Pain Management: Advances and Retreats

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42 nd Army Surgeon General and Former Commanding General, US Army Medical

Military & Emergency Medicine Uniformed Services University of the Health

Science Symposia Series Then and Now: Advances in Wounded Warrior

1 42 nd Army Surgeon General and Former Commanding General, US Army Medical Command Professor and Vice-Chair for Leadership, Centers & Programs, Military & Emergency Medicine Uniformed Services University of the Health Sciences, Bethesda, MD Pain Management: Advances and Retreats State of the Science Symposia Series Then and Now: Advances in Wounded Warrior Rehabilitation Care 16 NOV 2018 Eric B. Schoomaker, MD, PhD, FACP, Lieutenant General US Army (retired)

2 Disclosures Financial relationships with commercial interests: Eric B. Schoomaker, MD, PhD has documented that he has nothing personal to disclose. His spouse is a yoga therapist, mindfulness teacher and co-owner of Myndwell, a mindfulness training program. This presentation does not contain off-label or investigational use of drugs or products The opinions expressed represent solely the views of the presenter and do not reflect official policy of the DoD or USU.

3 Learning Objectives Attendees should appreciate the complex interconnectedness of chronic pain and the spectrum of co-morbid service-connected health and well-being issues. Attendees should gain an understanding of the close coordination among the Federal health and healthcare agencies military, VA and other Federal agencies in opening the aperture of pain management approaches to an integration of evidence-based complementary and conventional practices. Attendees should have an appreciation of the unique features of serviceand combat-related wounds, injuries and illnesses and comorbidities that have led to chronic pain problems including chronic opioid problems after more than a decade and a half of armed conflict.

The proper management of pain remains, after all, the most important obligation, the main objective, and the crowning achievement of every physician. John J. Bonica, M.D.

4 The proper management of pain remains, after all, the most important obligation, the main objective, and the crowning achievement of every physician. John J. Bonica, M.D. in The Management of Pain (1953) [Former Chief of Anesthesiology, MAMC ] Treating pain is one of medicine s oldest and most fundamental responsibilities, yet modern medicine continues to be challenged in its efforts to understand and treat acute and chronic pain. DoD Pain Management Task Force Report (2010)

5 Unprecedented Battlefield Survival Improvements on the battlefield Better trained medics Improved equipment Far forward emergency & surgical care Improvements in evacuation Improvements in recovery & rehabilitation

6 CASE STUDY: SPC BW, USA OIF 2003 RPG into his HUMVEE

7 Joint Theatre Trauma System - Comprehensive Trauma Care Spans the spectrum from preventive measures, wounding, treatment through to rehabilitation and return to duty Systematic and integrated Focus not just on writing papers but on functional products Knowledge-based as well as product-based TRAUMA SYSTEMS TEAM: TRAUMA NURSE COORDINATORS

9 The Pain Challenge in VHA: DoD is the Gateway In Veterans, chronic pain is common. Veterans: more than 50% of older Veterans experience chronic pain 60% of Veterans from Middle East conflicts; Up to 75% of female Veterans More than 2 Mil Veterans with chronic pain diagnosis (In 2012, 1/3 on opioids) National Health Interview Survey (NHIS) (2016) 66% of Veterans vs. 56% of non-veterans with pain in prior 3 month Most common pain conditions in Veterans (as % of all Veterans): Joint pain (43.6%) Back pain (32.8% - axial 20.5%, sciatica 12.2%) Neck pain (15.9%) Migraine (10.0%) Jaw pain (3.6%) } Musculoskeletal NHIS: interview of 67,696 US adults in pain conditions Nahin RL, J. Pain

10 Rising Musculoskeletal & Mental Disorders Ambulatory Visits

11 The intersection of mind & body Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma Chronic Pain N= % 10.3% 16.5% 2.9% PTSD N= % 12.6% 42.1% 6.8% TBI N= % 5.3% Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD. Slide 11

12 Problems of Polypharmacy and Prescription Drug Deaths Prescription Opioids

13 An Epidemic in Opioid Problems in the US

14 And we weren t exempt

15 Another epidemic: Cholera Managing An Epidemic London, 1854: Cholera, John Snow and the Broad Street Pump

Pain Management Task Force Provide recommendations for a DoD comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the

