Wednesday, May 18, 2016
The accompanying article is excerpted from Justin O. Schmidt's new book "The Sting of the Wild: The Story of the Man Who Got Stung for Science," published this spring by John's Hopkins University Press.
Howard Evans, the great naturalist and author of the classic book "Life on a Little Known Planet," was an expert on solitary wasps. Howard, a slight, reserved man with a shock of white hair and a sparkle in his eyes, was especially fond of tarantula hawks. Once, in his dedication to the investigation of these wasps, Howard netted perhaps 10 female tarantula hawks from a flower. He enthusiastically reached into the insect net to retrieve them and, undeterred after the first sting, continued, receiving several more stings, until the pain was so great he lost all of them and crawled into a ditch and just sobbed. Later, he remarked that he was too greedy.
I know of only two people who were "voluntarily" stung by tarantula hawks. I say "voluntarily" as both were performing their duties as part of documentary films, which, among other things, "encouraged" being stung. One was a young, handsome athletic entomologist who knew of the wasps. He deftly reached into the large cylindrical battery jar and grabbed a wasp by the wings. He had her in such a position that her sting harmlessly slid off his thumbnail. We prattled for a minute or so about tarantula hawks while the camera scanned close up to the long sting as it slid harmlessly, missing its mark. Then with a great heave the wasp pulled its abdomen back and thrust the sting under the nail. Yeee…ow (I can't recall if any expressions unsuitable for general audiences were uttered), the wasp was hurled into the air and flew off unharmed. One point for wasp, zero for human.
The other was a solidly built fellow who was apparently a master of performing pain-defying acts of bravery. For the film, I was charged with catching the wasp and delivering it to the scene. Five or six tarantula hawks were easily netted from flowers of an acacia tree; unfortunately, the net snagged on some thorns, and all but one wasp escaped. The remaining wasp appeared to be a male, so I summoned the cameraman to demonstrate how males cannot sting and are harmless. I reached in and casually grabbed "him." At this point, I realized that I was holding a "her." Yeee…ow, except this time it was me. I managed to toss her back in the net, while attempting to explain my blunder and pain on camera. As I was not in the film – perhaps fortunately – the footage was relegated to some obscure studio archive, perhaps someday to be resurrected on YouTube. That episode over, the tarantula hawk was delivered to the rightful actor. He grabbed her, was stung, and showed no reaction beyond a begrudging "Ouch, that did hurt a bit." I figured the guy had no nerves. But his director then handed him a habanero pepper, a tarantula hawk of chili peppers, which he enthusiastically bit into. He became instantly speechless, convinced fire was blasting from his mouth, nose, and ears. Apparently, he did have some nerves — sensitive at least to chili peppers.
How could such a small animal as a tarantula hawk be so memorable? Several years ago I attempted to address this question in a paper entitled "Venom and the Good Life in Tarantula Hawks: How to Eat, Not Be Eaten, and Live Long." The natural history of tarantula hawks provides some insights. Tarantula hawks are the largest members of the spider wasp family Pompilidae, a family some 5,000-species strong that prey solely on spiders. The feature of tarantula hawks that makes them so special is their choice of the largest of all spiders, the fierce and intimidating tarantulas, as their target prey. The old saying "you are what you eat" rings true for tarantula hawks: if you eat the largest spiders, you become the largest spider wasps. As with other spider wasps, the female wasp provides each young with only one spider that serves as breakfast, lunch, and dinner for its entire growing life.
Thursday, May 12, 2016
"We needed to talk about congestive heart failure or diabetes or out-of-control hypertension," said Dr. Sarah Chouinard, the chief medical officer at Community Care of West Virginia, which runs primary care clinics across a big rural chunk of this state. "But we struggled over the course of a visit to get patients to focus on any of those."
Worse, she said, some of the organization's doctors were prescribing too many opioids, often to people they had grown up with in the small towns where they practiced and whom they were reluctant to deny. So four years ago, Community Care tried a new approach. It hired an anesthesiologist to treat chronic pain, relieving its primary care doctors and nurse practitionersof their thorniest burden and letting them concentrate on conditions they feel more comfortable treating.
Since then, more than 3,000 of Community Care's 35,000 patients have seen the anesthesiologist, Dr. Denzil Hawkinberry, for pain management, while continuing to see their primary care providers for other health problems. Dr. Chouinard said Community Care was doing a better job of keeping them well over all, while letting Dr. Hawkinberry make all the decisions about who should be on opioid painkillers.
"I'm part F.B.I. investigator, part C.I.A. interrogator, part drill sergeant, part cheerleader," said Dr. Hawkinberry. He is also a recovering opioid addict who has experienced the difficulties of the drugs himself.
Even for people with access to the best doctors, it is hard to safely control chronic pain. Community Care is trying to do so for a disproportionately poor population, in a state that has been ground zero for opioid abuse from the very beginning of what has become a national epidemic.
Now, the difficult work of addressing the nation's overreliance on opioids, while also treating debilitating pain, is playing out on a patient-by-patient basis, including in a patchwork of experiments like this one. About 70 percent of the 1,200 patients currently in Community Care's pain management program receive opioids as part of their treatment, which may also include nonnarcotic drugs, physical therapy, injections and appointments with a psychologist.
Many had already been on opioids "for many years before they met me," Dr. Hawkinberry said, adding that his goal is to get them on lower doses, and to try other ways of managing their pain, with his own experience as a cautionary lesson.
