Saturday, March 31, 2007

Pain drug development booming, reports anesthesiologist

The number of new drugs being developed to relieve neuropathic pain – a chronic, devastating condition affecting three to eight per cent of the population – has quadrupled over the past year and a half, a Queen's University study shows.

But under present regulations, pharmaceutical companies are not required to test their products against currently used neuropathic pain drugs, notes Dr. Ian Gilron, Director of Clinical Pain Research for Queen's Departments of Anesthesiology, and Pharmacology & Toxicology, and an anesthesiologist at Kingston General Hospital. "We would like to see more comparative drug trials, whenever possible, so that the increased value of new drugs is clearly shown."

His review, co-authored with Dr. Terence Coderre of McGill University, will be published in the March 2007 issue of the journal Expert Opinion in Emerging Drugs.

"We were surprised to discover how rapidly this area has mushroomed in a period of less than two years," says Dr. Gilron. His survey of recent submissions to Investigational Drugs (IDdb) and Pharmaprojects databases revealed that the number of new drugs under development to treat neuropathic pain has jumped from 13 to 48.

Defined as "pain caused by a lesion of the nervous system," neuropathic pain is a condition that has puzzled health care workers for years because it is often experienced in areas of the body that appear to be uninjured. Generally longstanding, severe, and resistant to over-the-counter painkillers, it may result from a wide variety of causes, including degenerative spinal disease, diabetes, cancer and infectious diseases that affect the brain, spinal cord and/or peripheral nerves.

"What's particularly exciting is the emergence of entirely new types of drugs to combat this unique pain condition," says Dr. Gilron. "With so much work in basic science happening today, and the recognition now that this is such a prevalent public health problem, scientists in both universities and industry are able to apply the new knowledge."

Traditionally, the drugs used to treat neuropathic pain have been anti-depressants, anti-convulsants, and sometimes opioids like morphine. On average they reduce pain intensity by 20 to 40 per cent.

Wednesday, March 28, 2007

Surviving the perils of a life without pain

Surviving the perils of a life without pain

A disorder that prevents people from feeling injuries can be dangerous. But their gene may give others hope.

Globe and Mail

No good parent wishes pain upon her child, but Verna Mahar wished it for two of her sons -- the eldest, Owen, most of all.

From the time he was a baby he was a roughhouser -- banging his head against walls and table corners without a whimper. When he was a toddler he'd bite his fingers to the bone unless she made him wear mittens indoors. His lips she could do nothing about: Owen chewed them happily until they bled.

"My husband and I didn't understand it. He didn't cry for nothing," Ms. Mahar said. "We couldn't understand why he wasn't feeling."

"Didn't it hurt?" she'd ask the growing boy. "No," Owen would say. "Well why not?" "I don't know, Ma."

Not until Owen was 3 -- the year he broke a bone in his foot and kept right on walking -- did the family from Bird Cove, Nfld., receive an explanation. Doctors told them their son had a rare and storied disorder -- a genetic condition that prevents the ability to perceive pain. He is normal in every other way, able to distinguish hot from cold and pat from pinprick; only the sensation of pain does not register.

The Newfoundland family is one of only 15 worldwide known to be affected by congenital indifference to pain, or CIP. But the curse of their inheritance could become a blessing for the rest of the world.

Scientists have found the mutant gene behind the bizarre condition and believe that mimicking its effects could lead to a new age of painkillers.

An international research effort led by Vancouver biotech firm Xenon Pharmaceuticals Inc. has confirmed that a single mutant gene is responsible for this rare pain disorder in nine families of different ethnicities in seven countries. Among them are the Mahars in Bird Cove, a 12-hour drive north from St. John's, where at least four members of three related families have been diagnosed, including Owen, now 20, and his brother Joshua, 11.

In a report to be published in the journal Clinical Genetics in April, the researchers list what patients have suffered without suffering -- double hip dislocations, lower-limb amputations, corneal abrasions, burns, stabs, gashes, head trauma and mutilating tongue-biting. A Swiss woman has experienced painless childbirth; one U.S. patient was able to undergo a cystoscopy, a painful exploratory bladder procedure, without anesthetic.

"It is somewhat surprising that one gene has such a profound effect," said study co-author Michael Hayden, co-founder of Xenon and a geneticist at the University of British Columbia. "This tells us that there is a primary target for pain perception that's most profound."

James Nachtwey - Photographs

I have been a witness, and these pictures are

my testimony. The events I have recorded should

not be forgotten and must not be repeated."

-James Nachtwey

New York Times review:

World’s Cruelty and Pain, Seen in an Unblinking Lens

If this were a perfect world, everybody would see the photographer James Nachtwey’s astonishing shows at the United Nations and at 401 Projects in the West Village.

Sadly, as Mr. Nachtwey knows, this isn’t a perfect world, a point he brings home in the work shown here. “Inferno,” the title of a 1999 book of the photographs he shot in Kosovo, Rwanda and other hellholes, aptly describes the horror in these two exhibitions.

For years, in Time magazine and elsewhere, he has demonstrated the good uses to which art can be put. Since 2000, he has crisscrossed Southeast Asia and Africa, documenting the resurgence of tuberculosis related to the global AIDS epidemic. (The show at the Visitors Center at the United Nations was timed to coincide with World TB Day last Saturday.) He has also photographed the war wounded in Iraq, where he himself was injured by a grenade a few years ago, and traveled with Medevac units to field hospitals and emergency rooms.

