1. Battlefield to Bedside and Beyond:
The Continuum of Pain Care in the
Military and Veterans Health Systems
Rollin M. Gallagher, MD, MPH
Deputy National Program Director for Pain Management
Veterans Health Administration
Co-Chair, Working Group on Pain Management
DoD-VA Health Executive Council
Clinical Professor of Psychiatry and Anesthesiology
Director of Pain Policy and Primary Care Research,
Penn Pain Medicine
University of Pennsylvania

2. Disclosures
• Board of Directors of the American Academy
of Pain Medicine
• Board of Directors of the American Pain
Foundation
• Board of Directors, Audubon Pennsylvania

3. “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
Ex it W ounds: A Survival Guide to Pain M anagem ent
for Returning Veterans and Their Fam ilies
www.exitwoundsforveterans.org American Pain Foundation

4. Frequency of Possible Diagnoses OEF / OI F Veterans
Diagnosis (Broad ICD-9 Categories) Frequency Percent
Infectious and Parasitic Diseases (001-139) 68,569 13.5
Malignant Neoplasms (140-208) 5,809 1.1
Benign Neoplasms (210-239) 25,491 5.0
Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 135,250 26.6
Diseases of Blood and Blood Forming Organs (280-289) 14,342 2.8
Mental Disorders (290-319) 243,685 48.0
Diseases of Nervous System/ Sense Organs
202,298 39.8
(320-389)
Diseases of Circulatory System (390-459) 94,671 18.6
Disease of Respiratory System (460-519) 116,308 22.9
Disease of Digestive System (520-579) 172,462 33.9
Diseases of Genitourinary System (580-629) 63,421 12.5
Diseases of Skin (680-709) 93,635 18.4
Diseases of Musculoskeletal
265,450 52.2
System/Connective System (710-739)
Symptoms, Signs and Ill Defined Conditions
233,443 45.9
(780-799)
Injury/Poisonings (800-999) 130,300 25.6
*These are cumulative data since FY 2002, with data onfrom 1st Quarter FY 2002 through 4th Quarter FY can have multiple
Cumulative hospitalizations and outpatient visits as of September 30, 2009; Veterans 2009 4
diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories,
so the above numbers add up to greater than 508,152; percentages add up to greater than 100 for the same reason.4
Slide

5. Goals of Presentation
1) Review challenges of managing:
- Acute pain after battlefield injury
- The transitions of pain care after injury
- War zone to hospital
- Acute hospital care to rehabilitation
- Military care to Veterans Health System and
community
2) Describe DoD-VHA systems redesign:
the medical home model and stepped care
Primary Care<>Pain Medicine <> Pain Rehabilitation

6. Why chronic pain in OEF-OIF troops?
Wear and tear of military duty during war
a) Prolonged, repeated deployments
b) Osteoarthritis and spinal / limb injuries
c) Post-traumatic stress
90% survival, battlefield injuries:
a) Physical wounds
b) Blast injuries and TBI
c) Psychological wounds
Organizational issues in health care

7. The Beginning: Battlefield
polytrauma
Courtesy of C. Buckenmaier, MD

8. Prevalence of Chronic Pain, PTSD and TBI in a
sample of 340 OEF/OIF veterans with polytrauma
Chronic Pain PTSD
N=277 N=232
16.5%
81.5% 2.9% 68.2%
10.3%
42.1
12.6% % 6.8%
TBI 5.3%
N=227
66.8%
Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and
Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD.
Slide 9

9. Chronification of Pain to Maldynia
Pathology:
Pathophysiology of Maintenance:
-Radiculopathy -Muscle atrophy,
-Neuroma traction weakness;
-Myofascial sensitization -Bone loss;
-Brain, SC pathology -Immunocompromise
(atrophy, reorganization)
-Depression
Psychopathology
of maintenance: Acute injury Central
-Encoded anxiety and pain Sensitization
dysregulation -Neuroplastic Disability
- PTSD changes
-Emotional Less active
allodynia Kinesophobia
Peripheral Decreased
-Mood disorder Neurogenic
Sensitization: motivation
Inflammation: New Na+ channels Increased
- Glial activation cause lower isolation
- Pro-inflammatory threshold
Role loss
cytokines
- blood-nerve barrier Sleep disorder
dysruption
Gallagher RM in Ebert in Kerns, 2010

10. SECONDARY PREVENTION: BLOCKING THE STIMULUS TO
PREVENT CENTRAL SENSITIZATION: Index Case, 7 October 2003, 21st CSH,
Iraq
Courtesy of C. Buckenmaier, MD
Stojadinovic et al, Pain Medicine 2006;7(4):330-338

13. Results
Buckenmaier et al Pain Medicine 2009:10(8):1487-96
• Greater worry during transport (p<0.05) and higher
worst pain (p<0.001):
– explained 72.3% (p<0.001) of the variance in average pain
levels during transport
– Is this a trait (worrying) worth exploring, similar to ‘trait anxiety’
and / or catastrophizing that predict pain disability?
– Does chronic activation, or low threshold for activation, of
noradrenergic “stress centers” facilitate encoding of pain and
fear memories, and central sensitization?
– Should these traits be assessed, much like physical capacity,
as part of fitness, and addressed with resiliency training?
• Participants receiving continuous peripheral nerve
blocks (CPNBs) at LRMC reported significantly better
percent pain relief (p < 0.05) than those who did not,
despite higher worst pain intensity in the CPNB group

14. PAIN BETTER

15. Novel pain control methods and equipment
on battlefield and transport after injury
Ketamine nasal spray
Gabapentin
Paracetamol
MORPHINE ?
Slide 17

16. THE END: A 21th century pain image
HAPPY CAMPERS !!
No CRPS in our soldier: Injury Iraq
HAPPY CAMPERS !!

17. Regional Anesthesia and Military Battlefield Pain Outcome study
(RAMBPOS), Preliminary Results:
Brief Pain Inventory (BPI) Pain Intensity Mean Scores (95% CIs) by
NRS 0 =No Pain to 10 = As Bad as can Imagine
Months (N=180)
8 Pain right now Pain on average
Worst pain past 24 hours
7
6 P<0.05
5
4
3 P<0.01
2
1
0
Baseline 3 6 9 12 15 18 21 24
Months from Start of Rehabilitation Gallagher, Polomano et al,
Pain Med 2011: 12(3);473

18. Col. Chester “Trip” Buckenmaier and Index Regional Anesthesia
Patient John at the opening of the Acute Pain Research Unit
Walter Reed Army Medical Center

19. Transition to Com m unity Care:
MILITARY HOSPITAL, USA
MILITARY BASE CLINIC, USA
COMMUNITY
HEALTH ? VETERANS
HEALTH
SYSTEM SYSTEM
COMMUNITY
SUPPORT
SYSTEM

20. National Pain Management Strategy
Objective is to develop a comprehensive,
multicultural, integrated, system-wide approach
to pain management that reduces pain and
suffering for Veterans experiencing acute and
chronic pain associated with a wide range of
illnesses, including terminal illness.

21. VHA Pain Management Directive
(2009-053)
 Objectives of National Pain Management Strategy
 Stepped pain care model
 Pain Management Infrastructure
 Roles and responsibilities
 Pain Management Standards
 Pain assessment and treatment
 Evaluation of outcomes and quality
 Clinician competence and expertise
http://www.va.gov/painmanagement/docs/vha09paindirective.pdf

22. VA Stepped Pain Care
RISK
RISK Advanced pain medicine
diagnostics & interventions STEP
CARF accredited pain
rehabilitation
3
Comorbidities
Pain Medicine
Rehabilitation Medicine
Behavioral Pain Management STEP
Treatment Multidisciplinary Pain Clinics 2
Refractory SUD Programs
Mental Health Programs
Routine screening for presence & intensity of pain
Comprehensive pain assessment
Management of common pain conditions STEP
Complexity Support from MH-PC Integration, OEF/OIF, &
Post-Deployment Teams
1
Expanded care management
Opioid Renewal Pain Care Clinics

23. Organized for Implementation:
VHA Pain Management Strategy
National Pain Management Office, Patient Care Services
National PMgmt Strategy 23 VISN (Regional Health
Coordinating Committee Systems) Pain Points of Contact
Education
- Conferences (National) 152 Facility Pain Points of
- Website materials Contact
- Vapain list serve
Research
Standing Subcommittees
* Journal Special issues:
JRR&D, Pain Medicine
* HSRD / RR&D Merit
Awards, Training Awards
* PRIME Research Center

