401 vehu pccpain_burgo_hunt-8.5
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Integrated Pain Care:A Nuts and Bolts Approach
Dr. Lucille Burgoand
Dr. Stephen Hunt
Part 1:
Pain Concerns in Veterans
73.36 million High Blood Pressure
17.0 million Diabetes
16.8 million Coronary Heart Disease
11.7 million Cases of Cancer
100+ million Pain Sufferers
Poll Question
What percentage of outpatient clinic visits are related to pain?
A. 10%B. 20%C. 30%D. 40%
Rates of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold --- United States, 1999--2010
Poll Results
40%
The bulk of pain care is provided in the primary care
setting
< 5% of chronic pain patients will be managed by a pain specialist
40% of all outpatient visits are related to pain
Pain in Veterans
• 50% of male Veterans report chronic pain
• Pain in women Veterans may be as high as 75%
• Pain is among the most costly disorders treated in VHA settings
How do pain concerns impact our returning combat Veterans?
• 26 y/o; deployed once to Iraq and once to Afghanistan• infantryman; convoy security • exposed to frequent direct and indirect fire, • saw many casualties, lost several close friends • multiple IED exposures; • screens positive for TBI, PTSD and depression. • chronic back pain; taking hydrocodone. • initial PACT assessment; desires refill of his
hydrocodone and a refill of his clonazepam (for sleep) • no mental health treatment in the past year
Karl
How can we best help Karl?
Poll Question
What percentage OIF/OEF/OND veterans reported chronic pain after deployment?
A. 14%B. 33%C. 47%D. 96%
What are the health concerns of OEF/OIF/OND veterans seen in the VA?
• Musculoskeletal 56.7%• Mental disorders 52.8%• Symptoms/signs 51.9%• Nervous system (hearing) 44.8%• GI (dental)
36.0%• Endocrine/Nutrition 32.4%• Injury/Poisoning 28.8%• Respiratory 26.3%
VHA Office of Public Health and Environmental Hazards March 2012
Pain is the primary physical problem afflicting service
members
Poll answer
47%
Pain in OEF/OIF/OND Veterans
16
• 47% OIF/OEF/OND veterans reported chronic pain after deployment– 80% have musculoskeletal concerns– 28% report moderate to severe pain
• Pain is the primary physical problem afflicting soldiers – often begins in basic training (25% of male and
50% of female recruits experience at least one pain-related injury during Basic Combat Training)
– #1 complaint of OEF/OIF/OND Vets
Poll Results
Wounding Patterns
IED’s
Body Armor
Time in vehicles
Improvements in Medical Care
Factors Contributing to Rise in Pain
How do pain concerns impact our returning combat Veterans?
Poll Question
Chronic pain is present in what percentage of patients with PTSD?
A. 12-29%B. 21-36%C. 38-48%D. 45-87%
Co-morbid Concerns in Combat Veterans
PTSD
TB
IPA
IN
TBI/Pain
TBI/PTSD Pa
in/P
TSD
P3 Multi-symptomDisorder
5.3%
2.9%
16.5%
10.3%
12.6%
6.8% 42.1%
Poll Results
45-87%
Pain and mental health concerns• Pain and depressive disorder co-occur 30-60% of the
time• Anxiety disorders occur in 35% of persons with
chronic pain• 20-34% of persons with chronic pain meet criteria for
PTSD • Chronic pain occurs in 45-87% of persons with PTSD• 37-61% of patients seeking substance use treatment
have chronic pain • Pain undermines treatment for depression, anxiety
disorders, PTSD, and substance use disorders
Pain
Loss of FunctionStress
DepressionPTSD
71% of Primary Care Providersreport chronic pain management
to be challenging
(VHA PC Survey, 2008)
Culture of “Cure”• Urgent and absolute relief:
appropriate in acute and cancer pain
• Inappropriate in chronic pain Rehabilitation Restoring and preserving
function• Acute strategies are
inappropriate for chronic pain
Barriers to Pain Management in Primary Care
Inadequacies in education and trainingLack of consultant support Psychosocial complexity Time pressures Skepticism Systems limitations
Lincoln et al Survey, VA Connecticut HCS
Monitoring opioid use in primary care%
of p
atien
ts
Becker, WC Ann Fam Med 2011
So how are we going to help Karl?
What is our mission? What is our plan?
Who is on our team?What tools do we have to help us?
How are we going to make it happen?
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Factors that influence pain experience
• Biological Factors– Severity of injury/damage– Presence of source of nociception.
• Psychological Factors– Mood– Anxiety (PTSD)– Stress/Anger– Cognitions/attention
• Social Factors– Activity – Occupational status– Social interactions (+ and -) –Social
role
Social Biological
Psychological
Biopsychosocial Model
We must understand the “whole person with pain”.
Veteran Centered Pain Management
Collaborative Care requires a new Communication style
Engage
Empathize
Educate
Enlist
(Keller VF, Carroll JG, Patient Education and Counseling, 1994)
Find It
Fix It
Veteran centered, team based, coordinated care
PACT
Creating the Veteran’s team
Part 2:
The MissionThe PlanThe Team
The TrainingMaking It Happen
The Mission
Highest quality, evidence based pain care
for all Veterans.
