Review of Posttraumatic Stress Disorder and Chronic Pain: The Path to Integrated Care

Article excerpt


As of November 17, 2011, 6,320 U.S. servicemembers have been killed in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) [1]. An estimated 50,000 to 100,000 servicemembers have experienced nonmortal wounds and injuries during military deployments in OIF/OEF. The number of those injured is staggering, with an unprecedented number of injured U.S. servicemembers returning home compared with previous historical military actions.

OIF/OEF have resulted in the highest wounded to fatality ratio compared with past conflicts involving U.S. servicemembers. The wounded to fatality ratio for our current military actions is 16 servicemembers wounded per every fatality. During World War I and World War II, there were two servicemembers wounded per every fatality. For the conflicts in Korea and Vietnam, the wounded to fatality ratio was close to three wounded per every fatality [2]. Our nation's wars prior to OIF/OEF resulted in a far greater loss of American lives, with not only fewer servicemembers surviving war injuries, but also a greater number being called to serve in combat.

With a significantly greater number of servicemembers surviving devastating combat injuries today, it is clear that much credit is due to the incredible advances in military medicine. More servicemembers are surviving major combat injuries with the resulting medical, psychological, and social costs to servicemembers, their families, and the Department of Defense (DOD) and Department of Veterans Affairs (VA) medical systems to provide care for those with combat-related injuries. This has resulted in the emergence of multimodal pain management with the identification of proactive, not reactive, pain management to contribute to early rehabilitation and recovery [3]. These Veterans and servicemembers require complex medical care and our medical systems are constantly challenged to address their physical as well as psychological injuries, such as posttraumatic stress disorder (PTSD), as Veterans take steps forward in their lives following military discharge.

In response to the comorbid presentations of both PTSD and chronic pain, the VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress was revised in 2010 with a special section devoted to the management and treatment of pain in patients who have PTSD. This article will highlight the clinical practice guideline with the primary purpose of helping clinicians gain a deeper understanding of these conditions as we continue to or begin to develop models of care to best meet the treatment needs of these patients. We must work in collaboration to integrate the care provided in our medical centers for all Veterans with both PTSD and chronic pain.


A search of Medline (Medical Literature Analysis and Retrieval System Online), CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine Database), and PsycINFO (Psychological Information Database) was performed. No start date limit on the search criteria of the databases was set, but the end date was the first week of August 2011.

The search was performed using the following combinations of terms:

* "PTSD and Chronic Pain" within title and abstract.

* "Posttraumatic Stress Disorder and Chronic Pain" within title and abstract.

* "(Posttraumatic Stress Disorder or Chronic Pain) AND therapy" within title and abstract.

* "(Posttraumatic Stress Disorder or Chronic Pain) AND medications" within title and abstract.

* "(Posttraumatic Stress Disorder or Chronic Pain) AND depression."

* "(PTSD or Chronic Pain)) and Substance Abuse" within title and abstract.

* "Chronic Pain and Opioids" within title and abstract.

* "Chronic Pain and Buprenorphine" within title and abstract.

* "Chronic Pain and Headaches" within title and abstract. …