System: Battlefield Acupuncture and Beyond Chester Trip Buckenmaier - - PowerPoint PPT Presentation

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System: Battlefield Acupuncture and Beyond Chester Trip Buckenmaier - - PowerPoint PPT Presentation

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Introduction of Acupuncture to the Military Health System: Battlefield Acupuncture and Beyond Chester Trip Buckenmaier III, MD COL (ret), MC, USA Director, DVCIPM Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228)

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Oct 2019

COL (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

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Oct 2019

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

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Oct 2019

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

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.

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Oct 2019

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

– Provide recommendations for a MEDCOM comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state

  • f

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

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Oct 2019

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

  • 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.

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Oct 2019

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

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 Strategy MHS Review

IOM “Pain in America” Report VHA Pain Mgt Directive

2009-053

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

Organizations/Groups Products/Deliverables

Presidential Memorandum

Opioid Prescribing Guidelines

CDC White House

CARA Act

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Oct 2019

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

  • 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

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Oct 2019

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

“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 McGinnis

Exit Wounds: A Survival Guide to Pain Management for Returning Veterans and Their Families www.exitwoundsforveterans.org American Pain Foundation

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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)

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Oct 2019

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

TRICARE Enrollees

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Oct 2019

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

US Country Prescriptions 2016

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Oct 2019

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

Opioid Prescribing Weighted by Proportion of TRICARE Enrollees.

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Oct 2019

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

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

  • pioid 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.

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Oct 2019

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

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,

  • steopathic manipulative treatment, massage therapy, and physical therapy),

relaxation therapy, and cognitive behavioral therapy

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Oct 2019

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

Acupuncture

History – Ancient Roots

“The four humors consisted

  • f blood, yellow bile,

phlegm and black bile”

A patient’s disease or disability was thought to come from an excess or deficiency

  • f one or more of these “humors”.
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Oct 2019

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

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Oct 2019

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

Five Known Mechanisms for the Effects

  • f 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

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Oct 2019

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

Battlefield Acupuncture

Omega 2 Shen Men Point Zero Cingulate Gyrus Thalamus

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Oct 2019

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

Stepped Care Model

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Oct 2019

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

What should we measure?

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Oct 2019

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

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.

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Oct 2019

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

A new take on an old scale…

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Defense and Veterans Pain Rating Scale (front)

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Defense and Veterans Pain Rating Scale (back)

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Oct 2019

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

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
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Oct 2019

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

PASTOR Clinical Report

  • Pain Mapped by

Region

  • Clinical Alerts
  • Patient Defined Goals
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Oct 2019

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

  • Gen population percentile indicator
  • Color Coding on each graph
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Oct 2019

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

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

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Oct 2019

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

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.

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Oct 2019

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

“If the camel once gets his nose in the tent, his body will soon follow.” –Arabian Proverb

Show me the data…

Acupuncture

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Oct 2019

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

Questions?

www.dvcipm.org

Defense & Veterans Center for Integrative Pain Management DVCIPM For the latest on DoD pain management information.