Saturday, August 20, 2016

In Search Of An Opioid That Offers Help Without The Risks : Shots - Health News : NPR

Once people realized that opioid drugs could cause addiction and deadly overdoses, they tried to use newer forms of opioids to treat the addiction to its parent. Morphine, about 10 times the strength of opium, was used to curb opium cravings in the early 19th century. Codeine, too, was touted as a nonaddictive drug for pain relief, as was heroin.

Those attempts were doomed to failure because all opioid drugs interact with the brain in the same way. They dock to a specific neural receptor, the mu-opioid receptor, which controls the effects of pleasure, pain relief and need.

Now scientists are trying to create opioid painkillers that give relief from pain without triggering the euphoria, dependence and life-threatening respiratory suppression that causes deadly overdoses.

That wasn't thought possible until 2000, when a scientist named Laura Bohn found out something about a protein called beta-arrestin, which sticks to the opioid receptor when something like morphine activates it. When she gave morphine to mice that couldn't make beta-arrestin, they were still numb to pain, but a lot of the negative side effects of the drug were missing. They didn't build tolerance to the drug. At certain dosages, they had less withdrawal. Their breathing was more regular, and they weren't as constipated as normal mice on morphine.

Before that experiment, scientists thought the mu-opioid receptor was a simple switch that flicked all the effects of opioids on or off together. Now it seems they could be untied. "The hope is you'd have another molecule that looks like morphine and binds to the same receptor, but the way it turns the receptor on is slightly different," says Dr. Aashish Manglik, a researcher at Stanford University School of Medicine who studies opioid receptors.

After Bohn's discovery, a number of people, including a team that includes Manglik, started looking for a drug that could connect to the mu-opioid receptor in a way that avoids the negative effects of beta-arrestin.

To do that, they mapped the receptor's structure in a computer program and started looking for chemicals that would stick to it. "We tried to look for molecules that would still bind to this 3-D structure, but are as far away from morphine and codeine as possible," Manglik says.

The team ran 3 million possibilities through the computer and picked the 23 best candidates to test in a lab. One chemical, PZM21, seems to do what they hoped: Turn the opioid receptor on without using much beta-arrestin. They report their findings in Nature on Wednesday.

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http://www.npr.org/sections/health-shots/2016/08/17/490380937/scientists-engineer-an-opioid-that-may-reduce-pain-with-less-risk?

The Connoisseur of Pain - The New York Times

Within minutes of our first meeting, and more or less in response to my saying good morning, Justin Schmidt began lamenting our culture's lack of insect-based rites of passage. He told me about the Sateré-Mawé people in northwestern Brazil, who hold a ceremony in which young men slip their hands into large mitts filled with bullet ants, whose stings are so agonizing they can cause temporary paralysis; when initiates pass the test, they're one step closer to becoming full members of society.

Schmidt believes we could learn something from this. By trade, he is an entomologist, an expert on the Hymenoptera order — wasps, bees and ants — but his interest in this insect ritual was not merely academic. He has two teenage boys, and, on this particular morning at least, I found him wondering whether they might benefit from a pain ritual to help introduce them to adulthood.

"I mean, it wouldn't kill them," Schmidt said. "And I think that may be the key to the whole thing: It can't kill you and yet something very real is happening."

It was a bit before 7:30 on a windy weekday morning in Tucson, and Schmidt had just dropped off his 14-year-old at school. At 69, Schmidt has a head of red hair that stubbornly refuses to go gray and a boyish face that glints of mischief. We were driving in his 1999 Toyota Corolla down a road that may have been a desert highway or a city thoroughfare: My East Coast eyes couldn't tell the difference. We pulled up to a traffic light, next to a giant saguaro cactus whose short, upturned arm gave it the look of a crossing guard gesturing us to stop.

Schmidt's new book, "The Sting of the Wild: The Story of the Man Who Got Stung for Science," weaves his theories about stinging insects through a narrative of his personal experiences digging in the dirt. For many readers, the highlight of the book will be the appendix, his celebrated Pain Scale for Stinging Insects, which rates the pain level of dozens of insect stings, an index he created mostly by firsthand experience, either by suffering stings incidentally during field research or, in some cases, by inducing them.

Because stings of the same magnitude don't necessarily feel the same, Schmidt has written haiku-like descriptions for each of the 83 sting entries:

Anthophorid bee, Pain Level 1, "Almost pleasant, a lover just bit your earlobe a little too hard."

Maricopa harvester ant, Level 3, "After eight unrelenting hours of drilling into that ingrown toenail, you find the drill wedged into the toe."

Termite-raiding ant, Level 2, "The debilitating pain of a migraine contained in the tip of your finger."

Club-horned wasp, Level 0.5, "Disappointing. A paper clip falls on your bare foot."

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Tuesday, August 09, 2016

NYTimes: Minorities Suffer From Unequal Pain Treatment

Roslyn Lewis was at work at a dollar store here in Tuscaloosa, pushing a heavy cart of dog food, when something popped in her back: an explosion of pain. At the emergency room the next day, doctors gave her Motrin and sent her home.

Her employer paid for a nerve block that helped temporarily, numbing her lower back, but she could not afford more injections or physical therapy. A decade later, the pain radiates to her right knee and remains largely unaddressed, so deep and searing that on a recent day she sat stiffly on her couch, her curtains drawn, for hours.

The experience of African-Americans, like Ms. Lewis, and other minorities illustrates a problem as persistent as it is complex: Minorities tend to receive less treatment for pain than whites, and suffer more disability as a result.

While an epidemic of prescription opioid abuse has swept across the United States, African-Americans and Hispanics have been affected at much lower rates than whites. Researchers say minority patients use fewer opioids, and they offer a thicket of possible explanations, including a lack of insurance coverage and a greater reluctance among members of minority groups to take opioid painkillers even if they are prescribed. But the researchers have also found evidence of racial bias and stereotyping in recognizing and treating pain among minorities, particularly black patients.

"We've done a good job documenting that these disparities exist," said Salimah Meghani, a pain researcher at the University of Pennsylvania. "We have not done a good job doing something about them."

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http://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?

