Tuesday, September 21, 2010

A Perk of Our Evolution: Pleasure in Pain of Chilies - NYTimes.com

Late summer is chili harvest time, when the entire state of New Mexico savors the perfume of roasting chilies, and across the country the delightful, painful fruit of plants of the genus Capsicum are being turned into salsa, hot sauce and grizzly bear repellent.

Festivals abound, often featuring chili pepper-eating contests. "It's fun," as one chili pepper expert wrote, "sorta like a night out to watch someone being burned at the stake."

In my kitchen, as I turn my homegrown habaneros into hot sauce while wearing a respirator (I'm not kidding) I have my own small celebration of the evolutionary serendipity that has allowed pain-loving humans to enjoy such tasty pain.

Some experts argue that we like chilies because they are good for us. They can help lower blood pressure, may have some antimicrobial effects, and they increase salivation, which is good if you eat a boring diet based on one bland staple crop like corn or rice. The pain of chilies can even kill other pain, a concept supported by recent research.

Others, notably Dr. Paul Rozin at the University of Pennsylvania, argue that the beneficial effects are too small to explain the great human love of chili-spiced food. "I don't think they have anything to with why people eat and like it," he said in an interview. Dr. Rozin, who studies other human emotions and likes and dislikes ("I am the father of disgust in psychology," he says) thinks that we're in it for the pain. "This is a theory," he emphasizes. "I don't know that this is true."

But he has evidence for what he calls benign masochism. For example, he tested chili eaters by gradually increasing the pain, or, as the pros call it, the pungency, of the food, right up to the point at which the subjects said they just could not go further. When asked after the test what level of heat they liked the best, they chose the highest level they could stand, "just below the level of unbearable pain." As Delbert McClinton sings (about a different line of research), "It felt so good to hurt so bad."

I have to agree, although by true chili-head standards, I am a wimp. I can tolerate only a moderate degree of pain, perhaps because I came to chilies late in life. My son was quite impressed with an in-law who grew up in Mexico and ate habanero peppers whole, so my wife suggested a father-son gardening project. The first year only one plant survived the woodchucks and deer. But what a plant — it produced a bumper crop of killer orange habaneros. Nothing ate them. In my mind I still see that plant dangling its little orange heat grenades in front of the deer and growling, "Bite me, Bambi."

Habaneros are very hot, although there's a lot of variation. On the standard Scoville heat scale (Bell peppers 0, the hottest Indian jolokia peppers 1,000,000) orange habaneros run 100,000 to 350,000. By comparison, jalapenos can go anywhere from 5,000 to 50,000. Two percent capsaicin bear spray is advertised at 3.3 million units, and pure capsaicin — the chemical that causes the pain — hits 16 million.

This is the kind of plant that endears itself to a teenage boy. These weren't vegetables, they were weapons! And it was legal to grow them. We started planning the next year's garden at once.

The garden grew, year by year, and led to the bottling of hot sauce, and then to my first hesitant steps into the capsaicin demi-monde. I met some pain junkies at work. I bought the T-shirt with the capsaicin molecule on it. I marveled at the uncountable number of artisanal hot sauces on the market, and at the frequency with which the words "death," "nuclear" and "devil" were used in the names. I have to say that I drew the line at getting a capsaicin molecule tattoo. And I did not buy the T-shirt with the flaming red mouth and the legend "Pain Is Good."

This chest-beating may be particular to the United States, where one hot sauce maker actually markets a limited edition of pure capsaicin. In places like Central America, Asia and the Indian subcontinent, hot chili peppers are an integral part of the cuisine. Only the commercial genius of American marketing could come up with a product that is marketed on the basis that you won't be able to use it.

End of Life Hot Sauce! So Painful You Will Die! Visa, MasterCard, Discover or PayPal accepted. Well, darn, sign me up for that.

How did this happen? The story of how chilies got their heat is pretty straightforward. A recent study suggested that capsaicin is an effective defense against a fungus that attacks chili seeds. In fact, experiments have shown that the same species of wild chili plant produces a lot of capsaicin in an environment where the fungus is likely to grow, and very little in drier areas where the fungus is not a danger.

The fact that capsaicin causes pain to mammals seems to be accidental. There's no evolutionary percentage in preventing animals from eating the peppers, which fall off the plant when ripe. Birds, which also eat fruits, don't have the same biochemical pain pathway, so they don't suffer at all from capsaicin. But in mammals it stimulates the very same pain receptors that respond to actual heat. Chili pungency is not technically a taste; it is the sensation of burning, mediated by the same mechanism that would let you know that someone had set your tongue on fire.

But humans took to them quickly. There is evidence that by 6,000 years ago domesticated Capsicums (hot peppers) were being used from the Bahamas to the Andes. Once Columbus brought them back from the New World chilies spread through Europe, Asia and Africa. Jean Andrews, in the classic "Peppers: The Domesticated Capsicums" (in which she made the comment above about pepper competitions and being burned at the stake), tracks the spread of peppers by early writers. By the mid-1500s, they were known in Europe, Africa, India and China.

No one knows for sure why humans would find pleasure in pain, but Dr. Rozin suggests that there's a thrill, similar to the fun of riding a roller coaster. "Humans and only humans get to enjoy events that are innately negative, that produce emotions or feelings that we are programmed to avoid when we come to realize that they are actually not threats," he said. "Mind over body. My body thinks I'm in trouble, but I know I'm not." And it says, hand me another jalapeƱo.

Other mammals have not joined the party. "There is not a single animal that likes hot pepper," Dr. Rozin said. Or as Paul Bloom, a Yale psychologist, puts it, "Philosophers have often looked for the defining feature of humans — language, rationality, culture and so on. I'd stick with this: Man is the only animal that likes Tabasco sauce."

That's from Dr. Bloom's new book, "How Pleasure Works: The New Science of Why We Like What We Like," in which he addresses the general nature of human pleasure, and some very specific, complicated pleasures. Some, like eating painfully spicy food, are accidental, at least in their specificity. A complicated mind is adaptive, but love of chilies is an accident.

And that is what I celebrate behind my respirator as my son and I dice habaneros, accidental pleasures. A taste for chilies has no deep meaning, no evolutionary value. It's just a taste for chilies. I might add, though, that since it takes such a complicated brain and weird self-awareness to enjoy something that is inherently not enjoyable, only the animal with the biggest brain and the most intricate mind can do it.

Take heart, chili heads. It's not dumb to eat the fire, it's a sign of high intelligence.


Friday, September 17, 2010

Health professionals address reducing drug misuse in pain treatment - Guelph (Ontario) Mercury

General practitioner Dr. Kevin Librach sometimes treats
people for chronic pain, but doesn't relish being
manipulated, on occasion, by those consuming prescription
opiates simply to get high.

"We all get fooled sooner or later," he said Thursday, a day
after attending a forum for health professionals on treating
pain while reducing any potential harmful effects and
avoiding misuse.

It's a timely subject with growing public concern over the
risk of some patients becoming dependent, even addicted, to
prescribed opiates, called psychotherapeutic drugs, and the
ready black market in Guelph and elsewhere.

"The problem is we have a lot of people with chronic pain
and a few bad apples wrecking it for genuine people" for
whom doctors are trying "to alleviate suffering," the Guelph
doctor said.

The dilemma came into sharp focus at Wednesday's forum,
presented by the Wellington-Guelph Drug Strategy, an
organization dedicated to easing the impact and incidence of
substance misuse.

Audience member Ben Bair, a Guelph police constable, noted
almost 60 per cent of drug charges laid this year were for
misuse of prescription medications.

Police information officer Doug Pflug said Thursday the top
medications seized in that 59.4 per cent included oxycodone,
benzodiazepine, hydromorphone and morphine. The opioid
analgesic oxycodone, a popular street drug, is best known by
its brand name, OxyContin.

"They fetch a good price on the street, that's for sure,"
Librach lamented. "It's a tough problem."

The two dozen doctors and other health professionals
including addiction advisers, who made up the audience of
almost 100 at the Elora Mill Inn heard pain expert Dr. Roman
Jovey stress while the risks associated with prescription
opiates aren't minor, the drugs are a boon in the treatment
of chronic pain.

