Saturday, August 23, 2014

Why Do Amputees Feel the Ache of Nothingness? - Facts So Romantic - Nautilus

or amputees, it's adding insult to injury. They've already lost pieces of themselves that they thought they could always count on, limbs that they first discovered while waving the chubby things in their cribs. Yet after that life-changing loss comes a new kind of suffering: They begin to feel pain in the voids, in the places where their limbs used to be.

The phenomenon of phantom limb pain is both cruel and common; some studies have estimated that about 75 percent of amputees feel pain in their nonexistent limbs. It's also so mysterious that psychologists, doctors, and neuroscientists have argued for centuries about the pain's cause, with some asserting that the trouble is manufactured in the mind, and others insisting that it comes from a bodily malfunction. Now a study by Israeli and Albanian researchers has brought a new twist.

The affliction, which was described as early as the 1500s, was long thought to be a product of a mind twisted by loss; in the early 20th century, psychologists formalized this idea with arguments that the pain stemmed from some "neurotic process" or "obsession" with the missing limb. In later decades, scientists began to spurn psychoanalytic explanations for mental problems and turned instead toward neurological explanations. Doctors identified overgrowths of nerve fibers in amputees' limb stumps, called neuromas, and declared that phantom limb pain must originate in signals from those misfiring peripheral nerves.

Then the pendulum swung back again. Over the last 20 years, as brain science has increasingly taken the spotlight, researchers consensed around a top-down explanation for the phenomenon. Imaging techniques revealed that the area of the cortex responsible for receiving signals from the amputated limb gets taken over, essentially colonized, by neurons associated with other body parts. Why that "cortical reorganization" should result in phantom pain—well, that scientists couldn't exactly say. But there was strong evidence for a relationship. One influential paper, published in 1995 in Nature, found that amputees with more extensive brain changes experienced greater pain in their phantom limbs. 

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Monday, July 14, 2014

Pain and Depression: A Comorbidity Conundrum | Pain Research Forum

Interest in pain is on the rise at the US National Institutes of Health (NIH), said Nora Volkow, chief of the National Institute on Drug Abuse, welcoming participants to the 9th Annual NIH Pain Consortium Symposium, held May 28-29, 2014, in Bethesda, US. Volkow noted a significant increase in research funding at the NIH for chronic pain conditions, which amounted to $400 million in 2014, up from $279 million in 2008. That is still just about 1 percent of the entire NIH pie, but in an era of shrinking budgets overall, that is no small progress.

The increase follows the 2010 Affordable Care Act (aka Obamacare), which mandated a hard look at the state of pain education, care, and research. That legislation led to the 2011 report from the Institutes of Medicine on the public health impact of pain (see PRF related story and commentary).

 For those who want to know where that money and other federal funds are going, the NIH recently announced the launch of a database of all the federal grants related to pain (see press release and news coverage). The Interagency Pain Research Portfolio is a publicly accessible, searchable resource that for the first time collects information on all federal research, including efforts by the NIH, the Centers for Disease Control, the Department of Defense, the Food and Drug Administration, and others in one place.The database reflects the Pain Consortium's mission to enhance pain research and promote collaboration across government agencies.

 Volkow also announced that on September 29-30, 2014, the NIH Office of Disease Prevention will sponsor a workshop on the role of opioids in treating chronic pain. Prescription opioid misuse, addiction, and overdose deaths have grabbed the attention of physicians, patients, the media, and policy makers, but data that would support the proper use of these drugs for chronic pain are severely limited. The workshop will tackle the scientific issues around opioid use for chronic pain. Registration will open in June. For more information, see 2014 NIH Pathways to Prevention workshop on The Role of Opioids in the Treatment of Chronic Pain.

The theme of this year's symposium was biological and psychological factors that contribute to chronic pain. Over one and a half days, speakers discussed comorbid factors including depression, sleep disturbances, and inflammation. Summaries of selected talks on pain and depression are presented here; Part 2 deals with pain and sleep. In addition, an archived webcast of the entire meeting is available on the NIH website (view Day 1 and Day 2). The complete meeting agenda is here.

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Sunday, July 13, 2014

How to Talk About Pain - NYT

LONDON — IN 1926, Virginia Woolf published an essay on pain, "On Being Ill." Isn't it extraordinary, she observed, that pain does not rank with "love, battle and jealousy" among the most important themes in literature. She lamented the "poverty of the language of pain." Every schoolgirl who falls in love "has Shakespeare, Donne, Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry."

Where are the novels or epic poems devoted to typhoid, pneumonia or toothaches, Woolf wondered? Instead, the person in pain is forced to "coin words himself, and, taking his pain in one hand, and a lump of pure sound in the other (as perhaps the inhabitants of Babel did in the beginning), so to crush them together that a brand new word in the end drops out."

The difficulty in talking about painful sensations forces people to draw on metaphors, analogies and metonymies when attempting to communicate their suffering to others. Woolf — writing nearly a century after the popularization of ether, the first anesthetic — was perhaps too pessimistic about the creativity of sufferers. Take lower back pain, the single leading cause of disability worldwide. In the 1950s, one sufferer of back pain said that it felt like "a raging toothache — sometimes like something is moving or crawling down my legs." Half a century later, one person confessed that "my back hurt so bad I felt like I had a large grapefruit down about the curve of the back."

Woolf would not have been impressed perhaps by claims that backs hurt like a toothache or a grapefruit, but she was right to recognize that people in pain seek both to describe their suffering and to give meaning to it.

Some descriptions of pain have been consistent over time. It is frequently said to resemble a burning fire, a biting cat, a stabbing knife. Others arise as a result of specific innovations. In the 19th century, electricity and new weapons provided vivid analogies. From the 1860s, people increasingly spoke about pain as a mechanical monster. In the words of the physician Valentine Mott, writing in 1862, the pain of neuralgia was like "a powerful engine when the director turns some little key, and the monster is at once aroused, and plunges along the pathway, screaming and breathing forth flames." It was "like electric shocks in both legs" or "a lyddite shell," as one author observed in 1900, just four years after the introduction of that explosive into the British Army.

