First Acute Pain Service Established in a Theater of War Reflects Paradigm Shift in Understanding of Pain

PALM SPRINGS, CA — After nearly 250 years of American military operations, the first acute-pain service in a theater of war was instituted in 2009 in Afghanistan, attendees of the 2012 American Academy of Pain Medicine Annual Meeting were told.

“This is no less than a cultural change and harmonization of all attributes about pain and its consequences within the military,” noted Chester C. Buckenmaier, III, MD, COL MC USA, of the Defense & Veterans Center for Integrative Pain Management, Rockville, MD.

The mission of the Army Pain Management Task Force was to provide recommendations for a comprehensive pain-management strategy “that is 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.”

The paradigm shift in the treatment of acute pain within the military reflects both an increased understanding of the nature of pain as a disease process rather than a symptom of trauma or disease and the ability to treat patients who previously would have died. Today, a patient wounded in Iraq can have treatment initiated in the field, be evacuated, and arrive at a hospital in Landstuhl, Germany, within 24 hours.

In 2003, at the beginning of the Iraq war, morphine was the only agent administered for pain; today, the option exists to treat with continuous peripheral nerve blocks, regional anesthesia, patient-controlled analgesia with morphine, and ketamine and IV acetaminophen.

Dr. Buckenmaier presented data on the first 392 surgical trauma patients triaged in Afghanistan between April and July 2009; 160 (40.8%) were seen by the acute-pain service. He said while this figure may appear low, the other patients did not have an immediate need for the service: approximately 40% were sedated and on an IV and 20% did not have injuries severe enough to be treated.

Of those treated, 155 were male and 5 were female; mean age was 25.8 years and 19 patients were treated more than once. A total of 91 catheters were placed and 129 single blocks were performed.

Average pain score prior to treatment was 5.266 and posttreatment, 0.734. Dr. Buckenmaier said the 0–10 pain-rating scale was revised to a color-coded scale make it more relevant to a patient's situation: red = “treat”; yellow = “supplement”; and green = “good to go.” Four additional questions were asked with respect to general activity, mood, sleep, and stress.

A survey of physicians and nurses about their perceptions of the acute-pain service found them to be satisfied (7.7 of 10), in the categories of "care beneficial" (7.7 of 10) and "the service important to deploy" (8.5 of 10). They also agreed that patients managed by the acute-pain service obtained greater levels of pain relief and decreased levels of pain, resulting in a significant impact on patient outcomes.

Acute pain, if not managed well, can lead to chronic pain, resulting in the psychopathology of maintenance, which includes encoded anxiety dysregulation (resulting in posttraumatic stress disorder), emotional allodynia, and mood disorder, as well as disability that includes a sense of increased isolation, role loss, and sleep disorder. These outcomes may be contributing to the increased suicide rates observed among troops, he said.

For more information about the Defense & Veterans Center for Integrative Pain Management, visit www.dvcipm.org.