Still, health professionals must respect their potency,
minimize the potential for misuse and be wary of patient
dependency and diversion from intended use.

"Street drugs were good enough for my generation," quipped
the 30-year doctor, who now specializes almost exclusively
on pain treatment.

"Addiction's a big problem; pain's a far bigger problem," he
said, asking the audience to weight prescription drug misuse
against the larger benefit of effective pain management for
those who need this in the absence of practical alternatives.

Chronic pain and its effects, such as lost productivity,
costs the Canadian economy about $40 billion a year, said
Jovey, medical director of a chain of pain management
clinics and a past president of the Canadian Pain Society.

"Like it or lump it, opioids have evidence" of
effectiveness, he said.

Jovey reported those most likely to misuse prescription
medications, typically 16 to 34 years of age, see them as
safer than street drugs and less likely to land them to
jail, with the justice system's priorities elsewhere.

Addiction has a variety of causes, including perhaps a
genetic or biological predisposition, he continued. He
cautioned against despairing in the face of what American
doctors are increasingly calling 'substance use disorder.'

"It begins with a choice and it ends in a choice (to seek
help)," Jovey said.

The pain management goals of health professionals, he said,
are threefold: reduce pain, improve a person's functioning
and minimize medication risks.

"We're the gatekeepers," of those medications, he said.
"There's no risk-free option, including no action."

Drug strategy committee chair Heather Kerr said Thursday the
forum illuminated a hot topic in the health field. "We
wanted to talk about the whole issue of opiate misuse in the
community," said Kerr, executive director of Guelph's
Stonehenge therapeutic centre.


Study: Glucosamine, Chondroitin No Help for Arthritis - WebMD

The popular supplements glucosamine and chondroitin don't do much to relieve the pain associated with hip or knee osteoarthritis (OA), according to a new analysis of 10 studies.

This is not the first time that research has cast doubt on the effectiveness of these two supplements. The heavily anticipated, government-funded Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) also showed that overall they did not improve knee OA pain. A follow-up arm of this study showed that they did not do any better than placebo in slowing loss of cartilage that occurs in osteoarthritis of the knee. OA is the wear-and-tear form of arthritis, and affects more than 20 million people.

A smaller subset of GAIT participants with moderate-to-severe OA pain, however, did get some relief with the combined supplements. Because this group was small, researchers said the findings were preliminary and needed to be confirmed in further studies.

The new analysis of 10 studies, comprising 3,803 people, reinforces the negative findings of the GAIT trial.Glucosamine, chondroitin, or their combination are no better than placebo (dummy pill) when it comes to joint pain and joint space narrowing, the new study shows.

But the supplements are safe, the study researchers write.

The findings appear online in BMJ.

"We see no harm in having patients continue these preparations as long as they perceive a benefit and cover the cost of treatment themselves," write the researchers, who were led by Peter Jüni of University of Bern in Switzerland.

"The jury is in, and we have given these supplements a fair try," says David Pisetsky, MD, chief of rheumatology at Duke University Medical Center in Durham, N.C. "I don’t think there is a strong impetus for more study."

Pisetsky does have a number of patients who take, and will likely continue to take, these supplements.

"If you want to take them and perceive a benefit, that's fine, but tell your doctor," he says.

Jason Theodosakis, MD, an assistant clinical professor at the University of Arizona College of Medicine in Tucson, and the author of several books that on the supplements, is unwavering in his support of their use in OA. He points out that there have been many positive studies, and there have been some major flaws with the design of the negative studies -- including the new analysis.

"The safety of these supplements has never been doubted," he says in an email. "You have to ask yourself, would you take a supplement containing glucosamine and chondroitin, have about two-thirds of a chance of getting significant relief, with some evidence that you can slow your disease progression, or just numb your symptoms with acetaminophen or anti-inflammatory drugs and risk ulcers, allergies, kidney or liver damage, hypertension, heart attacks and possibly death."  These are some risks that have been associated with prescription and over-the-counter painkillers.

