Friday, April 29, 2011

One hundred years of migraine research: major clinical and scientific observations from 1910 to 2010 - PubMed result

One hundred years of migraine research: major clinical and scientific observations from 1910 to 2010
Tfelt-Hansen PC, Koehler PJ 
Headache 2011 05; 51 (5): 752-78

Pain research, and headache research in particular, during the 20th century, has generated an enormous volume of literature promulgating theories, questions, and temporary answers. This narrative review describes the most important events in the history of migraine research between 1910 and 2010. Based on the standard textbooks of headache: Wolff's Headache (1948 and 1963) and The Headaches (1993, 2000, and 2006) topics were selected for a historical review. Most notably these included: isolation and clinical introduction of ergotamine (1918); further establishment of vasodilation in migraine and the constrictive action of ergotamine (1938); identification of pain-sensitive structures in the head (1941); Lashley's description of spreading scotoma (1941); cortical spreading depression (CSD) of Leão (1944); serotonin and the introduction of methysergide (1959); spreading oligemia in migraine with aura (1981); oligemia in the wake of CSD in rats (19 82); neurogenic inflammation theory of migraine (1987); a new headache classification (1988); the discovery of sumatriptan (1988); migraine and calcitonin gene-related peptide (1990); the brainstem "migraine generator" and PET studies (1995); migraine as a channelopathy, including research from the genetic perspective (1996); and finally, meningeal sensitization, central sensitization, and allodynia (1996). Pathophysiological ideas have evolved within a limited number of paradigms, notably the vascular, neurogenic, neurotransmitter, and genetic/molecular biological paradigm. The application of various new technologies played an important role within these paradigms, in particular neurosurgical techniques, EEG, methods to measure cerebral blood flow, PET imaging, clinical epidemiological, genetic, and molecular biological methods, the latter putting migraine (at least hemiplegic migraine) within a completely new classification of diseases.

Thursday, April 28, 2011

Over the Counter Painkillers Can Dilute Effects of Antidepressants | Health News

Why do antidepressants work effectively for some and not others? There are a number of reasons which may explain the phenomenon. One of the most common is misdiagnoses of the problem, such as a milder or situational form of anxiety being read as depression. The other is being prescribed the wrong class of anti-depressants; different classes block or produce different chemicals in the brain, meaning that a patient given the wrong class may not have the correct imbalance targeted. Or, their ineffectiveness could be as simple as a drug interaction, suggests a new study from The Rockefeller University in New York City.

Researchers found that mice consistently given a combination of a common painkiller and an SSRI (the largest class of antidepressants) had a reduced response—and in some cases no response—to the antidepressant compared to mice given an SSRI alone.

The research team then scoured data from a previously completed seven-year clinical trial of depressed patients known as the Sequenced Treatment Alternatives to Relieve Depression (STAR*D), which involved over 4,000 patients aged 18 to 75, looking for the same effect in humans. They found that SSRIs relieved depressive symptoms in 54 percent of patients not taking NSAIDs, compared with 40 percent of those who reported taking both antidepressants and anti-inflammatory painkillers.

The findings were surprising since the researchers had theorized that combining an anti-inflammatory with an antidepressant would improve, not reduce, depressive symptoms since inflammation is thought to worsen or cause depression in some people, said researcher and co-author of the study Dr. Jennifer Warner-Schmidt. "It appears there's a very strong antagonistic relationship between NSAIDs and SSRIs. This may be one reason why the response rate (in patients of SSRIs) is so low."

Dr. Warner-Schmidt says until a "double-blind real clinical trial is done," they aren't sure what dosage of anti-inflammatory is required or over what period of time the painkiller would have to be taken to produce the negative effect. "We may only be looking at people who are taking NSAIDs over a long period of time, but it's not clear," she said.

Experts urge that patients currently taking these medications should NOT discontinue their use on their own, but should talk to their doctor if they have concerns. "If people out there are having trouble with SSRI efficacy and they happen to be taking anti-inflammatory drugs, they may want to speak with their clinician to evaluate whether they need to continue on the anti-inflammatory drugs, and if so, they may consider changing their antidepressant to a different class of antidepressant," said Dr. Warner-Schmidt.
According to the National Institute of Mental Health, major depression is estimated to affect 16.5 percent U.S. adults over their lifetime. In 2010 there were 253 million prescriptions for antidepressants, the bulk of which were SSRIs, in the U.S. alone.

The study findings were published in the April 25 online edition of the Proceedings of the National Academy of Sciences.

Saturday, April 23, 2011

The War On Drugs Versus Developing World Pain Relief |

I've noted on a few occasions the tensions between the policy objectives of the "war on drugs" and people's legitimate desire to secure relief from intense pain. What I've written before about this has been about rich countries and regulatory/logistical hurdles to obtaining effective opioid pain relievers. But as Charli Carpenter writes, there's also a developing world version of the problem in which actual shortfalls of medicine are the issue:

However, a significant (and solvable) aspect of the problem is simply the relationship of supply to demand: the need for analgesics like morphine far outweighs the available supply. In part, this is due to the fact that such analgesics are produced from opium, the sap of the poppy. Since the same plant extract can also be used to produce heroin, a significant amount of political effort is now being expended worldwide to actually inhibit, rather than encourage, opioid production. This fuels shortages of analgesics.

Writing in the Journal of Epidemiology and Community Health, Amir Attaran and Andrew Boozary suggest a seldom-mentioned way to increase supply: re-framing Afghanistan's poppy problem as "an opportunity for global public health." In short, the authors suggest pro-government forces abandon efforts to eradicate Afghan poppy cultivation and instead redirect them toward the production of licit opiods for analgesic pain medication.

For the vast majority of human history, there was really very little one could do about the problem of chronic pain. Consequently, most cultures have come to valorize stoical perseverance in the face of pain as a major virtue. The reality, however, is that few things are more misery-inducing than prolonged stretches of pain. Ameliorating severe pain where possible can provide giant gains in human welfare relative to more conventional goals like boosting incomes and measured GDP.

