dr rollin gallagher presn to can pain summit 042412
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Rollin M. Gallagher, MD, MPH Deputy National Program Director for Pain Management
Veterans Health Administration
Co-Chair, Working Group on Pain Management DoD-VA Health Executive Council
Clinical Professor of Psychiatry and Anesthesiology Director of Pain Policy and Primary Care Research,
Penn Pain Medicine University of Pennsylvania
Battlefield to Bedside and Beyond: The Continuum of Pain Care in the
Military and Veterans Health Systems
Disclosures
• Board of Directors of the American Academy of Pain Medicine
• Board of Directors of the American Pain Foundation
• Board of Directors, Audubon Pennsylvania
“It’s now four years since I lay in the dirt, near death, on the side of the road in Fallujah. I’m grateful for all I have, and proud of the things I’ve accomplished.
In the end though, I don’t measure how far I’ve come by goals achieved, or academic degrees earned, or running trophies won. For me, what counts is that pain no longer rules my life.” –Derek McGinnis
Ex it Wounds: A Survival Guide to Pain Management for Returning Veterans and Their Families www.exitwoundsforveterans.org American Pain Foundation
Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 2009 4
Diagnosis (Broad ICD-9 Categories) Frequency Percent Infectious and Parasitic Diseases (001-139) 68,569 13.5 Malignant Neoplasms (140-208) 5,809 1.1 Benign Neoplasms (210-239) 25,491 5.0 Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 135,250 26.6 Diseases of Blood and Blood Forming Organs (280-289) 14,342 2.8 Mental Disorders (290-319) 243,685 48.0 Diseases of Nervous System/ Sense Organs (320-389)
202,298 39.8
Diseases of Circulatory System (390-459) 94,671 18.6 Disease of Respiratory System (460-519) 116,308 22.9 Disease of Digestive System (520-579) 172,462 33.9 Diseases of Genitourinary System (580-629) 63,421 12.5 Diseases of Skin (680-709) 93,635 18.4 Diseases of Musculoskeletal System/Connective System (710-739) 265,450 52.2
Symptoms, Signs and Ill Defined Conditions (780-799)
233,443 45.9
Injury/Poisonings (800-999) 130,300 25.6
Frequency of Possible Diagnoses OEF / OIF Veterans
*These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2009; Veterans can have multiple diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories,
so the above numbers add up to greater than 508,152; percentages add up to greater than 100 for the same reason. Slide 4
Goals of Presentation
1) Review challenges of managing: - Acute pain after battlefield injury - The transitions of pain care after injury - War zone to hospital - Acute hospital care to rehabilitation - Military care to Veterans Health System and
community
2) Describe DoD-VHA systems redesign: the medical home model and stepped care
Primary Care<>Pain Medicine <> Pain Rehabilitation
Why chronic pain in OEF-OIF troops?
Wear and tear of military duty during war a) Prolonged, repeated deployments b) Osteoarthritis and spinal / limb injuries c) Post-traumatic stress
90% survival, battlefield injuries: a) Physical wounds b) Blast injuries and TBI c) Psychological wounds
Organizational issues in health care
Courtesy of C. Buckenmaier, MD
The Beginning: Battlefield polytrauma
PTSD N=232 68.2% 2.9%
16.5%
42.1% 6.8%
5.3%
10.3%
12.6%
TBI N=227 66.8%
Chronic Pain N=277 81.5%
Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma
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 9
Chronification of Pain to Maldynia
Pathology: -Muscle atrophy, weakness; -Bone loss; -Immunocompromise -Depression
Less active Kinesophobia Decreased motivation Increased isolation Role loss Sleep disorder
Disability
Pathophysiology of Maintenance: -Radiculopathy -Neuroma traction -Myofascial sensitization -Brain, SC pathology (atrophy, reorganization)
Psychopathology of maintenance: -Encoded anxiety dysregulation - PTSD -Emotional allodynia -Mood disorder
Neurogenic Inflammation: - Glial activation - Pro-inflammatory cytokines - blood-nerve barrier dysruption
Acute injury and pain
Peripheral Sensitization: New Na+ channels cause lower threshold
Central Sensitization -Neuroplastic changes
Gallagher RM in Ebert in Kerns, 2010
SECONDARY PREVENTION: BLOCKING THE STIMULUS TO PREVENT CENTRAL SENSITIZATION: Index Case, 7 October 2003, 21st CSH, Iraq
Courtesy of C. Buckenmaier, MD
Stojadinovic et al, Pain Medicine 2006;7(4):330-338
Results Buckenmaier et al Pain Medicine 2009:10(8):1487-96
• Greater worry during transport (p<0.05) and higher worst pain (p<0.001): – explained 72.3% (p<0.001) of the variance in average pain
levels during transport – Is this a trait (worrying) worth exploring, similar to ‘trait anxiety’
and / or catastrophizing that predict pain disability? – Does chronic activation, or low threshold for activation, of
noradrenergic “stress centers” facilitate encoding of pain and fear memories, and central sensitization?
