Saturday, May 19, 2018

Chronic pain treatment: Psychotherapy, not opioids, has been proven to work - Vox

When pain settled into Blair Golson's hands, it didn't let go.

What started off as light throbbing in one wrist 10 years ago quickly engulfed the other. The discomfort then spread, producing a pain much "like slapping your hands against a concrete wall," he says. He was constantly stretching them, constantly shaking them, while looking for hot or cold surfaces to lay them on for relief.

But worse was the deep sense of catastrophe that accompanied the pain. Working in tech-related startups, he depended on his hands to type. "Every time the pain got bad, I would think some variation of, 'Oh no, I'm never going to be able to use computers again; I'm not going to be able to hold down a job; I'm not going to be able to earn a living; and I'm going to be in excruciating pain the rest of my life,'" he says.

Like many patients with chronic pain, Golson never got a concrete diagnosis. For a decade, the 38-year-old Californian went from doctor to doctor, trying all the standard treatments: opioids, hand splints, cortisone injections, epidural injections, exercises, even elective surgery.

Golson's pain was not caused by anything physically wrong with him. But it wasn't imagined. It was real.

After weaning himself off the opioid Vicodin and feeling like he had exhausted every medical option, Golson turned to a book that described how pain could be purely psychological in origin. That ultimately took a pain psychologist, a therapist who specializes in pain — not a physician — to treat the true source: his fearful thoughts. Realizing that psychological therapy could help "was one of the most profoundly surprising experiences of my life," Golson says. No doctor he ever saw "even hinted my pain might be psychogenic," meaning pain that's psychological in origin.

More ...

https://www.vox.com/science-and-health/2018/5/17/17276452/chronic-pain-treatment-psychology-cbt-mindfulness-evidence

Friday, May 18, 2018

New Drug Offers Hope to Millions With Severe Migraines - The New York Times

The first medicine designed to prevent migraines was approved by the Food and Drug Administration on Thursday, ushering in what many experts believe will be a new era in treatment for people who suffer the most severe form of these headaches.

The drug, Aimovig, made by Amgen and Novartis, is a monthly injection with a device similar to an insulin pen. The list price will be $6,900 a year, and Amgen said the drug will be available to patients within a week.

Aimovig blocks a protein fragment, CGRP, that instigates and perpetuates migraines. Three other companies — Lilly, Teva and Alder — have similar medicines in the final stages of study or awaiting F.D.A. approval.

"The drugs will have a huge impact," said Dr. Amaal Starling, a neurologist and migraine specialist at the Mayo Clinic in Phoenix. "This is really an amazing time for my patient population and for general neurologists treating patients with migraine."

Millions of people experience severe migraines so often that they are disabled and in despair. These drugs do not prevent all migraine attacks, but can make them less severe and can reduce their frequency by 50 percent or more.

As a recent editorial in the journal JAMA put it, they are "progress, but not a panacea."

More ...

https://www.nytimes.com/2018/05/17/health/migraines-prevention-drug-aimovig.html?

Thursday, May 10, 2018

Treatments Prescribed For Lower Back Pain Are Often Ineffective, Report Says : NPR

Chances are, you — or someone you know — has suffered from lower back pain.

It can be debilitating. It's a leading cause of disability globally.

And the number of people with the often-chronic condition is likely to increase.

This warning comes via a series of articles published in the medical journal Lancet in March. They state that about 540 million people have lower back pain — and they predict that the number will jump as the world's population ages and as populations in lower- and middle-income countries move to urban centers and adopt more sedentary lives.

"We don't think about [back pain] the same way as cancer or heart attacks. But if you look at disability it causes, especially in middle- and low-income where there isn't a safety net, it impacts half a billion people," says Roger Chou, a physician who is a pain specialist at the Oregon Health and Science University and a co-author of the articles.

Disability from chronic back pain can hurt a person's ability to earn a living. One of the Lancet studies found that among rural Nigerian farmers, half reduced their workload because of back pain — an example of how the disability could contribute to the cycle of poverty in countries that lack benefits such as sick days or a social safety net.

Another study from Australia found that people who retired early because of back pain potentially lost out on hundreds of thousands of dollars of accumulated wealth when compared with healthy people who worked all the way to 65.

An overarching issue with back pain management is that the treatments doctors prescribe are often the wrong ones, the report concludes. Also, in many low-income countries, accessing health care is challenging — and getting appropriate care of back pain, specifically, is even harder. In some poor parts of Asia, pain medications are hard to come by and doctors may not have been trained on the most effective treatments.

More ...

https://www.npr.org/sections/goatsandsoda/2018/04/05/597505825/report-ineffective-treatment-often-prescribed-for-lower-back-pain

Tuesday, April 10, 2018

Lack Of Research On Medical Marijuana Leaves Patients In The Dark : Shots - Health News : NPR

By the time Ann Marie Owen, 61, turned to marijuana to treat her pain, she was struggling to walk and talk. She was also hallucinating.

