RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03827
BRANCH OF SERVICE:  MARINE CORPS	SEPARATION DATE:  20050415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Rifleman, medically separated for “intractable headache with migraine features”, opioid dependence” and “substance abuse with intravenous narcotic injection post rehabilitation with persistent oral narcotic use” with a disability rating of 0%.  

CI CONTENTION:  The CI requested consideration of all conditions. The CI’s complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.    

RATING COMPARISON:  

SERVICE PEB –20050110	VARD - 20060801	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intractable Headache…	Combined Effect	0%	Chronic Migraine Headache	8100	30%	20051021	
Opioid Dependence			Narcotic Dependence	9440	NSC	20051021	
Substance Abuse …							
History of Recurrent Cellulitis	Cat III	Chronic Cellulitis	7820	NSC	20051021	
History of Right Upper Extremity Deep Vein Thrombosis		Thrombophlebitis…	6522	NSC	20051021	
History of Right Sphenoid Sinusitis…		Chronic Sphenoid Sinusitis	6514	0%	20051021	
Adjustment Disorder with Depressed Mood		PTSD …	9411	NSC	20051021	
		Depression/ Anxiety	9435	NSC	20051021	
Chronic Rhinitis		Recurrent Allergic Rhinitis	6522	NSC	20051021	
Color Blindness	Cat IV	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDTIONS:  30%	

ANALYSIS SUMMARY:  

Overall Effect of Intractable Headaches, Opioid Dependence, and Substance Abuse.  According to the narrative summary (NARSUM) and service Treatment Records (STRs), the CI reported headaches beginning the second month of his enlistment.  On 26 December 2002, 2 months after accession, he reported a 1 day history of headaches and a past history of migraines (which were denied at accession).  He was diagnosed with migraines.  He had both CT scans and an MRI as part of the evaluation; these showed abnormalities of the sphenoid sinus (behind the nose) which was surgically treated in April 2003.  Following surgery, the headaches improved and were less frequent and easier to control.  He was then cleared for full duty by otolaryngology (ENT) on 11 June 2003.  However, he subsequently presented to the emergency room (ER) with an upper respiratory infection (URI) complicated with recurrent headaches on 8 July 2003.  He was re-evaluated in ENT the next day and thought to have either migraines or cluster headaches.  Over the next few weeks, he was seen frequently and treated with narcotic medications for the headaches and ultimately treated surgically.  Initially, he had a good response and was returned to full duty.  However, over the course of the next year, he had recurrent headaches and pain.  He was treated with additional surgery.  His clinical course was complicated by significant drug abuse including illegal purchase of legal drugs; the use of heroin, cocaine, crystal meth, and marijuana; and positive drug screens for amphetamines and barbiturates.  He was given a direct order to only receive his medications from a USN provider and did not comply with this order.  Administrative action was contemplated, but not pursued due to the co-existent medical issues.  An addendum to the NARSUM from the substance abuse rehabilitation program (SARP) dated 13 August 2004, 8 months prior to separation, noted that the CI had been diagnosed with attention deficit hyperactivity disorder (ADHD) at age 7 and given medications for this.  He had multiple sinus surgeries since accession.  It was noted that he did not believe that he had a substance abuse problem and did not follow medical advice.  He had co-dependent behaviors which enabled his abuse of narcotics.  The MEB NARSUM was dated 24 August 2004), 8 months prior to separation, and dictated by the primary physician.  It noted the onset of headaches in the second month after accession.  A history of three sinus surgeries was documented.  Despite this, the CI had intractable headaches which responded only to narcotic pain relief.  It also noted that the CI had over 90 prescriptions for narcotics the prior 20 months with over 1600 doses.  During this period, he was also hospitalized over 50 days.  (This did not include the prescriptions from civilian providers nor the medications obtained illegally).  The addendum also recorded the complications from self-injection of drugs.  In February 2004, he was admitted for detoxification.  The following month he was found minimally responsive in his room after injecting crushed OxyContin tablets.  In addition, random drug tests were positive about 1/3 of the time and showed medications for which he had not been prescribed.  A drug screen done the day of the NARSUM was positive for opiates.  The final diagnoses were: intractable headaches with migraine features; substance abuse; right sphenoid sinusitis; chronic rhinitis; history of right upper extremity (RUE) deep vein thrombosis (DVT), self-induced, resolved; history of cellulitis, self-induced, resolved; and color blindness.  The ENT addendum to the NARSUM was dated 31 August 2004 and accomplished by one of the treating physicians.  It noted that the sinus condition was an allergic fungal sinusitis managed by surgery with long term maintenance of nasal rinses with (periodic) follow-up.  On 31 October 2004, the CI rebutted the NARSUM and the response to the rebuttal was done the same day.  The CI noted that the cellulitis and DVT were from the intravenous (IV) lines and not from substance abuse.  It was thought by the treating physician that, in fact, the complications were from self-injection of drugs and manipulation of the IVs by the CI, the latter of which he (the treating physician) had witnessed himself.  The mental health addendum was dated 2 November 2004.  It noted that the CI had been first seen in March of that year with a several month history of depressive symptoms.  However, the CI had not had a clear period of abstinence (from drugs) and therefore, it was unclear if his symptoms were secondary to the drug use, withdrawal, or a primary mood disorder.  He had taken medications for depression but was not on any at the time of the dictation.  He was thought to have an adjustment disorder with depressed mood and an opioid dependence.  The primary impairment to duty was thought to be the headache condition and the opioid dependence rather than the adjustment disorder.  The adjustment disorder was thought to be unlikely to resolve until his headaches were better controlled and he no longer used opioids.  The neurology addendum was dated 11 November 2004, 5 months prior to separation.  The neurologist noted that the CI had failed all treatment modalities other than narcotic medications.  The final diagnoses were chronic migraine headaches, a history of chronic sphenoid sinus disease with multiple surgeries, and a history of RUE DVT (resolved).  The PEB was on 10 January 2005, 3 months prior to separation.  The medical officer noted that the sinus condition was not separately unfitting although it did contribute to the headache condition.  The adjustment disorder and narcotic dependence were Category IV (conditions which do not constitute a physical disability).  It was observed that it was difficult to determine the extent of organic pathology from drug seeking behaviors in view of the normal neurological evaluation and examinations and poor compliance.  Separation due to overall effect at 0% was recommended.  The line officers concurred in this assessment.  The VA C&P examinations were dated 21 October 2005 (general), 22 October 2005 (eye), and 4 December 2005 (mental health), 6, 6, and 8 months after separation, respectively.  The CI reported that he continued to control his headaches with Percocet (a narcotic).  The sinuses were well healed after the surgery without evidence of infection.  Stigmata of drug abuse were apparent on his skin.  He was thought to have pain from a migraine like condition rather than from sinus disease.  The VA rated the headache condition at 30%, coded 8100 (migraine headaches).  The eye examination noted the presence of a Horners Syndrome (constricted pupil, droopy upper eyelid, and lack of sweating on the affected side), but made no comment on the color vision.  The mental health examination noted that the CI reported multiple episodes of sexual abuse as a child.  He also reported being assaulted in basic training; this is not recorded previously in the records.  He was thought to have possible post-traumatic stress disorder (PTSD), but it could not be attributed definitively to the alleged assault while on active duty.  

