Saturday, August 22, 2009

Generation B - When You’re Your Mother’s Keeper -

WHEN Suzanne Cooper's elderly mother moved in three years ago, her Alzheimer's was in an early stage. The 84-year-old was still fairly lucid, so Mrs. Cooper could leave her home, while picking up her son, Griffin, from nursery school or going food shopping.

But in time, the mother turned more inward, having long conversations with herself at the kitchen table or just staring. "She goes into the other world and you try to pull her back, but it gets harder," Mrs. Cooper said. She would come home with Griffin, 5, and find her mother sitting by the back door holding her blanket and looking lost.

Soon, the 49-year-old Mrs. Cooper couldn't leave her alone and the days became logistical brainteasers, as she tried to balance the needs of her son and those of her mother.

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Friday, August 21, 2009

Study Shows Pain Is "intolerable" For Over A Third Of Cancer Patients, But Nearly Three Quarters Are Battling Burden Of Side Effects Of Pain Treatment

Cancer pain and the side effects associated with its treatment are having a significant impact on the quality of life of many cancer patients across Europe and Israel, according to findings published in the Annals of Oncology.1 Results from the European Pain in Cancer survey (EPIC) reveal the emotional and physical impact of cancer pain, with over a third of patients (36 percent) describing their pain as intolerable (n=573) and over two thirds (69 percent) experiencing difficulties in performing normal activities in daily life as a result of their pain (n=5,084). 

The survey highlights the extent to which cancer pain affects the everyday lives of patients, but also its impact on their relationships with family, friends and work colleagues. Almost a third of patients (30 percent) are in too much pain to care sufficiently for themselves or others and four in ten (43 percent) feel that their pain makes them an increased burden to others (n=573). Half (51 percent) say their pain stops them concentrating or thinking (n=573) and of those still in employment, half (52 percent) report that their pain impacts on their work performance (n=136). 

Findings reveal that many patients are not receiving optimal treatment for their pain, with almost two thirds of patients (63 percent) on prescribed medication reporting breakthrough pain or inadequate pain relief (n=441). However, of those who are prescribed opioid medication for their pain, many patients are experiencing further problems as a result of the side effects of their treatment. Of those patients prescribed opioid medication (n=266), nearly three quarters (74 percent) experience side effects, of which constipation is the most commonly reported (37 percent). Of the patients who experience opioid-induced constipation, a quarter (25 percent) are not being co-prescribed a laxative by their clinician (n=266). In addition, other frequently reported side effects include nausea and vomiting (33 percent), whilst one in five (20 percent) experience sedation (n=266). 

"The results of the EPIC study underline the impact of cancer pain on the day-to-day lives of patients but also strongly highlight that side effects of pain treatments can cause further problems. Many patients must choose between endure their pain, or suffer the side effects from their pain medication," commented Professor Harald Breivik, Faculty of Medicine, University of Oslo. "Clinicians need to adhere to pain management guidelines, specifically the World Health Organisation's pain relief ladder2, in order to improve access to the appropriate level of pain medication for patients. Keeping a close track of the pain relief obtained and the side effects of these medications, and adjusting therapy to both aspects, are mandatory in order to improve pain patients' quality of life." 

The survey demonstrates that cancer pain and its management issues can affect the relationship between healthcare professionals and their patients. When asked about their healthcare professional's understanding of pain and its impact, one in two patients (50 percent) believe their healthcare professional does not consider their quality of life as an important aspect of their overall care plan (n=573) and over a third (38 percent) believe that their clinician would rather treat their cancer than the accompanying pain (n=573). Over a quarter (26 percent) believe their clinicians do not know how to treat moderate-to-severe cancer pain (n=573). 

"These findings demonstrate a need for improved communication between patients and their clinicians," said Dr Beverly Collett, Past-President of the British Pain Society. "Patients need to make clinicians more aware of the impact of their pain and clinicians need to be better prepared to assess, discuss and understand cancer pain and its impact on their patients." 

