1. AMERICAN SOCIETY OF ADDICTION MEDICINE ANNUAL MEDICAL- SCIENTIFIC SYMPOSIUM --DR. MICHAEL KILPATRICK, MD “Treatment of the Returning Military Veteran” Friday, April 15, 2011

2. Treatment of the Returning Military Veteran Traumatic Brain Injury (TBI)

3. Traumatic Brain Injury Data from Defense Veterans Brain Injury Center (DVBIC) Spectrum of TBI range from Mild to Severe Mild62% Operational Breakout OIF96% OEF4% Source: Defense Veterans Brain Injury Center 2006

7. 2000 9000 10000 10,96 3 28,557 2000 0 6,282 (27%) 7,200 (25%) (16%4,442 ) 20072008 2009 DoD BaselineDoDOIF/OEFDoDOIF/OEFDoDOIF/OEF 23,00 2 OVERALL TBI CASES HAVE MORE THAN DOUBLED 27,86 2 DoD Total Data Source: AFHSC Deployed Forces DoD TBI Numbers at www.dvbic.org & www.health.mil Overall TBI Snapshot…

8. 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

9. Highlights from the DTM

10. OASD(HA) FHP&R Data drivers: inform DoD TBI policy updates and MHS Strategic Communica tions 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 USF-I Monthl y BECIR Data drivers: Establish procedures for capturing and reporting data Quality assurance JIEDDO DDR&E Data drivers: Medical/no n-medical RDT&E Support RDT&E investment decisions JTAPIC Fort Detrick MD Data 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

11. Co-Morbidities Associated with mTBI  Sleep disorders  Substance abuse  Psychiatric illness  Vestibular disorders  Visual disorders  Cognitive disorders PTSD N=232 68.2% 2.9% 16.5% 42.1% 6.8% 5.3% 10.3% 12.6% TBI N=227 66.8% Chronic Pain N=277 81.5% 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

12. DoD TBI Research Initiatives Blast Physics/ Blast Dosimetry Force Protection Testing & Fielding Complementary Alternative Medicine Field Epidemiological 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

13. Treatment of the Returning Military Veteran Surveillance

14. Physical Psychological Nutritional Spiritual Medical Environmental Behavioral Social Total Fitness Access Immunizations Screening Prophylaxis Dental Heat/Cold Altitude Noise Air Quality Strength Endurance Flexibility Mobility Food quality Nutrient requirements Supplement Use Food choices Social support Task cohesion Social cohesion Substance abuse Hygiene Risk mitigation Service values Positive beliefs Meaning making Ethical leadership Accommodate diversity Total Force Fitness Coping Awareness Beliefs/appraisals Decision making Engagement Total Force Fitness Model

15. 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

16. December 2010 MSMR Data

17. 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

18. 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.)

19. Treatment of the Returning Military Veteran Millennium Cohort

20. 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

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

22. Induction Demographic Data Immunization Data Deployment Data Mortality Data Recruit Assessment Program Dept of Veterans Affairs Data Medical History Survey Data, PDHA/RA Exposure Data Military Inpatient and Outpatient Care Civilian Inpatient and Outpatient Care Family Data e.g., DoD Birth and Infant Health Registry DoD and VA Data Sources Environmental DoD Serum Repository Pharmacologic Data

23. Current Status 2001: Study launched 77,047 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-up 43,440 enrolled / 71,942 followed-up 2010: Panel 4 enrollment (50,000), Panels 1-3 follow-up, and enrollment of Family Cohort Of 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

24. Millennium Cohort Environmental 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

25. 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)