Waging a War on Pain

Chester “Trip” Buckenmaier III, MD, can see the silver lining in a black cloud. The program director for the Defense and Veterans Center for Integrative Pain Management in Washington, DC, often says that war—that most dreadful and deadly of human inventions—can be a catalyst for positive medical change.

That’s looking on the bright side. But Dr. Buckenmaier is no Pollyanna. The retired army colonel, military doctor and professor doesn’t relish the thought of war (he calls it “the human condition at its worst”), but says medical innovations have arisen as a result.

After 14 years of conflict in the Middle East, thousands of soldiers now bear the scars of war. Missing limbs are one of the most obvious signs. But Dr. Buckenmaier candidly points out that “while post-traumatic stress disorder, traumatic brain injury and chronic pain don’t necessarily carry the red badge of courage or evoke the empathy that physical injuries do, these conditions are no less devastating.”

He treats members of the military and veterans for these conditions, but what he’s learning in the process has implications for civilians.

“Military medicine is a reflection of civilian medicine,” he says. “The two feed off each other.”

And have something to teach each other, too. According to Dr. Buckenmaier, when the United States goes to war, military doctors take with them all the current medical knowledge and then are forced to improvise on the battlefield in a way civilian physicians don’t usually have to. As a result, new techniques and treatments may be developed that benefit everyone, not just American soldiers.

PAIN, DECLARING WAR

Unlike most other medical conditions, Dr. Buckenmaier points out, there’s no blood test or other screening for pain, which can make it easy for cynics to deny that pain is a real medical condition. And that’s a great disservice to the 100millionAmericans living with chronic pain—a figure Dr. Buckenmaier said may be a “gross underestimate.”

“America loves to declare war on things,” says the military doc. And he believes it’s time for America to wage war on pain. “Richard Nixon began a ‘war on cancer’ and mistakenly believed there’d be an ‘answer for cancer’ within ten years,” says Dr. Buckenmaier. There’s still no cure, but one thing’s been made plain in the years since Nixon signed the National Cancer Actin 1971, and that’s this: There is no one-size-fits-all answer to cancer.”

Cancer requires individualized treatment and usually a number of different modalities. It’s the same with pain.“No one thing fixes pain,” Dr. Buckenmaier affirms. However, several treatments, when used in combination, can help alleviate it.

NEW PAIN PERSPECTIVES, NEW CENTURY

Although he now serves as one of the military’s primary pain consultants, Dr. Buckenmaier didn’t start out with a desire to specialize in pain treatment. He was undergoing specialty training in regional anesthesia at Duke University at the time of9/11. Suddenly, the country was at war.

He and others realized that America was waging modern warfare using pain relief methods from the 1800s.The trauma medicine may have been state of the art, but pain relief was woefully inadequate.

Recent conflicts have been especially cruel for limbs. Improvised explosive devices (IEDs)—often referred to as roadside bombs—are designed to kill or maim. Military doctors in Iraq and Afghanistan needed to confront treating pain in patients who had lost one or more limbs, a process that starts immediately after injury.

During his military service, Dr. Buckenmaier was stunned to realize “the only pain relief tool available to us was a 200-year-old answer: morphine”—the same treatment used by Civil War physicians.

There was even a saying in the military about the prevalence of morphine, and how it was used in ever-increasing doses with little regard to its long-term effects. The more pain, the morepheen,” the saying went. he motivation was noble: stopping the pain. But there wasn’t much attention paid to the consequences of a morphine-only approach for pain. As we now know, prescription medication deaths, particularly from opioids like morphine, have reached epidemic proportions in the United States, outpacing deaths from automobile crashes in many states. Modern physicians and soldiers needed a better way.

Dr. Buckenmaier and his multidisciplinary colleagues (and other research physicians across the country) began to advocate for a new strategy: a multidisciplinary and multimodal approach with the patient at the center. “Pain medicine,” he says, “needs to be a team sport.”

NO LAUGHING MATTER, INTEGRATIVE APPROACH REALLY WORKS

Military medicine, Dr. Buckenmaier says, has finally begun to recognize the role of integrative medicine—yoga, massage, acupuncture, biofeedback and the like—in treating pain.

Trip Buckenmaier, MD, has an education as impressive as his military background. He was a fellow in regional anesthesiology at Duke University after completing his residency in anesthesiology at Walter Reed Army Medical Center. In the1990s, he was a brigade flight surgeon based first in Panama and then at Fort Bliss, Texas.

The attacks on September 11, 2001, happened during his fellowship at Duke and changed his life, as they did so many others. Once he saw the outdated pain relief methods the US military was still relying on, Dr. Buckenmaier knew he had found his calling: finding a better, safer way to get pain relief to soldiers, one that didn’t have the long-term and potentially disastrous side effects of opioids.

Since 2013, he’s been a professor of anesthesiology at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland. Dr. Buckenmaier was also a director at large of the American Academy of Pain Medicine and is the director of the Defense & Veterans Center for Integrative Pain Management (www.DVCIPM.org) at the Uniformed Services University. Whether in the classroom, the operating room or on a battlefield, Dr. Buckenmaier has made pain management his mission

“In the military, we used to snicker,” he admits. “I would smirk about integrative medicine techniques. But they offer very real answers.

“We’re not going to find answers just in neuromodulation, or just in acupuncture,” he continues. “It’s going to take doctors and practitioners from a number of disciplines working together to make a dent in the chronic pain epidemic.”

And focusing on chronic pain alone isn’t the solution. Chronic pain often begins with acute pain, and the health care community has got to get better at treating it, says Dr. Buckenmaier. “If we can effectively manage acute pain, we can lessen or avoid chronic pain.”

During wartime, we need “aggressive management of acute pain on the battlefield, or we risk setting the patient up for a multitude of major problems during rehabilitation and recovery, up to and including death.” The current opioid misuse and abuse problem in the military and country in general is a symptom of the larger pain problem the nation is facing, he says.

Perhaps toughened from the military, Dr. Buckenmaier is unafraid to take on skeptics. “I’m concerned that medicine today is being hijacked by pharmaceutical companies and device makers. Some very important therapies—acupuncture, yoga, massage therapy—don’t always get their full due because there’s no money to be made in advocating for those options.”

CHASING ZERO, OLD MANAGEMENT METHODS DON’T WORK

Pain doctors have gotten used to asking the question, “What’s your level of pain from 0 to 10?” And patients have gotten used to (and maybe a little tired of) answering the question.

But Dr. Buckenmaier says whatever the patient’s answer is, it’s not effective information. He’s had soldiers and veterans tell him, “My pain today is a 7. My pain yesterday was a 7. And my pain, as far as I can see, is always going to be a 7.” They feel hopeless.

According to Dr. Buckenmaier, asking patients about their pain number and holding out the hope of 0 sets up unrealistic expectations. There’s even a saying in the military—“chasing 0”—that gives the impression that a life with no pain is the only acceptable goal.

“There are so many other things we should be measuring,” Dr. Buckenmaier says. “Physical function, social function, getting better sleep, mood …all of that counts. And we should be asking about it all. Our focus has got to be on maximizing function.”

PAIN ASSESSMENT SCREENING TOOL AND OUTCOMES REGISTRY (PASTOR)

In 2010 a team of military doctors developed a tool that does ask about more than pain level. (See sidebar at left.) The Pain Assessment Screening Tool and Out comes Registry (PASTOR) is a free, online tool that helps patients look at a host of other measurements besides pain intensity to gauge quality of life from a holistic perspective.

Dr. Buckenmaier calls former Army Surgeon General Lt. Gen. Eric Schoomaker “the real hero” in developing the measurement tool. The MD and PhD chartered the military’s Pain Management Task Force.

The Task Force’s final report, published in May 2010, contains more than 100 recommendations for a multidisciplinary and multimodal pain management strategy to address acute and chronic pain. An addiction specialist was among the task force members—along with anesthesiologists, orthopedists, nurses and more.

THE HOPE IN A MULTIDISCIPLINARY APPROACH

The military and civilian population suffering from pain has an ally in Dr. Buckenmaier. He is working to ensure that pain is taken seriously and that pain patients get the best, customized care regimen for them—whether that’s an ancient method of healing or a state-of-the-art implant. {PP}