The EPIC survey was conducted across 12 countries* between 2006 and early 2007 and aimed to explore the burden of cancer pain, current pain treatment practices across Europe and Israel and their effects in all cancer types** and cancer stages. 5084 adult patients were contacted for screening interviews. Of these, 2864 patients completed the screening interview, rated their pain to be 5 or above on a pain scale and had experienced recurrent pain several times a month or more in the last month. Following this phase, 573 patients were then randomly selected to complete in-depth attitudinal questionnaires. 

About the EPIC Survey

The EPIC survey was conducted by an independent market research company under the auspices of the European Association of Palliative Care (EAPC) and with the help of a Steering Panel comprising of the European Oncology Nursing Society (EONS), the Lance Armstrong Foundation and OPEN Minds - a group of leading experts from across Europe specialising in research and the management of persistent pain - and sponsored by an educational grant from Mundipharma International Limited. 

The objectives of the survey were to: 

- Investigate the impact of pain on cancer patients 
- Establish the prevalence of pain for patients across all cancer stages in Europe 
- Understand current treatment practices and levels of satisfaction, and identify the gaps in the existing provision of effective pain management for cancer patients across Europe 
- Explore the impact of pain on sufferers' quality of life 


The EPIC survey was conducted in 11 European countries: Czech Republic, Denmark, Finland, France, Ireland, Italy, Norway, Romania, Sweden, Switzerland, UK; and Israel. 

Patients were recruited from a broad cross section of the population, including patients with all stages of disease (early, locally advanced, advanced and metastatic). In each country as many potential routes of recruitment as possible were undertaken, including recruitment via physicians in both primary and secondary care, patient groups, online patient panels and newspaper advertisements. However, methods of recruitment were to a certain extent limited by individual country's regulations. Specialist pain units and palliative care centres were not approached to avoid bias in the collection of data. 

5,084 patients across Europe and Israel were contacted for screening interviews to assess the prevalence, severity and frequency of cancer pain. 56 percent (2,864) of the patients contacted completed the screening interview, rated the intensity of their pain to be 5 or above (on a scale of 0 to 10, where 0 means no pain at all, and 10 is the worst pain imaginable) and had experienced recurrent pain several times a month or more in the last month. All patients who screened in were aged 18 or above and were suffering from a solid or blood borne tumour. 2,220 (44 percent) patients screened out. 

From those patients that screened in to the survey, 573 patients were randomly selected to complete an in-depth attitudinal questionnaire. These patients were suffering from recurrent pain in the last month with a frequency greater than several times per week. 

The EPIC survey was supported by an educational grant from Mundipharma International Ltd, Cambridge, England

*Czech Republic, Denmark, Finland, France, Ireland, Israel, Italy, Norway, Romania, Sweden, Switzerland and the UK. 

** The survey included almost all cancer types, solid tumour and blood-borne cancers, with the exception of skin cancers.

Tuesday, August 18, 2009

Ouch! Gene makes some prone to pain, snubs

A social snub can deliver a seemingly painful blow. Now, it turns out that sting may be real. A gene linked with physical pain is also associated with a person's sensitivity to rejection, a new study finds.

The discovery doesn't suggest that being chosen last for a pick-up ball game, say, will send you limping off the field. Rather, a rare form of the so-called mu-opioid receptor gene (OPRM1) is likely involved in the emotional aspect of physical pain — essentially, how much a person is bothered by a throbbing leg, for instance.

In the study, 122 participants indicated how much they agreed or disagreed with statements, such as "I am very sensitive to any signs that a person might not want to talk to me." Their saliva was also analyzed for OPRM1.

(People with a rare form of OPRM1 experience more physical pain than others.)

Then, the researchers used functional magnetic resonance imaging (fMRI) to scan the brains of 31 of the participants during a virtual ball-tossing game. Initially, each participant was included with two virtual players before being excluded when the virtual players stopped throwing the ball to them.

Individuals with the rare OPRM1 variant were more sensitive to social rejection. The mutant-gene carriers also showed more activity in brain regions linked with physical and social pain, including the dorsal anterior cingulate cortex and anterior insula.

Such social pain may have benefited our ancestors. "Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them," said study researcher Naomi Eisenberger of UCLA.

