Wednesday, December 28, 2011

A young woman struggles with oxy addiction and recovery - Tampa Bay Times


When her mom came to pick her up for drug court that morning, Stacy Nicholson was still high.

She staggered to the door, fumbled with the bungee cord that kept it closed, blinked back the sunlight.

"You ready?" asked her mom.

Stacy and two of her cousins had been holed up for months in this rundown house, shooting crushed-up pain pills. Used syringes littered an end table. Stacy's mom had kept telling her: Someone in this house is going to die.

Stacy, then 28, knew she was right. Days before, she had told her mom she was tired of stealing and doctor shopping to get pills. She was in trouble for skipping her last court date, so today, she planned to turn herself in.

"Okay," Stacy said. "Let's go."

She twisted her long, honey-colored hair into a knot. Zipped her sweatshirt. Underneath, she was wearing two bras, a tank top, two white T-shirts and three pairs of panties.

She wanted to be sure she would have a change of underwear in jail.

COURTROOM 10 WAS PACKED when Stacy and her mom, Sherry Alkire, slid into the back row. It was Feb. 1, a Tuesday.

More than 100 women, most 20 to 40 years old, filled the wooden benches. Some were visibly pregnant. Others trailed toddlers. Many of the women struggled to hold up their heads.

Just before 9 a.m., a thin, chestnut-haired woman in a black robe strode through the back door. "All rise!" called the bailiff. "The honorable Judge Dee Anna Farnell presiding."

The judge raised her arms and smiled. "Welcome to Ladies' Day," she said. America's first all-female drug court was in session.

Soon the judge called Stacy's name. Stacy slouched down the aisle, clasped her hands behind her back and hung her head.

Eighteen months earlier, she had been arrested for using a fake prescription to buy oxycodone, the painkiller she had been snorting or shooting for four years. The charge carried a possible five-year prison sentence.

The judge had offered a deal: Plead guilty and go on probation. If you go through rehab, if you go to 12-step meetings and get a job and stay sober, you can stay out of jail — and have your felony record wiped clean.

For a while, Stacy had tried. But then she failed a drug test, stopped going to counseling, started skipping court. Now she faced a sentence of 10 years instead of five.

The judge could send her to a long-term treatment facility or halfway house. Or she could put her in prison for violating her probation.

Farnell asked Stacy about her children. Stacy said her 12-year-old daughter had been staying with her paternal grandparents for almost a year. Her mom was taking care of her 2-year-old son.

"What are you going to test positive for today?" asked the judge.

Stacy shuffled her Air Jordan slides. "Well, I've been smoking and drinking. So marijuana and alcohol." She paused. "And benzos. And maybe …"

The judge shook her head. "Okay," she said. "What do you want to do? Do you want to opt out? Or keep trying?"

Stacy wanted what a lot of addicts want: to get clean, but also to get high. She wanted to have her kids back, but also to have no responsibility. She wanted to feel better, and to feel nothing.

She wiped her nose on her shoulder, looked up and said, "I want to keep trying."

PRESCRIPTION DRUG abuse kills 40 Americans every day. That's more than a threefold increase in the last decade, according to the U.S. Centers for Disease Control and Prevention.

Oxycodone is the deadliest drug of all. An opiate found in such painkillers as OxyContin and Percocet, it's prescribed after surgeries and car wrecks, and to people in chronic pain.

Others take it just for the high. The drug works by blocking the spinal cord's pain receptors. It doesn't make the pain go away, but prevents people from feeling it, creating a sense of euphoria. Soon, they need to take more to get the same pleasurable escape.

Oxy makes junkies out of people who would never buy from a street dealer. It is everyman's high, heroin in a pill.

Of all the oxycodone prescribed in America in the first half of last year, 98 percent was dispensed in Florida. According to the state medical examiner's office, an average of seven Floridians die from prescription drug overdoses every day — more than from car accidents.

In recent years, Pinellas has lost more people to prescription drugs than any other county in the state — 249 just last year. That's an increase of 60 over the year before.

"Everyone knows someone who has gone through this addiction and you just feel so helpless. It's a horrible, vicious disease," said Pinellas County sheriff's spokeswoman Marianne Pasha.

"These aren't Dumpster-diving drug addicts," she said. "These people are getting their pills from doctors. It's the person in line beside you at Publix, the woman next to you in the pew at church."

A few years ago, drug court Judge Farnell started seeing more and more women charged with prescription drug abuse. By 2009, almost half of her drug court defendants were women.

That year, Pinellas County received a $900,000, three-year federal grant to fund substance abuse treatment for women in drug court.

That's how Tuesdays became "Ladies' Day."

Instead of punishing the women, the judge offers them a chance to start over. They come to court once a month. She creates incentives for them: Do yoga, run a 5K, quit smoking, and we'll waive your $52 monthly probation fee. She makes sure they know how to get a bus pass. If she gets a bad vibe about a boyfriend, she'll order a woman to steer clear of him.

She tells defendants, "You can do this. It's going to be hard. But it will be worth it."

When a woman slips, the judge scolds her and sends her back to jail to detox. Then she offers another chance.

About 500 defendants came to court on Ladies' Days this year. St. Petersburg Times journalists attended week after week. They interviewed dozens of women. They followed addicts as they bounced between jail and treatment, stayed in abandoned houses, looked for jobs and stumbled toward recovery or relapse.

One woman let the journalists follow her all year.

