Dr Rollin Gallagher Presn to Can Pain Summit 042412


Published on

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Dr Rollin Gallagher Presn to Can Pain Summit 042412

  1. 1. Battlefield to Bedside and Beyond: The Continuum of Pain Care in the Military and Veterans Health Systems Rollin M. Gallagher, MD, MPHDeputy 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
  2. 2. Disclosures• Board of Directors of the American Academy of Pain Medicine• Board of Directors of the American Pain Foundation• Board of Directors, Audubon Pennsylvania
  3. 3. “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 McGinnisEx it W ounds: A Survival Guide to Pain M anagem entfor Returning Veterans and Their Fam ilieswww.exitwoundsforveterans.org American Pain Foundation
  4. 4. Frequency of Possible Diagnoses OEF / OI F Veterans 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 202,298 39.8 (320-389) 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 265,450 52.2 System/Connective System (710-739) Symptoms, Signs and Ill Defined Conditions 233,443 45.9 (780-799) Injury/Poisonings (800-999) 130,300 25.6 *These are cumulative data since FY 2002, with data onfrom 1st Quarter FY 2002 through 4th Quarter FY can have multiple Cumulative hospitalizations and outpatient visits as of September 30, 2009; Veterans 2009 4diagnoses 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.4 Slide
  5. 5. Goals of Presentation1) 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 community2) Describe DoD-VHA systems redesign:the medical home model and stepped carePrimary Care<>Pain Medicine <> Pain Rehabilitation
  6. 6. 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 stress90% survival, battlefield injuries: a) Physical wounds b) Blast injuries and TBI c) Psychological woundsOrganizational issues in health care
  7. 7. The Beginning: Battlefield polytraumaCourtesy of C. Buckenmaier, MD
  8. 8. Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans with polytrauma Chronic Pain PTSD N=277 N=232 16.5% 81.5% 2.9% 68.2% 10.3% 42.1 12.6% % 6.8% TBI 5.3% N=227 66.8%Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder andPost-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD. Slide 9
  9. 9. Chronification of Pain to Maldynia Pathology: Pathophysiology of Maintenance: -Radiculopathy -Muscle atrophy, -Neuroma traction weakness; -Myofascial sensitization -Bone loss; -Brain, SC pathology -Immunocompromise (atrophy, reorganization) -DepressionPsychopathologyof maintenance: Acute injury Central-Encoded anxiety and pain Sensitization dysregulation -Neuroplastic Disability - PTSD changes-Emotional Less active allodynia Kinesophobia Peripheral Decreased-Mood disorder Neurogenic Sensitization: motivation Inflammation: New Na+ channels Increased - Glial activation cause lower isolation - Pro-inflammatory threshold Role loss cytokines - blood-nerve barrier Sleep disorder dysruption Gallagher RM in Ebert in Kerns, 2010
  10. 10. SECONDARY PREVENTION: BLOCKING THE STIMULUS TOPREVENT CENTRAL SENSITIZATION: Index Case, 7 October 2003, 21st CSH,IraqCourtesy of C. Buckenmaier, MD Stojadinovic et al, Pain Medicine 2006;7(4):330-338
  11. 11. 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
  12. 12. PAIN BETTER
  13. 13. Novel pain control methods and equipment on battlefield and transport after injuryKetamine nasal spray Gabapentin Paracetamol MORPHINE ? Slide 17
  14. 14. THE END: A 21th century pain image HAPPY CAMPERS !! No CRPS in our soldier: Injury Iraq HAPPY CAMPERS !!
  15. 15. Regional Anesthesia and Military Battlefield Pain Outcome study(RAMBPOS), Preliminary Results: Brief Pain Inventory (BPI) Pain Intensity Mean Scores (95% CIs) byNRS 0 =No Pain to 10 = As Bad as can Imagine Months (N=180) 8 Pain right now Pain on average Worst pain past 24 hours 7 6 P<0.05 5 4 3 P<0.01 2 1 0 Baseline 3 6 9 12 15 18 21 24 Months from Start of Rehabilitation Gallagher, Polomano et al, Pain Med 2011: 12(3);473