Friday, April 22, 2011

First Canadian guidelines issued for opioid painkillers - The Globe and Mail

Published Monday, May. 03, 2010

The first Canadian guidelines have been created to keep powerful opioid painkillers out of reach of potential abusers and put them into the hands of patients who need them.

The guidelines urge doctors to thoroughly assess patients before prescribing the painkilling drugs and closely monitor them to mitigate risks of abuse, addiction and overdose. Doctors must also stop prescribing opioids if patients don't respond to treatment or there is a serious risk of addiction, misuse or other problems.

The guidelines, published yesterday in the Canadian Medical Association Journal, are the first comprehensive attempt at helping health professionals navigate the minefield of prescribing opioids to non-cancer patients who experience chronic pain.
Opioids are a class of powerful painkilling drugs used to treat severe pain. There are several different kinds of opioids, but those made with oxycodone, such as Percocet and OxyContin, have become a source of concern in recent years as prescriptions skyrocketed and countless stories of addiction began to emerge.

But an issue that is often overshadowed by reports of opioid misuse is that many patients who could benefit from the drugs aren't getting them. Fears of addiction and abuse of opioids has led to the undertreatment of chronic pain in some cases, a problem that helped spark the creation of the new national guidelines.

"Physicians may be uncertain or even afraid to prescribe opioids for chronic non-cancer pain in some cases," said Clarence Weppler, co-chair of the National Opioid Use Guideline Group and manager of physician prescribing practices with the College of Physicians and Surgeons of Alberta. "The fear is very real."

But even as undertreatment of chronic pain becomes a growing concern, prescription rates for opioids suggests that in some cases, the drugs are prescribed too liberally and with too few checks to guard against misuse. Spending on opioid prescriptions has increased dramatically in recent years, and Canada has the third-largest per capita consumption of opioids in the world, after the United States and Belgium.

And as the consumption of opioid painkillers grows, so does the rate of problems, including addiction. The drugs are also extremely potent, which increases the risk of potential overdose. A study published last December in the Canadian Medical Association Journal found that Ontario deaths related to drugs made with oxycodone increased fivefold from 1999 to 2004.

However, a commentary published with the article highlighted the fact the increased death rate corresponds to an increase in prescriptions for oxycodone painkillers – meaning the drugs aren't killing a higher proportion of people than they were a decade ago, but that the volume of people taking them has increased.

The key issue, according to Benedikt Fischer and Jurgen Rehm, authors of the commentary, is that Canada seems to be relying too heavily on opioid painkillers even though health professionals may not fully understand their potential risks or how to monitor patients to prevent potential problems.

Those gaps are addressed by the new guidelines, which offer broad but comprehensive advice for health professionals on best practices for prescribing opioids. The guidelines make 24 recommendations to health professionals, such as:

Consider screening a patient for potential opioid addiction before prescribing the medication.

Thoroughly explain to patients the potential benefits, problems, complications and risks of opioid therapy.

Start patients on a low dose of opioids and monitor its effectiveness.

Change a patient's prescription or discontinue therapy if the medication is ineffective or the patient experiences unacceptable adverse effects or risks, such as abuse.

Work with pharmacists and take precautions to reduce prescription fraud.

The national guideline group was formed in 2007 to create these recommendations. But the idea of relying on non-binding guidelines has been criticized by some who say more needs to be done to address this issue.

However, guidelines are merely the first step toward what needs to be a wide-ranging plan to help doctors understand how to properly prescribe opioid painkillers and reduce potential risks, Mr. Weppler said.

One of the major issues standing in the way of better policy is that not enough is known about opioid medication. Better research is needed to understand the effectiveness of opioids in patients with various diagnoses, how to properly prescribe opioids in patients with more than one medical issue, such as chronic pain in the elderly or those with a psychiatric condition, as well as understanding the long-term effectiveness of opioid painkillers.

"While waiting for the research that is needed, clinicians can use the new Canadian guideline as a clinically sensible framework for decisions that need to be made now," Mr. Weppler said.

The group has plans in place to ensure the guidelines are used in practice across the country. They will also be updated by 2015 by McMaster University'sMichael G. DeGrooteInstitute for PainResearch and Care.

Roger Chou, professor of medicine at Oregon Health and Science University in Portland and author of U.S. opioid guidelines, wrote a commentary published alongside the guidelines urging better research. He said significant gaps in knowledge are a major factor that is contributing to problems associated with opioid painkillers.

"In my opinion, it's really quite shocking that we don't have a lot of strong research evidence to back up what we're actually doing for these patients," Dr. Chou said in an interview.

Painkiller abuse sparks new Canadian guidelines - CTV News

With the growing use -- and misuse -- of prescription painkillers in Canada, several groups of Canadian experts have created new guidelines for prescribing these powerful drugs to patients.

The use of opioid painkillers has grown significantly in Canada in recent years. There was a 50 per cent increase in the use of the drugs between 2000 and 2004 and Canada is now thought to be the third-largest opioid consumer per capita in the world.

Opioid medications, which include morphine, codeine and oxycodone, can be highly effective in treating patients with chronic pain, defined as pain that persists for more than six months. But they are also extremely potent and can also be addictive.

Just last December, a study in the Canadian Medical Association Journal found that Ontario deaths related to drugs made with one opioid called oxycodone increased fivefold from 1999 to 2004. What's more, opioids are highly coveted by drug dealers, who often sell the pills for high prices on the street.

With growing use of opioids in Canada have come growing problems, leading Canada's provincial colleges of physicians and surgeons to create the National Opioid Use Guideline Group.

A review article of the guideline was published Monday in the Canadian Medical Association Journal, and contains recommendations designed to help doctors prescribe the medications safely to patients who need them while keeping them away from those who might abuse them.

The full guideline is available from the National Pain Centre at McMaster University, and can be found on their website here.

"We hope that one of the benefits of these guidelines, will be to reduce the diversion and abuse and addiction problems with these drugs, because these are really good medications," says lead researcher Dr. Andrea Furlan, of the Toronto Rehabilitation Institute.

