Where have we come since 1999? Over the ensuing decade, progress was slow. Our health-care system continued to expand in costs and size without any indication that quality was improving and with considerable data demonstrating deterioration in many sectors and a widening of disparities in health care. Much was written about chronic pain’s role in the health economy and its contribution to its costs and disparities. Although certain sectors of American health care (e.g., the Veterans Health System followed by JCAHO) promoted evaluating pain systematically, and the United States Congress declared the “Decade of Pain Control and Research,” 2001–2010 [3, 4], the medical establishment made little progress in addressing the deficits in research funding and training and the organizational factors in the health system that perpetuated the public health problem of pain [5, 6].

During the early part of the decade, concerted efforts by the American Pain Foundation joined by the Pain Care Coalition (American Academy of Pain Medicine, American Pain Society, American Headache Association) led to a bill (the so-called Rogers Bill named after its sponsor in Congress, Rep. Bill Rogers from Michigan) to establish a Pain Institute at NIH and more funding for research. Congressional support for this bill was tepid however. The AAPM and American Board of Pain Medicine made applications to the ACGME to establish expanded training for pain medicine specialists but was turned down on two occasions by a negative vote by ABMS members of the review committee – although other non-ABMS members voted for expanding training. Finally, beginning in 2008, the concept of pain as a major public health problem began gaining traction in a wider sector of American society, fueled by three intersecting societal crises. First, pain was demonstrated to contribute to the problem of rising health-care costs and its effects on the competiveness of American business and America’s economy [7]. Second, hundreds of thousands of American troops were returning home from Iraq and Afghanistan for care in the military and veteran health systems with chronic pain, many with comorbidities such as PTSD and post-concussive syndrome, and as substance abuse and suicide rates rose in this population, pain was discovered to be a driving factor [8–10]. Third, emerging data demonstrating a growing epidemic of prescription analgesic drug abuse [11, 12] was brought to American consciousness by the national press. Meanwhile, the American Pain Foundation led the development of the Pain Forum, a consortium of professional, patient-centered, and industry organizations, and the Pain Care Coalition expanded to include a powerful partner, the American Society of Anesthesiology. Together, these groups successfully helped marshal three bills through congress: the Veterans Pain Care Act (2008) [13], the Military Pain Care Act (2009) [14], and the inclusion of the provisions of the original NIH Rogers Bill in the national health-care bill for health-care reform (2011) [15]. With the passage of these bills, which require a yearly progress report to congress, rapid transformative changes are occurring in pain management and research in the veterans and military health systems and in NIH. The former two systems, which are capitated and deliver care to a population of patients under a fixed budget, are most relevant to a discussion of the immediate changes that are needed in the health-care system. The NIH, which has long overlooked funding for the naturalistic, health systems, and combination trials demanded by the public health problem of pain [16], much less the development of new treatments, is most relevant in the long run for promoting research that improves the evidence basis for pain management.

The VA Health Administration (VHS) has instituted a progression of activities, consistent with the PMPCCR model, leading to the publication and dissemination of a Directive, written by this author and Robert Kerns, National Program Director for Pain Management. The Directive outlines a new standard of care for pain for the entire VA [17], Stepped Pain Care [18] Rosenberger et al. Federal Practitioner (2011), which directs that a biopsychosocial model of patient-centered chronic pain care be provided seamlessly and collaboratively in primary care, secondary care, and tertiary care with movement between sectors depending on complexity, treatment refractoriness, comorbidities, and risk. The model is consistent with the medical home model in the national health act in that it emphasizes routine primary care screening for pain and comprehensive assessment, case management by interdisciplinary teams, shared decision-making with patients and their families, and patient self-management. System support for primary care is provided by pharmacy through medication and opioid management, by behavioral health with screening and management of mental health comorbidities, and by evidence-based guidelines and clinical algorithms, as in Fig. 20.2. The evidence basis for this model is emerging from clinical trials and cohort studies in primary care systems, most notably in the VHA, in which specific primary care enhancements improve outcomes in primary care practices managing pain [19–25].

To promote this transformation in all 153 VHA medical facilities and their related outpatient clinics, the VHA’s national pain management office is supported by the National Pain Management Strategy Coordinating Committee (NPMSCC), consisting of representatives from several other program offices (e.g., anesthesia, education, mental health, neurology, nursing, primary care, PM&R, research, and quality improvement), and a National Pain Leadership Group consisting of VISN (regional) and facility “points-of-contact,” which discuss implementation progress in monthly meetings. National and regional workshops for “pain champions” in each primary care setting are being held in conjunction with transformation of VA care to primary care Pain Aligned Care Teams (PACT) in the medical home model. National workgroups have identified core “competencies” for VHA primary care providers in pain management, as listed in Table 20.1. To provide for the needs of the huge population requiring pain management, these competencies will necessarily be extended considerably to encompass many office-based procedures and interventions as improved training proceeds in primary care, both in postgraduate medical education and continuing education.

