Thursday, February 17, 2011

Negative experiences can stop painkillers working -BBC News

A patient's belief that a drug will not work can become a self fulfilling prophecy, according to researchers.

They showed the benefits of painkillers could be boosted or completely wiped out by manipulating expectations.

The study, published in Science Translational Medicine, also identifies the regions of the brain which are affected.

Experts said this could have important consequences for patient care and for testing new drugs.

Heat was applied to the legs of 22 patients, who were asked to report the level of pain on a scale of one to 100. They were also attached to an intravenous drip so drugs could be administered secretly.

The initial average pain rating was 66. Patients were then given a potent painkiller, remifentanil, without their knowledge and the pain score went down to 55.

They were then told they were being given a painkiller and the score went down to 39.

Then, without changing the dose, the patients were then told the painkiller had been withdrawn and to expect pain, and the score went up to 64.

Friday, February 11, 2011

Freakonomics Radio: Bring on the Pain! -

Most people do what they can to avoid pain. That said, it's an inevitable part of life. So how do you deal with it?

That's the question we explore in our latest Freakonomics Radio podcast (you can download/subscribe at iTunes, get the RSS feed, listen live via the link in box at right or read the transcript here). We look into a few different kinds of pain, inflicted in different circumstances, to see what we can learn. The biggest takeaway: it's not necessarily how much something hurts; it's how youremember the pain.

We start off underground, in the New York City subway, where noise pollution abounds and where one particular noise is downright painful. You'll hear it in the podcast, and we talk about it with Pete Foley, a longtime "revenue equipment maintainer" with the Metropolitan Transit Authority. He admits that the entry/exit setup in the subway is way sub-optimal, producing lots of needless noise from bleating alarms:

SJD: Do you think there are any hidden benefits, though, to this alarm? Do you think maybe it keeps rats out of the subway?

Foley: No, but with the amount of usage of these gates and the poor design, the hinges and the push bars, and things like that, we get a lot of overtime to fix them … and fix the alarms that wear out all the time, so in my department we get a lot of overtime because of it.

SJD: So you're pro-alarm?

Foley: Actually I'm not as a taxpayer … [but] the overtime's good.

You'll also hear about a very different kind of pain — jaw-breaking physical pain — from a couple of New York Islanders defensemen, Jack Hillen andAndrew MacDonald. The Islanders are among the league leaders in blocked shots, and some of them hurt an awful lot. So how do players withstand the pain, and put it behind them in order to keep hauling their bodies onto the ice night after night?

Here's a look at Hillen taking one of the most brutal shot-blocks you're likely to see, a puck off the stick of Alexander Ovechkin:

We also talk to Governor Martin O'Malley of Maryland, who recently had to talk his constituents through the pain of accepting a massive budget shortfall. We happened to interview O'Malley the day before his State of the State address, and asked how often he's mentioned the words pain or painful:

O'Malley: You know what, I've been well-advised … not to use the word pain and not to use the word painful. Those words cause pain, and those words are painful.

The heavyweight of our pain episode isDonald Redelmeier, a Toronto physician and researcher whose clever and creative research you may have read about in the paston this blog. Redelemeier has a lot of experience helping people in pain:

Redelmeier:I'm usually called to see people when there are many things going wrong at the same time… so, a person has been smashed in a roadway crash and they've also had a heart attack. Or somebody else has fallen down a staircase and they've also got AIDS. Or somebody else has been shot in the chest and they also have got diabetes.

We talk to Redelmeier about his research, done in collaboration with Daniel Kahneman, on colonoscopy patients — how they experience pain during the procedure but also, more important, how they remember the experience of the pain. Much of what they learned is fascinating, and surprising, and tells us a lot about how human beings process any kind of pain — whether it comes from a colonoscope, a tight budget, a hockey puck or a shrieking subway alarm.

So have a listen. We promise: it won't hurt a bit.