While the guidelines are aimed at family doctors and surgeons, pharmacists, nurses, and dentists may also find it useful, the authors note.

The guidelines include 24 practice recommendations to help doctors decide when and how to prescribe narcotics to patients with chronic pain. They include:

  • Advice on which medications are effective for which kinds of pain
  • Recommendations of giving patients urine tests before treatment to see if they are already using painkillers.
  • Dosage recommendations that call for increasing painkiller doses gradually and then monitoring effectiveness.
  • Advice on how to monitor for adverse side effects
  • Signs of possible abuse, including how to spot and prevent prescription fraud
  • Guidelines for how to treat specific kinds of patients, such as adolescents, pregnant patients and those with psychiatric illnesses
  • Guidelines for weaning patients off of opioids

In a related commentary in the CMAJ, Dr. Roger Chou, the director of Guideline Development at The American Pain Society, says it's unfortunate that that most of the recommendations in the new Canadian guideline were based primarily on consensus opinion, rather than on strong evidence.

"In other words, the developers of the guidelines found that what we know about opioids is dwarfed by what we don't know," he writes.

He says what's needed are more long-term studies that look at high-risk patients to see how they fare taking opioids for long periods. As well, he writes, there needs to be more studies to determine the best way to choose which patients are best for which medications, how to choose dosages, and how to monitor and discontinue therapy.

The groups involved in researching and reviewing the new guideline included:

  • A research team of academics
  • A National Advisory Panel of 49 individuals, including pain specialists, addiction experts, nurses and others
  • The National Opioid Use Guideline Group, which consists of 18 representatives from Canadian Medical Regulatory Authorities and the Federal Medical Regulatory Authorities of Canada

UW group ends drug firm funds - JSOnline

A University of Wisconsin School of Medicine and Public Health organization that has been criticized for its advocacy of controversial uses of narcotic painkillers says it has decided to stop taking money from the drug industry.

UW made the announcement after an April 3 investigative report in the Journal Sentinel revealed that its UW Pain & Policy Studies Group had taken about $2.5 million over a decade from companies that make opioids. The money came while the group pushed for what critics say was a pharmaceutical industry agenda not supported by rigorous science: the liberalized use of narcotic painkillers for non-cancer chronic pain.

While the expanded use of the medications boosted drug company sales, it also has been linked to a burgeoning epidemic of opioid painkiller abuse.

Just this week, federal officials announced a plan to curtail the epidemic, including efforts to reduce misprescribing and misuse of the drugs.

In concert with the White House, the Food and Drug Administration announced a new risk reduction plan for extended-release opioids, such as OxyContin, which often are misprescribed, misused and abused. The plan will focus on educating doctors about proper pain management and patient selection and improving patient awareness about how to use the drugs safely.

By far the biggest chunk of money the UW Pain Group got was from Purdue Pharma, the maker of OxyContin. In 2007 the company was accused by the U.S. Department of Justice of fraudulently misleading doctors by claiming, with no proof, that the drug was less addictive, less likely to cause withdrawal and less subject to abuse than other pain medications.

The company and three of its executives pleaded guilty to various charges. Court-imposed fines and restitution payments totaled $635 million.

Between 1999 and 2010, Purdue paid the UW Pain Group about $1.6 million, according to university records obtained by the Journal Sentinel through an open records request.

The UW Pain Group may have helped pave the way for OxyContin's widespread use.

On several occasions, the newspaper found that research papers and medical articles written by UW Pain Group officials often did not disclose the group's funding from drug companies or that those individuals were paid personally by drug companies.

Emails to chancellor

In response to the news report, members of organizations concerned about opioid abuse sent emails to UW Chancellor Biddy Martin complaining about the UW Pain Group.

One of the emails came from Ada Giudice-Tompson, a woman in Ontario whose 29-year-old son died in 2004 of an opioid overdose. Giudice-Tompson also is vice president of Advocates for the Reform of Prescription Opioids.

She said her son, who had been treated for kidney stones, was prescribed 13,000 pills over 15 months.

"The most difficult part is knowing how Universities such as yours have terribly misdirected the medical profession," she wrote to Martin. "The medical community has received biased and manipulated data supporting the liberal use of prescription opioids. What's even worse is the motive behind the pushing of narcotics - 'profit and greed.' This was no honest mistake.

"Chancellor Martin, I ask you to look into your heart and soul and help stop the epidemic of death and addiction caused by prescribed opioids."

In response to Giudice-Tompson's email and others, the UW Pain Group issued a written statement Wednesday saying that it promotes the idea of balance, that opioids must be available to those who need them and that misuse, abuse and diversion must be controlled.

Separately, on April 5, two days after the story ran, a doctor who heads another group that is trying to curtail inappropriate use of opioids emailed the World Health Organization, asking it to end its relationship with the UW Pain Group.

"Many public health experts believe that aggressive promotion of opioids for chronic non-cancer pain and deregulation of physician prescribing are the main causes of this public health disaster," Andrew Kolodny, a New York psychiatrist and president of Physicians for Responsible Opioid Prescribing, said in his email to WHO. "The Wisconsin group has played a prominent role in this effort on behalf of pharmaceutical companies."

On April 11, Cecilia Sepulveda, a doctor with WHO in Geneva, Switzerland, replied, saying WHO was looking into the matter.

Sepulveda and other WHO officials could not be reached for comment.

Last week, UW issued a statement on behalf of Robert Golden, dean of the medical school, saying the money the UW Pain Group got from drug companies came as unrestricted gifts that conformed to university regulations and standards.

Golden's statement said that in September 2010, the UW Pain Group successfully reapplied to be a WHO collaborating center so that it could continue to address the lack of access to opioids for pain relief around the world.

"(The UW Pain Group) decided to meet the WHO's new conflict of interest standards and to no longer accept funding from industry involved in the sale and marketing of opioids," Golden wrote. "This decision was made prior to the recent newspaper story, which described past support but failed to mention the decision to no longer accept industry support."

