Prevention begins early in the process as patients present with pain. “That’s where the real action is, that I think is very exciting for the VA,” said Gallagher. “Not only have we worked closely with HHS [Department of Health and Human Services] on developing the National Pain Strategy, where they call out the VA’s approach, but we’ve also in the VA been able to institute some very rigorous training programs to skill-up our workforce and offer additional alternative treatments for pain when it starts, or when it first comes up in the VA system with a veteran.”
The good news for veterans is that the medications that can be prescribed – buprenorphine and injectable naltrexone – are available through the VA national formulary. For methadone treatment, the VA has 32 OTPs at facilities nationwide, but many veterans also receive treatment in non-VA community OTPs. Even with increased demand for treatment, currently approximately 34 percent of veterans diagnosed with OUD receive medication-assisted treatment, up from about 26 percent when the effort began.
These are training programs like for acupuncture, Gallagher explained, and this training is one example of several education programs that the VA and the Department of Defense (DOD) work jointly on to improve pain management in both organizations. “We’ve trained, with the DOD, over 2,400 providers in battlefield acupuncture across the system,” he said. “But more importantly in terms of sustainment, we’ve trained over 100 medical acupuncturists who are now faculty in their facilities across the system, who are trained now to train every provider – nurse practitioner, PA [physician assistant], or physician – that wants training in battlefield acupuncture and [to] be able to use it as a frontline treatment right in the clinic and not wait until after the pain has gone on too long or after pills haven’t worked or after they’re already exposed to opioids.”
Other examples of therapies emphasized in the primary care setting as an alternative to opioids include CBT, exercise, physical therapy, yoga, and meditation. Gallagher said those kinds of treatments make a difference long-term in chronic pain and may prevent exposure to opioids in the beginning.
Another example of the VA’s response is its Opioid Safety Initiative (OSI), piloted in 2012 and rolled out nationwide in 2013. “Since that time, we have had tremendous success in reducing the risk of opioid use disorder among veterans by improving pain management and reducing unsafe opioid prescribing,” said Drexler.
As evidence of the effect of the multiple VA efforts, Drexler provided the following comparison figures: From 2011 to 2014, the number of “CMS Part B” [Medicare] enrollees using opioids for non-cancer, non-palliative care increased by 22 percent. In the VA, opioid utilization over that same time period decreased by 7 percent, even with an increase in the VA patient population.
The OSI includes multiple components focusing on education for patients and care providers as well as monitoring opioid prescribing safety practices with mechanisms for feedback and support. For example, “Recognizing the risks of opioids long-term, we developed a policy that every veteran who’s going to be considered for long-term opioid therapy [more than three months and not for palliative or cancer care] undergoes a signature informed consent procedure where they’ll actually go through a whole educational program about pain itself, all the different treatment approaches for pain and particularly going over the risks of opioids,” explained Gallagher.
Other components of the OSI utilize software tools “to help providers know when they may be over-relying on a certain type of treatment like opioids, and then giving them individual support and instruction through academic detailing, which is monitoring care, feeding back outcomes of that care to the providers, and then providing instruction and support,” Gallagher said. “That really helps them change their prescribing behaviors as well as learn new ways of managing pain.”
But Gallagher pointed out that pain is a symptom in some serious chronic conditions that require not just alternative approaches but also skillful use of medications. “Opioids are part of a toolbox and providers need training, and we’re doing that right now across the whole system to train all of our providers in safe opioid prescribing, to treat pain in many different ways and avoid over-exposure to opioids,” he said.