The series of Iraq pictures, some of which were first published in National Geographic, are called “The Sacrifice.” The title refers to the medics and physicians who treat everyone, including wounded insurgents. The insurgents are given goggles so they can’t see and later seek out to kill the Iraqi translators helping the medics, for which reason Mr. Nachtwey doesn’t photograph translators. He does photograph an Iraqi child mangled in a suicide attack: the boy is screaming beneath his oxygen mask.

The title also refers to American soldiers whose work daily forces them to play Russian roulette with roadside bombs, soldiers regularly sacrificed in the war. Mr. Nachtwey devised a collage of photos (grainy, black-and-white, shot under the fluorescent glare of military trauma centers) suggesting the choreographed chaos in which American doctors tend to failing patients. The last of the pictures, a mordant coda, shows a dead soldier on a gurney under a blanket, a chaplain’s arm reaching into the frame and holding up a dog tag.

It matters not a little that Mr. Nachtwey is such an artful composer of images, that his work, although almost too painful to look at, is so graphic and eloquent. He snaps a picture just at the moment that the arms of rushing, dodging medics trading scalpels and scissors form a perfect zigzag of thrusting lines ending with a nurse pressing a fist into a patient’s head wound — the punctum of the image, to borrow Roland Barthes’s term. The nurse’s gesture has a strangeness that carries something of the quality of grace.

He finds the same encapsulating detail, concentrated by simple geometry, in a photograph of two doctors. (You just see their arms.) They’re gingerly examining the spine of a rail-thin woman with AIDS; she is sitting on the floor and facing away from Mr. Nachtwey so that only her bare left foot, leathered, turned toward the camera, reveals her advanced age. One of the doctors presses his index finger into her back — another memorable motion, subtly conveying care and dignified by the stately, condensed order of the picture.

Beauty is a vexed matter in scenes of suffering, cruelty and death. The difference between exploitation and public service comes down to whether the subject of the image aids the ego of the photographer more than the other way around. The two are not mutually exclusive.

Along with bravery and perseverance, Mr. Nachtwey’s pictorial virtue makes him a model war photographer. He doesn’t mix up his priorities. His goal is to bear witness, because somebody must, and his pictures, devised to infuriate and move people to action, are finally about us, and our concern or lack of it, at least as much they are about him and his obvious talents.

He finds heroes in the most woebegone spots. These are the soldiers and the doctors and the aid workers, but also the wives, mothers, children and priests who try to ease the pain of the afflicted.

In Thailand, north of Bangkok, he came across an American priest named Michael Bassano who spends endless days with the most desperate of AIDS patients, massaging their feet, changing their diapers, helping them die. Their flesh clings like cellophane to their bones, and their eyes roll up in their heads. In one photograph Father Bassano’s arm just barely extends into the lower right corner of the frame, clasping the tiny wrist of a young woman named Lek. She stares doe-eyed back at him, as if from the grave.

And I hardly know what to say about three remarkable photographs of an orphaned 12-year-old Cambodian peasant named Va Ling. Barefoot, he leads a small procession down a dirt road, clutching to his chest the wedding photo of his dead 33-year-old mother, Am Nita.

Elsewhere, she is a flesh-draped skeleton on a bier, utterly unrecognizable; his head shaved, Va Ling closes her eyes for her, a gesture in which you see him grow up all at once. In the third picture, he stands before her funeral pyre, engulfed in smoke, wearing a loose white sash, a swatch of rough black cloth pinned at his shoulder. He is lost in thought.

Beside that photograph at the United Nations is a vitrine displaying the medicine that, at modest cost (about $20 per patient per month), could eradicate tuberculosis if the drugs were properly distributed and taken; but they aren’t, because of corruption, politics and ignorance. With the pictures, the message is devastating.

Mr. Nachtwey’s work about the war wounded in Iraq is no less haunted. Finding the most human detail amid chaos, he photographs an unconscious soldier on the operating table at the instant his wedding band is removed from his hand. He photographs Brian Price, an Army sergeant wounded by an improvised explosive device in Ramadi, wincing on a gurney, the camera focused on the name of the soldier’s four-month-old daughter, Ashlynn Jaide, tattooed in script over his heart.

In a separate image a nurse lifts and turns the limp Sergeant Price over. His back has several small holes. The scene is like a Pietà. You read in the nurse’s fallen face the sudden realization that the soldier’s spine has been severed.

And at a military hospital in Germany, Mr. Nachtwey found Pvt. Andrew Bouwma in a coma, watched over by his stunned parents. His mother, Kandi, smiling in her University of Wisconsin sweatshirt, gently caresses his hair. His father, Jim, sunglasses perched on his head, rubs one eye and leans with his other hand on the railing of the bed for support. A chaplain’s hand, extending into the picture, touches Andrew’s shoulder. They’re praying. It’s frozen drama, like a Jeff Wall staging, but true. Breathing through a respirator, eyes shut, Private Bouwma looks heartbreakingly young.

Is this how these men would wish to be remembered? Are the pictures an invasion of privacy?

