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11 Articles in Volume 11, Issue #8
Pain Following Combat Trauma In the 21st Century: A New Look at an Old Problem
Part 2: Fibromyalgia: Practical Approaches To Diagnosis and Treatment
Advances in Regenerative Medicine: High-density Platelet-rich Plasma and Stem Cell Prolotherapy For Musculoskeletal Pain
Implant Technologies for Severe Pain: Why, When, and the Outcomes
Value of EMG in Patients With Non-Migrainous, Persistent Head Pain
Drug Interactions Among HIV Patients Receiving Concurrent Antiretroviral and Pain Therapy
Etiology of Chronic Pain and Mental Illness: The Biopsychosocial Component
Insights Into Patients’ Views About Topical Opioids: Observations From a Small Clinical Study
Teenage Boy With Multiple Pain Disorders
The Bench Delivers and It Matters
Renewing Opioid Prescriptions Over the Phone

Pain Following Combat Trauma In the 21st Century: A New Look at an Old Problem

The new pain management system adopted by the military is holistic, multidisciplinary, evidence-based, and integrated across the entire care continuum to address both acute and chronic pain conditions.

Following a 6-month evaluation of pain management in the Department of Defense (DoD), the U.S. Army Surgeon General’s Pain Task Force (PTF) published its Pain Management Task Force Report in May 2010.1 The PTF was chartered in response to the increasing recognition of the need for a comprehensive strategy for military pain management. Additionally, Section 711 of the National Defense Authorization Act for fiscal year 2010 tasked the Secretary of Defense to “develop and implement a comprehensive policy on pain management by the military healthcare system.” The PTF report is unique in military medical history, representing the first systematic review of DoD, regional medical commands, and military healthcare facility clinical policies and regulations from the perspective of pain management.

Practical Pain Management spoke with the authors to discuss some of the lessons learned from the current conflicts in Afghanistan and Iraq, as well as why pain management is an important military issue.

PPM: What prompted the PTF?

A: The Army Surgeon General, Lt. Gen. Eric B. Schoomaker chartered the PTF in August 2009 to review current military pain practice and make recommendations for a pain management strategy “that was holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for soldiers and other patients with acute and chronic pain.”1

PPM: Who makes up the PTF?

A: The PTF comprises a variety of medical specialties and disciplines representing the Air Force, Army, Navy, TRICARE Management Activity, and Veterans Health Administration.

PPM: What were the findings of the PTF?

A: The PTF found that military pain management practices were consistent with community standards of care and that there were many instances of superior pain management practices throughout the system. Unfortunately, it also was recognized that there was an absence of a comprehensive pain management strategy that resulted in unwarranted variations in care between military facilities and fragmentation of best pain care practices.

Perhaps the most concerning product from the lack of synchronization of pain management across the DoD was an apparent overreliance on opioid-based medications for pain management and subsequent instances of medication misuse, abuse, and dependence. The PTF report included 109 recommendations for the development of a DoD pain management strategy to achieve the Army Surgeon General’s goals for a comprehensive, holistic, and multidisciplinary approach that would standardize and optimize pain management for warriors and their families.

The PTF report and the resulting Army Pain Campaign Plan that is presently under way to implement the PTF recommendations are epic in scope and ambitious in their goal to reorient military healthcare’s culture toward a more integrative approach to pain management.

PPM: What has changed to necessitate such revolutionary change within a military healthcare system during a time of active conflict?

A: Advances in trauma surgery and critical care management of wounded soldiers has improved greatly during the conflicts of the 21st century, culminating with the latest statistic of fewer than 10% of wounded soldiers dying once they enter the military medical system.2 The evolution of pain management of these same casualties has been far less dramatic. At the onset of the Afghanistan and Iraq wars, reliance on morphine as the sole battlefield analgesic had essentially remained unchanged from the 19th century. Morphine was the answer for battlefield pain following September 11, 2001, and if the soldier continued to complain of pain, he or she received, “More-phine.” The relatively static development of pain management options within both military and civilian medicine likely relates to a general lack of understanding of the impact that poorly managed pain has as a disease process involving both the peripheral and central nervous systems.3

Additionally, the wounded in previous conflicts tended to remain static for days to weeks within the war theater until they were “stable” enough for transport. Exclusive morphine management of pain in this situation was likely a viable strategy because the stationary nature of patients would allow appropriate monitoring and titration of the drug over time. This has not been the case in contemporary conflicts because the current paradigm for casualty management relies on rapid air evacuation of “stabilized” casualties out of the theater within hours to days. The exclusive use of morphine in this challenging, relatively austere, aeromedical environment has not been ideal owing to the inherent challenges in patient monitoring and the potentially life-threatening side effects associated with opioid medication.

