joint session with american osteopathic academy of ... 2019 slides/20… · 10/24/2019 · defense...

October. 2019Kevin Galloway/(301)400-4234/ [email protected]

Kevin Galloway

COL, US Army (Retired)

Deputy Director, Strategic Communications and Policy

Defense and Veterans Center for Integrative Pain Management

Joint Session with American Osteopathic Academy of

Addiction Medicine and Association of Military Osteopathic

Physicians and Surgeons

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Nothing to disclose

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• DoD Integrative Pain Management and Opioid Safety Strategies; The Way Ahead

• Combat Yoga

• Osteopathic Manipulative Medicine

• Trans Cranial Magnetic Stimulation

• Introduction of Acupuncture to the Military Health System: Battlefield Acupuncture

and Beyond

Joint Session with American Osteopathic Academy of

Addiction Medicine and Association of Military Osteopathic

Physicians and Surgeons

3

October. 2019Kevin Galloway/(301)400-4234/ [email protected] 4


DoD and VA Health Systems

Military Health System:

• 9.6 million Active Duty Service Members, Retirees, Family Members

• Annual budget of $50 billion

• Worldwide network of 59 military hospitals, 360 health clinics, private-sector health business partners

• Includes the Uniformed Services University

-DVCIPM

Veterans Health Administration:

• Care for 8.9 million Veterans each year

• Annual budget of $68 billion

• 168 VA Medical Centers

• 1,053 outpatient sites of care

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The Pain Challenge in DoD and VA

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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%)

Nahin RL, J. Pain 2016

NHIS: interview of 67,696

US adults in 2010-14

} Musculoskeletal

pain conditions


The Pain Challenge……cont

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In Veterans, chronic pain is often severe.

➢ 9.1% of Veterans vs 6.3% of non-veterans with severe pain*

➢ 7.8% of younger veterans vs 3.2% of non-veterans with severe pain

In Veterans, pain is often complex.

– Service-connected injuries often result in life-long moderate to severe

pain related to musculoskeletal system/nerve damage.

– Co-concurrence with PTSD and TBI particularly challenging.

– “The most frequently identified risk

factor among Veterans who died by

suicide was pain”.Behavioral Health Autopsy Program 2015

– Mental Health comorbidities are

common in Veterans with chronic pain.

Nahin RL, J. Pain 2016

*Severe pain: pain which occurs "most days" or

"every day" and bothers the individual "a lot,"


DoD: PMTF

Report

(2010)

IOM: Pain Report

(2011)

NCCIH: DoD and

VA Effectiveness

Research on

Complementary

Integrative

Medicine

Interventions

(2014)

HHS: National

Pain Strategy

(2014)

CDC Opioid

Prescribing

Guidelines

(2016)

Presidential

Memo:

Rx Medication

and

Heroin Abuse

(2015) Comprehensive Addiction

and Recovery Act (2016)

US Surgeon General’s

Report:

Facing Addiction in

America(2017)

DHA PI

Pain Mgt & Opioid Safety

Naloxone

(2018)

DoD/VA CPG Opioid

Therapy for Chronic Pain

(2017)

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• PMTF Report: https://www.dvcipm.org/clinical-resources/pain-management-task-force/

• IOM Pain in America Report: http://www.nationalacademies.org/hmd/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-

Research.aspx

• NCCIH WG Report: https://nccih.nih.gov/about/naccih/military-report

• National Pain Strategy: https://www.iprcc.nih.gov/National-Pain-Strategy/Objectives-

pdates#targetText=The%20National%20Pain%20Strategy%20(NPS,evidence%2Dbased%20care%20for%20pain.

• Presidential Memo Rx Medication and Heroin Abuse: https://obamawhitehouse.archives.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-

prescription-drug-abuse-and-heroin

• CDC Opioid Therapy Prescribing Guidelines: https://www.cdc.gov/drugoverdose/prescribing/guideline.html

• Comprehensive Addiction and Recovery Act: https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara

• DoD/VA Opioid Therapy for Chronic Pain CPG: https://www.healthquality.va.gov/

• US Surgeon General Addiction in America Report: https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf

• DHA Procedural Instructions: https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Resources-and-Management/DHA-Publications

• HHS Guide for Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics: https://www.hhs.gov/opioids/sites/default/files/2019-

10/Dosage_Reduction_Discontinuation.pdf

Pain/Opioid Safety Document Links

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https://www.dvcipm.org/clinical-resources/pain-management-task-force/

http://www.nationalacademies.org/hmd/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx

https://nccih.nih.gov/about/naccih/military-report

https://www.iprcc.nih.gov/National-Pain-Strategy/Objectives-UpdatestargetText=The%20National%20Pain%20Strategy%20(NPS,evidence%2Dbased%20care%20for%20pain

https://obamawhitehouse.archives.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-and-heroin

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara

https://www.healthquality.va.gov/

https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf

https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf


MHS Pain Mgt Strategy

➢ Standardized Pain Management

Services across MTFs

➢ Integrated Primary Care thru Specialty Care

➢ Team-Based

➢ Focused on function & optimizing quality of

life

➢ Utilizing Evidence-Based Complementary

and Integrative Therapeutic Modalities

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MHS Pain Strategy

Improved Measurement: Develop/Deploy

New Pain Scale that emphasizes

improvements in function and quality of life

(DVPRS)

Standardize Pain Education: Joint Pain Education Project (JPEP) developed common

DoD/VA Pain curriculum

Non-medication Pain Treatments: Expand

access to non-medication (non-opioid) pain

treatments (Acupuncture, Yoga, Massage…..)

Promote New Pain Paradigm: Developing educational products for patients and providers

Implement tiered pain management VA/DoD Stepped Care ModelEmbrace Best Practices: Adapt ECHO to

increase capacity of MTFs to deliver quality pain care without on-site pain specialists

Improve Provider Tools: Pain Assessment Screening Tool and Outcome Report (PASTOR) and Opioid Registry

Improve transitions of care:Align DoD and VA pain resources and strategies via HEC PMWG

Improve External Collaborations: Established research collaborations with academic medical centers

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MHS Pain Strategy




(DVPRS)












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Defense and Veterans Pain Rating Scale

(DVPRS)

• Goal: Standardized Pain Assessment Tool

• A common language DoD and VHA pain assessment tool with visual

cues and a common set of measurement questions—linked to

function.

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Patient Reported Outcome Clinical Record

• PROCR is a MHS IT platform that enables the efficient collection of patient

reported outcomes (PRO’s)

– Current use cases are PASTOR (for pain) and MOTION (for musculoskeletal injury)

• Provides evidence-based assessment, treatment decision support, and business

analytics

• PROCR leverages NIH’s > $120M RDT&E investment in the Patient Reported

Outcomes Measurement Information System (PROMIS)

– Standardized set of patient reported outcomes

– Computer Adaptive Testing (CAT) scales

• Only if there is no PROMIS equivalent to a particular legacy scale (e.g., PTSD

Checklist), PROCR use existing legacy scales.

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ADD’L DATAOther patient-reported and medical data points and measures can be collected

PROMIS CATSCAT-Based NIH PROMIS. Measure save response burden and leverage NIH investment.

Prior to clinic visit, patient notified to complete measures specific to

their condition (e.g., PASTOR, MOTION).

PROCR data fulfills two essential clinical needs.

User-Case-Specific Report

Shared with patient to improve communication and inform individual treatment plans.

Seamless Flow from Collection to Application

Data Repository

Big data resource for clinical research and health utilization studies.

MOTIONA Use Case

focused on

musculoskeletal

health. Includes

measures specific

to musculoskeletal

outcomes,

readiness, and

screening.

PROCR Communities (Use Cases)All Use Cases (functional communities) utilize Computer Adaptive Testing

(CAT) PROMIS scales. PROMIS CAT scales save response burden &

leverage NIH investments. A common set of PROMIS measures will be

collected across Use Cases. PROMIS can be configured to meet Use Case

needs, such as collecting additional data unique to their focus areas.

Assessment & Data

CollectionData captured via the MHS

Enterprise platform fill critical

unmet needs.

Registration &

DemographicsPatients are registered into the

PROCR via a MHS Enterprise

platform.

PASTORA Use Case for pain

& functional

assessment.

Includes measures

on pain, functioning,

pain- related

psychosocial

factors, screening &

treatment history.

FUTURE USE

CASES New components

can be added to

PROCR to

accommodate

requirements from

new Use Cases.Data can be shared across PROCR Use Cases to provide

a holistic view of a patient’s progress through the

continuum of care.

Patient Reported Outcome Clinical Record

in the Military Health SystemPROCR

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Pain Assessment Screening Tool and

Outcomes RegistryPASTOR

PROMIS Alcohol Use

PROMIS Rx Pain Medication

Misuse

Treatment History & Effectiveness

History of Present Illness

PROMIS Physical Function

PROMIS Fatigue

PROMIS Sleep-Related Impairment

3 Activities and Pain Impact Scale

PROMIS Depression

PROMIS Anxiety

PROMIS Anger

PROMIS Social Role Satisfaction

Primary Care PTSD Screen

Defense & Veterans Pain Rating

Scale

Pain Catastrophizing Scale

TBI QOL Headache

PROMIS Pain Interference

PROMIS Neuropathic Pain Scale

Pain Diagram

Pain

Beh

avio

ral

Psy

cho

soci

alP

hys

ical

Scales and Measures

Provider Reports

Automated Clinical Note (HPI)

Dashboards Coming

Soon

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Military Orthopaedics Tracking Injuries and

Outcomes Network (MOTION)MOTION

Treatment History & Effectiveness

History of Present Illness

Military Deployability

Limited Duty Status

PROMIS Physical Function

PROMIS Sleep-Related Impairment

ASES

HOOS

HOS-ADL

IHOT-12

IKDC

Marx (Knee, Shoulder)

