**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Transforming Pain Care, Transforming Healthcare**

**Presenters: Stephen C. Hunt, MD, MPH; Lucile Burgo, MD**

**March 5, 2013**

**Transforming Pain Care, Transforming Healthcare**

**March 5, 2013**

Dr. Robert Kerns:Good morning everyone. This is Bob Kerns. I’m a National Program Director for Pain Management, and Director of the Pain Research, Informatics, Medical Comorbidities and Education, or PRIME Center, both of which are two sponsors along with CIDER, the Center for Information Dissemination and Education Resources, also an HSR&D National Resource Center. It’s my pleasure today to welcome you to this month’s Spotlight on a Pain Management webinar. 

Today we have two speakers who are close colleagues and friends of mine who have been providing leadership, particularly on our efforts to address care issues related to our returning soldiers from Iraq and Afghanistan, or Veterans from that era. Today, they’re here to talk about their exciting efforts to collaborate with our Program Office and Center in advancing pain care within the primary care or PACT setting. It’s my pleasure to introduce Dr. Stephen C. Hunt. Dr. Hunt is a physician and also has a Master’s in Public Health. He is the National Director of the VHA Post-Deployment Integrated Care Initiative, or PDICI. He established and is currently the Chief Consultant for the Deployment Health Clinic at the VA Puget Sound in Seattle. Dr. Hunt has spent the past eighteen years providing care for and conducting clinical research on combat Veterans from the 1991 Gulf War, and is a member of the VA National Gulf War Veterans Illnesses Task Force. He regularly gives lectures and trainings on Post-Deployment Care nationwide for both VA and Non-VA groups and other organizations. He serves on numerous panels, advisory groups, and work groups in the VA related to Post-Deployment Care. Dr. Hunt also directs the program at the VA Puget Sound that provides evaluations and care for Veterans with Agent Orange exposures, Ionizing Radiation exposures, and other toxic environmental exposures related to military service. He’s currently a Clinical Associate Professor of Medicine at the University of Washington Occupational and Environmental Medicine Program. 

Joining Dr. Hunt is Dr. Lucille Burgo. Dr. Burgo is a Primary Care Internist and Clinician Educator with a twenty-five year VA career, and is Assistant Clinical Professor at the Yale University School of Medicine. She is the National Co-Director of the Post-Deployment Integrated Care Initiative, Associate Primary Care Director of the VA Connecticut Healthcare System, and an enthusiastic Patient Aligned Care Team member. She supports many initiatives to provide the best care to all Veterans, including PACT implementation, rural health education, telehealth and pain initiatives, and integration in mental health services in primary care, as well as promoting clinical social networking tools in VA, and translating evidence-based strategies in the clinical practice. With that introduction, I’m going to turn things over to Doctor’s Hunt and Burgo, who are going to be presenting on Transforming Post-Deployment Care, Transforming Pain Care, and Transforming Health Care, Researchers as Team Mates. 

Dr. Stephen C. Hunt:Bob, thank you very much. That was a very kind introduction. It’s interesting to hear Bob talk about us in those terms. Lucille, Bob, and I are very close friends. We’ve worked together for many years. Relevant to our presentation today, we are colleagues and team mates. What we’re going to be talking about today is how all of us, everyone on this call regardless of your role or position or what it is that you do exactly, we’re all working together to accomplish some very interesting and important things in terms of healthcare services for our Veterans. Lucille and I are very, very pleased to be here with you today, and to talk about these things. We really appreciate your being here. I appreciate Bob, PRIME, CIDER, and HSR&D for the invitation to be with you. We were originally going to give this talk a year ago. And at that point, we were going to talk about Transforming Post-Deployment Care. 

What’s happened within the last year and one of the things we’re going to be talking about today is instead of the emphasis being on post-deployment care, the emphasis is really on transformation of care. Lucille and I are both Primary Care providers and have been in the VA for a long time. We’ve had the incredible opportunity to participate in shaping post-deployment care in the VA over these last several years as Co-Director’s of the Post-Deployment Integrated Care Initiative and to work with all of you on the call and all of the folks around the country, particularly with OEF/OIF Program Managers and Care Coordinators, Pain and Mental Health colleagues, Primary Care Mental Health Integration colleagues, and our War Related Illness and Injury Study Center colleagues to restructure the way that we provide post-deployment care. We’re going to start off today by talking about that, but then we’re going to merge into talking about the pain care transformation that’s been underway for several years in the VA. There are very close relationships obviously between post-deployment care and pain care. The operative word is “transformation.” We’re really changing the way that we provide health care services in the VA. 

Many of you on the call are researchers for the primary part of your work or maybe certainly for a part of your work. We’re going to be thinking about these transformations of care in terms of your role as researchers as team mates, not from doing something off in the corner that gives us some information that we can use, but with someone that we work with very closely and intimately to shape and to articulate the questions, to find answers, and to find ways of applying the information that we get to transforming care. Where that takes us ultimately is to transforming healthcare in general. We’ll be talking a little bit about the Patient Aligned Care Team, the purpose of which is to provide the Veterans-centered team based care that post-deployment care demands, pain care demands, and really all of health care demands. Lucille, do you want to say anything in terms of introduction as we get going here?

[chatter]

Dr. Lucille Burgo:I’m very excited to present this with Steve, and have been working closely with Bob around transforming pain care for many years. This is very near and dear to my heart. I would like to welcome everyone. We’d like to start out by finding out who’s in the audience, and we have a couple of poll questions that Molly’s going to bring up on the screen now. 

Molly:Thank you very much Dr. Burgo. We have launched the poll question. You do see a blue screen audience members with the poll question, “What is your primary role in VA?” Please click the circle next to one of the options: student, trainee, or fellow, clinician, researcher, manager or policy-maker, or other. We’ve already had two-thirds of our audience vote, and we’ll leave it open for a few more seconds. We do appreciate your answering this poll question as it helps the presenters gauge their talk towards the audience. 

Dr. Stephen C. Hunt:These poll questions remind us of what this is really about regardless of what your role is. It will be interesting to see how many folks from different roles are on the call. You have a part in post-deployment care. You have a part in pain care, and you’re a team member in patient aligned care. So we’ll be interested to see here who is with us. 

Dr. Lucille Burgo:I see the results now of what is your primary role in VA? Six percent are students, trainees, or fellows. Fifty-three percent are clinicians. Fourteen percent are researchers. Twelve percent are managers or policy-makers, and sixteen percent are others. Thank you. We have one more poll question I think Molly.

Molly:Yes we do. I’ll go ahead and launch it right now, and please send your responses in. The question is, “Do you have a role in PACT, which is the Patient Aligned Care Team?” The options are: teamlet member, expanded PACT member, manager or policy-maker, or other. This is a great audience, almost everybody is responding. We had an eighty-five percent response rate on the last question, and we’re looking at two-thirds already on this question. I’ll leave it open for a few more moments as we do still have people responding. A couple of people have written in to say that they have no role in PACT, “How would you like me to respond?” You can either not respond or you can use “other.” 

Dr. Stephen C. Hunt:The thing about that that’s important for us all to remember is that PACT in a sense started out as a notion having to do with the teamlets in primary care. We’re really thinking in terms of an expanded PACT, and we’re thinking about, “What is your role?” Even if you don’t consider yourself to be a part of PACT, what is your role in helping to support Veterans with post-deployment care needs or Veterans with pain care needs?

