Beyond medications final

Select SLIDE MASTER to Insert Briefing Title Here

Military Workshop
Beyond Medications: Military Medicine’s Expansion of Pain
Management Treatment Options

National RX Drug Abuse Summit
Orlando, Florida

COL RICHARD P. PETRI, Jr., MC
William Beaumont Army Medical Center
Interdisciplinary Pain Management Center

4 April 2013

Information Brief
Unclassified

COL Richard P Petri, Jr., MC/ WBAMC IPMC / (915) 742-7407 (DSN 969) / richard.petri@us.army.mil FOUO
Apr-9-13


Disclosure

Richard Petri has no financial relationships with
proprietary entities that produce health care goods or
services.

Picture/clip art is non-copyrighted material taken off the internet

Apr-9-13

Learning Objectives

1.  Outline strategies to provide community
level support to soldiers and their families
struggling with prescription pain addiction.
2.  Plan how to establish a support group for
spouses and children of military families.
3.  Identify ways to leverage partnerships to
impact your community.

Apr-9-13

Questions

•  What are the current integrative modalities used by the
Department of the Army for pain management.

•  Describe the tiered approach to integrative modalities
for use in the Department of the Army pain
management programs.

•  Name five of the pillars of approach to the wholistic
pain management program within the Department of
the Army

Apr-9-13

Goals

Understand the history of, present day usage and impact of
Integrative Medicine (IM) in the United States as well as the military

Identify the expansion of IM within the military over the past four
years

Identify several IM research projects within the DoD

Understand the importance, now and in the future of IM especially as
it relates to the Military

Apr-9-13


Apr-9-13


In the beginning…..

The History
of
Alternative
Medicine

Apr-9-13


2000 BC
“Where is my root?”

Apr-9-13


1000 AD
“That root is heathen,
say this prayer”

Apr-9-13


1850 AD
“That prayer is
superstition, drink
this potion”

Apr-9-13


1900 AD
“That potion
is snake oil,
swallow this
pill”

Apr-9-13


1945 AD
“That pill is
ineffective, take this
antibiotic”

Apr-9-13


AD 2000
“That antibiotic is artificial,
eat this root”

Apr-9-13


The cycle of
herbals

Apr-9-13


COL Richard P Petri, Jr., MC/ WBAMC IPMC / (915) 742-7407 (DSN 969) / richard.petri@us.army.mil FOUO Picture/clip art is non-copyrighted material taken off the internet
Apr-9-13

CAM Definition

NCCAM
deﬁnes
CAM
as
a
group
of
diverse
medical
and
health

care
systems,
prac6ces,
and
products
that
are
not
generally

considered
part
of
conven8onal
medicine
as
prac8ced
by
holders
of
M.D.

(medical
doctor)
or
D.O.
(doctor
of
osteopathy)
degrees
and
by
their
allied

health
professionals
such
as
physical
therapists,
psychologists,
and
registered

nurses.

Conven8onal
medicine
is
also
known
as
Western
or
allopathic
medicine.

The
boundaries
between
CAM
and
conven8onal
medicine
are
not
absolute,
and

speciﬁc
CAM
prac8ces
may,
over
8me,
become
widely
accepted.

NCCAM
Publica8on
No.
D347.
“CAM
basics
What
Is
Complementary
and
Alterna8ve
Medicine
?
Update
April
2010.
15
Jul
2010

<hTp://nccam.nih.gov/health/wha8scam>

Apr-9-13

CAM Definitions
•  Complementary medicine refers to use of CAM together with
conventional medicine
Example- Acupuncture for pain management. Most use of CAM by Americans is
complementary

•  Alternative medicine refers to use of CAM in place of conventional
medicine
Example-herbals instead of chemotherapy for cancer management

•  Integrative medicine (also called integrated medicine) refers to a
practice that combines both conventional and CAM treatments for
which there is evidence of safety and effectiveness
Example- Chiropractic Manipulation for low back pain

•  Integrative Health and Healing is similar to Integrative Medicine but
replaces the term “medicine” for “Health and Healing”; two concepts
representing the goal of the practice of medicine