In earlier centuries, pain was more likely to be assigned a spiritual force. It was a result of sin, a guide to virtuous behavior, a stimulus to personal development or a means of salvation. As Lady Darcy Maxwell, a prominent Methodist, wrote in her diary in 1779, her severe "bodily pain" enabled her to truly "enjoy greater nearness to God, more sensible comfort, and a considerable increase of hungering and thirsting after righteousness."

The invention of effective anesthetics dealt a serious blow to the doctrine that pain had a spiritual function. If suffering could be sidestepped, belief in its divine provenance could be jettisoned. In the words of the author of "The Function of Physical Pain: Anaesthetics," published in 1871, now that pain had been "made optional" by anesthetics, it was necessary to revise "the theories of the purposes of bodily pain hitherto held by moralists." A 1935 Lancet article went further: pain was not even a sign by nature that something had gone wrong since it persisted long after "its value as a warning signal is past."

Stripped of its mysticism and its virtuous solicitations, pain was emptied of positive value. Rather than being passively endured, pain became an "enemy" to be fought and ultimately defeated. The introduction of effective relief made submission to pain perverse rather than praiseworthy.

A parallel shift changed the way doctors and other people responded to suffering. When Virginia Woolf lamented the difficulties in communicating pain, she was implicitly criticizing 20th-century medicine. In earlier periods, doctors regarded pain stories as crucial in enabling them to make an accurate diagnosis. But within a century, clinical attitudes had radically changed. Elaborate pain narratives became shameful, indicative of malingering, "bad patients."

And patients internalize this — I know I did. A few years ago, I lay in a hospital bed writhing with pain after a major operation. I remember clutching the morphine button. It didn't seem to be working, and yet I was hesitant to tell the nurse, in case she thought I was a complainer. I didn't want to "bother" her.

From the 1840s, anesthetics silenced the acute pain sufferer; effective analgesics blunted the minds of chronic ones. Knowledge taken from microbiology, chemistry, physiology and neurology enabled physicians to bypass patient narratives in their search for an "objective diagnosis." Increasingly, pain narratives were stripped of any deeper significance beyond the rudimentary cry, "It hurts, here!" Chemical and neurological tests replaced stories; statistics replaced language.

THIS is not to imply that physicians became less caring of their patients. Rather, what constituted a caring response changed. The "men of feeling" of the 18th century, who approached patients with hearts swollen with compassion, represent a very different conception of the display of sympathy from that of contemporary "men (and women) of science."

This valorization of detachment has gone too far, however. People in chronic pain experience their suffering not as contained and isolated in their bodies, but in interaction with other people in their environments. When I was in the hospital, I told a visiting friend that my pain was "beyond language," only to have him remind me that I had been speaking about my suffering for the past hour. Perhaps, he mildly remarked, the problem is not that people in pain cannot communicate, but that witnesses to their pain refuse to hear. I was so struck by his observation that I forgot how much pain I was experiencing. For a few moments, his empathy overcame my suffering.

We have made great strides in making patients more comfortable over the last few centuries. We may no longer believe that pain is sent by God to test us; and we may no longer need lengthy descriptions of pain to arrive at diagnoses. But pain will always be with us, and by listening closely to the stories patients tell us about their pain, we can gain hints about the nature of their suffering and the best way we can provide succor. This is why the clinical sciences need disciplines like history and the medical humanities. By learning how people in the past coped with painful ailments, we can find new ways of living with and through pain.

Joanna Bourke is a professor of history at Birkbeck College and the author of "The Story of Pain: From Prayer to Painkillers."

http://www.nytimes.com/2014/07/13/opinion/sunday/how-to-talk-about-pain.html

Thursday, July 03, 2014

Prescription Rates For Painkiller Vary Widely By State : Shots - Health News : NPR

There's no getting around the fact that the abuse of prescription painkillers is a huge problem in the U.S. Prescription drug overdoses now kill more people each year than car crashes.

But the overdose risks vary quite a bit depending on where in the country you live. One reason is that how often doctors prescribed the drugs, such as Percocet, Vicodin and generic opioids, varies widely by state.

The Centers for Disease Control and Prevention analyzed a commercial database of drug prescriptions looking for patterns. Nationwide, there were 82.5 prescriptions written for opioid painkillers for every 100 Americans in 2012.

But the rates were much higher in some southern states. In Alabama, which led the country, there were 143 painkiller prescriptions for every 100 people in 2012. There were 11 other states where each adult, on average, got a least one painkiller prescription that year, including Tennessee, West Virginia and Kentucky.

CDC Director Dr. Thomas Frieden told reporters that officials don't think the high rates of prescribing in some states are because people living there have more pain. "This is an epidemic that was largely caused by improper prescribing practices," he said during a media briefing.

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http://www.npr.org/blogs/health/2014/07/01/327308769/state-of-the-painkiller-nation-wide-variation-in-prescription-rates?

Wednesday, July 02, 2014

Common Back and Leg Pain Treatment May Not Help Much, Study Says - NYTimes.com

A widely used method of treating a common cause of back and leg pain — steroid injections for spinal stenosis — may provide little benefit for many patients, according to a new study that experts said should make doctors and patients think twice about the treatment.

Hundreds of thousands of injections are given for stenosis each year in the United States, experts say, costing hundreds of millions of dollars.

But the study, the largest randomized trial evaluating the treatment, found that patients receiving a standard stenosis injection — which combine a steroid and a local anesthetic — had no less pain and virtually no greater function after six weeks than patients injected with anesthetic alone. The research, involving 400 patients at 16 sites, was published Wednesday in The New England Journal of Medicine.

"Certainly there are more injections than actually should happen," said Dr. Gunnar Andersson, the chairman emeritus of orthopedic surgery at Rush University Medical Center in Chicago, who was not involved in the research. "It's sort of become the thing you do. You see this abnormality on the M.R.I. and the patient complains, and immediately, you send the patient for an epidural injection."

Some people can still benefit from injections, he said, but now physicians "will be more cautious" and patients should ask, "Should I really do this?' "

Mostly, steroid injections are safe, carrying small risks of infection, headaches and sleeplessness. But in April, the Food and Drug Administration warned that they may, in rare cases, cause blindness, stroke, paralysis or death, noting that injections have not been F.D.A.-approved for back pain and their effectiveness has "not been established."

