Aligning Care to Treat Pain in Veterans with PTSD: A Demonstration Project

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Aligning Care to Treat Pain in Veterans with
PTSD A Demonstration Project

• Steve Dobscha MD
• Portland VA Medical Center
• September 30, 2009

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Context

• VHA interest in implementing stepped-care
• Several recent VA studies have shown that
  stepped/collaborative care can be effective for
  chronic pain and comorbid depression (Kroenke
  and Bair (2009) and Dobscha et al (2009))
• Northwest MIRECC and Portland REAP on Comorbid
  Psychiatric and Medical Conditions offer an
  opportunity to develop and test clinical
  demonstration project
• A key focus of NW MIRECC is PTSD

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GoalsDemonstration project

• Realign local pain care system to provide high
  quality pain care for veterans with PTSD
• Improve clinician satisfaction, system
  efficiency, and patient outcomes and satisfaction
• Develop systemic approaches that can be
  transported to other clinical settings
• Create structure that facilitates research
  generates useful pilot/outcome data

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My goals for today

• This is very much work in progress
• Generate discussion, ideas about next steps
• Specific questions
• Specific components of clinical program?
• Clinical Demonstration vs. Research?
• IRB issues?

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Outline

• Background on pain and PTSD
• Promising Treatments/Models
• Individual treatments
• System approaches
• Demonstration project
• Clinical program
• Evaluation
• Discussion

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Prevalence

• Pain is common
• 1/2 of veterans in primary care
• PTSD is common
• 7 in general population
• Much more that among OEF/OIF veterans
• Co-occurrence is also common
• 35 in sample with work-related injury (Asmundson
  1998) to 80 in sample of Viet Nam veterans
  (Beckham 1997)

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• Combination of pain and PTSD is associated with
  worse outcomes
• Worse pain
• More affective distress
• Greater rates of disability
• Less responsive to treatment (childhood trauma)

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• Shared symptoms include
• Autonomic arousal
• Irritability
• Avoidance
• Somatic focus
• Catastrophic thinking

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Shared vulnerabilities (see Otis et al 2003)

• Biological
• Psychological
• Anxiety sensitivity
• (fear of arousal related sensations)
• Lack of control
• Somatic focus (and triggering)
• Acceptance
• Difficulty focusing on meaning in life

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Promising models
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Integrated treatmentCBT

• Little published about treating conditions
  concurrently or using integrated model
• Otis is testing integrated CBT approach
• 12 session treatment incorporating elements of
  CPT for PTSD and CBT for chronic pain
• Address anxiety sensitivity through exposure
• Address avoidance
• ID maladaptive thoughts (cognitive restructuring)

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Behavioral Activation

• Currently being tested with veterans with PTSD
  (Wagner, Jakupcak)
• Premise Problems in vulnerable individuals
  lives and behaviors reduce ability to experience
  rewards from environments
• Aims to systematically increase activation so
  that pts experience greater reward in their lives
  and solve life problems
• Addresses avoidance, worry, acceptance

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Behavioral Activation for PTSDConceptualization
(Wagner)
Prior Life Functioning
Traumatic Events (s)
Symptoms Affective (Mood) Avoidance
Behaviors Cognitive Physiological
Behavioral Activation Focus Present centered
therapy Working from the outside-in
Restricted Range of Behavior Less Rewarding Life
Goals Broadening behavior Defining values
achieving goals More fulfilling life
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Acceptance and CommitmentTherapy

• Focus on accepting rather than modifying internal
  experience
• Emphasizes behavioral shift towards seeking a
  valued life
• Some studies for pain (Geisser 1992, Gutierrez
  2004, McCracken 1998) some more recent
  application to PTSD (Orsillo and Batten 2005)

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Common therapy elements

• CBT structure including
• Acceptance
• Activation
• Seeking meaning in life

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Opioid Renewal Clinic(Wiedemer and Gallagher)

• Goals
• Provide appropriate treatment for each patient,
  opioid therapy when indicated, addictions
  treatment when indicated
• Assist confidence of PCPs in prescribing
• Improve monitoring and documentation
• Reduce costs through
• Decrease misuse or overuse of resources
• Decrease oxycodone SA use

