VA Initiates Pain Management Program

Pain is one of the most common reasons people consult a physician, according to the American Academy of Pain Medicine and the American Pain Society. In fact, it is the primary symptom in more than 80 percent of all doctor visits and affects more than 50 million people. In January 1999, the Department of Veterans Affairs (VA) took the lead in pain management by launching a nationwide effort to reduce pain and suffering for the 3.4 million veterans who use VA health care facilities.

VA and Pain Management

VA believes that no patient should suffer preventable pain. Doctors and nurses throughout VA’s 1,200 sites of medical care are required to treat pain as a “fifth vital sign,” meaning they should assess and record patients’ pain just as they note the other four health-care basics — blood pressure, pulse, temperature and breathing rate. They ask patients to rate their pain on a scale of zero to 10, then consult with the patients about ways to deal with it.

“It changed how VA approached pain,” said Dr. Jane Tollett, national coordinator of VA pain management strategy. “We’re too often obsessed with finding out what’s going on at the molecular, cellular and pharmacological levels as opposed to asking: Is the person feeling better?” Measuring pain as a vital sign was part of the first step in the following comprehensive strategy to make pain management a routine part of veterans’ care.

Pain Assessment and Treatment: Procedures for early recognition of pain and prompt effective treatment began at all VA medical facilities. Pain management protocols were set up, including ready access to resources such as pain specialists and multidisciplinary pain clinics. VA updated its Computerized Patient Record System (CPRS) to document a patient’s pain history. Patient and family education about pain management was included in patient treatment plans.

Evaluation of Outcomes and Quality of Pain Management: VA began to systematically measure outcomes and quality of pain management, including patient satisfaction measures. Across the nation, VA set up quarterly data collection to evaluate: Was the patient assessed for pain using a 0-10 scale? Was there intervention if pain was reported as 4 or more? Was there a plan for pain care? Was the intervention evaluated for effectiveness?

Research: VA expanded research on management of acute and chronic pain, emphasizing conditions that are most prevalent among veterans. Currently, there are nine pain research projects funded by VA. Research funded by the Health Services Research and Development Service focuses on identifying research priorities, providing scientific evidence for pain management protocols throughout VA and evaluating and monitoring the quality of care.

Education of Health Care Professionals

VA is assuring that clinical staff, such as physicians and nurses, have orientation and education on pain assessment and pain management. In collaboration with the Department of Defense and the community, VA is developing clinical guidelines for pain associated with surgery, cancer and chronic conditions.

Additionally, VA initiated an extensive education program for health care providers that includes orientation for new employees and professional trainees, four internet sessions on “pharmacotherapy of acute and chronic pain,” satellite broadcasts and interactive sessions with VA health care facilities, guest lectures on topics like pain assessment and treatment of the demented, purchase and distribution of pain management videos, and a Web site “vaww.mst.lrn.va.gov/nmintranet/pain.”

VA also focuses on pain management education for medical students and health care professional trainees through VA’s affiliations with academic institutions. Among recent milestones:

The Robert Wood Johnson Foundation last year awarded VA a grant of $985,595 to help train physicians in end-of-life care, including pain management.

The VA Office of Academic Affiliations recently awarded additional funding to nine VA medical facilities to support graduate education residencies in anesthesiology pain management, including VA medical centers in Milwaukee, Wis.; Durham, N.C.; and Loma Linda, Calif. and the health care systems in North Texas, New Mexico, Puget Sound (Wash.), Palo Alto (Calif.), and North Florida-South Georgia.

National Pain Management Strategy

The complexity of chronic pain management is often beyond the expertise of a single practitioner, especially for veterans whose pain problems are complicated by such things as homelessness, post traumatic stress disorder and combat injuries. Additionally, pain management has been made an integral part of palliative and end-of-life care. The effective management of pain for all veterans cared for by VA requires a nationwide coordinated approach. To accomplish this, VA formed a team made up of representatives from an array of disciplines — anesthesiology, nursing, psychiatry, surgery, oncology, pharmacology, gerontology and neurology.

Funded by an unrestricted educational grant, VA is producing a Web-based physician education program aimed at end-of-life issues and an online forum for VA pain management in which more than 200 clinicians actively participate.

In December 2000, a pain management and end-of-life conference is scheduled to showcase innovations and effective practices within VA, address specialized topics with expert faculty and solve systematic problems that cause barriers to improving pain management care. Additionally, VA will set up programs to support clinicians in settings that are remote from pain experts, centers or clinics.

“Untreated or undertreated pain takes its toll not just in monetary loss but also in the psychosocial and physical cost to patients and their families. Pain can exacerbate feelings of distress, anxiety and depression. . . . When severe pain goes untreated and/or depression is present, some people may consider or attempt suicide. The message is clear: all those in pain have the right to systematic assessment and ongoing management of pain by health care professionals.” (The Journal of Care Management, November 1999)