Concerns regarding the difficulties in managing pain in the new, rapid-evacuation environment forced medical leaders to reassess battlefield pain practices and quickly develop new, innovative ways of managing pain. In order to coordinate this effort across the three services, the Military Advanced Regional Anesthesia and Analgesia (MARAA) organization was formed in 2002. MARAA consisted of pain specialty leaders from the Air Force, Army, and Navy and tasked itself with finding novel pain treatments and technologies that effectively and safely managed pain, addressed modern rapid air evacuation realities, and were consistent with the most modern pain medicine science.

PPM: What have been some of the lessons learned from the current military conflicts?

A: One of the most significant advancements in battlefield pain management developed from the current conflicts has been the re-emphasis of regional anesthesia in Combat Support Hospitals (CSH), specifically the techniques of epidural and continuous peripheral nerve block (CPNB) catheter placement and management technology. Since 2003 when the first CPNB catheters were used to evacuate a casualty from Iraq to Landstuhl, Germany, CPNB has been notably effective in the management of traumatic limb amputations that result from signatory use improvised explosive devices in the current conflicts.4-6 The use of CPNB in theater has been greatly enhanced during the first decade of the 21st century with the integration of ultrasound technology to regional anesthesia.7 The ability to visualize target nerves and surrounding structures greatly enhances accuracy of CPNB needle placement. In providing acute pain services (APS) in Afghanistan, ultrasound technology has proved indispensible in managing pain patients with traumatic limb amputations.8

In order to realize the benefits of continuous analgesia provided by infusions of local anesthetics to target nerves in evacuating wounded, pain medication pump technology had to be introduced to the aeromedical environment. MARAA, working in a triservice manor, was able to overcome service-specific differences and requirements, to coordinate the introduction of the first military pain infusion pump in 2004.9 MARAA also coordinated the creation of protocols and standards for using epidural and CPNB infusions during aeromedical flights.

The incorporation of pain infusion pump technology also opened up other treatment possibilities that are unique to the current conflicts. For example, the pumps also are used for patient-controlled analgesia (PCA) with morphine, hydromorphone, or ketamine. This capability is significant because patients are now in control of their pain medication, and there is less reliance on limited nursing resources for pain needs both at the CSH and on the evacuation flight.10,11 These technological advances greatly enhanced the efficiency and capability of military clinicians to provide enhanced pain management plans beyond intermittent boluses of morphine. In fact, the wounded could now be transported with a local anesthetic CPNB and a PCA infusion, which represented the first truly multimodal approach to pain management during evacuation.

PPM: Is there now an integrated pain management system?

A: Although the use of advanced pain catheters and infusions was a significant step forward in battlefield pain management of combat polytrauma patients, these techniques did result in new patient management issues within the evacuation system. In major civilian hospitals that routinely use these techniques, there are established information systems that ensure physicians’ pain orders are clearly communicated, accurately recorded, and readily available for healthcare provider review. The more than 6,000-mile evacuation chain from Iraq and Afghanistan, to Landstuhl, Germany and then on to military medical centers in the United States made communication concerning pain management plans between providers and medical care nodes extremely difficult. Initially, this communication was achieved through emails between a few early adopters of these novel approaches. As the benefits of this approach to casualty pain management became clearer and more widely employed, this informal communication was no longer acceptable.

MARAA developed the Regional Anesthesia and Analgesia Tracking System (RATS) in 2005 as a temporary solution to this communication issue. The system was maintained on an encrypted, DoD server and allowed providers to enter basic patient demographic information, pain histories, and procedural and clinical notes on pain care. The most important feature of RATS was its “patient transfer” function. Pain providers would transfer pain management patients on RATS to the next identified healthcare facility in the evacuation chain. This would generate warning emails to pain providers at the next facility that a patient with pain technology requiring further management was headed their way. This system was extremely valuable in reducing confusion, improving safety, and ensuring proper follow-up of pain patients. In May 2011, RATS was updated and transferred to the Theater Medical Data Store (TMDS), which is the official electronic medical record for the battlefield. The new note, named “Pain Management,” has all the previous functionality of RATS but it is now integrated into the patient’s full medical record.

