integrated mental health and pain care for returning oef ... … · the cprp: who are we? •...
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Integrated Mental Health and Pain Care for Returning
OEF/OIF Service MembersOEF/OIF Service Members
Michael E. Clark, Ph.D.Clinical Director, Chronic Pain Rehabilitation Program
Chair, VA National Polytrauma Pain WorkgroupChair, VA National Polytrauma Pain WorkgroupAssociate Professor, Department of Psychology,
University of South Florida
DisclosuresDisclosuresDisclosuresDisclosures• No Conflicts of Interest to disclose• This presentation was supported in part by VA
HSR&D research grant # SDR-07-047
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Objectives1. Describe the prevalence of pain and
emotional comorbidities among serviceemotional comorbidities among service members who have returned from deployment.
2. Review the characteristics of Post-deployment Multi-symptom Disorder (PMD) and the empirical and pragmatic rationale for this conceptualization.
3 P d l f i t t d h i l3. Propose a new model of integrated physical and emotional health care for returning service members with PMDservice members with PMD.
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CollaboratorsCollaboratorsCollaboratorsCollaborators• Robyn L. Walker, Ph.D., CPRP PolytraumaRobyn L. Walker, Ph.D., CPRP Polytrauma
Pain Psychologist, Tampa VA• Ronald J. Gironda, Ph.D., Assistant Chief, , , ,
Mental Health & Behavioral Sciences Service, Tampa VA
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The CPRP: Who Are We?• Opened as an inpatient interdisciplinary pain
program in 1989• Remain the VA’s largest comprehensive Pain Center
and the only one accredited continually by CARF• Received the VA Secretary’s Teague Award in 2004• Received the VA Secretary s Teague Award in 2004,
multiple VA designations as a Clinical Center of Excellence, VA Model Team awards, and in 2007 the A i P i S i t ’ Cli i l C t fAmerican Pain Society’s Clinical Center of Excellence award
• Approximately 50 clinical staff (including 13 FTApproximately 50 clinical staff (including 13 FT psychologists)
• Since opening, the inpatient CPRP has titrated ALL i i ff f i id d iparticipants off of opioids during treatment
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Tampa VA Pain ServicesTampa VA Pain Servicespp
Outpatient InterdisciplinaryServices/Programs
TransdisciplinaryServices/Programs
CPRP Screening andFollow Up Clinics
Interventions Clinics
Services/Programs
Inpatient CPRP National Pain TeamTraining Program
Services/Programs
Headache Clinics Medical Pain Clinics
Pain Medical Fellowship Pain Psychology
Outpatient CPRP Inpatient PolytraumaPain Services
Outpt Polytrauma Post DeploymentPain Medical FellowshipProgram
Pain PsychologyResidency Program
Pain Executive andFacility Council Committee
Inpatient HospitalConsultation
Outpt PolytraumaPain Servi
Post DeploymentClinic Pain Svcs
OEF/OIF TransitionalPain Program
Post DeploymentMulti-symptom Disorder
P
Opioid ManagementConsultation Committee
Funded ResearchProgram
Program
Integrated Care programs
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Polytrauma PainPain prevalence = 96% Pain prevalence = 96% Clark, Bair, Buckenmaier III, Gironda, & Walker, 2007
• Headaches and cervical pain from traumatic brain injuries and blast injuries (65%)
• Extremity pain from blast injuries (55%)• Neuropathic pain from fasciotomies (30%)• Phantom limb pain from amputations (20%)• Back pain (20%)• Burn pain from blast injuries (10%)• Burn pain from blast injuries (10%)• Diffuse pain from numerous soft tissue shrapnel
wounds (10%)
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( )Walker & Clark, 2006
Polytrauma Pain ComplexityPolytrauma Pain Complexityy p yy p y
HeadacheTBIHearing
Polytrauma Pain
Polytrauma Pain
Otalgia
Surgical revisions
TBIHearing Loss & Tinnitus
Orthopedic & Neuropathic
Acute PainSCINerveInjury
Soft Tissue Trauma
Pain
Central
Amputations
PhantomPain
NociceptivePain
CentralPain
Adapted with permission from Steven G. Scott, 2008
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Course of PainCourse of Pain-- PrePre--existing Back Painexisting Back Pain10
8
9
10
6
7
4
5Back Pain
2
3
0
1
Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
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Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
10
Course of PainCourse of Pain-- Shrapnel Injury PainShrapnel Injury Pain
8
9
10
6
7
4
5 Back PainShrapnel
2
3
0
1
Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
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Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
10
Course of PainCourse of Pain-- BlastBlast--related Headacherelated Headache
8
9
10
6
7
4
5 Back PainShrapnelHeadache
2
3
0
1
Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
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Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
10
Course of PainCourse of Pain-- Surgical RevisionsSurgical Revisions
8
9
10
6
7
4
5Back Pain
Shrapnel
Headache
2
3 New Surgery
0
1
Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
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Pre-deploy Blast 3 Months 6 Months 9 Months 12 Months
Polytrauma Pain CoursePolytrauma Pain Course
POST-ACUTE PAIN
BreakthroughSurgical Revision &
ACUTEPAIN
CHRONICPAINTransition to chronic pain via unremitting acute pain
BreakthroughPain
Surgical Revision &Other Iatrogenic Pain
PAIN PAINp g p
Post-Traumatic Stress R ti & OthPain Associated with Reaction & Other
Psychosocial FactorsProlonged Tissue Healing
f CReprinted from Clark et al., 2007
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Polytrauma Emotional Polytrauma Emotional yyComorbiditiesComorbidities
65%65% received a mental Health Diagnosis:• Adjustment Disorder: 47%47%Adjustment Disorder: 47%47%• PTSD: 29%29%• Depressive Disorder: 24%24%ep ess e so de %%• Substance Abuse: 7%7%• Acute Stress Disorder: 5%5%cute St ess so de 5%5%
Walker & Clark, 2006
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Treatment OutcomesTreatment Outcomes
Measure Non-Combat(n=43)1
Combat/Blast (n=51) 1
Combat/Non-Blast (n=34) 1
Pre Post Pre Post Pre Post
FIM Score 84.0 111.9 82.9 109.4 81.1 111.0
Rancho Level 5.3 6.5 5.8 6.8 5.7 6.4
Opioid Dose2 28.3 9.0 125.5 40.1 53.7 17.3
Pain Score3 4.5 2.1 5.4 4.8 4.4 2.4Cl k W lk Gi d & S h lt 20091All pre to post changes were significant for all groups.
2In morphine equivalent milligrams per day3Significant group X time interaction
Clark, Walker, Gironda, & Scholten, 2009
CLARK- 2009CLARK -2010 16
Pain ChangePain Change6
4
5
2
3Non‐Combat
Combat/Blast
Combat/Non‐Blast
1
/
0
Pre Post
Clark Walker Gironda & Scholten 2009
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Clark, Walker, Gironda, & Scholten, 2009
Latest DataLatest Data• VA-funded multisite study examining
polytrauma and OEF/OIF pain andpolytrauma and OEF/OIF pain and emotional issuesParticipants recruited either from the• Participants recruited either from the polytrauma network of care or local OEF/OIF registriesOEF/OIF registries
• Follow all participants for 12 months• Following data represent a “first look”
at some results for 239 participants
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Most Recent DataMost Recent Data-- OEF/OIFOEF/OIFDeployed fromDeployed from Blast TypeBlast Type
Active duty 53 1% IED 41 6%Active duty 53.1% IED 41.6%Inactive reserve 33.1% Mortar 27.9%Active reserve 13.4% RPG 4.9%
Deployed toDeployed to All other 11.5%OEF only 9.2% Mean # of blastsMean # of blasts 97.8
OIF onlyAdjusted mean # of Adjusted mean # of
OIF only69.9% blastsblasts 21.0
Both OEF/OIF 16.7% LOCLOC 18.4%Total deployment Total deployment titi 14 07
Injuries from blastInjuries from blast36 0%timetime 14.07
jj36.0%
Mean time since Mean time since returnreturn 41.54
Mean Mean distance from distance from blastblast 365 feet
Exposed to blast(s)Exposed to blast(s) 86 2% Polytrauma %Polytrauma % 58 6%
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Exposed to blast(s)Exposed to blast(s) 86.2% Polytrauma %Polytrauma % 58.6%
Pain• Persistent pain present in 87%, average pain 4.1
• Significant pain (4 or >) 50.6% • Headache prevalence 63 2%• Headache prevalence 63.2%
• Days/week with headaches 3.6• Most common primary pain locations:
Location PercentHead 19.7% Shoulder 11.2%Knee 7.5% Neck 5.6%Hand/wrist 4.7% Ankle/foot 3.8%Leg/Hip 2.8%
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Arm/elbow 1.9%
DSMDSM--IV Mental Health DiagnosesIV Mental Health DiagnosesAt least 1 M.I.N.I. DxAt least 1 M.I.N.I. Dx 58.6%58.6% PTSDPTSD 29.3%29.3%
DepressionMood disorder with psychotic features
3.1%
Major Depression 30 30% Antisocial Personality Disorder 4 0%Major Depression 30.30% Antisocial Personality Disorder 4.0%
Dysthymia 1.60% Substance Use Disorders
1 or more depressive disorders 36.9% ETOH dependence 13.8%
Hypomania 24.9% ETOH Abuse 9.80
Anxiety Opioid Dependence 2.2%
Panic disorder 20.4% Opioid Abuse 0.9%p
Agoraphobia 27.6% Other Substance Dependence 1.8%
Social Phobia 9.80% Other Substance Abuse 2.3%
Ob i l i di d 16 4% P l b t Ab 0 5%Obsessive‐compulsive disorder 16.4% Polysubstance Abuse 0.5%
Generalized Anxiety Disorder 14.70%1 or more substance use disorders
24.3%
1 or more anxiety disorders 49 4%
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(except PTSD)49.4%
Diagnostic Overlap (NRS >=4)Diagnostic Overlap (NRS >=4)Diagnostic Overlap (NRS 4)Diagnostic Overlap (NRS 4)
Pain prevalence 87 0% Comorbidities for NRS >=4Pain prevalence 87.0% Comorbidities for NRS >=4
Significant pain (NRS >=4) 53.8% Pain and PTSD only 43.8%
PTSD Dx 43.8% Pain and mTBI only 26.4%
mTBI Dx (based on LOC) 26.4% PTSD and mTBI only 0.0%
mTBI only (no pain or PTSD) 2.4% Pain, PTSD, and mTBI 16.5%
PTSD only (no pain or mTBI) 0.8% Pain and Substance Abuse 28.1%y ( p )
Pain only (no PTSD or mTBI) 44.6 %
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Symptom Burden 1Symptom Burden 1
70 Pain >3 Only Pain >3/mTBI Pain >3/PTSD Pain >3/PTSD/mTBI
50
60
30
40
10
20
0
CES‐D State Anxiety
Trait Anxiety
MFSI Total
SPQ Slp prob
SPQ Slp overall
DAS
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y y p
Symptom Burden 2Symptom Burden 2
35 Pain >3Only Pain >3/mTBI Pain >3/PTSD Pain >3/PTSD/mTBI
25
30
35 Pain >3Only Pain >3/mTBI Pain >3/PTSD Pain >3/PTSD/mTBI
15
20
0
5
10
0
POQ Mob
POQ ADLs
POQ Vit POQ NA POQ Fear
FABQ Act
FABQ Work
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Symptom Burden 3