BBC News - Pain reduced by changing what you look at

What you look at can influence how much pain you feel, a study has revealed.
Contrary to many people's compulsion to look away during a painful event such as an injection, scientists found that looking at your body - in this case the hand - reduces the pain experienced.
The team also showed that magnifying the hand to make it appear larger cut pain levels further still.
The study, published in Psychological Science, is shedding light on how the brain processes pain.
The researchers say that gaining a better understanding of this could lead to new treatments.
Look away?
The University College London (UCL) and University of Milan-Bicocca research, which was funded by the Biotechnology and Biological Sciences Research Council (BBSRC), was carried out with the help of 18 volunteers.
The scientists applied a heat probe to each participant's hand, gradually increasing the temperature. As soon as this began to feel painful, the probe was removed and the temperature was recorded.
Patrick Haggard, professor of cognitive neuroscience from UCL, explained: "This gives us a measure of the pain threshold, and it is a safe and reliable way of testing when the brain pathways that underline pain become active."
The scientists then used a set of mirrors to manipulate what the volunteers saw.
The team found that volunteers could tolerate on average 3C more heat when they were looking at their hand in the mirror, compared with when their hand was obscured by a block of wood.
Professor Haggard said: "You always advise children not to look when they are having an injection or a blood sample taken, but we have found that looking at the body is analgesic - just looking at the body reduces pain levels.
"So my advice would be to look at your arm, but try to avoid seeing the needle - if that's possible. "
Brain pain
In another experiment, the researchers used convex mirrors to enlarge the appearance of the participant's hand. They found that doing so meant the volunteers were able to tolerate higher temperatures.
Conversely, when the team made the volunteers' hands look smaller, their pain threshold decreased.
The researchers said the fact that pain levels were directly proportional to the size the body was viewed at was helping them to better understand the neurological basis of pain.
Professor Haggard said: "We know quite a lot about the pathways that carry pain signals from the body to the brain, but we know rather less about how the brain processes these signals once they arrive.
"Our interest has been in the relationship between the experience of pain and the representation that your brain makes of your own body.
"And we've shown there is an interesting interaction between the brain's visual networks and the brain's pain networks."
The researchers hope that understanding more about the science underpinning pain could one day help to lead to new treatments for chronic conditions.
Dr Flavia Mancini, lead author of the paper, said: "Psychological therapies for pain usually focus on the source of pain, for example by changing expectations or attention.
"However, thinking beyond the pain stimulus, to our body itself, may lead to novel clinical treatments."
And doctors say this is vital.
Dr Paul Nandi, a consultant in pain medicine at UCL Hospitals' Pain Management Centre, said: "Pain is an enormous problem in the National Health Service and in society generally.
"We do not have precise figures, but it affects several million people in the UK, and it has a huge impact on quality of life.
"It also produces a huge economic burden - if you look at chronic back pain alone, it is estimated that it costs £16bn per annum.
"But this is still widely under-appreciated, and hasn't received the same attention and resources as other areas perceived as 'exciting' in the medical profession."
However, he said that studies like this could help to drive more research.
Dr Nandi explained: "A lot of research in the past few years has focussed on identifying targets in the nervous systems that can be used for treatments.
"But increasingly there is an interest in what the brain does to pain signals, and I think this will be a very exciting field for research in the next few years."

Monday, February 07, 2011

Best of the year: David Biro on Pain | FiveBooks | The Browser

David Biro is an Associate Professor of Dermatology at SUNY Downstate Medical Centre in New York. He teaches in the medical humanities division, directing a course on medicine and literature. Dr. Biro's first book, One Hundred Days: My Unexpected Journey from Doctor to Patient, chronicles his experiences undergoing a bone marrow transplant.

The professor of dermatology talks about the ferocious inwardness and aching solitude of pain. Pain destroys language, reducing the sufferer to a pre-linguistic state - to primal screams.

Saturday, February 05, 2011

Treating Chronic Pain and Managing the Bills -

Maybe the question is not who suffers from some type of chronic pain, but who doesn't?

"If you tally up everybody who has chronic, recurring back, headache and musculoskeletal problems, it includes almost everybody by the time people get into their 30s," said Dr. Perry Fine, a professor of anesthesiology at the Pain Research Center and the University of Utah and incoming chairman of the American Academy of Pain Medicine.

Given the prevalence of chronic pain — often defined as recurrent pain that lasts more than three to six months — you might expect that by now medical science would have figured out how to alleviate it and that health insurers would routinely cover its treatment.

If only it were that simple. Pain is a sneaky opponent. Invisible, it cannot be detected with a blood test or a scan; sometimes it has no identifiable cause. Pain is perception, and what one person considers intolerable may be only moderately uncomfortable to another.

This makes treatment challenging. And insurers often do not make it any easier.

For the last 15 years, Ernie Merritt III, 46, has been coping with the aftermath of a back injury he suffered working as a pipefitter in southeastern Maine. At the time, he thought he had just pulled a muscle. But after an M.R.I.revealed a herniated disc pressing on his sciatic nerve, he underwent the first of four operations.