"The risk/benefit for glucosamine and chondroitin far outweighs that of the FDA-approved drugs for osteoarthritis," he says.

More ...


Tuesday, September 14, 2010

Researcher hopes soy can prevent chronic pain from developing

A top pain expert is attempting a pre-emptive strike against pain by enlisting a common food ingredient — soy.

Scientists already know soy is a key player in reducing pain in rats, said Yoram Shir, head of the McGill University Health Centre pain clinic — who pioneered rodent studies in universities in Israel and the United States before coming to McGill.

Shir discovered the analgesic effects were even more dramatic when rats got a soy-rich diet prior to nerve injury.

It seemed like the soy was protecting them from developing pain.

"Study results were so robust that I didn't believe it," he said. "So I repeated the study and the results were even better."

After spending a decade trying to find the active anti-pain ingredient in soy, Shir switched tracks.

It was time to upend the current model of pain management, he said, in which traditional opiate and morphine therapy is applied after the patient complains of constant pain and tries to find medical help.

"It's hopeless because once established, chronic pain is a cureless disease, to some extent," Shir said. "I've treated hundreds of patients . . . so the idea of trying to prevent chronic pain from developing is where we should invest our money now."

Statistics from the 13th World Congress on Pain held recently in Montreal suggest that one in five people suffer pain that lingers beyond three months and many are severely disabled by it.

Links between diet and health issues such as cancer, cardiovascular disease and depression are well established, Shir says, and there's similar link between diet and pain.

But before encouraging folks to load up on soy milk and tofu, Shir's team at the Alan Edwards Pain Management Unit has launched a large-scale, double-blind study in humans to replicate the rat findings.

The team will spend three years looking at the benefits of soy in preventing chronic pain in women following breast cancer surgery.

Half the participants in the study will receive soy protein and half will get milk protein supplements.

Participants will be asked to substitute 40 to 50 grams of their usual protein with soy (or the placebo) daily for two weeks prior to surgery and will get the help of a nutritionist for meal plans.

Researchers expect to find a diet of soy will decrease the number of women with post-surgery chronic pain by 50 per cent compared to the control group getting a milk supplement.




Sunday, September 05, 2010

Welcome to PainSTORY - Pain Study Tracking Ongoing Responses for a Year


  • We recruited patients who were suffering from moderate to severe chronic pain, eg osteoarthritis, back pain/lower back pain, osteoporosis, neuropathic pain, mixed pain, or other long-term pain. For more information on types of pain, see the Patient Resources.
  • For 12 months, we followed the lives of participants, recording information about what types of pain people were feeling, who they had consulted for help and what treatments were offered.
  • Over the year, the participants recorded their pain journey experience. They made diary notes and illustrations that demonstrated not only their physical pain, but also their emotional pain. They described how chronic pain was impacting on their lives, affecting relationships with friends and family, their jobs and social lives.
The results of the PainSTORY survey demonstrate that chronic pain has a significant impact on patients' quality of life, highlighting the need for improved pain management.
Despite 1 year of treatment...
  • 6 in 10 patients feel that chronic pain controls their life.
  • 95% of patients report they are suffering moderate to severe pain.
  • 19% of patients feel that their pain is getting worse.
And yet...
  • 64% of patients believe that they are on the most appropriate treatment.
  • Over half feel that everything possible is being done to help them.
  • Only 12% are being prescribed a strong opioid medication to control their pain.
A 1-year journey through pain
By the end of the 12-month survey, 95% of patients undergoing treatment reported being inmoderate or severe pain, with 46% of this group suffering severe pain by the end of the year. For the majority of patients, pain levels had not improved dramatically despite medical intervention for 1 year.
Although patients' pain remained relatively static throughout the year, daily symptoms of pain fluctuated, leading to frustrating consequences.
Impact of pain on daily life
The study findings highlight the significant impact that chronic pain has on the daily lives of patients. Over half of patients still feel pain has a 'huge' impact on their daily life at the end of the study, with 6 in 10 reporting that chronic pain controls their life.
8 in 10 respondents confirm that their pain has an impact on their quality of life, with:
  • 64% reporting problems walking.
  • 30% reporting problems washing and dressing.
  • 60% reporting problems sleeping.
  • 73% of patients reporting problems with everyday activities such as housework or family/leisure pursuits.
  • 44% exercising less because of their pain.
Patients also highlight increasing challenges associated with childcare, with 53% reportingdifficulties in looking after children at the end of the research compared to 47% at the beginning.
The survey reveals that pain has a significant impact on patients' ability to work: 65% worry that their pain will mean they have to stop work completely, 38% claim they have had to change the way they work and 33% have had to reduce the hours they work.
The emotional impact of pain
The emotional impact of pain is just as detrimental as its physical impact. Across the year, 44%of patients report feeling alone in tackling their pain and two-thirds of patients feel anxious or depressed as a result of their pain. For 28% of patients, their pain is so bad that they sometimeswant to die. Patients report feeling trapped by a pain which may vary in intensity, but continuously affects every aspect of their life.
Results also highlight the impact that pain has on relationships with others. One-third of patients think people treat them differently and said they have fewer friends as a result of their pain.

