All right, welcome everybody to another presentation. This one will be by Dr. Decker, titled Substance Use Disorder in Veterans and Active Duty Service Members. Dr. Decker is currently the Chief Medical Officer of the Division of Developmental Disabilities for the State of Arizona. He's committed to the mission of advocating for our members in DDD. Previously, he retired after 37 years of federal service. Lastly, being a member of the primary care service line at the Gallup Indian Medical Center in the Indian Health Service. He was born and raised in Western Michigan and graduated from Hope College in Holland, Michigan. He completed his osteopathic education at Michigan State University in 1978. He completed his internship in family medicine residency at the Chicago College of Osteopathic Medicine and an adolescent and young adult medicine fellowship at Rush Presbyterian St. Louis Medical Center in Chicago. As a public health scholar, he served in Chicago Southside for 14 years. He was professor and chair of family medicine at the Kansas City University of Medicine and clinical associate professor at the University of Kansas Medical Center and the University of Missouri Kansas City during his four years in Kansas City. He served in the Indian Health Service from 1998 to 2010 in the Phoenix Indian Medical Center as the associate director, ambulatory care and community health and 2020 and 2022 at the Gallup Indian Medical Center. He has also served in the Department of Defense and the Northern Arizona VA Healthcare System. Dr. Decker is board certified in family practice and osteopathic manipulative treatment, adolescent and young adult medicine, addiction medicine and pain medicine. He's a fellow in numerous professional societies. His areas of expertise include developmental disorders, addiction medicine, chronic pain syndromes, informatics, high-risk youth, domestic violence and behavioral health. Past faculty appointments include clinical professorships at George Washington University and currently at the Burrell College of Osteopathic Medicine and A.T. Steele University. Thank you, Dr. Decker. Thank you, Dr. Wessel. I have no disclosures. I don't represent any state or federal organization. So my opinions are simply my opinions for this educational program. We are broadcasting okay with a disclosure slide? Good. Okay. So our learning objectives for this presentation are to look at the risks of substance use disorder in veterans and active duty service members and awareness of mild TBI and traumatic brain injuries and risk behaviors, utilize screening and motivational techniques for veterans and active duty service members in the area of substance use disorders and have an awareness of the relationship of chronic pain and substance use disorder in both veterans and active duty service members. This is a patient I took care of from 2010 to 2015. I was the medical director of the Residential Treatment Program, Addiction Medicine Programs. We had a 20 bed inpatient unit along with a 60 bed post-hospital day hospital and a 300 member Army Substance Abuse Program at Fort Belvoir, which is now Alexander Alexandra Medical Center. This is a 19 year old male who was in a minesweeper. The video of this, he's strapped in, you can see him at the top of the minesweeper and the medic is talking to him right there. The 68 Whiskey said he was still conscious. The vehicle was blown 10 meters in the air and then came down on all four wheels. The member was, he said he doesn't remember things, he said he doesn't remember things, but the 68 Whiskey said that he definitely was conversant at the time. And the 68 Whiskey is a medic. He was transported because he had severe headache, he had some blurred vision. He was brought back to base despite general order number one, which is no alcohol consumption in Afghanistan or Iraq. He was able to get a hold of alcohol, which he said he had to have to help him sleep. When he returned to Fort Drum, which is a mountain unit, he reported that he was drinking on a regular basis and then was subsequently referred by his team, by his command down to Fort Belvoir. One of the things that happened in both wars, the Iraq and the Afghan wars, was that there was significant exposure to trauma. IEDs claimed a significant toll, not only on mortality, but also on significant morbidity. This is a Bradley, which normally has a crew of three and six staff, either Marines or 11 Bravos in the back. And they're flying across at night using night vision and the water table is 70 feet below the surface of the land. And so they have these dugout areas that cannot be seen. This vehicle snapped in to the hole, dropped 70 feet, landed on its side. Both escape hatches were covered with rocks that could not get out. And because there were 70 feet down a shaft, they couldn't radio out. Finally, a helicopter was going back and forth, heard something and then went back and listened over the hole. And then had the extraction. Two of the members inside this vehicle were killed. The other seven members survived, all of them having significant injuries with long bone fractures and with traumatic brain injuries. When we look at the Department of Defense data in regard to DPI occurrence, penetrating injuries would be anything that goes through the calvarium. Severe injury would be any type of injury that required surgical intervention. Moderate injuries would be a loss of consciousness for at least 12 hours. Moderate would be a loss of consciousness for one hour or more. A mild would be less than one hour and not classifiable. In other words, the person, either the medics, corpsmen or the 68 whiskeys could not figure out what was going on. We had a total number of injuries of 300,000. And so when you think about that, this is the population are now back in the States. Most of them are out of the military at this point in time. These were people that were injured back in the 2000, the 2000 to 2014 area. And when we look at garrison versus deployed traumatic brain injuries, the dark line is garrison associated. Deployed is a green bars. You can see that prior to 2003, we didn't have any deployed injuries. From 2003, we started getting more and more numbers. The first bar is 5,000. So in 2008, we had 5,000 traumatic brain injuries secondary to deployment. That could be by transport, car accidents being the number of vehicle accidents being the number one cause, or it could be explosive devices. But you can see the numbers are significant. Again, looking at 2000 to 2012 garrison, and then 2014 with the deployment injuries. Concussion management had gone through several permutations in the military. Jim Kelly, who is originally from Northwestern University, who went to University of Colorado, had been doing a significant amount of work in regard to traumatic brain injuries in sports, collision sports, mostly hockey, football, wrestling type injuries. But he had been published in numerous areas and developed protocols for both professional and collegiate sports concussion protocols. He was grabbed up by the Department of Defense and deployed to the old National Naval Medical Center, which became the Walter Reed National Military Medical Center. The Intrepid Center, which is just on the South end of the complex, was the traumatic brain injury program. We had a sister program, Heechin Jae, who