Post-Deployment Chronic Pain Comorbidities by PAINWeek

Post-Deployment Chronic Pain Comorbidities Ilene R. Robeck, MD Moderator

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Learning Objectives List the common comorbidities associated with post deployment pain Describe the impact of post deployment pain, PTSD, TBI and substance use disorder on the family Describe the role that non-VA providers can have when patients opt to get some or all of their care outside of the VA setting

Chronic Pain, PTSD, TBI, SUD  Common military comorbidities that impact VA, military and civilian patients  50 % of Veterans do not seek health care in the VA system and are seen elsewhere  Of those seen by the VA many veterans will also be seen in the private sector  100% of Veteran’s families impacted by post deployment problems will seek healthcare in the private sector  Many non military patients share the above co morbidities that complicate diagnostic consideration and treatment options

OEF/OIF Issues Affecting Treatment Multiple Deployments Multiple Blast Exposures Under stress for prolonged periods of time Long War Co morbidities of Chronic Pain, PTSD, TBI and Substance Use Disorder

Special Issues for Women Post Deployment           

Pregnancy and other Reproductive Health Needs Gynecologic Health Needs Menstrual Disorders Fibromyalgia and Chronic Fatigue Military Sexual Trauma Issues of leaving/reconnecting with children Homelessness/women with children Marital conflicts Potential for domestic violence Often fewer social supports than men (may be only or one of few women in unit) Many women veterans are single mothers

– over 30,000 single mothers have served in OEF-OIF (Department of Defense, 2009)

Physical Health Outcomes Post-Deployment  Medical literature supports

– Elevated rates of hypertension – Elevated rates of eating disorders and weight changes in women – Elevated rates of chronic pain and medically unexplained symptoms – Elevated rates of Vitamin D deficiency – Elevated rate of new onset and recidivism of nicotine use – Increased risk of excess alcohol use and alcohol related problems in combat veterans – Higher rates of other substance abuse – Multiple combat deployments with complex, protracted readjustment challenges VA Data

Mental Health Risks  Incidence - 36.9 % met criteria for mental health diagnoses – 21.8 % diagnosed with PTSD – 17.4 % diagnosed with depression

 Higher rates of depression for women veterans compared to men  Women more commonly report military sexual trauma and eating disorders  Increased risk of new onset heavy weekly drinking, binge drinking, and alcoholrelated problems has been reported in younger deployed service members  Higher rates of substance use disorders  Higher rates of anxiety disorders.  “Sub-syndromal”mental health symptoms such as sleep disturbances and irritability  Rates of suicide in younger male veterans are elevated

Understanding the Returning Family Member  The returning family member may seem preoccupied with the experience of their deployment. They may be unable to talk about it or may excessively talk about it  in a war zone, there was the constant threat of loss of life or injury. The family member may have witnessed injuries, deaths and destruction  The returning family member may have suffered physical or emotional injury or disability  The returning family member may expect extra attention and support for some time after their return  The returning family member may have serious concerns about their financial or employment future American Academy of Child and Adolescent Psychiatry./Facts for Families

Understanding the Adult that Stayed at Home ď&#x201A;§ Life has gone on and the adult at home has had to keep the family moving forward during the deployment. They may have had to take over many functions normally performed by the deployed family member ď&#x201A;§ Often the adult at home has handled many small and not so small crises These problems are old news at home but may be big surprises for the returning family member ď&#x201A;§ The adult at home may expect extra attention and credit regarding the performance during the deployment. They also may expect the returning family members to automatically accept the family as it now exists and begin to perform a role with which they are uncomfortable or unfamiliar

Understanding The Children  Children generally are excited about a reunion with their returning parent. However, the excitement of the reunion is stressful for children. Children may also be anxious and uncertain about the reunion  Toddlers may not remember the parent well and act shy or strange around them. School age children may not understand the returning parent’s need to take care of themselves and to spend time with their spouse. Teenagers may seem distant as they continue their activities with friends  Children may need a period of time to warm up and readjust to the returning parent. This should not be misinterpreted or taken personally

Understanding the Family  Couples may find the deployment has strained their relationship. Time and negotiation will help the couple work toward a new loving relationship  Family problems that existed before the deployment frequently reappear after the deployment  Extended family members such as grandparents, aunts and uncles may have provided support and service to the family during the deployment. They may have difficulty redefining their role with the family  Families should utilize the help offered by the military and other organizations to readjust to the reunion  Most families will change. Children have been born or have grown. An adult at home may have become more independent. The returning family member had a life changing experience. The goal is to form a healthy, new life together

