Monday, January 14, 2019
But today's parents may be shocked to learn that was not always the case. As recently as the early 1980s, the pain of children and infants was thought to be different from that of adults and was sometimes treated differently, or sometimes not treated at all.
Change doesn't always come easily in medicine, so there's a certain onus on parents to make sure that their children get state-of-the-art pain management around procedures, large and small. That means preparation before any planned surgery, ideally with a child life specialist, and it means careful attention to the child's pain afterward, with parents well backed up by medical specialists.
Thursday, December 20, 2018
THE OPIOID EPIDEMIC is devastating America. Overdoses have passed car crashes and gun violence to become the leading cause of death for Americans under 55. The epidemic has killed more people than H.I.V. at the peak of that disease, and its death toll exceeds those of the wars in Vietnam and Iraq combined. Funerals for young people have become common. Every 11 minutes, another life is lost.
So why do so many people start using these drugs? Why don't they stop?
Some people are more susceptible to addiction than others. But nobody is immune. For many, opioids like heroin entice by bestowing an immediate sense of tranquility, only to trap the user in a vicious cycle that essentially rewires the brain.
Getting hooked is nobody's plan. Some turn to heroin because prescription painkillers are tough to get. Fentanyl, which is 50 times more potent than heroin, has snaked its way into other drugs like cocaine, Xanax and MDMA, widening the epidemic.
To understand what goes through the minds and bodies of opioid users, The New York Times spent months interviewing users, family members and addiction experts. Using their insights, we created a visual representation of how the strong lure of these powerful drugs can hijack the brain.
Thursday, November 15, 2018
But while that toxicity will lay up any mammal dumb enough to chew on the resin spurge, resiniferatoxin has also emerged as a promising painkiller. Inject RTX, as it's known, into an aching joint, and it'll actually destroy the nerve endings that signal pain. Which means medicine could soon get a new tool to help free us from the grasp of opioids.
Saturday, September 29, 2018
"We need to go to the hospital," my mother whispered in my ear, clutching her stomach.
She knew; it was the same pain she had experienced many times before.
We were in California, many miles from home, many miles from my father (a doctor), who always knew what to do. At the time, I was early in my medical school training, although I knew all the intricate details of my mother's medical history and realized she needed to get medical attention.
When we arrived at the local emergency room in an affluent neighborhood, my mother was placed in a wheelchair and taken to the waiting room. She curled up on the cold barren hospital floor, the only position she could find comfortable. Although my mother usually puts on lipstick and high heels to go to the grocery store, this time, her hair was unkempt and her pajamas worn out. Her knees were tucked into her chest and her belly was distended.
It should have been clear to onlookers that she was in agonizing pain, but people were hesitant, skeptical even.
"Ma'am," someone yelled. "Ma'am, we can't have you lying on the floor. Get up."
My mother lay still.
"Get up, ma'am," she was told again, again more forcibly.
They helped her back into the wheelchair.
"Help me," she said. "The pain is unbearable."
Reluctantly, they put her in a stretcher and prepared to place an IV in her arm. To convince them the pain was real, we asked them to call my father, who could fill in all of the medical details: her multiple prior hospitalizations, surgeries and diagnoses.
Friday, September 21, 2018
Illusions as Painkillers: the Analgesic Value of Resizing Illusions in Knee Osteoarthritis - Scientific American
Following on this tradition, a study published PeerJ last month showed that visuotactile illusions can help the pain experienced by patients suffering from knee osteoarthritis.
According to lead author Tasha Stanton, from the University of South Australia, the idea for the study originated from her observation that "people with knee osteoarthritis have an altered perception of their own body. [Their affected knee] often feels too big, and they also have changes to the way that touch and movement information is represented in the brain." She hypothesized that patients may "respond to illusions that change the way their knee looks."
Wednesday, September 19, 2018
The pain narrative videos collected here give unique insight into the lives of patients experiencing chronic pain. Their intended use is as educational material or for patient advocacy, in pieces or as a whole.
Too Good to Be True? A Nonaddictive Opioid without Lethal Side Effects Shows Promise - Scientific American
Opioid drugs like morphine and Oxycontin are still held as the gold standard when it comes to relieving pain. But it has become brutally obvious that opioids have dangerous side effects, including physical dependence, addiction and the impaired breathing that too often leads to death from an overdose. Researchers have long been searching for a drug that would relieve pain without such a heavy toll, with few results so far.
Monday, September 17, 2018
Body in Mind - Research into the role of the brain and mind in chronic pain - University of South Australia
Friday, September 14, 2018
Most Doctors Are Ill-Equipped to Deal With the Opioid Epidemic. Few Medical Schools Teach Addiction. - The New York Times
According to his chart, he had residual pain from a leg injury sustained while working on a train track. Now he wanted an opioid stronger than the Percocet he'd been prescribed. So why did his urine test positive for two other drugs — cocaine and hydromorphone, a powerful opioid that doctors had not ordered?
It was up to Clark Yin, 29, to figure out what was really going on with Chris McQ, 58 — as seven other third-year medical students and two instructors watched.
"How are you going to have a conversation around the patient's positive tox screen results?" asked Dr. Lidya H. Wlasiuk, who teaches addiction awareness and interventions here at Boston University School of Medicine.
