Joint Education Pain Management Project
Transforming DoD/VHA Pain Care
Presented by: CDR Steven Hanling
Disclosures
• The presenter has no financial relationships to disclose.
• This continuing education activity is managed and accredited by Professional
Education Services Group in cooperation with AMSUS.
• Neither PESG,AMSUS, nor any accrediting organization support or endorse
any product or service mentioned in this activity.
• PESG and AMSUS staff has no financial interest to disclose.
• Commercial support was not received for this activity.
Learning Objectives:
At the conclusion of this activity, the participant will be able
to:
1. Describe the desired elements of quality pain care that shaped development of the Joint Pain
Education Project curriculum.
2. Recognize the importance of comprehensive pain management strategies in building pain care
competencies in the medical home or PACT models
3. Be knowledgeable about the content and available platforms to access the Joint Pain Education
Project curriculum
Joint Pain Education Project
•A DoD and VHA effort to develop a standardized pain management
curriculum to improve complex patient and provider education and
training
•Developed in response to the DoD/VHA Health Care Sharing Incentive
Fund signed by the Under Secretary of Defense, Personnel and Readiness
and the Deputy Secretary, Department of Veterans Affairs in June 2004
•Critical to the quality of care our Servicemembers receive while active
duty and as they transition to Veteran status and into the VHA and
national health system
JPEP Objectives
The objectives of the JPEP is to achieve the following:
1. Standardize DoD/VA education curriculum content, supporting
materials, and a variety of commonly accessible delivery systems
2. Enhance pain care transition between DoD and VHA
3. Commit to learning and training our teams, centers, and agencies
together; ultimately building a new model of pain care
JPEP Desired Outcomes
• Decreased variance of pain management care education products and
messages
• DoD/VA providers, patients, and leaders have knowledge of their roles
and responsibilities as part of the shared DoD/VA pain management
strategy
Essentials to High Quality Pain Care
1. Develop team approach to better coordinate care by the DoD/VHA
2. Education of patients and families on adoption of self-efficacy models
of care
3. Early implementation of non-pharmacological interventional treatment
modalities
4. Institution of safe medication prescribing programs including safe
opioid use
5. Standardize core education curriculum among DoD/VHA for providers
and patients
6. Establish common metrics to guide pain care
Presidential Memorandum --Addressing Prescription
Drug Abuse and Heroin Use (21Oct15)
• Ensure that medical professionals receive adequate training on appropriate
pain medication prescribing practices, and the risks associated with these
medications
• Training efforts must be accelerated given the urgency of the problem
• The training of Federal health care personnel should be a model for similar initiatives developed
across the country
• Federal Prescriber Training Must Address:
1. Best practices for appropriate and effective prescribing of pain medications
2. Principles of pain management
3. The misuse potential of controlled substances, identification of potential substance use disorders and
referral to further evaluation and treatment
4. Proper methods for disposing of controlled substances
Joint Pain Education Project (JPEP)
(LOE = Line of Effort)
Mission:
Develop standardized
content for patient,
primary care and
subspecialty pain
management education
and training for
DoD/VHA providers,
Synchronize DoD/VHA
education curriculum
content, supporting
materials, and a variety
of commonly accessible
delivery systems, and
Enhance pain care
transition between DoD
and VHA.
Learning and Training
together:
“Our Patients, Our
Teams, Our agencies,
Our shared model of
Quality Pain Care”
LOE 1 : (Disseminate) Ensure newly developed pain content is disseminated across
DoD and VHA programs in variety of platforms.
DoD & VHA
ECHO Programs
E-Learning
Platforms
Training
Programs
Face-to Face
Trainings
LOE 2 : (Evaluate) Conduct formal evaluation of curriculum to verify that the JPEP curriculum
materials and instruction achieves the desired impact for providers and patients.
Reaction
Level 1
Learning
Level 2
Behavior
Level 3
Results
Level 4
LOE 3: (Augment) Develop additional provider and patient content to augment
core primary care curriculum.
Patient and
Transitions of
Patient
Pain School
Provider
Care
Handouts
Videos
LOE 4: (Sustain) Develop /Implement plan to maintain validated, valued,
and ongoing DoD/VHA pain management education and training
HEC PMWG and
HEC Clin Care &
Operations Bus Line
DHA Education &
Training Directorate
VHA Employee
Education Services
End State:
DoD and VHA
Health Care
Systems share
common
understanding of
optimum pain
management
practice, respective
roles of Patients,
Providers, and
Leaders in our
shared DoD/VHA
pain management
strategy, resulting
in improved
transitions and
better care of
patients between
DoD and VHA
Health Care
Systems.
1: Understanding Pain Introduction
10-3: Transitional and Chronic Low Back Pain
2-1: Pain and Societal Impacts of Pain and Understanding 11-1: Shoulder Pain
11-2: Hip Pain
Pain
2-2: Pain Terminology, Taxonomy, and Physiology
11-3: Knee Pain
12-1: Myofascial, Connective Tissue, and Fibromyalgia
2-3: DoD/VA Pain Care Delivery Systems,
Pain
3-1: Assessment of Pain
13-1: Central Neuropathic Pain
3-2: Assessment Tools
13-2: Peripheral Neuropathic Pain
4-1: Acetaminophen, NSAIDS and Opioid Basics
14-1: Headache Pain
4-2: Anti-epileptics,
15-1: Visceral Pain
16:-1: Psychological and Psychiatric Conditions Related to
5-1: Chronic Opioid Therapy (COT) Risk Evaluation and
Pain
Mitigation
16-2: Sleep and Pain
5-2: Chronic Opioid Therapy Dose Reduction and
Discontinuation
16-3: Substance Use Disorder
6-1: Behavioral Management of Chronic Pain – Treatment 17-1: Geriatric Pain
7-1: Physical Based Therapeutic Approaches to Pain MGT 17-2: Palliative and Oncologic Pain
18-1: Women Pain Related Issues
8-1: Integrative Pain Medicine
18-2: Opioids and Preganancy
9-1: Pain Medicine Specialty Care
18-3: Pelvic Pain and Women
10-1: Neck Pain
10-2: Acute Low Back Pain & Red Flags
1: Pain Management Introduction
1: Course Introduction
What is Pain
History of Pain in the Military
Pain and Society
Joint Pain Education Program
2: Introduction to Pain Care
2-1: Pain and Societal Impacts of Pain and
Understanding Pain
Impact of Pain on Society
2-2: Pain Terminology, Taxonomy, and Physiology
Pain Terminology
Modern Understanding of Pain
Pain Taxonomy
Pain Pathways and Physiology
2-3: DoD/VA Pain Care Delivery Systems, and
Interprofessional Expanded Pain Care Teams
Biomedical to Biopsychosocial Care Model
Transformation
DoD and VA Systems of Pain Care Delivery: Stepped
Care Model of Pain Management
Inter-professional, Expanded Pain Care Team
Primary Care Pain Teams
Specialty Pain Care Team Models
JPEP Module Sample
SERIES TEN
SPINE PAIN CONDITIONS
MODULE 10–2: ACUTE LOW BACK PAIN
Lead Authoring Subject Matter Experts
Veterans Health Administration
Department of Defense
Dr. Beth Murinson
LCDR Ian Fowler, USN
13
© 2014 JPEP Pain Management
© 2014
Curriculum
JPEP Pain Management Curriculum
By the end of the module,
you will be able to:
• Describe lumbo-sacral anatomy and the exam of
the back and lower extremities.
• Discuss the differential diagnosis of acute low back
pain and identify Red Flag conditions.
• Know how to treat and when to refer patients with
acute low back pain.
We will review:
Topic One: Anatomy and Physical Exam
Topic Two: Differential Diagnosis and Red Flags
Topic Three: How to Treat and When to Refer
Topic One
Anatomy and Exam
16
Low back pain is anywhere
between the tip of the last
thoracic spinous process
to the tip of the sacro coccygeal joints.
Back pain can refer to the
lower extremity above and
below the knee.
Topic Two
Differential Diagnosis and Red Flags
19
Never forget the OPQRSTU
mnemonic
Onset of pain
Provocation/Palliation
Quality/Character
Region/Radiation
Severity/Intensity
Timing (continuous, intermittent)
U/you (impact on activities)
To rule out Red Flag
conditions look for:
Recent significant trauma (any age)
Osteoporosis, use of steroids
Age over 70
Weight loss, pain at night
Fever, immunosupression
Neurological deficit
History of cancer or IV drug abuse
Red Flag conditions to
consider are:
Tumors – lung, breast, GI, prostate, lymphoma,
myeloma
Infections – myelitis, abscess, cauda equina, conus
medullaris, Guillian-Barre
Fractures – osteoporotic compression
Visceral referral – aortic aneurysm, pelvic or
retroperitoneal disease
To detect these conditions use a checklist:
23
Features
Cauda Equina Syndrome
Conus Medullaris
Vertebral level
L2-sacrum
L1-L2
Spinal level
Injury to the lumbosacral nerve roots
Injury of the sacral cord segment (conus and epiconus)
and roots
Severity of symptoms
and signs
Usually severe
Usually not severe
Symmetry of symptoms
and signs
Usually asymmetric
Usually symmetric
Pain
Prominent, asymmetric, and radicular
Usually bilateral and in the perineal area
Motor
Weakness to flaccid paralysis
Normal motor function to mild or moderate weakness
Sensory
Saddle anesthesia, may be asymmetric
Symmetric saddle distribution, sensory loss of pin prick,
and temperature sensations (Tactile sensation is spared.)
Reflexes
Areflexic lower extremities; bulbocavemosus reflex is
absent in low CE (sacral) lesions
Areflexic lower extremities (If the epiconus is involved,
patellar reflex may be absent, whereas bulbocavernosus
reflex may be spared.)
Sphincter and sexual
function
Usually late and of lesser magnitude; lower sacral
roots involvement can cause bladder, bowel, and
sexual dysfunction
Early and severe bowel, bladder, and sexual dysfunction
that results in a reflexic bowel and bladder with impaired
erection in males
EMG
Multiple root level involvement; sphincters may also
be involved
Mostly normal lower extremity with external anal sphincter
involvement
Outcome
May be favorable compared with conus medullaris
syndrome
The outcome24may be less favorable than in patients
24 with
CES
Facilitator Guides
Understanding Pain Video:
https://www.youtube.com/watch?v=bPbgRh0dUzE&feature=youtu.be
For more information on JPEP or DoD/VHA
Pain Management Initiatives:
JPEPLearn@dvcipm.org
Obtaining CME/CE Credit
If you would like to receive continuing education credit for this activity,
please visit:
http://amsus.cds.pesgce.com