Saturday, January 17, 2015

The Problem With Treating Pain in America | TIME

Chronic pain affects an estimated 100 million Americans, and between 5 to 8 million use opioids for long-term pain management. Data shows the number of prescriptions written for opioids as well opioid overdose deaths have skyrocketed in recent years, highlighting a growing addiction problem in the U.S. In response, the National Institutes of Health (NIH) released a report on Monday citing major gaps in the way American clinicians are treating pain.


In September, the NIH held a workshop to review chronic pain treatment with a panel of seven experts and more than 20 speakers. The NIH also reviewed relevant research on how pain should be treated.

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http://time.com/3663907/treating-pain-opioids-painkillers/

Panel cites need for individualized, patient-centered approach to treat and monitor chronic pain - NIH

An independent panel convened by the National Institutes of Health concluded that individualized, patient-centered care is needed to treat and monitor the estimated 100 million Americans living with chronic pain. To achieve this aim, the panel recommends more research and development around the evidence-based, multidisciplinary approaches needed to balance patient perspectives, desired outcomes, and safety.

"Persons living with chronic pain have often been grouped into a single category, and treatment approaches have been generalized with little evidence to support this practice," said Dr. David B. Reuben, panel chair and professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles. "Chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, multifaceted approach."

Photo of independent panel

Back row, left to right: Takamaru Ashikaga, David C. Steffens, Christopher M. Callahan. Front row, left to right: David M. Murray, David B. Reuben, G. Anne Bogat, Anika A.H. Alvanzo, Victoria Ruffing.

Chronic pain is often treated with prescription opioids, but the panel noted widespread concern with this practice. Although some patients benefit from such treatment, there are no long-term studies on the effectiveness of opioids related to pain, function, or quality of life. There is not enough research on the long-term safety of opioid use. However, there are well-documented potential adverse outcomes, including substantial side effects (e.g., nausea, mental clouding, respiratory depression), physical dependence, and overdose—with approximately 17,000 opioid-related overdose deaths reported in 2011.

"Clearly, there are patients for whom opioids are the best treatment for their chronic pain. However, for others, there are likely to be more effective approaches," stated Dr. Reuben. "The challenge is to identify the conditions for which opioid use is most appropriate, the alternatives for those who are unlikely to benefit from opioids, and the best approach to ensuring that every patient's individual needs are met by a patient-centered health care system."

The panel identified several barriers to implementing evidence-based, patient-centered care. For example, many clinicians do not have tools to assess patient measures of pain, quality of life, and adverse outcomes. Primary care practices often do not have access to multidisciplinary experts, such as pain management specialists. Insurance plans may not cover team-based, integrative approaches that promote comprehensive, holistic care. In addition, some plans do not offer effective non-opioid drugs as first-line treatment for chronic pain, thus limiting a clinician's ability to explore other avenues of treatment. Once a health provider has made the decision to use opioids, there are insufficient data on drug characteristics, dosing strategies, or tapering to effectively guide clinical care.

"Chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, multifaceted approach."

Dr. David B. Reuben
Panel chair and professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles

"We have inadequate knowledge about treating various types of pain and how to balance effectiveness with potential harms. We also have a dysfunctional health care delivery system that promotes the easiest rather than the best approach to addressing pain," noted Dr. Reuben.

To address knowledge gaps, the panel cited a need for more research on pain, multidisciplinary pain interventions, the long-term effectiveness and safety of opioids, as well as optimal opioid management and risk mitigation strategies. However, because well-designed longitudinal studies can be large, expensive, and difficult for recruitment, the panel encouraged the development of new research design and analytic methods to answer important research and clinical questions.

The panel also recommended engaging electronic health record vendors and health systems to provide pain management decision support tools for clinicians. In addition, the panel advised the NIH and other federal agencies to sponsor more conferences to harmonize pain assessment and treatment guidelines to facilitate consistent clinical care for the treatment of chronic pain.

The panel will hold a press telebriefing on Friday, Jan. 16, at 3 p.m. EST to discuss its findings with members of the media. To participate, call  888-428-7458 (toll free for United States and Canada) or 862-255-5398 (toll for other international callers) and reference the NIH Pathways to Prevention program on The Role of Opioids in the Treatment of Chronic Pain. Audio playback will be available shortly after the conclusion of the telebriefing and can be accessed by calling 888-640-7743 (United States and Canada) or 754-333-7735 (other international callers) and entering replay code 114001.

To better understand the role of opioids in the treatment of chronic pain, the NIH Office of Disease Prevention (ODP) convened a Pathways to Prevention workshop on Sept. 29–30, 2014, to assess the available scientific evidence. The panel's final report, which identifies future research and clinical priorities, incorporates the panel's assessment of an evidence report, expert presentations, audience input, and public comments. The panel's report, which is an independent report and not a policy statement of the NIH or the federal government, is now available at https://prevention.nih.gov/programs-events/pathways-to-prevention/workshops/opioids-chronic-pain/workshop-resources.