He became addicted to the opioid fentanyl when he was an anesthesiology resident, he said, and had to wage a legal fight to stay in the program. He relapsed four years later while working at a West Virginia hospital and underwent treatment and monitoring by a state program for doctors with addiction problems. He says he has been in recovery and has not used drugs for almost nine years.
Dr. Chouinard said that Dr. Hawkinberry's experience made him "all the better positioned to know what this is like" and well-positioned to screen for drug abuse.
Patients who are prescribed opioids have to submit urine samples at each monthly appointment and at other random times, and to bring their pills to every visit to be counted. About 500 have been kicked out of the program for violations since it started in 2012.
In addition, Community Care's pain management clinic is closely monitored by the state as one of six licensed to operate under a 2012 law meant to cut down on pill mills.
The organization's primary care providers talk frequently with Dr. Hawkinberry about the patients they share with him. Because they use the same electronic medical record system, they can keep close tabs on how their patients' pain is being treated — and he on how their other health problems, like high blood pressure, are being addressed.
Wednesday, May 11, 2016
While we welcome all proposals relevant to basic or clinical migraine research, we are particularly interested in translational projects and those related to migraine variants, childhood migraine, and chronic migraine.
Tuesday, May 10, 2016
"It's this turbulent, violent sensation that feels electric and stinging," Delp says, describing the pain at its worst. "I've run out of the building screaming like a lunatic before because it's been so bad."
Delp has erythromelalgia, a rare condition in which a person's body (typically the feet and the hands, though Delp experiences pain all over) reacts to mild warmth as though it is on fire. Mild exertion, even just standing, will set it off for Delp, which meant quitting her job of 15 years as a flight attendant. Two years of countless doctors' appointments finally got her a diagnosis in 2012, but current medications are unable to relieve pain in most patients.
"I'm pretty much a prisoner in my own home," she says. Her house in Tacoma, Washington, is kept at a chilly 58 degrees Fahrenheit, thanks to some special duct work that her husband, coincidentally in the heating and cooling business, was able to arrange. Delp spends most of her time reading, watching TV, or working on her computer to maintain an online erythromelalgia support group that she co-founded.
But, this horrific condition has handed pain researchers their most promising drug target in years. In 2004, a study of an inherited version of erythromelalgia pinpointed a mutation in a gene that directs the making of a sodium channel, called Nav1.7; sodium channels are proteins that help control the electrical excitability of neurons.
"The channel sets the sensitivity of pain-signaling neurons, and when you have those Nav1.7 mutations, the neurons fire when they shouldn't," says Stephen Waxman of Yale University School of Medicine, New Haven, US, and the Veterans Affairs Medical Center, West Haven, Connecticut. Waxman was the first to study the effects of Nav1.7 mutations in neurons.
Delp doesn't know if she has this type of mutation, but medicines that calm the channel may still give her relief. Multiple clinical trials are underway to test Nav1.7 channel blockers, not only in inherited erythromelalgia, but in more common conditions, like sciatica and trigeminal neuralgia, which both involve intense shooting pain in different parts of the body.
Patients would no longer have to wake up in the middle of the night to take their pills, Purdue told doctors. One OxyContin tablet in the morning and one before bed would provide "smooth and sustained pain control all day and all night."
On the strength of that promise, OxyContin became America's bestselling painkiller, and Purdue reaped $31 billion in revenue.
But OxyContin's stunning success masked a fundamental problem: The drug wears off hours early in many people, a Los Angeles Times investigation found. OxyContin is a chemical cousin of heroin, and when it doesn't last, patients can experience excruciating symptoms of withdrawal, including an intense craving for the drug.
The problem offers new insight into why so many people have become addicted to OxyContin, one of the most abused pharmaceuticals in U.S. history.
The Times investigation, based on thousands of pages of confidential Purdue documents and other records, found that:
• Purdue has known about the problem for decades. Even before OxyContin went on the market, clinical trials showed many patients weren't getting 12 hours of relief. Since the drug's debut in 1996, the company has been confronted with additional evidence, including complaints from doctors, reports from its own sales reps and independent research.
• The company has held fast to the claim of 12-hour relief, in part to protect its revenue. OxyContin's market dominance and its high price — up to hundreds of dollars per bottle — hinge on its 12-hour duration. Without that, it offers little advantage over less expensive painkillers.
• When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to "refocus" physicians on 12-hour dosing. Anything shorter "needs to be nipped in the bud. NOW!!" one manager wrote to her staff.
• Purdue tells doctors to prescribe stronger doses, not more frequent ones, when patients complain that OxyContin doesn't last 12 hours. That approach creates risks of its own. Research shows that the more potent the dose of an opioid such as OxyContin, the greater the possibility of overdose and death.
• More than half of long-term OxyContin users are on doses that public health officials consider dangerously high, according to an analysis of nationwide prescription data conducted for The Times.
Over the last 20 years, more than 7 million Americans have abused OxyContin, according to the federal government's National Survey on Drug Use and Health. The drug is widely blamed for setting off the nation's prescription opioid epidemic, which has claimed more than 190,000 lives from overdoses involving OxyContin and other painkillers since 1999.
The internal Purdue documents reviewed by The Times come from court cases and government investigations and include many records sealed by the courts. They span three decades, from the conception of OxyContin in the mid-1980s to 2011, and include emails, memos, meeting minutes and sales reports, as well as sworn testimony by executives, sales reps and other employees.
The documents provide a detailed picture of the development and marketing of OxyContin, how Purdue executives responded to complaints that its effects wear off early, and their fears about the financial impact of any departure from 12-hour dosing.
Reporters also examined Food and Drug Administration records, Patent Office files and medical journal articles, and interviewed experts in pain treatment, addiction medicine and pharmacology.
