Tuesday, February 28, 2012

NIH Pain Consortium

The NIH Pain Consortium was established to enhance pain research and promote collaboration among researchers across the many NIH Institutes and Centers that have programs and activities addressing pain. To this end, the following goals have been identified for the Pain Consortium:

  • To develop a comprehensive and forward-thinking pain research agenda for the NIH - one that builds on what we have learned from our past efforts.

  • To identify key opportunities in pain research, particularly those that provide for multidisciplinary and trans-NIH participation.

  • To increase visibility for pain research - both within the NIH intramural and extramural communities, as well as outside the NIH. The latter audiences include our various pain advocacy and patient groups who have expressed their interests through scientific and legislative channels.

  • To pursue the pain research agenda through Public-Private partnerships, wherever applicable. This underscores a key dynamic that has been reinforced and encouraged through the Roadmap process.

Thursday, February 23, 2012

Life Before Death Movie's Channel - YouTube

LIFE Before Death is a multi-award winning documentary series that asks the fundamental question underpinning our mortality.

This beautifully filmed journey takes us to 11 countries as we follow the remarkable health care professionals battling the sweeping epidemic of pain that threatens to condemn one in every ten of us to an agonizing and shameful death. Through the eyes of patients and their families we discover the inherent humanity that empowers the best of us to care for those beyond cure.

This is an intimate hopeful and life-affirming collection of stories about living well and dying better, advocating for making the most of every moment in our life before death.

LIFE Before Death comprises a Feature Film, 50 Short Films and a Television Documentary.



TMJ Association Scientific Symposium: The Puzzle of Comorbid Chronic Pain | Pain Research Forum

At a recent scientific symposium sponsored by the Temporomandibular Joint Association (TMJA), researchers and patient advocates outlined an agenda for a dramatic change in how a sett of common and often co-occurring chronic pain conditions are classified and treated. Conferees laid out the latest science, and then went beyond that to envision a new, large-scale, longitudinal study of comorbid chronic pain conditions (CCPC). The design of the proposed study takes after two ongoing pain projects and signals an emerging acceptance among researchers that multidisciplinary, multicenter, comprehensive approaches are needed to solve the puzzle of chronic pain.

The TMJA is a nonprofit advocacy group with a mission to improve the lives of people affected by disorders of the jaw, which often involve severe and disabling facial pain. People with temporomandibular joint disorders (TMJDs) also suffer at higher rates from other pain conditions, including chronicfatigue syndrome, chronic headache/migraine, endometriosis, fibromyalgia, irritable bowel syndrome, interstitial cystitis, and vulvodynia. These conditions, which are sometimes also called functional pain syndromes, constitute CCPC.

The goal of the meeting, which took place 5-7 June 2011 in Bethesda, Maryland, was to identify gaps in knowledge and research into CCPC. Why are people with one functional pain condition at greater risk for others? Do the conditions have a common underlying cause, and/or shared risk factors? Are there common genetic factors at play? Are some CCPC the same disease, just called by different names?

To attack these questions, the organizers assembled a cross-section of the research world, gathering basic neurobiologists, imaging experts, clinical researchers, and even biomedical engineers for sessions aimed at defining new research directions. The participants faced chasms in the understanding of CCPC, starting with inconsistent case definitions, a lack of epidemiological data, and little understanding of biological markers or mechanisms. In response, the working groups laid out an ambitious wish list of studies that would redraw the boundaries of CCPC, transcending the current state of symptom- and organ-based definitions in favor of a classification grounded in an understanding of detailed phenotypes and biology.

A Problem of Definitions

The challenge for researchers is clear: Functional pain syndromes have, for the most part, unknown etiology and no apparent pathophysiology. The conditions often have no clear pain generator (e.g., no evidence of nerve damage or entrapment as in neuropathic pain, or obvious nociceptive input as in inflammatory pain). They do seem to be augmented by central nervous system processing (central sensitivity), and people with these conditions are more likely to be female, and to have a family history of chronic pain and a personal history of centrally mediated symptoms such as fatigue, insomnia, and sleep disturbances. Patients also tend to display catastrophizing, diffuse hyperalgesia, attenuated descending analgesia, and changes in functional neuroimaging measures.

