“Treatment of the Returning Military Veteran” Friday, April 15, 2011

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

3. Traumatic Brain InjuryData from Defense Veterans Brain Injury Center (DVBIC) Source: Defense Veterans Brain Injury Center 2006

7. Overall TBI Snapshot… 28,557 27,862 DoD Total 23,002 20000 Deployed Forces 10,963 10000 9000 7,200 (25%) 6,282 (27%) Data Source: AFHSC (16%4,442 ) OVERALL TBI CASES HAVE MORE THAN DOUBLED DoD Baseline DoD OIF/OEF DoD OIF/OEF DoD OIF/OEF 2009 2000 2007 2008 DoD TBI Numbers at www.dvbic.org & www.health.mil

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. MTBI DTM Data Flow • Data drivers: • Medical/non-medical RDT&E • Support RDT&E investment decisions JIEDDO DDR&E ISAF Tampa, FL ISAF Blast Injury Research PCO Monthly BECIR Joint Staff JTAPIC Fort Detrick MD • Data drivers: • Develop event-specific monitoring summaries • Supplement current JTAPIC data collection efforts • Data drivers: • Establish procedures for capturing and reporting data • Quality assurance USF-I • Data drivers: • Clinical Data Analysis • Develop TBI CPG recommendations • Provide DoD leadership with activity summaries • Data drivers: • inform DoDTBI policy updates and MHS Strategic Communications OASD(HA) FHP&R DCoE Timeline 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

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

12. DoD TBI Research Initiatives FY06–FY10: Over $400Mfor TBI Research Blast Physics/ Blast Dosimetry Neuroprotection & Repair Strategies: Brain Injury Prevention Treatment & Clinical Improvement Rehabilitation & Reintegration: Long Term Effects of TBI Field Epidemiological Studies (mTBI) Complementary Alternative Medicine Concussion: Rapid field Assessment Force Protection Testing & Fielding • 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)

13. Surveillance Treatment of the Returning Military Veteran

14. Total Force Fitness Model Social Physical Social support Task cohesionSocial cohesion Behavioral Strength Endurance FlexibilityMobility Substance abuseHygieneRisk mitigation TotalForceFitness Total Fitness Environmental Heat/Cold AltitudeNoiseAir Quality Psychological AccessImmunizations ScreeningProphylaxisDental Food quality Nutrient requirementsSupplement UseFood choices Service values Positive beliefs Meaning making Ethical leadership Accommodate diversity Medical Nutritional Spiritual CopingAwarenessBeliefs/appraisalsDecision makingEngagement

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 FY06–FY10: Over $345Mfor PH Research Child and Family Studies Sleep Studies Clinical Treatment: Psychotherapy and Pharmacotherapy Co-morbidities (TBI, Pain Management, Substance Use Disorders, etc.) Pre/Peri/Post-Deployment Behavioral Skills Training for Service Members and Spouses Suicide Prevention and Screening Complementary and Alternative Medicine Genetics and Biomarkers • 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

19. Millennium Cohort Treatment of the Returning Military Veteran

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

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

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)