Robert D. Kerns, Ph.D.
Professor of Psychiatry, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
Dr. Robert D. Kerns is Professor of Psychiatry, Neurology, and Psychology at Yale University. He recently retired from the Department of Veterans Affairs (VA) Connecticut Healthcare System (VACHS) and service to VA following a nearly 38 year career when he served as VACHS Chief of Psychology and founding Director of the Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation and as VA National Program Director for Pain Management. He is a Fellow of the American Psychological Association and of the Society of Behavioral Medicine, and he has held leadership positions in these and other professional and scientific societies. He has published over 250 articles and two books in the area of behavioral medicine and pain management and is the recipient of numerous honors and awards. He was a member of the Institute of Medicine Committee on Advancing Pain Research, Care and Education and National Pain Management Strategy Oversight Panel that developed a National Pain Strategy for transforming pain care in America. He also served as co-chair of the Federal Interagency Workgroup that produced a National Action Plan for Prevention of Opioid-related Adverse Drug Events. His research has been funded through the VA, the National Institutes of Health NIH) and through other federal and private sources for over 35 years.
Dr. Kerns is one of three directors of the Yale-based NIH-DoD-VA Pain Management Collaboratory Coordinating Center (PMC3). This initiative was launched in September 2017 as a joint activity of the NIH, the Department of Defense (DoD), and the VA. The NIH-DoD-VA Pain Management Collaboratory (PMC) is an unprecedented cooperative activity involving seven NIH institutes, centers, and offices (ICs)—NCCIH, NINDS, NIDA, NIAAA, NICHD (NCMRR), ORWH, NINR—plus the Clinical and Rehabilitative Medicine Research Program (CRMRP) and the Military Operational Medicine Research Program (MOMRP) at DoD, and the Health Services Research & Development (HSR&D) program at the VA. This initiative builds on three ongoing activities: a long-term history of collaboration between the NIH, DoD, and VA, the NIH Health Care Systems Research Collaboratory, and the work and most recent report of the NCCIH Advisory Council Working Group, entitled Strengthening Collaborations with the U.S. Department of Defense and U.S. Department of Veterans Affairs: Effectiveness Research on Mind and Body Interventions. The PMC currently funds 11 multi-site pragmatic clinical trials within DoD and VA.
1. Can you briefly explain the goals of the NIH-DoD-VA Pain Management Collaboratory (PMC)? What unique opportunities are presented through this initiative?
The long-term objective of the Collaboratory is to improve capacity, tools, and skills available to health care providers to provide timely, equitable and cost-effective integrated, patient-centered, multimodal and interdisciplinary pain care that incorporates evidence-based nonpharmacological approaches to pain management while reducing the reliance on opioid and other potentially harmful medications and invasive procedures. In support of this objective, the PMC is helping develop the capacity to conduct large scale pragmatic clinical research in military and veteran health care systems focusing on nonpharmacological approaches to pain management and comorbid conditions. The principal goals are to successfully conduct 11 high-impact pragmatic clinical trials of nonpharmacological approaches to pain management and models of care that incorporate these approaches and to disseminate and support implementation of positive outcomes and products to address key scientific knowledge and practice gaps necessary to improve care and outcomes for veterans and military service members and their dependents. A separately funded Pain Management Collaboratory Coordinating Center (PMC3) serves to support the trials and ensure that the “whole is greater than the sum of the parts.”
The Collaboratory is addressing a critical gap between science and practice in pain management highlighted by the National Pain Strategy. Despite growing evidence of the efficacy and effectiveness of nonpharmacological approaches for pain management, no large scale, pragmatic effectiveness studies have been conducted that can inform clinical practice. Through the leadership of the sponsoring agencies, the PMC3 and the pragmatic clinical trials, the Collaboratory is a coordinated effort that can provide answers to key scientific and practice questions and inform design of effective initiatives to support timely and equitable access to safe and effective care for military service members, veterans and their families with chronic pain and comorbidities.
This initiative will represent a major advance in the field of pain and pain management by producing the first ever comprehensive guidance for the conduct of pragmatic clinical trials for nonpharmacological approaches for the management of chronic pain in military and veteran health care settings. Guidance will take several forms including technical policy guidelines and summaries of best practices and lessons learned based on the experiences of highly selected teams of investigators, complemented by the expertise of the PMC3.
2. What are the clinical and public policy implications of the PMC?
The PMC addresses several research recommendations from the National Pain Strategy and key scientific knowledge gaps highlighted in the Federal Pain Research Strategy. Findings and products will be particularly useful in informing clinical and policy decisions in the veteran and military health care systems. Positive trial results may encourage greater organizational investments in specific nonpharmacological approaches and models of care and practice guidance and educational initiatives to reinforce evidence-based practice consistent with the findings and products of the Collaboratory are likely to be important. It is hoped that results and products and recommendations that emerge from the Collaboratory will also be useful for other integrated health care systems and may be valued by health care professionals in other settings to guide development and enactment of successful integrated patient-centered, evidence-based, multimodal, and interdisciplinary pain care plans.