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Veterans Manage PTSD

25. ARMY PAIN TASK FORCE - Site Visit Map
WESTERN Region NORTHERN Region
Army VA
Navy Civilian
Air Force
PACIFIC Region SOUTHERN Region EUROPEAN Region
Fort Lewis (MAMC) & Puget Sound 4 Fort Carson (EACH)
8
Landstuhl (LRMC) & Baumholder 11 Honolulu (TAMC)
AHC
1 VA & Univ of Washington & Swedish Fort Bliss (WBAMC) & Fort Hood
Hospital 5 (CRDAMC) 12
Fort Gordon (DDEAMC) &
Duke Univ & Camp Lejeune & Fort Stewart (WACH)
9 Fort Bragg (WAMC)
2 Fort Drum (GAHC) 6 Tampa VA & Univ of S Florida
San Antonio VA,& Wilford Hall & Fort 13 White River Junction VA
3 Balboa Naval Hospital) & Travis 10 Fort Campbell (BACH)
Sam Houston (BAMC) 7
Slide 28 AFB & Scripps Center 14 Walter Reed (WRAMC)

26. A continuum of care requires partnership
of DoD and VHA
Army Pain Management Task Force Report
Health Executive Committee Pain Management
Work Group (PMWG)
 Co-Chairs:
 VA: Rollin Gallagher, MD, MPH
 DoD: Barry Cohen, MD
Charge: The PMWG will actively collaborate in
supporting the development of a model system
of integrated, timely, continuous, and expert pain
management for Servicemembers and Veterans.

27. Tertiary care: Evidence-based Relative proportion of
pain care, by setting
PM Subspecialties Continuum of Care
- Neurorem odeling
- Gene therapies (Gallagher, AAPM 2008; Subspecialty: tertiary
- Neurostim ulation Dubois , Gallagher, Lippe prevention
Pain Med 2009)
- Rehabilitation Centers
Secondary care: Pain Medicine PAIN
- Biopsychosocial assessm ent Specialty, Subspecialty:
** pain generators, mechanisms SPECIALTY Secondary / tertiary
** perpetuating factors -Practice prevention
- - - peripheral, CNS, psychosocial -Training
- Biopsychosocial Form ulation
- Research
Primary care
- M ech. Based Drug Algorithm s Primary / secondary /
- Stepped Behavioral Care tertiary prevention
- P hysical Therapy
- Office procedures
- CAM
Self-care , Community Care Primary / secondary /
- m editation - ex ercise tertiary prevention
- w eb-training - social m odeling
-social supports
DISEASE MANAGEMENT IN A POPULATION OF PATIENTS IN PAIN

28. READINGS
• McGinnis D. Exit Wounds: A Survival Guide to Pain Management for Returning
Veterans and Their Families www.exitwoundsforveterans.org
• Gallagher RM. Pain medicine and primary care: A community solution to pain as a
public health problem. Med Clin N Am 1999; 83(5): 555-585
• Gallagher RM. Integrating medical and behavioral treatment in chronic pain
management. Med Clin N Am 83(5): 823-849, 1999
• Dubois M, Gallagher RM, Lippe P. Pain Medicine Position Paper. Pain Med
2009;10(6): 972-
• Davies SJ, Quintner JL, Parsons RW, et al. Pre-clinic group education sessions
reduce waiting times and costs at public pain medicine units. Pain Med
2011;12(1):59–71.
• Davies SJ, Hayes C, Quintner JL. System plasticity and integrated care: Informed
consumers guide clinical reorientation and system reorganization. Pain Med
2011;12(1):4–8.
• VHA Pain Management Directive (VHA Directive 2009-053).
http://www.va.gov/painmanagement/docs/vha09paindirective.pdf
• Army Pain Task Force Report.
http://www.amedd.army.mil/reports/Pain_Management_Task_Force.pdf
• Hayes C, Hodson FJ. A whole person model of care for persistent pain: from
conceptual framework to practical application. Pain Med 2011; 12(12):1738-49