Pain care urged as a priority for wounded, returning veterans

Physicians are called upon to stop pain to prevent lasting changes in the nervous system and a downward spiral toward disability.

By Susan J. Landers, amednews staff. Dec. 3, 2007.

Washington -- Wounded veterans returning from Iraq and Afghanistan are surviving injuries that would have been fatal in earlier wars. That's the good news. But these serious wounds also are causing a great deal of pain, which, if untreated, can trigger a cascade of life-disrupting changes, according to pain experts speaking at an Oct. 30 Capitol Hill briefing.

Without fast and effective pain relief, the many returning vets could find it difficult to work, sleep and have social relationships, pain experts said.

Special circumstances
Older depressed vets less a suicide risk than younger ones
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There are nearly 700,000 veterans of fighting in Iraq and Afghanistan. Among them are 200,000 who already are receiving care at Dept. of Veterans Affairs facilities. Given these numbers, primary care physicians likely will be called upon to treat this group of patients. They may participate in collaborative care models led by pain specialists, said Rollin M. Gallagher, MD, MPH, director of pain services at the Philadelphia VA Medical Center.

Dr. Gallagher wants to see a major effort to link primary care, pain specialists, social workers and others to meet this need. Pain is a common problem, and its solution will depend on good primary care, because there are not enough specialists to go around.

"We want to avoid having veterans sent from one specialist to another without getting good pain treatment," Dr. Gallagher said.

The briefing was sponsored by the American Pain Foundation, a nonprofit organization based in Baltimore. A grant from Endo Pharmaceuticals, a Chadds Ford, Pa., firm that specializes in pain medication, funded the event.

More than 90% of all wounded vets have episodes of pain.

The foundation began to focus on the returning vets' pain three years ago when the number of phone calls from this population escalated, said Executive Director Will Rowe.

More than 90% of all wounded vets report pain, according to a recent survey of soldiers treated in the four VA Polytrauma Centers for seriously wounded veterans.

Untreated acute pain can trigger changes in the brain and spinal cord that can lead to chronic pain.

"You have the maintenance of pain from injured nerves firing away," Dr. Gallagher said. The result can be disability, depression and substance abuse. "It's a vicious cycle."

A physician's job is "to stop pain in its tracks as early as possible," he added.

The changes in the nervous system can be charted. "Advances in neuroscience, such as neuroimaging, show that unrelieved pain, regardless of its initial cause, can be an aggressive disease that damages the nervous system, causing permanent pathological changes in sensory neurons and in tissues of the spinal cord and brain," said Brenda Murdough, RN, coordinator of the Military/Veterans Initiative of the American Pain Foundation.

Complex traumas

The injuries that trigger pain in returning vets are not commonly seen in community health settings and had become rare at the VA, Dr. Gallagher noted.

For example, amputations are common. Although protective gear shields vital organs, arms and legs are often so mangled in blasts that amputations are the only medical recourse. Amputations can trigger phantom pain in the missing limb.

60% of blast wounds produce symptoms of traumatic brain injury.

Blasts from improvised explosive devices and land mines can cause nerve damage and cognitive changes. Soldiers come home with hidden injuries, such as hearing loss. Sixty percent of the blast wounds produce symptoms of traumatic brain injury.

The chronic pain that can result from these battlefield injuries can be devastating to the soldier and his or her family, Murdough said.

In addition, posttraumatic stress disorder is common and may intensify an individual's experience of both the stress and the pain. This circumstance adds even more obstacles to a return to normal life, she noted.

2nd Lt. Mark Little, 24, of Fairfax, Va., lost both legs below the knee when an IED exploded under his vehicle Sept. 7 just south of Baghdad. He noted that he experiences not only pain in his upper legs but also, and even more intensely, phantom pain in his missing lower legs. Little spoke at the briefing of the need to move pain care closer to the front lines of battle.

Although pain control was a top priority after he arrived back in the United States, it wasn't adequate while he was en route.

"The flight, which took from eight to nine hours, from Germany to Andrews Air Force Base [in Maryland], was one of the most painful experiences in my time here on this great earth," he said.

ADDITIONAL INFORMATION:

Special circumstances

Many veterans return from service with significant health issues that complicate pain management. Among the most complex are PTSD, traumatic brain injuries and amputations. Care can be even more difficult in areas that lack medical resources. The American Pain Foundation summarizes the associated symptoms and treatment issues:

PTSD: Posttraumatic stress disorder commonly affects soldiers returning from war and is triggered by exposure to a situation or event that is or could be perceived as highly threatening to a person's life or those around him/her. It may not emerge for years after the initial trauma. Chronic pain symptoms and PTSD frequently co-occur and may intensify an individual's experience of both. Chronic pain and PTSD result in fear, avoidance behaviors, anxiety and feelings of isolation.

Amputations: Although there have been major advances in medicine, prosthetics and technology that allow amputees to lead more independent lives, most patients continue to need specialized long-term or lifelong support. Managing wound, postoperative, phantom and stump pain is important to improve quality of life.

TBI: Managing pain in veterans with traumatic brain injuries may be complicated by memory lapses affecting medication management, difficulty organizing and following pain management regimens, and difficulty learning new coping skills. Rehabilitation should incorporate efforts to relieve associated pain.

Older depressed vets less a suicide risk than younger ones

A study of more than 800,000 depressed military veterans found that suicide risk is highest among young, male, non-Hispanic whites. The study was published online Oct. 30 in the American Journal of Public Health.

Thought to be the largest and most up-to-date examination of suicides among depressed veterans, the researchers from the VA Ann Arbor Healthcare System, the University of Michigan Health System and the university's Depression Center said they hoped to provide guidance for screening those at risk.

Vets with substance abuse issues and those hospitalized for psychiatric reasons in the year before their depression was diagnosed also had a higher suicide risk.

Older veterans who had been diagnosed with posttraumatic stress disorder in addition to depression had a lower overall rate of suicide than did those without a PTSD diagnosis. The researchers thought this might be because those veterans were more likely to receive care through VA programs. Also, depressed veterans who did not have a service-connected disability were more likely to commit suicide than were those with a service-connected disability. The researchers thought this also might be due to greater access to treatments or more stable incomes from compensation payments.

In all, the study found that 1,683 of the depressed veterans, 0.21%, committed suicide during the study period of 1999 to 2004. The study divided veterans into three age groups: 18 to 44, 45 to 64 and 65 years and older. It is slated for print publication in the December issue of the journal.