Friday, September 28, 2007

Oncology Nursing Society's Pain Management Special Interest Group

The Oncology Nursing Society (ONS) is a national organization of more than 33,000 registered nurses and other healthcare professionals dedicated to excellence in patient care, teaching, research and education in the field of oncology. A prime goal of ONS is to provide a network of peer support and exchange for oncology nurses. To do so, ONS established a formal structure of Special Interest Groups (SIG) to facilitate the networking of members in an identified subspecialty area. The Pain Management SIG was established in 1989.

Pain Management SIG Mission

The mission of the Pain Management SIG is to promote excellence in oncology nursing through the promotion of optimal pain control for all persons throughout their cancer experience by studying, researching, and exchanging information, and to provide a system for networking and resource sharing for nurses with a special interest and/or expertise in pain management.


  • Provide a system for networking and resource sharing.
  • Identify non-pharmacological pain treatment modalities which may benefit individuals with cancer.
  • Collaborate with the Patient Education SIG to evaluate current patient education resources for cancer pain and to develop a plan for public education regarding pain management.
  • Support the distribution and implementation of the AHCPR Cancer Pain Management Guidelines.
  • Support the work of State Cancer Pain Initiatives (CPIs).
  • Explore the impact of pain management as related to the physician assisted suicide movement in the United States.
  • To assist, as needed, with the update of ONS Pain Position Paper.


The Pain Management SIG fulfills their mission and goals through: working with various ONS project teams; working with the Patient Education SIG to collect samples of patient education materials regarding cancer pain management; preparing topic submissions on pain issues for presentation at ONS educational events (i.e. Congress and Institutes of Learning); collaborating with other organizations which focus on the oncology pain population (e.g., Alliance of State Cancer Pain Initiatives and the City of Hope MayDay project); and promoting the expertise of Pain Management SIG members through nominating SIG members for Excellence Awards.

Jim Morrison on pain

"Pain is meant to wake us up. People try to hide their pain. But they're
wrong. Pain is something to carry, like a radio. You feel your strength
in the experience of pain. It's all in how you carry it. That's what
matters. Pain is a feeling. Your feelings are a part of you. Your own
reality. If you feel ashamed of them, and hide them, you're letting
society destroy your reality. You should stand up for your right to feel
your pain."

Jim Morrison (1943-1971)

Thursday, September 27, 2007

How one man conquered chronic pain -

How one man conquered chronic pain
  • As many as one in three American adults suffer from chronic pain
  • Chronic pain continues a month or more beyond usual recovery period 
  • Expert: Pain is the top reason patients seek medical care

BOSTON, Massachusetts (CNN) -- Timothy Connick was in agony for six years. In bed at night, it felt as if a pair of scissors was sticking out of his foot. "I turn over, and it's just like they're getting jammed in more."

Connick, 52 from Lynn, Massachusetts, injured his foot falling from a loading dock at work 11 years ago. "I fell about seven feet onto the concrete and smashed my heel. It started hurting that moment and kept hurting for six years after that."

Connick is among millions. As many as one in three American adults suffer from chronic pain, according to the American Chronic Pain Association.

The organization defines chronic pain as "pain that continues a month or more beyond the usual recovery period for an injury or illness or that goes on for months or years because of a chronic condition." It's usually not constant, the group says, but can disrupt the sufferer's life.

Over the years, Connick consulted multiple doctors and tried two dozen medications for pain management, but nothing eased the pain and the resulting depression. "It was pretty much a no-win situation as long as that pain was going to be there," he recalls.

He was eventually referred to neurologist Anne Louise Oaklander, director of the nerve injury unit at Massachusetts General Hospital in Boston. "Pain is the No. 1 reason why patients seek medical care, but until recently it hasn't been part of the medical school curriculum," she says. "Many physicians and nurses feel uncomfortable and unqualified to treat these patients."

Oaklander sees many patients whom she describes as "bouncing around the health care system" for years with no firm diagnosis. She divides chronic pain sufferers into two groups. "One is the group that has an ongoing cause of their pain," she says. "The classic example of that is patients with arthritis. They have pain in their joints every day." Much more difficult, she says, is the second group: "Patients who have chronic pain without an obvious cause of tissue injury."

Connick falls in the second category, Oaklander says, noting that X-rays show broken bones, but not nerve damage. "It was only many years later when he was examined by a neurologist that his underlying nerve injury was identified and able to be treated," she said. 

Oaklander says pain medications can help most patients, but there are other options. For instance, she says, if the pain is related to an orthopedic problem, physical therapy may be the best choice.

In Connick's case, relief came through surgery to implant a peripheral nerve stimulator above his hip. Based on pacemaker technology, the stimulator is placed under the skin and works by giving off benign pulses that override pain signals to the brain, Oaklander explains.

She cautions that minor surgery is involved, and the device works in only about half the patients who get it.

For Connick, it made all the difference. "The day they put it in and I turned it on, I was up seven flights of stairs before they stopped me. Everything that I hadn't been able to do and everything that made me happy was back available to me again and I knew it right away."

These days, Connick is back at work loading trucks. He's on his feet all day and doesn't complain about any pain.

Oaklander concludes: "If you have chronic pain, don't take no for an answer....I think it's important for chronic pain patients to keep a sense of purpose, optimism and hope despite the indignities that many are subjected to."

Tuesday, September 25, 2007

Canadian Pain Society: Accreditation Manual

Making It Happen! 

Unrelieved pain remains one of the most common and most poorly treated complaints of patients in our society today. In some cases this simply reflects our limited understanding of the puzzle of pain. However in most cases, poor pain management is due to factors which are well understood, including: a lack of appropriate pain education in most health care professional schools; a lack of awareness or an unreasonable fear of using the treatment tools already available to us; an attitude that treating pain is not important and a lack of awareness on the part of the public that, indeed, pain can be better managed.

