In a recent report, “Relieving Pain in America: 

A Blueprint for Transforming Pain Prevention, Care, Education, and Research,” the 

Institute of Medicine (IOM) asserted that pain 

is a significant public health problem and estimated that as many as 100 million Americans 

experience persistent pain at a cost of as much 

as $635 billion in treatment costs and lost productivity.1

 The report invites the Department 

of Veterans Affairs (VA) to join with other 

agencies to transform care of persons with 

pain, to educate and train providers and consumers of pain management services, and to 

conduct more pain research. The IOM specifically calls on agencies such as VA to improve 

its collection and use of data to support this 

transformation. Among its recommendations 

for research, the report encourages increased 

support for interdisciplinary research, longitudinal research, and training of pain researchers. The report emphasizes the development 

of strategies to minimize disparities in pain 

care, and it identifies Veterans of military service as one of several vulnerable groups. The 

VA provides a unique laboratory in which to 

conduct effectiveness and implementation research required for this transformation. 

Pain Management – A Top Priority

In late 1998, the former Under Secretary for 

Health, Kenneth Kizer, launched the VA National Pain Management Strategy to provide 

a system-wide standard of care to reduce suffering from preventable pain. Support for the 

Strategy has served to elevate pain management 

as a top priority within VA, and to spark innovation in the planning and provision of high 

quality pain care. Among the several primary 

goals of this initiative is an explicit emphasis 

on promoting pain-relevant research. Data 

document a strong and growing commitment 

to funding pain-relevant research through the 

intramural research program of the Office 

of Research & Development (ORD). In Fiscal Year 2011, ORD invested $11.4 million in 

support of 56 investigator-initiated research 

projects and career development awards for 

early career investigators. The Health Services 

Research & Development Service (HSR&D), in 

particular, continues to invest in and strengthen 

its pain research portfolio with particular attention to research that promotes improvement 

in the organization, delivery, safety, and equity 

of pain management services. A national Pain 

Research Working Group (PRWG), comprised 

of over 75 scientists and scholars, plays a key 

role in advancing VA’s pain research agenda 

and in promoting its impact. Special topic issues of leading scientific journals including the 

Journal of Rehabilitation Research and Development, 

Pain Medicine, Translational Behavioral Medicine, 

and Clinical Journal of Pain highlight some of the 

important contributions of PRWG members. 

A monthly “Spotlight on Pain Management” 

webinar series offered through a partnership 

among the Pain Management Program Office, the HSR&D’s Pain Research, Infomatics, Medical comorbidities, and Education 

(PRIME) Center, and the Center for Information Dissemination and Educational Resources 

(CIDER) supports the shared interests of VA’s 

research, practice, and policy communities in 

advancing National Pain Management Strategy. 

s

FORUM

Translating research into quality health care for Veterans

Commentary

Transforming Pain Management Services 

for Veterans

Robert D. Kerns, Ph.D., Pain Research, Informatics, Medical Comorbidities, and Education 

(PRIME) Center, VA Connecticut Healthcare System 

 August 2012

Contents

Director’s Letter 2

VA Pain Management and 

Research: From Good to Great 3

Improving Opioid Prescribing 

Practices 4

Post-Deployment Pain: 

Musculoskeletal Conditions in Male 

and Female OEF/OIF Veterans 5

Painful Truths About Pain 

Screening 6 

HSR&D and QUERI Hold National 

Meeting 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, in 

conjunction with AcademyHealth. 
The Role of Health Services 

Investigators

VA health services investigators have played 

instrumental roles in advancing the theoretical 

and empirical foundations for core pain management policies and clinical practice guidance 

as established in VA’s Pain Management Directive (2009-053).2

 For example, investigators 

have published empirical tests of integrated 

and collaborative care models in the primary 

care setting that support the establishment of 

a Stepped Care Model of Pain Management 

(SCM-PM) as the single standard of pain care 

for VA.The SCM-PM provides the ability to 

assess and treat pain in primary care settings 

by integrated Patient Aligned Care Teams 

(PACTs), while maintaining the capacity to escalate treatment options to include specialized 

care and interdisciplinary approaches to pain 

care, if necessary. The SCM-PM can similarly 

be applied for pain management in other settings, including management of acute pain 

in inpatient settings, management of pain in 

specialty mental health and substance use disorders treatment settings, and management of 

pain in the context of palliative and hospice 

care. VA health services investigators continue 

to conduct high-impact work in each of these 

settings.3

Other high priority areas in which health 

services research has already had considerable impact on policy and practice can be 

cited. Promoting equitable access, safety, 

and effectiveness of opioid therapy for the 

management of chronic pain has emerged 

as a particularly important challenge. Several 

teams of VA investigators collaborate with 

VA patient care and operations partners to 

ensure that policies and practice guidance are 

informed by strong science. Development and 

evaluation of alternative treatment approaches 

such as behavioral interventions that promote 

adaptive pain self-management is another area 

of interest and importance. 

