Mark J. Lema, M.D., Ph.D.
Mr. Chairman and members of the Subcommittee, my name is Mark J. Lema, M.D., Ph.D. I am Chair of the Department of Anesthesiology, Critical Care and Pain Medicine at the Roswell Park Cancer Institute in Buffalo, New York, and Professor and Chair of the Department of Anesthesiology at the University of Buffalo, State University of New York, School of Medicine and Biomedical Sciences. I also serve as the current President of the American Society of Anesthesiologists.
I am pleased to testify today on behalf of the Pain Care Coalition, a national advocacy effort of the American Academy of Pain Medicine, American Pain Society, American Headache Society and American Society of Anesthesiologists. Collectively, these organizations represent more than 50,000 physicians and other clinicians, researchers, and educators who provide clinical leadership in the increasingly specialized field of pain management. Some of these individuals work either full or part time in the VA health system, and many others are involved in collaborative relationships with research and clinical care programs throughout the VA system.
We appreciate the opportunity to appear today and present our views on the state of pain research at the VA. As professionals in the pain care field, nothing we do is more important than assuring that those who serve our country in times of war get the very best pain care possible during all stages of their service, and in all settings of the military and veteran health and medical systems. These settings range from the battlefield to the clinics, hospitals, rehabilitation centers and long term care facilities of the VA. As a complement to these clinical care responsibilities, those of us in pain medicine have a continuing interest and responsibility in pain care research within the VA’s Medical and Prosthetic Research Program, as well as other public and private research efforts with which the VA collaborates.
THE SCOPE OF THE PAIN PROBLEM
Pain is a very large public health problem in this country. It is the most common reason people access the medical care system, a major cause of lost productivity in the workplace, and a substantial contributor to short and long term disability. It affects Americans at all stages of life and in all walks of life. For example, 26 million Americans of working age have frequent back pain, and chronic back pain is the leading cause of disability for those under 45 years of age. 25 million suffer from migraine headaches. Four million, mostly women, suffer from a complex pain syndrome known as fibromyalgia.40 million have arthritis pain.
Pain imposes a terrible burden on those who suffer and on their families, and it imposes large costs on the health care and disability income systems. Medical costs and lost productivity alone are estimated to top $100 billion annually. Pain is often poorly understood by those who suffer and by those around them. It is often undiagnosed or misdiagnosed, and under-treated or mistreated. Sometimes pain is the symptom of other diseases as in the case of cancer, arthritis, heart disease, and diabetes. Other times, pain is the disease itself as with migraine, chronic back pain and various diseases associated with damage to the nervous system, such as post-herpetic neuralgia, diabetic neuropathy, or injuries to the nervous system such as commonly occur in combat, including phantom limb pain, post-injury or post-surgery neuralgias, and traumatic brain injury.
The most recent complete study of soldiers enrolled in VA Polytrauma Centers show that more than 90 % have chronic pain, that most have pain from more than one part of the body, and that pain is the most common symptom in returning soldiers. Advances in neuroscience, such as neuroimaging, now demonstrate that unrelieved pain, regardless of its initial cause, can be an aggressive disease that damages the nervous system, causing permanent pathological changes in sensory neurons and in the tissues of the spinal cord and brain.
Pain can be acute and effectively treated by short term interventions, or it can be chronic, often without effective “cures” and sometimes without consistent and effective means of alleviation. Those who suffer severe chronic pain see their daily lives disrupted—sometimes forever. Their pain and their constant search for relief affects their function, their relationships with those they love, their ability to do their work effectively, and often their self esteem. Chronic pain is often accompanied by or leads to sleep disorders, emotional distress, anxiety, depression, and even suicide.
If these facts are true in the general population, which we know them to be, then they are doubly true in the military and veteran populations. The physical and emotional stresses of military service make inevitable the disproportionate incidence of both acute and chronic pain among active duty personnel. If miners, movers and construction workers suffer low back pain from heavy lifting, imagine the toll on the spine of those in active duty combat situations. If truckers develop back pain from long hauls, imagine the toll of armored vehicles going long distances on poor or non-existent roads. If the stresses of daily civilian life serve as triggers for those suffering severe migraine, imagine the impact of battlefield conditions.
