Friday, December 25, 2015

Ending chronic pain with new drug therapy | EurekAlert! Science News

A brain region controlling whether we feel happy or sad, as well as addiction, is remodeled by chronic pain, reports a new Northwestern Medicine study. 

And in a significant breakthrough for the millions of Americans suffering from chronic pain, scientists have developed a new treatment strategy that restores this region and dramatically lessens pain symptoms in an animal model. 

The new treatment combines two FDA-approved drugs: a Parkinson's drug, L-dopa, and a non-steroidal anti-inflammatory drug. The combined drugs target brain circuits in the nucleus accumbens and completely eliminate chronic pain behavior when administered to rodents with chronic pain. The key is administering the drugs together and shortly after an injury. 

As a result of the study's findings, the scientists are pursuing a clinical trial. The treatment has the potential to prevent chronic pain if used early enough after injury, the scientists said.

The study will be published December 21 in Nature Neuroscience

'It was surprising to us that chronic pain actually rewires the part of the brain controlling whether you feel happy or sad," said corresponding author D. James Surmeier, chair of physiology at Northwestern University Feinberg School of Medicine. "By understanding what was causing these changes, we were able to design a corrective therapy that worked remarkably well in the models. The question now is whether it will work in humans." 

"The study shows you can think of chronic pain as the brain getting addicted to pain," said A. Vania Apkarian, also a corresponding author and a professor of physiology at Feinberg. "The brain circuit that has to do with addiction has gotten involved in the pain process itself."

A group of neurons thought to be responsible for negative emotions became hyper-excitable and more strongly connected with other regions of the brain linked to feeling bad within days after an injury that triggers chronic pain behavior, the study showed. It went on to show this change was triggered by a drop in dopamine, a critical neurotransmitter.

When scientists administered the non-steroidal anti-inflammatory drug and L-dopa, which raises dopamine levels, the changes in the brain were reversed and the animals' chronic pain behavior stopped. 

"These results establish chronic pain cannot be viewed as a purely sensory phenomenon but instead is closely related to emotions," Apkarian said.

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Patient Care: Doctors Can Ease Patient Suffering By Asking 'What's The Worst Part Of This?'

Modern medicine in the Western world relies primarily on treating existing illnesses with drugs or unnecessary procedures and a quick turnaround in the doctor's office in order to treat more people. In the midst of all this hectic chaos, doctors will skim over a patient's record and medical history, get a mere glimpse into their emotional lives, and leave mental health care to the side.

But Dr. Ronald Epstein, a University of Rochester professor, wants to change the way doctors approach their patients. Suffering is seen in all corners of hospitals and medical centers — from the emotional pain of a mother who just lost an unborn baby to an older man facing a terminal illness, yet doctors often don't address it.

In a new essay published in the Journal of the American Medical Association, Epstein and a co-author, oncologist Anthony Back of the University of Washington, reviewed medical literature on the ways doctors approach suffering. They found that an approach to suffering is rarely discussed in the medical world, and that this needs to change.

"Physicians can have a pivotal role in addressing suffering if they can expand how they work with patients," the authors wrote. "Some people can do this instinctively, but most physicians need training in how to respond to suffering — yet this kind of instruction is painfully lacking."

Epstein and Back note that physicians can improve their approach by listening to the patient and learning about his/her experience. In addition to the typical "diagnosing and treating," the authors argue that doctors should also "turn toward" the patient, and recognize their suffering. They can do that by asking questions like, "What's the worst part of this for you?" Sometimes an acknowledgment that their pain is real, and that it matters to someone, is all a patient needs to open up.

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Monday, December 21, 2015

CDC Guideline for Prescribing Opioids for Chronic Pain (Guideline) -

The Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (HHS) announces the opening of a docket to obtain public comment on the draft CDC Guideline for Prescribing Opioids for Chronic Pain (Guideline). The Guideline provides recommendations regarding initiation or continuation of opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessment of risk and addressing harms of opioid use. The Guideline is intended to be used by primary care providers (e.g., family physicians or internists) who are treating patients with chronic pain (i.e., pain lasting longer than 3 months or past the time of normal tissue healing) in outpatient settings. The draft Guideline is intended to apply to patients aged 18 years of age or older with chronic pain outside of palliative and end-of-life care. The Guideline is not intended to apply to patients in treatment for active cancer. The Guideline is not a federal regulation; adherence to the Guideline will be voluntary.