As emphasized in the IOM report, VA is 

uniquely positioned to provide leadership in 

the development of comprehensive registries, 

databases, and quality improvement efforts 

that can have widespread impact on pain management within and outside VA. Particularly 

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter: Health Services Research Must 

Prove Its Value Now

Health care issues facing the VA are similar to those facing the nation: dramatic increases in health care cost, health care of modest 

quality, wide practice variation and inequities, and overutilization. 

The coming health care budget squeeze and the competitive challenge resulting from expanded health care benefits for the Veteran 

and his/her family under the Affordable Care Act require that VA provide health care 

of unequaled QUALITY and VALUE. The time is now for health services researchers to unequivocally demonstrate the importance of our contributions to Veterans’ 

health. To facilitate success, attention to six areas is required.

• Expand the Concept of the Research Team. The concepts of program/operations 

and patient stakeholder engagement in research, as embodied in the CREATE 

and COIN programs, must be extended to all research efforts.

• Speed Research. Stakeholders must be engaged at the outset of research to ensure speedy implementation of products, and experienced investigators must direct the IRB process. For critical, nearly-fundable projects, HSR&D will substitute 

the rapid SDR (Service Directed Research) revise-and-review approach for the 

semi-annual ‘revise and resubmit’ process.

• Ensure Focused Research Objectives. Research can no longer be undertaken simply because data is handy and the research questions ‘interesting.’ Projects must 

be undertaken within the scope of a broader vision that emphasizes generalizable principles, models, and acquisition of new knowledge that moves the field 

measurably forward. 

• Adopt Health Care Informatics Technologies. Investigators must gain a working 

knowledge of VINCI’s data and data sharing, applications, and computational 

abilities. Because informatics will be a core component of health services research, every investigator must become familiar with natural language processing (NLP) and understand the concepts and applications of ‘big data.’

• Share Methodology and Outcomes Knowledge. Investigators must routinely 

share their research methodology (e.g., statistical code, tools) and products (e.g., 

data, registries) with colleagues under guidelines that respect individual efforts 

and intellectual property.

•Intensify Mentoring. Mentoring is the responsibility and requirement of every 

investigator. 

Our research environment is stronger than ever. We have VA leadership support, 

a substantial budget, a vast health care database, a strong informatics program, 

outstanding investigators, the freedom to transparently study issues, and the ability to implement evidence based results. We must now demonstrate that we can 

contribute value to Veterans’ health. 

 

Seth Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service August 2012

Continued on page 8
VA Office of Research & Development, Health Services Research & Development Service August 2012

In his 2001 book, Good to Great, James Collins describes characteristics that distinguish 

a merely “good” company from a competitor who moves beyond “good” to become a 

“great” market leader. VA efforts to advance 

our understanding and management of pain 

over the past 15 years are well-articulated by 

Kerns in the lead commentary article for this 

issue of FORUM. At the same time, actions 

that might further solidify and strengthen 

clinical care and research related to pain management warrant our attention.

Since launching its National Pain Management 

Strategy in 1998, the VA has witnessed substantial strides in pain clinical care and research. The 

Pain Research Working Group, Pain Management Program Office, and PRIME Center have 

all played pivotal roles in advancing VA’s pain 

research agenda through special topic issues in 

scientific journals, a monthly webinar series on 

pain management, and other initiatives. Numerous projects centered on pain have been funded 

by the Office of Research & Development. The 

VA Pain Management Directive issued in 2009 

provides comprehensive policy and implementation procedures for elevating the standards of 

care for pain management across all VA facilities. The 2011 Institute of Medicine report was 

a milestone in bringing national attention to the 

importance of pain and, moreover, in highlighting the potential role of the VA as a lead agent. 

Steps toward Becoming “Great”

According to Kerns, the 1998 VA National 

Pain Management Strategy “has served to 

elevate pain management as a top priority 

within the VA.” However, as of 2011, pain 

had not yet risen to being one of the official 

HSR&D Priorities for Investigator-Initiated Research. Ascending to this top tier would signify 

that pain has truly “arrived” as an HSR&D 

research priority. A second step would be to 

provide targeted money for pain research, 

similar to the request for application issued by 

the NIH when it identifies areas of particular 

importance. Congress passed the National 

Pain Care Policy Act in 2003, which declared 

the first decade of the 21st century as the 

“Decade of Pain Control and Research.” 

