Improving pain care for combatinjured soldiers and veterans
By Rosemary C. Polomano, PhD, RN, FAAN
Advances in battlefield trauma management have significantly improved survival among
military personnel injured in the current Afghanistan and Iraq conflicts, compared to soldiers wounded in previous wars. Yet soldiers with serious combat injuries face devastating life-altering effects, such as major limb deformities, amputations, and traumatic brain injuries.
Combat injuries can damage the peripheral and central nervous systems, resulting in severe acute pain. In many cases, prolonged acute pain leads to complex chronic pain syndromes. After overcoming life-threatening consequences of their injuries, wounded soldiers commonly face prolonged recovery and rehabilitation marked by challenges in coping with persistent pain and the stress of reintegration into civilian life. Pain is a leading cause of veterans’ disability, and acute and chronic pain afflict military personnel and veterans in proportions far exceeding those of the general population.
Thousands of military service members have been injured in Iraq and Afghanistan, and many receive care in military and Veterans Affairs (VA) healthcare facilities. Eventually, many are able to return to civilian life, where they require care in civilian health settings and encounter civilian nurses.
Nurses provide pain-management care to military personnel and veterans and promote transitions across all levels of care in the Department of Defense (DoD) and VA systems. Military nurses deliver care in military hospitals, VA medical centers, and primary care settings.
- In deployed combat support hospitals, nurses deliver life-saving care for patients with devastating injuries and, in conjunction with other providers, make critical decisions regarding pain treatments in preparation for and during evacuation to other military treatment facilities.
- At military hospitals, nurses participate in early and aggressive multimodal pain care, from initial hospitalization to rehabilitation.
- In VA medical centers, nurses contend with the aftermath of chronic pain and its management and assist veterans in their ongoing rehabilitation and reintegration into society.
Across all these levels of care, nurses assume responsibility for ensuring safe, high-quality pain management based on scientific knowledge, technical proficiency, effective collaboration, and patient and family advocacy. Specialized pain-management nursing care is provided throughout military and VA facilities in accordance with the 1996 Standards of Clinical Nursing Practice for Pain Management. In 1998, the American Society for Pain Management Nursing (ASPMN) issued its own Standards of Clinical Practice for the Specialty of Pain Management Nursing. As the primary professional organization representing the largest number of nurses specializing in pain management, ASPMN seeks to establish core competencies through a core curriculum and national certification exam.
This American Nurse Today special report examines scientific and literaturebased perspectives on management of acute and chronic pain in injured military personnel across the continuum of care in the military and VA health services. It complements a supplement to the June 2011 issue of The Federal Practitioner based on a live meeting of pain-management experts. The latter publication provides a more extensive discussion of our current understanding of pain mechanisms and the continuum of care for military personnel. It highlights models for effective pain management in place at many DoD and VA facilities—models that can be applied systemwide to achieve the goal of standardization of care for military personnel with pain. These care models are applicable to civilian healthcare facilities.
Effective pain management is a critical component of healthcare for soldiers and veterans. Nurses’ knowledge of the principles of pain management and analgesic pharmacotherapy, the patient and family-centered care they provide, and the trusting relationships they build with patients and families define professional nursing practice in alleviating pain and suffering and promoting health and well-being. We are indebted to our colleagues in military and VA nursing practice who devote their careers to serving our country through the expert compassionate care they deliver.
Rosemary C. Polomano is an associate professor of pain practice at the University of Pennsylvania School of Nursing and an associate professor of anesthesiology and critical care (secondary) at the University of Pennsylvania School of Medicine in Philadelphia.
Understanding pain and pain mechanisms
By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; and Rosemary C. Polomano, PhD, RN, FAAN
Pain is a significant challenge both for those who experience it and those who treat it. A highly personal and subjective experience, it can be difficult to quantify and measure objectively. What’s more, the peripheral and central complexity of pain necessitates a targeted approach to ensure effective pain management.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain may be acute or of short duration (3 months or less) or chronic, generally defined as a duration exceeding 3 months. Acute pain acts as a self-limiting physiologic warning after tissue injury. Generally, acute pain is easier to treat than chronic pain, responding well to short-term analgesic therapy. But unless treated effectively in a timely manner, acute pain may evolve into chronic pain—a relentless pathologic condition.
Chronic or persistent pain commonly requires long-term management with various pharmacologic and nonpharmacologic strategies. Affecting more than 75 million Americans, it’s the primary reason why people seek medical attention. Its consequences include lost work productivity, disability, and increased healthcare costs. Unrelieved and persistent chronic pain contributes to depression, anxiety, poor sleep patterns, and decreased quality of life.
Pain in the military
Pain is a significant problem among military personnel, including those injured during combat operations or training exercises and veterans with long-lasting effects from service-related injuries. As of 2007, more than 21,000 deployed military service members had sustained wounds to multiple body regions while serving in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). Blast-related injuries accounted for 65% of combat injuries; 50% to 79% of combat injuries were traumatic extremity injuries, including trauma to one or both legs or arms, amputation, and mangled leg or arm injuries. Among service members and OEF and OIF veterans who’ve sustained major traumatic limb loss, 62.5% have residual limb pain and 76% have phantom limb pain.
Approximately 60% of injured military service members also experience signs and symptoms of traumatic brain injury. Military service members with polytrauma commonly must undergo multiple surgical procedures—an average of 5.5 per person. This places them at increased risk for developing unremitting pain, given that 10% to 50% of patients who have general surgery develop persistent pain. Preventing pain and reducing its severity early are critical to mitigating the lasting effects of chronic pain associated with injury.
Many military service members with polytrauma require inpatient rehabilitation; nearly all (96%) experience at least one pain problem during their stay. Although pain from combat related polytrauma is significant, the most common type of pain among military service members from OIF is low back pain (53%). In about 24% of these cases, a precipitating event isn’t identified.
