ORIGINAL ARTICLE
Health Service and Medication Use Among Veterans With Persistent Postconcussive Symptoms Paul R. King, PhD,* Michael J. Wade, MS,Þ and Gregory P. Beehler, PhD, MA*þ
Abstract: Persistent postconcussive symptoms (PPCS) are noted when a series of cognitive, emotional, and somatosensory complaints persist for months after a concussion. Clinical management of PPCS can be challenging in the veteran population because of the nonspecific nature of symptoms and co-occurrence with affective disturbances such as posttraumatic stress disorder (PTSD) and chronic pain. In this study, we compared health service and medication use patterns in a sample of 421 veterans with PPCS with an age-matched cohort of case controls. The results suggest that the veterans with PPCS showed high rates of medical and mental health service utilization during a mean treatment period of 2 years. Although chronic pain commonly co-occurs with PPCS in veterans, service use and medication prescribing trends seem to have been influenced more by the presence of PTSD than chronic pain. Our findings reinforce the overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in veterans. Key Words: Chronic pain, health service utilization, persistent postconcussive symptoms, posttraumatic stress disorder, veterans (J Nerv Ment Dis 2014;202: 231Y238)
N
umerous accounts demonstrate the prevalence of concussions in the veteran population. Although figures vary, some estimates suggest that as many as one in five combat veterans have sustained a head injury (e.g., Tanielian and Jaycox, 2008). Although concussionrelated symptoms typically resolve within several weeks (Iverson, 2005; McCrea et al., 2009; Ryan and Warden, 2003), some patients report an enduring experience of cognitive, emotional, and somatosensory difficulties, such as difficulty concentrating, irritability, headache, and vestibular disturbance (Axelrod et al., 1996; Mickeviciene et al., 2004; Sta˚lnacke, 2012). In rare instances, these symptoms have been documented to last from months (Røe et al., 2009; Sigurdardottir et al., 2009) to several years after injury (Binder et al., 1997; Jakola et al., 2007). A number of publications have referred to the ongoing experience of these symptoms as postconcussion syndrome (e.g., Ryan and Warden, 2003), although recent guidelines favor the term persistent postconcussive symptoms (PPCS; see Department of Veterans Affairs and Department of Defense [VA/DOD], the Management of Concussion/mild traumatic brain injury Working Group, 2009). Specific diagnostic criteria vary between ICD (World Health Organization, 1992) and the description of postconcussional disorder of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 2000), yet the key clinical feature is a collection of symptoms that persist well beyond
*Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, NY; †Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY; and ‡The University at Buffalo, State University of New York, Buffalo, NY. Send reprint requests to Paul R. King, PhD, Center for Integrated Healthcare (116N), VA Western New York Healthcare System, 3495 Bailey Ave, Buffalo, NY, 14215. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20203Y0231 DOI: 10.1097/NMD.0000000000000103
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expected recovery parameters. Notwithstanding taxonomy, the topic of PPCS is controversial, and clinical management of PPCS can be challenging because of the nonspecific nature of symptoms. Civilian literature suggests that most health concerns of patients with PPCS are managed by physicians (Evans et al., 1994; Mittenberg et al., 2001). Most often, physicians surveyed in the sample of Evans et al. (1994) prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and selective serotonin reuptake inhibitors (SSRIs) to manage mild pain, including headache, and affective symptoms that may accompany concussion. Roughly one third prescribed muscle relaxants, and 10% to 25% prescribed opioid analgesics and/or benzodiazepines. Current VA/ DOD, the Management of Concussion/mTBI Working Group (2009), guidelines suggest a number of preferred pharmacological treatments of PPCS that include NSAIDs, SSRIs, abortive and prophylactic agents for headache, sleep agents, vestibular suppressants, and psychostimulants but advise against the use of benzodiazepines where possible. A similar recommendation against benzodiazepine use exists for posttraumatic stress disorder (PTSD) as well (Bernardy et al., 2012; Lund et al., 2013; VA/DOD, the Management of Post-Traumatic Stress Working Group, 2010). In addition to medical treatment, evidence suggests that as many as 40% of patients with PPCS also receive behavioral health referrals (Evans et al., 1994; Mittenberg et al., 2001). Such referrals are especially fitting because studies have shown strong links between PPCS severity and affective disturbance, particularly depression (Garden and Sullivan, 2010; Suhr and Gunstad, 2002) and PTSD (Hoge et al., 2008; King et al., 2012; Meares et al., 2011), as well as chronic pain conditions (Smith-Seemiller et al., 2003; Sta˚lnacke, 2012). Each of these conditions has separately been linked to increased health service utilization (Gore et al., 2012; Outcalt et al., in press; Possemato et al., 2010; Taylor et al., 2012). Enduring sequelae of PPCS may include longterm emotional, behavioral, and neurological complications (Vanderploeg et al., 2007) and negative impacts on psychosocial functioning and quality of life (Nestvold and Stavem, 2009), which also have the potential to contribute to increased health service utilization over time. Recent research demonstrates the unique interplay of PPCS, PTSD, and chronic pain in returning veterans. For example, Lew et al. (2009) found that more than 42% of veterans evaluated at a VA polytrauma clinic endorsed co-occurring PPCS, PTSD, and chronic pain (P3). Notwithstanding the prevalence of both head injury and pain among veterans, recent reviews (e.g., Dobscha et al., 2009) suggest little guidance in managing pain concerns among polytrauma patients. Some research (e.g., Walker et al., 2010) calls for the development of new treatment paradigms capable of addressing these conditions in unison. Despite the exponential growth in research on head injury in veterans since the advent of the conflicts in Iraq and Afghanistan, generally little is known about the interaction between veterans with PPCS and the VA healthcare system. Better characterizing this relationship may improve our knowledge of the interaction of veterans’ mental and physical conditions, promote awareness of current clinical management practices, and identify areas for improved service delivery. As such, the present study aimed to describe health service and medication use in a sample of Operations Enduring and Iraqi Freedom
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(OEF/OIF) veterans with PPCS and to investigate the relative impact of co-occurring PTSD and chronic pain on these variables.
METHODS This study is part of a larger investigation of health care use in OEF/OIF veterans with history of head injury. Data for the current study were extracted from a retrospective review of all electronic medical records of OEF/OIF veterans in VA Veterans Integrated Service Network 2, which includes upstate New York and parts of northern Pennsylvania. This project was approved by the institutional review board at the VA Western New York Healthcare System (Buffalo, New York).
Study Sample Participants were drawn from the pool of OEF/OIF veterans who used VA primary care (PC) between October 2001 and September 2011. The primary inclusion criterion for the PPCS sample was at least one visit coded for postconcussion syndrome (ICD code 310.2). This criterion was intentionally broad to allow for the capturing of cases that had specific treatment of ongoing symptoms. Participants with PTSD (PTSD+) were identified by the presence of an encounter for ICD code 309.81. Participants with chronic pain (pain+) were classified as such if they were treated for conditions commonly associated with pain for 3 or more months. For example, neck pain was identified by the presence of ICD codes such as 333.83, 353.2, and 721.0. Chronic neck pain was then defined if the time elapsed between encounters was greater than or equal to 90 days from the initial encounter. Case controls (controls) consisted of OEF/OIF veterans with no documented history of VA treatment of head injury. An additional exclusion criterion for the controls was the presence of coded personal history of traumatic brain injury (V15.52). All controls were selected and age matched on the basis of a statistical matching algorithm (Parsons, 2001).
Procedure Health Service and Medication Use The initial encounter for ICD code 310.2 served as the start date for observation in the PPCS group, with a maximum 5-year observation period per case. Initial encounter dates were used as an index for the age-matched case controls. Final ICD code 310.2 encounter dates served as the upper limit for calculation of PPCS treatment duration. We used a ‘‘greedy matching’’ algorithm to age match the controls to the members of the PPCS group (Parsons, 2001); such algorithms generate propensity scores to maximize fit between test cases and controls and to reduce matched-pair bias. Health service uilization was based on clinic stop codes for general medical and mental health (MH) services and relevant consultative services, such as rehabilitation medicine, chronic pain management, neurology, neurosurgery, neuropsychology, and audiology clinics. Recorded medical services included PC and internal medicine visits, emergency department (ED) visits, polytrauma clinic visits, and the number of encounters coded for imaging studies. MH services included the number of PC MH visits, specialty MH outpatient clinic visits, and substance use disorder clinic visits. Pharmacy data for the PPCS group were gathered from VA drug classifications such as CNS (CN) medications, cardiovascular (CV) medications, hormones/synthetics/modifiers (HS), and musculoskeletal (MS) medications. Agents that are typically unrelated to management of PPCS, PTSD, or chronic pain were excluded from analysis (antiparasitics, etc.).
Analysis of Primary Research Questions The numbers of visits to medical, MH, and other specialty clinics were recorded during the course of the observation period and were treated as count variables. Use of individual clinics was also coded 232
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dichotomously (i.e., did versus did not use service) to allow for calculation of probability of consultation as well. Time elapsed between the first and the last encounter for PPCS was used to estimate treatment duration. Notably, count variables are typically skewed, not amenable to transformations, and tend to follow a Poisson distribution. Because exploratory data analyses showed an overdispersed Poisson distribution, we used negative binomial regression to account for excess variation observed in the data and to estimate the mean and standard error for clinic visits. We used logistic regression to estimate the probability of consultation with infrequently used specialty/consultative services (i.e., pain clinic, neurology, neurosurgery, neuropsychology, audiology, and ED). Pharmacy data were coded dichotomously (i.e., prescribed versus not prescribed), with frequencies of medication use provided for descriptive purposes. Subset analyses were used within the PPCS/ PTSD+ cohort to assess the relative impact of chronic pain on service use. Age matching was possible for the general PPCS and control groups but not in subset analyses because of sample size limitations from subdivision among the PTSD and pain groups within the PPCS cohort. Because observation of time and age were significantly different between pain groups, outcomes were adjusted for age, and the log number of years was included as an offset term within the statistical analysis procedure. Thus, the results of the pain group comparison of health service utilization and consults are adjusted for age and presented in terms of the number of visits and the probability of a consult per year, respectively. We set the level of significance at > = 0.05 and performed all analyses with SAS version 9.3 (SAS Institute Inc, Cary, North Carolina).
