Case Presentation Operation Iraqi Freedom Veteran with Chronic Pain

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Case PresentationOperation Iraqi Freedom Veteran
with Chronic Pain

• Mordecai Potash, M.D.
• Director, Behavioral Pain Management Programs
• Southeast Louisiana Veterans HCS
• Associate Professor of Clinical Psychiatry,
• Tulane University School of Medicine

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Introduction

• The veteran, Mr. B, is a 27 y/o male who first
  presents to the Baton Rouge OPC on December 16,
  2005 after recently being discharged from the
  Army through Fort Hood.
• He brings with him detailed medical records from
  Fort Hood, which greatly aids in initial
  assessment.

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Injury Incident

• Mr. B is identified as having severe pain issues
  stemming from injury in Iraq and is referred to
  our Behavioral Pain Management Program for
  comprehensive assessment.
• Mr. B was in the US Army as a health care
  specialist and was in good health until 09/30/04,
  when he was severely injured by two improvised
  explosive devices during a ceremony in Iraq for
  the opening of a new sewage plant.

AP Photo Just Prior to Blast

• Mr. B was at the ceremony when a Nissan pick-up
  truck exploded 20 meters away from him. He, and
  other soldiers, were surrounded by children and
  handing out candy when the blast occurred.

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Two IED Explosions

• Iraqi National Guards had been charged with
  checking parked vehicles for improvised explosive
  devices (IEDs) before the ribbon cutting event.
• Multiple pieces of shrapnel imbedded in his jaw
  and veteran and his company retreated. There were
  obviously many dead children at that time and at
  least one dead US soldier as well.
• On-lookers rushed in to help the children.
• About ½ an hour later, a gray Deawoo sedan nudged
  into the crowd and exploded.
• This explosion occurred behind Mr. B, sending
  shrapnel into his legs. Several soldiers in his
  company were killed, as well as a number of
  civilians who had rushed in to help the already
  injured.
• Mr. B relates that he had loss of consciousness
  soon after the second blast.

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Vehicle Borne IEDs (VBIEDs)
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Reported by News Outlets

• This incident is captured on film by reporters
  who were present for the opening ceremony and
  details of the incident are described by major
  news outlets around the world.
• Mr. Bs recollection is very poor after the
  second explosion. He recalls that the second
  explosion killed several soldiers he was very
  close to.
• After several days of emergent treatment, he is
  transported back to the US for treatment.

The New York Times, October 1, 2004 Friday 2 CAR
BOMBINGS IN IRAQ KILL 41, MANY CHILDREN A pair of
car bombs tore through a street celebration on
Thursday called to mark the opening of a new
sewer plant, killing 41 Iraqis, at least 34 of
them children, and wounding and maiming 139 more,
in one of the most horrific attacks in this city
since the fall of Saddam Hussein.
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Treatment at Fort Hood

• During treatment at Fort Hood, he is found to
  have bilateral open non-displaced fibular
  fractures, and multiple soft tissue wounds to the
  lower extremities. He requires several skin graft
  procedures to wounds on the left lower extremity.
• He is also found to have multiple traumatic nerve
  injuries to the lower extremities, including the
  sural and tibial nerves. Serial EMG NCS studies
  are done which demonstrate neuropathy and sensory
  deficits in the lower extremities.
• He is also found to have suffered a mandibular
  fracture with avulsive injury, necessitating
  removal of five teeth. He also underwent
  inter-maxillary surgical fixation to promote bone
  re-growth to aid in placement of dental implants.
• During this time in Fort Hood, he also begins
  having severe pain in the back of his left leg /
  knee. He also has pain in his face and jaw.

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Sural Nerve
Tibial Sural Nerves
Mandible
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Treatment at Fort Hood

• Mr. B is treated with several different pain
  medications at Fort Hood. He eventually is placed
  on Methadone 20mg TID with Percocet 10/650 for
  breakthrough pain.
• The major problem he has with pain medications is
  a sense of fuzziness or sedation from
  medications.
• Interestingly, he relates that his sense of
  fuzziness or difficulties with attention,
  memory, recall, and complex thought, did not
  improve with lowering of dosing of pain
  medications or even when pain medications were
  changed to non-narcotic alternatives with
  Percocet for PRN pain.
• While at Fort Hood, Mr. B is also evaluated by a
  psychiatrist is found to have depressive
  symptoms as well as Post-Traumatic Stress
  Disorder. PTSD incidents include the car
  explosions as well as earlier incidents during
  his military tour.

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Presentation to Veterans Affairs HCS

• When he first comes to Baton Rouge OPC, he
  continues to be on Methadone and Percocet. He
  strongly wants to try another pain medication
  prior to his first assessment in Behavioral Pain
  Mgmt, so his PCP tries MS Contin.
• MS Contin causes constipation, sedation, and
  provides much less pain relief, so he is put back
  onto Methadone and Percocet.
• Mr. B then asks to be referred to CPET Behavioral
  Pain Management for a comprehensive review of his
  pain management options.
• He misses his first initial evaluation and I call
  veteran when he does not show. We reschedule and
  Mr. B is seen in CPET for initial evaluation in
  March 2006.