Dr. Lucille Burgo:This is helpful. Thirteen percent are teamlet members. Welcome. Seventeen percent are expanded PACT members, eight percent are managers or policy-makers, and sixty-two percent are others. So I will spend some time explaining what PACT is during this talk. Do you see the title page now?

Molly:Yes, we’re all set.

Dr. Lucille Burgo:Okay, so Steve?

Dr. Stephen C. Hunt:Yeah. Lucille and I are primarily clinicians, but we are involved with clinical research. We don’t consider ourselves to be primarily research. As we oriented towards this talk, we were thinking about what’s the role of research in helping us to shape care? We looked at the HSR&D website. As I thought about even the term “Health Services Research and Development,” I’ve always thought, “That’s the researchers. Those are the people that do the studies and then they publish the papers and we get the information that helps us change care.” But as I looked at this and looked at what HSR&D does, it’s really about health services. The emphasis is certainly on research, but it’s health services that we’re looking at, what we’re thinking about, what we’re asking questions about, we’re finding answers about, we’re understanding more deeply, and then development.  We’re using that to actually change care. On the website it talks about health services research and development is research that underscores all aspects of VA healthcare, not just the VA’s management, but all aspects of healthcare delivery. The VA is really shifting in a direction away from simply being great to these managements which we are very good at, but also good at healthcare as a whole. Patient Care, care delivery, health outcomes, cost, and quality as well as critical issues for returning combat Veterans, which has been very near and dear to Lucille and my hearts and work. HSR&D researchers focus on identifying and evaluating innovative strategies that lead to accessible, high quality, cost-effective care for Veterans and the nation. Again, let’s remember whatever your role is in healthcare delivery in the VA, the important aspect of HSR&D as team members in the process.

As I said, Lucille and I have had this incredible opportunity to participate in Transforming Post-Deployment Care. After Vietnam, what happened to Veterans when they came back? They came to the VA. We didn’t even know what PTSD was. We maybe had some rudimentary mental health services for them. But basically, they came to the VA and we tried to take care of their physical medical problems, and we did the best we could we mental health problems. But honestly, we did not have a good systematic approach to taking care of them in terms of their exposure issues and so on. Even after the first Gulf War, we had the Gulf War Registry, so we had an entre into care, but we didn’t use it so much clinically. We’ll be talking about that in a minute also. What has happened in post-deployment care is we have developed a systematic way of addressing the healthcare needs of someone that’s been off to a war and they’ve come back and their health has changed along a number of dimensions that we’ll be talking about.

 Let’s talk about Transforming Post-Deployment Care. What did we know as we went into this? Take a look at the pictures here of all of the different sorts of things that can occur in combat. We knew that the health risks of combat were many. And as we look at these pictures, think of all the ways in which health can be impaired by the things that are occurring in these pictures, whether they be physical health impacts, psychological health impacts, or emotional and spiritual health impacts, we knew that the health risks of combat were many. We started needing data. We needed numbers. We need science. We need information. How are we going to learn about how to take care of these folks? Of course we had the scientific and the clinical literature on mental health issues and on pain to draw on. What we really needed was real-time numbers about what we were seeing and who we were seeing. So through Dr. Kahn in DC, we started getting the data in from the Office of Public Health on the denominator of how many of these folks are there, and then what sort of health problems do they have? This was incredibly important for us to see, that the health impacts of deployment were highly prevalent and very common health concerns that affected many of these folks. 

We began to be able to quantify them. Over half had musculoskeletal problems with pain. Over half had diagnosed mental health conditions. We don’t even look at subsyndromal mental health conditions on this list, but we did see that also. The third most common thing was symptoms/signs. Essentially, that’s related to chronic multisymptom illness, or medically unexplained symptoms, health impairments that don’t necessarily have a specific disease attacked to them, but they impact a person’s life in many ways. So signs and symptoms is really medically unexplained symptoms. This data was incredibly important for us to begin to get a sense of, “What are we seeing? What do we need to do about it?” 

We saw that the health issues were complex and co-occuring. This is a slide that probably many of you have seen. It’s one that we use all the time in our talks. It shows that pain and polytrauma or TBI and PTSD highly co-occur. We couldn’t think in terms of, “Do we treat someone for this or that? Or, do we send someone here for one thing and there for another?” We began to see that if we’re going to take care of these people, we need to do it in a holistic integrated way. So this sort of research became very, very important to us. The next slide shows this paper from Dr. Lew. Bob was on this paper as well with Mike Clark, Dave Cifu and John Otis. This reminds us that we have the most remarkable array of resources and personnel and expertise in the VA. Sometimes when I look at it, it’s astounding really. We are able to do things that really no other healthcare system can do. We have been able to implement Patient Aligned Care Teams, and we’ll talk about that in a bit. We have been able to do this transformation in post-deployment care because we have mental health folks, care coordinators, pain experts, rehab polytrauma folks, and behavioral health folks embedded in our clinics. So just to remind us all that we are taking on some very imposing tasks, and post-deployment care was one of them. We’ve done a great job with it because of two things. We’ve stayed Veteran-centered, and we work together in team-based care.

In the past we haven’t been able to do the sort of post-deployment care that Veterans really needed and served obviously. When we think about Agent Orange for example, with this whole issue of exposures related to deployment, we have come to the point of having one of the most proactive approaches to this of any system you’ll find anywhere in terms of the Agent Orange benefits related to Vietnam Veterans, but it’s taken us a long time. It’s brought us to a place where we have transformed our approaches also to deployment related exposures. Now we’re starting to see it with burn pits, depleted uranium, and in other exposure concerns related to the current deployments. The other thing that we see on this slide is with the Gulf War Veterans and of chronic multi-symptom illness, in other words, symptoms that we can’t find a specific disease for. It’s been incredibly challenging, but we’re getting much better at taking care of these Veterans because we’re using the approaches that are basically Veteran-centered and team-based. It’s exactly what we’re doing in PACT, and interestingly exactly what the Institute of Medicine in their report that came out just a few weeks ago was recommending in terms of what returning combat Veterans from the first Gulf War needed if they have chronic multisymptom illness. So we’re getting real-time information about these Veterans, not just when they first come back, but over time. And so our Transformation Post-Deployment Care is not just about combat Veterans coming back these days, it’s long-term health impacts of deployment related issues, such as exposures or other residuals of conflict like chronic multisymptom illness.

For me this has been a very personal and important reality, because I started taking care of returning combat Veterans when I was doing the Gulf War Registry exams after the first Gulf War. That led to a Gulf War Veterans Clinic that got morphed into a post-deployment clinic. It was this idea of having integrated care for returning combat Veterans, which we’ll talk about in a minute. One of the interesting dilemmas was when the Veterans started to come back from the first Gulf War with these medically unexplained symptoms. They had physical symptoms, for which we could not find a diagnosis. We couldn’t tell if this was related to exposures or to psychological traumas. This was a study that was archived in Internal Medicine. What we were finding was that if we asked our medical providers, “Do you think this Gulf War illness, these unexplained symptoms, is a mental health condition or a medical condition?” The medical provider said, “We think it’s a mental health condition, because we do all sorts of tests and they’re all negative.” The mental health folks said, “It’s a medical condition because they really don’t meet criteria for any mental health diagnosis, so we think that we should send them back to their medical provider.” This did not point out a deficit in the quality of our providers, or even of their understanding. It was a problem with our paradigm of providing care. It didn’t work if we thought in terms of, “Is this a medical or a mental health problem?” The answer has to be, “Yes and yes.” It’s a health problem. Dualism doesn’t work.

