Colorado VA researcher discusses the challenges living with chronic pain


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VA’s Erica Sprey, host of the podcast series “Voices of VA Research,” speaks with Dr. Joseph Frank, both a primary care physician at the VA Eastern Colorado Health Care System in Denver and a researcher at the Center of Innovation for Veteran-Centered and Value-Driven Care. Dr. Frank’s research is focused on improving care for Veterans who are living with chronic pain—especially strategies for safely tapering the use of long-term opioid medication.  Listen to the full discussion here — an excerpt of the discussion is below


Can you tell me about the work you are doing for VA?

IMAGE: Dr. Joseph Frank, both a primary care physician at the VA Eastern Colorado Health Care System in Denver and a researcher at the Center of Innovation for Veteran-Centered and Value-Driven Care.As a primary care physician, I am particularly interested in how we provide chronic pain care in primary care settings. I have pursued three related lines of research that are important to me as a physician. The first of those is for patients who are taking opioid medications long term. For these patients, the process of stopping or reducing those medications—sometimes referred to as opioid tapering—can be very challenging. We need to understand how to deliver high-quality pain care during and after opioid tapering.

The second line of research focuses on who delivers this care. As with many chronic conditions, primary-care physicians are most effective when working as part of a team. I am interested in how we should design teams in primary care to deliver pain care that is patient-centered and effective.

And finally, as a primary care physician, I know it’s critical that we help patients get involved in and lead their own plans for pain management. As a researcher, I believe this means we must also help patients get involved in pain research; therefore, I am very interested in how we can better involve patients in all phases of the research process.

Can you tell me what the VA policy is for tapering or reducing opioid doses in Veterans?

VA policy is guided by the most recent guidelines released by the Departments of Veterans Affairs and Defense. The guideline was released just last year in 2017. The guideline recommends that for patients who are on long-term opioids, it is important to assess the risks and benefits of ongoing treatment with opioid medications for the individual Veteran. That guideline also notes that it is important to assess the risks and benefits of tapering. This is challenging currently because we don’t have much evidence to help providers assess those risks and benefits. So the decision-making is challenging, but importantly should focus on the individual Veterans and their unique needs.

Importantly, what that policy does not include is a recommendation to reduce opioid dose based on dose alone or without attention to individual risks and benefits. I think a place where we risk getting beyond the evidence, beyond the VA guidelines, and other related guidelines is by unilaterally making changes to medications that don’t take into consideration an individual patient’s unique needs.

In an article published in Pain Medicine, you interviewed primary care physicians to find out about their experiences with tapering opioid therapy. What did they say are the barriers and harms associated with tapering opioid therapy?

We conducted focus groups with 40 providers across three health care systems here in Denver, Colorado. We identified three key themes related to their perceived barriers to opioid tapering. First, providers that we spoke with described discussions of opioid tapering with their patients to be uniquely emotionally charged, and at times, exhausting. Health care systems are asking providers to have these conversations more often these days, and it’s important that we recognize the impact on providers as well as the impact on patients.

Second, providers described a sense that they had inadequate resources to support opioid tapering, specifically, but also chronic pain care generally. They described a lack of training specific to this process, as well as a lack of other team members and resources in their clinics and communities.

And third, they reported that opioid tapering did not go well when there was a lack of trust between their patient and themselves.

You also mentioned in that study that you identified some facilitators or best strategies that would help primary care physicians safely taper long-term opioid therapy. Can you tell me what those are?

In addition to barriers, the primary care physicians that we spoke with also identified strategies that they found helpful. They noted the importance of empathizing with their patients’ experiences—both their experience of pain and their concern about making medication changes. We have learned from patients that this process can be very anxiety-provoking. And so providers noted the importance of acknowledging that anxiety.

Providers also described opioid tapering as a long-term process that benefits from planning and preparation. They described ways in which working with individual patients to think long-term about goals as it relates to the medication was a productive process.

And finally they reported feeling supported by guidelines and local policies that sought to standardize care processes related to opioid prescribing and opioid tapering.

What types of strategies would you like to see developed to help primary care physicians work with chronic pain patients and assist them in tapering opioids?