Drug industry records

In January, the Journal Sentinel first requested records of drug industry funding of the UW Pain Group. Since then, the paper made several requests to interview officials with the group about its funding, including questions that also were sent to public affairs personnel with the medical school.

At no time did the university say that the UW Pain Group had decided to stop taking money from companies that make narcotic painkillers.

Lisa Brunette, a UW spokeswoman, said the issue of the UW Pain Group halting its drug industry funding was not divulged before the Journal Sentinel story was published because the paper never asked about it.

Asked Wednesday whether the UW Pain Group had stopped taking any funds from companies that make or market opioids as of September 2010, the UW Pain Group said it certified to WHO "that it would not accept funds from companies that have a commercial interest in opioids."

But, it added, "any existing contracts between (the UW Pain Group) and those companies ended when those contracts expired and any new funding from those companies will not be accepted."

The UW Pain Group also said it could not say whether its staff members or officials personally had stopped taking funds from companies that make narcotic painkillers because the deadline for them to file personal disclosure forms with the university is April 30.

Thursday, April 21, 2011


Goalistics was created by two psychologists, Dr. Linda Ruehlman and Dr. Paul Karoly. The mission of the company is to create affordable and easy-to-use computer-based tools to help people manage psychological, social, and health-related problems that are often treated in mental health or physical health care settings.  Unfortunately, several barriers stand in the way of face-to-face treatment for millions of people, including inadequate finances, reluctance to seek treatment, and reduced access in rural areas. A highly cost-effective avenue for making inroads into this problem is the use of technology as a supplement to the traditional administration of services.Technology-based programs are affordable, self-paced, and are available 24 hours a day to people with reduced access to traditional treatment, such as people living in rural areas, with communication or other disabilities, with busy or inflexible schedules, or who lack child care, transportation, or insurance coverage.

Goalistics uses a variety of electronic tools to provide a uniquely dynamic foundation for learning such as DVD, online assessments and the scoring and reporting of data, interactive learning, electronic messaging, in-stream video, online discussion forums, as well as online data tracking and graphing. Features such as self-assessment, homework exercises, and self-monitoring can be created to suit the specific goals of a program.

Drs. Ruehlman and Karoly have translated what they have learned over several decades of clinical and research experience into a set of computer based teaching tools that enable committed users to master the essentials of self-regulation. The company name, Goalistics, is meant to capture the dynamic nature of human motivation, suggesting that the path to meaningful life change is potentially within the individual's grasp when appropriate goals and supportive skills are systematically mobilized. Armed with an array of regulatory skills and computer-based supportive technology, persons subscribing to the specific programs offered by Goalistics will be well on their way toward overriding years of bad habits and reasserting their control over what they do, feel, and think.

Wednesday, April 20, 2011

Prescription Drug Abuse Takes Toll on Appalachia -

PORTSMOUTH, Ohio — This industrial town was once known for its shoes and its steel. But after decades of decline it has made a name for itself for a different reason: it is home to some of the highest rates of prescription drug overdoses in the state, and growing numbers of younger victims.

Their pictures hang in the front window of an empty department store, a makeshift memorial to more than two dozen lives. The youngest was still in high school.

Nearly 1 in 10 babies born last year in this Appalachian county tested positive for drugs. In January, police caught several junior high school students, including a seventh grader, with painkillers. Stepping Stone House, a residential rehabilitation clinic for women, takes patients as young as 18.

In Ohio, fatal overdoses more than quadrupled in the last decade, and by 2007 had surpassed car crashes as the leading cause of accidental death, according to the Department of Health.

The problem is so severe that Gov. John R. Kasich announced $36 million in new spending on it this month, an unusual step in this era of budget austerity. And on Tuesday, the Obama administration announced plans to fight prescription drug addiction nationally, noting that it was now killing more people than crack cocaine in the 1980s and heroin in the 1970s combined.

The pattern playing out here bears an eerie resemblance to some blighted cities of the 1980s: a generation of young people who were raised by their grandparents because their parents were addicts, and now they are addicts themselves.

"We're raising third and fourth generations of prescription drug abusers now," said Chief Charles Horner of the Portsmouth police, who often notes that more people died from overdoses in Ohio in 2008 and 2009 than in the World Trade Center attack in 2001.

"We should all be outraged," Chief Horner said. "It should be a No. 1 priority."

Scioto County (pronounced sy-OH-tuh), of which Portsmouth is the seat, has made it one, bringing what had been a very private problem out into the public.

A coroner and a pharmacist are among its state lawmakers, and a bill in the state legislature would more strictly regulate pain clinics where drugs are dispensed. The most popular drug among addicts here is the painkiller OxyContin.

The county's efforts got the attention of political leaders in the state, including Governor Kasich, who declared the county a pilot project for combating addiction.

The problem is so bad that a storage company with business in the county recently complained to Chief Horner that it was having trouble finding enough job candidates who could pass drug tests.

"Around here, everyone has a kid who's addicted," said Lisa Roberts, a nurse who works for the Portsmouth Health Department. "It doesn't matter if you're a police chief, a judge or a Baptist preacher. It's kind of like a rite of passage."

About 10 years ago, when OxyContin first hurtled through the pretty hollow just north of town where the Mannering family lives, the two youngest children were still in high school. Their parents tried to protect them, pleading with neighbors who were selling the drug to stop. By mid-decade, they counted 11 houses on their country road that were dealing the drug (including a woman in her 70s called Granny), and their two youngest children, Nina and Chad, were addicted.

A vast majority of young people, officials said, get the drugs indirectly from dealers and other users who have access to prescriptions. Nina and Chad's father, Ed Mannering, said he caught a 74-year-old friend selling the pills from his front door. The sales were a supplement, the man said sheepishly, to his Social Security check.

"You drive down the road here, and you think, 'All these nice houses, no one's doing any of that stuff,' " said Judy Mannering, Nina and Chad's mother. "But they are. Oh, they are."

