Introduction of Acupuncture to the Military Health System ... 2019... · Introduction of...

Oct 2019COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org

Introduction of Acupuncture to the Military Health

System: Battlefield Acupuncture and Beyond

Chester ‘Trip’ Buckenmaier III, MD

COL (ret), MC, USA

Director, DVCIPM

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.

– 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

• 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.

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

“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

Presidential

Memorandum

Opioid

Prescribing

Guidelines

White House

• 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

“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)

TRICARE Enrollees

US Country Prescriptions 2016

Opioid Prescribing Weighted by Proportion of

TRICARE Enrollees.

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.

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

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”.

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

Battlefield Acupuncture

Omega 2

Shen Men

Point Zero

Cingulate Gyrus

Thalamus

Stepped Care Model

What should we measure?

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.

A new take on an old scale…

Defense and Veterans Pain Rating Scale

(front)

Defense and Veterans Pain Rating Scale

(back)

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

PASTOR Clinical Report

• Pain Mapped by

Region

• Clinical Alerts

• Patient Defined Goals

• Gen population percentile indicator

• Color Coding on each graph

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,

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

nonpharmacologic therapies

for pain management.

“If the camel once gets his nose in the tent, his body will soon

follow.” –Arabian Proverb

Show me the data…

Acupuncture

Questions?

www.dvcipm.org

Defense & Veterans Center for Integrative Pain Management

DVCIPM

For the latest on DoD pain management information.

Introduction of Acupuncture to the Military Health System ... 2019... · Introduction of...

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