Pain and Opioid Management in Veterans: Evidence, Lessons Learned, and Future Directions in the Use of Collaborative and Integrated Care Approaches

Veterans suffer disproportionately from chronic pain. War-related mental and physical trauma amplifies the experience of chronic pain, increasing risk for disability and adverse outcomes related to overuse of medication. No studies to date have tested a primary care–based collaborative approach to improving pain management and decreasing opioid risk among veterans. The overall goal of the OPTI study (Options for Pain Treatment Interventions) is to pilot test a novel collaborative care intervention to improve pain, opioid safety, and use of nonpharmacologic pain management strategies in veterans in VA primary care. Specifically, we will discuss this ongoing pilot randomized controlled trial among 100 veterans in VA primary care with chronic pain and high-risk prescription opioid use (e.g., early opioid refills, high-dose opioid therapy). We will compare pain- and opioid-related outcomes resulting from the use of telephone motivational interviewing sessions vs. neutral telephone check-ins performed by a collaborative care manager added to primary care provider-based scripted pain care planning (in both arms). We will elaborate on the development of the scripted primary care-based intervention for both arms that involves the use of shared decisionmaking and “SMART” goal planning to develop a multi-modal pain care plan that aligns with veterans’ personal values and goals for health and wellness. We will discuss trial methods, trial innovations, preliminary results, and lessons learned in the course of conducting this pragmatic trial in VA primary care settings. We will also explore how this trial and other similar studies are laying the groundwork for a generation of new research investigating biopsychosocial, nonpharmacologic care for veterans with chronic pain.

Learning Objectives 

After attending this presentation, participants will be able to:

1. Describe the literature and research that explains the high prevalence of chronic pain and opioid misuse in veterans.
2. Explain the process of pain care planning to develop a multi-modal biopsychosocial approach to pain management in accordance with veterans’ personal values and goals for health and wellness.
3. Discuss the potential roles for collaborative care and motivational interviewing in encouraging veterans to make progress toward their “SMART” goals for pain reduction, improved functioning, and quality of life.

About the Speaker

Dr. Karen Seal is a professor of Medicine and Psychiatry at the University of California, San Francisco (UCSF). She is based at the San Francisco VA Health Care System (SFVAHCS) where she is the director of the Integrated Care Clinic for Iraq and Afghanistan Veterans and Director of the Integrated Pain Team (IPT) Clinic. In these roles and as a practicing primary care internist and health services researcher, she has dedicated her career to developing and testing new integrated care interventions to address comorbid mental and physical health problems, including chronic pain and opioid misuse, among veterans. Currently, she is the prinicipal investigator (PI) of two pragmatic effectiveness trials testing the implementation of telephone motivational coaching, in one study to achieve engagement in mental health treatment among rural veterans (“COACH”) and in the other (“OPTI”), decreased reliance on prescription opioids among veterans with chronic pain. She has assumed the role of co-PI on a recently funded nine-site national Patient-Centered Outcomes Research Institute (PCORI) study, which is a comparative effectiveness trial of an integrated pain team approach (modeled after the SFVAHCS IPT Clinic) versus telephone collaborative management to improve pain and decrease opioid use among veterans who use the VA. This past year, Dr. Seal was appointed chair of the SFVAHCS Integrative Health Advisory Committee to promote the development of complementary and integrative health services for veteran patients and VA staff in her system. In this capacity, through VA clinical funding, Dr. Seal and her colleagues have been gradually building complementary and integrative health capacity at the SFVAHCS, which includes system-wide training in VA Whole Health personalized health planning and coaching and supporting mind and body skills training for VA staff. Dr. Seal and colleagues hope to leverage this clinical funding as well as her group’s prior research experience to conduct a large-scale implementation-pragmatic effectiveness trial of the VA’s Whole Health Team Model in veterans with chronic pain.