LANDSTUHL, Germany — Wounded servicemembers were first injected with morphine during the Civil War, and in the nearly 150 years since, morphine has remained the first — and many times the only — option for treating troops hurt in combat.
Thanks to faster battlefield care and better body armor, about 95 percent of troops wounded in Iraq and Afghanistan are surviving, a major increase from earlier wars. But until recently, pain control has lagged behind advances in surgical and trauma care.
Doctors at downrange hospitals and Landstuhl Regional Medical Center are now treating wounded troops with innovative nerve-numbing devices and techniques that target and block pain while keeping patients lucid. Effective but not addictive, these high-tech nerve-blocking treatments have profoundly changed pain control on the battlefield.
“If you have nothing else, [morphine] is certainly worth taking,” said Dr. (Maj.) Ronald L. White, director of pain management at Landstuhl. “But these medicines work at cutting the wire chemically.”
Veterans Affairs doctors, meanwhile, have developed new therapies for treating pain, even as troops return with myriad injuries — everything from aches and strains to shrapnel wounds, head injuries and amputations.
“Just look at headaches alone,” said Dr. Michael Clark, clinical director of the VA’s largest and most comprehensive pain management and rehabilitation program in Tampa, Fla. “I’ve not seen this many headaches in my 30 years of working at the VA.”
Blocking the nerve
When a person is injured, nerves relay pain messages in the form of electrical impulses to the spinal cord. The spinal cord then releases a series of neurotransmitters, interpreted by different parts of the brain as pain.
For troops in Iraq and Afghanistan, many of whom are maimed in bomb blasts, morphine dulls the pain, but provides only limited relief.
“You are not treating the pain completely,” White said.
A heavy dose of morphine might render a badly injured person unconscious, he said, but the pain remains even through sedation, and patients risk developing tolerance and dependence as doses are increased.
Morphine “affects multiple receptors in the brain,” White said, not all of them related to pain. “You get these people that are nauseous, itchy, sedated, but still in a lot of pain.”
Surgical anesthesia, by contrast, works by depressing the central nervous system and interfering with the electrical signaling of all the nerve cells. But general anesthesia becomes dangerous when given for prolonged periods and requires careful monitoring. The pain also returns shortly after patients awake, which means they will still need morphine or other opiates to treat what lingers.
But nerve-blocking treatments, developed by civilian researchers and used increasingly by White and other downrange specialists, work altogether differently: By targeting specific nerves, they stop pain impulses from reaching the spinal cord in the first place.
Using ultrasound, doctors search for the nerve that has been injured or severed. An analgesic, such as Novocain, is pumped by tiny catheters into the membrane of the damaged nerve, bathing it in medicine and blocking its ability to send pain impulses.
For White, the advantages of nerve blockers over traditional methods of pain control are clear: Patients remain alert, and there is a reduced risk of dependency, a common problem with opiates such as morphine. The catheters also allow patients to adjust the level of medication as they need it, and they continue working weeks after surgery.
Better still, White said, since troops’ brains are not being medicated, their prospects for recovery from mild traumatic brain injuries, or concussions, are increased.
“Their cognitive functioning is improved,” he said, “because you got them off all these medications that affect the brain.”
Patients also sleep more soundly than when they are medicated with opiates, concealing one of the most disturbing symptoms of post-traumatic stress disorder — insomnia.
New research suggests these nerve blockers lessen or prevent long-term pain as well, said Dr. Rollin M. Gallagher, deputy national program director for pain management for the VA.
After traumatic nerve injuries, pain signals bombard the brain and central nervous system, frequently altering them forever and causing a nerve disorder called chronic regional pain syndrome. Patients with the disorder feel an intense, searing pain in their hands, feet or limbs because the pain has been “encoded in the central nervous system,” Gallagher said.
Some patients described it as having their limbs dipped in fire, Gallagher said. At that point, even the faintest stimulation can cause pain.
Nerve blockers, however, stop pain signals from reaching the nervous system, potentially reducing the chances it will be altered and start misfiring, Gallagher said.
“There is strong basic science,” Gallagher said, “that early intervention may make a big difference longitudinally.”
Even in the absence of combat injuries, repeated deployments are leaving troops in pain.
Gallagher estimated that roughly one-half of Iraq and Afghanistan veterans treated at the VA suffer from some form of back, joint or muscle pain. Carrying heavy loads — often more than 100 pounds — and being unable to rest after minor injuries is partly to blame, Gallagher said. “It’s just a lot of wear and tear on the body.”
White said even small injuries have cumulative effects. “It’s kind of like their bodies are aging rapidly,” he said. “There are very few sergeants first class who, when they retire, don’t have some sort of chronic pain.”
As more troops return from the battlefield with chronic pain, the military has seen a spike in the number of prescriptions for opiate painkillers. More troubling, abuse of painkillers is on the rise: About 22 percent of soldiers admitted misusing prescribed drugs, mostly painkillers, in a 12-month period, according to the results of a Pentagon survey released this year.
At the VA hospital in Tampa, all patients taking painkillers are incrementally tapered off them, Clark said.
Because chronic pain never completely goes away, the hospital’s staff emphasizes physical rehabilitation to strengthen muscles and joints near the pain source. When the injury involves the brain — as in PTSD and mild TBIs — the focus is on treating symptoms that could exacerbate pain.
“Pain may make it more difficult to treat those issues,” Clark said, because “all these things interact.”
At Landstuhl, White also looks for alternatives to pain medication, including numbing damaged nerves or heating them to 180 degrees, effectively killing them. For patients whose pain cannot be treated with simple methods, such as amputees, White has implanted spinal cord stimulators.
Attached to a thin cord, the device’s head looks like a leech, with a series of metal prongs on the underside. The prongs emit electrical impulses that scramble or block the pain signals traveling through the nervous system, preventing them from reaching the brain.
“Instead of an ache or throb,” White said, “they feel a pins-and-needles sensation.”
The device, along with a battery that lasts 25 years, can be implanted anywhere along the spinal cord, but most often it is attached near the abdominal area, which relates to leg pain, or at the base of the neck, which relates to arm pain. Patients can even control the level of stimulation with a remote control and can turn it on or off at will.
As innovative as White’s methods are, not all troops in pain have access to them. White is one of only six multidiscipline pain specialists in the Army, trained not only in pain management, but also neurology, psychology, anesthesiology and physiatry, or physical therapy.
Every year, White and his staff treat about 3,000 patients with chronic pain at Landstuhl, and his services are in such demand that he is forced to defer about 900 visits per month to local providers for conventional pain management. (The situation is less dire in the United States, he said, where there are more pain specialists.)
White said that he is hiring several more civilian doctors like himself and is eager to see more troops’ pain treated through the new techniques.
“Very few of my patients are on narcotics,” White said, “Because I know all these ways to get around it.”