The Changing Science of Pain

Late into the night of May 2, 1863, a few hours after Thomas (Stonewall) Jackson took two bullets in his left arm at the Battle of Chancellorsville, surgeon Hunter Holmes McGuire sawed off the bleeding limb, trying to save the general's life. With the knife came another medical tool, one fairly new to the battlefield—a rag soaked in chloroform. As he awaited amputation, Jackson, who would die a week later, was as stoic as his nickname suggested. But as he slipped into unconsciousness, it's said, he betrayed his vulnerability in the face of pain just once, mumbling that the anesthesia was "an infinite blessing."

For most of the 144 years since then, the military has stuck with similarly crude techniques for treating its soldiers' pain. Morphine, also given to Jackson and many others in the Civil War, is still the Army's most commonly used painkilling drug. It works, but compared with more-modern options, it's one step above chloroform and two above biting the bullet. Now, though, with casualties mounting in Iraq and Afghanistan, the military is being forced to change its strategy. More than 90 percent of wounded soldiers have made it off the battlefield—the highest survival rate in American history—only to overwhelm chronic-pain clinics when they come home. "We're seeing the tip of a tidal wave of pain," says Lt. Col. Chester (Trip) Buckenmaier, an anesthesiologist at Walter Reed Army Medical Center, who has emerged as a sort of pain czar for the Army. After decades of "sucking it up," the military has finally started to respond in new and innovative ways to this escalating pain crisis. Even as the VA hospital system has come under fire for poor care, Army doctors haven't just joined up in medicine's larger war against pain—they're leading the charge.

Winning this medical war is crucial, and not just for the sake of the soldiers, who are far from the only burgeoning new group of pain sufferers. Chronic pain is one of the most pervasive and intractable medical conditions in the United States, with one in five Americans afflicted. Aging baby boomers have reported in surveys more aches and pains than any previous generation. Cancer patients have more treatments to choose from than ever, but more pain, too. Even retired NFL players—a suck-it-up group if ever there was one—have started speaking out about the wear and tear on their bodies. Civilian chronic pain already costs the country $61 billion in lost productivity and many more in medical fees. Treating the soldiers in the coming years will add at least $340 billion to the toll.

As the number of patients has grown, though, so has medicine's understanding of what pain is. Scientists once viewed it as merely a symptom of injury, an intuitive idea that resonated with laymen. "The public understanding of pain has been that it's a stubbed toe or a broken bone," says Will Rowe, executive director of the American Pain Foundation. "But that's just one aspect of it. Now there's a growing awareness that pain is a disease of its own."

This is far more than a semantic change, Rowe adds: it's "tectonic." Docs now know that the brain and spinal cord rewire themselves in response to injuries, forming "pain pathways" that can become pathologically overactive years later. They are trying to sever this maladaptive mind-body connection with a host of new drugs and approaches. Some focus on recently discovered chemical receptors in the brain and muscles. Others pack all the punch of narcotics with less of the specter of addiction. (Patients can still become dependent on a new form of the morphine derivative called Kadian, for instance, but if they crush one of the pills for snorting, its center explodes, releasing a substance that blocks the euphoric high.) New types of electrical stimulators targeting the brain, the spine and the muscles hit the market almost every year. Fentanyl skin patches, first introduced in 1990, have evolved into a patient-controlled, push-button device called IONSYS, available by the end of this year. And complementary and alternative medicine offer a parallel universe of treatments: herbs, yoga, acupuncture, chiropractic, massage and "prolotherapy," which injects various solutions, including cod-liver oil, into ligaments and tendons near the area of pain.

The military is pioneering its own new approaches. Since 2003, a small but growing number of soldiers in Iraq have been treated at the front with high-tech nerve-blocking devices that are effective but not addictive. They are common in civilian life, but their use on the battlefield is unprecedented. Back at home, many VA clinics are offering extensive and elaborate pain treatments, and they're learning how to get tough guys and girls to soften up and admit they need help. At Walter Reed, Buckenmaier's team is conducting groundbreaking research on the link between acute and chronic pain; his findings, due in the next few years, could revolutionize treatment. "The military needs people to be functioning out on the field," says Rollin (Mac) Gallagher, chief of pain medicine at the Philadelphia VA hospital. "What we're now starting to recognize is that if you control people's pain, they're not liabilities—they're assets."