RESULTS Sample Characteristics As shown in Table 1, a total of 421 PPCS cases were age matched 1:1 to the controls (mean age, 30.3 years; SD, 7.6; range, 30.3Y58.6), yielding a total sample of 842. More than 75% of all cases and controls were younger than 33 years. The veterans with TABLE 1. Selected Characteristics of Veterans With PPCS vs. Case-Controls PPCS
Control
Characteristic
(n = 421)
(n = 421)
p
Age, mean (SD) Male, n (%) No PTSD/no pain PTSD, n (%) Chronic pain, n (%) Abdominal Back Amputation/prosthetics Headache Arthritis Neck Other Branch of service, n (%) Air Force Army Marine Navy Follow-up, mean (SD), yrs
30.3 (7.6) 406 (96) 19 (4.5) 365 (87) 320 (76) 12 (3.8) 193 (60) V 160 (50) 173 (54) 57 (18) 107 (33)
30.3 (7.6) 369 (88) 140 (33) 175 (42) 218 (52) 9 (4.1) 97 (45) V 45 (21) 138 (63) 23 (11) 50 (23)
0.967 G0.001 G0.001 G0.001 G0.001
13 (3.1) 303 (72) 90 (21) 15 (3.6) 1.93 (1.1)
42 275 64 40 1.83
G0.001 (10) (65) (15) (10) (1.07)
0.163
Chronic pain, identifiable pain condition present for 3 months or longer.
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Health Service Utilization in PPCS
TABLE 2. Health Service Utilization in Veterans With PPCS vs. Case-Controls Clinic a
Medical (C) PC/internal medicinea EDa Imaginga Polytraumaa MH (C)a PC MHa Specialty MHa Substance use disorder clinica MH (C),c n (%) PC MHc Specialty MHc Substance use disorder clinicc Rehabilitation/pain (C)a Pain clinicb Rehabilitation clinica Specialty consult (C)a Neurologyb Neurosurgeryb Neuropsychologyb Audiologyb
PPCS
Control
(n = 421)
(n = 421)
p
15.0 T 0.60 6.5 T 0.23 0.19 T 0.05 2.9 T 0.17 4.6 T 0.35 21.4 T 1.8 2.1 T 0.28 11.9 T 1.0 3.8 T 1.1 373 (89) 149 (35) 345 (82) 63 (15) 5.1 T 0.57 0.114 T 0.009 4.44 T 0.50 2.4 T 0.15 0.48 T 0.024 0.024 T 0.007 0.287 T 0.022 0.432 T 0.024
5.9 T 0.25 3.9 T 0.15 0.12 T 0.03 1.1 T 0.08 0.50 T 0.05 7.0 T 0.60 1.3 T 0.17 3.82 T 0.34 1.4 T 0.43 237 (56) 113 (27) 192 (46) 29 (7) 1.4 T 0.17 0.036 T 0.015 1.4 T 0.16 0.50 T 0.04 0.093 T 0.014 0.007 T 0.004 0.045 T 0.010 0.181 T 0.019
G0.001 G0.001 0.211 G0.001 G0.001 G0.001 0.006 G0.001 0.023 G0.001 0.007 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 0.065 G0.001 G0.001
a
The mean T standard error number of clinic visits during the observation period. The probability of a consultation. Number and percentage of veterans using services. C indicates composite clinic category.
b c
PPCS were primarily male (96%) and Army veterans (72%). Most of the PPCS group was diagnosed with PTSD (87%) and/or chronic pain (76%), whereas only 4.5% had neither condition. The controls were also primarily male (88%) and Army veterans (65%), although significantly fewer were diagnosed with PTSD and chronic pain (42% and 52%, respectively, p G 0.001). Relatively few veterans with PPCS were diagnosed with neither PTSD nor pain (4.5%), compared with 33% of the controls. Complaints of arthritis-related pain were common in both groups, although the PPCS group evidenced notably higher rates of back pain and headache. Almost all (99%) veterans in the PPCS group had their final encounter for ICD code 310.2 within a 5-year time frame. Duration of PPCS treatment assumed an approximately normal distribution, with a mean of 1.93 years (SD, 1.1).
Health Service Utilization in PPCS The PPCS group evidenced significantly higher health service utilization in all composite categories and most individual domains when compared with the controls during the course of nearly 2 years (Table 2). The most notable differences between the PPCS and control groups were found in general medical (15.0 visits vs. 5.9 visits, p G 0.001) and MH service use (21.4 visits vs. 7.0 visits, p G 0.001). In addition to higher overall rates of service use, the PPCS group was also significantly more likely to have ever used any MH service when compared with the controls (89% vs. 56%, p G 0.001), with the most noteworthy difference found in rates of consultation with specialty MH clinics (82% vs. 46%, p G 0.001).
Characteristics of Veterans With PPCS and PTSD Among the veterans with both PPCS and PTSD, 78% were also treated for chronic pain (Table 3). The veterans with P3 were * 2014 Lippincott Williams & Wilkins
significantly older than those with PPCS and PTSD only (mean, 31.4; SD, 8.1) but were otherwise demographically similar. Back pain was the most common physical complaint in this group (60%), followed by arthritis (54%) and headache (51%).
TABLE 3. Selected Characteristics in Veterans With PPCS and PTSD Pain+
Painj
Characteristic
(n = 283)
(n = 82)
p
Age, mean (SD) Male, n (%) Branch of service, n (%) Air Force Army Marine Navy Follow-up, mean (SD), yrs Pain location, n (%) Abdominal Back Headache Arthritis Neck Other
31.4 (8.1) 276 (97)
27.7 (5.2) 79 (96)
G0.001 0.700 0.587
8 (2.8) 214 (76) 53 (19) 8 (2.8) 2.1 (1.0)
2 (2.4) 57 (70) 21 (26) 2 (2.4) 1.4 (1.1)
11 170 145 152 50 99
G0.001
(3.9) (60) (51) (54) (18) (35)
Pain, identifiable pain condition present for 3 months or longer.
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TABLE 4. Health Service Utilization in Veterans With PPCS and PTSD Clinic a
Medical (C) PC/internal medicinea EDa Imaginga Polytraumaa MH (C)a PC MHa Specialty MHa Substance use disorder clinica MH (C),c n (%) PC MHc Specialty MHc Substance use disorder clinicc Rehabilitation/pain (C)a Pain clinicb Rehabilitation clinica Specialty consult (C)a Neurologyb Neurosurgeryb Neuropsychologyb Audiologyb
Pain+
Painj
(n = 283)
(n = 82)
9.1 T 3.7 T 0.07 T 1.7 T 2.7 T 14.0 T 1.4 T 7.5 T 2.3 T
0.41 0.14 0.02 0.10 0.21 1.0 0.20 0.50 0.68
269 (95) 108 (38) 259 (92) 45 (16) 3.5 0.081 3.2 1.4 0.417
T T T T T
0.40 0.013 0.37 0.10 0.031
7.6 2.8 0.02 0.89 2.2 13.7 0.9 5.3 4.3
T 0.74 T 0.24 T 0.01 T 0.14 T 0.40 T 1.9 T 0.27 T 0.73 T 2.5
76 (93) 28 (34) 67 (82) 16 (20)
p
0.090 0.002 0.086 G0.001 0.333 0.908 0.183 0.028 0.323 0.412 0.508 0.011 0.440
T 0.44 T 0.009 T 0.43 T 0.18 T 0.052
0.011 0.024 0.022 0.180 0.021
0.249 T 0.051 0.344 T 0.058
0.163 0.832
1.7 0.009 1.7 1.1 0.265
d
0.178 T 0.020 0.331 T 0.028
Pain, identifiable pain condition present for 3 months or longer. a The mean T standard error number of clinic visits per year. b The probability of a consultation T standard error. c Number and percentage of veterans using services. d Model will not converge because of small cell counts. C indicates composite clinic category.
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(17%), with more than half (53%) also having been prescribed an analgesic. P3 accounted for the largest subgroup (n = 275) and was accompanied by high rates of prescribing among many CN and CV medications, such as analgesics (86%), antidepressants (76%), anticonvulsants (60%), and sedative-hypnotics (48%). Common pain control agents used in this sample included NSAIDs (62%), opioids (58%), and other nonopioids (34%). Substantially fewer veterans were prescribed antimigraine agents (20%), glucocorticoids (13%), or muscle relaxants (1.1%). SSRIs comprised the most frequently prescribed antidepressants (53%) but were followed closely by other antidepressants (i.e., trazodone, mirtazapine, bupropion). Tricyclics and serotonin-norepinephrine reuptake inhibitors (SNRIs) were less frequently prescribed (17%Y19%). Among anticonvulsants, divalproex and clonazepam were the most common prescriptions (31% and 24%, respectively). More than a quarter of the veterans in the P3 sample were prescribed an antipsychotic (29%) or a benzodiazepine (27%). Alpha blockers were the most common CV medications (32%), with prazosin accounting for most of these prescriptions (30%). Overall rates of prescribed pain control medications appeared grossly similar in the P3 and pain+/PTSDj subgroups. Stimulant use was infrequent in each diagnostic subgroup. Rates of other CN and CV medications appeared highest overall in the P3 subgroup, most notably with regard to benzodiazepines; anticonvulsants; antipsychotics; alpha blockers (i.e., prazosin); and ‘‘other’’ antidepressants such as trazodone, mirtazapine, and bupropion. Of note, many medications coded in the P3 group were refills. This suggests that more than half of the veterans in this group had been previously prescribed a variety of medications such as most antidepressants (71%); benzodiazepines (68%); antipsychotics (62%); and analgesics (70%), including opioids (54%), before commencing the observation period. Abortive and prophylactic headache agents such as sumatriptan, zolmitriptan, divalproex, and topiramate were more likely to be newly prescribed after commencing the observation period in 62% to 75% of the P3 cases.
DISCUSSION Health Service Utilization in P3 Table 4 provides a summary of health service utilization per year among the veterans with PPCS and PTSD. The veterans diagnosed with P3 evidenced higher service use in several domains when compared with the veterans with only PPCS and PTSD. In particular, significantly higher use was found in PC/internal medicine ( p = 0.002), imaging ( p = 0.001), specialty MH ( p = 0.028), and pain ( p = 0.024) and rehabilitation clinics ( p = 0.022). With the exception of higher use within the rehabilitation and pain composite category and, to a slightly lesser degree, medical visits ( p = 0.090), adjusted rates of overall MH services ( p = 0.908) and probabilities of referral for specialty services ( p= 0.18) were grossly similar.
Medication Use in PPCS Medication data were available on 400 of 421 veterans with PPCS. Table 5 provides a summary of medications prescribed across subsamples. Because of the sample size diminishing with subdivision, robust statistical comparisons between groups were not possible. However, notable trends based on visual inspection were identified. The lowest rates of overall prescription use were found in the PPCS only subgroup, with the single most common prescription being NSAIDs (40%). The next largest subgroup (pain+/PTSDj) demonstrated more frequent prescribing of analgesics (82%) and antidepressants (50%). The painj/PTSD+ subgroup evidenced more frequent use of numerous CN medications, including antidepressants (64%), sedative-hypnotics (32%), anticonvulsants (28%), and antipsychotics 234
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We conducted a retrospective review of electronic medical records to describe health service utilization in a large sample of OEF/ OIF veterans treated for PPCS and age-matched controls. Our results showed that the veterans with PPCS used significantly more medical and MH services in comparison with the controls and were also more likely to use a variety of specialty services. Specifically, the veterans with PPCS had more than 2.5 times as many visits for medical services and more than 3 times as many visits to MH providers. Furthermore, the veterans with PPCS were medically treated for these complaints for a mean of nearly 2 years. The distribution of treatment time frames assumed a grossly normal shape, in contrast to the positively skewed distribution suggested in civilian studies (e.g., Mickeviciene et al., 2004). Of note, 89% of the veterans with PPCS had at least one visit with an MH provider, which is more than double that of civilian samples (Evans et al., 1994; Mittenberg et al., 2001). Although rates of PTSD are known to be higher in veteran samples in comparison with civilians (Hoge et al., 2004; Kessler et al., 2005; Milliken et al., 2007), most of the veterans with PPCS in our sample had been treated for PTSD. They were also significantly more likely to have been treated for a chronic pain condition than the controls, although rates of treatment of chronic pain were high in each group. The most common pain conditions we observed among the veterans with PPCS included back pain, arthritis, and headache, all at higher rates than in the controls. The rates of back pain and headache we observed were grossly similar to figures reported in the study of polytrauma patients in Lew et al. (2009; 58% and 55%, respectively). Headache itself is among the most common concussion-related symptom (Lucas et al., 2012), and this was exemplified in that more * 2014 Lippincott Williams & Wilkins
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Health Service Utilization in PPCS
TABLE 5. Prescribed Medications in Veterans With PPCS Medication Purpose
Pain control, n (%) CN101: opioid analgesics CN102: opioid antagonist analgesics CN103: nonopioid analgesics CN104/MS102: NSAIDs (any) Ibuprofen Naproxen CN105: antimigraine agents (any) Sumatriptan Zolmitriptan MS200: muscle relaxants HS051: glucocorticoids Antidepressants, n (%) CN601: tricyclics CN609: SSRIs (any) Citaloprama Sertralinea CN609: SNRIs CN609: other Sedative-hypnotics, n (%) CN300: benzodiazepines (any) Diazepam Lorazepam CN300: other (zolpidema) Stimulants, n (%) CN801: amphetamines CN802: amphetamine-like stimulants (methylphenidatea) Other psychopharmacological interventions, n (%) CN400: anticonvulsants (any) Divalproexa Clonazepam Gabapentin Topiramate CN500: antiparkinson agents CN550: antivertigo agents (meclizine) CN700: antipsychotics CN750: mood stabilizers (lithium) CV, n (%) CV100: beta blockers/related (any) Metoprolol CV150: alpha blockers/related (prazosin) CV200: calcium channel blockers CV400/490: other antihypertensive drugs
Painj/PTSDj (n = 15)
Pain+/PTSDj (n = 34)
7 (47) 1 (6.7) V 3 (20) 6 (40) 3 (20) 2 (13) V V V V 1 (6.7) 3 (20) 2 (13) V V V V 1 (6.7) 2 (13) V V V 2 (13) 1 (6.7) V 1 (6.7)
28 (82) 20 (59) V 10 (29) 23 (68) 11 (32) 5 (15) 7 (21) 7 (21) 4 (12) V 3 (8.8) 17 (50) 7 (21) 3 (8.8) 2 (5.9) 2 (5.9) 1 (2.9) 10 (29) 8 (24) 2 (5.9) V 1 (2.9) 6 (18) 1 (2.9) V 1 (2.9)
1 (6.7) V V V V V 2 (13) V V 1 (6.7) V V V V V
1 5 1 4 1
2 1 6 2 1 3 2
(2.9) (15) (2.9) (11.8) (2.9) V V (5.9) (2.9) (18) (5.9) V (2.9) (8.8) (5.9)
Painj/PTSD+ (n = 76)
Pain+/PTSD+ (n = 275)
40 15 1 10 31 17 10 3 3 1 1 1 49 10 39 16 20 3 23 24 12
(53) (20) (1.3) (13) (41) (22) (13) (4) (4) (1.3) (1.3) (1.3) (64) (13) (51) (21) (26) (4) (30) (32) (16) V 6 (7.9) 17 (22) 1 (1.3) 1 (1.3) V
237 (86) 159 (58) 4 (1.5) 94 (34) 171 (62) 96 (35) 65 (24) 56 (20) 48 (17) 19 (6.9) 3 (1.1) 36 (13) 210 (76) 48 (17) 146 (53) 79 (29) 65 (24) 53 (19) 132 (48) 133 (48) 74 (27) 21 (7.6) 34 (12) 79 (29) 15 (5.5) 2 (0.7) 11 (4)
21 3 10 3 2
165 (60) 84 (31) 66 (24) 70 (25) 53 (19) 3 (1.1) 3 (1.1) 81 (29) 5 (1.8) 127 (46) 33 (12) 7 (2.6) 83 (30) 17 (6) 16 (5.8)
(28) (4) (13) (4) (2.6) V V 13 (17) 2 (2.6) 15 (20) 2 (2.6) 1 (1.3) 14 (18) V 1 (1.3)
NSAIDs were coded as MS agents, and clonazepam was listed as CN400 (anticonvulsant) versus CN302 (benzodiazepine) in the pharmacy database. Pain, identifiable pain condition present for 3 months or longer. a First-line pharmacological agent as identified in the VA/DOD Clinical Practice Guidelines for Management of Concussion/mTBI.
than 3.5 times the number of cases in our study experienced chronic headache compared with the controls. However, complaints of headache are also common in veterans with PTSD (Afari et al., 2009). Despite that the veterans with PPCS did use a greater amount of services than the veterans in the comparison group, the combination of a high base rate of MH consultation within the veteran population and the high frequency of PTSD in this sample likely contributed to the notable rates * 2014 Lippincott Williams & Wilkins
of MH service use we observed. This consideration is supported by recent studies that have shown that the presence of affective disturbance may have an additive effect on PPCS reporting because of shared symptoms such as sleep difficulty, depression, anxiety, and lowered frustration tolerance (e.g., King et al., 2012). We were unable to rigorously evaluate differences in service use between the veterans with PPCS who did versus did not have www.jonmd.com
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PTSD. In examining the relative influence of chronic pain among veterans with PPCS and PTSD, the 275 veterans who were classified in the P3 subgroup did use significantly more rehabilitation and pain services than the veterans with PPCS and PTSD only. Overall, however, the two groups used roughly similar amounts of combined medical, MH, and specialty services (p = 0.090Y0.908). This finding is not altogether different from previous works. Despite the relatively consistent finding that patients with a chronic pain diagnosis typically show greater rates of health service utilization (Arnow et al., 2009; Engel et al., 1996; Luo et al., 2004), some studies indicate that the contribution of pain to health service utilization varies by comorbidity status (Beehler et al., 2013; Ritzwoller et al., 2006; Tamcan et al., 2010). Patients with chronic pain may also seek care more frequently, but encounters may be for other ill-defined health conditions and MH concerns other than chronic pain (Von Korff et al., 2005). Thus, the current study’s finding suggests that although chronic pain may account for predictable differences in use of painspecific services, the presence of PTSD may better explain inflated rates of other medical and MH services. In terms of medication use, NSAIDs were frequently prescribed among all veterans with PPCS. This finding is consistent with earlier civilian studies (e.g., Evans et al., 1994), although in contrast, SSRIs were infrequently prescribed in our PPCS-only and PPCS/pain+ subgroups. The P3 group evidenced similar rates of prescriptions for analgesics compared with the veterans in the PPCS/pain+ subgroup but generally higher rates of medication use than the veterans with PPCS and PTSD only. Among the veterans with P3, high rates of antidepressants, anticonvulsants, sedative-hypnotics, alpha blockers, and antipsychotics were recorded, although data suggest that many of these medications may have predated official diagnosis of PPCS. One of the most noteworthy features of this investigation was the composition of the P3 group, which accounted for more than two thirds of the overall PPCS cohort. By and large, this group comprised most frequently male Army veterans in their early 30s who frequently faced chronic complications from back pain, headache, and arthritis and used a high degree of clinical resources. The average veteran with P3 used 9 medical appointments and 14 MH appointments per year of observation along with a wide variety of medications. The veterans with P3 most frequently used analgesics and antidepressants, although most had also been treated with other medications, or combinations of medications, as well. High rates of antidepressant and sleep aid use in the P3 group are not surprising given that these are commonly used in treating PTSD (Ravindran and Stein, 2009). More interesting are the seemingly high rates of prescriptions for anticonvulsants and antipsychotics given mixed findings on their efficacy in treating PTSD symptoms (Ravindran and Stein, 2009). In addition, more than a quarter of the P3 group (higher if clonazepam is included in the estimate) was, at one point, treated with benzodiazepines, which VA/ DOD guidelines (VA/DOD, the Management of Concussion/mTBI Working Group, 2009; VA/DOD, the Management of Post-Traumatic Stress Working Group, 2010) advise against in both cases of concussion and PTSD because of cognitive side effects, treatment interference, and addiction potential. Although benzodiazepines were once commonly used to manage acute PTSD symptoms, current evidence suggests that these medications show little benefit in reducing symptoms and can actually have deleterious effects on the trauma recovery process (VA/DOD, the Management of PostTraumatic Stress Working Group, 2010). The rates of prescription use that we observed, particularly in the P3 group, were comparable with other recent VA pharmacy reviews that have reported similar rates of antidepressant, antipsychotic, and benzodiazepine use in veterans with PTSD (Bernardy et al., 2012; Lund et al., 2013). The work of Lund et al. suggested that although variation in benzodiazepine prescribing practices for veterans with PTSD may be declining 236
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with time, high rates of benzodiazepine use remain and seem to reflect a degree of clinical uncertainty among providers in terms of optimally managing PTSD. At a minimum, our findings, in concert with other recent literature on pharmacological intervention in PTSD, suggest the possibility that multiple medications may have been prescribed for a variety of overlapping or ambiguous symptoms. Our results are applicable to rehabilitative practice for veterans with PPCS in a number of ways. Perhaps most germane may be impetus toward collaborative, interdisciplinary care including individual case management. As a group, these veterans used notably high rates of medical and MH services, were likely to receive care for PPCS for an extended period, and were prescribed a wide variety of psychotropic medications. Most of the veterans with PPCS in our sample were also concurrently diagnosed with both PTSD and chronic pain conditions, and PTSD in particular seemed to influence the rates of care use we observed. Although nearly all veterans with PPCS had at least one contact with an MH provider, specialty pain services were infrequently used. An interdisciplinary approach could serve to promote holistic, veteran-centered, and practice guidelineYadherent care, while at the same time consolidating medical appointments, optimizing prescribed medications, and reducing burden on PC clinics. Such an approach also has the potential to reduce overall cost of care by providing a planned care structure with follow-up coordinated at appropriate intervals. As a retrospective chart review, our findings are limited in several ways. As with all retrospective studies, we were not able to exert the same measure of rigorous control consistent with a prospective cohort design, and we are precluded from establishing any strong causal links on the basis of our findings. Our operational definitions of primary groups and subgroups used in this study were based entirely on the presence of encounters diagnostically coded for postconcussion syndrome, PTSD, and treatment of a variety of conditions that likely represent pain during a period of 90 days or longer. Further, we had to select a start date for case observation, which was defined as the first coded encounter for postconcussion syndrome. It is plausible that we may have missed veterans who had long-lasting complaints of typical postconcussive or PTSD symptoms but lacked encounters coded as such, even if they had received some form of treatment of these symptoms. We also limited our investigation to veterans who used VA PC services and are thus unable to comment on how these results might generalize to veterans who do not use VA for routine medical care. With regard to treatment time frames, our estimate is based solely on encounters coded for postconcussion syndrome, a controversial diagnostic practice in and of itself given that many common postconcussion symptoms are frequently reported in other psychiatric conditions (e.g., King et al., 2012) and nonclinical samples (Iverson and Lange, 2003). We are thus unable to comment on whether the veterans stopped having PPCS or whether providers stopped coding for them. As is typical with retrospective medical record reviews, we did not have access to many other potentially important details, for example, specific PPCS reported; use of non-VA care; and pretreatment variables, such as the length of time that PPCS may have been present before initiating VA care, treatment history, mechanism of injury, or number of total head injuries sustained. Pharmacy data in particular should be interpreted with caution. Our ability to interpret these data was limited to whether selected classes of medications were prescribed during the observation period, regardless of duration, dose, or condition being treated. This limitation is exemplified in our inability to provide detail on why more than half of the PPCS/ PTSD+/painj group was prescribed analgesics. Our analysis does not take into account that any given medication could have been trialed and discontinued, with another selected in its place. Furthermore, we are unable to confirm that the veterans adhered to their medications as prescribed. Even in light of these limitations, several strengths remain inherent in our investigation. The strengths of the retrospective nature * 2014 Lippincott Williams & Wilkins
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of this study are found in the ability to sample, follow, and extract data on a large number of cases with a low base rate condition for a lengthy period. Although descriptive in nature, this may be the first study to broadly explore interactions of veterans with PPCS and the VA healthcare system. By relying on encounters that the trained clinicians coded, we may have enhanced the specificity of data collected during the observation period. In addition, this investigation furthered knowledge of demographics of veterans with P3 and elaborated on the relative contribution of physical and MH conditions to health service and medication use in our sample. Finally, our results, taken in context with other recent research, may serve to generate hypotheses for future investigations, perhaps pertaining to the efficacy of interdisciplinary care in managing P3; targeted MH interventions or medication optimization in veterans with PPCS and PTSD; provision of support to clinicians in implementing VA/DOD guideline-adherent care; and perceptions, experiences, and training needs of medical and MH providers who treat P3.
CONCLUSIONS Veterans with PPCS use a substantial amount of medical services and medications, may present for treatment of PPCS longer than civilian samples, and are very likely to use behavioral and MH services. Although pain was a common feature in our sample, with the exception of analgesic and rehabilitative service use, general health service utilization and medication prescribing trends seem to have been more greatly influenced by the presence of PTSD than chronic pain. Our findings ultimately support previous research in reinforcing the strong overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in OEF/OIF veterans. ACKNOWLEDGMENTS The authors thank Glenn Mead for his assistance with data collection. DISCLOSURES This study was supported by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the Department of Veterans Affairs Center for Integrated Healthcare, VA Western New York Healthcare System at Buffalo. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. All authors are employees of the Department of Veterans Affairs. The authors declare no conflict of interest. REFERENCES Afari N, Harder LH, Madra NJ, Heppner PS, Moeller-Bertram T, King C, Baker D (2009) PTSD, combat injury, and headache in veterans returning from Iraq/ Afghanistan. Headache. 49:1267Y1276. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th edYtext rev). Washington, DC: American Psychiatric Association. Arnow BA, Blasey CM, Lee J, Fireman B, Hunkeler EM, Dea R, Robinson R, Hayward C (2009) Relationships among depression, chronic pain, chronic disabling pain, and medical costs. Psychiatr Serv. 60:344Y350. Axelrod BN, Fox DD, Lees-Haley PR, Earnest K, Dolezal-Wood S, Goldman RS (1996) Latent structure of the Postconcussion Syndrome Questionnaire. Psychol Assess. 8:422Y427. Beehler GP, Rodrigues AE, Mercurio-Riley D, Dunn AS (2013) Primary care utilization among veterans with chronic musculoskeletal pain: A retrospective chart review. Pain Med. 14:1021Y1031. Bernardy NC, Lund BC, Alexander B, Friedman MJ (2012) Prescribing trends in veterans with posttraumatic stress disorder. J Clin Psychiatry. 73:297Y303.
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Binder LM, Rohling ML, Larrabee GJ (1997) A review of mild head trauma. Part I: Meta-analytic review of neuropsychological studies. J Clin Exp Neuropsychol. 19:421Y431. Department of Veterans Affairs and Department of Defense (VA/DOD), the Management of Concussion/mTBI Working Group (2009) VA/DOD clinical practice guideline for management of concussion/mild traumatic brain injury (MTBI). Washington, DC: Department of Veterans Affairs & Department of Defense. Department of Veterans Affairs and Department of Defense (VA/DOD), the Management of Post-Traumatic Stress Working Group (2010) VA/DOD Clinical Practice Guideline for management of post-traumatic stress. Washington, DC: Department of Veterans Affairs & Department of Defense. Dobscha SK, Clark ME, Morasco BJ, Freeman M, Campbell R, Helfand M (2009) Systematic review of the literature on pain in persons with polytrauma including traumatic brain injury. Pain Med. 10:1200Y1217. Engel CC, Van Korff M, Katon WJ (1996) Back pain in primary care: Predictors of high health-care costs. Pain. 65:197Y204. Evans RW, Evans RW, Sharp MJ (1994) The physician survey on the postconcussion and whiplash syndromes. Headache. 34:268Y274. Garden N, Sullivan KA (2010) An examination of the base rates of postconcussion symptoms: The influence of demographics and depression. Appl Neuropsychol. 17:1Y7. Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D (2012) The burden of chronic low back pain. Spine. 37:E668YE677. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (2004) Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 351:13Y22. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA (2008) Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 358:453Y463. Iverson GL (2005) Outcome from mild traumatic brain injury. Curr Opin Psychiatry. 18:301Y317. Iverson GL, Lange RT (2003) Examination of ‘‘postconcussion-like’’ symptoms in a health sample. Appl Neuropsychol. 10:137Y144. Jakola AS, Mu¨ller K, Larsen M, Waterloo K, Ingebrigtsen T (2007) Five-year outcome after mild head injury: A prospective controlled study. Acta Neurol Scand. 115:398Y402. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62:617Y627. King PR, Donnelly KT, Donnelly JP, Dunnam M, Warner G, Kittleson CJ, Bradshaw CB, Alt MA, Meier ST (2012) Psychometric Study of the Neurobehavioral Symptom Inventory. J Rehabil Res Dev. 49:879Y888. Lew HL, Otis JD, Tun C, Kerns R, Clark ME, Cifu DX (2009) Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad. J Rehabil Res Dev. 46:697Y702. Lucas S, Hoffman JM, Bell KR, Walker W, Dikmen S (2012) Characterization of headache after traumatic brain injury. Cephalalgia. 32:600Y606. Lund BC, Abrams TE, Bernardy NC, Alexander B, Friedman MJ (2013) Benzodiazepine prescribing variation and clinical uncertainty in treating posttraumatic stress disorder. Psychiatr Serv. 64:21Y27. Luo X, Pietrobon R, Sun SX, Liu GG, Hey L (2004) Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine. 29:79Y86. McCrea M, Iverson GL, McAllister TW, Hammeke TA, Powell MR, Barr WB, Kelly JP (2009) An integrated review of recovery after mild traumatic brain injury (MTBI): Implications for clinical management. Clin Neuropsychol. 23:1368Y1390. Meares S, Shores EA, Taylor AJ, Batchelor J, Bryant RA, Baguley IJ, Chapman J, Gurka J, Marosszkey JE (2011) The prospective course of postconcussion syndrome: The role of mild traumatic brain injury. Neuropsychology. 25:454Y465. Mickeviciene D, Schrader H, Obelieniene D, Surkiene D, Kunickas R, Stovner LJ, Sand T (2004) A controlled prospective inception cohort study on the postconcussion syndrome outside the medicolegal context. Eur J Neurol. 11:411Y419. Milliken CS, Auchterlonie JL, Hoge CW (2007) Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 298:2141Y2148. Mittenberg W, Canyock EM, Condit D, Patton C (2001) Treatment of post-concussion syndrome following mild head injury. J Clin Exp Neuropsychol. 23:829Y836. Nestvold K, Stavem K (2009) Determinants of health-related quality of life 22 years after hospitalization for traumatic brain injury. Brain Inj. 23:15Y21.
