Jerry P. Kalangara, MD, ASA Committee on Pain Medicine and Educational Track Subcommittee on Pain Medicine, Assistant Professor of Anesthesiology, Emory University School of Medicine, and Division Chief of Pain Medicine, Atlanta VA Health Care System.

Jerry P. Kalangara, MD, ASA Committee on Pain Medicine and Educational Track Subcommittee on Pain Medicine, Assistant Professor of Anesthesiology, Emory University School of Medicine, and Division Chief of Pain Medicine, Atlanta VA Health Care System.

Sudheer Potru, DO, ASA Educational Track Subcommittee on Pain Medicine, Assistant Professor of Anesthesiology, Emory University School of Medicine, and Staff Physician, Atlanta VA Health Care System.

Sudheer Potru, DO, ASA Educational Track Subcommittee on Pain Medicine, Assistant Professor of Anesthesiology, Emory University School of Medicine, and Staff Physician, Atlanta VA Health Care System.

Anna Woodbury, MD, CAc, ASA Educational Track Subcommittee on Pain Medicine and Abstract Review Subcommittee on Chronic and Cancer Pain, Associate Professor of Anesthesiology, Emory University School of Medicine, Associate Program Director, Emory Multi-disciplinary Pain Fellowship, and Staff Physician, Atlanta VA Health Care System.

Anna Woodbury, MD, CAc, ASA Educational Track Subcommittee on Pain Medicine and Abstract Review Subcommittee on Chronic and Cancer Pain, Associate Professor of Anesthesiology, Emory University School of Medicine, Associate Program Director, Emory Multi-disciplinary Pain Fellowship, and Staff Physician, Atlanta VA Health Care System.

Pain management has been undergoing a gradual but progressive transformation to encompass more integrative practices within its discipline. The theoretical basis for these interventions stem from the biopsychosocial pain model that implicates not just physical but also social and psychological impairments in the pathogenesis of chronic pain. Integrative health emphasizes the patient-provider relationship as a team and utilizes lifestyle changes and all available therapies and health care modalities to optimize health (asamonitor.pub/371erOF). These practices have been particularly impactful in the Veterans Affairs Health Care System (VA), where there is a high prevalence of chronic pain combined with psychosocial stressors, which makes the veteran population particularly amenable to this multidisciplinary approach. The VA currently offers multiple evidence-based Complementary and Integrative Health (CIH) options within the framework of the Whole Health System (WH) in order to address chronic pain in veterans.

The large-scale implementation of WH began with the Comprehensive Addiction and Recovery Act (CARA) legislation of 2016, which aimed to combat the opioid epidemic. The VA has 18 WH flagship sites and anticipates a next wave of 37 Whole Health sites across the nation (asamonitor.pub/371erOF). The following CIH approaches are included in the VA's medical benefits package and may be tailored to patient-centered indications:

  • Acupuncture

  • Biofeedback

  • Clinical hypnosis

  • Guided imagery

  • Meditation

  • Tai chi/qi gong

  • Therapeutic massage

  • Yoga.

These approaches were reviewed and vetted by expert advisory workgroups and committees and were found to show, at minimum, evidence of safety and potential benefit after evaluation and in-depth reviews of the scientific literature by the VA Evidence Synthesis Program (ESP).

All VA facilities offer CIH approaches, either on-site or in the community depending on their stage of implementation. In addition to expanding on-site services through internal education and training, VA has created new occupations for qualified acupuncturists and chiropractors. As an example, over 2,900 providers have been trained in the Battlefield Acupuncture (BFA) technique, an easy to apply auricular acupuncture approach for treating pain (asamonitor.pub/371erOF). In recent months due to COVID19, multiple CIH approaches have been converted into virtual formats (virtual acupressure and yoga classes) to increase patient access.

