - Implementation of the Stepped Care Model (PPT)


1.Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 3rd ed., American Pain Society: 1992. p.2.      
2.New Guidelines on Managing Chronic Pain in Older Persons, JAMA. July 22/29, 1998. Vol. 280, No.4.      
3.American Pain Society Bulletin. 6:1, p. 17. Jan/Feb., 1996.      
4,Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain, JAMA, December 20, 1995 - Vol.274, No. 23. p. 1874-1880.      
5.VHA Pain Management Survey. Headquarters Anesthesia Service; July 1997.