Friday, January 16, 2015

A Meditation on Pain | Longreads Blog

It's happening, says the woman I love to someone in the other room. The someone is most likely her sister, and I hear the shuffle of clogs on the ruined carpet, the swish and swirl of her turquoise dress. I feel the shadow of her body in the doorway. I hear her breathing, tiny bursts of air through the nose and mouth. I feel and hear everything, but I am not a body. And because I am no longer a body, I do not register sound or voice. I do not register anything. Even my presence on the scratchy carpet. I do not know that I have been lying in the lap of the woman I love as she soothes my sweat-drenched hair, as she whispers that this will pass. I do not hear her because I do not have ears. I do not have eyes. I do not see the hazy outline of her humid-frizzed hair or the worry etched in her face or how she looks down at me and then out the window, out past the dilapidated houses of this rundown block in Lafayette, Colorado, past the Rockies rising in jagged edges to snowy peaks, past logical explanation. Because right now, I do not register logic. Because this pain is not logical. This pain makes me whimper, makes me produce a noise that is octaves higher and sharper than I can otherwise make. I become a supplicant to its needs. I have a mouth. Of this I am sure. I have a mouth but it acts without my guidance. Saliva seeps from corners. Lips chapped as cracked earth. The woman I love feeds me water. I sip from a straw, but all of it dribbles out from the corners of my mouth. All of it wetting my cheeks and chin, like a child sloppy with food. I am a child. I am helpless. I am without strength. I am without will. I believe I might die. That this might be the end of me, this moment. I believe that death would be a relief from it all.

Hang on, she says. It's almost over, she says. The end is in sight, she says. 

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Chronic Pain Associated with Activation of Brain's Glial Cells - Scientific American

Patients with chronic pain show signs of glial activation in brain centers that modulate pain, according to results from a PET-MRI study.

"Glia appears to be involved in the pathophysiology of chronic pain, and therefore we should consider developing therapeutic approaches targeting glia," Dr. Marco L. Loggia from Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, told Reuters Health by email.

"Glial activation is accompanied by many cellular responses, which include the production and release of substances (such as so-called 'pro-inflammatory cytokines') that can sensitize the pain pathways in the central nervous system," he explained. "Thus, glial activation is not a mere reaction to a pain state but actively contributes to the establishment and/or maintenance of persistent pain."

To test their hypothesis that patients with chronic pain demonstrate in vivo activation of brain glia, Dr. Loggia's team imaged the brains of 19 individuals diagnosed with chronic low back pain as well as 25 pain-free healthy volunteers using 11C-PBR28, a PET radioligand that binds to the translocator protein (TSPO), a protein upregulated in activated microglia and reactive astrocytes in animal models of pain.

In the thalamic region of interest, 11C-PBR28 uptake was significantly higher in patients with chronic low back pain than in healthy controls (p<0.01 left thalamus, p<0.05 right thalamus), according to the January 12 Brain online report.

Each patient exhibited higher 11C-PBR28 uptakes than his/her age-, sex-, and TSPO genotype-matched control in the thalamus, and there were no brain regions for which the healthy controls showed statistically higher uptakes than the patients with chronic low back pain.

11C-PBR28 uptakes, and presumably TSPO levels, were negatively associated with pain measures and with circulating levels of proinflammatory cytokines in the chronic pain patients.

"It's important to stress that although TSPO upregulation is a marker of glial activation and therefore of a pro-inflammatory state, animal studies suggest that its role is actually to limit the magnitude of glial responses after their initiation, thereby promoting the return to pre-injury pain-free status and recovery from pain," Dr. Loggia explained. "This means that what we are imaging may be the process of glial cells trying to 'calm down' after being activated by the pain. Thus, subjects with low levels of pain-related TSPO upregulation on activated glia may be less able to adequately inhibit neuroinflammatory responses, and have a more exaggerated response that ultimately leads to more inflammation and pain."

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http://www.scientificamerican.com/article/chronic-pain-associated-with-activation-of-brain-s-glial-cells/

Brain signature of emotion-linked pain is uncovered - health - 14 January 2015 - New Scientist

You're not imagining the pain. But your brain might be behind it, nonetheless. For the first time, it is possible to distinguish between brain activity associated with pain from a physical cause, such as an injury, and that associated with pain linked to your state of mind.

A fifth of the world's population is thought to experience some kind of chronic pain – that which has lasted longer than three months. If the pain has no clear cause, people can find themselves fobbed off by doctors who they feel don't believe them, or given ineffective or addictive painkillers.

But a study led by Tor Wager at the University of Colorado, Boulder, now reveals that there are two patterns of brain activity related to pain. One day, brain scans could be used to work out your relative components of each, helping to guide treatment.

"Pain has always been a bit of a puzzle," says Ben Seymour, a neuroscientist at the University of Cambridge. Hearing or vision, for example, can be traced from sensory organs to distinct brain regions, but pain is more complex, and incorporates thoughts and emotions. For example, studies have linked depression and anxiety to the development of pain conditions, and volunteers put in bad moods have a lower tolerance for pain.