3. What are the special pain management needs of the DoD and VA patient population compared to the broader civilian population in the United States?
Military service members and veterans are disproportionately at risk for both acute and chronic pain, particularly chronic musculoskeletal pain and pain in the context of polytrauma and other serious injuries. Numerous reports estimate that the majority of veterans receiving care in VA facilities report the presence of pain. Rates of pain among postcombat military service members are estimated to be over 40%. When pain is present, ratings of pain intensity and pain interference are reliably higher among military service members and veterans relative to civilians. The complexity of the pain experience in these populations is associated with particularly high rates of medical and mental health comorbidities and trauma histories. Geography and other social vulnerabilities often represent additional barriers to accessing high quality pain care.
4. What are some of the unique benefits and challenges of pain management care within the VA and DoD systems?
VA and DoD health care systems are advantaged as the largest integrated health systems in the country. Providers generally work within high functioning interdisciplinary teams and have access to an integrated electronic health record (EHR) and state-of-the art information technology tools and resources at the point of care. Patients are empowered through easy access to their EHR and timely access to healthcare teams either remotely or in person. Use of telehealth modalities such as high-speed video conferencing, electronic consultation, and other approaches address geographic and other barriers to accessing care. As early as 1998, VA identified pain and pain management as a high priority and chartered a National Pain Management Strategy. Within the next decade, VA adopted the population-based and empirically-informed stepped care model of pain management as its single standard of care. In this same time frame, the military health system embraced similar standards for delivery of health quality pain care. VA and DoD continue to address barriers to delivery of high-quality pain care that are common in all US health care settings including a range of organizational, provider and patient level barriers. Meeting the pain care needs of the large number of persons seeking pain care in the military and veteran health care systems is challenging. This challenge is exacerbated by high multimorbidity rates, and in many cases, social disadvantages such as disability, unemployment, low education, and poverty.
5. Leadership within the VA and DoD often highlights how the medical system within these settings can be translated to the civilian population. Can you share your thoughts and explain how pain management care within the VA or DoD could be translated to the civilian population?
VA and DoD have a long history generating innovative solutions to some of the most vexing health care challenges including the area of pain management. The VA and DoD's stepped care model of pain management has emerged as one of the most prominently cited models for the delivery of pain care, regardless of setting. These systems’ ongoing investments in person-centered and team-based approaches to pain management, including transformative initiatives to build capacity for timely and equitable access to “whole health” approaches to care and evidence-based nonpharmacological approaches to pain management, are exciting and will serve as a model for other health care systems. Results and products of the PMC promise to reinforce the view that the VA and DoD are leading the way in providing models for feasible, cost-effective pain management that can be translated into other settings.
6. The VA and DoD have made a big push to provide non-pharmacological pain management strategies for patients. Please elaborate on the benefits of non-pharmacological treatments within the VA and DoD population and the broader civilian population.
In 2016, nine specific nonpharmacological approaches were identified with sufficient evidence to support implementation in VA facilities for a range of chronic musculoskeletal conditions. These included structured exercise, tai chi and yoga that were classified as exercise/movement approaches; cognitive-behavioral therapy, acceptance and commitment therapy and mindfulness-based stress reduction characterized as psychological approaches; and massage, acupuncture and spinal manipulation classified as manual approaches. Senior leadership in the VA were briefed on these recommendations and supported their adoption. Data from VA (and DoD) confirm rapid increases in availability of these approaches across the veteran and military health systems.
Improved capacity for delivering nonpharmacological approaches is entirely consistent with the VA and DoD stepped care model of pain management and related practice guidelines and recommendations. These approaches are considered a key components of integrated, patient-centered plans of care that support patients’ achievement of desired levels of pain control and valued functional goals while simultaneously reducing risk of harms commonly associated with medications and more invasive medical procedures and surgery. Increasing integration of these approaches for the management of many common pain conditions, especially musculoskeletal pain, is supported by complementary initiatives in both the VA and DoD. For example, VA’s Whole Health Initiative designed to promote veteran-centered care and wellness is particularly important in promoting these approaches. The Defense and Veterans Center for Integrative Pain Management (DVCIPM) provides leadership in military treatment settings in promoting similar objectives.
7. The Interagency Pain Research Coordinating Committee (IPRCC) was created in 2012 to enhance pain research efforts and promote collaboration across the government. What role do you see the IPRCC playing in current and future pain initiatives?