The pain matrix is actually a cluster of regions in the brain that prior imaging studies indicated are involved in processing pain perception, including the posterior insula and the anterior cingulate cortex. This has been so broadly accepted that the signature pattern has been used to declare that emotional pain (like social rejection) and physical pain are the same thing, as far as the brain is concerned. The argument goes that something like a bad romantic breakup has the same effect on brain activity as spilling a hot cup of coffee on your shirt.
More recent studies have cast doubt on those conclusions, however. And now researchers at the University of Reading and University College London have concluded that this cluster of regions in brain is not specific to pain. It also responds to loud noises, bright lights, a strong non-painful touch (like a firm handshake), and yes, social rejection. They describe their findings in a new paper published today in JAMA Neurology.
"I wouldn't say that's it's wrong to say that the 'pain matrix' is involved in processing pain," lead author Tim Salomons (University of Reading) told Gizmodo. "What's wrong is the idea that it is specific to pain—in other words, that when you observe this pattern, you can just assume that person is in pain."
Most of these studies employ functional magnetic resonance imaging (fMRI). Unlike conventional medical MRI, which creates a static image of the brain similar to an x-ray, fMRI monitors the brain in action. When enough neurons fire together in response to a given stimulus, blood flow increases to those parts of the brain involved in processing that input. The fMRI detects this as slight increases in blood oxygen levels—the so-called BOLD response–in those different regions. The resulting gorgeous full-color images make for terrific eye candy, but they aren't actually real-time snapshots of the brain in action; rather, they're visualizations of statistical data.
So how can scientists know for sure if the pattern they're seeing is really an indicator for pain (or any other type of cognitive process)? The gold standard is cognitive neuroscience studies that involve patients with existing brain damage, according to Bradley Voytek, a neuroscientist at the University of California, San Diego, who was not involved with the study. So if you want to prove that a particular cluster of brain regions encodes pain, you must first determine that patients with damage to those regions can no longer feel pain.
Wednesday, May 04, 2016
Tuesday, May 03, 2016
That panel had concluded that the training might help stem the epidemic of overdose deaths involving prescription narcotics, or opioids. At first, Dr. Katz, who had been on the panel, thought that drug makers had pressured the F.D.A. to kill the proposal. Then an agency official told him that another group had fought the recommendation: the American Medical Association, the nation's largest doctors organization.
"I was shocked," said Dr. Katz, the president of Analgesic Solutions, a company in Natick, Mass. "You go to medical school to help public health and here we have an area where you have 15,000 people a year dying."
Now, as the White House, the Centers for Disease Control and Prevention and other federal and state agencies scramble to find solutions to the vexing opioid problem, the role of doctors is coming back to center stage. The Obama administration recently announced that it supported mandatory training for prescribers of opioids.
On Tuesday, a new F.D.A. panel of outside experts will meet to review once again whether such training should be required. The hearing will almost certainly touch off an intense debate inside the medical community and focus attention on medical groups like the A.M.A., which have resisted governmental mandates affecting how doctors practice for both ideological and practical reasons. The panel is expected to make its final recommendation on Wednesday. An F.D.A. spokeswoman said the agency now supported mandatory training.
Monday, May 02, 2016
Are there any taboo subjects left in literature? Graphic violence and sex in any of its endless variations have become mainstream. Even excretion is now explicit: Think of the unforgettable scene of Joey searching for a ring in his own shit in Jonathan Franzen's Freedom. But read almost any novel in which childbirth, one of the most universal of human events, takes place, and you will find that the actual act has been deleted. An author as celebrated for her visceral and detailed accounts of female experience as Elena Ferrante offers the following as a description, in full, of the birth of the narrator's first child in the third book of the Neapolitan novels, Those Who Leave and Those Who Stay:
I had atrocious labor pains, but they didn't last long. When the baby emerged and I saw her . . . I felt a physical pleasure so piercing that I still know no other pleasure that compares to it.
Pages later, the birth of her second child gets even less elaboration: "Everything went smoothly. The pain was excruciating, but in a few hours I had another girl."
Certain ways of avoiding a childbirth scene in contemporary fiction have become almost predictable, as clichéd as the clothes scattered on the floor in a movie rated PG-13: the frantic car ride to the hospital, followed by a jump cut to the new baby; or the played-for-laughs episode of the laboring woman screaming at her clueless husband, followed by a jump cut to the new baby. What happened to what actually happens?
My latest novel, Eleven Hours, takes place entirely during one labor and delivery in an urban hospital. I've been through childbirth twice myself, and found it the most physically painful and most transformative experience of my life. I wanted to write something I felt I hadn't read: a story that described childbirth from the inside. I wanted to depict the alterations of consciousness that come from the confrontation with great pain, and the ways in which the crisis of labor can cause a woman to find in herself previously unknown strengths. I wanted to conjure up the feeling of long waiting punctuated by intense activity. I wanted to show what it felt like to be so very close, simultaneously, to the creation of life and the possibility of death.
When Eleven Hours had been accepted for publication in the U.S. and my agent was shopping it abroad, a publisher that had taken one of my earlier books turned it down. "Sales and marketing did not feel confident they would know how to pitch it," I was told. "It's such a specific experience recounted here."
Such a specific experience? You mean, one that billions of women have been through? Did not feel confident they would know to pitch it? The novel, as I saw it, was about the severe challenge to mind and body that childbirth is for a woman, just as combat is a severe challenge to the minds and bodies of men. Would any publisher ever claim that they wouldn't know how to pitch a war narrative?
