1. Aligning Care to Treat Pain in Veterans with PTSD: A Demonstration Project Steve Dobscha MD Portland VA Medical Center September 30, 2009

2. 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

3. Goals—Demonstration 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

4. 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?

5. Outline Background on pain and PTSD Promising Treatments/Models –Individual treatments –System approaches Demonstration project –Clinical program –Evaluation Discussion

6. 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)

7. 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)

8. Shared symptoms include: –Autonomic arousal –Irritability –Avoidance –Somatic focus –Catastrophic thinking

9. 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

10. PROMISING MODELS

11. Integrated treatment—CBT 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)

12. 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

13. Behavioral Activation for PTSD Conceptualization (Wagner) Prior Life FunctioningTraumatic Events (s) Symptoms *Affective (Mood) *Avoidance Behaviors *Cognitive *Physiological Restricted Range of Behavior Less Rewarding Life Goals *Broadening behavior *Defining values & achieving goals *More fulfilling life Behavioral Activation Focus: Present centered therapy Working from the outside-in

14. Acceptance and Commitment Therapy 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)

15. Common therapy elements CBT structure including: Acceptance Activation Seeking meaning in life

16. 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

17. 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

18. Opioid Renewal Clinic—Results # 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

19. Key Steps in the Treatment of Any Chronic Disease Systematic Screening Other Identification Initial Assessment And Triage Treatment Initiation Outcome Monitoring Treatment Adjustments Adapted/borrowed (with permission) from: David Oslin, MD MIRECC VISN-4 VA Philadelphia University of Pennsylvania

20. Behavioral Health Lab (Oslin 2004) Annual Screening Direct consult New treatment for depression Consult request BHL Assessment Referral to BHC Recommendations to PCP and Patient Enroll in Depression monitoring Referral to Specific Research No referrals made F/U Monitoring – 3 months Watchful Waiting – 8 weeks Referral Management

21. 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

22. Treatment Approach Treatment Options

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

24. 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

25. 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

26. 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

27. 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