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