Tuesday, May 26, 2015
Friday, May 22, 2015
Now hundreds of former players are bringing the issue to court after they filed a lawsuit claiming all 32 NFL teams, their doctors, trainers and medical staffs often illegally obtained and provided painkillers to players.
The lawsuit reprises some of the allegations made in a federal lawsuit last year on behalf of 1,300 former players against the NFL. That complaint was filed in May, 2014 and dismissed in December by Judge William Alsup of the U.S. Northern District in California. Alsup wrote that the collective bargaining agreement between the league and the NFL Players Association was the appropriate forum to resolve such claims. That decision is being appealed.
The new lawsuit was filed Thursday in the U.S. Northern District of Maryland. It names each NFL team individually as a defendant and lists 13 plaintiffs, including Hall of Fame cornerback Mel Renfro of the Dallas Cowboys and Etopia Evans, the widow of Charles Evans, a running back who played eight years with the Minnesota Vikings and the Baltimore Ravens and retired after the 2000 season. Evans died of heart failure in October 2008 at age 41.
"This lawsuit alleges intentional activity by the teams, not negligence," said plaintiffs' attorney Steve Silverman. "It's another part of a unified effort to provide health care and compensation to the thousands of former players who have been permanently injured or died as a result of playing professional football."
Both lawsuits contend NFL teams and their medical staffs withheld information from players about the nature and seriousness of their injuries, while at the same time handing out prescription painkillers, anti-inflammatories and other dangerous drugs to mask pain and minimize lost playing time. Among other claims, the players contend prescriptions were filled out in their names without their knowledge.
The new lawsuit also claims that several former head coaches and assistants — among them, Don Shula, Howard Schnellenberger, Wayne Fontes, Mike Holmgren and Mike Tice — warned players they would be cut from their teams unless they took painkillers and returned to the field.
Tuesday, May 19, 2015
Solicitation of Public Comments on Draft National Pain Strategy - The Interagency Pain Research Coordinating Committee (IPRC)
- Describe how efforts across government agencies, including public–private partnerships, can be established, coordinated, and integrated to encourage population-focused research, education, communication, and community-wide approaches that can help reduce pain and its consequences and remediate disparities in the experience of pain among subgroups of Americans.
- Include an agenda for developing physiological, clinical, behavioral, psychological, outcomes, and health services research and appropriate links across these domains.
- Improve pain assessment and management programs within the service delivery and financing programs of the federal government.
- Proceed in cooperation with the Interagency Pain Research Coordinating Committee and the National Institutes of Health's Pain Consortium and reach out to private-sector participants as appropriate.
- Involve the appropriate agencies and entities.
- Include ongoing efforts to enhance public awareness about the nature of chronic pain and the role of self-care in its management.
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain (draft)
Monday, April 27, 2015
Monday, March 02, 2015
The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention WorkshopEffectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain | Annals of Internal Medicine
Friday, February 27, 2015
To test this notion, Daniel Harvie at the University of South Australia and his colleagues put chronic neck pain sufferers through a series of twists and turns, first with no equipment and then fitted with Oculus Rift headsets. The headsets were programmed to show indoor and outdoor scenes, and they used gyroscopes to monitor the wearer's head movements. The patients were then told to turn their heads left or right until they felt pain.
When patients turned their heads just a bit, they sometimes perceived that they were moving much further, or vice versa. If participants moved their heads within a normally non-painful range, they experienced pain when the headset's visuals made them think they'd performed a much greater rotation. Similarly, the volunteers often experienced no pain when the headsets made it appear to them that they'd performed smaller, normally pain-free turns—even if they moved into a normally painful pose. The results suggest that chronic sufferers create an association between movement and pain, so that the mere visual suggestion of motion its own signal of danger to the body.
"It is important to recognize here what pain actually is," Harvie says. "Pain is not a linear result of messages from the body. Rather, pain is one of the brain's protective responses, produced when, after evaluating all of the evidence, it decides that body tissue is in danger and that we need warning. In this case, because of the association between pain and movement, learned through past experience, visual signals of movement themselves have become signals of threat to the body and therefore, triggers of pain."
Virtual reality has been used previously for other types of pain research. In 2014 Swedish scientists detailed in the journal Frontiers in Neuroscience how virtual reality helped phantom limb pain, which plagues some 70 percent of amputees. Muscle signals from a patient's stump were recorded by electrodes and processed by a software program that enabled each patient to control a virtual limb just by thinking about it. The treatment caused a reduction in phantom pain, perhaps because the illusion tricked the brain into thinking that the missing limb was again part of the body.
Harvie sees similar potential for developing future pain treatments based on his team's research, such as training the brain to target the cues it interprets as danger signals.
