October 2017

30th October – 5th November

TBI Severity and Dementia Diagnosis in Veterans

Traumatic brain injury (TBI) is common in veterans. Moderate and severe TBI have been linked to an increase in dementia risk and earlier disease onset but it is uncertain whether this link applies to mild TBI, the most prevalent form of TBI. Researchers from the University of California recently aimed to examine the link between TBI severity and the age of onset of dementia diagnosis. They retrospectively analysed data from 1,410,292 military US veterans and the results indicated that there was an association between incidence of dementia and increasing TBI severity. For instance, no TBI was associated with the lowest dementia incidence. Very mild and mild TBI were associated with 2-3 fold increases in diagnoses of dementia, respectively, and moderate-severe TBI had the highest dementia incident rates. Additionally, veterans with TBI were significantly younger when diagnosed with dementia and had a higher likelihood of psychiatric disorders than non-TBI veterans.

The article’s poster presentation can be downloaded here.


A Mobile Application for Pain Self-Management

Veterans are disproportionately affected by chronic pain with approximately 40-60% expecting to be suffering. Researchers from Yale University recently published the results of their pilot testing of a new mobile application called Health eRide: Your Journey to Managing Pain. This application uses gaming, text messaging and social networking to engage veterans in the treatment. The program addresses healthy strategies for pain self-management, stress management and sleep interventions in order to provide an integrated treatment for veterans with pain and co-occurring conditions such as PTSD and traumatic brain injury. The pilot study recruited 44 veterans who used Health eRide for 30 days. The results suggested that the program significantly reduced veterans’ pain, pain impact and stress, whilst sleep was not significantly affected. Mobile applications may be a suitable method for delivering pain management strategies to veterans, however, more research is necessary to decide whether they are able to replace pain clinics and face-to-face services.

A summary of the article can be accessed here.


23rd – 29th October

The Military Charity Combat Stress releases three publications:

A Profile of Mental Health Treatment-Seeking Veterans

Previous evidence suggests veterans with mental health issues face worse treatment outcomes than their civilian counterparts. Researchers at Combat Stress wanted to address this concern by distributing questionnaires to 403 randomly selected UK veterans who had engaged with mental health support in order to establish whether there were any specific factors relating to poorer outcomes. The results revealed that the most common mental health issue reported was PTSD, followed by anger, common mental health difficulties and alcohol misuse. Complex comorbidities were also identified leading researchers to the conclusion that from this sample of treatment seeking veterans, the level of complex conditions may explain why there are poorer treatment outcomes. It is therefore important to address the need for multi-disciplinary services that are able to treat concurrent conditions to help improve treatment outlook for veterans.

The article was published in The Journal of Mental Health which can be accessed online here.

Health Risks of Treatment-Seeking Veterans in Different Areas of the UK

Little is known about whether the health needs of veterans differ depending on location in the UK.  Researchers at Combat Stress asked 403 treatment-seeking veterans to fill in a questionnaire to assess demographics, mental health and physical health. Results indicated that veterans in Northern Ireland tended to be older and more likely to take a longer time to seek help. Scotland and Wales reported higher incidences of smoking and alcohol misuse, whereas mental health conditions did not differ depending on location. These results will help tailor services and resources to match the level of need for veterans in varying locations of the UK.

The article was published in the Journal of The Royal Army Medical Corps and can be accessed here.

Review of Tele-Therapy used to Treat PTSD in Veterans 

Tele-therapy is the remote treatment of patients by means of telecommunication technology. Veterans may find that they face barriers when attempting to access treatment, thus tele-therapy provides one possible way to get around certain barriers, such as location and travel difficulties. This review aimed to establish the lessons learned so far from using tele-therapy for PTSD. A total of 41 articles were reviewed. Results revealed that in the majority of cases tele-therapy was an effective and appropriate method to help reduce PTSD symptoms, at a level that was comparable to in-person interventions. Challenges identified included a sense of discomfort for certain veterans using tele-therapy, technological difficulties and a lack of non-verbal communication between therapist and patient. However, overall tele-therapy proved to be a successful alternative for in-person PTSD treatment in veterans.

The article was published in the Journal of Telemedicine and Telecare and can be accessed here.

Additional research from Combat Stress can be found here.


16th – 22nd October

Assessing Attitudes towards Ex-Service Personnel in Northern Ireland

Forces in Mind Trust has awarded £31,500 to Ulster University to produce a report on the public attitudes towards ex-service personnel in Northern Ireland. Public attitudes towards serving and ex-serving personnel will be surveyed as part of the Northern Ireland Life and Times Survey. It will be important to gather this information as part of the ongoing attempt to provide support and wellbeing to military veterans.

More information can be found here.


