introduction of acupuncture to the military health system ... 2019... · introduction of...
TRANSCRIPT
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Introduction of Acupuncture to the Military Health
System: Battlefield Acupuncture and Beyond
Chester ‘Trip’ Buckenmaier III, MD
COL (ret), MC, USA
Director, DVCIPM
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
This presentation was prepared by Dr. Chester
Buckenmaier in his personal capacity. The opinions
expressed in this presentation are the author's own and
do not necessarily reflect the views of the Uniformed
Services University, Department of Defense, or the
United States government.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
– Provide recommendations for a MEDCOM
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
– Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education and
Research » June 2011
Pain Management Task Force
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
• Not later than March 31, 2011, the Secretary of Defense shall develop and
implement a comprehensive policy on pain management by the military
health care system.
Legislative Milestones
2010 NDAA SEC. 711. COMPREHENSIVE POLICY ON PAIN
MANAGEMENT BY THE MILITARY HEALTH CARE SYSTEM
Comprehensive Addiction and Recovery Act (CARA)
•The Comprehensive Addiction and Recovery Act (CARA) was signed into
law by President Obama on July 22, 2016. CARA authorizes over $181 million
dollars to respond to the epidemic of opioid abuse, and is intended to greatly
increase both prevention programs and the availability of treatment programs.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
2009/2010 2011/2012 2013 2014 2015-17
Pain Management
Task Force Report
NCCIH: Strengthening Collaborations w/ DoD and VA:
Effectiveness Research on Mind/Body Interventions
National Pain
StrategyMHS Review
IOM
“Pain in America” Report
VHA Pain Mgt
Directive2009-053
DoD Pain Mgt
Task Force
NIH Interagency Pain Research Coordinating Committee
VHA Pain
Program Office
Institutes of Medicine as directed by
Affordable Care Act
NCCIH Council Working Group
Military Health System
Federal Medicine
Pain Management Initiatives
Org
an
iza
tio
ns/G
rou
ps
Pro
du
cts
/De
live
rab
les
Presidential
Memorandum
Opioid
Prescribing
Guidelines
CDC
White House
CARA
Act
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
• Lack of predictable pain management
capabilities across our MTFs
• Lack of standardization not unique to
MEDCOM or DoD
• Lack of non-medication modalities for
pain mgt
• Overwhelming majority of Providers not
satisfied with pain management care
received in network
• Need to improve translational research
for pain management
• Current research not fully leveraging
the interest/capabilities power of
clinicians in research
• We are not able to track sufficient
“actionable” pain data for our patients
RESOURCES
RESEARCH
2010 PMTF Findings
CAPABILITIES
• Integrative Pain Management (Tripler Army Hospital, Hawaii, and Naval Hospital San Diego)
• Acute Pain Medicine (Walter Reed Army Medical Center)
• Interventional Pain Medicine (Military Medical Centers)
BEST PRACTICES
• Warrior Transition Command Medication Policies/Initiatives
– Sole Provider
– Medication Reconciliation
– WTU Pharmacist
– Embed Pain Mgt Resources in WTU
• Primary Care Providers feel they are ill-prepared to handle “pain patients” and look to move them to specialty care ASAP
• Lack of common orientation to pain among medical staff
– Taxonomy
– Practice
• Lack of common orientation to pain among Patients
• Many Providers not aware of Clinical Practice Guidelines for pain management
• Clinical Practice Guidelines are not “user friendly”
• MEDCOM not fully leveraging IM/IT capabilities to influence/optimize pain mgt practice
• Need improved pain assessment tool
• The perception of working in a system that asks for "A" (quality/satisfaction) but rewards "B" (productivity)
EDUCATION
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
“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 McGinnisExit Wounds: A Survival Guide to Pain Management
for Returning Veterans and Their Families
www.exitwoundsforveterans.org American Pain Foundation
In 2008, there were 14,800 prescription painkiller deaths.1
1.CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6
“Medicine is not a
science; it is
empiricism founded on
a network of
blunders.”
