Sunday, August 17, 2014
A VA Clinic Tries a New Course
New England vets will be treated with a process called "ACT." Veterans and others seeking relief from chronic pain could be spared joining the millions unwillingly addicted to narcotic pain pills. So what is "Acceptance Community Therapy?"
Good news for veterans this week came in the form of a $10 billion bill devoted to emergency spending over three years to pay doctors and other health professionals to care for veterans who can't get appointments at VA facilities. The VA has had a tough year. Revelations of the widespread cover up of wait times has led to the firing of employees in Wyoming and Colorado, and the resignation of VA Secretary Eric Shineski.
The bill includes $5 billion for hiring more VA doctors, nurses and other medical staff and $1.3 billion to open 27 new VA clinics across the country.
One clinic that is to become the flagship for the treatment of chronic pain in the New England region is the ACT for Pain Clinic at Togus in Maine. And having been selected to serve the entire New England region, the Togus facility will almost certainly become the model for many new facilities funded by the new bill.
Dr. Amanda Adcock heads up the ACT for Pain Clinic. She talked exclusively to The Fix about the work they’ve been doing helping vets deal with chronic pain.
Adcock says when treating chronic pain, medication alone is not the answer.
“A narcotic pain medication numbs the ability to feel so you're really also numbing certain emotional reactions. That causes some of the social interaction difficulties.”
Adcock believes that dealing with pain must first start with acceptance.
ACT teaches patients to accept their situation in their private lives without trying to better control their thoughts, feelings, memories and other private events as taught in traditional cognitive behavioral therapy (CBT). In other words it asks patients to stop avoiding pain and in a sense, embrace it.
Though the concept of ACT has been around for a while, it’s pretty radical stuff for many health care professionals and it hasn’t been easy to get doctors in the VA away from the traditional response to chronic pain: medication. But she says things are changing.
“I think with a lot of the research coming out about accidental OD deaths on prescribed medication over the past several years that it hasn’t been as difficult a conversation. There’s been a huge push for improved opioid safety initiatives…and a huge push to offer alternatives.”
This Maine clinic is one of those alternatives currently being embraced at the VA in New England at Togus—the oldest VA facility in the country. It was the first of the fledgling regional homes for disabled volunteers to open in November 1866.
Vets are introduced to ACT during a five day interdisciplinary, intensive outpatient course. They are shown new ways to think about physical therapy, occupational therapy and complementary alternatives such as yoga to better their health and well-being.
At the end of the week in a graduation ceremony, they tell their friends, family and support people what they’ve learned, what changes they want to make and how they will make those changes. They get a certificate and are asked to sign themselves back into a ‘full and meaningful life.' In doing so they make a commitment to themselves to do things for themselves.
“We have the vets come up with an action plan in the form of a diagram..We rely on it heavily. Towards on one side, and away on the other.”
‘We know from basic science that when a human being says out loud a commitment to do something, that commitment is 80% more likely to be followed through on.”
Invariably the families and caregivers are happy to see this. Anyone who’s spent time in recovery can describe their process in similar terms and family members with these experiences have the most recognition.
“I mean its like AA or any other treatment program,” says Adcock. “People who are one step ahead and looking back explaining how to get there to the new guy.”
The eureka moment comes when they realize:
“All along they’ve being doing all these things (avoidance, denial, substance abuse, etc.) in the service of pain instead of the service of well-being or their family and the things they care about.”
One of the biggest problems PCPs run into when helping a sufferer of chronic pain is when reliance on pain medication becomes an addiction.
ACT can be useful in treating different substance abuse problems too. It allows for conversations on how different behaviors, including addictive behavior, get in the way of a full life.
“Addictive behavior is no more stigmatized than any other behaviors. Acceptance of emotional reactions—not just about pain—but also about all sorts of internal reactions: Memory, feelings, emotions, thoughts, anything that would be going on inside the skin. We address it in the same way.”
The key word is "mindfulness":
“To watch these things occur (memory, thoughts etc.) and from that we get to choose – are we going to react to that experience? Or are we going to choose to do a behavior that moves us towards something that we care about?”
This therapy isn’t replacement for medication at all:
“We have a broad perspective, a common language, to think about how to use any pain treatment for the purposes of getting back into life rather than simply the elimination of pain.”
This approach allows PCPs to use meds more effectively.
“Sometimes I have people I work with who use meds constantly and chronically and perhaps have a problem with medication. What we do is help someone to use meds more functionally. [For example,] if I know I react poorly to a medication perhaps I can I adjust when I take my doses, in order to be more able to engage with my family."
Sometimes it does mean getting off of painkillers altogether.
“I’ve worked with several vets who have come completely off narcotic pain meds and are maybe using some other nerve medication and they say things to me like: “Now I know that when I experience the pain, the pain makes me feel alive.”
One of the core goals of the ACT program at Togus is to get patients in touch with some of the things in their life they used to enjoy before the onset of chronic pain, to reintroduce them to things that gave their life meaning and value.
“What are the things in life that maybe you’ve given up because of pain and how are we going to work hand in hand in getting those things back for you?” She asks patients.
“Specifically getting reengaged with the family, perhaps getting back to work, perhaps just getting engaged with the community. Acceptance of chronic pain as something’s that’s always going to be there. Something that hijacks the brain and takes over but it’s something we can learn to live with.”