CDC developed the draft Guideline to provide recommendations about opioid prescribing for primary care providers who are treating adult patients with chronic pain in outpatient settings, outside of active cancer treatment, palliative care, and end-of-life care. The draft Guideline summarizes scientific knowledge about the effectiveness and risks of long-term opioid therapy, and provides recommendations for when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. The draft Guideline identifies important gaps in the literature where further research is needed.

To develop the recommendations, CDC conducted a systematic review on benefits and harms of opioids and developed the draft Guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. CDC drafted recommendations and consulted with experts on the evidence to inform the recommendations. CDC hosted webinars in September 2015 and also provided opportunities for stakeholder and peer review of the draft Guideline. The Guideline is not a federal regulation; adherence to the Guideline will be voluntary. For additional information on prescription drug overdose, please visit

Supporting and Related Material in the Docket

The docket contains the following supporting and related materials to help inform public comment: The Guideline; the Clinical Evidence Review Appendix; the Contextual Evidence Review Appendix; and three documents that comprise the Comment Summaries and CDC Responses (Constituent Comment Summary, Peer Review Summary, and Stakeholder Review Group Summary). The Clinical Evidence Review Appendix and the Contextual Evidence Review Appendix include primary evidence, studies, and data tables that were used by CDC to develop the recommendations in the Guideline. The Constituent Comment Summary reflects input obtained in response to webinars hosted on September 16 and September 17, 2015, during which CDC shared an overview of the development process and draft recommendation statements. The Stakeholder Review Group Summary also reflects input obtained from stakeholders (comprised of professional and community organizations) following their review of a prior draft of the Guideline. Finally, the Peer Review Summary reflects input obtained from three scientific peer reviewers following their review of a draft of the full Guideline, along with a summary of comments received and CDC responses.!documentDetail;D=CDC-2015-0112-0001

Sunday, December 13, 2015

NYTimes: Where Is the Cure for the Migraine?

At least 36 million Americans suffer from migraines, and while more and more medical professionals are on the case, they have never found satisfactory answers for why the pain starts, let alone how to make it end.

Lately, it seems I can't attend a gathering of friends without at least one complaining about headaches, and another offering advice: It's your glasses, your diet or, the old standby, your stress level. Regarding the latter, let me say that a friend and I once spent four days at a spa, doing nothing but exercise classes and beauty treatments, and we were still popping pills for our pounding heads nonstop.

Over the last few decades, migraines (intensely painful headaches that make it difficult to function and are often accompanied by other symptoms like vomiting) have become big business. Billions of dollars are spent annually on over-the-counter and prescription remedies, as well as visits to the increasing number of specialized clinics and hospital departments around the country. Even dermatologists, dentists and non-Western holistic practitioners are getting in on the action.

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Friday, December 04, 2015

Woman who has never felt pain experiences it for the first time | New Scientist

A woman born incapable of feeling pain has been hurt for the first time – thanks to a drug normally prescribed for opioid overdoses. She was burned with a laser, and quite liked the experience.

The breakthrough may lead to powerful new ways to treat painful conditions such as arthritis.

Only a handful people around the world are born unable to feel pain. These individuals can often suffer a range of injuries when they are young. Babies with the condition tend to chew their fingers, toes and lips until they bleed, and toddlers can suffer an increased range of knocks, tumbles and encounters with sharp or hot objects.

The disorder is caused by a rare genetic mutation that results in a lack of ion channels that transport sodium across sensory nerves. Without these channels, known as Nav1.7 channels, nerve cells are unable to communicate pain. Researchers quickly sought to make compounds that blocked Nav1.7 channels, thinking they might be able to block pain in people without the disorder.

"It looked like a fantastic drug target," says John Wood at University College London. "Pharma companies went bananas and made lots of drugs." But while a few compounds saw some success, none brought about the total pain loss seen in people who lack the channel naturally.

To find out why, Wood and his colleagues studied mice that had been genetically modified to lack Nav1.7. These animals don't feel pain, either – they show no reaction when their tails are exposed to extreme hot or cold temperatures, for example.