Wednesday, July 27, 2016

NYTimes: Naloxone Eases Pain of Heroin Epidemic, but Not Without Consequences

PORTLAND, Me. — A woman in her 30s was sitting in a car in a parking lot here last month, shooting up heroin, when she overdosed. Even after the men she was with injected her with naloxone, the drug that reverses opioid overdoses, she remained unconscious. They called 911.

Firefighters arrived and administered oxygen to improve her breathing, but her skin had grown gray and her lips had turned blue. As she lay on the asphalt, the paramedics slipped a needle into her arm and injected another dose of naloxone.

In a moment, her eyes popped open. Her pupils were pinpricks. She was woozy and disoriented, but eventually got her bearings as paramedics put her on a stretcher and whisked her to a hospital.
Every day across the country, hundreds, if not thousands, of people who overdose on opioids are being brought back to life with naloxone. Hailed as a miracle drug by many, it carries no health risk; it cannot be abused and, if given mistakenly to someone who has not overdosed on opioids, does no harm. More likely, it saves a life.

As a virulent opioid epidemic continues to ravage the country, with 78 people in the United States dying of overdoses every day, naloxone's use has increasingly moved out of medical settings, where it has been available since the 1970s, and into the homes and hands of the general public.

But naloxone, also known by the brand name Narcan, has also had unintended consequences. Critics say that it gives drug users a safety net, allowing them to take more risks as they seek higher highs. Indeed, many users overdose more than once, some multiple times, and each time, naloxone brings them back.

Advocates argue that the drug gives people a chance to get into treatment and turn their lives around. And, they say, few addicts knowingly risk needing to be revived, since naloxone ruins their high and can make them violently ill.

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http://www.nytimes.com/2016/07/28/us/naloxone-eases-pain-of-heroin-epidemic-but-not-without-consequences.html?

Wednesday, July 20, 2016

Financial Stress Hurts, Literally - Scientific American

Few things feel worse than not knowing when your next paycheck is coming. Economic insecurity has been shown to have a whole host of negative effects, including low self-esteem and impaired cognitive functioning. It turns out financial stress can also physically hurt, according to a paper published in February in Psychological Science.
Eileen Chou, a public policy professor at the University of Virginia, and her collaborators began by analyzing a data set of 33,720 U.S. households and found that those with higher levels of unemployment were more likely to purchase over-the-counter painkillers. Then, using a series of experiments, the team discovered that simply thinking about the prospect of financial insecurity was enough to increase pain. For example, people reported feeling almost double the amount of physical pain in their body after recalling a financially unstable time in their life as compared with those who thought about a secure period. In another experiment, university students who were primed to feel anxious about future employment prospects removed their hand from an ice bucket more quickly (showing less pain tolerance) than those who were not. The researchers also found that economic insecurity reduced people's sense of control, which, in turn, increased feelings of pain.

Chou and her colleagues suggest that because of this link between financial insecurity and decreased pain tolerance, the recent recession may have been a factor in fueling the prescription painkiller epidemic. Other experts are cautious about taking the findings that far. "I think the hypothesis [that financial stress causes pain] has a lot of merit, but it would be helpful to see additional rigorous evidence in a real-world environment," says Heather Schofield, an economist at the University of Pennsylvania who was not involved in the study. Given that stress in general is well known to increase feelings of pain, further research is needed to disentangle financial anxiety from other sources of pressure.

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http://www.scientificamerican.com/article/financial-stress-hurts-literally/

Friday, July 15, 2016

One striking chart shows why pharma companies are fighting legal marijuana - The Washington Post

There's a body of research showing that painkiller abuse and overdose are lower in states with medical marijuana laws. These studies have generally assumed that when medical marijuana is available, pain patients are increasingly choosing pot over powerful and deadly prescription narcotics. But that's always been just an assumption.

Now a new study, released in the journal Health Affairs, validates these findings by providing clear evidence of a missing link in the causal chain running from medical marijuana to falling overdoses. Ashley and W. David Bradford, a daughter-father pair of researchers at the University of Georgia, scoured the database of all prescription drugs paid for under Medicare Part D from 2010 to 2013.

They found that, in the 17 states with a medical-marijuana law in place by 2013, prescriptions for painkillers and other classes of drugs fell sharply compared with states that did not have a medical-marijuana law. The drops were quite significant: In medical-marijuana states, the average doctor prescribed 265 fewer doses of antidepressants each year, 486 fewer doses of seizure medication, 541 fewer anti-nausea doses and 562 fewer doses of anti-anxiety medication.

But most strikingly, the typical physician in a medical-marijuana state prescribed 1,826 fewer doses of painkillers in a given year.

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Wednesday, July 06, 2016

Pfizer agrees to truth in opioid marketing - The Washington Post

Pfizer, the world's second- ­largest drug company, has agreed to a written code of conduct for the marketing of opioids that some officials hope will set a standard for manufacturers of narcotics and help curb the use of the addictive painkillers.

Though Pfizer does not sell many opioids compared with other industry leaders, its action sets it apart from companies that have been accused of fueling an epidemic of opioid misuse through aggressive marketing of their products.

Pfizer has agreed to disclose in its promotional material that narcotic painkillers carry serious risk of addiction — even when used properly — and promised not to promote opioids for unapproved, "off-label" uses such as long-term back pain. The company also will acknowledge there is no good research on opioids' effectiveness beyond 12 weeks.

The terms of the agreement were reached with the city of Chicago, which two years ago sued five other opioid manufacturers over alleged misleading marketing of opioids. An announcement of the agreement is expected Wednesday. Pfizer has also been aiding the city's investigation and lawsuit.

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https://www.washingtonpost.com/national/health-science/pfizer-agrees-to-truth-in-opioid-marketing/2016/07/05/784223cc-42c6-11e6-88d0-6adee48be8bc_story.html

Thursday, June 23, 2016

New Ways to Treat Pain Meet Resistance - The New York Times

A few months ago, Douglas Scott, a property manager in Jacksonville, Fla., was taking large doses of narcotic drugs, or opioids, to deal with the pain of back and spine injuries from two recent car accidents.

The pills helped ease his pain, but they also caused him to withdraw from his wife, his two children and social life.

"Finally, my wife said, 'You do something about this or we're going to have to make some changes around here,'" said Mr. Scott, 43.