MARAA also created the first battlefield handbook on acute pain medicine as a supplement to the Emergency War Surgery manual.12 The Military Advanced Regional Anesthesia and Analgesia handbook was published in 2009 and is a standard pain management training text in the military.13

PPM: What are the biggest challenges currently facing pain management in the military?

A: Although there have been significant advancements during the current conflicts in the military’s capabilities to manage acute pain on the battlefield, the application of these new capabilities to the individual soldier has been, at best, inconsistent.7 The reasons for this variability in care are numerous. Establishment of new CSH pain equipment requirements has been difficult and provider skills to use advanced pain technologies, especially at the start of the conflicts, was at times lacking.

Notwithstanding these issues, perhaps the greatest challenge for constancy in the delivery of APS throughout the evacuation chain has been a lack of clear healthcare provider “ownership” of pain management. Pain management in the CSH has usually been an implied or assumed duty of the unit anesthesia service or in some cases thought to be a general responsibility of all providers at a particular CSH. In this situation, where everyone has an assumed duty to manage pain, no provider is really “responsible” when pain is managed poorly. This attitude was understandable because the traditional view of pain has been that it is a symptom of some other disease, and as such, if you managed the underlying disease process (trauma or illness) the pain would take care of itself.

The PTF report has fundamentally rejected this view by defining “pain” as a disease process that if poorly managed can develop into a chronic and debilitating state. The new medical status of pain as a disease in military medicine allows the proper resourcing of personnel and equipment to manage this important health problem.

Efforts are also under way to provide combat medics other options for pain in field situations. Other medications, such as ketamine, have been proposed for use by medics in the initial care of wounded.14 New training curricula are being developed to provide special forces medics, who often are isolated from medical care, additional training in basic regional anesthesia, acupuncture, and basic physical manipulation techniques.

Finally, a cultural and educational reorientation to the importance of effective battlefield acute pain management will have to take place within all military specialties. For improvements in battlefield pain management to become established and to continue, medical unit commanders will have to see effective pain management of the wounded in their facilities as a marker of their leadership success. In support of this concept, the PTF has recommended a new pain rating scale to evaluate pain care of the wounded throughout the evacuation system. Called the Defense and Veterans Pain Rating Scale (DVPRS; Figure 1, page 30), this new scale grounds the traditional 11-point pain scale with functional language and supplements the scale with four additional scales dealing with general activity, mood, stress, and sleep.

A Way Forward

Important steps are being undertaken to enhance battlefield pain care and reduce unwarranted variations in wounded pain management. Most significantly, the first Joint Theater Trauma System Clinical Practice Guideline—Guidelines for the Establishment and Operation of Joint Theater Acute Pain Medicine Service was approved for field use in July 2010. In order to realize the full potential of the guidelines to improve pain care following combat trauma, pain management-trained physicians and nurses will necessarily need to be assigned responsibility for the APS at each CSH. The existing MARAA handbook is a ready outline and reference for the clinical operation of the CSH APS. The new TMDS pain medicine note provides an effective communication link between pain services. The DVPRS will provide a consistent standard for measuring effectiveness of pain care across the continuum of care from battlefield to home.

Although these changes to battlefield medicine are important and historic in scope, they represent only a fraction of the changes called for in the PTF report. The need for enhanced pain care for our combat wounded seems an intuitive need that few would find an effective argument against. In reality, this population, although important, represents just the tip of the iceberg of pain issues that impact soldiers and families daily. The stresses and musculoskeletal strains of military life lead to pain issues that, although not so obvious, are no less insidious in their potential to derail careers, degrade quality of life, and lead to chronic disease states. The pain management system called for in the PTF report is holistic, multidisciplinary, evidence-based, and integrated across the entire care continuum. Combat has historically been a catalyst for medical innovations, and although the transformation called for by the PTF is sobering in its scope and complexity, it appears that the current conflicts will be the catalyst for sweeping and needed change in pain medicine.

Last updated on: November 3, 2011
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