A closer analysis of the rodents' nerves showed that mice lacking Nav1.7 had a huge increase in the expression of genes responsible for opioid peptides, the body's natural painkiller. The mice seem to be making more of these pain-relieving peptides, which might explain why people lacking the channel don't feel pain, either.

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Sunday, November 29, 2015

The end of migraines is close: A new drug could stop debilitating headaches before they start -

The 63-year-old chief executive couldn't do his job. He had been crippled by migraine headaches throughout his adult life and was in the middle of a new string of attacks. "I have but a little moment in the morning in which I can either read, write or think," he wrote to a friend. After that, he had to shut himself up in a dark room until night. So President Thomas Jefferson, in the early spring of 1807, during his second term in office, was incapacitated every afternoon by the most common neurological disability in the world.

The co-author of the Declaration of Independence never vanquished what he called his "periodical head-ach," although his attacks appear to have lessened after 1808. Two centuries later 36 million American migraine sufferers grapple with the pain the president felt. Like Jefferson, who often treated himself with a concoction brewed from tree bark that contained quinine, they try different therapies, ranging from heart drugs to yoga to herbal remedies. Their quest goes on because modern medicine, repeatedly baffled in attempts to find the cause of migraine, has struggled to provide reliable relief.

Now a new chapter in the long and often curious history of migraine is being written. Neurologists believe they have identified a hypersensitive nerve system that triggers the pain and are in the final stages of testing medicines that soothe its overly active cells. These are the first ever drugs specifically designed to prevent the crippling headaches before they start, and they could be approved by the U.S. Food and Drug Administration next year. If they deliver on the promise they have shown in studies conducted so far, which have involved around 1,300 patients, millions of headaches may never happen.

"It completely changes the paradigm of how we treat migraine," says David Dodick, a neurologist at the Mayo Clinic's campus in Arizona and president of the International Headache Society. Whereas there are migraine-specific drugs that do a good job stopping attacks after they start, the holy grail for both patients and doctors has been prevention.

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Tuesday, November 17, 2015

'War on drugs means millions are dying in pain' -

Ruth Dreifuss is former President of Switzerland and Minister of Home Affairs. Anand Grover is former U.N. special rapporteur on the Right to Health, India. Michel Kazatchkine is former executive director of the Global Fund to fight AIDS, Tuberculosis and Malaria. The opinions expressed in this commentary are theirs.

Millions of people are dying in pain because of the repressive stance the world has taken on drugs. That's because states are obsessed by the fear that people will use controlled medicines such as morphine as recreational drugs, thereby neglecting their important medical uses. 

Where you live determines whether you will be able to access to controlled medicines, particularly opiates, when confronting an acute terminal, chronic or painful illness. Ninety-two per cent of the world's morphine is consumed by only 17% of the world's population, primarily the United States and Europe. Seventy--five percent of the world's people in need do not have access to pain relieving medicine. 

In other words, most of the global population, outside the affluent countries in the North, dying in pain, including from terminal cancers, do so in the absence of dignified palliative care. 

This is a horrendous situation for millions of patients and families. Essential medicines such as morphine, taken for granted as the standard relief of severe pain in the global North, do not enjoy the same status in the global South. Quite the opposite. Chances are, if a person living in any developing country ends up with an illness associated with extreme and avoidable pain, they will endure the pain simply because their government has created obstacles to morphine use in hospitals.

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Wednesday, November 11, 2015

CDC assists in heroin, fentanyl investigation in Greater Cincinnati | Local News - WLWT Home

Cincinnati - The heroin problem in Ohio is now getting attention from the Centers for Disease Control and Prevention.

The federal agency has been asked to come here and help find answers to a disturbing new trend that is costing lives – heroin mixed with a prescription pain medication.

State and local health experts said they are hoping what they learn during meetings Tuesday at the Hamilton County Board of Health will help them tackle the heroin crisis.

The CDC has a six-person team on the ground in Ohio, meeting with the Ohio Department of Health, and the Hamilton County Health Department.

Officials said they're focusing on a particular part of the heroin crisis – the number of deaths related to fentanyl.

Authorities said fentanyl is a prescription pain medication that has been showing up in heroin. The big mystery is why it's being mixed with heroin.

"We don't fully understand the fentanyl situation, and that's one of the reasons we wanted their help with this," said Dr. Mary DiOrio, the medical director of the Ohio Department of Health.

