Saturday, September 23, 2017

The Cost of the Opioid Crisis | The New Yorker

In September, 2016, Donald Trump delivered a speech at the Economic Club of New York. "Today, I'm going to outline a plan for American economic revival," he said. "It is a bold, ambitious, forward-looking plan to massively increase jobs, wages, incomes, and opportunities for the people of our country." He went on to talk about lowering taxes and removing regulations, renegotiating trade deals and building a border wall. But he overlooked one of the most pressing issues facing the American economy today: the opioid crisis.

Politicians tend to talk about the crisis in moral terms, focussing on the ways in which opioid addiction has ravaged families and communities. The New Jersey governor, Chris Christie, whom Trump appointed to lead a commission to study the issue, has compared opioid-overdose fatalities to terrorist attacks, saying, "We have a 9/11-scale loss every three weeks." Opioids, which include prescription painkillers and drugs like heroin and fentanyl, are indeed responsible for large-scale human suffering. According to the National Survey of Drug Use and Health, 97.5 million Americans used, or misused, prescription pain pills in 2015. Drug-overdose deaths have tripled since 2000, and opioid abuse now kills more than a hundred Americans a day. But often omitted from the conversation about the epidemic is the fact that it is also inflicting harm on the American economy, and on a scale not seen in any previous drug crisis.

In July, when economists at Goldman Sachs analyzed how the 2008 financial crisis and its aftermath may have contributed to levels of opioid addiction, they noted that fewer prime working-age men are participating in the labor force than in the past, and that many of these men have been found to be taking prescription pain medication. Research by the Princeton economist Alan Krueger, published last week, indicates a definitive link between the two.

Other studies have tried to put an exact figure on the cost of the epidemic. A study published in the journal Pain Medicine in 2011 estimated that health-care costs related to prescription opioid abuse amounted to twenty-five billion dollars, and criminal-justice-system costs to $5.1 billion. But the largest cost was to the workplace, which accounted for $25.6 billion, in the form of lost earnings and employment. "There are major consequences to the economy, not just to the employer and employee who are losing productivity but also to civil society," Howard Birnbaum, a health-care economist with the Analysis Group and one of the authors of the study, told me recently. "If people don't have jobs, they don't have money to spend in the grocery store, on gasoline. It's the old multiplier effect: the socioeconomic burden is much broader than on any individual or any firm." The study estimated a total cost to the economy of $55.7 billion, but, Birnbaum said, "I suspect it is even larger now."Another study, just two years later, reached a total of $78.5 billion.

When I spoke with Anupam Jena, a health economist and physician at Harvard Medical School, he argued that such figures don't include the most dramatic cost: the economic value of the loss of life. Taking a conservative estimate of twenty to thirty thousand opioid-related deaths a year and multiplying those numbers by five million dollars—a figure commonly used by insurance companies to value a human life—Jena estimated that loss of life alone costs the economy an additional sum of between a hundred and a hundred and fifty billion dollars a year. All these figures suggest that addiction prevention and treatment should be a part of any serious policy discussion about how to strengthen the U.S. economy.

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https://www.newyorker.com/magazine/2017/09/18/the-cost-of-the-opioid-crisis?

To treat back pain, look to the brain not the spine | Aeon Essays

For patient after patient seeking to cure chronic back pain, the experience is years of frustration. Whether they strive to treat their aching muscles, bones and ligaments through physical therapy, massage or rounds of surgery, relief is often elusive – if the pain has not been made even worse. Now a new working hypothesis explains why: persistent back pain with no obvious mechanical source does not always result from tissue damage. Instead, that pain is generated by the central nervous system (CNS) and lives within the brain itself.

I caught my first whiff of this news about eight years ago, when I was starting the research for a book about the back-pain industry. My interest was both personal and professional: I'd been dealing with a cranky lower back and hip for a couple of decades, and things were only getting worse. Over the years, I had tried most of what is called 'conservative treatment' such as physical therapy and injections. To date, it had been a deeply unsatisfying journey.

Like most people, I was convinced that the problem was structural: something had gone wrong with my skeleton, and a surgeon could make it right. When a neuroscientist I was interviewing riffed on the classic lyric from My Fair Lady, intoning: 'The reign of pain is mostly in the brain,' I was not amused. I assumed that he meant that my pain was, somehow, not real. It was real, I assured him, pointing to the precise location, which was a full yard south of my cranium.

Like practically everyone I knew with back pain, I wanted to have a spinal MRI, the imaging test that employs a 10-ft-wide donut-shaped magnet and radio waves to look at bones and soft tissues inside the body. When the radiologist's note identified 'degenerative disc disease', a couple of herniated discs, and several bone spurs, I got the idea that my spine was on the verge of disintegrating, and needed the immediate attention of a spine surgeon, whom I hoped could shore up what was left of it.

Months would pass before I understood that multiple studies, dating back to the early 1990s, evaluating the usefulness of spinal imaging, had shown that people who did not have even a hint of lower-back pain exhibited the same nasty artefacts as those who were incapacitated. Imaging could help rule out certain conditions, including spinal tumours, infection, fractures and a condition called cauda equina syndrome, in which case the patient loses control of the bowel or bladder, but those diagnoses were very rare. In general, the correlation between symptoms and imaging was poor, and yet tens of thousands of spinal MRIs were ordered every year in the United States, the United Kingdom and Australia.

Very often, the next stop was surgery. For certain conditions, such as a recently herniated disc that is pressing on a spinal nerve root, resulting in leg pain or numbness coupled with progressive weakness, or foot drop, a nerve decompression can relieve the pain. The problem is that all surgeries carry risks, and substantial time and effort is required for rehabilitation. After a year, studies show, the outcomes of patients who opt for surgery and those who don't are approximately the same.

More invasive surgeries carry greater risks. Lumbar spinal fusion – surgery meant to permanently anchor two or more vertebrae together, eliminating any movement between them – is recognised as particularly hazardous. Even when the vertebral bones fuse properly, patients often do not get relief from the pain that sent them to the operating room. Beyond that, fusion surgery often results in 'adjacent segment deterioration', requiring a revision procedure.

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https://aeon.co/essays/to-treat-back-pain-look-to-the-brain-not-the-spine?

Tuesday, September 05, 2017

The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years - The New York Times

Drug overdoses killed roughly 64,000 people in the United States last year, according to the first governmental account of nationwide drug deaths to cover all of 2016. It's a staggering rise of more than 22 percent over the 52,404 drug deaths recorded the previous year — and even higher than The New York Times's estimatein June, which was based on earlier preliminary data.

Drug overdoses are expected to remain the leading cause of death for Americans under 50, as synthetic opioids — primarily fentanyl and its analogues — continue to push the death count higher. Drug deaths involving fentanyl more than doubled from 2015 to 2016, accompanied by an upturn in deaths involving cocaine and methamphetamine. Together they add up to an epidemic of drug overdoses that is killing people at a faster rate than the H.I.V. epidemic at its peak.

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https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?

Pain News - Medical Xpress

https://medicalxpress.com/search/sort/date/3d/?search=pain

Monday, September 04, 2017

Opioids Aren’t the Only Pain Drugs to Fear - The New York Times

Last month, a White House panel declared the nation's epidemic of opioid abuse and deaths "a national public health emergency," a designation usually assigned to natural disasters.

A disaster is indeed what it is, with 142 Americans dying daily from drug overdoses, a fourfold increase since 1999, more than the number of people killed by gun homicides and vehicular crashes combined. A 2015 National Survey on Drug Use and Health estimated that 3.8 million Americans use opioids for nonmedical reasons every month.

Lest you think that people seeking chemically induced highs are solely responsible for the problem, physicians and dentists who prescribe opioids with relative abandon, and patients and pharmacists who fill those prescriptions, lend a big helping hand. The number of prescriptions for opioids jumped from 76 million in 1991 to 219 million two decades later. They are commonly handed to patients following all manner of surgery, whether they need them or not.

A new review of six studies by Dr. Mark C. Bicket and colleagues at Johns Hopkins University School of Medicine found that among 810 patients who underwent seven different kinds of operations, 42 percent to 71 percent failed to use the opioids they received, and 67 percent to 92 percent still had the unused drugs at home.

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https://www.nytimes.com/2017/09/04/well/opioids-arent-the-only-pain-drugs-to-fear.html?_r=0

Wednesday, August 30, 2017

Cutting down on opioids has made life miserable for chronic pain patients - Slate

On July 26, Todd Graham, 56, a well-respected rehabilitation specialist in Mishawaka, Indiana, lost his life. Earlier that day, a woman complaining of chronic pain had come to Graham's office in hope of receiving an opioid such as Percocet, Vicodin, or long-acting OxyContin. He reportedly told her that opioids were not an appropriate first-line treatment for long-term pain—a view now shared by professionals—and she, reportedly, accepted his opinion. Her husband, however, became irate. Later, he tracked down the doctor and shot him twice in the head.