So does this mean we can think our way into or out of pain? To find out, Wager and his colleagues used fMRI to look at the brain activity of 33 healthy adults while they were feeling pain. First, the team watched the changing activity as they applied increasing heat to the volunteers' arms. As the heat became painful, a range of brain structures lit up. The pattern was common to all the volunteers, so Wager's team called it the neurologic pain signature.

The group then examined whether the volunteers could control the pain by thought alone. "We asked them to rethink their pain, either as a blistering heat, or as a warm blanket on a cool day," Wager says. Although the volunteers couldn't change the level of activity in the neurologic pain signature, they could alter the amount of pain they felt. As they did this, a distinct set of brain structures linking the nucleus accumbens and ventromedial prefrontal cortex became active (PLoS Biology, doi.org/x55).

"It's a major finding," says Vania Apkarian at Northwestern University in Chicago. "For the first time, we've established the possibility of modulating pain through two different pathways."

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http://www.newscientist.com/article/dn26799-brain-signature-of-emotionlinked-pain-is-uncovered.html

Wednesday, January 14, 2015

Joint Pain, From the Gut - The Atlantic

Doctors aren't entirely sure what triggers rheumatoid arthritis, a disease in which the body turns on itself to attack the joints, but an emerging body of research is focusing on a potential culprit: the bacteria that live in our intestines.

Several recent studies have found intriguing links between gut microbes, rheumatoid arthritis, and other diseases in which the body's immune system goes awry and attacks its own tissue.

A study published in 2013 by Jose Scher, a rheumatologist at New York University, found that people with rheumatoid arthritis were much more likely to have a bug called Prevotella copri in their intestines than people that did not have the disease. In another study published in October, Scher found that patients with psoriatic arthritis, another kind of autoimmune joint disease, had significantly lower levels of other types of intestinal bacteria.

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http://www.theatlantic.com/health/archive/2015/01/joint-pain-from-the-gut/383772/?

Saturday, January 03, 2015

Complex Regional Pain Syndrome: Pathophysiology, Diagnosis, and Treatment - Pain Medicine News

Complex regional pain syndrome (CRPS) is a chronic, predominantly neuropathic and partly musculoskeletal pain disorder often associated with autonomic disturbances. It is divided into 2 types, reflecting the absence or presence of a nerve injury.

Patients with either type may exhibit symptoms such as burning pain, hyperalgesia, and/or allodynia with an element of musculoskeletal pain. CRPS can be distinguished from other types of neuropathic pain by the presence of regional spread as opposed to a pattern more consistent with neuralgia or peripheral neuropathy. Autonomic dysfunction (such as altered sweating, changes in skin color, or changes in skin temperature); trophic changes to the skin, hair, and nails; and altered motor function (such as weakness, muscle atrophy, decreased range of motion, paralysis, tremor, or spasticity) also can be present.

At least 50,000 new cases of CRPS are diagnosed in the United States annually.1 Although the incidence rate is subject to debate, a large epidemiologic study from The Netherlands involving 600,000 patients suggests an incidence of 26.2 per 100,000 individuals. The study also found that women are 3 times more likely to be affected, with postmenopausal women having the greatest risk.

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http://www.painmedicinenews.com/ViewArticle.aspx?d=Educational+Reviews&d_id=95&i=December+2014&i_id=1129&a_id=28988

Saturday, December 27, 2014

Pain Really Does Make Us Gain - The New Yorker

Last year, Dimitris Xygalatas, the head of the experimental anthropology lab at the University of Connecticut, decided to conduct a curious experiment in Mauritius, during the annual Thaipusam festival, a celebration of the Hindu god Murugan. For the ten days prior to the festival, devotees abstain from meat and sex. As the festival begins, they can choose to show their devotion in the form of several communal rituals. One is fairly mild. It involves communal prayer and singing beside the temple devoted to Murugan, on the top of a mountain. The other, however—the Kavadi—is one of the more painful modern religious rituals still in practice. Participants must pierce multiple parts of their bodies with needles and skewers and attach hooks to their backs, with which they then drag a cart for more than four hours. After that, they climb the mountain where Murugan's temple is located.

Immediately after each ritual was complete, the worshippers were asked if they would be willing to spend a few minutes answering some questions in a room near the temple. Xygalatas had them rate their experience, their attitude toward others, and their religiosity. Then he asked them a simple question: They would be paid two hundred rupees for their participation (about two days' wages for an unskilled worker); did they want to anonymously donate any of those earnings to the temple? His goal was to figure out if the pain of the Kavadi led to increased affinity for the temple.

For centuries, societies have used pain as a way of creating deep bonds. There are religious rites, such as self-flagellation, solitary pilgrimages, and physical mutilation. There are the rites of passage into adulthood, like the Melanesian rite where boys "may be extensively burned, permanently scarred and mutilated, dehydrated, beaten, and have objects inserted in sensitive areas such as the nasal septum, the base of the spine, the tongue, and the penis." There are also the less intense initiation rituals of fraternity houses and military branches, of summer camps and medical residencies. Painful rites seem to be a way of engineering the kind of affinity that arises naturally among people who have suffered similar traumatic experiences.