However, from 2003 to 2007, NIH funding 

for pain research declined sharply—an average of 9 percent per year.1

 Thus, the lip-service Congress paid to pain research was not 

heeded by the NIH. While VA ORD has been 

more supportive of pain research according 

to Kern’s figures, pain-targeted research announcements would further accelerate the 

research agenda. Other steps might include 

funding of a pain QUERI and support of 

multi-center pain trials through the Cooperative Studies Program.

Quality Chasms in Pain Care

Nowadays, quality gaps in the care of specific 

diseases are often identified and targeted for 

quality improvement initiatives as well as clinical research. Until the past few decades, pain 

has been sufficiently ignored that some of the 

gaps are more like chasms. The appropriate 

use of opioid analgesics remains one of the 

great divides. The pendulum swings between 

highly restrictive and more liberal usage. 

While we await the results from currently 

funded studies, disparate guidelines from 

various organizations complicate practice.2

Even the universal vs. selective use of opioid 

contracts and urine drug screens are debated 

by experts. A second major gap is measurement which, paradoxically, is not resolved by 

VA’s Pain as the 5th Vital Sign initiative.3 First, 

it is unclear the single 0 to 10 rating of current pain initially developed for acute pain, 

often in hospitalized patients, performs as 

well in assessing and monitoring chronic pain. 

Second, frequent feedback of pain scores 

to busy clinicians without having systemsbased interventions in place is analogous to 

the inadequacy of depression screening in 

the absence of systems in place to provide 

adequate monitoring, treatment adjustments, 

and specialty support. Integration of pain 

care constitutes a third chasm. Because pain 

is ubiquitous across diseases and central to 

many specialties, pain care can be coordinated 

by primary care clinicians and Patient Aligned 

Care Teams (PACTs), but cannot be disarticulated from multiple other practice settings. 

Also, pain management relies more on patient 

report and less on laboratory testing than 

many other medical disorders, making pain 

particularly well-suited to tele-care management. Other important gaps include Veterans’ 

acceptance of and access to behavioral treatments for pain; the appropriate and efficient 

use of highly-specialized pain programs; 

effective provider-patient communication regarding pain; and reduction in excessive imaging and other diagnostic testing, and disability 

determinations in Veterans with chronic pain.

In the past 15 years, the clinical care and research in Veterans with chronic pain has advanced considerably. For the VA to move from 

“good” to “great” and assume the mantle of 

leadership encouraged by the Institute of Medicine report, parity of pain with other medical 

and mental disorders will be paramount.

References

1. Bradshaw, H. et al. “Trends in Funding for Research 

on Pain: A Report on the National Institutes of Health 

Grant Awards Over the Years 2003 to 2007,” Journal of 

Pain 2008; 9:1077-87.

2. Von Korff, M. et al. “Long-term Opioid Therapy Reconsidered,” Annals of Internal Medicine 2011; 155:325-8.

3. Lorenz, K.A. et al. “How Reliable is Pain as the Fifth 

Vital Sign?” Journal American Board of Family Medicine 2009; 

22:291-8. 

Response to Commentary

VA Pain Management and Research: 

From Good to Great

Kurt Kroenke, M.D., VA Center of Excellence for Implementing Evidence-Based 

Practice, Indianapolis, Indiana

FORUM — Translating research into quality health care for Veterans 3
Opioids are prescribed at high and increasing rates in the United States both within and 

outside VA; over 23 percent of VA patients received an opioid prescription in FY10. Opioids 

are considered a core pain management tool, 

but long-term effectiveness of opioid therapy 

for chronic pain is untested, and opioid use is 

associated with a number of serious risks, including death from unintentional overdose or 

suicide, sedation-related accidents, and medication interactions. The VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic 

Pain (CPG) outlines care practices designed to 

reduce the risks and increase the effectiveness 

of opioid therapy. But guideline recommended 

practices are not consistently followed. 