"Movement is a common example of something that is often associated with pain when we have an injury, and might therefore become a 'learned' signal of danger and trigger of pain, even after injury healing," he says. "If we can teach the brain anew that movement and other learned triggers are actually safe, then their ability to contribute to pain will be extinguished."
Saturday, February 21, 2015
That's because our perception of pain is shaped by brain circuits that are constantly filtering the information coming from our sensory nerves, says David Linden, a professor of neuroscience at Johns Hopkins University and author of the new book Touch: The Science of Hand, Heart, and Mind.
"The brain can say, 'Hey that's interesting. Turn up the volume on this pain information that's coming in,' " Linden says. "Or it can say, 'Oh no — let's turn down the volume on that and pay less attention to it.' "
This ability to modulate pain explains the experiences of people like Dwayne Turner, an Army combat medic in Iraq who received the Silver Star for valor.
In 2003, Turner was unloading supplies when his unit came under attack. He was wounded by a grenade. "He took shrapnel in his leg, in his side — and he didn't even notice that he had been hit," Linden says.
Despite his injuries, Turner began giving first aid and pulled other soldiers to safety. As he worked, he was shot twice — one bullet breaking a bone in his arm. Yet Turner would say later that he felt almost no pain.
"Soldiers in the heat of the moment don't recognize the pain that's happening," Linden says. But once that moment is over, those same soldiers may feel a lot of pain from something minor, like a hypodermic needle, he says.
The brain also determines the emotion we attach to each painful experience, Linden says. That's possible, he explains, because the brain uses two different systems to process pain information coming from our nerve endings.
One system determines the pain's location, intensity and characteristics: stabbing, aching, burning, etc.
"And then," Linden says, "there is a completely separate system for the emotional aspect of pain — the part that makes us go, 'Ow! This is terrible.' "
Friday, February 06, 2015
Chronic pain is at epidemic levels and has become the highest-cost condition in health care. This course uses evidence-based science with creative and experiential learning to better understand chronic pain conditions and how they can be prevented through self-management in our cognitive, behavioral, physical, emotional, spiritual, social, and environmental realms.
Chronic musculoskeletal pain (including head, neck, and back pain) is a significant cause of suffering, disability, and health care in the world. Care for chronic pain often involves surgery, multiple medications (including opioids), endless physical and chiropractic therapy, injections, implanted devices, and other passive treatments-- making it the highest cost condition in health care. The burden upon individuals in terms of ongoing pain and suffering is incalculable.
Consider an alternative. By using a human systems approach, we can better understand how individual risk factors in the cognitive, behavioral, physical, emotional, spiritual, social, and environmental realms of our lives can interact to perpetuate chronic pain and, if improved, can prevent it.
During this course, you will: Identify the problems of our health care system in dealing with chronic pain. Review the diagnosis, mechanisms, and etiology of chronic pain conditions. Explore specific risk factors that can contribute to chronic pain. Learn how a human systems approach can be applied through evidence-based self-management strategies to prevent chronic pain. Experience active strategies designed to enhance the protective factors that can transform our own lives, and those of our patients, to one of health and wellness.
This course was first offered in spring of 2014. The course evaluations were carefully reviewed and the course was modified to improve its quality. Overall, 91% of participants believed the overall experience was satisfying, 92% believed it met the objectives, 93% believed that it made a difference in their life, and 85% believed that it made a difference in the care of patients.
Saturday, January 17, 2015
In September, the NIH held a workshop to review chronic pain treatment with a panel of seven experts and more than 20 speakers. The NIH also reviewed relevant research on how pain should be treated.
Panel cites need for individualized, patient-centered approach to treat and monitor chronic pain - NIH
An independent panel convened by the National Institutes of Health concluded that individualized, patient-centered care is needed to treat and monitor the estimated 100 million Americans living with chronic pain. To achieve this aim, the panel recommends more research and development around the evidence-based, multidisciplinary approaches needed to balance patient perspectives, desired outcomes, and safety.
"Persons living with chronic pain have often been grouped into a single category, and treatment approaches have been generalized with little evidence to support this practice," said Dr. David B. Reuben, panel chair and professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles. "Chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, multifaceted approach."
Chronic pain is often treated with prescription opioids, but the panel noted widespread concern with this practice. Although some patients benefit from such treatment, there are no long-term studies on the effectiveness of opioids related to pain, function, or quality of life. There is not enough research on the long-term safety of opioid use. However, there are well-documented potential adverse outcomes, including substantial side effects (e.g., nausea, mental clouding, respiratory depression), physical dependence, and overdose—with approximately 17,000 opioid-related overdose deaths reported in 2011.
"Clearly, there are patients for whom opioids are the best treatment for their chronic pain. However, for others, there are likely to be more effective approaches," stated Dr. Reuben. "The challenge is to identify the conditions for which opioid use is most appropriate, the alternatives for those who are unlikely to benefit from opioids, and the best approach to ensuring that every patient's individual needs are met by a patient-centered health care system."