That’s an important question. I think first it takes a team. And in a system like the VA, it will take guidance to help teams develop effective processes in their own local sites. Primary care providers, nurses, psychologists, pharmacists—the list goes on. Each provider has a unique expertise that may be helpful to patients during opioid tapering. The challenge ahead is to create systems that connect each patient with the right team at the right time during opioid tapering and chronic pain management generally.

The VA is leading in this area with some very interesting work to compare different types of teams and to understand which Veterans benefit from which team structure. It will be important that we learn from those ongoing studies and as researchers try and help leaders in VA integrate those lessons into routine care as quickly as we can.

I’ll mention two other resources that I think are potentially impactful in VA. The first is an important role for peer support. While I as a primary care physician try to help my patients know what to expect during opioid tapering, I think a fellow Veteran who has been through the process can provide practice insights and support that I just can’t match.

And finally, as we discussed, opioid medications are just one tool in the chronic pain toolkit. I think it’s important that we continue to improve Veterans’ access to the full range of treatments and continue to improve the quality of evidence that guides our approach to multimodal pain care.

Author

Gary Hicks

  is a public affairs specialist and serves as the senior writer in the Office of Public and Intergovernmental Affairs. He is a former managing editor of a daily newspaper and served in both the Army and Air Force prior to joining VA in 2006. Gary’s wife is an Air Force Senior NCO stationed at Joint Base Andrews in Maryland.

Comments

  1. Edward A. Swisher    

    People that have a (past history) of substance abuse are routinely denied opiods for chronic pain. There should be a system/panel set up (to fully assist) in that decision, not just the PCP and Pain Clinic physician. Even those that may have abused (or came up positive on a UA for such) should be given the opportunity to immediately be notified of such so that they can have another UA tested outside of the facility. I have had (false negative UAs) AND (false positive UAs).at both the Phoenix VAMC and the Kansas City VAMC). As the system is set up now, the UAs do not have to be confirmed before an adverse action is taken against the veteran. I am a chronic pain sufferer who was in that situation. I know veterans that turn to street drugs due to the hassle of dealing with VA. As for my pain issues, some days are “okay” and other days my pain level goes to a 10+ depending on the weather and activities. When I was taking opiods, I took them as prescribed and never had an issue with abusing them nor did I become “addicted” to morphine/oxycodone).

  2. ALVIN WINSTON    

    VA doesno tampering at alll so here talking about tampering really. VA basically let DEA SET THE POLICIES ON HOW THE DRUGS WERE GOING TO BE DONE AND VA WENT BY THAT “” ONLY” SO THE BUSINESS OF VA DOES TAMPERING IS BS .WHEN DEA MADE HYDROCODONE A SCHEDULE 2 VA BECAUSE THEY ARE SCARE OF THE DEA CUT MY MEDICINE FROM 240 TO 180 THEN THE NEXT MONTH TO NONE SO DEA KNOWS NOTHING ABOUT TAMPERING PEOPLE AND FOR THEM TO SCARED VA LIKE THESE IS WRONG . I WENT THRU DVTS WITH NO HELP FROM VA AT ALL SO WHERE WAS THE TAPERING AT. REALLY VA U ARE GOING TO AND SAY U HAVE A TAMPERING PROGRAM WHO U TRYING TO IMPRESS NOT THE VETREANS FOR SURE