NCCAM
Publica8on
No.
D347.
“CAM
basics
What
Is
Complementary
and
Alterna8ve
Medicine
?
Update
April
2010.
15
Jul
2010


Apr-9-13

Terminology

• Conven8onal
or
Allopathic

• Complementary
and
Alterna8ve

Medicine
(CAM)
or
now
know
as

Integra8ve
Medicine
(IM)

OR
• Scientifically Proven with
Evidence Based Research
• Unproven Practices

Apr-9-13

NCCAM Classification ofBriefing Title Here
Select SLIDE MASTER to Insert CAM Therapies
with Examples and Prevalence of Selected Modalities

•  Natural Products (17.7%)*
–  Herbals/Botanicals
–  Supplements
–  Probiotics
•  Mind-body Medicine
–  Meditation (9.4%)*
–  Yoga (6.1%)*
–  Acupuncture ** (1.4%)*
–  Guided Imagery
–  Hypnotherapy • Based
on
the
2007
Na6onal
Health

Interview
Survey
(NHIS)

–  Progressive Relaxation
–  Qi Gong **Also
considered
part
of
Energy
,

–  Tai Chi Manipula6ve
and
Body
Based
Methods

•  Manipulative and Body-Based methods and
TCM

–  Osteopathic and Chiropractic Manipulation (8.6%)*
–  Massage (8.3%)* NCCAM
Publica8on
No.
D347.
“CAM
basics

•  Other CAM Practices What
Is
Complementary
and
Alterna8ve

–  Movement Therapies Medicine
?
Update
April
2010.
15
Jul
2010


–  Traditional Healers
–  Energy (Magnet, Light, Qi Gong, Reiki, Healing Touch)
–  Whole Medical Systems (Ayurvedic, TCM)

Apr-9-13

CAM in the United States
•  42.1% of patient seek CAM treatments
•  72% conceal use from doctors
•  83% use in combination with conventional
medicine
•  21.2 billions of dollars per year spent per year [1]
•  More visits than to Primary Care (60M)
•  “Minor” treatments include weight loss,
performance enhancement, self-care, pediatrics
[1]
Eisenberg DM, Davis RB, Ettner SL, Appel S, et al. Trends in alternative medicine use in the United States. Journal of the American
Medical Association. 1998;280: 1569-1575
Updated Tindle, H., Davis, R., Phillips, R., Eisenberg, DM, Trends in Use of Complementary and Alternative Medicine by US Adults:
1997-2002. Alternative Therapies in Health and Medicine Jan/Feb 2005 Vol 11 (1), 42-49.


Apr-9-13

What is the usage of CAM in the Military?

•  35% of US adults use some type of CAM [1]
•  Military has a higher percentage of usage than the general public at
81% [2] [4]

•  Herbal use has the highest usage [1],[2]
•  Low back pain is the most common reason patients use CAM [3]
•  Military personnel reported using three CAM stress-reduction therapies
at 2.5-7 times the rate of civilians. [4]
1
Tindle
et
al

Trends
in
use
of
complementary
and
alterna8ve
medicine
by
US
adults:

1997-‐2002

Altern
Ther
Health
Med
2005
Jan-‐Feb;
11(1)
42-‐9

2

McPherson
F
Schwenka
MA,
Use
of
complementary
and
alterna8ve
therapies
among
ac8ve
duty

soldiers,
military
re8rees,
and
family
members
at
a
military
hospital
Mil
Med
2004
May;169(5):354-‐7

3

Sherman,
et
al,
Complementary
and
alterna8ve
medical
therapies
for
chronic
low
back
pain:

What

treatments
are
pa8ents
willing
to
try?