This horrific story has been showcased to confirm that physicians who specialize in chronic pain confront real threats from patients or their loved ones, particularly regarding opioid prescriptions. But Graham's death also draws attention to another fraught development: In the face of an ever-worsening opioid crisis, physicians concerned about fueling the epidemic are increasingly heeding warnings and feeling pressured to constrain prescribing in the name of public health. As they do so, abruptly ending treatment regimens on which many chronic pain patients have come to rely, they end up leaving some patients in agonizing pain or worse.

Last month, one of us was contacted by a 66-year old orthopedic surgeon in Northern California, desperate to find a doctor for herself. Since her early 30s, Dr. R suffered from an excruciating condition called Interstitial Cystitis (IC). She described it as a "feeling like I had a lit match in my bladder and urethra." Her doctor placed her on methadone and she continued in her medical practice on a relatively low dose, for 34 years. As Dr. R told one of us, "Methadone has saved my life. Not to sound irrational, but I don't think I would have survived without it." Then a crisis: "Unfortunately for me, the feds are clamping down on docs prescribing opiates. My doctor decided that she did not want to treat me anymore, didn't give me a last prescription, and didn't wait until I found another pain doctor who would help me." For the past 30 years, Dr. R has been an advocate for better treatment of IC and reports "many suicides in the IC patient population due to the severity of the pain."

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http://www.slate.com/articles/health_and_science/medical_examiner/2017/08/cutting_down_on_opioids_has_made_life_miserable_for_chronic_pain_patients.html?

Tuesday, August 29, 2017

The Conversation Placebo - The New York Times

In my daily work as a primary care internist, I see no letup from pain. Every single patient, it seems, has an aching shoulder or a bum knee or a painful back. "Our bodies evolved to live about 40 years," I always explain, "and then be finished off by a mammoth or a microbe." Thanks to a century of staggering medical progress, we now live past 80, but evolution hasn't caught up; the cartilage in our joints still wears down in our 40s, and we are more obese and more sedentary than we used to be, which doesn't help.

So it's no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.

What's often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.

In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.

Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients' situation and offered words of encouragement about getting better.

Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.

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https://www.nytimes.com/2017/01/19/opinion/sunday/the-conversation-placebo.html

Thursday, August 24, 2017

A New Brain Measure of Nociception in Infants | Pain Research Forum

Unlike adults, infants can't tell you if they're in pain. Instead, clinicians must interpret behaviors such as crying and physiological measures such as heart rate to determine what a newborn is experiencing. Since these can occur for reasons unrelated to nociception, the pain field has long sought more objective ways to measure pain in this nonverbal population. Now, in a new study, investigators have identified pain-related brain activity in infants that could be measured with a simple electroencephalogram (EEG) recording and used the activity to create an EEG template that allowed them to test the efficacy of an analgesic.

A team led by Rebeccah Slater, University of Oxford, UK, found that the EEG template of brain activity correlated with the presence and intensity of pain-related behavior and validated the template across four independent samples of infants. Intriguingly, a topical analgesic dampened the brain signal, showing how the new approach could be used to assess the effect of pain medications in infants undergoing painful procedures.

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http://painresearchforum.org/news/82405-new-brain-measure-nociception-infants

Sunday, August 20, 2017

Women are flocking to wellness because modern medicine still doesn’t take them seriously - Quartz

The wellness movement is having a moment. The more luxurious aspects of it were on full display last weekend at the inaugural summitof Gwyneth Paltrow's lifestyle brand Goop, from crystal therapy to $66 jade eggs meant to be worn in the vagina. Meanwhile, juice cleanses, "clean eating," and hand-carved lamps made of pink Himalayan salthave all gone decidedly mainstream. I myself will cop to having participated in a sound bath—basically meditating for 90 minutes in a dark room while listening to gongs and singing bowls. (I felt amazingly weird afterward, in the best possible way.)

It seems that privileged women in the US have created their own alternative health-care system—with few of its treatments having been tested for efficacy, or even basic safety. It's easy to laugh at the dubious claims of the wellness industrial complex, and reasonable to worry about the health risks involved. But the forces behind the rise of oxygen bars and detox diets are worth taking seriously—because the success of the wellness industry is a direct response to a mainstream medical establishment that frequently dismisses and dehumanizes women.

To be fair, the American health-care system is generally unpleasant for everyone: impersonal, harried, and incredibly expensive. "The doctor-patient relationship has been slowly eroding, not only with specialization and the fact that people now see panels of doctors, but because emergency rooms are slammed, there are insurance-coverage problems, et cetera," Travis A. Weisse, a science historian at the University of Wisconsin, told Taffy Brodesser-Akner in an article for Outside magazine. "It can make a patient feel devalued."

The medical system is even more terrible for women, whose experience of pain is routinely minimized by health practitioners. In the emergency room, women routinely wait longer than men to receive medication for acute pain. At the gynecologist's office, severe period-related pain is often dismissed or underestimated. Ingrained sexism means that doctors may regard women as either earth mothers or hypochondriacs; that is, either women possess deep wellspring of internal pain control that they ought to be able to channel during childbirth, or their pain is psychological in nature—a symptom of hysteria.

Conditions that affect women at higher rates than men, including depression and autoimmune diseases like fibromyalgia, are much more likely to be dismissed as having a psychological rather than a physiological source. Chronic fatigue syndrome sufferers are still instructed to rely on exercise and positive thinking, despite research that indicates these measures do not cure the condition. Many women with autoimmune diseases, endometriosis, or even multiple sclerosis go undiagnosed for years, despite multiple trips to doctors and specialists—all the while being told that their symptoms could just be stress.

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https://qz.com/1006387/women-are-flocking-to-wellness-because-traditional-medicine-still-doesnt-take-them-seriously/

Sunday, August 13, 2017

A comprehensive guide to the new science of treating lower back pain - Vox

Cathryn Jakobson Ramin's back pain started when she was 16, on the day she flew off her horse and landed on her right hip.

For the next four decades, Ramin says her back pain was like a small rodent nibbling at the base of her spine. The aching left her bedridden on some days and made it difficult to work, run a household, and raise her two boys.

By 2008, after Ramin had exhausted what seemed like all her options, she elected to have a "minimally invasive" nerve decompression procedure. But the $8,000 operation didn't fix her back, either. The same pain remained, along with new neck aches.

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https://www.vox.com/science-and-health/2017/8/4/15929484/chronic-back-pain-treatment-mainstream-vs-alternative

Surgery Is One Hell Of A Placebo | FiveThirtyEight

The guy's desperate. The pain in his knee has made it impossible to play basketball or walk down stairs. In search of a cure, he makes a journey to a healing place, where he'll undergo a fasting rite, don ceremonial garb, ingest mind-altering substances and be anointed with liquids before a masked healer takes him through a physical ritual intended to vanquish his pain.

Seen through different eyes, the process of modern surgery may look more more spiritual than scientific, said orthopedic surgeon Stuart Green, a professor at the University of California, Irvine. Our hypothetical patient is undergoing arthroscopic knee surgery, and the rituals he'll participate in — fasting, wearing a hospital gown, undergoing anesthesia, having his surgical site prepared with an iodine solution, and giving himself over to a masked surgeon — foster an expectation that the procedure will provide relief, Green said.

These expectations matter, and we know they matter because of a bizarre research technique called sham surgery. In these fake operations, patients are led to believe that they are having a real surgical procedure — they're taken through all the regular pre- and post- surgical rituals, from fasting to anesthesia to incisions made in their skin to look like the genuine operation occurred — but the doctor does not actually perform the surgery. If the patient is awake during the "procedure," the doctor mimics the sounds and sensations of the true surgery, and the patient may be shown a video of someone else's procedure as if it were his own.

Sham surgeries may sound unethical, but they're done with participants' consent and in pursuit of an important question: Does the surgical procedure under consideration really work? In a surprising number of cases, the answer is no.

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https://fivethirtyeight.com/features/surgery-is-one-hell-of-a-placebo/?

Wednesday, August 02, 2017

Almost half of all opioid misuse starts with a friend or family member's prescription | PBS NewsHour

More than half of adults who misused opioids did not have a prescription, and many obtained drugs for free from friends or relatives, according to a national survey of more than 50,000 adults.

Although many people need medical narcotics for legitimate reasons, the National Survey on Drug Use and Health reported Monday that regular access to prescription opioids can facilitate misuse. The results, outlined in the Annals of Internal Medicine, indicate when the medical community overprescribes opioids, unused drugs are then available for abuse.

