Monday, April 18, 2016
All three botulinum toxin type A formulations are supported by level A evidence for use in upper limb spasticity, and onabotulinumtoxinA (Botox) received a level A recommendation in chronic migraine, although the magnitude of the benefit is small, according to David Simpson, MD, of Icahn School of Medicine at Mount Sinai in New York, and colleagues.
The new guidance, which is the first since 2008, was published online in Neurology and reported here at the American Academy of Neurology meeting.
There are four types of botulinum toxin available on the U.S. market: three type A and one type B. Type A botulinum toxins include abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), onabotulinumtoxinA (Botox), and the lone Type B product is rimabotulinumtoxinB (Myobloc).
Simpson and colleagues reviewed the evidence for botulinum toxin in four conditions: cervical dystonia, blephrospasm, limb spasticity, and headache.
"We chose these diseases because we had a sense that there were sufficient data to show they were going to change in particular ways," Mark Hallett, MD, of the National Insitute of Neurological Disorders and Stroke, a co-author of the guideline, said during a press briefing. "We already had a feeling for what we were going to find, but we had to prove it carefully."
All three botulinum toxin type A drugs had level-A evidence supporting their use in upper limb spasticity, and abobotulinumtoxinA and onabotulinumtoxinA had level A evidence behind their use in lower limb spasticity, the researchers reported.
There was also strong level-A evidence that onabotulinumtoxinA works in chronic migraine, since the drug had been approved by the FDA in 2010 for this condition -- although the magnitude of benefit was small, Simpson said, with a 15% reduction in headache days per month compared with placebo.
Monday, April 11, 2016
A new University of Virginia study suggests that many medical students and residents are racially biased in their pain assessment, and that their attitudes about race and pain correlate with falsely-held beliefs about supposed biological differences—like black people having thicker skin, or less sensitive nerve endings than white people—more generally.
The study highlights how a confluence of mistaken attitudes—about race, about biology, and about pain—can flourish in one of the worst possible places: medical schools where the future gatekeepers of relief are trained. And it illuminates what I've called the divided state of analgesia in America: overtreatment of millions of people that feeds painkiller abuse at the same time that, with far less public attention, millions of others are systematically undertreated. Think of it as a pain gap between the haves and the have-nots, along lines of class and race.
Unfortunately, the UVA findings are neither surprising nor fundamentally new. Back in the 1990s, two studies—one in an Atlanta emergency room, the other in Los Angeles—found that white patients being treated for long bone fractures were dosed more liberally than Latino patients in L.A., and more liberally than black ones in Atlanta. The authors put forward several possible explanations of the disparity: Perhaps patients in different groups expressed pain differently, or maybe caregivers interpreted pain differently in these groups, or perhaps nurses and doctors saw pain the same way across groups but just chose to remedy pain differently.
By the late 1990s, other studies found similar disparities in cancer care, where people receiving outpatient cancer care in places that mostly served minorities were three times more likely to be under-medicated with analgesics than patients in other settings. Speculation about the causes deepened: Perhaps inadequate prescribing for minority patients resulted from concerns about potential drug abuse, or maybe minority patients had more difficulty finding pharmacies that stocked opioid prescriptions, or again perhaps there was a cultural barrier in doctor-patient understanding and assessment. Into the 2000s, additional reports have confirmed the gap—again with no agreement about any single cause.
Monday, March 28, 2016
"I'm going touch your ankle in a few places," the doctor said shortly after I was brought in. "I want you to describe the pain on a scale from 1 to 10."
He pressed down onto various parts of my foot, each one more painful than the last. And yet, the numbers I uttered barely nudged, moving up from 5 to 5.5, and then from 5.5 to 6. I never said anything higher than that.
When the X-rays were in, the doctor showed them to me and told me two things. The first was that I had fractured my ankle. The second was that there was no way the pain was less than an 8. He joked that if I had sought medical care somewhere else, somewhere less precautionary in its practices, I might have been sent away with a prescription for a mild painkiller and a bag of ice.
Machismo, the driver of so many questionable decisions made by men, is a fickle thing. Sometimes, a little bit of it — a tinge of toughness — doesn't seem to hurt. In sport, for instance. Or maybe negotiation. Other times, it turns out, it can do more harm than good. Like, say, when it comes to caring for one's health.
Tuesday, March 22, 2016
- Developing methods and metrics to monitor and improve the prevention and management of pain.
- Supporting the development of a system of patient-centered integrated pain management practices based on a biopsychosocial model of care that enables providers and patients to access the full spectrum of pain treatment options.
- Taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations.