That was the Bush administration’s excuse for prohibiting photographs of returning coffins. But then there’s the argument made at the opening of the show at 401 by a ex-marine who lost his right arm in Iraq. (He was among a number of veterans who stopped by the gallery, a nonprofit space devoted to this sort of exceptional photographic projects, to pay tribute to Mr. Nachtwey.) The marine said he thought these pictures should be on billboards in Times Square so that everybody would know what’s really happening over there, and nobody could miss seeing them.

Wouldn’t that be something? Public art of real consequence and quality for a change, bringing home a war that the whole country is conducting but that only the small percentage of families in the volunteer military experience firsthand. There would be no chance to turn the page or flip the channel or skip the exhibition.

If the AIDS pictures were blown up onto billboards too, there would be no sanctuary from images like the one of the black stick-figure man in a white-walled hospital in Zimbabwe, struggling alone down a narrow, bending corridor to a shower for lack of a doctor’s or nurse’s help.

Nor would there be any way to avoid the photograph of Derek McGinnis, an amputee from Iraq, on Pismo Beach in California, under a leaden sky, leaning over, his head obscured behind his surfboard, so that man, prosthesis, surfboard and fin make a perfect right angle. It’s an amazing image. He’s a modern-day Discobolus.

That’s a redemptive sight, celebrating a brave soldier who survived the inferno and made the best out of what he had left. We would prefer not to see him, perhaps, but Mr. Nachtwey calls us out in our discomfort and neglect.

The least we should do is not look away.

NPR : Groopman: The Doctor's In, But Is He Listening?

· Jerome Groopman is a doctor who discovered that he needed a doctor. When his hand was hurt, he went to six prominent surgeons and got four different opinions about what was wrong. Groopman was advised to have unnecessary surgery and got a seemingly made-up diagnosis for a nonexistent condition.

Groopman, who holds a chair in medicine at Harvard Medical School, eventually found a doctor who helped (Audio). But he didn't stop wondering about why those other doctors made the wrong diagnoses. And he wrote about their mistakes in a new book called How Doctors Think (Excerpt).

"Usually doctors are right, but conservatively about 15 percent of all people are misdiagnosed. Some experts think it's as high as 20 to 25 percent," Groopman tells Steve Inskeep. "And in half of those cases, there is serious injury or even death to the patient."

Why do you think that doctors would be wrong that often?

Well, you know, it's very hard to be a doctor. We're working under tremendous time pressure, especially in the current medical system. But the reasons we are wrong are not related to technical mistakes, like someone putting the wrong name on an X-ray or mixing up a blood specimen in the lab. Nor is it really ignorance about what the actual disease is. We make misdiagnoses because we make errors in thinking.

Errors in thinking...

We use shortcuts. Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what's wrong. And too often, we make what's called an anchoring mistake — we fix on that snap judgment.

Which could be based on the first thing the patient says. It could be based on something on their chart or in their file that somebody else has concluded in the past. It could be anything.

It could be anything. There's very frequently a telephone call that precedes a visit where the first doctor says, 'Oh, you know this is a very nervous woman who's in menopause and the feelings she's having are related to change of life.' And that causes what's called an attribution error or a stereotype and I write about that in the book where a woman saw five doctors. And she said, 'You know what, I really feel these explosions in my body.' And everyone thought she was crazy.

And it turned out that she had a tumor that was producing adrenaline. So every once in a while, the tumor would release this burst of adrenaline which made her jittery and sweaty and nervous. And she was indeed a high-strung person. But she said finally to the doctor who made the right diagnosis, 'I know that I'm a tense individual, but something's different. Something has changed.'

What is some advice that you would give to avoid misdiagnosing in this kind of situation?

Most importantly, I think, the patient and the doctor can partner. These thinking errors are made in the moment. They're made when the doctor is listening to the patient or examining the patient — these snap judgments.

Or not listening to the patient...

Or not listening to the patient. And so a patient or a family member or a friend who knows how doctors think well and how they don't think well can help get the doctor back on track by asking some appropriate questions.


Tuesday, March 27, 2007

Prescription Pain Medication and Drug Trafficking Law Suits - New York Times

Trafficker or Healer? And Who's the Victim?

ALEXANDRIA, Va., March 26 — The case of the United States v. William Eliot Hurwitz, which began in federal court here on Monday, is about much more than one physician. It's a battle over who sets the rules for treating patients who are in pain: narcotics agents and prosecutors, or doctors and scientists.

Dr. Hurwitz, depending on which side you listen to, is either the most infamous doctor-turned-drug-trafficker in America or a compassionate physician being persecuted because a few patients duped him.

When Dr. Hurwitz, who is now 62, was sent to prison in 2004 for 25 years on drug trafficking and other charges, the United States attorney for Eastern Virginia, Paul J. McNulty, called the conviction "a major achievement in the government's efforts to rid the pain management community of the tiny percentage of doctors who fail to follow the law and prescribe to known drug dealers and abusers."

Siobhan Reynold, the president of an advocacy group called the Pain Relief Network, hailed Dr. Hurwitz's singular dedication and compared his plight to Galileo's. Some of the country's foremost researchers in pain treatment and addiction supported his appeal for a retrial, which was ordered because the jury in the first case was improperly instructed to ignore whether Dr. Hurwitz had acted in "good faith." These scientists say they are upset by how their research has been distorted by prosecutors in this case, and suppressed by the Drug Enforcement Administration in its campaign against the misuse of OxyContin and other opioid painkillers.