– Should these traits be assessed, much like physical capacity, as part of fitness, and addressed with resiliency training?
• Participants receiving continuous peripheral nerve blocks (CPNBs) at LRMC reported significantly better percent pain relief (p < 0.05) than those who did not, despite higher worst pain intensity in the CPNB group
PAIN BETTER
Novel pain control methods and equipment on battlefield and transport after injury
Paracetamol
Slide 17
Ketamine nasal spray
Gabapentin
MORPHINE ?
HAPPY CAMPERS !! THE END: A 21th century pain image
No CRPS in our soldier: Injury Iraq
HAPPY CAMPERS !!
0
1
2
3
4
5
6
7
8
Baseline 3 6 9 12 15 18 21 24
NR
S 0
=No
Pain
to 1
0 =
As B
ad a
s ca
n Im
agin
e
Months from Start of Rehabilitation
Pain right now Pain on average Worst pain past 24 hours
Regional Anesthesia and Military Battlefield Pain Outcome study (RAMBPOS), Preliminary Results: Brief Pain Inventory (BPI) Pain Intensity Mean Scores (95% CIs) by Months (N=180)
P<0.05
P<0.01
Gallagher, Polomano et al, Pain Med 2011: 12(3);473
Col. Chester “Trip” Buckenmaier and Index Regional Anesthesia
Patient John at the opening of the Acute Pain Research Unit Walter Reed Army Medical Center
COMMUNITY HEALTH SYSTEM
VETERANS HEALTH SYSTEM
COMMUNITY SUPPORT SYSTEM
MILITARY HOSPITAL, USA
MILITARY BASE CLINIC, USA
Transition to Community Care:
?
National Pain Management Strategy
Objective is to develop a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain and suffering for Veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness.
VHA Pain Management Directive (2009-053)
Objectives of National Pain Management Strategy
Stepped pain care model
Pain Management Infrastructure
Roles and responsibilities
Pain Management Standards
Pain assessment and treatment
Evaluation of outcomes and quality
Clinician competence and expertise
http://www.va.gov/painmanagement/docs/vha09paindirective.pdf
Routine screening for presence & intensity of pain Comprehensive pain assessment
Management of common pain conditions Support from MH-PC Integration, OEF/OIF, &
Post-Deployment Teams Expanded care management
Opioid Renewal Pain Care Clinics
Pain Medicine Rehabilitation Medicine
Behavioral Pain Management Multidisciplinary Pain Clinics
SUD Programs Mental Health Programs
Advanced pain medicine diagnostics & interventions
CARF accredited pain rehabilitation
STEP 1
STEP 2
STEP 3
VA Stepped Pain Care
Complexity
Treatment Refractory
Comorbidities
RISK RISK
Organized for Implementation: VHA Pain Management Strategy
National Pain Management Office, Patient Care Services
National PMgmt Strategy Coordinating Committee
Education - Conferences (National) - Website materials - Vapain list serve Research Standing Subcommittees * Journal Special issues: JRR&D, Pain Medicine * HSRD / RR&D Merit Awards, Training Awards * PRIME Research Center
23 VISN (Regional Health Systems) Pain Points of Contact
152 Facility Pain Points of Contact
FOR IMMEDIATE RELEASE April 19, 2011
VA/DOD Smart Phone App Helps Veterans Manage PTSD
Mobile App: PTSD Coach
The PTSD Coach app can help you learn about and manage symptoms that commonly occur after
trauma. Features include: •Reliable information on PTSD and treatments that work
•Tools for screening and tracking your symptoms •Convenient, easy-to-use skills to help you handle stress
symptoms •Direct links to support and help
•Always with you when you need it
I tunes free PTSD Coach Download