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http://www.nytimes.com/2014/07/03/health/treatment-for-back-pain-provides-little-help-study.html?

Wednesday, June 18, 2014

I don't feel your pain - Ideas - The Boston Globe

IF YOU STOPPED the average person in an emergency room and asked why she's there—not just her guess at the problem, but what really motivated her to show up—the number one answer would be "pain."

For all that modern medicine has learned about disease and treatment, it's alleviating pain that still lies at the heart of the profession. And in recent years, the notion of treating "pain" as its own entity has been rising to the forefront in medicine. Pain management now has its own journals, conferences, clinics, and specialists, and pain relief is sometimes referred to as a human right. The Institute of Medicine reports there are more than 100 million chronic pain sufferers in the United States, and others have estimated the problem costs $60 billion a year in lost productivity. In September, a coalition that includes the FDA, the CDC, and the NIH is expected to release a long-awaited "National Pain Strategy."

But as pain rises on the agenda for clinicians and patients, research is uncovering some unsettling facts about how it really affects people. First, not everyone experiences pain similarly. In experiments, women and black people have frequently shown lower pain tolerance when asked to do things like hold their hands in ice water. Gender differences in pain prevalence and intensity emerge in adolescence, and for reasons not fully understood, women are particularly vulnerable to conditions including migraines, back pain, and fibromyalgia. Low-income Americans, too, are more likely to suffer pain than their high-income peers: They are likelier to be engaged in manual labor, to eat poorly, and to go to the doctor less often, to name just a few causes. Among pain patients, blacks and Hispanics are likelier to report their pain is severe.

It's also clear that not everyone's pain receives equal attention. A robust and growing body of evidence suggests that the groups who suffer the most also receive less effective treatment for that suffering. Pain is "a huge public health problem," said Carmen Green, a pain specialist at the University of Michigan who has researched disparities in care. But because a disproportionate number of its victims belong to traditionally disempowered groups, "it's been a silent epidemic."

Pain, it appears, is distributed with a kind of inequality distinct from the other inequalities in American health care—one with its own contours, its own logic, and its own disturbing history. And because chronic pain, in particular, often lacks a discrete location in the body, it leaves both diagnosis and treatment almost completely up to a doctor's own judgment, which brings in a range of subtle prejudices that psychologists and other scholars are only beginning to understand. "Chronic pain greatly exacerbates already existing inequality within society," said Joanna Bourke, an historian at Birkbeck College in London, whose new book, "The Story of Pain: From Prayer to Painkillers," makes the intriguing argument that both experiences of and responses to pain have evolved since the 18th century.

Bourke's book, and the emerging research on pain, suggest that pain mirrors existing prejudices in society in ways that medicine is only beginning to grapple with. There's no quick route to solving the problem of pain care, and its thorniness suggests that doctors must first face the steep challenge of understanding both the history and psychology of a problem that medicine, often, would rather not talk about.

'IN OUR PROCESS of being civilized we have won, I suspect, intensified capacity to suffer," renowned American neurologist Silas Weir Mitchell wrote in 1892. "The savage does not feel pain as we do." It was an uncontroversial statement at the time: Jews, the Irish, Southern Europeans, Native Americans, and black people were just a few of the groups that had been long assumed to possess inferior awareness of pain. White women, by contrast, were thought to be exquisitely sensitive.

Paradoxically, the same groups accused of insensitivity often were also said to respond to pain with insufficient stoicism. Black people's supposed indifference to pain was used to justify colonization and slavery; at the same time, slaves were often accused of overreacting to pain. Bourke looked as far back as the 18th century and found that some groups were accused of widely disparate kinds of "improper" pain responses practically all at the same time. "It's a really a Catch-22," she said. "They're either not really feeling, and it's just reflexes, or they're feeling too much and it's exaggerated or it's hysterical."

It was only in the 1940s that mainstream medicine started to question the notion that northern European and "primitive" women experienced pain differently. And as late as 1959, doctors were still debating whether eye color correlated to tolerance for pain. Dark-eyed patients, the editors of the British Medical Journal wrote, are likelier to have descended from "more excitable Mediterranean people." One doctor wrote in to say he "eased [his] burden considerably" by choosing to work with as many blonde, blue-eyed children as possible: "Nordic children," he wrote, "either have a higher pain threshold than other children or greater self-control."

There was little mainstream medical interest in the question of pain until the 1970s, when researchers began looking into pain itself, not just pain as a byproduct of various conditions. The field of pain management got its own medical society in 1983, and by then it was starting to become clear that not every pain patient was treated the same. Studies had begun to show, for example, that minorities being treated for metastatic cancer pain were twice as likely as white patients to receive inadequate pain relief. A 1981 study conducted in Hawaii found that white surgery patients were more likely to be given analgesics than Filipino, Japanese, or Chinese patients, in part because of stereotypes about how different ethnic groups respond to pain.

It sounds like the kind of paternalism that would be easy for modern doctors to shed, but the evidence shows that such inequalities persist. "I don't think things have changed as much as we tell ourselves," said Bourke. Women still receive less effective pain treatments, even though they are significantly likelier than men to experience pain. A 2007 study of heart-surgery patients found that men were likelier to be given pain medication, and women were likelier to be given sedatives. An earlier study found women with metastatic breast cancer were less likely to receive "optimal" pain treatment than men with prostate cancer. With chronic pain in particular, convincing doctors to take pain seriously can be difficult. "With childbirth, we don't say to the woman, 'Oh, you're making up the pain, stop being such a wuss,'" said Judy Foreman, a former health reporter for the Globe and the author of the recent book "A Nation in Pain: Healing Our Biggest Health Problem." "With chronic pain, the pain can be way worse than childbirth, and you don't know if it's going to go away, and people don't believe you."

The evidence for undertreatment of pain in minority patients is even more striking. Black pain patients are less likely than white patients to receive pain medication; when they do receive it, they receive less. Studies of post-operative care have repeatedly found white patients receiving higher doses of opioids than minorities. The same is true for chronic pain. A 2005 study found that minorities are also less likely to be able to get their prescriptions for analgesics filled at their local pharmacies. A more recent study even found that Hispanic children received 30 percent less opioid analgesic than white children for their tonsillectomies.