  16. 16. Col. Chester “Trip” Buckenmaier and Index Regional Anesthesia Patient John at the opening of the Acute Pain Research Unit Walter Reed Army Medical Center
  18. 18. National Pain Management StrategyObjective is to develop a comprehensive,multicultural, integrated, system-wide approachto pain management that reduces pain andsuffering for Veterans experiencing acute andchronic pain associated with a wide range ofillnesses, including terminal illness.
  19. 19. 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 expertisehttp://www.va.gov/painmanagement/docs/vha09paindirective.pdf
  20. 20. VA Stepped Pain Care RISK RISK Advanced pain medicine diagnostics & interventions STEP CARF accredited pain rehabilitation 3 Comorbidities Pain Medicine Rehabilitation Medicine Behavioral Pain Management STEP Treatment Multidisciplinary Pain Clinics 2 Refractory SUD Programs Mental Health Programs Routine screening for presence & intensity of pain Comprehensive pain assessment Management of common pain conditions STEPComplexity Support from MH-PC Integration, OEF/OIF, & Post-Deployment Teams 1 Expanded care management Opioid Renewal Pain Care Clinics
  21. 21. Organized for Implementation: VHA Pain Management Strategy National Pain Management Office, Patient Care ServicesNational PMgmt Strategy 23 VISN (Regional HealthCoordinating Committee Systems) Pain Points of ContactEducation- Conferences (National) 152 Facility Pain Points of- Website materials Contact- Vapain list serveResearchStanding Subcommittees* Journal Special issues:JRR&D, Pain Medicine* HSRD / RR&D MeritAwards, Training Awards* PRIME Research Center
  22. 22. 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 FOR IMMEDIATE RELEASE from this app. PTSD Coach was created by the VAs April 19, 2011 National Center for PTSD and the DoD’s NationalVA/DOD Smart Phone App Helps Center for Telehealth and Technology Veterans Manage PTSD
  23. 23. ARMY PAIN TASK FORCE - Site Visit Map WESTERN Region NORTHERN Region Army VA Navy Civilian Air Force PACIFIC Region SOUTHERN Region EUROPEAN Region Fort Lewis (MAMC) & Puget Sound 4 Fort Carson (EACH) 8 Landstuhl (LRMC) & Baumholder 11 Honolulu (TAMC) AHC1 VA & Univ of Washington & Swedish Fort Bliss (WBAMC) & Fort Hood Hospital 5 (CRDAMC) 12 Fort Gordon (DDEAMC) & Duke Univ & Camp Lejeune & Fort Stewart (WACH) 9 Fort Bragg (WAMC)2 Fort Drum (GAHC) 6 Tampa VA & Univ of S Florida San Antonio VA,& Wilford Hall & Fort 13 White River Junction VA3 Balboa Naval Hospital) & Travis 10 Fort Campbell (BACH) Sam Houston (BAMC) 7 Slide 28 AFB & Scripps Center 14 Walter Reed (WRAMC)
  24. 24. 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.
  25. 25. Tertiary care: Evidence-based Relative proportion of pain care, by setting PM Subspecialties Continuum of Care - Neurorem odeling - Gene therapies (Gallagher, AAPM 2008; Subspecialty: tertiary - Neurostim ulation Dubois , Gallagher, Lippe prevention Pain Med 2009) - Rehabilitation Centers Secondary care: Pain Medicine PAIN - Biopsychosocial assessm ent Specialty, Subspecialty: ** pain generators, mechanisms SPECIALTY Secondary / tertiary ** perpetuating factors -Practice prevention - - - peripheral, CNS, psychosocial -Training - Biopsychosocial Form ulation - Research Primary care - M ech. Based Drug Algorithm s Primary / secondary / - Stepped Behavioral Care tertiary prevention - P hysical Therapy - Office procedures - CAM Self-care , Community Care Primary / secondary / - m editation - ex ercise tertiary prevention - w eb-training - social m odeling -social supportsDISEASE MANAGEMENT IN A POPULATION OF PATIENTS IN PAIN
  26. 26. READINGS• 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