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http://www.pbs.org/newshour/rundown/opioid-misuse-starts-friend-family-members-prescription/?

Friday, July 14, 2017

‘Extreme’ Use of Painkillers and Doctor Shopping Plague Medicare, New Report Says - ProPublica

In Washington, D.C., a Medicare beneficiary filled prescriptions for 2,330 pills of oxycodone, hydromorphone and morphine in a single month last year — written by just one of the 42 health providers who prescribed the person such drugs.

In Illinois, a different Medicare enrollee received 73 prescriptions for opioid drugs from 11 prescribers and filled them at 20 different pharmacies. He sometimes filled prescriptions at multiple pharmacies on the same day.

These are among the examples cited in a sobering new report released today by the inspector general of the U.S. Department of Health and Human Services. The IG found that heavy painkiller use and abuse remains a serious problem in Medicare's prescription drug program, known as Part D, which serves more than 43 million seniors and disabled people.

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https://www.propublica.org/article/extreme-use-of-painkillers-and-doctor-shopping-plague-medicare

Thursday, July 13, 2017

The weird power of the placebo effect, explained - Vox

Over the last several years, doctors noticed a mystifying trend: Fewer and fewer new pain drugs were getting through double-blind placebo control trials, the gold standard for testing a drug's effectiveness.

In these trials, neither doctors nor patients know who is on the active drug and who is taking an inert pill. At the end of the trial, the two groups are compared. If those who actually took the drug report significantly greater improvement than those on placebo, then it's worth prescribing.

When researchers started looking closely at pain-drug clinical trials, they found that an average of 27 percent of patients in 1996 reported pain reduction from a new drug compared to placebo. In 2013, it was 9 percent.

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https://www.vox.com/science-and-health/2017/7/7/15792188/placebo-effect-explained

Thursday, July 06, 2017

Bring On the Exercise, Hold the Painkillers - The New York Times

Taking ibuprofen and related over-the-counter painkillers could have unintended and worrisome consequences for people who vigorously exercise. These popular medicines, known as nonsteroidal anti-inflammatory drugs, or NSAIDs, work by suppressing inflammation. But according to two new studies, in the process they potentially may also overtax the kidneys during prolonged exercise and reduce muscles' ability to recover afterward.

Anyone who spends time around people who exercise knows that painkiller use is common among them. Some athletes joke about taking "vitamin I," or ibuprofen, to blunt the pain of strenuous training and competitions. Others rely on naproxen or other NSAIDs to make hard exercise more tolerable.

NSAID use is especially widespread among athletes in strenuous endurance sports like marathon and ultramarathon running. By some estimates, as many as 75 percent of long-distance runners take ibuprofen or other NSAIDs before, during or after training and races.

But in recent years, there have been hints that NSAIDs might not have the effects in athletes that they anticipate. Some studies have found that those who take the painkillers experience just as much muscle soreness as those who do not.

A few case studies also have suggested that NSAIDs might contribute to kidney problems in endurance athletes, and it was this possibility that caught the attention of Dr. Grant S. Lipman, a clinical associate professor of medicine at Stanford University and the medical director for several ultramarathons.

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https://www.nytimes.com/2017/07/05/well/move/bring-on-the-exercise-hold-the-painkillers.html?

Thursday, June 22, 2017

The opioid crisis changed how doctors think about pain - Vox

WILLIAMSON, West Virginia — This town on the eastern border of Kentucky has 3,150 residents, one hotel, one gas station, one fire station — and about 50 opiate overdoses each month.

On the first weekend of each month, when public benefits like disability get paid out, the local fire chief estimates the city sees about half a million dollars in drug sales. The area is poor — 29 percent of county residents live in poverty, and, amid the retreat of the coal industry, the unemployment rate was 12.2 percent when I visited last August— and those selling pills are not always who you'd expect.

"Elderly folks who depend on blood pressure medications, who can't afford them, they're selling their [painkillers] to get money to buy their blood pressure drug," Williamson fire chief Joey Carey told me when I visited Williamson. "The opioids are still $5 or $10 copays. They can turn around and sell those pills for $5 or $10 each."

Opioids are everywhere in Williamson, because chronic pain is everywhere in Williamson.

Dino Beckett opened a primary care clinic there in March 2014, on the same street with the hotel and the gas station. A native of the area with a close-cropped beard and a slight Southern drawl, Beckett sees the pain of Williamson day in and day out.

He sees older women who suffer from compression fractures up and down their spines, the result of osteoporosis. He sees men who mined coal for decades, who now experience persistent, piercing low back pain. "We have a population that works in coal mines or mine-supporting industries doing lots of manual labor, lifting equipment," he says. "Doing that for 10 to 12 hours a day for 15 to 20 years, or more, is a bad deal."

Beckett sees more pain than doctors who practice elsewhere. Nationally, 10.1 percent of Americans rate their health as "fair" or "poor." In Mingo County, where Williamson is, that figure stands at 38.9 percent.

Williamson has some of West Virginia's highest rates of obesity, disability, and arthritis — and that is in a state that already ranks among the worst in those categories compared with the rest of the nation. An adult in Williamson has twice the chance of dying from an injury as the average American.

This is why the opioid crisis is so hard to handle, here and in so many communities: The underlying drugs are often being prescribed for real reasons.

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https://www.vox.com/2017/6/5/15111936/opioid-crisis-pain-west-virginia

Tuesday, June 13, 2017

Neurobiology of Pain - Journal - Elsevier

Neurobiology of Pain is an international journal for the publication of basic and translational research on the mechanisms of acute and chronic pain. It focuses on experimental studies of pain mechanisms at every level from molecular and cellular to brain imaging and behavioural. The journal primarily publishes original basic and translational studies, but will consider clinical studies which address mechanistic aspects of pain based on experimental approaches in human subjects.


The scope of the journal addresses all areas of pain neurobiology, including:

  • Molecular substrates and cell signaling
  • Genetics and epigenetics
  • Spinal and brain circuitry
  • Structural and physiological plasticity
  • Developmental aspects
  • Laboratory models of pain
  • Brain imaging
  • Neuroinflammation
  • Pain and cognition
  • Pain and emotion

https://www.journals.elsevier.com/neurobiology-of-pain/

Wednesday, June 07, 2017

Your mind can be trained to control chronic pain. But it will cost you - STAT

There was plenty to blame: the car wreck that broke his back. The job pouring concrete that shattered his spine a second time. The way he tore up his insides with cigarettes, booze, cocaine, and opioids.

It all amounted to this: Carl White was in pain. All the time. And nothing helped — not the multiple surgeries, nor the self-medication, not the wife and daughter who supported him and relied on him.

Then White enrolled in a pain management clinic that taught him some of his physical torment was in his head — and he could train his brain to control it. It's a philosophy that dates back decades, to the 1970s or even earlier. It fell out of vogue when new generations of potent pain pills came on the market; they were cheaper, worked faster, felt more modern.

But the opioid epidemic has soured many patients and doctors on the quick fix. And interest is again surging in a treatment method called biopsychosocial pain management, which trains patients to manage chronic pain with tools ranging from physical therapy to biofeedback to meditation. It helped Carl White, a 43-year-old social worker from Leroy, Minn.

The catch? It can take weeks and cost tens of thousands of dollars — and thus remains out of reach for most patients with chronic pain.

"We've been banging our heads on the wall, and banging our fists on the door, trying to get insurers to pay for this," said Dr. Bob Twillman, executive director for the Academy of Integrative Pain Management. "For the most part, they will not."

Chronic pain affects nearly 50 million Americans, according to the American Pain Foundation. The largest drivers include migraines, arthritis, and nerve damage — but in many cases, emotional trauma also contributes to the sense of misery.

"We have a lot of people in this country who are unhappy, isolated, and hurting," said Jeannie Sperry, a psychologist who co-chairs the division of addictions, transplant, and pain at Mayo Clinic. "Depression hurts. Anxiety hurts. It's rare for people to have chronic pain without one of these co-morbidities."

Indeed, chronic pain has a substantial psychological element: Being in pain often leads to self-imposed isolation. That loss of a social network then leads to anxiety, depression, and a tendency to catastrophize the pain — so that it's all a patient can think about.

More …

https://www.statnews.com/2017/05/30/chronic-pain-management/

NIH Releases Federal Pain Research Strategy Draft Research Priorities - American Society of Anesthesiologists

On May 25, the Interagency Pain Research Coordinating Committee (IPRCC) and the Office of Pain Policy of the National Institutes of Health (NIH) released draft Federal Pain Research Priorities, which were presented and discussed at a forum and public comment period on June 1. The forum immediately followed the Annual NIH Pain Consortium Symposium, where presentations highlighted multidisciplinary strategies for the management of pain. Following the open public comment period, written comments will be accepted until June 6.