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Outcalt SD, Yu Z, Hoen HM, Pennington TM, Krebs EE (in press) Health care utilization among veterans with pain and posttraumatic stress symptoms. Pain Med. Parsons L (2001) Reducing bias in a propensity score matched-pair sample using greedy matching techniques. SAS Users Group Proc. 2001:214Y226. Possemato K, Wade M, Andersen J, Ouimette P (2010) The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF Veterans. Psychol Trauma. 2:218Y223. Ravindran LN, Stein MB (2009) Pharmacotherapy of PTSD: Premises, principles, and priorities. Brain Res. 1239:24Y39. Ritzwoller DP, Crounse L, Shetterly S, Rublee D (2006) The association of comorbidities, utilization and costs for patients identified with low back pain. BMC Musculoskelet Disord. 7:72 doi:10.1186/1471-2474-7-72. Røe C, Sveen U, Alvsa˚ker K, Bautz-Holter E (2009) Post-concussion symptoms after mild traumatic brain injury: Influence of demographic factors and injury severity in a 1-year cohort study. Disabil Rehabil. 31:1235Y1243. Ryan LM, Warden DL (2003) Post concussion syndrome. Int Rev Psychiatry. 15:310Y316. Sigurdardottir S, Andelic N, Røe C, Jerstad T, Schanke A (2009) Post-concussion symptoms after traumatic brain injury at 3 and 12 months post-injury: A prospective study. Brain Inj. 23:489Y497. Smith-Seemiller L, Fow NR, Kant R, Franzen MD (2003) Presence of postconcussion syndrome symptoms in patients with chronic pain vs. mild traumatic brain injury. Brain Inj. 17:199Y206. Sta˚lnacke BM (2012) Postconcussion symptoms in patients with injury-related chronic pain. Rehabil Res Pract. 1Y5. doi:10.1155/2012/528265.
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Suhr JA, Gunstad J (2002) Postconcussive symptom report: The relative influence of head injury and depression. J Clin Exp Neuropsychol. 24:981Y993. Tamcan O, Mannion AF, Eisenring C, Horisberger B, Elfering A, Mu¨ller U (2010) The course of chronic and recurrent low back pain in the general population. Pain. 150:451Y457. Tanielian T, Jaycox LH (Eds) (2008) Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: The RAND Corp. Taylor BC, Hagel EM, Carlson KF, Cifu DX, Cutting A, Bidelspach DE, Sayer N (2012) Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War VA users. Med Care. 50:342Y346. Vanderploeg RD, Curtiss G, Luis CA, Salazar AM (2007) Long-term morbidities following self-reported mild traumatic brain injury. J Clin Exp Neuropsychol. 29:585Y598. Von Korff M, Crane P, Lane M, Miglioretti DL, Simon G, Saunders K, Stang P, Brandenburg N, Kessler R (2005) Chronic spinal pain and physicalYmental comorbidity in the United States: Results from the National Comorbidity Survey Replication. Pain. 113:331Y339. Walker RL, Clark ME, Sanders SH (2010) The ‘‘Postdeployment Multi-Symptom Disorder’’: An emerging syndrome in need of a new treatment paradigm. Psychol Serv. 7:136Y147. World Health Organization (1992) International statistical classification of diseases and related health problems (10th ed). Geneva, Switzerland: World Health Organization.
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Health Service and Medication Use Among Veterans With Persistent Postconcussive Symptoms Paul R. King, PhD,* Michael J. Wade, MS,Þ and Gregory P. Beehler, PhD, MA*þ
Abstract: Persistent postconcussive symptoms (PPCS) are noted when a series of cognitive, emotional, and somatosensory complaints persist for months after a concussion. Clinical management of PPCS can be challenging in the veteran population because of the nonspecific nature of symptoms and co-occurrence with affective disturbances such as posttraumatic stress disorder (PTSD) and chronic pain. In this study, we compared health service and medication use patterns in a sample of 421 veterans with PPCS with an age-matched cohort of case controls. The results suggest that the veterans with PPCS showed high rates of medical and mental health service utilization during a mean treatment period of 2 years. Although chronic pain commonly co-occurs with PPCS in veterans, service use and medication prescribing trends seem to have been influenced more by the presence of PTSD than chronic pain. Our findings reinforce the overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in veterans. Key Words: Chronic pain, health service utilization, persistent postconcussive symptoms, posttraumatic stress disorder, veterans (J Nerv Ment Dis 2014;202: 231Y238)
N
umerous accounts demonstrate the prevalence of concussions in the veteran population. Although figures vary, some estimates suggest that as many as one in five combat veterans have sustained a head injury (e.g., Tanielian and Jaycox, 2008). Although concussionrelated symptoms typically resolve within several weeks (Iverson, 2005; McCrea et al., 2009; Ryan and Warden, 2003), some patients report an enduring experience of cognitive, emotional, and somatosensory difficulties, such as difficulty concentrating, irritability, headache, and vestibular disturbance (Axelrod et al., 1996; Mickeviciene et al., 2004; Sta˚lnacke, 2012). In rare instances, these symptoms have been documented to last from months (Røe et al., 2009; Sigurdardottir et al., 2009) to several years after injury (Binder et al., 1997; Jakola et al., 2007). A number of publications have referred to the ongoing experience of these symptoms as postconcussion syndrome (e.g., Ryan and Warden, 2003), although recent guidelines favor the term persistent postconcussive symptoms (PPCS; see Department of Veterans Affairs and Department of Defense [VA/DOD], the Management of Concussion/mild traumatic brain injury Working Group, 2009). Specific diagnostic criteria vary between ICD (World Health Organization, 1992) and the description of postconcussional disorder of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 2000), yet the key clinical feature is a collection of symptoms that persist well beyond
*Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, NY; †Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY; and ‡The University at Buffalo, State University of New York, Buffalo, NY. Send reprint requests to Paul R. King, PhD, Center for Integrated Healthcare (116N), VA Western New York Healthcare System, 3495 Bailey Ave, Buffalo, NY, 14215. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20203Y0231 DOI: 10.1097/NMD.0000000000000103
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expected recovery parameters. Notwithstanding taxonomy, the topic of PPCS is controversial, and clinical management of PPCS can be challenging because of the nonspecific nature of symptoms. Civilian literature suggests that most health concerns of patients with PPCS are managed by physicians (Evans et al., 1994; Mittenberg et al., 2001). Most often, physicians surveyed in the sample of Evans et al. (1994) prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and selective serotonin reuptake inhibitors (SSRIs) to manage mild pain, including headache, and affective symptoms that may accompany concussion. Roughly one third prescribed muscle relaxants, and 10% to 25% prescribed opioid analgesics and/or benzodiazepines. Current VA/ DOD, the Management of Concussion/mTBI Working Group (2009), guidelines suggest a number of preferred pharmacological treatments of PPCS that include NSAIDs, SSRIs, abortive and prophylactic agents for headache, sleep agents, vestibular suppressants, and psychostimulants but advise against the use of benzodiazepines where possible. A similar recommendation against benzodiazepine use exists for posttraumatic stress disorder (PTSD) as well (Bernardy et al., 2012; Lund et al., 2013; VA/DOD, the Management of Post-Traumatic Stress Working Group, 2010). In addition to medical treatment, evidence suggests that as many as 40% of patients with PPCS also receive behavioral health referrals (Evans et al., 1994; Mittenberg et al., 2001). Such referrals are especially fitting because studies have shown strong links between PPCS severity and affective disturbance, particularly depression (Garden and Sullivan, 2010; Suhr and Gunstad, 2002) and PTSD (Hoge et al., 2008; King et al., 2012; Meares et al., 2011), as well as chronic pain conditions (Smith-Seemiller et al., 2003; Sta˚lnacke, 2012). Each of these conditions has separately been linked to increased health service utilization (Gore et al., 2012; Outcalt et al., in press; Possemato et al., 2010; Taylor et al., 2012). Enduring sequelae of PPCS may include longterm emotional, behavioral, and neurological complications (Vanderploeg et al., 2007) and negative impacts on psychosocial functioning and quality of life (Nestvold and Stavem, 2009), which also have the potential to contribute to increased health service utilization over time. Recent research demonstrates the unique interplay of PPCS, PTSD, and chronic pain in returning veterans. For example, Lew et al. (2009) found that more than 42% of veterans evaluated at a VA polytrauma clinic endorsed co-occurring PPCS, PTSD, and chronic pain (P3). Notwithstanding the prevalence of both head injury and pain among veterans, recent reviews (e.g., Dobscha et al., 2009) suggest little guidance in managing pain concerns among polytrauma patients. Some research (e.g., Walker et al., 2010) calls for the development of new treatment paradigms capable of addressing these conditions in unison. Despite the exponential growth in research on head injury in veterans since the advent of the conflicts in Iraq and Afghanistan, generally little is known about the interaction between veterans with PPCS and the VA healthcare system. Better characterizing this relationship may improve our knowledge of the interaction of veterans’ mental and physical conditions, promote awareness of current clinical management practices, and identify areas for improved service delivery. As such, the present study aimed to describe health service and medication use in a sample of Operations Enduring and Iraqi Freedom
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(OEF/OIF) veterans with PPCS and to investigate the relative impact of co-occurring PTSD and chronic pain on these variables.
METHODS This study is part of a larger investigation of health care use in OEF/OIF veterans with history of head injury. Data for the current study were extracted from a retrospective review of all electronic medical records of OEF/OIF veterans in VA Veterans Integrated Service Network 2, which includes upstate New York and parts of northern Pennsylvania. This project was approved by the institutional review board at the VA Western New York Healthcare System (Buffalo, New York).