In the first trial, the prosecution accused Dr. Hurwitz of crossing the line from doctor to trafficker by prescribing irresponsibly high doses of painkillers to his patients in the Virginia suburbs of Washington. He was accused of ignoring blatant "red flags" or signs that some patients were misusing or selling the drugs. That is an emotionally powerful argument for a jury: warning signs can seem perfectly clear with the benefit of hindsight.

But to researchers who study deceptive patients, there is no such thing as a blatant red flag. Deception is notoriously difficult to spot, as Dr. Beth F. Jung and Dr. Marcus M. Reidenberg of Cornell University document in a new survey of the literature. They note, for starters, an experiment showing that even police officers and judges — ostensibly experts at detecting fraud — do no better than chance at detecting lying.

Doctors are especially gullible because they have a truth bias: they are trained to treat patients by trusting what they say. Doctors are not good at detecting liars even when they have been warned, during experiments, that they will be visited at some point by an actor faking some condition (like back pain, arthritis or vascular headaches). In six studies reviewed by the Cornell researchers, doctors typically detected the bogus patient no more than 10 percent of the time, and the doctors were liable to mistakenly identify the real patients as fakes.

When treating people with chronic pain, doctors have to rely on what patients tell them because there is no proven way to diagnose or measure it. Also, there is no standard dosage of medicine: A prescription for opioids that would incapacitate or kill one patient might be barely enough to alleviate the pain of another.

Monday, March 26, 2007

Sound Medicine: Solving the Mystery of Pain (click at top right to listen to audio)

Solving the Mystery of Pain

Air date: February 25, 2007

Hosts: Barbara Lewis, David Crabb, MD

Interview: Ted Cummins, PhD
Indiana University School of Medicine

On a recent episode of "Gray's Anatomy," doctors puzzled over a young patient who could feel no pain.

This is a real condition.

Researchers have now isolated the gene involved in this rare disorder -- a discovery that could help scientists learn more about pain and one day lead to better pain killers and other medications.

Dr. David Crabb, Sound Medicine's expert on internal medicine, interviews Ted Cummins, a neuroscientist at the IU School of Medicine, about what causes pain -- and what can happen when someone doesn't feel it.

Sound Medicine: Pain and the Brain (click on Real Media or Windows Media for audio)

Pain and the brain

Air date: March 15, 2003

The brain controls the pathways and chemicals that produce pain, and thanks to medical research today we understand much about pain relief. But brain researchers are still exploring new ways for relieving pain, especially chronic pain. We hear more from Michael Vasko, MD, professor of pharmacology at the Indiana University School of Medicine.

Nerves in our skin and organs communicate signals from the body to the brain. Some nerves (also called sensory neurons) carry touch signals, but others carry sensations, some of them noxious, like pain. When activated, the nerves conduct the signal to the spinal cord, to the brain, and to the center of the brain, which perceives it as bad. The brain then causes us to register a response -- to cry out or pull away.

Dr. Vasko discusses nerve stimuli, body chemicals called prostaglandins, and the basic mechanism that causes many pain medications, including new ones like COX-2 inhibitors (i.e. Celebrex) to work. Although it's unclear why people perceive pain and respond to drugs differently, Dr. Vasko explains how new techniques in brain imaging can help researchers understand how pain signals travel through the somatosensory cortex.

Of especial interest to Dr. Vasko is chronic pain, which modern drugs do not treat well. We often don't even know what causes chronic pain, he says, since often the injury itself is gone. It's a "neuropathic pain," a pathology of the nerves. One syndrome is "central pain," a lesion in the brain; another is "phantom limb" pain. Imaging techniques might help solve the riddle, perhaps by revealing ways we can train the brain to adapt. Dr. Vasko talks about current, holistic treatments for chronic pain. He also explains how gene therapy may help reduce people's sensitivity to pain.

Sound Medicine: Solving the Mystery of Pain (click at top right to listen to audio)

Solving the Mystery of Pain

Air date: February 25, 2007

Hosts: Barbara Lewis, David Crabb, MD

Interview: Ted Cummins, PhD
Indiana University School of Medicine

On a recent episode of "Gray's Anatomy," doctors puzzled over a young patient who could feel no pain.

This is a real condition.

Researchers have now isolated the gene involved in this rare disorder -- a discovery that could help scientists learn more about pain and one day lead to better pain killers and other medications.

Dr. David Crabb, Sound Medicine's expert on internal medicine, interviews Ted Cummins, a neuroscientist at the IU School of Medicine, about what causes pain -- and what can happen when someone doesn't feel it.

Saturday, March 24, 2007

Approaching Pain's Layers Through Hypnosis (The Scientist)

Under the suggestive power of hypnosis, subjects can be convinced that they're feeling pain when no stimulus is given. Other subjects can be taught to control the amount of pain they feel, as with a dial. Appearing to work well in as many as 15% of people tested, hypnosis can tap into the brain's ability to produce and modulate pain as well as the maddening subjectivity of the experience. Using sophisticated brain imaging techniques in concert with the power of suggestion, scientists are getting closer to parsing the emotional and sensory aspects of pain.

Relieve Your Child's Chronic Pain: A Doctor's Program for Easing Headaches, Abdominal Pain, Fibromyalgia, Juvenile Rheumatoid Arthritis, and More

Relieve Your Child's Chronic Pain: A Doctor's Program for Easing Headaches, Abdominal Pain, Fibromyalgia, Juvenile Rheumatoid Arthritis, and More

by Elliot J. Krane, M.D. and Deborah Mitchell 

An essential survival guide for parents whose children suffer with persistent and often debilitating pain

Approximately ten million children are living with chronic pain. Most people would be surprised at such numbers, but for the parents of these children, the challenge of helping a pain-stricken child live a normal life is a frightening and frustrating reality. Chronic pain in children can manifest as abdominal, migraine, or facial pain. It also stems from a wide variety of disorders such as juvenile rheumatoid arthritis, cystic fibrosis, hemophilia, and childhood cancers. No matter what type of chronic pain the child suffers with, a parent must be armed with an understanding of how a child's expression and experience of pain differs from an adult's.

Trained in pediatric anesthesia and intensive care at Boston Children's Hospital, Dr. Elliot Krane has devoted his entire professional life to refining and innovating techniques, strategies, and therapies to relieve the suffering of children with pain. In his book, Relieve Your Child's Chronic Pain, parents will find the information and tools they need to get the very best care for their child. It will help you:

  • Recognize, measure, and evaluate your child's pain properly
  • Learn about the many alternative pain-management approaches that can be used at home
  • Dispel fears about addiction if your child is prescribed a narcotic
  • Find an appropriate pain-management clinic for your child
  • Reduce the stress and anxiety in the home in a way that benefits the entire family

You may not always be able to eliminate chronic pain entirely, but you can succeed in minimizing your child's suffering.


International Association for the Study of Pain | Core Curriculum for Professional Education in Pain, 3rd Edition

Core Curriculum
for Professional Education in Pain, 3rd edition

This book is available FREE ONLINE in pdf format.
To read, click here.

The third revision of the International Association for the Study of Pain® (IASP®) Core Curriculum has been many years in gestation. It follows the very successful format used by Dr. Howard L. Fields, editor of the second edition. The content has been expanded by over one-third; new chapters have been added, and virtually all the text and the references have been revised. It is hoped that members will find this a significantly improved resource for patient care and training purposes.

In the future, the curriculum core group believes the Web to be an ideal way to bring timely and rapid updates of this curriculum to the widest possible audience. We hope that this resource can become a dynamic and freely available asset for anyone with an interest in pain.

Part I.  General 
1. Anatomy and Physiology 
2. Pharmacology of Pain Transmission and Modulation 
3. The Development of Pain Systems 
4. Designing, Reporting, and Interpreting Clinical Research Studies about Treatments 
for Pain: Evidence-Based Medicine 
5. Animal Models of Pain and Ethics of Animal Experimentation 
6. Ethical Standards in Pain Management and Research 
Part II.  Assessment and Psychology of Pain 
7. Pain Measurement in Humans 
8. Placebo and Pain 
9. Clinical Nerve Function Studies and Imaging 
10. Epidemiology 
11. Psychosocial and Cultural Aspects of Pain 
12. Sex and Gender Issues in Pain 
Part III.  Treatment of Pain 
A. Pharmacology 
13. Opioids 
14. Antipyretic Analgesics: Nonsteroidals, Acetaminophen, and Phenazone Derivatives 
15. Antidepressants and Anticonvulsants 
16. Miscellaneous Agents 
B. Other Methods 
17. Psychological Treatments (Cognitive-Behavioral and Behavioral Interventions) 
18. Psychiatric Treatment 
19. Stimulation-Produced Analgesia 
20. Interventional Pain Management Including Nerve Blocks and Lesioning 
21. Surgical Pain Management 
22. Physical Medicine and Rehabilitation 
23. Work Rehabilitation 
24. Complementary Therapies 
Part IV.  Clinical States 
A. Taxonomy 
25. Taxonomy of Pain Syndromes 
B. Tissue Pain 
26. Acute and Postoperative Pain 
27. Cancer Pain 
28. Cervical Radicular Pain
29. Neck Pain 
30. Lumbar Radicular Pain 
31. Low Back Pain 
32. Musculoskeletal Pain 
33. Muscle and Myofascial Pain 
C. Visceral Pain 
34. Visceral Pain 
35. Chronic Urogenital Pain 
36. Pain in Pregnancy and Labor 
D. Headache and Facial Pain 
37. Headache 
38. Orofacial Pain 
E. Nerve Damage 
39. Neuropathic Pain 
40. Complex Regional Pain Syndromes 
F. Special Cases 
41. Pain in Infants, Children, and Adolescents 
42. Pain in Older Adults 
43. Pain Issues in Individuals with Limited Ability to Communicate Due 
to Cognitive Impairment 
44. Pain Relief in Substance Abusers 
45. Pain Relief in Areas of Deprivation and Conflict

Psychosocial and Cultural Aspects of Pain: IASP Core Curriculum for Professional Education in Pain

Meta-analysis of psychological interventions for chronic low back pain

Meta-analysis of psychological interventions for chronic low back pain
Hoffman BM, Papas RK, Chatkoff DK, Kerns RD
Health Psychol. 2007 Jan;26(1):1-9.