What Family Members Need to Know About Returning Veterans Thoughts, they might: Be forgetful and have trouble concentrating Relive bad memories of traumatic events Have thoughts of death or suicide Feelings, they might feel: Sad Hopeless Worthless Paranoid

Anxious Guilty Angry Behaviors, they might: Avoid situations that trigger flashbacks of their traumatic experiences Not want to socialize Have low energy Use drugs or drink too much

What Family Members Need to Know  TBI Symptoms can include:  Constant headaches  Confusion  Light headedness or dizziness  Changes in mood or behavior  Trouble remembering or concentrating  Repeated nausea or vomiting  Problems with seeing or hearing.  Psychosocial Risks of Deployment

– Marital instability, unemployment/ underemployment, financial decline, social isolation, and legal problems – Higher incidence of mental health diagnoses in spouses of veterans who have deployed, particularly if there has been a prolonged deployment

Insights from RAND Research on Deployment  As early 2003, a survey of soldiers and marines serving in Iraq found that 89 percent of soldiers and 95 percent of marines reported having been attacked or ambushed  Deployed troops have had to face snipers, suicide bombers, improvised explosive devices (IEDs), and they have seen their fellow soldiers and friends killed or shattered by blasts, and may have had to kill enemy fighters, handle human remains, and may have inadvertently killed or injured civilians  Average temperatures in Iraq are over 120 degrees in July and August and below freezing in January  Sandstorms pelt personnel and equipment with fine grit, and camel spiders are a lurking danger of sleeping in the open

Children and Deployment ď&#x201A;§ In 2008-2009, RAND surveyed parent caregivers, usually the mother, and their children ages 11 to 17 who had applied to Operation Purple Camp, a summer camp for children of service members. The children in the study experienced behavioral and emotional difficulties at rates above the national average. This finding was apparent in the first survey and remained much the same in the follow-up surveys at 6 and 11 months ď&#x201A;§ Anxiety was a specific problem. 30 percent of the children in the study sample had elevated symptoms of anxiety, which is twice the rate found in other child studies ď&#x201A;§ Older teens experienced more difficulties such as having to take on more household responsibilities, take care of siblings, and missing school activities, and had trouble getting to know their deploying parent again and adjusting to the parent fitting back into the household routine

Families and Deployment  Girls reported more difficulties during the parent’s reintegration into the family including worrying about the parent’s next deployment, dealing with the parent’s mood changes, and worrying about how parents were getting along  Children in families where the non-deployed parent is coping with emotional health issues tended to experience more difficulties  Longer total months of deployment were associated with more problems for children  The probability of divorce increases as total months of deployment increases

Children  Children whose parents have deployed 19 months or more since 2001 have modestly lower (and statistically different) achievement scores compared with those who have experienced less or no parental deployment  Teachers and counselors identified a range of deployment-related issues that may affect children’s academic success, including problems with homework completion, school attendance, and parental engagement  Options for improving support to children include providing additional resources to assist students with schoolwork, improving information flow to schools, and increasing the number of providers trained in child and adolescent behavioral health issues

PTSD and Chronic Pain after MVA  Clinically significant PTSD-like symptoms have been found in more than 50% of patients receiving treatment for chronic pain after MVC  14.6% of MVC survivors with chronic pain met full criteria for current PTSD and a further 9.1% exhibited PTSD in partial remission  Chronic pain has also been found to be common in patients with PTSD with 25% to 30% of outpatient samples with PTSD also having chronic pain complaints Hickling EJ, Blanchard EB. Post-traumatic stress disorder and motor vehicle accidents. J Anxiety Disord 1992;6:285–91.

PTSD and Medical Conditions in Women  LS Spine disorders  Headache  Lower extremity joint disorders  Skin disorders  Tendonitis/Myalgia  Dental Disorders  Allergies  Vision Defects  Acute Respiratory Tract Infections  Overweight/Obesity

Civilian TBI The incidence is 500 per 100,000 people The peak incidence is between the ages of 15 and 24 and older than the age of 64 years In the civilian population, alcohol is involved in more than half the cases of TBI Motor vehicle accidents (MVAs), particularly motorcycle accidents, account for the most frequent civilian cause of TBI Centers for Disease Control and Prevention: http://Available at: http://www.cdc.gov/ncipc/pubres/TBI_in_US_04/TBI%20in%20the%20US_Jan_2006.pdfTraumatic Brain Injury in the United States. Accessed December 10, 2008.