Mr. Yin threw up his hands. "I have no idea," he admitted.
Chris McQ is a fictional case study created by Dr. Wlasiuk, brought to life for this class by Ric Mauré, a keyboard player who also works as a standardized patient — trained to represent a real patient, to help medical students practice diagnostic and communication skills. The assignment today: grappling with the delicate art and science of managing a chronic pain patient who might be tipping into a substance use disorder.
How can a doctor win over a patient who fears being judged? How to determine whether the patient's demand for opioids is a response to dependence or pain?
Addressing these quandaries might seem fundamental in medical training — such patients appear in just about every field, from internal medicine to orthopedics to cardiology. The need for front-line intervention is dire: primary care providers like Dr. Wlasiuk, who practices family medicine in a Boston community clinic, routinely encounter these patients but often lack the expertise to prevent, diagnose and treat addiction.
Sunday, July 08, 2018
Shannon Hubbard never imagined it was the prologue to one of the most debilitating pain conditions known to exist, called complex regional pain syndrome.
It's a condition that causes the nervous system to go haywire, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.
For Hubbard, it manifested several years ago following surgery on her foot. That's a common way for it to take hold.
"My leg feels like it's on fire pretty much all the time. It spreads to different parts of your body," the 47-year-old Army veteran says.
Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It's red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.
"That started as a little blister and four days later it was like the size of a baseball," she says. "They had to cut it open and then it got infected and because I have blood flow issues, it doesn't heal."
She knows that soon it will happen again.
"Over the past three years, I've been prescribed over sixty different medications and combinations, none have even touched the pain," she says.
She holds up a plastic bag filled with discarded pill bottles — evidence of her elusive search for a solution to the pain.
Monday, June 25, 2018
Wearing thick rubber gloves, the student squeezed a dollop of pale-orange cream into the center of the square and delicately spread it to the edges, as if frosting a cake. The cream contained capsaicin, the chemical responsible for the burn of chili peppers. "We love capsaicin," Tracey said. "It does two really nice things: it ramps up gradually to become quite intense, and it activates receptors in your skin that we know a lot about." Thus anointed, I signed my disclaimer forms and was strapped into the scanning bed of a magnetic-resonance-imaging (MRI) machine.
Tuesday, June 12, 2018
Monday, June 04, 2018
Thursday, May 31, 2018
The decision seemed to run counter to what my records showed. A few weeks earlier, I had ended up in the emergency room with chest pains and a heart rate hitting 220 beats per minute. The ER crew told me it was a panic attack, gave me Xanax and told me to try to sleep.
I'd had panic attacks before. I knew this episode was not one. So I went to my doctor.
He put me on a heart monitor overnight. Bingo: I had another episode, this time recorded. It didn't matter. I still left his office thinking it was perhaps anxiety. And so, listening to the advice, I tried to ignore the pain.
Until it happened again. And again. First every month, then every week. Over the following nine years, I would complain about it and be told again that I was having panic attacks or anxiety, that women don't feel heart pain the way I was feeling it, and that maybe I was just confused.
• 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.
Saturday, May 19, 2018
What started off as light throbbing in one wrist 10 years ago quickly engulfed the other. The discomfort then spread, producing a pain much "like slapping your hands against a concrete wall," he says. He was constantly stretching them, constantly shaking them, while looking for hot or cold surfaces to lay them on for relief.
But worse was the deep sense of catastrophe that accompanied the pain. Working in tech-related startups, he depended on his hands to type. "Every time the pain got bad, I would think some variation of, 'Oh no, I'm never going to be able to use computers again; I'm not going to be able to hold down a job; I'm not going to be able to earn a living; and I'm going to be in excruciating pain the rest of my life,'" he says.
Like many patients with chronic pain, Golson never got a concrete diagnosis. For a decade, the 38-year-old Californian went from doctor to doctor, trying all the standard treatments: opioids, hand splints, cortisone injections, epidural injections, exercises, even elective surgery.
Golson's pain was not caused by anything physically wrong with him. But it wasn't imagined. It was real.
After weaning himself off the opioid Vicodin and feeling like he had exhausted every medical option, Golson turned to a book that described how pain could be purely psychological in origin. That ultimately took a pain psychologist, a therapist who specializes in pain — not a physician — to treat the true source: his fearful thoughts. Realizing that psychological therapy could help "was one of the most profoundly surprising experiences of my life," Golson says. No doctor he ever saw "even hinted my pain might be psychogenic," meaning pain that's psychological in origin.
Friday, May 18, 2018
The drug, Aimovig, made by Amgen and Novartis, is a monthly injection with a device similar to an insulin pen. The list price will be $6,900 a year, and Amgen said the drug will be available to patients within a week.
Aimovig blocks a protein fragment, CGRP, that instigates and perpetuates migraines. Three other companies — Lilly, Teva and Alder — have similar medicines in the final stages of study or awaiting F.D.A. approval.
"The drugs will have a huge impact," said Dr. Amaal Starling, a neurologist and migraine specialist at the Mayo Clinic in Phoenix. "This is really an amazing time for my patient population and for general neurologists treating patients with migraine."
Millions of people experience severe migraines so often that they are disabled and in despair. These drugs do not prevent all migraine attacks, but can make them less severe and can reduce their frequency by 50 percent or more.