For four years, her doctor prescribed a wide range of opioids for transverse myelitis, a debilitating disease that caused pain, muscle weakness and paralysis.

The drugs not only failed to ease her symptoms, they hooked her.

When her home state of New York legalized marijuana for the treatment of select medical ailments, Owens decided it was time to swap pills for pot. But her doctors refused to help.

"Even though medical marijuana is legal, none of my doctors were willing to talk to me about it," she says. "They just kept telling me to take opioids."

Although 29 states have legalized marijuana to treat pain and other ailments, the growing number of Americans like Owen who use marijuana and the doctors who treat them are caught in the middle of a conflict in federal and state laws — a predicament that is only worsened by thin scientific data.

Because the federal government considers marijuana a Schedule 1 drug, research on marijuana or its active ingredients is highly restricted and even discouraged in some cases.

Underscoring the federal government's position, Health and Human Services Secretary Alex Azar recently pronounced that there was "no such thing as medical marijuana."

Scientists say that stance prevents them from conducting the high-quality research required for FDA approval, even as some early research indicates marijuana might be a promising alternative to opioids or other medicines.

Patients and physicians, meanwhile, lack guidance when making decisions about medical treatment for an array of serious conditions.

More ...

https://www.npr.org/sections/health-shots/2018/04/07/600209754/medical-marijuanas-catch-22-limits-on-research-hinders-patient-relief

Saturday, April 07, 2018

Naloxone Stops Opioid Overdoses. How Do You Use It? - The New York Times

The United States surgeon general issued a rare national advisory on Thursday urging more Americans to carry naloxone, a drug used to revive people overdosing on opioids.

The last time a surgeon general issued such an urgent warning to the country was in 2005, when Richard H. Carmona advised women not to drink alcohol when pregnant.

More ...

https://www.nytimes.com/2018/04/06/us/naloxone-narcan-opioid-overdose.html

Wednesday, March 28, 2018

Medicare Is Cracking Down on Opioids. Doctors Fear Pain Patients Will Suffer. - The New York Times

Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.

Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.

But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.

More ...

https://www.nytimes.com/2018/03/27/health/opioids-medicare-limits.html?

Friday, March 23, 2018

America's War on Pain Pills Is Killing Addicts and Leaving Patients in Agony - Reason.com

Craig, a middle-aged banking consultant who was on his school's lacrosse team in college and played professionally for half a dozen years after graduating, began developing back problems in his early 30s. "Degenerative disc disease runs in my family, and the constant pounding on AstroTurf probably did not help," he says. One day, he recalls, "I was lifting a railroad tie out of the ground with a pick ax, straddled it, and felt the pop. That was my first herniation."

After struggling with herniated discs and neuropathy, Craig consulted with "about 10 different surgeons" and decided to have his bottom three vertebrae fused. He continued to suffer from severe lower back pain, which he successfully treated for years with OxyContin, a timed-release version of the opioid analgesic oxycodone. He would take a 30-milligram OxyContin tablet twice a day, supplemented by immediate-release oxycodone for breakthrough pain when he needed it.

Then one day last May, Craig's pain clinic called him in for a pill count, a precaution designed to detect abuse of narcotics or diversion to nonpatients. The count was off by a week's worth of pills because Craig had just returned from a business trip and forgot that he had packed some medication in his briefcase. He tried to explain the discrepancy and offered to bring in the missing pills, to no avail. Because the pill count came up short, Craig's doctor would no longer prescribe opioids for him, and neither would any other pain specialist in town.

More ...

http://reason.com/archives/2018/03/08/americas-war-on-pain-pills-is

What's in a Name for Chronic Pain? | Pain Research Forum

For decades, pain researchers have set their sights on understanding pain mechanisms—the cellular and molecular machinery underlying chronic pain. In doing so, they became increasingly aware that the terms they used to describe the neurobiological workings of pain did not always match what they had learned.

But now, official adoption by the International Association for the Study of Pain (IASP) of an IASP terminology task force recommendation for a so-called "third mechanistic descriptor" of chronic pain could move the field forward in its efforts to more fully characterize the known pathophysiological mechanisms of pain. The new term, christened "nociplastic pain," joins "nociceptive pain" and "neuropathic pain" as terms officially adopted by the association to describe the underlying neurobiological basis of chronic pain.

More ...

https://www.painresearchforum.org/news/92059-whats-name-chronic-pain

Tuesday, March 13, 2018

Handing out naloxone doesn’t fix opioid crisis | Dalla Lana School of Public Health

In the midst of a national opioid crisis, take-home naloxone programs have expanded rapidly. Ontario's Minister of Health and Long Term Care Dr. Eric Hoskins recently announced that naloxone kits will be provided to fire and police departments across the province, but U of T researchers are questioning whether naloxone distribution might distance people from health-care services or worsen health inequities.