16 Pain Management Task Force Provide recommendations for a DoD comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain. Army Pain Management Task Force Charter; signed 21 Aug 2009 Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research Institute of Medicine; June 2011

Comprehensive Pain Management Evidence-Based

pain Since PMTF Report have added: Music

17 Comprehensive Pain Management Evidence-Based Complementary and Alternative Therapeutic Modes Acupuncture Biofeedback Yoga Meditation Standardizes Pain Management Services at echelons of care across our Medical Treatment Facilities: Team-Based Provides optimal quality of life for Soldiers and patients with acute and chronic pain Since PMTF Report have added: Music therapy Mindfulness Meditation Medical Massage Chiropractic Tai Chi/Qi Gung

18 Shoulder Mass: Imaging Studies Ultrasound MRI Plain Radiograph Deep soft tissue lucency

19 Deltopectoral approach Operative Result

Evolution of Federal Medicine Pain Management & Opioid

Force HEC Pain Mgt Work Group Chartered Institute of

NIH Interagency Pain Research Coordinating Committee

Memorandum: Prescription Med and Heroin Abuse DVCIPM

Comprehensive Addiction and Recovery Act (CARA)

Products/Deliverables VHA Pain Mgt Directive: 2009-053

Report MHS Policy Comprehensive Pain Management DoD

Collaborations w/ DoD and VA on CIH Pain Therapies Pres

Opioid Guidelines DoD/VA Opioid Clinical Practice

and Opioid Safety Army Comprehensive Pain Management

20 Evolution of Federal Medicine Pain Management & Opioid Safety Mandate/Organizations Army/DoD Pain Mgt Task Force HEC Pain Mgt Work Group Chartered Institute of Medicine: IAW Affordable Care Act DoD PMWG Chartered NIH Interagency Pain Research Coordinating Committee NCCIH National Advisory Council Presidential Memorandum: Prescription Med and Heroin Abuse DVCIPM designated as DoD CoE for Pain Mgt FEB 2016 Comprehensive Addiction and Recovery Act (CARA) Products/Deliverables VHA Pain Mgt Directive: Pain Management Task Force Report IOM Pain in America Report MHS Policy Comprehensive Pain Management DoD Battlefield Pain Mgt CPG NCCIH Report: Strengthening Collaborations w/ DoD and VA on CIH Pain Therapies Pres Memo Directed: DoD Opioid Prescriber Training CDC: Opioid Guidelines DoD/VA Opioid Clinical Practice Guideline HHS National Pain Strategy DHA PI: Pain Mgt and Opioid Safety Army Comprehensive Pain Management Campaign Navy Comprehensive Pain Management Program 20 NCCIH/DoD/VA Pain Research Collaboratory

21 IOM: Pain Report (2011) NCCIH: DoD and VA Effectiveness Research on Complementary Integrative Medicine Interventions(2014) HHS: National Pain Strategy Presidential Memo: (2014) Rx Medication and Heroin Abuse CDC Opioid (2015) Prescribing Guidelines (2016) Comprehensive Addiction and Recovery Act (2016) Working Together DoD: PMTF Report (2010) US Surgeon General s Report: Facing Addiction in America(2016)

22 Advancing Evidence-Based Complementary & Integrative Practices and Consensus Guidelines

Defense and Veterans Pain Rating Scale (DVPRS): Changing the Culture of Pain Care Defense and Veterans Pain Rating Scale (DVPRS) Validated: Measures pain intensity AND biopsychosocial and functional

23 Defense and Veterans Pain Rating Scale (DVPRS): Changing the Culture of Pain Care Defense and Veterans Pain Rating Scale (DVPRS) Validated: Measures pain intensity AND biopsychosocial and functional impact of pain (sleep/stress/mood/activity) Pain Medicine. 2012:14; Improved objective components to evaluate treatment effectiveness Provides greater insight on treatment progress and improvements in function and quality of life Adaptable to multiple clinical settings and scenarios throughout the continuum of care and research (e.g. battlefield, transport, Primary Care, specialty services) Since its initial validation in 2012, the DVPRS has been integrated into clinical practice in a variety of clinical settings across the MHS and in growing number of clinicians/organizations in civilian practice. Formerly designated as the MHS pain scale for adolescents and adults per the DHA PI for Pain Management and Opioid Safety (April 2018) Download DVPRS at:

Clinical Report/Decision Tool Longitudinal pt pain/function/alert data in concise format

24 RESEARCH l OUTCOMES REGISTRY l CLINICAL DECISION TOOL Web application served from MAMC Clinical Assessment Using validated computer adaptive testing (CAT) PROMIS instruments Clinical Report/Decision Tool Longitudinal pt pain/function/alert data in concise format Patients Enter Information Prior to Appointments Using the web capable device of their choice

25 Lessons from the Samueli Chronic Pain Breakthrough Collaborative From Chronic Pain Care Model, ; Samueli Institute Chronic Pain Breakthrough Collaborative, Alexandria, VA

26 Military Health System Stepped Care Model (Based on VA Model) 26

27 ARMY Pain Management Network NORTHERN Region WESTERN Region PACIFIC Region SOUTHERN Region EUROPEAN Region INTERDISCIPLINARY PAIN MANAGEMENT CENTER (IPMC): Serves as hub for pain management synchronization for designated MTFs within RMC. Provides pain management specialty referral /consultation services, patient and provider education, and coordination of research initiatives. Primary Care Pain Champion- Designated member of PCMH team responsible to provide enhanced pain management in the medical home. Pain management education, training, and practice standards; linked to a designated IPMC for support. ECHO TELEMENTORING: Weekly CME awarding educational activity hosted by IPMCs for PCPC and WTC primary care providers. IPMC Ft Gordon Ft Hood Ft Bliss Joint Base Lewis-McChord Joint Base San Antonio Landstuhl Tripler Ft Bragg IPMC (Light) Fort Campbell Fort Carson Fort Drum Ft Benning Ft Campbell Ft Carson Ft Drum Ft Eustis Ft Huachuca Ft Irwin Ft Jackson Ft Lee Ft Knox Ft Leonard Wood Ft Meade PCPC in PCMH Ft Polk Ft Riley Ft Richardson Ft Sill Ft Stewart Ft Wainwright Ft Leavenworth West Point Schofield Barracks Stuttgart Vilceck Wiesbaden Vicenza Ft Gordon Ft Bragg TAMC LRMC WRMC ECHO Hub

28 ARMY Pain Management ECHO Network NORTHERN Region WESTERN Region PACIFIC Region SOUTHERN Region EUROPEAN Region INTERDISCIPLINARY PAIN MANAGEMENT CENTER (IPMC): Serves as hub for pain management synchronization for designated MTFs within RMC. Provides pain management specialty referral /consultation services, patient and provider education, and coordination of research initiatives. Primary Care Pain Champion- Designated member of PCMH team responsible to provide enhanced pain management in the medical home. Pain management education, training, and practice standards; linked to a designated IPMC for support. ECHO TELEMENTORING: Weekly CME awarding educational activity hosted by IPMCs for PCPC and WTC primary care providers. Ft Gordon Ft Hood Ft Bliss Ft Lewis Ft Sam Houston Landstuhl Tripler Ft Bragg IPMC Ft Benning Ft Campbell Ft Carson Ft Drum Ft Eustis Ft Huachuca Ft Irwin Ft Jackson Ft Lee Ft Knox Ft Leonard Wood Ft Meade PCPC in PCMH Ft Polk Ft Riley Ft Richardson Ft Sill Ft Stewart Ft Wainwright Ft Leavenworth West Point Schofield Barracks Grafenwoehr Katterbach Vicenza Vilceck Wiesbaden Ft Gordon Ft Bragg TAMC LRMC WRMC ECHO

29 JG. Katzman, et al. (2018) Army and Navy ECHO Pain Telementoring Improves Clinician Opioid Prescribing for Military Patients: an Observational Cohort Study. J Gen Intern Med DOI: /s

