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Expert: Move pain management into 21st century

Narcotics should not be first solution, doctor says

Aug. 29, 2014 - 12:46PM   |  
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Contrary to a popular military tenet, pain is not weakness leaving the body.

In truth, untreated chronic pain can stress the heart, decrease lung function, dampen appetite and cause a host of psychological issues like depression, anxiety, sleep disturbances and social isolation.

With more troops being saved on the battlefield — and many coming home from combat with chronic pain — officials at the Defense & Veterans Center for Integrative Pain Management are seeking to change how doctors approach pain, starting at the moment of injury.

“Chronic pain and the devastating issues it has on patients starts as the patient is going toward the event that’s going to wound them. The way we manage the acute pain determines whether it becomes a lifelong disease,” said Col. Trip Buckenmaier, DVCIPM program director.

A recent study of an Army infantry brigade found that nearly half the unit reported chronic pain after deploying to Afghanistan — nearly twice the rate of chronic pain in the general population.

The same study, conducted at the Walter Reed Army Institute of Research, also found that soldiers used narcotic painkillers at three times the rate of civilians, even as many of them reported having no severe pain in the previous month.

Given the prevalence of chronic pain among troops and veterans, the DVCIPM is looking to alter physician perceptions of pain and offer alternatives to medications.

“Just as we’ve coordinated our medical response to trauma, we need to coordinate our medical response to pain. If you aggressively manage pain, it impacts positively on rehabilitation and improves long-term prognosis,” Buckenmaier said.

He noted that the military has made advancements in this area in Iraq and Afghanistan, from adopting alternative treatments like acupuncture to using non-narcotic analgesics like ketamine.

But approaches are as varied as individual health providers, Buckenmaier told members of the Defense Health Board on Aug. 11.

“The first thought in pain should not be an opioid. But we don’t have the infrastructure to make other options available universally to our patients,” he said.

In 2010, an Army-led joint task force published a report containing 109 recommendations on pain control, providing a standard training program for military providers, calling for increased patient participation in pain management and offering a menu of options for controlling pain. Some of the recommendations have been adopted but implementation has not been universal, Buckenmaier said.

“We have the doctrine, but as is often the case, we don’t always follow the doctrine,” he said.

Physicians all too often still turn to a 200-year-old solution for treating pain: morphine. “When I arrived in Iraq in 2003, if you had pain on the battlefield, you got morphine. If you had more pain, you got ‘more-’phine,’ ” he said.

Buckenmaier, who is retiring in the fall, introduced regional anesthesia to the field — a pain management technology in which the nerve to an entire leg or arm is blocked using a catheter or a needle. He also pressed for other tools — drugs like hydromorphone, fentanyl, ketamine and alternatives like biofeedback and yoga.

At the very least, he wants to see universal implementation of a new pain rating scale that combines the familiar number and smiley-to-frowny-face system with descriptive phrases and a color scheme that ranges from green for “no pain” to red for excruciating “my body is on fire” agony.

The new chart, with words like “notice pain but does not interfere with activities” or “awful, hard to do anything,” with corresponding facial expressions and colors are more accurate descriptors and can help physicians better define a patient’s pain and treat it without overmedicating, he explained.

Sometimes, zero pain isn’t the goal, he added. “This chart gets us away from ‘chasing zero.’ We can get to zero with medications, but if being at zero means you’re sitting on the couch all day watching ‘I Love Lucy,’ how good is that? It should be about minimizing pain and maximizing function.”

Among Buckenmaier’s top aims are universal application of the task force’s recommendations, pill packs with antibiotics and analgesics in every troop’s ruck and Tricare coverage for acupuncture.

“If you told me 10 years ago I’d be a certified acupuncturist, I would have laughed. But it’s been an incredible change to my practice. It works and we need to push Tricare to cover it,” Buckenmaier said.

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