# Presentation: 132805

## Case PresentationOperation Iraqi Freedom Veteran with Chronic Pain

- Mordecai Potash, M.D.
- Director, Behavioral Pain Management Programs
- Southeast Louisiana Veterans HCS
- Associate Professor of Clinical Psychiatry,
- Tulane University School of Medicine

## Introduction

- The veteran, Mr. B, is a 27 y/o male who first presents to the Baton Rouge OPC on December 16, 2005 after recently being discharged from the Army through Fort Hood.
- He brings with him detailed medical records from Fort Hood, which greatly aids in initial assessment.

## Injury Incident

- Mr. B is identified as having severe pain issues stemming from injury in Iraq and is referred to our Behavioral Pain Management Program for comprehensive assessment.
- Mr. B was in the US Army as a health care specialist and was in good health until 09/30/04, when he was severely injured by two improvised explosive devices during a ceremony in Iraq for the opening of a new sewage plant.

- Mr. B was at the ceremony when a Nissan pick-up truck exploded 20 meters away from him. He, and other soldiers, were surrounded by children and handing out candy when the blast occurred.

**AP Photo Just Prior to Blast**

## Two IED Explosions

- Iraqi National Guards had been charged with checking parked vehicles for improvised explosive devices (IED’s) before the ribbon cutting event.
- Multiple pieces of shrapnel imbedded in his jaw and veteran and his company retreated. There were obviously many dead children at that time and at least one dead US soldier as well.
- On-lookers rushed in to help the children.
- About 1⁄2 an hour later, a gray Deawoo sedan nudged into the crowd and exploded.
- This explosion occurred behind Mr. B, sending shrapnel into his legs. Several soldiers in his company were killed, as well as a number of civilians who had rushed in to help the already injured.
- Mr. B relates that he had loss of consciousness soon after the second blast.

## Vehicle Borne IEDs (VBIEDs) 

- Vehicle Borne IEDs (VBIEDs)

## Reported by News Outlets

- This incident is captured on film by reporters who were present for the opening ceremony and details of the incident are described by major news outlets around the world.
- Mr. B’s recollection is very poor after the second explosion. He recalls that the second explosion killed several soldiers he was very close to.
- After several days of emergent treatment, he is transported back to the US for treatment.

***The New York Times*****, October 1, 2004 Friday **
**2 CAR BOMBINGS IN IRAQ KILL 41, MANY CHILDREN**
**A pair of car bombs tore through a street **_[celebration](http://www.srch-results.com/lm/dir_rxt.asp?k=celebration)__ on Thursday called to __[mark](http://www.srch-results.com/lm/dir_rxt.asp?k=mark)__ the opening of a __[new](http://www.srch-results.com/lm/dir_rxt.asp?k=new)__ __[sewer](http://www.srch-results.com/lm/dir_rxt.asp?k=sewer)__ plant, killing 41 Iraqis, at least 34 of them children, and wounding and maiming 139 more, in one of the most horrific attacks in this city since the fall of Saddam Hussein. _

## Treatment at Fort Hood

- During treatment at Fort Hood, he is found to have bilateral open non-displaced fibular fractures, and multiple soft tissue wounds to the lower extremities. He requires several skin graft procedures to wounds on the left lower extremity.
- He is also found to have multiple traumatic nerve injuries to the lower extremities, including the sural and tibial nerves. Serial EMG & NCS studies are done which demonstrate neuropathy and sensory deficits in the lower extremities.
- He is also found to have suffered a mandibular fracture with avulsive injury, necessitating removal of five teeth. He also underwent inter-maxillary surgical fixation to promote bone re-growth to aid in placement of dental implants.
- During this time in Fort Hood, he also begins having severe pain in the back of his left leg / knee. He also has pain in his face and jaw.

## Sural Nerve

**Sural Nerve**

**Tibial & Sural Nerves**

**Mandible**

## Treatment at Fort Hood

- Mr. B is treated with several different pain medications at Fort Hood. He eventually is placed on Methadone 20mg TID with Percocet 10/650 for breakthrough pain.
- The major problem he has with pain medications is a sense of fuzziness or sedation from medications.
- Interestingly, he relates that his sense of “fuzziness” or difficulties with attention, memory, recall, and complex thought, did not improve with lowering of dosing of pain medications or even when pain medications were changed to non-narcotic alternatives with Percocet for PRN pain.
- While at Fort Hood, Mr. B is also evaluated by a psychiatrist & is found to have depressive symptoms as well as Post-Traumatic Stress Disorder. PTSD incidents include the car explosions as well as earlier incidents during his military tour.