Surgery has not been enough. Mr. Merritt's back still hurts, and now he must wear a brace full time to stabilize it. He has developed carpal tunnel syndrome and shoulder problems. The nerves in his legs are damaged, and doctors cannot figure out why.

Because Mr. Merritt is disabled, he qualifies for Medicare, but he says he had to drop the Part B outpatient portion of the coverage. With all of his doctor visits — neurologists, orthopedists and physical therapists, not to mention his regular primary care physician — the 20 percent co-insurance charges were more than he and his wife could afford.

Now he pays $3,000 a year for coverage with his wife's health plan through her job at the county courthouse. Specialist co-payments are a flat $15 per visit, and he can see his primary care doctor free.

Given his medical needs, it was the right decision, he said: "I have so many things going on that they can't explain."

If you have chronic pain, chances are you have discovered that getting the care you need at a price you can afford can be, well, excruciating. These suggestions may help.

A MEDICAL 'HOME' The most common causes of chronic pain are musculoskeletal conditions — including arthritis, lower back problems and fibromyalgia — and recurrent headaches. Chronic pain also afflicts many patients with such serious illnesses as cancerAIDS and irritable bowel syndrome.

Pain management almost always involves medication, and physical or occupational therapy is common. But there is no one-size-fits-all approach, and patients often see several doctors on a regular basis.

It is important to find a primary care provider who will serve as your "medical home" and will work with you to coordinate care. You will avoid duplicative tests and procedures, and you are more likely to find the care you need.

In addition, many primary care doctors provide therapies like nerve blocks, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians. A savvy primary care physician can help keep expenses in check.

MENTAL HEALTH People with chronic pain are twice as likely to suffer from depression and anxiety as the general population, but insurance coverage for mental health problems often is inadequate for these patients. Fortunately, the recently passed mental health parity law should help make those services more available.

Until then, consider some alternate community resources. Stanford University, for instance, has developed a chronic disease self-management program that is available in nearly every state through local area agencies on aging. The six-week program teaches participants relaxation and cognitive behavioral therapy techniques, among other things, and is free in many areas.

For a quicker fix, check out the American Chronic Pain Association's free five-minute relaxation guide.

STRETCHING OUT "People in pain don't exercise," said Penney Cowan, founder and executive director of the American Chronic Pain Association. Big mistake. Exercise is one of the most effective and most affordable ways to manage chronic pain. Gentle stretching and exercises to increase range of motion and strength training are all helpful. (Get the go-ahead from your doctor before starting, though.)

Although physical and occupational therapy are often recommended for people with chronic pain, insurance plans typically cover only a limited number of sessions. Make the most of your visits by asking the therapist to teach you what you can do on your own, said Dennis Turk, a professor of anesthesiology and pain research at the University of Washington.

"Eight to 15 sessions of physical therapy may be more than enough if the patient is learning what to do on their own," he said.

INSURANCE APPEALS Insurance coverage for many types of pain management treatment is often inadequate, say advocates and physicians who treat it. Medication and interventional therapies like nerve blocks are more likely to be routinely covered than physical or behavioral therapy.

Part of the problem is that pain management is complex, and people respond to therapies differently. "When people keep coming back and saying something's not working, insurers begin to doubt that reality," Ms. Cowan said.

If your plan turns down your request for physical or behavioral therapy, or any other treatment, get a copy of the policy and read the fine print, said Jennifer C. Jaff, executive director of Advocacy for Patients With Chronic Illness.

If the policy says therapies are covered only if they are medically necessary, for example, you may be able to challenge the denial in an appeal. Sometimes insurers say they are denying coverage because you have not shown improvement, a standard that someone with chronic pain may find impossible to meet. Appeal those decisions, too. Ms. Jaff's organization files free insurance appeals for patients.

AFFORDABLE DRUGS Medication is a mainstay for people with chronic pain, and drug therapy is one of the few chronic pain treatments that insurance plans reliably cover, said Mr. Turk.

Even if you have coverage, however, it can be tough to figure out which drugs will effectively manage your pain. People with severe chronic pain may take prescription opioids like codeine and oxycodone, as well as antidepressantsand muscle relaxants.

Some insurers require that patients do "step" therapy: trying to relieve symptoms with aspirin for a few months, for example, before going on to a more powerful painkiller. In addition, some doctors are reluctant to prescribe some analgesics because they fear serious side effects and worry that patients may become dependent on them.