WH is also continually attempting to address the fragmentation between mental and physical health care services by further integration into the primary care setting. Whole Health life coaches assess the Veteran's social and occupational environments and provide appropriate interventions – the goal being to focus on the personal priorities of the individual patient. The prioritization of activities and endeavors they value provides a fuller life where pain is not the primary focus. The impetus is therefore to shift the model of care delivery away from passive therapies (performed by someone else) that may be ineffective toward active self-care measures (Figures 1 and 2) (asamonitor.pub/371erOF). Our preliminary data demonstrated a 193% increase in utilization of WH services among veterans with chronic pain since 2017 in WH Flagship facilities and found that 26% of Veterans with chronic pain have started using CIH approaches (asamonitor.pub/3jOLSre).

Figure 1

The Whole Health Circle of Health

Figure 1

The Whole Health Circle of Health

Figure 2

The Whole Health System

Figure 2

The Whole Health System

WH efforts have also aligned with the VA's focus to decrease opioid prescribing for chronic pain in the past decade. The creation of the VA Opioid Safety Initiative (OSI) in 2013 and the development of the CARA-based multidisciplinary pain management model have led to successful reduction of opioid prescribing; this model features a team of specialists with expertise in pain, addiction, rehabilitation, and behavioral medicine coordinating efforts in pain management (Pain Med 2018;19:1419-24; asamonitor.pub/3iYs7fH). These efforts have been further enhanced by WH. Preliminary data suggests that WH has positively impacted rates of opioid use among Veterans with a three-fold reduction in opioid use among those who used WH services (38% decrease compared with 11% decrease among WH non-users) (asamonitor.pub/3jOLSre). Further, VA also emphasizes pain education through platforms like the Empower Veterans Program (EVP), which coaches Veterans to acquire new self-care skills focusing on neuromuscular re-education and mindfulness practices. The combination of all these integrated pain practices has translated into significant reductions in opioid prescriptions by more than 60% from 2012 to 2020 (asamonitor.pub/3lwasgI).

Outside of WH, the VA also integrates mental health with pain medicine and primary care through the VA SCOUTT initiative (Stepped Care for Opioid Use Disorder Train the Trainer). This initiative has sought to expand evidence-based medication treatment for opioid use disorder (MOUD, formerly known as MAT) from specialty substance abuse clinics to the pain and primary care setting, particularly for “stable” patients who no longer require intensive specialty care (Am J Prev Med 2019;57:106-10). MOUD has been shown to be highly effective in preventing relapse among patients with OUD, and two of the three FDA-approved medications for OUD (methadone and buprenorphine) afford some benefit for pain as well due to their opioid agonism (Subst Abus 2020;41:275-82). The major focus of SCOUTT has been to increase the prescription of buprenorphine due to its safety profile, allowing for use in the office-based setting, unlike methadone (Subst Abus 2020;41:275-82). Overall, the SCOUTT initiative has been highly successful with >40% of veterans diagnosed with OUD being currently managed with medications, compared to less than 30% nationwide (asamonitor.pub/33PVpbL).

The VA also supports research in furthering CIH for the management of chronic pain conditions. As an example, the Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial is a multi-site trial that plans to randomize 2,529 veterans with chronic low back pain across 20 centers in a pragmatic effectiveness study to identify the best non-surgical and non-pharmacological approaches for treating back pain, including enhanced physical therapy, yoga, spinal manipulation, and cognitive behavioral therapy (NCT04142177) (asamonitor.pub/2IhyIoB). VA-funded multisite trials also include evaluation of repetitive transcranial magnetic stimulation for Gulf War syndrome and cranial electrical stimulation for fibromyalgia (asamonitor.pub/3dmqU0g; asamonitor.pub/2IwD3EH).

Through evidence-based CIH, whole health approaches, and transformational research, the VA seeks to empower veterans and providers to better manage chronic pain with the underlying message of shared decision-making and self-care. We therefore anticipate that WH will continue to be a significant strategic initiative for the Department of Veterans Affairs. In the future, it would be informative to assess the additional benefit derived from these multidisciplinary measures as compared with conventional pharmacologic and interventional treatments for chronic pain. It is also important to perform economic analyses of the benefits and costs in order to facilitate broader implementation.