[DOCID: f:sr267.110]
From the Senate Reports Online via GPO Access
[wais.access.gpo.gov]
Calendar No. 586
110th Congress Report
SENATE
2d Session 110-267
======================================================================
VETERANS PAIN CARE ACT OF 2007
_______
February 28, 2008.--Ordered to be printed
_______
Mr. Akaka, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany S. 2160]
The Committee on Veterans' Affairs (hereinafter, ``the
Committee''), to which was referred the bill (S. 2160), to
amend title 38, United States Code, to establish a pain care
initiative in health care facilities of the Department of
Veterans Affairs, and for other purposes, having considered the
same, reports favorably thereon, and recommends that the bill
do pass.
Introduction
On October 15, 2007, Committee Chairman, Senator Daniel
Akaka, introduced S. 2160, the proposed ``Veterans Pain Care
Act of 2007.'' The bill would require every Department of
Veterans Affairs (hereinafter, ``VA'') health facility to have
an initiative on pain care. VA would also be required to
designate an appropriate number of facilities as cooperative
centers on the research and education of pain. S. 2160 is
cosponsored by Committee Member Senator Sherrod Brown.
On October 24, 2007, the Committee held a hearing on
pending veterans' health legislation, at which testimony on S.
2160, among other bills, was offered by: Michael J. Kussman,
MD, MS, MACP, VA Under Secretary for Health; Carl Blake,
National Legislative Director, Paralyzed Veterans of America;
Joy J. Ilem, Assistant National Legislative Director, Disabled
American Veterans; and Brenda Murdough, MSN, RN-C, Military/
Veterans Initiative Coordinator, American Pain Foundation. The
witnesses from Paralyzed Veterans of America, Disabled American
Veterans, and the American Pain Foundation supported S. 2160.
VA did not support the legislation, believing it to be
superfluous and duplicative of existing VA programs on pain
care management.
Committee Meeting
After carefully reviewing the testimony from the foregoing
hearing, the Committee met in open session on November 14,
2007, to consider, among other legislation, S. 2160. The
Committee agreed by voice vote to report favorably S. 2160 to
the Senate.
Summary of S. 2160 as Reported
S. 2160, as reported (hereinafter, ``the Committee bill''),
would provide a Congressional mandate for VA's existing efforts
in the area of pain care management and significantly enhance
VA's pain management research and education. The Committee bill
would require the establishment of a pain care initiative at
each health care facility of the Department of Veterans
Affairs. The Committee bill would also require the Secretary of
Veterans Affairs (hereinafter, ``the Secretary'') to designate
an appropriate number of facilities of the Department as
cooperative centers for research and education on pain.
Further, national oversight and leadership of VA's pain
management efforts would be secured through the designation of
an appropriate officer to manage the program's operations.
Section 2 of the Committee bill contains eight of Congress'
findings as follows:
Paragraph (1) recognizes the prevalence of acute and
chronic pain among the veteran population.
Paragraph (2) finds that modern warfare, including the
prevalence of improvised explosive devices, produces a
substantial number of battlefield casualties with damage to the
central and peripheral nervous system.
Paragraph (3) notes that the success of military health
care has resulted in high survival rates among severely injured
military personnel. The higher survival rate is anticipated to
result in the affliction of many survivors with significant
pain disorders.
Paragraph (4) finds that the failure to treat pain
appropriately at the time of transition from the Department of
Defense to receipt of care from the VA contributes to the
development of long-term chronic pain syndromes and can be
accompanied by long-term mental health and substance use
disorders.
Paragraph (5) observes that pain is a leading cause of
short-term and long-term disability among veterans.
Paragraph (6) recognizes that VA has implemented some
worthwhile pain care initiatives, but has yet to adopt a
comprehensive pain care program available to all patients in
need.
Paragraph (7) finds that the inconsistent and ineffective
pain care provided by VA leads to pain-related impairments,
occupational disability, and other complications for veterans
with acute and chronic pain; and that these problems result in
substantial long-term costs for both VA and society at large.
Paragraph (8) finds that the research, diagnosis,
treatment, and management of acute and chronic pain among
veterans constitute a health care priority.
Section 3(a) of the Committee bill would require the
Secretary to carry out a pain care initiative at each VA health
care facility.
Section 3(b) of the Committee bill is a clerical amendment
which would add a separate section on pain care at the
beginning of chapter 17 of title 38.
Section 3(c) of the Committee bill establishes a timeline
for implementation of the pain care initiative by January 1,
2008, for inpatient care and January 1, 2009, for outpatient
care.
Section 4(a) of the Committee bill would require the
Secretary to carry out a program of research and training on
pain.
