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Director's Letter

At a recent HSR&D meeting to discuss non-opioid alternatives for treating chronic pain, Bob Kerns, a longtime VA pain clinician and researcher, observed that he could "remember when opioids were bad, before they were good, before they were bad again." These oscillations in clinical attitudes and policy reflect the challenge of adequately treating chronic pain while avoiding the problems caused by inappropriate or indiscriminate use of opioids. After a period when the focus was on addressing under-treatment of pain, most agree that the pendulum in the United States has swung too far towards overuse of opioid pain medication—last year a study tied declining life expectancy in middle-age whites to problems related to substance abuse, including opioids. This problem is particularly important for VA, given the high prevalence of musculoskeletal pain in Veterans returning from conflicts in Iraq and Afghanistan.

While the effectiveness of opioids for chronic pain remains debated, the side effects of prescription opioids are well known, including dependence, potential overdose, and death. Their toll has received increasing attention at state and national levels, and last Fall the White House convened a Summit on the Opioid Epidemic. A key to addressing this problem is to equip clinicians with better options for addressing pain in their patients, as outlined in the articles in this issue. Stepped care therapy, cognitive behavioral therapy, structured exercise programs, and certain integrative approaches can all be effective in certain patients. The challenge for VA, and for other health systems, is to build an effective program that integrates pain management into primary care, providing an array of alternative strategies so that the busy primary care clinician doesn't feel compelled to reach for their prescription pad.

There is no easy fix for our current crisis, just as there often is no easy fix for our patients with chronic pain. But by being clear about our goals and honest about the challenges, and by incorporating careful research into our attempts to improve clinical care and policy, we can chart a path forward for improving care for our Veterans as well as improving practice and policy as a nation.

David Atkins, MD, MPH, Director, HSR&D

References

1. CMS Alliance to Modernize Healthcare. Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs. Volume 1: Integrated Report. September 1, 2015. The report may be accessed at www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf