Friday, October 10, 2014
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."
Monday, October 06, 2014
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."
Friday, October 03, 2014
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.
Wednesday, October 01, 2014
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.
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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.
Tuesday, September 23, 2014
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.
Monday, September 22, 2014
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.
Get instant updates on #PainMonth14
Saturday, August 23, 2014
Monday, July 14, 2014
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.
Sunday, July 13, 2014
LONDON — IN 1926, Virginia Woolf published an essay on pain, "On Being Ill." Isn't it extraordinary, she observed, that pain does not rank with "love, battle and jealousy" among the most important themes in literature. She lamented the "poverty of the language of pain." Every schoolgirl who falls in love "has Shakespeare, Donne, Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry."
Where are the novels or epic poems devoted to typhoid, pneumonia or toothaches, Woolf wondered? Instead, the person in pain is forced to "coin words himself, and, taking his pain in one hand, and a lump of pure sound in the other (as perhaps the inhabitants of Babel did in the beginning), so to crush them together that a brand new word in the end drops out."
The difficulty in talking about painful sensations forces people to draw on metaphors, analogies and metonymies when attempting to communicate their suffering to others. Woolf — writing nearly a century after the popularization of ether, the first anesthetic — was perhaps too pessimistic about the creativity of sufferers. Take lower back pain, the single leading cause of disability worldwide. In the 1950s, one sufferer of back pain said that it felt like "a raging toothache — sometimes like something is moving or crawling down my legs." Half a century later, one person confessed that "my back hurt so bad I felt like I had a large grapefruit down about the curve of the back."
Woolf would not have been impressed perhaps by claims that backs hurt like a toothache or a grapefruit, but she was right to recognize that people in pain seek both to describe their suffering and to give meaning to it.
Some descriptions of pain have been consistent over time. It is frequently said to resemble a burning fire, a biting cat, a stabbing knife. Others arise as a result of specific innovations. In the 19th century, electricity and new weapons provided vivid analogies. From the 1860s, people increasingly spoke about pain as a mechanical monster. In the words of the physician Valentine Mott, writing in 1862, the pain of neuralgia was like "a powerful engine when the director turns some little key, and the monster is at once aroused, and plunges along the pathway, screaming and breathing forth flames." It was "like electric shocks in both legs" or "a lyddite shell," as one author observed in 1900, just four years after the introduction of that explosive into the British Army.
In earlier centuries, pain was more likely to be assigned a spiritual force. It was a result of sin, a guide to virtuous behavior, a stimulus to personal development or a means of salvation. As Lady Darcy Maxwell, a prominent Methodist, wrote in her diary in 1779, her severe "bodily pain" enabled her to truly "enjoy greater nearness to God, more sensible comfort, and a considerable increase of hungering and thirsting after righteousness."
The invention of effective anesthetics dealt a serious blow to the doctrine that pain had a spiritual function. If suffering could be sidestepped, belief in its divine provenance could be jettisoned. In the words of the author of "The Function of Physical Pain: Anaesthetics," published in 1871, now that pain had been "made optional" by anesthetics, it was necessary to revise "the theories of the purposes of bodily pain hitherto held by moralists." A 1935 Lancet article went further: pain was not even a sign by nature that something had gone wrong since it persisted long after "its value as a warning signal is past."
Stripped of its mysticism and its virtuous solicitations, pain was emptied of positive value. Rather than being passively endured, pain became an "enemy" to be fought and ultimately defeated. The introduction of effective relief made submission to pain perverse rather than praiseworthy.
A parallel shift changed the way doctors and other people responded to suffering. When Virginia Woolf lamented the difficulties in communicating pain, she was implicitly criticizing 20th-century medicine. In earlier periods, doctors regarded pain stories as crucial in enabling them to make an accurate diagnosis. But within a century, clinical attitudes had radically changed. Elaborate pain narratives became shameful, indicative of malingering, "bad patients."
And patients internalize this — I know I did. A few years ago, I lay in a hospital bed writhing with pain after a major operation. I remember clutching the morphine button. It didn't seem to be working, and yet I was hesitant to tell the nurse, in case she thought I was a complainer. I didn't want to "bother" her.