It is important to find a doctor who will work with you to find a drug regimen that manages your pain and who will advocate on your behalf with an insurer. As with any drug, it pays to ask your doctor if an older, generic drug might be a reasonable substitute for a brand-name prescription.

If you do not have insurance or if a drug you need is not on your plan's list of covered drugs, check out, a clearinghouse for programs that provide free or discounted drugs to people, generally based on income.

Thursday, February 03, 2011

Purification by pain: The masochism tango | The Economist

Catholic theology says that heaven awaits the pure of heart while hell is reserved for unrepentant sinners. For the sinful but penitent middle, however, there is the option of purgatory—a bit of fiery cleansing before they are admitted to eternal bliss. Nor is inflicting pain to achieve purification restricted to the afterlife. Self-flagellation is reckoned by many here on Earth to be, literally, good for the soul.

Surprisingly, the idea that experiencing pain reduces feelings of guilt has never been put to a proper scientific test. To try to correct that, Brock Bastian of the University of Queensland, in Australia, recruited a group of undergraduates for what he told them was a study of mental acuity.

At the start of the study, 39 of the participants were asked to write, for 15 minutes, about a time when they had behaved unethically. This sort of exercise is an established way of priming people with feelings associated with the subject written about. As a control, the other 23 wrote about an everyday interaction that they had had with someone the day before.

After the writing, all 62 participants completed a questionnaire on how they felt at that specific moment. This measured, among other things, feelings of guilt on a scale from one (very slightly guilty or not at all) to five (extremely guilty).

Participants were then told they were needed to help out with a different experiment, associated with physical acuity. The 23 who had written about everyday interactions and 20 of the 39 who had written about behaving unethically were asked to submerge their non-dominant hand (ie, left, if they were right-handed, and vice versa) into a bucket of ice for as long as they could. The remaining 19 were asked to submerge their non-dominant hand into a bucket of warm water for 90 seconds, while moving paper clips one at a time between two boxes, to keep up the illusion of the task being related to physical capabilities. That done, participants were presented with the same series of questions again, and asked to answer them a second time. Then, before they left, they were asked to rate on a scale of zero (no hurt) to five (hurts worst) how much pain they experienced in the warm water and the ice.

Dr Bastian reports in Psychological Science that those who wrote about immoral behaviour exposed themselves to the ice for an average of 86.7 seconds whereas those who had written about everyday experiences exposed themselves for an average of only 64.4. The guilty, then, either sought pain out or were inured to it. That they sought it out is suggested by the pain ratings people reported. Those who had written about immoral behaviour rated the ice-bucket experience at an average of 2.8 on the pain scale. The others rated it at 1.9. (Warm water was rated 0.1 by those who experienced it.)

Furthermore, the pain was, indeed, cathartic. Those who had been primed to feel guilty and who were subjected to the ice bucket showed initial and follow-up guilt scores averaging 2.5 and 1.1 respectively. By contrast, the "non-guilty" participants who had been subjected to the ice bucket showed scores averaging 1.3 and 1.2—almost no difference, and almost identical to the post-catharsis scores of the "guilty". The third group, the guilt-primed participants who had been exposed to the warm bucket and paper clips, showed scores averaging 2.2 and 1.5. That was a drop, but not to the guilt-free level enjoyed by those who had undergone trial by ice.

Guilt, then, seems to behave in the laboratory as theologians have long claimed it should. It has a powerful effect on willingness to tolerate pain. And it can be assuaged by such pain. Atonement hurts. But it seems to work—on Earth at least.

It’s Contest Time: Write Something to Share | How To Cope With Pain Blog

I think it's time for another contest.  I've collected an assortment of books related to pain, so it's time to send them your way.  As well, the contributions you send in are one of my favorite things to read.  And readers love to hear from each other.  So February is "Write Something To Share" month.

Here are the guidelines:

1. Write something for How to Cope with Pain to share with other readers.  This can be anything related to pain that has not been published elsewhere.  (Don't be modest or shy, or feel you have nothing to say.)  Topics can include:

  • your own pain condition
  • what you've learned from coping with pain
  • what your best coping techniques are
  • an inspirational quote, video or photo
  • any format – an article, poem, photo, artwork, etc

2.  Send in your submission here.  You have 1 month – the deadline is Monday, February 28.