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• Managed by NP and Pharmacist supported by a
  multidisciplinary pain management team
• Located in primary care clinic
• PCPs sent consults after completing opioid
  treatment agreement and doing baseline UDS
• Team developed individualized treatment plans,
  monitored and worked with patients over time

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Opioid Renewal ClinicResults

• of opioid treatment agreements increased
• Decline in ED and unscheduled primary care visits
• Providers satisfied
• Of 171 patients referred for aberrant behaviors,
  38 self-discharged
• 13 referred for addictions treatment
• Greater use of UDS by PCPs
• Decreased prescribing of oxycodone SA

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Key Steps in the Treatment of Any Chronic Disease
Outcome Monitoring
Systematic Screening
Initial Assessment And Triage
Treatment Initiation
Treatment Adjustments
Other Identification
Adapted/borrowed (with permission) fromDavid
Oslin, MDMIRECC VISN-4 VA PhiladelphiaUniversit
y of Pennsylvania
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Behavioral Health Lab (Oslin 2004)
Annual Screening
New treatment for depression
Direct consult
Consult request
BHL Assessment
Recommendations to PCP and Patient
Referral to BHC
Enroll in Depression monitoring
Referral to Specific Research
No referrals made
F/U Monitoring 3 months
Watchful Waiting 8 weeks
Referral Management
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Levels of care

• VISN 20 ACA
• LEVEL 1
• Limited support and education needs
• Can readily receive pain tx in primary care
• LEVEL 2
• More complex, with comorbid conditions
• More intensive tx needs but likely go back to PCP
• LEVEL 3
• Complex
• Need specialty care

• VHA Opioid Group
• LOW RISK
• No previous hx SUD
• Primary Care can manage
• MEDIUM RISK
• Past SUD or some concerns
• Primary care based tx with assistance
• HIGH RISK
• Active SUD
• Other aberrant concerns
• Co-manage with PCP

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Treatment Approach Treatment Options
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DEMONSTRATION PROJECT
Direct consult
PTSD screen in pt with pain
pain screen in PTSD pt
Consult request
If TBI, Neuropsych. assess.
BHL-PAP Triage Assessment
Preliminary Recs. to PCP and PMHCP Education and
Recs. to Patient
PTSD specialty care
Complex Care Module
Basic Consult
Collaborative care module
F/U Monitoring
Interven- tional care
Opioid renewal clinic
PCP/PMHCP management
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Basic Consult (Level 1 patients)

• Minimal active comorbidity
• Veteran currently using biopsychosocial approach
  minimal barriers to learning
• Motivated to use educational materials, report
  back to BHL-PAP for assistance
• OR not interested in further care
• Pain Internist confers with BHL-PAP technician to
  develop recommendations for patient and provider

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Collaborative Module (Level 2)

• Nurse Care Manager (NCM) provides initial
  assessment, patient education/activation
• Provider and Family education/support
• Develops treatment plan with Pain Internist
• X-sessions individual psychosocial Tx
  (telephone?, Internet?)testing ground?
• Time-limited or consultative psychopharmacologic
  care for pain, PTSD
• Stepped specialty care (incl. PTSD, TBI,
  specialty care) or referral to Complex care

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Complex Care (Level 3)

• Northwest Pain Network already provides
  multidisciplinary assessment including limited
  addictions consultation add PTSD expertise
• Nurse added to monitor/support pts over time
• Expand Addictions assessment follow-up
• Utilize additional collaborative module treatment
  as appropriate
• Opioid Renewal Clinic used when patients taking
  opioids

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Evaluation Clinical outcomes Process
Outcomes

• Pain-related function, pain severity
• PTSD, depression alcohol misuse severity
• Global assessment of change
• SF-12 health status
• Satisfaction with pain care

• Demographics
• Diagnoses
• Prescriptions
• Indicators of potential opioid misuse
• Utilization of visits
• Presence of opioid treatment agreement
• VA healthcare costs
• Providers satisfaction