By Sandra Basu
WASHINGTON – Trauma-related pain – both acute and chronic — has always been a universal problem among war-injured troops. What has changed in recent years is efforts by DoD and VA officials to offer injured servicemembers a larger variety of evidence-based treatment modalities to resolve that pain.
“Chronic pain can be very challenging so we focus a lot on their functionality—being able to restore their function as well as bringing their pain down to the extent that we can. Even for people who cannot have their pain eliminated, many of them can have an improvement in the quality of their life,” Lt. Col. Scott Griffith, MD, the Army’s pain management consultant told U.S. Medicine.
In some ways, battlefield medical treatment changed little from the Civil War to the beginning of the 21st century, with morphine being the primary medication used for pain control.
With higher rates of survival among military personnel in recent conflicts in Afghanistan and Iraq, however, managing acute and chronic pain has become a bigger issue than ever for military healthcare providers. Now, the military is employing a range of pain relief techniques from traditional opioids to continuous nerve blocks and multimodal drug therapy.
The innovations are sorely needed, according to some recent research. A June 2014 report in JAMA Internal Medicine of 2,597 study participants found that 44% of troops experienced chronic pain after combat deployment and 15.1% regularly used opioids. Moreover, VA officials testified before Congress earlier this year at a hearing that chronic pain is the most common medical problem in veterans returning from the last decade of conflict.
“Options for managing chronic pain among our veteran population are paramount to improving quality of life and reintegration,” Senate Committee on Veterans’ Affairs Chairman Bernie Sanders (I-VT) said at that hearing.
These days, one of the most common causes of chronic pain is musculoskeletal injury, which is usually unrelated to battlefield wounds. Causes include training and job performance, including increasingly heavy protective equipment, as well as sports and recreation, according to recent reports.
The challenge for federal medicine providers is how to alleviate chronic pain for active-duty troops and veterans, while also reducing the likelihood of opioid addiction and abuse.
In 2003, the Defense & Veterans Center for Integrative Pain Management (DVCIPM) was established to provide a coordinating role in pain research and education and to improve pain management.
Six years later, the Army surgeon general established a pain task force membership that included representatives from the military services, TRICARE, and VHA to make recommendations for a comprehensive pain management strategy. That task force issued a May 2010 report suggesting the military needed a holistic, multimodal and multidisciplinary approach to pain management, including complementary and alternative medicine.
Addressing the report’s concerns has led to a more structured approach to clinical care for pain, Griffith explained, including the Army’s Comprehensive Pain Management Campaign Plan.
In addition, the Army has established Interdisciplinary Pain Management Centers and the use of a “stepped care” strategy that makes “it more likely that a patient is going to be moved to a higher level of care in an organized fashion when they need to be, to standardize care, but also to expand the types of care that might be available,” he said.
Meanwhile, VA officials told lawmakers earlier this year how it was one of the first health systems in the United States to establish a robust policy on chronic pain management and to implement a system-wide approach to addressing the risks of opioid analgesia. The agency, officials said, has a number of ongoing initiatives to address pain including applications for smart phones that can be used by veterans and their care partners to develop self-management skills.
VA officials also told lawmakers at a hearing about their collaboration with DoD on pain management issues. Officials said in written testimony that the DoD-VA Health Executive Council Pain Management Work Group was chartered to develop a model system of integrated pain management for servicemembers and veterans. The Work Group participates in VA/DoD Joint Strategic Planning process to develop and implement the strategies and performance measures.
Meanwhile, the research into nondrug approaches to treating pain is ongoing. VA and National Institutes of Health’s National Center for Complementary and Alternative Medicine (NCCAM) announced in a partnership in September where $21.7 million will be used for 13 research projects over five years to explore nondrug approaches to managing pain and related health conditions such as post-traumatic stress disorder, drug abuse, and sleep issues. The research will take place at academic institutions and VAMCs across the U.S.
“The need for nondrug treatment options is a significant and urgent public health imperative. We believe this research will provide much-needed information that will help our military and their family members, and ultimately anyone suffering from chronic pain and related conditions.” Josephine P. Briggs, MD, director of NCCAM, said in a written statement.
Among the projects is research at Rush University Medical Center in Chicago testing the feasibility of a morning bright light treatment to reduce and help manage chronic low-back pain and improve PTSD symptoms, mood, and sleep in veterans. Another project funded by VA will examine the extent and cost-effectiveness of complementary and alternative medicine use among veterans being treated at the VA for musculoskeletal disorder-related pain and related conditions.
On the national level, innovations in drug development are giving clinicians another tool to help patients and others avoid opioid addiction. Last month, the Food and Drug Administration (FDA) announced it had approved new labeling for the third extended-release opioid analgesic to be approved with abuse-deterrent properties.
“The science behind developing prescription opioids with abuse-deterrent properties is still evolving and these properties will not completely fix the problem. But they can be part of a comprehensive approach to combat the very serious problem of prescription drug abuse in the U.S,” explained Sharon Hertz, MD, acting director of the Division of Anesthesia, Analgesia, and Addiction Products in the FDA’s Center for Drug Evaluation and Research.
Douglas Throckmorton, MD, deputy center director for regulatory programs for FDA’s Center for Drug Evaluation and Research, explained in an FDA blog post in July that “current abuse-deterrent technologies tend to focus on making the drug either harder to crush, which makes them harder to snort or inject; harder to extract, which means the opioid cannot be easily separated from the other ingredients in the drug for purposes of abuse; more difficult to abuse orally, which is the most common form of opioid abuse; or less attractive for abuse.”
He noted that “abuse-deterrent” is not the same as “abuse-proof.”
“For example, someone who wants to “get high” from prescription opioids can still swallow more than the prescribed amount, and this simple but common form of abuse can result in overdose and death,” Throckmorton wrote.