Stacy Nicholson grew up in St. Petersburg. A streetwise, Southern-fried tomboy, she loves the Florida Gators, Chevy pickups, Lil Wayne and Toby Keith. She believes in dream catchers and her Gemini horoscope, craves Cocoa Puffs and smokes Newports. She never wears makeup, always spritzes on Victoria's Secret body spray. When it comes to men, she likes the smell of trouble.

Her history of drug use and dysfunction stretches back to puberty. She tried marijuana at 13 and alcohol at 14, had her first baby at 16 and her second, with a different man, at 27.

But the pursuit of the oxy buzz erased any chance of a productive life.

For addicts, using quickly becomes a necessity, not a choice. Getting the next pill becomes more important than work, friends, family, even food. The addict's values shift to justify whatever it takes to get more oxys. Hard workers can no longer hold jobs. Smart students drop out. Good moms neglect their kids, drain their bank accounts, steal from family members.

If addicts stop using, they suffer horrible symptoms: vomiting, headaches, intense bone pain. That's why many are afraid to even try to get sober. They need to stay high so they don't crash.

After Stacy got hooked, she lost her personality, spark, motivation. Every new boyfriend was a red flag, but she never saw it. She dragged her kids from bad apartments to cheap motel rooms, and finally gave them up.

In Judge Farnell's court in February, Stacy entered what everyone agreed was a fight for her life. She could get better, or she could become one of Florida's seven a day.

She had a lot going for her: a mother who supported her even after all the times Stacy had broken her heart. Two children who desperately needed her love and attention. A treatment program backed by almost $1 million in taxpayer money. Drug counselors who wanted her to succeed. Other recovering addicts eager to share their experiences at 12-step meetings. An empathetic judge who was willing to give Stacy chance after chance, if only she would try.

Working against her: a little blue pill and Stacy's need to numb herself with it.

More ...

Thursday, December 15, 2011

Emergency contraceptives over the counter: Are they more dangerous than other drugs? - Slate Magazine

Health and Human Services Secretary Kathleen Sebelius overruled the FDA's recommendationthat emergency contraception be made available over the counter to patients of all ages on Wednesday. Her argument was that its effects on 11-year-olds have not been thoroughly studied. Critics pointed out that many over-the-counter drugs are far more dangerous than emergency contraceptives. What's the most dangerous drug you can buy without a prescription?
It's hard to say. As far as the Explainer can tell, no researcher has ever compared the fatality rates of every drug available over the counter—probably because the number of deaths from overdose of antacids and many other products is so small as to make the study a waste of time. There is, however, a large body of research on pain relievers. Analgesic overdoses are pretty common in the United States. In 2000, poison-control centers received more than 130,000 calls from people who believed they had taken a dangerous amount of an over-the-counter painkiller. Nearly one-half of those calls concerned acetaminophen, best known as the active ingredient in Tylenol. Approximately 0.2 percent of those cases ended in death. That's higher than the reported death rate for nonsteroidal anti-inflammatory drugs like Advil (ibuprofen) and Aleve (naproxen), but lower than the fatality rate for aspirin. (Aspirin is technically in the same category, but is often separated for research purposes.)* However, most of the aspirin deaths appear to have been suicides, while accidental overdose is more common than intentional overdose for acetaminophen. Between the years 1990 and 1998, 458 people died from taking too much acetaminophen.*
Pseudoephedrine, a very common cold medication, is also implicated in a number of deaths every year. In 2004, for example, poison-control centers reported 21 deaths in which the chemical was involved. However, most of those patients took a cocktail of drugs—often including acetaminophen—and many of the cases were ruled suicides. It's also not entirely correct to call pseudoephedrine an over-counter drug. A 2005 act of Congress forced retailers to move it behind the counter because of its use in the production of methamphetamine.
Of course, many other drugs can be fatal if you go way overboard. Even Epsom salts, which are commonly used as a laxative, can cause cardiac arrest. A hospital in Scotland reported a case of attempted suicide by Epsom salts in 2009. The woman ingested an incredible 4.4 pounds of the stuff. She suffered some acute cardiac complications, but doctors were able to save her.

It's not easy to determine the fatal dose of over-the-counter drugs. Take the example of acetaminophen. A person's ability to handle the drug depends on a variety of factors, including the condition of their liver, how much they've eaten, and whether they take the pill in conjunction with alcohol. (Bad idea.) Compared to other over-the-counter drugs, acetaminophen has a relatively narrow safety margin—that is, the difference between a safe-but-effective dose and an overdose is relatively small. Doctors have reported liver failure from as little as 2.5 grams in a day, which is 1.5 grams less than the approved limit.

The FDA has considered reducing the approved daily dose (PDF) of over-the-counter acetaminophen, but that wouldn't help in all cases. Many patients don't realize how much of the drug they're taking. Those who are prescribed the painkiller Percocet, for example, might take over-the-counter acetaminophen as an adjunct for different or breakthrough pain. The problem is that Percoset contains acetaminophen, and the combination can easily put them over the dose limit.
What's the fatal dose of emergency contraceptive? Nobody knows. The drug certainly has side effects, like nausea, vomiting, dizziness, fatigue, and the like. Women who use the morning-after pill as their regular form of contraception can also experience some menstrual irregularities. But no one has taken a fatal dose of Plan B.