  3. R. Michael Maddox    

    This doctors ideas are great. IF the VA used what he says about “Tapering”. I know that at the facility I use for care, they do NONE of that. The Veteran gets his prescription in the mail and the dose is lower. No one discusses with the Vet. He gets a FORM LETTER in the mail with these stupid ass Opioid Crisis nonsense and that their dose has been lowered “per VA policy”. The letter has no ones signature either. I have witnessed it first hand with MANY Vets. I am scared to death every month that mine will be reduced. Luckily I have a GREAT PCP. Caring, compassionate and understanding. He has retired but still working part time. I dread the day he stops working completely. I am quite sure whomever the assign me next will use the excuse of these new procedures to reduce my dosage. It is REDICULOUS the way we, as chronic pain sufferers are being treated. If it aint broke don’t try to fix it. The CDC, this week, admitted that a discrepancy in their algorithm contributed to VERY misleading numbers in regards to Opioid Overdoses. But all this BS has gotten out there and no one will even listen to us. When I hear them say that long term opioid use does not help chronic pain sufferers, I just want to scream. I know for a FACT that statement is incorrect. I have been using them for over 20 years and they allow me to enjoy some semblance of LIFE! I understand that they are treating the symptoms not the disease. But when a person has an illness that can not be cured, then treating the symptom, PAIN, is what must be done. It sounds real good, what this doc says. But the VA is NOT doing as he says. MOST VA docs, per their orders, are just cutting ALL patients meds. While saying, “They told me I had to stop giving these pain meds.” When asked Who THEY are, no response coming. I have heard MANY of the talking heads in the VA saying similar things as this doctor, to the press. But I am here to tell you, IT IS NOT BEING DONE THAT WAY!! We patients have NO SAY in the matter. I know I probably should not be posting this. I will surely piss someone off and be punished by losing the only thing that keeps me alive, My Pain Medications. But I just can not continue to sit by and hear these lies and do nothing about it. It has been PROVEN over and over, that prescription opioids have nothing to do with the Made Up Crisis. The CDC’s own studies, in 2014 and 2016 PROVE that Less Than 1% of All deaths are from patients receiving prescriptions from their doctors. We, as compassionate Americans, MUST stop the Torture of our citizens that are already suffering from Intractable, Chronic Pain. They are, at the least, violating The Americans With disabilities Act. Not to mention The Hippocratic Oath- “First Do No Harm”. By allowing your patients to suffer needlessly in pain, They are doing harm- FIRST! Oh well, let me get off here. I am quite sure no one that can do anything about OUR CRISIS really cares. Thank you for the soapbox. Have A Blessed Day, and Life!!

    1. Marilyn Wise    

      I agree. The needs of the patient do not come first. Only 1 out of 4 people are prone to addiction, and yet we are all considered criminals, even when proved innocent. You don’t hear these statistics in the media. They only talk about the deaths from ‘opioids’ and don’t mention that most are from the counterfeit pills coming from China and Mexico laced with fentanyl. Not the ones prescribed by physicians. Just like always, the government morons feel obligated to do something to get reelected , but don’t really care if it really works. Suicide is going up because people no longer matter to our government, only their reelection, and I mean both sides.

  4. Jerome Rodgers    

    Why does it seem that all opioid related efforts, articles, etc focus on tapering with little focus on the patient’s pain but more importantly, quality of life? I am a 100% disabled vet and I’ve been on various opioids for back pain (6 levels fused) since 2005 . I now have a morphine pain pump implanted so the dosage is automatically controlled and can only be changed by my pain doc. As it is, even with the pain pump my quality of life is poor but I cannot imagine what I would do without the opiods! I understand that some people abuse drugs and we must do something but we must ensure that the politicians, medical community, et al, don’t lose sight on patient needs and quality of life.

  5. Fred R. Eisenhauer    

    My last visit to the VA for my primary care Doctor went OK as usual. But first I had to see a nurse as usual. This time it was a male nurse. He stated like I take a pain pill every time I had a little pain. I informed him that I take one pill each morning and one at bedtime. I also told him that I am in pain 24 hours a day. I do not over use my pain pills. I am 80 years old and was hit in the small of my back in Vietnam (1966) and have been in awful pain ever since. I served 4 years in Vietnam and was ate up with Agent Orange. I have no problems at all with the VA. However this male nurse seems to think if you are old you are not worth anything. It takes all kinds.

  6. Eric Roberts    

    How about instead, research the proper treatment of chronic pain instead of this draconian BS. Taking us off of opioid pain meds without an alternative is not the answer. Unless the VA is willing to be OK with medical Marijuana, you need to get you head out of your backsides with this tapering BS and start actually treating the chronic pain. You are not a hero…you are a monster. As the above poster stated, some days are just fine, other days are complete and utter hell because of weather or increased physical activity. The VA gets very Nazi-like in attitudes with pain meds. If I need to take more because the pain is greater, there is nothing o compensate for that. You all would rather be slaves to policy than actually treat us properly. You all should be ashamed of yourselves. No, the answer isn’t to just throw pain meds at us, but neither is this draconian BS.