In a clinical trial published March 22 in the Journal of the American Medical Association (JAMA), subjects who underwent mindfulness training for eight weeks were more likely to report improvements in pain, lasting up to a year, compared to people who received whatever other care they chose. The study was led by Daniel Cherkin, Group Health Research Institute, Seattle, US, and Judith Turner, University of Washington, also in Seattle.
A second study, published March 16 in the Journal of Neuroscience and led by Fadel Zeidan, Wake Forest School of Medicine, Winston-Salem, North Carolina, US, and Robert Coghill, now at Cincinnati Children's Hospital, Ohio, US, hints at how mindfulness might reduce pain. The researchers showed in healthy subjects that meditation reduced acute pain independent of endogenous opioids, which account for the vast majority of other brain-based manipulations—such as the placebo effect or conditioned pain modulation.
Monday, April 18, 2016
All three botulinum toxin type A formulations are supported by level A evidence for use in upper limb spasticity, and onabotulinumtoxinA (Botox) received a level A recommendation in chronic migraine, although the magnitude of the benefit is small, according to David Simpson, MD, of Icahn School of Medicine at Mount Sinai in New York, and colleagues.
The new guidance, which is the first since 2008, was published online in Neurology and reported here at the American Academy of Neurology meeting.
There are four types of botulinum toxin available on the U.S. market: three type A and one type B. Type A botulinum toxins include abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), onabotulinumtoxinA (Botox), and the lone Type B product is rimabotulinumtoxinB (Myobloc).
Simpson and colleagues reviewed the evidence for botulinum toxin in four conditions: cervical dystonia, blephrospasm, limb spasticity, and headache.
"We chose these diseases because we had a sense that there were sufficient data to show they were going to change in particular ways," Mark Hallett, MD, of the National Insitute of Neurological Disorders and Stroke, a co-author of the guideline, said during a press briefing. "We already had a feeling for what we were going to find, but we had to prove it carefully."
All three botulinum toxin type A drugs had level-A evidence supporting their use in upper limb spasticity, and abobotulinumtoxinA and onabotulinumtoxinA had level A evidence behind their use in lower limb spasticity, the researchers reported.
There was also strong level-A evidence that onabotulinumtoxinA works in chronic migraine, since the drug had been approved by the FDA in 2010 for this condition -- although the magnitude of benefit was small, Simpson said, with a 15% reduction in headache days per month compared with placebo.
Monday, April 11, 2016
A new University of Virginia study suggests that many medical students and residents are racially biased in their pain assessment, and that their attitudes about race and pain correlate with falsely-held beliefs about supposed biological differences—like black people having thicker skin, or less sensitive nerve endings than white people—more generally.
The study highlights how a confluence of mistaken attitudes—about race, about biology, and about pain—can flourish in one of the worst possible places: medical schools where the future gatekeepers of relief are trained. And it illuminates what I've called the divided state of analgesia in America: overtreatment of millions of people that feeds painkiller abuse at the same time that, with far less public attention, millions of others are systematically undertreated. Think of it as a pain gap between the haves and the have-nots, along lines of class and race.
Unfortunately, the UVA findings are neither surprising nor fundamentally new. Back in the 1990s, two studies—one in an Atlanta emergency room, the other in Los Angeles—found that white patients being treated for long bone fractures were dosed more liberally than Latino patients in L.A., and more liberally than black ones in Atlanta. The authors put forward several possible explanations of the disparity: Perhaps patients in different groups expressed pain differently, or maybe caregivers interpreted pain differently in these groups, or perhaps nurses and doctors saw pain the same way across groups but just chose to remedy pain differently.
By the late 1990s, other studies found similar disparities in cancer care, where people receiving outpatient cancer care in places that mostly served minorities were three times more likely to be under-medicated with analgesics than patients in other settings. Speculation about the causes deepened: Perhaps inadequate prescribing for minority patients resulted from concerns about potential drug abuse, or maybe minority patients had more difficulty finding pharmacies that stocked opioid prescriptions, or again perhaps there was a cultural barrier in doctor-patient understanding and assessment. Into the 2000s, additional reports have confirmed the gap—again with no agreement about any single cause.
Monday, March 28, 2016
"I'm going touch your ankle in a few places," the doctor said shortly after I was brought in. "I want you to describe the pain on a scale from 1 to 10."
He pressed down onto various parts of my foot, each one more painful than the last. And yet, the numbers I uttered barely nudged, moving up from 5 to 5.5, and then from 5.5 to 6. I never said anything higher than that.
When the X-rays were in, the doctor showed them to me and told me two things. The first was that I had fractured my ankle. The second was that there was no way the pain was less than an 8. He joked that if I had sought medical care somewhere else, somewhere less precautionary in its practices, I might have been sent away with a prescription for a mild painkiller and a bag of ice.
Machismo, the driver of so many questionable decisions made by men, is a fickle thing. Sometimes, a little bit of it — a tinge of toughness — doesn't seem to hurt. In sport, for instance. Or maybe negotiation. Other times, it turns out, it can do more harm than good. Like, say, when it comes to caring for one's health.
Tuesday, March 22, 2016
- Developing methods and metrics to monitor and improve the prevention and management of pain.
- Supporting the development of a system of patient-centered integrated pain management practices based on a biopsychosocial model of care that enables providers and patients to access the full spectrum of pain treatment options.
- Taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations.
- Increasing public awareness of pain, increasing patient knowledge of treatment options and risks, and helping to develop a better informed health care workforce with regard to pain management.
- Improving provider education on pain management practices and team-based care in which multiple treatment options are offered – moving away from an opioid-centric treatment paradigm.