HSR&D/QUERI has supported several studies 

designed to inform and support VA efforts to 

improve the safety and effectiveness of opioid 

therapy for chronic pain. We describe studies 

that focused on three strategies for improving 

the quality of opioid therapy in VA: 1) improve 

point-of-care clinical decision-making around 

opioids by providing CPG-based patient-specific 

recommendations, tailored data, and tools to 

primary care providers; 2) increase understanding of patient experience and behaviors around 

opioid therapy to develop better methods of 

communicating with patients and managing their 

opioid-related risks; and 3) develop measures 

of adherence to CPG-recommended practices 

for opioid therapy to identify variation in clinical 

practice, and motivate and guide quality improvement efforts. 

Improving Point-of-Care Clinical 

Decision Support

Primary care clinicians report feeling inadequately trained to deliver safe and effective 

pain management, but are being increasingly 

relied upon to treat chronic pain and are frequent prescribers of opioid therapy. To support 

primary care clinicians in opioid prescribing, we 

iteratively developed and tested a computerized 

decision-support system based on the CPG 

and the core ATHENA-Decision Support 

System software architecture. Development 

of ATHENA-Opioid Therapy (OT) involved 

operationalization of the CPG content with 

key CPG authors, design of a graphical user 

interface with pain and primary care clinic staff 

input, and lab-based and in-clinic usability testing with providers.1 ATHENA-OT includes 

patient-specific alerts and instructions on how 

to change prescriptions, filtered and highlighted 

opioid-relevant patient-data, and tools to facilitate CPG-recommended practices. Usability and 

implementation evaluation suggested a need 

for methods to coordinate PACT and specialty 

team-based management, increase prioritization 

of good pain management practices, and support clinician communication around emotionladen topics. 

Understanding Patient Behaviors 

and Experience

To understand and identify risk factors for 

patients using opioid medications in problematic ways, we conducted structured interviews 

with 191 Veterans who had at least one opioid 

prescription in the last year. Pain and physical 

functioning, prescription drug use, substance 

abuse history, and mental health conditions were 

assessed. Findings confirmed previous research 

identifying existing substance use and mental 

health problems as risk factors, but also identified novel and straightforward approaches to 

address behaviors in patients to improve opioid 

use. For example, clinicians prescribe—and patients use—different strategies for taking opioid 

medications. Symptomatic use of opioid medications—in response to pain or distress— was 

most common, but associated with worse painrelated mental health. Patients who used opioid 

medications on a schedule reported better 

pain-related mental health. While literature has 

focused on patient overuse of opioids, in our 

sample, problematic underuse of opioid medications was more prevalent (20 percent) than 

overuse (9 percent).2 Lastly, most patients saved 

their extra medications, and roughly one-third 

reported borrowing or sharing opioid medication at least once. These findings suggest new 

interventions, including modifying prescription 

instructions and monitoring use and disposal 

of medication that could improve safety and effectiveness. 

Motivating and Guiding Opioid 

Therapy Quality Improvement

A team of VA leadership, clinicians, and measurement experts developed metrics to assess 

CPG adherence using VA administrative data.3

These metrics assess use of care practices to improve opioid safety and effectiveness including 

use of urine drug tests, managing patients with 

substance use disorders in addiction specialty 

care, avoiding co-prescription of sedative medications, avoiding sole reliance on opioid therapy 

for pain management, and serious adverse 

events. Some practices vary widely across VA 

facilities; for example, while urine drug testing 

is conducted routinely at some facilities others 

rarely use this practice. Other measures indicate 

non-optimal, but relatively consistent practice 

patterns across facilities, such as co-prescribing 

sedative and opioid medications. These measures 

are being monitored by VA Central Office and 

emphasize the need for development and targeting of effective interventions to improve opioid 

prescribing practices. 

Together, these studies have increased our 

understanding of the current challenges and 

strengths of VA pain management practice. 

Findings suggest opportunities for quality 

improvement and development of new interventions to improve safety and effectiveness 

of opioid prescribing. 

References

1. Trafton, J.A. et al. “Evaluation of the Acceptability and 

Usability of a Decision Support System to Encourage 

Safe and Effective Use of Opioid Therapy for Chronic, 

Non-Cancer Pain by Primary Care Providers,” Pain Medicine 2010; 11(4):575-85.

2. Lewis, E. et al. “Reasons for Under-use of Prescribed 

Opioid Medications by Patients in Pain,” Pain Medicine

2010; 11(6):861-71.

