Managing the Intricacies of Pain
From Combat & Casualty Care, Fall 2018 Issue
Womack Army Medical Center, Fort Bragg, North Carolina, is at the forefront of a DoD-wide campaign to target and mitigate the effects of long-term opiate use — and in some cases abuse — among its ranks.
By Dr. (COL) Donald Algeo, WAMC Pain Management Specialist
The current utilization of opiates has been multifactorial for several years across the Army and DoD. The popular thought in predominant teaching was that health-care providers were undertreating pain. This has been reported and written about at length in other venues. The fact is that, because of the need to be physically and mentally ready to fight and win our nation’s wars, overutilization and chronic use of opiates for chronic benign pain were recognized as problems several years ago. This was one reason why the Office of The Surgeon General developed the Army’s Comprehensive Pain Management Campaign. One of the purposes of this campaign was to develop better education for primary care on treatment of pain. It was also to set up non-pharmaceutical treatment for pain.
In 2010, as part of the Army’s Comprehensive Pain Management Campaign, the physicians in the Inter Disciplinary Pain Management Service recognized that many patients in today’s Army and across the DoD were being treated with chronic opiate management. In many of these cases , polypharmacy was being utilized with two or more medications that could potentially become very dangerous. It was also discovered that treatment for more than 90 days was frequently happening without appropriate monitoring. Working with the Lazarus Project, NC, which was prescribing Noloxone nasal spray inhalers for heroin overdoses, Womack Army Medical Center (WAMC), Ft. Bragg, NC, first introduced the Noloxone Rescue Program for use in treating heavy opiate users. At the same time, WAMC developed a larger umbrella program called Operation Opiates Safe in 2011. The program was designed to identify and stratify risk, provide patients and families with education on the risks of chronic, high-dose opiate use, and communicate risk to the unit commanders. Under the program, the utilization and prescribing of Noloxone nasal spray was initiated. Also introduced was the concept of communicating with unit commander’s through the utilization of the profiling system for controlled substances. These programs were specifically designed for people with chronic pain that had been identified as being chronic opiate users for the treatment of pain.
wAround the same time, WAMC stood up The Integrated Pain Medicine Center (IPMC) — not as a replacement for the appropriate identification and treatment for addiction and substance abuse, but as a body focused on finding other modalities beyond pharmaceuticals to help people manage their pain and improve patient’s abilities to perform physical functions. The overall result is improving long-term outcomes and quality of life. Utilizing the concepts of Operation Opiates Safe, the IPMC has brought about awareness that medication treatment is by no means the only method for addressing pain issues and, in many cases, a secondary or lower-level solution. Out of a cross-pollination of care methodologies between the DoD and the Department of Veterans Affairs (DVA), came the DVA’s adoption of the Naloxone Rescue Program as a standard of care.
Managing Multi-Faceted Care
The pain management capability at WAMC is one of DoD’s best. Several of the concepts and practices that were developed are now being considered standard of care. This includes, but is not limited to, the Naloxone rescue, controlled substance profiles, and risk stratification. The latter, risk stratification, has been an evolving tool for identifying those individuals who are most likely to inadvertently overdose. Risk categories of high, medium, and low were developed and applied through the utilization of the electronic medical profile system. This aided in communication with unit commanders to allow them to see what level of risk their soldiers were in. Previous to the implementation of this risk stratification and substance profiling, unit commanders were most often unaware of any personnel at risk unless contacted by the soldier’s physician or nurse. Recognizing this, WAMC’s IPMC began implementing an electronic profile system enabling physicians to pass along risk factor information to unit commanders directly, labeling personnel on opiate regimens as high, medium, or low risk. This substance-profiling risk stratification has since become a standard of care practice across the Army for monitoring of many different types of pharmaceutical usage.
Determination of risk level for opiate use specifically starts with a good history and physical examination (H&P). The H&P is augmented with several different opiate risk questionnaires. Risk stratification also uses a morphine milli-equivalent dose per day to identify risk. Greater than 90 milligrams/day is considered high risk, less than 90 but greater than 50 milligrams/day as medium risk, and less than 50 milligrams/day as low risk. The combined review of the H&P, questionnaire results, and daily dose gives the final level of risk. In many cases of polypharmacy, patients are generally considered high risk based on the types of medication being taken. A similar high-risk assessment may also be made for patients on lower dosages if they have a background involving substance abuse. In cases where patients are taking opiates and other types of medications affecting the nervous system (such as sleep medications, seizure medications, depression medications, benzodiazepines and more), a high-risk assessment can be made based on the likelihood of combinational effects on the body. Patients failing to recognize significant side effects can also lead to a being high risk.
To support the regular implementation of risk stratification, WAMC was one of the first Army medical centers to establish the use of clinical pharmacists in the IPMC for monitoring changes to risk assessment levels due to altering dosages, other medication introduction, and even age-related risk factors. Perhaps the largest single benefit for the inclusion of clinical pharmaceutical support in determining risk assessment was the fact that before having the clinical pharmacist support the only risk assessment was done by individual treatment teams. There was no review from all sources for the patient’s care. The treatment teams were “stove piped” and may only view the patient from the point of view of their care plan. With the introduction of clinical pharmacists who were tasked to monitor a patient’s pharmacological intake regardless of source, a broader view of a patient’s true risk could now be seen.
Addressing Acute vs. Chronic
Treating patients with a dual diagnosis of chronic pain and substance abuse is a very difficult situation. If a patient gets to the point where they need to be in a detoxification and recovery program for drug abuse, then the risk of continuing to use pharmaceuticals for pain management may be too high. The utilization of pharmaceuticals in this instance is made on a case-by-case basis and based off of risk versus benefit. There are many non-opiate pharmaceuticals that we can employ. In no way has the opiate epidemic in the United States affected our treatment of acute pain.
We have attempted to employ several different techniques in acute pain to decrease the use and dosage of opiates. One example of this is peripheral nerve blocks prior to surgery. From a health-care management standpoint, prevention of opiate abuse includes having a good history and physical, an appropriate diagnosis, risk assessment of the patient and the medications, and significant patient and family member education on the dangers of utilizing controlled substances. Health care providers must ensure there is an intentional goal to minimize polypharmacy, and a solid treatment program to include reevaluations and a timeline expectation for the utilization of controlled substances for chronic pain needs to be looked at on an individual and case-by-case basis. The utilization of these substances needs to be tied to functional improvement for the patient. These strategies are the main focus of our primary care outreach program.
Sustaining Continuity in Standard of Care
Perhaps one of the larger challenges in achieving long-term, high-standard care has been overcoming the changeover in highly qualified caregivers who are transferred from and to post particularly after solid patient-caregiver relationships have been established. Though there is no one modality for success in pain management, perhaps the biggest factor in positive outcomes is the value of human-to-human contact and understanding as to how and what pain is experienced. Especially since the relationship that medication has with a patient is generally only hand-to-mouth.
With this in mind, WAMC began utilizing an integrated pain management treatment team in 2010. Some of the care groupings that this team offers includes functional restoration with physical therapy, occupational therapy, movement therapy consisting of yoga and tai chi, aquatic therapy, health psychology, massage therapy, chiropractic care, and acupuncture in conjunction with a traditional comprehensive interventional pain clinic.
Another major WAMC focus in maintaining continuity of care was the development of a primary care outreach program. This outreach program employs the University of New Mexico’s Extension of Community Healthcare Outcomes or ECHO program. The purpose of this program is to train primary care pain champions for each outlying primary care clinic. We accomplish and sustain this through the utilization of primary care pain consultants. The primary care pain consultants have weekly meetings for didactics and to discuss very difficult patient cases.
ECHO consultants meet with the primary care teams at the outlying clinics to co-manage high-risk and difficult patients. They also help coordinate and run the sole provider programs at all primary care clinics. In cases of acute opioid abuse/addiction, the pain clinic helps identify these individuals and then refers them to the appropriate treatment and recovery programs.
On a Combined Front
The goal of long-term pain management without the use of controlled substances will continue to evolve as we find modalities to help treat pain and improve function. We can treat the physical and the psychological aspects of pain, but unless both are addressed as the integral system of treatment, then we’re likely to fail to improve on the patient’s function and quality of life. Attacking pain from a combined body, mind, and spirit perspective is the ultimate goal in determining the optimal course of treatment to maximize function even when physical pain cannot be completely eliminated.