Nine in 10 Iraq and Afghanistan veterans return with some form of pain and about 60 percent have significant pain, mainly from the cumulative effect of exposure to recurring blasts which cause unimaginable injuries, according to prominent VA pain clinicians speaking at the American Pain Society's annual scientific meeting.
"We are talking about a complicated set of problems involving cognitive issues, deep emotional impacts, and acute and chronic pain that have serious, long-term implications for our veterans and make effective pain treatment outcomes far more difficult to achieve," said Michael E. Clark, Ph.D., clinical director of the Veteran Administration's largest and most comprehensive pain management and rehabilitation program in Tampa, and associate professor, department of psychology, University of South Florida. "The pain constellation exhibited by returning service members is the most complex situation I have ever seen in my 30 years of practice and calls for a revolutionary new approach to simultaneously address the spectrum of shared, common symptoms across these severe disorders."
"These Middle East conflicts, with their very high level of blast injury survivors, call for the military, the VA and the civilian health system to treat post-injury pain as a priority after military discharge to prevent pathophysiology, with a focus of providing effective pain control and rapid restoration of function and social networks to prevent disability and secondary negative health and personal consequences of chronic pain," said Rollin M. Gallagher, M.D. MPH, deputy national program director for pain management for the VA and clinical professor of psychiatry and anesthesiology, Penn Pain Medicine, University of Pennsylvania
Dr. Clark added that the severity and breadth of the problem has been aggravated by the prevalence of multiple tours of duty for many service members, including weekend National Guardsmen who can be older with families and jobs, a situation not seen in previous U.S. conflicts.
Dr. Gallagher further noted the VA's pain care challenge is magnified by a 90 percent injury survivor rate from these conflicts compared with only 40 percent in the Vietnam War. VA clinicians are now challenged to manage pain in blast survivors with one or several other consequences of blast, such as head injuries causing mild to severe TBI, physical disfigurement and social stigma, emotional trauma, and often post traumatic stress disorder (PTSD).
"The evidence is compelling that the symptoms of these comorbidities, as well as others such as substance abuse, depression and sleep problems, overlap significantly," Dr. Clark explained, "and there is ample reason to believe they will not respond as favorably to traditional interdisciplinary pain treatment when compared to other groups of former soldiers."
"The need is for a fully integrated, system-wide and evidenced-based continuum of pain management from the battlefield to military hospitals to our community care facilities with increased pain care access, state-of-the art treatment protocols, high competence levels for care providers, and the integration of pain education into professional training," said Dr. Gallagher.
Dr. Gallagher pointed out that earlier and more aggressive acute pain treatment intervention closer to the battlefield may help to prevent or lessen longer-term disabilities and secondary consequences of chronic pain. "Present research will tell us definitely what we know from our clinical experience - that early blockage of neurological pain impulses to the spinal cord and brain close to the site of injury using peri-neural catheters and nerve blocks , along with more aggressive analgesic treatment, is proving more effective than the traditional method of just morphine injections," he said. "And the soldiers appreciate the earlier intervention."
VA's Integrated Pain Care Approach
The overlapping disorders of pain, mild traumatic brain injury (TBI), and post-traumatic stress (PTSD) among returning soldiers is leading to new initiatives at the VA.
"The VHA has directed a new pain management strategy with a stepped-care model that offers a comprehensive continuum of treatment from acute pain at injury to longitudinal management of chronic pain, and this approach is now being considered by the Department of Defense in collaboration with the VHA," Dr. Gallagher said. "The goal is to reduce pain and suffering and improve the quality of life for our returning Iraq and Afghanistan service men and women suffering acute and chronic pain."
"The use of silo treatment pathways in chronic pain treatment is insufficient, less effective and less efficient," Dr Clark said, "because they typically focus solely or primarily on pain-related symptoms and either exclude those with concurrent PTSD and/or TBI symptoms or occasionally refer them to relevant specialty programs for simultaneous but independent treatment."
As an example of the VA's health care system refocus, Dr. Clark reviewed current work at the Tampa VA facility using a single team approach and a post-deployment behavioral health program with specialties in behavioral medicine, pain, PTSD, TBI, substance abuse, physical therapy and case management.
"Our objectives are to maximize function and life adjustment, prevent symptom development or exacerbation, and reduce stress through a single team effort," Dr. Clark said. "Treatment involves established and modified cognitive behavioral therapy interventions targeting PTSD, pain, mild TBI, sleep and substance abuse, typically in combination, and with a physical training component.
"As we extend and refine our PMD treatment components and complete more research on PMC treatment and how overlapping comorbidities interact, our hope is that this raised awareness level for integrated care within the VA will eventually be reflected in community care center treatment for our returning service personnel," Dr. Clark summarized.
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