TBI and Chronic Pain  In a recent prospective study of patients who had been hospitalized on an acute rehabilitation unit for TBI, Hoffman and colleagues found that at 1-year post injury – 72.6% of individuals complained of pain of some form, with 47.2% reporting mild pain and 25.4% reporting moderate to severe pain

 Being female, having a lower functional status, and being depressed were associated with increased pain severity Hoffman JM, Pagulayan KF, Zawaideh N, Bell KR. Pain after traumatic brain injury: predictors and correlates [poster presentation]. Chicago: American Congress of Rehabilitation Medicine; 2005

TBI and Chronic Pain  A guiding principle in traumatic brain injury rehabilitation should be the promotion of cognitive recovery  Patients with TBI may be even more vulnerable than other patients to the cognitive side effects of certain analgesic medications  The use of nonsedating analgesics (eg, acetaminophen, nonsteroidal antiinflammatory drugs, and transdermal lidocaine patches) should be a first line in treating pain in patients with TBI  The most common persisting symptoms after such an injury are headache and neck pain  These painful conditions may occur in combination with cognitive complaints such as reduced attention, memory impairment, and slowed processing speed, completing the picture of persistent post-concussion syndrome Ivanhoe CB, Hartman ET. Clinical caveats on medical assessment and treatment of pain after TBI. J Head Trauma Rehabil 2004;19(1):29–39.

TBI Symptoms Headache Dizziness Tinnitus Hearing Loss Blurred Vision Sleep Disturbances Fatigue Anxiety

Sensory Impairment Attention and Concentration Deficits Slowed Mental Processing Memory Impairment Lability Irritability Depression

TBI Late Effects Seizures Hydrocephalus Infection Pain Spasticity Endocrine  SIADH  Up to 21 % with Thyroid Hormone Abnormalities

Medicine Side Effects Mental Health Issues Sleep Disturbance Sexual Disturbance Effects of Immobility

PTSD and Alcohol  Worsens sleep disorders  Increased emotional numbing, social isolation, anger, irritability, depression, hypervigilance  Increase in Anxiety Disorders, Mood Disorders, Disruptive Behavior, Abuse of other substances, Chronic Physical Illness (Diabetes,Heart Disease or Liver Disease), Chronic Pain

TBI and Substance Abuse  Increased use of substances to cope with frustration, anger, and sorrow  Tolerance levels of substances are decreased  Ability to self-monitor appropriate social behavior is decreased  Social groups change  Pain or potential seizure activity after an injury may require prescription drugs

Post Deployment Addiction Associated with issues related to –PTSD –TBI –Chronic Pain –Relationship Issues –Employment Issues

Caffeine  Energy Drinks: 50-505 mg caffeine per serving  12 oz cola:

34-54 mg caffeine per serving

 6 oz coffee:

77-150 mg caffeine per serving

 Energy Shots:

100-350 mg caffeine per serving JAMA, February 9, 2011 Vol 306 No 6

Energy Drink Effects Hypertension Sleep Disturbances Late Miscarriages, still birth and small for gestational age infants in pregnant women Headaches

Caffeine Withdrawal Symptoms  Headache  Fatigue  Decreased attentiveness  Irritability  Depression  Difficulty concentrating  Nausea  Muscle pain/Stiffness

Alcohol and Energy Drinks Higher volumes of alcohol per session Increase incidence of sexual Assault Increased incidence of Driving While Intoxicated Underestimation of impairment Increased risk of alcohol dependence Increased risk of non medical prescription drug use

Afterdeployment.org                

18 Topics 29 Self-Assessments Multiple Media Libraries Self-Paced Workshops Video-Based Personal Stories Community Forums Expert Blogs Links to Hotlines Links to Other Sites/ Content Provider Locator Tool Provider Portal Podcasts RSS Feeds Polls and Quick Health Tips Social Media Links Daily Quotes

AfterDeployment.org: Topics Covered PTSD Depression Anger Sleep Families and Friendships Anxiety Alcohol and Drugs Tobacco Work Adjustment

Physical Injury Mild TBI Life Stress Stigma Resilience Military Sexual Trauma Health and Wellness Families with Kids Spirituality

Mobile APPS

Online Resources for Families  http://apps.mhf.dod – Military Youth on the Move is the Defense Department’s one-stop shop where kids and teens can get advice and access resources on moving – Visit Family Matters for tips to ease summertime moves

 MilitaryKidsConnect.org offers online journals and videos to connect with other military kids  www.sesameworkshop.org – Talk, Listen, Connect offers tool kits and videos that help families manage deployments, grief and changes

 familiesnearandfar.org Moving tips for preschoolers, school-age children and families offered through— with resources for grown-ups, too

6 Tips for Families Coping with Post-Deployment Stress 1. You can experience secondary trauma 2. Education is power 3. Make time as a couple 4. Have your own support group 5. Avoid one-upping each other 6. You canâ&#x20AC;&#x2122;t fight fire with fire Defense Centerâ&#x20AC;&#x2122;s fo Excellence