Study Sample Participants were drawn from the pool of OEF/OIF veterans who used VA primary care (PC) between October 2001 and September 2011. The primary inclusion criterion for the PPCS sample was at least one visit coded for postconcussion syndrome (ICD code 310.2). This criterion was intentionally broad to allow for the capturing of cases that had specific treatment of ongoing symptoms. Participants with PTSD (PTSD+) were identified by the presence of an encounter for ICD code 309.81. Participants with chronic pain (pain+) were classified as such if they were treated for conditions commonly associated with pain for 3 or more months. For example, neck pain was identified by the presence of ICD codes such as 333.83, 353.2, and 721.0. Chronic neck pain was then defined if the time elapsed between encounters was greater than or equal to 90 days from the initial encounter. Case controls (controls) consisted of OEF/OIF veterans with no documented history of VA treatment of head injury. An additional exclusion criterion for the controls was the presence of coded personal history of traumatic brain injury (V15.52). All controls were selected and age matched on the basis of a statistical matching algorithm (Parsons, 2001).
Procedure Health Service and Medication Use The initial encounter for ICD code 310.2 served as the start date for observation in the PPCS group, with a maximum 5-year observation period per case. Initial encounter dates were used as an index for the age-matched case controls. Final ICD code 310.2 encounter dates served as the upper limit for calculation of PPCS treatment duration. We used a ‘‘greedy matching’’ algorithm to age match the controls to the members of the PPCS group (Parsons, 2001); such algorithms generate propensity scores to maximize fit between test cases and controls and to reduce matched-pair bias. Health service uilization was based on clinic stop codes for general medical and mental health (MH) services and relevant consultative services, such as rehabilitation medicine, chronic pain management, neurology, neurosurgery, neuropsychology, and audiology clinics. Recorded medical services included PC and internal medicine visits, emergency department (ED) visits, polytrauma clinic visits, and the number of encounters coded for imaging studies. MH services included the number of PC MH visits, specialty MH outpatient clinic visits, and substance use disorder clinic visits. Pharmacy data for the PPCS group were gathered from VA drug classifications such as CNS (CN) medications, cardiovascular (CV) medications, hormones/synthetics/modifiers (HS), and musculoskeletal (MS) medications. Agents that are typically unrelated to management of PPCS, PTSD, or chronic pain were excluded from analysis (antiparasitics, etc.).
Analysis of Primary Research Questions The numbers of visits to medical, MH, and other specialty clinics were recorded during the course of the observation period and were treated as count variables. Use of individual clinics was also coded 232
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dichotomously (i.e., did versus did not use service) to allow for calculation of probability of consultation as well. Time elapsed between the first and the last encounter for PPCS was used to estimate treatment duration. Notably, count variables are typically skewed, not amenable to transformations, and tend to follow a Poisson distribution. Because exploratory data analyses showed an overdispersed Poisson distribution, we used negative binomial regression to account for excess variation observed in the data and to estimate the mean and standard error for clinic visits. We used logistic regression to estimate the probability of consultation with infrequently used specialty/consultative services (i.e., pain clinic, neurology, neurosurgery, neuropsychology, audiology, and ED). Pharmacy data were coded dichotomously (i.e., prescribed versus not prescribed), with frequencies of medication use provided for descriptive purposes. Subset analyses were used within the PPCS/ PTSD+ cohort to assess the relative impact of chronic pain on service use. Age matching was possible for the general PPCS and control groups but not in subset analyses because of sample size limitations from subdivision among the PTSD and pain groups within the PPCS cohort. Because observation of time and age were significantly different between pain groups, outcomes were adjusted for age, and the log number of years was included as an offset term within the statistical analysis procedure. Thus, the results of the pain group comparison of health service utilization and consults are adjusted for age and presented in terms of the number of visits and the probability of a consult per year, respectively. We set the level of significance at > = 0.05 and performed all analyses with SAS version 9.3 (SAS Institute Inc, Cary, North Carolina).
RESULTS Sample Characteristics As shown in Table 1, a total of 421 PPCS cases were age matched 1:1 to the controls (mean age, 30.3 years; SD, 7.6; range, 30.3Y58.6), yielding a total sample of 842. More than 75% of all cases and controls were younger than 33 years. The veterans with TABLE 1. Selected Characteristics of Veterans With PPCS vs. Case-Controls PPCS
Control
Characteristic
(n = 421)
(n = 421)
p
Age, mean (SD) Male, n (%) No PTSD/no pain PTSD, n (%) Chronic pain, n (%) Abdominal Back Amputation/prosthetics Headache Arthritis Neck Other Branch of service, n (%) Air Force Army Marine Navy Follow-up, mean (SD), yrs
30.3 (7.6) 406 (96) 19 (4.5) 365 (87) 320 (76) 12 (3.8) 193 (60) V 160 (50) 173 (54) 57 (18) 107 (33)
30.3 (7.6) 369 (88) 140 (33) 175 (42) 218 (52) 9 (4.1) 97 (45) V 45 (21) 138 (63) 23 (11) 50 (23)
0.967 G0.001 G0.001 G0.001 G0.001
13 (3.1) 303 (72) 90 (21) 15 (3.6) 1.93 (1.1)
42 275 64 40 1.83
G0.001 (10) (65) (15) (10) (1.07)
0.163
Chronic pain, identifiable pain condition present for 3 months or longer.
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Health Service Utilization in PPCS
TABLE 2. Health Service Utilization in Veterans With PPCS vs. Case-Controls Clinic a
Medical (C) PC/internal medicinea EDa Imaginga Polytraumaa MH (C)a PC MHa Specialty MHa Substance use disorder clinica MH (C),c n (%) PC MHc Specialty MHc Substance use disorder clinicc Rehabilitation/pain (C)a Pain clinicb Rehabilitation clinica Specialty consult (C)a Neurologyb Neurosurgeryb Neuropsychologyb Audiologyb
PPCS
Control
(n = 421)
(n = 421)
p
15.0 T 0.60 6.5 T 0.23 0.19 T 0.05 2.9 T 0.17 4.6 T 0.35 21.4 T 1.8 2.1 T 0.28 11.9 T 1.0 3.8 T 1.1 373 (89) 149 (35) 345 (82) 63 (15) 5.1 T 0.57 0.114 T 0.009 4.44 T 0.50 2.4 T 0.15 0.48 T 0.024 0.024 T 0.007 0.287 T 0.022 0.432 T 0.024
5.9 T 0.25 3.9 T 0.15 0.12 T 0.03 1.1 T 0.08 0.50 T 0.05 7.0 T 0.60 1.3 T 0.17 3.82 T 0.34 1.4 T 0.43 237 (56) 113 (27) 192 (46) 29 (7) 1.4 T 0.17 0.036 T 0.015 1.4 T 0.16 0.50 T 0.04 0.093 T 0.014 0.007 T 0.004 0.045 T 0.010 0.181 T 0.019
G0.001 G0.001 0.211 G0.001 G0.001 G0.001 0.006 G0.001 0.023 G0.001 0.007 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 G0.001 0.065 G0.001 G0.001
a
The mean T standard error number of clinic visits during the observation period. The probability of a consultation. Number and percentage of veterans using services. C indicates composite clinic category.
b c
PPCS were primarily male (96%) and Army veterans (72%). Most of the PPCS group was diagnosed with PTSD (87%) and/or chronic pain (76%), whereas only 4.5% had neither condition. The controls were also primarily male (88%) and Army veterans (65%), although significantly fewer were diagnosed with PTSD and chronic pain (42% and 52%, respectively, p G 0.001). Relatively few veterans with PPCS were diagnosed with neither PTSD nor pain (4.5%), compared with 33% of the controls. Complaints of arthritis-related pain were common in both groups, although the PPCS group evidenced notably higher rates of back pain and headache. Almost all (99%) veterans in the PPCS group had their final encounter for ICD code 310.2 within a 5-year time frame. Duration of PPCS treatment assumed an approximately normal distribution, with a mean of 1.93 years (SD, 1.1).
Health Service Utilization in PPCS The PPCS group evidenced significantly higher health service utilization in all composite categories and most individual domains when compared with the controls during the course of nearly 2 years (Table 2). The most notable differences between the PPCS and control groups were found in general medical (15.0 visits vs. 5.9 visits, p G 0.001) and MH service use (21.4 visits vs. 7.0 visits, p G 0.001). In addition to higher overall rates of service use, the PPCS group was also significantly more likely to have ever used any MH service when compared with the controls (89% vs. 56%, p G 0.001), with the most noteworthy difference found in rates of consultation with specialty MH clinics (82% vs. 46%, p G 0.001).
Characteristics of Veterans With PPCS and PTSD Among the veterans with both PPCS and PTSD, 78% were also treated for chronic pain (Table 3). The veterans with P3 were * 2014 Lippincott Williams & Wilkins
significantly older than those with PPCS and PTSD only (mean, 31.4; SD, 8.1) but were otherwise demographically similar. Back pain was the most common physical complaint in this group (60%), followed by arthritis (54%) and headache (51%).
TABLE 3. Selected Characteristics in Veterans With PPCS and PTSD Pain+
Painj
Characteristic
(n = 283)
(n = 82)
p
Age, mean (SD) Male, n (%) Branch of service, n (%) Air Force Army Marine Navy Follow-up, mean (SD), yrs Pain location, n (%) Abdominal Back Headache Arthritis Neck Other
31.4 (8.1) 276 (97)
27.7 (5.2) 79 (96)
G0.001 0.700 0.587
8 (2.8) 214 (76) 53 (19) 8 (2.8) 2.1 (1.0)
2 (2.4) 57 (70) 21 (26) 2 (2.4) 1.4 (1.1)
11 170 145 152 50 99
G0.001
(3.9) (60) (51) (54) (18) (35)
Pain, identifiable pain condition present for 3 months or longer.