Chronic pain in veterans
Research demonstrates a high prevalence of chronic pain among veterans. A limited cohort study (n = 340) of OEF and OIF veterans found 81.5% experienced chronic pain. Many other studies show that a concerning number of veterans from previous conflicts have chronic noncancer pain. Severe chronic pain is associated with increased suicide risk, which prompted the incorporation of suicide assessment and suicide prevention interventions into routine plans of care at Veterans Administration medical centers and primary-care settings that treat veterans.
In addition to the broad classification of pain as either acute or chronic, pain may be classified based on its characteristics, cause, or the mechanisms involved in sustaining it. One classification system divides pain into nociceptive and non-nociceptive. (See Classification of pain by clicking the PDF icon above.)
Nociceptive pain results from activation of ongoing pain receptors (nociceptors) in either the surface or deep tissues of the body. Two types of nociceptive pain exist:
- Somatic pain is caused by injury to the skin, muscle, bone, joint, or connective tissue. It’s generally sharp or burning (as with injury to the skin or tissue just below the skin) or dull, aching, and localized (as with injury to deeper tissues).
- Visceral pain results from ongoing injury to internal organs or the tissues that support them. Generally, it’s poorly localized and described as cramping (as with injury to a hollow structure, such as the gallbladder or intestine) or pressure-like and stabbing (as with injury to a solid organ).
Non-nociceptive pain stems from nerve-cell damage in the peripheral nervous system (PNS) and central nervous system (CNS, termed neuropathic pain); or from overactivity in the sympathetic nervous system with CNS and PNS mechanisms (sympathetic pain).
- Neuropathic pain occurs when injury to a nerve causes it to become electrically unstable and fire signals randomly in a disordered pattern. A person with this type of pain is hypersensitive to stimuli (such as hot, cold, and touch), and the injury elicits such sensations as numbness, electric shocklike or tingling, burning, “pins and needles,” sharp pain, or lancinating pain. Also, pain may be referred to an area that the injured nerve normally supplies (for example, sciatica from a herniated intervertebral disc).
- Sympathetic pain follows fractures and soft-tissue injuries. It’s marked by extreme hypersensitivity in the skin surrounding the injury and peripherally in the limb, which may be so painful the person refuses to use it.
Goals of pain management
The most important goal of pain management is to restore the patient’s function to its original or optimal state. The traditional approach of treating pain as a symptom of some other disease process fails because it doesn’t consider pain mechanisms or recognize that pain fundamentally alters the PNS and CNS, leading to sustained and amplified pain.
Current research focuses instead on understanding pain mechanisms, the transition from acute to chronic pain, and rational pain therapy. Consequently, the primary goals of effective pain care are to target specific pain mechanisms in the PNS and CNS, prevent development of
chronic pain, and improve overall patient outcomes. Many pain specialists believe the best approach to managing pain is to consider pain a disease process. A holistic, evidence-based approach to understanding pain and its management is crucial to designing and administering the most successful pain therapies.
Scientists have identified the mechanisms and mediators of pain. The ascending (excitatory) systems of pain processing facilitate pain through increases in substance P and other excitatory neurotransmitters, nerve growth factor, and cytokines. Balancing the excitatory systems are descending (inhibitory) pathways from the brain that modulate nociceptive signals from being sent upward to the brain.
Ultimately, the perception of pain is affected by interactions between these excitatory and inhibitory systems. Pain can occur when these systems are disrupted or incapable of
modulating sensory input. Pain therapies are directed toward reducing excitatory processes and maximizing inhibitory mechanisms within these systems. (See Targeting drug therapy to the pain mechanism and Pain pathways and the drugs that affect them by clicking the PDF icon above.)
Nociceptive pain is initiated by a stimulus (such as a burn or an injury) that activates primary nociceptors. The nociceptors convert mechanical, electrical, chemical, or thermal energy into an action potential, transmitted to the dorsal horn of the spinal cord by A-delta and C nerve fibers. Thin, myelinated A-delta fibers provide rapid transmission and are responsible for the immediate pain sensation (“fast pain”). Unmyelinated C fibers provide slower conduction that leads to a delayed secondary pain sensation. These fibers synapse in the dorsal horn, where spinal transmission is mediated by the release of glutamate and other excitatory neurotransmitters. Then the nociceptive signal is transmitted through ascending spinal-cortical pathways to the brain, which generates the sensory, emotional, and evaluative aspects of pain.
Inflammatory pain follows cellular or tissue damage, resulting in release of chemical mediators that induce an inflammatory response and sensitize and provoke nociceptors. This leads to sensitization of somatosensory components of the PNS.
Transition from acute to chronic pain
Undertreated acute pain has many clinical consequences, including psychosocial distress, physiologic responses that impair tissue healing and lead to hemodynamic and metabolic disturbances, limitations of mechanical function, and delayed ambulation. What’s more, undertreated acute pain can lead to chronic pain, which results from complex changes in the CNS and PNS.
The transition from acute to chronic pain is marked by sensitization, which may be primary (occurring at the injury site and known as peripheral sensitization) or secondary (occurring in the CNS). After injury, peripheral sensitization occurs when inflammatory mediators bind to Gprotein–coupled receptors and activate protein kinases (such as A or C), which phosphorylate nociceptor ion channels and receptors. This reduces the threshold required for nociceptor activation, in turn amplifying or prolonging subsequent responses to pain. The result may be abnormal pain conditions, such as:
- hyperalgesia—extreme sensitivity to painful stimuli; this condition of neuronal hyperexcitability at the injury site may extend into surrounding uninjured tissue
- allodynia—pain from typically non-noxious stimuli.