BMC
Complementary
and
AlternaFve
Medicine
2004,
4:9

4
Goertz
et
al
Military
Report
More
Complementary
and
Alterna8ve
Medicine
Use
Than
Civilians
J

Altern
Complement
Med
2013
Jan
16
[Epub
ahead
of
print]

Apr-9-13

Growth of CAM Studies from 1966 to 2009

60000
Pub Med Citations Under "Alternative, Complementary or Integrative

* Pubmed Citations Under Alternative Medicine
53371
** Pubmed Citations Under "Alternative, Complementary or Integrative Medicine"
50000

44813
40000 37538

34014
30000
22875
17237 21695
Medicine"

20000 6559 12543
7006 8739 9888
15083
6989 8671 9769 11538
3441
10000

1
1
0 7
14
50
66-69 162
70-74 312 989
75-79 2476
80-84
85-89
Integrative 90-94
Year Range 95-99
Complementary 00-04
05-09
Alternative Data derived from PubMed http://www.ncbi.nlm.nih.gov/pubmed

Apr-9-13

Select SLIDEed
Cita6ons
by
Publica6on
Type

Pub
M MASTER to Insert Briefing Title Here
2009

Evalua8on
Studies
(887)

LeTers
(946)

13%

20%

Case
Reports
(1,471)

13%

Compara8ve
(2,611)

7%
RCT
(2,682)

23%

5%
Clinical
Trials
(4,054)

4%

Other
includes
30+
categories

15%
Reviews
(4,657)

Others
(2,935)

Data derived from PubMed http://www.ncbi.nlm.nih.gov/pubmed

Apr-9-13

Public’s Concerns With Conventional Medicine

• Medical Health Costs
• Safety and Iatrogenic
Complications
• Aging and chronic illness
• Technology and knowledge
(depersonalization)
• Role of science in medicine


Apr-9-13


Depersonaliza8on


Apr-9-13



Apr-9-13

Unique Aspects of Military and IM

•  Lifestyle of being a Soldier
•  The “testosterone” effect
•  Demands of the job
•  Leads to a culture of health promotion
•  Universal health care
•  More flexibility toward available services
•  Visibility
1 Baldwin CM, Long K, Kroesen K, Brooks AJ, Bell IR, Arch Intern Med. 2002 Aug 12-26;162(15):
1697-704
2 McPherson F Schwenka MA, Use of complementary and alternative therapies among active duty

soldiers, military retirees, and family members at a military hospital Mil Med 2004 May;169(5):354-7

Apr-9-13

Psychiatric Drug use among military children on the rise!
US Navy Seals blog 2011

Two Army Families deal with PTSD, and Suicide
ABC World News 2010

Mild TBI Remains Little Understood and Hard to
Mild TBI Remains Little Understood and Hard to
Diagnose TBI Remains Little Understood and US Medicineto
Mild Hard 2012
Mild Hard 2012
Mild Hard 2012
Mild Hard 2012
Mild Hard 2012
Mild Hard 2012
Diagnose US Medicine 2012
Diagnose US Medicine 2012

Senators raise concerns with prescription-drug use in military
Virginian -Pilot 2008

Army Responds to Rising Suicide Rates
www.army.mil 2008

Apr-9-13


A Return to the Basics


Apr-9-13


Empower

Energize

Enrich

Apr-9-13


April 19, 2011
US aims at its deadliest
drug problem: painkillers

Apr-9-13

Concern for Abuse

Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or Older: 2007.
Department of Health and Human Services, et al.[6]

Apr-9-13

Concerns Among PCMs

Top concerns among primary care physicians -- related to controlled substance prescribing.
From Bhamb B, et al.[5]

Apr-9-13

Poisoning Deaths, 1999 – 2006

Apr-9-13

Overview

•  One of most frequent reasons for physician care
•  Over 50 million Americans suffer with chronic pain
•  Annual cost ~ $100 billion
–  Health care expenses
–  Lost income
–  Lost Productivity
•  Back pain – leading cause of disability for Americans < 45 y/
o

Apr-9-13


2011

1980

1984

2005
Apr-9-13

Military Relevance

Apr-9-13

Musculoskeletal Injuries

Total
MSK
disabili8es
of
veterans
who
served
from
2001
–
2010:

386, 562 100%
Limited motion, 58, 642 15.2%
ankle
Tenosynovitis 65, 364 16.9%
Limited flexion of 74, 627 19.3%
leg
Degenerative 77, 420 20.0%
arthritis, spine
Lumbosacral or 110, 509 28.6%
cervical strain

Apr-9-13

Integrative Medicine in the Military Systems


Apr-9-13

Select SLIDE MASTER Integrative Medicine
The Center for to Insert Briefing Title Here
~A Department of Defense First~
•  Established Nov 2003 at The Center for Integrative
Medicine ~ A Department of Defense First~

•  Began with acupuncture and chiropractic services.
Currently offering holistic approach to pain with
“Conventional” and “Alternative” modalities

•  New facility constructed Dec 2008 on Ft Bliss- name
changed to the Interdisciplinary Pain Management
Center (IPMC) in 2012

•  The Center has brought in over $800,000 research
dollars and had the first senior Samueli Institute
Conceptual Plan for an Institute for Integrative Health research associate in the DoD (2004)
and Healing. The current WBAMC Interdisciplinary Pain
Management Center (IPMC) Campus buildings are on Ft •  The Center conducted the first Military Chiropractic
Bliss, Buildings 2485D and 2487 study for Acute Low Back Pain in the United States
with Samueli Institute and Palmer College of
Chiropractic. Approved for publication in Spine As a
result of the study, Congress mandated a follow up
study with $7.2M funding.

•  The Center provides valuable complementary
modalities for difficult medical conditions.

•  Built and sustained on passion, compassion and “out
of the box” ideology

Apr-9-13


Integrative Medicine Model

The mission of the Integrative Medicine Model is to
provide an environment that promotes existing
and new medical treatments that may offer safe
and effective approaches to the health and healing
care through education, clinical practices and
research. Additionally, the mission is to
implement those modalities that meet research
standards into the current standards of patient
health care through collaborative partnerships
with existing medical practices.

Apr-9-13

ARMY SURGEON GENERAL ANNOUNCES RECOMMENDATIONS OF
PAIN MANAGEMENT TASK FORCE AND RELEASES REPORT

June 23, 2010
•  Lt. Gen. Eric B. Schoomaker, Former Army Surgeon General and Commander, U.S.
Army Medical Command, said that “this report is a pivotal effort to better understand
and treat the growing challenges of providing comprehensive pain management for our
patients.

•  Recommendations for a MEDCOM comprehensive pain management strategy that
was 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

•  Focus on a holistic, patient-centered approach
which employs all modes of therapy--from more
conventional means which rely upon the use of
drugs, to complementary and alternative modes
such as acupuncture, meditation, biofeedback,
yoga and others
http://ausar-web01.inetu.net/publications/ausanews/
specialreports/2011/06/Pages/
AAPMhonorsfiveArmymedicalofficers.aspx

Apr-9-13

TSG Select TF Recommendations for CAMHere Pain
Pain SLIDE MASTER to Insert Briefing Title for
Management
•  Recommendation 4.2.1.1
Adopt a tiered approach for the effective integration of integrative modalities to augment pain management for
military and Veteran populations.

Establish integrative pain medicine capabilities at RPCoE's and DoD sites (Army, Navy, and Air Force) to
champion integrative pain care with a focus on the best clinical practices, education, and research.

Establish baseline data on the clinical integrative practices being used, along with provider and patient
perspectives, through a comprehensive DoD survey, utilizing existing survey models (if appropriate).

Develop an advisory board, with scholarly leaders in various integrative medicine fields, to assist in the
development of appropriate programs, ensure proper credentialing of providers, and establish necessary
guidelines for outcome measures and uniformed quality of care.

Establish standardized and appropriate strategic communication plans on integrative health care methods for pain
medicine.

Develop and fund pilot programs across DoD in the delivery of integrative pain.

Request Health Affairs undertake the evaluation of integrative medicine modalities in Tier I for inclusion as
covered TRICARE benefits.

