AMERICAN SOCIETY OF ADDICTION MEDICINE ANNUAL MEDICAL-SCIENTIFIC SYMPOSIUM

--DR. MICHAEL KILPATRICK, MD

“Treatment of the Returning Military Veteran”

Friday, April 15, 2011

Treatment of the Returning Military Veteran

Traumatic Brain Injury (TBI)

Traumatic Brain InjuryData from Defense Veterans Brain Injury Center (DVBIC)

Blast62%

Vehicular13%

Fragment11%

Fall6%

Bullet4%

Other4%

TBI Injury Mechanism

Mild62%

Moderate18%

Severe14%

Penetrating5%

Unknown1%

TBI Severity of Injury

Spectrum of TBI range from Mild to SevereMild 62%

Operational BreakoutOIF 96%OEF 4%

Source: Defense Veterans Brain Injury Center 2006

2000

9000

10000 10,963

28,5572000

0

6,282 (27%)

7,200 (25%)

(16%4,442

)

2007 2008 2009DoD Baseline DoD OIF/OEF DoD OIF/OEF DoD OIF/OEF

23,002

OVERALL TBI CASES HAVE MORE THAN DOUBLED

27,862

DoD Total

Data Source: AFHSC

Deployed Forces

DoD TBI Numbers at www.dvbic.org & www.health.mil

Overall TBI Snapshot…

Policy Guidance for the Management of Concussion/mTBI in the Deployed Setting

Directive-Type Memorandum (DTM) 09-033

Issued 21 June 2010 by DEPSECDEF

Involves commitment of line commanders and medical community DCoE coordination with FHP/R, JS, CENTCOM, JTAPIC, Service TBI POC’s

Describes mandatory processes for identifying those service members involved in potentially concussive events Exposed to blast, vehicle collision, witnessed loss of consciousness, other head

trauma

DCoE developed specific protocols for management of concussed service members and those with recurrent concussion

Transition from symptom driven reporting to incident driven

DESIRED END STATE: the mitigation of the effects of potential concussive events on both service member health, readiness and ongoing operations

Highlights from the DTM

•Mandatory event driven protocols, for exposure to potentially concussive events

•Requires a medical evaluation and a rest period

•All sports and activities with risk of concussion are prohibited until medically cleared

•Military Acute Concussion Evaluation (MACE) documentation will include MACE 3-part score

•Service Members diagnosed with mTBI will be given a standardized educational sheet

•New protocols for anyone sustaining 3 or more mTBIs within 12 months

OASD(HA) FHP&R

Data drivers:• inform DoD TBI policy updates and MHS Strategic Communications

ISAF Tampa, FL

BECIR = Blast Exposure and Concussion Incident Report

CIDNE = Combined Information Data Network Exchange

JTAPIC = Joint Trauma Analysis and Prevention of Injury in Combat

OASD (HA) FHP&R = Office of the Assistant Secretary of Defense for Health Affairs, Force Health Protection and Readiness

DDR&E = Director, Defense Research & Engineering

JIEDDO = Joint Improvised Explosive Device Defeat Organization

BIR PCO = Blast Injury Research Program Coordinating Office

End of month (EoM)

EoM + 10 days

EoM + 15 days

EoM + ? days

EoM + ? days

USF-I

Monthly

BECIR

Data drivers:• Establish procedures for capturing and reporting data

• Quality assurance

JIEDDO

DDR&E

Data drivers:• Medical/non-medical RDT&E

• Support RDT&E investment decisions

JTAPICFort Detrick

MDData drivers:• Develop event-specific monitoring summaries

• Supplement current JTAPIC data collection efforts

DCoE

Data drivers:• Clinical Data Analysis

• Develop TBI CPG recommendations

• Provide DoD leadership with activity summaries

Timeline

MTBI DTM Data Flow

Blast Injury Research

PCO

Joint Staff

ISAF

Co-Morbidities Associated with mTBI

Sleep disorders Substance abuse Psychiatric illness Vestibular disorders Visual disorders Cognitive disorders

PTSD N=23268.2%

2.9%16.5%

42.1% 6.8%

5.3%

10.3%

12.6%

TBIN=22

766.8%

Chronic Pain N=27781.5%

Lew, et al: “Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OIF/OEF Veterans: Polytrauma Clinical Triad”, Dept. of Veterans Affairs, Journal of Rehabilitative Research and Development, Vol. 46, No. 6, 2009, pp. 697-702, Fig. 1

DoD TBI Research Initiatives

Blast Physics/Blast

Dosimetry

Force Protection Testing & Fielding

Complementary Alternative Medicine

Field Epidemiologica

l Studies (mTBI)

Rehabilitation &

Reintegration: Long Term

Effects of TBI

Neuroprotection & Repair Strategies: Brain Injury Prevention

Concussion: Rapid field

Assessment

Treatment & Clinical

Improvement

Close collaboration among the line, medical, and research communities

Key areas Rapid field assessment of concussion (i.e., rapid eye movement

tracking, biomarkers) Novel therapeutics (i.e, omega-3, progesterone, HBO2, cognitive

rehabilitation) Blast dynamics (i.e., neuroimaging)