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Thursday, December 11, 2014

U.S. Doctors Cutting Back on Painkiller Prescriptions: Study - Healthday.com

Nine out of 10 primary care doctors in the United States are concerned about prescription drug abuse in their communities, a new study finds. 

And, nearly half of the physicians surveyed said they were less likely to prescribe powerful painkillers than they were just a year ago.

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Tuesday, December 09, 2014

Patients Prescribed Narcotic Painkillers Use More of Them for Longer, Study Finds - NYTimes.com

While a major public health campaign has had some success in reducing the number of people who take potentially addictive narcotic painkillers, those patients who are prescribed the drugs are getting more of them for a longer time, according to a new study.

Nearly half the people who took the painkillers for over 30 days in the study's first year were still using them three years later, a sign of potential abuse.

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Saturday, November 29, 2014

A Pain Research Agenda for the 21st Century - The Journal of Pain

Chronic pain represents an immense clinical problem. With tens of millions of people in the United States alone suffering from the burden of debilitating chronic pain, there is a moral obligation to reduce this burden by improving the understanding of pain and treatment mechanisms, developing new therapies, optimizing and testing existing therapies, and improving access to evidence-based pain care. Here, we present a goal-oriented research agenda describing the American Pain Society's vision for pain research aimed at tackling the most pressing issues in the field.

Perspective

This article presents the American Pain Society's view of some of the most important research questions that need to be addressed to advance pain science and to improve care of patients with chronic pain.

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http://www.jpain.org/article/S1526-5900(14)00913-4/fulltext

Pain and itch neurons grown in a dish : Nature News


Nerve cells that transmit pain, itch and other sensations to the brain have been made in the lab for the first time. Researchers say that the cells will be useful for developing new painkillers and anti-itch remedies, as well as understanding why some people experience unexplained extreme pain and itching.

"The short take-home message would be 'pain and itch in a dish', and we think that's very important," says Kristin Baldwin, a stem-cell scientist at the Scripps Research Institute in La Jolla, California, whose team converted mouse and human cells called fibroblasts into neurons that detect sensations such as pain, itch or temperature1. In a second paper2, a separate team took a similar approach to making pain-sensing cells. Both efforts were published on 24 November in Nature Neuroscience.

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Thursday, November 27, 2014

'Off switch' for pain discovered: Activating the adenosine A3 receptor subtype is key to powerful pain relief -- ScienceDaily

In research published in the medical journal Brain, Saint Louis University researcher Daniela Salvemini, Ph.D. and colleagues within SLU, the National Institutes of Health (NIH) and other academic institutions have discovered a way to block a pain pathway in animal models of chronic neuropathic pain including pain caused by chemotherapeutic agents and bone cancer pain suggesting a promising new approach to pain relief.
The scientific efforts led by Salvemini, who is professor of pharmacological and physiological sciences at SLU, demonstrated that turning on a receptor in the brain and spinal cord counteracts chronic nerve pain in male and female rodents. Activating the A3 receptor -- either by its native chemical stimulator, the small molecule adenosine, or by powerful synthetic small molecule drugs invented at the NIH -- prevents or reverses pain that develops slowly from nerve damage without causing analgesic tolerance or intrinsic reward (unlike opioids).
An Unmet Medical Need 
Pain is an enormous problem. As an unmet medical need, pain causes suffering and comes with a multi-billion dollar societal cost. Current treatments are problematic because they cause intolerable side effects, diminish quality of life and do not sufficiently quell pain.
The most successful pharmacological approaches for the treatment of chronic pain rely on certain "pathways": circuits involving opioid, adrenergic, and calcium channels.
For the past decade, scientists have tried to take advantage of these known pathways -- the series of interactions between molecular-level components that lead to pain. While adenosine had shown potential for pain-killing in humans, researchers had not yet successfully leveraged this particular pain pathway because the targeted receptors engaged many side effects.
A Key to Pain Relief 
In this research, Salvemini and colleagues have demonstrated that activation of the A3 adenosine receptor subtype is key in mediating the pain relieving effects of adenosine.
"It has long been appreciated that harnessing the potent pain-killing effects of adenosine could provide a breakthrough step towards an effective treatment for chronic pain," Salvemini said. "Our findings suggest that this goal may be achieved by focusing future work on the A3AR pathway, in particular, as its activation provides robust pain reduction across several types of pain."
Researchers are excited to note that A3AR agonists are already in advanced clinical trials as anti-inflammatory and anticancer agents and show good safety profiles. "These studies suggest that A3AR activation by highly selective small molecular weight A3AR agonists such as MRS5698 activates a pain-reducing pathway supporting the idea that we could develop A3AR agonists as possible new therapeutics to treat chronic pain," Salvemini said.
Journal Reference:
  1. J. W. Little, A. Ford, A. M. Symons-Liguori, Z. Chen, K. Janes, T. Doyle, J. Xie, L. Luongo, D. K. Tosh, S. Maione, K. Bannister, A. H. Dickenson, T. W. Vanderah, F. Porreca, K. A. Jacobson, D. Salvemini. Endogenous adenosine A3 receptor activation selectively alleviates persistent pain statesBrain, 2014; DOI: 10.1093/brain/awu330

http://www.sciencedaily.com/releases/2014/11/141126132639.htm

Tuesday, November 25, 2014

When The Doctor Says This Won’t Hurt A Bit — And Incredibly, It’s True | CommonHealth

In May, my six-year-old daughter, Julia, smashed into our front door handle and got a deep, bloody gash in her forehead.

