Wednesday, October 24, 2012
Sunday, October 14, 2012
Most of us have patients who always seem to be complaining about some ache or pain. There are those patients who keep coming back time and again with the same pain, despite our best efforts to help them. This can be frustrating for the patient and the provider. I know many providers who "tune out" when these patients start discussing their pain.
I've been thinking about people's perception of pain all week. I had some minor cartilage repair in my wrist that turned out to be a more extensive surgery than anticipated. I've had great pain control post-operatively, but it reminded me that this isn't always the case.
Seven years ago, I had laproscopic surgery and was in excruciating agony when I came out of anesthesia. I was reporting a 10 out of 10 on the pain scale during recovery, but the nurses just brushed me off, telling me that I had no pain tolerance and to go home and take my painkillers. "Don't tell a woman who has given birth without pain medication or an epidural that she has no pain tolerance," I thought.
Eighteen awful hours later I had a huge hematoma. It looked like a bikini bottom made from bruising. When I saw the surgeon, he was appalled that no one had called him about my unusual pain. If they had alerted him, he might have been able to stop the internal bleeding and prevent the hematoma from growing so large.
Managing pain is a huge part of my profession, and I see such extremes in the way people respond to pain. I've seen women roll onto the labor floor laughing and chatting. "Well, we know she's not in labor," says the nurse. And the nurse is right, most of the time. But every now and then we are wrong, and the mom is in active labor with advanced cervical dilatation.
More often we see the moaning, cursing, writhing women, not in active labor yet, but in obvious pain. The puzzle, as an obstetric provider, is how to best get her comfortable before active labor starts. Who am I to say that a patient's early labor pain isn't as intense as another's active labor pain? A patient's pain is what she says it is.
I also see many women complaining of chronic dysmenorrhea or dyspareunia, often complex and difficult to manage disorders. Typical pain management strategies can be ineffective for these women and they are often frustrated, having been written off by practitioners as hypochondriacs or drug seekers. Sometimes patients complaining of chronic pain are drug seeking, but isn't addiction a form of pain as well?
I try to keep listening when my patients tell my about their pain, then work on developing a plan with the patient to best meet their needs and get them out of pain as quickly as possible. This may include referral to a specialist or to pain management.
Pain can be debilitating and can be a cause, as well as an effect, of depression. In my experience, pain is usually a sign that something is wrong, somewhere. If we listen well, ignoring our own judgments and preconceived notions, we may actually be able help relieve the pain.
Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.
Saturday, October 13, 2012
Perry D. Clark says that a steroid injected near his spine to relieve persistent back pain instead left him "way, way worse." Twelve years later, he still suffers from continuous stinging in his legs and feet and occasional bursts of excruciating pain.
"It's like somebody took a hot poker out of a fire and jammed it into my foot for two or three seconds," said Mr. Clark, a retired media professional from Petoskey, Mich.
The outbreak of fungal meningitis that has killed 14 people and sickened 156 more has focused attention on the risk of infection from spinal injections. But the same injections have also long been linked to other rare but devastating complications, including nerve damage, paralysis and strokes.
The Food and Drug Administration is already reviewing how to reduce the risk of "catastrophic neurological injuries" from the injections, said Dr. James P. Rathmell, chief of pain medicine at Massachusetts General Hospital, who is involved in the review. The risk of infections did not even factor into the review, though it will now, he said.
The meningitis outbreak is raising new questions about the steroid spinal injections, which are given to millions of Americans. Use has mushroomed even as clinical trials have found only modest evidence that the injections help. Moreover, the steroids, while approved for uses like relieving inflammation in joints, have not been approved by the F.D.A. for epidural injections, next to the spinal cord.
"Not only were these people killed, but there was no ethical reason to give this treatment," said Dr. William Landau, a professor of neurology at Washington University in St. Louis, referring to those who died of meningitis.
Many pain specialists dispute that conclusion. Doctors are allowed to, and often do, prescribe drugs for unapproved uses, they say, and steroids have been used to treat back pain for decades. They contend the injections can be less risky than narcotics or surgery.
Even Dr. Rathmell, who has been calling attention to the complications, said they occur in only about one in 10,000 cases. "In the right individuals, they are a tremendous help," he said of the injections.
Kenny Alhadeff, the producer of the Broadway musical "Memphis," says he is one of them. Several years ago, he said, he had such severe back pain that "I could barely get into a car." His first injection brought immediate relief. Now, after a few years of periodic injections, he is pain-free.
But some defenders of the practice concede that injections are overused. They are most useful for people with herniated disks and pain radiating into the legs or arms. But a study published in the journal Spine in 2007 found that fewer than half of the injections given were for these conditions.
"We are doing too many of these, and many of those don't meet the proper criteria," said Dr. Laxmaiah Manchikanti, who runs a pain clinic in Paducah, Ky., and is chairman of the American Society of Interventional Pain Physicians. He also said that about 20 percent of doctors who perform the procedures were not adequately trained.
Dr. Manchikanti said his own review of Medicare records found an increase of nearly 160 percent in the number of injections from 2000 to 2010.
The increased use is driven by the aging of the population, the desperation of patients and the desire of physicians to help — and there are financial incentives. Medicare and private insurers pay $100 to several hundred dollars for an injection, and there are pain clinics that do almost nothing but injections.
Dr. Richard Deyo, a professor of family medicine at Oregon Health and Science University, said that despite the increase in injections and other aggressive treatments, surveys and Social Security disability records suggest that "people with back pain are reporting more functional limitations and work limitation, rather than less."
Evidence on the effectiveness varies by the condition being treated, the drug used and the injection technique.
A review last year by Washington State, which was considering whether to pay for such procedures, found that for one set of circumstances, there were seven clinical trials that showed the injections were helpful, another seven that found them no better or even worse than a placebo, and three with unclear results.
The state agency decided that the evidence was strong enough to justify paying for injections under certain circumstances.
The serious complications, while extremely rare, are more noticeable because of the explosive growth in the number of injections. In one anonymous survey, 287 pain physicians reported 78 serious complications, including 13 deaths, among their patients.
The injections are made into the epidural space just outside the spinal column. This is the same site used in numbing the pain of childbirth, though women in labor receive an infusion of a local anesthetic, not an injection of a steroid.
But the needle can sometimes go astray, putting the drug into the spinal fluid or arteries, causing nerve damage, hemorrhages and death to nerves by depriving them of oxygen. Many doctors use imaging and fluorescent dye to position the needle, but even that technique is not foolproof.
Another complication is arachnoiditis, an inflammation of a membrane surrounding the nerves of the spinal cord that is marked by pain, nerve damage and bowel and bladder dysfunction. Mr. Clark who said he has this condition, uses a catheter to urinate.
The F.D.A. review is focusing on developing best practices for injection techniques with the aim of reducing the risk of injury.
Some doctors are turning to steroids that are free of preservatives, which may damage nerves, and particles, which may clog tiny blood vessels feeding the spinal cord.
But such products in general are not made by drug manufacturers, causing doctors to turn to compounding pharmacies, which are lightly regulated. One of them, the New England Compounding Center, supplied a contaminated drug — called methylprednisolone acetate — that is suspected of causing the fungal meningitis outbreak.
Moreover, the particle-free steroids may not provide lasting relief, said Dr. Christopher Gharibo, an associate professor of anesthesiology and orthopedics at New York University.
Last year, the label for the steroid Kenalog, made by Bristol-Myers Squibb, was changed to say that epidural injection was not recommended. But the label for Pfizer's Depo-Medrol, the brand name version of methylprednisolone acetate, does not have such a warning.
A Pfizer spokesman said the company did not condone the epidural use of Depo-Medrol.
Dennis J. Capolongo, who runs an advocacy group called the End Depo Now Campaign, says the lack of warning is inexplicable.
A former photojournalist in Washington, Mr. Capolongo said an epidural injection of Depo-Medrol to treat hip pain in 2001 inflamed his nerves, leaving him hospitalized for weeks and bedridden for two years. The pain, while no longer so intense, is not completely gone.
"There are nights I cry myself to bed," he said.
Friday, October 12, 2012
Wednesday, October 10, 2012
Contaminated drug draws attention to steroid injection procedure Physicians divided on value of low-back steroid injections - The Boston Globe
Monday, October 08, 2012
It was the first estimate of the potential scope of the meningitis outbreak, which has been traced by federal and state investigators to three lots of methylprednisolone acetate injections produced by New England Compounding Center. Some 105 people in nine states have been sickened by fungal meningitis, said Curtis Allen, a spokesman for the Centers for Disease Control and Prevention.
Tennessee, Virginia, Indiana, Maryland and Michigan reported new cases. Tennessee—with 35 cases, the most of any state—also reported an additional death, its fourth, according to the CDC.
Investigators from the U.S. Food and Drug Administration and state officials are probing the Framingham, Mass., facility where NECC made the 17,676 potentially tainted steroid injections, which were then shipped to 75 clinics in 23 states, according to federal and state officials.
A CDC spokesman said it isn't possible to know how many cases there will be. The CDC and state health officials scrambled last week and over the weekend to track down patients who received the shots to see if they had been sick and to warn them to watch for possible symptoms.
The numbers of cases are rising sharply now not necessarily because people are continuing to get sick, but because investigators are pinpointing more illnesses among those who already received the injections of methylprednisolone acetate for relief of back and neck pain.
The injections were given between July and September. So far, those who have been infected developed symptoms between one and four weeks after receiving their injections.
"There's no evidence that new infections are occurring at a more rapid rate," said John Jernigan, medical epidemiologist at the CDC who is involved in the investigation.
It is too early to know how many people ultimately will be affected. Federal and state investigators must determine how many people received potentially contaminated injections, then track down each one. They must then confirm that those who have subsequently become ill actually had fungal meningitis and not another disease. There are "too many variables to speculate on the number of possible cases," said a CDC spokesman.
The FDA had already advised medical professionals last week not to use NECC-made products.The compounding pharmacy that produced the injections in question issued a recall Saturday of all products made at its compounding center. "This action is being taken out of an abundance of caution due to the potential risk of contamination," NECC said in a statement. The company has said it is cooperating with investigators.
Meningitis is a potentially deadly inflammation of the brain or central nervous system. It is usually caused by viruses or bacteria, but can also be brought on by fungi. The two fungi found thus far in some patients—known as aspergillus and exserohilum—are commonly found in the air and soil.
The fungal form of meningitis is particularly difficult to diagnose because the symptoms can be vague and mild initially, including fever, headache, nausea and stiffness of the neck, according to the CDC. People with fungal meningitis can also experience dizziness and confusion. Several of the patients in the current outbreak have had strokes.
Most of the people who have been sickened had normal immune systems, Dr. Jernigan said, meaning they weren't at particular risk of infections. While the investigation into how patients became infected is ongoing, there is some evidence to suggest that the fungi in the medication penetrated the lining protecting the central nervous system after being injected epidurally, Dr. Jernigan said.
While the fungi aren't harmful in the environment, they can become deadly when they flourish in a medication and are then injected directly into a part of the body that should not have germs, Dr. Jernigan said.
Ms. Reed underwent an autopsy; the lawyer said he didn't yet know the results.One possible victim, 56-year-old Tennessee resident Diana Reed, died Wednesday; she got meningitis after receiving steroid injections, says a lawyer for her family. She had received the injections at a facility that has since been closed because of a meningitis outbreak, according to its Web site.
The outbreak has drawn renewed attention to the little-regulated world of compounding pharmacies. The FDA is hampered by federal law and conflicting federal court decisions over its authority to regulate compounding pharmacies. Current and former senior FDA officials said the agency has sought greater authority over the past decade, but so far has been stymied.
Government officials say the FDA is especially concerned about large compounding pharmacies that send out large amounts of drugs across the country—as opposed to a small pharmacy that may compound a medication three or four times a year.
In particular, the agency hasn't been able to take the normal steps it would take to ensure the safety of a drug produced at a compounding pharmacy. That includes requiring and evaluating clinical trials, and inspection of manufacturing facilities.
Attempts in the past by the agency to regulate more strenuously have been challenged in court.
Pain has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not.
It has no future but itself,
Its infinite realms contain
Its past, enlightened to perceive
New periods of pain.