Nina Mannering tried to quit, her mother said. She had a small daughter to care for. She was in a counseling program for a few months, but was told to leave when her boyfriend brought her pills. At one point, Ms. Mannering counted the number of schoolmates in four graduating classes who had died from overdoses, her mother recalled. The total was 16.

"It's like being in the middle of a tornado," said Ed Hughes, director of the Counseling Center, a network of rehabilitation and drug counseling clinics in the county. "It was moving so fast that families were caught totally off guard. They had no idea what they were dealing with."

In January 2010, Ms. Mannering was killed less than a mile from her parents' house. A man broke into the house where she was staying with a 65-year-old veteran who had access to prescriptions, and shot them both, looking for pills, the police said. She was 29. Her daughter, who was 8 at the time, watched.

"It was like your worst fear that could ever come true," said Judy Mannering, who discovered her daughter's body at dusk, bathed in the light of a flickering, soundless television. Her son, Chad, served three years in prison for robbery. He is now sober.

Families are joining forces to combat the problem. Mothers whose children died from addiction have started to picket clinics that they believed were reckless with prescriptions. Last month the City Council passed a moratorium on new clinics.

"If you look at the problem, it's the darkest most malevolent thing you've ever seen," said Terry Johnson, a former Portsmouth coroner who is now a state assemblyman. "But right now, people are feeling like they are making a difference, and that's the most important thing. We need to capture that spirit."

The authorities have had some successes. Last month, agents raided a doctor's office and revoked his license. Another doctor from the area, Paul Volkman, is on trial in federal court in Cincinnati and accused of illegally disbursing prescription painkillers. But the drugs are legal, and it is hard to prosecute the people selling them. There are still five clinics in the county, several of them run by felons, officials said.

Chief Horner believes the problem will continue to fester without a coordinated effort by local, state and federal law enforcement agencies.

The state is stepping up efforts with prevention and rehabilitation, a spokeswoman for Governor Kasich said, but there are no plans to increase local financing for law enforcement, which remains, in the view of Chief Horner, woefully inadequate.

The trial of the man who shot Nina Mannering begins in June. Her mother awaits it with a mixture of dread and anticipation. For a while Judy Mannering felt so suffocated by grief that she could not leave the house, but that has passed.

Her grandchildren keep her going, as does her husband, Ed, a logger, who at 59 is still working full time, having spent their entire retirement savings on legal fees and rehab programs.

Mrs. Mannering has joined a group of other grieving mothers, who made the memorial of photographs in the store window. She has protested with them, holding up a sign with her daughter's photograph outside a clinic that dispenses pills. It was something she had never done before, but the ache of her loss gave her the courage.

"I miss her so much," she said of Nina. "If you had 100 kids, you'll never replace the one you've lost."

Administration Wants Tighter Painkiller Rules -

The Obama administration said on Tuesday that it would seek legislation requiring doctors to undergo training before being permitted to prescribe powerful painkillers like OxyContin, the most aggressive step taken by federal officials to control both the use and abuse of the drugs.

In the last decade, the abuse of pain medications like OxyContin has remained at epidemic levels, and medical experts have expressed concern that the legitimate use of the drugs may also pose patient risks. For years, the question of whether doctors should be trained as a condition of prescribing such medications has been fiercely debated.

Proponents of the training argue that it would help doctors better identify patients who would benefit from treatment with long-acting narcotics, and help them unmask patients feigning pain to get drugs they then abuse. Opponents say a training requirement will reduce the number of doctors prescribing pain drugs and hamper patient care.

Such a measure would probably entail Congressional approval of an amendment to the Controlled Substances Act to require that doctors undergo training as a condition of the renewal of licenses issued by the Drug Enforcement Administration for the prescription of narcotics. The law now gives the D.E.A. the authority to approve prescription licenses if a doctor merely shows an active license to practice medicine. Federal officials announced the legislative initiative on Tuesday along with outlining other measures they hope will reduce prescription drug abuse.

"The White House is absolutely committed to legislation that will make prescriber education mandatory," R. Gil KerlikowskePresident Obama's top drug policy adviser, said in an interview. "Of all the things we're proposing, this is certainly the one that's got a real bright light behind it."

Mr. Kerlikowske said his office had already approached several lawmakers about the legislation and intended to help draft it. He acknowledged that it was unclear when a bill would be submitted but said he hoped backers in Congress would do so by year's end.

Any proposal is likely to be fought by drug makers, some doctors and patient groups, who have argued that doctor training should be voluntary, not mandatory. In addition, proposed legislation would most likely encounter opposition among some lawmakers who have already mounted campaigns against what they consider to be the overregulation of the health care industry.

Among the drugs that would most probably fall under a stricter licensing measure are OxyContin, fentanyl, hydromorphone and methadone. They are considered critical to pain treatment. But they also have been associated in recent years with a national epidemic of prescription drug abuse and addiction and thousands of overdose-related deaths. OxyContin is the brand name for a long-acting form drug oxycodone. Dilaudid is the brand name for hydromorphone.

The administration's move comes after a panel of experts assembled by the Food and Drug Administration overwhelmingly rejected last year its proposal that physician training be voluntary. Those experts said that mandatory training was needed.

The F.D.A. has long argued that only Congress has the authority to mandate physician training as a condition of prescribing narcotics. That is because the legal distribution of the drugs is regulated by the Controlled Substances Act of 1970, and the licensing of doctors to prescribe them is overseen by the D.E.A., not the F.D.A.

In a related development, the F.D.A. released new regulations on Tuesday that would require the makers of long-acting or extended release painkillers to provide training to doctors but would not require doctors to take such courses. This proposal is similar to the one rejected as too weak in last year's debate. Dr. Janet Woodcock, who heads the F.D.A. Center for Drug Evaluation and Research, indicated that the new agency rules were effectively a placeholder until legislation was passed or were to be used if a relevant bill failed.

In response to a reporter's question, she said officials of the F.D.A., the D.E.A. and other federal agencies had agreed on the mandatory training requirement.