― Emmet Densmore
(1837-1911)
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
TRICARE Enrollees
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
US Country Prescriptions 2016
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Opioid Prescribing Weighted by Proportion of
TRICARE Enrollees.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Notes:
Only counties that had an opioid rx rate >100 per 100 people were selected.
Then, weighted the data with the % of TRICARE enrollees.
By selecting only the high rx counties, this ensures that the risk rate is not due to
an extremely large TRICARE population.
• The highest-risk counties included:
• 1. Okaloosa County, Florida (Duke Field, Eglin AFB and Hurlburt Field)
• 2. Cumberland County, North Carolina (Fort Bragg)
• 3. Montgomery County, Tennessee (Fort Campbell)4. Onslow County, North Carolina (Marine Corps Base, Camp Lejeune)
• 5. Hardin County, Kentucky (Fort Knox)
Conclusion: We do not know how the external civilian environment impacts opioid use for service members and their family members. However, we have some ideas of where to start examining risk and resilience factors, especially the environmental factors extending beyond the boundaries of an MTF.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Why it matters?
Effective January 1, 2018
Elements of Performance for LD.04.03.13
2. The hospital provides nonpharmacologic* pain treatment modalities.
* Nonpharmacologic strategies have previously been defined as: physical
modalities (for example, acupuncture therapy, chiropractic therapy,
osteopathic manipulative treatment, massage therapy, and physical therapy),
relaxation therapy, and cognitive behavioral therapy
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
AcupunctureHistory – Ancient Roots
“The four humors consistedof blood, yellow bile,phlegm and black bile”
A patient’s disease or disability was thoughtto come from an excess or deficiencyof one or more of these “humors”.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Five Known Mechanisms for the Effects
of Acupuncture• Local – ‘axon reflex’ & calcitonin gene-
related peptide.
• Segmental – afferent nerves to the
spinal cord dorsal horn depress activity
•Extrasegmental – stimulation of the
dorsal horn activates other segments and
the brainstem suppressing pain
•Central – cerebral cortex, hypothalamus,
limbic system regulator effects
•Myofacial trigger points – relaxes small
knots of tight muscle or trigger points
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Battlefield Acupuncture
Omega 2
Shen Men
Point Zero
Cingulate Gyrus
Thalamus
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Stepped Care Model
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
What should we measure?
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Pain Intensity
Perspective
Intensity of Chronic Pain — The Wrong Metric?
Jane C. Ballantyne, M.D., and Mark D. Sullivan, M.D., Ph.D.
N Engl J Med 2015; 373:2098-2099 November 26, 2015
DOI: 10.1056/NEJMp1507136
Both the idea that chronic pain could be effectively and safely managed with opioids and the
principles of opioid pain management were based on the successful use of these drugs to
treat acute and end-of-life pain. That success was based on the “titrate to effect” principle:
the correct dose of an opioid was whatever dose provided pain relief, as measured by a
pain-intensity scale.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
A new take on an old scale…
Defense and Veterans Pain Rating Scale
(front)
Defense and Veterans Pain Rating Scale
(back)
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
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
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
PASTOR Clinical Report
• Pain Mapped by
Region
• Clinical Alerts
• Patient Defined Goals
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
• Gen population percentile indicator
• Color Coding on each graph
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Integrative Medicine
"It is more important to know what sort of person has a disease than to
know what sort of disease a person has."~Hippocrates (460-377 B.C.)
The future of
“integrative medicine”
is too close for comfort
- Posted by David
Gorski on September 2,
2013
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
DHA Procedural Instruction for Acupuncture
in Medical Treatment Facilities (DRAFT)
….establishes guidance for
implementing tiered
acupuncture training,
privileging, and
documentation, supporting
the clinical practice of
acupuncture by designated
clinical staff throughout the
DoD, as a complement to
existing pharmacologic and
non- pharmacologic therapies
for pain management.
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
“If the camel once gets his nose in the tent, his body will soon
follow.” –Arabian Proverb
Show me the data…
Acupuncture
Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) [email protected]
Questions?
www.dvcipm.org
Defense & Veterans Center for Integrative Pain Management
DVCIPM
For the latest on DoD pain management information.