Today, Mr. Scott is no longer taking narcotics and feels better. Shortly after his wife's ultimatum, he entered a local clinic where patients are weaned off opioids and spend up to five weeks going through six hours of training each day in alternative pain management techniques such as physical therapy, relaxation exercises and behavior modification.

Mr. Scott's story highlights one patient's success. Yet it also underscores the difficulties that the Obama administration and public health officials face in reducing the widespread use of painkillers like OxyContin and Percocet. The use and abuse of the drugs has led to a national epidemic of overdose deaths, addiction and poor patient outcomes.

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http://www.nytimes.com/2016/06/23/business/new-ways-to-treat-pain-without-opioids-meet-resistance.html?

Thursday, June 16, 2016

Survey shows lots of people save leftover painkillers - Futurity

More than half of patients who get a prescription for opioid painkillers have leftover pills and keep them to use later, a practice that could potentially exacerbate the United States' epidemic of painkiller addiction and overdoses.

Researchers reporting in JAMA Internal Medicine also found that nearly half of those surveyed reported receiving no information on how to safely store their medications to keep them from children who could accidentally ingest them or from someone looking to get high.

One in five respondents said they had shared their medication with another person, many saying they gave them to someone with pain. Nearly 14 percent said they were likely to share their prescription painkillers with a family member in the future and nearly 8 percent said they would share with a close friend.

"The fact that people are sharing their leftover prescription painkillers at such high rates is a big concern," says Colleen L. Barry, who directs Johns Hopkins University's Center for Mental Health and Addiction Policy Research. "It's fine to give a friend a Tylenol if they're having pain, but it's not fine to give your OxyContin to someone without a prescription."

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Sunday, June 12, 2016

An E.R. Kicks the Habit of Opioids for Pain - The New York Times

Brenda Pitts sat stiffly in an emergency room cubicle, her face contorted by pain. An old shoulder injury was radiating fresh agony down to her elbow and up through her neck. She couldn't turn her head. Her right arm had fallen slack.

Fast relief was a pill away — Percocet, an opioid painkiller — but Dr. Alexis LaPietra did not want to prescribe it. The drug, she explained to Mrs. Pitts, 75, might make her constipated and foggy, and could be addictive. Would Mrs. Pitts be willing to try something different?

Then the doctor massaged Mrs. Pitts's neck, seeking the locus of a muscle spasm, apologizing as the patient groaned with raw, guttural ache and fear.

"Quick prick," said Dr. LaPietra, giving Mrs. Pitts a trigger point injection of Marcaine, a numbing, non-opioid analgesic.

Within seconds, Mrs. Pitts blinked in surprise, her features relaxing, as if the doctor had sponged away her pain lines. She sat up, gingerly moving her head, then beamed and impulsively hugged the doctor, vigorously and with both arms.

Since Jan. 4, St. Joseph's Regional Medical Center's emergency department, one of the country's busiest, has been using opioids only as a last resort. For patients with common types of acute pain — migraines, kidney stones, sciatica, fractures — doctors first try alternative regimens that include nonnarcotic infusions and injections, ultrasound guided nerve blocks, laughing gas, even "energy healing" and a wandering harpist.

Scattered E.R.s around the country have been working to reduce opioids as a first-line treatment, but St. Joe's, as it is known locally, has taken the efforts to a new level.

"St. Joe's is on the leading edge," said Dr. Lewis S. Nelson, a professor of emergency medicine at New York University School of Medicine, who sat on a panel that recommended recent opioid guidelines for the Centers for Disease Control and Prevention. "But that involved a commitment to changing their entire culture."

In doing so, St. Joe's is taking on a challenge that is even more daunting than teaching new protocols to 79 doctors and 150 nurses. It must shake loose a longstanding conviction that opioids are the fastest, most surefire response to pain, an attitude held tightly not only by emergency department personnel, but by patients, too.

Pain is the chief reason nearly 75 percent of patients seek emergency treatment. The E.R. waiting rooms and corridors of St. Joe's, where some 170,000 patients will be seen this year, are frequently pierced by high-pitched cries and anguished moans.

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http://www.nytimes.com/2016/06/14/health/pain-treatment-er-alternative-opioids.html

Tuesday, May 31, 2016

Why taking morphine, oxycodone can sometimes make pain worse | Science | AAAS

There's an unfortunate irony for people who rely on morphine, oxycodone, and other opioid painkillers: The drug that's supposed to offer you relief can actually make you more sensitive to pain over time. That effect, known as hyperalgesia, could render these medications gradually less effective for chronic pain, leading people to rely on higher and higher doses. A new study in rats—the first to look at the interaction between opioids and nerve injury for months after the pain-killing treatment was stopped—paints an especially grim picture. An opioid sets off a chain of immune signals in the spinal cord that amplifies pain rather than dulling it, even after the drug leaves the body, the researchers found. Yet drugs already under development might be able to reverse the effect.

It's no secret that powerful painkillers have a dark side. Overdose deaths from prescription opioids have roughly quadrupled over 2 decades, in near lockstep with increased prescribing. And many researchers see hyperalgesia as a part of that equation—a force that compels people to take more and more medication, while prolonging exposure to sometimes addictive drugs known to dangerously slow breathing at high doses. Separate from their pain-blocking interaction with receptors in the brain, opioids seem to reshape the nervous system to amplify pain signals, even after the original illness or injury subsides. Animals given opioids become more sensitive to pain, and people already taking opioids before a surgery tend to report more pain afterward.

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Friday, May 27, 2016

The Itch Lab — The California Sunday Magazine

The rash, which has spread from the crook of my elbow to the base of my wrist, is starting to sprout puffy, crimson welts. It's been three minutes since I rubbed a mound of coarse blond fibers onto my forearm, and what began as a mild prickling sensation has escalated into a throbbing itch. Diana Bautista doesn't seem concerned. "Will scratching make it worse?" I ask. She nods. "Yes, but it will feel really good while you're doing it."
This unsanctioned self-experiment is taking place in the kitchenette of Bautista's University of California, Berkeley, lab. The source of my discomfort is itch powder, the kind anyone can pick up at a novelty store. Its blue packet shows a cartoon man writhing in agony. Below him, in bold letters, are the words, SURPRISE THAT SPECIAL FRIEND! "It's kind of weird people can just buy this stuff on Amazon and not know what it is," Bautista says. A professor of cell and developmental biology, she's pretty sure she knows what the ingredients are: rose-hip hairs and fiberglass. Itchy stuff for sure, but there are far more distressing things in her lab.
Bautista is one of a small but growing number of researchers in the United States trying to decode the molecular secrets of itchiness. She arrived at the specialty the way many others in her field have: by studying pain. For most of medical history, itch and pain were considered variants of the same sensation — itch being just a mild form of pain. What Bautista and others have shown is that while the two share many cellular receptors and molecules, itch has its own biological infrastructure. It's these largely unmapped internal pathways that Bautista has been working to identify for the past seven years.