ODH asked the CDC to help look into the problem.

"We think that some people don't even know that it's in what they're injecting so we're trying to fully understand what people do and don't know so we can target the messages appropriately so we can protect lives," DiOrio said.

We've seen the deadly consequences of fentanyl in Greater Cincinnati.

Kenneth Gentry is facing charges in the overdose death of an Arlington Heights man earlier this year that was blamed on fentanyl.

Authorities said the fentanyl problem causes only a fraction of the deaths heroin alone causes – but it's a problem that's growing quickly.

Authorities said heroin deaths increased 18 percent in Ohio last year to a total of nearly 2,500. In 2014 there were about 500 deaths linked to fentanyl – an increase of nearly 600 percent from the year before.

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How Doctors Helped Drive the Addiction Crisis - The New York Times

There has been an alarming and steady increase in the mortality rate of middle-aged white Americans since 1999, according to a study published last week. This increase — half a percent annually — contrasts starkly with decreasing death rates in all other age and ethnic groups and with middle-aged people in other developed countries.

So what is killing middle-aged white Americans? Much of the excess death is attributable to suicide and drug and alcohol poisonings. Opioid painkillers like OxyContin prescribed by physicians contribute significantly to these drug overdoses.

Thus, it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality. The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.

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Monday, November 09, 2015

Phantom pain: It feels real even though it’s all in the brain - The Washington Post

Several years ago, Peggy Chenoweth began having excruciating cramping in her ankle. It felt severely sprained and as if her toe were twisting to the point where it was being ripped off her foot.

"The pain is right here," she told an orthopedic surgeon, "in my ankle and foot." But the 41-year-old Gainesville, Va., resident no longer had that ankle and foot. Her leg had been amputated below the knee after a large piece of computer equipment fell off a cart, crushed her foot and caused nerve damage. Further, she insisted that since the amputation, she could feel her missing toes move.

Chenoweth's surgeon knew exactly what was going on: phantom pain.

Lynn Webster, an anesthesiologist and past president of the American Academy of Pain Medicine, explains the phenomenon: "With 'phantom pain,' nerves that transmitted information from the brain to the now-missing body part continue to send impulses, which relay the message of pain."

It feels as if the removed part is still there and hurting, but pain is actually in the brain. The sensation ranges from annoying itching to red-hot burning.

Physicians wrote about phantom pain as early as the 1860s, but U.S. research on this condition has increased recently, spurred by the surge of amputees returning from warfare in Iraq and Afghanistan and by increasing rates of diabetes. (Since 2003, nearly 1,650 service members have lost limbs, according to the Congressional Research Service. In 2010, about 73,000 amputations were performed on diabetics in the United States, according to the Centers for Disease Control and Prevention.)

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Saturday, November 07, 2015

Gimlet Media | Podcast #42 Blind Spot

SRUTHI: Okay. So this is a story about a woman whose body started breaking down in increasingly weird ways. It's as if her body turns into a David Lynch movie, and there's nothing she can do to understand it, and nothing she can do to convince people it's real. For the purposes of the story, we will call this woman "Hope." And it all starts last year. Hope is 29, living in the suburbs of Pittsburgh. And one beautiful winter morning…

HOPE: I was walking at a soccer field that's near my house when I first noticed, "Well that feels weird, my eye feels such a weird nagging eye pressure. Almost like my eye was bulging a little bit, from the inside out.

SRUTHI: It's so bad that she feels as if people can see it, like it's bulging so much, this one eye.

PJ: Can she, like if she stands in front of the bathroom mirror and stares at her face, can she feel like she can see her eye bulging?

SRUTHI: No. So it goes on for a couple of weeks, doesn't go away. And then she says you know what, I'm just gonna have this looked at.

HOPE: I actually just went to the eye doctor that's in Walmart, and she looked at my eye, and she didn't find anything at all wrong with the eye. The eye was perfectly healthy and normal.

SRUTHI: This bulging feeling, it goes on for a whole month. And then one day, she wakes up and it's gone.

HOPE: This would, be I should say this, this would be something in my life that I would probably never give a second thought to, this mild eye problem that I had for a month, if… what happened next hadn't happened.

SRUTHI: It's evening. Hope is working. She's a wedding photographer, and she's setting up room in her house where she can meet clients.