Mr. Kerlikowske, the White House drug czar, said he had sought input from doctors, medical schools and representatives of the pharmaceutical industry, which he said would pay for the training. The training would focus on opioid painkillers like OxyContin because they were the most widely abused and dangerous class of drugs prescribed by doctors, he said.

"That's where, right now, the impetus and the public concern is," he said. "You don't want to be accused of overreaching."

During the F.D.A. review, some drug makers strenuously opposed mandatory physician training. But an executive of Covidien, which sells the painkiller fentanyl, said his company supported such a requirement.

"The proposed amendment to the Controlled Substances Act giving authority to the D.E.A. to require prescriber training would be a valuable measure," said that executive, Dr. Herbert Neuman.

A spokeswoman for the maker of OxyContin, Purdue Pharma, said it also supported the approach. "The D.E.A. process to authenticate training would seem to be the best way to gain compliance," that spokeswoman, Libby Holman, stated in an e-mail.

About 600,000 doctors, dentists and physician assistants are licensed by the D.E.A. to prescribe controlled substances, according to Mr. Kerlikowske's office.

"They don't get a lot of information in their training about pain management, about addiction, about tolerance and dependence," he said.

Several other pending Congressional bills are aimed at prescription drug abuse. One of them, submitted by Representative Mary Bono Mack, Republican of California, would direct the F.D.A. to limit the approval of OxyContin and other controlled-released forms of oxycodone to the treatment of severe pain.

Tuesday, April 19, 2011

Arthritis Pain Relief Optical Illusion - ABC News

An optical illusion that harnesses the power of
suggestion might one day deliver drug-free pain
relief to arthritis sufferers, British researchers say.

Analgesic and anti-inflammatory pills and physical
therapy are among traditional approaches to reducing
or eliminating the aches and pains of chronic
osteoarthritis, common among men and women older
than 50. In recent years, many sufferers have tried
complementary and alternative approaches such as
yoga, massage and acupuncture to counter the pain
and stiffness of the wear and tear on their joints.
Now, psychologists at the University of Nottingham
say that they might have serendipitously stumbled
upon a new, non-invasive way of turning down the
pain dial by tapping into brain-body connections.

They achieve relief by fooling the brain with
something they call "illusory manipulation." It's
similar to the "mirror therapy" administered to reduce
phantom pain some amputees experience where their m
issing limbs used to be. A mirror and lens optically
"resurrect" the missing limb; shrinking the image
lessens the pain.

At an open house last April, University of Nottingham
psychologists Roger Newport and Catherine Preston
were demonstrating Mirage technology, which they
developed to study how the brain processes visual
and other sensory signals. Curious children took
turns sticking their hands into the Mirage box and
watching cool-looking illusions that make them seem
to be wider, narrower, longer or shorter -- much like
what happens when you stand in front of body-
distorting mirrors in a fun house -- except that
Mirage uses real-time video and computer-generated
images projected onto a screen. Youngsters can
watch on-screen as one of the researchers gently
pushes or pulls at their fingers. Through the magic of
mirrors and computer effects, the on-screen image
seems to show their fingers growing longer just as
they're feeling the researcher pull, or shrinking as
they feel the researcher push.

At one point, "the grandmother of one of the children
wanted to have a go, but warned us to be gentle
because of the arthritis in her fingers," said Preston, a
psychologist now at Nottingham Trent University. "We
were giving her a practical demonstration of illusory
finger stretching when she announced, 'My finger
doesn't hurt anymore' and asked whether she could
take the machine home with her. We were just
stunned. I don't know who was more surprised, her
or us."

Intrigued by the grandmother's reaction, Preston
and Newport, an associate psychology professor at
the University of Nottingham, wanted to investigate
further. They contacted a local osteoarthritis support
group to find volunteers who might help determine
more scientifically whether Mirage's effects were real,
or just an illusion.

They recruited 20 volunteers, average age 70, with
painful arthritis. With a hand in the Mirage box,
volunteers' brains processed both the sensations they
felt and what they saw on the screen. When they rated
their pain, 85 percent of participants on average said
it was halved. Pain vanished for six patients.

More ...

Phantom pain: Teenager who broke foot 7 years ago still takes painkillers | Mail Online

A teenage girl lives in constant agony because of a rare condition that tricks her brain into believing she has never recovered from a broken foot she suffered seven years ago.

Kiera Ward, 17, takes a daily cocktail of 39 painkillers for the excruciating pain - even though the fracture is fully healed and the pain is all in her head.

She broke her foot during a playground game of tug-of-war aged 11 but doctors believe the trauma of delays in her treatment triggered a condition called Complex Regional Pain Syndrome (CRPS).

The ailment causes her brain to experience phantom pain as if the injury is still there - and Kiera lives in excruciating pain 24 hours a day.

She said: 'The pain is unbearable, I can't describe to anyone else how it feels.

'There are so many days where I can't get out of bed or where I'm with my friends and I just burst into tears because I can't take it any more.

'The hardest thing is that my foot isn't hurt, my brain is just telling me it is. There's no reason why this is happening.'

Kiera broke her heel bone in September 2004 on a school trip to Kilbowie, near Oban.

She was playing tug-of-war when she fell under a group of classmates. No one realised she was badly injured until two days later when she could not walk.

The schoolgirl was taken to hospital, where doctors did not X-ray her but said she had ligament damage and sent her home with instructions to rest and take ibuprofen.

Two weeks later, she was in such pain her parents took her to Wishaw General where the fracture was found.

The delay in her treatment could have sparked Kiera's condition, which sometimes affects young, sporty girls for reasons no one understands.

She should have been off her crutches after six weeks but instead could not walk for 18 months.

It was not until September 2005 that doctors at Yorkhill Children's Hospital in Glasgow finally diagnosed Kiera with CRPS.

More ...

The Body Odd - #@*! Swearing really is a powerful painkiller, study shows

Next time you stub your toe, go ahead and let those four-letter words fly. Cursing actually does help dull our perception of pain, research suggests.

In the study, researchers from the UK's Keele University asked participants for five words they'd likely use after hitting their thumb with a hammer; the first word listed would be their go-to profanity during the experiment. (They were also asked to list five boring words -- ones they'd use to describe a table.)

