Pain as Part of Trauma Spectrum Disorder in Military Populations

There was a very somber tone to the Saturday morning session, "Pain as Part of Trauma Spectrum Disorder in Military Populations." Perhaps it was the very notable date of the presentation: the 9-year anniversary of the September 11 terrorist attacks. Perhaps it was the speaker—Kathleen Brown, PhD, CPE, the director of the Pain Rehabilitation Service at Tripler Medical Center—whose grandfather served in World War II, whose husband is a retired officer, and whose grandson is a marine. Or perhaps it was the moving first-hand accounts written by service men and women that Brown read early in her presentation.

Prior to reading portions of those accounts, Brown asked the audience to listen and try to "immerse yourself in the environment our military personnel face on a daily basis." It was not a difficult thing to do, given the vividness of the accounts she read, and the obvious emotion that the words elicited, for both Brown and for the rapt attendees.

One account told movingly of a soldier who repeatedly came under sniper fire and was concerned that his return fire, in the confusion, could be injuring innocents. Later, the same soldier talked of a large car bomb that destroyed a marketplace, killing dozens and spraying body parts. In the chaos, the serviceman focused briefly on a small shoe that still had a foot in it. A pink shoe, with flowers on it. Brown read, "It just smoldered and was sitting there on the side of the road. This was a little girl, she was obviously an innocent, and her life was snuffed out in a second. And you're just numb to it. There’s a great numbness that creeps over everybody."

The purpose behind reading the soldiers' stories was to help the pain practitioners understand not just the physical pain challenges that a soldier may present with, but also the context and culture that the soldier is bringing with him or her. All pain practitioners are going to need to know how to deal with this population, said Brown, because nearly three-fourths of all military personnel will at some point be treated in the civilian sector, and pain practitioners will be handling the bulk of this care. "This is generally a young population, so these are patients who will probably be with you for some time," she noted.

Brown referenced the "Acceptance and Commitment Therapy" presentation by Alessandra Strada, PhD, on Wednesday. "At this meeting," Brown said, "I’ve been touched by the focus on the concept of acceptance. Acceptance and Commitment Therapy was important, because it's value-based, and I think military culture is very values-based."

Though she talked about acceptance as a concept, Brown pointedly said that she hated the phrase, "You’re going to have to just live with it," and said that it should be stricken from a pain practitioner's language. She said a common reaction to that phrase might be, "What, doc, you’re saying I'm going to live with this pain for the rest of my life? I’m going to put a gun to my head." This phrase is particularly dangerous for military patients, she says, because the culture is one that values selflessness, toughness, and a philosophy of "no pain, no gain." That "warrior ethos," as Brown called it, works well for basic training or physical conditioning, but can delay needed treatment for military patients, often exacerbating an acute injury to something more chronic in nature.

Understanding the military culture goes well beyond making assumptions about the attitude a pain patient may bring to the physician visit. It's helpful in understanding what patients may be holding back from telling you, recognizing that they may be down-playing their pain, and understanding the connection between mind and body that may be fueling their pain.

Opioid abuse was also a major focus of Brown's presentation. She said that the Department of Defense has been attempting to identify those individuals who may be at risk for abuse through screening measures to identify the factors tied to the potential for opioid abuse. Providers, she said, need to use an opioid agreement whenever opioids are prescribed, to help both the provider and the patient understand each of their responsibilities.

Brown talked about trauma spectrum disorder, which is a constellation of symptoms that includes pain; psychological disturbances, such as depression and anxiety; post-traumatic symptoms; and sometimes cognitive changes, such as post-concussive symptoms, that soldiers may have following deployment. The presence of co-morbidities for many patients brings significant clinical challenges. "What do you treat first?" asks Brown. "What takes priority? There are no clinical algorithms that tell you how to put together a treatment plan. This requires an integrated approach to clinical care that crosses traditional medical specialties. Primary care physicians and patients are the hub of the wheel. All the consultants and specialists are the spokes. If the PCP is not involved, gap and fragmentation in care are likely."