Within the CNS, changes occur that alter processing of sensory impulses by the dorsal horn, which has become sensitized. While multiple mechanisms explain how central sensitization occurs, all of them lead to increased dorsal-horn neuronal excitability and responsiveness, due to a barrage of pain signals from C fibers. This increases the likelihood that painful signals will be transmitted upward to the brain, reducing the capability for pain inhibition. Long-term central sensitization causes expansion of the area of perceived pain and increases the response to noxious stimuli.
Protracted central sensitization also may cause long-term changes in the expression of neurotransmitters or receptors, or in neuronal structure and survival; as a result, the CNS becomes overresponsive to sensory input and pain. This chain of neurochemical and neurophysiologic changes leads to rapid, independent firing of spinal neurons in response to excessive input from the PNS without a stimulus—a process called wind up. Such changes alter normal stimulus-response characteristics and play an important role in the transition
from acute to chronic pain and the development of chronic pain syndromes. Many patients with chronic pain syndromes have severe persistent pain that continues beyond the expected recovery time and is disproportionate to their tissue injuries.
Protracted central sensitization also may lead to neuroplasticity—the brain’s natural ability to form new connections to compensate for injury or environmental changes. Neuroplasticity can be adaptive, as when one learns new skills to cope with pain, or pathologic. With pathologic neuroplasticity, changes in neuronal structure and pain messaging and processing become permanent. The result: spinal cord sensitization and disinhibition, which contribute to many chronic pain conditions, including complex regional pain syndromes, phantom limb pain, and chronic low back pain. Examples of wind up, these painful conditions commonly are less responsive to analgesics because the underlying pathophysiologic abnormalities are complex. The complexity of the underlying mechanisms underscores the need for alternative pain-management approaches.
Cognitive and affective dimensions of pain
Over the last decade, scientists have gained a greater appreciation of the brain’s role in the perception of pain and factors relevant to this perception. (See Factors involved in pain perception by clicking the PDF icon above.) Use of imaging techniques during application of various nociceptive stimuli (such as heat, cold, and electrical impulses) has led to a clearer understanding and mapping of the brain areas involved in pain. These techniques show marked variability in brain activation in response to pain among individuals, and suggest that the lateral area of the brain is involved with sensory components of pain (for instance, location, intensity, and quality), whereas the limbic forebrain is involved with emotional and cognitive dimensions.
Attention/distraction is one of the factors that influence pain perception. The influence of distraction on pain perception occurs in wounded soldiers who don’t feel pain during the heat of combat. Studies support distraction as a feasible pain-modulating technique; this provides a therapeutic basis for advising patients with pain to take a walk, read a book, or listen to music. Activities that focus attention on achieving goals are particularly effective in distracting from pain and form a basic component of pain rehabilitation programs. Distraction as a pain-modulating technique also can be used as an adjunct to other pain-treatment modalities, such as medications.
Anticipation or expectation of pain also plays a role in pain perception. Anticipating pain is an adaptive response in acute pain but a maladaptive one in chronic pain. For example, a healed lower-back injury is no longer an obvious source of nociception, but fear of previously experienced pain may cause a person to stiffen or become guarded—triggering a cycle of more fear and pain, which in turn may cause significant disability. Anticipating pain increases
pain and activates brain regions linked to the processing of pain perception. Multiple factors, including existing fear and anxiety, gender, ethnicity, and psychological state, contribute to the vast differences in how individuals perceive pain in response to a given stimulus or injury. In fact, pain perception may have more to do with how much pain a person expects to experience than the actual intensity of the stimulus itself.
Better understanding, better treatments
Acute pain is common and often selflimiting. But acute pain that goes untreated or undertreated can progress to chronic pain. Our understanding of pain, its mechanisms, and the development of chronic pain is evolving. The idea that chronic pain is best viewed as a disease entity in its own right rather than simply a symptom of a condition has gained wider acceptance. Neuroimaging studies show chronic pain is a degenerative condition promoting central sensitization and abnormal neuroplasticity. Insight into the complexity of pain mechanisms has led to more rational and targeted approaches to pain therapies and to safer and more effective pain treatments.
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Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rosemary C. Polomano is an associate professor of pain practice at the University of Pennsylvania School of Nursing and an associate professor of anesthesiology and critical care (secondary) at the University of Pennsylvania School of Medicine in Philadelphia.
Pain management across the military continuum
By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; and Rollin M. Gallagher, MD, MPH
In the military healthcare system, the need for aggressive management of acute pain associated with combat injuries and trauma is obvious. An equally important and possibly greater issue facing military medicine is how to treat military service members who develop significant pain caused by mechanical injuries related to wearing body armor, repeatedly jumping from vehicles, and riding for many hours in vibrating vehicles or helicopters. This population requires ongoing surveillance to identify the prevalence and nature of their pain syndromes and to assess for and manage chronic pain, which generally is of musculoskeletal origin.
The Defense and Veterans Pain Management Initiative (DVPMI), established in 2003 as the Army Regional Anesthesia & Pain Management Initiative, seeks to improve pain management in military and civilian medicine. Through research and clinical care, DVPMI dedicates experts and resources to address pain across the military’s continuum of care from level 1 (combat medic/buddy aid at the point of injury) to level 2 (forward surgical team or aid station) to level 3 (combat support hospital) and on to level 4 (major hospital outside the theater of war), with transition to services of the Veterans Health Administration (VHA) and ultimately the civilian community.
In 2009, the Army Surgeon General chartered a Pain Management Task Force to assess current painmanagement delivery in the military and provide recommendations for a comprehensive pain-management strategy that takes a holistic, interdisciplinary, multimodal approach. With additional representation from the Air Force, Navy, and national Veterans Administration (VA), the Task Force was directed to include all appropriate science technologies and approaches to pain management that would broaden the goals to optimizing quality of life and function for military service members and veterans with acute and chronic pain. The Task Force report, completed in May 2010, concluded that while the military meets accepted standards of care for pain management, the orientation, practice, and resourcing of pain management varies. Task Force members compiled more than 100 recommendations to advance a comprehensive pain-management strategy for military medicine.