Saturday, September 04, 2010

The politics of pain - BMJ

Pain relief is often taken for granted in the Western world, but in about 150 countries the use of morphine is severely restricted. Tatum Anderson investigates how this has come about, and what steps are being taken to stop patients living and dying in extreme pain.

Dozens of recycled plastic mineral water bottles are filled with brightly coloured solutions. The bottles are full of oral morphine, colour coded for different strengths—green for the weakest, then pink, and blue for the strongest. Every day, teams of nurses take them to paediatric and cancer wards and patients living at home near Kampala, Uganda.

In a country where fewer than 5% of cancer patients ever receive radiotherapy or chemotherapy, and with a high HIV/AIDS prevalence, the need for pain relief is crucial, says Anne Merriman, an Irish palliative care specialist who set up Hospice Africa there in 1993.

She agreed to establish the service on condition the government changed its rules on morphine provision. Previously only doctors, dentists, and vets were allowed to prescribe opioids—although midwives could prescribe pethidine. In the early 1990s oral morphine was used only rarely, and with a shortage of doctors, few patients ever met a health worker allowed to prescribe it. In 1992 the government agreed to allow nurses and clinical officers trained in palliative care at Hospice Uganda to prescribe oral morphine. "The government had seen so much suffering with the AIDS epidemic. Everyone had a family member who had died in agony," says Dr Merriman.

Lack of oral morphine

Today, despite Hospice Africa's attempts to export the model, widely available oral morphine remains an exception rather than the rule. In about 150 countries,1including Indonesia and India, severe restrictions on the use of morphine for pain relief means patients are still living and dying in severe pain.

Although WHO guidelines for the treatment of moderate to severe pain in cancer state there can be no substitute for [strong] opioid analgesics such as morphine,2weaker drugs are often used to treat pain in people with terminal cancer and HIV/AIDs patients. Gabriel Madiye, executive director of the Shepherd's Hospice in Sierra Leone says: "We have tried codeine [a weak opioid], diclofenac, and paracetamol. They are not enough."

Recently WHO estimated that 5.5 million people with terminal cancer, a million late stage HIV/AIDS patients, and 800 000 patients with unintentional injuries or injuries caused by violence are not receiving the pain relief they need. Also, many patients with conditions, such as sickle cell anaemia, those recovering from surgery, and HIV/AIDs patients on antiretrovirals, require relief but do not get it. Controlled drugs that are used to treat drug addiction or obstetric complications, such as ergometrine, are severely restricted too.3

Most countries do not have bans on opioids for medical use, but their policies and rules are so onerous the result is lack of access for patients. In some countries only oncologists and palliative care specialists are allowed to prescribe opioids, or they can only prescribe extremely limited amounts. Some formulations, such as oral morphine, are not allowed (see box 1). Indian pharmacies require so many licences to stock controlled drugs that many do not bother (see box 2). Nigeria and Cameroon each have just one government pharmacy stocking oral morphine, says Faith Mwangi-Powell, executive director of the African Palliative Care Association, which is studying the African opioid supply chain.