- Increasing public awareness of pain, increasing patient knowledge of treatment options and risks, and helping to develop a better informed health care workforce with regard to pain management.
- Improving provider education on pain management practices and team-based care in which multiple treatment options are offered – moving away from an opioid-centric treatment paradigm.
- Improving patient self-management strategies, as well as patient access to quality, multidisciplinary care that does not depend solely on prescription medications, especially for vulnerable populations.
- Encouraging the evaluation of risks and benefits of current pain treatment regimens.
- Providing patients with educational tools to encourage safer use of prescription opioids.
- Conducting research to identify how best to provide the appropriate pain treatments to individual patients based on their unique medical conditions and preferences.
These efforts will build on the current work underway at HHS to equip providers with the tools and information they need to make informed patient-centered treatment decisions that include safer and appropriate opioid prescribing.
The goals of the National Pain Strategy can be achieved through a broad effort in which better pain care is provided, along with safer prescribing practices, such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain.
Wednesday, March 16, 2016
Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.
Yet rather than increasing her dose, Dr. Wergin was tapering her down. "Susan, we've got to get you to five pills a day," he said gently.
Such conversations are becoming routine in doctors' offices across the country. A growing number of states are enacting measures to limit prescription opioids, highly addictive medicines that alleviate severe pain but have contributed to a surging epidemic of overdoses and deaths. This week the federal government issued the first national guidelines intended to reduce use of the drugs.
In Nebraska, Medicaid patients like Ms. Kubicka-Welander, 56, may face limits this year that have been recommended by a state drug review board. "We don't know what the final numbers will be," Dr. Wergin told her, "but we have to get you ready."
This first national guidance on the subject is nonbinding, and doctors cannot be punished for failing to comply. But the head of the Centers for Disease Control and Prevention, which issued the guidelines, said the effort was critical to bringing about "a culture shift for patients and doctors."
"We are waking up as a society to the fact that these are dangerous drugs," Director Tom Frieden said in an interview. "Starting a patient on opiates is a momentous decision, and it should only be done if the patient and the doctor have a full understanding of the substantial risks involved."
After record numbers of overdose deaths from opioid painkillers and heroin, 2016 may prove to be the year that the federal government begins to forcefully address what has become a major public health crisis. In addition to the CDC, the Food and Drug Administration is reassessing its policies on opioid medications, the Senate has passed legislation that would expand drug abuse treatment and prevention, and the Drug Enforcement Administration is pushing physicians for more responsible prescribing. The departments of Veterans Affairs and Defense already have opioid policies for their patients.
"For the first time, the federal government is communicating clearly that the widespread practice of prescribing opioids for chronic pain is inappropriate, that the risks outweigh the benefits," said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, a nonprofit that has been urging a curb on the use of opiates.
Given the CDC's influence in the medical community, its recommendations are "a game changer," Kolodny said.
Lawmakers who have faulted past federal efforts to tackle the addiction epidemic also welcomed the announcement.
"I have pushed for the release of these guidelines because I have seen firsthand the devastating effects of prescription drug abuse on individuals, families, and communities," said Democratic Sen. Joe Manchin of West Virginia, which is one of the hardest-hit states. His statement called the guidelines "a critical part of our fight to end this epidemic."
Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, said the organization has "long supported policies that will help combat this critical public health issue, while also ensuring access to these medicines for patients with legitimate medical needs." Such policies include expanded provider education and training on pain management and access to treatment options, she said.
Nearly 28,700 people died from overdoses of prescription opioids and heroin in 2014, according to the most recent data available. Since 1999, 165,000 people have fatally overdosed on prescription painkillers, the CDC said.
In just the past month, it said, 4.3 million have diverted the drugs for nonmedical uses.
"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," Frieden and Debra Houry, director of the agency's National Center for Injury Prevention and Control, wrote Tuesday in the New England Journal of Medicine.
The guidelines, which were delayed a few months by disputes with drug industry groups, are aimed predominantly at primary care physicians. These doctors prescribe many of the opioids but complain that they have insufficient training in how to do so.
Frieden agrees that many doctors need a refresher course on how to approach prescribing pain medications.
"When I went to medical school I had exactly one lecture on pain, and the lecture said if you give an opioid to a patient in pain, they will not get addicted," Frieden said. "Completely wrong, and yet a generation of doctors grew up being taught that."
The recommendations are not intended for doctors managing pain after cancer or surgery or during end-of-life care.
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
My eyes met his. I observed every fleeting facial expression, hoping to gauge his intentions. The discussion about whether to continue to prescribe this medication was one I'd had too many times with too many patients over the past few months.
"My arthritis is always worst in the winter," he said, rubbing his lower back.