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https://story.californiasunday.com/itch-lab-diana-bautista?

Wednesday, May 18, 2016

The Sting of the Tarantula Hawk: Instantaneous, Excruciating Pain - Undark

Stung by a tarantula hawk? The advice I give in speaking engagements is to lie down and scream. The pain is so debilitating and excruciating that the victim is at risk of further injury by tripping in a hole or over an object in the path and then falling onto a cactus or into a barbed-wire fence. Such is the sting pain that almost nobody can maintain normal coordination or cognitive control to prevent accidental injury. Screaming is satisfying and helps reduce attention to the pain of the sting. Few, if any, people would be stung willingly by a tarantula hawk. I know of no examples of such bravery in the name of knowledge, for the reputation of spider wasps — specifically tarantula hawks — is well known within the biological community. All stings experienced occurred during a collector's enthusiasm in obtaining specimens and typically resulted in the stung person uttering an expletive, tossing the insect net into the air, and screaming. The pain is instantaneous, electrifying, excruciating, and totally debilitating.

The accompanying article is excerpted from Justin O. Schmidt's new book "The Sting of the Wild: The Story of the Man Who Got Stung for Science," published this spring by John's Hopkins University Press.
Howard Evans, the great naturalist and author of the classic book "Life on a Little Known Planet," was an expert on solitary wasps. Howard, a slight, reserved man with a shock of white hair and a sparkle in his eyes, was especially fond of tarantula hawks. Once, in his dedication to the investigation of these wasps, Howard netted perhaps 10 female tarantula hawks from a flower. He enthusiastically reached into the insect net to retrieve them and, undeterred after the first sting, continued, receiving several more stings, until the pain was so great he lost all of them and crawled into a ditch and just sobbed. Later, he remarked that he was too greedy.

I know of only two people who were "voluntarily" stung by tarantula hawks. I say "voluntarily" as both were performing their duties as part of documentary films, which, among other things, "encouraged" being stung. One was a young, handsome athletic entomologist who knew of the wasps. He deftly reached into the large cylindrical battery jar and grabbed a wasp by the wings. He had her in such a position that her sting harmlessly slid off his thumbnail. We prattled for a minute or so about tarantula hawks while the camera scanned close up to the long sting as it slid harmlessly, missing its mark. Then with a great heave the wasp pulled its abdomen back and thrust the sting under the nail. Yeee…ow (I can't recall if any expressions unsuitable for general audiences were uttered), the wasp was hurled into the air and flew off unharmed. One point for wasp, zero for human.

The other was a solidly built fellow who was apparently a master of performing pain-defying acts of bravery. For the film, I was charged with catching the wasp and delivering it to the scene. Five or six tarantula hawks were easily netted from flowers of an acacia tree; unfortunately, the net snagged on some thorns, and all but one wasp escaped. The remaining wasp appeared to be a male, so I summoned the cameraman to demonstrate how males cannot sting and are harmless. I reached in and casually grabbed "him." At this point, I realized that I was holding a "her." Yeee…ow, except this time it was me. I managed to toss her back in the net, while attempting to explain my blunder and pain on camera. As I was not in the film – perhaps fortunately – the footage was relegated to some obscure studio archive, perhaps someday to be resurrected on YouTube. That episode over, the tarantula hawk was delivered to the rightful actor. He grabbed her, was stung, and showed no reaction beyond a begrudging "Ouch, that did hurt a bit." I figured the guy had no nerves. But his director then handed him a habanero pepper, a tarantula hawk of chili peppers, which he enthusiastically bit into. He became instantly speechless, convinced fire was blasting from his mouth, nose, and ears. Apparently, he did have some nerves — sensitive at least to chili peppers.

How could such a small animal as a tarantula hawk be so memorable? Several years ago I attempted to address this question in a paper entitled "Venom and the Good Life in Tarantula Hawks: How to Eat, Not Be Eaten, and Live Long." The natural history of tarantula hawks provides some insights. Tarantula hawks are the largest members of the spider wasp family Pompilidae, a family some 5,000-species strong that prey solely on spiders. The feature of tarantula hawks that makes them so special is their choice of the largest of all spiders, the fierce and intimidating tarantulas, as their target prey. The old saying "you are what you eat" rings true for tarantula hawks: if you eat the largest spiders, you become the largest spider wasps. As with other spider wasps, the female wasp provides each young with only one spider that serves as breakfast, lunch, and dinner for its entire growing life.

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http://undark.org/article/tarantula-hawk-wasp-sting-pain/

Thursday, May 12, 2016

Treating Pain Without Feeding Addiction at ‘Ground Zero’ for Opioids - The New York Times

BRIDGEPORT, W.Va. — The doctors wanted to talk about illness, but the patients — often miners, waitresses, tree cutters and others whose jobs were punishingly physical — wanted to talk only about how much they hurt. They kept pleading for opioids like Vicodin and Percocet, the potent drugs that can help chronic pain, but have fueled an epidemic of addiction and deadly overdoses.

"We needed to talk about congestive heart failure or diabetes or out-of-control hypertension," said Dr. Sarah Chouinard, the chief medical officer at Community Care of West Virginia, which runs primary care clinics across a big rural chunk of this state. "But we struggled over the course of a visit to get patients to focus on any of those."

Worse, she said, some of the organization's doctors were prescribing too many opioids, often to people they had grown up with in the small towns where they practiced and whom they were reluctant to deny. So four years ago, Community Care tried a new approach. It hired an anesthesiologist to treat chronic pain, relieving its primary care doctors and nurse practitionersof their thorniest burden and letting them concentrate on conditions they feel more comfortable treating.