We rushed her, head wrapped like a tiny mummy, to the medical center at MIT, where we generally go for pediatric care. Julia wept while the nurse cleaned and examined her lacerated skin. After a short exam, she sent us to the emergency department at Children's Hospital Boston for stitches. "How bad is that, generally?" I asked, having never experienced suturing either for myself or my cautious, risk-averse, older daughter.

"It can be traumatic," the nurse said.

Julia cried, "I don't want stitches."

It's a large needle, but Julia is too busy coloring to notice.

So I braced myself for the worst: an endless wait and nerve-wracking bustle; screaming, germ-laden children and brusque, end-of-shift staff. But more than anything, I dreaded the inevitable pain in store for my small child with the deep cut.

(I know, kids get banged up on the path to adulthood and some pain is unavoidable. Still, when bloody heads are involved, I tend to overreact.)

Indeed, I was in full Mama Bear mode when into our exam room strode Dr. Baruch Krauss, the attending physician that evening.

Dark, lean and intense, Dr. Krauss shook my hand and then went straight to Julia, complimenting her pink, sparkly shoes. She lit up and was eager to chat. They talked about exactly how old she was (nearly six-and-three-quarters) and what she likes to do (climb trees). Then he gently rubbed a bit of Novocaine gel on her cut and said he'd be back.

I hovered nervously around Julia, checking and rechecking the cut and generally exuding anxiety, while my husband sat quietly, telling me to calm down. Sure, that'll work.

Five times over the next 40 minutes or so, Krauss came in and re-applied the anesthetic, gently squeezing the site with his thumb and forefinger. Why, I wasn't sure. Was it a dosing thing? Was he just numbing the wound even more before the scary stitching began? With each visit, he engaged Julia to learn something new about her. For instance, she loves to draw.

And, she loves snacks. On my way back from the cafe with treats, Krauss stopped me in the hall and said something like, "I'm going to stitch her up; it really won't be bad." I rolled my eyes. But, he added, "I need you to work with me. I'm going to give you a task." Fine, I said, though the whole thing sounded a little gimmicky.

Krauss returned with an oversized 101 Dalmations coloring book and a handful of Magic Markers. He opened to a page overflowing with dog outlines. "Julia," he said. "I want you to color each dog's ear a different color, OK? Which color do you want to start with?"

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Saturday, November 22, 2014

2014-2015 Global Year Against Neuropathic Pain - IASP

Neuropathic pain is pain that arises as a direct consequence of a lesion or diseases affecting the somatosensory system. Despite the availability of many effective drugs and guidelines for the treatment of neuropathic pain, evidence from the United States and Europe suggests that they are not widely used, and many cases remain under- or untreated. Our goal through the global year campaign is to raise awareness of issues surrounding neuropathic pain.
Monday's launch includes a press release, a series of fact sheets examining the many aspects of neuropathic pain, and other resources for you to learn more about this important form of pain. Many are available to download free of charge.

http://www.iasp-pain.org/GlobalYear/NeuropathicPain


Thursday, October 30, 2014

The New Heroin Epidemic - The Atlantic

In a beige conference room in Morgantown, West Virginia, Katie Chiasson-Downs, a slight, blond woman with a dimpled smile, read out the good news first. "Sarah is getting married next month, so I expect her to be a little stressed," she said to the room. "Rebecca is moving along with her pregnancy. This is Betty's last group with us."

"Felicia is having difficulties with doctors following up with her care for what she thinks is MRSA," Chiasson-Downs continued. "Charlie wasn't here last time, he cancelled. Hank ..."

"Hank needs a sponsor, bad," said Carl Sullivan, a middle-aged man with auburn hair and a deep drawl. "It kind of bothers me that he never gets one."

"This was Tom's first time back in the group, he seemed happy to be there," Chiasson-Downs went on, reading from her list.

"He had to work all the way back up," Sullivan added.

Chiasson-Downs and the other therapists with the Chestnut Ridge Center's opiate-addiction program had gathered to update each other on the status of their patients before launching into the day's psychotherapy sessions. Here in West Virginia, where prescription painkillers have long "flowed like water," as Sullivan said, the team works to keep recovering addicts sober through a combination of therapy and buprenorphine, a drug used to treat painkiller and heroin addiction.