Section 4(b) of the Committee bill is a clerical amendment,
which would add a new section on the program of research and
training on acute and chronic pain in the appropriate tables of
sections of title 38.
Background and Discussion
The Committee bill was developed in response to the need
for better pain management of veterans. Pain can be a cause of
short-term and long-term disability among veterans of all eras.
Modern warfare has produced a new range of battlefield
injuries. This is due to factors such as the use of body armor,
the prevalence of improvised explosive devices, and
improvements in battlefield medicine. Today's servicemembers
are surviving injuries that would have been fatal in previous
conflicts. Traumatic brain injury and polytrauma are among the
hallmark injuries of the military operations in Iraq and
Afghanistan. In many cases, these wounded servicemembers suffer
from damage to the central and peripheral nervous system,
necessitating a better understanding of pain and more effective
management techniques.
A study of Iraq and Afghanistan veterans found that 47%
reported at least a mild level of pain, and 28% reported
experiencing pain of moderate to severe intensity. The study
concluded that a substantial percentage of these veterans will
experience clinically significant pain following their military
service. (Gironda, Ronald J. PhD, et. al, ``Pain among Veterans
of Operations Enduring Freedom and Iraqi Freedom.'' Pain
Medicine, Vol. 7, No. 4, 2006).
Another study, focused broadly upon veterans of all eras,
found a correlation between pain and other conditions such as
depression and PTSD. Nearly three-fourths of participants in
the study said that pain has ``very much'' interfered with
their quality of life and ability to work. Additionally, only
6% of participants rated their pain care management as ``very
effective,'' while nearly twice as many rated their pain care
as ``very ineffective.'' (``Survey of Veterans and Pain,''
American Pain Foundation, November 2006).
Research led by Robyn L. Walker, a clinical psychologist at
the James A. Haley VA Medical Center in Tampa, Florida,
revealed that 96 percent of polytrauma patients experienced
more than one pain problem during rehabilitation, and 70
percent of the patients experienced pain in more than one site.
The study also found that 56 percent of patients were diagnosed
with PTSD and other mental health conditions. The study
concluded that ``pain needs to be consistently assessed,
treated, and documented.'' Further, the study found the need
for consistency of pain assessment and treatment across the
continuum of care. (Walker, Robyn L., Ph.D., ``Pain Problems,
Pain Related Impairments, and Emotional Problems in Polytrauma
Patients,'' 2007).
Further, the testimony of Brenda Murdough of the American
Pain Foundation at the Committee's October 24, 2007, hearing on
this bill indicated that failure to treat pain appropriately at
the outset of the injury, or when pain carries on into the
rehabilitation period, is a leading cause of long-term chronic
pain syndromes. In turn, mismanaged or unmanaged pain
oftentimes leads to or accompanies long-term mental health and
substance use disorders.
VA has had a pain management program in place for some
time, although the program's focus was initially directed
towards pain associated with end-of-life care. It is the
Committee's view, however, that the program has not received
necessary priority for full implementation via the
establishment of consistent standards for assessment that are
practiced uniformly across the VA health care system. The
Committee seeks to expedite that process with this legislation.
The lack of standardized implementation of VA's own pain
care management strategy has limited the effectiveness of pain
care for veterans. VA's current program is decentralized and
has languished since its inception in 2003, despite the growing
need for pain care management and research. For example, VA has
stopped holding regular conferences at the national level on
pain and distributing educational materials. However, the
existing program provides a foundation for the renewed focus
upon pain that the Committee bill would require. Some Veterans
Integrated Service Networks (hereinafter, VISN's), such as VISN
23 and VISN 4, still have health care professionals
participating in internal quarterly phone conferences,
utilizing an e-mail list serve, and informally sharing
information on pain care. Accordingly, some VISN's have better
developed pain management strategies and more proficient
personnel than others.
Medical professionals familiar with VA's pain management
efforts provided the Committee with input that underscored the
need for VA to focus upon and assume a leadership position in
the field of pain management. This need is heightened by the
distinct demographic characteristics of veterans and the unique
challenges some face. For example, men make up a greater
proportion of the veteran population than the civilian
population, and some of the injuries suffered by veterans,
including blast injuries and shrapnel wounds, tend to be much
more prevalent among veterans than their civilian cohorts. The
Pain Forum, and other groups, have formally and informally
identified research opportunities on co-morbidity with
substance use disorder, and alcoholism, and on co-morbidity
with mental health issues, including depression and post-
traumatic stress disorder.