From the 1840s, anesthetics silenced the acute pain sufferer; effective analgesics blunted the minds of chronic ones. Knowledge taken from microbiology, chemistry, physiology and neurology enabled physicians to bypass patient narratives in their search for an "objective diagnosis." Increasingly, pain narratives were stripped of any deeper significance beyond the rudimentary cry, "It hurts, here!" Chemical and neurological tests replaced stories; statistics replaced language.
THIS is not to imply that physicians became less caring of their patients. Rather, what constituted a caring response changed. The "men of feeling" of the 18th century, who approached patients with hearts swollen with compassion, represent a very different conception of the display of sympathy from that of contemporary "men (and women) of science."
This valorization of detachment has gone too far, however. People in chronic pain experience their suffering not as contained and isolated in their bodies, but in interaction with other people in their environments. When I was in the hospital, I told a visiting friend that my pain was "beyond language," only to have him remind me that I had been speaking about my suffering for the past hour. Perhaps, he mildly remarked, the problem is not that people in pain cannot communicate, but that witnesses to their pain refuse to hear. I was so struck by his observation that I forgot how much pain I was experiencing. For a few moments, his empathy overcame my suffering.
We have made great strides in making patients more comfortable over the last few centuries. We may no longer believe that pain is sent by God to test us; and we may no longer need lengthy descriptions of pain to arrive at diagnoses. But pain will always be with us, and by listening closely to the stories patients tell us about their pain, we can gain hints about the nature of their suffering and the best way we can provide succor. This is why the clinical sciences need disciplines like history and the medical humanities. By learning how people in the past coped with painful ailments, we can find new ways of living with and through pain.
Joanna Bourke is a professor of history at Birkbeck College and the author of "The Story of Pain: From Prayer to Painkillers."
Thursday, July 03, 2014
But the overdose risks vary quite a bit depending on where in the country you live. One reason is that how often doctors prescribed the drugs, such as Percocet, Vicodin and generic opioids, varies widely by state.
The Centers for Disease Control and Prevention analyzed a commercial database of drug prescriptions looking for patterns. Nationwide, there were 82.5 prescriptions written for opioid painkillers for every 100 Americans in 2012.
But the rates were much higher in some southern states. In Alabama, which led the country, there were 143 painkiller prescriptions for every 100 people in 2012. There were 11 other states where each adult, on average, got a least one painkiller prescription that year, including Tennessee, West Virginia and Kentucky.
CDC Director Dr. Thomas Frieden told reporters that officials don't think the high rates of prescribing in some states are because people living there have more pain. "This is an epidemic that was largely caused by improper prescribing practices," he said during a media briefing.
Wednesday, July 02, 2014
A widely used method of treating a common cause of back and leg pain — steroid injections for spinal stenosis — may provide little benefit for many patients, according to a new study that experts said should make doctors and patients think twice about the treatment.
Hundreds of thousands of injections are given for stenosis each year in the United States, experts say, costing hundreds of millions of dollars.
But the study, the largest randomized trial evaluating the treatment, found that patients receiving a standard stenosis injection — which combine a steroid and a local anesthetic — had no less pain and virtually no greater function after six weeks than patients injected with anesthetic alone. The research, involving 400 patients at 16 sites, was published Wednesday in The New England Journal of Medicine.
"Certainly there are more injections than actually should happen," said Dr. Gunnar Andersson, the chairman emeritus of orthopedic surgery at Rush University Medical Center in Chicago, who was not involved in the research. "It's sort of become the thing you do. You see this abnormality on the M.R.I. and the patient complains, and immediately, you send the patient for an epidural injection."
Some people can still benefit from injections, he said, but now physicians "will be more cautious" and patients should ask, "Should I really do this?' "
Mostly, steroid injections are safe, carrying small risks of infection, headaches and sleeplessness. But in April, the Food and Drug Administration warned that they may, in rare cases, cause blindness, stroke, paralysis or death, noting that injections have not been F.D.A.-approved for back pain and their effectiveness has "not been established."