The IPRCC is an important asset in efforts to transform pain care in America. It’s role in review of the portfolio of federally funded pain research has helped identify key scientific knowledge and practice gaps used to guide decisions regarding priorities for future research. It has helped draw attention to particular research findings and products with high impact that can guide policy and practice recommendations. In this context, intergovernmental agency initiatives to promote safe and effective pain management that incorporate evidence-based nonpharmacological approaches are particularly noteworthy. For example, collaboration with leadership from the Centers for Medicare and Medicaid Services (CMS) can address gaps in the current payment system of pain management interventions that incentivize risky medications and invasive procedures relative to generally safe and effective nonpharmacological approaches. The Centers for Disease Control (CDC) and Prevention is an important partner in providing much needed data that can inform key initiatives. Of course, the inclusion of representatives from the VA and DoD, along with numerous other governmental and non-governmental members supports a unique opportunity for cross-agency collaborations that can have broad implications for the general population.
8. What made you decide to specialize in pain care and research? What has been your most exciting breakthrough and biggest challenge?
My decision to specialize in pain care and research was a product of more general interests in the interface between psychology and health and a series of fortuitous events. I pursued a doctoral degree in an innovative program in Bio-Clinical Psychology that fostered my interests in the interface between psychology and health and brain-behavior relationships. Upon completion of my training, I accepted a position at the VA Connecticut Healthcare System (formerly the West Haven VA Medical Center), an affiliate of the Yale School of Medicine. My primary responsibility was to develop an integrated, interdisciplinary clinical, research, and training program in the emerging area of behavioral medicine and clinical health psychology. I had the pleasure of meeting Dennis Turk, a new faculty member in the Yale Department of Psychology who was interested in an extension of the principles of cognitive social learning theory and the potential for developing and testing the efficacy of a novel cognitive behavioral therapy for chronic pain (CBT-CP). Together, and with the involvement of numerous psychology students and trainees and faculty and staff from other relevant disciplines, we developed the VA-based Comprehensive Pain Management Center, modeled after other pioneering multidisciplinary pain programs and emphasizing clinical research. Our early work included one of the first randomized controlled trials of CBT-CP and the development of the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), one of the first patient-reported measures of the multidimensional experience of chronic pain. A decade later, I adapted the concept of stages of behavior change to the domain of pain self-management and developed the Pain Stages of Change Questionnaire to promote investigation of the factors and processes that might promote engagement in CBT-CP and other nonpharmacological approaches designed to support adaptive pain self-management. These contributions have spurred a large body of science and have long been recognized for their value in clinical care settings. These early contributions continue to be among those for which I am most proud. It is gratifying to see that CBT-CP is widely recognized as the “gold standard” for chronic pain management, and that the constructs introduced and measured by the WHYMPI including pain interference and social responses to expressions of pain are widely recognized for their value in both clinical and research settings. Finally, I believe that my scientific and conceptual contributions have reinforced widespread acceptance of the biopsychosocial model that draws attention to the central importance of psychological factors and social contexts and their interactions with biological factors as the predominant model of pain and pain management.
As the founding national program director for pain management in the VA, I established the VA’s stepped care model of pain management as a population-based and empirically-informed single standard of pain care for VA. Establishment of this model as VA policy has helped revolutionize our systems of pain care to emphasize the central role of primary care teams in addressing most common pain conditions supported by a range of pain specialty and tertiary care, all in support of patient empowerment and activation in pursuing optimal pain self-management. This model has been largely adopted in the VA and was similarly endorsed in the DoD. It has been highlighted in numerous venues as a model system of care.
Despite advances in the field of pain management, there are many challenges and barriers to full implementation of empirical supported models of pain care and the widespread uptake of empirically-supported nonpharmacological approaches. Even in VA, large variance in implementation of the SCM-PM and the availability of nonpharmacological pain management approaches across the health care system remain. Within and outside VA, numerous patient, provider, and organizational factors limit full implementation of the model. Initiatives such as the NIH-DoD-VA Pain Management Collaboratory stand to address important gaps between scientific evidence supporting these approaches and full implementation.
9. How has the field of pain care changed over your career and where do you see it going in the next decade?
It is truly gratifying to look back over my career and to take stock of the advances in our field. As a psychologist, perhaps one of the most salient advances in our field relates to the widespread acceptance of the key role that psychological science and psychological practice can play in addressing the public health problem of pain and ineffective pain management. Central to these contributions is a dramatic shift from relying on a reductionistic biomedical model of pain to one that emphasizes adaptive pain self-management as a foundational objective for the successful management of most common pain conditions. I expect that advances in the science and practice of pain management over the next decade will take full advantage of the contributions of psychologists as members of interdisciplinary scientific and practice teams. In this context, I am excited to be engaged in cutting edge research with many of my colleagues who are leading the way in finding solutions for using innovative technologies to engage persons with pain in approaches that encourage acquisition and incorporation of adaptive pain self-management approaches into everyday life.
I am proud to be considered a “painiac” and I am genuinely privileged to be a member of a strong and growing pain management community that is working to transform pain care, education and research.