Pain care urged as a priority for wounded, returning veterans

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.

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.

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.

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.