came from Spalding Rehab Center at Harvard, took over that program for the TBI program at Fort Belvoir. So the goal was to really look at a significant change in how we do this. One is we wanna prevent injuries. Two is we want early detection. Three was tracking and treatment. And then four, whatever type of rehabilitation or recovery and reintegration that could be done. So concussion basics, the key is to understand that just because the calvarium is intact and there's no abnormality on imaging, that does not mean that a concussion did not occur. Concussions were one of the major injuries in the last two wars that we've had in the Middle East. So we know that there's a mild traumatic brain injury mentality, which is if you didn't have an abnormal MRI or CT scan, if you're only unconscious or just wobbly for a while, you should be fine. That turned out not to benefit the members area and the active duty service population or the VA population. We know that significant brain dysfunction can occur after a traumatic injury. And we started looking at blast injuries. Every blast has three phases. You have the first phase where there's the explosion and then you have particle mass that's scattered in all directions. If one of those particle masses, a two inch piece of concrete hits the side of your helmet, it could actually crack the helmet and cause an intracranial bleed. But you also have people standing on the other side of the blast wall. And the second phase is the pressure wave. And that pressure wave can go around corners, can go through vehicles. You can be in a building that's hit by a missile and it can cause injury on the opposite side of the structure. And then the third wave is the implosion. So if you get blown down going out, but you can also get blown forward. And so when you're thinking about the fighting force for these two wars, typically your 11 Bravos and your Marines are running towards the action. But the MOS that had the highest percentage of injuries were actually the 88 Mikes, the people who drove vehicles. Because they were easy targets, they were large targets, they were hit by both stationary and mobile or projectile explosive devices. So you can have a mild brain injury even without being knocked out, knocked down or blocked out. So we started looking at those possible causes. You have vehicle collisions. And this was the number one cause of brain injury in the garrison based population. You can have a blow to the head from sporting activities, from defense training, recreational activities or a combination of any of the above. If you're within 50 meters of a blast, both inside or outside of protective device. So if you were inside of an MRAP, a mine resistant vehicle, you could still have a blast injury being on the inside of that vehicle. The young man who was blown up in the air from the mine sweeper had no injuries no intracranial bleeds, but his personality changed dramatically after that particular event. Command directed evaluation is when the command decides that there's something going on with this person. And it may be related because the vast majority of explosive experiences were never reported or never documented down range. In other words, in the combat fields, you got blown, there was an explosion 25 meters away you were knocked down, but you get up and go because there's people shooting at you at the same time. Now, this is a neuron looking on a cross section of his axon and this is a good example of the damage that occurs on a microscopic level. So here you have the neuron and here you have the neural lemma which clearly has edema or fluid under the neural lemma the lining around the axon sheath. And so this axonal injury is the underlying cause of traumatic brain injury. So we have a thing called the military acute concussion evaluation and it evaluates essentially three parts, your cognition, your neurologic exam and your symptoms. And so what happens is the person is asked, number one, what happened? Tell me what you remember. Were your days confused? Did you see stars? Did you hit your head or did something hit your head? And then was it a blunt object? Was it a motor vehicle event? Was it an IED? Was it someone throwing a rocket at you and hit you in your helmet? Was your helmet worn? And that was a very important question to ask in regard to what happened. Both amnesia retrospective and amnesia prospective in other words, I can't remember what happened for the 15 minutes prior to the event. That's an important issue. Now, don't think that this is only from the OEF and OIF wars. I have a veteran that I took care of who a rocket propelled grenade hit his Jeep. He was a driver, killed both the officers in the backseat, killed his navigator in the front seat. It blew him out of the vehicle. Disarticulated both of his hips at the hip joint and he was covered with 85% third degree burns but he landed in the rice paddy. He was airlifted out, taken to Brook. He was in the burn unit for two years. A real happy story there is the nurse who took care of him married him. They had three boys and a girl after that. And he was a successful businessman in Phoenix for many years until he retired. But the military acute concussion evaluation was developed by Jim Kelly. And part of this is doing some basic things. What day, month, date, week, day of the week, year and time is a scoring process. I want you to look at these words here. I'm gonna give you five words. I want you to say them back to me. Elbow, apple, carpet, saddle, bubble. And so the military person would repeat elbow, apple, carpet, saddle, bubble. Then I'm gonna ask you again in five minutes and I'm gonna ask you again at the end of our interview which is about 30 minutes. Now, when Jim Kelly went to Afghanistan, remember he's a civilian in the military as I was. And he went to Afghanistan to speak to the corpsman and the medics. When he went out and went to a barracks of Marines, he noticed that the men had a little clip of paper on the side of their helmets. And it said, elbow, apple, carpet, saddle, bubble. And he said, why do you have this? They said, if I can't say that, they're gonna pull me out of my unit. He was furious. He said, this is not to be given to the fighting force. He said, we're trying to find out can they remember short term and can they have a longer term memory response? He said, so even the mace did not have accurate assessment. So the neurologic screening is pupils, verbal and motor response. Now, when you look at this, looking at TBI in both the Operation Enduring Freedom and Operation Iraqi Freedom, 16% of returning army soldiers screened positive. 15% of returning army soldiers screened positive for in a second study. 18% of veterans screened positive in a third study. 23% of army soldiers screened positive in the four studies. I have each of these studies listed for you here. And 18.5% of veterans in VA medical centers screened positive. So when we look at Fort Carson, they're looking at both acute symptoms and chronic symptoms post-deployment. So downrange, back in the combat zone, after a concussion-type event, headache was seen in over 80 percent. But six months later, post-deployment, they're down to 20 percent. Dizziness still has significant erosion from initial symptoms to post-deployment. Balance symptoms also has significant erosion. But look what doesn't go away. Irritability, memory loss, both of those stay with the member. Now, they're not as frequent, so 25 percent post-concussion have irritability, but 21 percent still have it six months later. And this is when spouses would come into the facility and say, he's not the same. There's something different. And the same thing goes with memory. Short-term memory loss, can't find the keys, can't remember where you put your shoes, can't remember where the TV channel exchange is. We started looking at the actual brain fibers. This is functional MRI. And so we can get the brain to light up. And this has to be done with a T3 unit or greater. And we had these units both at Walter Reed National Military Medical Center, but we also had two units down at Fort Belvoir. And they would have to put in a new package, a program package every night, three hours to load the program package up, and then they had to go back to the regular T3 unit for the following morning. So we were doing almost all of our MRIs, functional MRIs, at nighttime. But you can see the breaks in the neural fibers. Now, these are not individual neurons. These are 50 to 100 neurons in a fiber. And then looking at this little mark right here where the arrow's at, that's a bundle of nerves, not a single neuron. And so when you have hundreds of nerves that have been broken, and when you look at the importance of going back and forth across the corpus callosum in regard to developing some neural normacy, you can see that it's created some issues. So with a big Venn diagram, we look at TBI on one side, headaches, dizziness, irritability, PTSD, which goes along with all the wars, flashbacks, nightmares. And then we have what is on both sides, which is attention problems, depression, insomnia, anxiety. And unfortunately, there's a population of people in the military. And this is partly because the military is an alcohol-based society. The PX, which is where you buy your groceries, has a wide variety of things, like a regular grocery store. But the PX by the shell station, or the gas station, or the small walk-in PX that's like a 7-Eleven, they have one aisle of baby stuff, one aisle of snack food, and three aisles of alcohol. And the problem at Fort Belvoir is you could buy a fifth of vodka for $6. And that was in 2015 when I left. So when you put PTSD and TBI together, you can start to see that we have an overlap issue. Then when we look at our next slide, you can see that there's all kinds of other things that go along with it. Now, when a person has physical injuries, they're missing a leg, missing an arm, if it was an explosive event, you know that they must have had significant exposure to TBI. But when you add on depression, pain, anxiety, substance use disorder, and depression become significant co-factors. And when we look at the unacceptably high rate of active duty servicemen or suicides and veteran suicides, that triad of PTSD, substance use, depression was the most common factor. So when we look at the fourth tetrad with TBI added onto it, with impulsivity and poor impulse control, you can see how we're starting to end up in more problems. So what can we do? Well, first off, by the way, every American war, from the Revolutionary War, when Benjamin Rush, who signed the Declaration of Independence, clearly said, people who've been through war drink more. And those who drink more, there's a population of people who have uncontrolled drinking. We saw that in every military event. After the Civil War, there was a huge epidemic of not only alcohol, but also morphine use and opium use. And then we can go back to the Spanish-American War, World War I, World War II, the Korean War, the Vietnam War. It's been the same every time. So when we start looking at this, though, we want to be able to try to identify information as quickly as possible. So BICEP is an acronym for brief evaluation. In other words, less than three days. You want immediacy from the standpoint of focus on early identification and treatment. You want centrality that the therapy is separate from unit in one area, emphasizes good prognosis, expectancy, expect a rapid recovery, proximity, have the therapy as close as possible to the unit. And this is downrange and simplicity. Now, the thing is, is that all that's fine, but that means that you have a person who has a concussive event, he got knocked down, he saw stars, he doesn't see a whole lot of things. Almost all the 88 mics that I ended up seeing were female because they were the truck drivers. And they also had these same type of evaluations. And they ended up in, remember, 88 mics had a higher rate of injury than the 11 Bravo's. And so the thing that's an issue here is rapid assessment and rapid redeployment is not really the best idea in regard to protecting neural function. Opioid therapy treatment goals. Now we do know that if a person is going to receive opioids, the last thing you want to do is give too much of them. So they need to have specific goals. One is improvement of physical function. Two is improvement of general function, increased self-management for persistent pain. The number one reason that veterans or active duty service members see a healthcare provider is still for pain. That is not the case for the civilian population. So pain is the primary diagnosis. Now the VA from 2012 to 2019 decreased the amount of prescribed opioids by over 60% because we realized that when pharmaceuticals and other people who intervened on the prescribing habits, including the joint commission, which said that pain is a fifth vital sign and that you must evaluate and treat it. What ended up happening was we had people getting opioids for reasons that they should not have gotten those opioids. And we got those doses bumped up. I would get people on more than a thousand milligrams of oxycodone a day from Walter Reed on a regular basis and told to magically get them off of this stuff because the requirement for pain resolution kept on rising in those individuals. But you can see here that reduction of pain, reduction of emotional duress and achievement of the goals while reducing the risk of misuse and optimized treatment to avoid harm, that's a pretty lofty goal that sometimes would work, but many times would not. So when we started looking at this, there's a multitude of peer-reviewed articles that identify that opioids and back pain did not seem to cause significant improvement. When you start looking at this, you start to realize that on a systemic review, starting opioids, there better be a really good reason to do it. You need to monitor it. You need to be careful not to accelerate the use of opioids. And it resulted in the 2016 CDC guidelines, which created all kinds of problems for everyone because first we're told evaluate and treat pain to goal, and then we're told stop using opioids. And there were many people who decided, I'm going to just stop using opioids completely. And we had several people in the military who simply said, I'm not going to give opioids to this person because I don't believe in them. The pendulum swung too far in that direction. So when we started looking at back pain, 38 peer-reviewed studies here, a final analysis that the effectiveness for opioids in chronic back pain was questionable. First off, more than two-thirds of those studies were pharmaceutically sponsored. When you start to look at a meta-analysis of that data, you realize that there was significant question about the response on the part of the experimenters, in other words, experimenter bias, and the response in regard to the individual subjects in the study. Because if they didn't report a pain level of seven or more, they didn't get an opioid. And you can see how that would create all kinds of conflict in regard to the experimenter population and in the subject population. When we look at active duty service member pain and addiction medicine evals and treatment, use of an illegal substance is grounds for being separated from the military. Now we sent them to fight in Afghanistan, where 90% of the heroin is harvested for the entire world. So it should not be a surprise to know that people could get a hold of opium and opium product, including heroin, which is diacetylmorphine. I mean, you have to cook it with acetic acid or vinegar to get to that point. Evaluation and treatment of substance use disorders and active duty service members requires a highly coordinated team. The goal is not to find people and say, aha, we caught you. That service member who drove that minesweeper was an important person. He went back to Afghanistan after his evaluation and treatment. He had good psychomotor skills. He was not dependent on opioids. He was willing to get drug screened every week, his entire deployment. And as a Marine, six months later, he came back without any events. It needs to be a regimented program, and it's run by the military. I was one of the few people that did not wear uniform on the unit. Most of our nurses were active duty. All of our 68 whiskeys and our corpsmen were active duty. Two of our administrators were active duty. So it was working with that team. And all of our patients on the unit also wore their uniforms with their rank. Every once in a while, we would have a general or an admiral who said they don't want to be with an E1 or an E2. And we have to remind them the reason that they're there. And we had the Admiral Milner and Admiral Chiarelli, both four stars from the Pentagon, from the Joint Chiefs, would come in every month and sit down with all the members on the unit and talk about how they have a disease, they got injured, the military is going to cover all the costs related to this, and we want you to stay in the military. And so if a person was going to check out, that typically was not something that would be referred to our unit. So typically our average person was an E6, which is a staff sergeant or above. But we did have some people who were bucked down because you get into a DUI in Afghanistan, you're typically going to wake up in Dover being flown back to the U.S. Staff needs to be highly trained and familiar with military life, protocols, expectations, chain of command. On the VA side, asking a veteran, can you tell me, as you're going through your information, can you tell me what your MOS was? And the Army, Navy, Coast Guard, Air Force, and the Marines all have different systems for that MOS. But they can tell you what they did, and then you, as time goes on, you'll become more experienced in understanding why truck driving in Afghanistan was a dangerous MOS. Service member needs to be motivated, they need to be valued, they need to understand that we will do everything we can, they need to be motivated to do everything they can. Individual therapy to work on post-traumatic stress disorder, childhood traumas. I always say people run to the military for one of two reasons. They run to it because they believe in it, or they're running away from something else, and the military becomes their family. So it's interesting when you start looking at all the parameters in there because childhood traumas, which are unbelievably important in trauma-informed care, as to the one of the foundational co-factors in substance use disorders. And so that same thing happens on the military side, too. Military sexual trauma. The sex who is most likely to be a victim of military sexual trauma is males. People forget that, but keep in mind that 80% of the military is male. And of the unit that we took care of, and I personally took care of over 3,000 active duty service members in those five years, 95% of the female population had experienced military sexual trauma, and it only came out in their trauma-informed care when they went through the treatment program. Now, this is the Alexander Augusta Military Medical Center. You're looking there. It is one half mile from the south end to the north end. They have parking lots on both ends, or parking towers. And one of the things that was interesting is that you see in the front of this slide on the right a Navajo blanket from Crystal, Arizona, which was a prayer blanket for one of our Navajo men. He was a staff sergeant, took a platoon into a dangerous area, he had two brand new people. He sent one of them to an obvious place of defense. It was a trap. As soon as the service member got in there, he was blown up and was killed. The staff sergeant could not forgive himself for that mistake. And he participated in the funeral. He started drinking heavily. He was drinking about a fifth a day, tried to commit suicide, and then was sent into the psych unit for treatment of suicide, a serious suicide gesture, but also was transferred to our unit after he was stabilized. He did very, very well. One of the interesting things was that we're in the D.C. area. I contacted the Indian Health Service in Rockville. They were able to send us down a medicine man who was from Navajo, who was able to pray with him in Navajo. It was interesting because the woods that are just east of the hospital still had six inches of snow on it when this picture was taken. And this service member was from Pinyon, which is way up in the mountains on Navajo. And part of the ceremony is to be washed with snow. So they were able to do that. And they set up a big campfire and we had to notify the fire department, do not come and do not put that fire out. But we were able to provide a variety of services in that setting that were instrumental in helping service members navigate that healing process. So the therapeutic milieu needs to be shared with the treatment staff. We had a Sergeant Nathan, who was also a Staff Sergeant, E6, who was in the K-9 Corps, who had 91 tasks that he could do. But the most important task was when someone was yelling, screaming, or crying, he would come in, stand at attention in front of them. And when the person would sit down, he would put his mouth on, he was a golden retriever, on the thigh and just sort of rock his head back and forth to help the person get back to the right place. Now, the government always uses the lowest bidder. Whenever we had fire alarm tests at Fort Belvoir, the same voice, it's a woman's voice, says, alert, alert alert code red six four two and it tells you where the code red is at and if you have to do a transfer well that same woman's voice was what they had when they were in the combat zone and our the members on our unit as soon as they would hear that they would get into a corner flip their butt up on the side get into a defensive position and our nurses would have to go in and say okay fill the ground fill the ground now it's not sand it's carpet and they would have to reorient them