The VA Should Encourage Alternatives to Opioid Pain Medications, Such as Spinal Cord Stimulation, to Treat Veterans Experiencing Chronic Pain
Testimony before Committee on Veterans’ Affairs
Subcommittee on Health
United States House of Representatives
October 10, 2013
Medically retired First Sergeant, U.S. Army
My name is Justin Minyard and I want to thank Chairman Benishek and Ranking Member Brownley for the opportunity to appear before the committee and address this vital subject.
I am a medically retired member of the U.S. Army. Before being forced to retire from the Army due to my debilitating back pain, I was a first responder at the Pentagon on 9/11 and a special operations interrogator in Afghanistan and Iraq. But due to injuries sustained in combat operations, I struggled with serious chronic pain and a dependence on the opioid medication that was the only option provided to me by the Armed Services healthcare system. Finally, after several years searching, I found lasting pain relief through spinal cord stimulation, or SCS. Today, I am proud to say that I have not taken a single dose of opioid pain medication in the last two years. No veteran should have to struggle for as long as I did – early access to interventionalists in the VA is critical.
Being free from opioid dependence has allowed me to serve as the founder of Operation Shifting Gears, a non-profit dedicated to serving injured or disabled veterans and as spokesperson for RaceAgainstPain.com, a community of chronic pain sufferers. I take it upon myself to personally encourage veterans and others suffering from chronic pain to explore options outside of opioid pain relief, such as spinal cord stimulation.
I first developed chronic back pain when I was serving as a member of the Presidential Escort, 3rd U.S. Infantry Old Guard, stationed at Fort Meyer. On 9/11, my unit was one of the first responders at the Pentagon. For the next 72 hours, we searched for survivors, working on adrenaline to move huge pieces of rubble. As a result of those efforts, I sustained a serious back injury – damaged discs and fractured vertebrae.
My back pain drastically impacted my life from September 11th onwards. I didn't seek treatment immediately, but instead took over-the-counter painkillers and tried to simply work through the pain. I volunteered to learn Arabic and become an interrogator. During my deployment to Afghanistan, I experienced another incident where I fell two stories out of the back of a helicopter, causing a disc to rupture and fracturing my vertebrae. I returned home due to the pain and had my first back surgery, a laminectomy, to replace one of the bulging discs and repair the fracture.
Despite the fact that my daughter Mackenzie was only three weeks old, it was 2007 and the army was in need of experienced interrogators like me to serve in Iraq, so I volunteered to go. While there, the weight of carrying a full 80-100 lb. combat load every day combined with a vehicle rollover caused further damage to my back. I came home and met with the army doctors, who told me that my spine was rapidly deteriorating and I needed reconstructive back surgery.
The physician left the room and I turned to my wife, Amy, and said, "What do you think we should do?" I knew she wanted me to stay home; I knew I should stay home. Mackenzie was only 5 months old at this point and Amy was working full-time. But I thought about my unit that was still in Iraq and the fact that I wanted to complete the mission we were sent there to do. So when my doctor came back in the room and I told him I was going to go against his advice and return to Iraq, he said, “If you insist on going back, this is really the only way you are going to be able to make it through.” He handed me a prescription for opioids and I said, “Okay, if that's what we need to do, that's what we will do." I had the bottle in my hand and I was ready to go.
For the next 10 months in Iraq, I was able to do my job. My pain was fluctuating somewhere on a daily basis between a four and a nine on a 1-to-10 scale, but I was regularly taking about four to eight pills of high-dose opioid pain medication at the time. It was a very rough situation, but I was able mask that with the opioid pain medications. That was a double-edged sword – the opioids allowed me to continue combat operations, but they allowed me to continue damaging my back as well. But because of the way opioid pain medication works with your body, you build up a tolerance quickly and for me, in the middle of the desert, I didn’t have a lot of other options for pain relief. I sought help from a Special Forces medic, who was able to call back to the States and request spinal cord epidural kits to be shipped to the base. So there I was, in an army tent in the middle of the desert, getting epidurals in order to continue working in Iraq.
August 4th, 2008 was my breaking point. I came back to the team house after an extremely challenging 3-day mission. I stepped out of my Humvee and my right leg simply gave out. I couldn’t take another step. I learned later on that it was because of nerve damage that had occurred due to the compression putting pressure on the main nerve running through my right leg. It was terrifying – I arrived at the team house at about 5:00 in the afternoon and by 6:15 p.m., I was on a helicopter being medevac’d to Balad Air Force Base.