Wednesday, June 18, 2014
For all that modern medicine has learned about disease and treatment, it's alleviating pain that still lies at the heart of the profession. And in recent years, the notion of treating "pain" as its own entity has been rising to the forefront in medicine. Pain management now has its own journals, conferences, clinics, and specialists, and pain relief is sometimes referred to as a human right. The Institute of Medicine reports there are more than 100 million chronic pain sufferers in the United States, and others have estimated the problem costs $60 billion a year in lost productivity. In September, a coalition that includes the FDA, the CDC, and the NIH is expected to release a long-awaited "National Pain Strategy."
But as pain rises on the agenda for clinicians and patients, research is uncovering some unsettling facts about how it really affects people. First, not everyone experiences pain similarly. In experiments, women and black people have frequently shown lower pain tolerance when asked to do things like hold their hands in ice water. Gender differences in pain prevalence and intensity emerge in adolescence, and for reasons not fully understood, women are particularly vulnerable to conditions including migraines, back pain, and fibromyalgia. Low-income Americans, too, are more likely to suffer pain than their high-income peers: They are likelier to be engaged in manual labor, to eat poorly, and to go to the doctor less often, to name just a few causes. Among pain patients, blacks and Hispanics are likelier to report their pain is severe.
It's also clear that not everyone's pain receives equal attention. A robust and growing body of evidence suggests that the groups who suffer the most also receive less effective treatment for that suffering. Pain is "a huge public health problem," said Carmen Green, a pain specialist at the University of Michigan who has researched disparities in care. But because a disproportionate number of its victims belong to traditionally disempowered groups, "it's been a silent epidemic."
Pain, it appears, is distributed with a kind of inequality distinct from the other inequalities in American health care—one with its own contours, its own logic, and its own disturbing history. And because chronic pain, in particular, often lacks a discrete location in the body, it leaves both diagnosis and treatment almost completely up to a doctor's own judgment, which brings in a range of subtle prejudices that psychologists and other scholars are only beginning to understand. "Chronic pain greatly exacerbates already existing inequality within society," said Joanna Bourke, an historian at Birkbeck College in London, whose new book, "The Story of Pain: From Prayer to Painkillers," makes the intriguing argument that both experiences of and responses to pain have evolved since the 18th century.
Bourke's book, and the emerging research on pain, suggest that pain mirrors existing prejudices in society in ways that medicine is only beginning to grapple with. There's no quick route to solving the problem of pain care, and its thorniness suggests that doctors must first face the steep challenge of understanding both the history and psychology of a problem that medicine, often, would rather not talk about.
'IN OUR PROCESS of being civilized we have won, I suspect, intensified capacity to suffer," renowned American neurologist Silas Weir Mitchell wrote in 1892. "The savage does not feel pain as we do." It was an uncontroversial statement at the time: Jews, the Irish, Southern Europeans, Native Americans, and black people were just a few of the groups that had been long assumed to possess inferior awareness of pain. White women, by contrast, were thought to be exquisitely sensitive.
Paradoxically, the same groups accused of insensitivity often were also said to respond to pain with insufficient stoicism. Black people's supposed indifference to pain was used to justify colonization and slavery; at the same time, slaves were often accused of overreacting to pain. Bourke looked as far back as the 18th century and found that some groups were accused of widely disparate kinds of "improper" pain responses practically all at the same time. "It's a really a Catch-22," she said. "They're either not really feeling, and it's just reflexes, or they're feeling too much and it's exaggerated or it's hysterical."
It was only in the 1940s that mainstream medicine started to question the notion that northern European and "primitive" women experienced pain differently. And as late as 1959, doctors were still debating whether eye color correlated to tolerance for pain. Dark-eyed patients, the editors of the British Medical Journal wrote, are likelier to have descended from "more excitable Mediterranean people." One doctor wrote in to say he "eased [his] burden considerably" by choosing to work with as many blonde, blue-eyed children as possible: "Nordic children," he wrote, "either have a higher pain threshold than other children or greater self-control."
There was little mainstream medical interest in the question of pain until the 1970s, when researchers began looking into pain itself, not just pain as a byproduct of various conditions. The field of pain management got its own medical society in 1983, and by then it was starting to become clear that not every pain patient was treated the same. Studies had begun to show, for example, that minorities being treated for metastatic cancer pain were twice as likely as white patients to receive inadequate pain relief. A 1981 study conducted in Hawaii found that white surgery patients were more likely to be given analgesics than Filipino, Japanese, or Chinese patients, in part because of stereotypes about how different ethnic groups respond to pain.
It sounds like the kind of paternalism that would be easy for modern doctors to shed, but the evidence shows that such inequalities persist. "I don't think things have changed as much as we tell ourselves," said Bourke. Women still receive less effective pain treatments, even though they are significantly likelier than men to experience pain. A 2007 study of heart-surgery patients found that men were likelier to be given pain medication, and women were likelier to be given sedatives. An earlier study found women with metastatic breast cancer were less likely to receive "optimal" pain treatment than men with prostate cancer. With chronic pain in particular, convincing doctors to take pain seriously can be difficult. "With childbirth, we don't say to the woman, 'Oh, you're making up the pain, stop being such a wuss,'" said Judy Foreman, a former health reporter for the Globe and the author of the recent book "A Nation in Pain: Healing Our Biggest Health Problem." "With chronic pain, the pain can be way worse than childbirth, and you don't know if it's going to go away, and people don't believe you."
The evidence for undertreatment of pain in minority patients is even more striking. Black pain patients are less likely than white patients to receive pain medication; when they do receive it, they receive less. Studies of post-operative care have repeatedly found white patients receiving higher doses of opioids than minorities. The same is true for chronic pain. A 2005 study found that minorities are also less likely to be able to get their prescriptions for analgesics filled at their local pharmacies. A more recent study even found that Hispanic children received 30 percent less opioid analgesic than white children for their tonsillectomies.
Potential explanations for these disparities include conscious and unconscious bias, and doctors' assumptions about minorities' ability to pay for medication. But a separate strain of research suggests that doctors may not even recognize the full extent of that pain in the first place. In experiments published in a 2012 study, Sophie Trawalter, an associate professor of public policy and psychology at the University of Virginia, asked participants to think about how much pain they would experience in certain scenarios, and then showed them pictures of either a black person or a white person and asked how much pain they would expect that person to feel.
The results were striking: White participants and black participants all rated blacks' pain as less intense than whites'. When the experiment was repeated with nurses and nursing students, the results were the same. And people with nondiscriminatory racial attitudes make the same kind of perception errors as measurably prejudiced people do. A related study published in February found that racial bias in pain perception appears in children as young as 7. "If you can't recognize the pain, you can't treat it," Trawalter said.
Trawalter's work suggests that the problem of pain inequality may turn out to be more stubborn than it looks. "At least one thing that contributes to this bias is the belief that on average, black people have harder lives, which is true," she said. "But then there's the belief that hardship leads to toughness....It's a cultural narrative we have that unfortunately backfires in this really tragic way." In a perverse irony, sympathy seems to diminish empathy.
PAIN IS A SPECIAL CASE, even within the tilted playing field of American health care. One reason is its inherent, even radical, subjectivity. Western medicine is founded on objectivity: When a patient says something is wrong, doctors look for a discrete problem that can be tested and correlated to a diagnosis. Pain, by contrast, is defined by what the patient feels. The most common tool for measuring it is a simple 0-to-10 scale of the patient's own perception. As nurse and pain-management pioneer Margo McCaffery put it in 1968 in a definition still widely cited, pain is "whatever the person experiencing the pain says it is, existing whenever the person says it does."
Chronic pain in particular often doesn't have a discrete material location, or an identifiable cause. "That doesn't fit into the rubric of what it means to be a Western medical practitioner," said Daniel Goldberg, a bioethicist at East Carolina University and author of the recent book "The Bioethics of Pain Management." This leaves its sufferers vulnerable to skepticism, prejudice, and "accusations of malingering," he said. It doesn't help that many pain medications are addictive, and some people really do feign pain to scrounge their next prescription.
Because pain has such a strong psychological component, finding objective tools to diagnose it is not a simple proposition. Research emerging in the last few years has suggested that certain types of pain create a distinct signature in the brain, and even that sensitivity to pain might be connected to brain structure. But the idea of a practical and affordable tool for measuring all kinds of patient pain is a distant dream at best. And that leaves pain susceptible to doctors' prejudices, including unconscious ones. What it comes down to is: Do they trust their patient's account of their own pain?
It is easy to forget, amid tales of chronic pain, that the story of pain relief since those dark days is a genuinely triumphant one: Modern painkillers are often quite cheap and effective, and the stronger ones can make serious pain almost magically endurable. But ironically, advancements in medicine may have made it harder to deal with the pain that remains. As Bourke wrote in a recent essay for Aeon magazine, there was a "rich language of suffering" before the days of general anesthesia and formal pain management. Patients still talk about their pain—particularly online—but doctors do not listen like they used to, she suggests: Modern pain management is "moving the subjective experience of pain further towards the periphery of medical discourse."
As awareness of the undertreatment problem spreads, there's hope that it will start to change how pain is greeted by hospitals and doctors' offices. There's a long way to go: Foreman's book reports that most medical students receive less than 10 hours of pain education in four years of classes, and that only four medical schools in the country require students to take a course in chronic pain. Foreman says, in all seriousness, that veterinary schools currently do a better job training their students in pain management than medical school do.
Some see psychology offering tools for change. In a series of experiments similar to Trawalter's, psychologist Brian Drwecki, now of Regis University, found that asking subjects in pain-perception experiments to briefly pause to consider the other person's perspective drastically reduces racial bias. It almost sounds too good to be true—even easy—but the idea still faces plenty of hurdles. "Empathy is often downplayed in [the medical] community as something that will hurt you," Drwecki said, referring to doctors' fears of "burnout." "It's a difficult job, and one of the protective mechanisms is to push away empathy."
Just as pain has become its own field of medicine, the rise of pain as its own cause may be what catalyzes change. Foreman points out that in recent decades, groups including AIDS and breast cancer patients have banded together to shout down the stigmas surrounding their diseases. They have organized marches, told their stories in the press, and written letters to Congress for increased funding for research. As they have, their causes have tended to emerge as more kaleidoscopic problems—the kinds that demand, and get, more ambitious and imaginative solutions. "Our best hope is for pain patients to get very active," Foreman said. Sometimes the only reasonable response to pain is to scream a bit louder.
Friday, June 06, 2014
An online training module designed for the evaluation and care of chronic pain greatly improved medical student clinical skills, according to a report in the Journal of the American Geriatrics Society. The module, built by the University of Pittsburgh and using an elderly woman with chronic lower back pain as a case study, is the first curriculum resource created through the efforts of the National Institutes of Health Pain Consortium's Centers of Excellence in Pain Education program (CoEPEs). The program was developed in response to the Affordable Care Act's mandate to advance the science, research, care and education of pain.
"Management of chronic lower back pain is one of the most common and difficult problems that patients and health care providers face," said Josephine P. Briggs, M.D., director of the NIH's National Center for Complementary and Alternative Medicine (NCCAM) and member of the NIH Pain Consortium Executive Committee. "The educational materials that have been developed through this partnership will be a great asset in helping the next generation of physicians build clinical skills to support their chronic pain patients."
The CoEPEs were selected in 2012 to act as hubs for the development, evaluation, and distribution of pain management curriculum resources for medical, dental, nursing, and pharmacy schools. The NIH Pain Consortium developed the centers to improve how health care professionals are taught about pain and its treatment. The module is the first to be completed and evaluated for effectiveness.