3. Midboe,A.M. et al. “Measurement of Adherence to Clinical Practice Guidelines for Opioid Therapy for Chronic 

Pain,” Translational Behavioral Medicine 2012; 2:57-64.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service August 2012

Research Highlight

Improving Opioid Prescribing Practices

Jodie A. Trafton, Ph.D. and Eleanor T. Lewis, Ph.D., both with the VA Palo Alto Center 

for Health Care Evaluation, Substance Use Disorder QUERI, and Office of Mental 

Health Operations Program Evaluation and Resource Center, Menlo Park, California 
VA Office of Research & Development, Health Services Research & Development Service August 2012

FORUM — Translating research into quality health care for Veterans 5

Musculoskeletal conditions are among 

the most common diagnoses of men and 

women Veterans returning from deployment. Studies of Persian Gulf War Veterans 

as well as Operation Enduring Freedom/

Operation Iraqi Freedom (OEF/OIF) 

Veterans show that diseases of the musculoskeletal system are the most frequent 

diagnoses in cumulative reports of both 

inpatient and outpatient encounters. Musculoskeletal injuries sustained during training 

or active duty may go on to cause chronic 

persistent pain, which is emerging as a 

highly prevalent and clinically important 

problem among the population of OEF/

OIF Veterans.

More than 200,000 women have now been 

deployed in support of the wars in Iraq and 

Afghanistan, representing up to 15 percent 

of the armed forces. Like their male counterparts, female soldiers are subjected to the 

many physical stresses of war. Although 

still excluded by law from participating in 

combat, women are serving in a variety of 

roles where they come under direct fire. Additionally, women soldiers carry heavy loads, 

wear gear originally designed to fit men, and 

participate in strenuous physical training.

Because research in the civilian sector has 

demonstrated that women are more likely 

to report painful musculoskeletal conditions 

than men, and to report more severe and 

longer lasting pain than men, we hypothesized that women Veterans might be at particular risk for the development of chronic 

musculoskeletal pain. In a series of studies, 

we utilized VA administrative data to examine pain and musculoskeletal conditions in 

male and female Veterans after deployment.

HSR&D Studies Reveal Differences 

Our HSR&D-funded study initially examined 

medical and mental health conditions in men and 

women Veterans who utilized VA care within one 

year after return from deployment. Our study 

population was composed of Veterans from the 

VA’s OEF/OIF roster provided by the Defense 

Manpower Data Center-Contingency Tracking 

System Deployment File. Data from the OEF/

OIF roster was linked with the VA National Patient Care Database, Decision Support Systems, 

and the Corporate Data Warehouse. We evaluated records for 19,520 female and 144,292 male 

Veterans, using previously validated diagnostic 

code groupings, and found that back problems, 

joint disorders, and musculoskeletal conditions 

were among the most frequent diagnoses for 

both men and women.1

In a second study, we evaluated pain numeric 

rating scores, which are recorded along with 

vital signs at each clinical encounter in VA. We 

evaluated records for all male and female Veterans who had one year of observation after the 

end of their last deployment. Results indicated 

that 60 percent of both men and women were 

assessed for pain. Men (44 percent) were more 

likely to report pain than women (38 percent), 

but among those with pain, women were more 

likely to report moderate to severe pain than 

men.2

A third study examined the prevalence of 

back, musculoskeletal, and joint conditions in 

female compared to male Veterans in years 1-7 

after return from deployment. For each year 

of analysis, we limited the sample to Veterans 

who had an encounter during that year. We used 

previously validated diagnostic code groupings 

for back problems, joint disorders, and musculoskeletal/connective tissue disorders, and 

counted only those conditions that were coded 

at least once for an inpatient stay, or twice for 

an outpatient visit. For both male and female 

Veterans, the prevalence of painful musculoskeletal conditions increased each year after 

deployment. After adjustment for significant 

demographic differences, women were more 

likely than men to have back problems, 

musculoskeletal problems, or joint problems 

and the odds of having these conditions 

increased each year for women compared to 

men in years 1-7 after deployment. Among 

patients who had been seen in VA for 7 

years, 20 percent of women (compared to 17 

percent of men) had back problems; 12 percent of women and 10 percent of men had 

musculoskeletal conditions; and 19 percent 

of women and 17 percent of men had joint 

problems.3 

Further Research Needed

The growing difference in prevalence of 

painful musculoskeletal conditions between 

women and men over time may represent 

a difference in the chronicity of musculoskeletal problems sustained during military 

service, a difference in the incidence of newly 

reported pain between men and women over 

time, or a difference in the effectiveness of 

treatment. Compared with men, women may 

face challenges in pain treatment such as 

stigmatization, misunderstanding, and gender 

bias. These factors may be particularly important in the VA health care system where 

most pain treatment protocols have been developed for a largely male population. Further 

research will be critical to determine factors 

leading to development of chronic pain so 

that prevention and treatment protocols can 

be tailored to meet the needs of women Veterans.