Participants were then instructed to submerge their unclenched hand in a container of 41-degree water, and keep it there -- while repeatedly cursing -- for as long as they could. Before and after plunging their hands into the chilly water, their heart rate was recorded. And after they could no longer stand the cold temperature, they were asked to rate the amount of pain they were in, too.

What's surprising is that the researchers had thought that swearing would make the cold water feel much colder, lowering the participants' tolerance for pain and heightening their perception of it. "In fact, the opposite occurred -- people withstood a moderately to strongly painful stimulus for significantly longer if they repeated a swear word rather than a nonswear word," write the team, led by Keele University psychologist Richard Stephens, in the journal Neuroreport.

From the way participants' heart rates accelerated post-swearing, the psychologists believed their fight-or-flight response had been activated -- that may be because cursing can amp up feelings of aggression. (Think of a bunch of rowdy NFL players psyching each other up before a big game.)

Interestingly, women reported feeling less pain after swearing a blue streak. (Hilariously, the researchers report that cussing "did not increase pain tolerance in males with a tendency to catastrophise." That's the polite British way of saying some of the boys were total drama queens.)

Sunday, April 10, 2011

Dependent on Prescription Drugs, Even Before Birth -

Newly Born, and Withdrawing From Painkillers

Published: Sunday, April 10, 2011 at 6:30 a.m. 

BANGOR, Me. — The mother got the call in the middle of the night: her 3-day-old baby was going through opiate withdrawal in a hospital here and had to start taking methadone, a drug best known for treating heroin addiction, to ease his suffering.

The mother had abused prescription painkillers like OxyContin for the first 12 weeks of her pregnancy, buying them on the street in rural northern Maine, and then tried to quit cold turkey — a dangerous course, doctors say, that could have ended in miscarriage. The baby had seizures in utero as a result, and his mother, Tonya, turned to methadone treatment, with daily doses to keep her cravings and withdrawal symptoms at bay.

As prescription drug abuse ravages communities across the country, doctors are confronting an emerging challenge: newborns dependent on painkillers. While methadone may have saved Tonya's pregnancy, her son, Matthew, needed to be painstakingly weaned from it.

Infants like him may cry excessively and have stiff limbs, tremors, diarrhea and other problems that make their first days of life excruciating. Many have to stay in the hospital for weeks while they are weaned off the drugs, taxing neonatal units and driving the cost of their medical care into the tens of thousands of dollars.

Like the cocaine-exposed babies of the 1980s, those born dependent on prescription opiates — narcotics that contain opium or its derivatives — are entering a world in which little is known about the long-term effects on their development. Few doctors are even willing to treat pregnant opiate addicts, and there is no universally accepted standard of care for their babies, partly because of the difficulty of conducting research on pregnant women and newborns.

Those who do treat pregnant addicts face a jarring ethical quandary: they must weigh whether the harm inflicted by exposing a fetus to powerful drugs, albeit under medical supervision, is justifiable.

"I've had pharmacies that have just called back and said: 'This lady's pregnant. Why do you want me to fill this scrip? I can't do that,' " said Dr. Craig Smith, a family practitioner in Bridgton, Me. "But when you stop and think about what actually happens during withdrawal and how violent it can be, that would certainly be not in the baby's best interest."

Still, even doctors who advocate treating pregnant addicts have had moments of doubt.

"At first I was going, 'Gosh, what am I doing?' " said Dr. Thomas Meek, a primary care physician in Auburn, Me. " 'Am I really helping these people?' "

There are no national figures that document the extent of the problem, but interviews with doctors, researchers, social workers and women who abused painkillers while pregnant suggest that it has grown rapidly, especially in rural regions, where officials say such abuse is most common.

In Maine, which has been especially plagued by prescription drug abuse, the number of newborns treated or watched for opiate withdrawal, known as neonatal abstinence syndrome, at the state's two largest hospitals climbed to 276 in 2010 from about 70 in 2005. Hospitals in states including Florida and Ohio reported similar increases, and experts said the numbers were probably higher since pregnant women are rarely tested for drug use and many mothers do not admit to abusing opiates.

Tonya, 24, said she was introduced to painkillers like OxyContin, Percocet and Vicodin while working the overnight shift at an industrial bakery an hour from her home. Everyone — including co-workers, the boyfriend she met on the job and their manager — was taking pills, she said.

"It was a lot easier to get through life and have energy," Tonya said at Eastern Maine Medical Center here in January, holding Matthew a month after his birth. He was still being weaned off methadone.

Before she was pregnant, Tonya said, she quickly became addicted, spending all of her money on pills bought on the street. She and her boyfriend, Josh, needed to stave off withdrawal and get through the day, she said.

Now that she is in treatment, Tonya, who like most mothers interviewed for this article did not want her last name used, said her focus was on Matthew. "We put him in this situation," she said, "and we have to help him out of it."

'How Little We Know'

Rigorous studies on treating infant withdrawal are scarce, and the American Academy of Pediatrics has not published guidelines since 1998.

"It's really remarkable how little we know about the effect of prescription drugs and even nonprescription drugs on the fetus," said Dr. Nora D. Volkow, director of the National Institute for Drug Abuse. "There are real roadblocks in terms of helping us advance the field."

Dr. Mark L. Hudak, a neonatologist in Jacksonville, Fla., is helping to revise the pediatrics academy's guidelines. "There are commonalities, but it's not like you can go to a Web site that says, 'This is what should be used by everyone,' " Dr. Hudak said. "No one knows what the best approach is."

Within states, every hospital that delivers babies exposed to painkillers may have its own approach. Eastern Maine treats affected newborns with tiny doses of methadone, while Maine Medical Center in Portland uses morphine combined with phenobarbital, a barbiturate that prevents seizures. Some hospitals are also experimenting with clonidine, a mild sedative that can relieve withdrawal symptoms.