Potential explanations for these disparities include conscious and unconscious bias, and doctors' assumptions about minorities' ability to pay for medication. But a separate strain of research suggests that doctors may not even recognize the full extent of that pain in the first place. In experiments published in a 2012 study, Sophie Trawalter, an associate professor of public policy and psychology at the University of Virginia, asked participants to think about how much pain they would experience in certain scenarios, and then showed them pictures of either a black person or a white person and asked how much pain they would expect that person to feel.

The results were striking: White participants and black participants all rated blacks' pain as less intense than whites'. When the experiment was repeated with nurses and nursing students, the results were the same. And people with nondiscriminatory racial attitudes make the same kind of perception errors as measurably prejudiced people do. A related study published in February found that racial bias in pain perception appears in children as young as 7. "If you can't recognize the pain, you can't treat it," Trawalter said.

Trawalter's work suggests that the problem of pain inequality may turn out to be more stubborn than it looks. "At least one thing that contributes to this bias is the belief that on average, black people have harder lives, which is true," she said. "But then there's the belief that hardship leads to toughness....It's a cultural narrative we have that unfortunately backfires in this really tragic way." In a perverse irony, sympathy seems to diminish empathy.

PAIN IS A SPECIAL CASE, even within the tilted playing field of American health care. One reason is its inherent, even radical, subjectivity. Western medicine is founded on objectivity: When a patient says something is wrong, doctors look for a discrete problem that can be tested and correlated to a diagnosis. Pain, by contrast, is defined by what the patient feels. The most common tool for measuring it is a simple 0-to-10 scale of the patient's own perception. As nurse and pain-management pioneer Margo McCaffery put it in 1968 in a definition still widely cited, pain is "whatever the person experiencing the pain says it is, existing whenever the person says it does."

Chronic pain in particular often doesn't have a discrete material location, or an identifiable cause. "That doesn't fit into the rubric of what it means to be a Western medical practitioner," said Daniel Goldberg, a bioethicist at East Carolina University and author of the recent book "The Bioethics of Pain Management." This leaves its sufferers vulnerable to skepticism, prejudice, and "accusations of malingering," he said. It doesn't help that many pain medications are addictive, and some people really do feign pain to scrounge their next prescription.

Because pain has such a strong psychological component, finding objective tools to diagnose it is not a simple proposition. Research emerging in the last few years has suggested that certain types of pain create a distinct signature in the brain, and even that sensitivity to pain might be connected to brain structure. But the idea of a practical and affordable tool for measuring all kinds of patient pain is a distant dream at best. And that leaves pain susceptible to doctors' prejudices, including unconscious ones. What it comes down to is: Do they trust their patient's account of their own pain?

It is easy to forget, amid tales of chronic pain, that the story of pain relief since those dark days is a genuinely triumphant one: Modern painkillers are often quite cheap and effective, and the stronger ones can make serious pain almost magically endurable. But ironically, advancements in medicine may have made it harder to deal with the pain that remains. As Bourke wrote in a recent essay for Aeon magazine, there was a "rich language of suffering" before the days of general anesthesia and formal pain management. Patients still talk about their pain—particularly online—but doctors do not listen like they used to, she suggests: Modern pain management is "moving the subjective experience of pain further towards the periphery of medical discourse."

As awareness of the undertreatment problem spreads, there's hope that it will start to change how pain is greeted by hospitals and doctors' offices. There's a long way to go: Foreman's book reports that most medical students receive less than 10 hours of pain education in four years of classes, and that only four medical schools in the country require students to take a course in chronic pain. Foreman says, in all seriousness, that veterinary schools currently do a better job training their students in pain management than medical school do.

Some see psychology offering tools for change. In a series of experiments similar to Trawalter's, psychologist Brian Drwecki, now of Regis University, found that asking subjects in pain-perception experiments to briefly pause to consider the other person's perspective drastically reduces racial bias. It almost sounds too good to be true—even easy—but the idea still faces plenty of hurdles. "Empathy is often downplayed in [the medical] community as something that will hurt you," Drwecki said, referring to doctors' fears of "burnout." "It's a difficult job, and one of the protective mechanisms is to push away empathy."

Just as pain has become its own field of medicine, the rise of pain as its own cause may be what catalyzes change. Foreman points out that in recent decades, groups including AIDS and breast cancer patients have banded together to shout down the stigmas surrounding their diseases. They have organized marches, told their stories in the press, and written letters to Congress for increased funding for research. As they have, their causes have tended to emerge as more kaleidoscopic problems—the kinds that demand, and get, more ambitious and imaginative solutions. "Our best hope is for pain patients to get very active," Foreman said. Sometimes the only reasonable response to pain is to scream a bit louder.


http://www.bostonglobe.com/ideas/2014/06/14/don-feel-your pain/cIrKD5czM0pgZQv7PgCmxI/story.html

Friday, June 06, 2014

NIH Pain Consortium’s first pain care curriculum improves clinical skills - NIH.gov

An online training module designed for the evaluation and care of chronic pain greatly improved medical student clinical skills, according to a report in the Journal of the American Geriatrics Society. The module, built by the University of Pittsburgh and using an elderly woman with chronic lower back pain as a case study, is the first curriculum resource created through the efforts of the National Institutes of Health Pain Consortium's Centers of Excellence in Pain Education program (CoEPEs). The program was developed in response to the Affordable Care Act's mandate to advance the science, research, care and education of pain.

Preview of e-learning chronic pain care module, "Edna"

"Management of chronic lower back pain is one of the most common and difficult problems that patients and health care providers face," said Josephine P. Briggs, M.D., director of the NIH's National Center for Complementary and Alternative Medicine (NCCAM) and member of the NIH Pain Consortium Executive Committee. "The educational materials that have been developed through this partnership will be a great asset in helping the next generation of physicians build clinical skills to support their chronic pain patients."

