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Interdisciplinary Care for Veterans with Complex Chronic Pain

March 01, 2021

Chronic pain and the medical and psychiatric co-morbidities that commonly accompany it are widely prevalent among Veterans of all ages and may lead to significant impairments in quality of life and social, occupational and general function. A standard treatment for chronic pain, long-term opioid therapy, while widely prevalent, is increasingly recognized as harmful—increasing risk of falls, fractures, endocrinologic dysfunction, addiction and overdose among other harms, and often providing limited benefit in terms of meaningful long-term improvement in function. To address the often complex needs of Veterans with chronic pain on long-term opioid therapy, in 2011 Will Becker, MD, Associate Professor of Medicine, General Internal Medicine and Ellen Edens, MD, MPE, Associate Professor of Psychiatry, started VA Connecticut’s Opioid Reassessment Clinic (ORC), an interdisciplinary referral clinic. Through team-based care, including internal medicine, psychiatry, psychology, pharmacy and nursing, the ORC strives to use patient-centered, evidence-based approaches to improving pain, function and overall wellness among Veterans with chronic pain. Sara N. Edmond, PhD, the clinic’s Clinical Health Psychologist said, “One of the best parts about working at the VA is the ability to provide high-quality interdisciplinary care, and the ORC is one of the best examples of truly integrated pain care.”

Intake visits involve multiple providers meeting with Veterans as a team, leading to a care plan with Veteran input, and then longitudinal follow up that may last over a year to ensure patient stability. Since 2011, the ORC has seen nearly 1000 Veterans and in a retrospective cohort study, engagement in ORC care led to 5x increased likelihood of a change to safer opioid regimen compared to usual care with high levels of patient satisfaction. In qualitative work, one Navy Veteran, who worked with the ORC to reduce from 600 mg oxycodone a day and switch to buprenorphine/naloxone while engaging in regular structured exercise through the help of our Clinical Health Psychologist, said: “The moment I met Dr. B, my whole world changed... too many times people feel they have it all figured out, but often they need more support to get to where they want to be.”

The ORC is also a training site for a diverse array of learners: students, residents, fellows in a wide variety of health professions, and we are a rotation site for the combined Psychiatry/Primary Care clerkship for Yale School of Medicine. Additionally, we are funded by VA’s Quality Enhancement Research Initiative to disseminate our integrated approach to treating chronic pain and substance use disorders to 6 other VA facilities nationally.

Some of ORC’s clinical innovations and quality improvement initiatives have been the building blocks of formal research studies: VA Connecticut is an enrollment site for two large ORC-inspired randomized trials, one PCORI and one NIH-funded, on which Dr. Becker is a PI. The ORC is tightly affiliated with VA Connecticut’s Pain Research, Informatics, Multimorbidities & Education Center of Innovation – a center that studies the interactions between medical and behavioral health factors to develop and implement interventions that can improve health by employing medical informatics, behavioral science, implementation science, and health services research. One of the focused areas of research of the center is improving pain care and opioid management for Veterans. In addition to the aforementioned randomized trials, Dr. Becker is also PI of a funded pilot trial, Development and pilot testing of LIMIT (Less Is More In Opioid Treatment), that is using an app and peer support to assist Veterans through voluntary opioid tapers and co-investigator on another project deploying a virtual care model of the ORC to Veterans to improve access to pain care during the COVID-19 pandemic. Below are links to some key publications about their work:

The ORC not only provides high-quality, evidence-based, safe, integrated team-based care to Veterans with chronic pain, it also serves as a learning laboratory for clinical innovation and an excellent training site for healthcare professionals from a wide array of disciplines.

Submitted by Ruth Arnold on March 01, 2021