20 Pain ≤3 Only Pain ≤3/mTBI Pain ≤3/PTSD Pain ≤3/PTSD/mTBI
15
5
10
0
CSQ CSQ CSQ CSQ CPCI CPCI CPCI CPCI Cat freq
Cat eff Cope freq
Cope eff
Relax Task Rest Guard
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PostPost--Deployment MultiDeployment Multi--symptom symptom DisorderDisorder
TBI/Pain
Post‐deploymentM l iMulti‐symptom
Disorder
PTSD
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PMD ExamplePMD ExampleppLew, Otis, Tun, Kerns, Clark, & Cifu, 2009Sample = 340 OEF/OIF outpatients at Boston VA
TBI/Pain12.6%
Post‐deployment5.3%
10.3%
Multi‐symptomDisorder
% 16.5%6.8%
Overall prevalence:Pain 81.5% PTSD
42.1% 16.5%
TBI 68.2%PTSD 66.8%
PTSD2.9%
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Integrated Stepped PMD Careg pp
• Step 1: Post-deployment Clinic• MH orientation and brief screening (all patients)• Full screening and brief Tx for mild symptoms
R f l f d t bl• Referral for moderate or severe problems• Step 2: P3+ Program
• Treatment focuses on maximizing QOLTreatment focuses on maximizing QOL• Integrated, transdisciplinary care• Outcomes driven; eligibility based on adjustment ; g y j
issues rather than Dx• Step 3: Specialty Programs (e.g., PTSD, Pain; TBI)
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OEF/OIF PMD TreatmentOEF/OIF PMD TreatmentPostPost--Deployment Behavioral Health ProgramDeployment Behavioral Health Program
PP3+
PostconcussionPostconcussionCLARK -2010 30
P3+ TeamP3+ TeamP3+ Team P3+ Team
Staff with specialties inStaff with specialties in PainMedicine PTSD TBI SUD SUD Rehabilitation therapies
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Stepped Integrated Care FlowStepped Integrated Care FlowSt St P t P t D l t D l t Cli iCli i PNS d D D R f lPNS d D D R f lStep 1Step 1: Post : Post Deployment Deployment ClinicClinic PNS and DoD ReferralsPNS and DoD Referrals
Step 2: P3+ Step 3:
TBI Tx TBI Tx
Specialty ProgramsSpecialty ProgramsEvaluation/Tx PlanningEvaluation/Tx Planning
R i d C T t t R i d C T t t
Step 2: P3 p
Pain Tx Pain Tx
Required Core Treatment: Required Core Treatment: Life NeedsLife Needs (Sleep Hygiene, (Sleep Hygiene,
Relaxation Skills; Relaxation Skills; Substance Substance Use Tx)Use Tx)
Optional Core Treatments:Optional Core Treatments:Anger ManagementAnger ManagementAffect RegulationAffect Regulation
PTSD Tx PTSD Tx
S b t S b t Affect RegulationAffect RegulationCognitive AdaptationCognitive Adaptation
Relationship EnhancementRelationship EnhancementWork SkillsWork Skills
Substance Substance Abuse TxAbuse Tx
Voc Rehab Voc Rehab Physical ConditioningPhysical Conditioning
Voc Rehab Voc Rehab
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Treatment DirectionsTreatment Directions•• Extend and refine PMD treatment componentsExtend and refine PMD treatment components
• Are core components necessary or sufficient?Are core components necessary or sufficient?• Enhance efficiency of Tx
• Develop shared (PTSD and Pain) avoidance p ( )behavior inventory
• Integrate PTSD, Sleep, and Pain treatmentI t d ti iti kill i t T• Incorporate adaptive cognitive skills into Tx
•• Increase consumer focusIncrease consumer focus• Extended clinic hours (evenings & weekends)• Extended clinic hours (evenings & weekends)• Utilize technology and fitness (internet; Wii; gym)
•• Assess Tx outcomes and modify PMD Tx as neededAssess Tx outcomes and modify PMD Tx as needed
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Assess Tx outcomes and modify PMD Tx as neededAssess Tx outcomes and modify PMD Tx as needed