The CoEPEs were selected in 2012 to act as hubs for the development, evaluation, and distribution of pain management curriculum resources for medical, dental, nursing, and pharmacy schools. The NIH Pain Consortium developed the centers to improve how health care professionals are taught about pain and its treatment. The module is the first to be completed and evaluated for effectiveness.

A team of six experts in education, information technology, pain management, and geriatrics at the University of Pittsburgh developed the module, focusing on common errors in clinical exams, expert modeling, interactivity, and feedback. The module presented a standardized case of an elderly back pain patient called Edna, with brief video clips that showed her interacting with her clinician. The module also contains a multiple choice pre-test, interactive questions, and a multiple choice post-test. Twenty-seven medical students were exposed to the module and 28 were not. The students in the group exposed to the module did significantly better on their objective structured clinical examinations, an exam during which medical students rotate through multiple stations, each with an objective examiner, demonstrating clinical skills and knowledge while interviewing real or simulated patients. Ninety-three percent of the students in the exposed group passed the exam, compared to 60 percent of the non-exposed group. To view the paper (published May 15), go to http://onlinelibrary.wiley.com/doi/10.1111/jgs.12871/abstract .

"To our knowledge, this is the first study that has demonstrated the potential of an online interactive module to improve medical student clinical skills related to evaluating a patient with chronic pain," said the study's lead author Debra K. Weiner, M.D. "While our module focused specifically on an older adult with chronic low back pain, we see this type of educational intervention as a powerful and efficient curriculum tool for a variety of patient scenarios. We look forward to continuing to work with the NIH Pain Consortium in its effort to improve pain care across the country for many different pain conditions that plague patients of all ages."

The CoEPE program is coordinated by the National Institute on Drug Abuse (NIDA), one of 27 Institutes and Centers at the National Institutes of Health. "We are so pleased that the first successful curriculum product created by the CoEPEs relates to solutions for chronic back pain, one of the most common pain conditions in America," said NIDA Director Nora D. Volkow, M.D. "While we know opioids can be powerful clinical allies, a balanced approach that includes a range of pain management options is needed to ensure that people suffering from chronic pain can get the relief they need while minimizing the potential for abuse."

The CoEPEs are creating and testing online, case-based pain education modules for use in their own teaching institutions. Edna and several other modules will be made available to other teaching institutions beginning in the fall of 2014 athttp://painconsortium.nih.gov/CoEPEs.html. These modules are also accessible by the general public to help them learn how to discuss chronic pain with their doctors. A preview of the module is available at http://bit.ly/1g3HTo4 .

Chronic pain affects approximately 100 million Americans, costing up to $635 billion in medical treatment and lost productivity and contributing to poor quality of life. Yet, pain treatment is not taught extensively in many health professional schools. The curriculum resources developed by the CoEPEs aim to advance the assessment and safe treatment of multiple pain conditions for diverse population groups, while minimizing the abuse of opioid pain relievers. The curriculum resources developed by this program will teach about the various types of chronic pain, medications to treat specific pain conditions, and factors that contribute to both under- and over-prescribing of pain medications. The courses will include the latest research in complementary and integrative pain management.


http://www.nih.gov/news/health/may2014/nida-21.htm

Wednesday, May 28, 2014

A Move Toward Sex Equality in Preclinical Research | Pain Research Forum

Women suffer from chronic pain conditions in far greater numbers than do men, and recent research suggests that the basic biology of men's and women's experiences of pain might differ. Yet the overwhelming majority of basic pain studies are performed on male animals and male-derived cells. That is set to change, at least for researchers funded by the US National Institutes of Health (NIH), with new NIH guidelines mandating equal representation of both sexes in preclinical research. NIH director Francis Collins and Janine Clayton, director of the NIH's Office of Research on Women's Health, Bethesda, US, outlined the new policy in a commentary published May 14 in Nature.

 

According to the commentary, "The NIH is now developing policies that require [grant] applicants to report their plans for the balance of male and female cells and animals in preclinical studies in all future applications, unless sex-specific inclusion is unwarranted," such as in research of diseases affecting only males or only females.

 

The move will surely benefit women in the long run, said Rebecca Craft, who studies sex differences in pain at Washington State University Pullman, US. "This [policy] is finally going to hold people's feet to the fire to test female [animals]," Craft told PRF.

 

Jeffrey Mogil at McGill University, Montreal, Canada, also praised the new policy, which he described as particularly relevant to pain research. "There are huge, striking sex differences in pain—big stuff, not just a little more or a little less of something," he said. "Robust evidence of sex differences is as good or better in pain than in any other field," Mogil told PRF.

 

Clinical study design has undergone a revolution over the past 20 years, since the NIH began requiring equal numbers of women and men in nationally funded clinical trials. For decades, women took prescription drugs that were tested solely in men. In some cases, that practice led to unforeseen side effects and risks for women from medications. Although the transformation to gender-balanced trials took years to implement, researchers today hail it as a great achievement in medicine.

 

Now the NIH has taken the next step toward gender equality in science by requiring equal sex representation in animal experiments, and in work done with cells. The change is particularly important to pain researchers, said Craft, considering that "a number of pain syndromes are much more common in women." Without testing female animals, she added, "you are really not modeling the phenomenon very well."

 

Mogil echoed that sentiment. Whether or not there are sex differences that affect pain on a cellular level, "there are sex differences in the circuitry, and that is all you need to have the biology be robustly and fundamentally different between males and females," Mogil said.

 

The news has some researchers worried that the change might come with high costs, but Mogil said that fear is unfounded. "There is no downside and no tradeoff. We have everything to gain and very little to lose at all," he told PRF.

For example, if twice the animals will be required, that could double the price of breeding, housing, and tracking the animals. But Mogil doubts the new decree will drastically change research costs. "If you're using 12 animals, for example, you just use six male and six female," Mogil said, and track the data separately, "and combine again if there are no sex differences."

 

"I don't think six animals per sex is enough," to reveal subtle sex differences, Craft said, but then, that is not the purpose of the policy. "This is definitely a start. What we need to know most is when there are big differences … which would leap out at you, even with that small sample size."

 

The new rule could affect the progress of target validation and drug development. "For agents based on mechanisms determined from experiments performed on males, there is the possibility the biology is less relevant to females," said Mogil.