1. Haskell, S.G. et al. “The Burden of Illness in the First 

Year Home: Do Male and Female VA Users Differ in 

Health Conditions and Healthcare Utilization,” Women’s 

Health Issues 2011; 21-1:92-7.

2. Haskell, S.G. et al. “Pain Among Veterans of Operations 

Enduring Freedom and Iraqi Freedom: Do Women and 

Men Differ?” Pain Medicine 2009; 10(7):1167-73.

3. Haskell, S.G. et al. “The Prevalence of Painful Musculoskeletal Conditions in Female and Male Veterans in 

7 Years After Return from Deployment in Operations 

Enduring Freedom/Operation Iraqi Freedom,” Clinical 

Journal of Pain 2012; 28(2):163-7.

Research Highlight

Post-Deployment Pain: Musculoskeletal 

Conditions in Male and Female OEF/

OIF Veterans

Sally G. Haskell, M.D., Pain Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System 
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service August 2012

Recognizing the importance of pain, VA has, 

for over a decade, routinely required staff to 

assess and document the intensity of pain 

using the 5th Vital Sign, a 0 to 10 numeric 

rating scale (NRS). The patient’s report is 

central to efforts to relieve pain, but pain of 

equal intensity can accompany a range of 

human experiences—from the torture of 

metastatic cancer to the joy of childbirth. 

Can a simple measure of pain intensity inform efforts to manage pain effectively? 

How Informative of the Patient 

Experience is “the 5th Vital Sign”?

The HELP-Vets Study found that the NRS 

measure of current pain intensity was only 

moderately accurate for chronic disabling pain 

measured with the Brief Pain Inventory (BPI). 

HELP-Vets evaluated the variability and clinical usefulness of pain screening at random 

outpatient encounters in the VA Los Angeles 

and Long Beach Healthcare Systems (March 

2006 - June 2007) at 19 oncology, cardiology, 

and primary care clinics in three large urban 

Southern California counties. HELP-Vets targeted the screening experience with baseline 

surveys of clinic-based physician and nursing 

staff followed by post-encounter patient and 

physician surveys to characterize each encounter combined with chart reviews.1

Reasons for suboptimal performance of the 

NRS included the chronicity of pain in primary 

care and the lack of fidelity in scale administration. Substituting a rating of average pain over 

the past week significantly improved sensitivity 

for clinically important pain. HELP-Vets also 

found that staff used informal queries (e.g., “Is 

your knee good today?”) rather than the NRS 

in about 50 percent of cases; this practice was 

associated with pain underestimation. Although 

direct patient reports could avoid errors related 

to fidelity in scale use, clinicians tended to document more severe, and possibly more actionable 

pain, suggesting the importance of comparing 

clinician-documented and patient-reported approaches. 

Why Doesn’t the 5th Vital Sign 

Lead to Better Management? 

HELP-Vets informs why the linkage between 

pain assessment and improved care is missing. 

Busy providers noted pain score information in 

two-thirds of encounters but acted on moderate 

to severe pain with augmented management in 

only 15 percent of cases.2 Knowledge, as well as 

attitudes and skills, proved important—including physicians’ perception of the accuracy of 

nurses’ pain reports. The most commonly cited 

reasons not to act on the NRS value included 

that the patient preferred not to change his/

her approach (56 percent); everything has been 

done (35 percent); and the patient is not experiencing pain (26 percent).

A VA CDA-funded qualitative study of primary care opioid management identified additional concerns about pain assessment. Patient 

interviews identified a strong theme that physicians did not want to listen to patients’ pain 

experiences and did not understand the effect 

of pain on patients’ lives. Patients felt the NRS 

lacked meaning and did not accurately reflect 

their experience of chronic pain; for example, 

“this business about what kind of pain are you 

feeling from 1 to 10, I don’t do real well with 

that because I don’t know how do you rate 

what’s a 1 and what’s a 10, you know.” Several 

participants indicated that the NRS detracted 

from individualized treatment of patients, by 

reducing their experience to a number. As one 

stated, “I mean, just a question like, ‘tell me 

something in your daily life, how your pain 

affects it.’ That would be the most beautiful 

question in the world.”

Our research suggests that assessment of pain 

intensity alone will not likely change practice. 

Pain assessment that incorporates more patientcentered information (such as pain-related 

impairment), and that allows clinicians to assess 

response to therapies might facilitate individualized care. Furthermore, screening needs to be 

meaningfully linked to management, and needs 

to include a focus on high value clinical conditions and expanded options, especially nonpharmacologic approaches, for management.

