The American Academy of Pain Medicine

Breaking News & Updates

• Mental Health Bill Becomes Law - 10/17/08
• Defense Bill Becomes Law - 10/14/08
• Veteran's Pain Care Act Becomes Law - 10/13/08
• Senate Passes VA and Military Pain Bills, but Fails to Vote on HR 2994 - 10/03/08
• IDDS Coverage in Washington State - 9/18/08
• VA Expands Funding for Pain Program - 8/20/08

Mental Health Bill Becomes Law

October 17, 2008 -- Mental health advocates who had been working for 10 years to enact a bill putting mental health insurance coverage on a par with other types of healthcare coverage finally succeeded, by attaching the bill to the $700 billion financial industries bailout package.

The new law does not require health insurance plans to cover addiction or mental health; it only bars insurers from imposing any caps or limits on behavioral healthcare services that are not applied to other healthcare conditions. It applies to all businesses with 50 or more employees.

With passage of the new law, the discriminatory practices by insurance companies and employers of limiting mental health therapy sessions to fewer than healthcare visits allowed for other medical reasons and setting higher co-payments for mental health treatment have ended.

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Defense Bill Becomes Law

October 14, 2008 -- The On September 24, the House passed the Senate's version of the defense appropriations bill (S 3001), which includes an important pain care initiative titled the "Pain Care Initiative in Military Health Care Facilities." Because the House amended S 3001, it went back to the Senate for a final vote. On September 27, the Senate passed S 3001. President Bush is expected to sign the bill into law this week.

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Veteran's Pain Care Act Becomes Law

October 13, 2008 -- The Veterans' Mental Health and Other Care Improvements Act of 2008 (S 2162), which includes the Veterans Pain Care Act, became law on October 10 when President Bush signed it.  The bill's original sponsor, Sen. Daniel Akaka (D-HI), chairman of the Senate Veterans Affairs Committee, has issued a press release:
http://veterans.senate.gov/public/index.cfm?pageid=12&release_id=11812.

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Senate Passes VA and Military Pain Bills,
which President Bush signs into law, but Fails to Vote on HR 2994  

October 3, 2008 -- In a disappointing finish to the final hours of the current Congressional session, the Senate failed to take action on the National Pain Care Policy Act of 2007 (HR 2994) before adjournment. Despite this disappointment, AAPM was able to achieve two of its legislative priorities when President Bush signed into law:
1) the Veterans' Mental Health and Other Care Improvements Act of 2008, which contains all of the elements of the original Veterans Pain Care Bill; and,
2) the National Defense Authorization Act of 2009, which contains the all of the elements of the original Military Pain Bill.

These two bills culminate two years of dedicated work by AAPM members working with representatives of the other organizations, particularly the ASA, in the Pain Care Coalition, and by AAPM members working with the leadership of the American Pain Foundation.

The Senate's failure to vote on HR 2994 followed a flurry of last-minute maneuvering to get the bill, or some portion of it, up for a vote before adjournment for the elections. The Pain Care Coalition (PCC), of which AAPM is a founding member; the American Pain Foundation (APF); and the American Cancer Society (ACS) all joined forces to see this bill through to passage in the House of Representatives.  This coalition then worked feverishly through Sen. Orrin Hatch (R-UT), a supporter of the bill, to force it to a vote before the full Senate. At one point, a compromise looked possible that would have achieved passage of parts of the bill, with assurances that the remainder of the bill would get serious consideration in the next Congress. That compromise fell apart, however, when Senate leaders would not let the modified bill come to a vote without first going through the committee process. Even had that approach worked, the House probably would not have had time to re-consider and adopt the modified version before adjournment.

In addition to achieving passage of the military and veterans-related bills that were signed into law, AAPM comes out of the final days of his legislative session as part of a strong coalition of physician groups intent on passing the National Pain Care Policy Act in the next session. "With substantial leadership from AAPM, we passed two significant bills for Pain Medicine this year, and there is significant hope that an even stronger Pain Care Policy Act will emerge and succeed in the next Congress," says Dr. Scott Fishman, AAPM's former president, who is also AAPM's representative to the PCC as well as chair of the Board of Directors of the APF.

AAPM is committed to continuing its role as one of the leaders of the movement to enact seriously needed pain care legislation. It will continue to work with the coalition to take advantage in 2009 of the legislative momentum it built in 2008.

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IDDS Coverage in Washington State

by Bob Barnett Jr.

September 19, 2008 -- AAPM is urging Washington State's Health Care Authority (HCA) to reject a poorly considered recommendation by the state's Health Technology Clinical Committee (HTCC) that implantable drug delivery systems (IDDS) not be a covered treatment for non-cancer pain. If the recommendation is upheld, state employees and those using the state's Medicaid system, workers' compensation system, Veterans Administration system, and the Uniform Medical Plan and Basic Health Plan who receive IDDS will not have those costs covered under their health plans.

Currently, Medicare, most private insurers, most state workers' compensation programs, and most state Medicaid programs provide IDDS coverage. As a result, when Washington's HTCC issued its recommendation that IDDS not be a covered benefit, AAPM felt that it had to respond on behalf of chronic pain sufferers who might benefit from IDDS. In Washington State, the HTCC is an independent committee of health practitioners that reviews evidence of medical devices and procedures and makes recommendations to the HCA.

Acting through its membership in the Neuromodulation Therapy Access Coalition (NTAC), a national coalition of medical societies that seeks to ensure proper access to neuromodulation therapies, AAPM has sent a letter to the HCA, signed by President Todd Sitzman, MD, and other NTAC member presidents, arguing that HTCC's decision contradicted state law and regulations requiring that the committee's decision "be consistent with decisions under the federal Medicare program."

Furthermore, the letter says, Washington law requires that the committee's decision be consistent with expert treatment guidelines "unless the committee concludes, based on its review of the systematic assessment, that substantial evidence...supports a contrary determination" (emphasis added). Because the committee found little evidence, much less substantial evidence, to support its conclusion, NTAC is arguing that the HTCC failed to follow state law. The committee seemed to "cherry pick the evidence to support its position," says Eric Hauth, NTAC's executive director. If you examine the grounds stated in the HTCC's recommendation, he says, "there isn't anything even close to the substantial evidence standard."

The medical evidence is actually that IDDS is safe and cost-effective for well-selected chronic pain patients. As further proof, four NTAC members, including AAPM, have drafted treatment guidelines for intrathecal drug delivery, which the NTAC attached to its letter and asked the HCA to consider. In addition to AAPM, other NTAC members include the American Society of Interventional Pain Physicians, the American Pain Foundation, the International Spine Intervention Society, the North American Neuromodulation Society, Boston Scientific Neuromodulation, Medtronic Neuromodulation, and St. Jude Medical/Advanced Neuromodulation Systems.

The HCA has a meeting scheduled for October 17, at which the HTCC recommendation is expected to be considered.

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VA Expands Funding for Pain Program

August 20, 2008 -- In a move that may have far-ranging implications for the practice of Pain Medicine, the Veterans Administration has approved funding for a major expansion of pain treatment throughout the VA system and its 23 regional operations (VISNs).  In addition, the VA has established a separate pain office at VA headquarters that will report directly to the VA medical chief, just as other medical program offices currently do.

The VA thus becomes the first major health system in the U.S. to recognize pain as a separate medical issue and to devote an office and a budget for its management. The move follows recent VA reports that found that 40-43 percent of new veterans coming into the system-many, of course, from Iraq and Afghanistan-are experiencing chronic pain.  Many of these veterans are suffering also from related mental health problems, such as PTSD and depression, and mild to severe cognitive problems associated with blast injuries.  All need focused pain management services to help them rebuild productive lives, according to Rollin "Mac" Gallagher, MD, MPH, director of pain management at the Philadelphia VA Medical Center and professor and director for pain policy research and primary care at the Penn Pain Medicine Center at the University of Pennsylvania School of Medicine and President elect of AAPM..

The decision to expand the pain program within the VA is the culmination of several years of work that began in 1998 with the enactment of the Veterans Health Administration (VHA) National Pain Management Strategy, which established pain management as a national priority for the VHA.  With a national directive from the VHA, the National Pain Management Strategy Coordinating Committee (NPMSCC), under the leadership of Jane Tollett until 2003, provided guidance to the VHA for improving pain management throughout the veterans' healthcare system.  In 2004, the VHA created the office of Program Director for Pain Management in the VHA and named Dr. Robert Kerns, to this position.  A prominent pain psychologist and professor at Yale and the West New Haven VA Medical Center in Connecticut, Dr. Kerns was elected as one of AAPM's first honorary scientific members for his work as Senior Editor of its academic journal, Pain Medicine. 

Dr. Gallagher joined the VA Health System and NPMSCC in 2004 and has worked closely with Dr. Kerns and others on developing several aspects of the new national program, including a research program and education and training projects.  He says that the new commitment of resources for pain care "makes a statement that the VA cares about veterans' pain and wants to provide them with some of the best care anywhere." 

Implications for Pain Care Professionals

The VA's decision to increase funding for pain programs has important implications for pain care professionals. The large numbers of veterans suffering chronic pain, as well as the severity of the pain they suffer from, offer an opportunity for the pain care community to evaluate the VA treatment approaches in a way and on a scale that just isn't otherwise possible in the private sector. In the private sector, multidisciplinary pain centers for complex patients are closing, and even simple behavioral treatments are unavailable for routine cases, because of lack of reimbursement for such services, despite their proven success.  However, the VA program aims to offer a full range of pain and related services to the more than 100,000 new veterans from the OEF-OIF conflict with chronic pain, as well as to the growing number of severely injured from polytrauma, who are expected to number 9 or 10 times the number killed in those theatres.

The complexity and severity of war injuries, in addition to the high frequency of neuronal-psychological traumas associated with battlefield service, will require the VA to develop and provide intensive and sophisticated longitudinal treatment approaches that integrate pain treatment with physical and neurological rehabilitation and mental health care.  The experiences learned in treating these severe cases can then presumably be used by private sector pain care professionals in treating their patients' pain conditions.

The increased VA funding, Dr. Gallagher says, includes additional funding for focused research on learning about the course and outcome of pain following traumatic injuries and the impact of new treatment approaches.  As one example, he is studying the effects of early interventions to block pain after injuries in conjunction with military physicians such as Dr. Trip Buckenmaier from Walter Reed Army Medical Center, who instituted regional anesthesia practices in the battlefield zone.  A common problem, now increasingly recognized in civilian auto accidents and blast injuries from terrorist attacks, is the management of pain in conjunction with traumatic brain injuries and PTSD.  This research, he says, "will be a great benefit to society in understanding how to better manage trauma and traumatic brain injuries from natural and civilian accidents and disasters as well as from the battlefield."

Since the VA must treat all qualifying veterans regardless of their pain condition, which should provide a truer picture of the successes and failures of a full-service pain management program than might otherwise be available in a private sector study. "There's no cost shifting in the VA system," Dr. Gallagher says. "Once you're in the system, you are always part of it. There is no ‘passing the buck' by discharging or referring to another specialist those  patients who might be especially difficult or who might have particularly challenging conditions, as occurs regularly in the private sector."

The pain management of large numbers of older veterans currently in the system, primarily from Vietnam, should also help the private sector learn more about treating aging populations at risk for pain common in that age group, such as from cancer, neuropathies and arthritis. The conditions suffered by these older veterans should mirror conditions suffered by the general population, particularly of large numbers of baby boomers who are in the later stages of life. Thus, the VA pain management experience will encompass not only the full range of pain conditions, from the routine to the most severe war-induced traumas, but it will also include the full range of life experiences, from young soldiers with full lives ahead of them to the older veterans grappling with late-life pain issues.

The VA treatment experience will also benefit from the VA's single electronic database which enables the study of large numbers of patients with a single condition or combination of conditions.  The private sector experiences, in contrast, are captured in various insurance company databases that are not uniform from state-to-state and are closed to public inspection.  Thus, the VA's databases capturing the collective treatment experiences of its patient population is potentially available to all interested investigators.

The VA's Pain Care Delivery Model

Another important long-term implication for pain care professionals is the VA's choice of pain care delivery model, which is known as the Pain Medicine and Primary Care Community Rehabilitation Model (Gallagher RM. Med Clin N Am 1999). Dr. Gallagher believes that this model "will ultimately be the model for society" at large because it provides "the most cost-effective model for managing pain as a chronic disease in a population." The model's underlying philosophy is that pain care can be effective only if the patient has immediate access to effective pain treatment when they encounter the health care system - in the hospital after injury or surgery and as part of his or her primary care that is informed by evidence-based algorithms and closely supported by pain medicine specialty services.  

In implementing this model, the VA will employ a three-tiered approach to pain care, according to Dr. Gallagher. Because most new veterans enter the system at the primary care level, new primary care pain programs will be developed that will provide high quality pain care and treat the co-morbidities associated with pain, such as mental health, at the primary care level. The goal will be to help veterans reorganize their lives and re-integrate into society.

The second tier will be access to trained Pain Medicine specialists for those who need specialized pain treatment beyond the primary care level. The VA foresees having a pool of Pain Medicine specialists who will provide targeted Pain Medicine expertise if primary care isn't able to address all of the patient's pain care needs.

The third tier will be centers of excellence that will provide tertiary pain care, primarily as pain rehabilitation centers for those with severe conditions, such as traumatic brain injuries and PTSD. These pain rehab centers will be available for those vets who need longer term solutions to pain management. The VA is expected to be aggressive in outsourcing pain services to the private sector until it can develop the full range of pain services internally.

Another aspect of this pain care delivery model, Dr. Gallagher says, is "informed" patient self-care. Research demonstrates considerable variability in adherence to complicated medication regimens common in older patients with one or more chronic illnesses, including chronic pain disease.  Many patients will benefit from learning physical and behavioral techniques that will enhance their outcomes and improve their likelihood of response to medical treatment with or without medication, much as diabetes patients do now. With a combination of techniques that may include physical exercise, active pain avoidance, cognitive behavioral techniques and job negotiations with employers, appropriately in conjunction with other needed medical treatments, these patients will be able to improve their long-term pain outcomes and reduce treatment costs. "It's a public health approach to pain care," Dr. Gallagher says, "and an evidence-based approach that uses resources wisely and always looks to outcomes."

The AAPM's efforts, often in collaboration with other societies, to publicize the importance of appropriate pain treatment are bearing fruit. The Pain Care Coalition (PCC), of which AAPM is a founding member, and other groups, particularly the American Pain Foundation, have worked tirelessly over the years with governmental offices and legislators to promote the need for additional funding for pain research, education and clinical care in society at large, and more recently in the VA and military, and for more pain-focused research at the NIH.  These efforts are now paying off with new awareness of the importance of high quality pain treatment to the lives of people in pain, their loved ones and to businesses and taxpayers who ultimately bear the costs of poorly managed chronic pain.

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