The Changing Science of Pain

Insurers usually prefer to pay for single therapies, like opioids, the narcotics that block messages in the brain and make patients care less about their pain. The drugs are hugely widespread; almost 200 million opioid prescriptions get written in America each year, most of them for Vicodin, OxyContin and various forms of fentanyl. But "widespread" doesn't mean "effective," nor does it mean "popular." In opioid trials, fewer than a third of patients on average report relief, and more than a third drop out of the same trials rather than deal with the side effects, which include nausea, constipation and trouble breathing. "Most of the soldiers I treat say they don't want to take these strong medications," says Walker, the Tampa VA psychologist. "They say, 'These things make me groggy. I want to get back to my life'."

Opioid users also run two parallel risks: that they will become addicted, and that they will suffer the stigma of addiction even if they're not abusing the drugs. Steven Passik, a pain specialist at Memorial Sloan-Kettering Cancer Center, notes that "the issue of addiction doesn't lie in the drugs," but in a complex interaction between the chemicals and biological predispositions. Still, many patients struggle. Brooks Bono, 28, was born with a tumor on his spine and has spent his whole life in pain. At one point he was on so much OxyContin that "the dosages would have killed someone else," says his mother, Kadie Dempsey. He sees Passik now for counseling, and a few months ago he switched to methadone. It's not as addictive, says Bono, but it does little to dull the pain and it brings its own problems. "I went to about 20 different pharmacies," he says, "and they told me, 'We don't treat drug addicts here'."

No one wants to avoid an epidemic of drug abuse more than the military. Addicted Vietnam vets still wander into VAs, and as Gallagher notes, "if our soldiers can't get pain relief in the medical system, they'll turn to other ways." Many VA clinics make a point of cutting down on soldiers' use of opioids and other drugs. At a congressional hearing on pain in December 2005, Capt. John Pruden said he'd talked with one of his old buddies, who had been wounded in Iraq. "As we were talking, he bragged how he was not using his pain meds," Pruden told the audience. "But unfortunately it turns out he was self-medicating with alcohol to cope with the pain."

The military is now pursuing a new pain strategy: stop the trouble before it starts. Historically, wars have led to medical advances, and this one is no different; the notion of a kind of pre-emption has captured the interest and excitement of the entire pain-medicine community. Treat acute pain early, the thinking goes, and you stop the brain from responding to it. You might just wipe out chronic pain in the process.

This is where Buckenmaier's research comes in. His team is responsible for bringing those high-tech nerve blocks to the battlefield. Since 2003, hundreds of injured soldiers have received anesthetic pumps within hours of their injuries. Buckenmaier and Gallagher are jointly tracking these soldiers over the next year and beyond. If the ones who got pumps quickly have less chronic pain—and animal studies suggest they will—the research will not only point the way to new treatments, says Gallagher: for civilians and soldiers alike, "it will be a revolution." It may mean that injuries will be treated much more aggressively. That sprained ankle that only registered a 4 on the pain scale? If you want to avoid chronic pain later, you might need serious therapy, and right away.

It's too soon to say what will ultimately become of the Walter Reed study, though the hospital believes in Buckenmaier's work: despite being short-staffed and underfunded, it decided two weeks ago to fully finance his vision for a new acute-pain-management service, one that may remain in place after the war is over. There is much else left to do. Buckenmaier's nerve-block program needs to be expanded; thousands of soldiers injured in Iraq still don't get the advanced treatment. And, he says, on the battlefield there's usually "no one in charge" of pain in any given unit. The VA system, like the rest of the country, needs more pain specialists, not to mention mental-health professionals. Indeed, there's call for change at every level of a lumbering bureaucracy that, as has been amply documented in NEWSWEEK and elsewhere, lets too many soldiers fall through the cracks.