She added, "Over the course of evolution, the social attachment system — which ensures social connection — may have actually borrowed some of the mechanisms of the pain system to maintain social connections."

Sunday, August 16, 2009

Search engine comparison: pain @ Bing vs. Google

Is it possible that marijuana, long believed to dull pain, could actually make it worse? -

A study published this week in Science suggests that the active ingredient in marijuana, cannabinoids—which include THC and other chemicals—may limit the body's ability to tamp down pain responses, and, as a result, turn short term acute pain into more long term discomfort. While there has been a growing amount of research analyzing the pain reduction effects of cannabis, an international group of researchers led by Hanns Ulrich Zeilhofer from the University of Zurich's Institute of Pharmacology and Toxology and collaborators from the University of Texas Medical Branch at Galveston think they may have uncovered evidence that marijuana can achieve just the opposite effect.

By applying a mimic of endocannibanoids, the body's homegrown version of cannibanoids, to the spinal columns of mice, researchers saw that instead of amplifying the capacity of pain inhibitor neurons, the chemical managed to shut them down. That is, the electrical signals that indicate pain inhibition is underway effectively went dark. In a second trial, they attempted the same technique on mice that had been genetically engineered to lack the specific receptors necessary for endocannibanoids. In this group, pain inhibition neurons functioned normally.

Yet, does the apparent neuronal on/off switch flicked by cannabis chemicals actually signify an increased sensation of pain? To test that out, researchers put rats who had endocannabinoids in their systems under anesthesia, and then injected small amounts of capsaicin—the chemical that makes chillies spicy—into their hindpaws. The result was a quick uptick in pain response. And for these rats, even stimuli that wouldn't have caused discomfort earlier now produced a pain response, a phenomenon known as allodynia. When the researchers administered an endocannabinoid blocker, however, "this increase was reversed," they write.

Finally, to see if this trend persisted in humans, they subjected volunteers to mild electrical shocks on the forearm to induce hyperalgesia—heightened pain sensitivity—in that specific region. They then gave half of the volunteers a placebo, and half the endocannabinoid receptor blocker rimonabant to take for a month, after which time they came back to get tested again. There was little change in the placebo group, but, consistent with their findings in mice and rats, the researchers say, there was a marked decline in hyperalgesia and allodynia in the previously tested regions of those who had taken the blocker. There was not, however, any reduction in acute pain—the discomfort caused at the site of the new round of shocks.

Their conclusion? While the researchers began their project with the idea that cannabis should help dull pain, in fact they found that endocannabinoids play an "unexpected role" in governing pain-inhibitor neurons in the spine, and may even possibly increase the risk for turning short term, sharp pain, into more long term pain. And, since the active ingredient in pot is so chemically similar to endocannabinoids, marijuana could potentially cause the same problems. Yet, while these results certainly open the door for further research—and might provide a word of caution for recreational pot smokers—many more studies still have to be done before these findings can upend the existing evidence for the predominately pain-reducing qualities of cannabis.

Tuesday, August 11, 2009

Oh, Sting, Where Is Thy Death?

Not long ago, I got stung by a yellow jacket, and after the usual ow-plus-obscenities moment, I found myself thinking about pain, happiness, and Justin O. Schmidt. He's an Arizona entomologist and co-author of the standard text in the insect sting field, "Insect Defenses: Adaptive Mechanisms and Strategies of Prey and Predators." But he's more widely celebrated as the creator of the "Justin O. Schmidt Sting Pain Index," a connoisseur's guide to just how bad the ouch is, on a scale of one ("a tiny spark") to four ("absolutely debilitating").

Among connoisseurs of insect stings, it's the equivalent of Robert Parker's wine ratings. Schmidt has been stung by about 150 different species on six continents and seems to have opinions about all of them. In faux-Parker mode, he once described a bald-faced hornet sting as "Rich, hearty, slightly crunchy. Similar to getting your hand mashed in a revolving door." Other researchers tend to regard his work with fascination. But hardly anyone tries to replicate his results.