Needed: Integrated care
Although managing pain is one of the most fundamental and basic responsibilities of healthcare professionals, clinicians and researchers continue to wrestle with evidencebased and best practices to achieve effective pain management and reduce physical and psychological morbidity associated with suffering. The understanding of and approach to pain management by healthcare personnel are influenced significantly by their education and training, respective pain curricula, mentors, cultural beliefs, and personal experiences with pain. Thus, considerable variability exists in pain-management practices. To a degree, this has contributed to needless suffering, delayed access to pain experts, ineffective or inappropriate pain treatments, and financial burdens to the healthcare system.
Many patients and providers believe pain management falls within one of two categories:
- intervention-centered (for instance, nerve blocks, joint injections, or acupuncture)
- medication-centered (for example, pills and capsules).
However, neither of these unimodal approaches adequately meets the needs of many patients, who have complicated pain etiologies and histories. Instead, an effective strategy typically requires a comprehensive, integrated approach that incorporates the perspectives of various disciplines and professions, along with multimodal approaches to pain and individualized plans of care. The tools to implement this strategy fall outside of what insurance providers normally reimburse or what’s available in the average pain-management
practice. Besides a physician, effective pain care may require nurses, physical therapists, behavioral health specialists, pharmacists, and other providers. Standard use of medications and procedural interventions often requires the complementary use of acupuncture, massage therapy, mind-body techniques, and other integrative modalities.
While the military healthcare system’s pain-management challenges resemble those of civilian healthcare systems, military and VA facilities face unique challenges because of their distinctive mission, structure, and patient population. Caring for service members and their families involves responsibilities that extend beyond the usual relationship between a healthcare system and its patients. During times of war, the importance of optimizing care is heightened. The likelihood that military patients will have their health care coordinated by a single primary- care manager is relatively low because of the transience of military personnel (patients) and military healthcare providers.
Less-than-optimal continuity of care is extremely problematic when attempting to develop and implement long-term treatment plans for pain management and other chronic medical conditions. As a result, patients may face duplicate appointments, laboratory tests, and diagnostic and treatment procedures. Veteran populations commonly need care from multiple specialists and services, both within the VA system and the community. Access to consistent providers and services is paramount to continuity of care and reducing delays in care, confusion regarding point-of-care providers, and frustration encountered in navigating complex healthcare systems.
Fortunately, due to advances in combat technologies, such as improved body armor and combat casualty care, most military service members survive wounds that usually proved fatal in previous military conflicts. Survivors of complex polytrauma, however, must contend with significant life-altering challenges and pain, along with comorbid conditions, such as postconcussive syndrome, mild traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). These conditions require integrated approaches to clinical care that cross the traditional organization of healthcare specialties and patient care.
Army Pain Task Force interviews with healthcare professionals across all specialties found variability in how pain is assessed and the perceived value placed on patients’ pain scores in directing pain care. While military physicians, nurses, and medics all reported they vigilantly assess pain during each patient encounter, usually using the numeric rating scale (0–10) and the visual analog scale, significant variations occurred in how patients were instructed to report their pain levels. Also, the healthcare professionals perceived pain-assessment scales as vague and highly subjective, with few functional anchors to help patients quantify and qualify their pain.
In response to these findings, the Task Force developed a revised pain scale, called the DoD/VA Pain Rating Scale, which uses a combination of validated pain-assessment scales and
functional anchors incorporated to standardize reporting of pain levels. After a comprehensive validation research study is completed, this pain scale is expected to become the standard for all Department of Defense (DoD) and VA healthcare settings. Use of a common patient-reported pain instrument is expected to promote consistency in pain-assessment practices and offer a common understanding of pain in terms of severity, function, and impact on key biopsychosocial areas. With this improved pain reporting scale, the actionable value of pain assessments should increase exponentially.
Another product from the DVPMI is The Military Advanced Regional Anesthesia and Analgesia Handbook. (See “Resources for additional information.”) The first textbook written specifically for management of battlefield pain in military service members, it was developed based on a recommendation by the Joint Theater Trauma System Clinical Practice Guideline that all healthcare providers be trained and focused on pain management far forward on the battlefield and in military hospitals. The book contains 32 chapters, many of which address regional anesthesia techniques and the associated care of patients receiving this therapy. This text is an outstanding resource for all nurses who collaborate with anesthesiologists to develop regional anesthesia programs.
Transitions to other healthcare systems
Another finding from the Pain Task Force highlighted the importance of coordinating care among the multiple healthcare systems used by the military. Military service members and their families often receive care across a continuum of facilities in the DoD (Army, Navy, and Air Force), VA, and civilian hospitals. The “warm hand-off” between the transferring and accepting teams is a critical component in preventing duplicate laboratory tests and unnecessary
medical procedures, as well as ensuring continuity of ongoing effective treatments.
This process depends on a recently developed network of military case managers, most of them registered nurses. Case managers are part of a clinical and administrative team that coordinates communications and care among patients, families, the clinical care team, and military commands. The role of case managers is extremely important as patients move between healthcare systems that may have different formularies, equipment, and treatment protocols for treating pain.
Considerations for acute pain management
The primary objective of acute pain management is to treat pain early and aggressively. For military service members, this means starting pain management far forward on the battlefield.
Those who receive prompt, aggressive treatment from an acute pain service experience a greater degree of pain relief, decreased pain intensity, and improved outcomes. Survey data found that among those treated by an established acute pain service at a combat support hospital in Afghanistan, approximately 30% experienced pain relief in the first 1 to 3 hours, increasing to more than 80% in 7 to 10 hours. Coalition forces deployed to Iraq who received far forward treatment with early and aggressive pain management at an interventional pain service at a Baghdad hospital had a 95% rate of return to duty; more than 90% were treated for less than 48 hours with multimodal therapy. The most common diagnosis was radiculopathy (63%), which was treated with epidural steroid injections, physical therapy, and pharmacotherapy (primarily nonsteroidal anti-inflammatory drugs), or a combination.