The Board first considered if the intractable headaches, opioid dependence, and substance abuse conditions were separately unfitting.  The CI reported the headaches shortly after accession, but had a prior history of these prior to accession.  He denied improvement with surgery or multiple medication regimens other than narcotic administration.  The record clearly shows a pattern of substance abuse of prescribed legal drugs, illegally obtained legal drugs, legally obtained legal drugs in violation of a direct order, and multiple illegal drugs including heroin.  The CI was non-compliant with direct orders and treatment.  The Board determined that there was not a preponderance of evidence to overturn the PEB adjudication of overall effect at a 0% rating.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination for the overall effect from the intractable headache, opioid dependence, and substance abuse conditions.  

Contended PEB Conditions:  History of Recurrent Cellulitis, History of RUE DVT, History of Right Sphenoid Sinusitis, Adjustment Disorder with Depressed Mood, Chronic Rhinitis, and Color Blindness.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the overall effect from the intractable headaches, opioid dependence, and substance abuse conditions and IAW DoDI 1332.38 E3.P3.4.4., the Board majority recommends no change in the PEB adjudication.  The single voter of dissent recommended re-characterization and did not elect to submit a minority opinion.  In the matter of the contended history of recurrent cellulitis, history of RUE DVT, history of right sphenoid sinusitis, adjustment disorder with depressed mood, chronic rhinitis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended color blindness condition, the Board unanimously recommends no change from the PEB determination as Category IV.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 21 Oct 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC