401 vehu pccpain_burgo_hunt-8.5

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