The Pain Outcomes for Warriors Experiences Research initiative demonstrated that more effective painmanagement strategies are needed to prepare injured military service members for long evacuation flights. A survey completed by 110 wounded military service members evacuated from Iraq and Afghanistan to a regional medical center in Germany found that only 65% reported 50% or less pain relief during transport. Pain relief scores improved at the regional medical center, with only 33% indicating 50% or less pain relief.
For military nurses deployed to combat support hospitals, pain management begins at the point of injury. Nurses working in military hospital settings assist in developing effective analgesic regimens. (See Mission of nursing in acute pain management by clicking the PDF icon above.) Raising the pain assessment to the level of the “fifth vital sign” and using standardized assessment and documentation tools greatly improve pain-management care.
Acute pain management relies on a systematic approach to treatment. (See Acute pain management: Key considerations by clicking the PDF icon above.) For nurses, an integral component of patient care is performing regular physical pain assessments and reassessments. These detailed, concise evaluations provide important data for all healthcare team members and serve as the basis for treatment plans. Elements secondary to the pain process, such as psychosocial factors, the patient’s coping mechanisms, family dynamics, and variable levels of patient and family understanding, require nurses to establish trust and a working relationship with patients and families.
Considerations for chronic pain management
For military service members, the rapid transition from being a soldier in a combat zone to returning home to the previous role as spouse, parent, or both is difficult at best. Sustaining serious polytrauma, emotional distress, and psychological exhaustion during military service significantly complicates this transition. At the outset of the current military conflicts, neither DoD nor VA was accustomed to treating survivors of serious blast injuries with significant polytrauma and other associated comorbidities. VHA directive 2009-053 calls for early and continuous treatment of military service members within the DoD, with transition of care to the VA and an integrated stepped pain-management program. Transition to the VA is promoted by a local or regional team to ensure timely initial health assessments, and by coordinators who advocate for care.
Challenges of complex polytrauma
The more complex polytrauma patients with their broader spectrum of physical injuries and comorbidities—including the triad of chronic pain, PTSD, and persistent postconcussive symptoms (the “3 Ps”)—challenge not only current perspectives of the pain continuum and its association with tissue damage and healing. They also challenge pain-management models.
For example, wounded warriors with painful injuries and postconcussive cognitive impairments may require a much more structured environment for successful use of a complex multimodal pain treatment approach. PTSD activates neuropathic pain and worsens cognitive and behavioral controls. Patients with PTSD have higher rates of psychiatric and social problems and less improvement in pain compared to those without PTSD. An effective treatment plan addresses physical and emotional signs and symptoms while providing on-going assessments for and treatment of TBI, PTSD, chronic pain, and substance abuse.
A new disorder, postdeployment multisymptom disorder, has been identified to address the prevalence and greatly increased symptom burden of patients whose pain is clustered with PTSD, mild TBI, PTSD with mild TBI, or substance abuse in patients with polytrauma. To effectively treat these patients requires not just managing individual symptoms but using multifaceted care approaches that focus on function, reintegration into family and social systems, and quality of life.
Currently, DoD and VA are evaluating a new transdisciplinary, stepped, and integrated mental healthcare model centered on maximizing quality of life for patients with postdeployment multisymptom disorder. Core treatments in this model address aspects of daily living and psychosocial functioning; specialty programs are designed to deal with specific diagnoses. Future directions include refining the model, enhancing efficiency of therapy, increasing the consumer focus (such as expanding hours for access to care), and conducting research to determine how interactions among comorbid states affect pain
and identify the most effective treatments for these conditions.
Nurse’s role in chronic pain management Nurses are instrumental in achieving the goals of chronic pain therapy by helping patients navigate all aspects of treatment. Specific nursing actions include medication management, counseling (including adherence to therapy), promoting lifestyle changes (such as smoking cessation, physical therapy, and nutrition counseling), and assisting with complementary and alternative therapies. Of course, nurses are uniquely positioned to conduct pain assessments and monitor responses to analgesic therapies.
Nurses must apply the principles of multimodal analgesia and understand the rationale for both pharmacologic and nonpharmacologic approaches to pain control. Targeted
pain treatments, especially multiple analgesics, require knowledge of drug mechanisms of action, dosing parameters for optimal pain relief, synergistic effects that may potentiate adverse drug effects, and guidelines for safe patient monitoring.
In both military and civilian settings, nursing is contributing to improved pain management through clinical practice and research. Nurses are integral to the success of research
programs on pain at military and VHA facilities and have made substantial contributions to advancing pain science in such roles as research coordinators and associate or principal investigators. Nurses also serve as primary patient advocates in both military and civilian healthcare systems.
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Buckenmaier CC 3rd, Rupprecht C, McKnight G, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med. 2009;10(8):1487-1496.
Clark ME, Bair MJ, Buckenmaier CC 3rd, et al. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice. J Rehabil Res Dev. 2007;44(2):179-194.
Clark ME, Walker RL, Gironda RJ, et al. Comparison of pain and emotional symptoms in soldiers with polytrauma: unique aspects of blast exposure. Pain Med. 2009; 10(3):447-455.
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Lew HL, Otis JD, Tun C, et al. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev. 2009;46(6):697-702.
Office of the Army Surgeon General. Pain Management Task Force. Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and Their Families. Final Report; May 2010. http://armymedicine.mil/Documents/R2D-U.S._Army_Pain_Management_Campaign.pdf. Accessed July 21, 2011.
Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rollin M. Gallagher is Deputy National Program Director for Pain Management in the Veterans Affairs Health System at the Philadelphia Veteran Affairs Medical Center in Philadelphia, Pennsylvania; he is also a clinical professor of psychiatry, anesthesiology, and critical care and Director of Pain Policy Research and Primary Care at Penn Pain Medicine at the University of Pennsylvania School of Medicine in Philadelphia.
Multimodal and multidisciplinary therapy for pain management
By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; Rollin M. Gallagher, MD, MPH; and Rosemary C. Polomano, PhD, RN, FAAN
An important initial step in pain management is setting goals, which differ for acute and chronic pain. Acute pain management aims to gain rapid, effective control of pain and eliminate further sources of pain. In contrast, management of chronic pain, such as low back pain or polytrauma pain, requires a biopsychosocial approach. The goals of chronic pain treatment include:
- communicating realistic expectations (including the message that freedom from pain isn’t realistic)
- improving the patient’s quality of life
- increasing function and mobility
- reducing the degree to which pain interferes with activities
- relieving associated psychological stressors
- minimizing the risk of opioid misuse, abuse, and addiction, which can be associated with long-term opioid analgesics.
Advances in treating combat-related pain
From the 1800s until recently, morphine was the sole pain-control method used by the military. One of the drug’s benefits, researchers recently found, is that morphine given during early resuscitation and trauma care may reduce the risk of posttraumatic stress disorder in military service members who don’t have serious traumatic brain injury. But in the modern combat environment, morphine has many undesirable—and at times deadly—properties. As the Iraq and Afghanistan conflicts continued and more military service members were treated, the need for alternative pain-management methods became increasingly obvious.
The destructiveness of the weapons used and the severity of combat injuries have been greater in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) than in previous conflicts. Yet nearly 90% of OEF and OIF service members have survived their injuries, compared to a 76% survival rate during the Vietnam War. The higher survival rates stem from improvements in modern battlefield care, including advanced frontline surgical and resuscitation capabilities.
For wounded military patients who are hemodynamically stable and have isolated and uncomplicated orthopedic injuries or extremity wounds, oral transmucosal fentanyl citrate is an advance in acute pain management. This is particularly true in austere combat environments, such as those lacking ventilators, where multiple surgeries must be performed in one operating room, or where multiple patients must be placed on a single monitor. One oral fentanyl dose can provide rapid, sustained pain management for up to 5 hours, generally with only minor adverse effects (itching, nausea, vomiting, and light-headedness).
Austere environments challenge the traditional mindsets and training of surgeons, anesthesiologists, and nurses, who must adapt to environmental conditions and develop innovative anesthetic and analgesic plans as resources are consumed. In these environments, regional anesthesia is more common than general anesthesia, and anesthesia complications can be minimized with training and experience.
Rapid transport of wounded soldiers over great distances by air to increasingly sophisticated trauma-care levels contributes to the higher survival rate. Nonetheless, while rapid air transport to the next level of care is an advance, evacuation flights are crowded, light conditions are low, vibration and noise are high, monitoring resources are constrained, and healthcare personnel are limited. These limitations may contribute to the suboptimal pain relief during air transport reported by some military patients with polytrauma.
Recent advances in treating combatrelated pain during evacuation flights and postoperatively include regional analgesia via continuous peripheral nerve blocks (CPNB) and patient controlled analgesia (morphine or hydromorphone). Regional analgesia, which may be administered by certified registered nurse anesthetists, is a preventive strategy that yields improved analgesia, outcomes, and patient satisfaction. Regional analgesia with CPNB also provides pain relief during the frequent trips to the operating room that service members with polytrauma undergo at military treatment facilities and during multiple dressing changes and surgical debridements. Compared to patients who undergo general anesthesia, those who receive CPNB have less pain, receive less analgesia, suffer less postoperative nausea, and experience fewer anesthesia-related complications. Risks of regional anesthesia include local anesthetic toxicity, nerve injury, and infection from the indwelling catheter.
Ongoing pain management
Optimal pain management requires a comprehensive strategy with a multimodal approach that includes pharmacologic therapy, psychological therapy, physical and occupational
therapy, and procedural treatments. (See Multimodal treatments for optimal pain management by clicking the PDF icon above.)
The rationale for multimodal therapy is to improve analgesia by taking advantage of the synergistic action between drugs and the various techniques and delivery approaches that affect different mechanisms in the pain perception-modulation system, or that affect the same mechanism but in different parts of the peripheral nervous system (PNS) or central nervous system (CNS). Synergistic action may allow use of lower dosages and avoid complications of opioid-centered analgesia. A tenet of treating pain patients is that they have a right to have their pain assessed regularly and managed effectively—but they don’t have the right to abuse or violate the terms of their treatment programs.
Multimodal pharmacologic therapy
Many drugs other than opioids are available for treating pain. A rational approach to pharmacologic therapy is to consider a drug’s mechanism of action and the source or type of pain. Multimodal analgesia refers to the use of more than one agent from different pharmacologic analgesic classes that target different mechanisms of CNS or PNS pain. The goals of multimodal analgesia are to:
- improve analgesia quality
- achieve more balanced analgesia
- reduce adverse events.
An example of multimodal pharmacologic therapy is use of an anticonvulsant (such as gabapentin or pregabalin) with an opioid for postoperative neuropathic pain. This
combination reduces opioid requirements and adverse effects while providing better pain relief. Another multimodal strategy is to use a single agent with dual mechanisms of action. An example is monotherapy with tramadol or tapentadol; both drugs have mu-opioid receptor agonism and inhibit reuptake of neurotransmitters (primarily serotonin with tramadol and norepinephrine with tapentadol).
Nonpharmacologic strategies for ongoing management of both acute and chronic pain include physical and occupational therapy, procedural techniques, and psychological measures. These strategies aim to restore function and mobility and to reduce psychosocial stressors that contribute to pain. An example of multidisciplinary, multimodal pain management is the treatment of military service members with polytrauma at entry to rehabilitation; all of these patients receive medication (opioids, 58%; nonsteroidal anti-inflammatory drugs [NSAIDs], 50%; anticonvulsants, 20%). Other forms of therapy are individualized and may include physical therapy (40%), occupational therapy (38%), individual psychotherapy (49%), and cognitive behavioral therapy (13%).