You are perhaps thinking that this does not sound like it has much to do with happiness, especially not on a hot summer day with the insect world chattering and buzzing just outside the screen door. But Schmidt struck me as a happy guy when I first looked him up a few years ago at the home in Tucson he shares with a wife, two kids, and a large collection of venomous arthropods. I was researching my book "Swimming With Piranhas at Feeding Time," and he seemed like a good fit with my subtitle about "doing dumb stuff with animals." We sat down to talk at the kitchen table. The only condiment was a tube of Itch-X.

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Acupuncture boosts effects of painkillers, natural or prescription

High-tech images of the brains of chronic pain sufferers have found that the ancient practice ofacupuncture fights pain by making key brain cells more sensitive to the pain-dampening effects of opioid chemicals. The study, published online in the August issue of the journal NeuroImage, comes less than a year after the publication of a controversial study that concluded acupuncture was no more effective than sham treatment at reducing pain.

Researchers at the University of Michigan's Chronic Pain and Fatigue Research Center used a positron emission tomography (PET) scanner to view the brains of 20 women diagnosed with fibromyalgia who reported suffering nerve and muscle pain at least 50% of the time. The PET scans were conducted during each woman's first acupuncture session and, a month later, her eighth.

In the regions of the brain that process and dampen pain signals -- the amygdala, caudate, cingula, thalamus and insula -- the PET scans showed an increase in the receptivity -- and possibly the number -- of brain cells to which opioid substances bind. Study author Richard E. Harris said that suggests that acupuncture appears to make the body more responsive to opioid painkillers.

But the mainstay of traditional Chinese medicine also appears to enhance the body's ability to regulate pain naturally, Harris said. Many of the analgesic chemicals the body produces, including endorphins (the source of what endurance athletes call "the runner's high") and enkephalins (which act to tamp down the sensation of pain), also bind to the opioid receptors. So if acupuncture treatments enhance those chemicals' ability to find a receptor to bind to, these natural painkillers work better as well.

Harris, a molecular and cell biologist at the University of Michigan and a licensed acupuncturist, said the group's findings are consistent with research that has found patients treated with acupuncture before surgery often need less post-operative medication to manage their pain. The acupuncture in these cases may have the effect of sensitizing the brain's opioid receptors to medication, making it work better.

The study may even support the controversial earlier finding that sham acupuncture works as well as real acupuncture to reduce pain, but that the two work in to reduce pain in different ways. In that experiment, patients seemed to gain considerable pain relief merely by a procedure that inserted needles into the body randomly, as oppose to following the paths of energy meridians that guide needle placement in acupuncture.

The random sinking of needles through the skin may prompt the body to increase its production of pain-dampening endorphins and enkephalins, Harris surmised. True acupuncture may work differently: Its painkilling effect may come not from boosting the supply of circulating natural analgesics, but by improving the ability of those chemicals to dock at a brain cell and exert their painkilling effects.

While many patients may turn to acupuncture as an alternative to conventional medication, Harris said his group's study suggests that the two means of pain relief can complement each other.

"I don't see them as mutually exclusive, and in some cases, they may work synergistically," Harris said.

Friday, August 07, 2009

Are Patients in Part to Blame When Doctors Miss the Diagnosis? -

Marla (not her real name) came to our clinic with breast cancer. The clinic nurse stopped me before I went into Marla's exam room. "She's different," the nurse whispered to me. "The last doctor just threw up his hands."

In her 40s, with long blonde braids and blue eyes, Marla dressed in flowing robes, as if she had just walked off the set of "A Midsummer's Night Dream." She smiled and spoke softly as she answered my initial questions but became more animated when she began to describe her lifestyle and the kinds of herbal supplements she took.

It turned out that Marla was like my mother, a preventive health and alternative medicine enthusiast. When Marla heard that I, as a child, had choked down bowls of pungent, muddy brew boiled up from unrecognizable Chinese herbs and shriveled animal parts, she laughed so hard that tears welled up in her eyes. She had served similar concoctions to her loving but apparently long-suffering husband.

But throughout our conversation, I noticed that despite her laughter, Marla never moved. She sat stiffly, hunched over and cocked slightly to the left, with her left arm bent against her chest, as if cradling a baby.