HOPE: And all of the sudden I stood up, and I couldn't see out of my right eye. I thought, "Oh my gosh, am I having a stroke?" I had field of vision in like three-quarters of the eye, but the one quarter was completely covered by this weird zigzag freaky thing. It's almost like a kaleidoscope when you were a kid, and you used to hold up a kaleidoscope to your eye and it would… it would like shine and shimmer, like a piece of mirrored paper in there. So I actually remember waking up my sister, and she said "what are you talking about?" and I said "I can't see out of my eye, I'm freaking out."

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Saturday, October 31, 2015

At first, this man thought he had food poisoning. It turned out to be something far worse. - The Washington Post

Jeffrey Sank always knew when he was going to have an attack: Its onset was signaled by the same kind of uneasy, "uh-oh" feeling that portends an impending cold.

But Sank's problem wasn't in his head — it was in his gut. And when he felt the initial abdominal pangs, he knew that he had about 12 hours before he was miserable, or at worst incapacitated, for the next day or two.

"It almost felt like I'd done 1,000 sit-ups or been punched in the gut 100 times," said the digital media specialist, 43, who lives in the District. At first the attacks were intermittent. But after several months the pain, centered in the right upper quadrant where the liver and gallbladder are located, increased in severity and frequency.

For nearly a year, Sank, with the help of his stepmother, a physician, struggled to determine the reason for his pain. He saw multiple doctors, including two gastroenterologists, a kidney specialist and an infectious-disease physician. He underwent workups for reflux disease, a liver disorder, an intestinal blockage and malaria. One doctor suspected he might be faking.

Sank's problem turned out to be none of those things. His diagnosis was partly the result of serendipity: The second gastroenterologist he consulted was familiar with the malady, which is common in other parts of the world but not the United States. To complicate matters, Sank's case did not fit the standard diagnostic criteria.

"It's in the differential [a list of possible disorders suggested by symptoms], but since we never really see it, you don't necessarily think of it," said Montgomery County gastroenterologist William Steinberg. Luckily, something Steinberg had seen two decades earlier on a medical trip to the Middle East resonated when an increasingly desperate Sank consulted him in April 2010.

The first time he suffered stomach pain in June 2009, Sank assumed he had food poisoning. "I really didn't think much about it," he recalled.

When it kept recurring, he consulted his stepmother, Catherine Shaer, a retired pediatrician, for advice. Sank was otherwise healthy, and Shaer agreed that he should see a gastroenterologist.

At his initial appointment in October 2009, the gastroenterologist told Sank he suspected his pain was the result of gallstonesand ordered a sonogram.

The test was memorable: Sank said that during the procedure the technician began acting strangely and then summoned a radiologist. In a somber voice, Sank recalled, the radiologist "told me that there was a huge lesion on my liver and they were going to send me immediately for a CT scan."

The radiologist then told him, Sank recalled, "there was something very serious going on here and that I needed to prepare myself and my family for what I had to deal with." Sank also remembers the specialist saying that his "door was always open."

"I thought I had liver cancer and was going to die," Sank remembered. At the time, his first child was only a few months old.

While waiting for the CT scan, Sank telephoned his stepmother and a friend who is an oncologist. Both told him that they were sure that the growth on his liver, the size of a large strawberry, would turn out to be a benign hemangioma. He had no cancer symptoms, and such tumors are common. A few hours later, Sank, hugely relieved, learned they were right. He didn't have cancer. Nor did he have gallstones. "We were back to square one," he recalled.

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Thursday, October 22, 2015

PA-14-244: Research on Chronic Overlapping Pain Conditions (R01)

