Thursday, December 11, 2014
Tuesday, December 09, 2014
While a major public health campaign has had some success in reducing the number of people who take potentially addictive narcotic painkillers, those patients who are prescribed the drugs are getting more of them for a longer time, according to a new study.
Nearly half the people who took the painkillers for over 30 days in the study's first year were still using them three years later, a sign of potential abuse.
Saturday, November 29, 2014
Chronic pain represents an immense clinical problem. With tens of millions of people in the United States alone suffering from the burden of debilitating chronic pain, there is a moral obligation to reduce this burden by improving the understanding of pain and treatment mechanisms, developing new therapies, optimizing and testing existing therapies, and improving access to evidence-based pain care. Here, we present a goal-oriented research agenda describing the American Pain Society's vision for pain research aimed at tackling the most pressing issues in the field.
This article presents the American Pain Society's view of some of the most important research questions that need to be addressed to advance pain science and to improve care of patients with chronic pain.
Nerve cells that transmit pain, itch and other sensations to the brain have been made in the lab for the first time. Researchers say that the cells will be useful for developing new painkillers and anti-itch remedies, as well as understanding why some people experience unexplained extreme pain and itching.
"The short take-home message would be 'pain and itch in a dish', and we think that's very important," says Kristin Baldwin, a stem-cell scientist at the Scripps Research Institute in La Jolla, California, whose team converted mouse and human cells called fibroblasts into neurons that detect sensations such as pain, itch or temperature1. In a second paper2, a separate team took a similar approach to making pain-sensing cells. Both efforts were published on 24 November in Nature Neuroscience.
Thursday, November 27, 2014
'Off switch' for pain discovered: Activating the adenosine A3 receptor subtype is key to powerful pain relief -- ScienceDaily
- J. W. Little, A. Ford, A. M. Symons-Liguori, Z. Chen, K. Janes, T. Doyle, J. Xie, L. Luongo, D. K. Tosh, S. Maione, K. Bannister, A. H. Dickenson, T. W. Vanderah, F. Porreca, K. A. Jacobson, D. Salvemini. Endogenous adenosine A3 receptor activation selectively alleviates persistent pain states. Brain, 2014; DOI: 10.1093/brain/awu330
Tuesday, November 25, 2014
Saturday, November 22, 2014
Thursday, October 30, 2014
In a beige conference room in Morgantown, West Virginia, Katie Chiasson-Downs, a slight, blond woman with a dimpled smile, read out the good news first. "Sarah is getting married next month, so I expect her to be a little stressed," she said to the room. "Rebecca is moving along with her pregnancy. This is Betty's last group with us."
"Felicia is having difficulties with doctors following up with her care for what she thinks is MRSA," Chiasson-Downs continued. "Charlie wasn't here last time, he cancelled. Hank ..."
"Hank needs a sponsor, bad," said Carl Sullivan, a middle-aged man with auburn hair and a deep drawl. "It kind of bothers me that he never gets one."
"This was Tom's first time back in the group, he seemed happy to be there," Chiasson-Downs went on, reading from her list.
"He had to work all the way back up," Sullivan added.
Chiasson-Downs and the other therapists with the Chestnut Ridge Center's opiate-addiction program had gathered to update each other on the status of their patients before launching into the day's psychotherapy sessions. Here in West Virginia, where prescription painkillers have long "flowed like water," as Sullivan said, the team works to keep recovering addicts sober through a combination of therapy and buprenorphine, a drug used to treat painkiller and heroin addiction.
Chiasson-Downs' patients are in the "advanced" group—so called because they're well into their recoveries. She relayed a few success stories—a new baby here, a relapse averted there—but even years after they've found sobriety, her charges' lives are still precariously balanced.
What Tom (not his real name) was attempting to work his way back up from was the weekly "beginner" group, where advanced patients are sent if they relapse and cannot stay clean. It happens fairly frequently, Sullivan, the director of the treatment program, said.
For patients in the less advanced groups, the therapists' updates are gloomier.
"Trent called in crisis last week, and he didn't come," said Laura Lander, another therapist. An acquaintance who was supposed to give Trent a ride to the clinic instead stole his money and medication and then left him by the side of the road.
"He went without his meds," Doug Harvey, the case manager, added.
"He will have used this week," Sullivan concluded.
"Jessica, she's still living with her boyfriend, who is actively using." Lander said.
"So she's craving every day," Sullivan noted.
"She's financially dependent on him," Lander said. "Three kids and nowhere to go. He's a jerk to her."
"She lives out in the middle of nowhere," Sullivan added. "She talked about her neighborhood being full of people who use. Her family all uses. I'd be surprised if she's clean today."
The therapists' stories go on, sketching a picture of a region that's understaffed and under-resourced, and that found itself unprepared for an epidemic it has disproportionately been affected by. One woman has been skipping meetings and "doing weird things with her meds." Another patient filled his prescription with a new doctor, raising the possibility he was "doctor-shopping," or getting multiple prescriptions from different physicians simultaneously. A woman who lives more than two hours away wasn't going to make it in—the Medicaid van that normally brings her fell through this week.
Prescription drug overdoses, a dangerous side effect of the nation's embrace of narcotic painkillers, are a "substantial" burden on hospitals and the economy, according to a new study of emergency room visits.
Overdoses involving prescription painkillers have become a leading cause of injury deaths in the U.S. and a closely watched barometer of an evolving healthcare crisis. Little was known, however, about the nature of overdoses treated in the nation's emergency rooms.
A new analysis of 2010 data from hospitals nationwide found that prescription painkillers, known as opioids, were involved in 68% of opioid-related overdoses treated in emergency rooms. Hospital care for those overdose victims cost an estimated $1.4 billion.
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.
Continue reading the main storyContinue reading the main storyContinue reading the main story
Several organizations, such as Global Access to Pain Relief Initiative, Hospice Without Borders and Human Rights Watch, are devoted to easing the global crisis of untreated cancer pain, but it is a Sisyphean undertaking for a handful of cash-strapped nongovernmental organizations. Still, by partnering with international organizations and developing innovative delivery systems, certain resource-challenged areas in the developing world have made progress.
The sparsely populated, war-ravaged country of Uganda has made strides in providing morphine to its cancer patients, thanks to the determination of public health advocates like Dr. Jack Jagwe, a former adviser to the Ugandan Health Ministry. In the 1990s, Dr. Jagwe and others partnered with foreign doctors and members of the international community to write into the health code that every Ugandan citizen had the right to palliative care, which was a first in Africa.
Thanks in part to this initiative, Uganda amended its rigid narcotics laws, allowing nurses to prescribe morphine to cancer patients without having a doctor present, which proves essential in delivering morphine to patients in rural areas who are unable to trek long distances to city clinics.
That regulatory easing has opened the door for a nongovernmental entity, Hospice Africa Uganda, to produce its own morphine. This process not only frees Hospice Africa Uganda from dealing with international suppliers; it makes the market more efficient by allowing it to manufacture morphine on demand — indeed, per-patient pain-control costs are now estimated to be about $1 per week. That experience, though still a work in progress, should be a model for other resource-challenged countries.
As with all successful human rights movements, we need to put a face on the injustice of untreated cancer pain. Witnessing a clinic full of poor children with advanced cancer, crying in agony, should convince anyone that access to morphine is a human right.
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.