Pain Care in the Department of Veterans Affairs: Understanding How a Cultural Shift in Pain Care Impacts Provider Decisions and Collaboration

Kristin Mattocks, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.
Marc I. Rosen, VA Connecticut Healthcare System, West Haven, Connecticut.
John Sellinger, VA Connecticut Healthcare System, West Haven, Connecticut.
Tu Ngo, Bedford VA Medical Center, Bedford, Massachusetts.
Brad Brummett, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.
Diana M. Higgins, VA Boston Healthcare System, Boston, Massachusetts.
Thomas E. Reznik, Providence VA Medical Center, Providence, Rhode Island.
Paul Holtzheimer, White River Junction VA Medical Center, White River Junction, Vermont.
Alicia M. Semiatin, VA Manchester Medical Center, Manchester, New Hampshire.
Todd Stapley, VA Maine Medical Center, Togus, Maine, USA.
Steve Martino, VA Connecticut Healthcare System, West Haven, Connecticut.


OBJECTIVE: Over the past decade, the Department of Veterans Affairs (VA) has experienced a sizeable shift in its approach to pain. The VA's 2009 Pain Management Directive introduced the Stepped Care Model, which emphasizes an interdisciplinary approach to pain management involving pain referrals and management from primary to specialty care providers. Additionally, the Opioid Safety Initiative and 2017 VA/Department of Defense (DoD) clinical guidelines on opioid prescribing set a new standard for reducing opioid use in the VA. These shifts in pain care have led to new pain management strategies that rely on multidisciplinary teams and nonpharmacologic pain treatments. The goal of this study was to examine how the cultural transformation of pain care has impacted providers, the degree to which VA providers are aware of pain care services at their facilities, and their perceptions of multidisciplinary care and collaboration across VA disciplines. METHODS: We conducted semistructured phone interviews with 39 VA clinicians in primary care, mental health, pharmacy, and physical therapy/rehabilitation at eight Veterans Integrated Service Network medical centers in New England. RESULTS: We identified four major themes concerning interdisciplinary pain management approaches: 1) the culture of VA pain care has changed dramatically, with a greater focus on nonpharmacologic approaches to pain, though many "old school" providers continue to prefer medication options; 2) most facilities in this sample have no clear roadmap about which pain treatment pathway to follow, with many providers unaware of what treatment to recommend when; 3) despite multiple options for pain treatment, VA multidisciplinary teams generally work together to ensure that veterans receive coordinated pain care; and 4) veteran preferences for care may not align with existing pain care pathways. CONCLUSIONS: The VA has shifted its practices regarding pain management, with a greater emphasis on nonpharmacologic pain options. The proliferation of nonpharmacologic pain management strategies requires stakeholders to know how to choose among alternative treatments.