**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Integrating Treatment for Pain and PTSD**

**Presenter: Steven Dobscha**

**April 2, 2013**

**Integrating Treatment for Pain and PTSD**

**April 2, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**Steven.Dobscha@va.gov*

Dr. Robert Kerns:Good morning everybody; welcome to this month’s webinar series on pain management. I guess you all know by now, this is a webinar series that’s sponsored, or co-sponsored by the HSRD Center for Information Dissemination and Education Resources, CIDER, The Pain Research Informatics Medical Comorbidities and Education Center, and the National Pain Management Program Office. 

It is my great pleasure today to introduce Doctor Steven Dobscha who has been a wonderful collaborator and active participant, in fact leader, in our pain management and pain research community. Doctor Dobscha is a research director in the mental health and clinical neurosciences division at the Portland VA Medical Center in Portland, Oregon; and professor in the department of psychiatry at the Oregon Health Sciences University. He is also a core investigator of the center for the study of chronic comorbid mental and physical disorders at the Portland VA Medical Center, and principle investigator on several projects including a National Institute of Aging funded study to examine correlates of improvements in pain scores over time among older Veterans. 

He is co-investigator on our projects from our pain management CREATE that’s based at the West Haven campus of the VA Connecticut Health Care Center and I’m delighted to invite him to provide his view on his research today on integrating treatment for pain and PTSD. Doctor Dobscha.

Doctor Dobscha:Thank you very much Bob and welcome everybody. Today as Bob mentioned, I am going to be speaking about integrated treatment for pain and PTSD in many ways doing somewhat of an overview. There actually turned out to be a pretty considerable literature that I want to thank my research team for helping me pull together for this talk. Just to give a little bit of disclosure, I do not have any relevant financial relationships to disclose. This morning, I will first talk about the prevalence of pain and of PTSD and then the prevalence of comorbid pain and PTSD. Then move on to discussing some of the impacts of comorbid pain and PTSD on morbidity as well as care utilization. I then hope to present an overview of models that have been used to describe the relationship between pain and PTSD as well as some models for approaching integrated care with those conditions. I will spend some time discussing a clinical demonstration project that we have been conducting at the Portland VA; and discuss some other ongoing, or proposed research in the VA system and hope to conclude with some best practice suggestions. 

I also want... another disclaimer... I just want to apologize in advance if I missed somebody’s project or research area. I think there is a lot going on in this area right now and it is quite possible that I am not aware of certain projects. I will also mention that there is a list of some selected key references at the end, so if you get access to those handouts, you should be able to find some of the papers and studies that I refer to. 

Before we move on, I wanted to move on with a little bit of a survey just to get a sense of who is in the audience and Heidi, I am wondering if you can help with that. 

Heidi:I have it up on the screen right now. I will give people a few seconds to respond and I will put the results up here for you. 

Doctor Dobscha: I know this, just do your best to pick one of three, just to give me some sense of who is in the audience. Pick the most appropriate response. 

Heidi:And there we go. 

Doctor Dobscha:Wow. Okay... all right, well it looks like most of us are from the clinical world and I will certainly keep that in mind and thank you very much. 

All right, so let’s go ahead and move on. First thing I want to talk about is the prevalence of pain and PTSD. Pain is the most common physical symptom that is reported to physicians; and it is estimated that between one-third and one-half of patients treated in ambulatory care clinics have some type of chronic pain problem. In the VA system, the number is probably closer to fifty percent and it turns out that among OEF, OAF, OIF and OND, or otherwise known as returning Veterans, they are probably at the higher end of that as well. And, if you examine Veterans who are treated at poly-trauma settings, you’ll see rates well above eighty percent for people having problems with persisting pain. 

With respect to PTSD if you look at the general population, the prevalence is somewhere between seven and twelve percent. Among Vietnam Veterans, it has been estimated that a lifetime risk is up to thirty percent and for returning Veterans, current estimates are somewhere between thirteen to seventeen, maybe slightly higher percent and maybe higher with multiple deployments. In addition, I will mention that among women Veterans reporting pain, they may be more likely to have moderate to severe pain and traditionally, rates of PTSD or diagnosed PTSD has been higher than the general population. 

So, let’s look for a moment at comorbid pain and PTSD. A number of studies would suggest that among patients who present to pain programs, so they are coming in for pain treatment somewhere between about thirty-five and fifty percent have PTSD or at least significant PTSD symptomatology. I will mention that in a study that we had conducted here in Portland of four hundred patients with chronic pain who were recruited from a primary care setting, the numbers were a bit lower. About seventeen percent had a positive trauma scan as well as an elevated PTSD checklist score. But again, that’s a primary care setting and not a pain treatment setting. Similarly, among patients who present for PTSD treatment, it is estimated that between forty-five and eighty percent have some type of chronic pain problems. Up to a half of patients with pain that is secondary to motor vehicle accidents or burns have symptoms of PTSD, and it has been shown that among immigrant refugee populations who have trauma exposure, that about half have morbid pain PTSD. 

I would note that there is a little bit of literature to suggest that there may be important differences when you have the same event resulting in both the pain, or the injury resulting in pain, as well as the PTSD. It seems to increase rates of both conditions. 

So, we can see that the prevalence of comorbid pain and PTSD is actually quite high. As far as the impacts, multiple studies have shown that compared to patients who have either condition alone, patients with both disorders have more intense pain, more affective distress and great levels of life interference and disability. 

There is also some evidence that some patients who have comorbid pain and PTSD have greater healthcare utilization. A study by Samantha Outcalt, and I apologize if I didn’t say that correctly, was recently published in Pain Medicine, showing that Veterans who had pain and PTSD had seven percent more primary care visits than patients who had only pain; and that pain and PTSD had forty-six  more primary care visits than patients who had only PTSD.   In addition, rates of opioid and non-opioid analgesics, antidepressants and benzodiazepines were higher in the pain and PTSD group. This is a retrospective study done of forty-one thousand Veterans in VISN 11. You can see that there are some important impacts on utilization and costs. You can infer that there would be important implications for cost as well. 

I did want to speak a little bit about PTSD and prescription opioids, especially since there has been a fair amount of press and discussion about that. It’s pretty clear... well, it’s very clear that across all mental disorders, or patients who have mental disorders, they have a two to five times increased risk of being prescribed opioids or chance of being prescribed opioids, and there’s some evidence that is also true of post-traumatic stress disorder. In addition, there are several studies that suggest patients with post-traumatic stress disorder are likely to receive higher doses than Veterans without mental disorders. And one study I wanted to mention was Karen Seal’s study done on a hundred and forty-one thousand returning Veterans over one year. This was a national cohort, and she found that eighteen percent of Veterans in that group who had PTSD were prescribed opioids compared to twelve percent of Veterans with other mental health disorders, and seven percent with no diagnosed mental health disorders. 

Veterans with PTSD were more likely to receive high doses, and receive a sedative if not benzodiazepines compared to the no mental health diagnosis group. In a subset of the data looking at in-patient and emergency room data, she found that the PTSD group also had a greater incidence of opioid related accidents and overdoses, self-inflicted injuries and violence related injuries. She did do some subsequent analysis just to look at benzodiazepine use might have been driving that increase in injuries; although that was increased in magnitude, that did not explain that. Only, it does not look like, or I am not sure whether they looked at whether dose made a difference, because if Veterans were receiving higher doses of opioids, that also could have contributed to more accidents and injuries. We now know that there were multiple studies, other studies, showing that opioid dose is associated with unintentional overdose and death. 

It is clearly an important problem. Let’s talk about why pain and PTSD are so frequently comorbid and how they might interact. I want to present several models, and I know there are other models and there are a number of variations on these models. But, the thing that I think we should focus on today, one model of mutual maintenance, another set of models with shared or triple vulnerability models. I also want to talk a little bit about depression and coping as a mediator between pain and PTSD, and then I will talk a little bit about some biological models. 

Before we get to the models, I think we should talk about some key definitions of some constructs that you will see throughout this literature. The first one has to do with anxiety sensitivity. Anxiety sensitivity is a dispositional tendency, or a trait to be fearful of arousal related sensations, or anxiety based on beliefs that they may have harmful social, somatic or psychological consequences. The idea here is that people become fearful of the anxiety itself and anxiety sensitivity has actually been fairly well studied. It can be measured and it has been associated with worse anxiety among patients with panic disorder. There is some evidence to support that anxiety sensitivity is important in chronic pain and PTSD specifically. 

Now, related... at least I think related to this constrict is the idea of fear avoidance, or kinesophobia. This comes out of more of the pain literature, and this refers to the fear that the pain will lead to more injury or damage that then leads to increased avoidance of activities. We know that with chronic pain, that most of the time, increased pain that is associated with activity is not indicative of more physical damage being done. Yet, we find that among many patients, who have chronic pain, there is a strong belief there is an attribution of meaning to that pain and they believe that they are injuring themselves. In some ways, I see this as being akin to anxiety sensitivity in one case being afraid of anxiety, somatic invasions; and another being afraid of the pain, or developing a fear of the pain. 

The third construct I would like to talk about is catastrophizing. This is a particular coping style in which one worries about uncontrollable and inevitably negative outcomes; in other words thinking the worst. Again, I think representing... in some way there’s a component of meaning in this such that when you may perceive an experience of pain or anxiety and take that to mean that you’re not able to control it and that it’s going to lead to a negative outcome such as more physical damage or other types of consequences. 

Let’s talk a little bit about mutual maintenance, which is one of the main models that we see describing the relationship between pain and PTSD. In this model, physiological, affective and behavioral components of PTSD maintain or exacerbate symptoms of pain and cognitive, affective and behavioral components of chronic pain maintain or exacerbate symptoms of PTSD. There are seven basic mechanisms that contribute to the neutral maintenance model and this is a diagram from Sharp and Harvey. I will just walk us through those pretty quickly. 

The first known as intentional or reasoning biases refers to the pain or PTSD symptoms, or the threat of those symptoms being more demanding of attention. That can lead to amplification of the pain or PTSD symptoms. 

The second is anxiety symptom, or anxiety sensitivity, which we just discussed and I think in combination with catastrophizing, has been shown to lead to more dysfunction and disability. 

The third is reminders of the trauma, so it has been suggested that pain itself can be a reminder of the traumatic experience or the trauma, especially if the injury causing the pain occurred at the time of the trauma. Similarly, a trauma related memory can then focus attention on pain that otherwise would not be attended to. 

The fourth is avoidance. While some avoidance in both conditions has the potential to be adapted in the long term, it leads to, with pain, deep conditioning, disability and with both disorders, increased social isolation and more opportunity to focus on symptoms. For PTSD, it is felt that avoidance leads to less exposure to conditioned cues, or the cues that cause the anxiety, and then this prevents there to be extinction of the learned fear over time. And finally, avoidance also interferes with the reinforcement of rewarding behaviors, things that would bring meaning to ones life. 

Depression is certainly common in both disorders and it is well documented that anxiety enhances pain perception. 

The final category is related to cognitive demand, which is the idea that a focus on symptoms limits use of more adaptive coping cognitions or activities. 

I think this is a fairly comprehensive model and you can see how many of these, or most, or all fit with both pain and PTSD. 

This is the shared vulnerability model, and in that model the idea is that there is a psychological vulnerability that combines with a life event and a biological predisposition to result in emotional responses that then eventually contribute to disability. In the triple vulnerability model, which I think is fairly closely related, there is similarly a set of vulnerabilities that must be present in order to develop an anxiety disorder, in this case PTSD or conceivably pain. The three components in that model would be a generalized biological vulnerability, such as a genetic predisposition, a generalized psychological vulnerability such as poor coping skills. If we think about catastrophizing or a coping style, that might fit that criteria; and then a specific psychological vulnerability, which in this case would include a fear of somatic sensation such as pain or anxiety. 

So, let me move to a different type of a model. This is a set of models... a mediation models. The first one comes from Roth, and in this model, depression was found to mediate the relationship between PTSD and pain. What they did here is they worked with two hundred and forty-one patients and they collected data in a cross-sectional study and they used structural equation modeling, which is a set of statical techniques that allow a set of causal relationships between variables to be modeled. They tested a number of models, and this is the one with the best fit, essentially finding that PTSD had a strong, direct influence on depression, which subsequently had a strong, direct influence on disability, which had a fairly strong direct influence on pain. 

There is also some partial influence of depression on pain, but the idea here is that PTSD would then contribute to depression, which would contribute to disability, which then leads to increased pain levels. 

I will mention that one of the limitations of these models, when they are done cross-sectionally, is that you really cannot say anything about the direction of causality. This all leads from PTSD to pain, but theoretically, it could be the other direction. I would also mention, this does somewhat contradict a prior study done by Rudy which found that disability mediates the relationship between PTSD and depression; so, in that study, this box was actually kind of up here somewhere, however there were different population figures. 

This is a different mediation analysis that was done by Morasco and others here in Portland. This was a study of two hundred and one patients with chronic pain who had been tested for Hepatitis C at one medical center; but they all did not have Hepatitis C. This was also cross-sectional, and in this study, what they found is that PTSD was related to pain interference, but through two pathways, one through depression and the other through illness focused pain coping styles. This was from Mark Jensen’s chronic pain coping inventory and essentially found that there were three illness focused coping styles, which seemed to mediate this relationship; those being guarding, resting and asking for assistance. There are other types of coping styles, which are health focused and probably more helpful. 

The other... there are two models here, on is on pain interference, the other is on pain severity. Anyway, I thought this was also quite interesting. Looking at coping style being one of the main ways that PTSD interacts with pain interference. 

Before we move on to some treatment considerations, I wanted to talk about some biological models. It has been shown that autonomic nervous system and endogenous opioid system and serotonergic system dysregulations have been observed in both pain and PTSD. It has been documented that both state and trait anxiety levels that contribute to hyperalgesia. There was a fairly recent study suggesting that genetic factors, and a fair amount of variants in anxiety sensitivity train can be attributed to genetic factors. More recently, investigators have been working with neuropeptides Y and neuroactive steroids all pregnenolone and pregnenolone. These are compounds that have been found to regulate pain and be low in persons with pain and to be inversely correlated with PTSD symptom severity, so there’s a number of studies that have suggested that these compounds are important for both pain and PTSD. 

So, in summary, these models suggest that there are a number of factors and systems that may contribute to the interaction of pain and PTSD. Also, I think which suggest some potential targets for treatment approaches. To further summarize, I think that anxiety sensitivity, fear avoidance, catastrophizing, these constructs are all very intertwined and these factor likely work together to enhance fear of somatic sensations and that this fear contributes to avoidance and depression and ultimately more disability and symptoms due to increased isolation, deconditioning and decreased habituation to anxiety provoking cues. 

Moving on to integration: why an integrated approach? Well first, we have a number of models that suggest that there is substantial overlap in causes, maintenance and potential treatment approaches. It is well known that cognitive behavioral treatment approaches have been shown to be effective for both conditions, and there is often substantial overlap in content. We already have some tools to work with. I think there are also efficiencies to be gained in terms of implementation, especially since the comorbidity of these two conditions is so common. 

There are also problems when treatment is not integrated, as many of you are aware. One has to do with communication between involved clinicians. Often a primary care provider working with pain and a mental health specialist working with PTSD... there may be some differences in opinion or messaging to the patient. For example the role of opioid therapy, that comes up a lot here at Portland. In addition, one of the untreated conditions may limit response to the other condition, so if they are not really being looked at as a whole, there is risk that we are going to get stuck. 

One of the most promising integrated approaches; I think the first set relates to cognitive behavioral treatments, which are goal oriented psychotherapy approaches that systematically address maladaptive thoughts and behaviors. There are really three... at least that I have selected... that I think show special promise. The first is cognitive processing therapy, which John Otis has been testing, and I will come back to that in a minute. In CPT, it is a form of CBT, which incorporates trauma specific cognitive techniques, in particular addressing issues of safety, trust, power, control, esteem and intimacy. 

Another promising approach, I think would work well for pain and PTSD is acceptance and commitment therapy, which focuses on accepting, rather than modifying internal experience and emphasizing a shift towards seeking a valued life. It is really outcomes driven and I think in large part related to that would be behavioral activation, which is focused on helping patients engage in activities that are rewarding and consistent with long term goals. I will be talking a little bit about that in a minute, but I would be curious if we could do another survey, Heidi if you could help with that, in really understanding how many people in the audience may have heard about... well, there are several questions here. I will let you answer those. 

Heidi:Responses are coming in, we will give it just a few more seconds, and then I will show the results up here. There we go. 

Doctor Dobscha:All right so about half of us have heard of behavioral activation and then I think we are also curious for the people who have used behavioral... heard of it and how they used it. I do not know if we could put that up as well. 

Heidi:Yep, there we go. 

Doctor Dobscha:The reason that I put not sure is because behavioral activation is really derived from the behavioral elements of CBT, so I think if you’ve done CBT, it’s quite likely that you’ve been using elements of behavioral activation. So, we have about forty percent who have used and okay... all right, well that’s good. I think... I find this a very exciting approach for several reasons, so let me just walk us through that a little bit for those of who are not familiar with behavioral activation. 

This is a figure that is adapted from two sources, from Jacobsen, Martell, and Dimidjian, as well as Lori Richell in 2011. What we have here at the top is what might be considered a typical behavioral response in depression, such as there is a trigger, which creates a response, in this case negative emotions, which contributes to avoidance, which then feeds back to more negative emotions and this negative cycle. The example that Doctor Richell gives in her paper is that a college student fails a test and that then contributes to feeling sad and hopeless, which then contributes to staying home in the dorm room, sleeping a lot, not studying, not answering the phone, which again feeds back to the set of sadness and hopelessness. 

What behavioral activation needs to do is change the contextual factors through alternative coping. In this model what we might be helping that student do is when experiencing the sadness and hopelessness, to develop alternative coping styles. Which might be, for example, getting a tutor, talking to a teacher about missed work, learning about extra credit, or finding a study partner; which if that’s done, it is possible you can leave this negative pathway and move to a set of new responses, which will be fewer negative emotions and more of a sense of mastery. Such that the next time there’s a test, perhaps the student gets a B. in this case there is a more positive response emotionally, which then reinforces the alternative coping strategy. There is really a focus on trying to identify alternative behavioral coping strategies, and behavioral responses, that then reward the alternative coping strategies, which lead to a more rewarding life. 

We will come back to behavioral activation in a moment. Another promising model I just wanted to briefly mention was the collaborative care model, which comes from the chronic disease model that Ed Wagner, and others have developed over time. This is also a potentially promising integrated type of approach for pain and PTSD. Collaborative interventions have been designed to increase adherence to guideline criteria to be applied in primary care settings for the most part. The idea with collaborative care is in order to produce functional and clinical outcomes... or improved outcomes... you need to have productive interactions between informed activated patients and prepared proactive practice teams. In order to create those productive interactions, you really need a number of components. First is self-management support and education. There needs to be a delivery system, design changes that are principally care management approaches. There needs to be decision support, so there needs to be some access to experts when needed to help guide primary care teams treating the condition and there also needs to be changes in the clinical information systems that facilitate communication between people providing care management, decision support, and the primary care team. 

This is, in general, found to be a robust model and effective in treating a number of chronic conditions in primary care, including diabetes, congestive heart failure, depression, panic disorder and more recently, chronic pain. This is another potentially promising type of approach. 

I wanted to mention integrative or complimentary and alternative medicine therapies. This is a diagram that comes from the National Center for Complementary and Alternative Medicine, which suggests that there are some types of treatments for pain that show promise. For most of these therapies, there’s a limited to perhaps moderate level of evidence supporting effectiveness, thus you’ll see the term promising use pretty frequently. In this case, acupuncture, massage, spinal manipulation, progressive relaxation and yoga, show promising evidence of benefit. 

For chronic pain, the evidence base is probably strongest for use of acupuncture, yoga and massage. The other thing I’ll mention that isn’t on here, and partly because I’m not quite sure if it falls into complimentary alternative medicine versus more traditional, is mindfulness... therapies which are increasingly being studied and also show great promise. 

I wanted to present a slide on integrated therapies for PTSD and this was adapted from the VA-DOD clinical practice guideline for the management of posttraumatic stress. There is actually less literature in this area with respect to complimentary and alternative approaches. But they do suggest that certain CAM approaches, mindfulness, yoga, acupuncture, massage and others may be considered for adjunctive treatment of hyperarousal symptoms of PTSD and there’s probably a little bit stronger evidence to support the CAM approaches as maybe adjunctive approaches to address some of the comorbid conditions. For example, acupuncture being used for pain. 

I think overall looking at the overlaps between pain and PTSD with respect to integrated therapies, I think the most promising approaches would include mindfulness or other types of meditation or relaxation. Perhaps yoga, which may be a little bit more physically activating, then massage, although probably not as well tested in pain patients and perhaps acupuncture as well. 

Now, getting back to the other terminology integrated, which is where we started, which means integrating treatments for pain and PTSD, I did want to mention several small studies that have been done. These two studies were done with traumatized refugees. The first being a study of CBT plus biofeedback plus physical activity and finding that patients who got all three of those components showed greater change in cognitive coping style. In the second study by Morina, Doctor Morina combined... or patients had ten sessions of biofeedback followed by ten sessions of narrative exposure therapy and narrative exposure therapy is therapy that has been created for traumatized refugees and is focused on imaginative exposure to memories of a traumatic event and reorganization of those memories to a chronological narrative. And this study also found significant pre post reductions in symptoms. 

Another study was done by Muller with the biofeedback and CBT again showing positive effects comparing pre to post measures. Finally, a study by Wald of five women from an urban area with pain and PTSD who received four sessions of inter receptive exposure followed by eight sessions of trauma related exposure therapy. Inter receptive exposure is really targeted toward anxiety sensitivity and what this is an exposure to feared bodily sensation through brief physical exercises such as running in place or hyperventilating. The idea is if you do these exercises that the repeated exposure will lead to a learning response that the feared sensations were not dangerous. 

I would like to mention the program out of Salt Lake City. This is at the VA Salt Lake City Healthcare System. This is an outpatient program that currently offers ten non-pharmacologic CAM therapies in mind-body skills classes. All patients... this is an out patient program and people are typically referred from other out patient programs. All Veterans receive an initial assessment and development of a treatment plan as well as follow up reassessments. They may have a number of... any combination of these various therapies and classes. 

Doctor Smeeding has collected data from that program over a two-year period. She did a retrospective study, which was a post-hoc quasi-experimental analysis, which looked at three different groups: people who had anxiety; and a particular high versus low anxiety depression; and PTSD. Looking across those three types of symptoms; and found that within each of those groups, during the program, there were improvements in depression and anxiety scores as well as some health-related quality of life scores over six months, with some of those improvements persisting for at least twelve months; again, some very promising initial data here. 

I wanted to spend a few minutes talking about the demonstration project that we have been doing here at the Portland VA. It’s called IMPPROVE, which is the Integrated Management of Pain and PTSD in Returning OEF/OIF/OND Veterans, and this is a project that’s been supported by funding from VA mental health services through the Pacific Northwest MIRECC, and I want to acknowledge my contributors here. 

The goals of the IMPROVE primarily are to provide integrated treatment for chronic pain and PTSD, but also to improve collaboration among primary care, mental health and other clinicians to facilitate treatment of the two conditions, so it’s really borrowing from the collaborative care model. We take most of our referrals from post deployment and primary care clinics. The program is run by a psychologist, Jane Plagge, who is working with a part-time physiatrist, Doctor Karl. Doctor Plagge does an initial evaluation and some limited ongoing care management, and additionally patient data are collected routinely to facilitate care and make alterations in care plans as needed. The psychologist meets weekly with the physiatrist, who has an opportunity to review the medical record and together they create recommendations, which go back to the primary care provider. So this is really bringing in that collaborative care element. 

In addition, Veterans who enter the program receive up to eight behavioral activation sessions and just to describe some of the components of those behavioral activation sessions; it is certainly a flexible approach, which tends to be guided by the Veteran’s values, goals, and priorities. There is some initial education about chronic pain, PTSD and avoidance, which is then supported... there is more additional education as needed during the course of the program. Patients are given the rationale for behavioral activation, values are explored, and they identify treatment goals and barriers, and identify specific areas for activation. And activity scheduling is frequently used to increase the awareness of the interaction between activities, emotions, pain, and PTSD symptoms and also to identify helpful and unhelpful behavioral patterns. Various types of problem solving and alternative coping strategies are identified. 

Just to present some preliminary outcomes, I do want to leave us about ten minutes for questions, so I’m going to move through this somewhat quickly, but we did a retrospective analysis of the first fifty-eight Veterans who came in to the project. We obtained data from the VISN twenty data warehouse and initially compared our completers to non-completers and examined outcome measures over time. Our main focus was on the PTSD checklist score, chronic pain grade severity and chronic pain grade interference. What we found is that of seventy-three Veterans who were eligible for the program, about eighty percent decided to participate and most of those Veterans had been referred from primary care or post deployment clinics, but there were some that came in from the health clinicians. The median age was thirty-three, almost all male, and almost all white, and the most frequently recommended pain strategies by our decision support team were physical therapy, pain medication, or pain medication adjustments, imaging or other work up, and psychiatric medications. 

I mention that we had previously done a study of collaborative care for chronic pain with an older patient population and the recommendations for imaging their work up were much less. However, with this population who are often coming right out of deployments or soon after deployments, it was felt that there were still additional workups that often needed to be done. 

Looking at the completers and noncompleters, only about fifty percent completed the behavioral activation program, which for most Veterans was eight sessions. We found that completers were older than noncompleters, the average age, thirty-nine versus thirty, but otherwise did not differ on any other variables. Looking at the reasons for discontinuation, about half of the group that discontinued, we do not really know. They just did not respond to additional outreach. There were several who, we felt, needed to be discontinued for various reasons including poor treatment adherence, various crises... we just didn’t think this was the most appropriate treatment for them at this time. Several people had geographic or travel problems and so forth. We also found that dropouts were linear over the course of treatment as people dropped out. This is a major limitation of the program, as it currently exists. 

This is a very busy slide, but just to point out a couple things that essentially we had a significant improvement across all variables except for the audit C score, which was not specifically targeted. They are pretty substantial across most of these measures including the pain catastrophizing scale and the Tampa Kinesophobia Scale, which measures fear avoidance. The other thing to notice about this is that almost of the gains in our primary measures occurred by mid intervention before the fifth session. 

Additional findings that intervention completers were generally satisfied with the program, and generally, on average, felt somewhat better. So, our next steps here are first to try decreasing the number of sessions and there are several reasons for this. One is that as I mentioned, most gains were made by five sessions. We are hoping it may reduce dropouts, especially if people are committing up front to a fewer number of sessions. It may improve feasibility of translating the program to standard clinical settings, where there are a lot of clinical demands, and there’s also evidence from other behavioral activation intervention programs that a shorter number of sessions can work. 

We are also expanding our reach to non-returning Veteran groups via non-Veterans. We are currently taking more referrals directly from PTSD clinical teams and we are now testing it in a group format. Thus far, we seem to be getting more steady referrals and fewer dropouts. It may be, though that the fewer dropouts may have to do from the fact that the returning Veterans group in particular are younger group have traditionally been a bit more challenging to engage in ongoing care, and that seems to be a national problem. 

I wanted to briefly mention a couple more projects that are ongoing, so John Otis has created a CBT and an integrated treatment, which uses elements from Cognitive Behavioral Treatment and Cognitive Processing Therapy and his initial pilot was published in 2009. This involved a twelve-session treatment, which again takes various components from those two types of treatments and creates one program. Just to point out the original program included Cognitive Restructuring, Inter receptive Exposure Activities, and some more PTSD specific types of sessions as well.

This is a slide from the first three patients who participated in that program. I borrowed this from Doctor Otis, and you can see some pretty pronounced predisposed changes across most of the measures. However, since that time, Doctor Otis has expanded his work in this area, and he currently has a VA RR and D funded study of a hundred and two Veterans from VA Boston and VA Connecticut who have comorbid chronic pain and PTSD. In this study, participants are being randomized to an intensive integrated pain or PTSD treatment versus standard care. One of the ways that the intervention has changed based on his preliminary findings, is it is now a six, bi-weekly out patient... or it is done in six bi-weekly sessions of ninety minutes, so it’s much more focused than previously. 

That study is currently in progress. Another study I wanted to mention is a study that has been proposed by Erica Scioli, and again, I am sorry if I did not pronounce that correctly. She is also out of Boston, VA Boston, and this is a project, which we use exercise training for pain and PTSD and the rationale here is that exercise programs have been shown to be effective for pain, and to some extent helpful for PTSD. Certainly, it has been shown to be helpful for anger, stress, depression and self-esteem. She is particularly interested in some of the biological mediators of the relationship between pain, PTSD and outcomes. There have been a number of studies that suggest that exercise may affect the anti stress hormones Allopregnanolone and pregnenolone as well as neuropeptide Y. So her aims are to propose to test the effects of a twelve-week progressive exercise training program on the symptoms of pain and PTSD, pain thresholds and tolerance, but also stress hormone levels and look for relationships among all those variables. 

I think this looks like a very exciting study. Then another study I just wanted to mention going on, this was funded to the DOD at the South Texas Research Organizational Network guiding studies on trauma and resilience. This was a strong start project run by Robert Gatchel. In this project, which is a randomized clinical trial, there are four arms: treatment as usual, pain treatment, which is really five sessions focused more on self care, PTSD treatment only group, which is a five session adaptation of prolonged exposure therapy, and then a combined treatment group which is combining the pain and PTSD treatment modules. They are going to be examining psychosocial and functional measures over twelve months. 

I want to conclude here, and I apologize that I used up a little bit more time than I planned, but just talking about what I think some of our current best practices for pain and PTSD are or should be. And these are really in many ways adapted from the 2010 VA DOD guidelines on PTSD which actually includes a section on comorbid PTSD and pain, and I would urge you to take a look at that if you haven’t already. But with an integrated approach to pain and PTSD, the first step would be to conduct a thorough assessment including a bio-psychosocial history assessing for other medical and psychiatric problems including risk of misuse of substances. Certainly, a common comorbid condition with both pain and PTSD, I think a focus on evaluating the impacts of pain on function, activities and particular activities that bring a person aboard and are consistent with their values, and I think identification of avoidance behaviors that may contribute to emotional distress, or impaired function. 

It is pretty clear that management should be multi-disciplinary and multi-modal in addressing physical, social, psychological and spiritual components in an individualized plan. CBT should be strongly considered, in particular with components that address fear avoidance related to pain. I think with a behavioral activation emphasis, at least that seems to be an interesting way to go, and to be able to focus on rewarding behaviors that... or emphasizing behaviors that bring a person positive reward, and then cognitive and behavioral coping skills perhaps to replace or diminish the role of catastrophizing. 

I think that non-pharmacological modalities such as biofeedback, physical therapy or complimentary alternative modalities should be considered, and I am particularly excited by mindfulness, meditation, yoga and acupuncture approaches here. Then finally, just to mention that centrally acting medications should be used in caution with patients with PTSD, particularly because of some of the risks that we had... I had discussed earlier. Patients with pain and PTSD are more likely to receive opioids and benzodiazepines and especially with benzodiazepines with PTSD, these medications are likely to have limited, if any value for chronic pain or chronic stress. I’m going to stop so we have just a few minutes for questions, but I will mention, or maybe Heidi wants to mention, I’m going to be here for about fifteen minutes afterwards, after the call. 

Heidi:Oh, you’re leaving it wide open for everyone now. They are all going to be sending in even more questions than we already have. That is fine; we do have several pending questions, so we are going to get started on that. 

Bob if you want to add anything to the questions, I have un muted your line so you are able to talk on here now also. 

Bob:Before too many people scatter, thank you Steve that was an excellent presentation. I am sure there are going to be a lot of questions. We are appreciative that you are willing to spend a few more minutes answering at least a few questions and then because this topic really is of considerable importance to the VA... maybe none as more important. So, I’ll turn things back over to Heidi and Steve and we will take a crack at some of those questions. 

Heidi:Fantastic, thanks Bob. The first question I have here, what is a positive trauma stem? I am unfamiliar with that terminology. 

Doctor Dobscha:Oh, okay sure, that was... maybe that is just our own local terminology. When we did our study on chronic pain and primary care, in order to assess for PTSD we wanted to initially find out if someone had had a traumatic experience. Since we did not do a diagnostic interview or a diagnostic measure, and only used the PCL50, which measures symptom severity, we also included the trauma stem from just asking if they had been exposed to trauma in order to improve specificity of that measure. 

Heidi:Are you aware of any studies using beta-blockers at the time of severe trauma, and whether there are any outcome differences in terms of both pain and PTSD severity? 

Doctor Dobscha:That sounds... I have heard of that, but I do not really know anything about it and maybe Bob... I do not know if you know anything about those studies. 

Heidi:Sounds like Bob may be paying attention to something else. That is okay. 

Bob:I’m sorry, I got distracted. What was the question? 

Doctor Dobscha:The question had to do with are we aware of any studies where beta-blockers are being used at the time of trauma and I really did not have an answer for that. 

Bob:No, I do not either, sorry. 

Doctor Dobscha:There are several studies, I know that are underway looking at biological pharmacotherapies being used at the time of trauma, but I am not familiar with beta-blockers being used in that way. 

Bob:The only thing I can say is not about that. I know that Doctor Gallagher is the PI on an important study looking at early analgesia even in the battlefield, related to pain management and then following those service members forward and even into their care in VA. I know that’s not exactly what’s being asked, but the idea about early interventions to reduce the impact of trauma and pain on subsequent pain and development, or expression of PTSD is a reasonable strategy to promote, but frankly I don’t know of anybody that’s doing that pharmacologically with the idea of suppressing, for example a stress response. 

Heidi:What is prolotherapy? 

Doctor Dobscha:Prolotherapy... I’m trying to remember, it’s in I think injecting... I do not remember. Bob, do you remember what that is? 

Bob:No, I do not. 

Doctor Dobscha: I apologize for that. 

Bob:I think it is a very... I that think the points that you were making Steve about the growing that’s still limited evidence based to support complimentary alternative medicines for these kinds of problems is important. I think you particularly emphasize those kinds of strategies that might have a mechanism of a effect via regulation of emotional arousal makes most sense and is intuitive in the pain world. Adding to that, the growing evidence about acupuncture makes really good sense, and simultaneously, I think there is growing evidence related to some additional kinds of complimentary and alternative medicines approaches or integrated care, that are frankly not revealing good evidence. In fact, maybe evidence that they are not particularly effective and I think the key policy message from pain management is consistent with the message that has been advanced from mental health services and Tony Zeiss the former chief consultant of mental health services, which is that Veterans really deserve first line treatments. The treatments for either or both, pain and posttraumatic stress disorder, that are known to be effective, at least for large numbers of people. That only once those interventions, or in the context of providing those interventions, should we be thinking about adding on additional therapies, particularly complimentary and alternative medicine, or integrated approaches, have less evidence that may be helpful for individuals. 

Doctor Dobscha:Yes, thanks I could not agree more with that. 

Heidi:In the biofeedback studies, do you know what modality was used? 

Doctor Dobscha:You know, I do not. I think it varied, in fact I can recall that in several of those studies, it really did not provide a lot of information about those. I think those are included in the reference list. Yes, I can see them on the reference list if you want to look at them. 

Heidi:Have you seen any studies of physical activity, specifically aerobic exercise with heart rate monitoring for pain or PTSD and if so what were the results? 

Doctor Dobscha:I also do not have a lot of information about that. I know that studies have certainly been done for both of those conditions, but off hand, I do not have references to tell you about. 

Bob: I can maybe refer to an important study that was conducted in VA. It was a cooperative studies program targeting Gulf War Veteran Illness included in population. In the sample were Veterans from the first Persian Gulf war who had diffuse musculoskeletal pain, chronic fatigue, and memory or cognitive deficits and it was a two by two randomized, controlled trial of cognitive behavior therapy versus aerobic fitness and exercise. In that trial, there were really modest effects on any of the outcomes and not strong evidence of either one treatment relative to the other, or the incremental benefits of the combined intervention. The senior author is Danza it was probably published in the mid to late 1990s, so that trial was a very important trial for us in VA. It was well powered trial and I would encourage the person asking the question, or others that are interested, to go look for that trial. I do believe that was published in either JAMA or Annals of Internal Medicine. 

Doctor Dobscha:I want to add that anybody... there is a lot of things I don’t know the answer to off hand, but if you send me an e-mail in VA Outlook I’ll be happy to look it up and answer it. 

Bob:Maybe I will add that on that same line, but not related to aerobic fitness, is work that’s been presented on this in the past by Sara Krein at the Ann Arbor VA. Essentially a walking study, and designed to promote activity in Veterans with chronic musculoskeletal pain, and so some of you will remember that presentation, and it’s not quite what’s being asked by this question, but it’s along the same theme that Doctor Dobscha and others have been encouraging that we attend to. Which are the potential benefits of behavioral activation strategies, any kind of strategies to promote exercise and structured activity? And maybe the end of the continuum is studies of aerobic  conditioning. 

Heidi:Regarding the common but risky and non-guideline based therapy of benzodiazepines for PTSD and pain, when and how would you suggest tapering off benzodiazepines with your current model? 

Doctor Dobscha:That sounded like more than a question, but it’s a good one and I’m not sure the model I’m talking about necessarily, that I can see, impacts how you would taper benzodiazepine other than to emphasize that one important aspect would be to work with the patient in attempting to identify some alternative coping strategies. As far as I can tell from my reading, I did not see any specific literature regarding the relationship between anxiety sensitivity and benzodiazepines. But I would think that it would be important to make sure there’s education and support about the potential role of anxiety sensitivity, so that the patient can at least be aware that they may have a predisposition to being especially fearful of the anxiety, and maybe work with the patient on the meaning of that. Other than that, I am not sure that I see it as being all that different than any other type of benzodiazepine taper that you might consider. I do not know if I quite answered the question. 

Heidi:I totally agree with the relationship with PTSD and pain. Working from the pain clinic, how do you recommend encouraging your mental health providers to treat pain and PTSD together? How do you recommend requesting treatments that might help PTSD and pain at the same time, behavioral activation, CBT... how do you find the specialist who will treat using these techniques used to treat pain and PTSD together? 

Doctor Dobscha:I think my initial response is that there is probably a pretty substantial gap in education. I think if you went to many mental health providers, they would profess not being aware of what would be the best approaches for pain and PTSD. I guess one of the hopes of this talk or the literature in this area would be that I think the mental health providers can do a great deal by focusing in particular on some of those common elements for pain and PTSD in particular the behavioral activation component. So, I think education is an important issue. I also think that often there’s not enough communication between mental health and other specialists or primary care providers regarding focusing on improving function and frank discussions about opioid treatment or other types of approaches. I think without having an ongoing relationship or a dialogue about those types of things, it is going to be very hard to engage the mental health providers in treating pain. There are other types of programs that mental health clinicians can use to treat chronic pain. Stanford has a program and I think there are plenty of types of approaches that mental health can use if they are exposed to them. 

Heidi:I am particularly interested in further understanding the impact of unresolved PTSD in Korea or Viet Nam era Veterans and the impact of PTSD as these Veterans approach end of life. Are you aware of interventions currently being utilized to treat this population in an integrated model? 

Doctor Dobscha:I am not aware of an intervention related to treating integrated intervention for pain and PTSD to treat that population. I have not seen anything in the literature. We are certainly expanding our focus here in Portland beyond the OEF, OIF, OND population, partly in an effort to see how that might work. I also know that there are certainly clinical projects and programs that focus on treating older Veterans who have PTSD but I am not familiar about combining an approach to chronic pain. 

Heidi:Have you considered using emotional freedom technique to increase sense of mastery and lower anxiety? 

Doctor Dobscha:I do not know what those are, unfortunately. That sounds like a specific approach, and I do not really know what that is. 

Heidi:We cannot expect you to know everything, so that’s I think a fair answer. You mentioned younger Veterans are more difficult to engage in care and this is nationwide. These groups seem to be the ones who are repeatedly deployed, thus increasing their risk for pain or PTSD, so what are the suggestions to further engage them? I am aware the stigma associated with seeking treatment is being rigorously addressed. 

Doctor Dobscha:Right, so I think stigma is an issue, but I also think that there’s a number of competing priorities for returning Veterans. Many are working and trying to develop and improve relationships, and there are a lot of distractions. One of the things that we talked about, the psychologist in our demonstration project got very interested in the idea of trying to help Veterans remember to come to appointments. A number of times it was a matter of just being distracted. We talked about exploring texting Veterans to remind them of appointments. I think some of this is a matter of simply reminding people to come in or make contact. I think in addition to logistics, I would just hazard to say that a more patient centered approach and trying to really understand what those Veterans are most valuing in their lives and trying to build care around that. That seems to be one way that I would approach the problem. It is actively being studied. I think there are a lot of people very interested in this problem of engagement and trying to enhance engagement. I do not think we quite know the answers yet. 

Heidi:Do we have time to sneak one more question in here? 

Doctor Dobscha:Sure, one more. 

Heidi:What are your thoughts on use of alpha stem for chronic pain and PTSD? 

Doctor Dobscha:I have... it has been a while, several years since I read about alpha stem. My understanding is that there is some very preliminary, or limited evidence, to support its use in both of those areas, but I think a lot more research needs to be done. I do not think this is at a point where it could be recommended. Now, some things may have been published or found in the last few years that I am not aware of; but based on my prior readings. 

Bob:This is Bob; I strongly concur with that. I know that there’s been considerable interest with this approach within VA and the company itself has done quite a bit of work to market it within VA, but in fact, despite some promising evidence, mostly from Gabriel Tan who was at the DeBakey VA in Houston, there really is, as Doctor Dobscha said, quite limited evidence. So, the idea that this would be promoted as a therapeutic approach in VA, I think is one that we really don’t necessarily encourage. 

Heidi:Okay, thank you. With that, we are going to wrap up today’s session. Doctor Dobscha, I really want to thank you for taking the time to prepare and present today’s presentation. We really appreciate the time and effort you put into this. For our audience, thank you very much for joining us, and for those of you who stayed late, to sit in on the Q and A portion, we appreciate you taking that extra time. 

As you leave today’s session, you will be prompted with a feedback survey. We would really appreciate if you would take a few moments to fill that out. We really do read all of the feedback that comes in, so please do not feel like it is not being looked listened to. We really do take all that into consideration. 

I want to thank everyone for joining us for today’s session and I just wanted to check... our next session is scheduled for May 7 at eleven a.m. eastern and we will be getting registration information out to everyone on that within the next couple of weeks. Thank you everyone for joining us for today’s spotlight on Pain Management Cyber Seminar, and we hope to see you at a future session. Thank you. 

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