to help them get back to the place they know that they're in a safe setting so you have to have staff that are able to do those things and to really emphasize you're in a safe place now you have people who will work with you so when you start looking at that the 28-day program uh was an opportunity to get into the program the co-occurring partial hospital program was four to six weeks and could be opened to longer than that that was a seamless process we typically would tell command six months to a year to get this member back to a deployable state we monitored the first 600 people who went through the program we had 88 percent who were still alcohol and drug free two years later with weekly urine drug screens and etstg and phosphatidyl ethyls so without a doubt it was a very successful intervention for this population graduation command had to come to bring you in command had to be there when you got out and then if you went to the wtb the wear transition brigade your command had to take you over there and participate in that process too typically the iops the intensive outpatient programs would be back at the home base so if you're from fort drum you go back to fort drum for your um army something's abuse program if you're from uh newport news you're going to go back to the uh navy program uh and then and so it depended again where people were from uh and the the thing to remember on in the civilian population if you're if you're driving and you have a blood alcohol or breathalyzer that's greater than 0.8 that's intoxicated driving on every base for army navy coast guard it's 0.5 at the air force base it's 0.2 if you have anything it goes up in one piece and comes back in one piece so one drink at the officer's club could put you at risk of being above 0.2 so you can see how there's different rules for the active duty service population so when we look at tbi and co-occurring conditions ptsd is one of the leading co-factors in regard to tbi co-occurring disorders and substance use disorder chronic pain both re-exacerbations of acute pain or just chronic pain because you've got blown discs from when the the young man who's blown up in the minesweeper had two blown discs in his neck he did not consider it to be an issue but he was only 19 years old so the thing that's an issue is when he's 42 years old you know that's going to become an issue but it's a service-connected injury the va should be able to work with them substance use disorders dual sensory impairments so tinnitus very common uh injury that occurs from any type of explosive exposure was very common and then you add on balance problems hearing problems if there's any visual events that occur all those things become sensory impairments depression anxiety and unfortunately suicide is highly associated with the triad of ptsd tbi and substance use disorder when you start looking at consequences of ptsd one of the biggest problems is relationship issues so if you have someone and we would say this on the unit all the time if whatever you think in your head comes out of your mouth very few good things are going to happen so you have to learn to take a breath think about it then respond and so it's a interpersonal relationship basis this is going to have a significant impact and the sad reality is the significant number of veterans who go through family failure uh with divorce and typically kids are involved uh is is unacceptably high um employment problems after leaving the military can become an issue fifty percent of the males in the washington dc homeless population are veterans it's hard to get that data because many veterans are are embarrassed to admit they're a veteran if they're homeless the rule is if you're a marine you're always a marine you cannot leave that status problem with the law incarceration we have so many people incarcerated from the military in the uh in the jail in phoenix that we actually have a military unit uh for them so with families we know that stressors uh result in frequent separations there's long work hours in the military it's dangerous work it's a dangerous work environment there's role ambiguity during employment because what happens is you have to do what you're told protective factors are you have behaviors interpersonal violence can result in a discharge provision of health care housing and family services is a benefit uh one of the things i found out in the military that i was shocked about is a person can be an e1 or an e2 and if they have two or three kids their salary is so low they qualify for food stamps that's an absolute unacceptable situation you know if you have people who are willing to volunteer and put themselves in harm's way we've got to be able to give them a salary that's livable mental health problems post-deployment these are looking again at a variety of studies so combat experiences 65 that's from oif oef 46 this is operation iraqi freedom and operation enduring freedom afghanistan any mental health concern suicidal ideation seen in between 0.2 to up to 1.1 percent um and this is something that uh is a sad outcome uh in regard to what's going on and we're going to add in you know substance use disorder increases that likelihood and termination of opioids which i'll talk about later on in the oliva study was highly associated with helplessness hopelessness and and completed suicides psychiatric hospitalization after the first year of deployment uh almost six percent alcohol problems post-deployment almost 12 percent of active duty 15 of national guard and reservists so we actually had a higher rate of substance use disorders in the national guard and reserve population and part of it is because many of them don't have that same close connection to their unit to their best friends or lifelong friends that they get by being active duty when we start looking at who gets help this is old data from 2008 but it is still the same today in 2021 data which is of the people who need help that have some kind of substance use disorder 95 do not feel they need help so what do we do we have to use motivational interviewing we have to have permission to bring up the topic we have to negotiate with them we have to make help them feel that they are still in control because it's their decision it's not our decision but we don't want to say you want to stop drinking no okay next uh it's it's got to be one in which they feel and it's because it's got to be genuine on your part you really do care about them and so working with them becomes a critical part of it only four percent of the population actually get and are able to complete their treatment well let's take a 26 year old male um this uh uh this is army staff sergeant who was on two tours uh oef he was an 11 bravo he took an ied uh close blast it actually went through his cheek blew out tooth on his right side blew out a tooth on his left side and blew out his left face he had damage to his trigeminal nerve um madigan thought that they could take care of the situation they did a laforte procedure on him uh pulled his his anterior face forward about eight millimeters thinking they would take pressure off of the trigeminal nerve it didn't work he had more pain by the time he was sent to walter reed and sent down to us for the concern regarding something's abuse issues he was on 1200 milligrams oxycodone a day in our