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TABLE 4. Health Service Utilization in Veterans With PPCS and PTSD Clinic a
Medical (C) PC/internal medicinea EDa Imaginga Polytraumaa MH (C)a PC MHa Specialty MHa Substance use disorder clinica MH (C),c n (%) PC MHc Specialty MHc Substance use disorder clinicc Rehabilitation/pain (C)a Pain clinicb Rehabilitation clinica Specialty consult (C)a Neurologyb Neurosurgeryb Neuropsychologyb Audiologyb
Pain+
Painj
(n = 283)
(n = 82)
9.1 T 3.7 T 0.07 T 1.7 T 2.7 T 14.0 T 1.4 T 7.5 T 2.3 T
0.41 0.14 0.02 0.10 0.21 1.0 0.20 0.50 0.68
269 (95) 108 (38) 259 (92) 45 (16) 3.5 0.081 3.2 1.4 0.417
T T T T T
0.40 0.013 0.37 0.10 0.031
7.6 2.8 0.02 0.89 2.2 13.7 0.9 5.3 4.3
T 0.74 T 0.24 T 0.01 T 0.14 T 0.40 T 1.9 T 0.27 T 0.73 T 2.5
76 (93) 28 (34) 67 (82) 16 (20)
p
0.090 0.002 0.086 G0.001 0.333 0.908 0.183 0.028 0.323 0.412 0.508 0.011 0.440
T 0.44 T 0.009 T 0.43 T 0.18 T 0.052
0.011 0.024 0.022 0.180 0.021
0.249 T 0.051 0.344 T 0.058
0.163 0.832
1.7 0.009 1.7 1.1 0.265
d
0.178 T 0.020 0.331 T 0.028
Pain, identifiable pain condition present for 3 months or longer. a The mean T standard error number of clinic visits per year. b The probability of a consultation T standard error. c Number and percentage of veterans using services. d Model will not converge because of small cell counts. C indicates composite clinic category.
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(17%), with more than half (53%) also having been prescribed an analgesic. P3 accounted for the largest subgroup (n = 275) and was accompanied by high rates of prescribing among many CN and CV medications, such as analgesics (86%), antidepressants (76%), anticonvulsants (60%), and sedative-hypnotics (48%). Common pain control agents used in this sample included NSAIDs (62%), opioids (58%), and other nonopioids (34%). Substantially fewer veterans were prescribed antimigraine agents (20%), glucocorticoids (13%), or muscle relaxants (1.1%). SSRIs comprised the most frequently prescribed antidepressants (53%) but were followed closely by other antidepressants (i.e., trazodone, mirtazapine, bupropion). Tricyclics and serotonin-norepinephrine reuptake inhibitors (SNRIs) were less frequently prescribed (17%Y19%). Among anticonvulsants, divalproex and clonazepam were the most common prescriptions (31% and 24%, respectively). More than a quarter of the veterans in the P3 sample were prescribed an antipsychotic (29%) or a benzodiazepine (27%). Alpha blockers were the most common CV medications (32%), with prazosin accounting for most of these prescriptions (30%). Overall rates of prescribed pain control medications appeared grossly similar in the P3 and pain+/PTSDj subgroups. Stimulant use was infrequent in each diagnostic subgroup. Rates of other CN and CV medications appeared highest overall in the P3 subgroup, most notably with regard to benzodiazepines; anticonvulsants; antipsychotics; alpha blockers (i.e., prazosin); and ‘‘other’’ antidepressants such as trazodone, mirtazapine, and bupropion. Of note, many medications coded in the P3 group were refills. This suggests that more than half of the veterans in this group had been previously prescribed a variety of medications such as most antidepressants (71%); benzodiazepines (68%); antipsychotics (62%); and analgesics (70%), including opioids (54%), before commencing the observation period. Abortive and prophylactic headache agents such as sumatriptan, zolmitriptan, divalproex, and topiramate were more likely to be newly prescribed after commencing the observation period in 62% to 75% of the P3 cases.
DISCUSSION Health Service Utilization in P3 Table 4 provides a summary of health service utilization per year among the veterans with PPCS and PTSD. The veterans diagnosed with P3 evidenced higher service use in several domains when compared with the veterans with only PPCS and PTSD. In particular, significantly higher use was found in PC/internal medicine ( p = 0.002), imaging ( p = 0.001), specialty MH ( p = 0.028), and pain ( p = 0.024) and rehabilitation clinics ( p = 0.022). With the exception of higher use within the rehabilitation and pain composite category and, to a slightly lesser degree, medical visits ( p = 0.090), adjusted rates of overall MH services ( p = 0.908) and probabilities of referral for specialty services ( p= 0.18) were grossly similar.
Medication Use in PPCS Medication data were available on 400 of 421 veterans with PPCS. Table 5 provides a summary of medications prescribed across subsamples. Because of the sample size diminishing with subdivision, robust statistical comparisons between groups were not possible. However, notable trends based on visual inspection were identified. The lowest rates of overall prescription use were found in the PPCS only subgroup, with the single most common prescription being NSAIDs (40%). The next largest subgroup (pain+/PTSDj) demonstrated more frequent prescribing of analgesics (82%) and antidepressants (50%). The painj/PTSD+ subgroup evidenced more frequent use of numerous CN medications, including antidepressants (64%), sedative-hypnotics (32%), anticonvulsants (28%), and antipsychotics 234
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We conducted a retrospective review of electronic medical records to describe health service utilization in a large sample of OEF/ OIF veterans treated for PPCS and age-matched controls. Our results showed that the veterans with PPCS used significantly more medical and MH services in comparison with the controls and were also more likely to use a variety of specialty services. Specifically, the veterans with PPCS had more than 2.5 times as many visits for medical services and more than 3 times as many visits to MH providers. Furthermore, the veterans with PPCS were medically treated for these complaints for a mean of nearly 2 years. The distribution of treatment time frames assumed a grossly normal shape, in contrast to the positively skewed distribution suggested in civilian studies (e.g., Mickeviciene et al., 2004). Of note, 89% of the veterans with PPCS had at least one visit with an MH provider, which is more than double that of civilian samples (Evans et al., 1994; Mittenberg et al., 2001). Although rates of PTSD are known to be higher in veteran samples in comparison with civilians (Hoge et al., 2004; Kessler et al., 2005; Milliken et al., 2007), most of the veterans with PPCS in our sample had been treated for PTSD. They were also significantly more likely to have been treated for a chronic pain condition than the controls, although rates of treatment of chronic pain were high in each group. The most common pain conditions we observed among the veterans with PPCS included back pain, arthritis, and headache, all at higher rates than in the controls. The rates of back pain and headache we observed were grossly similar to figures reported in the study of polytrauma patients in Lew et al. (2009; 58% and 55%, respectively). Headache itself is among the most common concussion-related symptom (Lucas et al., 2012), and this was exemplified in that more * 2014 Lippincott Williams & Wilkins
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Health Service Utilization in PPCS
TABLE 5. Prescribed Medications in Veterans With PPCS Medication Purpose
Pain control, n (%) CN101: opioid analgesics CN102: opioid antagonist analgesics CN103: nonopioid analgesics CN104/MS102: NSAIDs (any) Ibuprofen Naproxen CN105: antimigraine agents (any) Sumatriptan Zolmitriptan MS200: muscle relaxants HS051: glucocorticoids Antidepressants, n (%) CN601: tricyclics CN609: SSRIs (any) Citaloprama Sertralinea CN609: SNRIs CN609: other Sedative-hypnotics, n (%) CN300: benzodiazepines (any) Diazepam Lorazepam CN300: other (zolpidema) Stimulants, n (%) CN801: amphetamines CN802: amphetamine-like stimulants (methylphenidatea) Other psychopharmacological interventions, n (%) CN400: anticonvulsants (any) Divalproexa Clonazepam Gabapentin Topiramate CN500: antiparkinson agents CN550: antivertigo agents (meclizine) CN700: antipsychotics CN750: mood stabilizers (lithium) CV, n (%) CV100: beta blockers/related (any) Metoprolol CV150: alpha blockers/related (prazosin) CV200: calcium channel blockers CV400/490: other antihypertensive drugs
Painj/PTSDj (n = 15)
Pain+/PTSDj (n = 34)
7 (47) 1 (6.7) V 3 (20) 6 (40) 3 (20) 2 (13) V V V V 1 (6.7) 3 (20) 2 (13) V V V V 1 (6.7) 2 (13) V V V 2 (13) 1 (6.7) V 1 (6.7)
28 (82) 20 (59) V 10 (29) 23 (68) 11 (32) 5 (15) 7 (21) 7 (21) 4 (12) V 3 (8.8) 17 (50) 7 (21) 3 (8.8) 2 (5.9) 2 (5.9) 1 (2.9) 10 (29) 8 (24) 2 (5.9) V 1 (2.9) 6 (18) 1 (2.9) V 1 (2.9)
1 (6.7) V V V V V 2 (13) V V 1 (6.7) V V V V V
1 5 1 4 1
2 1 6 2 1 3 2
(2.9) (15) (2.9) (11.8) (2.9) V V (5.9) (2.9) (18) (5.9) V (2.9) (8.8) (5.9)
Painj/PTSD+ (n = 76)
Pain+/PTSD+ (n = 275)
40 15 1 10 31 17 10 3 3 1 1 1 49 10 39 16 20 3 23 24 12
(53) (20) (1.3) (13) (41) (22) (13) (4) (4) (1.3) (1.3) (1.3) (64) (13) (51) (21) (26) (4) (30) (32) (16) V 6 (7.9) 17 (22) 1 (1.3) 1 (1.3) V
237 (86) 159 (58) 4 (1.5) 94 (34) 171 (62) 96 (35) 65 (24) 56 (20) 48 (17) 19 (6.9) 3 (1.1) 36 (13) 210 (76) 48 (17) 146 (53) 79 (29) 65 (24) 53 (19) 132 (48) 133 (48) 74 (27) 21 (7.6) 34 (12) 79 (29) 15 (5.5) 2 (0.7) 11 (4)
21 3 10 3 2
165 (60) 84 (31) 66 (24) 70 (25) 53 (19) 3 (1.1) 3 (1.1) 81 (29) 5 (1.8) 127 (46) 33 (12) 7 (2.6) 83 (30) 17 (6) 16 (5.8)
(28) (4) (13) (4) (2.6) V V 13 (17) 2 (2.6) 15 (20) 2 (2.6) 1 (1.3) 14 (18) V 1 (1.3)
NSAIDs were coded as MS agents, and clonazepam was listed as CN400 (anticonvulsant) versus CN302 (benzodiazepine) in the pharmacy database. Pain, identifiable pain condition present for 3 months or longer. a First-line pharmacological agent as identified in the VA/DOD Clinical Practice Guidelines for Management of Concussion/mTBI.