The Committee bill has broad support among experts in the
pain care management field. It has been endorsed by the Pain
Forum, which consists of over 25 health care and health care
advocacy groups, including the American Academy of Pain
Management, American Academy of Pain Medicine, Alliance of
State Pain Initiatives, American Cancer Society, American
Chronic Pain Association, American Hospice Foundation, American
Pain Foundation, American Pain Society, American Pharmacists
Association, American Society for Pain Management Nursing,
Federation of State Medical Boards, National Coalition for
Cancer Survivorship, National Hospice & Palliative Care
Organization, and the National Pain Foundation.
Pain Initiatives at VA Health Care Facilities. Section 3(a)
of the Committee bill would add a new section to title 38,
proposed section 1720F, entitled ``Pain Care,'' that would
require VA to implement a comprehensive pain management
program. Under this new section 1720F, the Secretary would be
required to develop and carry out an initiative on pain care at
every VA health care facility, and to assess every patient for
pain at the time of their admission or initial treatment, and
periodically thereafter. Under this new section, VA would be
required to utilize a ``professionally recognized pain
assessment tool or process.'' In practice, this would require
VA to adopt a uniform pain assessment tool or process. VA has
done work in this area before, notably through the ``fifth
vital sign'' education project, first implemented in 1999, that
added a screening for pain to the traditional assessment of
blood pressure, temperature, and other vital signs at check-in.
However, inconsistencies remain system-wide in the practical
implementation of this internal policy.
At the Committee's October 24, 2007, hearing, Brenda
Murdough of the American Pain Foundation spoke of the benefits
of a pain management program for veterans. According to Ms.
Murdough:
[While] many of our military and veterans treatment
facilities offer the highest level of skill and
expertise in treating these painful conditions suffered
by our wounded armed service men and women, we need to
ensure that all of our veterans' facilities are
consistently providing the highest level of effective,
comprehensive pain management to prevent long term
suffering and disability.
Carl Blake of Paralyzed Veterans of America provided
insight on the positive impact of pain management upon
individuals suffering spinal cord injuries:
We have seen firsthand the benefits of pain care
programs, as each VA facility that supports a spinal
cord injury (SCI) unit also maintains a pain care
program. Veterans with spinal cord injury know all too
well the impact that pain, including phantom pain, can
have on their daily life. The pain care programs that
SCI veterans have access to have greatly enhanced their
rehabilitation and improved their quality of life.
As such, this section of the Committee bill would require
that each patient be provided appropriate pain care, and when
necessary, be provided access to specialty pain management
services, including individualized counseling and psychological
support, anesthesiology, and other tools as needed.
Implementation of Pain Care Initiatives. Section 3(c) of
the Committee bill would require the Secretary to ensure that
the implementation of the pain care initiative at all health
care facilities occurs no later than January 1, 2008, for
inpatient care; and January 1, 2009, for outpatient care.
Research and Training Programs. Section 4(a) of the
Committee bill would add a new section 7330A to title 38,
entitled ``program of research and training on acute and
chronic pain,'' that would require VA to carry out, within the
Medical and Prosthetic Research Service of the Veterans Health
Administration, a program of research and training on acute and
chronic pain. It is the Committee's view that there is a need
for expanded research and education of VA's health care workers
in how to assess and treat pain.
Subsection (b) of proposed section 7330A would describe the
program's goals, including the identification of research
priorities, promotion and coordination of research
opportunities, and education of VA's health care personnel. It
is the Committee's understanding, based on informal input from
commentators familiar with current VA pain management efforts,
that while there has been a slow decline of the pain management
program at VA, there is also enthusiasm about the prospect of a
renewed focus upon pain research. Some contributors suggested
that VA could explore research opportunities focused upon co-
morbid substance use disorder, post-traumatic stress disorder,
multiple chronic pain, and other conditions that have a higher
incidence among veterans than comparable civilian cohorts.
Subsection (c) of proposed section 7330A would provide for
the designation of an appropriate number of health centers to
serve as cooperative centers for research and education on
pain. The Secretary would also be required to select a lead
center for research on pain attributed to central and
peripheral nervous system damage, and another for the
coordination of research activities of all other centers. The
center designated to do so would be required to review and
evaluate research, collect and disseminate information, and
develop educational materials and products.
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the CBO, estimates that enactment of
the Committee bill would increase spending by $2 million in
2008 and by $17 million over the 2009-2013 period. Enactment of
the Committee bill would not affect direct spending or
receipts, and would not affect the budget of state, local or
tribal governments.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office,
Washington, DC, January 15, 2008
Hon. Daniel K. Akaka,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 2160, the Veterans
Pain Care Act of 2007.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sunita
D'Monte.
Sincerely,
Peter R. Orszag,
Director.
Enclosure.