The Federal Pain Research Strategy (FPRS) is an effort to oversee development of a long-term strategic plan for pain research. This is especially important, as most analgesics and anesthetics are used, despite known side effects and no new pharmacologic treatments for pain have emerged in recent years. The draft priorities acknowledge this and encompass this as one of the priorities, stating, "Given the adverse effects, risks of tolerance, dependence, and addiction, associated with opioids, new safer and more effective pharmacologic and non‐pharmacologic approaches for pain management are needed."  ASA is pleased to see this as a focus, as chronic pain effects millions of Americans and the ongoing struggle to address the opioid epidemic persists.

The draft research priorities are a culmination of a diverse and balanced group of scientific experts, patient advocates, and federal representatives working together for nearly two years to identify and prioritize research recommendations. The process included a steering committee to report back to the broader IPRCC and five workgroups based around the continuum of pain: prevention of acute and chronic and pain; acute pain and acute pain management; transition from acute to chronic pain; chronic pain and chronic pain management; and disparities. The workgroups identified research priorities within their respective areas and together, in the areas where there was overlap, developed cross-cutting research priorities to incorporate their recommendations.

ASA members Steve Cohen, M.D. and David Clark, M.D. were part of the chronic pain and chronic pain management workgroup and were involved in developing research priorities to answer questions about the gaps in understanding around the mechanisms of chronic pain, effective treatments and self-management strategies.

The cross-cutting research priorities fall into these broader areas of research:

• Novel drugs and non-pharmacological treatments for pain
• Screening tools and outcome measures for assessments across the continuum of pain
• National registries, datasets and research networks
• Effective models of care delivery for pain management
• Precision medicine methodology to prevent and treat pain

More ... 

http://asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2017/06/nih-releases-federal-pain-research-strategy-draft-research-priorities

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Monday, May 29, 2017

The opioid epidemic could be cured with virtual-reality worlds that let patients escape their pain — Quartz

"It's like a crawly feeling inside," says Judy*. "You get hot, then chilled, and you feel like you want to run away." The 57-year-old has short dark-grey hair and a haunted expression. She's breathless and sits with her right leg balanced up on her walking stick, rocking it back and forth as she speaks.

Judy explains that she suffers from constant, debilitating pain: arthritis, back problems, fibromyalgia and daily migraines. She was a manager at a major electronics company until 2008, but can no longer work. She often hurts too much even to make it out of bed.

She's taking around 20 different medications each day, including painkillers, antidepressants, sedatives and a skin patch containing a high dose of the opioid drug fentanyl, which she says did not significantly help her pain and which she's now trying to come off. Her physician has been tapering the dose for months, so in addition to her pain she suffers withdrawal symptoms: the chills and crawling dread. Then her clinic announced that it would no longer prescribe any opioids at all, the unintended result of new, stricter measures aimed at clamping down on opioid abuse. Faced with losing access to the drug on which she is physically dependent, she has come to another clinic, Pain Consultants of East Tennessee (PCET) in Knoxville, desperate for help.

Ted Jones, the attending clinician, calls patients like Judy "refugees". He says that he sees "tons" of similar cases. Over 100 million Americans suffer long-term pain. Now they find themselves at the epicentre of two colliding health catastrophes in the USA: chronic pain and opioid abuse.

More ...

https://qz.com/973605/the-opioid-epidemic-could-be-cured-with-virtual-reality-worlds-that-let-patients-escape-their-pain/

Friday, May 26, 2017

The Federal Pain Research Strategy - NIH

The Federal Pain Research Strategy is an effort of the Interagency Pain Research Coordinating Committee and the Office of Pain Policy of the National Institutes of Health to oversee development of a long-term strategic plan for those federal agencies and departments that support pain research. A diverse and balanced group of scientific experts, patient advocates, and federal representatives identified and prioritized research recommendations as a basis for this long-term strategic plan to coordinate and advance the federal pain research agenda. The key areas of prevention of acute and chronic pain, acute pain and acute pain management, the transition from acute to chronic pain, chronic pain and chronic pain management, and disparities in pain and pain care provided the framework for development of the strategy. In addition, a set of cross-cutting research priorities were identified by the task force in topic areas for which similar research recommendations were developed across multiples work groups and merged. 

https://iprcc.nih.gov/docs/DraftFederalPainResearchStrategy.pdf

Saturday, May 20, 2017

Even short-term opioid use can set people up for addiction risks | Science News

Even though a sprained ankle rarely needs an opioid, a new study of emergency room patients found that about 7 percent of patients got sent home with a prescription for the potentially addictive painkiller anyway. And the more pills prescribed, the greater the chance the prescription would be refilled, raising concerns about continued use.

The research adds to evidence that it's hard for some people to stop taking the pills even after a brief use. State officials in New Jersey recently enacted a law limiting first-time prescriptions to a five-day supply, and other states should consider similar restrictions, says Kit Delgado, an assistant professor of Emergency Medicine and Epidemiology at the University of Pennsylvania.

"The bottom line is that we need to do our best not to expose people to opioids," Delgado says. "And if we do, start with the smallest quantity possible." The research was presented May 17 at the Society for Academic Emergency Medicine's annual meeting in Orlando.

Previous research has found that the more opioids such as hydrocodone and oxycodone are prescribed, the more likely patients are to keep taking them. But previous studies have been too broad to account for differences in diagnoses — for instance, whether people who received refills kept taking the drug simply because they still were in pain, Delgado says. He and colleagues limited their study to prescriptions written after ankle sprains to people who had not used an opioid in the previous six months. Usually, those injuries aren't serious and don't require opioids.

About 7 percent of 53,222 people who visited ERs with ankle sprains in 2011 and 2012 were sent home with an opioid prescription, the researchers found. Patients' experiences varied by state: Less than 2 percent treated in Delaware were prescribed an opioid compared with 16 percent in Mississippi.

The number of pills obtained within a week of those visits also varied greatly, from as few as five to more than 60. Typical prescriptions were for 15 to 40 pills. Those who received prescriptions for 30 pills or more were twice as likely to get refills as those with prescriptions for 15 or fewer, Delgado and colleagues found.

"Because these are patients who have a uniformly minor injury, it emphasizes how much arbitrariness there is in how physicians prescribe opioids," says Michael Barnett, an emergency physician at Brigham and Women's Hospital in Boston, who was not involved in the study.

More ...

https://www.sciencenews.org/article/minor-injury-opioid-painkiller-addiction-risks?tgt=nr

Saturday, May 13, 2017

Pain in Animals Workshop 2017 – Creating a Research Roadmap for measuring chronic pain in dogs and cats

Despite recent advances, chronic pain is one of the most poorly understood, under diagnosed, and under treated medical problems facing veterinary medicine today. One of the most frustrating parts of chronic pain therapeutic development in veterinary medicine is the lack of validated methods to measure chronic pain in different species and diseases.

In parallel, translational success has come under the spotlight. Numerous reviews have highlighted a lack of translation of basic research into new approved therapeutics for treatment of persistent pain in humans. The use of spontaneous painful disease in companion animals has been highlighted as one of the changes that could be made to help improve translation of basic science to new therapeutics, acting as a bridge between preclinical and clinical studies, with the goal of reducing the failure rates of human clinical trials, thus accelerating the approval of new therapeutics. Aspects that will undermine the utility of the 'spontaneous disease pain' model are the lack of valid outcome measures and the lack of knowledge of opportunities.

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https://paw2017.com/

Wednesday, May 10, 2017

The ACTTION–APS–AAPM Pain Taxonomy (AAAPT) Multidimensional Approach to Classifying Acute Pain Conditions - The Journal of Pain

As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions.

http://www.jpain.org/article/S1526-5900(17)30464-9/fulltext?

Tuesday, May 02, 2017

The opioid epidemic could be cured with virtual-reality worlds that let patients escape their pain — Quartz

"It's like a crawly feeling inside," says Judy*. "You get hot, then chilled, and you feel like you want to run away." The 57-year-old has short dark-grey hair and a haunted expression. She's breathless and sits with her right leg balanced up on her walking stick, rocking it back and forth as she speaks.
Judy explains that she suffers from constant, debilitating pain: arthritis, back problems, fibromyalgia and daily migraines. She was a manager at a major electronics company until 2008, but can no longer work. She often hurts too much even to make it out of bed.
She's taking around 20 different medications each day, including painkillers, antidepressants, sedatives and a skin patch containing a high dose of the opioid drug fentanyl, which she says did not significantly help her pain and which she's now trying to come off. Her physician has been tapering the dose for months, so in addition to her pain she suffers withdrawal symptoms: the chills and crawling dread. Then her clinic announced that it would no longer prescribe any opioids at all, the unintended result of new, stricter measures aimed at clamping down on opioid abuse. Faced with losing access to the drug on which she is physically dependent, she has come to another clinic, Pain Consultants of East Tennessee (PCET) in Knoxville, desperate for help.
More ...
https://qz.com/973605/the-opioid-epidemic-could-be-cured-with-virtual-reality-worlds-that-let-patients-escape-their-pain/?

