Citation Nr: 21026970 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 14-21 612 DATE: May 4, 2021 REMANDED Entitlement to service connection for pancreatitis is remanded. REASONS FOR REMAND The Veteran had active service from April 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO or AOJ). The Veteran requested a Travel Board Hearing in his May 2014 substantive appeal; however, he subsequently withdrew his request in August 2014 and again in January 2015 correspondence. In April 2018, the Board denied entitlement to service connection for pancreatitis. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In March 2019, the Court granted the parties' Joint Motion for Remand (JMR), returning the issue to the Board for action consistent with the terms of the JMR. The Board remanded the case for further development in January 2020. Additional failure to comply with remand directives necessitated yet another Board remand in October 2020. Here, the Veteran contends there is a relationship between his pancreatitis condition and his use of medication to alleviate pain associated with his service-connected residuals of a gunshot wound to his right foot. See January 2012 statement. Regrettably, for reasons discussed below, the appeal is once again remanded. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As previously discussed, the Board denied the Veteran's claim of entitlement to service connection for pancreatitis in an April 2018 decision. In its decision, the Board relied on findings from an October 2014 VA examination. However, in the March 2019 JMR, the parties agreed that the examination was inadequate because the opinion contained factual inaccuracies, did not address whether the Veteran's long- or short-term use of pain medications other than Darvocet caused or aggravated his pancreatitis, did not address known risk factors, and failed to address the PubMed article submitted by the Veteran in support of his claim. The parties further agreed that the examiner did not adequately explain the premise behind her conclusion that the Veteran's pain medication did not cause his pancreatitis. Pursuant to the JMR, the Board remanded the Veteran's claim in January 2020, to obtain a new VA examination by a physician with appropriate expertise to address the nature and etiology of the Veteran's pancreatitis. The examiner was asked to (1) identify all long- or short-term pain medications given to the Veteran for the gunshot wound to his right foot; and then, (2) provide an opinion as to whether it is at least as likely as not that pancreatitis has been (a) caused or (b) aggravated by any long- and/or short-term pain medications given for treatment of the gunshot wound to the right foot. The examiner was also asked to discuss the significance, if any, of the fact that the Veteran was taken off Darvocet in April 2010, four months prior to the diagnosis of pancreatitis in August 2010, and seven months prior to Darvocet being taken off the market in November 2010. The examiner was also asked to discuss the significance of the fact that the Veteran was prescribed Dilaudid in December 2010, more than eight months after being taken off Darvocet. The examiner was asked to further discuss the significance, if any, of the fact that the Veteran took multiple pain medications, including acetaminophen and opiates, as well as VA treatment records referencing heavy use of opioids for pain management. Lastly, the examiner was asked to discuss the PubMed article noting that a physician should have a "high index of suspicion" for drug-induced pancreatitis in specific subpopulations such as geriatric patients on multiple medications. In February 2020, the Veteran was afforded a new VA pancreatic conditions examination. In a February 2020 VA opinion, the examiner noted that the most common cause of a pancreatic pseudocyst is inflammation of the pancreas, called pancreatitis. The examiner explained that a less common cause or contributor is trauma, such as a blow to the abdomen. The examiner then explained that pancreatitis is most commonly caused by alcohol abuse and gallstones. The examiner then opined that given the length of time the Veteran used Darvocet, it is less likely than not that his pancreatitis condition was caused by the use of Darvocet. The examiner stated that the Veteran was started on Dilaudid for pain control of foot, likely due to his kidney function/renal stones which could affect renal function as the use of this opioid and their metabolites are less of problem with renal involvement than morphine. The examiner concluded that it is less likely than not that the use of Darvocet or Dilaudid caused a drug induced pancreatitis. An addendum opinion was obtained in August 2020, wherein the examiner further noted that the Veteran's medication was switched from Darvocet, in April 2010, due to presentation of symptoms of poly pharmacy. Moreover, Darvocet and Cyclobenzaprine were placed on hold and the Veteran was advised to try Tylenol or Ibuprofen as needed for pain. The Veteran was then diagnosed with pseudocyst formation in August 2010 and continued to have epigastric pain with nausea and vomiting. To manage his pain, the Veteran was started on Hydromorphone for pain management. The examiner also noted that the Veteran's medical records showed he was also prescribed Zolpidem, Valium for nerves, Lortabs 5, and Motrin 800 mg for pain. In addressing the PubMed article, the examiner stated that although there are few cases of pancreatitis associated with drugs the mechanism of injury is not well understood by