As a recent editorial in the journal JAMA put it, they are "progress, but not a panacea."
Thursday, May 10, 2018
It can be debilitating. It's a leading cause of disability globally.
And the number of people with the often-chronic condition is likely to increase.
This warning comes via a series of articles published in the medical journal Lancet in March. They state that about 540 million people have lower back pain — and they predict that the number will jump as the world's population ages and as populations in lower- and middle-income countries move to urban centers and adopt more sedentary lives.
"We don't think about [back pain] the same way as cancer or heart attacks. But if you look at disability it causes, especially in middle- and low-income where there isn't a safety net, it impacts half a billion people," says Roger Chou, a physician who is a pain specialist at the Oregon Health and Science University and a co-author of the articles.
Disability from chronic back pain can hurt a person's ability to earn a living. One of the Lancet studies found that among rural Nigerian farmers, half reduced their workload because of back pain — an example of how the disability could contribute to the cycle of poverty in countries that lack benefits such as sick days or a social safety net.
Another study from Australia found that people who retired early because of back pain potentially lost out on hundreds of thousands of dollars of accumulated wealth when compared with healthy people who worked all the way to 65.
An overarching issue with back pain management is that the treatments doctors prescribe are often the wrong ones, the report concludes. Also, in many low-income countries, accessing health care is challenging — and getting appropriate care of back pain, specifically, is even harder. In some poor parts of Asia, pain medications are hard to come by and doctors may not have been trained on the most effective treatments.
Tuesday, April 10, 2018
For four years, her doctor prescribed a wide range of opioids for transverse myelitis, a debilitating disease that caused pain, muscle weakness and paralysis.
The drugs not only failed to ease her symptoms, they hooked her.
When her home state of New York legalized marijuana for the treatment of select medical ailments, Owens decided it was time to swap pills for pot. But her doctors refused to help.
"Even though medical marijuana is legal, none of my doctors were willing to talk to me about it," she says. "They just kept telling me to take opioids."
Although 29 states have legalized marijuana to treat pain and other ailments, the growing number of Americans like Owen who use marijuana and the doctors who treat them are caught in the middle of a conflict in federal and state laws — a predicament that is only worsened by thin scientific data.
Because the federal government considers marijuana a Schedule 1 drug, research on marijuana or its active ingredients is highly restricted and even discouraged in some cases.
Underscoring the federal government's position, Health and Human Services Secretary Alex Azar recently pronounced that there was "no such thing as medical marijuana."
Scientists say that stance prevents them from conducting the high-quality research required for FDA approval, even as some early research indicates marijuana might be a promising alternative to opioids or other medicines.
Patients and physicians, meanwhile, lack guidance when making decisions about medical treatment for an array of serious conditions.
Saturday, April 07, 2018
The last time a surgeon general issued such an urgent warning to the country was in 2005, when Richard H. Carmona advised women not to drink alcohol when pregnant.
Wednesday, March 28, 2018
Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.
Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.
But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.
Friday, March 23, 2018
But now, official adoption by the International Association for the Study of Pain (IASP) of an IASP terminology task force recommendation for a so-called "third mechanistic descriptor" of chronic pain could move the field forward in its efforts to more fully characterize the known pathophysiological mechanisms of pain. The new term, christened "nociplastic pain," joins "nociceptive pain" and "neuropathic pain" as terms officially adopted by the association to describe the underlying neurobiological basis of chronic pain.
Tuesday, March 13, 2018
Monday, February 26, 2018
“Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain - Pain Research and Management
Thursday, February 08, 2018
The new therapies are based on research begun in the 1980s showing that people in the throes of a migraine attack have high levels of a protein called calcitonin gene–related peptide (CGRP) in their blood.
Step by step, researchers tracked and studied this neurochemical's effects. They found that injecting the peptide into the blood of people prone to migraines triggers migraine-like headaches, whereas people not prone to migraines experienced, at most, mild pain. Blocking transmission of CGRP in mice appeared to prevent migraine-like symptoms. And so a few companies started developing a pill that might do the same in humans.
Monday, February 05, 2018
PAS-18-624: Mechanistic investigations of psychosocial stress effects on opioid use patterns (R01- Clinical Trial Optional)
In light of the current opioid epidemic in the United States, there is an urgent need to understand how psychosocial stress influences the risk for opioid misuse, abuse, and use disorder. According to the 2014 National Survey on Drug Use and Health (NSDUH), over 4 million Americans engaged in non-medical use of prescription opioids in the previous month, and approximately 1.9 million Americans met criteria for OUD. Further, according to the Center for Disease Control (CDC), deaths from drug overdose in the US exceeded 60,000 last year, surpassing the number of AIDS-related deaths at the height of the HIV/AIDS epidemic. Another recent CDC report indicates that areas with the largest number of filled prescriptions for pain medications also have higher rates of poverty and unemployment, implicating psychosocial stressors as factors that exacerbate opioid use patterns across the country. Notably, relatively few mechanistic studies have investigated the relationship between psychosocial stress and substance use disorders, of which only a fraction pertains to OUDs specifically.