There is growing debate over treatment for pregnant women addicted to prescription drugs, in light of concerns over the effects on their babies. Many are slowly weaned from their dependence with methadone, the standard of care for decades. Methadone, when taken in prescribed doses, keeps a steady amount of opiate in the body, preventing withdrawal and drug cravings that occur when levels dip. But it, too, can be addictive and cause nagging side effects like drowsiness. And for addiction treatment, it can be obtained only at federally licensed clinics where most users have to report for a daily dose.

A growing number of addicts are instead taking buprenorphine, another drug used to treat addiction that some studies suggest staves off drug cravings as effectively as methadone but is less likely to cause withdrawal in newborns. In rural areas of the nation, where methadone clinics are few, buprenorphine is considered a promising alternative because it can be prescribed by primary care doctors and taken at home.

But buprenorphine also appears not to work for some addicts.

Still, a study published in December in The New England Journal of Medicine showed that babies whose mothers had taken buprenorphine required significantly less medication after birth and less time in the hospital than did babies whose mothers were treated with methadone. But researchers cautioned that exposure to buprenorphine in utero can still cause withdrawal symptoms and that further study was needed.

"We don't want it misconstrued that buprenorphine is a miracle drug," said Hendrée E. Jones, a Johns Hopkins University researcher and the study's lead author.

Even less is known about longer-term effects on babies exposed to painkillers, though in a second leg of their study, Dr. Jones and her fellow researchers plan to follow the 131 babies in the cohort until they turn 3.

A recent study by the Centers for Disease Control and Prevention found that babies exposed to opiates in utero, in this case legally prescribed painkillers, had slightly higher rates of birth defects, including congenital heart defects, glaucoma and spina bifida.

Experts say that since many drug users also smoke and abuse alcohol, not to mention that they face extenuating circumstances like poverty, it is difficult to tease out the effects of each substance on their offspring.

"Most of the literature suggests consistently that the drug exposure itself is not the primary concern," said Karol Kaltenbach, a professor at Jefferson Medical College in Philadelphia who studies addiction in pregnant women. "It's the cumulative effect of the drug-using lifestyle — poverty, chaos in the home, domestic violence. All those things affect development."

Not all newborns exposed to opiates have severe enough withdrawal to need medicine; at Maine Medical Center since 2003, about 55 percent of babies exposed to buprenorphine and 80 percent of those exposed to methadone have needed treatment. But it is hard to predict which ones will need it: a newborn whose mother was on a high dose of either drug might need none, while a baby whose mother took a low dose might experience acute withdrawal.

Babies known to have been exposed to drugs are often kept in the hospital for at least five days because withdrawal symptoms usually do not set in immediately. Nurses examine them for a checklist of symptoms every few hours, assigning each baby a score that, if high enough, calls for treatment.

"They don't stop crying, they can't settle down, they don't relax," said Geraldine Tamborelli, nursing director of the birthing unit at Maine Medical Center, which in 2010 diagnosed opiate withdrawal in 121 newborns. "They're struggling in your arms instead of snuggling into you like a baby that is totally fine."

In the neonatal intensive care unit at Eastern Maine, Kendra, 3 days old, was sleeping in a dark, silent room one morning, away from the bustle and bright lights that can be especially irritating to babies going through withdrawal. Nurses frequently crept in to observe her, though, and by the afternoon her limbs had stiffened and she was crying excessively and having tremors; it was enough to begin treatment.

"This seems to be ramping up fairly quickly for her," said Dr. Mark Brown, the hospital's chief of pediatrics, "so the decision was to start treatment more quickly."

On the pediatric ward, Matthew started fussing while his mother, Tonya, talked to reporters that afternoon in January; his cry had a strange, reedy pitch that nurses say is common to babies with his condition. The small dose of methadone he had received gave him gas and heartburn, for which he was given two stomach medications. He also was on clonazepam, a muscle relaxant and anti-anxiety drug that helped him metabolize the methadone more slowly.

Tonya said that at first she "didn't believe in" methadone treatment during pregnancy and that doctors had to persuade her that it would not hurt her fetus. She had experienced wrenching withdrawal when she stopped using painkillers after learning she was pregnant, she said, and the doctors had warned her that "when I was feeling that bad, he was feeling 1,000 times worse."

Tonya said that in a previous pregnancy, she quit using drugs altogether and miscarried a month later.

"That was the last thing I wanted to happen this time," she said.

Avoiding Addicts, and Liability

Treating drug-dependent mothers and babies is often lonely work, with little communication among the doctors who take it on. As Dr. Brown said, "My network for people who do this is really very small."

Dr. Mark R. Publicker, an addiction medicine specialist at Mercy Recovery Center in Westbrook, Me., is on a mission to get more of the state's doctors to treat pregnant prescription drug abusers and more hospitals to deliver their babies. Only a handful of doctors here treat pregnant women with buprenorphine, Dr. Publicker said, partly because they fear liability and do not want to deal with addicts.

The fact that most hospitals will not deliver the babies makes doctors even less likely to treat the women.

"It's mostly ignorance," Dr. Publicker said. "It's a concern that it's a risky proposition and that they're going to wind up with an ill baby."

In February, Dr. Smith persuaded Bridgton Hospital, which has only 25 beds, to deliver the babies of women on buprenorphine — a major victory, he said, because until then women in rural southwestern Maine had to drive an hour or more to Maine Medical to deliver.

Courtney, a patient of Dr. Smith's who discovered she was pregnant while in jail for stealing OxyContin from her landlord, said buprenorphine treatment seemed the best of her bleak options.

"I just don't want to mess up," she said.

Tonya, too, said she was determined to make things right for Matthew, who was five weeks old when she took him home to a trailer outside Bangor. He is off the methadone now and appears healthy, but Tonya still has to go to a methadone clinic in Bangor every day for her dose and resist the pressures to return to illicit drug use. Her boyfriend began using opiates as a young teenager, she said, and his father and grandmother abused OxyContin along with him.

"I'm proud that I changed my life," Tonya said. "But at the same time, when you see your child in pain and you know your child is in pain because of a life decision you made, it's the hardest thing in the world."