In spite of an ever increasing number of published reviews and guidelines over the past decade, published surveys show that pain continues to be poorly managed in most health care facilities. It is therefore very appropriate that the Canadian Council on Health Services Accreditation (CCHSA) has recently added pain assessment and management to the accreditation standards. This will raise the profile of appropriate pain management in accredited institutions and lead to better patient care. 

For those health care facilities in Canada who are struggling to improve pain management practices, a set of practical guidelines from others who have already been through this process would be an invaluable asset. This document, produced by the Special Interest Group on Nursing Issues, of the Canadian Pain Society, will be an excellent place to begin.


This guide has been prepared as a resource by the Special Interest Group on Nursing Issues of the Canadian Pain Society, and has been reviewed by an inter-professional group. It has been developed to help organizations and health care professionals meet the new pain assessment and management standard from the Canadian Council on Health Services Accreditation (CCHSA)

Research continues to uncover and document the prevalence of unrelieved pain despite evidence of physiological and psychological negative consequences. The revised accreditation standards include a pain-focused criterion to improve how pain is assessed and managed in all clinical settings. This guide is intended as a resource to assist in the development of pain assessment and management strategies in your organization.

No evidence magnet therapy dulls pain: study

No evidence magnet therapy dulls pain: study

Last Updated: Tuesday, September 25, 2007 | 9:18 AM ET
The Canadian Press

They're embedded in everything from mattresses to insoles for shoes to wrist bands — but there is no definitive scientific evidence that static magnets can relieve chronic pain, researchers say.

Products that incorporate static magnets are a multibillion-dollar business worldwide, and many chronic pain sufferers are drawn by the promise they hold for alleviating such nagging conditions as arthritis, fibromyalgia and low back discomfort.

The theory from proponents is that a magnetic field increases blood flow, causing increased oxygen, nutrients, hormones and painkilling endorphins to be distributed to tissues in the affected area.

Researchers at the universities of Exeter and Plymouth in England decided to search the medical literature to determine whether there is any proof magnets can reduce pain.

In their analysis of nine randomized trials comparing products containing magnets with those containing either no magnet or very weak ones, the researchers found that the data did not support the use of magnetic therapy for pain control.

"There is no definite grounds of being absolutely sure that a magnet works or not," lead author Dr. Max Pittler, a complementary medicine specialist, said Monday.

Monday, September 24, 2007

Richard Paey Is Free - TierneyLab - Science - New York Times Blog

Richard Paey Is Free

DAYTONA BEACH — A victim in the war on drugs, Richard Paey was just wheeled out of prison by a guard, a free man for the first time in 3 ½ years thanks to an immediate and unexpected pardon by Gov. Charlie Crist and the Cabinet this morning.

''I feel pretty good. I feel pretty good,'' he said, squinting in the sunshine from his wheelchair. "Today was the day for miracles. I didn't think this day would come.''

Mr. Paey, who was serving a 25-year sentence in connecton with prescription for painkillers, became a rallying cause for chronic-pain patients and doctors across America. (You can read more about his case in this column about my visit with Mr. Paey in prison, as well as another column about the prosecutor in the case.) After hearing his case presented to the state clemency board, Gov. Crist said: "We aim to right a wrong and exercise compassion and to do it with grace."

Then, according to the St. Petersburg Times, "Paey's wife Linda, their three children, a family friend and attorney John Flannery II hugged and cried at the podium, the entire cabinet meeting room erupting into applause at 9:40 a.m." The story continues:

It was a stunning turn in the long saga of Paey, a 48-year-old Hudson man who suffers debilitating pain from a 1985 car wreck, botched back surgery and multiple sclerosis that has left him needing the use of a wheelchair in prison.

He was first arrested in 1997 and convicted on the third try in 2004 of possessing, trafficking and illegally obtaining the medication he needs for the searing, fiery pain in his back and legs.

His supporters still contest every bit of the state's case and today, they finally found sympathetic ears eager to help. His medical condition is real, they told the cabinet, evidenced by the amount of painkillers the Department of Corrections itself now gives to Richard Paey every day.

What makes Thursday's development all the more surprising was that the Florida Parole Commission actually recommended against commuting Paey's sentence to time served.

But then Crist allowed Flannery to speak for nearly 30 minutes — much more than the 5-minute limit. Then the governor allowed Linday Paey, their three children and even a family friend to speak.

After their emotional presentation, the first comments from the dais came from the governor:

"I want to move that we grant a full pardon." All three cabinet members agreed.

The family had never hoped for a full pardon or even thought to ask. It was just the start of a day of surprises for Linda Paey and her children.

"I grabbed John's hand, we came into this so scared, trembling," she said. "I was so fearful when I heard the parole commission did not support his application.

"It was a complete shock," she said of Crist's recommending a full pardon and ordering her husband's release today. "I didn't know you could do that."

Acupuncture Tops Conventional Therapy for Low-Back Pain

Acupuncture Tops Conventional Therapy for Low-Back Pain 

By Charles Bankhead, Staff Writer, MedPage Today

BOCHUM, Germany, Sept. 24 -- Acupuncture offers an effective alternative to conventional therapy for low-back pain, investigators here reported.

Almost twice as many patients responded to acupuncture versus conventional therapy, Heinz G. Endres, M.D., of Ruhr-University Bochum, and colleagues reported in the Sept. 24 issue of Archives of Internal Medicine.

However, sham acupuncture worked just as well as verum, or true, acupuncture, they reported.

"Acupuncture constitutes a strong alternative to multimodal conventional therapy," the authors concluded. "Acupuncture gives physicians a promising and effective treatment option for chronic low-back pain, with few adverse effects or contraindications."

As for the equally good results with fake or real acupuncture, the authors said, "The superiority of both forms of acupuncture suggests a common underlying mechanism that may act on pain generation, transmission of pain signals, or processing of pain signals by the central nervous system and that is stronger than the action mechanism of conventional therapy."

Used to treat many medical conditions, acupuncture has a controversial role in the management of low-back pain, although a recent Cochrane review concluded that it might be useful as an adjunct to other therapies (Cochrane Database Syst Rev 2005;(1):CD001351).

