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Army on brink of new ways to fight pain

Jul. 11, 2011 - 08:13AM   |   Last Updated: Jul. 11, 2011 - 08:13AM  |  
A change in record-keeping methods may be partially responsible for a spike reported in prescription drug use among soldiers.
A change in record-keeping methods may be partially responsible for a spike reported in prescription drug use among soldiers. (Sgt. Samantha Beuterbaugh / Army)
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SAN ANTONIO — The Army is reinventing the way it treats pain. Based on 109 recommendations from an Army-led Pain Management Task Force, the Army is seeking to move away from merely dispensing pain medication to embracing a holistic, multidisciplinary approach to caring for soldiers.

This approach could include traditional medications coupled with more unconventional treatments such as massage therapy, acupuncture and yoga.

"Morphine is an extremely valuable tool, but when it's your only tool in your toolbox, you run into the problem of monolithic thinking," said Col. (Dr.) Trip Buckenmaier, director of Army Medical Command's Defense and Veterans Center for Integrated Pain Management. "[This is just] a means of providing a variety of different techniques that have proven worth and bringing those techniques to the patient."

Buckenmaier, who is an anesthesiologist trained in acute pain management, said history has shown that pain is usually thought of as merely a symptom of a larger problem.

"Now we realize pain is far more complex than that," he said. "Pain has an emotional component, it has a psychological component. It impacts the way you deal with your family. It impacts the way you deal with work."

The key is to find a way to manage pain in the best way possible, said Col. Kevin Galloway, chief of staff for the Pain Management Task Force.

"It's the dynamic of driving pain down to the lowest point possible and increasing quality of life, and the two points meet somewhere," he said.

He also emphasized that the Army isn't going to stop giving soldiers pain medication. It is merely seeking to also look at other methods and alternative treatments and therapies.

The issue of dealing with pain is not just an Army issue, Galloway said.

"There's no Army pain," he said. "There's just pain."

The wars in Iraq and Afghanistan have spurred the medical community to take a closer look at treating and managing pain, officials said.

"Opioids, particularly morphine, have been the answer for pain for many decades and it worked OK, but in the current conflict, things changed," Buckenmaier said. "We have a 90 percent survival rate now. We have more people surviving from horrible wounds than ever before, and we're beginning to see that this tool we were relying on was beginning to fail us."

Incidents of misuse, abuse or dependence on these medications also became a factor in exploring additional ways to treat pain, he said.

"We need to get a handle on the tsunami of pain that's going to hit America from these conflicts," Buckenmaier said. "Not just the wounded, but also the large population of pain we haven't seen yet but will soon from the wear and tear on soldiers' bodies and musculoskeletal pain."

Practitioners of Western medicine are good at reactionary, acute medicine, Buckenmaier said.

"There's nobody better at reacting to trauma and reacting to disease," he said. "Where we lack is preventing disease, [whether through] diet, or maintaining fitness so you're more resistant to musculoskeletal injuries."

Soldiers put their bodies through a lot, and "our job is to make those soldiers as strong and resilient as possible beforehand, and when they do get injured, to provide things beyond medicine," he said.

The Army — and the military as a whole — is the perfect place to bring about such change, Buckenmaier said.

"We have a system that allows us to affect change very rapidly," he said.

However, changing a culture and maybe turning skeptics of certain therapies into believers will take time, Buckenmaier said.

"We have no illusions," he said. "What we're asking of our community truly is a reorientation of the way we think about pain and how we think about medicine in general."

The Army is working to implement recommendations put forward by the pain task force. Highlights include:

• Interdisciplinary pain management centers. These centers consist of physicians and specialists in a variety of areas including acupuncturists, a clinical pharmacist, a movement therapist who specializes in areas such as yoga or tai chi, a chiropractor, a medical massage therapist, physical and occupational therapists and a neurologist.

Four centers will be stood up this fiscal year, at Tripler Army Medical Center, Hawaii; Madigan Army Medical Center at Joint Base Lewis-McChord, Wash.; Eisenhower Army Medical Center at Fort Gordon, Ga.; and Landstuhl Regional Medical Center, Germany.