 

Researchers have stayed stuck in the rut of studying predominantly male animals and cells mostly out of convention. A single sex animal pool, researchers reasoned, would yield more reproducible results. And until recently, clinical trials overwhelmingly tested drugs on men, so it made sense to stick with male animals at the preclinical stage. "Until funders or journals start requiring it, no one is going to change," Craft said. The new guidelines will provide that push, she added.

 

A popular misconception also contributed to the historical male dominance, Mogil said. "People resisted before because they thought that data would be more variable in females." But as he demonstrated years ago (Mogil and Chanda, 2005), "that idea is empirically false. If anything, there is more variability in males. So what people were worried about all this time turns out to be wrong."

 

For researchers daunted by the thought of embarking on a new experimental paradigm built around equal representation of male and female animals, Craft suggests two papers for guidance (Greenspan et al., 2007Becker et al., 2005), and the NIH will reportedly provide training materials as part of the rollout of the new policy. The change will mean more work for researchers unfamiliar with female biology, Craft said, but that will be a worthy investment indeed.

 

Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance writer in Southern California, US.


Tuesday, May 27, 2014

Grand Unified Theory of Female Pain by Leslie Jamison | VQR Online

http://www.vqronline.org/essays-articles/2014/04/grand-unified-theory-female-pain

‘The Empathy Exams,’ by Leslie Jamison - NYTimes.com

Regarding the pain of others requires more than just a pair of eyes. It necessitates an act of the imagination: a willingness to think or feel oneself into the interior of another's experience, to cross between what Susan Sontag once designated as the kingdoms of the sick and of the well. This kind of empathetic border crossing can be both difficult and dangerous, the sort of journey of which one might say: "I get across quickly because I'm headed in the right direction, by which I mean the wrong direction. I'm going where no one wants to stay."

This statement, actually describing a trip into Mexico, serves as a manifesto for "The Empathy Exams," Leslie Jamison's extraordinary and exacting collection of essays. Jamison is a young writer and the author of a novel, "The Gin Closet." For the past few years she's been publishing a steady stream of intense, original essays, gathered here for the first time. Though they roam widely in topic and location, their collective preoccupation is with pain: what it means and what to do about it, both when it occurs in our own lives and when its location is far distant from us.

Jamison opens with her experience as an actor playing patients for medical students. "I'm called a standardized patient, which means I act toward the norms set for my disorders." Sometimes, working from a script, she plays a mother whose baby's lips are turning blue, and sometimes a young woman whose grief over her brother's death manifests as seizures. The students are assessed on how empathically they respond to her character's pain. Sensitive questioning elicits vital detail; clumsy handling causes the actor-patient to clam up.

"Empathy," she writes, "means realizing no trauma has discrete edges. Trauma bleeds. Out of wounds and across boundaries. Sadness becomes seizure. Empathy demands another kind of porousness in response." She means a porousness in the witness, a willingness to let a stranger's troubles seep in and slowly unfurl their meaning. But there is a porousness, too, in her style. Her intricate reconstruction of the empathy exams gives way to a more personal case history, an anatomization of two medical procedures she underwent in close succession: first an abortion and then heart surgery. In the essay's virtuosic close, she presents a script for Leslie Jamison: an intimate document, aestheticized but not anesthetized by the assumed tone, the medical dressing.

The damaged physical body, the gulf between sufferer and witness, this is Jamison's territory. Elsewhere, she turns her searching gaze on the community of people who suffer from the condition known as Morgellons, in which patients believe they're infested with hairs or fibers (an opportunity for some remarkable thinking about why patients prefer a diagnosis of physical infection to mental illness). She examines the culture around an ultramarathon in Tennessee, explores the case of the West Memphis Three, and considers poverty and violence in Los Angeles and Bolivia in a set of linked essays entitled "Pain Tours." In almost all of these pieces, her own pain: getting punched in the face in Nicaragua, having a worm emerge from her ankle after a trip to Bolivia, bad boyfriends and the wounding, witty lines they'd deliver.
 
This is an approach fraught with dangers, which necessitates walking an ethical tightrope between voyeurism and narcissism, between an unnatural interest in the woes of others and an unattractive obsession with the wounds of the self. It is to Jamison's credit that she doesn't choose the easy neutrality of the distanced observer, but rather voyages deeply into both extremes, maintaining almost always an admirable awareness about the perils of her approach.

Throughout, she pays close attention to the mechanisms of empathy, addressing not only its importance, as Rebecca Solnit did in last year's "The Faraway Nearby," but also its ethical complexities. In an essay that tacks brilliantly between a consideration of saccharine sentimentality and the artificial sweetener saccharin, she notes how sentimentality and anti-sentiment charm us by "coaxing out the vision of ourselves we'd most like to see," continuing: "If the saccharine offers some undiluted spell of feeling, . . . then perhaps its value lies in the process of emerging from its thrall: that sense of unmasking, that sense of guilt." This capacity for critical thinking, for a kind of cool skepticism that never gives way to the chilly blandishments of irony, is very rare. It's not surprising that Jamison is drawing comparisons to Sontag, clearly an influence on much of the thinking here. The struggle between irony and empathy surfaces again in two of the more troubling essays of the collection, a linked manifesto on the importance of accepting female woundedness as a subject worthy of attention. I can't say I much like the heavy-handed gender essentialism of her approach, or the moments of over-identification with her subjects, something her best essays rarely permit. On the subject of the plaster corsets Frida Kahlo wore to support her damaged spine, Jamison writes, "She would have given anything, perhaps, to have a body that rendered them irrelevant," adding that after Kahlo's leg was amputated, "she died the next year, as if this loss — after so many others — was what she finally couldn't bear." This is both histrionic and reductive. But it's a danger in keeping with her larger point, which is that it's worth risking an excess of feeling, rather than taking up the fashionable pose of world-weariness, which all too easily shades into detachment and then to cruelty.

Jamison is capable of the most extraordinary flourishes of image. On the case of the West Memphis Three, in which three teenagers were imprisoned for 17 years for the murder of three boys (wrongfully, many believe; they have since been freed), she writes: "Years ago witches were torched like fields. Their bodies held the controlled burn. Their bodies held evil like vessels so that evil would not be understood as something diffused across other bodies, across everyone." There is a glory to this kind of writing that derives as much from its ethical generosity, the palpable sense of stretch and reach, as it does from the lovely vividness of the language itself.