 The next slide shows the other question that we asked, which was, “Do you think these folks should get their care through their medical provider with biological kinds of support, or through their mental health provider with psychological support?” It was the same thing. The medical provider said, “They probably could get more from their mental health providers.” Mental health providers said, “They probably could get more from their medical providers.” So this was a very enlightening realization for me, and an affirmation again of we cannot provide care for combat Veterans or really any Veterans or anybody without having integrated care.  And the next slide is, “Maybe Veterans don’t understand this. They must think that it’s either one or the other.” The truth is that about half of our Veterans know that there are these relationships between their mental, emotional, and physical health, and that all of these things need to be attended to. Almost half of Gulf War Veterans acknowledge that this is a mix of things. The bottom line is, “I’m not doing very well and I need some support.” So the bottom line for our support of these Veterans is we certainly need to be doing research to try to figure out what may be behind the symptoms. But even more importantly, we need to support these Veterans in getting what they need to do well in their lives. 

When we were trying to come up with the paradigm, “How do we provide care?” Thinking back again, we knew that there were these physical risks and impacts of combat, whether it was temperature, injury, immunizations, blast waves, or dietary changes, all of these physical things that can happen to a person and impact their health in a negative way. We had to take that into account.

We knew that there were these psychological impacts. It was the combat itself and non-combats like a lot of people call them, Military Sexual Traumas, which is a big concern as we all know. It was the anticipation of combat, simply being in an environment where harm or death could be around the corner. We needed to take into account the psychological impact of that experience, not for just the Veterans with PTSD, but for all Veterans who had been through this experience. The next slide shows how we needed to take into account how this affected people’s lives with their families, in their relationships, in their ways of relating to other people, and in their ways of relating to their fellow employees. 

The other thing is that we were drawing on information and research again that had been done on care integration. We had this nice program that was up and running in 2007, Primary Care-Mental Health Integration, where we were starting to do the development piece. So we had the health services research. We had information on integrated care and the benefits and how important it was, and we started to put these things into place. Ed Post and Andy Pomerantz and all of the folks who have been working with Primary Care-Mental Health Integration have done an amazing job of pushing that forward in the VA. So we drew on that information also. We came up with a model, which is not rocket science. It’s pretty basic. There are physical health implications and psychological health implications and psychosocial implications. We need to tie it all together. Joining forces with the OEF/OIF Program, which has been the backbone of post-deployment care, is social workers doing outreach and intake and triage and getting people settled into care and doing care management. Teaming up with them, we came up with a Post-Deployment Integrated Care Initiative to create platforms of care that were built upon this model. Lucille, do you have anything at this point that you wanted to add?

Dr. Lucille Burgo:No, keep on going. We’re twenty-five minutes into the talk.

Dr. Stephen C. Hunt: Okay. So that was kind of how the transformation of post-deployment care evolved in terms of putting together these integrated care platforms. It came out in 2008. So how did we get a sense of how we were doing? Again, the research people came through and the QuERI folks with Brian Mittman, and Clamar Wyte, and Casey MacGregor and their group, looked at what came out of your work here? What came out of this? This was mind blowing for Lucille and me and the PDICI folks, because we didn’t even know that this kind of research was at our fingertips. What did they find? They found that fifty-four percent of all of the centers that were surveyed in the country had actually designated clinics, thirty-four percent had this model where they had a few cohorts within primary care, and twelve percent had a consultative model where they would do consultation for returning combat Veterans having trouble. The Veterans themselves would be mainstreamed into their treatment teams. The next slide shows that this integration of mental health and social work was reaching levels of at least half in terms of mental health, and eighty-seven percent in terms of integration of medical care and social work there. So the QUERI study was incredibly important to us.

The next slide is important because it shows us who needs to be at the table for post-deployment care? Everybody on this call does. And even those of you who feel, “I don’t really have a role with PACT,” you have a role with something in VA or you wouldn’t be on this call. And whatever that is, it’s contributing in some way to the care of Veterans. So it’s important for each of us to think, “What is our role? What do we do? How does it fit with the overall picture?” This shows that suicide prevention, polytrauma, rehab for women’s health, and pain management with pain specialists, all were at the table and needed to be at the table in terms of our post-deployment care.

And this next slide shows more good research coming out of the VA with Antoinette Zeiss and Bradley Karlin in the study here on Integrating Mental Health and Primary Care Services. The next slide is looking at the barriers with Karen Seal and the San Francisco group. They’ve done an amazing job of putting out research that as soon as we get it, we snatch it up and we start shaping our care. This was a very, very important study that Karen and her group did. They’re a terrific group of researchers and clinicians in San Francisco. So we’re learning about post-deployment care in real-time. 

These are IOM reports on PTSD, burn pits, and substance abuse disorders in returning combat Veterans. “Returning Home” is publication on returning home and all of the various ways that the deployment impacted a person’s health. This information doesn’t do us any good, unless we build it into the system for the care we’re providing for Veterans coming back now. But as importantly, we need to build this into the system so we have good post-deployment care built into the VA for future deployment. That’s a major part of our work now. The next study with Drew Helmer is looking at exposures. This is very prominent in the landscape in Congress and in the VA. We’re getting better and better at it, but we’ve got a long way to go. It’s so important that we integrate into our post-deployment care, these issues around exposures. The next study of Patrick Calhoun and his group shows that medical service utilization for folks with PTSD, that these are factors that need to be considered in designing our care. They are higher utilizers of medical care, and they have higher morbidities down the road in terms of physical and medical problems. It’s another thing we’re discovering about folks with PTSD. The next slide is with Gulf War Veterans’ Health. This study told us that these problems do not go away for many Veterans. They’re up and down and they’re life long, so our care simply can’t be in the first year or two after deployment. The care is long-term and lifelong. That’s our commitment to the Veteran. The most recent thing to remind us about this is we need to be paying attention to the care of our Gulf War Veterans with Chronic Multisymptom Illness. There is going to be a big push in the VA to further improve the care we’re offering to these Veterans.

Let’s shift to, “Why are we talking about pain today?” Lucille and I have worked almost exclusively with Post-Deployment Care, but what we found in this picture of *Relieving Pain in America* from the Institute of Medicine Report from a few years ago was the fact that pain is a huge problem as we all know, and pain care is not at all where we want it to be. We have a great plan, the Pain Directive in the VA. We’ve made great strides. We’re really moving in the right direction, and now we’re going to push to move even further into a place where our pain care is aligned with the Pain Directive. We’re doing that through a number of projects we’ll be talking about in a little bit. It was a natural transition from post-deployment care transformation to a pain care transformation. All of you on the call are doing work that can contribute to this process of pain care transformation in the VA. So what were we seeing in returning combat Veterans? That there were relationships between pain and PTSD, and it made treatment difficult. It also made getting the proper services at the proper time difficult. These studies again were reinforcing and pushing us to not only think in terms of transforming post-deployment care, but transforming pain care.

This is one of Karen and her San Francisco group of their important work that they’re doing out there looking at Opioid and Benzodiazepine prescriptions in returning combat Veterans. We know that this is a huge issue. A part of the reason, another project that we’re all going to be working on and pushing to put in place in the VA is the Opioid Safety Initiative. How can we transform our prescribing practices of Opioids in a way that puts us on more solid ground in terms of the type of pain care that the Pain Directive calls for and the type of pain care that we want to be providing for our Veterans? So here’s more HSR&D; here’s more research that’s helping us to develop our programs. In the Hague Surveys we have incredible opportunities again to get the information, to get the numbers, to frame the questions, to do the studies, and to find the answers. And then most importantly regardless of what our studies show, how do we transform that information into action in changes in care, whether it be post-deployment care or pain care? The next one is the Clinical Practice Guidelines. We have incredible resources. We have incredible tools. We have incredible materials in the VA to help us with our pain care. 

