By Annette M. Boyle
SILVER SPRING, MD – Skyrocketing prescription opioid use in the civilian population has attracted widespread medical and media attention. While the DoD and VA implemented a pain management task force in 2010, relatively little research has been done on rates of chronic pain and opioid use in the military.
As a result, researchers at Walter Reed Army Institute of Research in Silver Spring, MD, sought to find out the prevalence of chronic pain and opioid use in previously deployed servicemembers by conducting a confidential survey of an infantry brigade after return from Afghanistan.
In a research letter published in a recent issue of JAMA Internal Medicine, almost half of the brigade reported chronic pain and 15% reported taking opioids three months post deployment.1
“The Army has long been aware of the significant amount of chronic pain and opioid use in its soldiers, so this just adds some data to that storehouse of knowledge,” explained lead researcher Lt. Cmdr. Robin Toblin, PhD, MPH, of the U.S. Public Health Service and Center for Military Psychiatry and Neuroscience at Walter Reed.
Of the 2597 study participants, 44% reported pain lasting more than three months, which the researchers categorized as chronic pain. For nearly half, 48.3%, the pain had lasted more than a year, and 55.6% reported nearly daily or constant pain. Moderate to severe pain was reported by 51.2%. About 26% of civilian adults report chronic pain.
“While we didn’t know what the prevalence rate was in the military, in my experience, treating military patients, the rates of baseline pain is higher in the military population and their use of drugs and opioids is also higher than among civilians,” said Wayne Jonas, MD, president and chief executive officer of the Samueli Institute, a nonprofit health research organization, and a retired Army lieutenant colonel who co-authored a commentary that accompanied the study. “Military patients are subject to a lot more wear and tear than couch potatoes or even weekend athletes. They’re engaged on a daily basis in physical tasks, and everyone has to be combat ready. Units on the front line experience more trauma, and that will result in more pain.”2
Combat injuries affected 45.4% of study participants. The similar percentage of those wounded in battle and those experiencing chronic pain indicates some significant overlap, but not perfect correspondence, Toblin told U.S. Medicine. “Of people injured in combat, 59.3% are reporting chronic pain three months after the deployment. Of those with chronic pain, 31% are reporting they had experienced a combat injury.”
The high rates of injury and pain surprised the researchers. “We expected pain after a long war and many injuries, but we didn’t expect it to be nearly one out of two, given that these are otherwise young, healthy soldiers,” Toblin said.
The use of opioids by so many servicemembers raised concerns for the researchers, as well. The reported rate of 15.1% is nearly four times the rate of opioid use among civilians. Of those who said they used opioids in the previous month, 38.5% reported experiencing mild pain and 5.6% said they experienced no pain in the previous month.DoD and VA guidelines recommend opioids for moderate to severe pain.
“There are a number of possible explanations for that finding and our data can’t sort between them,” Toblin noted. “The ‘no pain’ category referred to the average pain level in the last month, so it’s possible they had something like a dental procedure and took an opioid, but otherwise had a pain-free month.” It also is possible that the opioid reduced pain to what the respondent considered to be a zero level or that they were misusing their prescription, she said.
Finding such high rates of chronic pain and opioid use in a mostly young—41.3% of the respondees were 18-24 years old—non-treatment seeking group indicates a “large unmet need for assessment, management and treatment of chronic pain and related opioid use and misuse in military personnel after combat deployments,” the authors wrote.
The authors recommended a review of prescription practices to ensure that opioids are used appropriately and that physicians consider non-opioid options “whenever possible.”
Jonas and his commentary co-author, retired Lt. Gen. Eric B. Schoomaker, MD, of the Uniformed Services University of the Health Sciences, urged the DoD to implement more of the recommendations made in the pain management campaign to create an integrated, holistic, multidisciplinary and multimodal approach to pain.
“These guys and gals have to be in peak shape mentally and physically. We don’t want them buried in medications, especially opioids that interfere with sleep and cognitive function. We have to have other tools to bring to patients, particularly approaches that they can use themselves,” Jonas told U.S. Medicine. “We need more investment in and better understanding of how to utilize other options instead of and in conjunction with medication.”
The DoD called on the Samueli Institute to conduct a comprehensive set of systematic review on self-care and integrative approaches for pain. The institute convened an expert committee, the Active Self-care Therapies for Pain (PACT) Working Group, to review the evidence and the results of that review recently appeared in the journal Pain Medicine.
Based on the review, “weak recommendations were given in favor of using yoga, tai chi and music therapy for the self-management of chronic pain symptoms,” Jonas wrote in a summary of the Pain Medicine research. The review group was unable to recommend 11 other modalities because of a dearth of studies and poor research design.3
Efforts also are being made to produce safer medications. For patients who need opioids, several pharmaceutical companies are developing or have recently released new formulations to minimize abuse potential while providing extended relief from pain. In addition, several more powerful non-opioids and opioid/non-opioid combinations are in the pipeline. These potentially offer more effective options to both physicians and patients and might provide meaningful relief for those who cannot take opioids.
“It is disturbing that the use of opioids for the management of acute pain, where they may be quite effective, is being continued to such a large degree to manage chronic pain where the evidence for their effectiveness is far less,” said Shoomaker, who served as Army surgeon general from 2007 to 2012.
“New work in neuroscience and the causes of pain are demonstrating many changes in the central nervous system with chronic pain. We should be actively exploring evidence-based alternatives to the use of addicting drugs, the widespread use of which is now a serious national problem,” Shoomaker told U.S. Medicine.
Jonas added that acupuncture has been proven to help manage chronic pain.
“We need proper integration of these techniques with the use of drugs. Taking a whole-person approach can put opioid use in its appropriate place,” he said.
1Toblin RL, Quartana PJ, Riviere LA, Walper KC, Hoge CW. Chronic Pain and Opioid Use in US Soldiers After Combat Deployment. JAMA Intern Med. 2014 Aug 1;174(8):1400-1.
2Jonas WB, Schoomaker EB. Pain and Opioids in the Military: We Must Do Better. JAMA Intern Med. 2014 Aug 1;174(8):1402-3.
3Jonas WB. Why Self-Care Pain Medicine? Pain Medicine. 2014;15:S1-S3.