The US has seen a rise in the number of prescriptions of opioids to treat chronic pain; however, the rise has been associated with increased rates of addiction and deaths related to opioid abuse and heroin use. Chronic pain is associated with the use of prescription opioids in veterans, which sometimes complicates the concurrent treatment of mental health disorders.1-3 Also, opioid use issues, including suicide, have affected veterans at higher numbers than it has in the nonveteran population.4,5
Unfortunately, the prevailing Western medical model with its focus on treating disease has not proven to be adequate in solving the problem. Hence, the Department of Veterans Affairs (VA) is in the process of a paradigm shift to a whole person model that prioritizes health and well-being, as defined by the individual, while proactively addressing risk factors before illness develops.
The new model includes an emphasis on complementary and integrative health (CIH) therapies to promote optimal health, healing, and well-being.6 Yoga, massage, acupuncture, meditation, and guided imagery are some examples of VA-approved CIH therapies favored by veterans and their health care providers (HCPs) to treat and/or divert the subject’s attention from physical pain or mental anguish.7,8
In response to opioid overuse, Congress passed the Comprehensive Addiction and Recovery Act of 2016 (CARA).9 Title IX of CARA mandates the VA to work with the Department of Defense (DoD) to limit the amount of time a patient is prescribed an opioid.
Replacing opioids with other ways to control chronic pain may be helpful in addressing the real distress experienced by persons with these diagnoses. Hence, the CARA suggests augmenting opioid therapy with other pain management therapies and modalities, including CIH. Instead of focusing on the treatment of a specific illness after it develops, CIH therapies aim to promote wellness in the whole person. However, good intentions are not enough. Due to existing institutional culture and prioritization of resources, the adoption of CIH therapies across the VA has been inconsistent.10
The CARA furnishes the VA with an opportunity to serve as a leader in the innovative use of CIH therapies. Previous research conducted by the VA has shown that veterans and their HCPs would like increased availability of CIH through the VA.7,10,11 Research also suggests CIH for specific conditions in veterans, such as posttraumatic stress disorder or postoperative pain.12,13 For its part, the VA has declared the provision of personalized, proactive, patient-driven health care for veterans as its top strategic priority.
To achieve the organizational transformation associated with providing this type of care, the VA established the Office of Patient Centered Care and Cultural Transformation (OPCC&CT), which created the Integrative Health Coordinating Center (IHCC).6 The main functions of the IHCC are to identify and remove barriers to providing CIH within VA and to serve as a resource for practice and education for veterans as well as HCPs.
Several VA facilities already have demonstrated what can be done with the support and encouragement of the OPCC&CT plus an enormous amount of dedicated effort from local HCPs and highly supportive service chiefs. Examples include the Perry Point VA Residential Wellness Center in Maryland and the Integrative Medicine and Wellness Center in the Central Arkansas VA Healthcare System in Little Rock. Perry Point has a focus on veterans with substance abuse diagnoses and uses multiple therapies, including acupuncture, yoga, guided meditation, osteopathic manipulation, music, and creative arts. The Little Rock center focuses on skills building, self-care, and accountability with modalities such as yoga, acupuncture, mindfulness, and chiropractic.
The CARA mandates the continuance and expansion of similar pilot projects that assess the feasibility and advisability of CIH programs to complement the provision of pain management and related health care services, including mental health care services to veterans. Thus, the VA Secretary was directed to select at least 15 geographically diverse locations for the pilot projects. The VA has committed to conducting 18 full-scale demonstration projects in 2018—1 project in each VISN (Veterans Integrated Service Network). Section 933 of the CARA, prioritizes medical centers where the “prescription rate of opioids conflicts with or is otherwise inconsistent with the standards of appropriate and safe care.”9
Several issues must be addressed to make the provision of CIH in the VA a success.14 They include but are not limited to the following:
- Clarification that CIH services for veterans are included in the Medical Benefits Package, which requires that care meets generally accepted standards of medical practice.
- Vetting of CIH therapies to determine which ones should be recommended for inclusion in the Medical Benefits Package. Factors to consider include clinical evidence, community standards, practice guidelines, licensing and credentialing requirements, potential for harm, and veteran demand.
- Changes to VA business processes to provide the infrastructure for CIH delivery.
- Competition with existing VA programs for resources.
- Education of HCPs and administrators about CIH through the development of CIH instruction manuals, curriculum, and faculty.
Although the VA faces the daunting task of reducing opioid use while continuing to treat chronic physical and mental pain, CIH therapies seem to offer a viable adjunctive therapy. It will be incumbent on the VA to explore through ongoing research all that CIH therapies may have to offer; veterans deserve no less. If the VA can demonstrate the effectiveness of CIH in treating the challenges faced by veterans, the results will serve as a useful example for treating chronic pain in the nonveteran population as well.