The purpose of this meta-analysis of randomized controlled trials was to evaluate the efficacy of psychological interventions for adults with noncancerous chronic low back pain (CLBP). The authors updated and expanded upon prior meta-analyses by using broad definitions of CLBP and psychological intervention, a broad data search strategy, and state-of-the-art data analysis techniques. All relevant controlled clinical trials meeting the inclusion criteria were identified primarily through a computer-aided literature search. Two independent reviewers screened abstracts and articles for inclusion criteria and extracted relevant data. Cohen's d effect sizes were calculated by using a random effects model. Outcomes included pain intensity, emotional functioning, physical functioning (pain interference or pain-specific disability, health-related quality of life), participant ratings of global improvement, health care utilization, health care provider visits, pain medications, and employment/disability compensation status. A total of 205 effect sizes from 22 studies were pooled in 34 analyses. Positive effects of psychological interventions, contrasted with various control groups, were noted for pain intensity, pain-related interference, health-related quality of life, and depression. Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious. Multidisciplinary approaches that included a psychological component, when compared with active control conditions, were also noted to have positive short-term effects on pain interference and positive long-term effects on return to work. The results demonstrated positive effects of psychological interventions for CLBP. The rigor of the methods used, as well as the results that reflect mild to moderate heterogeneity and minimal publication bias, suggest confidence in the conclusions of this review.

News report:

Pain, Pain, Go Away

Psychological approaches help people cope with chronic pain

Chronic pain due to disease, disorder or accident affects nearly a third of the U.S. population every year. With arthritis, fibromyalgia, and low back or muscle pain among the top offenders, chronic pain takes a toll in the pain itself as well as associated disability and emotional distress, lost productivity and high medical costs. Psychologists are working with other health-care providers on multidisciplinary, multimodal ways to help manage the hurt.

To more effectively treat chronic pain, practitioners first need to understand it. Over the last quarter century, researchers have found that pain is as individual as the people who have it, and that subjective assessments of pain do not necessarily match the degree of actual bodily damage.

That realization came in part after the 1985 publication of the West Haven-Yale Multidimensional Pain Inventory. This pioneering assessment allowed patients to report on many key aspects of their pain, including its severity, interference with daily life, their mood and sense of control over their life, and impact on activities. The inventory included observations from people close to the patient. Validated through strong relationships with other standardized measures of pain severity and depression, the inventory helped to open the door to research on the cognitive and behavioral aspects of pain – and revealed the true complexity of chronic pain. As a result, pain assessment and management standards issued by the Joint Commission for the Accreditation of Healthcare Organizations now emphasize pain's multidimensional nature and call for the comprehensive assessment of pain's psychosocial impact.

Once it became clear that psychosocial factors play a role in chronic pain, psychologists developed ways to work with these patients. A rigorous 2006 meta-analysis of 22 randomized studies published between 1982 and 2003, of people with non-cancerous chronic low-back pain, confirmed the beneficial value of psychological interventions. The therapies evaluated in the original studies included behavioral (operant or respondent approaches), cognitive-behavioral, self-regulatory (biofeedback, relaxation or hypnosis), or supportive counseling (non-directive lay or professional counseling). Physical therapies were excluded.

Varied therapies, but especially cognitive-behavioral and self-regulatory treatments, helped to reduce pain intensity, improve emotional and physical functioning, reduce pain-specific disability, improve health-related quality of life, reduce health-care provider visits and pain-medication use, and lower employment/disability compensation costs. Importantly, multidisciplinary programs that included psychological help were better to other active treatments at bettering short-term and long-term work-related outcomes. Self-regulatory treatments such as biofeedback and relaxation training showed relatively strong effects, and may be even better than cognitive-behavioral therapy at relieving both pain intensity and the severity of pain-related depression.

Wednesday, March 21, 2007

Tuesday, March 20, 2007 How Doctors Think: Clinical Judgment and the Practice of Medicine: Books: Kathryn Montgomery

K Montgomery's book is the culmination of many years of working with physicians trying to dissect their way of reaching a complex diagnosis. She has an exceptional hability to put in words what takes 20 years of medical practice. Her concept of medicine not as science but a progressive growth based on experience ( memory of previous encounters with thousands of patients) + new developments is simply revolutionary. Practical reasoning is the essence of how doctors think in the practice of medicine!!!!! This is one of the best books I ever read. I recommend HIGHLY 
Daniel Sette Camara, MD,FACP,FACG, FASGE

Another book on How Doctors Think (Jerome Groopman)

Excerpt from Groopman's book:

Monday, March 19, 2007

Action Potential

Action Potential is a blog by the editors of Nature Neuroscience - and a forum for our readers, authors and the entire neuroscience community. We'll discuss what's new and exciting in neuroscience, be it in our journal or elsewhere. We hope for spirited conversation!

Sunday, March 18, 2007

Chronic Pain blog

My blog is about the "silent epidemic" as it is called Chronic Pain. The
truth about chronic pain is that it knows no age limits or racial
barriers. There are 70 million people in this country suffering from
this deadly and unrelenting disease. I hope to call attention to the
under treatment and stigma of chronic pain and the people who suffer
just like me. I welcome your feedback and comments.