The Plan
VA Stepped Pain Care Directive
RISK
1
2
3Comorbidities
Patient Aligned Clinical Team (PACT)Complexity
Treatment Refractory
RISK
Secondary Consultation
Tertiary Interdisciplinary Pain Centers
VA Stepped Pain Care
“Universal” Precautions in Pain Medicine
• Diagnosis /Differential• Mental Health Assessment• Informed Consent /OpioidAgreement• Pre/Post Assessment of Pain Level/Function• Appropriate Trial of Pharmacotherapy +/- opioids• Regularly Assess the “Four A’s” of Pain Medicine
• Analgesia, Activity, Adverse reactions, Aberrant behavior
• Periodically Reassesing• Baseline/periodic UDS with opioid
The Team
Expanded Patient Aligned Care Team
Veteran centered, team based, coordinated care
PACT
Creating the Veteran’s team
PACT teamlet
Pain Specialist
SW/CM
Pharmacy MH Behavioral Health SUD PT/RCS/CAM
PolytraumaChiropractic
I need you to refill my pain medications, because I am
almost out
How do you start?
What do you say?
The Tools
What’s in your toolbox?
Know your tools and have them handy.
Your most important tool is your relationship with the Veteran and your
commitment to the best pain care.
Start at the beginning…
.
VA/DoD opioid monitoring guidelines
• Informed Consent
• Visit Frequency
• Effectiveness
• Harms
• Adherence
• Collaboration of PCP, Pharm D, RN, PCMHI, PT/Rehab
• All promoting self-management, goal setting
• Pain school (self-management groups)• Group Medical Visits, Shared Medical
Appointments(SMA) • Care management of pain and depression • Health Coaches/Health Behavior
Coordinator
The expanded PACT works together to manage chronic pain
VA SCAN at work
New Age of Telemedicine
TELE PAIN
E-consults and phone consults
Pain Self-Management
• Education – pain; vocabulary; red flags;• Identifying /modifying fears and beliefs• Goal-setting and problem-solving• Exercise – strengthening; aerobic; etc.• Relaxation; deep-breathing;• Handling pain flare-ups • Working with clinicians and employers
Staff Education and Tools
Standardization of Opioid Prescribing for PACT
• Opioid pain agreement/informed consent/risk discussion
• Chronic Pain on problem list • Risk evaluation tool• Random UDS(Urine Drug
Screen)• 4 A’s on every visit• Opioid Renewal/Refill Clinics
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Communication Tools
• TEACH for Success
• Motivational Interviewing
Stepped Care Approach to Musculoskeletal Pain
Medications
• NSAIDS, topical analgesics
• TCAs or gabapentin for neuropathic pain
• muscle relaxants for spasm
• Appropriate medications for co-morbid conditions
such as PTSD/depression
Stepped Care Approach to Musculoskeletal Pain
Early utilization of self management and non-pharmacological modalities
• Pain school• Health psychology for relaxation training,
biofeedback, cognitive behavioral therapy• Chiropractor• Acupuncture• PT/OT/KT for TENS, massage, exercise• CAM with MBSR, yoga nidra, yoga with
movement, mindfulness meditation
Staff Education/Resources on Pain• Rural Health Series on PAIN TMS classes…Four
30 min trainings……• VISN 20 online education• Wiki • E-consult pilot• National Pain Meeting archives• OEF/OIF/OND National Sharepoint Archives• VA Pain site:http
://www1.va.gov/painmanagement/
Patient Education and Tools
Action Plan1. Goals: Something you WANT to do Begin Exercise2. Describe
How Walking Where NeighborhoodWhat 20 min Frequency 3x/weekWhen After dinner
3. Barriers - Dishes, safety (no sidewalks)4. Plans to overcome barriers - get kids to clean up, ask
neighbor or husband to join me, wear reflective vest
5. Conviction and Confidence ratings (0-10) - 9/86. Follow-Up: Will keep log and bring to next visit in 1
month
Taking medications
Psychological Strategies
Mindfulness
Depression
Massage
Physical Therapy
Diet/Weight Loss
(RI Dept of Health Chronic Care Collaborative)
Exercise
• Non-Opioid medications for pain • How to cope when you can’t cure• Health and healing through
leisure/ living with pain• Opioids and pain management • Physical therapy: improving your
pain and function• Pain management techniques to
break the cycle of pain
Pain School Schedule
But what if our PACT is a small CBOC and we don’t have a pain school?
• VTEL it in from your main facility or how about showing a YouTube!
• Provide the Veteran tools to build self efficacy
5 minute Patient Education
Mobile Applications
AFTERDEPLOYMENT.ORG
Karl and his Team have a Mission: the best pain careKarl and his Team have a PlanKarl and his Team are all trained to do their parts Karl and his Team work together and by doing so carry out the plan …and succeed in the mission!
Ask the Presenter
VA Pain site: http://www1.va.gov/painmanagement/VISN 20 LMS:
http://vhapugweb3/pain/ChronicPain/index.htmlwww.painedu.orgwww.painedu.comwww.globalrph.comwww.jpain.orgwww.ampainsoc.orgDobscha SK et al. Collaborative care for chronic pain in primary care: a
cluster randomized trial. JAMA.2009;301(12):1242-1252Kroenke K et al. Optimized antidepressant therapy and pain self-
management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009;301(20):2099-2110
References and useful websites
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