Chiasson-Downs' patients are in the "advanced" group—so called because they're well into their recoveries. She relayed a few success stories—a new baby here, a relapse averted there—but even years after they've found sobriety, her charges' lives are still precariously balanced.

What Tom (not his real name) was attempting to work his way back up from was the weekly "beginner" group, where advanced patients are sent if they relapse and cannot stay clean. It happens fairly frequently, Sullivan, the director of the treatment program, said.

For patients in the less advanced groups, the therapists' updates are gloomier.

"Trent called in crisis last week, and he didn't come," said Laura Lander, another therapist. An acquaintance who was supposed to give Trent a ride to the clinic instead stole his money and medication and then left him by the side of the road.

"He went without his meds," Doug Harvey, the case manager, added.        

"He will have used this week," Sullivan concluded.

"Jessica, she's still living with her boyfriend, who is actively using." Lander said.

"So she's craving every day," Sullivan noted.

"She's financially dependent on him," Lander said. "Three kids and nowhere to go. He's a jerk to her."

"She lives out in the middle of nowhere," Sullivan added. "She talked about her neighborhood being full of people who use. Her family all uses. I'd be surprised if she's clean today."

The therapists' stories go on, sketching a picture of a region that's understaffed and under-resourced, and that found itself unprepared for an epidemic it has disproportionately been affected by. One woman has been skipping meetings and "doing weird things with her meds." Another patient filled his prescription with a new doctor, raising the possibility he was "doctor-shopping," or getting multiple prescriptions from different physicians simultaneously. A woman who lives more than two hours away wasn't going to make it in—the Medicaid van that normally brings her fell through this week.

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Opioids prescribed by doctors led to 92,000 overdoses in ERs in one year - LA Times

Prescription drug overdoses, a dangerous side effect of the nation's embrace of narcotic painkillers, are a "substantial" burden on hospitals and the economy, according to a new study of emergency room visits.

Overdoses involving prescription painkillers have become a leading cause of injury deaths in the U.S. and a closely watched barometer of an evolving healthcare crisis. Little was known, however, about the nature of overdoses treated in the nation's emergency rooms.

A new analysis of 2010 data from hospitals nationwide found that prescription painkillers, known as opioids, were involved in 68% of opioid-related overdoses treated in emergency rooms. Hospital care for those overdose victims cost an estimated $1.4 billion.

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Friday, October 10, 2014

Pain Medicine News - Massive Research Project Targets Chronic Pain in the Military

Spanning five years, costing almost $22 million and spread across 13 separate research trials nationwide, several federal agencies are tackling head-on the mounting problem of how to treat chronic pain in the U.S. military without exacerbating the country's opioid abuse problem.

The new research program, spearheaded by the National Institutes of Health's National Center for Complementary and Alternative Medicine (NCCAM), the National Institute on Drug Abuse (NIDA) and the U.S. Department of Veterans Affairs (VA) Health Services Research and Development Division, will look at non-drug approaches for treating chronic pain and some of the conditions that go hand-in-hand with it, such as post-traumatic stress disorder (PTSD), drug abuse and sleep problems. Modalities to be studied will include, but are not limited to psychotherapy, bright light therapy and self-hypnosis.

The multicenter research effort, involving VA medical centers and academic institutions, will not only focus on active military and U.S. veterans but will look at the effects on their families as well.

According to NCCAM director Josephine Briggs, MD, more Americans turn to complementary and alternative therapies for pain relief than for any other condition. That fact, and the need to stem the increasing problem of prescription painkiller abuse among military personnel, has led to the large-scale research effort, she said.

"The need for non-drug treatment options is a significant and urgent public health imperative," Dr. Briggs said in a statement. "We believe this research will provide much-needed information that will help our military and their family members, and ultimately anyone suffering from chronic pain and related conditions."

A recent large-scale study (N=2,597) showed that chronic pain among U.S. military following deployment was reported by 44% of study subjects, compared with 26% in the general population, and opioid use was seen in 15% versus 4%, respectively. Of individuals reporting chronic pain in the study, 65.6% described it as constant, and 51.2% stated that their pain was moderate or severe. Estimated costs related to chronic pain and its treatment in military personnel are close to $5 trillion (JAMA Intern Med 2014;174:1402-1403).

"Prescription opioids are important tools for managing pain, but their greater availability and increased prescribing may contribute to their growing misuse," said Nora D. Volkow, MD, director of NIDA, in a statement. "This body of research will add to the growing arsenal of pain management options to give relief while minimizing the potential for abuse, especially for those bravely serving our nation in the armed forces."

http://www.painmedicinenews.com/ViewArticle.aspx?d=Web%2BExclusives&d_id=244&i=October+2014&i_id=1108&a_id=28331

Monday, October 06, 2014

After New Federal Rules, Popular Painkillers Will Be Harder to Get | Valley News

It's going to be more difficult to refill prescriptions for the most popular painkillers starting today, when new federal rules move products with hydrocodone into a stricter drug class reserved for the most dangerous and addictive substances.