Complications pile on when researchers try to look at the co-occurrence of several different pain conditions. Reviewing existing studies of CCPC, epidemiologist Gary Macfarlane, University of Aberdeen, U.K., found few high-quality studies looking at overlap of these conditions. A big problem is case definitions, and Macfarlane highlighted a striking commonality of symptoms across different conditions. Patients with fibromyalgia, for example, often meet the criteria for irritable bowel syndrome, chronic fatigue syndrome, or TMJD.

On top of that, the risk factors associated with each of these conditions are often the same, Macfarlane said, "so that it is not clear whether the diseases co-occur because of a shared pathophysiology or whether by virtue of shared risk factors, one person has simultaneous susceptibility to different diseases."

The CCPC Study

The lack of basic data on CCPC led the group to strongly recommend a large-scale, longitudinal, population-based study as the best way to gather the kind of data that would both yield mechanistic insights and inform clinical management. As described by discussion leader Emeran Mayer, University of California, Los Angeles, the ideal study would be a multicenter, international effort, and involve several thousand patients. Entry to the study would be based on current symptom criteria of the five to seven most common syndromes, but once in the study, all subjects would undergo a uniform and extensive characterization of symptoms and testing of sensory, psychological, and brain function.

In initial studies, investigators would look at easily achieved, high-throughput phenotypic measures: various types of "omics," brain imaging, and genotyping. After that, Mayer said, the old case definitions would go out the window. The investigators pool all the data and make an agnostic analysis, looking for new ways to classify diseases and patient groups.

Such a study should give definitive answers as to whether comorbid chronic pain is an entity distinguishable from neuropathic or inflammatory pain, and whether there are subgroups of patients that can be defined biologically. Based on the results of the first phase, the study could then progress to a second phase where researchers would carry out more specialized studies. In the end, the project would create a repository of data available to all researchers.

The goal, said William Maixner, University of North Carolina, Chapel Hill, is to "create a whole new diagnostic criterion for these patients, a paradigm shift in how they would be evaluated and diagnosed, not by specialty or site, but by a broader case definition." In a few years, maybe we'll have CCPC1, CCPC2, and CCPC3, he suggested. "The goal is to totally break down the way we put patients into categories."

As Mayer put it, "The most important point is that we should admit that concepts we have about these disorders are based on flawed hypotheses. To understand CCPC, we have to enhance our observation, collect the data, and then reclassify patients based on approaches available today."

Pioneering Efforts

There are precedents for such a study, and representatives of two such projects were present at the meeting. Maixner is the lead investigator on the OPPERA (Orofacial Pain: Prospective Evaluation and Risk Assessment) study, an ongoing, multisite, longitudinal program involving 3,200 subjects at risk for TMJ disorders and 200 patients with chronic pain. With support from the National Institute of Dental and Craniofacial Research, National Institutes of Health, the subjects have been deeply phenotyped with quantitative measures of sensory function, autonomic function, and psychological factors.

The study is now in its sixth year, and three quarters of the subjects are still in the study, Maixner reported. So far, 258 enrollees have developed TMJD or other facial pain. That has allowed the investigators to analyze predictors of case status, which the data reveal include pressure pain threshold, mood/stress/coping measures, sleep disturbance, level of somatic awareness, and autonomic dysfunction. The initial findings are now under review as a series of articles that should appear in print in the next few months, Maixner said.

OPPERA has an active genetic research component, looking for common polymorphisms that underlie the risk factors for complex and persistent pain conditions. The researchers were originally funded to examine polymorphisms in 20 candidate genes, and have now looked at 350 additional genes involved in nociceptor transmission, inflammation, mood, and affect. Now, Maixner reports, they will completely sequence 500 target genes, and hope with future support to do genomewide studies. (For a look at some of the OPPERA data, view slides from a March 2011 symposium sponsored by the International Research Diagnostic Criteria-Temporomandibular Disorders Consortium of the International Association for Dental Research.)