More ...

Monday, February 26, 2018

“Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain - Pain Research and Management

Background. Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity. Methods. A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach. Results. The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity. Conclusions. Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

https://www.hindawi.com/journals/prm/2018/6358624/

Thursday, February 08, 2018

Migraine Relief May Be On The Way With New Therapies In Development : Shots - Health News : NPR

Humans have suffered from migraines for millennia. Yet, despite decades of research, there isn't a drug on the market today that prevents them by targeting the underlying cause. All of that could change in a few months when the FDA is expected to announce its decision about new therapies that have the potential to turn migraine treatment on its head.

The new therapies are based on research begun in the 1980s showing that people in the throes of a migraine attack have high levels of a protein called calcitonin gene–related peptide (CGRP) in their blood.

Step by step, researchers tracked and studied this neurochemical's effects. They found that injecting the peptide into the blood of people prone to migraines triggers migraine-like headaches, whereas people not prone to migraines experienced, at most, mild pain. Blocking transmission of CGRP in mice appeared to prevent migraine-like symptoms. And so a few companies started developing a pill that might do the same in humans.

More ...

https://www.npr.org/sections/health-shots/2018/02/03/581092093/gone-with-a-shot-hopeful-new-signs-of-relief-for-migraine-sufferers?

Monday, February 05, 2018

PAS-18-624: Mechanistic investigations of psychosocial stress effects on opioid use patterns (R01- Clinical Trial Optional)

Psychosocial stress, defined here as socioenvironmental demands that tax the adaptive capacity of the individual (e.g., low socioeconomic status, childhood adversity, bullying), has repeatedly been linked to substance use disorders (SUDs). Neighborhood poverty and social support are shown to influence substance use patterns. Among smokers, multiple psychosocial stressors are associated with relapse, and acute psychosocial stress has been demonstrated to enhance cigarette craving and smoking behavior. Similarly, psychosocial stress has been associated with greater risk of relapse in individuals with alcohol and cocaine use disorders. Recent findings suggest that OUD might also be influenced by psychosocial stress, although the exact relationship and underlying mechanisms remain poorly understood.

In light of the current opioid epidemic in the United States, there is an urgent need to understand how psychosocial stress influences the risk for opioid misuse, abuse, and use disorder. According to the 2014 National Survey on Drug Use and Health (NSDUH), over 4 million Americans engaged in non-medical use of prescription opioids in the previous month, and approximately 1.9 million Americans met criteria for OUD. Further, according to the Center for Disease Control (CDC), deaths from drug overdose in the US exceeded 60,000 last year, surpassing the number of AIDS-related deaths at the height of the HIV/AIDS epidemic. Another recent CDC report indicates that areas with the largest number of filled prescriptions for pain medications also have higher rates of poverty and unemployment, implicating psychosocial stressors as factors that exacerbate opioid use patterns across the country. Notably, relatively few mechanistic studies have investigated the relationship between psychosocial stress and substance use disorders, of which only a fraction pertains to OUDs specifically.

This funding opportunity announcement seeks to address two specific mechanistic pathways via which psychosocial stress may modulate opioid use trajectories.The first pathway is through its effects on cognitive and affective systems that are also altered in OUDs. Stressful environments have been linked to impairments in reasoning, memory, inhibitory and cognitive control, and negative affect. Acute poverty, for example, has been shown to immediately impact performance on tasks measuring intelligence and cognitive control. Relatedly, there is substantial co-morbidity between OUD and stress-related affective disorders, including depression, anxiety and PTSD. Many neurobiological substrates and circuits that are thought to mediate cognitive and affective aspects of addiction are impacted by psychosocial stress. Taken together, these findings suggest that more research is warranted on the role of cognitive and affective systems mediating the effects of psychosocial stress on opioid use trajectories.

Psychosocial stress can also influence opioid use trajectories through its effects on pain processing. Of relevance here, adverse childhood experiences have been associated with an increased prevalence of pain-related medical conditions during adulthood and many individuals with stress-related psychiatric disorders have co-morbid chronic pain syndromes. This may be a consequence of overlapping neural circuits or substrates that are engaged by psychosocial stress and pain and that have been implicated in OUD. Recent estimates suggest that the rates of opioid misuse in patients with chronic pain range from 15-26%. Importantly, and germane to the discussion above, negative affect and the reduced ability to cope with negative emotions in pain appear to increase opioid misuse rates. Further research is needed to understand how the effects of psychosocial impacts on cognitive and affective components of pain may influence the opioid use trajectory. This knowledge may advance prevention and treatment strategies in chronic pain populations.