SANE

WOSI

PROMIS Depression

PROMIS Anxiety

OSPRO – Yellow Flag Assessment

Defense & Veterans Pain Rating

Scale

PROMIS Pain Interference

Pain Diagram Pain

Mis

cella

neo

us

Psych

oso

ci

al

Ph

ysic

al

Scales and Measures

Provider Reports

Automated Clinical Note (HPI)

Additional Dashboards

Coming Soon

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MHS Pain Strategy




(DVPRS)












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10-3: Transitional and Chronic Low Back Pain

11-1: Shoulder Pain

11-2: Hip Pain

11-3: Knee Pain

12-1: Myofascial, Connective Tissue, and Fibromyalgia

Pain

13-1: Central Neuropathic Pain

13-2: Peripheral Neuropathic Pain

14-1: Headache Pain

15-1: Visceral Pain

16:-1: Psychological and Psychiatric Conditions

Related to Pain

16-2: Sleep and Pain

16-3: Substance Use Disorder

17-1: Geriatric Pain

17-2: Palliative and Oncologic Pain

18-1: Women Pain Related Issues

18-2: Opioids and Preganancy

18-3: Pelvic Pain and Women

1: Understanding Pain Introduction

2-1: Pain and Societal Impacts of Pain and

Understanding Pain

2-2: Pain Terminology, Taxonomy, and

Physiology

2-3: DoD/VA Pain Care Delivery Systems,

3-1: Assessment of Pain

3-2: Assessment Tools

4-1: Acetaminophen, NSAIDS and Opioid

Basics

4-2: Anti-epileptics,

5-1: Chronic Opioid Therapy (COT) Risk

Evaluation and Mitigation

5-2: Chronic Opioid Therapy Dose

Reduction and Discontinuation

6-1: Behavioral Management of Chronic

Pain – Treatment

7-1: Physical Based Therapeutic

Approaches to Pain MGT

8-1: Integrative Pain Medicine

9-1: Pain Medicine Specialty Care

10-1: Neck Pain

10-2: Acute Low Back Pain & Red Flags 19


Pain Education Videos(dvcipm.org)

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Understanding Pain Medication Take Back Pain Assessment (DVPRS)

Chronification of Pain Essentials of Good Pain Care

Safe Opioid Prescribing and TaperingPain Outcomes (PASTOR) Stepped Pain Care Model

Understanding Pain


(dvcipm.org)

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New Pain Paradigm (Patient Focused)

Initiating Collaborative Opioid Tapering

(Provider Focused)


Pain Exam Videos DVCIPM.org

Exam: Back Pain

Exam: Knee Pain Exam: Hip Pain

Exam: Shoulder Pain

Exam: Neck Pain

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MHS Pain Strategy




(DVPRS)












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Stepped Care Model for Pain Management


MHS Stepped Care Model

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Acronyms:

• PCM: Primary Care Manager

• ER: Emergency Room

• IBCH: Internal Behavioral Health

Consultant

• ECHO®: Extension for Community

Healthcare Outcomes


MHS Pain Strategy




(DVPRS)












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MHS Pain Strategy




(DVPRS)












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Tier 1 Integrative Medicine Modalities

▪Acupuncture

▪Movement Therapy: Tai chi/Yoga

▪Meditation/Guided Imagery

▪Biofeedback

▪Massage therapy

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▪TMS

• Osteopathic and Physical Therapy manipulation

• Chiropractic Care


• Stepped Care Model for Pain Management

• Designates DVPRS as the MHS pain scale for Adults

• Designates PASTOR (PROCR) as the MHS patient reported outcomes system for

pain management

• Provides opioid prescribing “guidelines” for routine, acute pain management

• Defines MHS “high risk” categories of patients who require risk mitigation when

prescribed opioid therapy

– >90 MEDD - OUD/SUD

– Co-prescribed Benzodiazapines - LOT

– RIOSORD >32

DHA PI Pain Management and Opioid Safety

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DoD: PMTF

Report

(2010)

IOM: Pain Report

(2011)

NCCIH: DoD and

VA Effectiveness

Research on

Complementary

Integrative

Medicine

Interventions

(2014)

HHS: National

Pain Strategy

(2014)

CDC Opioid

Prescribing

Guidelines

(2016)

Presidential

Memo:

Rx Medication

and

Heroin Abuse

(2015) Comprehensive Addiction

and Recovery Act (2016)

US Surgeon General’s

Report:

Facing Addiction in

America(2016)

DHA PI

Pain Mgt & Opioid Safety

Naloxone

(2018)

DHA PI

Acupuncture

DoD/VA CPG Opioid

Therapy for Chronic Pain

(2017)

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Kevin Galloway

COL, US Army (Retired)

Deputy Director, Strategic Communications and Policy

Defense & Veterans Center for Integrative Pain Management (DVCIPM)

11300 Rockville Pike, Suite 709

Rockville, MD 20852

(301)400-4234

[email protected]

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joint session with american osteopathic academy of ... 2019 slides/20… · 10/24/2019 · defense...

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