Injectable morphine is not an option—too many safety problems are associated with it because it needs to be administered in controlled conditions. The same issues apply to controlled release forms of morphine.

Even countries that have embarked on strategies to change laws and increase palliative care provision, such as Malaysia, have run into problems. Too few doctors are trained to prescribe morphine says Ednin Hamzah, chief executive officer of Hospis Malaysia. "We organise many workshops and have started to get some palliative care content into undergraduate education, but it is very little."

More ...


Too many suffer in pain - Margaret Somerville - Ottawa Citizen

The following text is adapted from a video address by McGill medical ethicist Dr. Margaret Somerville to the International Association for the Study of Pain congress in Montreal. The final event of the congress was the International Pain Summit at which the Declaration of Montreal was to be presented and discussed. The declaration provides that access to pain management is a fundamental human right.

Many of us involved in trying to ensure people who require pain management get what they need have personal experiences involving pain in our background. That's true for me. I can remember as an 11-year-old, with life-threatening peritonitis from a ruptured appendix, consciously wanting to die the pain was so severe.

In 1983, my father was terminally ill with prostate cancer that had metastasized to his bones. I was telephoned in Montreal and told he was about to die, so I jumped on a plane to Australia.

I found my father in a university teaching hospital in horrible pain. I created a huge fuss and managed to get a pain specialist to see him -- in fact, that specialist was Dr. Michael Cousins, who has piloted the development of this declaration we are considering. My father's pain was brought under control and, as it turned out, he lived another nine months.

Dad said to me, "I want to live as long as I can, Margo, but I don't want to live if it means such terrible pain. It's great what you did for me, but not everyone has a daughter who can 'go berserk' to get them the pain relief they need. You have to do something to help other people in pain." That was the start of my research on ethical and legal aspects of access to pain relief treatment.

That research led to an invitation to speak at the International Association for the Study of Pain's meeting in Paris in 1993. I decided to consider whether we might be able to use ethics and law to improve access to pain relief treatment. I called the speech "Death of Pain," meaning to convey the double-entendre message that we could kill the person with the pain or we could kill the pain.

I'm adamantly against killing the person with the pain, that is, euthanasia, and passionately in favour of killing the pain. So, I argued that to implement that latter goal in practice, we should recognize that people in pain have a "fundamental human right" to have reasonable access to pain management and that unreasonable failure to provide such access was a breach of their human rights. And that is precisely what the Declaration of Montreal would establish.

Now, it's important to understand why we need this declaration and to do so we need to understand something about the nature of human rights. "Human rights" try to ensure the rightness or ethics of our interactions with each other at the most basic level of our humanness, at the level of its essence, that which makes us human. I cannot discuss that further here, but suffice to say, as the vast majority of people acknowledge, recognizing and respecting human rights is very important in creating moral and ethical societies.

Here, I want to make just two points about human rights that I believe are important in relation to pain management.

First, I do not believe we create human rights; rather, they exist independently of being recognized by any human agency. That's why no one can opt out of respecting them. What we do is articulate human rights. And that's why statements of them are called declarations. The Universal Declaration of Human Rights is a major example of such an articulation, but it was not the end of our declarations of human rights. New declarations have continued to appear and need to do so.

I believe that this latest declaration, the Declaration of Montreal of the right of access to pain management for all who need it, without discrimination, will rank with the major human rights declarations.

Second, I believe that what we call "human rights" is shorthand for a tri-partite concept that consists of human rights; human obligations; and human ethics. Sometimes we need to focus on one of these limbs, sometimes on another, and sometimes on all of them.

So, a human right to access to pain management means that health-care professionals and health-care institutions have ethical obligations, and sometimes legal ones, to offer patients such management.

But if, as I said, we don't create those obligations, they exist whether or not we declare them, why declare them? The answer is to help ensure that they are honoured and not breached. Formally recognizing them will make it much more likely that they will be respected.

The Declaration of Montreal is not just a piece of paper; it's what we call a "verbal act," that is, its words will change reality, just as a judge's verdict is not just words, but changes reality. The hope is that the declaration will help to change the horrible reality of people being left in pain.

The declaration will also function as an ethics guide in relation to pain management and an educational tool for health-care professionals and trainees. Sometimes, it will be used as evidence to justify giving necessary pain relief treatment, when others would prevent that. In particular, it will help to overcome the harmful beliefs of some health-care professionals who withhold pain management because they fear legal liability or that patients will become addicted. It will deliver a strong message that it's wrong not to provide pain management, not wrong to provide it.

And it will inform and, one hopes, guide institutions and governments in formulating health policy and law with respect to pain management. The declaration will help governments understand they have both domestic and international obligations, at the very least, not to unreasonably hinder either their own citizens' or other people's access to pain management.

It is an outrage and a human tragedy that, in developing countries, many people in serious pain do not have access to opioids, including as a result of the conditions some countries attach to their foreign aid to these developing countries. Imagine, as happens to many people in these countries, dying of excruciatingly painful cancer, with no pain relief.

We need to apply one of the most ancient and universally accepted maxims in making sure that everyone who needs pain management receives it: "Do unto others as you would that they would do unto you" -- the Golden Rule. The Declaration of Montreal spells out what those "others" have a human right to expect when they are in pain.

There is a beautiful Sanskrit salutation, namaste, that I've spoken of in other contexts. It can be roughly translated as, "The Light in me, recognizes the Light in you." It affirms our common humanity across all barriers and borders. One very important application of it could be rendered as "The pain in me recognizes the pain in you" -- which is another way to express the insight of the "wounded healer."

The Declaration of Montreal is a very important step forward in making sure that as many of us as possible, and especially health-care professionals, do recognize others' pain and see it as our privilege and obligation to do what we can to assuage it.

And, finally, the Declaration of Montreal could raise our sensitivity to the horror of breaches of human rights, in general. Fortunately, most of us don't experience breaches of our human rights in our everyday lives and, consequently, we don't personally identify with them, much as we might abhor them. But because pain is a universal human experience which we all want to avoid, wrongful failure to manage it is one of the rare breaches of human rights with which we can all personally identify and, as a result, better understand what breaches of human rights, in general, feel like. That is a lesson we should all heed carefully.

Margaret Somerville is director of the Centre for Medicine, Ethics and Law at McGill University, and author of The Ethical Imagination: Journeys of the Human Spirit. 


Friday, September 03, 2010

Efforts to battle chronic pain found lacking - The Globe and Mail

Chronic pain is a disease in itself and proper treatment a human right, doctor says

Some 80 per cent of people around the world who suffer from chronic pain can't get the treatment they need and governments must step up their efforts to tackle the issue, says Michael Cousins, an Australian anesthetist and the driving force behind the first International Pain Summit.

Fixing the problem would entail changing the curriculum in medical schools, co-ordinating between physicians to better treat chronic conditions and getting the word out to pain sufferers that there are alternatives to drugs, Dr. Cousins said.

Earlier this year, he had a hand in drafting a national pain management strategy for Australia - the first in the world - and the summit, which takes place in Montreal on Friday, will draw up guidelines to help other countries follow suit. As health professionals, academics and researchers gathered for the summit, Dr. Cousins told The Globe and Mail that chronic pain must be considered a disease in itself, that there is an enormous economic cost to not dealing with the problem, and that proper treatment is a human right.

Q: You say the vast majority of people who suffer from chronic pain can't get the treatment they need. Can you give us a sense of what's causing the problem?

A: If you wanted to characterize this era of health care, it's the fiscal era. It's one where the most important considerations are financial. There aren't any resources - it's as simple as that. A lot of my research over the last five years has been to measure the scale of the problem [of pain]. In my country, one in five people suffer from chronic pain. It costs $34-billion per annum. That's in health-care costs, lost work days and the entire economic burden of the disease.

Q: Often people think of pain simply as a symptom of illness, but you characterize chronic pain as a disease in its own right. Can you explain?