- Improving patient self-management strategies, as well as patient access to quality, multidisciplinary care that does not depend solely on prescription medications, especially for vulnerable populations.
- Encouraging the evaluation of risks and benefits of current pain treatment regimens.
- Providing patients with educational tools to encourage safer use of prescription opioids.
- Conducting research to identify how best to provide the appropriate pain treatments to individual patients based on their unique medical conditions and preferences.
These efforts will build on the current work underway at HHS to equip providers with the tools and information they need to make informed patient-centered treatment decisions that include safer and appropriate opioid prescribing.
The goals of the National Pain Strategy can be achieved through a broad effort in which better pain care is provided, along with safer prescribing practices, such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain.
Wednesday, March 16, 2016
Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.
Yet rather than increasing her dose, Dr. Wergin was tapering her down. "Susan, we've got to get you to five pills a day," he said gently.
Such conversations are becoming routine in doctors' offices across the country. A growing number of states are enacting measures to limit prescription opioids, highly addictive medicines that alleviate severe pain but have contributed to a surging epidemic of overdoses and deaths. This week the federal government issued the first national guidelines intended to reduce use of the drugs.
In Nebraska, Medicaid patients like Ms. Kubicka-Welander, 56, may face limits this year that have been recommended by a state drug review board. "We don't know what the final numbers will be," Dr. Wergin told her, "but we have to get you ready."
This first national guidance on the subject is nonbinding, and doctors cannot be punished for failing to comply. But the head of the Centers for Disease Control and Prevention, which issued the guidelines, said the effort was critical to bringing about "a culture shift for patients and doctors."
"We are waking up as a society to the fact that these are dangerous drugs," Director Tom Frieden said in an interview. "Starting a patient on opiates is a momentous decision, and it should only be done if the patient and the doctor have a full understanding of the substantial risks involved."
After record numbers of overdose deaths from opioid painkillers and heroin, 2016 may prove to be the year that the federal government begins to forcefully address what has become a major public health crisis. In addition to the CDC, the Food and Drug Administration is reassessing its policies on opioid medications, the Senate has passed legislation that would expand drug abuse treatment and prevention, and the Drug Enforcement Administration is pushing physicians for more responsible prescribing. The departments of Veterans Affairs and Defense already have opioid policies for their patients.
"For the first time, the federal government is communicating clearly that the widespread practice of prescribing opioids for chronic pain is inappropriate, that the risks outweigh the benefits," said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, a nonprofit that has been urging a curb on the use of opiates.
Given the CDC's influence in the medical community, its recommendations are "a game changer," Kolodny said.
Lawmakers who have faulted past federal efforts to tackle the addiction epidemic also welcomed the announcement.
"I have pushed for the release of these guidelines because I have seen firsthand the devastating effects of prescription drug abuse on individuals, families, and communities," said Democratic Sen. Joe Manchin of West Virginia, which is one of the hardest-hit states. His statement called the guidelines "a critical part of our fight to end this epidemic."
Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, said the organization has "long supported policies that will help combat this critical public health issue, while also ensuring access to these medicines for patients with legitimate medical needs." Such policies include expanded provider education and training on pain management and access to treatment options, she said.
Nearly 28,700 people died from overdoses of prescription opioids and heroin in 2014, according to the most recent data available. Since 1999, 165,000 people have fatally overdosed on prescription painkillers, the CDC said.
In just the past month, it said, 4.3 million have diverted the drugs for nonmedical uses.
"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," Frieden and Debra Houry, director of the agency's National Center for Injury Prevention and Control, wrote Tuesday in the New England Journal of Medicine.
The guidelines, which were delayed a few months by disputes with drug industry groups, are aimed predominantly at primary care physicians. These doctors prescribe many of the opioids but complain that they have insufficient training in how to do so.
Frieden agrees that many doctors need a refresher course on how to approach prescribing pain medications.
"When I went to medical school I had exactly one lecture on pain, and the lecture said if you give an opioid to a patient in pain, they will not get addicted," Frieden said. "Completely wrong, and yet a generation of doctors grew up being taught that."
The recommendations are not intended for doctors managing pain after cancer or surgery or during end-of-life care.
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
My eyes met his. I observed every fleeting facial expression, hoping to gauge his intentions. The discussion about whether to continue to prescribe this medication was one I'd had too many times with too many patients over the past few months.
"My arthritis is always worst in the winter," he said, rubbing his lower back.
It was a snowy afternoon in clinic, and M and I were in the midst of a debate. Oxycodone is an opioid medication, and, like other painkillers such as Oxycontin, Percocet, and Vicodin, it carries a significant risk of abuse.
M said he needed the pills for their pain-relieving effects. He wanted a new prescription. I was disinclined. Opioids are highly addictive. They're often abused. Worst, they decrease the body's drive to breathe, making them deadly in some cases. As much as I wanted to trust M, his story didn't quite add up. Was he abusing the drug, even selling it? Given the rising toll of prescription narcotics, these questions weren't unreasonable.
In Massachusetts where I am a physician, unintentional deaths from opioid overdoses increased from 5.3 to 10.1 per 100,000 residents between 2000 and 2013. In 2014, the number jumped to 18.6 per 100,000. These numbers include overdoses from heroin, which works the same way as opioid pills. Some people who become addicted to painkillers, unable to afford more medication or secure a prescription, then turn to heroin. But as of 2015, prescription opiates on their own account for 44 deaths each day in the United States.