Two years earlier, Marla had noticed a pebble-sized lump in her left breast. Her primary care physician scheduled her for a mammogram, but Marla wanted first to try alternative remedies, so she skipped the appointment. She never went back to see her doctor because she felt that as soon as she began talking about other treatment options, he "shut down. "

Months later, when it became clear that the mass was growing and not shrinking, her husband suggested she see a surgeon. "I thought I could take care of it," she said to me, recalling the sequence of events, "but I guess not."

Little could have prepared me for what I saw when Marla opened her gown. While the right side of her chest was unremarkable, her left breast was the size of a young child's head. The skin was stretched thin, and I could see an outline of the tumor within. That tumor was so large and so heavy that it seemed to pull the rest of her body down. Marla hunched over oddly and cradled her left arm not out of habit but to support the weight of the cancer within her breast.

We admitted Marla immediately to the hospital and removed her cancer the next day. Fortunately, the tumor was not an aggressive one, but her operation was far more extensive and fraught with risks than it would have been two years earlier. And as much as I liked Marla personally and enjoyed our conversations, I was also frustrated that she hadn't come forth sooner with some doctor about her cancer.

Marla was not the first patient I had seen who had waited until her cancer was advanced before seeing the doctor. But I have learned over the years that while my initial reaction is always to question if I or any other doctor missed the diagnosis, the situation is not always so cut and dry. While I need to understand and respect the beliefs of my patients, I still can't escape feeling a certain level of responsibility as a doctor. I find myself wondering when it comes to patients like Marla or others whose diagnoses are delayed for various personal, social and economic reasons, how responsible am I as the physician and are they as the patients?

Diagnostic failures, or diagnoses that are delayed or in error, are an increasingly popular topic of research in patient safety. While some researchers have focused on the role of doctors — are there flaws in the way they think? are "gut reactions" reliable? — others have looked at the steps involved in care, or the process of care. What has emerged most recently from this latter group of studies is that diagnostic failures are often due to missed steps, so-called "process of care lapses," that stem from both doctors and patients.

In the June issue of The Journal of General Internal Medicine, for example, investigators from Harvard Medical School studied the records of over 100 women with breast cancer diagnosed late or at advanced stages and found that roughly a quarter of patients had experienced process of care lapses. Examples of such lapses included inadequate physical exams, delayed physician involvement and incomplete diagnostic and laboratory tests. But while the investigators discovered that nearly 20 percent of the women were missing as many as two or more steps in their care, they also found that doctors and patients contributed equally to the resulting diagnostic failures.

"Clearly we found that about half of the process failures were due to something the patient did," said Dr. Saul N. Weingart, lead author of the study and a practicing internist and vice-president of Quality Improvement and Patient Safety at the Dana-Farber Cancer Institute in Boston. "These patients missed their mammogram appointments or never went to see the specialists their primary care physicians had recommended."

To address these lapses, experts in the field of patient safety like Dr. Weingart have proposed a variety of strategies to strengthen patient follow-up. One strategy that many physicians already use in one form or another is a "tickler system," electronic or paper reminders to check that diagnostic testing or referrals are completed. Other ways include implementing a type of technology that allows physicians to check specific tests across their entire practice, or panel, on a monthly basis. With "the push of a button," a doctor can see which patients have not yet followed through, for example, on their mammogram appointments.

And perhaps just as important as any technological change is one that involves transforming deep-rooted practice patterns. "It's not part of practices now," Dr. Weingart said, "but you can imagine creating an expectation among the medical community where if patients don't go, the referring doctors or practices will notify you."

But there are hidden obstacles in care as well. When Dr. Weingart and his co-investigators looked more closely at the group of individuals who had experienced lapses, they found that many were patients who were particularly vulnerable: they were minorities, possessed less education and came from challenging socioeconomic backgrounds, all of which contributed to practical obstacles or poor health literacy.

These findings "suggest that there are some intangible barriers," Dr. Weingart remarked. "Perhaps these patients don't know how to access care, need an interpreter, live farther away, or may be overwhelmed by family responsibilities. All of these factors are distractions for a patient and make getting care all that much harder."