It was a snowy afternoon in clinic, and M and I were in the midst of a debate. Oxycodone is an opioid medication, and, like other painkillers such as Oxycontin, Percocet, and Vicodin, it carries a significant risk of abuse.
M said he needed the pills for their pain-relieving effects. He wanted a new prescription. I was disinclined. Opioids are highly addictive. They're often abused. Worst, they decrease the body's drive to breathe, making them deadly in some cases. As much as I wanted to trust M, his story didn't quite add up. Was he abusing the drug, even selling it? Given the rising toll of prescription narcotics, these questions weren't unreasonable.
In Massachusetts where I am a physician, unintentional deaths from opioid overdoses increased from 5.3 to 10.1 per 100,000 residents between 2000 and 2013. In 2014, the number jumped to 18.6 per 100,000. These numbers include overdoses from heroin, which works the same way as opioid pills. Some people who become addicted to painkillers, unable to afford more medication or secure a prescription, then turn to heroin. But as of 2015, prescription opiates on their own account for 44 deaths each day in the United States.
In 2014, then-Massachusetts Gov. Deval Patrick declared opioid abuse and overdose a public health emergency. In June 2015, a task force established to address the issue recommended a plan that would set aside nearly $28 million to tackle the epidemic from numerous angles.
Because opioid abuse and addiction is such a widespread problem, the patients who receive prescriptions for these pills are not always the people who take them. There is a large street market for opioids, and once in the possession of people who abuse them, prescription painkillers — along with anti-anxiety medications, such as benzodiazepines like Klonopin — can become even more dangerous when incorporated into potent drug cocktails (much like cocaine-and-heroin "speedballing"). These mixtures can be lethal given the unpredictability and variability in their contents
The possibility of drug abuse, overdose, and diversion is the backdrop to every conversation I have with a patient about opioids. Some cases are clear-cut. A patient in pain from terminal cancer, whose need for narcotics is obvious and whose potential for dependence is immaterial — I don't worry too much with patients like that. But in most cases the decision "is far more fraught.
My task as a doctor is to take stock of each patient's risk for misuse of the medicines and weight it against the desire to treat his or her pain. There is an ever-present fear that, as much as I hate to believe it, a patient could be manipulating me.
I often recall the surprise, betrayal, and alarm one of my colleagues experienced when police caught her patient selling the pain pills she'd prescribed him for years. Safeguards such as Massachusetts's prescription monitoring program, "which logs all controlled substances prescribed to a patient and tests for drugs in the urine, "are helpful but can still be circumvented.
But my worst fear isn't the legal possibility of supplying an addict — so long as safeguards are reasonably followed, doctors are protected from their patient's criminal behavior. What I fear most is harming a patient or, worse yet, unwittingly playing a role in someone's death.
The simplest solution to avoid these risks, of course, is to not start patients on narcotics at all, instead relying on physical therapy, non-opioid pain medicines, and other adjuncts. But patients sometimes come to me already taking opioids. I inherited M from another physician who left the practice, and when he became my patient, he was already on a relatively high dose of Oxycodone.
His previous doctor started him on the painkillers after major back surgery with the goal of weaning him off them after he had recovered. But unlike other patients with clear motives — some sought a short course of painkillers for acute pain, for example, and then stopped the medicines as soon as possible — "M's case was tricky.
I don't want to deny pain relief to patients who truly feel opioids help them. A prima facie refusal to ever prescribe opioids contradicts expert opinion; according to the American Pain society, for the right patients and under close monitoring, narcotics can indeed be an option as part of a chronic pain regimen.
But I do discuss the data behind narcotics for pain relief with my patients. A recent study showed that opioids in conjunction with the non-narcotic painkiller naproxen for acute lower back pain worked no better than taking naproxen alone.
He couldn’t eat, drink or work. And doctors couldn’t explain his searing pain. - The Washington Post
Unable to work and on medical leave from his job as a financial consultant for a bank, Pace, then 59, had spent the first half of 2012 bouncing among specialists in his home state of Pennsylvania, searching for help from doctors who disagreed about the nature of his illness. Some thought his searing pain might be the side effect of a drug he was taking. Others suspected migraines, a dental problem, mental illness, or an attempt to obtain painkillers.
Even after a junior doctor made what turned out to be the correct diagnosis, there was disagreement among specialists about its accuracy or how to treat Pace. His wife, Carol, a nurse, said she suspects that the couple's persistence and propensity to ask questions led her husband to be branded "a difficult case" — the kind of patient whom some doctors avoid. And on top of that, a serious but entirely unrelated disorder further muddied the diagnostic picture.