This funding opportunity announcement seeks to address two specific mechanistic pathways via which psychosocial stress may modulate opioid use trajectories.The first pathway is through its effects on cognitive and affective systems that are also altered in OUDs. Stressful environments have been linked to impairments in reasoning, memory, inhibitory and cognitive control, and negative affect. Acute poverty, for example, has been shown to immediately impact performance on tasks measuring intelligence and cognitive control. Relatedly, there is substantial co-morbidity between OUD and stress-related affective disorders, including depression, anxiety and PTSD. Many neurobiological substrates and circuits that are thought to mediate cognitive and affective aspects of addiction are impacted by psychosocial stress. Taken together, these findings suggest that more research is warranted on the role of cognitive and affective systems mediating the effects of psychosocial stress on opioid use trajectories.
Psychosocial stress can also influence opioid use trajectories through its effects on pain processing. Of relevance here, adverse childhood experiences have been associated with an increased prevalence of pain-related medical conditions during adulthood and many individuals with stress-related psychiatric disorders have co-morbid chronic pain syndromes. This may be a consequence of overlapping neural circuits or substrates that are engaged by psychosocial stress and pain and that have been implicated in OUD. Recent estimates suggest that the rates of opioid misuse in patients with chronic pain range from 15-26%. Importantly, and germane to the discussion above, negative affect and the reduced ability to cope with negative emotions in pain appear to increase opioid misuse rates. Further research is needed to understand how the effects of psychosocial impacts on cognitive and affective components of pain may influence the opioid use trajectory. This knowledge may advance prevention and treatment strategies in chronic pain populations.
A Doctor’s Painful Struggle With an Opioid-Addicted Patient - Siddhartha Mukherjee - The New York Times
We were living, then, in what might be called the opioid pre-epidemic; the barometer had begun to dip, but few suspected the ferocity of the coming storm. Pain, we had been told as medical residents, was being poorly treated (true) — and pharmaceutical companies were trying to convince us daily that a combination of long- and short-acting opioids could cure virtually any form of it with minimal side effects (not true). The cavalier overprescription of addictive drugs was bewildering: After a tooth extraction, I emerged from an oral surgeon's office with a two-week supply of Percocet.
Saturday, February 03, 2018
Scientists at University College London found they could alleviate pain in animals with a nasal spray that delivered millions of soluble nanoparticles filled with a natural opioid directly into the brain. In lab tests, the animals showed no signs of becoming tolerant to the compound's pain-relieving effects, meaning the risk of overdose should be far lower.
The researchers are now raising funds for the first clinical trial in humans to assess the spray's safety. They will start with healthy volunteers who will receive the nasal spray to see if it helps them endure the pain of immersing one of their arms in ice-cold water.
"If people don't develop tolerance, you don't have them always having to up the dose. And if they don't have to up the dose, they won't get closer and closer to overdose," said Ijeoma Uchegbu, a professor of pharmaceutical nanoscience who is leading the research through Nanomerics, a UCL startup.
If the first human safety trial is successful, the scientists will move on to more trials to investigate whether the nasal spray can bring swift relief to patients with bone cancer who experience sudden and excruciating bouts of pain.
Tuesday, January 30, 2018
Saturday, January 27, 2018
Thanks to modern medicine, my hysterectomy was performed laparoscopically, without an overnight hospital stay. My only concern about this early release was pain management. The fibroids that necessitated the surgery were particularly large and painful, and the procedure would be more complicated.
I brought up the subject of painkillers with my gynecologist weeks before my surgery. She said that I would be given ibuprofen. "Is that it?" I asked. "That's what I take if I have a headache. The removal of an organ certainly deserves more."
"That's all you will need," she said, with the body confidence that comes from a lifetime of skiing in crisp, Alpine air.
I decided to pursue the topic with the surgeon.
He said the same thing. He was sure that the removal of my uterus would not require narcotics afterward. I didn't want him to think I was a drug addict, but I wanted a prescription for something that would knock me out for the first few nights, and maybe half the day.
With mounting panic, I decided to speak to the anesthesiologist, my last resort.
This time, I used a different tactic. I told him how appalled I had been when my teenager was given 30 Vicodin pills after she had her wisdom teeth removed in the United States. "I am not looking for that," I said, "but I am concerned about pain management. I won't be able to sleep. I know I can have ibuprofen, but can I have two or three pills with codeine for the first few nights? Let me remind you that I am getting an entire organ removed."
The anesthesiologist explained that during surgery and recovery I would be given strong painkillers, but once I got home the pain would not require narcotics. To paraphrase him, he said: "Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It's not good for your kidneys. Only take it if you must. Your body will heal itself with rest."
Wednesday, January 24, 2018
Monday, January 22, 2018
These receptors embed themselves in the walls of cells throughout the brain and peripheral nervous system. There, they serve as cellular gatekeepers, unlocking not just the painkilling properties for which opioids are prized, but the severe, addictive, and often lethal side effects that, in 2016, contributed to the deaths of more than 50,000 people in the US.
But it doesn't have to be that way. "The idea in the field for many years has been to make an opioid that provides beneficial analgesic properties without the harmful side effects," says pharmacologist Bryan Roth, a physician researcher at University of North Carolina School of Medicine. Design a drug that kills pain, not people.
To build that drug, though, researchers need to know the shape of its receptor. This week in the journal Cell, Roth and nearly two dozen of his colleagues report for the first time the structure of the kappa opioid receptor while it's bound to a drug molecule, a discovery that could accelerate the discovery of less-addictive—and less deadly—opioids.