In order to address these intangible barriers, Dr. Weingart suggested that "we need to develop not only risk assessment tools but also services geared toward patient vulnerabilities." But given that many physician practices, particularly those in the community, are already overstretched, organizing and maintaining such services may be close to or simply impossible. "Often when I talk to community practices about these findings," Dr. Weingart added, "the doctors will tell me that they can only do so much. When a patient doesn't show up, do I have to track him or her down? How many letters do I have to send the patient? What constitutes due diligence?"

How much responsibility, then, do doctors — and patients — bear in diagnostic failures?

"I don't think it's 50-50," Dr. Weingart reflected, "and I also don't think it's 100-zero. I think there's a shared responsibility. But given that the patients who fall through the cracks are usually the least resourceful and most vulnerable, there is at least a moral obligation for clinicians and health care systems to provide a robust safety net for these patients.

"I think we physicians need to support patient responsibility, but we also need to get our own house in order first. In terms of process failures, we need to make sure that the current system under health care providers is airtight. After we get that figured out, we then need to think about ways to help our patients do what they need to do."

Scientists Find "Itch Circuit" in Mice -- Torrice 2009 (806): 3 -- ScienceNOW

No one would confuse the pain of a bee sting with the itch of a mosquito bite. But neuroscientists have had a hard time figuring out how the body makes these distinctions. Now researchers have identified a previously unstudied set of spinal neurons in mice that communicates only itch. The discovery could lead to novel treatments for the irritating ailment.

Prevailing theory suggests that pain and itch are linked in the nervous system. In fact, doctors often prescribe pain medication to patients with chronic itch. But some neuroscientists favor a "labeled-line" theory, in which itch signals have their own neural circuits--or lines--to the brain. In 2001, researchers supported this idea by claiming to find itch-only neurons in the spinothalamic tract (STT), a set of cells that travel up the spine to the brain's thalamus. Subsequent studies, however, revealed that these neurons also respond to the burning pain of capsaicin--the spicy chemical in chili peppers.

Now, neuroscientist Zhou-Feng Chen of Washington University School of Medicine in St. Louis, Missouri, and colleagues believe they have found the most compelling evidence yet for an itch labeled line. Two years ago, the group discovered a gene necessary for itch, but not pain, called the gastrin-releasing peptide receptor (GRPR). In the new study, Chen and colleagues tried to figure out if cells expressing GRPR were the long-sought itch-only neurons. So they selectively killed GRPR cells in mice spines with a toxin called saporin tethered to a peptide that targets GRPR proteins. After 2 weeks, they had destroyed more than 75% of GRPR neurons.

To test the labeled-line hypothesis, the researchers gave the mice a battery of itch and pain tests. They separately injected six chemicals that make humans itch, such as histamine and the antimalarial drug chloroquine, under the mice's skin and noted how much the animals scratched. They also tested an alopecia drug that causes chronic itch in people. Chen and colleagues report online today in Science that mice without GRPR neurons scratched significantly less than normal mice did--about 80% less in each case. Next, the scientists tested the animals' response to pain in a number of different ways, including poking the mice's feet and injecting capsaicin under their skin. The normal animals and those without GRPR neurons exhibited similar pain responses.

The GRPR neurons appear to be distinct from the STT neurons that have been the center of the ongoing labeled-line debate, the researchers report. For one thing, the researchers still detected a marker found on most STT cells in the mice without GRPR neurons. And mice missing GRPR neurons did not experience less pain sensitivity, as opposed to what has been seen when STT cells are damaged. "We are looking at a different subset of neurons that were previously unknown," Chen says.

The findings provide "a candidate target for future therapies that relieve itch without minimizing the capacity for pain," says Robert LaMotte, a neuroscientist at Yale University. Gil Yosipovitch, a dermatologist at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina, agrees. But he points out that because patients experience multiple types of itch, the new findings don't diminish the importance of the STT in sending itch information to the brain. "There could be multiple itch pathways," he says.

Tuesday, August 04, 2009

Redheads' extra pain may cause fear of dentists - CNN

Despite two injections of anesthetic, Amy Anderson felt like her
dentist was jamming rods into her tooth during a root canal. She
writhed in pain as her infected tooth was hollowed with a drill, its
nerve amputated, and then sealed.

"I knew this time something was wrong. I could feel my lips," said
the Syracuse, New York, resident, who told her dentist the drugs
weren't working.

Her doctor kept assuring her she had given her a proper dose and
said: "I'm almost done."

"I was hurting so bad, I was hitting myself in the stomach," said
Anderson, a redhead. "I almost wanted to hit her."

Studies have indicated that redheads may be more sensitive to pain
and may need more anesthetics to numb them.

New research published in this month's Journal of American Dental
Association found that painful experiences at the dentist might cause
more anxiety for men and women with red hair, who were twice as
likely to avoid dental care than people with dark hair.

"Redheads are sensitive to pain," said Dr. Daniel Sessler, an
Outcomes Research Department chair at The Cleveland Clinic, in
Cleveland, Ohio, who is one of the authors.

"They require more generalized anesthesia, localized anesthesia. The
conventional doses fail. They have bad experiences at the dentist and
because of the bad experiences, they could avoid dental care."

Sessler, an anesthesiologist, began studying redheads' sensitivity to
pain after hearing chatter from colleagues.

"The persistent rumor in the anesthesia community was that redheads
were difficult to anesthetize," Sessler said. "They didn't go under,
had a lot of pain, didn't respond well to anesthesia. Urban legends
usually don't start studies, but it was such an intriguing observation."

This led to two studies. In 2004, research showed that people with
red hair need 20 percent more general anesthesia than blonds and

A 2005 study indicated that redheads are more sensitive to thermal
pain and are more resistant to the effects of local anesthesia.

Researchers believe variants of the melanocortin-1 receptor gene play
a role. This MC1R gene produces melanin, which gives skin, hair and
eyes their color.

While blond, brown and black-haired people produce melanin, those
with red hair have a mutation of this receptor. It produces a
different coloring called pheomelanin, which results in freckles,
fair skin and ginger hair. About 5 percent of whites are estimated to
have these characteristics.

While the relationship between MC1R and pain sensitivity is not
entirely understood, researchers have found MC1R receptors in the
brain and some of them are known to influence pain sensitivity.

Non-redheads can also carry a variant of the MC1R gene. In this
dental study that had 144 participants, about a quarter of the non-
redheads had variants of the MC1R gene. These people also experienced
heightened anxiety and avoided dental care compared with others who
did not have the variant.

There is no commercial test available for variations of the MC1R gene.

After Sessler and his colleagues published the first studies about
redheads and pain susceptibility, he received nearly 100 e-mails from
redheads around the country who complained of terrible experiences at
the dentist's office.

Dr. Catherine Binkley, an associate professor at the University of
Louisville's School of Dentistry, in Kentucky, also observed the same
phenomenon in her 25 years of practice.

Her redheaded patients seemed "anxious and didn't get numb. It's a
difficult experience for them," said Binkley, one of the study's

But this doesn't seem to affect all people with red hair.

"I have a [redheaded] hygienist that I have to numb up a lot more
than normal, " said Dr. Peter Vanstrom, an Atlanta, Georgia, dentist.
"She's very sensitive. I have another redheaded patient who is tough
as nails, but his father is extremely difficult to numb."

Binkley said the best tip for dentists is to "pay more attention,
evaluate everyone for dental anxiety, and ask them about previous

"If you know someone's anxious, do different things," she said. "Make
sure they're numb before you start working on them."

Patients who've had bad experiences with pain should inform their

The next phase of research is to evaluate whether more anesthesia is
needed for people with red hair and those with variants of the MCR1
gene for dental procedures.

The authors say an unpleasant incident -- much like the one Anderson
had this January -- could cause patients to postpone dental care and
exacerbate any problems they might have.

Anderson got a root canal because she dreaded the dentist after a bad
experience of getting cavity fillings. Inevitably, Anderson has to
return to her dentist to follow up on her root canal and this fills
her with apprehension.