multidisciplinary staffing i said let's i would recommend that we start tapering him down it's going to take a while for us to get there but i said that clearly he still has 10 out of 10 pain and so the oxycodone is not helping decision was to allow him to continue using oxycodone at any rate that he feels necessary he doubled the dose to 2400 milligrams a day he ran out of medications in two weeks the new medical officer that was taking care of him said i will not fill your medicines until they're due he was thrust into withdrawal he went down to the local sports store he bought an air pistol with his acus on that's his combat uniform and his name on his chest he walks into a cvs pharmacy in springfield virginia he has a piece of paper that says i need oxycodone the receptionist presses a button sets off the alarm she goes back and she gets oxycodone but she gets a garbage bag and fills the bag up with oxycodone boxes she comes back and on the tape he says i only needed a couple bottles and she and then he leaves and he goes out the front door and then he realizes as he's going out the front door of cvs he left the gun on the counter so he goes back all the way through the far the cvs picks up the gun says on the videotape i told you it was not a real gun and then he leaves hops in his car goes back to the wtb puts the rest of the oxycodone in his locker keeps a couple bottles for himself that he already started to use goes back to his home and the fairfax uh county sheriff is waiting for him at home and arrests him they take him to jail he gets depressed he tries to hang himself in jail he gets brought back to fort belvoir he's put on the unit on the psych unit stabilizes sent over to our side for something's abuse treatment for opioid dependence he goes through buprenorphine treatment does very well in the unit goes back and is released to go back to jail because he still has an outstanding charge his command did not even show up he received a second purple heart on our unit so his neck was blown up to the uh the happy news is that i told the judge that uh what happened uh the judge said i'm going to give you a suspended sentence this was in 2013 he said i'm gonna he said the minimum minimum time with a weapon in the state of virginia for any crime is six years he said i'm going to suspend your six-year sentence if you have a loss of recovery during these six years with the weekly urine drug screens you're going to have he said you'll be you'll be remanded immediately to come back to virginia to serve your time he called me up in 2019 he sent a christmas card to me every year he said i'm looking at a letter from the judge in fairfax county virginia that drops all charges he's he works as a crane operator i said what do you do with your pain he said i take motrin twice a day i have to take a a prilosec because it burns my stomach so it is possible to treat people and help them navigate these these troubled waters and it's a tragedy and i give every possibility to these men and women so institute of medicine identifies in 2011 that we have a problem uh the financial burden of chronic pain exceeds the effect of cancer and heart disease combined 2019 the national health interview survey identifies that one out of every five adults in the u.s has chronic pain remember that chronic pain presentation is greater in the military and the va population because they were doing things where the opposite side was actually trying to hurt them and same thing from our side i mean both sides lose and these in these uh wars so high impact pain is what affects you from your work activities and when we look at the military population there's a greater possibility of that happening so when you look at the prevalence of pain in veterans you can see the light blue line being veterans the dark blue line being non-veterans and you can look at every age category with the exception of greater than 65 veterans exceed the civilian population for chronic pain syndrome co-occurring pain and mental health problems have high impact issues uh the the reality is uh suicide in the va population and the active duty population are both rates of unacceptably high rates when we start looking at overdose deaths the onset of fentanyl in the early 2000 teens uh really changed everything i left the indian health service in 2021 i didn't have any more people using heroin everybody was on methamphetamine and fentanyl and and that included my my veteran population i actually had american indians that moved to the reservation to be able to see me at gallup indian medical center and i was i was surprised about that but i had six people who i treated at the fort belvoir unit that actually moved into the area to have continued care uh the relationship between prescription opioids and the rapid rise in opioid dependence we cannot deny it was us we did it so from the from the 2000s when joint commission said it's a fifth vital sign and that we had to evaluate and treat pain unfortunately we went to those dinners that told us that that long-acting opioids were safe and that increased doses were safe both were lies and so it we got into a situation where we had a large cohort of people who were physically dependent and then we rapidly remove that and then what happens is fentanyl pops up and then we have our problem right now so when we start looking at veterans we realize a couple things here we do know that i'm taking some data here between 2010 and 2016 there were about 6,500 veterans who died from opioid overdoses in 2016 alone there were 1,271 deaths of veterans in vh treatment about 3.5 per day in regard to opioid overdoses and we do know that the relationship of opioid overdose death is highly related to prescribed opioids initially and reduction of those prescribed opioids subsequently so we'll talk a little bit about that in more detail so we start looking at the dose that a person gets the likelihood that a person on treatment in other words they're in treatment with opioids for chronic pain syndrome an unintentional overdose increases almost seven fold if their dose is greater than 100 milligrams a day suicides double from one percent to two percent in regard to the risk ratio in people getting more than 100 milligrams of opioid per day so the the take-home out of this is if you have to use opioids use them if you have to if you don't have to don't use them if you have to use opioids use them for a very short time so you have a primary fracture you have to have surgery don't make a person navigate post-surgical pain especially orthopedic pain without having some kind of pain relief, but reassess the situation often. Don't give them a month's supply of pain medication. You should have that patient evaluated more often and make sure you have an informed consent that they understand these medications can cause more trouble than good and monitor that situation. So when you look at prescribing factors, dose and duration become critically important in regard to overdose risk and opioid use disorder risk. The type, long actings are more dangerous than short actings. I remember many times people saying a 40 oxycontin is safer than a five milligram oxycodone. It makes zero sense to talk like that because you're creating a dependency in that patient who's taking 40 TID versus a person who's taking five or 10 TID. Patient factors, so you're looking at the medical comorbidities, chronic pulmonary disease, sleep apnea, depression, bipolar disorder, other medical disorders that can contribute to overuse or misuse, including substance use disorder, including alcohol. So we look at a definition. The old definition of pain was an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The new definition is an unpleasant sensory or emotional experience associated with or resembling that associated with actual or potential physical or tissue damage. So we know that pain is a very subjective experience. Some people can have a little bit of pathology with a lot of pain experience. Other people can have significant physical pathology with minimal pain experience, and each person is different. And on a temporal basis, the same person could be different. Now, when we start looking about how do we take care of people with opioids, they're shifting towards this multimodal integrated team. So a biopsychosocial approach and away from this concept that we're only gonna treat a patient who has end-of-life pain or that opioid therapy can somehow make their life much better. And we did create a monster when we over-treated patients who complained of pain. So the biopsychosocial model really looks at biological factors, psychological factors, and social factors. These are all things that contribute to the response to pain and the response to decreasing pain. The military and the VA now uses a stepped model. And so what happens is that there's ongoing discussion regarding weight management exercise, which is probably the most significant factor in the prevention of maladaptive pain. So losing weight and getting back in shape has a dramatic improvement in the overall response. The second thing is that PAC teams, patient-aligned care teams, which is the ambulatory programs in the VA, are very engaged. You get elevated to specialty care, whether it's mental health services, rehab services, pain management services, and then tertiary care, if you need to have other types of interventions that may not even exist in the VA system, but need to have service. So when you look at individualized care, all the treatment options become available. So we're not excluding the use of opioids or the use of buprenorphine for the treatment of pain. Matter of fact, the 2023 guidelines included buprenorphine for the VA and for the active duty military. Now remember, a person on naloxone, naltrexone, buprenorphine cannot be deployed because they have to be deployable to stay in the military. So you only have a certain amount of time. You have one year from start to finish to get a person to stay in the military and get them deployable again. If it takes longer than that, then they're gonna have to consider some other option. When we look at the collaborative pain care being patient-centered, we want to make sure that this complex personal experience is evaluated. We wanna move away from just the use of opioids towards a multimodal process. When I was in the VA, five years, I was very, very engaged in using acupuncture and osteopathic manipulation for chronic pain syndrome with significant benefit and reductions by greater than 50% of people who are on opioids. Documentation. Be very careful of clone notes. With the new EHR systems, it's so easy to make clone notes. I would highly recommend that you individualize your notes as much as possible. You want to be very descriptive in what type of pain, where the pain's at, what makes it worse, what makes it better, and what types of exercises you're giving that person to improve their all function. Know where the different medications work. And so you can see that from the distant nerve endings, opioids, local anesthetics, anti-inflammatories all work at the distal end, but you also have afferent nerve pathways, you have descending tract involvement. So keep in mind that low back pain and opioids, they really don't seem to match well together. In the long term, you may be doing a disservice of giving a person opioids. Now, once they're on it, now you have a different set of problems. It's difficult to reduce and you have to ask yourself, is this the best thing for this patient? Risk stratification. We do know that American Indians and Caucasians, especially those in the Midwest and the West who have a lower end of the socioeconomic spectrum and lower formal education are more likely to have problems with prescription opioid misuse. We do know that people who have a prior history of PTSD or ongoing history, including adverse childhood events, borderline schizotypical, antisocial personality disorder, and keep in mind that the most common psychiatric occurrence for alcohol use disorder is antisocial personality disorder, major depressive disorder, and bipolar one. All of those make prescribing opioids more challenging. I have an old rule in medicine, don't go down alone, take all your friends with you. So is it medically appropriate to give a person opioids? How long should this dose be at that level? Is it safe for this particular member? What are the long-term outcomes? And have you discussed them with a member and documented them in the informed consent? Is there any evidence of aberrant behavior? Is there any sort of an evidence-based treatments being tried? So when you look at the 2016, 2019, and most recent 2023 VA and CDC guidelines, you start to realize that yes, we wanna keep the opioid load lower. It doesn't mean you can't use it, but you don't drop a person who is stabilized and doing well on their current load without significant involvement of the member expectation to reassess. PDMP is gonna monitor you. And that's a good thing because you should be looking at the PDMP if you're using opioids. Keep in mind, all the illicit opioids, things they buy on the street, are not going to be in the PDMP. And the methadone clinics are not going to include the methadone that's distributed by opioid treatment programs. Patient discussion, you wanna make sure you do. Behavioral health support, they are your buddies, use them appropriately. Respect the therapist because when you need them, you really need them. Practice pitfalls. You wanna make sure that the ground rules are being followed with a pain agreement. Avoid cloning your charts. I said that before. And please be careful about early refills. If they're consistently filled early, it's a sign that things are not working out really well. By the way, the VA, you send your medications out, make sure the medications are actually sent out. Work with your pharmacy. If they have a problem with send outs, you can't have a person who's on a certain opioid load, including buprenorphine, and just stop for two days because, oh, I forgot it was a Monday holiday. So you gotta work with them. So how did we get here? Well, I'm gonna point the finger at the Institute for Healthcare Improvement. Don Berwick, a pediatrician, said that he wanted to eliminate pain in healthcare. It's not gonna happen. Joint Commission said that pain's a fifth vital sign. It didn't do anybody any favors. That zero to 10 scale that you use, it's non-reproducible. It doesn't really help. We increased opioid prescribing by 400%. Purdue Pharma took us all for a steak dinner, told us that it was completely safe. The oxy 40s three times a day will take care of your patients and it blew up