Since then, more than 3,000 of Community Care's 35,000 patients have seen the anesthesiologist, Dr. Denzil Hawkinberry, for pain management, while continuing to see their primary care providers for other health problems. Dr. Chouinard said Community Care was doing a better job of keeping them well over all, while letting Dr. Hawkinberry make all the decisions about who should be on opioid painkillers.

"I'm part F.B.I. investigator, part C.I.A. interrogator, part drill sergeant, part cheerleader," said Dr. Hawkinberry. He is also a recovering opioid addict who has experienced the difficulties of the drugs himself.

Even for people with access to the best doctors, it is hard to safely control chronic pain. Community Care is trying to do so for a disproportionately poor population, in a state that has been ground zero for opioid abuse from the very beginning of what has become a national epidemic.

Now, the difficult work of addressing the nation's overreliance on opioids, while also treating debilitating pain, is playing out on a patient-by-patient basis, including in a patchwork of experiments like this one. About 70 percent of the 1,200 patients currently in Community Care's pain management program receive opioids as part of their treatment, which may also include nonnarcotic drugs, physical therapy, injections and appointments with a psychologist.

Many had already been on opioids "for many years before they met me," Dr. Hawkinberry said, adding that his goal is to get them on lower doses, and to try other ways of managing their pain, with his own experience as a cautionary lesson.

He became addicted to the opioid fentanyl when he was an anesthesiology resident, he said, and had to wage a legal fight to stay in the program. He relapsed four years later while working at a West Virginia hospital and underwent treatment and monitoring by a state program for doctors with addiction problems. He says he has been in recovery and has not used drugs for almost nine years.

Dr. Chouinard said that Dr. Hawkinberry's experience made him "all the better positioned to know what this is like" and well-positioned to screen for drug abuse.

Patients who are prescribed opioids have to submit urine samples at each monthly appointment and at other random times, and to bring their pills to every visit to be counted. About 500 have been kicked out of the program for violations since it started in 2012.

In addition, Community Care's pain management clinic is closely monitored by the state as one of six licensed to operate under a 2012 law meant to cut down on pill mills.

The organization's primary care providers talk frequently with Dr. Hawkinberry about the patients they share with him. Because they use the same electronic medical record system, they can keep close tabs on how their patients' pain is being treated — and he on how their other health problems, like high blood pressure, are being addressed.

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http://www.nytimes.com/2016/05/12/us/opioids-addiction-chronic-pain.html?

Wednesday, May 11, 2016

Research Grants - Migraine Research Foundation

The Migraine Research Foundation (MRF) and the Association of Migraine Disorders (AMD) announce the opening of a joint Request for Proposals for migraine research grants. MRF is committed to discovering the causes, improving the treatments, and finding a cure, and AMD stimulates increased research specifically in the area of migraine disorders. We are looking for projects that will help sufferers by advancing our ability to understand and treat migraine. As a result, we provide seed money grants for transformational projects that will lead to better treatment and quality of life for sufferers of migraine and migraine disorders.

While we welcome all proposals relevant to basic or clinical migraine research, we are particularly interested in translational projects and those related to migraine variants, childhood migraine, and chronic migraine.

https://migraineresearchfoundation.org/for-researchers/rfp-and-grant-application/

Tuesday, May 10, 2016

What Does Genetics Tell Us About Chronic Pain? - Relief: Pain Research News, Insights And Ideas

When the pain comes, Alina Delp retreats to air conditioning as soon as possible. What begins to feel like a mild sunburn will, if left unattended, turn into a raging, burning pain.

"It's this turbulent, violent sensation that feels electric and stinging," Delp says, describing the pain at its worst. "I've run out of the building screaming like a lunatic before because it's been so bad."

Delp has erythromelalgia, a rare condition in which a person's body (typically the feet and the hands, though Delp experiences pain all over) reacts to mild warmth as though it is on fire. Mild exertion, even just standing, will set it off for Delp, which meant quitting her job of 15 years as a flight attendant. Two years of countless doctors' appointments finally got her a diagnosis in 2012, but current medications are unable to relieve pain in most patients.

"I'm pretty much a prisoner in my own home," she says. Her house in Tacoma, Washington, is kept at a chilly 58 degrees Fahrenheit, thanks to some special duct work that her husband, coincidentally in the heating and cooling business, was able to arrange. Delp spends most of her time reading, watching TV, or working on her computer to maintain an online erythromelalgia support group that she co-founded.

But, this horrific condition has handed pain researchers their most promising drug target in years. In 2004, a study of an inherited version of erythromelalgia pinpointed a mutation in a gene that directs the making of a sodium channel, called Nav1.7; sodium channels are proteins that help control the electrical excitability of neurons.

"The channel sets the sensitivity of pain-signaling neurons, and when you have those Nav1.7 mutations, the neurons fire when they shouldn't," says Stephen Waxman of Yale University School of Medicine, New Haven, US, and the Veterans Affairs Medical Center, West Haven, Connecticut. Waxman was the first to study the effects of Nav1.7 mutations in neurons.

Delp doesn't know if she has this type of mutation, but medicines that calm the channel may still give her relief. Multiple clinical trials are underway to test Nav1.7 channel blockers, not only in inherited erythromelalgia, but in more common conditions, like sciatica and trigeminal neuralgia, which both involve intense shooting pain in different parts of the body.

More ...

http://relief.news/genetics-tell-us-chronic-pain/

'You want a description of hell?' OxyContin's 12-hour problem - Los Angeles Times

The drugmaker Purdue Pharma launched OxyContin two decades ago with a bold marketing claim: One dose relieves pain for 12 hours, more than twice as long as generic medications.

Patients would no longer have to wake up in the middle of the night to take their pills, Purdue told doctors. One OxyContin tablet in the morning and one before bed would provide "smooth and sustained pain control all day and all night."

On the strength of that promise, OxyContin became America's bestselling painkiller, and Purdue reaped $31 billion in revenue.

But OxyContin's stunning success masked a fundamental problem: The drug wears off hours early in many people, a Los Angeles Times investigation found. OxyContin is a chemical cousin of heroin, and when it doesn't last, patients can experience excruciating symptoms of withdrawal, including an intense craving for the drug.

The problem offers new insight into why so many people have become addicted to OxyContin, one of the most abused pharmaceuticals in U.S. history.