So on July 17, 2012, when Pace told his wife he thought he was dying, she fired off an emotional plea for help to the office of a prominent specialist in Baltimore. "I looked at Kim and it hit me: He was going to die," she said. "He was losing weight and his color was ashen" and doctors were "blowing him off. I thought, 'Okay, that's it,' and the nurse in me took over."
Her missive got results. Three weeks later Pace underwent corrective surgery for an uncommon problem that causes pain so intense and debilitating it is regarded by doctors as among the worst known.
"I knew the pain was real and I felt like my life was on the line and I just had to prove it to somebody," Pace said.
Pace's symptoms began in early 2012 when he developed an intermittent burning on the left side of his face and down his esophagus. The pain was mild at first but intensified during the day. Because Pace took medication for a host of chronic conditions including Type 2 diabetes, hypothyroidism, high cholesterol and severe depression, doctors at first suspected a drug reaction; Pace had switched antidepressants a few months earlier. Another possibility was acid reflux.
By the end of March he had developed a facial twitch, and the pain was worse, especially when he chewed. "Nothing really relieved it," he said. His family physician in Wilkes-Barre had suggested going off the antidepressant, but his psychiatrist disagreed. His symptoms were not known side effects of the medication, which was working well for Pace after other antidepressants had failed. The drug "turned my life around," said Pace, who was reluctant to stop taking it.
Saturday, February 27, 2016
"Our study indicates that some patients with dry eye have corneal somatosensory pathway dysfunction and would be better described as having neuropathic ocular pain," said Anat Galor, M.D., M.S.P.H., a cornea and uveitis specialist and associate professor of clinical ophthalmology at Bascom Palmer Eye Institute at the University of Miami Miller School of Medicine, and the lead author of the groundbreaking study, "Neuropathic Ocular Pain due to Dry Eye is Associated with Multiple Comorbid Chronic Pain Syndromes," published recently in the American Pain Society's Journal of Pain.
Roy C. Levitt, M.D., a neuroanesthesiologist, pain specialist, and geneticist also at the Miller School, and corresponding author, noted, "A multidisciplinary approach used for chronic pain treatment may also benefit these dry eye patients."
Galor and Levitt are part of a team of Bascom Palmer Eye Institute and UHealth physicians who treat dry eye.
Their research team evaluated 154 dry eye patients from the Miami Veterans Affairs Hospital. "Dry eye patients in our study reported higher levels of ocular and non-ocular pain associated with multiple chronic pain syndromes, and had lower scores on depression and quality-of-life indices consistent with a central sensitivity disorder," said Levitt, a professor and Vice Chair of Translational Research and Academic Affairs in the Department of Anesthesiology, Perioperative Medicine and Pain Management. "We also suspect that neuropathic ocular pain may share causal genetic factors with other overlapping chronic pain conditions."
Thursday, February 25, 2016
Monday, February 01, 2016
Saturday, January 30, 2016
Yearly programs will have a different theme and will bring together 30 trainees with six dynamic, internationally recognized pain investigators from around the world and NAPS permanent faculty for an intensive four-day workshop.
Friday, January 08, 2016
Since the first papers were published on optogenetics in the mid-aughts some researchers have mused about one day using optogenetics in patients, imagining the possibility of an off-switch for depression, for instance.
The technique, however, would require that a patient submit to a set of highly invasive medical procedures: genetic engineering of neurons to insert molecular switches to activate or switch off cells, along with threading of an optical fiber into the brain to flip those switches. Spurred on by a set of technical advances, optogenetics pioneer Karl Deisseroth, together with other Stanford University researchers, has formed a company to pursue optogenetics trials in patients within the next several years—one of several start-ups that are now contemplating clinical trials of the technique.
Circuit Therapeutics, founded in 2010, is moving forward with specific plans to treat neurological diseases. (It also partners with pharmaceutical companies to help them use optogenetics in animal research to develop novel drug targets for human diseases.) Circuit wants to begin clinical trials for optogenetics to treat chronic pain, a therapy that would be less invasive than applications requiring implantation deep inside the brain. Neurons affected by chronic pain are relatively accessible, because they reside in and just outside the spinal cord, an easier target than the brain. Even nerve endings in the skin might be targeted, making them much easier to reach. "In animal models it works incredibly well," says Scott Delp, a neuroscientist at Stanford, who collaborates with Deisseroth. The firm is also working to develop treatments for Parkinson's and other neurological disorders.
Friday, December 25, 2015
But Dr. Ronald Epstein, a University of Rochester professor, wants to change the way doctors approach their patients. Suffering is seen in all corners of hospitals and medical centers — from the emotional pain of a mother who just lost an unborn baby to an older man facing a terminal illness, yet doctors often don't address it.
In a new essay published in the Journal of the American Medical Association, Epstein and a co-author, oncologist Anthony Back of the University of Washington, reviewed medical literature on the ways doctors approach suffering. They found that an approach to suffering is rarely discussed in the medical world, and that this needs to change.
"Physicians can have a pivotal role in addressing suffering if they can expand how they work with patients," the authors wrote. "Some people can do this instinctively, but most physicians need training in how to respond to suffering — yet this kind of instruction is painfully lacking."
Epstein and Back note that physicians can improve their approach by listening to the patient and learning about his/her experience. In addition to the typical "diagnosing and treating," the authors argue that doctors should also "turn toward" the patient, and recognize their suffering. They can do that by asking questions like, "What's the worst part of this for you?" Sometimes an acknowledgment that their pain is real, and that it matters to someone, is all a patient needs to open up.
Monday, December 21, 2015
CDC developed the draft Guideline to provide recommendations about opioid prescribing for primary care providers who are treating adult patients with chronic pain in outpatient settings, outside of active cancer treatment, palliative care, and end-of-life care. The draft Guideline summarizes scientific knowledge about the effectiveness and risks of long-term opioid therapy, and provides recommendations for when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. The draft Guideline identifies important gaps in the literature where further research is needed.
To develop the recommendations, CDC conducted a systematic review on benefits and harms of opioids and developed the draft Guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. CDC drafted recommendations and consulted with experts on the evidence to inform the recommendations. CDC hosted webinars in September 2015 and also provided opportunities for stakeholder and peer review of the draft Guideline. The Guideline is not a federal regulation; adherence to the Guideline will be voluntary. For additional information on prescription drug overdose, please visit http://www.cdc.gov/drugoverdose/prescribing/guideline.html.
Supporting and Related Material in the Docket
The docket contains the following supporting and related materials to help inform public comment: The Guideline; the Clinical Evidence Review Appendix; the Contextual Evidence Review Appendix; and three documents that comprise the Comment Summaries and CDC Responses (Constituent Comment Summary, Peer Review Summary, and Stakeholder Review Group Summary). The Clinical Evidence Review Appendix and the Contextual Evidence Review Appendix include primary evidence, studies, and data tables that were used by CDC to develop the recommendations in the Guideline. The Constituent Comment Summary reflects input obtained in response to webinars hosted on September 16 and September 17, 2015, during which CDC shared an overview of the development process and draft recommendation statements. The Stakeholder Review Group Summary also reflects input obtained from stakeholders (comprised of professional and community organizations) following their review of a prior draft of the Guideline. Finally, the Peer Review Summary reflects input obtained from three scientific peer reviewers following their review of a draft of the full Guideline, along with a summary of comments received and CDC responses.
Sunday, December 13, 2015
Lately, it seems I can't attend a gathering of friends without at least one complaining about headaches, and another offering advice: It's your glasses, your diet or, the old standby, your stress level. Regarding the latter, let me say that a friend and I once spent four days at a spa, doing nothing but exercise classes and beauty treatments, and we were still popping pills for our pounding heads nonstop.
Over the last few decades, migraines (intensely painful headaches that make it difficult to function and are often accompanied by other symptoms like vomiting) have become big business. Billions of dollars are spent annually on over-the-counter and prescription remedies, as well as visits to the increasing number of specialized clinics and hospital departments around the country. Even dermatologists, dentists and non-Western holistic practitioners are getting in on the action.
Friday, December 04, 2015
The breakthrough may lead to powerful new ways to treat painful conditions such as arthritis.
Only a handful people around the world are born unable to feel pain. These individuals can often suffer a range of injuries when they are young. Babies with the condition tend to chew their fingers, toes and lips until they bleed, and toddlers can suffer an increased range of knocks, tumbles and encounters with sharp or hot objects.
The disorder is caused by a rare genetic mutation that results in a lack of ion channels that transport sodium across sensory nerves. Without these channels, known as Nav1.7 channels, nerve cells are unable to communicate pain. Researchers quickly sought to make compounds that blocked Nav1.7 channels, thinking they might be able to block pain in people without the disorder.
"It looked like a fantastic drug target," says John Wood at University College London. "Pharma companies went bananas and made lots of drugs." But while a few compounds saw some success, none brought about the total pain loss seen in people who lack the channel naturally.
To find out why, Wood and his colleagues studied mice that had been genetically modified to lack Nav1.7. These animals don't feel pain, either – they show no reaction when their tails are exposed to extreme hot or cold temperatures, for example.
A closer analysis of the rodents' nerves showed that mice lacking Nav1.7 had a huge increase in the expression of genes responsible for opioid peptides, the body's natural painkiller. The mice seem to be making more of these pain-relieving peptides, which might explain why people lacking the channel don't feel pain, either.
Sunday, November 29, 2015
The end of migraines is close: A new drug could stop debilitating headaches before they start - Salon.com
The co-author of the Declaration of Independence never vanquished what he called his "periodical head-ach," although his attacks appear to have lessened after 1808. Two centuries later 36 million American migraine sufferers grapple with the pain the president felt. Like Jefferson, who often treated himself with a concoction brewed from tree bark that contained quinine, they try different therapies, ranging from heart drugs to yoga to herbal remedies. Their quest goes on because modern medicine, repeatedly baffled in attempts to find the cause of migraine, has struggled to provide reliable relief.
Now a new chapter in the long and often curious history of migraine is being written. Neurologists believe they have identified a hypersensitive nerve system that triggers the pain and are in the final stages of testing medicines that soothe its overly active cells. These are the first ever drugs specifically designed to prevent the crippling headaches before they start, and they could be approved by the U.S. Food and Drug Administration next year. If they deliver on the promise they have shown in studies conducted so far, which have involved around 1,300 patients, millions of headaches may never happen.
"It completely changes the paradigm of how we treat migraine," says David Dodick, a neurologist at the Mayo Clinic's campus in Arizona and president of the International Headache Society. Whereas there are migraine-specific drugs that do a good job stopping attacks after they start, the holy grail for both patients and doctors has been prevention.
Tuesday, November 17, 2015
Millions of people are dying in pain because of the repressive stance the world has taken on drugs. That's because states are obsessed by the fear that people will use controlled medicines such as morphine as recreational drugs, thereby neglecting their important medical uses.
Where you live determines whether you will be able to access to controlled medicines, particularly opiates, when confronting an acute terminal, chronic or painful illness. Ninety-two per cent of the world's morphine is consumed by only 17% of the world's population, primarily the United States and Europe. Seventy--five percent of the world's people in need do not have access to pain relieving medicine.
In other words, most of the global population, outside the affluent countries in the North, dying in pain, including from terminal cancers, do so in the absence of dignified palliative care.
This is a horrendous situation for millions of patients and families. Essential medicines such as morphine, taken for granted as the standard relief of severe pain in the global North, do not enjoy the same status in the global South. Quite the opposite. Chances are, if a person living in any developing country ends up with an illness associated with extreme and avoidable pain, they will endure the pain simply because their government has created obstacles to morphine use in hospitals.
Wednesday, November 11, 2015
The federal agency has been asked to come here and help find answers to a disturbing new trend that is costing lives – heroin mixed with a prescription pain medication.
State and local health experts said they are hoping what they learn during meetings Tuesday at the Hamilton County Board of Health will help them tackle the heroin crisis.
The CDC has a six-person team on the ground in Ohio, meeting with the Ohio Department of Health, and the Hamilton County Health Department.
Officials said they're focusing on a particular part of the heroin crisis – the number of deaths related to fentanyl.
Authorities said fentanyl is a prescription pain medication that has been showing up in heroin. The big mystery is why it's being mixed with heroin.
"We don't fully understand the fentanyl situation, and that's one of the reasons we wanted their help with this," said Dr. Mary DiOrio, the medical director of the Ohio Department of Health.
ODH asked the CDC to help look into the problem.
"We think that some people don't even know that it's in what they're injecting so we're trying to fully understand what people do and don't know so we can target the messages appropriately so we can protect lives," DiOrio said.
We've seen the deadly consequences of fentanyl in Greater Cincinnati.
Kenneth Gentry is facing charges in the overdose death of an Arlington Heights man earlier this year that was blamed on fentanyl.
Authorities said the fentanyl problem causes only a fraction of the deaths heroin alone causes – but it's a problem that's growing quickly.
Authorities said heroin deaths increased 18 percent in Ohio last year to a total of nearly 2,500. In 2014 there were about 500 deaths linked to fentanyl – an increase of nearly 600 percent from the year before.
So what is killing middle-aged white Americans? Much of the excess death is attributable to suicide and drug and alcohol poisonings. Opioid painkillers like OxyContin prescribed by physicians contribute significantly to these drug overdoses.
Thus, it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality. The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.
Monday, November 09, 2015
"The pain is right here," she told an orthopedic surgeon, "in my ankle and foot." But the 41-year-old Gainesville, Va., resident no longer had that ankle and foot. Her leg had been amputated below the knee after a large piece of computer equipment fell off a cart, crushed her foot and caused nerve damage. Further, she insisted that since the amputation, she could feel her missing toes move.