Saturday, March 17, 2007

Pain, the Disease - New York Times

A modern chronicler of hell might look to the lives of chronic-pain patients for inspiration. Theirs is a special suffering, a separate chamber, the dimensions of which materialize at the New England Medical Center pain clinic in downtown Boston. Inside the cement tower, all sights and sounds of the neighborhood -- the swans in the Public Garden, the lanterns of Chinatown -- disappear, collapsing into a small examining room in which there are only three things: the doctor, the patient and pain. Of these, as the endless daily parade of desperation and diagnoses makes evident, it is pain whose presence predominates.

''Yes, yes,'' sighs Dr. Daniel Carr, who is the clinic's medical director. ''Some of my patients are on the border of human life. Chronic pain is like water damage to a house -- if it goes on long enough, the house collapses. By the time most patients make their way to a pain clinic, it's very late.'' What the majority of doctors see in a chronic-pain patient is an overwhelming, off-putting ruin: a ruined body and a ruined life. It is Carr's job to rescue the crushed person within, to locate the original source of pain -- the leak, the structural instability -- and begin to rebuild: psychically, psychologically, socially.

Harvard Medical International: A cure for pain

Pain is the great equalizer. It crosses geography, culture, language, religion, and socioeconomic status. You don't need a PhD to feel the tingling pain of a banged elbow, or the blinding pain of a migraine headache. And while you may say "Ouch, that stings!" or "Ai! Doi demasiado!" words only approximate the experience.

But pain isn't all bad. In fact, it's healthy and necessary. Pain is what keeps a person with a broken leg from walking on it. Pain is the signal that tells someone to pull his hand away from a hot stove. "Pain is so essential to survival that virtually all living organisms, even amoebas, have primitive pain systems," says Anne Louise Oaklander, MD, PhD, a neurologist and director of the Nerve Injury Unit in the Pain Center at Massachusetts General Hospital (MGH). "Pain is what keeps us out of harm's way."

But sometimes this helpful system goes into overdrive. Pain lingers, instead of disappearing with the injury or disease that produced it. It can persist for months beyond its original cause, taking on a life of its own. Today, doctors consider such chronic, or persistent, pain a disease in its own right. And it's a global problem. In this article, HMI World takes a look at what we are learning about the origins of pain, and what we might be able to do in the future to alleviate it.

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Friday, March 16, 2007

ABC News: Experts Seek Options on Painkiller Abuse

Experts Seek Options on Painkiller Abuse

Healthbeat: Scientists Hunt for Options in Balancing Painkiller Effects and Addiction

By LAURAN NEERGAARD, The Associated Press

WASHINGTON - Scientists are hunting new ways to help millions of pain sufferers from addiction-resistant narcotics to using brain scanners for biofeedback amid a worrisome rise in abuse of today's top prescription painkillers.

The good news: Only a tiny fraction of patients who are appropriately prescribed the most powerful painkillers drugs known as opioids, including morphine, Vicodin, fentanyl and Oxycontin ever will become dependent on them.

And scientists told the National Institutes of Health last week that those few who are vulnerable tend also to suffer such psychiatric disorders as depression and anxiety, giving doctors a clue about which patients need closer monitoring.

Opioids "are not dangerous if you know how to use them properly," stressed Dr. Nora Volkow, chief of NIH's National Institute on Drug Abuse. "We need to develop the knowledge that maximizes our ability to use them properly."

Amid fears that rising painkiller abuse will spark a backlash against pain sufferers, Volkow organized a two-day meeting involving several hundred scientists and primary care physicians, to bring the latest science on pain and addiction to doctors struggling to balance the drugs' clear benefits and potential harm.

Some form of chronic pain affects one of every three or four adults worldwide. The government says one in 10 Americans suffers pain that lasts a year or more. For millions, pain is severe enough to be disabling; up to 6 million patients are on long-term opioid therapy. It's not just a question of suffering: Serious pain can actually worsen recovery from various ailments.

How many need opioids but don't get them? Those numbers are hard to come by, but "pain is really under-treated in our society," opioid specialist Dr. Christopher Evans of the University of California, Los Angeles, told the NIH meeting.

By some estimates, as many as 40 percent of cancer patients and the terminally ill don't even get those medications.

At the same time, prescription drug abuse, particularly of opioid painkillers, is on the rise. One in 10 high school seniors admits to popping Vicodin for nonmedical purposes, and recent studies suggest about 2.2 million people age 12 and older first abused painkillers in the past year, outpacing new marijuana users. Some 415,000 people received treatment for painkiller abuse last year, Evans said.

So the hunt is on for pain relief that minimizes the abuse risk not just for the 2 percent of pain patients who might become dependent, but to discourage theft or other diversion of the drugs.

"We really need to get smarter," said Dr. Pamela Palmer, director of pain research at the University of California, San Francisco, who laments that the only way now to tell how patients are using painkillers is "making people pee in a bottle to see if the drug I prescribed is in there."

Under research now:

Pain Therapeutics Inc.'s Remoxy is in late-stage clinical trials to see if it offers an abuse-resistant version of oxycodone, the ingredient in Oxycontin. Oxycontin tablets are supposed to slowly dissolve for long-term pain relief, but abusers crush them and snort or inject the powder for a fast high. Remoxy is a thick gelatin version of oxycodone crushing it just yields goo.