30 Annualized Patients seen per year Comparison group 1,187,945 ECHO group 52,941 JG. Katzman, et al. (2018) Army and Navy ECHO Pain Telementoring Improves Clinician Opioid Prescribing for Military Patients: an Observational Cohort Study. J Gen Intern Med DOI: /s

31 County-Level Rates of Adult TRICARE Enrollees

32 Counties with Opioid Rx Rates > 1 for Each County Resident Weighted by TRICARE Enrollee Prevalence *Opioid Rx Rates derived from CDC 2016 data found at: cdc.gov/drugoverdose/maps/rxcounty2016.html

33 Teaching Our Own: BFA and Yoga

34 Internist Francis G. O Connor, MD, MPH Professor and Chair, Military and Emergency Medicine Uniformed Services University of the Health Sciences

35 Take Away Messages (Part 1) Much progress has been made in better understanding acute and chronic pain and the chronification of pain but we are still in our infancy. We have come a long way as well in gathering evidence for mind-body approaches to chronic pain management but we have not yet made them available. Bonica s model of a biopsychosocial approach to pain management with a patientcentered & tailored, team-based, multi-disciplinary, evidence-based, multi-modal approach is the optimal systems approach to pain care but we have not yet implemented it. Federal Medicine has made great strides in coordinating, synchronizing, and even integrating the research, policies and practices of pain management but we have drifted toward regulating opioid use and away from pain. DVCIPM.org

36 Take Away Messages The opioid epidemic is but one of a number of cascading epidemic of epidemics starting with poorly managed chronic pain. Management of chronic pain is a complex, individual experience often with comorbid elements for which care must be patient-centered, tailored, individualized, multidisciplinary and team-based: Federal Medicine is moving ahead. We MUST move beyond the use of opioids for acute & chronic pain they have their place but much less often than used now. CIM&H modalities for chronic pain management are powerful experiences but we must move beyond anecdotal reports...much progress has been made in evidence for use Well-designed studies that evaluate the effectiveness, safety and focus on clinical outcome are vital for CIM&H modalities to be trusted and adopted.

Acknowledgements & Thanks Pain management TF & DVCIPM: Tom Thomas, Mac Gallagher, Trip Buckenmaier, Kevin Galloway, Kelly Kiser, Richard Niemztow, Rich Petri Univ Wash: Heather Tick, C.

37 Acknowledgements & Thanks Pain management TF & DVCIPM: Tom Thomas, Mac Gallagher, Trip Buckenmaier, Kevin Galloway, Kelly Kiser, Richard Niemztow, Rich Petri Univ Wash: Heather Tick, C. Chan Gunn, Alex Cahana (now in NYC) Samueli Institute: Wayne Jonas, Joan Walter, Kevin Berry, Katherine Smith, Dawn Wallerstadt, Sandi Gordon, Kelly Gourdin, Adam Perlman (DUMC), Frido Fridovich, Martha Menard, Michael Saenger (ATL VAMC) CHAMP, USU: Patty Deuster, Bill Gilliland, Arnyce Pock, Jeff Quinlan, Charlie Beadling, Jeff Leggit, Neil Grunberg WRNMMC & MAMC: Chris Spevak, Scott Griffith, Diane Flynn, Steve Sharp DoD/DHA: Steve Hanling, Steve Phillips, Paul Cordts, Jeff Clark, Dave Lane VA: Mac Gallagher, Tracy Gaudet, Ben Kligler, Rich Stone, Lucille Burgo, Steve Hunt, Friedhelm Sandbrink NCCIH: Josie Briggs, Kristen Huntley, Eve Rieder, Wendy Weber GTU: Nancy Harazdak, Adi Haramati Bravewell Collaborative: Christy Mack Northwestern University: Richard Gershon, Karen Cook

38 Thank you! Questions?

Major Current Research Initiatives and Priorities: Department of Defense

Major Current Research Initiatives and Priorities: Department of Defense The Role of Nonpharmacological Approaches to Pain Management: A Workshop The National Academies of Science, Engineering, Medicine