Chenoweth's surgeon knew exactly what was going on: phantom pain.
Lynn Webster, an anesthesiologist and past president of the American Academy of Pain Medicine, explains the phenomenon: "With 'phantom pain,' nerves that transmitted information from the brain to the now-missing body part continue to send impulses, which relay the message of pain."
It feels as if the removed part is still there and hurting, but pain is actually in the brain. The sensation ranges from annoying itching to red-hot burning.
Physicians wrote about phantom pain as early as the 1860s, but U.S. research on this condition has increased recently, spurred by the surge of amputees returning from warfare in Iraq and Afghanistan and by increasing rates of diabetes. (Since 2003, nearly 1,650 service members have lost limbs, according to the Congressional Research Service. In 2010, about 73,000 amputations were performed on diabetics in the United States, according to the Centers for Disease Control and Prevention.)
Saturday, November 07, 2015
SRUTHI: Okay. So this is a story about a woman whose body started breaking down in increasingly weird ways. It's as if her body turns into a David Lynch movie, and there's nothing she can do to understand it, and nothing she can do to convince people it's real. For the purposes of the story, we will call this woman "Hope." And it all starts last year. Hope is 29, living in the suburbs of Pittsburgh. And one beautiful winter morning…
HOPE: I was walking at a soccer field that's near my house when I first noticed, "Well that feels weird, my eye feels such a weird nagging eye pressure. Almost like my eye was bulging a little bit, from the inside out.
SRUTHI: It's so bad that she feels as if people can see it, like it's bulging so much, this one eye.
PJ: Can she, like if she stands in front of the bathroom mirror and stares at her face, can she feel like she can see her eye bulging?
SRUTHI: No. So it goes on for a couple of weeks, doesn't go away. And then she says you know what, I'm just gonna have this looked at.
HOPE: I actually just went to the eye doctor that's in Walmart, and she looked at my eye, and she didn't find anything at all wrong with the eye. The eye was perfectly healthy and normal.
SRUTHI: This bulging feeling, it goes on for a whole month. And then one day, she wakes up and it's gone.
HOPE: This would, be I should say this, this would be something in my life that I would probably never give a second thought to, this mild eye problem that I had for a month, if… what happened next hadn't happened.
SRUTHI: It's evening. Hope is working. She's a wedding photographer, and she's setting up room in her house where she can meet clients.
HOPE: And all of the sudden I stood up, and I couldn't see out of my right eye. I thought, "Oh my gosh, am I having a stroke?" I had field of vision in like three-quarters of the eye, but the one quarter was completely covered by this weird zigzag freaky thing. It's almost like a kaleidoscope when you were a kid, and you used to hold up a kaleidoscope to your eye and it would… it would like shine and shimmer, like a piece of mirrored paper in there. So I actually remember waking up my sister, and she said "what are you talking about?" and I said "I can't see out of my eye, I'm freaking out."
Saturday, October 31, 2015
At first, this man thought he had food poisoning. It turned out to be something far worse. - The Washington Post
But Sank's problem wasn't in his head — it was in his gut. And when he felt the initial abdominal pangs, he knew that he had about 12 hours before he was miserable, or at worst incapacitated, for the next day or two.
"It almost felt like I'd done 1,000 sit-ups or been punched in the gut 100 times," said the digital media specialist, 43, who lives in the District. At first the attacks were intermittent. But after several months the pain, centered in the right upper quadrant where the liver and gallbladder are located, increased in severity and frequency.
For nearly a year, Sank, with the help of his stepmother, a physician, struggled to determine the reason for his pain. He saw multiple doctors, including two gastroenterologists, a kidney specialist and an infectious-disease physician. He underwent workups for reflux disease, a liver disorder, an intestinal blockage and malaria. One doctor suspected he might be faking.
Sank's problem turned out to be none of those things. His diagnosis was partly the result of serendipity: The second gastroenterologist he consulted was familiar with the malady, which is common in other parts of the world but not the United States. To complicate matters, Sank's case did not fit the standard diagnostic criteria.
"It's in the differential [a list of possible disorders suggested by symptoms], but since we never really see it, you don't necessarily think of it," said Montgomery County gastroenterologist William Steinberg. Luckily, something Steinberg had seen two decades earlier on a medical trip to the Middle East resonated when an increasingly desperate Sank consulted him in April 2010.
The first time he suffered stomach pain in June 2009, Sank assumed he had food poisoning. "I really didn't think much about it," he recalled.
When it kept recurring, he consulted his stepmother, Catherine Shaer, a retired pediatrician, for advice. Sank was otherwise healthy, and Shaer agreed that he should see a gastroenterologist.