Chronic pain management
Intervening early and aggressively in the chronic pain cycle is crucial to favorably influencing pain and qualityof-life outcomes and preventing progression of disabling pain. The Veterans Administration (VA) developed a stepped-care approach to pain management in response to the changing veteran population and in an effort to standardize pain management throughout the VA. This approach became official policy in 2009. (See VA stepped pain-care approach by clicking the PDF icon above.)
Besides using the stepped-care approach, other aspects of managing patients with chronic pain include:
- establishing a collaborative relationship with the patient to promote self-management
- shifting the patient from a biomedical to a biopsychosocial treatment model
- identifying long-term functional goals
- supporting the patient’s efforts to address other life problems.
OEF and OIF veterans have a high frequency of pain of musculoskeletal or connective tissue origin (52%) with significant comorbidities, including mental disorders (48%), nervous-system or sensory-organ diseases (40%), and ill-defined signs and symptoms (46%). The most common pain diagnosis among deployed military service members is low back pain, which may be exacerbated by combat. Although 80% of patients with their first episode of nonspecific low back pain recover within 1 month and another 10% recover within 3 months, the remaining 10% go on to develop chronic pain.
A thorough physical examination and comprehensive history are the most important tools in evaluating low back pain. The physical examination includes a head-to-toe evaluation
to determine which areas have structural abnormalities and to evaluate posture, inspect for skin changes (such as color), palpate muscles for knots and tender (trigger) points, assess reflexes, and evaluate range of motion. Patients also undergo neurologic and sensory exams and other special tests. The patient history includes the “5 Ps” of pain assessment—precipitation, pattern, prior treatments, patient beliefs, and predisposition. Diagnostic imaging isn’t necessary unless “red flags” are identified during the exam; imaging may be indicated if pain persists for 3 or more months after appropriate conservative treatment.
The goal of conservative treatment is to enable the patient to perform normal activities as soon as possible. Treatment measures include education and reassurance, brief rest (2 to 3 days), prevention of kinesiophobia (fear of movement) with gradual resumption of minimally painful activities, medications (NSAIDs plus muscle relaxants, which may promote a faster return to activity), and physical therapy.
Rational opioid prescribing
Over the last 30 years, use of opioid analgesics for treating chronic pain has increased. As a result, approximately 10% of American adults with chronic pain have a substance abuse disorder. An estimated 33% to 54% of persons with opioid addiction have chronic pain. This vulnerable population deserves effective pain control, but may require more stringent guidelines for opioid prescribing and monitoring. Brain circuits involved in drug abuse and addiction—reward, motivation, judgment, inhibitory control, and memory consolidation—also are involved in pain processing and perception.
Differentiating addiction, physical dependence, and tolerance
How do addiction, physical dependence, and tolerance differ? According to one definition, addiction is a chronic neurobiologic disease whose development and manifestations are influenced by genetic, psychosocial,and environmental factors. Addiction is characterized by one or more of the following:
- impaired control over drug use
- compulsive use
- continued use despite harm
Physical dependence occurs with regular use of mu-opioid agonists and is to be expected. Serious consequences occur when the opioid is withdrawn abruptly or reversed with an opioid antagonist, such as naloxone. Sudden cessation or reversal can lead to a withdrawal syndrome characterized by physiologic responses, such as agitation, rapid pulse, sweating, and orthostatic hypotension. In rare cases, life-threatening seizures may accompany withdrawal, particularly when the patient also is withdrawing from barbiturates or benzodiazepines (which may be coprescribed in patients with chronic pain, although rarely indicated because of synergistic respiratory depression).
Tolerance refers to decreased response to a constant dose of a drug, or the need for increasing doses to maintain a constant effect.
The goal of rational opioid prescribing is to provide pain relief while preventing the potential adverse outcomes of addiction—but recognizing that physical dependence and tolerance may develop, which may necessitate changes in the treatment plan.
The rising use of opioids to treat chronic pain over the last 30 years is tied to a greater number of opioid prescriptions written by providers with limited training in pain management, psychiatry, or addiction. This trend in both the civilian and military sectors may have contributed to a rise in prescription drug abuse in military, VA, and civilian populations. It has prompted the creation of risk-mitigation strategies and programs to minimize the risk of misuse, abuse, and diversion.
Risk-mitigation strategies should be used for patients with a history of opioid addiction who may receive opioids for pain management. Recommended strategies for these patients include:
- prescribing long-acting or timecontingent (rather than pain-contingent or as-needed) opioids
- providing small quantities of opioids that necessitate frequent visits to reassess pain and function
- prescribing the minimum dosage that relieves pain and maintains function
- continuing to educate the patient
- seeking specialists’ opinions and care when indicated by clinical complexity, comorbidities, treatment refractoriness, and higher risk.
When caring for patients who take opioids regularly before surgery, remember that they may require significantly higher opioid doses postoperatively to control pain.
Opioid Renewal Clinic
In 2002-2003, the Opioid Renewal Clinic (ORC) was established at the Philadelphia VA Medical Center to mitigate the risk of opioid misuse, addiction, and diversion. Developed by a nurse practitioner and clinical pharmacist (and supported by a multidisciplinary pain-management team that included an addiction psychiatrist, rheumatologist, neurologist and orthopedist), ORC is modeled on an anticoagulation clinic model. It uses various strategies to mitigate risk, including an opioid treatment agreement (and second-chance agreement), frequent visits, opioid prescribing on a short-term (weekly or biweekly) basis, periodic urine drug testing, pill counts, and comanagement with addiction services.
