Chronic pain is a common health care problem that remains a significant burden for the VHA.1,2 Some reports indicate that nearly 50% of VA patients report chronic pain.3,4 Both within and outside the VHA, primary care providers (PCPs) generally manage patients with chronic pain.5,6 Historically, a biomedical approach to chronic pain also included the use of opioid medications, which may have contributed to increased opioid-related morbidity and mortality especially among the veteran patient population.7-9 The use of opioids also is controversial due to concerns about adverse effects (AEs), long-term efficacy, functional outcomes, and the potential for drug abuse and addiction.10 Consequently, alternative treatment options that incorporate an interdisciplinary approach have gained significant interest among pain care providers.11 Interdisciplinary programs have been shown to improve functional status and psychological well-being and to reduce pain severity and opioid use.12-14 These benefits may persist for a decade or longer.15
Background
The Stepped Care Model for Pain Management (SCM-PM) is a specific pain treatment approach promoted by the VA National Pain Management Directive.16 This systematically adjusted approach is associated with improved patient satisfaction and health outcomes for pain and depression.17,18 At its core, the model promotes engaging patients as active participants in their care along with a team of doctors who can offer an integrated, evidence-based, multimodal, interdisciplinary treatment plan.
To successfully implement this strategy at the VA, patient aligned care teams (PACT) assess and manage patients with common pain conditions through collaboration with mental health, complementary and integrative health services, physical therapy, and other programs, such as opioid renewal clinics and pain schools.19 This collaborative care approach, which the PCP initiates, is step 1 of the SCM-PM. If initial treatment is not successful and patients are not improving as expected, specialty care consultation and collaborative comanagement through interdisciplinary pain specialty teams are sought (step 2). Finally, step 3 involves tertiary, interdisciplinary care, including access to advanced diagnostic and pain rehabilitation programs accredited by the Commission for Accreditation of Rehabilitation Facilities (CARF).
Although the advantages of interdisciplinary pain programs are clear, resource limitations as well as challenges related to competencies of the PCPs, nurses, and associated health care professionals in pain assessment and management can make implementation of these programs, including the SCM-PM, difficult for many clinics and facilities. Thus, identifying effective chronic pain models and strategies, incorporating the philosophy and key elements of interdisciplinary programs, and accounting for facility resources and capacity are all important.
At the Ann Arbor VAMC, development of a comprehensive interdisciplinary team started with the implementation of joint sessions with a clinical pharmacist and health psychologist embedded in primary care to enhance access to behavioral pain management interventions.20 This program was subsequently expanded to include a pain physician, 2 pain-focused physical therapists (PTs) and a pain nurse.
This article describes a novel team approach for providing more comprehensive, interdisciplinary care for patients with chronic pain along with the initial results for the patients who were part of an outpatient pain group program (OPGP).
Methods
Developing a more interdisciplinary pain management program included integrating different services and creating a strategy for comprehensive evaluation and management of patients with chronic pain. After patients were referred to the interdisciplinary pain clinic by their PCP, they received a systematically structured multidimensional assessment. The primary focus of this assessment was to create an individually directed treatment approach based on the patient’s responses to previous treatments and information collected from several questionnaires administered prior to evaluation. This information helped guide individual patient decision making and actively engaged patients in their care, thus following one of the central tenants of the SCM-PM model. Moreover, functional restoration was at the core of each patient’s evaluation and management. The primary focus was on nonpharmacologic treatment options that included psychological, physical, and occupational therapy; self-management; education; and complementary and alternative therapies. These modalities were offered either individually or in a group setting.
The first step after referral was an evaluation that followed the main core principles for complex disease management described by Tauben and Theodore.21 All new patients were asked to complete a 2-question pain intensity and pain interference measure, the 4-question Patient Health Questionnaire (PHQ-4), 4-question Primary Care-PTSD screening tool (PC-PTSD), and the STOP-BANG questionnaire to assess the risk for obstructive sleep apnea.22-24 Each measure allowed the physician to identify specific problem areas and formulate a treatment plan that would incorporate PTs or occupational therapists, psychologists and/or clinical specialists, and pharmacists if needed.
Patients who were found to have or expressed significant disability because of pain and who wished to learn pain self-management strategies could participate in an 8-week OPGP. This program included the use of cognitive behavioral therapy (CBT) strategies along with group physical therapy classes. Some patients also received individual therapies concurrently with the 8-week OPGP. Patients were excluded from participating in the OPGP only if their current medical or psychiatric status precluded them from full engagement and maximum benefit as determined by the pain physician and psychologist.