These are the essays of a working journalist. Most have been previously published in magazines like Vice, Harper's and Oxford American. Because they all work to some degree over the narrow field of personal experience, they inevitably turn up the same items of autobiography, perpetually introduced as if for the first time. This has a strange, unwitting effect in a book so preoccupied with the registering of and response to distress — it makes Jamison sound self-preoccupied, too caught up in her own stories to recognize that the reader has encountered them before. A small point, and clearly a consequence of the form, it makes one wonder a little hankeringly what this collection could have been if it had been worked just a touch more. But perhaps this is greedy. It's hard to imagine a stronger, more thoughtful voice emerging this year.

THE EMPATHY EXAMS
Essays
By Leslie Jamison
226 pp. Graywolf Press. $15.

Olivia Laing's latest book is "The Trip to Echo Spring: On Writers and Drinking."


Thursday, May 22, 2014

Genetic Switches Turn Off Pain - Forbes

Researchers at King's College London have discovered a link between four common chronic pain syndromes (CPS), suggesting that some people may be genetically predisposed to suffer from conditions of this type. The study, published in the journal Pain, examined identical and non-identical twins and established that IBS, musculoskeletal pain, pelvic pain and dry eye disease may have hereditary links. Migraine was shown, as previously, to have a degree of genetic susceptibility but was not genetically linked to the other conditions.
Chronic pain syndromes such as irritable bowel syndrome (IBS) and chronic pelvic pain can severely affect someone's quality of life and their diagnosis relies on the presentation of symptoms, not on evidence of inflammation or other biomarkers on testing. These types of conditions are poorly defined and a challenge to healthcare providers because of their complex physiology, poor response to therapy and associated psychological elements. Chronic pain syndromes are more often reported in women than men.
The research team, funded by the Pain Research Foundation, studied more than 8,000 pairs of twins from the TwinsUK cohort using questionnaires asking about subjects' chronic pain symptoms. The sample compared groups of identical twins (sharing 100 per cent of their DNA) and non-identical twins (sharing 50 per cent of their DNA), with the differences between these two groups providing important information about the heritability of the conditions.
All of the CPS studied were more likely to be found in both twins in a identical pair than in the non-identical group, leading to the conclusion that each of the five syndromes are heritable. There was also a higher prevalence of CPS in females than males as expected.
Further analysis of different combinations of these CPS in female twin pairs showed that there were also stronger links between the syndromes in the identical group than in the non-identical group, indicative of a genetic link between four of the conditions (migraine was excluded from this second analysis). This suggests a common genetic pathway for CPS in general which was estimated to be 66 per cent heritable.
Dr Frances Williams, lead researcher from the Department of Twin Research at King's College London said: 'This study is one of the first to examine the role of genetic and environmental factors in explaining the links between different chronic pain syndromes. The findings have clearly suggested that CPS may be heritable within families. With further research, these findings could then lead to therapies which may change the lives of those suffering with chronic pain.'
The presence of a possible genetic predisposition to CPS is also supported by similarities in symptoms and could explain why many sufferers have more than one of these kinds of diseases. Shared symptoms such as fatigue, memory loss, sleep disturbance are often seen. Migraine was found less commonly with the other CPS so appears to be a different disease entity and was excluded from simultaneous analysis with the other syndromes.
Conditions such as these are often overlooked and not considered a research priority and so, as one of the first studies to examine the role of genetic and environmental factors in explaining possible links, these findings can now justify further study to find common genetic variants.
The overlap found between CPS found in this study is suggestive of an underlying genetic pathway, common for all CPS and could lead to more effective, targeted therapies in the future. This has the potential to significantly increase the quality of life for sufferers of conditions with chronic pain.

http://www.forbes.com/sites/paulrodgers/2014/02/06/genetic-switches-turn-off-pain/

Key genetic link between chronic pain conditions like IBS discovered - Kings College London

Researchers at King's College London have discovered a link between four common chronic pain syndromes (CPS), suggesting that some people may be genetically predisposed to suffer from conditions of this type. The study, published in the journal Pain, examined identical and non-identical twins and established that IBS, musculoskeletal pain, pelvic pain and dry eye disease may have hereditary links. Migraine was shown, as previously, to have a degree of genetic susceptibility but was not genetically linked to the other conditions.
Chronic pain syndromes such as irritable bowel syndrome (IBS) and chronic pelvic pain can severely affect someone's quality of life and their diagnosis relies on the presentation of symptoms, not on evidence of inflammation or other biomarkers on testing. These types of conditions are poorly defined and a challenge to healthcare providers because of their complex physiology, poor response to therapy and associated psychological elements. Chronic pain syndromes are more often reported in women than men.
The research team, funded by the Pain Research Foundation, studied more than 8,000 pairs of twins from the TwinsUK cohort using questionnaires asking about subjects' chronic pain symptoms. The sample compared groups of identical twins (sharing 100 per cent of their DNA) and non-identical twins (sharing 50 per cent of their DNA), with the differences between these two groups providing important information about the heritability of the conditions.
All of the CPS studied were more likely to be found in both twins in a identical pair than in the non-identical group, leading to the conclusion that each of the five syndromes are heritable. There was also a higher prevalence of CPS in females than males as expected.
Further analysis of different combinations of these CPS in female twin pairs showed that there were also stronger links between the syndromes in the identical group than in the non-identical group, indicative of a genetic link between four of the conditions (migraine was excluded from this second analysis). This suggests a common genetic pathway for CPS in general which was estimated to be 66 per cent heritable.
Dr Frances Williams, lead researcher from the Department of Twin Research at King's College London said: 'This study is one of the first to examine the role of genetic and environmental factors in explaining the links between different chronic pain syndromes. The findings have clearly suggested that CPS may be heritable within families. With further research, these findings could then lead to therapies which may change the lives of those suffering with chronic pain.'
The presence of a possible genetic predisposition to CPS is also supported by similarities in symptoms and could explain why many sufferers have more than one of these kinds of diseases. Shared symptoms such as fatigue, memory loss, sleep disturbance are often seen. Migraine was found less commonly with the other CPS so appears to be a different disease entity and was excluded from simultaneous analysis with the other syndromes.
Conditions such as these are often overlooked and not considered a research priority and so, as one of the first studies to examine the role of genetic and environmental factors in explaining possible links, these findings can now justify further study to find common genetic variants.
The overlap found between CPS found in this study is suggestive of an underlying genetic pathway, common for all CPS and could lead to more effective, targeted therapies in the future. This has the potential to significantly increase the quality of life for sufferers of conditions with chronic pain.

