This paper examines how the Department of Veterans Affairs can enhance provider education for chronic pain management through a monthly pain management newsletter. It describes the VA's complex stepped-care healthcare system and identifies the interprofessional team members needed for optimal pain management delivery, including pain psychologists, nurses, pharmacists, and specialists. The paper outlines core competencies and role responsibilities for each team member, analyzes positive and negative factors affecting care delivery — such as provider bias, cultural and gender differences, patient reluctance, and knowledge gaps — and discusses how these challenges can be addressed. The conclusion underscores the newsletter as a practical tool for sustaining staff awareness of effective pain management practices.
Today, the Department of Veterans Affairs (VA) is the largest healthcare provider in the United States and one of the largest in the world. In fact, fully half of the physicians in the United States receive their training at a VA healthcare facility. This paper provides a description and explanation of the complex healthcare system to provide a framework for enhancing VA medical support staff knowledge of chronic pain management via a monthly "pain management" newsletter designed to improve pain management outcomes for veterans.
In addition, an examination of the various levels of the interprofessional team required for the optimal operation of the multidisciplinary pain management delivery system is presented, along with supporting rationale for each level. This is followed by a discussion of the core abilities required for each team member, including suggestions for role responsibilities. Finally, factors that may positively or negatively impact the delivery of provider and nursing care are identified, along with an assessment of how they will be addressed.
Because pain is a complex phenomenon that is highly subjective in nature, effective treatment requires a holistic approach that takes into account a wide range of factors that may contribute to or exacerbate the pain process. There is a general consensus that an interdisciplinary team approach is most effective for achieving optimal pain management outcomes (Woods, 2011). In this regard, Woods emphasizes that "interdisciplinary teams have been shown to improve patient care in complex clinical situations and also to deliver the best possible treatment to this challenging population" (2011, p. 15). The rationale for including additional healthcare professionals as part of an interdisciplinary pain management team is based on the premise that a single physician, irrespective of training and experience level, is unable to address all of the complex individualized needs of patients suffering from chronic pain (Woods, 2011). As Woods concludes, "The addition of a team of specialists partnering together in the best interest of the patient brings a more comprehensive treatment approach" (2011, p. 15).
Based on the recommendations provided by Clark and Norton (2009) for optimal interdisciplinary pain management teams, the core interprofessional team members needed for this initiative will include the following:
One full-time equivalent (FTE) pain psychologist: This physician will serve as the coordinator of the pain management training program and will be responsible for initiating and formulating interdisciplinary, transdisciplinary, and interprofessional practice.
One FTE pain RN: This healthcare professional will serve as the nurse educator, provide support, and be responsible for quality improvement.
Pain specialists in each discipline of the chronic pain rehabilitation program (CPRP) who will volunteer time to help educate training participants.
In addition, a dietitian, recreational therapist, social worker, and other specialists may be valuable additions to the pain management treatment team depending on the unique needs of the patient (Clark & Norton, 2009). Likewise, Kubotera and Fudin (2013) recommend that interdisciplinary pain management teams should also include a pharmacist. The addition of a pharmacist to the multidisciplinary pain management team is based on the rationale that "pain and related symptom management often involves complex polypharmacy, a keen understanding of pharmacotherapeutics across several drug classes, and collaboration with other healthcare disciplines" (Kubotera & Fudin, 2013, p. 37).
The full range of disciplines that may contribute to a chronic pain team includes medicine, psychology, psychiatry, occupational therapy, physical therapy, pharmacy, nursing, recreation therapy, social work, dietetics, pool therapy, and vocational rehabilitation. Although each patient's pain management requirements will be unique, the interdisciplinary pain management treatment team can generally facilitate the following:
Working toward a common goal; making collective therapeutic decisions; communicating and consulting with other team members in face-to-face meetings; possessing a combination of skills that no single individual demonstrates; and achieving more together than what individuals could achieve alone (Woods, 2011, p. 15).
Beyond the foregoing team members, the VA's current National Pain Management Strategy also mandates "a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain and suffering and improves quality of life for Veterans experiencing acute and chronic pain associated with a wide range of injuries and illnesses, including terminal illness" (VHA directive 2009-053, 2009, p. 1). For this purpose, the VA employs a stepped-care pain management model set forth in VHA directive 2009-053 (2009), described below.
Step One: Primary Care. Stepped care is instituted as a strategy to provide a continuum of effective treatment to a population of patients — from acute pain caused by injuries or diseases to longitudinal management of chronic pain conditions that may be expected to persist for more than 90 days, and in some instances, the patient's lifetime. This step requires the development of a competent primary care provider workforce (including behavioral health) to manage common pain conditions. To accomplish this, primary care requires the availability of system supports, family and patient education programs, collaboration with integrative mental health and primary care teams, and post-deployment programs.
Step Two: Secondary Consultation. This step requires timely access to specialty consultation in pain medicine, physical medicine and rehabilitation, polytrauma programs and teams, and pain psychology; occasional short-term co-management; inpatient pain medicine consultation; and the collaboration of pain medicine and palliative care teams.
Step Three: Tertiary, Interdisciplinary Care. This step requires advanced pain medicine diagnostics and pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).