S. 2160 would require the Department of Veterans Affairs
(VA) to implement an initiative on pain care at all VA health
care facilities, under which VA would assess and appropriately
treat acute and chronic pain. In addition, the bill would
require VA to establish a program of research and training on
treatment for acute and chronic pain--including centers for
research and education on pain--and to appoint a national
coordinator to oversee those programs.
According to VA, the department has already implemented
appropriate pain assessment and management protocols at its
medical facilities. Based on information from VA regarding
similar research programs, CBO expects that under S. 2160, VA
would establish three pain research and training centers at an
estimated annual cost of about $1 million each. Therefore, CBO
estimates that implementing the provisions on research,
training, and education would cost $2 million in 2008 and $17
million over the 2009-2013 period, assuming appropriation of
the estimated amounts. This estimate further assumes that
outlays will follow historical spending patterns for similar
programs and that the bill will be enacted this spring.
Enacting the bill would have no effect on direct spending or
revenues.
S. 2160 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act and
would impose no costs on state, local, or tribal governments.
The CBO staff contact for this estimate is Sunita D'Monte.
This estimate was approved by Peter H. Fontaine, Assistant
Director for Budget Analysis.
Regulatory Impact Statement
In compliance with paragraph 11(b) of rule XXVI of the
Standing Rules of the Senate, the Committee has made an
evaluation of the regulatory impact that would be incurred in
carrying out the Committee bill. The Committee finds that the
Committee bill would not entail any regulation of individuals
or businesses or result in any impact on the personal privacy
of any individuals and that the paperwork resulting from
enactment would be minimal.
Tabulation of Votes Cast in Committee
In compliance with paragraph 7 of rule XXVI of the Standing
Rules of the Senate, the following is a tabulation of votes
cast in person or by proxy by members of the Committee at its
November 14, 2007 meeting. On that date, the Committee, by
voice vote, ordered S. 2160 reported favorably to the Senate.
Agency Report
On October 24, 2007, Michael J. Kussman, MD, MS, MACP, the
Department of Veterans Affairs' Under Secretary for Health,
appeared before the Committee and submitted testimony on, among
other things, the Veterans Pain Care Act of 2007. Excerpts from
this statement are reprinted below:
Statement of the Views of the Administration
Michael J. Kussman, MD, MD, MACP
Under Secretary for Health for the Department of Veterans Affairs
Good morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the
Administration's views on several bills that would affect
Department of Veterans Affairs (VA) programs that provide
veterans benefits and services. With me today is Walter A.
Hall, Assistant General Counsel. I will address the five bills
on today's agenda and then I would be happy to answer any
questions you and the Committee members may have.
s. 2160 ``veterans pain care act of 2007''
S. 2160 would require the Secretary to carry out an
initiative on pain care management at each VA health care
facility. Under the initiative, each individual receiving
treatment in a VA facility would receive: (1) a pain assessment
at the time of admission or initial treatment and periodically
thereafter, using a professionally recognized pain assessment
tool or process; and (2) appropriate pain care consistent with
recognized means for assessment, diagnosis, treatment, and
management of acute and chronic pain, including, when
appropriate, access to specialty pain management services. The
initiative would have to be implemented at all VA health care
facilities by not later than January 1, 2008, in the case of
inpatient care and by not later than January 1, 2009, in the
case of outpatient care.
The bill would further require the Secretary to carry out a
program of research and training on acute and chronic pain
within VHA's Medical and Prosthetic Research Service. These
programs would be directed to meet the purposes specified in
the bill. The Secretary would also be required to designate an
appropriate number of facilities as cooperative centers for
research and education on pain. Each such center would focus on
research and training in one or more of the following areas:
acute pain; chronic pain, or a research priority identified by
VHA. The Secretary would also need to designate at least one of
those centers as a lead center for research on pain
attributable to central and peripheral nervous system damage
commonly associated with the battlefield injuries
characteristic of modern warfare. Another center would be the
lead for coordinating the pain care research activities
conducted by the centers and responsible for carrying out a
number of other duties specified in the bill.
The measure would permit these centers to compete for
funding from amounts appropriated to the Department each year
for medical and prosthetics research. It would also charge the
USH with designating an appropriate official to oversee their
operation and to evaluate their performance.
VA health care is delivered in accordance with patient-
centered medicine. Fundamental to this is effective pain
management. In 2003 VHA established a National Pain Management
Strategy to provide a system-wide approach to pain management
to reduce pain and suffering for veterans experiencing acute
and chronic pain associated with a wide range of illnesses. The
national strategy uses a system-wide standard of care for pain
management; ensures that pain assessment is performed in a
consistent manner; ensures that pain treatment is prompt and
appropriate; provides for continual monitoring and improvement
in outcomes of pain treatment; uses an interdisciplinary,
multi-modal approach to pain management; and ensures VA
clinicians are prepared to assess and manage pain effectively.