A team of six experts in education, information technology, pain management, and geriatrics at the University of Pittsburgh developed the module, focusing on common errors in clinical exams, expert modeling, interactivity, and feedback. The module presented a standardized case of an elderly back pain patient called Edna, with brief video clips that showed her interacting with her clinician. The module also contains a multiple choice pre-test, interactive questions, and a multiple choice post-test. Twenty-seven medical students were exposed to the module and 28 were not. The students in the group exposed to the module did significantly better on their objective structured clinical examinations, an exam during which medical students rotate through multiple stations, each with an objective examiner, demonstrating clinical skills and knowledge while interviewing real or simulated patients. Ninety-three percent of the students in the exposed group passed the exam, compared to 60 percent of the non-exposed group. To view the paper (published May 15), go to http://onlinelibrary.wiley.com/doi/10.1111/jgs.12871/abstract .
"To our knowledge, this is the first study that has demonstrated the potential of an online interactive module to improve medical student clinical skills related to evaluating a patient with chronic pain," said the study's lead author Debra K. Weiner, M.D. "While our module focused specifically on an older adult with chronic low back pain, we see this type of educational intervention as a powerful and efficient curriculum tool for a variety of patient scenarios. We look forward to continuing to work with the NIH Pain Consortium in its effort to improve pain care across the country for many different pain conditions that plague patients of all ages."
The CoEPE program is coordinated by the National Institute on Drug Abuse (NIDA), one of 27 Institutes and Centers at the National Institutes of Health. "We are so pleased that the first successful curriculum product created by the CoEPEs relates to solutions for chronic back pain, one of the most common pain conditions in America," said NIDA Director Nora D. Volkow, M.D. "While we know opioids can be powerful clinical allies, a balanced approach that includes a range of pain management options is needed to ensure that people suffering from chronic pain can get the relief they need while minimizing the potential for abuse."
The CoEPEs are creating and testing online, case-based pain education modules for use in their own teaching institutions. Edna and several other modules will be made available to other teaching institutions beginning in the fall of 2014 athttp://painconsortium.nih.gov/CoEPEs.html. These modules are also accessible by the general public to help them learn how to discuss chronic pain with their doctors. A preview of the module is available at http://bit.ly/1g3HTo4 .
Chronic pain affects approximately 100 million Americans, costing up to $635 billion in medical treatment and lost productivity and contributing to poor quality of life. Yet, pain treatment is not taught extensively in many health professional schools. The curriculum resources developed by the CoEPEs aim to advance the assessment and safe treatment of multiple pain conditions for diverse population groups, while minimizing the abuse of opioid pain relievers. The curriculum resources developed by this program will teach about the various types of chronic pain, medications to treat specific pain conditions, and factors that contribute to both under- and over-prescribing of pain medications. The courses will include the latest research in complementary and integrative pain management.
Wednesday, May 28, 2014
Tuesday, May 27, 2014
This statement, actually describing a trip into Mexico, serves as a manifesto for "The Empathy Exams," Leslie Jamison's extraordinary and exacting collection of essays. Jamison is a young writer and the author of a novel, "The Gin Closet." For the past few years she's been publishing a steady stream of intense, original essays, gathered here for the first time. Though they roam widely in topic and location, their collective preoccupation is with pain: what it means and what to do about it, both when it occurs in our own lives and when its location is far distant from us.
Jamison opens with her experience as an actor playing patients for medical students. "I'm called a standardized patient, which means I act toward the norms set for my disorders." Sometimes, working from a script, she plays a mother whose baby's lips are turning blue, and sometimes a young woman whose grief over her brother's death manifests as seizures. The students are assessed on how empathically they respond to her character's pain. Sensitive questioning elicits vital detail; clumsy handling causes the actor-patient to clam up.
"Empathy," she writes, "means realizing no trauma has discrete edges. Trauma bleeds. Out of wounds and across boundaries. Sadness becomes seizure. Empathy demands another kind of porousness in response." She means a porousness in the witness, a willingness to let a stranger's troubles seep in and slowly unfurl their meaning. But there is a porousness, too, in her style. Her intricate reconstruction of the empathy exams gives way to a more personal case history, an anatomization of two medical procedures she underwent in close succession: first an abortion and then heart surgery. In the essay's virtuosic close, she presents a script for Leslie Jamison: an intimate document, aestheticized but not anesthetized by the assumed tone, the medical dressing.