At his initial appointment in October 2009, the gastroenterologist told Sank he suspected his pain was the result of gallstonesand ordered a sonogram.
The test was memorable: Sank said that during the procedure the technician began acting strangely and then summoned a radiologist. In a somber voice, Sank recalled, the radiologist "told me that there was a huge lesion on my liver and they were going to send me immediately for a CT scan."
The radiologist then told him, Sank recalled, "there was something very serious going on here and that I needed to prepare myself and my family for what I had to deal with." Sank also remembers the specialist saying that his "door was always open."
"I thought I had liver cancer and was going to die," Sank remembered. At the time, his first child was only a few months old.
While waiting for the CT scan, Sank telephoned his stepmother and a friend who is an oncologist. Both told him that they were sure that the growth on his liver, the size of a large strawberry, would turn out to be a benign hemangioma. He had no cancer symptoms, and such tumors are common. A few hours later, Sank, hugely relieved, learned they were right. He didn't have cancer. Nor did he have gallstones. "We were back to square one," he recalled.
Thursday, October 22, 2015
IPRP Ontology | Interagency Pain Research Portfolio -The Federal Government's Pain Research Database
The Patient Protection and Affordable Care Act (PPACA) includes a number of provisions designed to advance pain research, care, and education, including the creation of the Interagency Pain Research Coordinating Committee (IPRCC) by the Department of Health and Human Services (HHS). On behalf of HHS, the NIH established the IPRCC to coordinate all pain research efforts within HHS and across other Federal Agencies. The Committee is composed of seven Federal members and twelve non-Federal members, six drawn from the scientific and medical communities and six members of the public and stakeholder groups. The Department of Health and Human Services Secretary will review the necessity of the Committee at least once every 2 years.
As specified in Section 4305(b) of the Public Law 111-148 ("Affordable Care Act (ACA)") the Committee has been asked to:
- Develop a summary of advances in pain care research supported or conducted by the Federal agencies relevant to the diagnosis, prevention, and treatment of pain and diseases and disorders associated with pain
- Identify critical gaps in basic and clinical research on the symptoms and causes of pain
- Make recommendations to ensure that the activities of the National Institutes of Health and other Federal agencies are free of unnecessary duplication of effort
- Make recommendations on how best to disseminate information on pain care
- Make recommendations on how to expand partnerships between public entities and private entities to expand collaborative, cross-cutting research
Sunday, October 18, 2015
I rushed into the bedroom and watched my wife, Rachel, stumble from the bathroom, doubled over, hugging herself in pain.
"Something's wrong," she gasped.
This scared me. Rachel's not the type to sound the alarm over every pinch or twinge. She cut her finger badly once, when we lived in Iowa City, and joked all the way to Mercy Hospital as the rag wrapped around the wound reddened with her blood. Once, hobbled by a training injury in the days before a marathon, she limped across the finish line anyway.
So when I saw Rachel collapse on our bed, her hands grasping and ungrasping like an infant's, I called the ambulance. I gave the dispatcher our address, then helped my wife to the bathroom to vomit.
I don't know how long it took for the ambulance to reach us that Wednesday morning. Pain and panic have a way of distorting time, ballooning it, then compressing it again. But when we heard the sirens wailing somewhere far away, my whole body flooded with relief.
I didn't know our wait was just beginning.
I buzzed the EMTs into our apartment. We answered their questions: When did the pain start? That morning. Where was it on a scale of one to 10, with 10 being worst?
"Eleven," Rachel croaked.
As we loaded into the ambulance, here's what we didn't know: Rachel had an ovarian cyst, a fairly common thing. But it had grown, undetected, until it was so large that it finally weighed her ovary down, twisting the fallopian tube like you'd wring out a sponge. This is called ovarian torsion, and it creates the kind of organ-failure pain few people experience and live to tell about.
"Ovarian torsion represents a true surgical emergency," says an article in the medical journal Case Reports in Emergency Medicine. "High clinical suspicion is important. … Ramifications include ovarian loss, intra-abdominal infection, sepsis, and even death." The best chance of salvaging a torsed ovary is surgery within eight hours of when the pain starts.
There is nothing like witnessing a loved one in deadly agony. Your muscles swell with the blood they need to fight or run. I felt like I could bend iron, tear nylon, through the 10-minute ambulance ride and as we entered the windowless basement hallways of the hospital.
And there we stopped. The intake line was long—a row of cots stretched down the darkened hall. Someone wheeled a gurney out for Rachel. Shaking, she got herself between the sheets, lay down, and officially became a patient.