Apr-9-13

Typical Stove Piped Approach

Clinic A
Clinic Clinic
Clinic B
C D

Requires a Cultural Shift in Healthcare Delivery
The IPMC is that shift

Apr-9-13


Integrative Modalities
Acupuncture
Movement-Yoga Warrior Tai Chi
Body Based Manipulation
Medical Massage
Biofeedback
Research
Spiritual Mind-Body/Mindfulness DoD Survey of IM
Mindfulness and PTSD
Core values
Spousal Needs Assessment
Perspective
Most Research in IM (VA/DoD)
Identity, Meaning and Purpose

Environmental Social Soldier and Family
Optimal Healing Philosophy Caregiver Support Groups
Green Spaces Educational Curriculum
Zen Gardens Social, Family and Task Cohesion
Labyrinth

Medical Management Behavioral
Substance Abuse Counseling
Primary Care Champions
Coping Skills
Clinical Pharmacist Functional Mind Wellness
Interventional Spine Restoration
Procedures
Strength
Endurance
Flexibility
Culinary Education
Healthy Choice Kitchen

Apr-9-13

Step Care Model of Treatment

Interdisciplinary
Pain Department
IPMC

Tertiary Level
Interventions
Advanced Pain Medicine
Diagnostics and
Interventions

Secondary Level Interventions
Rehabilitation Medicine
Behavioral Medicine

• In processing
Patient • Wellness Fusion Acute/Primary Care Management
Centered Campus PCM Pain Champions
Medical Home • Medical/Post
Initiative Early Interventions
Patient Self Management
Community • Outlying Clinics Prevention
Based Medical (PCM and
Home Specialty)

Goal of restoration with function, risk management
Apr-9-13

Pillars
of
Integra6ve
Health
Model

Clinical Care is Predicated
Provider
Patient Education on the Self
Community
Self Self
determination actualization

Self
Self care
awareness
Research
Self
Self discipline
responsibility

Clinical Care

Apr-9-13

Proposed IPMC Organizational Chart

Apr-9-13

IPMC Programs

•  Pain Clinic
•  Intensive Outpatient
Program (IOP)
•  Functional Restoration
Program
•  acute Intensive Outpatient
Program (aIOP)
•  Addiction based program

http://wunderkammer.ki.se/assets/uploads/image/asset/331/large_Bobbin_tandutdragning_med_tr_d.jpg

Apr-9-13

Interdisciplinary Pain Management Center IPMC Process Map 2013

Apr-9-13

Clinic Process
Chronic Pain Management
Referral Review
Individual Service Chiefs

Low
complexity
case

Medium/High
complexity
case
(CHUP)

Clinical Evaluation IOP
with Medical Provider

Multi-disciplinary Pain Management Clinic

PCM Rehab Behavioral
Interventional IM Health Functional Restoration
Champion Therapy

Pharmacological

Patient identified as good Interventional
candidates for holistic care
Integrative
Patient with minimal symptoms requiring only one provider
Behavioral
Follow-Up Clinical Evaluation
with Medical Provider Pain
Champion

Patient

Discharge
Return to PCM with treatment plan. Patient tailored care plans
ECHO consultation Multi-Disciplinary Weekly Team Meetings
prn PCM participation/education
Nurse Case Management
Apr-9-13

Clinic Process
Intensive Outpatient Program

Mul6disciplinary
Pa6ent
Intake
Evalua6on
(MDPIE)

High
risk,
at
risk
pa6ents

Developmental
Stages

Data
Analyst
to

follow

Day 1 outcomes

NCM

obtains

Individual
Assessments Team command

Patient Patient approval

Completed Interview Huddle Discharge/
BH Weekly
Question with Return to Duty
(30 mins)
(30 mins) Team Multi-D with recs. for
(90 mins) meeting Meets
IOP
PCM-
Criteria
Augmentation
Rehab Does
Not

Meet
IOP

(30 mins) Criteria
ECHO Follow-Up,
as needed

MD
(30 mins)
IOP Team (Individualized Care Plan)
Core
MD, Rehab, BH, Pharm, NCM, Education
Additional
Treatment recs. to
IM
PCM-Augmentation
Team with ECHO
follow-up PRN