Also being studied is a combination of naltrexone, a drug used to reduce alcohol craving, with oxycodone. The extra drug should tamp down oxycodone's brain-stimulating effect, Palmer said, but one question is whether that also will diminish pain relief.

Another approach now in early trials pairs technology with tiny tablets of a hospital-strength opioid, sufentanil, redesigned to dissolve almost instantly under the tongue. A computerized dispenser, the size of a remote control, is programmed with the patient's dose of Nanotabs and records how much is used and how often, information the doctor would require before allowing refills or adjusting doses, says Palmer, who is working with manufacturer AcelRx Pharmaceuticals.

Better would be drugs that more selectively target the brain receptors that react to opioids, blocking multiple ones at the same time so that it's harder to develop tolerance or suffer withdrawal. While that is still years away, an initial attempt worked in rats, and NIDA will push additional research to speed human trials, Volkow said. "That would be an amazing thing."

Then there's the non-drug approach: Omneuron Inc. and Stanford University researchers are trying to teach patients to control how much pain they feel by scanning their brains and showing them the real-time MRI images as they try out different techniques.

"The brain is built to be able to modulate its pain-control processes," says Omneuron chief executive Christopher deCharms. "We're teaching people to gain conscious control."

The first study, with a few chronic pain sufferers plus healthy people given painful zaps, suggests the approach may relieve pain right after participants are trained. Now the question is whether the pain relief is real and lasts. A larger trial to test that is under way.

Thursday, March 15, 2007

US upholds medical marijuana ban

A US federal appeals court has ruled that a California woman who uses marijuana to ease a number of ailments can be prosecuted on federal charges.

"Today I found out I'm basically a dead man walking," said Ms Raich, a 41-year-old mother of two in Oakland, California.

As well as the brain tumour, she has scoliosis, chronic nausea and other medical problems.

She said she takes marijuana every two hours to ease her pain and boost her appetite and said she would continue to do so.

"Today the court said I don't have the constitutional right to basically stay alive," she said.

The three-judge appeals panel acknowledged that although support for the medical use of marijuana was growing, the US was not yet at the point where "the right to use medical marijuana is 'fundamental' and 'implicit in the concept of ordered liberty'."

Ms Raich said she would lobby Congress to change the 1970 Controlled Substances Act that bans marijuana.

Wednesday, March 14, 2007

American Pain Foundation


Our job at the American Pain Foundation is to provide people with pain with practical, up-to-date, scientifically-sound information about pain and pain management. We also encourage people with pain to learn all they can about pain and pain management treatment options, become their own best advocates, and demand the treatment they need and deserve.

If you are a person with pain, you should know that:

  • Pain is a national healthcare crisis. As a person with pain, you are among either the more than 50 million Americans suffering from chronic pain, or the 25 million experiencing acute pain as a result of injury or surgery.
  • Although most pain can be managed or greatly eased with proper pain management, the tragedy is that most pain goes untreated, undertreated, or is improperly treated.
  • With proper pain management, your overall health, well-being, and quality of life will improve. Your mind and body will be less stressed. You'll be able to sleep better and enjoy relationships with friends and family. You may also be able to resume your normal activities including going to work and taking part in social activities.
  • Finding good pain care and taking control of pain can be hard work. As a person with pain, you should become your own best advocate. Learn all they can about pain and possible treatments, and insist on the care you need and deserve.

Multiple Sclerosis Sufferer Serving 25-Year Sentence for Taking Pain Killers

Jailing Richard Paey for taking pain pills serves no one -- not taxpayers, not pain patients, and certainly not the image of America as a decent, humane country.

Florida's Supreme Court has rejected an appeal from Richard Paey, a wheelchair-using father of three who is currently serving a 25-year mandatory prison sentence for taking his own pain medication. In doing so, the court let stand a decision which essentially claims that the courts have no role in checking the powers of the executive and legislative branches of government when an individual outcome is patently unjust.

Richard Paey -- who suffers both multiple sclerosis and from the aftermath of a disastrous and barbaric back surgery that resulted in multiple major malpractice judgments -- now receives virtually twice as much morphine in prison than the equivalent in opioid medications for which he was convicted of forging prescriptions.

He had previously been given legitimate prescriptions for the same doses of pain medicine -- but made the mistake of moving to Florida from New Jersey, where he could not find a physician to treat his pain adequately. Each of his medical conditions alone can produce agony. Paey has described his pain as constantly feeling like his legs had been "dipped into a furnace."

The Ivy-league educated attorney has no prior criminal convictions, and weeks of surveillance by narcotics agents did not find him selling the medications.

The Florida Court of Appeals had upheld his conviction -- despite the lack of evidence of trafficking and despite the fact that most of weight of the substances he was convicted of possessing (higher weights lead to longer sentences) was made up of Tylenol, not narcotics. The majority suggested that Paey seek clemency from the governor, claiming that his plea for mercy "does not fall on deaf ears, but it falls on the wrong ears."

In a jeremiad of a dissent, Judge James Seals called the sentence "illogical, absurd, unjust and unconstitutional," noting that Paey "could conceivably go to prison for a longer stretch for peacefully but unlawfully purchasing 100 oxycodone pills from a pharmacist than had he robbed the pharmacist at knife point, stolen 50 oxycodone pills, which he intended to sell to children waiting outside, and then stabbed the pharmacist."