The panel identified several barriers to implementing evidence-based, patient-centered care. For example, many clinicians do not have tools to assess patient measures of pain, quality of life, and adverse outcomes. Primary care practices often do not have access to multidisciplinary experts, such as pain management specialists. Insurance plans may not cover team-based, integrative approaches that promote comprehensive, holistic care. In addition, some plans do not offer effective non-opioid drugs as first-line treatment for chronic pain, thus limiting a clinician's ability to explore other avenues of treatment. Once a health provider has made the decision to use opioids, there are insufficient data on drug characteristics, dosing strategies, or tapering to effectively guide clinical care.
"We have inadequate knowledge about treating various types of pain and how to balance effectiveness with potential harms. We also have a dysfunctional health care delivery system that promotes the easiest rather than the best approach to addressing pain," noted Dr. Reuben.
To address knowledge gaps, the panel cited a need for more research on pain, multidisciplinary pain interventions, the long-term effectiveness and safety of opioids, as well as optimal opioid management and risk mitigation strategies. However, because well-designed longitudinal studies can be large, expensive, and difficult for recruitment, the panel encouraged the development of new research design and analytic methods to answer important research and clinical questions.
The panel also recommended engaging electronic health record vendors and health systems to provide pain management decision support tools for clinicians. In addition, the panel advised the NIH and other federal agencies to sponsor more conferences to harmonize pain assessment and treatment guidelines to facilitate consistent clinical care for the treatment of chronic pain.
The panel will hold a press telebriefing on Friday, Jan. 16, at 3 p.m. EST to discuss its findings with members of the media. To participate, call 888-428-7458 (toll free for United States and Canada) or 862-255-5398 (toll for other international callers) and reference the NIH Pathways to Prevention program on The Role of Opioids in the Treatment of Chronic Pain. Audio playback will be available shortly after the conclusion of the telebriefing and can be accessed by calling 888-640-7743 (United States and Canada) or 754-333-7735 (other international callers) and entering replay code 114001.
To better understand the role of opioids in the treatment of chronic pain, the NIH Office of Disease Prevention (ODP) convened a Pathways to Prevention workshop on Sept. 29–30, 2014, to assess the available scientific evidence. The panel's final report, which identifies future research and clinical priorities, incorporates the panel's assessment of an evidence report, expert presentations, audience input, and public comments. The panel's report, which is an independent report and not a policy statement of the NIH or the federal government, is now available at https://prevention.nih.gov/programs-events/pathways-to-prevention/workshops/opioids-chronic-pain/workshop-resources.
Friday, January 16, 2015
"Glia appears to be involved in the pathophysiology of chronic pain, and therefore we should consider developing therapeutic approaches targeting glia," Dr. Marco L. Loggia from Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, told Reuters Health by email.
"Glial activation is accompanied by many cellular responses, which include the production and release of substances (such as so-called 'pro-inflammatory cytokines') that can sensitize the pain pathways in the central nervous system," he explained. "Thus, glial activation is not a mere reaction to a pain state but actively contributes to the establishment and/or maintenance of persistent pain."
To test their hypothesis that patients with chronic pain demonstrate in vivo activation of brain glia, Dr. Loggia's team imaged the brains of 19 individuals diagnosed with chronic low back pain as well as 25 pain-free healthy volunteers using 11C-PBR28, a PET radioligand that binds to the translocator protein (TSPO), a protein upregulated in activated microglia and reactive astrocytes in animal models of pain.
In the thalamic region of interest, 11C-PBR28 uptake was significantly higher in patients with chronic low back pain than in healthy controls (p<0.01 left thalamus, p<0.05 right thalamus), according to the January 12 Brain online report.
Each patient exhibited higher 11C-PBR28 uptakes than his/her age-, sex-, and TSPO genotype-matched control in the thalamus, and there were no brain regions for which the healthy controls showed statistically higher uptakes than the patients with chronic low back pain.
11C-PBR28 uptakes, and presumably TSPO levels, were negatively associated with pain measures and with circulating levels of proinflammatory cytokines in the chronic pain patients.
"It's important to stress that although TSPO upregulation is a marker of glial activation and therefore of a pro-inflammatory state, animal studies suggest that its role is actually to limit the magnitude of glial responses after their initiation, thereby promoting the return to pre-injury pain-free status and recovery from pain," Dr. Loggia explained. "This means that what we are imaging may be the process of glial cells trying to 'calm down' after being activated by the pain. Thus, subjects with low levels of pain-related TSPO upregulation on activated glia may be less able to adequately inhibit neuroinflammatory responses, and have a more exaggerated response that ultimately leads to more inflammation and pain."
A fifth of the world's population is thought to experience some kind of chronic pain – that which has lasted longer than three months. If the pain has no clear cause, people can find themselves fobbed off by doctors who they feel don't believe them, or given ineffective or addictive painkillers.
