Spotlight on Pain Management Series      start at 45.32 of the audio – page 10 of this text file

1/3/2012        4:00:00 PM

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>> Good morning everybody. This is Bob Kerns from very cold VA Connecticut in West Haven CT. It’s my delight this morning    to welcome  you to this webinar presentation Spotlight on Pain Management I’m going to introduce Michael Clark our speaker. This is a hardship for me to keep this brief because Mike has so many accolades, deserving accolades, coming his way for his many contributions to the national pain management strategy and his personal friendship and support for to me, but I’ll try to be brief. Mike has over 30 years experience in the VA and the last 25 devoted entirely to his efforts to improve pain management for veterans. He is currently the director of several pain management programs at the James A Haley Veterans Hospital in Tampa, Florida. He is associate professor of psychology at the University of South Florida. He is the recipient of many awards from both VA and other organizations. The one I’d like to particularly highlight is an award from AMSA which many of you know as a leading organization of VA and DOD colleagues. He won the Outstanding Allied Health Professional Award two years ago. In 2007, his chronic pain rehabilitation program at the Tampa VA, the James Haley Veterans  Hospital was one of the six original recipients of the American Pain Society’s award for a clinical centers of excellence. And he really has shown outstanding leadership over his many years of contribution to the VA including his role as a founding member of the National Pain Management Strategy Coordinating Committee. It is with great pleasure that I introduce Michael Clark to you this morning,  who is going to speak on Pain and Emotional Comorbidities- When Pain Treatment Alone Is Not Enough.

>> Thank you very much, Bob, for that very generous introduction. I hope that I can live up to that in the succeeding slides here. We will see. And for those of you on the call, note that there are a few slides in here you may have seen in other presentations. You may not have, but they're also some new data in here. I think there's a little bit of something for everyone. Today I am going to be talking about pain and emotional comorbidities. In terms of disclosures, I really have no disclosures to report. Some of the data in this particular presentation was supported under a VA HSR&D funded research project and any opinions are my own and nobody else's. The objectives for today's talk are really first to briefly review some of the characteristics associated with OEF/OIF/OND injuries. To describe the constellation of symptoms and some early prevalence datas that we have that characterize what we call the postemployment multisystem disorder or PMD. And to identify some alternatives integrated care treatment strategies for PMD. We want to look at some of the outcomes that we've gotten, early outcomes, from this treatment approach, and I think that maybe a focus of some discussion or at least thought provoking to some of you. To see what you might want to do differently locally.

>> When we talk about the OEF/OIF/OND populations, we are talking about two levels of severity of injuries, within the greater group of OEF/OIF, the all encompassing folks who have been deployed recently during one of the theaters, on one of these theaters, and have registered for VA care, they represent the overall group that I will talk about. But within that is a smaller group, a subgroup, of those with what we have defined as polytrauma individuals. Those would be the people who meet the VA’s criteria for polytrauma. They tend to be – we have more active duty folks that are in that group than in the OEF/OIF/OND general population. They tend to present with more severe injuries, typically they are blast related. Not always, but often. And in that particular subgroup, moderate to severe TBIs are common, where in the greater OEF/OIF/OND group. Yes, there are TBIs; they tend to be mild. Those are the two groups that I will be focusing on with today's talk.

>> But first, I’m going to focus a little bit on polytrauma pain. There are some important differences and characteristics that everybody needs to be familiar with. This is a slide that I adapted with permission from Dr. Steve Scott here in Tampa just demonstrating that there are many, many pathways to pain and different types of pain resulting from polytrauma injuries. We really have a complex interaction that can develop between some of these different pain conditions, which we are going to go through in a little more detail here in the following slides. First, just in terms of talking about pain prevalence, when somebody has a polytrauma injury, or when they are classified as polytrauma, as you can see in data we have seen over the years it's extremely likely. We've found paying prevalence rate of up to 96%. Generally in the mid-80s to high 80s is very typical. We know that headaches and upper shoulder injuries, neck injuries, are much more common in the population than in any other pain treatment population we would be treating. Also with a lot of extremity pain due to the frequent blast injuries. As you know the extremities are not protected with armor and are more likely to suffer injuries at least from blast. A lot of neuropathic pain and phantom limb pain from the many amputations, back pain which often is pre-existing before people are even deployed. And then associated with the blast are often burned pain and a number of soft tissue injuries, shrapnel wounds, so forth, that lead to different pain conditions. What I'm going to go through first is a reminder to everybody is a series of slides looking at a hypothetical individual but not uncommon. This presentation we’re going to see is not uncommon among people with polytrauma pain. But I’m doing is to make a point. Within the pain treatment fields, we talk about global pain scores, overall pain. What is your overall pain average in the last week or two weeks. And as you can see in this graph, this is a graph of overall pain scores over a 12 month period of time for this hypothetical individual. You can see that pre-deployment, there was some pain and then there was deployment, a blast exposure, and then we go out 12 months following that and we have a course of increasing pain, typically we would look to probably associate with blast injury. And then declining somewhat over a period of time, slowly and gradually down to for 4.3 at 12 months post-blast. The point though is that this is not – it’s much more complex than this. This is really a simplified view in this population, and something we need to be aware of. If we start pulling it apart and actually seeing what we have, this hypothetical individual has some back pain prior to deployment. That's not uncommon, about 25% of the cases that we have looked at have had back pain prior to their deployment, and that is not surprising given their typically older age. A lot of these are reserves, or National Guard folks who may not be in the same physical shape. They may be older and like all of us as we get older, we have back pain or other problems. There was some mild back pain that was present before deployment, and the pain worsened after the blast exposure, and you can see going out to 12 months, that it declined slightly, but still is in the mild to moderate range. But in addition, this individual, following the blast exposure, experienced multiple shrapnel injuries. We talk about shrapnel or soft tissue injury and say there is a pain of nine associated after  the blast with that shrapnel injury, but we are really talk about multiple injuries. Shrapnel is very rarely one site. It may be literally up to hundreds of sites. Even talking about a shrapnel related soft tissue injury pain score we are really summarizing a number  of separate injuries. As you can see here, the pain was clearly much higher immediately following the blast, and then declined at a much steeper gradient over the period of time going out to 12 months to where it was really kind of minor at the 12 months end point. In addition, individuals who were exposed to blast, also tend to have headaches tend to follow somewhat of a different path. As you can see there was no headache prior to deployment, and at blast, or post-blast the headache developed although at that point it was really mild to moderate in intensity. Over time, the headache tends to intensify. As you can see in this particular graph, we have the headache pain increasing pretty substantially from before -- that was following the blast up to a pain rating of eight at 12 months post injury.

>> Another common source of pain is burned paying. Burn pain is difficult. Burn pain, one of the primary challenges for it is that it has a very long healing process. We typically talk about chronic pain developing during a transition period of 3 to 6 months after the onset of pain. But the healing period for burns extends out to two years. You can have pain that really isn’t chronic, that's related to burns, not chronic in the sense of it's going to be present for sure for that individual's entire life. But it may persist well beyond the 3 to 6 month window. In this case, you can see the burn pain was much more severe following the blast, and then slowly declined after about nine months. And now is more in the mild to moderate range. And in addition, people with polytrauma injuries have multiple surgeries. Sometimes 12 or 13, 15 surgeries. Each of the surgical revisions usually is associated with another type of pain. It's another source of pain. And while often, there's total or almost total recovery from that kind of pain, post surgically, there may be another surgical and another spike in pain as you can see here out towards the 9 to 12 month period. One thing about surgery related pain is that, although there may be a full recovery from it, the problem is that with increased numbers of surgeries, each time there is a surgical event, it increases the likelihood of developing some type of more chronic pain, neuropathic pain for example if a nerve is transected. And this may exist permanently, at least to some extent, after the surgery. It's like rolling the dice. The more surgeries there are, the more opportunities there are to develop a chronic source of difficulty.

>> So what we really see is this. This is really a picture of pain for an individual with polytrauma. Again, this is not -- all these sources of pain that you see at the top, back pain, shrapnel, headache pain, surgery, this is not atypical at all in individuals with polytrauma pain. We often see this type of presentation. The point is that first slide that I presented was the mean pain and gives a picture pain declining over a period of time, and being in a much more manageable area out towards 12 months. The point is that it depends. It really depends on what type of pain that you are talking about. In the pain field, we often want to know what is the primary source of pain. If you look at this particular combined chart, what is the primary source of pain? The answer is it depends on when you ask. And that is the point I want to make. What these individuals with these complex pain presentations, it is not enough to just talk about global pain or overall pain. What is important is to try to pull it apart, try to identify the course of each separate type of pain, and then to identify at the at the current time, what is the primary pain that you might want to focus on and what are the other pain conditions that go along with that. One of the difficulties, one of the challenges we face in treating pain in this population is that sometimes a primary type of treatment for one kind of pain may actually be contraindicated for another type of pain. A good example is, say that there is significant musculoskeletal pain, the person responds to opioid analgesics, so they are administered to reduce the pain. However, if the person also has significant headache, opioids are essentially contraindicated for headaches except as a last resort. It's important to actually note all of the sources of pain and try to balance treatment to be as overall effective as possible for the numerous sources of pain, but not to do something that is going to aggravate one or the other, unless there is really not any other alternative. So when we talk about polytrauma pain, we really don't know for sure what the course is. Because of the long recovery associated with burns, because of the frequent multiple surgeries that are required, we don't know when somebody goes in that they're going to come out in X number of months and we can say at that point they’re going to have chronic pain or they are fully recovered and right now the 3 to 6 months course really does not apply to those folks that have some of the more extended healing time or surgical revision. All we know is that during this period of time, this one to two years following injury, we need to follow them closely and provide whatever treatment we can for the individual pain condition because we know the more effectively we treat those during this recovery period, the less likely it will be that they will develop chronic pain or at least the chronic pain may not be as intense. And for this particular period, this extended period following injury, we really have called that post-acute pain. Because is not really the same as acute pain, it's not really the same as surgical pain necessarily, but it's not necessarily chronic pain either during this transition time. It's a period of time we really need to monitor folks very closely. 

>>We’re going to turn a little bit to the emotional injuries that accompany pain in these two populations and that’s really the focus of the talk today.  Really going to focus on the post-deployment multi-symptom disorder that I mentioned earlier. The timeline on this is was back in 2003-2006, we looked at and provided early data regarding people coming back from deployment to Iraq and later Afghanistan, seeing this very high rate of pain associated with polytrauma and, in addition, in the OEF/OIF returnees who did not have polytrauma, they were still reporting, 40 - 50% of them at least significant pain problems . We also found frequent symptoms of emotional disorders or problems, particularly PTSD, a lot of mild TBIs, depression, issues like that. So 2007, we engaged in the first VA study examining pain and the emotional comorbidities among these folks coming back from their deployment. And in 2008, we really identified what we called P3, it's been called different things by different people, but the three representing pain, PTSD and post concussive disorder or mild TBI as the most common core of difficulties that folks were appearing with. Then in 2009, we extended that  because we found that it's really not just these three problems that we’re also seeing substance use disorders, we’re seeing significant weight problems, many anxiety problems and it coalesced into  an overlapping group of disorders which is we think is challenging to treat and presents some major difficulties for people's adjustments. In 2010 on, we implemented the VA’s first interdisciplinary integrated care program specifically designed to treat PMD. We will be talk about that a little bit. In terms of the original symptoms overlap, and what we called P3 at that point, this paper by Lew et al, that looked at 340 outpatients in Boston  was really highly descriptive of the very concept that we are talking about today. What they did was look at the presentation prevalent of separate disorders like pain, TBI, PTSD, as well as the overlap, people who presented with all three or with different combinations. As you can see in the graphic on the screen, the pain was certainly the most common problem among this entire group. But in addition, the overlap between pain and TBI and PTSD was huge with about 42% reporting all three of these problem areas. Again, it's a situation where we are seeing comorbidities and within this group that reported these three problems, my bet is that there were more that other issues with been identified as well like sleep and things like that.

>> The definition of PMD that we eventually moved to was that of a constellation of overlapping physical and emotional symptoms common among OEF/OIF service members that negatively impact quality of life, daily function, and transition to life as a civilian. One of the issues we are trying to avoid with defining it as a very global general state is specific-kind of disorders. We are not going to say somebody has PTSD, depressive disorder, multiple other diagnoses. We don't focus on diagnoses so much. Because at least in our experience, diagnoses have sometimes gotten in the way of treatment, and we are trying to avoid that in terms of eligibility issues. We will see that a little bit more later on. The most common PMD symptoms are listed here. And first off, you'll notice that these are very general symptoms. These type of symptoms actually overlap considerably between diagnoses. You can see somebody with depression and most of the systems -- symptoms might be present. You can take somebody with PTSD, with an anxiety disorder, with a chronic pain problem, Most of these issues would probably be present. That is our point. There is a tremendous amount of overlap, but yet there are similarities. There is a core group of problem areas that define this population that we could associate with different diagnoses but it almost doesn't matter what diagnoses they are associated with. What matters is their functioning and how we can try to help them manage the problem or overcome it.

>> As I said, we have begun back in 2007 in a two site study looking at data specifically pertaining to these groups of people coming back from deployment. And I'm going to talk about some of these data. We have since closed out the study. We are in the process now of getting all the data together and looking at a number of different hypotheses and issues. In the study, which was longitudinal, we did a 12 month follow-up at these two sites, there were 353 participants, and they were recruited either as I showed in the original population slide, either from the OEF/OIF/OND registry, so we’re talking about in general the less severely injured or people who may not have any known injuries. Or they were recruited in the polytrauma network of care which is the most severely injured. One of the things we did in this study which was different was that every individual that was recruited was interviewed at length in person, and that we utilized a structured clinical diagnostic interview, which was the M.I.N.I  to establish some baseline DSM-IV diagnoses. And then also had a number of other symptom and function measures that were administered. We then followed these people for a year, saw them again at -- or actually redid the M.I.N.I.  sometimes in person or over the phone depending on where they were located, at six and 12 months to establish a longitudinal view of what happens to these individuals, at least for this 12 month period after we have identified them.

 >> These are some of the demographic data associated with participants in the study. You can see the average age was 35.1, which reflects that large group of National Guard and Army Reserve and career military that were involved in these deployments. 14.5 years of education on average, which indicates they were fairly highly educated. Mostly male, total deployment time averaged 14. 6 months, again because of the duration increasing from a one-year deployment to sometimes multiple deployments, 15 or 16 or 18 month deployments. A  42.4 months since return. On average, these people have been back from deployment for a considerable period of time. The type of injuries that they had experienced, as you can see, the combat and noncombat injuries, both of which occurred during deployment, were the primary sources. So most people were injured during deployment, with about half being combat injuries and half not. The primary entry method was blast, no surprise, and in terms of primary pin location, you can see that it's a little different than other populations. The percentage of back pain was lower than what we commonly see in other groups. And the percentage of pain in lower extremities which much higher. As was head and neck pain. This probably reflecting both the blast exposures as well as the physical demands of jumping out of trucks and jumping in foxholes and caring 60 pound packs or more. And the wear and tear that makes for not only the back but the lower extremities. In terms of mental health issues, these were self-reported mental health issues by the individuals who were interviewed. You can see that about half of them indicated that their mental health problems, those are were reporting a mental health problem which is about 2/3 of the sample, stated that the onset occurred after deployment. Not during deployment but after deployment. And in terms of resolution, almost 90% said that the problems were still ongoing, had not been resolved, which clearly indicates the challenge to us in terms of treating more effectively this range of emotional difficulties that returnees are reporting.

>> Turning to the DSM-4 diagnoses that we obtained from the structured clinical interview, you can see here that there was a very large number of people who met criteria for at least one axis one diagnoses. About two thirds. As you can see, there is a lot of overlap. That's why you see these large percentages. A lot of people at more than one diagnosis which we’ll see in a second. Almost 50% had one or more anxiety disorders, close to 50 percent had one or more depressive disorders, substance use was extremely common. The postconcussional disorder which is really mild TBI was around 16%. Pain was present in the vast majority, 86.6% that was the most common of all, and when we looked only at significant pain, trying to identify folks who likely experienced some impairment from their pain, we looked only at those with pain scores of four or greater and that was 55.9% of the sample. Looking across at the next graph, you can see some of the prevalence of diagnoses. Here you see that about 21% or 22% did not  meet criteria for any diagnoses including pain issues. Pain was the most frequent and then as you can see, we have high frequencies of many other emotional problem areas.

>> In terms of multiple diagnoses, one of the issues that lies behind PMD is that we have hypothesized that people report with these multiple overlapping conditions which might qualify them for might –qualify them for multiple diagnoses whether or not they have three or four or five diagnoses that they meet criteria for may not be all that critical in the treatment. As you can see in this graph, around 22% had one diagnosis, so they met criteria for at least one diagnosis from the MINI administration. But almost 60% met criteria for two or more. Again, we have this multiple symptom presentation that is occurring. Looking at sleep problems in particular across the different diagnoses that we obtained, you can see that sleep is characteristically a problem of just about every emotional diagnosis or pain diagnosis that we looked at. You can see the difference if there was no diagnoses, so they met no criteria for either DSM or for significant pain issues, sleep problems were at a much lower frequency. But were much higher with all of these other conditions.

>> Looking at the most frequent comorbid diagnoses, these are the actual -- the most frequent cluster of diagnoses that we would see among these 343 people, you can see that significant pain or pain of a four or greater was true of every one of the most common clusters we saw. And again, indicating how pervasive the pain problems are. You see as well that PTSD, anxiety, mood kind of issues predominated at a secondary level. In this particular population, almost 2/3 of the participants met criteria for a least one emotional disorder, and the majority at have more than one problem that met diagnostic criteria. Plus, more pain, mood disorders, anxiety disorders, PTSD, substance use disorders, mild TBI, and psychotic disorders. Sleep problems were characteristic of people with.... no matter what kind of other diagnoses they might carry. And both mild TBI and PTSD almost never occurred in the absence of other comorbidities. People who present with mild TBI or PTSD almost always had at least one comorbid diagnosis. We were not seeing cases of solely mild TBI or PTSD, or at least not very frequently. 

>>And on the next few slides, I'm for second going to briefly review some data that Dr. Dan Agliata  presented on one of these calls earlier because it pertains to something else we looked at. These really are data among folks coming in only OEF/OIF/OND individuals, not polytrauma, but people just registering for care at Tampa VA . They are not necessarily seeking care, but are registering so that they are at least eligible for care. We do a lengthy screening that includes an interview with the mental health provider of every person who comes in to register for care, and they go through a number of screening instruments. What we are really trying to do is to identify early on whether they report any PMD or any other mental health problems that we need to jump on right away. These are the results. Again the a slide that Dan presented shows the screening measures that we used, as you can see that what we look at the cutoff percent on the far right column, the sleep complaints and pain were the most common of all the problem areas. And regarding the cut off that we used, we used a fairly moderate level cutoff. We weren't looking at people just with mild depressive problems, but people that would meet criteria for moderate range of difficulty. Nevertheless, as you can see, there were an extremely large number of individuals who met those criteria when they register for care. If we look at the multiple problem presentation again versus single problem, the bottom row in this particular chart is really indicating the number of individuals with that specific number of problems. So 25.2% had zero problems, 18.1 percent had one, etc. The row in the back is really the cumulative disorder issue. The 100% indicates that 100% of them had zero or more problems; 74.8% had one or more problems, and so forth. If you look at two or more problems, that percentage, 56.7 percent is almost exactly what we obtained in our other study looking at polytrauma and OEF/OIF folks combined. That the majority presented with two or more difficulties when we look at these specific problem areas.

>> The implications of this are that the deployment related physical and emotional problems overlap, and they coexist, PTSD and mild TBI are rarely occurring without other comorbidities. Pain is the most common among all of the conditions that we look for. That there’s substantial evidence in the literature that some of these comorbidities at least can interact, which is strongest for interactions between pain, mild TBI, and PTSD and the complexities and challenges represented by PMD we think may require another look at how we provide care. And we have approached it in terms of an integrated care model. If you look at traditional specialties care, not only in the VA but also in the community, because the community treatment programs are really set up a the same way-. We have a situation where specialty programs have criteria. That Individuals are referred, they are screened, determine whether they meet the criteria, and if they meet the criteria, they go into the program and within the VA typically after they complete the program, they would exit and have follow-up care by a primary care. The Problem arises on the right. for The people who do not meet criteria for whatever reason. Sometimes it's because they don't qualify diagnostically. For example, sometimes in PTSD programs, an individual may have posttraumatic symptoms but not have -- not meet  at the current time criteria for PTSD. Some programs do not treat people who do not have a PTSD diagnosis. Partly because of the overwhelming number, and the fact that they are already overloaded with care. But for whatever reason, these individuals who do not meet criteria, and it may be for substance use programs, pain programs, TBI programs, whatever. A lot of individuals who do not meet the criteria. They go back to primary care for treatment typically . This has resulted over a period of time with sometimes a crisis in primary care, where we have providers who really are not well-versed in specialty problem treatment who yet are responsible for caring for these individuals. And I know here, that we have tried to respond to that, because of the difficulties of primary care teams were facing, to try to find another way, so that these individuals who did not make it into the specialty treatment would still have another alternative for a complex care. To do that, we develop our integrated care program. And here, we have individuals who still are referred to the specialty program, particularly if they have pretty well defined discrete disorders. If somebody has PTSD that clearly a primary problem, they might have other problems, but PTSD is presenting as a significant barrier for them in their life, probably they would go to a PTSD program would  other individuals with the more severe presentation. However, if they come with multiple problem areas, where it's not really clear that one is absolutely primary over another, what we do is we will screen them for our integrated care program. In this program, we attempt to treat this range of overlapping symptoms, irrespective of diagnoses. We don’t  required that they have a PTSD diagnosis or they have a anxiety disorder diagnoses, but what's required is that they have symptoms or problems the fall within the purview of our treatment approach. These individuals then would complete treatment in our integrated care program, would go back to Primary care for treatment, but  we also work with individuals who are in the specialty program. So even if somebody does have a problem that is primary, if they have significant overlapping problems and comorbidities that we are set up to treat, we work with them while they are in the PTSD program, or after they leave to try to do with those issues.

>> Advantages as we have seen it since we developed this, is that we think it provides comprehensive multi-symptom care within a single program at a single location, by a single group of providers. These providers share a common philosophy of treatment. We think that the integrated evaluations we do that focus on this entire range of problems and others provides a more complete picture of an individual's overall functioning. We think that it facilitates a continuum of care rather than discrete episodes of care. And we believe that it's more likely to address some of the specific problems of these symptoms as well as what happens when these conditions interact. For example, PTSD and pain. And we believe that we can get a little better handle and potentially treat some of these interactions a little bit more aggressively in this integrated care program. So we develop what we call the Center for Deployment Health and Education here in Tampa. It’s interdisciplinary. It includes individual and group therapy, physical therapy, medication management, uses weekly group and individual sessions. We have two tracks, one is a core which is the mandatory introductory treatment, and then a modularize focused treatment course, which really looks very specific problem areas. Treatment duration average is between three and five months; the range between 8 weeks than 8 months so far, and we have an elaborate outcomes package we administer as well. This is the flow of patients as we experience it where we receive them from post deployment clinics, polytrauma teams, primary care, mental health, women's center, and also interact with our specialty programs on the right as we try to provide and extend their specialty treatment.

>> The measures that we use to look at outcomes are broad-based. We use pain measures, the SA5 which is the NIDA alcohol use measure, sleep measures, adjustment measures, neurobehavioral symptom measures, the PCL-C for PTSD, effectiveness measures and so forth. So we try to have a pretty rough look at individuals problem areas. What I will present here in the last few minutes are some data that we just looked at. This is really our first look at 31 graduates that have come through this program. And as you can see, these are the demographics. The mean deployment, similar as we have seen in other groups, same with the education, age, all these characteristics are similar to our past research, but you can see that there is a very high percentage of headaches, 64.4% in this group. These are the pre-and post-outcome scores that we have. On the right of the significant levels associated with the pre-to post-comparison. Those that are in the darker shaded areas were all significant. We have three that were not significantly different, that was the SA5 for alcohol use and two subscales from the pain outcomes questionnaire. All of the other differences were significant and to give you a graphical representation, we’ll run through them here you can see what changed and how much pretty rapidly, on this particular one, the M2CQ on the right is a measure of military to civilian transition adjustment or problems. It was developed by Nina Sayer at the polytrauma clinic. And you can see that this is a reduction in problem areas following treatment.

>> Here we have the subscales of the pain outcomes questionnaire, looking at pain related impairment. We had a significant improvement in everything except the vitality and fear measures. The symptom measures the CESD for depression, the NSI for the neurobehavioral symptoms, trait anxiety, and the PCL civilian version for PTSD symptoms, also all changing significantly. Sleep measures declining, problem areas with the individuals we treated. And the satisfaction with life, which is  an instrument that is the being used more often on to look at rehab outcomes, which demonstrate how satisfying an individual is with their current condition and their life involvement. Here you can see a significant increase. Satisfaction data with treatment issues was high across all the categories that we used. Certainly participants were overall very satisfied with the treatments that they received.

>> Last, I want to go through eight case example of somebody who went through this integrated care. he is a 24-year-old married, currently unemployed male, three years military service, deployed to Iraq for a year, discharged in 2010 as an E4. Had both combat and trauma exposure, multiple blast exposures, had a herniated disc from a lifting injury, not a combat injury. No prior medical problems, no prior mental health history or treatment. When he presented to us with an onset of problems in 2009, which was after deployment after return from deployment, the problems that were listed including low back pain, due to the herniated disc, depression, anxiety irritability, poor sleep, marital problems, physical aggression towards the wife, hyper vigilance, feeling overwhelmed, intrusive thoughts, cognitive difficulties, somatic symptoms, loss of appetite and difficulty adjusting to civilian life. Recently he had begun to abuse “spice”. Spice is that synthetic marijuana that is all the rage now. Our treatment consisted of weekly core groups. This included introduction to this condition, PMD; sleep hygiene; relaxation skills; substance abuse; physical therapy for low back pain, 1-2 session per week with home exercises;  individual therapy, which focused on trying to reduce fear, promotes to increase relaxation and stress management, general activation, focused on some relationship issues and also substance use, in terms of medications, the muscle relaxant which the person had been receiving was discontinued. The individual continued receiving NSAIDs and Tramadol by primary care. Treatment duration was approximately 6 months. These are the outcomes in this particular case that we achieved. Going down, you can see quite a bit of change in pain, but also a lot of change in the emotional measures, and these changes really occurred -- overlapped diagnosis. That is that there were differences in PCL-C measuring PTSD issues, in the trait anxiety, looking at depression, a global response and improvement across the multiple problem areas or diagnoses, if you want to use the term that the individual faced.

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>> Qualitative outcomes associated with this also were the Tramadol and the NSAID S were reduced by primary care. He began college, was an A student at our last contact. Discontinued his use of spice, although there was a slight increase in alcohol use. Filed for divorce, that was his decision, he did not find his relationship workable. He began to reestablish contacts, continues his home exercise program for the back pain which he is managing, and is followed by mental health care and our post-deployment clinic staff who follow the PMD treatment folks.

>> In summary, the issue is that we really believe that some of these individuals that are coming back from deployment present with challenging conditions there really fall outside what we have been doing in our experience in the past. That some of them may have significant pain issues, but have a number of comorbidities that just do not disappear because -- when we effectively -- even if we effectively treat the pain. We have found that one of the things we need to do is to broaden our scope. To try to provide symptomatic care for these multiple other issues, as well as our ongoing pain care. And that our version of this, in the CPAG seems to be working. Does it work well enough? No, we are not satisfied with it. We need to improve it. We need to continue looking at how we can refine our treatment approach, but we think we've got a start. The one take-home message for me that I would hope that individuals, no matter where you are, everybody is faced with resource challenges or having to work within the realities of what we have available, but you might consider opportunities to reconceptualize treatment of these individuals. Are the things that you might do differently because of the multiple symptom presentation that we are seeing? Things that may not involve separate treatment programs, but will address some of the difficulties to hopefully assist all of these individuals in their efforts to transition home and to really reintegrate with society.  Thank you.

>> That was terrific. This is Bob Kearns. Heidi or Mike, can you see other questions that are coming from the field? Yes, I have the questions.

>> I will get started on those here. The first question we received. How do you deal with patients who suffer from addiction as well as chronic pain who report pain scores that are 8 to 10? If they look comfortable and have no other signs of pain? Often times these patients want more pain medication and get into conflict with nurses who do not want to give the medication and might label them as drug seekers? The way that we deal with them is that our first goal is really to identify what is the primary problem. And here, the distinction between whether it's a primary addiction problem or a primary pain problem is really the key. Sometimes neither one is primary. They may have both. If they have a primary pain problem, and it may be of use or misuse of medications rather than addiction, then we will probably take a pain track in terms of treatment. If it's a primary abuse problem, and not a pain issue, at least not as a primary issue, then we will probably take a substance use disorder treatment approach at least initially. The people who have both, where it's really not clear, and we really can't distinguish between the two, we would consider for our integrated care program, where we would treat both the pain and the substance use problems. The one caveat for that is if they substance abuse is really severe, so the individual is constantly abusing, then we are probably not going to try that track until they go through a more traditional substance use treatment that would focus on at least reducing their use.

>> Great, thank you. The next question. Would it be appropriate to look at the constellation of symptoms similar to clustering with respect to personality disorders and positive and negative symptoms with respect to schizophrenia? If so, might that help with treatment.

>> In terms of the clusters, we are looking at clusters of symptoms in trying to identify some of the primary clustering that occurs. Thus far, in the folks that we have seen, both clinically and in terms of various research studies we have done, the cluster of psychotic-like disorders is very limited, very, very limited. Probably because these people may be peeled off earlier and engaged in other kind of treatment. In terms of AXIS II issues, personality disorder issues, they're many of them. They're many AXIS II  problems. We are not really attempting to identify those at this point. Our approach is a very practical one at this time, trying to say what is it that interferes with this individual’s day to day adjustment in life? What is it that is holding them back? And if we identify that, we don't really care so much about diagnosis. It could be an AXIS II problem, could be an AXIS I problem, could be from an interaction between TBI and emotional disorders coupled with pain. But that's not really our primary interest area. What we're focusing on is can we do something, can we intervene to help these people manage their life better in a more general rehabilitation kind of approach.

>> Thank you. Next question. In light of these findings in OEF/OIF/OND veterans, might it be appropriate to look at Veterans of other or older conflicts in an attempt to see if there is similar symptomatology. Absolutely. The fact that we have identified this in this particular population in more recent years is really an artifact. We identify it because we were looking. We weren't looking in the past. And one of the issues that occurred with the first Gulf War was that we did not even identify pain as a primary problem at that point. It was only after the fact and as we see these people years later for treatment, that we became aware that pain was such an issue. If you go back to Vietnam, it is even more true. And one of the things that we have done here is that we provide this integrated care approach, it is open to everybody. Not just OEF/OIF/OND individuals, but to Vietnam veterans, first Gulf War Veterans, to anybody who is presenting with these multiple symptoms, because we totally believe that this is common, not just in this population, but overall for a lot of individuals who have been deployed to combat areas.

>> Thank you. What are currently practiced clinically to reflect these findings presented by the speaker in any VA healthcare system location? I can see this as a significant piece of education in the LPC see section among clinicians.

>> Here, as you've seen here, we have tried to integrate and approach things in a more integrated global manner. But we are not the only place. There are a number of individuals I have talked to around the country who have or are in the process of developing smaller scope integrated care approach is. And in fact, some integrated care like for PTSD and pain has been going on for a substantial period of time. At, for example Boston VA, where Dr. John Otis began looking at that several years ago. I think that there are some programs that are in existence, and what is also very clear is that individuals across the nation are becoming more aware of this cluster of difficulties. Integrated care is all the rage now in the VA, you'll see discussions of it within a lot of different contexts, and I think people really are looking at and taken a look at what they're doing, and maybe challenging some of their traditional approaches to see if they can do a better job, or address things in a way that efficiently assists somebody in their adjustment efforts. I think this is a process, it has already started, and I think the more aware people are of the range of difficulties that individuals who have been deployed are returning with, the more likely it is that we are going to consider alternative approaches at a number of different sites.

>> Thank you. The next question received, early in the presentation, you spoke about headache pain. Are you considering that is constant pain, intermittent, and are you including migraine? 

>>Headache pain typically is episodic or intermittent. Not always. There are individuals who present with chronic ongoing always present headache pain, but they are typically in the minority. They may have daily headaches, but still even these tend to be episodic headaches that are just occurring on a daily basis. What we talk about headache pain, we are not necessarily talking about people who have ongoing constant headache pain. But more than likely are having intermittent episodes of pain. It does include migraines, certainly. It includes cluster headaches, which we are seeing more and more commonly. And the headache issue is one that is key for these individuals who are returning. One of the issues that everybody needs to be aware of is that often times, people returning from deployment get asked about pain, and do not report headaches as the source of paid. They may deny it and say I have no pain. But if you specifically asked him, do you have headaches, they may say yes. And so I would urge everybody, if you are in a clinical situation with an incoming individual, doesn't matter whether they are  from OEF/OIF/OND  or somebody else to always ask about head pain just make sure that all pain conditions are identified.

>> Thank you. We received three very similar questions right in a row here, and I will pick the one that I think is holds the best description that encompasses the three here. Looking at completed suicides a couple of years ago we found the majority of Veterans reported chronic high pain scores prior to the event. Have you looked at this association?

>> We have not looked at this association in the sample. However, we have a couple different efforts here locally that are looking at that very issue. Because yes, pain is very frequently associated with suicide attempters and completers. And we know that it is a common difficulty in this particular group. And potentially an indication of risk... of higher risk for suicide or suicide attempts. We are very concerned with that. We don't really have a way with in this data set, this HSR&D data set, to look at that right now, other than the folks that we are tracking for 12 months. Where we would have information on at least any attempted suicides or any completers.

>> Thank you. The next question here, with respect to SUD do you include marijuana? How do you categorize marijuana as a drug of abuse or as a potential therapeutic alternative and/or adjunct to pharmacist  (indiscernible.)

>> We don't adopt an approach of identifying a drug as a problem area. What we try to identify is whether any substance, be it marijuana, alcohol, space, is interfering with the individual’s adjustments and difficulties. If that is true, if in fact their use of any substance is posing a problem for them and/or their family, then we are going to identify it as a problem and try to treat that. We do not at this time use marijuana or THC in any therapeutic capacity.

>> Thank you. Another we are just passing top of the hour. I spoke with you last week about staying a little bit late. We do still have 12 pending questions. Do still have time to stay on?

>> Yes.

>> I want to let our audience know that if you can't stay, we are recording this and it will be available in the archives if you do need to leave. Don't worry, we are recording this information and we will make it available after the session. 

>>Are there main treatment programs for each state?

>> Main treatment programs, in terms of PMD, not that I know of.

>> Thank you. The next question we have, in general, how do prioritize medication management in patients with multiple comorbidities? Will you treat pain and emotional disorders or treat one in hopes it will improve the other?

>> Again, our approach is... it depends. If pain is clearly a primary problem, and there are associated conditions like depression, anxiety, so forth, but they appear secondary, but we probably will at least first tried to treat the pain intensely. If there are secondary problems or overall presentation suggests a range of overlapping difficulties, we are going to try to treat them all simultaneously and concurrently within our integrated care program. We really try to make that distinction, which I think is an important one at the very outset of treatment to determine what we think would be most helpful for them.

>> Thank you. The next question is what types of staff are on the treatment team?

>> On the treatment team for the CPAG our integrated care approach, we have a psychiatrist, psychologist, a physical therapist, and then we utilize the medical resources of either primary care or one of our TBI programs, if they are referred from TBI, or other specialty programs if they are receiving co-occurring care from them.

>> Thank you. The next question that we have is our fundamental temperament changes often seem as happened in your example?

>> Yes, they are. Anybody who has been active in treating this group of individuals I think can speak to the fact that there are some challenges. Sometimes it's AXIS II issues, but we have seen a lot of problems with acting out behavior, with one of the difficulties that I think everybody can relate to is the number of no-shows or people who don't follow through with treatment. We have those same problems. But for those individuals who plug into treatment and persist, and continue with their care, yes we do see temperament changes. Whether those are permanent or not, we don't know. We haven't been around long enough to know. We don't have follow up data available. But we certainly have seen this occur. Another thing that we have seen frequently are people who present like in crisis. They are off the chart. Ever problem areas is about as that is it could possibly be, no matter how you measure it. It's at the very top. And even though they have these extreme self-reported problems, some of them, a subset, actually do incredibly well very rapidly. Partly, and we've heard this over and over again, partly it’s that I feel like I go and I am being pieced out in factory work. I have to go to all these different people in these different areas and it actually adds to the stress instead of reducing it. I've got an appointment over in this area at this time, and now I've got to go see some provider over for this problem at that time. And I think by saying we understand that you have multiple issues, this is A single place with A single team who is here today, they will be here tomorrow, they will be here the day after that, that you can come to try to address this coalescence of problem areas. And for us, and certainly for the subset of patients who have participated, it's worked very well.

>> Thank you. The next question we received, for the integrated care program, what were the key components that differed from the usual care? And was there any pushback from providers, primary care or mental health, for the new system and how did you overcome this to Burt

>> First of all, primary care was an extremely strong supporter of our efforts. Because it was primary care who primarily was being left out to handle this range of difficulties, and adjustment problems, and presentations and it was a very difficult challenge. They have been a continuing source of support for this. And continue to be a very positive about  our efforts. Mental health here has been very supportive. And I'm not going to -- I will say in a general way, that's not necessarily true everyplace else, mental health has a number of stressors in terms of areas in patient populations that they have to provide services to. And I think in some sites, the idea of pulling somebody out from mental health from maybe one of these other programs into this more general treatment approach might be resisted. But we had none of that here. We've got a very forward thinking mental health leadership,  great administrative support and leadership support at the hospital, and we have been able to do things that we felt were needed, but I know may not be available to everybody. I think the lesson that we have learned is that if you go back to the question of what will benefit these individuals the most, what in our knowledge base and our understanding seems to have the highest likelihood of helping, that if we always identify that that is our goal, that is what we are really about is try to help the patient, the opportunity for receiving support from a number of fronts may be there. And it is certainly something that we have experienced here.

>> Thank you. The next question we have, what is nociceptive pain?

>> Nociceptive pain, and I don't know if you're referring to a chart, but essentially it relates to musculoskeletal pain. The muscle connected tissue pain in general.

>> Great, thank you. What integrated complimentary mortalities have you considered? Seems large portion of the comorbid diagnoses may benefit from some self-care management techniques. Such as meditation, guided imagery, some aromatherapy, healing touch, etc.

>> What we have available for individuals within any of our treatment programs are certainly biofeedback and relaxation. Relaxation itself is a core portion of our integrated care program. Everybody goes through relaxation treatment. And then in addition may have additional services above and beyond that. Headache individuals, people with headache, a significant portion of the may undergo biofeedback for their headache pain. We do not have available at this time and don't utilize some of the other complementary approaches. We just don't have providers available to do that. We do have available chiropractic on a referral basis that we can utilize, and we do have in our pain program the ability to utilize some yoga training services. But that's about it. At the present time.

>> Great, thank you. Given the significance of sleep issues across all diagnoses, have you tried to incorporate CBT for insomnia? Sleep hygiene alone may not be it affecting the underlying sleep disorders.

>> Absolutely. Sleep is again, along with pain, the most common difficulty that people voice. And we do both. We provide a sleep hygiene approach as part of the core emphasis. But then an additional focus maybe specific sleep treatment approaches. We also will utilize, we have a great relationship with our pulmonary service and will persist and try to identify any ongoing sleep disordered breathing if that occurs. And we certainly try to look at medications as some of those that might interfere with sleep, or good quality sleep. And consider trying to alter those. We absolutely agree, a CBT approach to the harder core persistent sleep problems, yes. We do it and we think it is helpful.

>> Thank you. We've got five pending questions. To select you know where we are. 

>>Can you discuss using functional goals and function as a measure of pain management efficacy?

>> Yes. We began everything as a pain rehabilitation program. Our look at pain, and our concern about pain has always focused on function. We certainly utilize pain intensity scores as does just about everybody else as one measure of outcome, but what we are really interested in is how does the person function? Can a person become more active? Can they become more satisfied with their life and what they are doing. And we have utilized multi-domain measures to assess function, to assess mobility-based impairment, ADL kind of issues, strength and endurance for 20 some years. Yes, we do very much look at function within the integrated care program. We utilize a very similar approach. We are not as concerned with diagnosis as we are with how is a person functioning and what is leading to difficulties? What barriers, what obstacles, or challenges does this person face? And then trying to determine what the most efficient approach might be to address those barriers.