than 3.5 times the number of cases in our study experienced chronic headache compared with the controls. However, complaints of headache are also common in veterans with PTSD (Afari et al., 2009). Despite that the veterans with PPCS did use a greater amount of services than the veterans in the comparison group, the combination of a high base rate of MH consultation within the veteran population and the high frequency of PTSD in this sample likely contributed to the notable rates * 2014 Lippincott Williams & Wilkins
of MH service use we observed. This consideration is supported by recent studies that have shown that the presence of affective disturbance may have an additive effect on PPCS reporting because of shared symptoms such as sleep difficulty, depression, anxiety, and lowered frustration tolerance (e.g., King et al., 2012). We were unable to rigorously evaluate differences in service use between the veterans with PPCS who did versus did not have www.jonmd.com
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PTSD. In examining the relative influence of chronic pain among veterans with PPCS and PTSD, the 275 veterans who were classified in the P3 subgroup did use significantly more rehabilitation and pain services than the veterans with PPCS and PTSD only. Overall, however, the two groups used roughly similar amounts of combined medical, MH, and specialty services (p = 0.090Y0.908). This finding is not altogether different from previous works. Despite the relatively consistent finding that patients with a chronic pain diagnosis typically show greater rates of health service utilization (Arnow et al., 2009; Engel et al., 1996; Luo et al., 2004), some studies indicate that the contribution of pain to health service utilization varies by comorbidity status (Beehler et al., 2013; Ritzwoller et al., 2006; Tamcan et al., 2010). Patients with chronic pain may also seek care more frequently, but encounters may be for other ill-defined health conditions and MH concerns other than chronic pain (Von Korff et al., 2005). Thus, the current study’s finding suggests that although chronic pain may account for predictable differences in use of painspecific services, the presence of PTSD may better explain inflated rates of other medical and MH services. In terms of medication use, NSAIDs were frequently prescribed among all veterans with PPCS. This finding is consistent with earlier civilian studies (e.g., Evans et al., 1994), although in contrast, SSRIs were infrequently prescribed in our PPCS-only and PPCS/pain+ subgroups. The P3 group evidenced similar rates of prescriptions for analgesics compared with the veterans in the PPCS/pain+ subgroup but generally higher rates of medication use than the veterans with PPCS and PTSD only. Among the veterans with P3, high rates of antidepressants, anticonvulsants, sedative-hypnotics, alpha blockers, and antipsychotics were recorded, although data suggest that many of these medications may have predated official diagnosis of PPCS. One of the most noteworthy features of this investigation was the composition of the P3 group, which accounted for more than two thirds of the overall PPCS cohort. By and large, this group comprised most frequently male Army veterans in their early 30s who frequently faced chronic complications from back pain, headache, and arthritis and used a high degree of clinical resources. The average veteran with P3 used 9 medical appointments and 14 MH appointments per year of observation along with a wide variety of medications. The veterans with P3 most frequently used analgesics and antidepressants, although most had also been treated with other medications, or combinations of medications, as well. High rates of antidepressant and sleep aid use in the P3 group are not surprising given that these are commonly used in treating PTSD (Ravindran and Stein, 2009). More interesting are the seemingly high rates of prescriptions for anticonvulsants and antipsychotics given mixed findings on their efficacy in treating PTSD symptoms (Ravindran and Stein, 2009). In addition, more than a quarter of the P3 group (higher if clonazepam is included in the estimate) was, at one point, treated with benzodiazepines, which VA/ DOD guidelines (VA/DOD, the Management of Concussion/mTBI Working Group, 2009; VA/DOD, the Management of Post-Traumatic Stress Working Group, 2010) advise against in both cases of concussion and PTSD because of cognitive side effects, treatment interference, and addiction potential. Although benzodiazepines were once commonly used to manage acute PTSD symptoms, current evidence suggests that these medications show little benefit in reducing symptoms and can actually have deleterious effects on the trauma recovery process (VA/DOD, the Management of PostTraumatic Stress Working Group, 2010). The rates of prescription use that we observed, particularly in the P3 group, were comparable with other recent VA pharmacy reviews that have reported similar rates of antidepressant, antipsychotic, and benzodiazepine use in veterans with PTSD (Bernardy et al., 2012; Lund et al., 2013). The work of Lund et al. suggested that although variation in benzodiazepine prescribing practices for veterans with PTSD may be declining 236
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with time, high rates of benzodiazepine use remain and seem to reflect a degree of clinical uncertainty among providers in terms of optimally managing PTSD. At a minimum, our findings, in concert with other recent literature on pharmacological intervention in PTSD, suggest the possibility that multiple medications may have been prescribed for a variety of overlapping or ambiguous symptoms. Our results are applicable to rehabilitative practice for veterans with PPCS in a number of ways. Perhaps most germane may be impetus toward collaborative, interdisciplinary care including individual case management. As a group, these veterans used notably high rates of medical and MH services, were likely to receive care for PPCS for an extended period, and were prescribed a wide variety of psychotropic medications. Most of the veterans with PPCS in our sample were also concurrently diagnosed with both PTSD and chronic pain conditions, and PTSD in particular seemed to influence the rates of care use we observed. Although nearly all veterans with PPCS had at least one contact with an MH provider, specialty pain services were infrequently used. An interdisciplinary approach could serve to promote holistic, veteran-centered, and practice guidelineYadherent care, while at the same time consolidating medical appointments, optimizing prescribed medications, and reducing burden on PC clinics. Such an approach also has the potential to reduce overall cost of care by providing a planned care structure with follow-up coordinated at appropriate intervals. As a retrospective chart review, our findings are limited in several ways. As with all retrospective studies, we were not able to exert the same measure of rigorous control consistent with a prospective cohort design, and we are precluded from establishing any strong causal links on the basis of our findings. Our operational definitions of primary groups and subgroups used in this study were based entirely on the presence of encounters diagnostically coded for postconcussion syndrome, PTSD, and treatment of a variety of conditions that likely represent pain during a period of 90 days or longer. Further, we had to select a start date for case observation, which was defined as the first coded encounter for postconcussion syndrome. It is plausible that we may have missed veterans who had long-lasting complaints of typical postconcussive or PTSD symptoms but lacked encounters coded as such, even if they had received some form of treatment of these symptoms. We also limited our investigation to veterans who used VA PC services and are thus unable to comment on how these results might generalize to veterans who do not use VA for routine medical care. With regard to treatment time frames, our estimate is based solely on encounters coded for postconcussion syndrome, a controversial diagnostic practice in and of itself given that many common postconcussion symptoms are frequently reported in other psychiatric conditions (e.g., King et al., 2012) and nonclinical samples (Iverson and Lange, 2003). We are thus unable to comment on whether the veterans stopped having PPCS or whether providers stopped coding for them. As is typical with retrospective medical record reviews, we did not have access to many other potentially important details, for example, specific PPCS reported; use of non-VA care; and pretreatment variables, such as the length of time that PPCS may have been present before initiating VA care, treatment history, mechanism of injury, or number of total head injuries sustained. Pharmacy data in particular should be interpreted with caution. Our ability to interpret these data was limited to whether selected classes of medications were prescribed during the observation period, regardless of duration, dose, or condition being treated. This limitation is exemplified in our inability to provide detail on why more than half of the PPCS/ PTSD+/painj group was prescribed analgesics. Our analysis does not take into account that any given medication could have been trialed and discontinued, with another selected in its place. Furthermore, we are unable to confirm that the veterans adhered to their medications as prescribed. Even in light of these limitations, several strengths remain inherent in our investigation. The strengths of the retrospective nature * 2014 Lippincott Williams & Wilkins
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of this study are found in the ability to sample, follow, and extract data on a large number of cases with a low base rate condition for a lengthy period. Although descriptive in nature, this may be the first study to broadly explore interactions of veterans with PPCS and the VA healthcare system. By relying on encounters that the trained clinicians coded, we may have enhanced the specificity of data collected during the observation period. In addition, this investigation furthered knowledge of demographics of veterans with P3 and elaborated on the relative contribution of physical and MH conditions to health service and medication use in our sample. Finally, our results, taken in context with other recent research, may serve to generate hypotheses for future investigations, perhaps pertaining to the efficacy of interdisciplinary care in managing P3; targeted MH interventions or medication optimization in veterans with PPCS and PTSD; provision of support to clinicians in implementing VA/DOD guideline-adherent care; and perceptions, experiences, and training needs of medical and MH providers who treat P3.
CONCLUSIONS Veterans with PPCS use a substantial amount of medical services and medications, may present for treatment of PPCS longer than civilian samples, and are very likely to use behavioral and MH services. Although pain was a common feature in our sample, with the exception of analgesic and rehabilitative service use, general health service utilization and medication prescribing trends seem to have been more greatly influenced by the presence of PTSD than chronic pain. Our findings ultimately support previous research in reinforcing the strong overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in OEF/OIF veterans. ACKNOWLEDGMENTS The authors thank Glenn Mead for his assistance with data collection. DISCLOSURES This study was supported by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the Department of Veterans Affairs Center for Integrated Healthcare, VA Western New York Healthcare System at Buffalo. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. All authors are employees of the Department of Veterans Affairs. The authors declare no conflict of interest. REFERENCES Afari N, Harder LH, Madra NJ, Heppner PS, Moeller-Bertram T, King C, Baker D (2009) PTSD, combat injury, and headache in veterans returning from Iraq/ Afghanistan. Headache. 49:1267Y1276. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th edYtext rev). Washington, DC: American Psychiatric Association. Arnow BA, Blasey CM, Lee J, Fireman B, Hunkeler EM, Dea R, Robinson R, Hayward C (2009) Relationships among depression, chronic pain, chronic disabling pain, and medical costs. Psychiatr Serv. 60:344Y350. Axelrod BN, Fox DD, Lees-Haley PR, Earnest K, Dolezal-Wood S, Goldman RS (1996) Latent structure of the Postconcussion Syndrome Questionnaire. Psychol Assess. 8:422Y427. Beehler GP, Rodrigues AE, Mercurio-Riley D, Dunn AS (2013) Primary care utilization among veterans with chronic musculoskeletal pain: A retrospective chart review. Pain Med. 14:1021Y1031. Bernardy NC, Lund BC, Alexander B, Friedman MJ (2012) Prescribing trends in veterans with posttraumatic stress disorder. J Clin Psychiatry. 73:297Y303.
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Health Service Utilization in PPCS
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