Coming back from Iraq, it quickly became evident that I had to be in a wheelchair. Because of the damage to my back, I couldn't walk more than 2 or 3 steps without some help. The first time I sat in the wheelchair, I felt like a different person. I felt like I had lost something.
My life when I returned back home was not my life. It was terrible. I was in a great deal of pain. I was dealing with mental issues like anxiety and depression.
I started an intense opioid pain medication regimen. The metaphor I think best gives people an idea of what it is like is: once I started on high-dose opioid pain pills; once that train left the station, it was going 1,000 miles an hour and wasn’t making any stops. My life literally revolved around, “When is my next pill?,” "When is my next refill?” and “When does my dose get increased?” If you wanted to talk to me about my job performance, if you wanted to talk to me about Friday night dinner plans, if you wanted to talk to me about plans for Christmas, I just didn't care. Unless you were going to tell me that you were going to give me a ride to the pharmacy or you were going to tell me that it was time to take my next pain pill, I didn't care. In fact, I would either ignore you or treat you very poorly.
At my worst point, I was taking enough opioid pain medication to treat four terminally ill cancer patients. That was on a daily basis. It had enormous physical and mental effects on me - people would often look at me and my eyes would be rolled into the back of my head. When I talked to people, I just wouldn’t make any sense; it would all be incoherent. If I wasn’t babbling incoherently, I would be asleep or simply drooling on myself.
I was on an insane amount of opioid pain medication. My dependency happened so fast. It felt like I blinked and then I looked up and my life revolved around getting my fix. I remember a point when I realized, “Okay this is starting to become a problem!” But soon after that, even that thought left my mind. My days drifted by like this: wake up: pain pill; have lunch: pain pill; in the afternoon: pain pill; and on and on. It was not a pleasant experience.
I am very ashamed about those years because I treated the people that mattered most to me very poorly. There were years that I went without telling my wife, who stayed by my side throughout the entire process, “Thank you for taking care of me.” I was not the husband my wife deserved and I was not the father my daughter deserved. That was not the life I wanted. It was a very dark and difficult part of my life.
I continued to use a wheelchair but I didn’t want to accept the diagnosis I had been given, which was that it was most likely going to be part of my life for the rest of my days. But, I was offered no choice by the medical services to address the cause of my injuries; only means to mask the effects with ever increasing amounts of opioids. I was finally forced to look on my own for options that were available that could possibly repair the damage and help me start walking again. That led me to my second back surgery at Duke University Hospital: a highly invasive, extremely painful anterior/posterior inter-body fusion in which surgeons inserted eight titanium rods that form a cage around my spine to support all of the damage to my back.
In preparing for the surgery, Duke actually had to call in a special pain management team to figure out how and what medication they were going to use that would be strong enough to overcome my body's tolerance to the high amounts of opioids I was already using. The pain management team said, “Surely we are reading this chart wrong. This guy hasn’t really been on this amount of opioid pain medication for this long, has he?” They had to go back and do a case study to figure out what kind of anesthesia to prescribe.
That surgery was successful in that it allowed me to become more active and rely on the wheelchair less, but I was still in pain. I was still completely dependent on opioids and that was unacceptable to me. I hated having to rely on something else to get through the day and I knew my years of dependence on pain medication were negatively impacting my family – and would likely lead to fatal medical side effects.
The defining point for me, when I realized I could not go on living a life dependent on opioid medication, was watching a home video of myself on Christmas morning. In the video, you see my daughter approach me while we were all together in the family room and ask me to help her open a present. As she was handing it to me, I was trying to hold on to it. And all of a sudden my neck muscles and head just kind of rolled back. My eyes rolled back in my head. I started drooling on myself. I don't think there could be much more of an impactful, defining moment where you realize something is wrong, so I started trying to find another solution.
Without help from the Government, it was a major challenge navigating the maze of providers and bureaucracy before finally being referred to an interventional pain specialist at Fort Bragg. My doctor, who happened to be conducting a clinical trial of SCS therapy, took a vested, personal interest in my case and I credit him with turning my life around.
The VA didn’t make it easy for me to connect with people like him. My wife had to advocate for me, not taking “No” for an answer. But the VA hospitals and TRICARE should be doing everything they can to spread the word about his specialty: interventional pain management.