A newer large-scale study is the MAPP (Multidisciplinary Approach to the Study of Chronic Pelvic Pain) Research Network, which was described by Mayer. The project brings together researchers studying interstitial cystitis, painful bladder syndrome, chronic prostatitis, and chronic pelvic pain syndrome in a multisite, interdisciplinary effort. Recognizing that traditional bladder- or prostate-specific research and translational efforts have been unsuccessful, in 2007 the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the U.S. National Institutes of Health (NIH) decided to take a whole-body approach and committed U.S. $37.5 million to fund the project at six main sites. After the funding was committed, Mayer said, the NIDDK told investigators that there would be no checks written until the group devised, together, a common project covering five key areas: epidemiology, phenotyping, biomarkers, organ crosstalk, and neuroimaging.

The NIDDK wanted one unified effort to recruit study subjects, and the group came up with the current scheme, which revolves around an extensive epidemiological study with standardized deep phenotyping of 360 chronic pelvic pain (CPP) patients, pulled from all the discovery sites. Subject characterization includes urologic symptoms as well as personality measures, comorbid symptoms, and pain pressure threshold measures, along with collection of blood, urine, and DNA. The data and biological samples would feed into work including biomarker discovery, imaging, and mechanistic studies. In addition to CPP patients, the study also incorporates healthy controls and so-called positive controls—patients with conditions that commonly occur along with CPP, namely, fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.

The neuroimaging arm of MAPP, which Mayer leads, is enrolling 130 CPP patients, 80 healthy controls, and 80 positive controls at five sites, measuring grey and white matter and capturing resting-state functional magnetic resonance imaging (fMRI) images. The work will take advantage of the Laboratory of Neuro Imaging (LONI) at the University of California, Los Angeles, which has been a leader in other large multicenter imaging studies, including the Alzheimer's Disease Neuroimaging Initiative and the Parkinson's Progression Markers Initiative. Data that are collected at the study sites are transmitted to LONI, where the data enter the analysis pipeline and also become publicly available.

MAPP is now in its second year of five years of funding. Mayer said that an interim analysis of imaging data is planned for this summer. (For more information on MAPP, see the project website.)

Means of Support?

Because of these precedents, researchers interested in the constellation of CCPC need not start from scratch, but should be able to take elements from OPPERA and MAPP to design a new study in a relatively short time, said Maixner.

Is such a study possible, financially speaking? With funding for pain research scarce, talk turned toward how to support such an ambitious agenda. John Kusiak, director of the Molecular and Cellular Neuroscience Program at the National Institute of Dental and Craniofacial Research of the NIH, offered that this might actually be an opportune time to push for a new initiative. The NIH received a mandate in the health care legislation of 2010 to boost pain research, and leadership at the NIH is thinking about areas "that fit very nicely" with studies like that proposed, Kusiak said. It remains to be seen, however, whether and how the vision of an integrated approach to CCPC can become a reality.


Migraines Linked to Depression in Women | Women with Migraine Headaches More Likely to Develop Depression | MyHealthNewsDaily.com

Women who have had migraine headaches are more likely than other women to develop depression, according to a new finding based on 14 years of health data.

"This study confirms it: Having migraines increases your risk of depression, which we've suspected for many years," said Dr. Timothy A. Collins, a Duke University Medical Center neurologist who was not involved with the research. Collins specializes in headache treatment.

Researchers looked at more than 36,000 women enrolled in the Women's Health Study, and found that after 14 years, depression had developed among those who suffered from migraines at a higher rate than among those who didn't get the throbbing headaches.

Study researcher Dr. Tobias Kurth, an epidemiologist at Brigham and Women's Hospital in Boston, saidwomen who have migraines shouldn't assume they'll develop depression, but should be aware of the link to the increased risk.

