Multispecialty Opioid Risk Reduction Program Targeting Chronic Pain and Addiction Management in Veterans
A primary care pain clinic and telehealth program manages veterans at high-risk for noncancer chronic pain and addiction, offering education and support to multidisciplinary health care providers to reduce dependence on high-level opioids.
Ivana Vaughn is a Research Scientist at the New York Academy of Medicine in New York City. Rebecca Beyth is the Associate Director for Clinical Innovation at the North Florida/ South Georgia Geriatric Research Education and Clinical Center. Ted Gingrich is a Clinic Chief, Anesthesia Pain Medicine; and Stephen Mudra is Chief, Primary Care Pain Management; both at the Malcom Randall VA Medical Center in Gainesville, Florida. Mary Lynn Ayers is a VISN 19 Lead Physician Primary Care and a staff physician at the Veterans Affairs Eastern Colorado Health Care System in Denver. Joseph Thornton is an Associate Professor of Psychiatry, Ted Gingrich is a Courtesy Clinical Assistant Professor of Anesthesiology, and Rebecca Beyth is a Professor of Medicine, all at the University of Florida College of Medicine in Gainesville. Mary Lynn Ayers is an Assistant Professor at the University of Colorado – Anschutz Medical Campus. Rajiv Tandon is a Professor and Chair, Department of Psychiatry, Western Michigan University School of Medicine.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Chronic pain significantly affects 100 million Americans.1,2 Pain accounts for $560 to $635 billion in annual financial costs to society, including health care costs and loss of productivity (ie, days missed from work, hours of work lost, and lower wages).2,3 Although pain prevalence exceeds other chronic diseases, such as diabetes mellitus, cancer, and heart disease, it lacks a sufficient body of evidence-based research and guidelines on the underlying mechanisms, valid methods of assessment, and comparative effectiveness of treatments to effectively implement into clinical practice.2,4 Prevention and treatment of pain are often delayed, inaccessible, or inadequate.2 Primary care providers (PCPs) are most often sought for pain management and treat about 52% of chronic pain patients.2,3,5 Veterans are especially vulnerable to chronic pain and are at risk for inadequate treatment.2
There is an epidemic of drug abuse and mortality from opioid prescription medication.6 In the US, rates of overdose deaths from prescription opioids were 6.1 per 100,000 for men and 4.2 per 100,000 for women in 2017. Opioids were involved in 47,600 overdose deaths in 2017, accounting for 67.8% of all drug overdose deaths.7
A large number of patients on long-term opioids have preexisting substance use disorders and/or psychiatric disease, further complicating chronic pain management.8-10 Prescription opioid use has been the precursor for about 80% of people who are now heroin addicts.11 Iatrogenic addiction from prescription medications isn’t easily captured by standard addiction criteria. Consequently, in patients who are on opioid therapy for prolonged periods, separating complex opioid dependence from addiction is difficult.12 Improved addiction screening and risk mitigation strategies are needed along with aggressive treatment monitoring to curb the opioid epidemic.
Opioid Management in Primary Care
The majority of opioid medications are prescribed by PCPs, which is magnified in the US Department of Veterans Affairs (VA) health care system due to the high prevalence of service-related injuries.3,13 The VA is at the forefront of addressing the complexities of opioid addiction through several initiatives.14 The ability to offer the frequent visits needed to safely manage patients prescribed opioids and the integration of mental health and addiction treatment are often lacking in non-VA primary care clinics. Therefore, a key to solving the opioid crisis is developing these capabilities so they can be delivered within the primary care setting. There is substantial evidence in support of nonopioid alternatives to chronic pain management, including other pharmacologic approaches, exercise, physical therapy, acupuncture, weight loss, smoking cessation, chiropractic care, cognitive behavioral therapy (CBT), and other integrative health modalities.
A 2009 VA directive mandated the development of a comprehensive, integrated, systemwide approach to pain management.15 The VA Stepped-Care Biopsychosocial Model for Pain Management is dependent on timely access to secondary consultation from pain medicine, behavioral health, physical medicine, and other specialty consultation.15
History of VHA SCAN-ECHO Model
The Specialty Care Access Network–Extension for Community Health Outcomes (SCAN-ECHO) is a Veterans Health Administration (VHA) adaptation of a program that originated at the University of Mexico.16,17 The SCAN-ECHO model uses a multisite videoconferencing network to provide specialty care consultations to PCPs and patient aligned care teams (PACTs). During the 60- to 90-minute weekly sessions, case presentations are analyzed in real time so that over time, the PCPs gain knowledge, competency, and confidence in learning how to handle complex chronic conditions.