ALS in the Military

Amyotrophic lateral sclerosis (ALS) rates are suggested to be higher in military veterans than the general public. However, amongst the sparse studies, little has been done to examine the association between ALS and possible exposure risks. This week researchers at the Department of Epidemiology, University of North Carolina, USA, published an article in PLOS ONE looking at associations between ALS survival and aspects of military service, deployment and related exposures. Results showed that out of the 616 medical records that were followed up until death, there were shorter survival rates amongst those who: 1) had served less than 1 year in the military; 2) had been deployed prior to July 1950 or had been in WWII and 3) had been exposed to mixed or applied burning agents. More research is needed to assess these potential risks in a greater detail and to try and promote factors that are possibly protective against ALS for serving personnel.

The full report can be downloaded  here.


TelePain: An Initiative for Specialist Pain Treatment

Chronic pain continues to be a serious problem among military personnel. The US Pain Management Task Force have addressed this problem of appropriate access to specialist pain treatment by recommending the use of telehealth to provide specialist pain care to primary care providers of veterans, regardless of their geographic location. TelePain is a telehealth intervention that uses low cost and commercially available technology with two main components:

  1. To ensure military primary care providers receive pain management recommendations for specialist cases through video conferences with experts.
  2. That military primary care providers attend presentations based on the Joint Pain Education Program Curriculum in order to improve their understanding. (The curriculum can be found in Table 1 of the published article).

Challenges observed so far with TelePain have included enrolling patients and providers, as well as technical and logistic issues related to TelePain delivery. Establishing outreach programs and building on relationships are some of the methods that are being used to overcome these challenges.

The article can be accessed  here.


9th – 15th October

Finding A Solution to the Opioid Epidemic

Opioid pain medications are widely prescribed to treat chronic pain, even though there is little evidence to suggest their long-term benefits. A more negative connotation has recently surrounded prescription opioids due to their association with the burdening opioid epidemic that is sweeping across America. Large pharmaceutical companies are being sued by certain states that are experiencing a dramatic rise in opioid overdoses, since it has been reported that the amount of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled from 1999 to 2010, in the absence of an overall change in the amount of pain that Americans reported.

Two states with the highest overdose death rates are Ohio and West Virginia. Huntington, a small city in West Virginia, has been at the centre of the crisis and recently was televised on a Louis Theroux BBC documentary (click here to watch the documentary in full). The documentary reveals the extent of the damage with the majority of those addicted to heroin and fentanyl reporting that their downward spiral into addiction began by abusing opioid prescription drugs.

The documentary speaks less about military veterans who are particularly prone to the opioid epidemic due to the combination of mental and physical health comorbidities seen in veterans. It is reported that approximately 50% of military veterans suffer from chronic pain, which puts this population at a heightened risk for receiving prescription opioids. Unfortunately, the situation does not call for the mere restriction of these prescriptions since untreated chronic pain can lead to an increase in suicide rates, however there should be tighter regulations and alternative treatments available. Poorly managed opioid regimens have also shown to be fatal. Veterans are twice as likely to die from accidental opioid overdoses than non-veterans, according to a 2011 study by Bohnert and colleagues (https://insights.ovid.com/pubmed?pmid=21407033). It is crucial to educate healthcare providers, veterans and the general public about the dangers of opioids and to also promote alternative treatments that may be more efficacious in alleviating chronic pain in the long-term.

Steps are now being taken to research alternatives to opioid medication for chronic pain treatment. One of the largest projects is a collaborative approach set up by The US Department of Health and Human Services, The US Department of Defence and The US Department of Veterans Affairs [HHS-DoD-VA Initiative]. This is a 6-year-multicomponent research project that will focus on non-drug approaches to pain management, which is in line with initiatives to combat the opioid epidemic. Non-drug approaches will include mindfulness, structured exercise, manual therapies, psychological and behavioural interventions and multi-modal approaches. There are 12 proposed research projects, totalling approximately $81 million, that aim to provide important information about the feasibility, acceptability, safety, and effectiveness of nondrug approaches in treating pain.

The projects are listed below:

  1. Robert Kerns, Ph.D., Yale University. Dr. Kerns will establish the Pain Management Collaboratory Coordinating Centre. This centre will provide national leadership and serve as a national resource for development and refinement of innovative tools, best practices, and other resources in the conduct of clinical trials on nondrug approaches for pain management and other comorbid conditions in veteran and military health care systems. They will use their expertise in pain management, electronic health records, data systems, and the design and coordination of multi-site real-world trials to support the design and implementation of the pragmatic trials funded through this initiative.
  2. Julie Fritz, Ph.D., University of Utah. This project will research a stepped care approach for the treatment of low-back pain. Stepped care is a treatment process that begins with broadly accessible, less intensive interventions that can benefit many patients. Those who do not respond to initial treatments are stepped up to receive more intensive treatment.
  3. Karen Seal, M.D., Northern California Institute for Research and Education. The overarching goal of this demonstration project is to implement a new Whole Health model for chronic pain care, emphasizing nondrug pain self-management that reduces pain symptoms and improves overall functioning and quality of life in veterans.
  4. Alicia Heapy, Ph.D., Yale University. The overall goal of this project is to conduct a trial to examine the real-world effectiveness of an interactive voice response-based form of cognitive behavioural therapy for chronic pain called ‘Cooperative Pain Education and Self-management’.
  5. Christine Goertz, D.C., Ph.D., Palmer College of Chiropractic. The researchers will develop and implement a pragmatic randomized trial that looks at the effects of different doses and maintenance of chiropractic care for low-back pain.
  6. Steven George, Ph.D., Duke University. The goal of this planning and demonstration project is to improve access to recommended nondrug therapies for low-back pain in the Department of VA Health Care System.
  7. Marc Rosen, M.D., Yale University. This research will test the effectiveness and cost-effectiveness of Screening, Brief Intervention, and Referral to Treatment for Pain Management, designed to reduce pain and risky substance use.

The remaining 5 projects are set to be released in the upcoming few months.


Prince Harry Speaks Out About Mental Health in the Armed Forces

Prince Harry, along with the Ministry of Defence and the Duke and Duchess of Cambridge, has announced a new initiative to tackle mental health issues in the Armed Forces. The Prince reports that mental health is just as important as physical health and this needs to be implemented in service personnel training. Promoting positive mental health attitudes will hopefully lead to a combined effort to tackle mental health issues such as posttraumatic stress disorder (PTSD). Not only will this reduce long-term health problems for veterans but it could also promote improved performance in the Armed Forces.

Prince Harry said:

“Today we are saying that taking mental health seriously is what professional and dedicated servicemen and women must do to be above the rest and leading from the front.”

The initiative aims to offer advice and resources to improve training and education. Websites and briefings will help raise awareness of the importance of good mental health among the military. There is a hope that one-day mental health could be spoken about in the same way that physical health is.

The source of this post can be found here.


2nd – 8th October

Defining Optimal Opioid Prescription Duration Post Surgery

A study by Scully et al. (2017), recently published in JAMA Surgery, wanted to examine the optimum duration of opioid medication prescription following surgery. Opioid pain medications are being overprescribed which may be contributing to the opioid epidemic which is a considerable problem affecting military veterans. Few guidelines, however, are available for post-surgery pain medication prescriptions. Governments in certain US states are now beginning to take action, with some limiting the length of opioid prescriptions to less than seven days. The study took data from the Department of Defence Military Health System Data Repository was used in order to identify 215,140 individuals who have had general surgery between 2005 and 2014. Results showed that the median initial opioid prescription was 4-7 days, however, length of necessary prescription duration depended on procedure.  A 7-day limit may be suitable for many general surgeries; however, orthopaedic and neurological procedures may require longer prescription duration.

More information about the article can be found here.


Risk Factors that Predict Opioid Prescription Duration

A recent study by The University of Texas Health Science Centre assessed the factors that were associated with opioid prescriptions in 242,578 active duty service members. Chronic pain is more prevalent among active duty service members (44%) compared to civilians (26%), therefore, we would expect there to be a greater prescription rate for opioids in military members, contributing to a growing opioid epidemic that concerns not only veterans but also the general public. Prescription duration was divided into 4 categories: acute (less than 3 months), episodic (less than 120 days), long-term low-dose (LTLD) (more than 120 days and dosage less than 20mg) and long-term high-dose (LTHD) (more than 120 days and dosage more than 20mg). Results showed that those individuals who were co-prescribed benzodiazepines and antidepressants were more likely to be associated with the LTLD and LTHD prescription durations.

More information can be found here.


New Research Shows Armed Forces Charities Helping Tens of Thousands Access Education and Employment

Forces in Mind Trust (FiMT) and the Directory of Social Change (DSC) today (3 October) release the report Focus On: Armed Forces Charities’ Education and Employment Provision, which reveals that a small number of charities provide a much-needed range of educational and employment services to 35,800 people in the Armed Forces Community. Funded by the Forces in Mind Trust (FiMT), this report is the second of six Focus On reports from DSC which provide more detailed information on Armed Forces charities’ support for key areas of need. Figures reveal that 78 charities provide education support, which represents 6.5% of all UK armed forces charities. Of these charities, 59 also make provision for employment. In total, armed force charities spend around £25.6m on education and employment, serving at least 35,800 beneficiaries from the Armed Forces Community. The report covers educational and employment services, such as work opportunities and job searches, direct grants to individuals and organisations, as well as highlighting primary provider charities. Project Manager, Stuart Cole says: ‘The impact that education and employment can have is measured in more than just qualifications or status; increasingly, these areas define our quality of life. We are proud to present an analysis of those charities which support the educational and employment needs of the armed forces community.’

Download the full report here.

Download the executive summary here.

 

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