Thursday, October 04, 2012
Painkilling chemicals with no side effects found in black mamba venom | Not Exactly Rocket Science | Discover Magazine
The black mamba has a fearful reputation, and it's easy to see why. It can move at around 12.5 miles (20 kilometres) per hour, making it one of the world's fastest snakes, if not the fastest. Its body can reach 4.5 metres in length, and it can lift a third of that off the ground. That would give you an almost eye-level view of the disturbingly black mouth from which it gets its name. And inside that mouth, two short fangs deliver one of the most potent and fast-acting venoms of any land snake.
Combined with its reputation for aggression (at least when cornered) and you've got a big, intimidating, deadly, ornery serpent that can probably outrun you. It's not the most obvious place to go looking for painkillers.
But among the cocktail of chemicals in the black mamba's venom, Sylvie Diochot and Anne Baron from the CNRS have found a new class of molecules that can relieve pain as effectively as morphine, and without any toxic side effects. They've named them mambalgins.
Diochot and Baron started by searching animal venoms for chemicals that could block ASICs – not the shoe manufacturer, but a group of pain-inducing proteins called acid-sensing ion channels. They're like miniature gates, which dot the surface of neurons.
When we're injured, our damaged cells release an "inflammatory soup" of chemicals that triggers feelings of pain. Among the first of these harbingers are simple protons – positively charged particles that make the local tissues more acidic. The ASICs detect and respond to protons by opening up, allowing positive ions to flood inside, and causing the neurons to fire. They're warning systems that tell our bodies that something is wrong.
Diochot and Baron found two peptides (short proteins) from black mamba venom that block ASICs—mambalgin-1 and mambalgin-2. They act as padlocks that latch onto the closed proteins and stop them from opening, even when surrounded by protons. And they have characteristics that are almost too good to be true.
They work quickly and effectively against every type of ASIC found in our nervous system. As painkillers, they're as potent as morphine. They'll numb the sharp pain of a burn, as well as the dull throb of an inflamed limb. They're incredibly specific: they don't stop neurons from firing more generally, and they don't block any of the other gate-keeping proteins found in these cells. And unlike other similarly shaped proteins, they don't have any toxic effects, such as paralysis, convulsions or breathing difficulties. (The list of side effects that Diochot and Baron checked for, and saw no sign of, includes "death"; good to know.)
Animal venoms, of course, are better known for causing pain rather than dulling it. Many work through ASICs too. The Texas coral snake, for example, has venom that causes excruciating pain, thanks to a toxin called MitTx that makes ASICs much more sensitive to protons. The Trinidad chevron tarantula uses a different toxin that locks ASICs in their open state, allowing them to constantly trigger sensations of pain.
So why does the black mamba have potent painkillers in its arsenal? No one knows, but it's not alone. "Cobra venom, and more recently the corresponding purified cobrotoxin, have been used for instance for the control of pain in traditional Chinese medicine," says Baron. But cobrotoxin can also paralyse muscles; mambalgins, on the other hand, kill pain and little else.
The team is now exploring the properties of mambalgins even further. They're years away from turning these proteins into usable painkillers, but they've already been granted a patent, and found an industrial partner –a company called Theralpha that specializes in treatments for pain.
In the meantime, the mambalgins are already teaching us more about the basis of pain. In the central nervous system – the brain and spine –they mainly work by blocking a specific ASIC known as ASIC1a. If mice don't have this protein, mambalgins do nothing for them.
But it's a different story in the peripheral nervous system – the nerves that branch through the rest of our body. There, mambalgins are more than capable of relieving pain, even in mice that lack ASIC1a. That's because they work by blocking a different ASIC known as ASIC1b, whose role in pain has been unclear until now.
So, the black mamba has provided us with two leads in the quest for a better painkiller. Its venom has helped to identify proteins that could be targeted to soothe pain in the central and peripheral nervous systems, and it has given us two chemicals that could potentially do the job.
Monday, October 01, 2012
Is your relentless lower back pain more or less unbearable than my crushing headache? Problem is, pain is maddeningly subjective. In this short, producer Tim Howard introduces us to three attempts to put a number on pain in the hopes that we can truly understand the suffering of another.
We begin with entomologist Justin Schmidt's globe-trotting adventure to plot the relative nastiness of insect bites and stings. Then, Paula Michaels, a professor in the History of Medicine at the University of Iowa, brings us back to 1948, to a well-intentioned but ultimately misguided attempt to demystify the pain of childbirth. And we end with a very modern, very personal struggle for understanding as non-fiction writer Eula Biss tries to rate her own chronic pain.