The VA's stepped-care pain management model in primary care settings is supplemented by referrals to secondary resources including pain medicine, behavioral health, physical medicine and rehabilitation, specialty consultation, coordination with palliative care, tertiary care, advanced diagnostic and medical management, and rehabilitation services for complex cases involving comorbidities such as mental health disorders and traumatic brain injury (TBI) (VHA directive 2009-053, 2009, p. 1).
The VHA directive 2009-053 stipulates that the responsibilities for each pain management team member will be assigned by each regional VA office. The relationship among these interdisciplinary team members is depicted in Figure 1 (Clark & Norton, 2009, p. 7).
"Barriers and challenges in delivering pain care"
In other cases, elderly pain management patients may be reluctant to request assistance even when they are in severe pain, due to worries about being a "burden" to their healthcare providers and family members (Turk & Gatchel, 2002). In these situations, the provision of timely support by healthcare providers is essential because family members and other supportive associates may lack the training needed to recognize the severity of the problem, and pain levels may adversely affect quality-of-life considerations or even become life-threatening (Turk & Gatchel, 2002). According to current guidance from VHA directive 2009-053 and the Joint Commission, these types of issues must be factored into a pain management treatment program. For instance, VHA directive 2009-053 stipulates that "quality of life is now accepted by the medical field as a standard outcome measure of effectiveness of treatment, including treatment of pain. The concept includes such factors as level of physical and psychosocial functioning and treatment satisfaction" (2009, p. 2).
There are also significant religious, gender, and cultural differences in the experience and management of pain that must be taken into account when formulating treatment interventions (Gibbs, 2007). All patients need to fully understand their treatment plan and remain active participants in its execution in order to achieve optimal outcomes (Turk & Gatchel, 2002). Healthcare providers should also remain vigilant for pain management patients who attempt to project a "good patient" status — for example, stating "Don't worry about me. I'm doing fine, doc!" — because these responses may reflect an effort to please the provider rather than a legitimate account of their condition (Turk & Gatchel, 2002). In these situations, healthcare providers may fail to accurately and timely identify patients' needs because of self-reports suggesting they are doing well (Turk & Gatchel, 2002).
A typical pain management problem cited by the Joint Commission is the tendency to focus on one specific area to the exclusion of others that may also require pain management. For instance, Gebhart (2009) reports that "a typical problem is assessing and treating surgery site pain but forgetting about pain due to intubation or other causes" (p. 41). The Joint Commission's policies concerning pain management are focused on ensuring that pain is managed appropriately, rather than prescribing exactly how it should be managed (Gebhart, 2009). Consequently, Gebhart (2009) recommends the use of range orders for effective pain management, but with a caveat: "The sole proviso is that the group's policy and procedure manual contain adequate guidance for RPhs, nurses, and physicians" (p. 42). Range orders provide the framework within which nursing staff can provide timely pain management interventions without the delays required to obtain new orders every time a patient experiences a pain episode. Because nurses are on the front lines of patient care, this is especially important in tertiary healthcare settings such as VA medical centers. Gebhart emphasizes that "pain is personal. [Providers] cannot know in advance how much morphine a postoperative patient needs, but the nurse who sees the patient does. That nurse needs an order that allows freedom to make treatment decisions with no second-guessing" (p. 42).
Many healthcare providers from all disciplines remain woefully unprepared to provide effective and responsive pain management care because of a fundamental lack of knowledge about pain. According to Boschert (2009), a survey of healthcare practitioners typically included on a pain management team — including physicians, nurses, and pharmacists — revealed several significant gaps and inadequacies: (a) many healthcare providers do not believe that pain is real in patients who report it, and a lack of knowledge about the appropriate use of opioids likely results in undertreatment of pain; (b) healthcare workers, despite their training, allow bias to influence how they address patients' needs; and (c) one of the main challenges is getting staff to be more accepting of what patients tell them. The most reliable indicator that a person has pain is their verbally expressing that they have pain (Boschert, 2009, p. 82).
Therefore, healthcare providers in general, and those assigned to pain management teams in particular, must be educated concerning appropriate pain management practices (Boschert, 2009). In sum, a monthly pain management newsletter represents a valuable tool for this purpose, as well as a means of keeping the need for effective pain management practices fresh in the minds of VA staff.
Boschert, S. (2009, February). Many health workers need to bone up on pain management. Clinical Psychiatry News, 32(2), 82.
Clark, M. E., & Norton, C. (2009). Interdisciplinary pain team training program. Tampa: Chronic Rehabilitation Program.
Gebhart, F. (2009, November). JCAHO to release more pain management measures. Drug Topics, 146(21), 41–44.
Gibbs, L. (2007, Summer). Identifying work as a barrier to men's access to chronic illness (arthritis) self-management programs. International Journal of Men's Health, 6(2), 143.
Kubotera, N., & Fudin, J. (2013, April). Pain management for pharmacists: Concepts and definitions. Drug Topics, 157(4), 36–39.
Turk, D. C., & Gatchel, R. J. (2002). Psychological approaches to pain management: A practitioner's handbook. New York: Guilford Press.
VHA directive 2009-053. (2009). Department of Veterans Affairs. Retrieved from http://www.va.gov/painmanagement/docs/vha09paindirective.pdf
Woods, B. (2011, January–February). A comprehensive approach to pain management: A team of professionals can successfully address any and all comorbidities. Addiction Professional, 9(1), 14–19.
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