A: There are changes in the spine, pathophysiological changes [associated with pain]. There are extreme neuroplasticity changes in the brain for people with chronic pain. Catherine Bushnell at McGill has done extensive neuroimaging work showing a loss of brain tissue associated with chronic pain. It's my contention that sufferers are being discriminated against because they're being denied access to treatment for their chronic disease.

Q: What do governments around the world need to do to address the problem?

A: First, you need epidemiological research: You want to know what the magnitude of the problem is in your country. The second is pain education. It's got to start at the undergraduate level. All primary care doctors need to have more training in pain medicine. All countries also need to have physicians who specialize in pain. We're also recommending that the population be educated. The general public needs to know that they have access to all forms of treatment.

Q: Is a lack of access to medication also part of the problem?

A: With the new knowledge of the mechanisms of pain, there are now drugs being developed that target the causes of the problem. Most patients have the idea that taking a pill is the only option and that's completely untrue. [There are] things like cognitive behavioural therapy, physiotherapy.

Q: How do you make sure the recommendations on pain management that come out of the summit are adopted?

A: There are two approaches available. One is to go to governments and get them to work on that. In Montreal, there will be a high official from the U.K., a senior Canadian health official, the deputy health minister of Malaysia and a high-ranking official from Portugal will all be there. The second is to try to empower the general community, tell them that they have the right to effective pain medicine. I've spoken with human-rights organizations and human-rights lawyers, too.


Thursday, September 02, 2010

Pain Medicine News

Pain Medicine News is designed to meet the needs of the spectrum of physicians involved in pain medicine, including primary care physicians, neurologists, orthopedic surgeons, pain management specialists, rheumatologists, oncologists and more.

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Some preemie babies 'give up' to blunt repeated pain

 MONTREAL — Jabbing needles into the tiny heels of premature babies is proportionally like sticking a butcher knife into an adult foot.

Premature babies are repeatedly exposed to painful invasive procedures, yet only 36 per cent of premature babies in Canada get pain relief, according to Celeste Johnston, a McGill University nursing professor and expert in neonatal pain.

These babies "give up" to blunt the pain, Johnston said in an interview at the 13th World Congress on Pain that ends Thursday in Montreal.

"It's similar to depression or learned helplessness," Johnston said of the risk of long-term consequences. "About 20 to 25 per cent of preterm babies in our studies show no response when they have several painful procedures in a row."

Europeans prefer drawing blood from a vein but in North America, preemies get the heel lance.

There are clear Canadian Paediatric Society guidelines for pain relief during such procedures as chest tube insertion and heel lances, Johnston said. Babies should be swaddled, given a pacifier dipped in sucrose, or put in kangaroo care, which is skin-to-skin contact against the mother's chest.

"Why isn't it being done? Well, a lot of us have been studying this," she said. "Is it because they don't believe that the baby is having pain, or it's too much trouble . . . to get the sugar because they don't have enough time? We really don't know. But collaboration among staff predicted better analgesic care."

It was once wrongly believed that newborns do not feel pain. Babies can feel and express pain, Johnston said, noting that since the 1980s, a body of scientific literature emerged to document the many ways that babies communicate their suffering — apart from crying.

A baby in pain grimaces, its eyes squeeze shut, its mouth stretches open and the tongue curls; its oxygen consumption and stress hormones spike, and its tiny heart beats faster.

More recently, scientists found via imaging techniques, that pain activates cortical areas in the preterm newborn brain. The brain images correlated with facial grimaces, Johnston said.

These preemie babies who had many painful interventions during their medical care grow up to be less sensitive to pain as children.

"We thought it would make them more sensitive, so we were surprised," Johnston said. "Mothers of preterm babies have said to us, 'My kid can walk through a glass door and it wouldn't hurt him.' "

But there's a complication. Once they reacted to pain (for example a heat pad), school age children who were premature babies rated their pain higher than full-term children, Johnston said: "There's a difference between pain threshold and pain rating" which may have implications for chronic pain in adults.

Repeated exposure to pain in premature babies who have an extremely plastic and rapidly developing nervous system is critical, Johnston said. The most powerful tool is the kangaroo care. In one video Johnston presented, babies hardly noticed a heel lance when cradled in their mother's arms.