In approving the change, the Drug Enforcement Administration cited the 7 million Americans who abuse prescription drugs and the 100,000 overdose deaths from painkillers in the last decade. Hydrocodone combinations, including Vicodin, Lortab and Norco, now account for more prescriptions than any other drug, with more than 130 million filled each year.

Proponents of the new rules believe many prescriptions go to younger people for recreational use because they are less likely to suffer from arthritis or other chronic pain conditions.

But many doctors, pharmacists and patients say the rule change effectively punishes people suffering from pain conditions because a small minority of the population abuses the drugs. The changes will be most burdensome for patients with cancer, disabilities and those who live in rural areas or in nursing homes, advocates say.

"For some patients who are legitimately using hydrocodone products for pain, this will be more challenging for them," said Amy Tiemeier, associate professor at St. Louis College of Pharmacy. "For physicians, the hassle will make them think twice about whether it's really necessary to prescribe this drug or maybe they should prescribe something else that has less addiction potential."

More ..,

http://www.vnews.com/news/nation/world/13836289-95/after-new-federal-rules-popular-painkillers-will-be-harder-to-get



Friday, October 03, 2014

Pathways to Prevention Workshop on The Role of Opioids in the Treatment of Chronic Pain - NIH

Chronic pain is a major public health problem, which is estimated to affect more than 100 million people in the United States and about 20–30% of the population worldwide. The prevalence of persistent pain is expected to rise in the near future as the incidence of associated diseases (including diabetes, obesity, cardiovascular disorders, arthritis, and cancer) increases in the aging U.S. population.

Opioids are powerful analgesics that are commonly used and found to be effective for many types of pain. However, opioids can produce significant side effects, including constipation, nausea, mental clouding, and respiratory depression, which can sometimes lead to death.

In addition, long-term opioid use can also result in physical dependence, making it difficult to discontinue use even when the original cause of pain is no longer present. Furthermore, there is mounting evidence that long-term opioid use for pain can actually produce a chronic pain state, whereby patients find themselves in a vicious cycle in which opioids are used to treat pain caused by previous opioid use.

Data from the Centers for Disease Control and Prevention indicate that the prescribing of opioids by clinicians has increased threefold in the last 20 years, contributing to the problem of prescription opioid abuse.1 Today, the number of people who die from prescription opioids exceeds the number of those who die from heroin and cocaine, combined.

Health care providers are in a difficult position when treating moderate to severe chronic pain; opioid treatments may lessen the pain, but may also cause harm to patients. In addition, there has not been adequate testing of opioids in terms of what types of pain they best treat, in what populations of people, and in what manner of administration. With insufficient data, and often inadequate training, many clinicians prescribe too much opioid treatment when lesser amounts of opioids or non-opioids would be effective. Alternatively, some health care providers avoid prescribing opioids altogether for fear of side effects and potential addiction, causing some patients to suffer needlessly.

The 2014 National Institutes of Health (NIH) Pathways to Prevention Workshop on The Role of Opioids in the Treatment of Chronic Pain will seek to clarify:

  • Long-term effectiveness of opioids for treating chronic pain

  • Potential risks of opioid treatment in various patient populations

  • Effects of different opioid management strategies on outcomes related to addiction, abuse, misuse, pain, and quality of life

  • Effectiveness of risk mitigation strategies for opioid treatment

  • Future research needs and priorities to improve the treatment of pain with opioids.

    The workshop is co-sponsored by the NIH Office of Disease Prevention (ODP), the NIH Pain Consortium, the National Institute on Drug Abuse, and the National Institute of Neurological Disorders and Stroke.

    Initial planning for each Pathways to Prevention Workshop is coordinated by a Working Group that nominates panelists and speakers, and develops and finalizes questions that frame the workshop. After finalizing the questions, an evidence report is prepared by an Evidence-based Practice Center through a contract with the Agency for Healthcare Research and Quality. During the 11⁄2-day workshop, invited experts discuss the body of evidence, and attendees have opportunities to provide comments during open discussion periods. After weighing evidence from the evidence report, expert presentations, and public comments, an unbiased, independent panel will prepare a draft report that identifies research gaps and future research priorities. The draft report is posted on the ODP website, and public comments are accepted for two weeks. The final report is then released approximately two weeks later. 



https://prevention.nih.gov/docs/programs/p2p/OpioidPainTreatmnt_ProgramBook.pdf

Wednesday, October 01, 2014

Dying Without Morphine - NYTimes.com

Imagine watching a loved one moaning in pain, curled into a fetal ball, pleading for relief. Then imagine that his or her pain could be relieved by an inexpensive drug, but the drug was unavailable.

Each day, about six million terminal cancer patients around the world suffer that fate because they do not have access to morphine, the gold standard of cancer pain control. The World Health Organization has stated that access to pain treatment, including morphine, is an essential human right.

Most suffering because of a lack of morphine is felt in the poorer regions of the globe. About 90 percent of the world's morphine consumption is in countries in North America and Europe, whereas all the globe's low- and middle-income countries combined use a mere 6 percent. In sub-Saharan Africa, which has the world's lowest consumption of morphine and other opioids, 32 of 53 countries have little, if any, access to morphine.

