With the country at war on two fronts for most of the 21st century, it should come as no surprise that chronic pain, and the treatment of it, is a significant concern within the U.S. military.
A study published in JAMA Internal Medicine(2014;174:1400-1401) sought to gain unprecedented understanding of the scope of the chronic pain problem, and the consequences of its management, within the armed services by surveying more than 2,500 combat personnel who had served in either Iraq or Afghanistan in 2011. The goal was to discover the prevalence of chronic pain in this population, and to get a sense of the use of opioids (both appropriate and inappropriate).
According to lead author Robin L. Toblin, PhD, clinical research psychologist at the Walter Reed Army Institute, Bethesda, Md., the potential for abuse and misuse associated with opioids was a primary consideration in the design of the study. The use of opioids in the treatment of chronic pain within the civilian population was a focus of Dr. Toblin’s work during her time at the Centers for Disease Control and Prevention (CDC), where she served as an Epidemic Intelligence Service officer before joining Walter Reed. She acknowledged that given the combination of physical injuries and psychiatric issues (e.g., post-traumatic stress disorder) many of these soldiers face as a result of their service, proper use of opioid therapy is particularly crucial.
“I had conducted a similar study at [the] CDC because we felt that it was important to understand [the] use of opioids to get a greater context for misuse and abuse,” she said in an interview. “When I began my current position, we sought to look at the same constructs within a military population, who seemed to be that much more likely to be in pain due to the combat deployments over the last decade.”
Of the 2,597 soldiers surveyed by Dr. Toblin and her colleagues, 45.4% reported suffering from combat injuries, and 44% reported experiencing chronic pain. Of this latter group, 48.3% reported pain lasting at least a year and 55.6% stated that they suffered from “constant” pain; 51.2% reported that their pain was moderate to severe.
Although these numbers are hardly surprising for a population of soldiers serving on the front lines, the findings regarding the use of opioids within the sample are, at least on the surface, somewhat alarming. Overall, 15.1% of the soldiers surveyed said they received opioid-based therapy to manage their chronic pain; among these respondents, 23.2% said they had used opioids in the month before being surveyed, an indication that many of them were using these drugs long term. (Long-term opioid use is not recommended under the current U.S. military guidelines for pain management.)
“[Based on these findings], we hope that the military services will be more aware of the unmet needs for the assessment, management and treatment of pain and will broaden the services and availability of those services for servicemembers,” Dr. Toblin said.
As compelling as this data is, however, pain specialist Lynn Webster, MD, cautioned that opioid use among military personnel is not necessarily generalizable to the civilian population.
“The culture in the military is much different,” said Dr. Webster, vice president of scientific affairs, PRA International in Raleigh, N.C., and immediate past president of the American Academy of Pain Medicine. Dr. Webster was not involved in Dr. Toblin’s research. “But, I think it does suggest that opioids may be used in the military as a first-line therapy; alternatively, the soldiers could be using opioids to medicate other comorbid conditions. If true, it would be disturbing and could explain why the military is experiencing a crisis with prescription drug abuse.”
In a commentary published with Dr. Toblin’s research, Wayne B. Jonas, MD, Lt. Col. (Ret.) of the Samueli Institute, Alexandria, Va., and Eric B. Schoomaker, MD, PhD, Lt. Gen. (Ret.) of the Uniformed Services University of the Health Sciences, Bethesda, wrote that “the nation’s defense rests on the comprehensive fitness of its service members—mind, body and spirit. Chronic pain and use of opioids carry the risk of functional impairment of America’s fighting force” (JAMA Intern Med 2014;174 :1402-1403).
For those concerned about the overall issue of opioid abuse and misuse, those may indeed be fighting words.
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