Several measures demonstrate ORC’s success in reducing the risk of opioid misuse, addiction, and diversion. Most primary-care providers report they’re more comfortable managing patients with chronic pain (89%) and receive fewer complaints from patients regarding pain medications (77%). A 2-year assessment showed use of opioid treatment agreements and urine drug testing increased markedly; emergency department visits decreased by 73% and unscheduled visits to the primary-care provider dropped 60%. In addition, at 1 year, 49% of at-risk ORC patients demonstrated 100% adherence with the program and no aberrant behavior. The ORC has been deemed a best practice by the VA and is being established in various forms throughout the administration and in some civilian settings as well.
National opioid pain care agreement policy
Using a multidisciplinary task force composed of clinicians, ethicists, lawyers, and educational specialists, the VA embarked on a 3-year process to develop a national opioid pain care agreement policy that aimed to standardize and optimize the use of opioid analgesia in pain management. The proposed policy, which takes an informed and shared decision-making approach to risk management, was presented for review in 2009. It recommends routine use of a standardized opioid pain care agreement between provider and patient when chronic opioid therapy is instituted. Patient information resources include a patient guide, which details what the patient needs to know about opioids and pain care in the VA, and a brochure outlining policies and expectations. More recent discussions of this procedure have led to consideration of a standardized informed consent process to replace the opioid pain care agreement policy.
Complementary and alternative medicine for pain management
Complementary and alternative medicine (CAM) encompasses a diverse group of healthcare systems, practices, and products not generally considered part of conventional medicine. The following definitions are useful for understanding CAM terms:
- Complementary medicine is the use of CAM together with conventional medicine.
- Alternative medicine is the use of CAM in place of conventional medicine.
- Integrative medicine refers to a practice that combines conventional and CAM treatments for which evidence of safety and effectiveness exists.
For a summary of CAM techniques commonly used to manage pain, see CAM techniques used in pain management by clicking the PDF icon above.
Nurse’s role in pain management
The Army Pain Management Task Force, chartered by the Army Surgeon General in 2009, emphasizes the need for early and aggressive multimodal therapy for acute pain
with coordinated transition of care from one level to the next. (For more information on this Task Force, see “Pain management across the military continuum” in this supplement.) At all levels, care is an interdisciplinary team effort in which nurses play a central role that includes:
- communicating with team members and injured military service members
- educating patients about painmanagement strategies
- assessing and documenting pain and pain treatments.
Nurses develop unique and sustaining relationships with patients and families, engendering lasting trust that can be instrumental in achieving satisfaction with care and established goals in managing acute or chronic pain. The high survival rate after serious combat injuries in
the current conflicts will increase the population of military service members and veterans with acute and chronic pain. Nurses can make a profound contribution to their recovery and return to duty or active civilian life.
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Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rollin M. Gallagher is Deputy National Program Director for Pain Management in the Veterans Affairs Health System at the Philadelphia Veterans Affairs Medical Center in Philadelphia, Pennsylvania; he is also a clinical professor of psychiatry, anesthesiology, and critical care and Director of Pain Policy Research and Primary Care at Penn Pain Medicine at the University of Pennsylvania School of Medicine in Philadelphia. Rosemary C. Polomano is an associate professor of pain practice at the University of Pennsylvania School of Nursing and an associate professor of anesthesiology and critical care (secondary) at the University of Pennsylvania School of Medicine in Philadelphia.
Resources for additional information
The organizations, websites, guidelines, and publications below are excellent resources
for readers seeking more information on pain, pain management, and closely related topics.
Organizations and websites
American Society for Pain Management Nursing
The mission of the American Society for Pain Management Nursing is to advance and promote optimal nursing care for people affected by pain by promoting best nursing practices, accomplished through education, standards, advocacy, and research. The organization’s goals are to promote access to high-quality care for pain, advance public awareness of pain, provide education on pain management, and promote professional recognition to clinicians who manage patients with pain.
International Association for the Study of Pain
Founded in 1973, the International Association for the Study of Pain (IASP) is the leading professional organization for those engaged in the study of pain, its basic science, and its management as well as education in the field of pain. Any professional involved in pain research, diagnosis, or treatment can become an IASP member. IASP has more than 7,000 members in 100+ countries across the globe, as well as numerous U.S. national chapters and special interest groups.
Veterans Health Administration
This website aims to promote effective pain management by providing convenient, centralized access to the resources needed to provide pain-management services within the Veterans Administration (VA) healthcare system. Intended users of this site include veterans, their family members, caregivers, VA administrators, clinicians, and researchers with an interest in any aspect of pain management. The site provides quick access to relevant resources from both internal and external sources.
Assessment and management of low back pain
This guideline describes critical decision points in diagnosingand managing low back pain. It provides clear, comprehensive evidence-based recommendations that incorporate current information and practices for practitioners throughout the Department of Defense (DoD) and VA healthcare systems.
Management of opioid therapy for chronic pain
Describing the critical decision points in managing opioid therapy in patients with chronic pain, this guideline provides evidence-based recommendations and workgroup consensus statements.
Management of postoperative pain
Besides detailing critical decision points in managing postoperative pain, this guideline makes evidence-based recommendations that incorporate current information and practices for practitioners in the DoD and VA healthcare systems.
Practitioner’s Manual: An Informational Outline of the Controlled Substances Act (2006)
The Drug Enforcement Administration established this comprehensive website for information and resources on drug diversion and misuse. Users can access the Practitioner’s Manual from this site.
The Military Advanced Regional Anesthesia and Analgesia Handbook
Developed as a supplement to Emergency War Surgery: Third United States Revision (2004), this handbook is a resource for managing the pain of battlefield trauma. Its purpose is to educate anesthesiology residents in the art and science of advanced regional anesthesia techniques and acute pain medicine. The handbook is available for free download; readers can choose to download it by chapter or in its entirety.