A dedicated group of health care professionals specializing in pain management work together at the Veteran’s Administration Caribbean Healthcare System in San Juan, Puerto Rico. Participating in this interview were: Edwin Cedeño, MSN, ANP, Pain Program Coordinator, Marianela Cuadrado, MD, Medical Director of the Interdisciplinary Pain Rehabilitation Program, Janys Sanchez, PharmD, Clinical Pharmacist, and Virginia Grundler, PhD, Psychologist.

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Questions

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Evelyn Corsini:

Please describe your unique facility, its resources, and whom you serve.

Edwin Cedeño, MSN, ANP: The Veterans Affairs Caribbean Healthcare System comprises a main medical center in San Juan, Puerto Rico, multispecialty clinics in Ponce and Mayaguez, and community based outpatient clinics in Arecibo and Guayama. In the United States Virgin Islands veterans are served by community-based outpatient clinics in St. Thomas and in St. Croix. The VA Caribbean Healthcare System serves a total population of approximately 150,000 veterans in the area. In fiscal year 2007, the system registered 66,187 unique patients with 10,415 inpatients treated, and 873,649 outpatient visits. "Uniques" registers the first visit of a veteran. The VA Caribbean Healthcare System has the only interdisciplinary pain program in the region.

The interdisciplinary nature of the program means that we always evaluate the patient together as a team. The team meets twice a week for a comprehensive evaluation of the care of our out patients, with an interdisciplinary discussion so we can update our plan of care. As clinicians, we communicate with each other on a daily basis about the status of each of our patients. This is different from a multidisciplinary treatment approach, where the care can be uncoordinated, and depend primarily on referrals from one provider to another.

We believe that medical and psychosocial issues go hand in hand. We use a bio-psychosocial model and cognitive-behavioral approaches to pain management.

EC: Can you describe the patients you see?

EC: The VA Caribbean Healthcare System only services eligible veterans registered in the Veterans Health Administration of the Department of Veterans Affairs. Our facility receives about 35,000-45,000 outpatient visits per month. Currently we have 120 active patients in our pain program. We see about 4-5 new patients each week, and about a third of our patients are still active in the military. The patients come to us through a referral process that may begin with their primary care provider. Patients must meet specific criteria to enroll in the program. One of the biggest challenges in our patient population is treating polytrauma conditions, such as spinal cord injuries, amputations, and traumatic brain injuries. Many of the injuries will take their normal course and turn into chronic pain conditions. We are most interested in facilitating the rehabilitation of the patient, by maximizing their quality of life and minimizing their level of pain, with an integrated approach to pain management.

EC: How do you decide whether a patient is an appropriate candidate for treatment in the pain program? How do you involve the patient’s primary care provider in his/her care?

EC: The majority of the referrals come from the Primary Care Providers. Referrals also come from subspecialty clinics, such as Neurosurgery, Neurology, Orthopedics, Anesthesiology, and Interventional Clinics, among others. Military active patient referrals come through the coordination of Department of Defense. A liaison officer reviews returning veterans and prepares them for approval and entry into our program.

When the patient is screened we identify the issues that need to be assessed and addressed. The Pain Program Coordinator's role is to directly communicate with the primary care provider to acquire initial diagnostic studies, and begin initial treatments. Primary care providers are very pleased to have our consultation, so that they can devise a timely and appropriate assessment plan before we see the patient within the next 30 days.

Depending upon his/her progress and established goals, a patient can remain enrolled in our program for up to 4-6 months. Our goal is to stabilize the patient’s medications and exercise plans, and set appropriate treatment goals. During the initial screening process for the pain clinic, the primary provider receives information through the Computerized Patient Electronic Record (CPRS) regarding the patient admission to the Interdisciplinary Pain Program. After discharge the patient returns to his primary care provider with outcomes, recommendations and expected follow up.

Early this year Edwin Cedeño, the Pain Program Coordinator, distributed over 100 copies of the PainEDU.org Manual: A Pocket Guide to Pain Management, 3rd edition, in our facility, to primary care providers and specialty clinics. We are deeply thankful because this initiative enables our mission to be a patient-centered integrated health care organization for veterans providing excellent health care, research, and education. We are an organization where people choose to work; an active community partner; and a back-up for national emergencies.

After completion of the program, the patient returns to the care of their primary care provider, with a set of formulated treatment recommendations. The patient remains in our system, where he/she will continue to receive follow-up care. We will also make appropriate referrals to specialists in our facility for other issues indirectly related to chronic pain, for example, weight control. We strongly emphasize the importance of follow-up care to our patients.

EC: What kind of policies do you use to minimize your patient’s opioid drug abuse risk?

EC: We have specific guidelines we follow in terms of how and when to provide opioid medications to our patients. During the initial evaluation, we use substance abuse tools to identify and stratify patients by their level of risk. We rely on the help of our team psychologists to assess risk. We all meet and classify the patient as being at low, moderate or high risk of abuse. When we decide that a patient is a candidate for opioids, we use an opioid agreement. The opioid agreement specifies our opioid policy and the importance of follow-up and monitoring so that we can make sure the patient takes their medications correctly. We also do pill counts, and patients can only get their medications through our in-house pharmacy. We try to monitor them at least once a month.

If the patient is an active substance abuser or has a recent history of substance abuse, we will make a referral to a substance abuse program. If the patient agrees to attend the substance abuse program, we will continue caring for him and administer non-opioid medications. If the patient’s history of substance abuse is not recent, we administer a toxicology screening. If the results are negative for substances, we will administer opioids with very close monitoring. We also request the help of the patient’s family members and relatives to have responsibility for the opioid medications, and help administer them safely. They are also encouraged to sign the patient’s opioid agreement.

Patients can be enrolled in a substance abuse program and the pain program. Since we have an electronic medical record system that allows clinicians to share patient records across all of VA facilities, it is easy to coordinate their care between the two programs. We do not penalize patients with drug addiction problems. Addiction is a disease. The most important thing we can do is monitor them carefully and prescribe non-opioid alternatives. We want to contribute to their getting a better quality of life, not to their addiction.

Our Interdisciplinary Pain Team is very interested in the use of the Screener and Opioid Assessment for Patients in Pain (SOAPP) and would like to see it translated and validated to Spanish.

EC: What can you tell us about the Military Pain Care Act of 2008, HR 5465?

EC: The Veteran’s Administration has a mandate to provide immediate access to the VA system for military personnel with acute and chronic pain in the hopes of preventing the development of long-term chronic pain syndromes and mental health and substance abuse disorders. These complex patients are a unique and demanding population. We participate in a regularly scheduled national telephone conference call across the VA system, called VA Pain, where we try to address issues of access and how to improve our care.

We are fortunate at this facility to have all of the resources we need for these patients, and to be linked to the Medical Science Campus of the University of Puerto Rico. We are very pleased with the good and reliable outcomes and patient satisfaction we have seen since we started our program in 2003. We hope our system will become a model for others. Some VA facilities may have fewer resources. The provisions of the Military Pain Care Act will make it possible for the VA to contract outside of its system for the appropriate resources a Veteran needs, if they are not available through the VA system.