In the past few years, these side effects have plagued growing numbers of US citizens, plunging the country into the throes of a devastating opioid crisis in which nearly 100 people die from overdoses every day. Even so, opioids are still among the most effective pain-relief options available. "Over hundreds of years, [opioid receptors] have remained a target," says Laura Bohn, a biochemist at the Scripps Research Institute in Jupiter, Florida. "Therapeutically, it works."
Since the early 2000s, intriguing evidence has emerged suggesting that opioids' useful properties could be separated from their harmful attributes. (See "Pain and Progress," The Scientist, February 2014.) In 2005, Bohn, then at the Ohio State University College of Medicine, and colleagues showed that shutting down one of the signaling pathways downstream of the opioid receptor targeted by morphine not only amped up the drug's painkilling effects in mice, but also reduced constipation and respiratory depression (J Pharmacol Exp Ther, 314:1195-201).
That research opened the door to developing a new type of opioid: a "biased agonist" that could trigger analgesia without tripping the switches on other pathways that cause side effects. Now, more than a decade later, Trevena Inc.'s Olinvo (oliceridine)—a drug based on this principle and designated by the US Food and Drug Administration (FDA) as a breakthrough therapy—has completed Phase 3 clinical trials.
Olinvo is just one of many such drugs under development. From compounds that act only in specific regions of the body to those that engage multiple receptor types, researchers and pharmaceutical companies are trying many different tactics to produce less-dangerous opioids.
Wednesday, December 06, 2017
The emergency room and a series of doctors could do little but scratch their heads and offer her painkillers.
"I was living on oxycodone and very grateful for it," Levine said, then Harvard University's chief patent attorney. But it wasn't enough. "By January, I was on disability, because I was in such pain and could hardly walk."
Her internet search for answers led her to Dr. Anne Louise Oaklander, a neurologist at Massachusetts General Hospital, who was then developing a hypothesis about inexplicable pain disorders like Levine's: What if they were caused by an overactive immune system?
Oaklander treated Levine as if that were the case and the pain—thankfully—disappeared within five days. "I didn't know how I was going to live with that level of pain," Levine said, adding that it returns every time she stops treatment.
Now, Oaklander has published a series of 55 case reports including Levine's, suggesting that a number of people who suffer pain or other neurologic symptoms—which may have been diagnosed as fibromyalgia, chronic fatigue syndrome, mental illness, or a host of other problems.
Oaklander thinks that some percentage of people who have small fiber neuropathy—which can be caused by diabetes, chemotherapy, or other toxins—actually have a previously undiagnosed autoimmune problem.
Wednesday, November 29, 2017
Thursday, November 23, 2017
The doctor will have to take their word for it. And then, all too often, the doctor will prescribe a powerful and addictive opioid painkiller.
It's a longstanding — if imprecise and subjective — way of measuring and treating pain. And it's at least partly responsible for starting an opioid addiction crisis that killed 64,000 people last year.
"One of the things we heard from many physicians is that the pain-specific indicator contributed to this crisis," said White House Counselor Kellyanne Conway, President Trump's top adviser on the opioid crisis.
"We don't think health care by emoji is good idea," she said.
So the Trump administration, which has declared the opioid crisis a public health emergency, is backing efforts to find better ways of measuring and treating pain in the hope of developing precise treatments that would be more effective than opioids — and without the often catastrophic side effects.
Next month, the National Institutes of Health will open proposals for $4 million in small business grants to develop a device or technology to objectively measure pain. That could take the form of a blood test, a device to measure pupil dilation, or software to interpret facial expressions.
NIH Director Francis Collins calls it the "pain-o-meter."
It's not entirely clear what the pain-o-meter would look like, or exactly how it would work. It hasn't been invented — yet.
But the pain-o-meter isn't meant to be the end game. It's actually the first step in understanding the measurable indicators — or "biomarkers" — that can indicate pain. And that, in turn, could pinpoint causes and treatments, bringing precision medicine to pain management.
"There is this issue about whether we'll ever really get where we want to go in terms of developing effective pain management if we just consider pain to be one thing," Collins told the National Advisory Council for Complementary and Integrative Health last month. "Because we know that it's not."
The current tools of measuring pain don't take into account individual pain thresholds, which can be influenced by genetics, past experiences and other conditions. They often don't distinguish different causes of pain, or different pain sensations.
Tuesday, November 21, 2017
The authors had set out to ask and answer a simple question: Does placement of a small wire mesh (called a stent) inside the artery that feeds blood to the heart (the coronary artery) relieve chest pain? One might ask what was novel about this question. The truth is that there was and is nothing novel about the question. The novelty was in the methods the authors used to answer the question: They conducted a prospective randomized controlled clinical trial, or RCT, the gold standard of research. The best RCTs compare the effect of the active intervention to a placebo and the best of the best keep both the subjects and the investigators blind to the intervention. The authors managed to do this for stents and chest pain, something that had never been done before, and in doing so, they had the best chance of preventing the placebo effect from skewing the results.
