VA doctor to research approaches to chronic pain

A researcher for the Minneapolis Veterans Affairs hospital has been awarded a $12.5 million grant to compare approaches to pain management.

The study comes as the VA struggles for answers about how to deal with veterans with chronic pain. It also comes as the VA begins an era where it is greatly restricting the use of traditional painkilling medications called opioids.

Dr. Erin Krebs, an investigator with the VA's Center for Chronic Disease Outcomes Research and an associate professor at the University of Minnesota, will conduct the study, which will begin in early 2017.

The project will enroll 1,400 participants at nine VA sites to compare two approaches to pain management that differ in resource intensity.

It will test which of the pain-treatment strategies is better for managing pain and helping patients reduce opioid use.

For patients on high doses who want to cut back, it will test whether offering an extra option for tapering down helps them succeed. It also will look at the experience of patients and providers to establish ways to implement programs more broadly. Participants will be asked to stay in the study for 12 months.

One of the approaches involves a pharmacist and supervising physician working together to find the best medication options for each patient.

The other approach uses a physician, psychologist and physical therapist to use medications, but also other pain-management strategies such as exercise or talk therapies to deal with the physical aspects of pain and its emotional and social impact.

Participants on high opioid medication doses who want to reduce their use will be assigned, by chance, to a regular stepped taper or a choice between a regular taper or switching medications.

The study will track other outcomes, too, including quality of life, sleep, fatigue, depression, anxiety, and side effects, according to the Minneapolis VA.

Treatment with opioid pain medications (like hydrocodone and morphine) is common for severe pain, but studies show those medications may not always help and can cause serious problems, especially at high doses.

Patients have told the VA that the focus should be on finding better pain care strategies first, and dropping doses second, and only if the patient is ready.

The Minneapolis VA and Krebs have been pioneers in issues related to opioid medication use. In 2011, Krebs collaborated to establish the Opioid Safety Initiative, which was aimed at decreasing high-risk opioid prescribing practices throughout the VA.

The initiative was heralded for the number of opioid prescriptions it reduced. But critics charged that the policy abruptly cut many veterans off from their medications without providing alternatives.

The Star Tribune examined the issue in a series of stories last year. The stories can be found at tinyurl.com/nshmzlw.

Last month, as part of a broader bill to deal with the nation's opioid epidemic, President Obama signed sweeping narcotics reforms into law that are expected to dramatically change the way the VA dispenses and monitors opioids.

The legislation creates stronger opioid prescribing guidelines for the VA, including stricter standards against prescribing narcotics in combination with other drugs such as tranquilizers, and restrictions on prescribing opioids to patients with mental health issues. The law also requires the VA to develop alternative treatments.

Mark Brunswick • 612-673-4434