So the doctor said to me, “Have you heard about spinal cord stimulation (SCS)?” And I said, “Spinal cord what?” He explained the technology, made by Boston Scientific and others, to me. The implantable device would block my brain from receiving a pain signal and instead, mask that signal into a tingling feeling, as if a tuning fork is going off inside your body. He said, “It is a way for you to manage your pain and not have your pain manage you.” He even explained that I would have the chance to test drive the device for one week before moving forward with the permanent implant and see if it would provide effective relief and that I was a good candidate for a clinical trial with SCS that was just starting at Fort Bragg.
Having the ability to test drive SCS was the ultimate selling point for me. Unlike my anterior/posterior inter-body fusion surgery, I could actually try this device with a minimally invasive procedure. I find that very rare in medical treatment.
So I immediately asked, “When can you get me in for a trial?” I came in for a trial a few weeks later and in less than the time it takes to get a cavity filled, I had the trial device implanted in a simple, outpatient surgery.
During the trial period, they placed the two leads in the area of my back where I needed the most pain relief. As soon as I woke up, they used the computer to manipulate the system and set up my pain management programs. The first time the stimulator was activated it felt incredible. As cliché as it sounds, I thought to myself, “This device is going to be a life changer.” I was getting more pain relief from the one area the machine targeted in that moment than I had since I started on opioids years ago.
After that, the team went through my new Precision System’s four different pain programs. At each point they asked, "Can you feel here? Can you feel here?" And I would tell him, “Can you move it left?” and I felt it. It's not unpleasant - it's like an internal massage moving across your back. With each keyboard click I heard, I could feel the impulse moving through my body and hitting the target pain area. Once it locks in to wherever your pain is, it’s almost like magic. It's unbelievable because it is pain relief right where you need it. Not only does the SCS focus in on where you need it, but I was also given a remote that allows me to turn up the power to get even more relief in certain areas that are hurting on a given day. It is amazing to go for so many years struggling with pain relief and, all of a sudden, I can push a button and my pain can drop from a seven to a four.
I was floored. I wanted the permanent device implanted immediately. I said, “My test drive is done, I only need to go around the block once! I’m good.”
But the bottom line is everyone has to do the trial. Mine was three days, and when I went back in to remove the trial, I couldn’t wait to have the permanent version. I was counting down the minutes and calling the doctor’s office every day, saying, “Let me know if someone cancels. I’ll drive up there. I'll sleep in the doctor’s office, because I know this spinal cord stimulator is going to be it for me.”
Three weeks later, I had the permanent spinal cord stimulator implanted and that is where my life started to turn around. That was the defining moment. I was able to get the remote for my permanent SCS and start using it to manage my pain.
The relief I felt from SCS allowed me to start tapering down my medications. My goal was to ultimately be free of all opioids. That process took time and it was difficult, but it was completely worth it.
I am now at the point where I have not taken an opioid-based pain pill in more than 2 years. I actually have a medical directive that states that if I am taken to the hospital, I am not allowed to be administered a narcotic without my consent. And if I am unconscious, my wife has to give consent. I have this because I went through this process and I don't need the medications, nor do I want them anymore. Like I said before, once you start...once on that train... it is a very, very, very fast and scary progression to the point where it is out of control.
I just want to leave you with something. There are a lot of soldiers in my situation. And not just soldiers, but a lot of people in this country who were pushed onto the opioid pain train, and now they’re moving so fast and they can’t get off of it. I consider myself extremely lucky that I was able to push through the maze of providers in TRICARE and find the doctor who knew the secret – at least for me. But there are many soldiers who are not so lucky; soldiers who lack the resources and awareness to advocate for alternatives to opioid pain regimens and are left to the crushing reality of lifelong opioid dependence or worse. A recent VA study spotlighted the horrific epidemic of suicide amongst veterans, 22 per day.
Pain is a pervasive condition with the impacts and burdens reaching far beyond the patient – to families, society, etc. According to NIH, when including healthcare costs, lost income, and lost productivity, pain costs almost $100 billion per year. We must increase awareness about alternatives to opioid pain medication in the VA system. The VA must work to create accessible regional centers equipped with access to skilled interventional pain specialists. We must train more doctors in these techniques and devote more resources to raising awareness. We should also begin collecting data on long-term outcomes of interventional therapies versus opioid therapy so we have the numbers to show that the techniques that helped me will help other soldiers, too.
The VA is a great place to start, because so many veterans come home and struggle, just as I did. I continue to struggle with the VA in getting timely appointments with a specialist to manage my SCS therapy, but my hope is that in the future, policies will be in place to help people like me manage their SCS therapy and to help prevent soldiers and their families from the devastating effects of opioid dependence. Thank you all, so much, for listening to my story.