Chronic pain affects approximately 100 million Americans and exacts large economic, social and personal costs. It is a major public health challenge that needs to be addressed at multiple levels including the generation of new scientific knowledge that will enhance our understanding of these conditions. Current research efforts in chronic pain conditions have focused on single disorders or types of pain such as neuropathic and inflammatory pain. These research efforts have generated a substantial body of information advancing our discovery and understanding of the underlying mechanisms of pain onset and development, the transition from acute to chronic pain, and promising therapeutic targets for treating acute and chronic pain. Over the past twenty years sporadic reports have documented the presence of more than one chronic pain condition in subjects with pain. Studies have identified overlap between a number of chronic pain conditions, including temporomandibular joint disorder (TMD), fibromyalgia (FM), vulvodynia, functional gastrointestinal disorders such as irritable bowel syndrome (IBS), migraine, and urologic chronic pelvic pain syndromes (UCPPS). These results suggest that chronic pain conditions may not be localized conditions, but may share symptoms and mechanisms that involve a general central nervous system dysfunction as well as disorder-specific symptoms. More recent evidence is supportive of the idea that chronic pain conditions are complex disorders consistent with a biopsychosocial model of pain, and exhibit substantial overlap. Therefore, this may be an opportune time to encourage research efforts that focus, not on single pain conditions, but on subjects with multiple chronic pain disorders.

Chronic pain conditions represent a complex set of painful disorders that lack a firm mechanistic understanding, and are in need of hypothesis-driven research efforts. A new focus on overlapping pain conditions is warranted to develop therapies to prevent and treat these overlapping disorders and to develop approaches to better manage pain that can be disabling. A workshop sponsored by the NIH Pain Consortium was held in the summer of 2012 titled "A Workshop on Chronic Overlapping Pain Conditions". It brought together researchers with expertise in various pain conditions and other relevant expertise to discuss these conditions and to develop a forward-thinking research agenda. The workshop focused on our current understanding of chronic overlapping pain conditions, their etiology, risk factors, mechanisms of disease, outcome measures, and diagnosis. Topics of discussion included epidemiology of chronic overlapping pain conditions, risk factors and mechanisms of disease, leveraging of current data sets, and new scientific approaches incorporating systems biology. The recommendations derived from this workshop have, in part, informed the development of this FOA.

Some of the overlapping pain conditions under consideration include, but are not limited to: chronic headache, migraine headache, temporomandibular joint disorder, generalized pain conditions, functional gastrointestinal disorders such as irritable bowel syndrome, endometriosis, urologic chronic pelvic pain, vulvodynia, fibromyalgia, chronic fatigue syndrome and osteoarthritis.

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IPRP Ontology | Interagency Pain Research Portfolio -The Federal Government's Pain Research Database

The grants in the Federal pain research portfolio were classified using a multi-tiered system. In Tier 1, grants were designated as basic, translational, or clinical. Grants then were coded into 29 scientific topic categories (Tier 2). Following this classification, the Tier 2 categories were organized into 9 overarching themes based on similarity of topic.

The Interagency Pain Research Coordinating Committee (IPRCC)

The Patient Protection and Affordable Care Act (PPACA) includes a number of provisions designed to advance pain research, care, and education, including the creation of the Interagency Pain Research Coordinating Committee (IPRCC) by the Department of Health and Human Services (HHS).  On behalf of HHS, the NIH established the IPRCC to coordinate all pain research efforts within HHS and across other Federal Agencies.  The Committee is composed of seven Federal members and twelve non-Federal members, six drawn from the scientific and medical communities and six members of the public and stakeholder groups. The Department of Health and Human Services Secretary will review the necessity of the Committee at least once every 2 years.

As specified in Section 4305(b) of the Public Law 111-148 ("Affordable Care Act (ACA)") the Committee has been asked to:

  • Develop a summary of advances in pain care research supported or conducted by the Federal agencies relevant to the diagnosis, prevention, and treatment of pain and diseases and disorders associated with pain
  • Identify critical gaps in basic and clinical research on the symptoms and causes of pain
  • Make recommendations to ensure that the activities of the National Institutes of Health and other Federal agencies are free of unnecessary duplication of effort
  • Make recommendations on how best to disseminate information on pain care
  • Make recommendations on how to expand partnerships between public entities and private entities to expand collaborative, cross-cutting research

Sunday, October 18, 2015

How Doctors Take Women's Pain Less Seriously - The Atlantic

Early on a Wednesday morning, I heard an anguished cry—then silence.

I rushed into the bedroom and watched my wife, Rachel, stumble from the bathroom, doubled over, hugging herself in pain.

"Something's wrong," she gasped.

This scared me. Rachel's not the type to sound the alarm over every pinch or twinge. She cut her finger badly once, when we lived in Iowa City, and joked all the way to Mercy Hospital as the rag wrapped around the wound reddened with her blood. Once, hobbled by a training injury in the days before a marathon, she limped across the finish line anyway.

