Eric B. Schoomaker, MD, PhD, FACP, Lieutenant General US Army (retired)

42nd 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 Care16 NOV 2018

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.

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 service-and 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. in The Management of Pain (1953)[Former Chief of Anesthesiology, MAMC 1944-1947]

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)

Unprecedented Battlefield Survival

• Improvements in recovery & rehabilitation

• Improvements on the battlefield• Better trained medics• Improved equipment• Far forward emergency & surgical care

• Improvements in evacuation

CASE STUDY: SPC BW, USAOIF 2003—RPG into his HUMVEE

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 onfunctional products

• Knowledge-based as well as product-based

TRAUMA SYSTEMS TEAM: TRAUMA NURSE COORDINATORS

The Pain Challenge in VHA: DoD is the Gateway

9

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 monthMost 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

Rising Musculoskeletal & Mental Disorders—Ambulatory Visits

PTSDN=23268.2%2.9%16.5%

42.1%6.8%

5.3%

10.3%

12.6%

TBIN=22766.8%

Chronic Pain N=27781.5%

The intersection of mind & body

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

Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma

Prescription Opioids

Problems of Polypharmacy and Prescription Drug Deaths

An Epidemic in Opioid Problems in the US

And we weren’t exempt

Another epidemic: Cholera

London, 1854: Cholera, John Snow and the Broad Street Pump

Managing An Epidemic

– 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

Pain Management Task Force

– Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research Institute of Medicine; June 2011

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 andchronic pain

Since PMTF Report have added: Music therapy Mindfulness Meditation Medical Massage Chiropractic Tai Chi/Qi Gung

Shoulder Mass: Imaging Studies

Deep soft tissue lucency

Ultrasound MRI

Plain Radiograph

Operative Result

Deltopectoral approach

Evolution of Federal Medicine Pain Management & Opioid Safety

2009 - 2010 2011 - 2012 2013 2014 - 2015 2016 - 2018

Army/DoD Pain Mgt Task

Force

NIH Interagency Pain Research Coordinating Committee

Man

date

/Org

aniz

atio

nsPr

oduc

ts/D

eliv

erab

les

Institute of Medicine: IAW Affordable Care

Act

NCCIH National Advisory Council

Pain Management

Task Force Report

NCCIH Report: Strengthening Collaborations w/ DoD and VA on

CIH Pain TherapiesHHS National Pain Strategy

CDC: Opioid Guidelines

DoD/VA Opioid Clinical Practice Guideline

DHA PI: Pain Mgt and

Opioid Safety

Army Comprehensive Pain Management Campaign

NCCIH/DoD/VA Pain Research Collaboratory

Navy Comprehensive Pain Management Program

MHS Policy Comprehensive Pain

Management

VHA Pain Mgt

Directive: 2009-053

IOM “Pain in America” Report

Pres Memo Directed: DoD Opioid Prescriber Training

HEC Pain MgtWork Group

Chartered

Comprehensive Addiction and

Recovery Act (CARA)

DoD Battlefield Pain Mgt CPG

Presidential Memorandum: Prescription Med and Heroin Abuse

DVCIPM designated as DoD CoE for

Pain MgtFEB 2016

DoD PMWG Chartered

20(kevin.galloway.ctr@usuhs.edu)

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)

Working Together

Advancing Evidence-Based Complementary & Integrative Practices and Consensus Guidelines

Download DVPRS at: http://www.dvcipm.org/clinical-resources/pain-rating-scale

Defense and Veterans Pain Rating Scale (DVPRS): Changing the Culture of Pain Care

• Validated: Measures pain intensity AND biopsychosocial and functional impact of pain (sleep/stress/mood/activity) Pain Medicine. 2012:14;110-123

• 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)

Defense and Veterans Pain Rating Scale (DVPRS)

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

From “Chronic Pain Care Model”, 2013-2016; Samueli Institute Chronic Pain Breakthrough Collaborative, Alexandria, VA

Lessons from the SamueliChronic Pain Breakthrough Collaborative

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

26

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.

IPMCFt Gordon Ft HoodFt Bliss Joint Base Lewis-McChordJoint Base San AntonioLandstuhlTriplerFt Bragg

IPMC (Light)Fort CampbellFort CarsonFort Drum

PCPC in PCMH Ft BenningFt Campbell Ft CarsonFt Drum Ft EustisFt Huachuca Ft Irwin Ft Jackson Ft LeeFt Knox Ft Leonard Wood Ft Meade

Ft Polk Ft Riley Ft RichardsonFt Sill Ft Stewart Ft Wainwright Ft Leavenworth West Point

Schofield BarracksStuttgartVilceckWiesbadenVicenza

ECHO Hub

Ft GordonFt BraggTAMCLRMCWRMC

ARMY │ Pain Management Network

WESTERN Region

SOUTHERN Region

NORTHERN Region

EUROPEAN Region

PACIFIC 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 GordonFt HoodFt Bliss Ft Lewis Ft Sam Houston LandstuhlTriplerFt Bragg

PCPC in PCMH Ft BenningFt Campbell Ft CarsonFt Drum Ft EustisFt Huachuca Ft Irwin Ft Jackson Ft LeeFt Knox Ft Leonard Wood Ft Meade

Ft Polk Ft Riley Ft RichardsonFt Sill Ft Stewart Ft Wainwright Ft Leavenworth West Point

Schofield BarracksGrafenwoehrKatterbachVicenzaVilceckWiesbaden

ECHO

Ft GordonFt BraggTAMCLRMCWRMC

ARMY │ Pain Management ECHO Network

WESTERN Region

SOUTHERN Region

NORTHERN Region

EUROPEAN Region

PACIFIC Region

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: 10.1007/s11606-018-4710-5

30

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: 10.1007/s11606-018-4710-5

Annualized Patients seen per year

Comparison group 1,187,945

ECHO group 52,941

County-Level Rates of Adult TRICARE Enrollees

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

Teaching Our Own: BFA and Yoga

Francis G. O’Connor, MD, MPHProfessor and Chair, Military and Emergency MedicineUniformed Services University of the Health Sciences

Internist

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 patient-centered & 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

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, multi-disciplinary 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. 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

Thank you!

Questions?