Combating the opioid epidemic
By Sarah Marshall
Opioids are the main driver of drug overdose deaths across the U.S., and West Virginia has been among the hardest hit by the crisis, experiencing the highest overdose death rates in the country. With a shared vision of combating this growing epidemic, health care providers and researchers from the Uniformed Services University (USU) and West Virginia University (WVU) recently came together and established an official collaboration to pool their resources.
In 2015, the overdose death rate in West Virginia was an estimated 41.5 per hundred thousand people, an increase of about 17 percent from the year prior, according to the Centers for Disease Control and Prevention. One of the state’s worst spots, Cabell County, located in southern West Virginia, has a population of 96,000, and an estimated 10,000 of those residents are addicted to opioids. Additionally, the state’s indigent burial fund, which helps families pay for a funeral when they can’t afford one, reportedly ran out of money this year for the sixth consecutive year, largely due to the high number of overdose deaths.
As the opioid epidemic continues to have a substantial impact on the state, leaders from WVU reached out to USU’s Defense and Veterans Center for Integrative Pain Management (DVCIPM), aware of their efforts to successfully combat opioid misuse in the military over the last several years – perhaps lessons learned in the military would be applicable to their state’s current crisis. Leaders from both universities, earlier this year, developed a Cooperative Research and Development Agreement (CRADA), allowing them to now formally share pain management resources, developed by DVCIPM. The agreement also allows the DVCIPM an opportunity to measure the efficacy of the tools they’ve developed in a new environment – a collaboration that these leaders believe is already adding value to both civilian and military medicine.
Nearly a decade ago, at the height of the Global War on Terrorism, physicians were seeking to help troops get their chronic pain levels to “zero” as they survived combat injuries in record numbers. This was often achieved by using opioids – and using opioids as a single modality – which the military quickly realized was not effective. This approach was impacting many service members and their relationships with loved ones, work, and daily living.
In response, in 2009, then-Army Surgeon General Lieutenant General (Dr.) Eric Schoomaker chartered the Army Pain Management Task Force, which sought to make recommendations for a comprehensive pain management strategy, ensuring an optimal quality of life for service members and other patients dealing with pain. It became clear to the military that pain should be viewed as more than just a “number,” and over the last several years, the military has been dedicated to researching and developing more effective tools for pain management, ultimately reducing the number of those potentially exposed to opioid addiction. The task force’s efforts led to the development of DVCIPM, which was designated as a Department of Defense Center of Excellence last year.
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| Some states have more painkiller prescriptions per person than others, including the state of West Virginia. (Image credit: CDC) |
Schoomaker, now retired, continues to lead these efforts, serving as vice chair for Leadership, Centers, and Programs for USU’s Department of Military and Emergency Medicine, which oversees DVCIPM. He explained that with any epidemic, it’s necessary to manage more than just the disease, but also the source of the disease. In this case, as the military has learned, chronic pain is a disease in and of itself. The source of this epidemic then largely hovers around poorly managed pain, he said, or in many cases, is a second or third order consequence of using opioids as a primary treatment.
It’s important to note, too, that it’s not about avoiding the use of opioids altogether, he added. They can still be of great benefit to patients dealing with chronic pain, but what’s important is how they’re used. Using opioids as the sole modality can lead an individual with chronic pain to become reliant, and then eventually dependent, and possibly addicted to the medication, he said. Based on these lessons learned in the military, it’s become evident that using a variety of integrative treatment modalities is most effective.
“We now have good evidence for the use of non-pharmacologic, non-opioid treatments, such as yoga, guided imagery, medical massage, chiropractic, acupuncture, Tai Chi, as well as a closely related movement therapy called Qigong, and music therapy,” Schoomaker said. “We have pretty good research to endorse their use.”
Because these practices might not work the same for each person, he added, it’s important to use a variety of these modalities as part of a comprehensive program, tailored to the needs of an individual with chronic pain.
Now, thanks to the official collaboration between USU and WVU, DVCIPM will have the opportunity to continue researching the efficacy of various integrative modalities and the pain management tools and resources they’ve developed.
“We owe it to our patients, and we owe it to practitioners, to only use tools that have good evidence for their use,” Schoomaker said.
DVCIPM Director Dr. Chester “Trip” Buckenmaier added that DVCIPM’s tools and resources have mainly been used in a fairly selective population within the military. Studying their efficacy in a smaller system within a state’s civilian infrastructure will allow them to gather and measure data on how successful they can be in a broader population, which will continue to help illustrate the potential these tools have.
“This could have real value for service members,” Buckenmaier said. He added that DVCIPM would not be as effective in its endeavors without relationships like this one.
Dr. Schoomaker agreed.
“It’s important to have relationships like we have with West Virginia … they pay off in so many different ways that you can never anticipate,” he said.
Since the CRADA was established, WVU opened the doors in May to a new Integrative Pain Management Center, which is now treating local residents struggling with chronic pain. There, they’ve implemented a number of DVCIPM resources to support the residents in their community, such as a more comprehensive pain assessment survey, known as the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). This tool helps generate a detailed 3-page report for physicians about how their patient is experiencing pain. Providers can gather an incredible amount of information about a patient in a matter of just 20 minutes, as opposed to many hours. The pain management center also offers a range of psychiatric and psychological services, as well as movement therapy and massage.
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| Battlefield acupuncture is a unique auricular (ear) acupuncture
procedure providing an integrative modality to help treat chronic pain. It’s being taught to qualified providers in the military. Now, thanks to a new collaboration between USU and WVU, it’s also being employed in a new pain management center in West Virginia to help combat the opioid crisis. (Image credit: Sarah Marshall) |
The newly opened center is also using DVCIPM’s Defense and Veterans Pain Rating Scale (DVPRS), a visual guide that helps physicians better assess how pain is impacting a patient beyond just the standard “0 to 10” scale. This tool encourages patients to define their pain based on how it’s impacting their mood, level of stress, and overall well-being. They’ve also started practicing battlefield acupuncture in the clinical setting, placing tiny, gold acupuncture needles in very specific points in a patient’s ear to help reduce their pain – a technique being taught by DVCIPM and the VA to providers in the military. They’ve also introduced DVCIPM’s Joint Pain Education Program, a pain management curriculum designed to teach providers new models of pain care.
“They’re using as many tools as they feel are relevant and acceptable to their population,” Schoomaker said. “They have worked at warp speed. It’s just amazing to see how quickly a unified approach to this could take place … It’s really been rewarding to watch. They’ve demonstrated enormous leadership bordering heroic to do what they’re doing.”
Dr. Mike Brumage, WVU’s assistant dean for Public Health Practice and Service, initiated the effort by reaching out to USU about two years ago, wanting to do something about the issue impacting his native West Virginia. At the time, he had just retired after a 25-year career in the U.S. Army Medical Corps, and was able to connect with former military health colleagues, including Schoomaker and then-Army Maj. Gen. (Dr.) Richard Thomas, who was serving as the Defense Health Agency Chief Medical Officer. Thomas is now USU President, and an alumnus of WVU’s undergraduate, dental and medical programs. This quickly led to several more meetings and discussions, led by Dr. Clay Marsh, vice president and executive dean of WVU’s Health Sciences Center (HSC), and Dr. Bill Ramsey, assistant vice president of Coordination and Logistics for WVU’s HSC. Ultimately, they arrived at a CRADA, signed off by Thomas and Marsh, and have since continued looking for ways to make the most out of their collaboration.
Most recently, Buckenmaier and DVCIPM Deputy Director Dr. Kevin Galloway have traveled to WVU to conduct workshops for staff in their new pain center, open to the local community, in an effort to introduce new DVCIPM tools, such as an outreach program they’ve developed known as Project ECHO (Extension for Community Healthcare Outcomes). This allows providers, nationwide, to connect through video teleconference to share knowledge for both common and complex diseases, helping to bridge the gap between primary care clinicians and specialists. As a result, patients in rural and underserved urban areas can receive best practice care without long waits or having to travel long distances.
Dr. Marc Haut, chair of WVU’s Department of Behavioral Medicine and Psychiatry, has been leading efforts, as a principal investigator, to develop future research projects as part of the CRADA. He noted that this unique collaboration is in line with WVU School of Medicine’s mission: to provide clinical care, through evidence-based research, as well as to educate and train a new generation of providers. He hopes that this effort will matriculate beyond their walls, and ultimately support other providers, and residents, throughout the state.
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| Battlefield acupuncture is a unique auricular (ear) acupuncture
procedure providing an integrative modality to help treat chronic pain. It’s being taught to qualified providers in the military, and is now being used in West Virginia at a new pain management center as an integrative treatment modality to help those battling opioid addiction. (Image credit: HJF) |
“We have a serious problem, and this is really going to make an impact,” Haut said. “Our goal is to take care of the people in the state of West Virginia.”
Haut also hopes these endeavors will lead to additional collaborations, in the future, between both universities, within other departments and centers.
Ramsey echoed similar sentiments.
“The power of this collaboration is that DVCIPM and the military have developed these integrative techniques, and now it’s very important in a state like West Virginia to be able to offer better pain management. This is a huge opportunity,” he added. “They can learn from us, and we can learn from them.”
Marsh added the ability to apply lessons learned from the military, and to apply those solutions to the civilian setting, “binds us together.”
“Together we can leverage that skill and knowledge to develop and implement solutions that will impact many of the serious problems that confront our world today, including the opioid epidemic,” Marsh said.
It all comes down to changing the way we view pain, Schoomaker noted, and that’s a cultural change that needs to happen – a challenge because there’s no blueprint for it. But what West Virginia has demonstrated – the work they’ve been doing and their enormous leadership and initiative – borders heroic, he said. The hope is that this joint effort will galvanize further interest from other entities, he added, leading to other similar collaborations, ultimately continuing the fight against this crisis that’s impacting our entire nation.