Long-Term Study Sheds Light on Jaw Pain Disorders

People with disorders of long-term jaw pain were much more sensitive to mildly painful sensations elsewhere in the body, more aware of body sensations, and experienced greater heart rate increases under mild stress, according to the first large-scale clinical study of its kind by researchers, including those at the University of Maryland School of Dentistry.
The findings, published in the November issue of the Journal of Pain, provide insights into potential causes of temporomandibular joint disorders (TMJD), and should lead to new methods of diagnosing facial pain conditions, predicting who will be susceptible to them, and new treatment approaches, say the authors.
"There is a real difference. People with TMJ are more sensitive than those without TMJ on parts of the body other than the jaw," says co-author Joel Greenspan, PhD, professor and chair of the School's Department of Neural and Pain Sciences. "To us it means the nervous system for interpreting pain information is now altered. We think that general heightened pain sensitivity is part of the chronic pain problem."
The University of Maryland dental school is one of four testing sites in the study led by William Maixner, DDS, PhD, director of the Center for Neurosensory Disorders at the University of North Carolina School of Dentistry in Chapel Hill. The study is called the Orofacial Pain Prospective Evaluation and Risk Assessment, or OPPERA, in which researchers tracked followed 3,200 healthy volunteers aged 18 to 44 for three to five years to see how many develop the disorder. The other two sites are the University of Florida at Gainesville and the University at Buffalo.
Temporomandibular joint disorders produce pain that radiates from the jaw and surrounding muscles, restricting jaw movement and causing considerable suffering. Although the disorders vary in duration and severity, for some people the pain becomes an unrelenting and long-term feature of their lives.
Genetic factors may also play a role in chronic TMJD. The researchers identified several genes, including some known to influence stress response, psychological well-being, and inflammation that may point to targets for discovery of new drugs to treat TMJD and related chronic pain conditions.
And, the researchers report that the findings provide evidence that chronic TMJD is at least partially linked to a person's perception of and ability to suppress pain, which is determined by the body's physiological regulatory systems.
Greenspan said a principal contribution of the University of Maryland team was to develop the protocols for sensory testing, including development of some of the testing tools. Greenspan has worked in the field of "quantitative sensory testing" for 35 years, including assessments of pain sensitivity in a research setting. He says the results so far cannot distinguish cause and effect. "We cannot say whether a more pain sensitive person is more prone to develop TMJD, or whether chronic TMJD changes the nervous system to enhance pain signals," Greenspan says. "My expectation is more likely the latter, which we plan to evaluate in the future. There is a lot of animal research including studies performed by Dr. Ronald Dubner, a co-primary investigator on the study from the University of Maryland Dental School, showing that a long-term pain state changes the nervous system's responses to subsequent painful events. The question remaining is whether this is what is happening in human clinical conditions."
Adds Maixner: "Previous studies haven't been able to be as conclusive as OPPERA because they've often included fewer participants and didn't follow participants for an extended amount of time. OPPERA is allowing us to study potential biological, psychological, and genetic risk factors over a longer period of time, so we will be able to better evaluate the association of these factors with TMJD. This novel study will also allow us to learn more about pain disorders in general, and will improve our ability to diagnose and treat chronic pain conditions across the board."
The longitudinal study builds on earlier work by members of the multi-university research team, who designed a broad conceptual model to determine the condition's causes. Maixner said the new findings go far toward validating that model, which was first published in 2006.
"The model, like a compass to a traveler, predicts the route ahead in the development of specific persistent pain disorders," Maixner says. "In this case, we predicted that biological and psychological risk determinants, which are modified by both life history and genetic factors, contribute to the onset and persistence of TMJD."
The research team will publish additional findings and insights as they continue to analyze the study data.

American Academy of Pain Management e-Newsletter

Pain Studies In The News News/Research UPDATES

These UPDATES are a component of Pain Treatment Topics ( Our mission is to serve as a noncommercial resource for healthcare professionals & their patients, providing open access to clinical news, information, research, and education for a better understanding of evidence-based pain-management practices. News/Research UPDATES: Is the Shocking Prevalence of Chronic Pain True?

Many readers have questioned the latest figure that 116 million American adults suffer from chronic pain, which represents more than a third of the total population. Yet, looking at the original source of this data, the evidence seems generally reliable and, furthermore, the U.S. is not unique in the world — chronic pain seems to be a truly huge problem of global proportions.

That 116 million estimation of chronic pain in the U.S. comes from a lengthy Institute of Medicine (IOM) report released last June, 2011: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research [discussed in UPDATE here]. Apparently, many healthcare providers and opinion leaders find that number a bit far-fetched. Where did it come from and can it be trusted as being valid?

More ...

Staying socially connected while living with chronic pain |

Living with pain can interfere with quality of life on many levels, one of which is the ability to interact with people and contribute to life in a meaningful way. But being socially connected with others is essential for maintaining and improving productivity, self-esteem, and an overall sense of well-being.
In this lesson, you'll learn how to:
  • Recognize and manage feelings of isolation.
  • Take charge of your life.
  • Maintain old social connections and create new ones.

How to overcome common fears about chronic pain |

If you have pain that won't quit, you probably feel worried about it. You might even feel angry, helpless, or afraid. All of these thoughts are normal. These feelings may be especially strong at the time of diagnosis; when a set-back or flare-up occurs; or when a treatment doesn't seem to be working. After all, constant pain is hard on your body and your mind. Your life isn't what it used to be.
Being afraid, though, is one of the most common emotions for people struggling with chronic pain.
This lesson will help you:
  • Learn about the fears faced by people with chronic pain. 
  • Understand ways to fight those fears.
  • Get a sense of control over your own fears.