Together with professional medical treatment, PTSD Coach provides you dependable resources you can trust. If you have, or think you might have PTSD,
this app is for you. Family and friends can also learn from this app. PTSD Coach was created by the VA's
National Center for PTSD and the DoD’s National Center for Telehealth and Technology
WESTERN Region NORTHERN Region
SOUTHERN Region EUROPEAN Region PACIFIC Region
1 Fort Lewis (MAMC) & Puget Sound VA & Univ of Washington & Swedish Hospital
2 Fort Drum (GAHC)
3 San Antonio VA,& Wilford Hall & Fort Sam Houston (BAMC)
4 Fort Carson (EACH)
5 Fort Bliss (WBAMC) & Fort Hood (CRDAMC)
6 Tampa VA & Univ of S Florida
7 Balboa Naval Hospital) & Travis AFB & Scripps Center
8 Landstuhl (LRMC) & Baumholder AHC
9 Duke Univ & Camp Lejeune & Fort Bragg (WAMC)
10 Fort Campbell (BACH)
11 Honolulu (TAMC)
12 Fort Gordon (DDEAMC) & Fort Stewart (WACH)
13 White River Junction VA
14 Walter Reed (WRAMC)
ARMY PAIN TASK FORCE - Site Visit Map
Army
Navy
Air Force
VA
Civilian
Slide 28
A continuum of care requires partnership of DoD and VHA
Army Pain Management Task Force Report
Health Executive Committee Pain Management Work Group (PMWG) Co-Chairs: VA: Rollin Gallagher, MD, MPH
DoD: Barry Cohen, MD
Charge: The PMWG will actively collaborate in supporting the development of a model system of integrated, timely, continuous, and expert pain management for Servicemembers and Veterans.
Self-care , Community Care - meditation - exercise - web-training - social modeling -social supports
Primary care - Mech. Based Drug Algorithms - Stepped Behavioral Care - Physical Therapy - Office procedures - CAM
Secondary care: Pain Medicine - Biopsychosocial assessment ** pain generators, mechanisms ** perpetuating factors - - - peripheral, CNS, psychosocial - Biopsychosocial Formulation
Tertiary care: PM Subspecialties - Neuroremodeling - Gene therapies - Neurostimulation - Rehabilitation Centers
DISEASE MANAGEMENT IN A POPULATION OF PATIENTS IN PAIN
Relative proportion of pain care, by setting
Primary / secondary / tertiary prevention
Specialty, Subspecialty: Secondary / tertiary prevention
PAIN SPECIALTY -Practice -Training
- Research
Subspecialty: tertiary prevention
Evidence-based Continuum of Care
Primary / secondary / tertiary prevention
(Gallagher, AAPM 2008; Dubois , Gallagher, Lippe Pain Med 2009)
• McGinnis D. Exit Wounds: A Survival Guide to Pain Management for Returning Veterans and Their Families www.exitwoundsforveterans.org
• Gallagher RM. Pain medicine and primary care: A community solution to pain as a public health problem. Med Clin N Am 1999; 83(5): 555-585
• Gallagher RM. Integrating medical and behavioral treatment in chronic pain management. Med Clin N Am 83(5): 823-849, 1999
• Dubois M, Gallagher RM, Lippe P. Pain Medicine Position Paper. Pain Med 2009;10(6): 972-
• Davies SJ, Quintner JL, Parsons RW, et al. Pre-clinic group education sessions reduce waiting times and costs at public pain medicine units. Pain Med 2011;12(1):59–71.
• Davies SJ, Hayes C, Quintner JL. System plasticity and integrated care: Informed consumers guide clinical reorientation and system reorganization. Pain Med 2011;12(1):4–8.
• VHA Pain Management Directive (VHA Directive 2009-053). http://www.va.gov/painmanagement/docs/vha09paindirective.pdf
• Army Pain Task Force Report. http://www.amedd.army.mil/reports/Pain_Management_Task_Force.pdf
• Hayes C, Hodson FJ. A whole person model of care for persistent pain: from conceptual framework to practical application. Pain Med 2011; 12(12):1738-49
READINGS