In 2014, then-Massachusetts Gov. Deval Patrick declared opioid abuse and overdose a public health emergency. In June 2015, a task force established to address the issue recommended a plan that would set aside nearly $28 million to tackle the epidemic from numerous angles.
Because opioid abuse and addiction is such a widespread problem, the patients who receive prescriptions for these pills are not always the people who take them. There is a large street market for opioids, and once in the possession of people who abuse them, prescription painkillers — along with anti-anxiety medications, such as benzodiazepines like Klonopin — can become even more dangerous when incorporated into potent drug cocktails (much like cocaine-and-heroin "speedballing"). These mixtures can be lethal given the unpredictability and variability in their contents
The possibility of drug abuse, overdose, and diversion is the backdrop to every conversation I have with a patient about opioids. Some cases are clear-cut. A patient in pain from terminal cancer, whose need for narcotics is obvious and whose potential for dependence is immaterial — I don't worry too much with patients like that. But in most cases the decision "is far more fraught.
My task as a doctor is to take stock of each patient's risk for misuse of the medicines and weight it against the desire to treat his or her pain. There is an ever-present fear that, as much as I hate to believe it, a patient could be manipulating me.
I often recall the surprise, betrayal, and alarm one of my colleagues experienced when police caught her patient selling the pain pills she'd prescribed him for years. Safeguards such as Massachusetts's prescription monitoring program, "which logs all controlled substances prescribed to a patient and tests for drugs in the urine, "are helpful but can still be circumvented.
But my worst fear isn't the legal possibility of supplying an addict — so long as safeguards are reasonably followed, doctors are protected from their patient's criminal behavior. What I fear most is harming a patient or, worse yet, unwittingly playing a role in someone's death.
The simplest solution to avoid these risks, of course, is to not start patients on narcotics at all, instead relying on physical therapy, non-opioid pain medicines, and other adjuncts. But patients sometimes come to me already taking opioids. I inherited M from another physician who left the practice, and when he became my patient, he was already on a relatively high dose of Oxycodone.
His previous doctor started him on the painkillers after major back surgery with the goal of weaning him off them after he had recovered. But unlike other patients with clear motives — some sought a short course of painkillers for acute pain, for example, and then stopped the medicines as soon as possible — "M's case was tricky.
I don't want to deny pain relief to patients who truly feel opioids help them. A prima facie refusal to ever prescribe opioids contradicts expert opinion; according to the American Pain society, for the right patients and under close monitoring, narcotics can indeed be an option as part of a chronic pain regimen.
But I do discuss the data behind narcotics for pain relief with my patients. A recent study showed that opioids in conjunction with the non-narcotic painkiller naproxen for acute lower back pain worked no better than taking naproxen alone.
He couldn’t eat, drink or work. And doctors couldn’t explain his searing pain. - The Washington Post
Unable to work and on medical leave from his job as a financial consultant for a bank, Pace, then 59, had spent the first half of 2012 bouncing among specialists in his home state of Pennsylvania, searching for help from doctors who disagreed about the nature of his illness. Some thought his searing pain might be the side effect of a drug he was taking. Others suspected migraines, a dental problem, mental illness, or an attempt to obtain painkillers.
Even after a junior doctor made what turned out to be the correct diagnosis, there was disagreement among specialists about its accuracy or how to treat Pace. His wife, Carol, a nurse, said she suspects that the couple's persistence and propensity to ask questions led her husband to be branded "a difficult case" — the kind of patient whom some doctors avoid. And on top of that, a serious but entirely unrelated disorder further muddied the diagnostic picture.
So on July 17, 2012, when Pace told his wife he thought he was dying, she fired off an emotional plea for help to the office of a prominent specialist in Baltimore. "I looked at Kim and it hit me: He was going to die," she said. "He was losing weight and his color was ashen" and doctors were "blowing him off. I thought, 'Okay, that's it,' and the nurse in me took over."
Her missive got results. Three weeks later Pace underwent corrective surgery for an uncommon problem that causes pain so intense and debilitating it is regarded by doctors as among the worst known.
"I knew the pain was real and I felt like my life was on the line and I just had to prove it to somebody," Pace said.
Pace's symptoms began in early 2012 when he developed an intermittent burning on the left side of his face and down his esophagus. The pain was mild at first but intensified during the day. Because Pace took medication for a host of chronic conditions including Type 2 diabetes, hypothyroidism, high cholesterol and severe depression, doctors at first suspected a drug reaction; Pace had switched antidepressants a few months earlier. Another possibility was acid reflux.
By the end of March he had developed a facial twitch, and the pain was worse, especially when he chewed. "Nothing really relieved it," he said. His family physician in Wilkes-Barre had suggested going off the antidepressant, but his psychiatrist disagreed. His symptoms were not known side effects of the medication, which was working well for Pace after other antidepressants had failed. The drug "turned my life around," said Pace, who was reluctant to stop taking it.
Saturday, February 27, 2016
"Our study indicates that some patients with dry eye have corneal somatosensory pathway dysfunction and would be better described as having neuropathic ocular pain," said Anat Galor, M.D., M.S.P.H., a cornea and uveitis specialist and associate professor of clinical ophthalmology at Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, and the lead author of the groundbreaking study, "Neuropathic Ocular Pain due to Dry Eye is Associated with Multiple Comorbid Chronic Pain Syndromes," published recently in the American Pain Society's Journal of Pain.
Roy C. Levitt, M.D., a neuroanesthesiologist, pain specialist, and geneticist also at the Miller School, and corresponding author, noted, "A multidisciplinary approach used for chronic pain treatment may also benefit these dry eye patients."