## Presentation to Veterans Affairs HCS

- When he first comes to Baton Rouge OPC, he continues to be on Methadone and Percocet. He strongly wants to try another pain medication prior to his first assessment in Behavioral Pain Mgmt, so his PCP tries MS Contin.
- MS Contin causes constipation, sedation, and provides much less pain relief, so he is put back onto Methadone and Percocet.
- Mr. B then asks to be referred to CPET Behavioral Pain Management for a comprehensive review of his pain management options.
- He misses his first initial evaluation and I call veteran when he does not show. We reschedule and Mr. B is seen in CPET for initial evaluation in March 2006.

## CPET Initial Assessment

- 	PAIN IS MOST INTENSE IN THE BACK OF HIS LEFT LEG, BEHIND THE KNEE. PAIN DESCRIBED AS PULLING, GARBBING, BURNING, & RIPPING PAIN. PAIN IS MOST INTENSE IN THE POPLITEAL AREA, BUT ALSO EXTENDS INTO THE BICEP FEMORIS AS PAIN WORSENS. PAIN WORSENS AS THE DAY GOES ON. ALSO HAS SENSATIONS OF DEEP BRUISING. PAIN RIGHT NOW IS 3-4/10. PAIN HAS SPIKES TO 5-6/10. HOWEVER, THESE LOW PAIN SCORES ARE DUE TO TAKING METHADONE AND OXYCODONE 5 MG /ACETAMINOPHEN 325 MG TAB.
- 	HE HAS RUN OUT OF PAIN MEDICATION RECENTLY AND HIS PAIN WAS EXCRUTIATING AND UNBEARABLE, CLEARLY 10/10 WITHOUT PAIN MEDICATION.

## CPET Initial Assessment

- 	CURRENT MEDICATIONS:
- BUPROPION (WELLBUTRIN SR) 150MG SA TAB Sig: TAKE ONE TABLET BY MOUTH TWICE A DAY FOR DEPRESSION
- DULOXETINE HCL 60MG ORAL CAP Sig: TAKE ONE CAPSULE BY MOUTH DAILY
- METHADONE HCL 10 MG TABLET Sig: TAKE TWO TABLETS BY MOUTH THREE TIMES A DAY FOR CHRONIC PAIN
- OXYCODONE 5 MG /ACETAMINOPHEN 325 MG TAB Sig: TAKE 1-2 TABLETS BY MOUTH THREE TIMES A DAY AS NEEDED FOR BREAKTHROUGH
- 	IN REGARDS TO PAIN MEDICATION REGIME, PRESENT AND PAST, HE SAYS THAT METHADONE DOSING RIGHT NOW IS TOO STRONG FOR HIM, AND OFTEN FEELS STUPOROUS OR SEDATED ("THE WORLD IS GOING ON ALL AROUND YOU AND YOU DON'T KNOW WHAT IS GOING ON").

## CPET Initial Assessment

- MULTI-AXIAL INITIAL ASSESSMENT USED IN CPET:
- AXIS I
- 1. PAIN DISORDER DUE TO MEDICAL CONDITION
- 2. POST TRAUMATIC STRESS DISORDER DUE TO MILITARY TRAUMA
- AXIS II NO PERSONALITY DISORDERS ASSESSED
- AXIS III
- 1. CHRONIC PAIN DUE TO MULTIPLE TRAUMATIC NERVE INJURIES OF BOTH LOWER EXTREMITEIS REQUIRING MULTIPLE SURGICAL PROCEDURES
- 2. EPISODIC PAIN MANDIBULAR FRACTURE WITH AVULSIVE INJURY REQUIRING MULTIPLE SURGICAL PROCEDURES
- AXIS IV
- DISABLED DUE TO MILITARY TRAUMA WITH UPCOMING COMPENS & PENSION EXAMS FOR MEDICAL & PSYCH ISSUES
- AXIS V   GLOBAL ASSESSMENT OF FUNCTION = 50; SEVERE PAIN CAUSING SEVERE IMPAIRMENTS IN FUNCTIONING

## Follow-Up

- Vet is scheduled to have monthly follow-up visits and is given appointment cards and calls. However, he misses two appointments. I then call Mr. B at the end of May and tell him to come to CPET Clinic today. I discussed with vet his missed appointments and document the following:
- 	DISCUSSED WITH VET HIS MISSED APPOINTMENTS. VET WAS TRULY UNAWARE OF HIS MISSED APPOINTMENTS WITH ME AND ALSO HIS MISSED C&P APPOINTMENTS. HE SAYS THAT HE HAS BEEN FORGETFUL OF APPOINTMENTS IN GENERAL AND THAT HIS FAMILY HAS ALSO NOTICED HIS FORGETFULNESS AND LACK OF MOTIVATION AND INITIATIVE. I BELIEVE THAT HE HAS THESE SYMPTOMS FROM CLOSED-HEAD INJURY SUFFERED IN IED ATTACK IN IRAQ.
- Vet also having baseline pain scores of 4-5/10 but frequent and severe exacerbations to 6-8/10.