The findings will be presented in April at the annual meeting of the American Academy of Neurology in New Orleans.

A predominantly women's affliction

Migraines can last four to 72 hours and are often accompanied by pulsating pain, nausea, vomiting and sensitivity to light and sound.

One in 10 Americans has migraines, according to the National Institute of Neurological Disorders and Stroke, but they affect women three times more often than men.

One previous study found that women with more than 15 chronic headaches a month are four times more likely to have depression than women who have fewer than 15.

Collins noted a 2011 Canadian study that found people with migraines were more likely than others to have depression, but people with depression were no likelier than people without the condition to have migraines.

Although some antidepressants have been shown to reduce a high frequency of migraines, there is no evidence that shows that treating migraines will help with depression, Kurth said.

Women with any history of migraine are at risk

Kurth and fellow researchers looked at 36,154 women without depression who were enrolled in the Women's Health Study, an ongoing investigation conducted by Brigham and Women's Hospital and Harvard Medical School. Nearly 6,500 of the women reported having migraines, or suffering them in the past.

After 14 years, 3,971 of the women in the study had developed depression. Researchers found that women with any history of migraine had 1.3 times the risk of developing depression than women who'd never had a migraine.

"There are no good theories" to explain the link between depression and migraines, Collins said, though some have suggested hormones play a role. The drop in estrogen levels that occurs prior to menstruation is a trigger for headaches in many of his patients, he said.

Collins recommends that women talk with their doctors about how frequently they have their headaches.

"There's medication that can alleviate the pain as well as prevent them from happening so often," he said.

"Before this study, I didn't ask my patients if they had depression," Collins added. "But now I will."


US Senate Committee on Health, Education, Labor, & Pensions: Hearings - Hearing

Full Committee Hearing - Pain in America: Exploring Challenges to Relief


Tuesday, February 14 2012, 2:30 PM


430 Dirksen Senate Office Building

Witnessesreturn to top

Panel I

  • Lawrence A. Tabak, D.D.S., Ph.D. , Principal Deputy Director, National Institutes of Health, Washington, DC

Panel II

  • Philip A. Pizzo, M.D. , Dean of the School of Medicine, Stanford University School of Medicine, Stanford, CA
  • John E Sarno, M. D. , Professor of Clinical Rehabilitation Medicine, New York University School of Medicine, New York, NY
  • William Maixner D.D.S., Ph.D , Director, Center for Neurosensory Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC
  • Christin Veasley , Executive Director, National Vulvodynia Association, North Kingstown, RI

Women's Chronic Pain Misdiagnosed, Undertreated, Dismissed - ABC News Radio

Women make up the vast majority of the nation's 116 million chronic pain sufferers, yet doctors frequently dismiss their complaints as all in their heads, sending them on years-long searches for relief, a patient told senators Tuesday.

Although studies have observed women's chronic pain is more frequent, more severe and longer lasting than men's, many women still are told "their problem isn't real. Your pain doesn't exist, you must be imagining this," Christin Veasley testified.

In her case, she said, back and neck pain from an old car accident became "an unwanted companion for 21 years." Since 2008, migraine headaches, facial pain and jaw pain piled on more misery, she said.

"From the moment I open my eyes each morning, the first thing I feel is pain," said Veasley, executive director of the non-profit National Vulvodynia Association, which aims to help the one in four American women and "countless adolescents" suffering invisible but excruciating genital pain at some point during their lives.

Veasley, who has recovered from vulvodynia she had in her 20s, testified on behalf of the Chronic Pain Research Alliance. She said she hopes Congress will lead the way in enacting "long overdue change to help us regain our quality of life and ability to contribute to society."

She was among five witnesses appearing at a Capitol Hill hearing on "Pain in America: Exploring Challenges to Relief," called by Sen. Tom Harkin, D-Iowa, chairman of the Senate Committee on Health, Education, Labor and Pensions.

