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Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study.

  • Leonard, Chelsea1
  • Ayele, Roman1, 2
  • Ladebue, Amy1
  • McCreight, Marina1
  • Nolan, Charlotte1
  • Sandbrink, Friedhelm3, 4
  • Frank, Joseph W1, 5
  • 1 Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.
  • 2 Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado.
  • 3 Department of Neurology, Washington DC VA Medical Center, Washington, DC.
  • 4 Department of Neurology, George Washington University, Washington, DC.
  • 5 Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado.
Published Article
Pain medicine (Malden, Mass.)
Publication Date
May 21, 2021
DOI: 10.1093/pm/pnaa312
PMID: 32974662


Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers' and administrators' perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. We conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments. Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis. We interviewed 49 participants from 25 facilities from April through September of 2017. We identified three themes. First, the Veterans Health Administration's integrated health care system is both an asset and a challenge for multimodal chronic pain care. Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment. Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients. Early- and late-adopting sites differed in perceived resource availability. Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources. The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.

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