Wednesday, December 14, 2011

Painkillers for N.F.L. Players? Not So Fast -

The former professional football player is confused. It is difficult for him to pinpoint, after the pads have come off for good, the precise cause of his aching body and his aching soul. He knows that the game did it. But what part of the game? Was it the physical violence? The psychological warfare? The realization that his life peaked in his 20s? The drugs he took to stay on the field? Whatever the cause, there is always the pain. The pain is constant in football and as a result it is constantly being manipulated.

Last week a group of 12 former National Football League players filed a class-action lawsuit against the league, claiming that the N.F.L. and its teams failed to warn players of the side effects of the drug Toradol, widely administered to players before games to numb pain. The lawsuit contends that the use of the drug masked injuries like concussions and thus further endangered the athletes.

When I played for the Denver Broncos, from 2003 to 2008, Toradol was a popular pregame injection. The night before we took the field, 10 to 20 of us would go into a designated room and stand in line to receive our shots. I don't remember what, if any, specific injury I was nursing on any particular occasion. I do remember that my body was perpetually feeling bad, as were those of my teammates. Our training staff knew this and would encourage us to get a shot. We were told it would make us feel better. So we lined up for the needle.

When I got to the front of the line, I was told that the shot was known to cause internal bleeding in a very small percentage of patients but otherwise was safe. This disclaimer was given with needle in hand and a line of men waiting behind me. There was no hesitation, no trepidation, no point at which I felt that taking Toradol was a risk. I trusted our team doctors. They wouldn't suggest a drug if it was dangerous.

The big risk, in my mind, was not being at my best the next day. The big risk was not taking the shot, playing poorly and being viewed by the staff as unwilling to do what it took to help the team win. The big risk was losing my job.

The N.F.L. is a machine. The operators of the machine pull its levers more frantically every season, pushing it past its breaking point. So the league has stockpiled interchangeable spare parts. The broken ones are seamlessly replaced and the machine keeps rolling. The old pieces are discarded and left to rust in a scrap heap.

This harsh reality is softened by human relationships. Football players spend every day with the members of their team's medical staff. They learn to trust them. The athletic trainers nurse the players back to health when they are injured. The team doctors perform their operations. Friendships are formed and bonds are created. But underneath it all hums the machine.

Athletic trainers are paid to keep the machine humming. The long-term health of the individual player is not their first concern; the health of the team is. The faster a trainer gets his players back on the field, the more likely he'll be to keep his job. Trainers are under pressure to do this by masking a player's pain with drugs and designing a hasty rehabilitation schedule, even if it inevitably trades one injury for the next.

The player rarely if ever has a say in the treatment process. When he is injured, the athletic trainers and team doctors take the necessary X-rays and M.R.I.'s and decide on the course of action among themselves. Only afterward do they tell the player what injury they have found and how they will treat it. If the player seeks a second opinion, which he is technically allowed to do, it is taken as an affront to the medical staff, and he will be treated in the training room like a turncoat. The medical staff issues its reports to the head coach, and is often beholden to him, which is another reason that players don't challenge their diagnoses or treatments.

The player is not told how to access his medical records or whether he even has a right to them. The folder of my medical records was as thick as a dictionary and I never had access to it. Even after I filed a workers' compensation lawsuit against the Broncos a year ago that later included a request for that folder, I still don't have it. The team hasn't released it to me.

If the N.F.L. is serious about protecting its players, it should appoint a league-wide medical body, unaffiliated with any specific team, to oversee players' health. Such an institution would be able to provide care to the athlete without the interests of his team distorting treatment.

Until then, teams will continue to convince players that their bodies and brains are ready for professional football, even when they are not. The injured body needs coaxing. It needs to be stroked, rubbed, heated, stretched and lied to. There are coaches, owners, trainers, fans and a host of media people counting on the players, after all, ready to question their manhood if they decide that the pain is too much to bear.

But the next game, the game that right now feels so important, will pass. In a couple of weeks, few will ever speak of it again. And then it's on to the next one. And the machine will keep humming.

Nate Jackson is working on a book about life in the N.F.L.

Tuesday, December 06, 2011

N.F.L Sued by Ex-Players Over Painkiller Toradol -

In the latest lawsuit based on medical issues against the N.F.L., a dozen former players have accused the league and its teams of repeatedly administering the painkiller Toradol before and during games, worsening high-risk injuries like concussions.

The players also contend that the league and its teams failed to warn them of the consequences of taking the drug, a blood thinner that, according to the suit, "can prevent the feeling of injury" and therefore made it harder for players to recognize when they had concussions.

"The plaintiffs have described the situation as one of being in a pregame locker room with players lining up to receive injections of Toradol in a 'cattle call' with no warnings of any sort being given, no distinguishing between different medical conditions of the players, and regardless of whether the player had an injury of any kind," the suit alleges.

The dozen retired players, including Joe HornMatt Joyce and Jerome Pathon, played in the late 1990s and early 2000s and say they now have anxiety, depression, short-term memory loss, severe headaches, sleeping problems and dizziness, according to Christopher A. Seeger, the lead lawyer for the plaintiffs.

"We took it like clockwork," said Horn, a receiver who played 12 years with the Kansas City Chiefs, the New Orleans Saints and the Atlanta Falcons and who says he now experiences bouts of dizziness and blackouts. "They don't meet with you to tell you what will happen five years later. Had I known that there were going to be complications, I wouldn't have taken the shots."