Friday, November 17, 2017
Countering this lethal side effect without losing opioids' potent pain relief is a challenge that has enticed drug developers for years. Now, for the first time, the U.S. Food and Drug Administration (FDA) in Silver Spring, Maryland, is considering whether to approve an opioid that is as effective as morphine at relieving pain and poses less risk of depressing breathing.
Trevena, a firm based in Chesterbrook, Pennsylvania, announced on 2 November that it has submitted oliceridine, an intravenous opioid meant for use in hospitalized patients, to FDA for marketing approval. The drug, which would be marketed under the name Olinvo, is the most advanced of what scientists predict will be a growing crop of pain-relieving "biased agonists"—so called because, in binding a key opioid receptor in the central nervous system, they nudge it into a conformation that promotes a signaling cascade that kills pain over one that suppresses breathing. And in a paper out this week in Cell, a veteran opioid researcher and her colleagues unveil new biased opioid agonists that could surpass oliceridine, though they haven't been tested in people yet.
Tuesday, November 07, 2017
The results challenge common ER practice for treating short-term, severe pain and could prompt changes that would help prevent new patients from becoming addicted.
The study has limitations: It only looked at short-term pain relief in the emergency room and researchers didn't evaluate how patients managed their pain after leaving the hospital.
But given the scope of the U.S. opioid epidemic — more than 2 million Americans are addicted to opioid painkillers or heroin — experts say any dent in the problem could be meaningful.
Results were published Tuesday in the Journal of the American Medical Association.
Long-term opioid use often begins with a prescription painkiller for short-term pain, and use of these drugs in the ER has risen in recent years. Previous studies have shown opioids were prescribed in nearly one-third of ER visits and about 1 out of 5 ER patients are sent home with opioid prescriptions.
"Preventing new patients from becoming addicted to opioids may have a greater effect on the opioid epidemic than providing sustained treatment to patients already addicted," Dr. Demetrios Kyriacou, an emergency medicine specialist at Northwestern University, wrote in an accompanying editorial.
The study involved 411 adults treated in two emergency rooms at Montefiore Medical Center in New York City. Their injuries included leg and arm fractures or sprains. All were given acetaminophen, the main ingredient in Tylenol, plus either ibuprofen, the main ingredient in Motrin, or one of three opioids: oxycodone, hydrocodone or codeine. They were given standard doses and were not told which drug combo they received.
Patients rated their pain levels before taking the medicine and two hours later. On average, pain scores dropped from almost 9 on a 10-point scale to about 5, with negligible differences between the groups.
Sunday, October 29, 2017
There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).
But take too many and you have a problem. And America certainly has a problem.
Saturday, October 21, 2017
Tuesday, September 26, 2017
The numbers, released by the Centers for Disease Control and Prevention, are provisional and will be updated monthly, according to the agency.
Fueling the rise in deaths is fentanyl, a synthetic opioid up to 100 times more potent than morphine, and fentanyl analogs, or slight tweaks on the fentanyl molecule. This has not always been the case: As the chart below shows, the drivers of the opioid crisis have changed from prescription painkillers to heroin, and then to fentanyl.
As Dan Ciccarone, a professor at the University of California-San Francisco School of Medicine, recently wrote in the International Journal of Drug Policy:
This is a triple epidemic with rising waves of deaths due to separate types of opioids each building on top of the prior wave. The first wave of prescription opioid mortality began in the 1990s. The second wave, due to heroin, began around 2010 with heroin-related overdose deaths tripling since then. Now synthetic opioid-related overdoses, including those due to illicitly manufactured fentanyl and fentanyl analogues, are causing the third wave with these overdose deaths doubling between 2013 and 2014 .
The epidemic is straining the capacity of morgues, emergency services, hospitals, and foster care systems. Largely because of prevalent drug use and overdose, the number of children in foster care nationwide increased by 30,000 between 2012 and 2015.
Monday, September 25, 2017
1) You're damn lucky.
2) You can't begin to imagine how awful they are.
I had migraines – three times a month, each lasting three days — starting from age 11 and finally ending at menopause.
Although my migraines were not nearly as bad as those that afflict many other people, they took a toll on my work, family life and recreation. Atypically, they were not accompanied by nausea or neck pain, nor did I always have to retreat to a dark, soundless room and lie motionless until they abated. But they were not just "bad headaches" — the pain was life-disrupting, forcing me to remain as still as possible.
Despite being the seventh leading cause of time spent disabled worldwide, migraine "has received relatively little attention as a major public health issue," Dr. Andrew Charles, a California neurologist, wrote recently in The New England Journal of Medicine. It can begin in childhood, becoming more common in adolescence and peaking in prevalence at ages 35 to 39. It afflicts two to three times more women than men, and one woman in 25 has chronic migraines on more than 15 days a month.
But while the focus has long been on head pain, migraines are not just pains in the head. They are a body-wide disorder that recent research has shown results from "an abnormal state of the nervous system involving multiple parts of the brain," said Dr. Charles, of the U.C.L.A. Goldberg Migraine Program at the David Geffen School of Medicine in Los Angeles. He told me he hoped the journal article would educate practicing physicians, who learn little about migraines in medical school.
Before it was possible to study brain function through a functional M.R.I. or PET scan, migraines were thought to be caused by swollen, throbbing blood vessels in the scalp, usually – though not always — affecting one side of the head. This classic migraine symptom prompted the use of medications that narrow blood vessels, drugs that help only some patients and are not safe for people with underlying heart disease.