Dr. Endres and colleagues reported findings from what they believe to be the first randomized, controlled trial of verum versus sham acupuncture for treatment of low-back pain. The German Acupuncture Trials involved clinicians in 340 outpatient practices and included 1,162 patients who had a history of low-back pain lasting an average of eight years.

The patients were treated with either verum or sham acupuncture or conventional therapy, which consisted of a combination of drugs, physical therapy, and exercise. Verum acupuncture consisted of 10 30-minute sessions of treatment according to principles of traditional Chinese medicine. Patients assigned to sham acupuncture received superficial needling at non-acupuncture points.

The primary outcome was six-month response rate, with response defined as at least 33% improvement on three pain-related items on the Von Korff Chronic Pain Grade Scale or 12% improvement on the back-specific Hanover Functional Ability Questionnaire.

At the end of the study, 47.6% of patients in the verum acupuncture group had responded, as had 44.2% in the sham acupuncture group, and 27.4% in the group that received conventional therapy. Both acupuncture groups had significantly higher response rates compared with conventional therapy (P<0.001).

The inferiority of conventional therapy to both acupuncture groups "raises questions about qualitative and quantitative aspects of conventional therapy," the authors stated. Even so, results with conventional therapy exceeded those observed in a previous German-based study of routine care for low-back pain.

They also pointed out that "the effectiveness of sham acupuncture and the principle of nihil nocere suggest that a discussion is called for about the necessary depth of insertion of acupuncture needles."

The finding that both sham and true acupuncture relieved back pain is puzzling, commented Rex Marco, M.D., an orthopedic surgeon at the University of Texas Health Science Center in Houston. He speculated that the sham needling could have triggered endorphin release or other potentially therapeutic effects. The sham procedures also could have had an unexpectedly large placebo effect.

Alternatively, he said, the pain-relieving benefits of sham acupuncture might have been emotional or psychological in nature.

"It's possible that the physical contact during the sham procedures had a relaxing or soothing effect that helped relieve the pain," said Dr. Marco. "Maybe the contact and interaction with the acupuncturist was beneficial. It's really impossible to know why the sham procedures had a therapeutic effect. For that matter, it's entirely possible that the sham and true procedures worked through similar or the same underlying mechanisms."

The findings are at odds with previous studies that have shown a difference between true and sham acupuncture, said Eric Manheimer, a clinical research associate at the University of Maryland in Baltimore. More than one study has shown at least a trend in favor of true acupuncture.

Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer by Shannon Brownlee

Is a CT scan always necessary after your child suffers a bump on the head? Should you think twice before undergoing surgery for lower back pain? Are your elderly parents going to be allowed to die at home, or will they spend their last few weeks in a hospital, hooked up to machines and tubes, subjected to painful, unnecessary procedures?

These are the kinds of questions you may find yourself asking once you’ve read Overtreated. Each year, our medical system delivers an enormous amount of care that does nothing to improve our health or lengthen our lives. Between 20 and 30 cents on every health care dollar we spend goes towards useless treatments and hospitalizations, towards CT scans we don’t need, towards ineffective surgeries—towards care that not only does nothing to improve our health, but that we wouldn’t want if we understood how dangerous it can be. This is the surprising and deeply counterintuitive message of Overtreated.

Monday, September 17, 2007

News - TopAbstracts in Pain 09/13/2007

TopAbstracts in Pain

TopAbstracts™ in Pain are the abstracts most highly rated/most read by nearly 300,000 physicians who received a Doctor's Guide™ newsletter or visited a website Powered by Doctor's Guide™ in the past 7 days. Over 2000 peer-reviewed journals are covered by TopAbstracts.

Rating your pain from 0 to 10 might not help your doctor

Rating your pain from 0 to 10 might not help your doctor

INDIANAPOLIS -The most commonly used measure for pain screening may only be modestly accurate, according to researchers from the Indiana University School of Medicine and the University of North Carolina. In a study that appears in the October issue of the Journal of General Internal Medicine, they evaluate the usefulness of a scale that asks patients in primary care to rate their current pain from 0 (no pain) to 10 (worst pain).

Universal pain screening is an increasingly common practice, largely because of the Joint Commission on Accreditation of Healthcare Organization’s requirement that accredited hospitals and clinics routinely assess all patients for pain. JCAHO is the nation’s predominant standards-setting and accrediting body in health care.

“Our study is the first to evaluate the accuracy of the widely-used numeric rating scale [NRS] as a screening test to identify primary care patients with clinically important pain. Accurate screening is important because pain symptoms, both serious and not so serious, are among the most common complaints in primary care,” said Erin E. Krebs, M.D., M.P.H., assistant professor of medicine at the IU School of Medicine and a Regenstrief Institute research scientist. “To be helpful, a screening test needs to provide accurate information that doctors can use to improve care. If a test isn’t very accurate or useful, doctors learn to tune out the numbers.”

The authors found that, while the NRS is easy to administer, it fails to identify about a third of patients with pain serious enough to impair day-to-day functioning. Most patients in this study had long-standing pain, and many had more than one pain problem. The authors did not evaluate the accuracy of pain ratings in settings where short-term pain is more common, such as after surgery. The researchers noted that because it focuses on current pain, the NRS may miss intermittent symptoms. They also reported that “pain” was not the preferred word for some patients. For example, one study participant indicated that he felt discomfort, but not pain.

“Universal pain screening has become widespread despite a lack of research evaluating its accuracy and effectiveness. We know that pain is a serious problem in primary care, but pain screening may not be the best way to address this problem,” said Dr. Krebs, who is also with the Center on Implementing Evidence-based Practice at the Roudebush Veterans Affairs Medical Center in Indianapolis.

The sight of others' pain modulates motor processi...[Cereb Cortex. 2007]

The sight of others' pain modulates motor processing in human cingulate cortex.