Here we’ve broken down the Pain Directive into edible portions, or at least pieces that we can work on. The first of which has to do with Education, with the educating our Veterans and educating our teams. So again when we’re thinking in terms of research, what can help us understand the best way to do this? What are the most effective tools, most effective materials, and the most effective way to roll them out and to use them in terms of educating our Veterans and our teams? The next slide talks about the Implementation. We have this nice opportunity to put in place Pain Champions. We have a pain infrastructure that Bob and the pain folks have put together that’s incredible in terms of having the infrastructure we need to transform pain care. The table is set. We have the resources. We have the infrastructure. And now it’s just a very, very timely opportunity for us to be working together, which is the key, to put this all into place. So implementing it, putting our pain resource providers, our pain teams, our pain experts, and our pain champions working together effectively to enact this pain care transformation. It’s already happening in a lot of places, but it’s not happening nearly to the extent and breadth that we need it to at this point. The next slide is developing non-pharmacological modalities. Lucille, do you want to say anything about CAM?

Dr. Lucille Burgo:Yeah. With the issues of pain we have increasing availability of CAM, but often that’s under the construct of wellness. So it’s not something that we can easily offer our Veterans as a service. But more and more of our primary care teams are getting educated in CAM, because there is a lot available in the community and we do have a very active group. We have chiropractic now in many of our sites that can help us approach pain from a non-pharmacological approach. This is ongoing. There are active communities of practice around CAM that we encourage folks to get more involved in, and more research needs to be done to demonstrate efficacy of these approaches. 

Dr. Stephen C. Hunt:And going back to number three when we think about a Veteran’s self-efficacy and empowering Veterans with regard to their pain care or their post-deployment care, the whole behavioral health support helps behavior coordinators. Again, we have resources in our system that if we can put them together and work shoulder to shoulder we can accomplish things that no other system can. No other system has all of these resources and opportunities. That’s why it’s a very exciting time to be doing what we’re doing in terms of pain care in VA. 

They’re all important of course, but the next slide is a very important one, “How does the team function?” We’ve always thought in terms of pain specialists in primary care and, “Is this going to happen over there or is it going to happen here?” We’re really transforming even the way we think about pain care, and we’re thinking less in terms of, “Should they go to specialty care, or should they stay in primary care?” Instead we’re thinking, “What key members do we need for this Veteran to get the pain care that will best serve them?” And, “How do we make that team function happen?” So, “How do we bring together the people with all the various talents, the specialty folks in bringing them into and on the PACT teams?” We have again this wealth of new modalities, the consults. Ilene Robeck is doing an amazing job of educating and providing case-based support, but also just educational support for her community in Florida using e-consults and ECHO/SCAN. There is no reason anymore that any CBOC in the country should say, “We don’t have a pain specialist.” What we need to be saying is, “How do we bring our pain expertise onto our team, ECHO/SCAN or a telephone consult service or telehealth?” So when we think about research, “How can we be looking at these things in comparing them and figuring out what works best in what situation, and how can we frame questions and put together studies that will help us in this transformation?” Lucille, do you want to talk about that?

Dr. Lucille Burgo:Yes. I think that somehow I skipped the slide here. Instituting safe opioid prescribing is extremely important. There is an opioid safety initiative that is being rolled out. Bob may have some words to say about this at the end of the presentation. It’s so important that we have standard safety processes in place around the prescribing of opioids, and thinking of opioids as we think about other commonly prescribed medications, like Coumadin for A Fib and insulin for Diabetes. There are standard processes that we follow in prescribing these. Universal precautions are the first step in providing good pain care. We have a very large initiative that’s going to be rolling out in conjunction with even a bigger initiative. We’ll talk more about that in a bit. All across the country, metrics and dashboards are being developed to monitor how we are providing pain care looking at the number of prescriptions, the co-prescribing of benzos, the use of utoxics, and the use of opioid care agreements. There is a lot going on. What we need to think about is the old paradigm of how we bring the specialist onto the patient’s team. It would be sending the consult to the specialist, and then getting the information back from the specialty consult with a disposition plan. The plan is recorded in notes, and then the primary care provider often is required to carry out the plan. This really is not working together as a team. With the advent of PACT, we have many more tools now to figure out how to implement this team care around the Veteran and meeting the Veteran’s needs. I want to briefly explain what PACT is, because sixty-two percent of you aren’t involved in PACT at all.

The VA Patient Aligned Care Teams are VA Medical Homes. Its implementation started in 2010, and it’s going to be completed in 2015. It’s ongoing implementation now when all seven thousand eight hundred VA primary care providers will be officially in a PACT. A Veterans PACT, whether they’re in a rural community-based clinic or a tertiary care facility, provides a standardized package of patient centered longitudinal team-based care with standardized processes that focus on assuring access to care management and coordination for chronic illness, as well as prevention, and healthy living and wellness services. There is a core team of primary care provider and RN care managers and a Clerk Health Technician who partner with the Veterans and the team can then expand if needed for whatever conditions and concerns the Veteran has. This can be at the end of life or for our newly returning service members. We just build a team around the Veteran and we have now this sort of standard way to think about it, which hopefully will improve outcomes down the line. It’s a truly integrated patient-centered, team-based model. One of the key ingredients to this model is the presence of behaviorists and mental health providers on our team. They would be considered the expanded PACT, but they’re working side by side with us and can be pulled into the team in real-time. That is a very powerful way to work. 

Dr. Stephen C. Hunt:If I had to say in simple terms the essence of the paradigm shift is thinking less in terms of, “If we get to a place in care where we’re needing something else,” instead of thinking, “Where do I send the Veteran now to get x, y, or z?” Instead we’re thinking, “How do we bring what the Veteran needs onto their team? What’s the best way to bring it onto the Veteran’s team?” That’s essentially what this transformation is about.

Dr. Lucille Burgo:The step care model for the Pain Directive really looks at this as well, and so we have to figure out Step 1, Step 2, Step 3, where the specialist needs to be very much involved in the patient transfer that carry and transfer to the specialist. We’ll go over that with a couple of slides of how we think about this. At Level 3 where the Veteran and the team needs input from the specialist, but they don’t necessarily need a Veteran visit. They might need to follow-up with the pain assessment or other co-morbidity, PTSD, or anxiety. The patient is still sort of in the arms of the PACT team and stays in that location. How do you do this? We have all these new ways to do this, which Steve talked about a little bit. We can use Office Communicator on the day of the visit and pull the team members in if they’re geographically not with us. We can do non-visit consult notes. We document and we use View Alerts so that the team understands what the plan is so that we’re all on the same page with the treatment plan. 

At the next level, the Veteran needs specialized care that is best delivered in a more collaborative setting. So the specialist is working directly with the PACT team and the Veteran. This might be someone who has pain with or without PTSD. We have the behaviorists and the mental health specialists in primary care. The primary care mental health integration team works with us. We have rehab folks working with us in primary care. Many sites are now pulling the psychologist into their primary care clinics for sessions, and for quick advice on how to manage something. Telephone calls of course have always worked, but we have secure messaging now. More and more we are required to enroll everyone now through messaging if the Veteran has the capability at their end. It is a marvelous way to enhance connection with our Veterans. The specialists now are enrolled into this secure messaging process as well. Interdisciplinary team meetings at the second level is where the specialists can come to primary care and meet with the primary care team when they huddle around complex patients. That’s incredibly valuable all doing this together. I’m a part of a Interdisciplinary Post-Deployment Consultative Team. In different ones we didn’t have stand alone post-deployment clinics. We used the consultative model with the returning combat Veteran mainstream. It’s been very value learning how to work in this Interdisciplinary Team format. It is a process, and it’s learning how to do it and become efficient.