Furthermore, traditional remedies help only a minority of sufferers. They range from over-the-counter acetaminophen and NSAIDs like ibuprofen and naproxen to prescribed triptans like Imitrex, inappropriately prescribed opioids, and ergots used as a nasal spray. All have side effects that limit how much can be used and how often.
Saturday, September 23, 2017
Politicians tend to talk about the crisis in moral terms, focussing on the ways in which opioid addiction has ravaged families and communities. The New Jersey governor, Chris Christie, whom Trump appointed to lead a commission to study the issue, has compared opioid-overdose fatalities to terrorist attacks, saying, "We have a 9/11-scale loss every three weeks." Opioids, which include prescription painkillers and drugs like heroin and fentanyl, are indeed responsible for large-scale human suffering. According to the National Survey of Drug Use and Health, 97.5 million Americans used, or misused, prescription pain pills in 2015. Drug-overdose deaths have tripled since 2000, and opioid abuse now kills more than a hundred Americans a day. But often omitted from the conversation about the epidemic is the fact that it is also inflicting harm on the American economy, and on a scale not seen in any previous drug crisis.
In July, when economists at Goldman Sachs analyzed how the 2008 financial crisis and its aftermath may have contributed to levels of opioid addiction, they noted that fewer prime working-age men are participating in the labor force than in the past, and that many of these men have been found to be taking prescription pain medication. Research by the Princeton economist Alan Krueger, published last week, indicates a definitive link between the two.
Other studies have tried to put an exact figure on the cost of the epidemic. A study published in the journal Pain Medicine in 2011 estimated that health-care costs related to prescription opioid abuse amounted to twenty-five billion dollars, and criminal-justice-system costs to $5.1 billion. But the largest cost was to the workplace, which accounted for $25.6 billion, in the form of lost earnings and employment. "There are major consequences to the economy, not just to the employer and employee who are losing productivity but also to civil society," Howard Birnbaum, a health-care economist with the Analysis Group and one of the authors of the study, told me recently. "If people don't have jobs, they don't have money to spend in the grocery store, on gasoline. It's the old multiplier effect: the socioeconomic burden is much broader than on any individual or any firm." The study estimated a total cost to the economy of $55.7 billion, but, Birnbaum said, "I suspect it is even larger now."Another study, just two years later, reached a total of $78.5 billion.
When I spoke with Anupam Jena, a health economist and physician at Harvard Medical School, he argued that such figures don't include the most dramatic cost: the economic value of the loss of life. Taking a conservative estimate of twenty to thirty thousand opioid-related deaths a year and multiplying those numbers by five million dollars—a figure commonly used by insurance companies to value a human life—Jena estimated that loss of life alone costs the economy an additional sum of between a hundred and a hundred and fifty billion dollars a year. All these figures suggest that addiction prevention and treatment should be a part of any serious policy discussion about how to strengthen the U.S. economy.
I caught my first whiff of this news about eight years ago, when I was starting the research for a book about the back-pain industry. My interest was both personal and professional: I'd been dealing with a cranky lower back and hip for a couple of decades, and things were only getting worse. Over the years, I had tried most of what is called 'conservative treatment' such as physical therapy and injections. To date, it had been a deeply unsatisfying journey.
Like most people, I was convinced that the problem was structural: something had gone wrong with my skeleton, and a surgeon could make it right. When a neuroscientist I was interviewing riffed on the classic lyric from My Fair Lady, intoning: 'The reign of pain is mostly in the brain,' I was not amused. I assumed that he meant that my pain was, somehow, not real. It was real, I assured him, pointing to the precise location, which was a full yard south of my cranium.
Like practically everyone I knew with back pain, I wanted to have a spinal MRI, the imaging test that employs a 10-ft-wide donut-shaped magnet and radio waves to look at bones and soft tissues inside the body. When the radiologist's note identified 'degenerative disc disease', a couple of herniated discs, and several bone spurs, I got the idea that my spine was on the verge of disintegrating, and needed the immediate attention of a spine surgeon, whom I hoped could shore up what was left of it.
Months would pass before I understood that multiple studies, dating back to the early 1990s, evaluating the usefulness of spinal imaging, had shown that people who did not have even a hint of lower-back pain exhibited the same nasty artefacts as those who were incapacitated. Imaging could help rule out certain conditions, including spinal tumours, infection, fractures and a condition called cauda equina syndrome, in which case the patient loses control of the bowel or bladder, but those diagnoses were very rare. In general, the correlation between symptoms and imaging was poor, and yet tens of thousands of spinal MRIs were ordered every year in the United States, the United Kingdom and Australia.
Very often, the next stop was surgery. For certain conditions, such as a recently herniated disc that is pressing on a spinal nerve root, resulting in leg pain or numbness coupled with progressive weakness, or foot drop, a nerve decompression can relieve the pain. The problem is that all surgeries carry risks, and substantial time and effort is required for rehabilitation. After a year, studies show, the outcomes of patients who opt for surgery and those who don't are approximately the same.