Saturday, April 22, 2017

How a Single Gene Could Become a Volume Knob for Pain—and End America's Opioid Epidemic | WIRED

On a scale of 1 to 10, how would you rate your pain? Would you say it aches, or would you say it stabs? Does it burn, or does it pinch? How long would you say you've been hurting? And are you taking anything for it?

Steven Pete has no idea how you feel. Sitting in Cassava, a café in Longview, Washington, next to a bulletin board crammed with flyers and promises—your pain-free tomorrow starts today; remember: you're not alone in your battle against peripheral neuropathy!—he tells me he cannot fathom aches or pinches or the searing scourge of peripheral neuropathy that keep millions of people awake at night or hooked on pills. He was born with a rare neurological condition called congenital insensitivity to pain, and for 36 years he has hovered at or near a 1 on the pain scale. He's 5′ 8″, with glasses and thinning brown hair, and he has a road map of scars across his body, mostly hidden beneath a T-shirt bearing the partial crests of Batman, Green Lantern, Flash, and Superman. Because he never learned to avoid injury, which is the one thing pain is really good for, he gets injured a lot. When I ask how many bones he's broken, he lets out a quick laugh.

"Oh gosh. I haven't actually done the count yet," he says. "But somewhere probably around 70 or 80." With each fracture, he didn't feel much of anything—or even notice his injury at all. Whether he saw a doctor depended on how bad the break appeared to be. "A toe or a finger, I'd just take care of that myself," he says, wagging a slightly bent index finger. "Duct tape."

What about something more serious? Pete pauses for a moment and recalls a white Washington day a few years ago. "We had thick snow, and we went inner-tubing down a hill. Well, I did a scorpion, where you take a running start and jump on the tube. You're supposed to land on your stomach, but I hit it at the wrong angle. I face-planted on the hill, and my back legs just went straight up over my head." Pete got up and returned to tubing, and for the next eight months he went on as usual, until he started noticing the movement in his left arm and shoulder felt off. His back felt funny too. He ended up getting an MRI. "The doctor looked at my MRI results, and he was like, 'Have you been in a car accident? About six months ago? Were you skydiving?' "

"I haven't done either," Pete replied.

The doctor stared at his patient in disbelief. "You've got three fractured vertebrae." Pete had broken his back.

Throughout his body today, Pete has a strange feeling: "a weird radiating sensation," as he describes it, an overall discomfort but not quite pain as you and I know it. He and others born with his condition have been compared to superheroes—indomitable, unbreakable. In his basement, where the shelves are lined with videogames about biologically and technologically enhanced soldiers, there is even a framed sketch of a character in full body armor, with the words painless pete. But Pete knows better. "There's no way I could live a normal life right now if I could actually feel pain," he says. He would probably be constrained to a bed or wheelchair from all the damage his body has sustained.

His wife, Jessica, joins us at the café. She is petite and shy, with ice-blue eyes traced in black eyeliner. When I ask her what it's like to live with a man who feels no pain, she sighs. "I worry about him all the time." She worries about him working with his power tools in the basement. She worries about him cooking over a grill. She worries about bigger things too. "If he has a heart attack, he won't be able to feel it," she says. "He'll rub his arm sometimes, and I freak out: 'Are you OK?' " She looks over at Pete, who chuckles. "He thinks it's funny," she says. "I don't think it's funny."

More ...

https://www.wired.com/2017/04/the-cure-for-pain/?

Sunday, April 16, 2017

In pain? Many doctors say opioids are not the answer - Salon.com

Those of you who have experienced pain, especially gnawing, chronic pain, know that it affects your happiness, outlook and ability to function.

In the past couple of years, the treatment of chronic pain has undergone an earthshaking transformation as opioid addiction continues to claim — and ruin — lives.

Many primary care doctors no longer liberally prescribe opioid painkillers such as oxycodone, fentanyl and hydrocodone for back pain, migraines and other chronic conditions. Instead, they are increasingly turning to alternative medications and non-drug options such as acupuncture and physical therapy.

"Most primary care doctors are afraid to do pain management because of the opioid backlash," says Michael McClelland, a health care attorney in Rocklin, Calif., and former chief of enforcement for the state Department of Managed Health Care. "Either they don't prescribe anything, and the patient remains in pain, or they turn them over to pain management specialists so someone else is writing that prescription."

As a result, McClelland says, "people in genuine pain are going to find it more difficult to get medicine they may well need."

More ...

http://www.salon.com/2017/04/16/in-pain-many-doctors-say-opioids-are-not-the-answer_partner/

Thursday, March 30, 2017

How the opioid epidemic became America’s worst drug crisis ever, in 15 maps and charts - Vox

With all the other news going on, it can be easy to lose track of this fact. But it's true: In 2015, more than 52,000 people died of drug overdoses, nearly two-thirds of which were linked to opioids like Percocet, OxyContin, heroin, and fentanyl. That's more drug overdose deaths than any other period in US history — even more than past heroin epidemics, the crack epidemic, or the recent meth epidemic. And the preliminary data we have from 2016 suggests that the epidemic may have gotten worse since 2015.

This situation did not develop overnight, but it has quickly become one of the biggest public health crises facing America. To understand how and why, I've put together a series of maps and charts that show the key elements of the epidemic — from its start through legalpainkillers prescribed in droves by doctors to the recent rise of the highly potent opioid fentanyl.

More ...

http://www.vox.com/science-and-health/2017/3/23/14987892/opioid-heroin-epidemic-charts

Sunday, March 26, 2017

Chronic pain and depression are linked by brain gene changes | New Scientist

People who have chronic pain are more likely to experience mood disorders, but it's not clear how this happens. Now a study in mice has found that chronic pain can induce genetic changes in brain regions that are linked to depression and anxiety, a finding that may lead to new treatments for pain.

"At least 40 per cent of patients who suffer from severe forms of chronic pain also develop depression at some point, along with other cognitive problems," says Venetia Zachariou of the Icahn School of Medicine at Mount Sinai in New York.

To see if there might be a genetic link between these conditions, Zachariou and her team studied mice with damage to their peripheral nervous system. These mice show symptoms similar to chronic pain in people – they become hypersensitive to harmless touch, and avoid other situations that might also cause them pain.

Until now, pain behaviour in mice had only been studied for at most a week at a time, says Zachariou, whose team monitored their mice for 10 weeks. "At the beginning, we saw only sensory deficits and pain-like symptoms. But several weeks later, the animals developed anxiety and depression-like behaviours."

The team then examined gene activity in three regions in the mouse brains we know are associated with depression and anxiety. Analysing the nucleus accumbens, medial prefrontal cortex, and periaqueductal gray, they found nearly 40 genes where activity was significantly higher or lower than in mice without the nervous system damage.

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https://www.newscientist.com/article/2125680-chronic-pain-and-depression-are-linked-by-brain-gene-changes/

Sunday, March 19, 2017

Rapid Shift to Long-term Opioid Use After Initial Prescription - Medscape

For patients who need an initial opioid prescription, supplying 3 or fewer days' worth of medication reduces the likelihood of long-term opioid use, new data show.

In a large representative sample of opioid-naive, cancer-free adults who received a first prescription for opioid pain relievers, the likelihood of long-term opioid use increased with each additional day of medication supplied, starting with the third day, the study team found.

"Knowledge that the risks for chronic opioid use increase with each additional day supplied might help clinicians evaluate their initial opioid prescribing decisions and potentially reduce the risk for long-term opioid use," the authors, led by Bradley Martin, PharmD, PhD, at the University of Arkansas for Medical Sciences in Little Rock, write.

"Discussions with patients about the long-term use of opioids to manage pain should occur early in the opioid prescribing process," they advise in the Morbidity and Mortality Weekly Report of March 17.

More ...

http://www.medscape.com/viewarticle/877354

Friday, March 03, 2017

NYTimes: How to Block Out Pain

Pain is a personal experience, and success comes from self-management," says David Tauben, clinical professor in the department of pain medicine at the University of Washington. Respond to pain calmly — worry and fear activate the neural pathways through which pain travels and can amplify the sensations that cause it in the first place. Because pain has both mental and physical components, some researchers who study it combine psychology with the physical effects. "Be careful of negative thoughts and worrying," Tauben says. "If it's difficult to control them, find a professional to help you, like a psychologist or counselor."