Galor and Levitt are part of a team of Bascom Palmer Eye Institute and UHealth physicians who treat dry eye.
Their research team evaluated 154 dry eye patients from the Miami Veterans Affairs Hospital. "Dry eye patients in our study reported higher levels of ocular and non-ocular pain associated with multiple chronic pain syndromes, and had lower scores on depression and quality-of-life indices consistent with a central sensitivity disorder," said Levitt, a professor and Vice Chair of Translational Research and Academic Affairs in the Department of Anesthesiology, Perioperative Medicine and Pain Management. "We also suspect that neuropathic ocular pain may share causal genetic factors with other overlapping chronic pain conditions."
Thursday, February 25, 2016
Monday, February 01, 2016
Saturday, January 30, 2016
Yearly programs will have a different theme and will bring together 30 trainees with six dynamic, internationally recognized pain investigators from around the world and NAPS permanent faculty for an intensive four-day workshop.
Friday, January 08, 2016
Since the first papers were published on optogenetics in the mid-aughts some researchers have mused about one day using optogenetics in patients, imagining the possibility of an off-switch for depression, for instance.
The technique, however, would require that a patient submit to a set of highly invasive medical procedures: genetic engineering of neurons to insert molecular switches to activate or switch off cells, along with threading of an optical fiber into the brain to flip those switches. Spurred on by a set of technical advances, optogenetics pioneer Karl Deisseroth, together with other Stanford University researchers, has formed a company to pursue optogenetics trials in patients within the next several years—one of several start-ups that are now contemplating clinical trials of the technique.
Circuit Therapeutics, founded in 2010, is moving forward with specific plans to treat neurological diseases. (It also partners with pharmaceutical companies to help them use optogenetics in animal research to develop novel drug targets for human diseases.) Circuit wants to begin clinical trials for optogenetics to treat chronic pain, a therapy that would be less invasive than applications requiring implantation deep inside the brain. Neurons affected by chronic pain are relatively accessible, because they reside in and just outside the spinal cord, an easier target than the brain. Even nerve endings in the skin might be targeted, making them much easier to reach. "In animal models it works incredibly well," says Scott Delp, a neuroscientist at Stanford, who collaborates with Deisseroth. The firm is also working to develop treatments for Parkinson's and other neurological disorders.
Friday, December 25, 2015
But Dr. Ronald Epstein, a University of Rochester professor, wants to change the way doctors approach their patients. Suffering is seen in all corners of hospitals and medical centers — from the emotional pain of a mother who just lost an unborn baby to an older man facing a terminal illness, yet doctors often don't address it.
In a new essay published in the Journal of the American Medical Association, Epstein and a co-author, oncologist Anthony Back of the University of Washington, reviewed medical literature on the ways doctors approach suffering. They found that an approach to suffering is rarely discussed in the medical world, and that this needs to change.
"Physicians can have a pivotal role in addressing suffering if they can expand how they work with patients," the authors wrote. "Some people can do this instinctively, but most physicians need training in how to respond to suffering — yet this kind of instruction is painfully lacking."
Epstein and Back note that physicians can improve their approach by listening to the patient and learning about his/her experience. In addition to the typical "diagnosing and treating," the authors argue that doctors should also "turn toward" the patient, and recognize their suffering. They can do that by asking questions like, "What's the worst part of this for you?" Sometimes an acknowledgment that their pain is real, and that it matters to someone, is all a patient needs to open up.
Monday, December 21, 2015
CDC developed the draft Guideline to provide recommendations about opioid prescribing for primary care providers who are treating adult patients with chronic pain in outpatient settings, outside of active cancer treatment, palliative care, and end-of-life care. The draft Guideline summarizes scientific knowledge about the effectiveness and risks of long-term opioid therapy, and provides recommendations for when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. The draft Guideline identifies important gaps in the literature where further research is needed.
To develop the recommendations, CDC conducted a systematic review on benefits and harms of opioids and developed the draft Guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. CDC drafted recommendations and consulted with experts on the evidence to inform the recommendations. CDC hosted webinars in September 2015 and also provided opportunities for stakeholder and peer review of the draft Guideline. The Guideline is not a federal regulation; adherence to the Guideline will be voluntary. For additional information on prescription drug overdose, please visit http://www.cdc.gov/drugoverdose/prescribing/guideline.html.
Supporting and Related Material in the Docket
The docket contains the following supporting and related materials to help inform public comment: The Guideline; the Clinical Evidence Review Appendix; the Contextual Evidence Review Appendix; and three documents that comprise the Comment Summaries and CDC Responses (Constituent Comment Summary, Peer Review Summary, and Stakeholder Review Group Summary). The Clinical Evidence Review Appendix and the Contextual Evidence Review Appendix include primary evidence, studies, and data tables that were used by CDC to develop the recommendations in the Guideline. The Constituent Comment Summary reflects input obtained in response to webinars hosted on September 16 and September 17, 2015, during which CDC shared an overview of the development process and draft recommendation statements. The Stakeholder Review Group Summary also reflects input obtained from stakeholders (comprised of professional and community organizations) following their review of a prior draft of the Guideline. Finally, the Peer Review Summary reflects input obtained from three scientific peer reviewers following their review of a draft of the full Guideline, along with a summary of comments received and CDC responses.
Sunday, December 13, 2015
Lately, it seems I can't attend a gathering of friends without at least one complaining about headaches, and another offering advice: It's your glasses, your diet or, the old standby, your stress level. Regarding the latter, let me say that a friend and I once spent four days at a spa, doing nothing but exercise classes and beauty treatments, and we were still popping pills for our pounding heads nonstop.
