A State of Addiction: A New Model
Woodi Reed has been in chronic back pain for the last seven years. In her search for some relief, she has participated in pain clinics to treat her spinal stenosis at the Veterans Administration in Salt Lake City. There she has undergone hypnosis, nerve ablations and been prescribed opioids to help manage her pain. Despite the treatments, the pain has persisted.
“It's hard,” she said. “It's hard sometimes because I used to be a school bus driver and I actually had to quit the job that I loved because I developed the chronic pain in my back. So I am not working at all now. It actually does a couple of things; not only does it hurt you physically, it hurts you mentally when you feel that you're not contributing because you're not working.”
About two years ago Reed enrolled in a new program developed at the Salt Lake VA for chronic pain patients prescribed opioids by their primary care providers. It was created by a team
to improve patient safety and function using a whole health approach. Because veterans are twice as likely to die from an opioid overdose than members of the general population. And Utah has the unfortunate distinction of leading the nation in veteran overdoses. Jamie Clinton-Lont is the women's service medical director at the Salt Lake VA and all too familiar with these circumstances.
“In about 2005, I had an otherwise healthy female veteran and her husband called that she did not wake up—she had passed away,” she said. “She just had knee surgery. While those things happen, while I am not sure why she passed away, I wasn't quite sure if we had done our best. If we could have done more. If I could have educated her differently. If I could have gotten her involved in other forms of activities, something to help her in addition to pain medications. And so that ambiguity and not really knowing has caused a lot of grief for me as I go forward every time I write a prescription."
"And I think I am not alone," she said. "In talking to colleagues that they too have the same concerns and fears. And that I am not alone in prescribing the medications and people not waking up. And so it's a burden that we all live with.”
Clinton-Lont helped create the program because she, like many primary care providers, felt overwhelmed by patients' pain issues and the often contentious discussions surrounding prescription narcotics. She wanted to devise a better way for clinicians to monitor patient pain and function and identify potential opioid misuse. And she wanted to do it by bringing patients to the table and enlisting them as active partners in their own pain management.
Every six months, veterans in the opioid pain management program meet in Salt Lake City or in Orem by video conference for a 45 minute class where they are taught about the risks and benefits of opioids, personal risk factors for overdose, and develop individual treatment plans with VA staff. Participants are screened to make sure they're not taking illicit substances or acquiring additional pain medications from outside sources.
But a key component of the program is the requirement that each patient's plan include at least one non-pharmacological treatment such as cognitive behavioral therapy, mindfulness, trauma sensitive yoga, or aqua therapy. The idea is to help veterans develop additional skills to manage their pain using interventions that have been found to help alleviate some pain for chronic pain patients. Because opioids can only help so much.
“The actual thing that worked for me in the end was the yoga class that I got to,” Reed said. “It's for pain, it's tailored for chronic pain that you have. We have an instructor that is absolutely amazing. She takes the time to know you, she takes the time to show you the yoga. We have a camaraderie – I take the women's class – so you have camaraderie with the other women there. You can describe your pain with them, you can tell them what you tried."
"The yoga for me actually was a lifesaver," Reed said. "I take oxycodone for my back pain. At the time I started [yoga], I was on 4-6 a day because I was in so much pain in my back. Once I started the yoga I actually tapered down over a period of time. I've been going two years now and I take one pain medication a day. That's huge. That's a huge taper for me. It changed my life. It changed the way I can move around, the way I felt about myself, I felt more useful. And so the yoga for me is what really worked—that pain management.”
Reed is not the only veteran to taper her medication with this program. Clinton-Lont and her team have been collecting data on the program and that preliminary findings indicate that about 40 percent have reduced their doses or gone off opioids completely – many by choice – and the majority of veterans have reported increased function. Clinton-Lont is hoping that they will publish results soon and that this program may be held up as a potential model for care across the VA and beyond.
“The program's focus was on monitoring patients, educating patients, and offering them choice, but most importantly, making them a partner in their pain,” Clinton-Lont said. “That it wasn't my pain or the doctor's pain or anyone prescribing it, but your pain, and so what do you want to do about it? And so the premise, the hypothesis was if we can set expectations for what we can provide, and how we can do it safely, that the patients would have to become part of the problem solving with us, but also have to take the onus for their pain, and that their function would improve because they had ownership.”
This series is brought to you in part by the Association for Utah Community Health, providing training and technical assistance to health centers and affiliates across Utah. More information available here.