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) cbuckenmaier@dvcipm.org
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. Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Pain Management Task Force – 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 Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Legislative Milestones 2010 NDAA SEC. 711. COMPREHENSIVE POLICY ON PAIN MANAGEMENT BY THE MILITARY HEALTH CARE SYSTEM • 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. 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. Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Federal Medicine Pain Management Initiatives NIH Interagency Pain Research Coordinating Committee Organizations/Groups VHA Pain Program Office NCCIH Council Working Group Institutes of Medicine as directed by Affordable Care Act CDC DoD Pain Mgt Task Force Military Health System White House 2009/2010 2011/2012 2013 2014 2015-17 CARA Act Products/Deliverables VHA Pain Mgt IOM National Pain Directive MHS Review “Pain in America” Report Strategy 2009-053 Opioid Prescribing Guidelines NCCIH: Strengthening Collaborations w/ DoD and VA: Pain Management Effectiveness Research on Mind/Body Interventions Task Force Report Presidential Memorandum Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
2010 PMTF Findings BEST PRACTICES • Integrative Pain Management • Warrior Transition Command Medication (Tripler Army Hospital, Hawaii, and Naval Policies/Initiatives Hospital San Diego) – Sole Provider • Acute Pain Medicine (Walter Reed Army – Medication Reconciliation Medical Center) – • WTU Pharmacist Interventional Pain Medicine (Military – Medical Centers) Embed Pain Mgt Resources in WTU EDUCATION RESOURCES • Many Providers not aware of Clinical • Primary Care Providers feel they are ill- Practice Guidelines for pain management prepared to handle “pain patients” and look • Clinical Practice Guidelines are not “user to move them to specialty care ASAP friendly ” • Lack of common orientation to pain among • MEDCOM not fully leveraging IM/IT medical staff capabilities to influence/optimize pain mgt – Taxonomy practice • – Practice Need improved pain assessment tool • • Lack of common orientation to pain among The perception of working in a system that Patients asks for "A" (quality/satisfaction) but rewards "B" (productivity) RESEARCH CAPABILITIES • Lack of predictable pain management • Need to improve translational research capabilities across our MTFs for pain management • Lack of standardization not unique to • MEDCOM or DoD Current research not fully leveraging • the interest/capabilities power of Lack of non-medication modalities for clinicians in research pain mgt • • We are not able to track sufficient Overwhelming majority of Providers not “actionable” pain data for our patients satisfied with pain management care received in network 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 Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
In 2008, there were 14,800 prescription painkiller deaths. 1 “Medicine is not a science; it is empiricism founded on a network of blunders.” ― Emmet Densmore (1837-1911) 1.CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999-2008. MMWR 2011; 60: 1-6
TRICARE Enrollees Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
US Country Prescriptions 2016 Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Opioid Prescribing Weighted by Proportion of TRICARE Enrollees. 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 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. 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, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Acupuncture History – Ancient Roots “The four humors consisted of blood, yellow bile, phlegm and black bile” A patient’s disease or disability was thought to come from an excess or deficiency of one or more of these “humors”. Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
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 Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Battlefield Acupuncture Omega 2 Shen Men Point Zero Thalamus Cingulate Gyrus Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Stepped Care Model Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
What should we measure? 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. Oct 2019 COL (ret) Chester Buckenmaier III, MD (301)400-4228) cbuckenmaier@dvcipm.org
Recommend
More recommend