https://grants.nih.gov/grants/guide/pa-files/PAS-18-624.html

A Doctor’s Painful Struggle With an Opioid-Addicted Patient - Siddhartha Mukherjee - The New York Times

I once found myself entrapped by a patient as much as she felt trapped by me. It was the summer of 2001, and I was running a small internal-medicine clinic, supervised by a preceptor, on the fourth floor of a perpetually chilly Boston building. Most of the work involved routine primary care — the management of diabetes, blood pressure and heart disease. It was soft, gratifying labor; the night before a new patient's visit, I would usually sift through any notes that were sent ahead and jot my remarks in the margins. The patient's name was S., I learned. She had made four visits to the emergency room complaining of headaches. Three of those times she left with small stashes of opioids — Vicodin, Percocet, oxycodone. Finally, the E.R. doctors refused to give her pain medicines unless she had a primary-care physician. There was an open slot in my clinic the next morning, and the computer had randomly assigned her to see me.

We were living, then, in what might be called the opioid pre-epidemic; the barometer had begun to dip, but few suspected the ferocity of the coming storm. Pain, we had been told as medical residents, was being poorly treated (true) — and pharmaceutical companies were trying to convince us daily that a combination of long- and short-acting opioids could cure virtually any form of it with minimal side effects (not true). The cavalier overprescription of addictive drugs was bewildering: After a tooth extraction, I emerged from an oral surgeon's office with a two-week supply of Percocet.

More ...

https://www.nytimes.com/2018/02/01/magazine/a-doctors-painful-struggle-with-an-opioid-addicted-patient.html

Saturday, February 03, 2018

Natural painkiller nasal spray could replace addictive opioids, trial indicates | The Guardian

A nasal spray that delivers a natural painkiller to the brain could transform the lives of patients by replacing the dangerous and addictive prescription opioids that have wreaked havoc in the US and claimed the lives of thousands of people.

Scientists at University College London found they could alleviate pain in animals with a nasal spray that delivered millions of soluble nanoparticles filled with a natural opioid directly into the brain. In lab tests, the animals showed no signs of becoming tolerant to the compound's pain-relieving effects, meaning the risk of overdose should be far lower.

The researchers are now raising funds for the first clinical trial in humans to assess the spray's safety. They will start with healthy volunteers who will receive the nasal spray to see if it helps them endure the pain of immersing one of their arms in ice-cold water.

"If people don't develop tolerance, you don't have them always having to up the dose. And if they don't have to up the dose, they won't get closer and closer to overdose," said Ijeoma Uchegbu, a professor of pharmaceutical nanoscience who is leading the research through Nanomerics, a UCL startup.

If the first human safety trial is successful, the scientists will move on to more trials to investigate whether the nasal spray can bring swift relief to patients with bone cancer who experience sudden and excruciating bouts of pain.

More …

https://www.theguardian.com/us-news/2018/feb/01/natural-painkiller-nasal-spray-could-replace-addictive-opioids-trial-indicates?

Tuesday, January 30, 2018

News Archive | Pain Research Forum

All of our news and discussion content, research resources and member services are provided free to researchers, clinicians and others interested in the problem of chronic pain.

https://www.painresearchforum.org/news/archive

Saturday, January 27, 2018

After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea - The New York Times

MUNICH — I recently had a hysterectomy here in Munich, where we moved from California four years ago for my husband's job. Even though his job ended a year ago, we decided to stay while he tries to start a business. Thanks to the German health care system, our insurance remained in force. This, however, is not a story about the benefits of universal health care.

Thanks to modern medicine, my hysterectomy was performed laparoscopically, without an overnight hospital stay. My only concern about this early release was pain management. The fibroids that necessitated the surgery were particularly large and painful, and the procedure would be more complicated.

I brought up the subject of painkillers with my gynecologist weeks before my surgery. She said that I would be given ibuprofen. "Is that it?" I asked. "That's what I take if I have a headache. The removal of an organ certainly deserves more."

"That's all you will need," she said, with the body confidence that comes from a lifetime of skiing in crisp, Alpine air.

I decided to pursue the topic with the surgeon.

He said the same thing. He was sure that the removal of my uterus would not require narcotics afterward. I didn't want him to think I was a drug addict, but I wanted a prescription for something that would knock me out for the first few nights, and maybe half the day.

With mounting panic, I decided to speak to the anesthesiologist, my last resort.

This time, I used a different tactic. I told him how appalled I had been when my teenager was given 30 Vicodin pills after she had her wisdom teeth removed in the United States. "I am not looking for that," I said, "but I am concerned about pain management. I won't be able to sleep. I know I can have ibuprofen, but can I have two or three pills with codeine for the first few nights? Let me remind you that I am getting an entire organ removed."

The anesthesiologist explained that during surgery and recovery I would be given strong painkillers, but once I got home the pain would not require narcotics. To paraphrase him, he said: "Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It's not good for your kidneys. Only take it if you must. Your body will heal itself with rest."