Clinical Pearls  Address Barriers to Care  Establish a strong connection: acknowledge military service, take military history, and place this in visible, easy access to part of the chart  Conduct a specialized review of systems: – Combat exposures, Blast exposures/Concussive injuries – Illness/Injuries during deployments – Tinnitus, dental concerns, chronic pain, sleep disturbance, tobacco, alcohol or substance abuse, depression screen, PTSD screen, suicide assessment

 Involve all members of the health care team: construct an easy to follow, well sequenced and synthesized plan  De-stigmatize mental health care  Close follow-up is recommended  Focus on function and reintegration  Each VA facility has an OEF/OIF/OND program manager who acts as a community liaison and patient advocate Spelman, MD et al Post Deployment Care for Returning Combat Veterans. J Gen Intern Med published online 5/31/12

Taking a Military History  Branch: Army, Air Force, Navy, Marine Crops, and Coast Guard  Rank/Rate: Enlisted, Warrant officer, Commissioned officer – Enlisted: perform specific specialties (high school diploma or GED) – Warrant Officer: highly trained specialist – Commissioned Officer (college degree), from 2nd lieutenant to a four star general

 Dates in service  Deployments: location/dates  What they were trained to do, what did they do

Post Deployment and Chronic Pain  Pain relief needs to be approached from a functional, rehabilitative perspective utilizing pharmacologic, behavioral, and alternative treatment modalities  These include physical therapy, massage, TENS, thermal and aqua therapy, encouragement of regular exercise, chiropractic treatment, and acupuncture  Incorporating behavioral strategies into a comprehensive, collaborative treatment plan involving a health psychologist for cognitive behavioral therapy, biofeedback training, stress management, and alternative techniques such as deep relaxation training, meditation, and yoga have been shown to improve pain outcomes  Co-morbid mental health conditions or psychosocial stressors may lower the pain threshold and augment pain experiences

Post Deployment Pain and Opioids Opiates should be used with caution and reserved for refractory chronic pain conditions, given the high risk for abuse Co-morbid mental health conditions compound the risk for inappropriate use of opiates, as veterans may attempt to self-medicate their "psychological pain“ PTSD increases risk for opiate prescription, high risk opiate use and adverse events

Post Deployment Pain and Opioid (cont’d)  A total of 15,676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders,17.8% of veterans with PTSD and 11.7% with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses  Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higherdose opioids (22.7% vs 15.9%), receive 2 or more opioids concurrently(19.8% vs 10.7%), receive sedative hypnotics concurrently (40.7% vs 7.6%), or obtain early opioid refills (33.8% vs 20.4%)  Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%); which was most pronounced in veterans with PTSD Seal et al JAMA, March 7, 2012—Vol 307, No. 9

Prazosin ď&#x201A;§ Highly lipophilic alpha(1)-adrenergic receptor blocker that is traditionally used to treat hypertension and benign prostatic hyperplasia, has been shown to decrease the occurrence of trauma nightmares in both combat veterans and patients with non-combat-related PTSD ď&#x201A;§ The starting dose is 1 mg hs with titration upward to as high as 15 mg if necessary. Caution about orthostatic hypotension in the AM Pharmacotherapy. 2008 May;28(5):656-66

TBI Symptom Management  Headache is the single most common symptom associated with concussion/mTBI; assessment and management of headaches in individuals should parallel those for other causes of headache  Medication for ameliorating the neurocognitive effects is not recommended  Medications for headaches, musculoskeletal pain or depression/anxiety must be carefully prescribed to avoid the sedating properties, which can have an impact upon a person’s attention, cognition, and motor performance  Treatment of psychiatric symptoms following concussion/mTBI should be based upon individual factors and the nature and severity of symptom presentation, and may include both psychotherapeutic and pharmacologic treatment options Spelman, MD et al Post Deployment Care for Returning Combat Veterans. J Gen Intern Med published online 5/31/12

Taking Into Account The Unique Needs Of Returning Combat Veterans  High prevalence of physical injury, pain, TBI risk and mental health co-morbidities – Need for integration of medical care, mental health care, polytrauma, SW and pain management support

 High rates of psychosocial impairments impacting marriages, families, financial and occupational domains – Need for SW involvement and benefits counseling as a standard of care

 High risk of functional decline in early months and years post-deployment; increased suicide risk – Need for more intensive SW case management/care management

 Recognition that mainstream primary care not prepared to effectively meet the needs of this population

– Need for entire staff (clinicians and support staff) to be trained in post-combat health care needs