  7. Stan Riedel    

    You people are going crazy on this period epidemic. Careers are being created on other people’s suffering. The reduction of diploids in Kansas VA’s as far as I know is, your prescription is gone. But we will talk about it all you want. It is all BS, and people are made to suffer in silence for a bunch of hype about deaths that are inflated to make everyone feel good about themselves. The people’s quality of life is thrown out the window and some are ending the struggle with pain themselves. Everybody’s ego is being fed and the paychecks and job security is being established while others die or make themselves outlaws by getting relief on the streets. All with the permission and direction of the government that is winning a war first by using proven, documented pain patients. It’s a disgrace and should be stopped immediately. Let the doctors do their jobs, because the government and their enforcers do not nave the medical degree’s to decide who is entitled to a life free from long term chronic pain.

  8. jamie stewart    

    Now I would like to hear from the patients. As a veteran who uses VA Care – somewhat, I have a vested interest in this story. The described environment is unique and is not experienced at every single facility. Some regions have little to NO pain management, leaving patients with little choice but to use the civilian market. Lack of guidelines allows each region and location to set their own policy, whether or not it is in the best interest of the patient. Chronic pain is real, opioid abuse is real – but because a person with chronic pain uses an opioid it does NOT mean that person is abusing the drug. Unfortunately, this is becoming the narrative and I truly do worry we are over-correcting without caring about the patients being served.

  9. Theodore Gotthilf Matthiesen    

    I am a Vietnam Vet , my pain levels a year ago had gotten to the 7 to 8 level and medications didn’t seem to do much good. Thankfully my doctor introduced me to the whole health program, where I have had battlefield acupuncture, power of the mind classes,Tai Chi, sleep and nutrition classes these along with the help of a great therapist have resulted in pain levels normally around 1, and only Aleve for pain. All this thanks to the great care of Doctors in the St. Louis VMAC system.

  10. James Beauchamp    

    As I read this, one question came to mind repeatedly… What are you, as a medical provider, providing the patient as an alternative to opiod medication? The purpose of these medications, contrary to the public and political perceptions, is that properly managed opiods are a Godsend to many people. They allow patients with severe, life-long injuries (combat-wounded veterans especially) to live something closer to a functioning, normal life. Now that the “reefer madness 2017” culture has arrived, physicians are UNDERTREATING pain on a massive scale. What are you replacing the medications with? Spinal modulation? Ketamine? Local, long-acting nerve blocks? RF ablation? I see no information in this article that addresses anything other than “Get all patients off of opiods – screw thier quality of life, pain, or misery.”

    The answer, sadly, is that this has little to do with the patient. Today’s medical community doesn’t care about patients. Just get them off the opiods and kick them out the door before the cops show up and raid the cllinic. Screw the patients’ pain.

    The fact is, that the suicide rates for wounded veterans is skyrocketing because not only have you abandoned them physically, but mentally as well. Until an alternative is found, your “do no harm” promise means nothing. I have lost count of how many doctors have shown me the door within minutes of seeing the scars of three surgeries and discussion of the excruciating nerve pain it has turned into. My distrust and general feelings towards the medical community is one of complete disgust. You sent us to war, then discard us like a dystopian nightmare, and wonder why we are killing ourselves.

  11. John A Jameson    

    Your work is all well and good, but what about patients with real physical pain and existing on a medium dose of opioids? The pain only gets worse as I try to move around. I take frequent breaks so that I don’t wind up immobile. Any further reduction in dosage would not be beneficial nor productive.

  12. James Beauchamp    

    Guys, my comment was aimed at the quality of care the VA has failed to offer to my fellow veterans. I AM DOING FINE as I have found civilian medical practitioners that have found a proper protocol for my injuries. While I am very apreciative of the response you have given me personally, I AM DOING FINE. Please concentrate resources on those who are suffering, not as lucky and blessed to have the care I am receiving.

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