The Times investigation, based on thousands of pages of confidential Purdue documents and other records, found that:

• Purdue has known about the problem for decades. Even before OxyContin went on the market, clinical trials showed many patients weren't getting 12 hours of relief. Since the drug's debut in 1996, the company has been confronted with additional evidence, including complaints from doctors, reports from its own sales reps and independent research.
• The company has held fast to the claim of 12-hour relief, in part to protect its revenue. OxyContin's market dominance and its high price — up to hundreds of dollars per bottle — hinge on its 12-hour duration. Without that, it offers little advantage over less expensive painkillers.
• When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to "refocus" physicians on 12-hour dosing. Anything shorter "needs to be nipped in the bud. NOW!!" one manager wrote to her staff.
• Purdue tells doctors to prescribe stronger doses, not more frequent ones, when patients complain that OxyContin doesn't last 12 hours. That approach creates risks of its own. Research shows that the more potent the dose of an opioid such as OxyContin, the greater the possibility of overdose and death.
• More than half of long-term OxyContin users are on doses that public health officials consider dangerously high, according to an analysis of nationwide prescription data conducted for The Times.

Over the last 20 years, more than 7 million Americans have abused OxyContin, according to the federal government's National Survey on Drug Use and Health. The drug is widely blamed for setting off the nation's prescription opioid epidemic, which has claimed more than 190,000 lives from overdoses involving OxyContin and other painkillers since 1999.

The internal Purdue documents reviewed by The Times come from court cases and government investigations and include many records sealed by the courts. They span three decades, from the conception of OxyContin in the mid-1980s to 2011, and include emails, memos, meeting minutes and sales reports, as well as sworn testimony by executives, sales reps and other employees.

The documents provide a detailed picture of the development and marketing of OxyContin, how Purdue executives responded to complaints that its effects wear off early, and their fears about the financial impact of any departure from 12-hour dosing.

Reporters also examined Food and Drug Administration records, Patent Office files and medical journal articles, and interviewed experts in pain treatment, addiction medicine and pharmacology.

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http://static.latimes.com/oxycontin-part1/?utm_source=nextdraft&utm_medium=email

Scientists Have Been Using a Flawed Method to Diagnose Pain - Gizmodo

For many years, neuroscientists believed they had identified a specific pattern of brain activity acting as a kind of "signature" for pain in the brain. Recently this so-called "pain matrix" has been called into question, and a new study by British researchers may have shattered the myth once and for all.

The pain matrix is actually a cluster of regions in the brain that prior imaging studies indicated are involved in processing pain perception, including the posterior insula and the anterior cingulate cortex. This has been so broadly accepted that the signature pattern has been used to declare that emotional pain (like social rejection) and physical pain are the same thing, as far as the brain is concerned. The argument goes that something like a bad romantic breakup has the same effect on brain activity as spilling a hot cup of coffee on your shirt.

More recent studies have cast doubt on those conclusions, however. And now researchers at the University of Reading and University College London have concluded that this cluster of regions in brain is not specific to pain. It also responds to loud noises, bright lights, a strong non-painful touch (like a firm handshake), and yes, social rejection. They describe their findings in a new paper published today in JAMA Neurology.

"I wouldn't say that's it's wrong to say that the 'pain matrix' is involved in processing pain," lead author Tim Salomons (University of Reading) told Gizmodo. "What's wrong is the idea that it is specific to pain—in other words, that when you observe this pattern, you can just assume that person is in pain."

Most of these studies employ functional magnetic resonance imaging (fMRI). Unlike conventional medical MRI, which creates a static image of the brain similar to an x-ray, fMRI monitors the brain in action. When enough neurons fire together in response to a given stimulus, blood flow increases to those parts of the brain involved in processing that input. The fMRI detects this as slight increases in blood oxygen levels—the so-called BOLD response–in those different regions. The resulting gorgeous full-color images make for terrific eye candy, but they aren't actually real-time snapshots of the brain in action; rather, they're visualizations of statistical data.

So how can scientists know for sure if the pattern they're seeing is really an indicator for pain (or any other type of cognitive process)? The gold standard is cognitive neuroscience studies that involve patients with existing brain damage, according to Bradley Voytek, a neuroscientist at the University of California, San Diego, who was not involved with the study. So if you want to prove that a particular cluster of brain regions encodes pain, you must first determine that patients with damage to those regions can no longer feel pain.

More ...

http://gizmodo.com/new-study-casts-more-doubt-on-notion-of-the-brains-pain-1772653232?

Wednesday, May 04, 2016

Mind over back pain - Harvard Health Blog

To the surprise of doctors and patients alike, accumulating research suggests that most chronic back pain isn't actually the result of illness or injury. Study after study indicates instead that back pain is very often caused by our thoughts, feelings, and resulting behaviors. And an exciting new study now demonstrates that treatments aimed at our beliefs and attitudes can really help.

When our back hurts, it's only natural to assume that we've suffered an injury or have a disease. After all, most pain works this way. When we cut our finger, we see blood and feel pain. When our throat hurts, it's usually because of an infection.

But back pain is different. There simply isn't a close connection between the condition of the spine and whether or not people experience pain. Research has shown that a majority of people who have never had any significant back pain have the very same "abnormalities" (such as bulging or herniated spinal discs) that are frequently blamed for chronic back conditions. And then there are the millions of people with severe chronic back pain who show no structural abnormalities in their back at all.

On top of this, it turns out that people in developing countries, who do back-breaking labor and don't have easy access to medical treatment, have much fewer incidents of chronic back pain than people in the developed world who sit in ergonomically designed chairs, sleep on fancy mattresses, and have ready access to spinal imaging, surgery, and medications.

Because there's so little correlation between the condition of the spine and any given person's experience with back pain, clinicians and researchers have begun looking instead at treatments that address the psychological and behavioral patterns that can lock people into years of suffering. And they've just demonstrated that two of these treatments work much better than traditional medical interventions alone.

More ...

http://www.health.harvard.edu/blog/mind-back-pain-201605049517

Tuesday, May 03, 2016

F.D.A. Again Reviews Mandatory Training for Painkiller Prescribers - The New York Times

A pain management specialist, Dr. Nathaniel Katz, was stunned in 2012 when the Food and Drug Administration rejected a recommendation from an expert panel that had urged mandatory training for doctors who prescribed powerful painkillers like OxyContin.