clinicians. The examiner added that while some commonly prescribed medications have been linked to drug induced pancreatitis pathogenesis, the cause of injury, is not understood. However, the examiner did not address whether prescribed medications could aggravate the condition. In October 2020, the Board noted that the VA medical opinion regarding the etiology of the Veteran's pancreatitis was rendered by a VA nurse practitioner, and that it could not be determined whether the examiner has any expertise in that area. The AOJ was directed to send the Veteran's claims file to a physician with appropriate expertise to address the nature and etiology of the Veteran's pancreatitis. A new examination was to be scheduled if deemed necessary to address the remand directives as restated from the January 2020 Board remand. An addendum opinion was obtained in February 2021. The examiner indicated that medical records support no etiology for pancreatitis found except hypercalcemia due to hyperparthyroidism. In addressing the remand directives, the examiner merely restated the opinions provided by the October 2014 VA examiner and in the February 2020 VA medical opinion. The examiner then concluded that based on her review of the medical records, she could find no event, exposure, nor evidence that the Veteran's pancreatitis condition was aggravated beyond its natural progression by any long- and/or short-term pain medications given for treatment of the gunshot wound to the right foot. She stated that the Veteran's service treatment records are silent for any signs or symptoms of pancreatitis, and that it is her opinion the Veteran's pancreatitis was less likely than not incurred in military service. As an initial matter, the Board notes that the February 2021 VA medical opinion was rendered by a VA nurse practitioner. This led to the previous October 2020 Board remand. Additionally, none of the VA medical opinions to date adequately explain the premise behind the conclusion that the Veteran's pain medication did not cause or aggravate the Veteran's pancreatitis. The clinical significance, if any, of the Veteran's medical treatment records indicating that he was negative for alcohol abuse, gallstones, or elevated triglycerides has not been adequately addressed as well. See August 2010 VA treatment record. When VA undertakes to provide a VA examination or medical opinion, it must ensure the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Based on the above, the Board finds that remand is required for a new examination and an opinion from a physician with a background in the area of gastroenterology that adequately addresses the aggravation aspect of the Veteran's claim, with due consideration given to the Veteran's complete medical history. The matter is REMANDED for the following action: Schedule the Veteran for an examination with a physician or suitable specialist in the area of gastroenterology. The examining physician/specialist is to be asked to provide information to demonstrate that they are qualified to offer the above requested opinion (such as a curriculum vitae or similar demonstrable documentation (which may be redacted as deemed warranted)). This information is to be associated with the Veteran's claims file. The claims file, including a copy of this Remand, must be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should identify all long- or short-term pain medications given to the Veteran for service-connected residuals of a gunshot wound to his right foot. The examiner should provide the following opinions: (a) whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that pancreatitis is proximately due to any long- and/or short-term pain medications given for treatment of the Veteran's service-connected residuals of a gunshot wound to the right foot. (b) whether it is at least likely as not that the Veteran's pancreatitis condition underwent any incremental increase in disability, regardless of its permanence, due to any long- and/or short-term pain medications given for treatment of his service-connected residuals of a gunshot wound to the right foot. The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. In providing this opinion, the examiner must address the significance, if any, of the fact that the Veteran was taken off Darvocet in April 2010, four months prior to the diagnosis of pancreatitis in August 2010 and seven months prior to Darvocet being taken off the market in November 2010. See August 2010 VA progress note; April 2010 Emergency Department Note. The examiner should also discuss the significance of the fact that the Veteran was prescribed Dilaudid in December 2010, more than eight months after being taken off Darvocet. See December 2010 VA specialty care progress note. The examiner must further discuss the significance, if any, of the fact that the Veteran took multiple pain medications, including acetaminophen and opiates, and VA treatment records relating to his heavy use of opioids for pain management. The examiner must also discuss the significance, if any, of the Veteran's medical treatment records indicating that the Veteran was negative for alcohol abuse, gallstones, or elevated triglycerides. See August 2010 VA treatment record. Also, the examiner should address the PubMed article noting that a physician should have a "high index of suspicion" for drug-induced pancreatitis in specific subpopulations such as geriatric patients on multiple medications. A complete medical rationale for all opinions expressed must be provided. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.