More …

https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-germany-vicodin.html?

Wednesday, January 24, 2018

Sourcing Painkillers from Scorpions’ Stings | The Scientist Magazine

Studying scorpions comes with its share of danger, as biologist Bryan Fry of the University of Queensland knows all too well. On a 2009 trip to the Brazilian Amazon, Fry was stung while trying to collect the lethal Brazilian yellow scorpion (Tityus serrulatus), and for eight hours he says it felt as though his finger was in a candle flame. Meanwhile, his heart flipped between racing and stopping for up to five seconds at a time. "At least the insane levels of pain helped keep my mind off my failing heart," Fry writes in an email to The Scientist.

More ...

https://www.the-scientist.com/?articles.view/articleNo/51210/title/Sourcing-Painkillers-from-Scorpions--Stings/

Monday, January 22, 2018

Scientists Just Solved a Major Piece of the Opioid Puzzle | WIRED

When it comes to tackling the opioid crisis, public health workers start with the drugs: fentanyl, morphine, heroin. But biochemists have a different focus: Not the opioids, but opioid receptors—the proteins the drugs latch onto within the body.

These receptors embed themselves in the walls of cells throughout the brain and peripheral nervous system. There, they serve as cellular gatekeepers, unlocking not just the painkilling properties for which opioids are prized, but the severe, addictive, and often lethal side effects that, in 2016, contributed to the deaths of more than 50,000 people in the US.

But it doesn't have to be that way. "The idea in the field for many years has been to make an opioid that provides beneficial analgesic properties without the harmful side effects," says pharmacologist Bryan Roth, a physician researcher at University of North Carolina School of Medicine. Design a drug that kills pain, not people.

To build that drug, though, researchers need to know the shape of its receptor. This week in the journal Cell, Roth and nearly two dozen of his colleagues report for the first time the structure of the kappa opioid receptor while it's bound to a drug molecule, a discovery that could accelerate the discovery of less-addictive—and less deadly—opioids.

More …

https://www.wired.com/story/scientists-just-solved-a-major-piece-of-the-opioid-puzzle/

The Quest for Safer Opioid Drugs | The Scientist Magazine

Opioid drugs are well-established double-edged swords. Extremely effective at analgesia, they cause an array of harmful side effects throughout the body, including itching, constipation, and respiratory depression—the slowed breathing that ultimately causes death in overdose cases. What's more, the body's interaction with opioids is dynamic: our receptors for these compounds become desensitized to the drugs' activity over time, requiring ever larger doses to suppress pain and eventually provoking severe dependence and protracted withdrawal.

In the past few years, these side effects have plagued growing numbers of US citizens, plunging the country into the throes of a devastating opioid crisis in which nearly 100 people die from overdoses every day. Even so, opioids are still among the most effective pain-relief options available. "Over hundreds of years, [opioid receptors] have remained a target," says Laura Bohn, a biochemist at the Scripps Research Institute in Jupiter, Florida. "Therapeutically, it works."

Since the early 2000s, intriguing evidence has emerged suggesting that opioids' useful properties could be separated from their harmful attributes. (See "Pain and Progress," The Scientist, February 2014.) In 2005, Bohn, then at the Ohio State University College of Medicine, and colleagues showed that shutting down one of the signaling pathways downstream of the opioid receptor targeted by morphine not only amped up the drug's painkilling effects in mice, but also reduced constipation and respiratory depression (J Pharmacol Exp Ther, 314:1195-201).

That research opened the door to developing a new type of opioid: a "biased agonist" that could trigger analgesia without tripping the switches on other pathways that cause side effects. Now, more than a decade later, Trevena Inc.'s Olinvo (oliceridine)—a drug based on this principle and designated by the US Food and Drug Administration (FDA) as a breakthrough therapy—has completed Phase 3 clinical trials.

Olinvo is just one of many such drugs under development. From compounds that act only in specific regions of the body to those that engage multiple receptor types, researchers and pharmaceutical companies are trying many different tactics to produce less-dangerous opioids.

More ...

https://www.the-scientist.com/?articles.view/articleNo/51159/title/The-Quest-for-Safer-Opioid-Drugs/

Wednesday, December 06, 2017

Her Chronic Pain Was a Medical Mystery. Was It an Unexplained Condition? - The Daily Beast

Leslie Levine's searing pains started the day after Thanksgiving in 2006. They began in her toes, which turned strangely dark. Then the agony crept upward. "It felt like my legs were being dipped in boiling oil 24/7," she said.

The emergency room and a series of doctors could do little but scratch their heads and offer her painkillers.

"I was living on oxycodone and very grateful for it," Levine said, then Harvard University's chief patent attorney. But it wasn't enough. "By January, I was on disability, because I was in such pain and could hardly walk."