>> Thank you. Did primary care providers increase their delivery of mental health intervention? Did you work to increase comfort level and brief intervention skills of primary care providers?

>> We don't specifically work on that. But I think what happens is as we provide these services in team with primary care, who continues in most cases to do the medical management for these individuals, then I think some of that does develop. We have had good success enlisting the support of primary care providers in the follow-up management of cases after they go through treatment. Issues like potential medication misuse or abuse. Or their ongoing needs for continued mental health follow. We are not a long-term program, we are a short-term program. And just because somebody completes our treatment doesn't mean that they are not in need of significant continuing treatment. We have always thus far really found a receptive primary care provider audience to do that. We have not tried to train them to do this to themselves or to do other mental health or pain interventions themselves. If it's an individual with complex and challenging conditions, which is primarily who we see. So we are already getting the more challenging folks into this program here. And I assume that those that are less challenging are already being managed fairly successfully at the primary care provider level.

>> Thank you. The next question, how would you develop -- how would you suggest a smaller center develop a CPD/HNE analog to integrate the care? How is FTE assigned/shared?

>> The FTE issue and how someone goes about developing it locally is -- there's almost no general rules of thumb, because everything differs at every VA. Resources that are available, the organizational structure may be different, so it's hard to provide much in the way of direct suggestions. I think that emphasizing a team approach and recognizing that if there can be a team of individuals that might reflect different disciplines ... even if it’s two... a mental health provider and a physical therapist, that will probably work much better than two individuals working in isolation and communicating by our progress notes or even occasionally e-mails. We found the team element to be really necessary and a core component. One of the things I want to mention that I didn't mention the talk was that one of the surprising things we have seen in treating this group is the number of individuals who make it to us and have previously undiagnosed pain conditions. Many of which are eminently treatable... in fact, can be rapidly treated. We think that partly that's because when people come to register for care or come in for their primary care visit, they are not identifying this so much as a pain problem, that they may have many other stressors or primary issues that they're raising. But for whatever reason, when we see them at the second level. We see many folks who have pain conditions that have not been previously identified. And for a number of those individuals, physical therapy in the series of relatively brief treatments and exercise programs has made a world of difference. It is not at all uncommon to see people come in with pain persisting in the five or six range and to leave here is a relatively short period of time at zero or close to zero in terms of pain intensity. So it’s important that the pain assessment be thorough beginning with primary care but continuing throughout the episodes of care. 

>> Thank you. What do you think contributes to the increase in substance abuse?

>> It is hard to know how much of it is an increase and how much isn’t. If you mean increase compared to other populations, other deployment groups, I don't think we really know that. I don't think we -- I don't think our data are as good, as comprehensive, as they might be for prior deployment groups to be able to compare them. We do know that substance use is extremely common in individuals that we treat. And typically, if you look at studies in the literature, time and time again we are seeing about a quarter, somewhere around 25%, are seen in a variety of studies as having significant substance use problems. So 25% of the number of people who have been deployed is a huge number. It clearly is one of the primary problem areas that need to be treated. One of the issues that we face early on was the abstinence versus harm reduction issue. We knew that typically, individuals were going to be coming in with frequent substance use, that a lot of them would be younger, and prone to episodic substance use. And from the outset, decided we are not going to require an abstinence approach. To do so would essentially make our treatment unreachable for a number of these individuals. We adopted a harm reduction approach, saying that our intent is, if the person is treatable, if they're abusing so much that they're not treatable, that's a different situation. But if they have ongoing abuse, misuse, and still can profit from treatments, then our goal is going to be harm reduction. Our focus will be on reducing the substance use. Preferably eliminating it, but our start is going to be reducing it. And trying to minimize the harm that is associated with the substance. That so far has been an important core component of our approach.

>> Thank you. Considering sleep disturbance  is so prevalent, I wonder how much emphasis is placed on the street and, for example, CBT I within your integrated care program and if you think that treatment to sleep disturbance might help drive improvement to other conditions?

>> I think yes, improved sleep is going to help improve other conditions. But with this kind of group that we are treating, and the overlapping symptoms, I think we could say that about almost any problem. If we treat depression successfully, other things would improve too. If we treated successfully, other things will improve as well. I don't think there is a core -- a core problem area that is the key to all this. I think instead, the key is the fact that there is so much overlapping problem areas and interactions between these conditions. We don't --  and won’t at this time target any particular areas such as  this is the overall culprit, this is the one we need to emphasize, we are not doing that. On the other hand, when sleep is an issue, when sleep problems persist beyond a basic sleep hygiene approach, then yes, we will tackle that. Using CBT or other approaches to try to improve sleep. And we do have the capability of using actigraphy to assess ongoing sleep on a daily basis so we can actually track improvements more objectively.

>> That is all the questions that we have. Mike, did you or Bob have any closing remarks?

>> My only closing remarks would be that I am not trying to identify this as the approach that everybody should use. Nothing like that. But again, to go back and consider and look and think about what you're doing at the current time, and to try to decide whether there might be an alternative approaches that may be manageable or things that you might do differently that might enhance the overall care efforts. I think that's the key that we can all be innovative in our own way and the challenges to find what ways that we have available.

>> This is Bob Kerns. I want to again thank everybody for their active participation on the call today. I want to specifically thank Mike Clark for an outstanding presentation and for hanging in with all these really terrific questions. Great responses. I want to thank those affiliated with the Center for Information Dissemination and Education Resources particularly Heidi Schlueter, and the director of the program there. Gerry McGlynn, and others there for their support of this webinar -- please tell your friends about this seminar, every month, the first Tuesday of the month at 11 Eastern time. We are going to continue to work to have excellent presentation such as the one today, and build our capacity for education in the field related to pain management. So thank you all and happy new year

>> Thank you Bob. Happy new year to everyone and our next session in our series is scheduled for February 7 and we will get registration information sent out to everyone at the middle of January. We hope to see at next month’s session.

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