However, this grossly lopsided use of morphine is not about the unequal distribution of wealth. Morphine is easy to produce and costs pennies per dose. But its per-dose profits are also low, which decreases a drug company's incentive to enter low-income markets in the developing world.

If it were just about the money, the solution — subsidized access — would be obvious. However, the issue is complicated by a dizzying array of bureaucratic hurdles, cultural biases and the chilling effect of the international war on drugs, which can be traced back to the 1961 United Nations Single Convention on Narcotic Drugs that standardized international regulation of narcotics. Driven by its lopsided concern over the illicit use of opioids, a class of drugs that includes heroin, the Single Convention drove countless, onerous country-level restrictions on morphine use, for fear that it would be abused.

India offers a glaring example of how such restrictions can have devastating effects on human lives. In a powerful documentary, "The Pain Project," India's leading palliative care specialist, Dr. M. R. Rajagopal, explains that India's narcotic regulatory agencies are so irrationally stringent that in 27 of the country's 28 states doctors simply avoid prescribing morphine for cancer pain, for fear of running afoul of the law.

In the documentary, you see an aged Indian woman with terminal breast cancer lying on a cot and wailing in pain. It's agonizing to watch, but it illustrates the unrelenting soul-searing effects of untreated cancer pain.

Under mounting pressure, India recently eased some restrictions on the medical use of morphine and consolidated the licensing process from four or five agencies into a single authority. While a step forward, the new amendment doesn't address many harsh regulations that dissuade doctors from freely prescribing morphine. Adding to the regulatory roadblocks, India's health care delivery system is woefully fragmented and understaffed. And India is just one, albeit very large, country — the same story can be found across the developing world.

Continue reading the main storyContinue reading the main storyContinue reading the main story
Several organizations, such as Global Access to Pain Relief Initiative, Hospice Without Borders and Human Rights Watch, are devoted to easing the global crisis of untreated cancer pain, but it is a Sisyphean undertaking for a handful of cash-strapped nongovernmental organizations. Still, by partnering with international organizations and developing innovative delivery systems, certain resource-challenged areas in the developing world have made progress.

The sparsely populated, war-ravaged country of Uganda has made strides in providing morphine to its cancer patients, thanks to the determination of public health advocates like Dr. Jack Jagwe, a former adviser to the Ugandan Health Ministry. In the 1990s, Dr. Jagwe and others partnered with foreign doctors and members of the international community to write into the health code that every Ugandan citizen had the right to palliative care, which was a first in Africa.

Thanks in part to this initiative, Uganda amended its rigid narcotics laws, allowing nurses to prescribe morphine to cancer patients without having a doctor present, which proves essential in delivering morphine to patients in rural areas who are unable to trek long distances to city clinics.

That regulatory easing has opened the door for a nongovernmental entity, Hospice Africa Uganda, to produce its own morphine. This process not only frees Hospice Africa Uganda from dealing with international suppliers; it makes the market more efficient by allowing it to manufacture morphine on demand — indeed, per-patient pain-control costs are now estimated to be about $1 per week. That experience, though still a work in progress, should be a model for other resource-challenged countries.

As with all successful human rights movements, we need to put a face on the injustice of untreated cancer pain. Witnessing a clinic full of poor children with advanced cancer, crying in agony, should convince anyone that access to morphine is a human right.


http://www.nytimes.com/2014/10/01/opinion/dying-without-morphine.html

Tuesday, September 23, 2014

Health Researchers Will Get $10.1 Million to Counter Gender Bias in Studies - NYTimes.com

In an effort to begin addressing persistent gender bias in laboratory research, the National Institutes of Health announced Tuesday that it will distribute $10.1 million in grants to more than 80 scientists studying a diverse array of subjects, including drug addiction, fetal development, migraines and stroke.

The researchers will use the additional funds to include more human participants — generally women — in clinical trials and to ensure that their laboratory animals, even cell lines, are representative of both genders. The money also will be used to analyze gender differences in the resulting data, officials said.

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Monday, September 22, 2014

NIH Pain Consortium

The NIH Pain Consortium was established to enhance pain research and promote collaboration among researchers across the many NIH Institutes and Centers that have programs and activities addressing pain. To this end, the following goals have been identified for the Pain Consortium:

  • To develop a comprehensive and forward-thinking pain research agenda for the NIH - one that builds on what we have learned from our past efforts.

  • To identify key opportunities in pain research, particularly those that provide for multidisciplinary and trans-NIH participation.

  • To increase visibility for pain research - both within the NIH intramural and extramural communities, as well as outside the NIH. The latter audiences include our various pain advocacy and patient groups who have expressed their interests through scientific and legislative channels.

To pursue the pain research agenda through Public-Private partnerships, wherever applicable. This underscores a key dynamic that has been reinforced and encouraged through the Roadmap process.

http://painconsortium.nih.gov/index.html

September is Pain Awareness Month

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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