More invasive surgeries carry greater risks. Lumbar spinal fusion – surgery meant to permanently anchor two or more vertebrae together, eliminating any movement between them – is recognised as particularly hazardous. Even when the vertebral bones fuse properly, patients often do not get relief from the pain that sent them to the operating room. Beyond that, fusion surgery often results in 'adjacent segment deterioration', requiring a revision procedure.
Tuesday, September 05, 2017
Drug overdoses are expected to remain the leading cause of death for Americans under 50, as synthetic opioids — primarily fentanyl and its analogues — continue to push the death count higher. Drug deaths involving fentanyl more than doubled from 2015 to 2016, accompanied by an upturn in deaths involving cocaine and methamphetamine. Together they add up to an epidemic of drug overdoses that is killing people at a faster rate than the H.I.V. epidemic at its peak.
Monday, September 04, 2017
A disaster is indeed what it is, with 142 Americans dying daily from drug overdoses, a fourfold increase since 1999, more than the number of people killed by gun homicides and vehicular crashes combined. A 2015 National Survey on Drug Use and Health estimated that 3.8 million Americans use opioids for nonmedical reasons every month.
Lest you think that people seeking chemically induced highs are solely responsible for the problem, physicians and dentists who prescribe opioids with relative abandon, and patients and pharmacists who fill those prescriptions, lend a big helping hand. The number of prescriptions for opioids jumped from 76 million in 1991 to 219 million two decades later. They are commonly handed to patients following all manner of surgery, whether they need them or not.
A new review of six studies by Dr. Mark C. Bicket and colleagues at Johns Hopkins University School of Medicine found that among 810 patients who underwent seven different kinds of operations, 42 percent to 71 percent failed to use the opioids they received, and 67 percent to 92 percent still had the unused drugs at home.
Wednesday, August 30, 2017
This horrific story has been showcased to confirm that physicians who specialize in chronic pain confront real threats from patients or their loved ones, particularly regarding opioid prescriptions. But Graham's death also draws attention to another fraught development: In the face of an ever-worsening opioid crisis, physicians concerned about fueling the epidemic are increasingly heeding warnings and feeling pressured to constrain prescribing in the name of public health. As they do so, abruptly ending treatment regimens on which many chronic pain patients have come to rely, they end up leaving some patients in agonizing pain or worse.
Last month, one of us was contacted by a 66-year old orthopedic surgeon in Northern California, desperate to find a doctor for herself. Since her early 30s, Dr. R suffered from an excruciating condition called Interstitial Cystitis (IC). She described it as a "feeling like I had a lit match in my bladder and urethra." Her doctor placed her on methadone and she continued in her medical practice on a relatively low dose, for 34 years. As Dr. R told one of us, "Methadone has saved my life. Not to sound irrational, but I don't think I would have survived without it." Then a crisis: "Unfortunately for me, the feds are clamping down on docs prescribing opiates. My doctor decided that she did not want to treat me anymore, didn't give me a last prescription, and didn't wait until I found another pain doctor who would help me." For the past 30 years, Dr. R has been an advocate for better treatment of IC and reports "many suicides in the IC patient population due to the severity of the pain."
Tuesday, August 29, 2017
So it's no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.
What's often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.
In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.
Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients' situation and offered words of encouragement about getting better.
Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.
Thursday, August 24, 2017
A team led by Rebeccah Slater, University of Oxford, UK, found that the EEG template of brain activity correlated with the presence and intensity of pain-related behavior and validated the template across four independent samples of infants. Intriguingly, a topical analgesic dampened the brain signal, showing how the new approach could be used to assess the effect of pain medications in infants undergoing painful procedures.
Sunday, August 20, 2017
It seems that privileged women in the US have created their own alternative health-care system—with few of its treatments having been tested for efficacy, or even basic safety. It's easy to laugh at the dubious claims of the wellness industrial complex, and reasonable to worry about the health risks involved. But the forces behind the rise of oxygen bars and detox diets are worth taking seriously—because the success of the wellness industry is a direct response to a mainstream medical establishment that frequently dismisses and dehumanizes women.
To be fair, the American health-care system is generally unpleasant for everyone: impersonal, harried, and incredibly expensive. "The doctor-patient relationship has been slowly eroding, not only with specialization and the fact that people now see panels of doctors, but because emergency rooms are slammed, there are insurance-coverage problems, et cetera," Travis A. Weisse, a science historian at the University of Wisconsin, told Taffy Brodesser-Akner in an article for Outside magazine. "It can make a patient feel devalued."
The medical system is even more terrible for women, whose experience of pain is routinely minimized by health practitioners. In the emergency room, women routinely wait longer than men to receive medication for acute pain. At the gynecologist's office, severe period-related pain is often dismissed or underestimated. Ingrained sexism means that doctors may regard women as either earth mothers or hypochondriacs; that is, either women possess deep wellspring of internal pain control that they ought to be able to channel during childbirth, or their pain is psychological in nature—a symptom of hysteria.
Conditions that affect women at higher rates than men, including depression and autoimmune diseases like fibromyalgia, are much more likely to be dismissed as having a psychological rather than a physiological source. Chronic fatigue syndrome sufferers are still instructed to rely on exercise and positive thinking, despite research that indicates these measures do not cure the condition. Many women with autoimmune diseases, endometriosis, or even multiple sclerosis go undiagnosed for years, despite multiple trips to doctors and specialists—all the while being told that their symptoms could just be stress.