The incidence of acute pain among those injured in current conflicts will be virtually 100%, and for far too many, the original short term trauma will be followed by chronic pain of significant dimension and duration. For example, virtually all of those suffering the loss of one or more limbs in combat will suffer from phantom limb pain. While this can be managed with varying degrees of effectiveness, there is no known “cure.” Virtually all veterans fitted with prostheses will suffer some degree of pain at the device/body “interface.” Again, this can be managed to some degree, but it is rarely eliminated.
Far less visible, but even more prevalent, is the extensive damage to the central and peripheral nervous systems resulting from the horrific explosive devices deployed in the current conflicts. Unlike broken bones, flesh wounds and burns, many of which will eventually heal after aggressive treatment, extensive nerve damage may only be manageable, not curable, given the current state of science and clinical practice. Most returning veterans with extensive nerve damage will be chronic pain sufferers and will require long term pain management, with varying prognoses for success. Ironically, the proportion of these chronic pain sufferers among returning wounded servicemen and women will be far greater in the current conflicts than in previous wars because of the remarkable successes of military medicine which now keep so many of the very severely injured alive.
PCC’S INVOLVEMENT IN PAIN MANAGEMENT FOR VETERANS
On the battlefield and upon returning home from service, critically wounded men and women must receive the best, most advanced pain management interventions available. Members of the Pain Care Coalition have made significant contributions toward efforts to alleviate the suffering of our brave soldiers.
For example, Lt. Col. Chester “Trip” Buckenmaier III, an Army anesthesiologist and member of the American Society of Anesthesiologists, has been at the forefront of providing revolutionary pain care to wounded veterans. During a deployment to Iraq several years ago, Dr. Buckenmaier used portable infusion pumps to alleviate the pain of soldiers with grave injuries to their arms and legs. In a recent Wall Street Journal article, Dr. Buckenmaier described a situation in which a soldier changed his evaluation of his pain from 10 on a 10 point scale—“the worst pain imaginable”—to zero, after being treated with a portable infusion pump.
This example underscores the life-saving, life-changing pain management techniques increasingly used in military medicine. In fact, during an October 2005 hearing of the House Committee on Armed Services, Deputy Surgeon General Joseph G. Webb, Jr., highlighted the advances of pain medicine benefiting our soldiers. He said, “Wounded soldiers in Iraq and Afghanistan benefit from receiving some of the most advanced technologies and techniques in medicine today…The benefits of advanced pain management, during and after surgery, are improved postoperative outcomes and the potential to eliminate chronic pain, particularly in amputees.”
Dr. Buckenmaier’s story and Major General Webb’s testimony illustrate the potential and the challenge of deploying innovative and advanced pain management techniques to treat our veterans.
THE VA’S CURRENT PAIN RESEARCH EFFORT
Perhaps more than any other federal agency, the VA has been a leader in focusing institutional resources on the assessment and treatment of pain. Under a “National Pain Management Strategy” initiated in November of 1998 (“Strategy”), and pursuant to VHA Directive 2003-021, the Veterans Health Administration has made pain management a national priority. Among the specific objectives of the Strategy are:
- providing a system-wide standard of care to reduce suffering from “preventable” pain;
- ensuring consistency in the assessment of pain;
- ensuring prompt and appropriate treatment for pain;
- promoting an inter-disciplinary approach to pain management; and
- providing adequate training to and resources for clinicians in VA healthcare to achieve these objectives.
The Pain Care Coalition applauds the Strategy and generally supports its specific goals and objectives. At the same time, the Coalition has significant concerns with the current VA effort:
- Directive 2003-021 is only a five year plan. It is scheduled to expire in May of 2008;
- there has been, to the Coalition’s knowledge, no comprehensive assessment of the Strategy’s strengths, weaknesses and accomplishments; and
- reports from the field suggest that implementation has been far from consistent. Some VA facilities have made great strides in improving pain care, while for others it is more an aspirational goal than an operating reality. As a result, veterans get widely different treatment for pain depending on the expertise and resources of the particular VA facility at which they receive their care.
Significantly, and directly germane to the Subcommittee’s current inquiry, the Pain Care Coalition believes that, in order to ensure effectiveness, the VA’s pain management Strategy must be accompanied by and integrated with a significant research commitment to advancing the science of pain care, and to translating developments in the science to improved clinical care throughout the system.
The VA has had a long and continuing research interest in the phenomenon of phantom limb pain, with current work focused at the molecular level. It also has current research efforts in neural repair, which might someday lead to improvements in therapy for those veterans currently returning with significant damage to the nervous system. And it recently completed a successful study of the effectiveness of a shingles vaccine in older veterans which validated research findings elsewhere, and will improve care in the general population. Other important pain research initiatives are scattered amongst NIH research institutes.