That panel had concluded that the training might help stem the epidemic of overdose deaths involving prescription narcotics, or opioids. At first, Dr. Katz, who had been on the panel, thought that drug makers had pressured the F.D.A. to kill the proposal. Then an agency official told him that another group had fought the recommendation: the American Medical Association, the nation's largest doctors organization.

"I was shocked," said Dr. Katz, the president of Analgesic Solutions, a company in Natick, Mass. "You go to medical school to help public health and here we have an area where you have 15,000 people a year dying."

Now, as the White House, the Centers for Disease Control and Prevention and other federal and state agencies scramble to find solutions to the vexing opioid problem, the role of doctors is coming back to center stage. The Obama administration recently announced that it supported mandatory training for prescribers of opioids.

On Tuesday, a new F.D.A. panel of outside experts will meet to review once again whether such training should be required. The hearing will almost certainly touch off an intense debate inside the medical community and focus attention on medical groups like the A.M.A., which have resisted governmental mandates affecting how doctors practice for both ideological and practical reasons. The panel is expected to make its final recommendation on Wednesday. An F.D.A. spokeswoman said the agency now supported mandatory training.

More ...

http://www.nytimes.com/2016/05/03/business/fda-again-reviews-mandatory-training-for-painkiller-prescribers.html?

Monday, May 02, 2016

Unlike sex and violence, childbirth is rarely depicted in literary fiction - Slate

Are there any taboo subjects left in literature? Graphic violence and sex in any of its endless variations have become mainstream. Even excretion is now explicit: Think of the unforgettable scene of Joey searching for a ring in his own shit in Jonathan Franzen's Freedom. But read almost any novel in which childbirth, one of the most universal of human events, takes place, and you will find that the actual act has been deleted. An author as celebrated for her visceral and detailed accounts of female experience as Elena Ferrante offers the following as a description, in full, of the birth of the narrator's first child in the third book of the Neapolitan novels, Those Who Leave and Those Who Stay:

I had atrocious labor pains, but they didn't last long. When the baby emerged and I saw her . . . I felt a physical pleasure so piercing that I still know no other pleasure that compares to it.

Pages later, the birth of her second child gets even less elaboration: "Everything went smoothly. The pain was excruciating, but in a few hours I had another girl."

Certain ways of avoiding a childbirth scene in contemporary fiction have become almost predictable, as clichéd as the clothes scattered on the floor in a movie rated PG-13: the frantic car ride to the hospital, followed by a jump cut to the new baby; or the played-for-laughs episode of the laboring woman screaming at her clueless husband, followed by a jump cut to the new baby. What happened to what actually happens?

My latest novel, Eleven Hours, takes place entirely during one labor and delivery in an urban hospital. I've been through childbirth twice myself, and found it the most physically painful and most transformative experience of my life. I wanted to write something I felt I hadn't read: a story that described childbirth from the inside. I wanted to depict the alterations of consciousness that come from the confrontation with great pain, and the ways in which the crisis of labor can cause a woman to find in herself previously unknown strengths. I wanted to conjure up the feeling of long waiting punctuated by intense activity. I wanted to show what it felt like to be so very close, simultaneously, to the creation of life and the possibility of death.

When Eleven Hours had been accepted for publication in the U.S. and my agent was shopping it abroad, a publisher that had taken one of my earlier books turned it down. "Sales and marketing did not feel confident they would know how to pitch it," I was told. "It's such a specific experience recounted here."

Such a specific experience? You mean, one that billions of women have been through? Did not feel confident they would know to pitch it? The novel, as I saw it, was about the severe challenge to mind and body that childbirth is for a woman, just as combat is a severe challenge to the minds and bodies of men. Would any publisher ever claim that they wouldn't know how to pitch a war narrative?

More ...

http://www.slate.com/articles/arts/books/2016/05/unlike_sex_and_violence_childbirth_is_rarely_depicted_in_literary_fiction.html?

Mindfulness Effective for Chronic Low Back Pain in Clinical Trial | Pain Research Forum

Government officials, physicians, and the public are increasingly aware of a need to move away from using opiate drugs to treat chronic pain. More and more, doctors are searching for ways to help patients manage pain with non-pharmacological interventions. In line with this trend, new findings now support the use of mindfulness to treat chronic low back pain.

In a clinical trial published March 22 in the Journal of the American Medical Association (JAMA), subjects who underwent mindfulness training for eight weeks were more likely to report improvements in pain, lasting up to a year, compared to people who received whatever other care they chose. The study was led by Daniel Cherkin, Group Health Research Institute, Seattle, US, and Judith Turner, University of Washington, also in Seattle.

A second study, published March 16 in the Journal of Neuroscience and led by Fadel Zeidan, Wake Forest School of Medicine, Winston-Salem, North Carolina, US, and Robert Coghill, now at Cincinnati Children's Hospital, Ohio, US, hints at how mindfulness might reduce pain. The researchers showed in healthy subjects that meditation reduced acute pain independent of endogenous opioids, which account for the vast majority of other brain-based manipulations—such as the placebo effect or conditioned pain modulation.

More ...

http://www.painresearchforum.org/news/66166-mindfulness-effective-chronic-low-back-pain-clinical-trial

Monday, April 18, 2016

Botulinum Toxin Guidelines Overhauled | Medpage Today

VANCOUVER -- Guidelines for the use of botulinum toxin in various neurological disorders are getting an update, with the best evidence supporting the use of some formulations in spasticity and chronic migraine, researchers reported here.

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.

More ...

http://www.medpagetoday.com/MeetingCoverage/AAN/57409

Monday, April 11, 2016

The Pain Gap: Why Doctors Offer Less Relief to Black Patients - The Daily Beast

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.

More ...

http://www.thedailybeast.com/articles/2016/04/11/the-pain-gap-why-doctors-offer-less-relief-to-black-patients.html?

Monday, March 28, 2016

The perils of being manly - The Washington Post

A few years ago, I found myself in the emergency room. I had hurt my ankle playing basketball, and the pain was unbearable. I remember sitting there, waiting for someone to see me, thinking to myself that it must be broken, or fractured, or something similarly severe.

"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.