One innovative contribution of the academic and private sector to post-training continuing education is academic detailing, as established by the University of New Mexico’s ECHO model of using videoconferencing technology to train providers while they care for patients with complex chronic pain that is beyond the scope of their initial training. In the model of a resident case conference, interdisciplinary teams of clinicians (pain medicine specialists, psychologists, psychiatrists, social workers, and physical therapists) use videoconferencing links to supervise simultaneously several providers whose patients have difficulty accessing specialty pain care due to one or more factors such as distance, transportation, and illness severity. Evaluation of the impact of this model on the outcomes of patients with hepatitis C has shown outcomes equivalent to direct specialty care [26]. Although patient outcomes for pain specialty supervision are not yet published, supervised providers exhibit high satisfaction, confidence in pain care, and the growing capacity to manage chronic pain complexity independently of the specialty team. Providers must attend weekly 2-h conferences for a year and present to and follow with the pain team at least ten cases over that year before sufficient knowledge and skill transfer is achieved so they can approximate pain medicine practice at a specialist level. The ECHO concept has been adopted for trial in six different regions of the VHA in what is now called the Specialty Care Access Network or SCAN-ECHO, and each site is now actively providing such telehealth supervision with plans to link to direct telehealth patient care. The end result will be primary care providers with direct pain management training in a preceptorship model similar to residency training. To support such a successful postgraduate medical education intervention, credentialing organizations are now challenged to find an acceptable way to test and credentialing such providers in primary care pain medicine.

The Department of Defense (DoD), led by the Army Surgeon General and guided by the Defense and Veterans Pain Management Initiative (DVPMI), in 2009 chartered the Army Pain Task Force, including pain experts from the VA, Navy, and Air Force. The task force intensively studied the problem of pain management in the military over a 6-month period, making dozens of site visits to “best practices” as well as holding three retreats, and published a 163-page report [27] which thoroughly outlined the deficiencies in care and made over 100 recommendations for transforming pain care in the military. Key among the recommendations was adoption of the stepped care model for providing uniform standards for pain care in the military and in the VA. Subsequently, the VA-DoD Health Executive Council (HEC), codirected by the Under Secretaries for Health of both the VA and the DoD, chartered a Pain Management Working Group (PMWG). The PMWG, cochaired by this author, is charged with helping establish a single system of continuous, collaborative, and effective pain care, research, and education for the VA and DoD. The Defense and Veterans Center for Integrated Pain Management (DVCIPM) is a newly functional office chartered under the lead of the army to help operationalize the work of the HEC-PMWG. Projects underway include PASTOR, a standardized pain assessment to be used in all chronic pain encounters, no matter the setting but particularly in primary care, to assist providers in real-time clinical decision-making. The assessments will generate both cross-sectional reports for primary care providers at time of initial assessment as well as longitudinal reports on clinical outcomes. All data will be entered in a data registry and used to establish the benchmarks needed for health-care administrators to address planning and policy, consistent with the PMPCCR model as outlined in the beginning of this chapter. The HEC-PMWG hopes to coordinate DoD and VHA activities in at least two rapidly developing programs, the assessment and data registry project, PASTOR, and the SCAN-ECHO postgraduate training project.

Finally, led by the American Medical Association (AMA), other organizations outside the VA and military have called for changes based on wide recognition of pain medicine training deficiencies for all physicians, particularly primary on who fall the largest burden of care [28–30]. Through the concerted efforts of the AMA’s Pain and Palliative Medicine Specialty Section Council (PPMSSC), under the direction of its chairman, Philipp M. Lippe, MD, FACS, the AMA hosted the first national summit on Pain Medicine in 2009. The entire process and its outcomes are described in a 2010 paper in Pain Medicine [31]. The process began with the adoption of Resolution 321 (A-08) at an AMA Annual House of Delegates meeting in June 2008. Resolution 321 (A-08) states, in part, that “….the AMA encourages relevant specialties to collaborate in studying: (1) the scope and practice and body of knowledge encompassed by the field of Pain Medicine; (2) the adequacy of undergraduate, graduate, and post graduate education in the principles and practices of the field of Pain Medicine, considering the current and anticipated medical need for the delivery of quality pain care; and (3) appropriate training and credentialing criteria for this multi-disciplinary field of medical practice.” Over several months, representatives from all clinical specialties in the AMA convened in a modified Delphi process with representatives of the VA, the military, and major pain organizations. Their task was to identify the most pressing issues affecting the care of pain. The top five issues that emerged from this process are outlined in Tables 20.1 and 20.2.