In fiscal 2012, the plan is to add four more teams, at Womack Army Medical Center at Fort Bragg, N.C.; Brooke Army Medical Center at Fort Sam Houston, Texas; Darnall Army Community Hospital at Fort Hood, Texas; and William Beaumont Army Medical Center, Fort Bliss, Texas.

The work done by these teams, from their productivity to their outcomes in treating patients, will be collected and the data will be examined, Galloway said.

"If evidence comes in to show this works, we will argue for these teams to be everywhere [across the Army]," he said.

Defense and veterans pain rating scale. This new scale, which is being validated for use, replaces the commonly used 11-point chart that asks patients to rate their pain. This new scale retains the 11-point scale but adds functional language to each rating. For example, instead of just choosing a number from zero to 10, patients can rate their pain based on the language accompanying each number. A rating of four would mean the pain is distracting but the patient still can conduct normal activities. An eight would represent awful pain that makes it hard to do anything, while a 10 signifies pain so excruciating that nothing else matters.

In addition to the revamped pain scale, patients will be asked supplemental questions about their general activity, stress level, mood and sleep patterns.

"The reality is, in many patients I can't make your pain go away," Buckenmaier said. "The goal of any pain treatment team is to provide the patient the maximum quality of life and function as we can. It's not just about asking the pain question. It's about asking, ‘What are your goals?'"

Pain assessment and outcome registry. PASTOR is a clinical information and data system that allows patients to go online and fill out a comprehensive survey seeking information on areas such as lifestyle and health history that will be provided to the health-care provider before the patient's appointment.

"It's empowering the patient and giving them responsibility for their care," Buckenmaier said.

PASTOR also will give care providers more information than they might be able to glean from a short, routine check-up.

The Army hopes the new approach becomes standard across the Defense Department, which is why representatives from the Air Force and Navy were members of the pain task force and the group's report has been provided to the surgeon general for each service.

"We are embracing a cultural change within the military," Buckenmaier said. "It's going to take years, but we're not going to wait around. This is the direction the Army is rolling, and it's sometimes hard to get us to roll in a direction, but once we get moving, we get things done."

Ear acupuncture: headed to combat zones?

If you're in pain, some Army doctors might stick a needle in your ear.

Auricular acupuncture focuses on points in the ear, and some Army doctors who have practiced this form of pain management are looking to introduce formal training for some medics and increase its use across the Army.

"Acupuncture has been used in the Army for over a decade," said Maj. (Dr.) David Jamison, chief of the pain clinic at Walter Reed Army Medical Center in Washington, D.C. "Since I was a resident in 2004, people were using it already, but it's become much more mainstream. We're using it a lot more in training more people, and we're trying to have it be included more in our algorithms for treating pain, certainly here at Walter Reed."

Jamison and his colleagues are developing a plan that would add auricular acupuncture training to Special Forces medic training.

"This past fall, I attended the Special Operations Medical Association annual conference and talked about several types of acupuncture," Jamison said. "We're trying to push out some of these methods to the field environment, and we're trying to push it out so it can be used farther forward."

Right now, there's no formal training or requirement for Army medical personnel to be trained in acupuncture, auricular or otherwise. Instead, those who have the training will use it in addition to regular treatments.

"I'd say it's not a standard of care," Jamison said. "I use it in my practice, but it's mainly as an adjunct to our other therapies. When I was deployed, I was at a combat support hospital, but I brought acupuncture supplies with me and lots of people loved it there."

Auricular acupuncture would be an ideal way to introduce acupuncture to the battlefield because its basic form is easier to teach and simpler to practice than regular acupuncture, Jamison said.

"We think it can be used more in the field than it is," he said.

You can teach someone a few basic auricular acupuncture techniques over a weekend, Jamison said. You can use traditional acupuncture needles for 20 to 30 minutes at a time or insert a small needle that's attached to what looks like a small gold stud into the ear and the patient can leave it in for a couple of days, he said. Typically, an acupuncturist will put four or more needles in each ear.

Auricular acupuncture works, Jamison said. And with increasing acceptance of alternative therapies, he hopes this practice will become more common across the Army.

"I would say most people thought it sounded pretty strange to them maybe five years ago, but you hear a lot more about acupuncture now and there are enough people who have had it and had a good experience with it. Now people request it when they come in."

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