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https://www.washingtonpost.com/news/wonk/wp/2016/03/28/what-happens-when-a-manly-man-has-to-go-to-the-doctor/

Tuesday, March 22, 2016

National Pain Strategy - The Interagency Pain Research Coordinating Committee

The Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services today released a National Pain Strategy, outlining the federal government's first coordinated plan for reducing the burden of chronic pain that affects millions of Americans. Developed by a diverse team of experts from around the nation, the National Pain Strategy is a roadmap toward achieving a system of care in which all people receive appropriate, high quality and evidence-based care for pain.
"Chronic pain is a significant public health problem, affecting millions of Americans and incurring significant economic costs to our society," said Karen B. DeSalvo, M.D., M.P.H., M.Sc., HHS acting assistant secretary for health. "This report identifies the key steps we can take to improve how we prevent, assess and treat pain in this country."
In 2011, in recognition of the public health problem of pain in America, the Institute of Medicine called for a coordinated, national effort of public and private organizations to transform how the nation understands and approaches pain management and prevention. In response, HHS tasked the Interagency Pain Research Coordinating Committee (IPRCC), a group of representatives from  the Department of Defense, Department of Veterans Affairs, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Food and Drug Administration, National Institutes of Health and members of the public, including scientists and patient advocates, with developing a National Pain Strategy that recognizes access to safe and effective care for people suffering from pain as a public health priority. The final Strategy being released today makes recommendations for improving overall pain care in America in six key areas: population research; prevention and care; disparities; service delivery and payment; professional education and training; and public education and communication.
More specifically, the Strategy calls for:
  • 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. 

"Of the millions of people who suffer from chronic pain, too many find that it affects many or all aspects of their lives," said Linda Porter, Ph.D., director, NIH's Office of Pain Policy and co-chair of the IPRCC working group that helped to develop the report. "We need to ensure that people with pain get appropriate care and that means defining how we can best manage pain care in this country."
The IPRCC engaged with a broad range of experts, including pain care providers, scientists, insurers, patient advocates, accreditation boards, professional societies and government officials to develop the Strategy. Upon the release of the Strategy, the Office of the Assistant Secretary for Health, in conjunction with other HHS operating and staff divisions, will consider the recommendations included in the Strategy and develop an implementation and evaluation plan based on this process. In addition, the IPRCC is creating a research agenda to advance pain-related research in an effort to realize the goals of the Strategy.
"Pain can affect all aspects of a patient's life, so we wanted to hear from everyone," said Sean Mackey, M.D., Ph.D., chief, Division of Pain Medicine, Stanford University, and a co-chair of the IPRCC working group that helped to develop the report. "Similarly, to achieve the goals in this report, we will need everyone working together to create the cultural transformation in pain prevention, care and education that is desperately needed by the American public."
Better pain care, achieved through implementation of the National Pain Strategy, is an essential element in the Secretary's initiative to address the opioid epidemic. Access to care that appropriately assesses benefits and risks to people suffering from pain remains a priority that needs to be balanced with efforts to curb inappropriate opioid prescribing and use practices. The Strategy provides opportunities for reducing the need for and over-reliance on prescription opioid medications, including:  
  • 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.

http://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm

Wednesday, March 16, 2016

NYTimes: Patients in Pain, and a Doctor Who Must Limit Drugs

Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift. "We were really busy," she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. "Thursdays, it's Philly cheesesteaks."

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.

She winced.

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."

More ...

http://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html?

CDC warns doctors about the dangers of prescribing opioid painkillers - The Washington Post

With no end to the nation's opioid crisis in sight, the federal government on Tuesday issued final recommendations that urge doctors to use more caution and consider alternatives before they prescribe highly addictive narcotic painkillers.

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.

More ...

https://www.washingtonpost.com/news/powerpost/wp/2016/03/15/cdc-warns-doctors-about-the-dangers-of-prescribing-opioid-painkillers/

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm?s_cid=rr6501e1er_w


I’m a doctor. I worry every time I prescribe painkillers to a patient. - Vox

"Please, I need my Oxycodone!" my patient, M, pleaded with me.

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.

More ...

http://www.vox.com/2016/1/14/10760992/painkiller-prescription

He couldn’t eat, drink or work. And doctors couldn’t explain his searing pain. - The Washington Post

Kim Pace was afraid he was dying. In six months he had lost more than 30 pounds because a terrible stabbing sensation on the left side of his face made eating or drinking too painful. Brushing his teeth was out of the question and even the slightest touch triggered waves of agony and a shocklike pain he imagined was comparable to electrocution. Painkillers, even morphine, brought little relief.

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.

More …

https://www.washingtonpost.com/national/health-science/he-couldnt-eat-drink-or-work-and-doctors-couldnt-explain-his-searing-pain/2016/03/14/87c791ee-bc8c-11e5-829c-26ffb874a18d_story.html?

Saturday, February 27, 2016

'Dry eye' linked to chronic pain syndromes - Medical Xpress

Physician-researchers with Bascom Palmer Eye Institute, part of UHealth—the University of Miami Health System, have found a link between "dry eye" and chronic pain syndromes—a finding that suggests that a new paradigm is needed for diagnosis and treatment to improve patient outcomes.

"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."

More ...

http://medicalxpress.com/news/2016-01-eye-linked-chronic-pain-syndromes.html

Thursday, February 25, 2016

2016 Global Year Against Pain in the Joints - IASP

Joint pain affects millions of people who suffer from a wide variety of ailments and conditions. Chronic joint pain can be manageable, but treatment is often inadequate, and patients may continue to suffer. Indeed, medications are sometimes unsafe, making rehabilitation and physical therapy essential.

Joint pain also can exact substantial financial and other costs -- high medical expenses, lost work days, and diminished quality and productivity in people's work and personal lives. Aging populations, sedentary lifestyles, and an increasing propensity toward obesity all mean that the problem of joint pain is likely to continue unabated worldwide.

IASP's 2016 Global Year Against Pain in the Joints campaign will address these issues and concerns in the following ways:

  • Disseminating information on joint pain
  • Connecting pain researchers to health-care professionals who interact with patients
  • Increasing awareness of joint pain among government officials, the news media, the general public, and patient organizations worldwide, and
  • Encouraging government leaders, research institutions, and other individuals and organizations to support research aimed at producing more effective and accessible treatment methods and outcomes for people with joint pain