More ...


Tuesday, February 28, 2017

Is a new class of painkillers on the horizon? | Science | AAAS

Scientists are chasing a new lead on a class of drugs that may one day fight both pain and opioid addiction. It's still early days, but researchers report that they've discovered a new small molecule that binds selectively to a long-targeted enzyme, halting its role in pain and addiction while not interfering with enzymes critical to healthy cell function. The newly discovered compound isn't likely to become a medicine any time soon. But it could jumpstart the search for other binders that could do the job.

Pain and addiction have many biochemical roots, which makes it difficult to treat them without affecting other critical functions in cells. Today, the most potent painkillers are opioids, including heroin, oxycodone, and hydrocodone. In addition to interrupting pain, they inhibit enzymes known as adenylyl cyclases (ACs) that convert cells' energy currency, ATP, into a molecule involved in intracellular chemical communication known as cyclic AMP (cAMP). Chronic opioid use can make cells increase the activity of ACs to compensate, causing cAMP levels to skyrocket. When opioid users try to stop using, their cAMP levels remain high, and drugs that reduce those levels—like buprenorphine—have unwanted side effects.

More...

http://www.sciencemag.org/news/2017/02/new-class-painkillers-horizon

Tuesday, February 14, 2017

NYTimes: Lower Back Ache? Be Active and Wait It Out, New Guidelines Say

Dr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, has some advice for most people with lower back pain: Take two aspirin and don't call me in the morning.

On Monday, the American College of Physicians published updated guidelines that say much the same. In making the new recommendations for the treatment of most people with lower back pain, the group is bucking what many doctors do and changing its previous guidelines, which called for medication as first-line therapy.

Dr. Nitin Damle, president of the group's board of regents and a practicing internist, said pills, even over-the-counter pain relievers and anti-inflammatories, should not be the first choice. "We need to look at therapies that are nonpharmacological first," he said. "That is a change."

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https://www.nytimes.com/2017/02/13/health/lower-back-pain-surgery-guidelines.html?

Sunday, February 05, 2017

Welcome to Pain Researcher

Welcome to Pain Researcher, a community forum for anyone involved or interested in the study of pain. 

The major purpose of this forum is to facilitate discussion around any and all topics related to the pain research. One important gap that this forum aims to fill involves the sharing of knowledge needed to properly execute pain studies such as detailed protocols, technical tips, tool development, methodological considerations, etc. It is these crucial details that determine the quality and validity of the findings of pain studies, and so we hope that giving a space to discuss such details will improve pain research globally.

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http://forum.painresearcher.net/t/welcome-to-pain-researcher/8

Tuesday, January 24, 2017

A Bright Future for Brain Imaging of Pain | Pain Research Forum

Irene Tracey, University of Oxford, UK, summarized the contributions of neuroimaging to pain research, and directions for future investigations, during "Translating Neuroimaging Discovery Science for Patient Benefit," a plenary lecture held at the IASP 16th World Congress on Pain, which took place September 26-30, 2016, in Yokohama, Japan. Her take-home message was that findings from neuroimaging will lead to a brighter outlook for patients suffering from chronic pain. "The aim, ultimately, is to use metrics [discovered by imaging studies] to guide diagnosis and therapies," she said. Tracey called for neuroimaging work to help bridge scientific knowledge from cells to systems and across species in order to meet the unmet clinical need for new pain treatments.

More...

http://painresearchforum.org/news/76295-bright-future-brain-imaging-pain

Wednesday, January 11, 2017

I’ve seen the opioid epidemic as a cop. Living it as a patient has been even worse. - The Washington Post

A year ago, I woke in the night with pain so severe I was crying before I was fully aware what was going on. A 50-year-old cop sobbed like a child in the dark.

It was a ruptured disc and related nerve damage. Within a couple of months, it became so severe that I could no longer walk or stand. An MRI later, my surgeon soothingly told me it would all be okay. He would take care of me; the pain would end.

After surgery, I never saw that surgeon again. A nurse practitioner handed me a prescription for painkillers — 180 tablets, 90 each of oxycodone and hydrocodone.

I was lucky: I already knew how easily opioid addiction could destroy a life. I'd arrested addicts and helped people suffering from substance abuse. So as soon as I could, I weaned myself off the medication. Still, I fell into the trap when my pain returned months later, and I started taking the pills again.

Since then, I've been stuck like a growing number of people in a system that leaves patients beholden to terrible health policy, the horrific consequences of federal drug policy, uninformed media hysteria about an opioid epidemic and an army of uncoordinated medical professionals bearing — then seizing — bottles of pills.

I asked repeatedly for alternatives, but I was told none were available. I started physical therapy and sought treatment at an authorized pain management clinic. My first pain management doctor was terse as she prescribed more hydrocodone for daytime and oxycodone for the night, when my pain was worse. To her, I was just another person in a day of people receiving identical treatment. Later she'd say she had little choice: Insurance companies routinely deny even slightly adventurous prescriptions.

A nearby chain pharmacy refused to fill it, saying, "You can't mix hydrocodone and oxycodone." As my prescription testified, I was receiving the required "close monitoring" by a doctor when taking that particular combination. When I called the pain clinic for help, the staff berated me for bothering them. They asked whether I was seeking drugs. I was — the ones they had prescribed.

More ...

https://www.washingtonpost.com/posteverything/wp/2017/01/11/ive-seen-the-opioid-epidemic-as-a-cop-living-it-as-a-patient-has-been-even-worse/?

How much does it hurt? | Mosaic

One night in May, my wife sat up in bed and said, "I've got this awful pain just here." She prodded her abdomen and made a face. "It feels like something's really wrong." Woozily noting that it was 2am, I asked what kind of pain it was. "Like something's biting into me and won't stop," she said.

"Hold on," I said blearily, "help is at hand." I brought her a couple of ibuprofen with some water, which she downed, clutching my hand and waiting for the ache to subside.

An hour later, she was sitting up in bed again, in real distress. "It's worse now," she said, "really nasty. Can you phone the doctor?" Miraculously, the family doctor answered the phone at 3am, listened to her recital of symptoms and concluded, "It might be your appendix. Have you had yours taken out?" No, she hadn't. "It could be appendicitis," he surmised, "but if it was dangerous you'd be in much worse pain than you're in. Go to the hospital in the morning, but for now, take some paracetamol and try to sleep."

Barely half an hour later, the balloon went up. She was awakened for the third time, but now with a pain so savage and uncontainable it made her howl like a tortured witch face down on a bonfire. The time for murmured assurances and spousal procrastination was over. I rang a local minicab, struggled into my clothes, bundled her into a dressing gown, and we sped to St Mary's Paddington at just before 4am.

The flurry of action made the pain subside, if only through distraction, and we sat for hours while doctors brought forms to be filled, took her blood pressure and ran tests. A registrar poked a needle into my wife's wrist and said, "Does that hurt? Does that? How about that?" before concluding: "Impressive. You have a very high pain threshold."

More ...

https://mosaicscience.com/story/how-much-does-it-hurt-pain-agony-acute-chronic?

Friday, January 06, 2017

Snapshots of an Epidemic: A Look at the Opioid Crisis Across the Country - The New York Times

Opioid addiction is America's 50-state epidemic. It courses along Interstate highways in the form of cheap smuggled heroin, and flows out of "pill mill" clinics where pain medicine is handed out like candy. It has ripped through New England towns, where people overdose in the aisles of dollar stores, and it has ravaged coal country, where addicts speed-dial the sole doctor in town licensed to prescribe a medication.

Public health officials have called the current opioid epidemic the worst drug crisis in American history, killing more than 33,000 people in 2015. Overdose deaths were nearly equal to the number of deaths from car crashes. In 2015, for the first time, deaths from heroin alone surpassed gun homicides.

More ...

http://www.nytimes.com/2017/01/06/us/opioid-crisis-epidemic.html?

Tuesday, December 27, 2016

How scientists are hunting for a safer opioid painkiller | Science News

An opioid epidemic is upon us. Prescription painkillers such as fentanyl and morphine can ease terrible pain, but they can also cause addiction and death. The Centers for Disease Control and Prevention estimates that nearly 2 million Americans are abusing or addicted to prescription opiates. Politicians are attempting to stem the tide at state and national levels, with bills to change and monitor how physicians prescribe painkillers and to increase access to addiction treatment programs.

Those efforts may make access to painkillers more difficult for some. But pain comes to everyone eventually, and opioids are one of the best ways to make it go away.  

Morphine is the king of pain treatment. "For hundreds of years people have used morphine," says Lakshmi Devi, a pharmacologist at the Ichan School of Medicine Mount Sinai in New York City.  "It works, it's a good drug, that's why we want it. The problem is the bad stuff."

More ...

Sunday, December 25, 2016

Pain News Network

Pain News Network is a 501(c)(3) non-profit, independent online news source for information and commentary about chronic pain and pain management. Our mission is to raise awareness about chronic pain, and to connect and educate pain sufferers, caregivers, healthcare providers and the public about the pain experience. We reach over 100,000 people (unique readers) each month.

https://www.painnewsnetwork.org/

An opioid epidemic is what happens when pain is treated only with pills - The Washington Post

Too many opioids. Not enough opioids. Behold the opioid paradox.

The United States is in the midst of a massive opioid epidemic, as The Washington Post and other news organizations have documented extensively. In 2015, more than 33,000 people died from overdoses of opioids, meaning prescription painkillers, heroin, fentanyl or any combination. That easily keeps pace here with fatal motor vehicle accidents and gun-related deaths.

Certain states have been particularly affected. The Charleston Gazette just reported that opioid wholesalers shipped 780 million oxycodone and hydrocodone pills into West Virginia over a six-year period — enough for 433 pills for every person in the state. Meanwhile, 1,728 West Virginians died from overdoses of those two drugs.

But there's another side to the story. Opioids can be an effective treatment for chronic pain, and too many people around the world have limited access to them.

"We view pain relief as a human rights issue," Kathleen Foley, a neurologist at Memorial Sloan Kettering Cancer Center, said at a Princeton symposium on pain and opioids this month. Historically, she said, pain has been under-treated, and she is concerned that the opioid epidemic "has stigmatized all patients with pain."

Even in this country, some patients may be denied opioids because doctors are not convinced their described pain is real or fear the pills will be diverted to the illegal market. Keith Wailoo, a Princeton historian of medicine and health policy, who also spoke at the symposium, calls it a "pain gap" and says it is why African Americans with sickle cell disease, for example, have reported trouble getting prescription painkillers. "Think of it as a pain gap between the haves and the have-nots, along lines of class and race," Wailoo wrote in the Daily Beast.

https://www.washingtonpost.com/news/to-your-health/wp/2016/12/23/an-opioid-epidemic-is-what-happens-when-pain-is-treated-only-with-pills/?tid=sm_tw&utm_term=.fb49c82e397d

Sunday, November 13, 2016

Brain's Support Cells Could Explain Mysterious "Spreading Pain" - Scientific American

In people who suffer from pain disorders, painful feelings can severely worsen and spread to other regions of the body. Patients who develop chronic pain after surgery, for example, will often feel it coming from the area surrounding the initial injury and even in some parts of the body far from where it originates. New evidence suggests glia, non-neuronal cells in the brain, may be the culprits behind this effect.

Glia were once thought to simply be passive, supporting cells for neurons. But scientists now know they are involved in everything from metabolism to neurodegeneration. A growing body of evidence points to their key role in pain. In a study published today in Science, researchers at the Medical University of Vienna report that glia are involved in long-term potentiation (LTP), or the strengthening of synapses, in pain pathways in the spinal cord.

Neuroscientists Timothy Bliss and Terje Lømo first described LTP in the hippocampus, a brain area involved in memory, in the 1970s. Since then scientists have been meticulously studying the role this type of synaptic plasticity—the ability of synapses to change in strength—plays in learning and memory. More recently, researchers discovered that LTP could also amplify pain in areas where injuries or inflammation occur. "We sometimes call this a 'memory trace of pain' because the painful insult may lead to subsequent hypersensitivity to painful stimuli, and it was clear that synaptic plasticity can play a role here," says study co-author Jürgen Sandkühler, a neuroscientist also at the Medical University of Vienna. But current models of how LTP works could not explain why discomfort sometimes becomes widespread or experienced in areas a person has never felt it before, he adds.

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https://www.scientificamerican.com/article/brain-rsquo-s-support-cells-could-explain-mysterious-ldquo-spreading-pain-rdquo/

Saturday, November 12, 2016

A New Study Tests Marijuana's Potential to Replace Opioid Painkillers - The Atlantic

Emily Lindley's stash of marijuana is going to be very, very secure.

Lindley, a neurobiologist, is about to begin the first study ever to directly compare cannabis with an opioid painkiller (in this case, oxycodone) for treating people with chronic pain. She got a grant for this research two years ago, but it has taken that much time to meet all the requirements for working with a drug the federal government still considers highly dangerous.

Before it's given to patients, the marijuana will be kept inside steel narcotics lockers bolted to the wall in a room with surveillance cameras and a combination keypad on the door. Each locker has tamper-proof hinges and requires two keys—each held by a different person. If someone puts the wrong key in one of the locks, it will become inoperable and have to be drilled out.

All this is necessary to comply with rules imposed by the Drug Enforcement Agency to make sure drugs meant for research don't end up on the street, says Heike Newman, a senior regulatory manager at the University of Colorado's Anschutz Medical Campus, where Lindley's study will take place. Newman's job is to help researchers with the paperwork they need to file with various government agencies to get approval for their studies. She says the lockers and renovations to the storage room cost the university about $15,000.

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http://www.theatlantic.com/health/archive/2016/11/a-new-test-of-pots-potential-to-replace-painkillers/507200/?

Sunday, November 06, 2016

Why painkillers sometimes make the pain worse | Science | AAAS

Mark Hutchinson could read the anguish on the participants' faces in seconds. As a graduate student at the University of Adelaide in Australia in the late 1990s, he helped with studies in which people taking methadone to treat opioid addiction tested their pain tolerance by dunking a forearm in ice water. Healthy controls typically managed to stand the cold for roughly a minute. Hutchinson himself, "the young, cocky, Aussie bloke chucking my arm in the water," lasted more than 2 minutes. But the methadone patients averaged only about 15 seconds.

"These aren't wimps. These people are injecting all sorts of crazy crap into their arms. … But they were finding this excruciating," Hutchinson says. "It just fascinated me." The participants were taking enormous doses of narcotics. How could they experience such exaggerated pain?

The experiment was Hutchinson's first encounter with a perplexing phenomenon called opioid-induced hyperalgesia (OIH). At high doses, opioid painkillers actually seem to amplify pain by changing signaling in the central nervous system, making the body generally more sensitive to painful stimuli. "Just imagine if all the diabetic medications, instead of decreasing blood sugar, increased blood sugar," says Jianren Mao, a physician and pain researcher at Massachusetts General Hospital in Boston who has studied hyperalgesia in rodents and people for more than 20 years.

But how prevalent hyperalgesia is, and whether it plays a role in the U.S. epidemic of opioid abuse and overdose, is unclear. A lack of reliable testing methods and a series of contradictory papers have created believers and skeptics. A few researchers, like Mao, think hyperalgesia is an underappreciated puzzle piece in the opioid epidemic—a force that can pile on pain, drive up doses, and make it harder for chronic users to come off their drugs. Some of those researchers are looking for ways to turn down hyperalgesia, to help patients function on lower doses of their oxycodone, for example, or make it easier to taper off it altogether. Others see OIH as an oddity in the literature—real, and a powerful clue to the workings of pain pathways, but unlikely to tighten the grip of opioids on most patients. Hutchinson thinks the majority of physicians are either unaware of hyperalgesia or unconvinced of its importance. "I think if you surveyed prescribers of opioids, they would be divided probably 60–40."

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http://www.sciencemag.org/news/2016/11/why-painkillers-sometimes-make-pain-worse

Thursday, October 27, 2016

Placebos Can Work Even If You Know It's A Placebo : Shots - Health News : NPR

Placebos can't cure diseases, but research suggests that they seem to bring some people relief from subjective symptoms, such as pain, nausea, anxiety and fatigue.

But there's a reason your doctor isn't giving you a sugar pill and telling you it's a new wonder drug. The thinking has been that you need to actually believe that you're taking a real drug in order to see any benefits. And a doctor intentionally deceiving a patient is an ethical no-no.

So placebos have pretty much been tossed in the "garbage pail" of clinical practice, says Ted Kaptchuk, director of the Program for Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center. In an attempt to make them more useful, he's been studying whether people might see a benefit from a placebo even if they knew it was a placebo, with no active ingredients. An earlier study found that so-called "open-label" or "honest" placebos improved symptoms among people with irritable bowel syndrome.

And Kaptchuk and his colleagues found the same effect among people with garden-variety lower back pain, the most common kind of pain reported by American adults.

The study included 83 people in Portugal, all of whom had back pain that wasn't caused by cancer, fractures, infections or other serious conditions. All the participants were told that the placebo was an inactive substance containing no medication. They were told that the body can automatically respond to placebos, that a positive attitude can help but isn't necessary and that it was important to take the pills twice a day for the full three weeks.