Her internet search for answers led her to Dr. Anne Louise Oaklander, a neurologist at Massachusetts General Hospital, who was then developing a hypothesis about inexplicable pain disorders like Levine's: What if they were caused by an overactive immune system?

Oaklander treated Levine as if that were the case and the pain—thankfully—disappeared within five days. "I didn't know how I was going to live with that level of pain," Levine said, adding that it returns every time she stops treatment.

Now, Oaklander has published a series of 55 case reports including Levine's, suggesting that a number of people who suffer pain or other neurologic symptoms—which may have been diagnosed as fibromyalgia, chronic fatigue syndrome, mental illness, or a host of other problems.

Oaklander thinks that some percentage of people who have small fiber neuropathy—which can be caused by diabetes, chemotherapy, or other toxins—actually have a previously undiagnosed autoimmune problem.

More ...

https://www.thedailybeast.com/her-chronic-pain-was-a-medical-mystery-was-it-an-unexplained-condition?

Wednesday, November 29, 2017

What We Lose When We Undertreat Pain | Kate Nicholson | TEDxBoulder - YouTube

Kate Nicholson was working as a civil rights attorney for the Justice Department when a surgical error left her unable to sit or stand, largely bedridden, and in severe pain for almost 20 years. Using opioids as an appropriate pain management tool, she continued to function as a high-level federal prosecutor. In this talk, Kate pivots from her inspiring and excruciating story to examine the under-treatment of pain, showing how our approach to opioid abuse by 2.5 million Americans is hurting 50 million people in severe or persistent pain.

https://www.youtube.com/watch?v=u4vHSLeTe-s

Thursday, November 23, 2017

Opioid crisis: Could the 'pain-o-meter' be a solution? - USA Today

Every year, millions of Americans will go to their doctors complaining of pain, and their doctors will ask them to rate their degree of discomfort on a zero-to-10 scale, or using a range of smiley-face symbols.

The doctor will have to take their word for it. And then, all too often, the doctor will prescribe a powerful and addictive opioid painkiller.

It's a longstanding — if imprecise and subjective — way of measuring and treating pain. And it's at least partly responsible for starting an opioid addiction crisis that killed 64,000 people last year.

"One of the things we heard from many physicians is that the pain-specific indicator contributed to this crisis," said White House Counselor Kellyanne Conway, President Trump's top adviser on the opioid crisis.

"We don't think health care by emoji is good idea," she said.

So the Trump administration, which has declared the opioid crisis a public health emergency, is backing efforts to find better ways of measuring and treating pain in the hope of developing precise treatments that would be more effective than opioids — and without the often catastrophic side effects.

Next month, the National Institutes of Health will open proposals for $4 million in small business grants to develop a device or technology to objectively measure pain. That could take the form of a blood test, a device to measure pupil dilation, or software to interpret facial expressions.

NIH Director Francis Collins calls it the "pain-o-meter."

It's not entirely clear what the pain-o-meter would look like, or exactly how it would work. It hasn't been invented — yet.

But the pain-o-meter isn't meant to be the end game. It's actually the first step in understanding the measurable indicators — or "biomarkers" — that can indicate pain. And that, in turn, could pinpoint causes and treatments, bringing precision medicine to pain management.

"There is this issue about whether we'll ever really get where we want to go in terms of developing effective pain management if we just consider pain to be one thing," Collins told the National Advisory Council for Complementary and Integrative Health last month. "Because we know that it's not."

The current tools of measuring pain don't take into account individual pain thresholds, which can be influenced by genetics, past experiences and other conditions. They often don't distinguish different causes of pain, or different pain sensations.

More …

https://www.usatoday.com/story/news/politics/2017/11/21/pain-o-meter-solution-opioid-crisis/840027001/

Tuesday, November 21, 2017

The Power of the Placebo - Slate

Every so often, a new study comes along that challenges conventional wisdom in medicine or science. When the conditions are right, these studies can generate a lot of attention in both the popular press and the medical community. In early November, one of these such studies, called the ORBITA study, was published in the Lancet by a group of cardiologists.

The authors had set out to ask and answer a simple question: Does placement of a small wire mesh (called a stent) inside the artery that feeds blood to the heart (the coronary artery) relieve chest pain? One might ask what was novel about this question. The truth is that there was and is nothing novel about the question. The novelty was in the methods the authors used to answer the question: They conducted a prospective randomized controlled clinical trial, or RCT, the gold standard of research. The best RCTs compare the effect of the active intervention to a placebo and the best of the best keep both the subjects and the investigators blind to the intervention. The authors managed to do this for stents and chest pain, something that had never been done before, and in doing so, they had the best chance of preventing the placebo effect from skewing the results.