Cereb Cortex. 2007 Sep;17(9):2214-22

Neuroimaging evidence has shown that a network including cingulate cortex and bilateral insula responds to both felt and seen pain. Of these, dorsal anterior cingulate and midcingulate areas are involved in preparing context-appropriate motor responses to painful situations, but it is unclear whether the same holds for observed pain. Participants in this functional magnetic resonance imaging study viewed short animations depicting a noxious implement (e.g., a sharp knife) or an innocuous implement (e.g., a butter knife) striking a person's hand. Participants were required to execute or suppress button-press responses depending on whether the implements hit or missed the hand. The combination of the implement's noxiousness and whether it contacted the hand strongly affected reaction times, with the fastest responses to noxious-hit trials. Blood oxygen level-dependent signal changes mirrored this behavioral interaction with increased activation during noxious-hit trials only in midcingulate, dorsal anterior, and dorsal posterior cingulate regions. Crucially, the activation in these cingulate regions also depended on whether the subject made an overt motor response to the event, linking their role in pain observation to their role in motor processing. This study also suggests a functional topography in medial premotor regions implicated in "pain empathy," with adjacent activations relating to pain-selective and motor-selective components, and their interaction.

Sunday, September 16, 2007

A Hidden Cause of Headache Pain - New York Times

A Hidden Cause of Headache Pain


Sometimes, the cure is worse than the disease. Sometimes, the cure is the disease.

Four percent of Americans suffer headaches daily, and scientists have suspected culprits as diverse as undiagnosed jaw disorders, genetic susceptibility and stress. But according to recent research, a sizeable and growing number of headaches are being caused by the very medications taken to alleviate them — and the problem is far more common than scientists had realized. Half of chronic migraines, and as many as 25 percent of all headaches, are actually "rebound" episodes triggered by the overuse of common pain medications. Both prescription and over-the-counter drugs may be to blame.

Patients begin by popping too many pills to deal with a migraine or a simple tension-type headache. When the medications stop, another headache follows, similar to a hangover. Sufferers race again to the medicine cabinet, and before long they are locked in a cycle of headaches and overmedication.

At any given time, more than three million Americans are suffering from headaches they are inflicting on themselves, according to Dr. Stephen D. Silberstein, a professor of neurology and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia. "If a patient's headaches have grown markedly worse or more frequent, the problem is almost always medication overuse," Dr. Silberstein said.

The International Headache Society last year published revised criteria to help doctors recognize and treat headaches from medication overuse. Signs of trouble include headaches that occur 15 or more days a month, according to the society, along with the heavy use of pain medications for three months or more. Overuse is defined as taking pain medication for 15 or more days a month.

"Overuse has less to do with how many pills you take to relieve a single headache than with how often you take them," said Dr. Robert Kunkel, a headache specialist at the Cleveland Clinic Headache Center. "If you get more than two headaches a week and take pain pills for them, you're at risk."

The only way to know whether medication is contributing to your headaches is to stop taking them. Unfortunately, it can take as long as two months for medication-dependent patients to see an improvement.

Migraine sufferers seem to be especially susceptible to rebound episodes. Many doctors begin weaning these patients off painkillers by prescribing drugs to help prevent attacks, then gradually reducing doses of the painkillers used to treat acute episodes.

Several drugs have been approved to prevent migraines. The most recent is topiramate (Topamax), which studies suggest may lessen the frequency of attacks for up to 14 months. In addition, early trials suggest that Botox injected into the scalp can prevent or reduce the frequency of both migraines and tension headaches.

(Although not yet approved by the Food and Drug Administration for headaches, botulinum toxin is being offered by a growing number of headache clinics. When it works — which is by no means certain — it can provide relief for up to three months.)

Tension headaches can frequently be prevented with stress reduction techniques and avoidance of certain triggers. With close attention to prevention, sufferers should not need to resort to painkillers often enough to risk rebounding.

Yet almost any kind of pain pill can cause rebound problems if used to excess. Among over-the-counter drugs, those with caffeine, like Excedrin, are the likeliest villains, studies show. Among prescription drugs, triptans are most commonly associated with rebounding, Dr. Silberstein said.

But in terms of both rebound and dependence, the most problematic drugs are those containing butalbital, a barbiturate. Two such medications, Fioricet and Fiorinal, have been banned in Germany because they so often led to medication-related headaches. Both are still prescribed in the United States.

Now that research has begun to spotlight the extent of the problem of medication-overuse headaches, more and more doctors on are on the lookout for signs of trouble. "Believe me, a lot of patients don't want to hear that they have to stop taking their pain pills in order to get relief," Dr. Kunkel said. "But for these kinds of headaches, that's really the only solution."

Once weaned from medicine, most patients show significant improvement after three months. They also learn their lesson and steer clear of overusing pain pills, research shows. In one study, 87 percent continued to report significant improvement two years after stopping overusing painkillers. Many headache sufferers have been praying for a miracle cure. Now it's here, though it may not be what they expected.

Friday, September 14, 2007

Scientific American: Cephalon warns doctors over pain drug deaths

Cephalon warns doctors over pain drug deaths

By Kim Dixon and Toni Clarke

WASHINGTON/BOSTON (Reuters) - Cephalon Inc has warned doctors about deaths linked to improper use of its cancer pain drug Fentora, U.S. drug regulators said on Thursday, sending the company's shares down 5 percent.

The U.S. Food and Drug Administration posted on its Web site Cephalon's letter to doctors dated September 10, warning of deaths and serious side effects in patients treated with the pain killer.

Cephalon spokeswoman Candace Steele said the company has received reports of three deaths related to inappropriate prescribing of the drug. The deaths occurred during the summer and are most likely due to respiratory failure, she said.

Two deaths were in patients who could not tolerate narcotics and were prescribed Fentora for headache or migraine. One death was associated with improper dosing, Steele said.

Cephalon also received a report of a person who committed suicide while thought to be on the drug, although Fentora was not prescribed for that patient by a physician.

CIBC Markets analyst Bret Holley said he did not expect doctors to stop prescribing Fentora because it is among potent pain-killing drugs that are known to carry similar risks.

"The risk of death is a serious concern with any strong opioid," Holley said in an investor note. "The headline is scarier than any potential impact on sales."

Cephalon said 78,000 prescriptions were written for the drug between October 2006 and September 2007.

An FDA spokeswoman was not available for further comment.

Last year, an investigation by Connecticut's attorney general found that Cephalon illegally promoted some drugs for uses for which they are not approved, including Actiq, Cephalon's older cancer pain medicine.

Cephalon is also one of a host of companies that have been subpoenaed in a U.S. congressional probe into off-label treatments, which occurs when doctors prescribe products for uses other than those officially approved by regulators.

Fentora is approved to treat so-called breakthrough pain, pain experienced despite regular pain medication, in patients with cancer who are already receiving and able to tolerate opioid therapy such as morphine or oxycodone.

The company is seeking approval to expand use of the drug into other pain conditions, such as back pain.

Cephalon shares closed $3.99 lower to $72.55 on Nasdaq, after going as low as $71.86 earlier in Thursday's session.

Wednesday, September 12, 2007

Say Om: yoga and other therapies good for chronic pain

Ask devotees about the benefits conferred by alternative therapies such as yoga, tai chi and hypnosis, and they'll tell you the list is lengthy. After a recent review by researchers at the University of Pittsburgh, chronic pain management can be added to the list.

According to the study, chronic non-malignant pain occurs in up to 50 per cent of older adults.

Researchers reviewed 20 clinical trials involving eight mind-body therapies for adults who suffered from chronic, non-malignant pain, to assess their feasibility, effectiveness in pain management and safety.

The findings are published in Volume 8 of the journal Pain Medicine.

The therapies reviewed included biofeedback (learning to control body functions) , progressive muscle relaxation (tensing and releasing muscles), meditation, guided imagery (visualization techniques), hypnosis, tai chi chuan (a Chinese martial art consisting of sequences of very slow, controlled movements) qi gong (movements that include elements of meditation, relaxation and physical movement), and yoga.

All eight treatments were found to be feasible for older adults, and no adverse events or safety concerns were reported. Researchers found that progressive muscle relaxation may be particularly effective for older people with osteoarthritis pain, while meditation and tai chi appear to improve function and coping with low back pain and osteoarthritis.

The benefits of the various therapies were assessed individually:
  • Biofeedback: seen as beneficial for chronic low-back pain, headache and rheumatologic pain.
  • Progressive muscle relaxation: though some studies found that it improved headaches, little evidence exists about its effect on other types of chronic pain.
  • Mindfulness meditation and hypnosis meditation: seen as helpful in reducing low back pain.
  • Guided imagery: found to help improve mobility and reduce osteoarthritis pain
  • Tai chi, qi gong and yoga: these therapies improved arthritis pain, joint pain and stiffness; tai chi reduced falls in one study by 47.5 per cent; yoga improved hip extension and stride length, and reduced joint tenderness and hand pain in another study

"The trials we reviewed indicated that mind-body therapies were especially well suited to the older adult with chronic pain," lead author Natalia Morone said in a release. "This was because of their gentle approach, which made them suitable for even the frail older adult. Additionally, their positive emphasis on self-exploration was a potential remedy for the heavy emotional, psychological and social burden that is a hallmark of chronic pain."

The authors note that due to the scarcity of studies on the benefits of such therapies in older people, and the small sample sizes of many of the studies, more evidence about their effectiveness is needed.

"The small numbers of trials of mind-body therapies for chronic pain in the older adult are beginning to shed light on the potential benefits of these interventions," the review. "The many questions they leave unanswered provide ample opportunity for further research."

Seattle Post-Intelligencer: Funky Winkerbean


Lisa's Story

"A good cartoonist is one who can make people laugh. A great cartoonist is one who can make people laugh in the midst of fear, sadness, and uncertainty."

— Regina Brett, breast cancer survivor
and president of the National Society of Newspaper Columnists

"Tom Batiuk has brought breast cancer into the unique venue of the comic strip with sensitivity, realism, and wit – attributes essential to the breast cancer experience."

— Andrea Martin, breast cancer survivor
and founder and executive director of the Breast Cancer Fund

In March 2006, Lisa's cancer returned in a more serious form. Following another round of chemo, her cancer appeared to go into remission again in early 2007, but on May 9th, 2007, her doctor revealed that her medical charts had gotten mixed up and her disease was in fact progressing. In a King Features press release[1], it was revealed that "Lisa will start chemo again, learn that her long-range prospects aren't hopeful, stop chemo, deal with telling her daughter about her cancer situation, [and] testify before Congress about the need for cancer research and cope with friends and family." Batiuk has also been very open that Lisa's latest ordeal will end with her death[2] and some of the events that will take place as a result. The entire storyline, which is slated to end in October 2007, will be collected and published in a book entitled "Lisa's Story: The Other Shoe"[3]. The book will include the strips from Lisa's initial battle with cancer as well.

After the May 2007 strip ran, Tom Batiuk discussed his reasoning for pursuing the plotline was inspired by his own personal battle against prostate cancer[4].

Daily comic strip:

Tuesday, September 11, 2007

WNYC - The Leonard Lopate Show: Please Explain: Over-the-Counter Painkillers (podcast)

Please Explain: Over-the-Counter Painkillers

Americans spend more than $2 billion annually on non-prescription pain relievers. Today we'll find out what they are, how they work, how they differ from one another and from prescription drugs, what side effects they cause, and more. Rear Admiral Sandra Kweder, MD, deputy director of the Food and Drug Administration's Office of New Drugs, is here to answer your questions on aspirin, ibuprofen, acetaminophen, and all the rest.

WNYC - The Leonard Lopate Show: Please Explain: Pain (podcast)

Please Explain: Pain

What is pain? And why is it necessary? On today's edition of Please Explain, we'll find out what goes on in our brains and bodies when something hurts us. Joining us are Dr. Michael Salter, Director of University of Toronto Centre for Study of Pain, and Dr. Michael Weinberger, associate clinical professor of anesthesiology at Columbia University, and Director of the Pain Management Center at Columbia- Presbyterian Hospital.

Physicians at conference strive to understand what makes us itch

Several hundred experts in itch from all over the world are meeting in San Francisco this week to talk about everything from that little itch on your back to chronic itchiness that leaves sufferers unable to sleep.

"We want to help people realize that itching can be really severe and a terrible problem, almost as bad as chronic pain," said Earl Carstens, a professor of neurobiology, physiology and behavior at UC Davis who is organizing the Fourth International Workshop for the Study of Itch, which began Sunday at the Hilton San Francisco. "It's not usually life threatening, but it can be. I've read about cases of people who have such severe chronic itching that it drives them to suicide."

Everyone gets itchy sometimes, and most people have experience with some form of acute itchiness - chicken pox, perhaps, or a run-in with poison oak. Few studies about rates of chronic itch exist, but researchers estimate between 15 million and 31 million Americans have a form of atopic eczema, in which allergies cause itchy, inflamed skin.

Little is known about what makes people itch. The minor everyday itches everyone gets are usually caused by simple brushes with small irritants - a fly landing on a hand or a scratchy fabric in one's shirt. Sympathetic itch - the need to scratch when witnessing someone else scratch - probably happens because of an increased awareness of our own bodies.

No one knows for sure why people get itchy, but the main theory is that it's an evolutionary trait - we get itches so we'll scratch away something that irritates our sensitive skin, be it a mosquito or a hand cream that causes an allergic reaction. But that doesn't explain chronic itch.

For decades, researchers assumed itch was a minor form of pain, attached to the same nerves that make us feel pain. But research in the past five or so years has suggested that itch may have a separate nerve pathway.

Some doctors have suggested a sort of yin-and-yang relationship between itch and pain - scratching, a very mild form of pain, alleviates itch, and certain pain-relieving drugs cause itching.

"Pain and itch are different responses, but they're both geared toward protecting you," Carstens said. "You have distinct systems. One, itch, is evolved to get stuff off the surface of your skin, and the other, pain, is to remove yourself from something that is causing damage."

Monday, September 10, 2007

Audio Slide Show from New York Times: Dying of Pain

Fear about addiction leads millions of people to go without pain medicines that are safe, effective and cheap.

Japanese Slowly Shedding Their Misgivings About the Use of Painkilling Drugs - New York Times

September 10, 2007

Japanese Slowly Shedding Their Misgivings About the Use of Painkilling Drugs

OKAYAMA, Japan — If any nation ought to lead the world in the consumption of painkillers, it is Japan.

Its population is aging, and cancer is the leading cause of death.

It has universal health insurance, and few restrictions on prescription narcotics.

And it is a heavily medicated society; it consumes half the world's Tamiflu, the anti-flu drug.

Yet, on charts detailing the per capita consumption of narcotic painkillers throughout the world — routinely topped by the world's richest countries — Japan is down in the neighborhood of Bulgaria and South Africa. It consumes one-twelfth as much per capita as the United States.

The leading reason for that, said Dr. Fumikazu Takeda, a retired neurosurgeon who leads the fight for better pain control, is patients' fear.

Until recently, morphine was used only in hospitals, and near the end.

"People hate morphine because they think, 'As soon as the doctor injected morphine, my father died,' " Dr. Takeda said.

Also, until recently medical schools taught that narcotics should be used only briefly at low doses.

And some national sense of "gaman" — that suffering in silence is a virtue — persists even in hedonistic modern Japan.

"Long ago, a samurai who complained about pain was considered a very weak samurai," he said. Young people have other ideas, but with life expectancies over 80, the typical cancer patient is from another generation.

"Patients in their 70s and 80s who lived through World War II feel guilty to have survived the war," said Atsuko Uchinuno, vice president of the Japanese Society for Palliative Medicine. "I had one patient who told me, 'I need some pain, because I feel bad about the people who died.' "

Some experts scoff at that but admit that the reluctance exists.

"Saying we don't take morphine because of gaman in today's Japan is a stereotype like geishas and Mount Fuji," said Hajime Mizuno, who writes about medical issues. "The biggest reason is that doctors think morphine is evil because it causes addiction, and ordinary people do, too."

But those attitudes are changing. In 1980, Japan was using only 1 percent of the morphine it uses now. And last year, Parliament adopted a new national cancer plan.

Historically, governments feared opium because they saw it devastate China. After World War II, China had 40 million addicts, including the last empress. Mao cracked down ruthlessly, burning crops and executing dealers; by 1960, addiction was virtually gone.

Disdain for pain control is also a byproduct of Japan's medical system.

In May 2006, a member of the Parliament disclosed that he had cancer and said the system was so shamefully disorganized that it left thousands of "cancer refugees" roaming the archipelago looking for care.

Care is typically led by a surgeon who oversees chemotherapy and radiation as adjuncts and focuses less on drug management, including pain control, experts said.

And, until recently, patients were not even given their diagnoses. In a scene from a decade-old documentary well known here, a surgeon shows a family their mother's excised breast on a steel tray to point out the tumor; but she was not even told she had cancer.

Now disclosure is normal, and there is a government campaign urging patients to request pain relief. "Tell Us About Your Pain!" posters decorate hospital walls.

Drug enforcement agencies are struggling to adjust to the new reality.

Dr. Junichi Ikegaki, chief of palliative care at Hyogo Cancer Center, gave an example. His wife runs an outpatient clinic, and 100 OxyContin tablets disappeared from her narcotics cabinet.

In low-crime Japan, the theft of even 100 pills was such big news that television crews showed up with the police.

One narcotics officer criticized Dr. Ikegaki's wife, he said, because the cabinet was not bolted to the wall.

But the officer's partner, saying the country used too few painkillers, took her aside and asked her to prescribe more.

"Hon-ne and tatamae?" Dr. Ikegaki asked, using a Japanese expression for the difference between one's public facade and one's real feelings. "One was a suppressor and the other was a promoter."

Murakami Takahisa, director of drug compliance at the national Health Ministry in Tokyo, chuckled at the story.

His office is decorated with posters warning teenagers about the dangers of Ecstasy, but he is not worried about a crime wave, he said. Heroin use, for example, is negligible. His department sponsors symposiums encouraging doctors to prescribe more painkillers.

"In situations like this," he said, "narcotics officers have to change."

Kumi Takagi, 40, was initially reluctant to take morphine. Her breast cancer has spread to her spine and pelvis, and she has endured surgery, chemotherapy and radiation.

Touching her shoulder blades and lower back, she parsed her pain: "Up here, it was a stinging pain. But down here, it felt like the bones were grinding against each other, as if they were sticking and then breaking free. I wanted to slam my back against a wall."

She resisted until she found herself unable to get out of a chair without help. "Its image in Japan is that you will get hallucinations, or will have difficulties in your daily life," she said. "I was afraid I wouldn't be able to do my work or make my son's lunch."

She now takes morphine every 12 hours and carries a "rescue dose" for the sudden, severe pain called breakthrough pain.

"It's not all gone," she said, "but it's mild, and I can bear it. And I can sleep. Honestly — I wish I'd started it before."

Sunday, September 09, 2007

Drugs Banned, World’s Poor Suffer in Pain - New York Times

Drugs Banned, Many of World’s Poor Suffer in Pain


WATERLOO, Sierra Leone — Although the rainy season was coming on fast, Zainabu Sesay was in no shape to help her husband. Ditches had to be dug to protect their cassava and peanuts, and their mud hut’s palm roof was sliding off.

But Mrs. Sesay was sick. She had breast cancer in a form that Western doctors rarely see anymore — the tumor had burst through her skin, looking like a putrid head of cauliflower weeping small amounts of blood at its edges.

“It bone! It booonnnne lie de fi-yuh!” she said of the pain — it burns like fire — in Krio, the blended language spoken in this country where British colonizers resettled freed slaves.

No one had directly told her yet, but there was no hope — the cancer was also in her lymph glands and ribs.

Like millions of others in the world’s poorest countries, she is destined to die in pain. She cannot get the drug she needs — one that is cheap, effective, perfectly legal for medical uses under treaties signed by virtually every country, made in large quantities, and has been around since Hippocrates praised its source, the opium poppy. She cannot get morphine.

That is not merely because of her poverty, or that of Sierra Leone. Narcotics incite fear: doctors fear addicting patients, and law enforcement officials fear drug crime. Often, the government elite who can afford medicine for themselves are indifferent to the sufferings of the poor.

The World Health Organization estimates that 4.8 million people a year with moderate to severe cancer pain receive no appropriate treatment. Nor do another 1.4 million with late-stage AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease and so on — it issues no estimates but believes that millions go untreated.

Figures gathered by the International Narcotics Control Board, a United Nations agency, make it clear: citizens of rich nations suffer less. Six countries — the United States, Canada, France, Germany, Britain and Australia — consume 79 percent of the world’s morphine, according to a 2005 estimate. The poor and middle-income countries where 80 percent of the world’s people live consumed only about 6 percent.

Some countries imported virtually none. “Even if the president gets cancer pain, he will get no analgesia,” said Willem Scholten, a World Health Organization official who studies the issue.

In 2004, consumption of morphine per person in the United States was about 17,000 times that in Sierra Leone.

At pain conferences, doctors from Africa describe patients whose pain is so bad that they have chosen other remedies: hanging themselves or throwing themselves in front of trucks.

Westerners tend to assume that most people in tropical countries die of malaria, AIDS, worm diseases and unpronounceable ills. But as vaccines, antibiotics and AIDS drugs become more common, more and more are surviving past measles, infections, birth complications and other sources of a quick death. They grow old enough to die slowly of cancer.

About half the six million cancer deaths in the world last year were in poor countries, and most diagnoses were made late, when death was inevitable. But first, there was agony. About 80 percent of all cancer victims suffer severe pain, the W.H.O. estimates, as do half of those dying of AIDS.

Morphine’s raw ingredient — opium — is not in short supply. Poppies are grown for heroin, of course, in Afghanistan and elsewhere. But vast fields for morphine and codeine are also grown in India, Turkey, France, Australia and other countries.

Nor is it expensive, even by the standards of developing nations. One hospice in Uganda, for example, mixes its own liquid morphine so cheaply that a three-week supply costs less than a loaf of bread.

Nonetheless, it is still routinely denied in many poor countries.

“It’s the intense fear of addiction, which is often misunderstood,” said David E. Joranson, director of the Pain Policy Study Group at the University of Wisconsin’s medical school, who has worked to change drugs laws around the world. “Pain relief hasn’t been given as much attention as the war on drugs has.”

Doctors in developing countries, he explained, often have beliefs about narcotics that prevailed in Western medical schools decades ago — that they are inevitably addictive, carry high risks of killing patients and must be used sparingly, even if patients suffer.

Pain experts argue that it is cruel to deny them to the dying and that patients who recover from pain can usually be weaned off. Withdrawal symptoms are inevitable, they say — as they are if a diabetic stops insulin. But the benefits outweigh the risks.

Too Poor for Medicine

In Mrs. Sesay’s case, Alfred Lewis, a nurse from Shepherd’s Hospice, is doing what he can to ease her last days.

When he first saw her, her tumor was wrapped with clay and leaves prescribed by a local healer. The smell of her rotting skin made her feel ashamed.

She had seen a doctor at one of many low-cost “Indian clinics” who pulled at the breast with forceps so hard that she screamed, misdiagnosed her tumor as an infected boil, and gave her an injection in her buttocks that abscessed, adding to her misery.

Nothing can be done about the tumor, Mr. Lewis explained quietly. “All the bleeders are open,” he said. “Her risk now is hemorrhage. Only a knife-crazy surgeon would attend to her.”

Earlier diagnosis would probably not have changed her fate. Sierra Leone has no CAT scanners, and only one private hospital offers chemotherapy drug treatment. The Sesays are sharecroppers; they have no money.