The damaged physical body, the gulf between sufferer and witness, this is Jamison's territory. Elsewhere, she turns her searching gaze on the community of people who suffer from the condition known as Morgellons, in which patients believe they're infested with hairs or fibers (an opportunity for some remarkable thinking about why patients prefer a diagnosis of physical infection to mental illness). She examines the culture around an ultramarathon in Tennessee, explores the case of the West Memphis Three, and considers poverty and violence in Los Angeles and Bolivia in a set of linked essays entitled "Pain Tours." In almost all of these pieces, her own pain: getting punched in the face in Nicaragua, having a worm emerge from her ankle after a trip to Bolivia, bad boyfriends and the wounding, witty lines they'd deliver.
This is an approach fraught with dangers, which necessitates walking an ethical tightrope between voyeurism and narcissism, between an unnatural interest in the woes of others and an unattractive obsession with the wounds of the self. It is to Jamison's credit that she doesn't choose the easy neutrality of the distanced observer, but rather voyages deeply into both extremes, maintaining almost always an admirable awareness about the perils of her approach.
Throughout, she pays close attention to the mechanisms of empathy, addressing not only its importance, as Rebecca Solnit did in last year's "The Faraway Nearby," but also its ethical complexities. In an essay that tacks brilliantly between a consideration of saccharine sentimentality and the artificial sweetener saccharin, she notes how sentimentality and anti-sentiment charm us by "coaxing out the vision of ourselves we'd most like to see," continuing: "If the saccharine offers some undiluted spell of feeling, . . . then perhaps its value lies in the process of emerging from its thrall: that sense of unmasking, that sense of guilt." This capacity for critical thinking, for a kind of cool skepticism that never gives way to the chilly blandishments of irony, is very rare. It's not surprising that Jamison is drawing comparisons to Sontag, clearly an influence on much of the thinking here. The struggle between irony and empathy surfaces again in two of the more troubling essays of the collection, a linked manifesto on the importance of accepting female woundedness as a subject worthy of attention. I can't say I much like the heavy-handed gender essentialism of her approach, or the moments of over-identification with her subjects, something her best essays rarely permit. On the subject of the plaster corsets Frida Kahlo wore to support her damaged spine, Jamison writes, "She would have given anything, perhaps, to have a body that rendered them irrelevant," adding that after Kahlo's leg was amputated, "she died the next year, as if this loss — after so many others — was what she finally couldn't bear." This is both histrionic and reductive. But it's a danger in keeping with her larger point, which is that it's worth risking an excess of feeling, rather than taking up the fashionable pose of world-weariness, which all too easily shades into detachment and then to cruelty.
Jamison is capable of the most extraordinary flourishes of image. On the case of the West Memphis Three, in which three teenagers were imprisoned for 17 years for the murder of three boys (wrongfully, many believe; they have since been freed), she writes: "Years ago witches were torched like fields. Their bodies held the controlled burn. Their bodies held evil like vessels so that evil would not be understood as something diffused across other bodies, across everyone." There is a glory to this kind of writing that derives as much from its ethical generosity, the palpable sense of stretch and reach, as it does from the lovely vividness of the language itself.
These are the essays of a working journalist. Most have been previously published in magazines like Vice, Harper's and Oxford American. Because they all work to some degree over the narrow field of personal experience, they inevitably turn up the same items of autobiography, perpetually introduced as if for the first time. This has a strange, unwitting effect in a book so preoccupied with the registering of and response to distress — it makes Jamison sound self-preoccupied, too caught up in her own stories to recognize that the reader has encountered them before. A small point, and clearly a consequence of the form, it makes one wonder a little hankeringly what this collection could have been if it had been worked just a touch more. But perhaps this is greedy. It's hard to imagine a stronger, more thoughtful voice emerging this year.
THE EMPATHY EXAMS
By Leslie Jamison
226 pp. Graywolf Press. $15.
Olivia Laing's latest book is "The Trip to Echo Spring: On Writers and Drinking."