The third level is when the Veteran needs highly specialized care that’s usually delivered in the specialty setting. They might need interventional pain care. They have moderate to severe chronic pain and need more supportive specialty care, especially in mental health and substance abuse care for those with dependence. The folks with GBI may need to be in a setting where they can get intensive cognitive rehab occupational therapy. Here the specialist then will maintain contact with the primary care provider through documentation, through our with the VA patient-centered care plan where we can all enter and see what the over-arching care plan is. The role of the RN manager is going to be key in PACT in keeping all these moving parts connected. Steve, do you want to move into the Stepped Pain Care Model? We sort of talked about this. This is a slide that’s probably very familiar to all of you. It’s again what we can do at each step of care as we ramp up the risk, the Comorbidities, treatment refractory, and complexity. I’m not going to spend much time on this, because we want to get through the rest of the slides. Next is the Forum slide. Steve?

Dr. Stephen C. Hunt:This is an article by Bob that was on the Forum just on this whole issue of what we’re talking about today. It’s really amazing what the pain folks have done in VA in terms of putting this blueprint, putting this plan, and putting this infrastructure in place. Now what’s happening is that that is PACT and we’re kind of  we’re populating that plan. We’re populating the Pain Directive by bringing everyone in to pick up their shovels, pick up their tools, pick up their part, and start working together to create the sort of pain care that the Pain Directive outlines for us. HSR&D together with our research and clinical folks are working together and are really leading the way. It’s a very exciting time.

We like this next slide of the Veteran Centered Pain Management, because it reflects the shift from, “Oh, does the person have pain? What do we give them to make it less? What do we give them to get their pain score from eight to three?” There are situations in which that is important for sure, and we all know those situations. There are also many situations in which pain care is very, very different from that that’s in a sense much bigger and in a sense much more complex in certain ways. We start thinking about the Veteran and their experience of pain. We look at all the things on this list. That’s what we start thinking about when we think about pain, not getting a pain score from eight to three. Even though in many cases that’s what we need to do. There’s no question. But in many cases we need to shift the whole reality. In fact, we’re transforming our way of looking at and approaching particularly chronic pain care.

The next slide shows again that the way we’re doing is by building a team around the Veteran. That’s what we’ve done for Post-Deployment Care. That’s what we’re doing for pain care. That’s what we’re doing for Veterans healthcare. That’s what PACT is all about. That’s what the VA is all about. How do we all put these pieces together? How do we work together with this incredible array of resources that we have and the expertise, smart people, good researchers, and incredibly experienced clinicians? One of the big joys for Lucille and me is we work with this remarkable group of people all over the country that have put together the most amazing integrated care platforms for returning combat Veterans. There are hundreds of them. That’s what we’re doing across the board in the VA. We’re doing it with pain care. We’re going to really focus on that this year, and we’re going to get better and better and better at that. That’s our mission as a VA, to do that work together and to achieve levels of healthcare that really no one else can achieve. We’re doing that already.

So the next slide highlights a couple of things that we’ve already kind of mentioned, but there are all sorts of HSR&D Projects. I sat up late a couple of night ago making slides, and there were like fifteen HSR&D Projects on pain with many of you who are on this call. I wanted your names and projects to be up there, and then my PowerPoint crashed about eleven o’clock at night at that point and I didn’t remake it. But we do want all of you to know that are doing these pain-related or post-deployment projects how important your work is, and how it’s informing us and shaping the work that we’re doing. There are lots of projects in motion that we can’t talk about right now just because of time with the initiatives. There is just so much going on. As Lucille mentioned, the Opioid Safety Initiative is going to be Step 1. We’re going to be really pushing on that to accomplish this system wide within the next six months certainly. Bob can maybe comment on that, but the pilots are orienting towards getting going on that.

And then we have a very nice opportunity of having gotten some funding through joint DoD/VA JIF funding to do a Joint DoD Pain Education Project. It’s very exciting, and I know many of you on this call are involved with it. It’s going to give us an opportunity to take a step back and to look at what do we have in terms of educational resources that are already out there. How can we best put them together to move the Pain Directive forward in the VA, and also create pain care in the VA that’s the same as pain care in DoD. Because good pain care is good pain care wherever it’s given, just like good diabetes care is good diabetes care. It’s the same with pain care. This is going to give us an opportunity to create some joint educational opportunities, but more importantly to put together the educational resources and tools that we have at our fingertips in the VA to organize them and put them together in a way that’s going to work better for us. It’s going to be a very exciting time in the year ahead.

The next slide reminds us that this is not just about post-deployment and pain care. It’s about healthcare. It’s about servicing and supporting our Veterans and using what we have to have the healthiest group of Veterans possible. We do it through Veterans-Centered, Team-Based Care, which is what PACT is, which is what good pain care is, which is what good post-deployment care is. I love this. This is from IOM Crossing the Quality Chasm. It’s based on continuous healing relationships. It’s about connection with our Veterans. It’s about having a relationship with them and connecting and providing them things that help them and their families. It obviously cannot be one size fits all, “Where do we send everybody that’s got this or that going on?”  Its customizing care for the needs of that particular individual, and the power and control really resides with the patient. And we’re there to support the Veteran. Lucille, did you have anything else?

Dr. Lucille Burgo:Yes, I think we were going to close up. Thank you.

Dr. Stephen C. Hunt:Bob probably has some comments. We want to thank you all for taking the time today, and we hope some of this has been useful. If you have any questions, get a hold of Lucille or me. I think we’ll open up now for questions, and good luck to all of you in your work. It’s going to be a very exciting year in pain care in the VA. Bob?

Dr. Robert Kerns:I just want to thank Lucille and Steve. I think probably we want to turn things over to Molly and take the last few minutes for questions.

Molly:Excellent. Thank you very much. We do have several questions that have come in. I will read them in the order that they were received. For those of you raising your hand, I’m not going to unmute you, so please write your question in to the comment/question section and press “send.”

The first question is that the most common comment I hear from OEF/OIF combat Veterans is that their providers say they are, “Too young to have chronic pain,” and that they just need to, “deal with it.” How would you recommend that they handle this response to the PCP?

Dr. Stephen C. Hunt:How we need to handle that response is we’re trying to educate and train our providers so that people wouldn’t look at things that way and wouldn’t do things that way. Certainly if a Veteran ever has a provider where they have a problem, they can make changes in their providers if they need to. But the main thing we’re doing is trying to move away from anyone saying those sorts of things, because obviously it’s not correct. It’s also very insensitive.

Molly:Thank you for that response. The second question is most of the OEF/OIF Veterans I work with have medical marijuana cards for pain management. They tell me their providers don’t support this and label them as “drug addicts.” Is there any VA research on the efficiency of marijuana use?

Dr. Stephen C. Hunt:I wish Ilene was on the call. Many of you on the call are more of an expert on this than we are. I don’t think there’s really any good support other than for certain situations of cancer pain and nausea for the use of marijuana the way it’s used in many settings. It’s not something that we look at as a pain medicine in most chronic pain situations that don’t involve cancer. But certainly there are other people that may want to comment.