So Mr. Lewis was making a daily 10-mile trip from Freetown, the capital, to change her dressing, sprinkle on antibiotics, and talk to her. He asked a neighbor to plait her hair for her, so she would look pretty. Mrs. Sesay said she could not be bothered.

“It’s necessary for to cope,” he said. “For to strive for be happy.”

“I ‘fraid for my life,” she said.

“Are you ‘fraid for die?”

“No, I not ‘fraid. I ready.”

“So what is your relationship to God? You good with God?”

“I pray me one.”

He asked her, half-jokingly, if she still had sex with her husband.

No, she said, since the illness, he stayed in his room and she stayed in hers. She, too, was joking. In their hut, there is only the one room.

Life has become hard, she added, and her husband is getting too old for farm labor. She, too, is getting old, she said — she is somewhere in her 40s.

“We are really being punish.”

For her pain, Mr. Lewis gave her generic Tylenol and tramadol, a relative of codeine that is only 10 percent as potent as morphine. It was all he could offer. “I would consider putting her on morphine now, if we had morphine,” Mr. Lewis said.

In New York, she would have already started on it, or an equivalent like oxycodone or fentanyl.

Even if his hospice could get it, Mr. Lewis could not give it to her.

Under Sierra Leone law, morphine may be handled only by a pharmacist or doctor, explained Gabriel Madiye, the hospice’s founder. But in all Sierra Leone there are only about 100 doctors — one for every 54,000 people, compared with one for every 350 in the United States.

In only a few places — in Uganda, for example — does the law allow trained nurses to prescribe morphine.

And pharmacists will not stock it.

“It’s opioid phobia,” Mr. Madiye said. “We are coming out of a war where a lot of human rights violations were caused by drug abuse.”

During the war, the rebel assault on the capital was called Operation No Living Thing. Child soldiers were hardened with mysterious drugs with names like gunpowder and brown-brown, along with glue and alcohol.

Esther Walker, a British nurse who sometimes works with Mr. Lewis, said she once gave a lecture on palliative care at the national medical school.

There were 28 students, and she asked them, “Who has seen someone die peacefully in Sierra Leone?”

“Not one had,” she said.

The Burden on the Young

In the poorest countries like this one, even babies suffer.

Momoh Sesay, 2, (no relation to Zainabu) is a pretty lucky little guy — for someone who tumbled into a cooking pot of boiling water.

He lost much of the skin on his thighs, and his belly is speckled with burns as if he had been sloshed with pink paint.

But he was fortunate enough to live close to Ola During Children’s Hospital, the leading pediatric institution.

No doctor was in. There was not even any electricity. At night, nurses thread IV lines into babies’ tiny limbs by candlelight. “And our eyes are not magnets,” one of them, Josephine Maajenneh Sillah, complained.

But they knew Momoh would die of shock and pumped in intravenous fluids and antibiotics.

If he had been born in New York, Momoh would have had skin grafts. Here, that is unthinkable.

Momoh was given saline washes, and his dead skin was scrubbed off with debridement, a painful procedure. In New York, he would have had morphine.

So probably would Abdulaziz Sankoh, 7, in another bed, who has sickle cell disease. He moans at night when twisted blood cells clump together and jam the arteries in his spindly legs, slowly killing his bone marrow.

As would Musa Shariff, an 8-month-old boy whose scalp is so swollen by meningitis that his eyelids cannot close. Dr. Muctar Jalloh, the hospital director, said he would not prescribe morphine to babies or toddlers if he had it. Only in the case of third-degree burns, like Momoh’s, did he say: “I would consider it — maybe.”

That flies in the face of Western medicine, which allows careful use even in premature infants.

The strongest painkiller that Momoh, Abdulaziz and Musa can take, if their parents can afford $1.65 per vial, is tramadol. It is impossible to know what morphine would cost if it were here, but it is sold in India at 1.7 cents a pill by the same company that makes tramadol.

The nurses know the prices because they sell the drugs that are available. They have not been paid for three years, they say, so they support themselves in part by filling the prescriptions that the doctors write. Kind as they are — they do extend credit, and are sometimes moved to charity by the children — it is a business.

That is the other reason Dr. Jalloh said he would not order morphine. “I wouldn’t want to leave my staff in charge of morphine,” he said. “The potential for abuse is so high.”

Worries About Abuse

If morphine were to be imported to Sierra Leone, it would be overseen by two agencies: the National Pharmacy Board and the National Drugs Control Agency.

Kande Bangura, the rangy, sharp-eyed former police commander who runs the drug control agency, said the country had a serious drug-abuse problem, especially among former child soldiers.

It also is a smuggling route. He spread out pictures of an autopsy on a British citizen with Nigerian roots who had dropped dead in line at Freetown’s airport. His intestines were found to be packed with condoms full of cocaine, one of which had burst.

Mr. Bangura said he had no objections to morphine, however, “as long as it’s for medical use and is strictly controlled by the country’s chief pharmacist.”

Wiltshire C. N. Johnson, the chief of the enforcement arm of the National Pharmacy Board, explained why painkillers were not imported.

Scarce funds must go to the top five causes of death, he said: diarrhea, pneumonia, tuberculosis, malaria and sexually transmitted diseases. “I’m not saying that palliative care doesn’t top the list, too,” he said. “But it’s officially a very small percentage of the requirement.”

He also had fears like those of Dr. Jalloh. “There’s no way we’re going to put morphine in the hands of a pharmacy technician,” he said. “In the wrong hands, drugs, like guns, are a greater evil than a cure.”

Mr. Madiye, who predicted exactly those answers before the interviews started, vented his frustration later.

He founded Shepherd’s Hospice in 1995, saw it destroyed in the civil war and rebuilt it. But he cannot get the one drug that would let him give people like Zainabu Sesay the dignified deaths that in the West would be their birthright.

“How can they say there is no demand when they don’t allow it?” he asked. “How can they be so sure that it will get out of control when they haven’t even tried it?”;amp;amp;amp;amp;amp;amp;en=fe22c45cca06fb5b&ei=5090&partner=rssuserland&emc=rss