In accusing the league of negligence, fraud, fraudulent concealment, negligent misrepresentation and conspiracy, the former players are seeking an unspecified amount of compensatory and punitive damages, and the reimbursement of their legal costs.

The league disputed the suit's claims.

"The N.F.L. has long made player safety a priority and continues to do so," Greg Aiello, a league spokesman, said in a statement. "Any allegation that the N.F.L. intentionally sought to mislead players has no merit. It stands in contrast to the league's actions to better protect players and advance the science and medical understanding of the management and treatment of concussions."

The suit, which was filed in United States District Court in New Jersey, also alleged that the N.F.L. was late to acknowledge the problems raised by repeated concussions, and its efforts to combat the issue were half-hearted.

In recent years, the league has instituted a number of changes to protect players, including penalizing helmet-to-helmet hits. Commissioner Roger Goodell said he would not rule out other rule changes to minimize the potential for head and neck injuries.

In October, the league said it would broaden its study of the effects of concussions after an earlier study was scrapped because of problems in how the data was collected. The new study will include about 1,400 people, from 45 to 59 years old, and divided into three groups. The first group will be retired N.F.L. players; the second will be people who played college football but no professional football; and the third will be a control group of nonathletes who have some medical commonalities with the first two.

Saturday, December 03, 2011

New pain sensors explain why snake bites hurt - Technology & science - Science - LiveScience -

The Texas coral snake may seem benign enough, with crayon-colored rings adorning its body, but this serpent packs a mighty punch in its toxin-laden venom. And new research finds these toxins trigger a previously unknown pain mechanism in humans.
There are many different types of pain, said study researcher David Julius, of the University of California, San Francisco. Some respond to changes in heat or pressure; for example, if you burn your finger or get punched. Others respond to different chemicals, such as acids. Your body senses the painful trigger with a receptor on a pain-sensing nerve in your skin. That nerve signals the brain, which then tells the body that the pot is hot or the acid is burning you.
It seems the coral snake triggers a novel pain receptor on nerves. The finding could help researchers develop drugs to treat snakebites or other painful phenomena in a targeted fashion without having to use opiates. [ 5 Facts About Pain ]
"We find natural products from animals or plants that generate pain sensations and find out what they target on the cells," Julius told LiveScience. "In the future, these kinds of toxins will help us understand how these [pain-sensing] molecules are activated… that sort of information is important for producing drugs to reverse the action."
Julius and his colleagues screened a wide variety of snake venoms, looking specifically at their ability to activate certain pain-relaying nerve cells in rats. The Texas coral venom activated some of these nerve cells, a type of chemical-based pain-sensing cell that communicates the conditions of the body to the brain.
In that venom, the researchers found a toxin they named MitTx, which opens a channel on the outside of the skin's nerve cells, sending a signal up to the brain. Oddly, even though MitTx isn't acidic, it turned on a channel related to those that usually respond to acids.
The channels' acid-sensing relatives produce pain when tissues are deprived of blood and oxygen, but MitTx is specific for a channel that hasn't been implicated in pain sensation before.
"The one [pain pathway] that we've identified with this toxin isn't the one that people have paid the most attention to," Julius said. "This is an important site of action, and we should look at it more closely in how it produces pain."
The Texas coral snake (Micrurus tener tener) is about 2 feet long and is usually shy and secretive, as well as nocturnal, so it's not often you run across one.
They don't usually bite humans unless provoked, but their venom is a powerful neurotoxin and without treatment the bites are fatal about 10 percent of the time. Luckily, no deaths from coral snake bites, the Texas variety or others, have been reported in the United States since coral snake anti-venom has been available to hospitals. Even when not fatal, however, the venom of the Texas coral snake causes extreme pain that can last for hours.
Because this pain is mediated through this newly discovered pathway, it's possible that traditional pain relievers such as aspirin, which work through different receptors, wouldn't help the pain. The bites, if painful enough, are usually treated with opiate pain relievers, like morphine, but a more targeted and less addictive reliever would be beneficial, according to the researchers.
"Different types of injuries mediate pain through different types of mechanisms," Julius said. "That's the secret — figuring out what the mechanism is for different types of pain, so you can eventually target the right kinds of therapeutics for that."
The study is published in the Nov. 17 issue of the journal Nature.

Tuesday, November 22, 2011

Older ER Patients Less Likely to Get Pain Meds, Data Shows - Health News -

Elderly patients are less likely than middle-aged patients to receive pain medications in U.S. hospital emergency departments, even when they have severe pain.

That's the finding of researchers who analyzed data collected from U.S. emergency departments between 2003 and 2009.

Among patients with a primary complaint of pain, an analgesic (such as morphine, oxycodone or ibuprofen) was given to 49 percent of patients 75 and older, and 68 percent of patients aged 35 to 54.

An opioid (such as morphine or oxycodone) was given to about 35 percent of elderly patients and 49 percent of middle-aged patients, the investigators found.

Age-related differences in the use of pain medications remained even after the researchers adjusted for factors such as sex, race/ethnicity and pain severity. Elderly patients were nearly 20 percent less likely to receive an analgesic and 15 percent less likely to receive an opioid than middle-aged patients.

Even among those with severe pain, elderly patients were less likely to receive pain medications than middle-aged patients (67 percent versus 79 percent, respectively).

The study was published online ahead of print in the Annals of Emergency Medicine.

The reasons why elderly patients are less likely to receive pain medications aren't clear but doctors may be concerned about potential side effects in older patients, suggested lead author Dr. Timothy Platts-Mills, an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill School of Medicine.

"To us, the gap we observe in pain management for older patients highlights the need to better understand how best to manage pain in older patients and understand the barriers to doing this. All patients, regardless of age, deserve to have relief from pain, especially when it is severe," he said in university news release.

Each year in the United States, patients 65 and older make more than 20 million visits to hospital emergency departments and nearly half of those visits are pain-related.

Navigating the Long Road to a Sjogren's Diagnosis - ABC News

Suffering for over six years with widespread, unidentifiable pain and fatigue is a test of patience. For me, the answer came years after seeing dozens of doctors shrug their shoulders at my condition or say I was in excellent health since I looked well.

After enduring endless exams, rounds of blood drawing, body and brain scans, all for no diagnosis at all, I was determined to get answers somewhere else and that's what landed me mid-country. I finally found my diagnosis in the Midwest, thousands of miles away from my home in Massachusetts.

This specialist asked me to describe everything of concern. Then he examined me and began to write his note. Every few sentences, he stopped, turned the computer screen in our direction, and asked me and my husband whether he had captured my problem accurately. We were amazed since no other specialist had ever double checked with us before. No other doctor outright explained my care as a team effort.

And then, a week later, the diagnosis: Sjogren's syndrome -- an often overlooked but serious autoimmune disorder.

Nearly 4 million Americans suffer from Sjogren's, and 90 percent of whom are women. As I looked through the symptoms for Sjogren's, I found myself identifying with most characteristics I saw on the list – symptoms like widespread muscle soreness, joint pain, brain fog that ways so extreme I had trouble sorting through the mail. I also felt fatigue so extreme that I felt like I got hit by a truck.

More importantly, my pain had a name. And a name meant I would finally get the right treatments.

But coming to the diagnosis required a Herculean effort.

My medical file was stacked high with referral notes and test results, which translated into months of pain unexplainable by doctors, and a growing sense of hopelessness that I would ever be diagnosed, or recover. Five rheumatologists, two neurologists, two immunologists, one infectious disease specialist, several endocrinologists, two psychiatrists, three integrative medicine doctors, two functional medicine doctors and multiple primary care physicians later, I was fed up playing the medical pinball machine.

"She looks well and in excellent health," one part of my file read. "Would benefit from stress reduction dealing with the natural effects of aging, a little tucking in around the edges."

But I knew I wasn't well.

Another part of my file read that I was "doctor shopping," a term used to describe pain pill addicted patients who are fishing for a diagnosis just to get prescribed more pills.

As a PhD clinical psychologist and board member of one of Massachusetts's leading medical systems, I am involved in broader discussions about how patients can better navigate the system more efficiently to get the right diagnosis and treatment faster.

I never thought of health care as a maze until I found myself on the opposite side of one of the top healthcare systems in the nation, this time as a patient suffering from progressively debilitating pain. That may have been one the greatest eye openers on medical system operations than board meetings could offer.

More than 80 million people in the United States suffer from chronic pain, most of whom are women, according to the American Chronic Pain Association. And each year, nearly $100 billion is wasted due to reduced productivity, sick time and medical costs associated with chronic pain.

For the first time, these statistics made personal sense. I imagined that if I did not have the credentials or the backstage pass into the health care system -- if I was "the average patient" -- perhaps nothing could have navigated me through getting the right diagnosis and treatment for my pain.

I had been bounced from specialist to specialist in the greater Boston area where, despite my significant contacts were dismissed summarily to other specialists when my symptoms were confounding, and endured innumerable repetitions of paperwork, exams and lab protocols, many duplicating those done only days earlier.

I had experienced the emotional distress of a first-hand look at healthcare systems gone awry; even within the same healthcare system, clinicians had not consulted with each other, clinical record errors were passed on and further misconstrued, and countless dollars were unnecessarily expended.

Worse, no one seemed the least bit concerned. If I occasionally pointed out the lack or break in process, I was frequently met with a blank stare. It was almost as if no one cared, as if they themselves were not part owners of the process that was operating.

This problem persists in more places across the nation that just my neighborhood. Online patient chat boards echo the same story, and many chronic disease advocacy organizations, besides those dedicated to Sjogren's, spend entire meeting sessions dedicated to helping their members navigate a difficult to diagnose condition.

There's no cure or Sjogren's, but there are treatments to manage the symptoms. While it may be difficult for many of us, except for researchers, to curb the prevalence of chronic conditions like Sjogren's syndrome, there are certainly ways to reduce the personal cost burden and the frustration.

First, write a simple timeline of your problem connecting dates and symptoms. I tried to keep my timeline as concise and accurate as possible. Second, carry copies of your records with you for any visit. Despite electronic medical records, many doctors still aren't using them and, in any case, they usually can't see things across different healthcare systems. I owned my medical chart and it helped me understand my condition better throughout the process.

Third, persist. Don't discount your feelings if you think something is wrong. Experts are highly skilled and deserve the same respect given to you, but even they can't keep up with the flood of new discoveries being made. Be sure to put your most important questions first, in case the doctor and you run out of time.