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CPET Initial Assessment

• PAIN IS MOST INTENSE IN THE BACK OF HIS LEFT
  LEG, BEHIND THE KNEE. PAIN DESCRIBED AS PULLING,
  GARBBING, BURNING, RIPPING PAIN. PAIN IS MOST
  INTENSE IN THE POPLITEAL AREA, BUT ALSO EXTENDS
  INTO THE BICEP FEMORIS AS PAIN WORSENS. PAIN
  WORSENS AS THE DAY GOES ON. ALSO HAS SENSATIONS
  OF DEEP BRUISING. PAIN RIGHT NOW IS 3-4/10. PAIN
  HAS SPIKES TO 5-6/10. HOWEVER, THESE LOW PAIN
  SCORES ARE DUE TO TAKING METHADONE AND OXYCODONE
  5 MG /ACETAMINOPHEN 325 MG TAB.
• HE HAS RUN OUT OF PAIN MEDICATION RECENTLY AND
  HIS PAIN WAS EXCRUTIATING AND UNBEARABLE, CLEARLY
  10/10 WITHOUT PAIN MEDICATION.

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CPET Initial Assessment

• CURRENT MEDICATIONS
• BUPROPION (WELLBUTRIN SR) 150MG SA TAB Sig TAKE
  ONE TABLET BY MOUTH TWICE A DAY FOR DEPRESSION
• DULOXETINE HCL 60MG ORAL CAP Sig TAKE ONE
  CAPSULE BY MOUTH DAILY
• METHADONE HCL 10 MG TABLET Sig TAKE TWO TABLETS
  BY MOUTH THREE TIMES A DAY FOR CHRONIC PAIN
• OXYCODONE 5 MG /ACETAMINOPHEN 325 MG TAB Sig
  TAKE 1-2 TABLETS BY MOUTH THREE TIMES A DAY AS
  NEEDED FOR BREAKTHROUGH
• IN REGARDS TO PAIN MEDICATION REGIME, PRESENT
  AND PAST, HE SAYS THAT METHADONE DOSING RIGHT NOW
  IS TOO STRONG FOR HIM, AND OFTEN FEELS STUPOROUS
  OR SEDATED ("THE WORLD IS GOING ON ALL AROUND YOU
  AND YOU DON'T KNOW WHAT IS GOING ON").

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CPET Initial Assessment

• MULTI-AXIAL INITIAL ASSESSMENT USED IN CPET
• AXIS I
• 1. PAIN DISORDER DUE TO MEDICAL CONDITION
• 2. POST TRAUMATIC STRESS DISORDER DUE TO MILITARY
  TRAUMA
• AXIS II NO PERSONALITY DISORDERS ASSESSED
• AXIS III
• 1. CHRONIC PAIN DUE TO MULTIPLE TRAUMATIC NERVE
  INJURIES OF BOTH LOWER EXTREMITEIS REQUIRING
  MULTIPLE SURGICAL PROCEDURES
• 2. EPISODIC PAIN MANDIBULAR FRACTURE WITH
  AVULSIVE INJURY REQUIRING MULTIPLE SURGICAL
  PROCEDURES
• AXIS IV
• DISABLED DUE TO MILITARY TRAUMA WITH UPCOMING
  COMPENS PENSION EXAMS FOR MEDICAL PSYCH
  ISSUES
• AXIS V GLOBAL ASSESSMENT OF FUNCTION 50
  SEVERE PAIN CAUSING SEVERE IMPAIRMENTS IN
  FUNCTIONING

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Follow-Up

• Vet is scheduled to have monthly follow-up visits
  and is given appointment cards and calls.
  However, he misses two appointments. I then call
  Mr. B at the end of May and tell him to come to
  CPET Clinic today. I discussed with vet his
  missed appointments and document the following
• DISCUSSED WITH VET HIS MISSED APPOINTMENTS. VET
  WAS TRULY UNAWARE OF HIS MISSED APPOINTMENTS WITH
  ME AND ALSO HIS MISSED CP APPOINTMENTS. HE SAYS
  THAT HE HAS BEEN FORGETFUL OF APPOINTMENTS IN
  GENERAL AND THAT HIS FAMILY HAS ALSO NOTICED HIS
  FORGETFULNESS AND LACK OF MOTIVATION AND
  INITIATIVE. I BELIEVE THAT HE HAS THESE SYMPTOMS
  FROM CLOSED-HEAD INJURY SUFFERED IN IED ATTACK IN
  IRAQ.
• Vet also having baseline pain scores of 4-5/10
  but frequent and severe exacerbations to 6-8/10.