in our face and damaged and killed half a million people. Provider education needs to be done. The PDMP, which is the Pharmacy Drug Monitoring Programs, and in Arizona, we call it the Board of Medical Examiners or the Osteopathic Board, they're all watching right now. So this is a study that was done by Oliva. It was at the VA Menlo Park area. She looked at the entire VA population, 1.4 million veterans. Out of that 1.4, 800,000 had their opioid prescription stopped. That was 57%. There were 2,887 deaths from overdose or suicide and she stratified the population. So people who are on opioids less than 30 days, less than 90 days, less than 400 days or greater than 400 days. I'm going fast because I'm out of time but I want you to see the odds ratio. So this was overdose hazard ratios. It increased by four times for people who are on more than 400 or between 91 and 400 days. It increased overdose to almost six and a half, seven times. We looked at suicide for people who are on more than 90 to 400 days, almost five times and greater than 400 days suicide. Now, these are people who are on for more than 400 days and had their opioids stopped and their suicide rates increased by 800%. The study has been repeated in the civilian population, very similar numbers. So we need to look very closely at not only putting people on opioids but understanding that taking people off opioids is even more dangerous. So that's something that we need to be watching. So limits in morphine milligram equivalents is a problem but we got to watch that. But higher the dose, the greater likelihood of problems. We have lots of people who can prescribe medication assisted therapy. There is no more requirement for a waiver but we have very few people who actually prescribe buprenorphine. Cost-effectiveness of residential treatment is highly questionable. Effectiveness of sober living homes, highly questionable. Naloxone distribution is critically important to save lives but keep in mind, a person who's rescued on naloxone has a 70% chance of another overdose event and they need to be rescued again. Buprenorphine diversion, I mean, I realize it's an issue but most people use it to help them with withdrawal. The DEA requirements, the ex-DEA's drop now and some states require board-certified pain medicine consultation for opioids more than 90 MMEs one time but the thing is the waiting list is six months to a year for that so that's gonna make it very difficult. So where do we go from here? We need to recognize people in need. Active duty or VA, recognize them in need. Accept them as people who deserve the best treatment. Stigma is the biggest problem in addiction. Support people to be able to prescribe medication-assisted therapy. Work with people who are doing that. Realize that addiction is a complex and a multidisciplinary problem. Stigma, like I said, is critical to remove. Decriminalize the diagnosis of substance use disorder. Maximize acceptance for treatment. Realize it's a moving target. Xylosine is a huge problem on the East Coast, a moderate problem on the West Coast. It's not a problem in Phoenix, Arizona. We had 1,600 overdose opioid deaths in 2022 in Maricopa County. We had 22 cases of xylosine exposure and none of them were toxic enough to cause the death. So it hasn't come here yet. The cartels control what's on the street and so if the cartels decide not to use xylosine, not there. If they decide to use it, you got organized crime on the East Coast, that's what happens. And enhance the use of community services. So I'm Tony Decker. You see my email and my telephone number if you have any questions. I apologize for being a little bit over the line but thank you for the opportunity to share. I'll stay on if anyone wants to ask any questions. Thanks so much, Dr. Decker. We do have one in the chat where people are saying the question is VA and military now advise buprenorphine as first line for pain and after failing non-opioid, non-pharmacological remedies, do you think that will help the problems you described? Buprenorphine is a very interesting chemical. It goes into the cell through the mu receptor. It is almost like an attachment that doesn't break. Methadone and buprenorphine are very similar from that standpoint. So it actually internalizes into the cell. You turn your receptors over every 72 hours. So a person could actually be on once a day buprenorphine dose or even every other day buprenorphine dose and have the benefit of that partial agonism. For reasons that we cannot explain, and it may be because of the delta effect of the delta receptor effect or the kappa receptor effect but it seems to have a greater pain-relieving component for the neuropathic pain of spinal nerve compression. We don't understand that. That's one of the reasons why oxycodone and fulmino agonists are not really recommended for neuropathic pain but buprenorphine for reasons that we cannot completely explain. And I've seen this happen numerous times where people would get off of the oxycodone, get on the buprenorphine, they say, my back feels better than it's ever felt. And so the problem is that many states cap buprenorphine at 24 milligrams a day and you may need to go higher than that. So the science needs to prove what it can do. And we're still in that phase where we're trying to do what's best for our patients, but at the same time, because of the 100,000 plus deaths per year from opioids and they consider buprenorphine an opioid, it gets put in that category of, well, this is what's causing trouble more than anything else. And part of that is a stigma. I mean, I believe in science. I just want it to do the right thing. But yes, the 2023 guidelines from Sandbrink and Dr. Liberto, great stuff, great stuff. So look at that closely because if you're working with a VA or if you're a private doctor or a provider working with VA patients, please take a look at that because it's very helpful to look at that. Thank you, Dr. Decker. I will just tag on a comment. I'm in Illinois and we are bringing up that 24 dose limit at a state level and it is being called to attention at a national level too. So if attendees who are in different states, bring it to your HFS or your state addiction medicine chapters or state medical society. Absolutely. We were discussing that this morning on the expert mentors that the VA right now in Seattle is using doses at 32, 36 and 40 milligrams a day of buprenorphine with very beneficial effects. But the last thing you wanna do, I don't believe the DEA is out there hiding behind bushes to jump on you when you walk by, but if you're violating the state law or the federal law, they're gonna notice because everything's in the PDMP. So I don't see the DEA as the enemy here. I work with them on a regular basis. We do have some providers out there that are just mills. If you're seeing 200 people a day and giving out 32 milligrams of buprenorphine to every patient, stop it. That's not helping, but we do need to be available, competent, available and compatible care. I agree completely. Thanks everybody. Take care. Thank you. Bye-bye.

substance use disorder

chronic pain

veterans

active-duty service members

multidisciplinary approach

medication-assisted therapy

buprenorphine

behavioral health support

non-pharmacological remedies

opioid prescribing practices

biopsychosocial models of care