In 2006, through an initial grant funded privately, the VA brought together research investigators with interests in pain as part of a VA sponsored conference on pain and palliative care. That meeting identified several research interest groups including post-deployment pain, primary care pain programs, and opioid analgesics. These groups generated a number of new research projects, several of which have earned Merit Award funding through the peer-review process of the VA’s Office of Research Development (“ORD”). Work from these groups also spawned important articles in major journals and a special issue of the Journal of Rehabilitation Research and Development devoted to pain research. Based on this success, the VA’s ORD funded a second meeting of pain researchers just held in September of 2007. At this meeting, researchers identified other important projects which demonstrated the breadth and depth of research that is possible if a focused effort is made to organize and promote a VA research agenda dedicated to the basic and clinical sciences of pain medicine. I look forward to making the results of this most recent meeting available to the Subcommittee in the near future.
It is imperative that pain research be placed high on the list of current VA research priorities. Alarmingly, the VA’s justification accompanying the Administration’s proposed FY 2008 budget for the Medical and Prosthetic Research Program barely mentions pain. The Coalition is aware of no VA data to show what proportion of the research budget is devoted to pain, but we suspect it is a very small percentage.
The VA has identified four research priorities related to the current conflicts:
- burns; and
- chronic illness generally.
Three others are considered continuing priorities relevant to these and all preceding conflicts:
- PTSD; and
- vocational rehabilitation.
Pain is central to each of these seven priorities, and effective pain management is crucial to the restoration of a reasonable quality of life for all of these conditions, but there is little indication that pain research has been integrated with other research efforts in these seven areas, or coordinated across these and other research programs.
Unfortunately, pain is not an area where the VA’s leveraged research approach can rely on leadership from research partners at the NIH or in private industry. For example, despite the documentation that chronic pain is one of the most costly of all health problems to the U.S. economy, a recently conducted review of the NIH pain research portfolio showed that only 1% of NIH’s annual research funding is devoted to projects with a primary focus on pain. If projects where pain is a secondary concern are added, it only rises to 2%. There is no Institute or Center at NIH to provide a central home for pain research, and efforts to coordinate pain research across the various institutes and centers are in the very early stages of development.
While private industry has significantly advanced drug and device therapies for particular types of pain or classes of pain patients, industry alone can not be expected to carry the load of long term basic science research needed to better understand the mechanisms of pain, and in particular how chronic pain syndromes develop despite successful treatment of the original trauma.
RECOMMENDATIONS OF THE PAIN CARE COALITION
The Pain Care Coalition believes the VA’s pain research effort can and must be significantly enhanced. We urge the Subcommittee to develop targeted legislation with several basic components.
First, the Congress should require the VA to establish within the Medical and Prosthetic Research program at VA headquarters a focused program of research and training directed at acute and chronic pain. That program should identify research priorities in pain most relevant to veterans returning from the current conflicts, and should promote and coordinate basic and applied research on these priorities both within the VA, and with its research partners. The same centralized pain research program should boost education and training of VA personnel to ensure that research advances are rapidly disseminated throughout the VA care system.
Second, Congress should authorize and the VA should designate an appropriate number of cooperative centers throughout the country for research and education on pain. Each such center should take the lead on a priority area of basic science research on pain, or an aspect of acute or chronic pain most relevant to veterans returning from the current conflicts. At least one of the centers should be designated as the lead center for research on pain attributable to central and peripheral nervous system damage, and one such center shall be designated as the lead center to coordinate the work of all the centers.
Third, Congress should authorize these newly created pain research centers to compete on an equal basis with other priority research areas (TBI, PTSD, polytrauma, prosthetics and others) for funds appropriated each year to the Department’s overall medical and prosthetic research budget.
Mr. Chairman and members of the Subcommittee, pain is often characterized as an invisible disease—we can not see it, and unlike such diseases as cancer, diabetes, and heart disease, there are no affordable and widely available lab or imaging tests to confirm its presence and quantify its severity. But that’s no excuse for letting research efforts lag behind those of other priorities. The Pain Care Coalition is committed to advancing the practice of pain management. We strongly support new and increased efforts within the VA’s research, education and clinical care programs to ensure that our brave men and women returning from combat receive the best pain care possible. The Coalition, along with each of the organization’s it represents, stands ready to work with the Subcommittee and the VA toward that end.