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Follow-Up

• We also solicit comment from Mr. Bs family and
  they also have noticed Mr. Bs forgetfulness,
  loss of cognitive sharpness, difficulty with
  attention / concentration, and difficulty
  organizing complex tasks.
• Both Mr. B and his family comment that these
  problems were completely non-existent prior to
  injury
• I add the additional AXIS I diagnosis of
  COGNITIVE DISORDER DUE TO MEDICAL CONDITION
  (TRAUMATIC BRAIN INJURY)
• We modestly increase Methadone from 40mg per day
  in divided dosing to 60mg per day in divided
  dosing to better control pain complaints
• We also add Ritalin (methylphenidate) 10mg PO QAM
  QNOON ? 20MG PO QAM QNOON

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Follow-Up

• Over the summer of 2006, Mr. Bs pain control and
  cognitive abilities moderately improve and Mr. B
  is satisfied with his progress. He begins to
  consider returning to work or school.
• He also completes his CP examinations and is
  awarded 40 Service Connected Compensation for
  his injuries.
• In late summer, I receive an urgent call from Mr.
  B. He tells me that he has been estranged from
  his wife for several weeks.
• His wife stole his medications and overdosed on
  medications. Medication stolen include opiates
  and stimulants.
• Wife was taken to E.R. and stabilized. She is now
  in an inpatient psychiatric facility.
• Mr. B is now out of medication requests urgent
  renewals of stolen medications.

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Its Always Something!

• I discuss this situation with Mr. B over the
  phone for some time and document the following
• HAD CONVERSATION WITH VETERAN TODAY ON HIS CELL
  PHONE (225) XXX-XXXX. VET INFORMED ME THAT HIS
  ESTRANGED WIFE STOLE AND SWALLOWED A GOOD AMOUNT
  OF VETERAN'S PAIN MEDICATIONS. VET'S ESTRANGED
  WIFE RECEIVED URGENT MEDICAL CARE AND IS NOW AT
  AN INPATIENT PSYCHIATRIC FACILITY. VET WILL NOW
  RUN OUT OF HIS PAIN MEDICATIONS EARLY, IN A FEW
  DAYS.
• I TOLD VET THAT I UNDERSTOOD HIS SITUATION. I
  TOLD HIM THAT I NEEDED HIM TO REPORT THE THEFT OF
  HIS PAIN MEDICATION TO HIS PARISH'S LAW
  ENFORCEMENT OFFICIALS AND TO RECEIVE A COPY OF
  THIS LAW ENFORCEMENT REPORT AND TO BRING ME A
  COPY OF THAT REPORT.
• I WILL REVIEW REPORT WITH VETERAN. I WILL REVIEW
  REPORT WITH PHARMACY STAFF. I WILL ALSO CONTACT
  LAW ENFORCMENT OFFICIAL ON REPORT. IF
  APPROPRAITE, WILL THEN REPLACE STOLEN MEDICATION
  FOR VETERAN.

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Its Always Something!

• Mr. B presents the next day with a police report
  that documents the theft of medication.
• I then call the officer who made the report and
  confirm with him the specifics of the incident.
• The officer indicates that the Sherriffs Office
  is following the case. However, they are not
  planning on pressing charges as long as Mr. Bs
  wife complies with inpatient psychiatric
  treatment and has no further incidents or
  behavioral problems suggestive of drug abuse.
• Officer also confirms that it his belief that Mr.
  B had no direct role or knowledge in this theft
  of medication and attempted overdose.
• I discuss this with pharmacy and pharmacy agrees
  to replace the stolen medication this one time.

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Preventing Future Diversion of Medication

• Mr. B agrees to buy a safe where he will store
  his medication, except for a three day supply he
  will keep in a pill bottle on his person.
• In the months that follow, Mr. B reports that he
  and his wife have reconciled. Also, his symptoms
  remain well controlled and Mr. B returns to
  gainful and challenging employment with the
  support of his family
• A problem develops when, five months after the
  theft, Mr. Bs wife presents to clinic to pick up
  his medications.

Mr. Bs New Safe
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Preventing Future Diversion of Medication

• An alert was put on his prescriptions at the time
  of his initial theft, so pharmacy immediately
  notifies a mental health colleague, who pages me.
• I call Mr. B and tell him that, because of his
  wifes theft of medication, we would not release
  medications to her. I instructed Mr. B to present
  to clinic to pick up medication himself. Mr. B
  does so.
• In the last few months, Mr. B has picked up
  medication himself most months.
• Occasionally, we send medications by FedEx to his
  house but require delivery to be verified by
  drivers license verification and signature
  verification which is uploaded into pharmacys
  computer.

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Issues for Discussion

• Treatment of chronic pain stemming from recent
  military trauma.
• Unique pain characteristics of trauma inflicted
  by improvised explosive devices.
• Co-management of chronic pain and chronic
  cognitive difficulties stemming from trauma.

• Dealing with theft of medication and instituting
  reasonable methods to prevent misuse and
  diversion of medications prescribed for pain and
  symptom control.