Veterans and the Triad of Chronic Pain

An article earlier this year in the British Journal of Pain reminds us of the burden of what some may consider the mundane: There is a high rate of musculoskeletal pain in veterans. A survey of American Gulf War veterans found that back pain was the most common “severe” health care problem, affecting 17%, followed by joint pain in 15%. Our British comrades-in-arms in the Gulf conflict found back pain in 36% of those surveyed. However, 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. For example, among veterans of the Bosnian conflict, 24% complained of significant back pain. In fact, back pain is common in veterans who have been operationally deployed and in those who have not, and so is likely to represent a key healthcare need of veterans. However, as there are high rates of back pain in the general population, it is impossible to know whether these high prevalences are particularly related to military service.

Medical discharge statistics often tell the more telling tale, and it appears that musculoskeletal problems are the most common reason for a medical discharge, with women more likely to be discharged with such musculoskeletal injuries when compared with men. In Britain in particular, musculoskeletal rehabilitation services are of high quality, and thus for a soldier to have reached the point where a medical discharge was deemed necessary, the musculoskeletal problems must have been:

• Long-standing.

• Functionally interfering.

• Refractory to standard-of-care treatment—and then some.

And these are the features that lead to chronic pain in many chronic pain patients.

Unfortunately, those veterans seeking treatment are likely to have high rates of comorbid emotional problems, similar to civilian populations, but with the potential for particularly high rates of PTSD and alcohol problems. Encouragingly, most pain services, and particularly multidisciplinary pain management programs, have highly applicable skills for this veteran population. Developments in the US military have involved adapting interdisciplinary chronic pain programs for military settings. There will also be a minority of patients who have experienced severe injuries and have multiple chronic problems.

Even where diagnosable PTSD is not present, sub-clinical traumatic distress may be significant, and individuals may benefit greatly from disclosing trauma to a professional. One study of 23 US veterans seen by Veterans Administration staff suggested that they appreciated direct, informal questioning about trauma using open-ended questions. Disclosure was easier when the clinician did not hurry the patient, ensured privacy and made an attempt to ease the patient’s sense of shame. Civilian pain clinicians can be trained in recognizing PTSD symptoms, normalizing distress and reducing shame, and in the supportive interviewing skills that aid openness. This will usually require access to psychological supervision, in order to maintain skills, discuss mental health issues and prevent ‘burnout’ where traumatic disclosures are frequent or distressing. ‘Cultural’ training for civilian staff, to allow for a more natural and spontaneous interaction with a veteran, might include (1) knowledge of the range of branches and roles in the military (including the predominance of non-combat roles), (2) an idea of rank structures, (3) knowledge of military rehabilitation facilities and approaches, (4) familiarity of the discharge process and its impact, (5) an appreciation for the impact of family issues in the military and (6) services cultures around physical exercise.

Many veterans are willing to attend health services for the treatment of their chronic musculoskeletal pain. An important minority will also need pain treatment whilst living with the long-term consequences of severe injury. Veterans have the capacity to do well in multidisciplinary pain clinics. However, staff training around veterans’ issues is essential, and appropriate provision and support for the treatment of comorbid PTSD and alcohol problems is required to avoid treatment failure.

We have memories on a day such as Veterans Day. At the very least, the veterans should have hope.