FY06–FY10: Over $400M for TBI

Research

Treatment of the Returning Military Veteran

Surveillance

Physical

Psych

olo

gic

al

Nut

ritio

nal

Spiritual

Medical

En

viro

nm

en

tal

Behav

iora

l

Social

TotalFitness

AccessImmunizationsScreeningProphylaxisDental

Heat/ColdAltitudeNoiseAir Quality

StrengthEnduranceFlexibilityMobility

Food qualityNutrient requirementsSupplement UseFood choices

Social supportTask cohesionSocial cohesion

Substance abuseHygieneRisk mitigation

Service values Positive beliefs Meaning makingEthical leadershipAccommodate diversity

TotalForceFitness

CopingAwarenessBeliefs/appraisalsDecision makingEngagement

Total Force Fitness Model

Surveillance

2795 Predeployment Health Assessment (1998)

2796 Post Deployment Health Assessment (1998) Modified April 2003 – PTSD Screening Modified late 2007 – TBI

2900 Post Deployment Health Assessment (2005) Modified late 2007

All being modified in 2011

December 2010 MSMR Data

The inTransition Program: Maintaining Continuity of Care Across Transitions

inTransition is a Department of Defense (DoD) program created to assist service members who are receiving mental health services while transitioning between health care systems or providers

Developed in response to the DoD Mental Health Task Force recommendation to “Maintain continuity of care across transitions” (5.2.2)

Provides voluntary one-on-one coaching to service members

Designed as a bridge of support for service members when: Relocating to another assignment Returning from deployment Transitioning from active duty to reserve, reserve to active duty,

or returning to civilian life

DoD PH Research Initiatives

Sleep Studies

Genetics and Biomarkers

Suicide Prevention and

Screening

Pre/Peri/Post-Deployment Behavioral

Skills Training for Service

Members and Spouses

Child and Family Studies

Complementary and Alternative

Medicine

Clinical Treatment: Psychotherapy and Pharmacotherapy

Key areas Continued trials to treat deployment related PTSD, especially with co-

morbidities Novel therapeutics (e.g., virtual reality, mindfulness, telehealth,

pharmacotherapies) Establish validated models and measures of resilience

FY06–FY10: Over $345M

for PH Research

Co-morbidities (TBI, Pain

Management, Substance Use Disorders, etc.)

Treatment of the Returning Military Veteran

Millennium Cohort

Background

The Millennium Cohort Study is a longitudinal study designed to evaluate long-term subjective health and

chronic diagnosed health problems, in relation to exposures of military concern, especially deployments

>150,000 population-based with over-sampling for women, previous deployers, and Reserve/National

Guard

All services, active duty, Reserve/National Guard

Participants are re-surveyed at 3-year intervals, including after service through 2022

DMDC Reference # 00-0019 * RCS # DD-HA(AR)2106 * OMB Approval # 0720-0029

Basic Methodology

Survey refined based on focus group testing, pilot study, and expert review

Questionnaire leverages standard instruments (PHQ, PCL, SF-36V, others)

Includes measures of physical health, behavioral health, mental health

Includes exposure questions, and other metrics (deployment, sleep, etc.)

Participants respond via traditional paper, or over secure website

InductionDemographic Data

Immunization Data

Deployment Data

Mortality Data

Recruit Assessment Program

Dept of Veterans Affairs Data

Medical HistorySurvey Data, PDHA/RA

Exposure Data

Military Inpatient and Outpatient Care

Civilian Inpatient and Outpatient Care

Family Datae.g., DoD Birth andInfant Health Registry

DoD and VA DataSources

Environmental

DoD Serum Repository

PharmacologicData

Current Status

2001: Study launched77,047 enrolled in Panel 1

2004: Panel 2 enrollment and Panel 1 follow-up 31,110 enrolled / 55,021 followed-up

2007: Panel 3 enrollment and Panels 1-2 follow-up43,440 enrolled / 71,942 followed-up

2010: Panel 4 enrollment (50,000) , Panels 1-3 follow-up, and

enrollment of Family CohortOf the current participants (N = 151,597) :

• > 70% with at least 1 follow-up

• ~ 50% deployed in support of operations in Iraq and Afghanistan

• ~ 20% have left military service

Currently, 33 peer-reviewed publications and 190 scientific presentations with many awards

Millennium CohortEnvironmental Exposure Support

Health outcomes among infants born to women deployed to US military operations during pregnancy Birth defects research (Part A, In press)

Findings indicate that infants born to women who inadvertently deployed to military operations during pregnancy were not at increased risk of adverse birth or infant health outcomes

Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a

prospective population-based study (AJE, 2009)Deployment associated with respiratory symptoms in Army and Marine Corps personnel, independent of smoking status

Deployment length linearly associated with increased symptom reporting in Army personnel, and elevated odds of symptoms were associated with land-based deployment (vs. sea-based deployment)

Follow-up study in progress to assess chronicity of these findings

Burn Pit Studies

In progress are 4 burn pit studies that utilize 3 exposure measures: 1) within 2, 3, or 5 miles of burn pit; 2) cumulative

days of burn pit exposure; and 3) base assigned (Balad/Taji/Speicher)

Analysis of birth outcomes for personnel assigned to locations with burn pits and exposed before (women and men) and

during pregnancy (women)

Utilized DoD Birth and Infant Health Registry data

Compared live births for men and women deployed within 2, 3, or 5 miles of Balad/Taji/Speicher burn pits versus all

other deployers

Generally, no associations between burn pit exposure and birth defects or preterm births in infants of active-duty

personnel

However, infants born to men who were last exposed to a burn pit area > 280 days prior to infant’s estimated date of conception had an increased risk of birth defects (AOR

= 1.31, 95% CI = 1.04, 1.64)