"I have wicked dread of the dentist," she said. "I was up for two
hours in the middle of the night because of the dentist."

Sunday, August 02, 2009

Patients forced to live in agony after NHS refuses to pay for painkilling injections - Telegraph

The Government's drug rationing watchdog says "therapeutic"
injections of steroids, such as cortisone, which are used to reduce
inflammation, should no longer be offered to patients suffering from
persistent lower back pain when the cause is not known.

Instead the National Institute of Health and Clinical Excellence
(NICE) is ordering doctors to offer patients remedies like
acupuncture and osteopathy.

Specialists fear tens of thousands of people, mainly the elderly and
frail, will be left to suffer excruciating levels of pain or pay as
much as £500 each for private treatment.

The NHS currently issues more than 60,000 treatments of steroid
injections every year. NICE said in its guidance it wants to cut this
to just 3,000 treatments a year, a move which would save the NHS £33

But the British Pain Society, which represents specialists in the
field, has written to NICE calling for the guidelines to be withdrawn
after its members warned that they would lead to many patients having
to undergo unnecessary and high-risk spinal surgery.

Dr Christopher Wells, a leading specialist in pain relief medicine
and the founder of the NHS' first specialist pain clinic, said it was
"entirely unacceptable" that conventional treatments used by
thousands of patients would be stopped.

"I don't mind whether some people want to try acupuncture, or
osteopathy. What concerns me is that to pay for these treatments,
specialist clinics which offer vital services are going to be forced
to close, leaving patients in significant pain, with nowhere to go,"

The NICE guidelines admit that evidence was limited for many back
pain treatments, including those it recommended. Where scientific
proof was lacking, advice was instead taken from its expert group.
But specialists are furious that while the group included
practitioners of alternative therapies, there was no one with
expertise in conventional pain relief medicine to argue against a
decision to significantly restrict its use.

Dr Jonathan Richardson, a consultant pain specialist from Bradford
Hospitals Trust, is among more than 50 medics who have written to
NICE urging the body to reconsider its decision, which was taken in May.

He said: "The consequences of the NICE decision will be devastating
for thousands of patients. It will mean more people on opiates, which
are addictive, and kill 2,000 a year. It will mean more people having
spinal surgery, which is incredibly risky, and has a 50 per cent
failure rate."

One in three people are estimated to suffer from lower back pain
every year, while one in 15 consult their GP about it. Specialists
say therapeutic injections using steroids to reduce inflammation and
other injections which can deaden nerve endings, can provide months
or even years of respite from pain.

Experts said that if funding was stopped for the injections, many
clinics would also struggle to offer other vital services, such as
pain management programmes and psychotherapy which is used to manage
chronic pain.

Anger among medics has reached such levels that Dr Paul Watson, a
physiotherapist who helped draft the guidelines, was last week forced
to resign as President of the British Pain Society.

Doctors said he had failed to represent their views when the
guidelines were drawn up and refused to support the letter by more
than 50 of the group's members which called for the guidelines to be

In response, NICE chairman Professor Sir Michael Rawlins expressed
outrage over the vote that forced Dr Watson from his position,
describing the actions of the society as "shameful". He accused pain
specialists of refusing to accept that there was insufficient
scientific evidence to support their practices.

A spokesman for NICE said its guidance did not recommend that
injections were stopped for all patients, but only for those who had
been in pain for less than a year, where the cause was not known.

Iris Watkins, 80 from Appleton, in Cheshire said her life had been
"transformed" by the use of therapeutic injections every two years.
The pensioner began to suffer back pain in her 70s. Four years ago,
despite physiotherapy treatment and the use of medication, she had
reached a stage where she could barely walk.

"It was horrendous, I was spending hours lying on the sofa, or in
bed, I couldn't spend a whole evening out. I was referred to a
specialist, who decided to give me a set of injections. The
difference was tremendous",

Within days, she was able to return to her old life, gardening,
caring for her husband Herbert, and enjoying social occasions.

"I just felt fabulous – almost immediately, there was not a twinge. I
only had an injection every two years, but it really has transformed
my life; if I couldn't have them I would be in despair".