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http://www.npr.org/sections/health-shots/2016/10/27/499475288/is-it-still-a-placebo-when-it-works-and-you-know-its-a-placebo?

Opioids: Last Week Tonight with John Oliver (HBO)

https://youtu.be/5pdPrQFjo2o

Wednesday, October 26, 2016

Mice smell, share each other's pain | Science News

Pain is contagious, at least for mice. After encountering bedding where mice in pain had slept, other mice became more sensitive to pain themselves. The experiment, described online October 19 in Science Advances, shows that pain can move from one animal to another — no injury or illness required.

The results "add to a growing body of research showing that animals communicate distress and are affected by the distress of others," says neuroscientist Inbal Ben-Ami Bartal of the University of California, Berkeley.

Neuroscientist Andrey Ryabinin and colleagues didn't set out to study pain transfer. But the researchers noticed something curious during their experiments on mice who were undergoing alcohol withdrawal. Mice in the throes of withdrawal have a higher sensitivity to pokes on the foot. And surprisingly, so did these mice's perfectly healthy cagemates. "We realized that there was some transfer of information about pain" from injured mouse to bystander, says Ryabinin, of Oregon Health & Sciences University in Portland.

When mice suffered from alcohol withdrawal, morphine withdrawal or an inflaming injection, they become more sensitive to a poke in the paw with a thin fiber — a touchy reaction that signals a decreased pain tolerance. Mice that had been housed in the same cage with the mice in pain also grew more sensitive to the poke, Ryabinin and colleagues found. These bystander mice showed other signs of heightened pain sensitivity, such as quickly pulling their tails out of hot water and licking a paw after an irritating shot.

The results are compelling evidence for the social transmission of pain, says neuroscientist Christian Keysers of the Netherlands Institute for Neuroscience in Amsterdam.

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https://www.sciencenews.org/article/mice-smell-share-each-others-pain?

Monday, October 24, 2016

How drugs intended for patients ended up in the hands of illegal users: ‘No one was doing their job’ - The Washington Post

For 10 years, the government waged a behind-the-scenes war against pharmaceutical companies that hardly anyone knows: wholesale distributors of prescription narcotics that ship drugs from manufacturers to consumers.

The Drug Enforcement Administration targeted these middlemen for a simple reason. If the agency could force the companies to police their own drug shipments, it could keep millions of pills out of the hands of abusers and dealers. That would be much more effective than fighting "diversion" of legal painkillers at each drugstore and pain clinic.

Many companies held back drugs and alerted the DEA to signs of illegal activity, as required by law. But others did not.

Collectively, 13 companies identified by The Washington Post knew or should have known that hundreds of millions of pills were ending up on the black market, according to court records, DEA documents and legal settlements in administrative ­cases, many of which are being reported here for the first time. Even when they were alerted to suspicious pain clinics or pharmacies by the DEA and their own employees, some distributors ignored the warnings and continued to send drugs.

"Through the whole supply chain, I would venture to say no one was doing their job," said Joseph T. Rannazzisi, former head of the DEA's Office of Diversion Control, who led the effort against distributors from 2005 until shortly before his retirement in 2015. "And because no one was doing their job, it just perpetuated the problem. Corporate America let their profits get in the way of public health."

A review of the DEA's campaign against distributors reveals the extent of the companies' role in the diversion of opioids. It shows how drugs intended for millions of legitimate pain patients ended up feeding illegal users' appetites for prescription narcotics. And it helps explain why there has been little progress in the U.S. opioid epidemic, despite the efforts of public-health and enforcement agencies to stop it.

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https://www.washingtonpost.com/investigations/how-drugs-intended-for-patients-ended-up-in-the-hands-of-illegal-users-no-one-was-doing-their-job/2016/10/22/10e79396-30a7-11e6-8ff7-7b6c1998b7a0_story.html?

The First Fentanyl Addict | VICE

If the opiate crisis has taught us anything, it's that addiction affects everyone. An unprecedented surge in fentanyl-implicated death—across all incomes and backgrounds, obviously—has sparked public health emergencies across the US and Canada. With each fentanyl overdose reported, we're seeing ignorant assumptions about who uses drugs and why finally put to rest.

But there was a time when fentanyl was almost exclusively used by a very small group, and it had nothing to do with Margaret Wente's idea of a "typical drug addict" or poverty or organized crime. What the general public is oblivious to—but the medical community knows—is how fentanyl addiction took its roots in anesthesiology before it made its way into the mainstream.

Dr. Ethan Bryson, associate professor in the anesthesia and psychiatry departments at the Icahn School of Medicine at Mount Sinai, New York, believes it was anesthesiologists who, familiar with fentanyl's pharmacology and abuse potential, first began misusing the opioid.

"If you look at the history of morphine, cocaine, and heroin, these were all drugs which were initially developed for legitimate medical purposes, but subsequently became recreational pharmaceuticals," Bryson told VICE. "They were all experimented on with people with that access. That's well documented in history."

More …

http://www.vice.com/read/the-first-fentanyl-addict?

Wednesday, October 19, 2016

He ate a pepper so hot it tore a hole in his esophagus - The Washington Post

A ghost pepper's heat is described in terms normally reserved for carpet bombings. Its heat is measured at 1 million units on the Scoville scale, a per-mass measure of capsaicin — the chemical compound that imbues peppers with heat — that until recently was a world record. Peppers that pass the 1 million mark are called superhot; as a rule they are reddish and puckered, as though one of Satan's internal organs had prolapsed. To daredevil eaters of a certain stripe, the superhot peppers exist only to challenge.

When consumed, ghost peppers and other superhots provoke extreme reactions. "Your body thinks it's going to die," as Louisiana pepper grower Ronald Primeaux told the AP in October. "You're not going to die."

But, demonstrated by a rare though severe incident reported recently in the Journal of Emergency Medicine, superhot peppers can cause bodily harm. A 47-year-old man, unnamed in the case study, attempted a super-spicy feat — eating a hamburger served with a ghost pepper puree — and tore a hole in his esophagus.

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https://www.washingtonpost.com/news/morning-mix/wp/2016/10/18/he-ate-an-extremely-spicy-ghost-pepper-hours-later-doctors-found-a-hole-in-his-throat/?

Tramadol: The Opioid Crisis for the Rest of the World - WSJ

GAROUA, Cameroon—Not long ago, a Dutch neurobiologist announced a surprising discovery: A root used by rural West African healers to treat pain contains an apparently natural version of a man-made opioid.

The root from northern Cameroon had such high levels of a painkiller called tramadol that mice given an extract and placed on a hot plate didn't feel their feet burning at first.

A year later, German rivals came up with a different explanation for the unusual plant. Inexpensive, imported tramadol is so heavily abused in northern Cameroon that it seeps from human and animal waste into the groundwater and soil, where vegetation absorbs it, wrote Michael Spiteller and Souvik Kusari, chemists at the University of Dortmund.

Farmers in Northern Cameroon told the researchers that they take double or triple the safe dosage, and feed tramadol to cattle to help them pull plows through the scorching afternoon sun.

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http://www.wsj.com/articles/tramadol-the-opioid-crisis-for-the-rest-of-the-world-1476887401

Thursday, October 13, 2016

The shocking pain of American men - The Washington Post

Once upon a time, nearly every man in America worked. In 1948, the labor-force participation rate was a staggering 96.7 percent among men in their prime working years.

That statistic has been steadily declining ever since. Today, about 11.5 percent of men between the ages of 24-54 are neither employed nor looking for a job. Economists say that these people are "out of the labor force" — and they don't figure into statistics like the unemployment rate.

This demographic trend has been the subject of much noise and consternation lately. Nicholas Eberstadt, a demographer at the conservative American Enterprise Institute, calls the development a "quiet catastrophe: the collapse, over two generations, of work for American men."

Eberstadt concedes that he can't pinpoint the precise causes, but he implies that the problem, at its root, emanates from some kind of moral or societal dysfunction.

"Time-use surveys suggest [these men] are almost entirely idle," Eberstadt wrote in a Wall Street Journal op-ed a few weeks ago. "Unlike in the past, the U.S. is now evidently rich enough to carry them, after a fashion," he added.

Princeton professor Alan Krueger, a former chief economist at the Department of Labor and former chairman of Obama's Council of Economic Advisers, has taken a look at the same data — but he came away with a different conclusion.

What stood out to him is that a lot of these men say they are in considerable pain.

In a recently released draft of his paper, which he will present at a Federal Reserve conference in Boston on Friday, Krueger finds that 44 percent of male, prime-age labor force dropouts say they took pain medication the day prior — which is more than twice the rate reported by employed men.

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https://www.washingtonpost.com/news/wonk/wp/2016/10/13/a-record-number-of-men-arent-working-this-might-finally-explain-why/