http://www.kcl.ac.uk/newsevents/news/newsrecords/2014/May/Key-genetic-link-between-chronic-pain-conditions-like-IBS-discovered.aspx

Wednesday, May 14, 2014

Doubts Raised About Off-Label Use of Subsys, a Strong Painkiller - NYTimes.com

Almost overnight, a powerful new painkiller has become a $100 million business and a hot Wall Street story.

But nearly as quickly, questions are emerging about how the drug is being sold, and to whom.

The drug, Subsys, is a form of fentanyl, a narcotic that is often used when painkillers like morphine fail to provide relief. The product was approved in 2012 for a relatively small number of people — cancer patients — but has since become an outsize moneymaker for the obscure company that makes it, Insys Therapeutics. In the last year, the company's sales have soared and its share price has jumped nearly 270 percent.

Behind that business success is an unusual marketing machine that may have pushed Subsys far beyond the use envisioned by the Food and Drug Administration. The F.D.A. approved Subsys only for cancer patients who are already using round-the-clock painkillers, and warned that it should be prescribed only by oncologists and pain specialists. But just 1 percent of prescriptions are written by oncologists, according to data provided by Symphony Health, which analyzes drug trends. About half of the prescriptions were written by pain specialists, and a wide range of doctors prescribed the rest, including general practice physicians, neurologists and even dentists and podiatrists.

More ...


Tuesday, May 13, 2014

Study examines back pain and depression in seniors - Senior's Health - Press of Atlantic City

Researchers at the Univ-ersity of Pittsburgh School of Medicine are studying the most effective means of treating chronic low back pain and symptoms of depression - together - in those 60 or older.

The ADAPT (Addressing Depression And Pain Together) study has been going on for four years. Seventy-five men and 123 women, ranging in age from 60 to 94, have taken part.

About a third of seniors suffer from low back pain. Nearly 20 percent of Americans age 65 and older have clinically significant symptoms of depression, according to the National Alliance on Mental Illness.

Up to 25 percent of seniors may suffer from both, said Dr. Jordan F. Karp, associate professor of psychiatry, the principal investigator.

"Chronic low back pain and depression make each other worse," Karp said. "Both can cause poor sleep, keep people from enjoying their usual activities, isolate them at home. Patients can enter a vicious cycle of the blues, pain, physical deconditioning and feeling hopeless."

Nearly 40 percent of those who've participated in the ADAPT study so far have had back surgery that has not worked, Karp said.

"People who are contemplating surgery need to have their depression treated, because depression can negatively affect outco-mes," he said.

About 30 percent of ADAPT participants to date have fibromyalgia, which may make it more difficult to treat depression.

Doctors aren't sure what causes fibromyalgia, and there is no cure for it, but there are treatments that ease the discomfort it causes.

About 12 million Americans - roughly 90 percent of them women - suffer from it.

People with fibromyalgia ache all over. Muscles may feel as if they've been overworked or pulled. Some patients may be very sensitive to touch and pressure. Other symptoms include fatigue, chronic headaches, trouble with concentration and memory, hypersensitivity to cold or heat, and tingling in extremities.

Although fibromyalgia is the second most common musculoskeletal disorder after osteoarthritis, the percentage of ADAPT participants who suffer from it is higher than he expected, Karp said. Only about 7 percent of older women have fibromyalgia, he said.

There are two phases to the ADAPT study.

In the first, which lasts six weeks, all participants take the anti-depressant drug venlafaxine (Efflexor).

About a third of those who've participated in the ADAPT study so far have shown improvement during phase one, Karp said.

In the second phase, which lasts 14 weeks, participants who haven't improved during the first phase are given a higher dose of venlafaxine and are divided into two groups.

Half receive the higher dose of venlafaxine only.

The other half also get counseling on how to manage pain, mood, sleep and other difficulties seniors who suffer from both conditions typically experience.

The purpose of phase two is to determine whether people who didn't improve during phase one need the problem-solving therapy to get them feeling better, or if the higher dose of venlafaxine will suffice.

"One of the reasons we picked the medicine we used is not only because the FDA approves it for depression, but it also has been observed to have analgesic (painkilling) effects," Karp said.

Low doses of venlafaxine increase levels of the neurotransmitter serotonin, which regulates mood. Higher doses of the drug also increase levels of the neurotransmitter norepinephrine, which may regulate both mood and pain.

Neurotransmitters are chemicals in the brain that relay signals between nerve cells to tell the brain what's going on in the body. Both serotonin and norepinephrine tend to block some pain messages.

When people are depressed, they tend to feel pain more acutely. Having less pain can relieve depression. Attacking both problems at once can produce a double benefit.

"Getting people moving and in better control of their pain through healthy behavior changes may also help their mood and improve quality of life," Karp said.

Zelienople, Pa., resident Robert Boykin, 73, a financial consultant with AXA, emphatically agrees. He's suffered from chronic back pain due to spinal stenosis.

"On top of that, back in November, I went into a real tailspin of depression," Boykin said. Then he learned of the ADAPT study. His final session was a few weeks ago.

"It was a godsend," Boykin said. "They brought me out of the hole I was in."

The venlafaxine provided immediate relief. But for him, "the talk therapy was almost as important as the drug therapy," Boykin said. "(Senior clinician) Sunita (Chickering) was extremely effective at uncovering problems - chiefly anger issues - I've had over the years."

His back pain is pretty much gone, Mr. Boykin said. And although he still feels depressed from time to time, "at least I know now how to deflect it."