More ...

http://www.slate.com/articles/health_and_science/medical_examiner/2017/11/what_to_do_if_you_have_a_stent.html

Friday, November 17, 2017

New painkillers could thwart opioids’ fatal flaw | Science | AAAS

When people die from overdoses of opioids, whether prescription pain medications or street drugs, it is the suppression of breathing that almost always kills them. The drugs act on neuronal receptors to dull pain, but those in the brain stem also control breathing. When activated, they can signal respiration to slow, and then stop. The results are well-known: an epidemic of deaths—about 64,000 people in the United States alone last year.

Countering this lethal side effect without losing opioids' potent pain relief is a challenge that has enticed drug developers for years. Now, for the first time, the U.S. Food and Drug Administration (FDA) in Silver Spring, Maryland, is considering whether to approve an opioid that is as effective as morphine at relieving pain and poses less risk of depressing breathing.

Trevena, a firm based in Chesterbrook, Pennsylvania, announced on 2 November that it has submitted oliceridine, an intravenous opioid meant for use in hospitalized patients, to FDA for marketing approval. The drug, which would be marketed under the name Olinvo, is the most advanced of what scientists predict will be a growing crop of pain-relieving "biased agonists"—so called because, in binding a key opioid receptor in the central nervous system, they nudge it into a conformation that promotes a signaling cascade that kills pain over one that suppresses breathing. And in a paper out this week in Cell, a veteran opioid researcher and her colleagues unveil new biased opioid agonists that could surpass oliceridine, though they haven't been tested in people yet.

More ...

http://www.sciencemag.org/news/2017/11/new-painkillers-could-thwart-opioids-fatal-flaw

Tuesday, November 07, 2017

Drugstore pain pills as effective as opioids in ER patients - AP

Emergency rooms are where many patients are first introduced to powerful opioid painkillers, but what if doctors offered over-the-counter pills instead? A new study tested that approach on patients with broken bones and sprains and found pain relievers sold as Tylenol and Motrin worked as well as opioids at reducing severe pain.

The results challenge common ER practice for treating short-term, severe pain and could prompt changes that would help prevent new patients from becoming addicted.

The study has limitations: It only looked at short-term pain relief in the emergency room and researchers didn't evaluate how patients managed their pain after leaving the hospital.

But given the scope of the U.S. opioid epidemic — more than 2 million Americans are addicted to opioid painkillers or heroin — experts say any dent in the problem could be meaningful.

Results were published Tuesday in the Journal of the American Medical Association.

Long-term opioid use often begins with a prescription painkiller for short-term pain, and use of these drugs in the ER has risen in recent years. Previous studies have shown opioids were prescribed in nearly one-third of ER visits and about 1 out of 5 ER patients are sent home with opioid prescriptions.

"Preventing new patients from becoming addicted to opioids may have a greater effect on the opioid epidemic than providing sustained treatment to patients already addicted," Dr. Demetrios Kyriacou, an emergency medicine specialist at Northwestern University, wrote in an accompanying editorial.

The study involved 411 adults treated in two emergency rooms at Montefiore Medical Center in New York City. Their injuries included leg and arm fractures or sprains. All were given acetaminophen, the main ingredient in Tylenol, plus either ibuprofen, the main ingredient in Motrin, or one of three opioids: oxycodone, hydrocodone or codeine. They were given standard doses and were not told which drug combo they received.

Patients rated their pain levels before taking the medicine and two hours later. On average, pain scores dropped from almost 9 on a 10-point scale to about 5, with negligible differences between the groups.

More ...

https://apnews.com/c8a5e43be775463eaad55b4d2ae35cdb/Pain-relievers-worked-as-well-as-opioids-in-ER-patients

Sunday, October 29, 2017

Why opioids are such an American problem - BBC News

For every one million Americans, almost 50,000 doses of opioids are taken every day. That's four times the rate in the UK.

There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).

But take too many and you have a problem. And America certainly has a problem.

More ...

http://www.bbc.com/news/world-us-canada-41701718

Saturday, October 21, 2017

Federal Pain Research Strategy Overview | Interagency Pain Research Coordinating Committee

The NIH Office of Pain Policy is pleased to announce the release of the Federal Pain Research Strategy.

The Federal Pain Research Strategy (FPRS) is an effort of the Interagency Pain Research Coordinating Committee (IPRCC) and the National Institutes of Health, Office of Pain Policy to oversee development of a long-term strategic plan to advance the federal pain research agenda. The strategy is relevant to the missions all federal agencies and departments that support pain research.  The research priorities of the FPRS are intended to guide strategic research planning and to support funding decisions that will fill crucial gaps in the federal pain research portfolio. 