The hearing followed publication last year of an Institute of Medicine report that included recommendations for improving diagnosis, treatment and research into chronic pain, as well as boosting health professionals' recognition of both the problem and its toll.

The cost of chronic pain exceeds $600 billion each year -- more than cancer, heart disease and diabetes combined, the IOM report found. Chronic pain is defined as pain that lasts several months or more, according to testimony from Dr. Lawrence A. Tabak, principal deputy director of the National Institutes of Health. It may crop up as persistent pain after an injury heals, or arise as a debilitating symptom of long-term diseases like arthritis, diabetes or cancer.

Often, Tabak said, people suffer from chronic pain associated with more invisible conditions like fibromyalgia, irritable bowel syndrome, chronic headaches or jaw pain -- all more common in women than men.

"The majority of my patients are women," said Dr. Timothy A. Collins, a neurologist with the Duke Pain and Palliative Care Clinic in Durham, N.C., who was not involved in the hearing.

He said migraine headache is "three times as common in women compared to men." Fibromyalgia "appears more common in women than men," and "a number of pain conditions are directly caused by abuse (sexual and physical) and unfortunately, women are more commonly on the abused side of the equation."

Collins said U.S. culture encourages women "to voice feelings, emotions and physical complaints" while generally discouraging such complaints in men.

"This tends to affect the perception of the care provider -- if there are significant emotional issues, the other complaints may become attributed to the emotional complaints," he said.

In other words, if a woman with chronic pain also suffers from depression, a doctor may attribute all of her complaints "to being depressed, so no further evaluation or treatment is needed," Collins said.

Women with chronic pain also are subject to some of the same gender discrimination that contributes to their under-treatment for cardiac disease and or arthritis. For example, a 1999 study published in the New England Journal of Medicine found that white women (and black men) were 40 percent less likely to be referred for potentially life-saving cardiac surgery.

A 2008 study published by the Canadian Medical Association found doctors were more likely to recommend knee replacement surgery to male patients with knee arthritis than to female patients, suggesting that gender discrimination might contribute to women being three times less likely to undergo knee replacement than men.

In addition, when it comes to doctors' decisions about managing pain, a February 2003 study of doctors' pain management knowledge and attitudes, published in The Journal of Pain, found that women were less likely than men to receive "optimal treatment" for post-surgical or cancer-related pain. That study also found doctors set lesser goals for chronic pain relief than for acute pain and cancer pain.


Thursday, February 09, 2012

Canadian Pain Summit - April 24, 2012, Ottawa

Th Canadian Pain Summit will be held in Ottawa on April 24, 2012 at the Fairmont Chateau Laurier Hotel.

The Canadian Pain Society (CPS) and the Canadian Pain Coalition (CPC), along with their partner organizations will host this important event.

Up to 300 delegates are expected to attend the Summit, where all stakeholders - consumers, care givers and health professionals, along with educators, provincial, territorial and federal government representatives, business and not-for-profit groups will be able to provide valuable input to the National Pain Strategy for Canada.

The CPS developed a draft National Pain Stategy during the summer of 2010 and this document will be the focal point of a Stakeholder Forum to be held September 16, 2011 in Toronto. It is expected that a cross-section of up to 50 stakeholders will attend the Forum, to provide critical input to the draft strategy.

Once complete, the National Pain Strategy for Canada will be presented at the Canadian Pain Summit in April 2012 for final consideration and acceptance by all participants.

"Given the magnitude and scope of the problem of undertreated pain in Canada, a national strategy along with an associated Summit is the best way to proceed," says Dr. Mary Lynch, President of the CPS and Co-Chair of the Canadian Pain Summit 2012.

"We look forward to co-hosting this important Pain Summit event in Canada next year," advises Lynn Cooper, President of the CPC. "We learned a great deal from the International Pain Summit held last September in Montreal and we want to improve the situation for all Canadians living with pain," Cooper adds.


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