## Follow-Up

- We also solicit comment from Mr. B’s family and they also have noticed Mr. B’s forgetfulness, loss of cognitive sharpness, difficulty with attention / concentration, and difficulty organizing complex tasks.
- Both Mr. B and his family comment that these problems were completely non-existent prior to injury
- I add the additional AXIS I diagnosis of COGNITIVE DISORDER DUE TO MEDICAL CONDITION (TRAUMATIC BRAIN INJURY)
- We modestly increase Methadone from 40mg per day in divided dosing to 60mg per day in divided dosing to better control pain complaints
- We also add Ritalin (methylphenidate) 10mg PO QAM & QNOON  20MG PO QAM & QNOON

## Follow-Up

- Over the summer of 2006, Mr. B’s pain control and cognitive abilities moderately improve and Mr. B is satisfied with his progress. He begins to consider returning to work or school.
- He also completes his C&P examinations and is awarded 40% Service Connected Compensation for his injuries.
- In late summer, I receive an urgent call from Mr. B. He tells me that he has been estranged from his wife for several weeks.
- His wife stole his medications and overdosed on medications. Medication stolen include opiates and stimulants.
- Wife was taken to E.R. and stabilized. She is now in an inpatient psychiatric facility.
- Mr. B is now out of medication & requests urgent renewals of stolen medications.

## Its Always Something!

- I discuss this situation with Mr. B over the phone for some time and document the following:
- 	HAD CONVERSATION WITH VETERAN TODAY ON HIS CELL PHONE (225) XXX-XXXX. VET INFORMED ME THAT HIS ESTRANGED WIFE STOLE AND SWALLOWED A GOOD AMOUNT OF VETERAN'S PAIN MEDICATIONS. VET'S ESTRANGED WIFE RECEIVED URGENT MEDICAL CARE AND IS NOW AT AN INPATIENT PSYCHIATRIC FACILITY. VET WILL NOW RUN OUT OF HIS PAIN MEDICATIONS EARLY, IN A FEW DAYS.
- 	I TOLD VET THAT I UNDERSTOOD HIS SITUATION. I TOLD HIM THAT I NEEDED HIM TO REPORT THE THEFT OF HIS PAIN MEDICATION TO HIS PARISH'S LAW ENFORCEMENT OFFICIALS AND TO RECEIVE A COPY OF THIS LAW ENFORCEMENT REPORT AND TO BRING ME A COPY OF THAT REPORT.
- 	I WILL REVIEW REPORT WITH VETERAN. I WILL REVIEW REPORT WITH PHARMACY STAFF. I WILL ALSO CONTACT LAW ENFORCMENT OFFICIAL ON REPORT. IF APPROPRAITE, WILL THEN REPLACE STOLEN MEDICATION FOR VETERAN.

## Its Always Something!

- Mr. B presents the next day with a police report that documents the theft of medication.
- I then call the officer who made the report and confirm with him the specifics of the incident.
- The officer indicates that the Sherriff’s Office is following the case. However, they are not planning on pressing charges as long as Mr. B’s wife complies with inpatient psychiatric treatment and has no further incidents or behavioral problems suggestive of drug abuse.
- Officer also confirms that it his belief that Mr. B had no direct role or knowledge in this theft of medication and attempted overdose.
- I discuss this with pharmacy and pharmacy agrees to replace the stolen medication this one time.

## Preventing Future Diversion of Medication

- Mr. B agrees to buy a safe where he will store his medication, except for a three day supply he will keep in a pill bottle on his person.
- In the months that follow, Mr. B reports that he and his wife have reconciled. Also, his symptoms remain well controlled and Mr. B returns to gainful and challenging employment with the support of his family
- A problem develops when, five months after the theft, Mr. B’s wife presents to clinic to pick up his medications.

**Mr. B’s New Safe**

## Preventing Future Diversion of Medication

- An alert was put on his prescriptions at the time of his initial theft, so pharmacy immediately notifies a mental health colleague, who pages me.
- I call Mr. B and tell him that, because of his wife’s theft of medication, we would not release medications to her. I instructed Mr. B to present to clinic to pick up medication himself. Mr. B does so.
- In the last few months, Mr. B has picked up medication himself most months.
- Occasionally, we send medications by FedEx to his house but require delivery to be verified by driver’s license verification and signature verification which is uploaded into pharmacy’s computer.

## Issues for Discussion

- Treatment of chronic pain stemming from recent military trauma.
- Unique pain characteristics of trauma inflicted by improvised explosive devices.
- Co-management of chronic pain and chronic cognitive difficulties stemming from trauma.

- Dealing with theft of medication and instituting reasonable methods to prevent misuse and diversion of medications prescribed for pain and symptom control.