The strategy fulfills the IPRCC mandates to Identify critical gaps in basic and clinical research on the symptoms and causes of pain and to make recommendations to ensure that the activities of the National Institutes of Health and other Federal agencies are free of unnecessary duplication of effort.  The FPRS completes the National Pain Strategy NPS section on pain research in that it Includes an agenda for developing physiological, clinical, behavioral, psychological, outcomes, and health services research and appropriate links across these domains that align with the NPS.

https://iprcc.nih.gov/Federal-Pain-Research-Strategy/Overview

Interagency Pain Research Portfolio -The Federal Government's Pain Research Database

The Interagency Pain Research Portfolio database provides information on pain research and training activities supported by the Federal Government. The participating agencies – AHRQ, CDC, DoD, FDA, NIH, and VA – are represented on the Interagency Pain Research Coordinating Committee (IPRCC), a Federal advisory committee to enhance pain research efforts and promote collaboration across the government.

https://paindatabase.nih.gov/

Tuesday, September 26, 2017

The Latest Jaw-Dropping Numbers From the Opioid Crisis – Mother Jones

About 64,000 Americans died from drug overdoses last year—a staggering 21 percent increase from the 52,404 in 2015—according to the first government estimate of drug deaths in 2016. Overdoses now kill more Americans than HIV did at its peak in 1995, and far more than guns or cars do today.

The numbers, released by the Centers for Disease Control and Prevention, are provisional and will be updated monthly, according to the agency.

Fueling the rise in deaths is fentanyl, a synthetic opioid up to 100 times more potent than morphine, and fentanyl analogs, or slight tweaks on the fentanyl molecule. This has not always been the case: As the chart below shows, the drivers of the opioid crisis have changed from prescription painkillers to heroin, and then to fentanyl.

As Dan Ciccarone, a professor at the University of California-San Francisco School of Medicine, recently wrote in the International Journal of Drug Policy:

This is a triple epidemic with rising waves of deaths due to separate types of opioids each building on top of the prior wave. The first wave of prescription opioid mortality began in the 1990s. The second wave, due to heroin, began around 2010 with heroin-related overdose deaths tripling since then. Now synthetic opioid-related overdoses, including those due to illicitly manufactured fentanyl and fentanyl analogues, are causing the third wave with these overdose deaths doubling between 2013 and 2014 .

The epidemic is straining the capacity of morgues, emergency services, hospitals, and foster care systems. Largely because of prevalent drug use and overdose, the number of children in foster care nationwide increased by 30,000 between 2012 and 2015.

More …

http://www.motherjones.com/politics/2017/09/the-latest-jaw-dropping-numbers-from-the-opioid-crisis/?

Monday, September 25, 2017

Giving Migraine Treatments the Best Chance - The New York Times

If you've never had a migraine, I have two things to say to you:

1) You're damn lucky.

2) You can't begin to imagine how awful they are.

I had migraines – three times a month, each lasting three days — starting from age 11 and finally ending at menopause.

Although my migraines were not nearly as bad as those that afflict many other people, they took a toll on my work, family life and recreation. Atypically, they were not accompanied by nausea or neck pain, nor did I always have to retreat to a dark, soundless room and lie motionless until they abated. But they were not just "bad headaches" — the pain was life-disrupting, forcing me to remain as still as possible.

Despite being the seventh leading cause of time spent disabled worldwide, migraine "has received relatively little attention as a major public health issue," Dr. Andrew Charles, a California neurologist, wrote recently in The New England Journal of Medicine. It can begin in childhood, becoming more common in adolescence and peaking in prevalence at ages 35 to 39. It afflicts two to three times more women than men, and one woman in 25 has chronic migraines on more than 15 days a month.

But while the focus has long been on head pain, migraines are not just pains in the head. They are a body-wide disorder that recent research has shown results from "an abnormal state of the nervous system involving multiple parts of the brain," said Dr. Charles, of the U.C.L.A. Goldberg Migraine Program at the David Geffen School of Medicine in Los Angeles. He told me he hoped the journal article would educate practicing physicians, who learn little about migraines in medical school.

Before it was possible to study brain function through a functional M.R.I. or PET scan, migraines were thought to be caused by swollen, throbbing blood vessels in the scalp, usually – though not always — affecting one side of the head. This classic migraine symptom prompted the use of medications that narrow blood vessels, drugs that help only some patients and are not safe for people with underlying heart disease.

Furthermore, traditional remedies help only a minority of sufferers. They range from over-the-counter acetaminophen and NSAIDs like ibuprofen and naproxen to prescribed triptans like Imitrex, inappropriately prescribed opioids, and ergots used as a nasal spray. All have side effects that limit how much can be used and how often.

More ...

https://www.nytimes.com/2017/09/18/well/giving-migraine-treatments-the-best-chance.html?_r=0

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.

More ...

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.

More ...

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.

More …

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.

More …

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."

More ...


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.

More ...

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.

More ...

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.

More ...

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.

More ...

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.

More ...

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.

More ...

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.

More ...

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.

More ...

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.

More ...

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.

More ...

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

Document:

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