Dr. Robert Kerns:This is Bob Kerns. I would just jump in and point to the fact that there is a VHA Policy Directive about this topic, “Companion Clinical Guidance,” published by Patient Care Services. Hopefully it’s in your hands at your facilities. But if not, you can contact our Program Office and we can make sure that you get that guide.

Dr. Stephen C. Hunt:The bottom line is that we don’t officially support it for sure. I personally will often involve a substance abuse person to help in situations like that, because often there may be issues around substance abuse. But certainly there are issues around what’s good pain care and what’s not good pain care? We don’t have the evidence in most of these cases that I mentioned that it’s proven to be good pain care. 

Molly:The next question is, “Could you please address comorbid SUD, and violation of pain contracts VA use of alcohol or multiple CMS depressants while on a prescription benzo or narcotic?”

Dr. Stephen C. Hunt:That’s something I would defer to our substance abuse people, and get some input and help around that. Some type of action needs to be taken obviously, and I would involve one of our substance abuse people.

Dr. Lucille Burgo:Steve, this is about building the team. So as primary care docs, we recognize this early on. This is why it’s so important to have access to these services, because the primary care doc is often going to need to partner with the substance abuse and mental health folks. We have a lot of Veterans with comorbid conditions, and it’s not something that we should think of tackling on our own.

Dr. Stephen C. Hunt:Having a plan in place that everyone can say, “This is our plan. This is our approach. This is our agreement.” The whole team says it. It’s not just between a primary care provider and a Veteran. It’s really the team. Then the Veteran gets a consistent message wherever they go, “This is how we see good pain care. This is how we’re agreeing to do it. This is our plan including you.”

Dr. Robert Kerns:This is Bob again. I want to really emphasize what was just stated and to more explicitly acknowledge the history in our fields of pain management substance abuse disorder is that both communities kind of pointed the finger at the other community and suggested that a Veteran with comorbid pain and substance abuse disorder could present for the treatment needed to get their pain managed and their opioid addressed first before they can participate in a substance abuse disorder program and vice versa. Increasingly in the VA there are excellent models of better partnerships between the pain management and substance abuse disorder community. It’s an explicit aim when we talk about the Stepped Care Model in Step 3, Tertiary Interdisciplinary Pain Centers, to develop our capacity for helping Veterans who have those comorbidities. Of course in the context of PACT, it’s really important to emphasize what Lucille and Steve already said which is really trying to help Veterans by reaching out to our potential partners in the substance abuse disorder community to help address these very challenging issues. The last thing that I would emphasize is that it doesn’t do anyone a good service to identify a Veteran who has evidence of an emerging or frank substance abuse disorder, and to lay low or try to accommodate that without him calling a spade a spade. Help the Veteran acknowledge that problem and to get help in addressing it. I know that that’s a very big challenge for primary care providers or even teams in the PACT. But it’s so important that we really build in systems of care that can promote early identification of Veterans who are getting into trouble with drugs or alcohol, or who have frank alcohol or substance abuse disorders and to help promote their engagement and participation in specialty treatment.

Molly:Thank you very much Dr. Kerns. I just want to make a quick announcement. For those of you raising your hand, I’m not going to unmute you. You need to write your questions into the question box and to press “send.” That’s the only way we can receive it. We do still have eight pending questions. Are you all available to stay on for a few more minutes? We do have two hundred people still on the call.

Dr. Stephen C. Hunt:Yeah for Lucille and I. We apologize that we went over for those that have to leave the call, we certainly want to thank you for taking the time and we hope it’s been useful. If you have any questions or you need anything, get a hold of us if you have to sign off now. But yeah, we’ll stay on.

Molly:Thank you. Is there any discussion at the national level to allow chiropractic or acupuncture referrals to Veterans with chronic pain?

Dr. Robert Kerns:I would tell you absolutely. Our key partner in our efforts is actually the National Program Office for Chiropractic Care in the VA. Dr. Anthony Lisi is also a close colleague and has rehabilitation services more broadly. VA is aggressively working to build access to chiropractic services within the VA, and there’s been great growth and uptake of these services across the VA. Fee-based chiropractic care is also increasingly strongly encouraged where ready access to a chiropractor and chiropractic services within the VA are not readily available for Veterans. 

Dr. Stephen C. Hunt:Actually a JIF proposal is being considered right now for limited acupuncture, particularly auricular acupuncture for pain management to be delivered in primary care. So we’re going to be hearing more about many of these modalities. There’s a recent study that looked at massage and back pain, comparing it to other forms of PT and so on. So there’s going to be a lot evolving from this aspect.

Dr. Robert Kerns:It’s important to emphasize also as a part of the response that there’s a growing number of complementary and alternative medicine approaches, including acupuncture. And of course there is a broad array of chiropractic services. Some of these services have a growing evidence-based to support their effectiveness, at least with specific chronic pain or acute pain conditions. Some of them lack as evidence-based, meaning the research hasn’t been done or the research is equivocal. I want to also emphasize that in both domains there are some chiropractic services and certainly a number of modalities for which there is evidence that they are not particularly effective. That is for groups of people they don’t provide benefit. In an age of team building and promoting improvements in pain management, the VHA clearly wants to support and encourage access to evidence-based chiropractic services and evidence-based complementary and alternative medicine services. We don’t want to discourage innovation, but we want to ensure that our Veteran has the benefit of those specific chiropractic modalities that do have evidence to support their effectiveness.

Molly:Thank you both for those responses. The next question is, “I work an afterhours telephone triage and many vets call due to problems with getting pain meds delivered through the mail, and often are without meds over the weekend. Can we establish relationships with local pharmacies for meds to be picked up by the vets?”

Dr. Robert Kerns:This is Bob Kerns. I think I understand the question. I can speak to our own at VHA Connecticut, and I think that some systems have resolved this challenge by scheduling medication refills in a way that ensures their available before the Veteran is likely to run of these medications. And so before we leap to other more complicated solutions, I’d encourage people to work within their systems. This is an important challenge that I think can be met, likely within existing resources. That should be your first effort at the facility level. Lucille, you may know more about this?

Dr. Lucille Burgo:Yeah, we have processes in place to be proactive about things like this. It’s twenty-eight day refills. We have refill clinics that are set up so the provider knows that a refill is due for a narcotic. We have a check list that we go through and often contact the Veteran to find out how they’re doing, whether they’re meeting their functional goals, whether they’re exhibiting any behavior. This is about working with the Veteran around their goals and chronic pain, and getting help for the team. We have pharmacy refill clinics and the pharmacies in primary care are starting to run refill clinics, but we’re connecting with the Veteran about how they’re doing. This is what team-based care is about. So I wouldn’t ever actually see that happening in Connecticut where they’d have to go to an outside pharmacy. The other thing is with our specialty numbers, we may not be able to write prescriptions in local pharmacies. 

Molly:Thank you all for those responses. The next question we have is, “In the expanded PACT Teamlet Model, Access to Specialist Care, still seems to be a silo model. A specialist cannot be expected to give an opinion without seeing the patient, and generally does not have time to attend care management meetings.” It wasn’t really a question, but just a comment there.

Dr. Stephen C. Hunt:Yeah, and even though it’s just a comment, it’s so true that these things are very challenging and difficult. Working out ways to connect is the big challenge here. Of course many of the specialists aren’t going to be able to come to a staff meeting even once a month. So what can we do to actually have a connection? Maybe it’s a shared note or treatment plan. That’s okay. That’s good enough. Maybe the person does have to go see the specialist in the specialty clinic, but can we have some connection so that the Veteran doesn’t feel like they’re going off to see someone else. The Veteran needs to feel like, “Oh, I’ve got another team member. They just happen to have an office in another part of the hospital, but they’re another part of my team.” Can we actually make it a functional team where providers actually talk about each other? I would say, “We have a Rheumatologist, Dr. Starkubaum that we work with. We’re going to have you see him and see what he has to say about this.”