The national strategy also called for pain management protocols
to be established and implemented in all clinical settings and
directed all VHA medical facilities to implement processes for
measuring outcomes and quality of pain management.
To oversee implementation of the National Pain Management
System, VHA established an interdisciplinary committee. Part of
the committee's charge is to ensure that every veteran in every
network has access to pain management services. The committee
is also responsible for making certain that national employee
education is provided to VHA clinicians so that they have the
needed expertise to provide high quality pain assessment and
treatment and for identifying research opportunities and
priorities in pain management. It also facilitates
collaborative research efforts and ensures that VHA pain
management standards have been integrated into the curricula
and clinical learning experiences of medial students, allied
health professional students, interns, and resident trainees.
Because pain management is already a subject of systematic
and system-wide attention in the VHA health care system, S.
2160 is superfluous and duplicative of what is already
happening in VA healthcare. We would be very happy to meet with
the Committee to discuss VA's ongoing pain management program
and activities.
* * * * * * *
Changes in Existing Law Made by the Committee Bill,
as Reported
In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, changes in existing law made by the
Committee bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
TITLE 38--VETERANS' BENEFITS
PART II--GENERAL BENEFITS
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
Subchapter II--Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment
* * * * * * *
SEC.
1720F. PAIN CARE
* * * * * * *
SEC. 1720F. PAIN CARE
(a) In General.--The Secretary shall carry out at each
health care facility of the Department an initiative on pain
care.
(b) Elements.--The initiative at each health care facility
of the Department shall ensure that each individual receiving
treatment in such health care facility receives the following:
(1) An assessment for pain at the time of admission
or initial treatment, and periodically thereafter,
using a professionally recognized pain assessment tool
or process.
(2) Appropriate pain care consistent with recognized
means for assessment, diagnosis, treatment, and
management of acute and chronic pain, including when
appropriate, access to specialty pain management
services.
* * * * * * *
PART V--BOARDS, ADMINISTRATIONS, AND SERVICES
CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS
* * * * * * *
SEC.
7330A. PROGRAM OF RESEARCH AND TRAINING ON ACUTE AND CHRONIC PAIN.
* * * * * * *
(a) In General.--The Secretary shall carry out within the
Medical and Prosthetic Research Service of the Veterans Health
Administration a program of research and training on acute and
chronic pain.
(b) Purposes.--The purposes of the program shall include
the following:
(1) To identify research priorities most relevant to
the treatment of the types of acute and chronic pain
suffered by veterans.
(2) To promote, conduct, and coordinate research in
accordance with such research priorities--
(A) through the facilities and programs of
the Department; and
(B) in cooperation with other agencies,
institutions, and organizations, including the
Department of Defense.
(3) To educate and train health care personnel of the
Department with respect to the assessment, diagnosis,
treatment, and management of acute and chronic pain.
(c) Designation of Centers.--(1) The Secretary shall
designate an appropriate number of facilities of the
Department as cooperative centers for research and
education on pain. Each such center shall be designated
with a focus on research and training on one or more of
the following:
(A) Acute pain.
(B) Chronic pain.
(C) A research priority identified under
subsection (b)(1).
(2) The Secretary shall designate at least one of the
centers designated under paragraph (1) as a lead center
for research on pain attributable to central and
peripheral nervous system damage commonly associated
with the battlefield injuries characteristic of modern
warfare.
(3) The Secretary shall designate one of the centers
designated under paragraph (1) as the lead center for
coordinating the pain care research activities of the
centers designated under this subsection. The functions
of such center shall be the following:
(A) To review and evaluate periodically the
research of the centers designated under this
subsection and to ensure that such research is
conducted in accordance with the research
priorities identified pursuant to subsection
(b)(1).
(B) To collect and disseminate the results of
the research of the centers designated under
this subsection.
(C) To develop and disseminate educational
materials and products--
(i) to enhance the assessment,
diagnosis, treatment, and management of
acute and chronic pain by the health
care professionals and facilities of
the Veterans Health Administration; and
(ii) for veterans suffering from
acute or chronic pain and their
families.
(d) Award of Funding.--Centers designated under subsection
(c) may compete for the award of funding from amounts
appropriated to the Department each fiscal year for medical and
prosthetics research.
(e) National Oversight.--The Under Secretary of Health
shall designate an appropriate officer--
(1) to oversee the operation of the centers
designated under subsection (c); and
(2) to review and evaluate periodically the
performance of such centers.
<all>