Apr-9-13

Clinic Process
Acute Intensive Outpatient Program
Acute
Mul6disciplinary
Pa6ent
Intake
Evalua6on
(Acute
MDPIE)

Pain
less
than
7
days

No
history
unevaluated
trauma
(ER
or
PCM
level)

No
history
of
fracture

Data
Analyst
to

follow

Day 1 outcomes

Team
Assessment Individualized Care
Patient Patient Plan
Patient
presents to and Team Biweekly treatments
Interview Pain Huddle
clinic, given
with Champion Meets
Milieu environment
appointment
time for that Team aIOP
Telephonic/Records
Criteria

morning, (40 mins) Begin Nurse Case Management F/U
paperwork treatments over 3-6 mos
in 2 week re-evaluation with pain
completed champion
(30 mins) Rehab afternoon

Pa6ent

obtains
Continued treatment prn
command

approval
Team consists of MD, IM
Chiropractor/ Does
Not
providers, Rehab team,
Meet
Chiropractor/DO
DO aIOP

Long term Goals Criteria

Discharge/
Return to Duty
Create management
with recs. for
team at PCM/Unit levels IM Provider
Treatment recs. to PCM-
Educational Awareness PCM-Augmentation Augmentation
on Pain Management
Team or appropriate
IPMC service

Apr-9-13

WBAMC IPMC Patient Visits

FY12
FY13

FY
12

July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
Jul
Aug
Sept

Oct
FY13
Total

Total

IPMC
Pa6ent
Visits

Total
Since
Jul
12

Acupuncture
36
114
106
256
151
128
176
234
244
933
1189

Anodyne
25
59
87
171
102
22
39
13
13
189
360

Case
Management
8

Chiroprac6c
325
415
252
992
626
704
517
769
692
3308
4300

Clinical
Pharmacy
0
0
0

Clinical
Psychology
0
6
6
12
12

Electrodiagnos6cs
(EDx)
2
6
8
21
8
9
13
47
98
106

Interven6onal
Medicine
145
133
113
391
75
78
101
125
41
420
811

Massage
Therapy
0
0
0

Physical
Therapy
0
3
41
43
45
60
192
192

Primary
Care
94
128
109
331
114
82
110
93
132
531
862

Research
6
13
11
30
16
15
2
6
2
41
71

Yoga
0
9
65
81
120
65
340
340

Total
631
864
684
2179
1117
1143
1078
1424
1310
0
0
0
0
0
0
0
0
6064
8243

Apr-9-13


Chiropractic Care in the Military

Apr-9-13

Synergy between Integrative and Conventional Medicine

Interdisciplinary
Health and
Pain
Healing
Management
Center
Research
Endeavors Educational
Global Outreach
Combat Stress
Context
Disorder
PTSD Facility

Community
TBI
Treatment Facility
NICoE

Medicine Patient Surgery
Centered
Primary Care Care Perioperative
Patient Centered
Prescriptions Medical Home
Polypharmacy
Behavioral Care

Clinical Practices

Apr-9-13

Military IM Research

Slide 65 of Apr-9-13

Research

Survey of Complementary and Alternative Medicine Services within the Department of Defense

Acupuncture treatment for sinusitis

Apr-9-13

Survey of Complementary and Alternative Medicine Services within the
Department of Defense

Apr-9-13

Results

Change in the Number of Services Provided by Facility
N = 13
20
(% Change)
171%
18
Number of CAM Services Provided

Increase in Existing Services
16
133%
14
Decrease In 44% 333%
12 Existing Services
175%
New
233%
10 Services 80% 80%
60%
8 -36% -22%

6 2005
4 2009
50%

2
Walter Reed AMC

Madigan AMC

Brooke AMC

Wright-Patterson

Landstuhl AMC

Center San Diego

William Beaumont

Tripler AMC

Center Portsmouth

Malcolm Grow MC

Eisenhower AMC
Naval Health Clinic
Womack AMC
Naval Medical

Naval Medical
Great Lakes
AMC
MC

Facility

Apr-9-13

Beyond medications final

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Beyond medications final