Over the last few decades, migraines (intensely painful headaches that make it difficult to function and are often accompanied by other symptoms like vomiting) have become big business. Billions of dollars are spent annually on over-the-counter and prescription remedies, as well as visits to the increasing number of specialized clinics and hospital departments around the country. Even dermatologists, dentists and non-Western holistic practitioners are getting in on the action.
Friday, December 04, 2015
The breakthrough may lead to powerful new ways to treat painful conditions such as arthritis.
Only a handful people around the world are born unable to feel pain. These individuals can often suffer a range of injuries when they are young. Babies with the condition tend to chew their fingers, toes and lips until they bleed, and toddlers can suffer an increased range of knocks, tumbles and encounters with sharp or hot objects.
The disorder is caused by a rare genetic mutation that results in a lack of ion channels that transport sodium across sensory nerves. Without these channels, known as Nav1.7 channels, nerve cells are unable to communicate pain. Researchers quickly sought to make compounds that blocked Nav1.7 channels, thinking they might be able to block pain in people without the disorder.
"It looked like a fantastic drug target," says John Wood at University College London. "Pharma companies went bananas and made lots of drugs." But while a few compounds saw some success, none brought about the total pain loss seen in people who lack the channel naturally.
To find out why, Wood and his colleagues studied mice that had been genetically modified to lack Nav1.7. These animals don't feel pain, either – they show no reaction when their tails are exposed to extreme hot or cold temperatures, for example.
A closer analysis of the rodents' nerves showed that mice lacking Nav1.7 had a huge increase in the expression of genes responsible for opioid peptides, the body's natural painkiller. The mice seem to be making more of these pain-relieving peptides, which might explain why people lacking the channel don't feel pain, either.
Sunday, November 29, 2015
The end of migraines is close: A new drug could stop debilitating headaches before they start - Salon.com
The co-author of the Declaration of Independence never vanquished what he called his "periodical head-ach," although his attacks appear to have lessened after 1808. Two centuries later 36 million American migraine sufferers grapple with the pain the president felt. Like Jefferson, who often treated himself with a concoction brewed from tree bark that contained quinine, they try different therapies, ranging from heart drugs to yoga to herbal remedies. Their quest goes on because modern medicine, repeatedly baffled in attempts to find the cause of migraine, has struggled to provide reliable relief.
Now a new chapter in the long and often curious history of migraine is being written. Neurologists believe they have identified a hypersensitive nerve system that triggers the pain and are in the final stages of testing medicines that soothe its overly active cells. These are the first ever drugs specifically designed to prevent the crippling headaches before they start, and they could be approved by the U.S. Food and Drug Administration next year. If they deliver on the promise they have shown in studies conducted so far, which have involved around 1,300 patients, millions of headaches may never happen.
"It completely changes the paradigm of how we treat migraine," says David Dodick, a neurologist at the Mayo Clinic's campus in Arizona and president of the International Headache Society. Whereas there are migraine-specific drugs that do a good job stopping attacks after they start, the holy grail for both patients and doctors has been prevention.
Tuesday, November 17, 2015
Millions of people are dying in pain because of the repressive stance the world has taken on drugs. That's because states are obsessed by the fear that people will use controlled medicines such as morphine as recreational drugs, thereby neglecting their important medical uses.
Where you live determines whether you will be able to access to controlled medicines, particularly opiates, when confronting an acute terminal, chronic or painful illness. Ninety-two per cent of the world's morphine is consumed by only 17% of the world's population, primarily the United States and Europe. Seventy--five percent of the world's people in need do not have access to pain relieving medicine.
In other words, most of the global population, outside the affluent countries in the North, dying in pain, including from terminal cancers, do so in the absence of dignified palliative care.
This is a horrendous situation for millions of patients and families. Essential medicines such as morphine, taken for granted as the standard relief of severe pain in the global North, do not enjoy the same status in the global South. Quite the opposite. Chances are, if a person living in any developing country ends up with an illness associated with extreme and avoidable pain, they will endure the pain simply because their government has created obstacles to morphine use in hospitals.
Wednesday, November 11, 2015
The federal agency has been asked to come here and help find answers to a disturbing new trend that is costing lives – heroin mixed with a prescription pain medication.
State and local health experts said they are hoping what they learn during meetings Tuesday at the Hamilton County Board of Health will help them tackle the heroin crisis.
The CDC has a six-person team on the ground in Ohio, meeting with the Ohio Department of Health, and the Hamilton County Health Department.
Officials said they're focusing on a particular part of the heroin crisis – the number of deaths related to fentanyl.
Authorities said fentanyl is a prescription pain medication that has been showing up in heroin. The big mystery is why it's being mixed with heroin.
"We don't fully understand the fentanyl situation, and that's one of the reasons we wanted their help with this," said Dr. Mary DiOrio, the medical director of the Ohio Department of Health.
ODH asked the CDC to help look into the problem.
"We think that some people don't even know that it's in what they're injecting so we're trying to fully understand what people do and don't know so we can target the messages appropriately so we can protect lives," DiOrio said.
We've seen the deadly consequences of fentanyl in Greater Cincinnati.
Kenneth Gentry is facing charges in the overdose death of an Arlington Heights man earlier this year that was blamed on fentanyl.
Authorities said the fentanyl problem causes only a fraction of the deaths heroin alone causes – but it's a problem that's growing quickly.
Authorities said heroin deaths increased 18 percent in Ohio last year to a total of nearly 2,500. In 2014 there were about 500 deaths linked to fentanyl – an increase of nearly 600 percent from the year before.