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

CLARK -2010 2

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.

CLARK -2010 3

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

CLARK -2010 4

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

CLARK -2010 5

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

6CLARK -2010

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%)

CLARK -2010 7

( )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

CLARK -2010 8

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

CLARK -2010 9

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

CLARK -2010 10

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

CLARK -2010 11

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

CLARK -2010 12

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

CLARK -2010 13

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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 

15CLARK -2010

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

CLARK -2010 17

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

18CLARK -2010

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%

19CLARK -2010

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%

21CLARK -2010

(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 %

22CLARK -2010

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

CLARK -2010 23

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

CLARK -2010 24

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

CLARK -2010 25

PostPost--Deployment MultiDeployment Multi--symptom symptom DisorderDisorder

TBI/Pain

Post‐deploymentM l iMulti‐symptom

Disorder

PTSD

CLARK -2010 26

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%

CLARK -2010 27

CLARK -2010 28

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)

CLARK -2010 29

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

CLARK -2010 31

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 

CLARK -2010 32

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

CLARK -2010 33

Assess Tx outcomes and modify PMD Tx as neededAssess Tx outcomes and modify PMD Tx as needed