Finally, for a perplexing or very serious problem, seek out a medical center of excellence, preferably one that explicitly advertises itself as putting patients first. The system in the Midwest had this motto written everywhere, and it actually turned out to be the way people treated each other.

Diagnosis of what can be a progressive disease is a bittersweet experience. I learned that being an expert did not automatically make me an informed patient. Until bigger changes are made among healthcare stakeholders and experts -- the implementation of electronic medical records, more emphasis on patient-provider communication – it's up to patients to find shortcuts in the maze, and share those pearls of wisdom with those of us who took the long way to better health.

Jessica Wolfe, MPH, PhD, has been an entrepreneur, behavioral researcher, and executive in healthcare, health sciences, and public health for over 30 years.

Friday, November 11, 2011

Hurt All Over - Diagnosis - Dr. Lisa Sanders -

'Will you please see my sister?' the young woman asked Dr. David Podell, who was a friend of a friend and had a reputation as a kinder version of TV's Dr. Gregory House. People told her that Podell was a doctor who specialized in diagnosing odd diseases, and she hoped he might finally solve the puzzle of her older sister's mysterious illness.


Over the past 10 years, the patient — now 33 — became completely disabled by strange pains and odd episodes of weakness that no one could explain. The sister handed Podell a letter from the patient. "I am very desperate for help," she wrote, "and I am struggling every day all day without relief. I have heard you are the best, and if there is help out there, you are the one who will find it. . . . Please give me back my future."

Podell wasn't sure he could help but wanted to try. The patient, however, lived in Ohio, and Podell was in Middlebury, Conn. If she were going to travel, Podell told the sister, he wanted to make sure that he could do something for her. He would need copies of her medical records and recent test results, and he would need to talk with her before he saw her.

That weekend, Podell called the woman. Her voice was soft and high-pitched and sounded younger than her 33 years. She told him that her whole life had been one of near-constant pain. It became unbearable when she was pregnant and developed crippling back pain. Now, seven years after her daughter was born, her entire body ached almost all the time.


Her joints hurt, she told him. So did her muscles, even her skin. She was tired yet couldn't sleep. She had frequent migraine headaches. She had irritable bowel syndrome. She was severely depressed. She had fibromyalgia, anemia, endometriosis.

Recently she had episodes during which she would lose her strength on one side of her body. The first time it happened, it was just her left arm. She went to the emergency room, where a doctor was worried that she'd had a stroke. But a CT scan of her head was normal. Her strength returned within days. She had seen so many doctors, and no one knew what was wrong. Her voice broke on the phone. He could hear her sobbing quietly.


Podell is a rheumatologist — a specialist in diseases of the tissues that hold the body together — bones, muscles, tendons. He sees a lot of people who have pain all over their bodies. But he was worried about seeing this patient. "She'd put all her eggs in my basket," he told me. "And I didn't want to drop it." So in addition to having her doctor send him all the studies she had so far, he wanted her to get other tests — lots of tests. He was determined not to miss this diagnosis. "I went for the zebras," he said, meaning rare diseases, "because frankly, after all the doctors she's seen, I was pretty sure all the horses had already been looked at."


Podell has a list of unusual diseases that he considers in patients who have this kind of diffuse pain. The list includes hepatitis B and C; Lyme disease; Sjogren's syndrome (which affects the glands that produce tears and saliva); lupus and other diseases of the connective tissues; H.I.V.; thyroid disease; celiac disease (which affects the digestive system and is triggered by foods containing gluten).


The patient's doctor in Ohio sent records from the past two years. The patient had seen two pain specialists, a gastroenterologist and an allergist. She had been scoped, X-rayed and CT scanned. She'd been stuck for blood and pricked for allergies. Most of the tests were unrevealing. But two stood out: in 2009, two blood tests were performed for celiac disease, and both were positive.

Then results from tests that Podell ordered started to arrive. As before, most were unrevealing, with the sole exception of those testing for celiac disease, which were strongly positive. Podell was excited, but a blood test is not a diagnosis, he knew. False positives are not unusual, so generally a biopsy of the small intestine is recommended. The patient hadn't had one. In addition, the patient saw a gastroenterologist earlier that year, and he didn't even mention celiac in his note. Had it already been ruled out somehow?


Three weeks after they spoke on the phone, the patient came to Podell's office, accompanied by her mother and the sister who had made the arrangements. As they exchanged pleasantries, Podell quietly began his examination. The first thing he noticed was that the patient was much smaller than her sister and mother. She was only 4-foot-9. Otherwise she looked well. He listened carefully as the three women told him about the woman's years of pain.


While the patient undressed for the physical, Podell hurried to his office to read up on the ways celiac disease affects the body. He knew that short stature, abdominal pain and diarrhea were associated with the disease. What else? The list he found was long: neuropathic pain, headaches, psychiatric disorders, iron deficiency, vitamin D deficiency — she had all of these.

Podell examined the woman, and she was extremely tender; everywhere he touched was painful — especially her muscles and skin.

Podell then asked what might have been his most important question: Had she ever tried a gluten-free diet? If she had but hadn't improved, that would make celiac disease very unlikely. The patient said she had tried the diet. After the positive test two years earlier, she gave up pasta and bread for a month or so. But she didn't feel any better, so her doctor said to forget it. Podell smiled. She hadn't really been on a gluten-free diet. Even small amounts of gluten in, say, cereal or baked goods would make her sick. This was celiac disease. He would bet on it.


