This article is contributed by Michael E. Kilpatrick, M.D., Director of Strategic Communications for the Military Health System in the Office of the Assistant Secretary of Defense for Health Affairs.

In September 2009 I had the pleasure of attending and participating in a conference entitled “OEF/OIF Evolving Paradigms II: The Journey Home” presented by the Veterans in partnership with the DoD and the VA Employee Education System. The purpose of this conference was to provide VA and DoD health care providers and leaders with the information needed to meet the challenges facing veterans, families, and their caregivers with an integrated, multidisciplinary approach. This initiative involves DoD and VA health care benefits and the availability of community resources. The commitment to the challenges of this mission by those nearly 3,000 individuals attending was obvious, and the active participation of OEF and OIF service members and veterans who have been and still are receiving care emphasized the urgency for collaborative, integrated care.

I was intrigued by an excellent focus on managing and treating pain by multiple presenters and panels, and I’d like to highlight several of those demonstrating superb DoD-VA coordination with the focus constantly on our service members and veterans.

Pain management on the battlefield is an age-old issue. Early treatment of those wounded or injured in the combat theater starts with training of all deployed service members in “buddy care” —being able to provide almost immediate support to stop bleeding with tourniquets and bandages with clotting materials. Treatment of acute pain is also started early, with morphine as the primary drug. Unrelieved pain can result in abnormalities in multiple organ systems such as cardiovascular, respiratory, immunological, muscular, gastrointestinal, and renal, as well as producing psychological symptoms.

However, today’s medical care on the battlefield is approaching that of a major trauma center, with far-forward surgical teams equipped to perform acute pain management, including regional anesthesia in many circumstances.

Such acute pain therapy has traditionally been in major medical center settings, with support from the regional anesthesia providers, not just before or during surgery, but continuing outside the operating room to the ward and to the outpatient setting. Some examples given of regional anesthesia being used in the combat theater were pain relief for an above-the-knee amputation, with femoral and sciatic peripheral nerve catheters during medical evacuation, or post-blast exposure back pain relief with a patient-controlled infusion pump, which provides analgesia and a supraclavicular continuous peripheral nerve block for arm pain.

It is important that dialogue begins early between those providing therapy for acute pain and those who traditionally provide therapy for chronic pain, enabling a seamless transition for patients when necessary. This new capability going forward means that all medical providers who will be giving in-transit care during medical evacuation, supportive care along the evacuation route, definitive care at a major medical facility, and follow-on care in the outpatient setting, will need to be educated to understand how to provide continuity of pain management.

There must be uniformity in the care provided from the acute phase through chronic requirements as the patient transitions from one medical setting and providers to another setting and other providers.

DoD and VA medical providers are recognizing that for the service members and veterans returning from the combat theater there are a set of symptoms that can be present because of mild traumatic brain injury (post-concussive syndrome), PTSD, or chronic pain.

These common symptoms include memory impairment; concentration problems; irritability; insomnia/sleep problems; fatigue; headache; dizziness; intolerance of stress, emotion, or alcohol; mood changes; personality changes; and apathy. Therefore, when a physician is treating a patient diagnosed with TBI or PTSD, there should always be an evaluation for pain, because that contribution to the symptoms may otherwise be ignored.

Symptoms common to multiple medical conditions cannot be used to definitively diagnose a problem, and there is no single medical condition which is associated with all the symptoms listed. Appropriate therapy for any medical problems requires an accurate diagnosis, and treatment can only be expected to resolve the symptoms that are related to the diagnosis. For individuals returning from a combat theater, it is common to have several medical conditions diagnosed and “overlapping symptoms” can be problematic. The challenge to the medical community is to bring the expertise from multiple medical specialties together to evaluate and treat such patients with complex symptoms. These providers also need awareness of the conditions and events experienced by those who deploy. For those patients who are transitioning from a DoD medical facility to a VA medical facility, and their families, support from a Federal Care Recovery Coordinator is necessary to assure a smooth sharing of medical information between providers and support information for the patient and his/her family.

There was agreement among the many presenters discussing patients with PTSD and chronic pain that the ethical imperative was to provide the most effective pain treatment for the individual patient.

The development of DoD-VA Chronic Opioid Therapy Guidelines with the same educational materials is an indication of the commitment by both DoD and VA to a common patient-centered practice of care. When non-opioid drugs are not adequate to provide pain relief, there must be a thorough assessment of the patient by a multidisciplinary medical team to identify possible substance abuse disorders, or medical conditions such as sleep apnea, chronic pulmonary disease, cardiac conditions, or psychiatric disorders. Then the patient and family should be educated about opioid therapy—its goals and expectations, addiction, physical dependence, legal issues, adherence to a treatment plan, and the need to have a single prescriber and a single pharmacy to provide the drug. All this should be in context of the overall rehabilitation treatment goals individually tailored for the patient. With appropriate pain treatment, the individual patient will likely achieve gains in physical and social function. Continuity of therapy and routine follow-up are essential.

The most poignant messages at the “OEF/OIF Evolving Paradigms II: The Journey Home Conference,” were from the warriors who were wounded, injured, or ill while deployed. The eloquence came from the honesty and simplicity. “Please don’t start by telling me what you are going to do to me” was the first message to the medical providers. “Listen to me first” was the second, and “Please believe what I tell you” was the last. Those are truly words that all we who provide care to those who are serving and who have served our nation must live by!

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