What Should We Do Next? 

HELP-Vets identified approaches to routine 

pain assessment that may be more informative 

than the NRS, including a three-item measure 

that includes assessment of emotional and 

physical pain interference, the PEG.3 We plan 

to evaluate the PEG versus the NRS, as well as 

compare clinician-documented versus patientreported approaches directly in a multi-site 

randomized controlled pain assessment trial, the 

Effective Screening for Pain (ESP) Study. ESP 

will query clinicians about how to improve the 

pain assessment process—including linkage of 

pain assessment to management—and explore 

prototype approaches and tools to facilitate the 

assessment-management link.

In summary, measurement is a necessary but 

not sufficient step to improving patients’ pain. 

Pain measurement can be improved, especially 

by incorporating information about pain-related 

functional interference to inform individualized 

goals. Additionally, the assessment-management 

link must be strengthened, which will require 

better access to non-pharmacologic treatment. 

Pain is one of various patient-centered symptom concerns, so learning how to systematically improve care for Veterans living with pain 

should inform a more humanistic, quality of 

life-centered VA health care system. 

References

1. Lorenz, K.A. et al. “How Reliable is Pain as the Fifth 

Vital Sign?” The Journal of the American Board of Family 

Medicine 2009; 22:291-8.

2. Zubkoff, L. et al. “Does Screening for Pain Correspond 

to High Quality Care for Veterans?” Journal of General 

Internal Medicine 2010; 25:900-5.

3. Lorenz, K. A. et al. “Exploring Alternative Approaches 

to Routine Outpatient Pain Screening,” Pain Medicine

2009; 10: 1291-9.

Research Highlight

Painful Truths About Pain Screening 

Karl A Lorenz, M.D., M.S.H.S. VA Palliative Care Quality Improvement Resource 

Center (QuIRC), VA Greater Los Angeles Healthcare System, and Erin E. Krebs, 

M.D., M.P.H., Minneapolis VA Health Care System
VA Office of Research & Development, Health Services Research & Development Service August 2012

FORUM — Translating research into quality health care for Veterans 7

“Transforming Veteran Healthcare through 

Partner-Oriented Research” was the theme 

of the 29th VA Health Services Research and 

Development Service (HSR&D) and Quality 

Enhancement Research Initiative (QUERI) 

National Meeting. Hosted by HSR&D’s Center for Health Services Research in Primary 

Care, located in Durham, N.C. the meeting 

was held from July 16-19, 2012 in National 

Harbor, Md. Meeting participants selected 

among 121 peer-reviewed, highly rated scientific paper sessions, 40 workshops, and 146 

posters on vital healthcare issues, such as: 

chronic disease management (e.g., heart disease, hypertension, diabetes), mental health, 

substance use disorders, telemedicine, women 

Veterans’ healthcare needs, patient-aligned 

care teams (PACTs), and deployment-related 

health issues (e.g., traumatic brain injury, 

PTSD, chronic pain), to name a few. 

Partners in Research 

Many of the studies highlighted during the 

meeting depend upon partnerships between 

HSR&D and QUERI and other VA programs 

and offices, such as the Office of Informatics 

and Analytics, Patient Care Services, and the 

Office of Information & Technology. This 

year’s theme emphasized HSR&D’s commitment to increase high-quality, high-priority, 

partner-aligned research aimed at better meeting the needs of Veterans and the VA healthcare system. Research/operations partnerships 

will ensure continuous improvement and 

optimal delivery of healthcare for Veterans, 

so that research is more responsive to the prioritized needs of the organization—and the 

findings are more likely to be implemented 

and sustained in practice. 

National Meeting Highlights

The Honorable Robert A. Petzel, M.D., Under 

Secretary for Health, presented the Under 

Secretary’s Award for Outstanding Achievement in Health Services Research to Elizabeth 

Yano, Ph.D., M.S.P.H., Director of HSR&D’s 

Center for the Study of Healthcare Provider 

Behavior. Dr. Yano exemplifies high achievement in health services research, impact of 

research on healthcare, and contribution to 

the care of Veterans. “Her career has made 

an indelible mark on VA research, policy, 

and clinical operations,” stated Dr. Petzel. 

“Through her research, Dr. Yano has led significant scientific development in two newly 

formed scientific fields—organizational epidemiology, and the study of women Veterans 

and their care in VA. She has also carried out 

innovative work on VA primary care settings 

and their organizational characteristics.”

Madhu Agarwal, M.D., M.P.H., Deputy Under 

Secretary for Health for Policy and Services, 

presented Seth Eisen, M.D., M.Sc., Director 

of HSR&D, with the Under Secretary for 

Health’s Exemplary Service Award for his 

“outstanding leadership and dedication to the 

Veterans Health Administration, HSR&D, and 

to the Veterans we serve.” Dr. Agarwal spoke 

about Dr. Eisen’s important research, including his work in developing the Vietnam Era 

Twin Registry and his continued involvement 

in a national study of Gulf War Veterans and 

their families, as well as the progress he has 

fostered with VA’s IT and health informatics 

infrastructure. She also remarked on his guidance of HSR&D regarding its “increasing 

engagement with clinical and operations partners with the goal of improving the impact 

of health services research on areas of importance to our Veterans and to our system.”

Other meeting highlights included a Partnership Panel with two operations/research partner pairs that described their experiences and 

challenges in implementing innovations in VA 

healthcare; a plenary presentation on the “Direction for Implementation Science: Methods, 

Models, and Measures” by Russell Glasgow, 

Ph.D., Deputy Director of Implementation 

Science at the National Cancer Institute; and 

a session on “Engaging Operations Partnerships” that was led by Jeff Murawsky, M.D., 

Network Director, VISN 12, which was followed by lively participant interaction and 

debate. 

State of the Service

In his address to plenary attendees, Dr. 

Eisen emphasized that the time is NOW for 

HSR&D to prove its value to VA. To ensure 

continued success, he told HSR&D researchers that they need to engage both Veterans 

and stakeholders at the outset, speed and 

focus research, utilize informatics, and intensify mentoring. In his QUERI overview talk, 

David Atkins, M.D., QUERI Director, spoke 

about several of the program’s recent accomplishments; for example, the development of 

toolkits to improve care for lung and colorectal cancers. He also emphasized the importance of partnerships in QUERI’s success, 

including collaborations with VERC (Veterans 

Engineering Resource Center), My HealtheVet, and VA System Redesign, to name a few 

QUERI partners.

Visit the meeting website at www.hsrd.research.va.gov/

meetings/2012/ for presentation slides and other meeting 

information.

HSR&D and QUERI Hold National 

Meeting

Robert A. Petzel, M.D., Under Secretary for Health, and 

Elizabeth Martin Yano, Ph.D., M.S.P.H., recipient of the 2012 

Under Secretary’s Award for Outstanding Achievement in 

Health Services Research.

Madhu Agarwal, M.D., M.P.H., Deputy Under Secretary for 

Health for Policy and Services and Seth Eisen, M.D., M.Sc., 

Director of HSR&D, recipient of the Under Secretary for 

Health’s Exemplary Service Award
Peter L. Almenoff, M.D., FCCP, 

Director of Operational 

Analytics and Reporting, Office 

of Informatics and Analytics, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office, 

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H., 

Director of Clinical Analytics 

and Reporting, Office of 

Informatics and Analytics, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach, 

Long Beach, CA 

Richard Owen, M.D., Director, 

VA HSR&D Center of 

Excellence, Little Rock, AR 

Alan S. Perry, M.P.A., M.H.A., 

FACHE, Retired, 

VA Central California Health Care 

System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of 

Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

important are efforts targeting highly prevalent conditions such as musculoskeletal 

disorders and headache; high cost conditions such as low back pain and traumarelated pain; chronic pain and mental health 

comorbidities, especially post-traumatic 

stress disorder, substance use disorder, and 

depression; and conditions known to be associated with disparities and differences associated with age, gender (including gender 

specific disorders), and race/ethnicity. Finally, the use of these databases to identify 

explanatory and causal factors associated 

with the transition from acute to chronic 

pain and to develop interventions to reduce 

this likelihood is another particularly high 

priority.

References

1. Institute of Medicine. 2011. Relieving Pain in America: 

A Blueprint for Transforming Pain Prevention, Care, Education and Research. Washington, D.C.: The National 

Academies Press. 

2. Veterans Health Administration. 2009. VA Pain 

Management Directive (2009-053). Washington, D.C.: 

Department of Veterans Affairs.

3. Kerns, R.D. et al. “Implementation of the Veterans 

Health Administration National Pain Management 

Strategy,” Translational Behavioral Medicine 2011; Vol. 

1, 635-43.

Commentary – continued from page 2

FORUM

Translating research into quality health care for Veterans

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