Veterans and Pain Management

The British Journal of Pain studied veterans for pain, musculoskeletal problems, PTSD, and reasons for medical discharges. Problems uncovered include a lack of published evaluations, limited clinical services for vets, and veterans being passed from one specialist to another without adequate treatment. 

Introduction

Combat operations in Afghanistan and Iraq have resulted in a steady flow of casualties, with over 6500 British personnel admitted to field hospitals in Afghanistan as of January 2013. As a consequence, there is substantial government and media interest in the health of veterans. Military trauma care has improved, both in the field and in the UK, such that servicemen and women are surviving severe injuries that would have proved fatal in previous conflicts. Improved body armour has also increased survival rates. Thus, there are an increasing number of servicemen and women who will go on to survive with the long-term consequences of serious injury (i.e. amputation, head injury, pain). In the USA, veterans are treated in the Veterans Affairs (VA) system, a dedicated and extensive network of 1700 nationwide treatment facilities. However, in most other countries, veterans will be treated in the public health system after discharge. American data suggest a high rate of persisting pain in veterans seeking healthcare treatment, with moderate to severe pain intensity identified in 28% of US veterans seeking healthcare in a chart review. Pain appears to have a unique negative impact on the physical functioning of veterans, above and beyond variables such as depression and post-traumatic stress disorder (PTSD).³ This paper addresses this growing issue, and focuses on the treatment of chronic pain in veterans; we will emphasise the treatment of British veterans, but refer to international data, particularly that gathered in the VA system in the USA.

Although there has been an emphasis on severe combat injury, this may not be representative of the range of injury types and causes in the military. For example, there are many training injuries, and many casualties have experienced the military equivalent of a ‘work place injury’, whether in a combat zone or not on deployment. Military life in all services requires hazardous activity, such as operating heavy machinery in unpredictable environments. Accidents on land, in the air and at sea are inevitable. The importance of this broader focus is made clear by data from an American forward surgical team in Afghanistan; 42% of their work was non-combat injuries, with under half of their patients (49%) having battle injuries. British data indicate that 68% of Afghanistan field hospital admissions have been for disease or non-battle injuries. Specifically, lower back pain is not necessarily associated with the physical aspects of combat or infantry load-carrying; a study of 37,000 US Marines with back pain (all having been deployed to Iraq), indicated the highest rates in service/supply and electrical/mechanical trades, rather than infantry. However, there are no equivalent data for a British population. Therefore, this paper reviews existing data that may clarify the broad range of chronic pain problems in veterans being treated in the public health system.

Musculoskeletal pain and musculoskeletal injury

Several sources of data point to high rates of musculoskeletal pain in veterans and serving military personnel. The best-conducted surveys of veterans’ overall health investigated the experiences of Gulf War veterans. Kang et al. surveyed 11,000 American Gulf War veterans; the most commonly self-rated ‘severe’ healthcare problem (amongst all possible problems) was back pain (17%), followed by joint pain (15%). Unwin et al. surveyed 4000 British Gulf War veterans six years after deployment, and also found that back pain was the most common self-reported health problem at 36% (again, amongst all possible health problems; this reported rate is likely to be higher as there was no judgement of ‘severity’). These high rates of back and joint pain are not purely due to Gulf War deployment, as they are mirrored in comparable non-Gulf veteran cohorts. Unwin et al. also surveyed a similar-sized cohort deployed to…

 

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