Dr. Lucille Burgo:But we also have to think about other ways of reaching the specialist. The e-consult Program is pretty powerful, because many questions that we have in primary care for the specialist don’t require a face to face visit with the specialist so they e-consult. And then they’re deciding when they go to the chart and look at the e-consult whether they will need to see the Veteran themselves, or can respond by the e-consult. What’s really good about this program now is they’re getting workload credit for these e-consults. That was a big barrier in the past of getting specialists to buy into this virtual type of care. I think we’re all learning in primary care how to provide virtual care through telephone visits and secure messaging, and the specialists are doing the same. Then the question is, “How do we connect? How does primary care, PACT, connect with specialists?” That is difficult, but we have these little tools now. Office Communicator is one of them where if they’re green and you see that they’re sitting at their desk and you have a quick question, it’s a great way to connect and to pull the team together when you’ve got the patient in the room with you.

Dr. Stephen C. Hunt:Yeah, it’s about connection.

Molly:Thank you for those replies. Who are you referring to when you mentioned the Specialty Clinic Care Manager?

 Dr. Lucille Burgo:Some of the specialty clinics have case managers. I was referring to the RN Care Manager in PACT. PACT has each team; each primary care provider is associated and works with a nurse. That’s the RN Care Manager. They’re the linchpin of the PACT team, because they help make sure that everything stays coordinated. We also have more specialized case managers for the more complex Veterans that our RN care managers can’t handle. You can have case managers in all of the specialty disciplines. There are a lot of case managers in oncology. They require a lot of complex coordination, and also connect with the Veteran outside of their visits to the oncology clinic for their chemo for example. There are specialty case managers. So there’s a difference between care management and case management that is all a part of the PACT universe.

Molly:Thank you for that reply. Next is a three-part question, “Are there other pain researchers involved in research that also research anxiety and depression, but have aligned themselves with the PACT Team? How did they make this transition? Were you successful as the specialist in prescribing antidepressants, or were you more successful in having mental health prescribe it? If the specialist prescribed it, how did you communicate with the PACT Team and the plan of care?”

Dr. Robert Kerns:This is Bob. I can make one comment. There are some people in the HSR&D community that are specifically working to address the comorbidities of pain, depression, and anxiety. I site in particular colleagues Kirk Cronke and Matt Baylor and others at the Roudebush VA in Indianapolis, with their work on models of collaborative care for Veterans with for example musculoskeletal pain and comorbid depression and/or anxiety. Their work has been published in some of the most prestigious journals, for example the *Journal of the American Medical Association* that really argues for their, the strength of the science and also their potential impact. I might mention that there are discussions underway for example with Dr. Baylor in thinking about the quality enhancement research initiative folks to design and implement a further implementation study related to that collaborate care model. But there are many others. There is very large literature about pain and comorbid depress for example. I think you’re right in terms of the question about people who have been working largely in the mental health field and whether or not they can be brought successfully into addressing pain management. I think that there are many examples of mental health evidence-based psychotherapy initiative to build capacity for delivering therapy for Veterans with chronic pain. Many of the people who are likely to participate in that training are people who have already developed competencies in delivering CDP for either anxiety disorders or depression. So I think that we can easily expect that that crossover is likely to occur.

Dr. Stephen C. Hunt:And if you want to see a list of ongoing projects, just go to the HSR&D site and go under Current Projects and then search under Pain. You’ll get several dozen projects, many of which have that sort of overlap. It’s incredibly important research. That’s one of the points that we were trying to make today. The research that’s occuring between SUD and pain and mental health and primary care, that’s the research that’s very rich these days and really helping us to improve our team-based care.

Molly:Thank you both for those responses. The next question is, “Can you talk about the future of VA Pain Centers?”

Dr. Robert Kerns:Sure. I only recently received another list, so there’s a growing number that have been successful in developing multidisciplinary pain centers consistent with what’s prescribed in the Pain Directive, which includes two components. The first is the capacity for advanced pain medicine diagnostics and interventions. I think that almost all have successfully built that capacity. The more challenging seems to be the multidiscinplary chronic pain rehabilitation programs that can receive a Commission on Accreditation of Rehabilitation Facilities, or CARF. But a growing number of VISNs have solved that challenge. The most recent list that I have suggests that seven out of twenty-one VISNs have CARF accredited programs now. They include VISNs 7, 8, 10, 15, 12 and 22. We know that there are plans in place for 5, 10, 17, 18, 19, 20, 22 and 23 to develop such programs, leaving only a very small number that have not either received CARF accreditation for a program with at least one program, or have not become visible to us in identifying a facility that’s pursuing that accreditation.

Molly:Thank you Dr. Kerns. We have five pending questions. This next one you may have addressed it already. Regarding the use of medical marijuana, has the VA officially addressed the recent articles that have been in the news stating that marijuana may have efficacy in treating PTSD?

 Dr. Stephen C. Hunt:I’ve seen things in the news. I haven’t read good studies, and I’m not certainly an expert in that area. I’m not aware of any new strong studies that show evidence, but again I’m not an expert.

Dr. Robert Kerns:I have a comment. It’s always of course a balance of potential benefits and risks. I would say even in the area of analgesics. This is really about PTSD which is really out of the scope of what we’re talking about today. Even in the area of analgesics there are studies either pre-clinical or clinical that suggest some analgesic properties of cannabinoids. However, it’s also very important to acknowledge that there’s a much larger literature documenting the potential harms of smoked marijuana, as there are for other smoked substances. It seems intuitive to me that it’s very unlikely that our society more generally or the VA or the Federal Government will move in the direction of supporting a claim for the medicinal use of marijuana. That’s all occuring of course in a different context in which the science will continue to grow on pain or PTSD or other areas of health-related concerns. Also in the context of a growing number of states that are developing laws and publishing regulations that support the use of marijuana in the context of healthcare, and recently in terms of recreational issues. The question is, is VA aware of that. Of course the VA is paying attention and monitoring the changing landscape including the science, as it does with lots of other issues including how we think about medicines and our pharmaceuticals. The VA has an infrastructure that is constantly working to absorb the latest information and make decisions ultimately with an eye to the Veteran in the efforts to promote the health of Veterans. That may sound like a political statement, but I think the easiest way for me to try to summarize a really complex and rapidly changing political, social, cultural, and scientific landscape is to emphasize what I think is a reasonable assumption. which is,  it seems very unlikely in the near term that federal law is going to change about this or that the VA in particular is going to move in the direction of endorsing that marijuana smoked or otherwise has medicinal value.

Molly:Thank you Dr. Kerns. The next question, “Is there any plan to offer pool therapy in the communities sponsored by the VA for all Veterans with chronic pain? Driving long distances to the VA is impossible for many Veterans. 

Dr. Stephen C. Hunt:I know this is one of those things of fee-based reality. There are certainly many national policies. Some centers actually have pools, some centers do fee-based, and some of it is up to the centers at this point. I’m not aware that it’s a wide spread practice. I don’t know of any plans to change that.

Molly:Thank you for that reply. How should you best deal with a provider that “includes team members only to the extent of telling them exactly what is needed and ordering such, as opposed to asking the members their professional input when ordering as indicated and appropriate?”

Dr. Lucille Burgo:This is hard. This is about training folks how to work together as teammates. It’s not always easy. We have these lingering (inaud) in ourselves, and we’re trained as physicians also to be in control and to do our own thing. Learning how to be a good team member takes time. This is a part of what PACT training is doing. It’s educating folks in team culture and in communication styles as well. These trainings teach motivational interviewing help us not only work with our Veterans but also work with each other.

Molly:Thank you for that reply. Too what extent, if any, does the VA implement yoga and acupuncture in treatment plans?

Dr. Lucille Burgo:I implement yoga and acupuncture in any treatment plan that I am able to. It’s a place where I would start in someone with chronic pain who either comes to me on opioids and we might think about, “How do we best really improve your life and your health?” If they’re not doing any of these non-pharmacological alternate approaches, if they’re not exercising, it’s time to figure out how to do that. I find yoga is a really nice gentle way to start with a Veteran with musculoskeletal chronic pain. It’s just finding the places where they can do this. Now we have some yoga going on in our centers, but we can’t send a consult for yoga. People will tell you about what they did in Seattle, which is a fabulous program and one way to crack this nut. But often you just connect with your community. There’s a lot going on that you can benefit from.

Dr. Stephen C. Hunt:Yeah, and I would just reiterate what Lucille was saying. We can’t do everything for all Veterans. But what we can do is everything possible to support Veterans in getting what they need to be healthy. Some of that they may need to get from the community in other places. We can facilitate that. What we did in Seattle was actually a yoga teacher that I knew said, “Gosh, do you ever refer a Veteran for yoga?” And I said, “Sure, it can be often helpful especially with combat Veterans.” She said, “I’d be happy to give some free yoga.” So I said, “Just ask around and see if there are any other yoga teachers that would be interested in doing this. I’ll come and give a little training and talk about some of health issues of returning combat Veterans.” Three weeks later she got this training together. Forty-two yoga schools and teachers in the Seattle area offered free yoga to returning combat Veterans and for their spouses. Even though we don’t officially refer to them, we can say to the Veteran, “The yoga schools in the area have gotten together, and here’s a number that you can call if you’re interested.” I don’t know officially the liabilities. We don’t officially refer, but we have mobilized the yoga community in Seattle to offer support which they gladly will do to our returning combat Veterans and their spouses. So be creative in trying to help our Veterans get what they need.

Molly:That’s an excellent approach. Thank you Steve. 

Dr. Robert Kerns:We’re already over, and I’ve noticed the diminishing callers, so the last three questions would be great.

Molly:This is just a comment actually. There is a disconnect between the DoD and VA in regards to narcotic usage and ultimate goals of pain management. Hopefully the Joint DoD/VA Task Force will address this issue.

Dr. Stephen C. Hunt:Right. Whoever wrote that it’s true. It’s been a problem. That’s a part of the reason we’re having this Joint Educational Project, and it will give us an opportunity to improve pain care both in DoD and VA, specifically related to opioid prescribing so we’re more evidence-based and do a better job with that. And that we’re better at transitioning people as they come from DoD or VA. So this project will certainly help us out with that and that’s why we’re doing it. That’s a good comment.

Dr. Robert Kerns:I wanted to add to that by acknowledging actually the truth as he said in what was stated about different goals. I think for many service members the goals are quite different during their active duty status in the military than what may be true when they separate from the service and move to life as a Veteran. So those goals should be taken into account in terms of a development of different plans of care. So it’s important that we not imply in any way that the DoD is not trying to work hard to meet their service members goals, and that that’s a problem. We really do want to acknowledge the differences that these people are going through in goals in many cases, and with the role of the VA provider or team in working with the Veteran around developing potentially a new set of goals as they move into non-military life.

Dr. Stephen C. Hunt:That’s an important comment Bob. One of the wonderful things coming out of all these Joint DoD/VA Initiatives is that we’re learning that as a nation, we need to have a strong and healthy DoD military, and we need to have strong healthy Veterans. The missions may be different, but if you put the two together, it really serves our nation well. If the DoD and VA can work together, it certainly serves our men and women in uniform well, as well as serving our Veterans well once they get out of the military and through the remainder of their post-service lives. 

Molly:Thank you both for those replies. There are just two quick questions left. Dr. Burgo you mentioned you use Office Communicator. Is it safe to provide patient protected health information/patient identifiers via Office Communicator?

Dr. Lucille Burgo:No, it isn’t safe to provide patient protected information, but there are ways around that. You can say, “With my third patient today.”  I’ll send an Office Communicator to my nurse and ask her to come in and give a shot? So she’ll know what my schedule is. Or if I’m speaking with a behavioral health colleague down the corridor, I can put in the first letter of their last name and their last four or say, “Sam our mutual patient is in today. He’s supposed to be coming to see you.” There are ways around that. You have to be careful not to identify the patient, but there are ways to work with that.

Molly:Thank you. What is the evidence for chiropractic care for chronic versus acute pain?

Dr. Stephen C. Hunt:I wish Dr. Lisi was here. I don’t have the literature. Bob, I don’t know if you do or not. That would be a good one just to do a literature search and find out certainly that there is evidence that support both. But certainly the acute situations are more commonly used for that.

Dr. Robert Kerns:Yeah, I can say when you talk about chiropractic care just like any other healthcare professional, there is a broader array of strategies. Then there are broader array of both acute and chronic conditions. So you really have to be much more specific in the way that the question is framed. The answer is probably in a global way that there is a growing body of evidence supporting the efficacy of specific chiropractic procedures for specific acute and chronic pain conditions. We want to specifically encourage Veteran access to those evidence-based approaches. And at the same time, there are many other approaches that are commonly in the toolbox of the chiropractor that really aren’t specifically evidence-based, or are only evidence-based for specific conditions. It’s incumbent upon the provider team maybe not to know all of those, but to have the kind of relationship with the chiropractor that can help them decide and learn over time about the kind of problems that patients are experiencing that may benefit from specific chiropractic care.

 Molly:Thank you very much. A few more questions have come in, and I asked them to contact the presenter’s offline as we are out of time. But I would like to give any of you the opportunity to make any concluding comments.

Dr. Stephen C. Hunt:Lucille and I just want to thank you Bob for the invitation. And any of you still on the call, thanks. If you have any other questions just get a hold of us. It’s a very exciting time for us in the VA in terms of these changes in pain care, and it’s an exciting time to be working together to make it happen. So good luck to all of you in your work, and thanks for the opportunity to be with you today.

Dr. Lucille Burgo:Just stay tuned. There’s going to be a lot more educational opportunities around chronic pain with all of the things that we’ve been talking about, and how do we best really make this transformation happen. There are going to be trainings on the virtual university that’s been recently rolled out. There are trainings on the rural health initiatives. These are trainings geared towards frontline providers, but we’ll also have connections with the researchers because we need to present the evidence to our frontline teams. So stay involved and stay tuned.

Dr. Robert Kerns:I’ll close by thanking Lucille and Steve and Molly for your support for this, and of course to all of our participants, especially those who have hung in there for the last half hour or so. It really speaks to the strong interest in this issue, the importance of the topic and our shared commitment to build the capacity with the focus of our discussion today. We’ll look forward to having many of you, if not all of you, back for next month’s spotlight on Pain Management. Thanks.

Molly:Great. And I do want to thank all of our attendees and presenters for joining us today. As you exit today’s session, wait just a moment and a feedback survey will pop up on your screen. Please do provide us feedback as we update our program based on your responses. So thank you very much to everyone and enjoy the rest of your day.

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