Celiac is an inherited disease of the small intestine that causes abdominal pain, diarrhea and an inability to absorb nutrients. When affected individuals are exposed to gluten — a very common protein found in cereals and grains — they develop antibodies that attack the lining of the small intestine. Once the absorptive lining is injured, the small intestine can't do its job of taking up nutrients from food. The undigested foods go on to cause abdominal pain, bloating and diarrhea. This patient had some of these digestive symptoms, but mostly she had pain — nerve pain, muscle pain, headaches, depression. These are also seen in patients with celiac disease. What causes these other symptoms isn't known.


Podell sent the patient to a nutritionist to learn the fundamentals of the celiac diet. She has been disciplined about eating gluten-free for nearly three months. She has more energy and less pain, and she's back at work — not quite full time, but she's getting there.

I asked Podell why the patient did so much better this time than she did two years ago, when celiac was suggested as a possibility. He said that maybe her doctors didn't really think she had celiac, and so she didn't think she had it either. "I was very enthusiastic about this diagnosis. And I thought she really had it. So maybe it was the nonscientific component — the salesmanship — that made her try and stay with it."

This case is a reminder of an important precept in medicine: a diagnosis isn't really final until it is embraced by both the patient and the doctor. That's the real art of diagnosis and an essential part of the cure.

Monday, November 07, 2011

Are Doctors Really to Blame for the ‘Overdose Epidemic’? | TIME Healthland

Forty people die each day from what Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention (CDC), calls an "epidemic" of prescription drug overdose. Frieden largely attributes the rise in overdose deaths, which have tripled since 1999, to overprescribing by doctors. But the reality is much more complicated.

At Tuesday's teleconference announcing the release of new CDC data on the problem, Frieden said, "In fact, now the burden of dangerous drugs is being created more by a few irresponsible doctors than by drug pushers on the street corners."

Such hyperbole is unlikely to lead to effective solutions for an extremely complex problem. Panics over addiction have always tended to focus relentlessly on supply, while failing to understand demand. In this case, unnecessary hysteria may also serve to reduce legitimate patients' access to needed pain treatment.

MORE: U.S. Aims to Reduce Overdose Deaths, But Will the New Plan Work?

Let's start with the facts: the vast majority of people who misuse prescription painkillers — 7 out of 10, according to drug czar Gil Kerlikowske — get them from family or friends, not directly from doctors. Secondly, most people addicted to these medications have used illegal drugs previously; they do not become addicted while being treated for pain.

A 2007 study of nearly 1,400 people addicted to OxyContin, who were treated at rehabs across the country, found that 78% had never been prescribed the drug themselves; the same percentage had been in rehab for a previous drug problem. Earlier data found that 80% of those addicted to OxyContin had previously used cocaine, a rate many times that seen in the general population.

That overlap is not likely to be attributed to pain patients who suddenly decide to try cocaine. The more probable explanation is that painkiller addiction is primarily affecting people with current or previous drug problems, not innocent patients being treated by pill-happy doctors.

Indeed, it is impossible for a doctor to "make someone" into an addict. Even if the doctor tied the person down and injected him or her daily with heroin or other strong opioids, only physical dependence could be created. That means the person would suffer withdrawal symptoms when the doctor stopped, but whether such victims genuinely became addicted would be determined by their own actions after that point.

MORE: Fueled by Growing Painkiller Use, Overdose Deaths and Child Poisonings Are on the Rise

If the research data is anything to go by, most people who use illegal drugs don't subsequently go looking for dealers or rob their grandmothers to get money to buy more. Of those who try heroin, more than 80% do not become junkies. Likewise, among adults who are legitimately prescribed opioid painkillers and who do not have past histories of drug problems, more than 97% don't develop new addictions.

Normal, healthy people given these drugs tend to find them unpleasantly numbing, not overwhelmingly attractive. Even among soldiers who served in Vietnam — 45% of whom tried opium or heroin while serving — just 1% developed ongoing heroin addictions that persisted after they came home.

Addiction doesn't just "happen": it requires people to choose repeatedly to use drugs to get high or to escape. By definition, this behavior must occur despite ongoing negative consequences; otherwise, it is not classified as addiction.

Moreover, although people with addiction often have genetic predispositions or exposures to traumatic experience that make drugs especially attractive to them, and although continued use itself can impair decision-making, they are not automatons with no free will. Their ability to choose not to take drugs may be reduced as they get hooked, but it's not eliminated: after all, no one shoots up in front of the cops.

MORE: Should an Overdose Antidote Be Made More Accessible?

The fact that addiction is not just about access to drugs is why talk of drug "epidemics" rarely changes their course. Supply-side efforts have had little effect on addiction rates. The exponential growth on such spending since Ronald Reagan declared war on drugs in the 1980s has no correlation whatsoever with rates of drug problems. The recent crackdown on prescription opioids began in the mid-2000s, with intense concern over OxyContin misuse — and yet overdose deaths continue to rise.

If we want to reduce opioid addiction, it might help to try to figure out why so many people feel the need to escape. And if we want to reduce opioid overdose, it might make sense to distribute the antidote, naloxone (Narcan), with prescriptions and make it available over the counter. Unlike efforts to restrict prescribing, this won't hamper appropriate pain care, and unlike rhetoric about epidemics and associated crackdowns on supply, there's actually a growing body of literature suggesting that Narcan saves lives.

Maia Szalavitz is a health writer at Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland's Facebook page and on Twitter at @TIMEHealthland.