But a study led by Tor Wager at the University of Colorado, Boulder, now reveals that there are two patterns of brain activity related to pain. One day, brain scans could be used to work out your relative components of each, helping to guide treatment.
"Pain has always been a bit of a puzzle," says Ben Seymour, a neuroscientist at the University of Cambridge. Hearing or vision, for example, can be traced from sensory organs to distinct brain regions, but pain is more complex, and incorporates thoughts and emotions. For example, studies have linked depression and anxiety to the development of pain conditions, and volunteers put in bad moods have a lower tolerance for pain.
So does this mean we can think our way into or out of pain? To find out, Wager and his colleagues used fMRI to look at the brain activity of 33 healthy adults while they were feeling pain. First, the team watched the changing activity as they applied increasing heat to the volunteers' arms. As the heat became painful, a range of brain structures lit up. The pattern was common to all the volunteers, so Wager's team called it the neurologic pain signature.
The group then examined whether the volunteers could control the pain by thought alone. "We asked them to rethink their pain, either as a blistering heat, or as a warm blanket on a cool day," Wager says. Although the volunteers couldn't change the level of activity in the neurologic pain signature, they could alter the amount of pain they felt. As they did this, a distinct set of brain structures linking the nucleus accumbens and ventromedial prefrontal cortex became active (PLoS Biology, doi.org/x55).
"It's a major finding," says Vania Apkarian at Northwestern University in Chicago. "For the first time, we've established the possibility of modulating pain through two different pathways."
Wednesday, January 14, 2015
Several recent studies have found intriguing links between gut microbes, rheumatoid arthritis, and other diseases in which the body's immune system goes awry and attacks its own tissue.
A study published in 2013 by Jose Scher, a rheumatologist at New York University, found that people with rheumatoid arthritis were much more likely to have a bug called Prevotella copri in their intestines than people that did not have the disease. In another study published in October, Scher found that patients with psoriatic arthritis, another kind of autoimmune joint disease, had significantly lower levels of other types of intestinal bacteria.
Saturday, January 03, 2015
Complex regional pain syndrome (CRPS) is a chronic, predominantly neuropathic and partly musculoskeletal pain disorder often associated with autonomic disturbances. It is divided into 2 types, reflecting the absence or presence of a nerve injury.
Patients with either type may exhibit symptoms such as burning pain, hyperalgesia, and/or allodynia with an element of musculoskeletal pain. CRPS can be distinguished from other types of neuropathic pain by the presence of regional spread as opposed to a pattern more consistent with neuralgia or peripheral neuropathy. Autonomic dysfunction (such as altered sweating, changes in skin color, or changes in skin temperature); trophic changes to the skin, hair, and nails; and altered motor function (such as weakness, muscle atrophy, decreased range of motion, paralysis, tremor, or spasticity) also can be present.
At least 50,000 new cases of CRPS are diagnosed in the United States annually.1 Although the incidence rate is subject to debate, a large epidemiologic study from The Netherlands involving 600,000 patients suggests an incidence of 26.2 per 100,000 individuals. The study also found that women are 3 times more likely to be affected, with postmenopausal women having the greatest risk.
Saturday, December 27, 2014
Tuesday, December 23, 2014
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.
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Several organizations, such as Global Access to Pain Relief Initiative, Hospice Without Borders and Human Rights Watch, are devoted to easing the global crisis of untreated cancer pain, but it is a Sisyphean undertaking for a handful of cash-strapped nongovernmental organizations. Still, by partnering with international organizations and developing innovative delivery systems, certain resource-challenged areas in the developing world have made progress.
The sparsely populated, war-ravaged country of Uganda has made strides in providing morphine to its cancer patients, thanks to the determination of public health advocates like Dr. Jack Jagwe, a former adviser to the Ugandan Health Ministry. In the 1990s, Dr. Jagwe and others partnered with foreign doctors and members of the international community to write into the health code that every Ugandan citizen had the right to palliative care, which was a first in Africa.
Thanks in part to this initiative, Uganda amended its rigid narcotics laws, allowing nurses to prescribe morphine to cancer patients without having a doctor present, which proves essential in delivering morphine to patients in rural areas who are unable to trek long distances to city clinics.
That regulatory easing has opened the door for a nongovernmental entity, Hospice Africa Uganda, to produce its own morphine. This process not only frees Hospice Africa Uganda from dealing with international suppliers; it makes the market more efficient by allowing it to manufacture morphine on demand — indeed, per-patient pain-control costs are now estimated to be about $1 per week. That experience, though still a work in progress, should be a model for other resource-challenged countries.
As with all successful human rights movements, we need to put a face on the injustice of untreated cancer pain. Witnessing a clinic full of poor children with advanced cancer, crying in agony, should convince anyone that access to morphine is a human right.