WPF was established to provide educational resources that inform patients, medical professionals and the general public about the latest clinical advances, management and treatment options for pain. WPF mission is to:
* Foster professional standards among pain specialist professionals and industry
* Provide for communication among all of those affected by pain, including the general public, medical professionals and interested parties in government, business, and education
* Provide for education through the development of resources, publishing of articles and books, professional papers, and the sponsoring of seminars and conferences
* Stimulate the continued research, and advocacy by providing a forum for the raising of new ideas and an effective mechanism for dialog on these issues
Study uncovers simple way of predicting severe pain following breast cancer surgery - University of Warwick
Women having surgery for breast cancer are up to three times more likely to have severe pain in the first week after surgery if they suffer from other painful conditions, such as arthritis, low back pain and migraine, according to a Cancer Research UK study published in the British Journal of Cancer.
Of the women surveyed, 41 per cent reported moderate to severe pain at rest, and 50 per cent on movement, one week after their surgery. Most patients having breast cancer surgery are discharged home by this time.
Psychological state was also important, with women who felt more optimistic before their surgery found to suffer lower intensity pain in the week afterwards. While those who had more extensive surgery to remove their lymph nodes were prone to more severe pain in the week after surgery.
The findings could be used as a simple way of identifying before surgery which breast cancer patients might benefit from extra pain relief or support, according to the researchers, based at the Universities of Warwick, Aberdeen and Dundee.
Study leader Dr Julie Bruce, from the University of Warwick, said: "Women generally receive the same advice and treatment for pain relief following breast cancer surgery, but this study shows how factors such as a patient's psychological state and whether they have a prior history of chronic pain can really affect their recovery.
"Importantly, doctors may be able to use this as a way of identifying women who need more intensive pain relief immediately after surgery. These results are particularly important because research shows that severe pain in the first week after surgery can significantly delay recovery."
Three hundred and thirty-eight patients from across North Scotland took part in the study. Each patient was asked to fill out detailed questionnaires before surgery, asking about their general health, how they were feeling and whether they had any existing pain. A week after surgery, patients were contacted by a member of the research team and asked specific questions about the amount and type of any pain they were experiencing and whether they had taken pain killers.
Catherine Harkin, a GP from Edinburgh, was diagnosed with breast cancer six years ago, aged 49. Her cancer was discovered by chance after she had a mammogram to investigate a large benign cyst in her left breast, revealing a small 1cm tumour in the opposite breast. After several attempts at removing the tumour surgically, she opted to have a mastectomy with full breast reconstruction.
She remembers what it was like afterwards: "I'd been very against having a mastectomy, but in some ways it was a relief because it meant an end to the rollercoaster of having lumps removed and then waiting for the results. In total I spent five days in hospital, after which I was given anti-inflammatory drugs and sent home. The drugs really helped with the pain, but it was a long time before I felt myself again and that's something that no one can really prepare you for."
"For me the worst part was not feeling in control of my pain, so it's really interesting to hear about research into ways of finding out in advance which women are likely to need extra help to recover from their surgery. I think this could really improve people's quality of life in the long term.
"I still suffer some after-effects from my surgery, but one of the real turning points for me was earlier this year, when I decided to join a local Dragon Boat paddling team set up especially for breast cancer survivors and their friends and family. It's great exercise and really helped me get my body confidence back and realise that, while I may not be as strong as I was, there are still lots of activities I can get involved in."
Liz Woolf, head of Cancer Research UK's information website, CancerHelp UK, said: "As well as being extremely important for a patient's comfort, post operative pain levels can have a significant impact on their treatment – for example it can increase risk of complications because they are unable to move as much as they should. It may also lead to them missing appointments, or being unable to carry out important postoperative exercises which aid their recovery. This is why it's so important to be able to identify in advance those who may be in need of extra pain relief or support.
"Earlier studies suggest that up to half of women who undergo surgery for breast cancer may continue to suffer from pain for up to a year afterwards. This study is ongoing and it will be helpful to see what impact things like having a history of chronic pain and psychological state may have on longer term pain after surgery."