So when I saw Rachel collapse on our bed, her hands grasping and ungrasping like an infant's, I called the ambulance. I gave the dispatcher our address, then helped my wife to the bathroom to vomit.

I don't know how long it took for the ambulance to reach us that Wednesday morning. Pain and panic have a way of distorting time, ballooning it, then compressing it again. But when we heard the sirens wailing somewhere far away, my whole body flooded with relief.

I didn't know our wait was just beginning.

I buzzed the EMTs into our apartment. We answered their questions: When did the pain start? That morning. Where was it on a scale of one to 10, with 10 being worst?

"Eleven," Rachel croaked.

As we loaded into the ambulance, here's what we didn't know: Rachel had an ovarian cyst, a fairly common thing. But it had grown, undetected, until it was so large that it finally weighed her ovary down, twisting the fallopian tube like you'd wring out a sponge. This is called ovarian torsion, and it creates the kind of organ-failure pain few people experience and live to tell about.

"Ovarian torsion represents a true surgical emergency," says an article in the medical journal Case Reports in Emergency Medicine. "High clinical suspicion is important. … Ramifications include ovarian loss, intra-abdominal infection, sepsis, and even death." The best chance of salvaging a torsed ovary is surgery within eight hours of when the pain starts.

There is nothing like witnessing a loved one in deadly agony. Your muscles swell with the blood they need to fight or run. I felt like I could bend iron, tear nylon, through the 10-minute ambulance ride and as we entered the windowless basement hallways of the hospital.

And there we stopped. The intake line was long—a row of cots stretched down the darkened hall. Someone wheeled a gurney out for Rachel. Shaking, she got herself between the sheets, lay down, and officially became a patient.

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Monday, October 12, 2015

Long-term Opioid Therapy Less Effective for Many Women | Psych Central News

A new study shows that women — especially younger women — are less likely than men to find relief from pain with long-term opioid use.

The new study, published in the Journal of Women's Health, found that only one in five women reported low levels of pain and high levels of function with chronic opioid therapy.

In the study, researchers led by Linda LeResche, Sc.D., of the Department of Oral Medicine at the University of Washington School of Dentistry in Seattle, evaluated pain status among chronic opioid therapy users.

The researchers report that young and middle-aged women are at particularly high risk for unfavorable global pain status.

Additionally, young and middle-aged women face "unique risks" from opioid use, such as reduced fertility and potential effects of opioids used during pregnancy on the developing fetus, the researchers reported.

"Given the high rates of chronic opioid use in women, along with evidence of poor relief from pain and concerning risks, particularly in reproductive-aged women, we need more effective and safer options for managing pain in this population," noted Susan G. Kornstein, M.D., editor-in-chief of the Journal of Women's Health, executive director of the Virginia Commonwealth University Institute for Women's Health in Richmond, Virginia, and president of the Academy of Women's Health.

Friday, October 09, 2015

Strong placebo response thwarts painkiller trials : Nature News

Most new painkiller drugs fail in clinical trials — but a growing placebo response may be to blame.

Drug companies have a problem: they are finding it ever harder to get painkillers through clinical trials. But this isn't necessarily because the drugs are getting worse. An extensive analysis of trial data1 has found that responses to sham treatments have become stronger over time, making it harder to prove a drug's advantage over placebo.

The change in reponse to placebo treatments for pain, discovered by researchers in Canada, holds true only for US clinical trials. "We were absolutely floored when we found out," says Jeffrey Mogil, who directs the pain-genetics lab at McGill University in Montreal and led the analysis. Simply being in a US trial and receiving sham treatment now seems to relieve pain almost as effectively as many promising new drugs. Mogil thinks that as US trials get longer, larger and more expensive, they may be enhancing participants' expectations of their effectiveness.

Stronger placebo responses have already been reported for trials of antidepressants and antipsychotics23, triggering debate over whether growing placebo effects are seen in pain trials too. To find out, Mogil and his colleagues examined 84 clinical trials of drugs for the treatment of chronic neuropathic pain (pain which affects the nervous system) published between 1990 and 2013.

Based on patients' ratings of their pain, the effect of trialled drugs in relieving symptoms stayed the same over the 23-year period — but placebo responses rose. In 1996, patients in clinical trials reported that drugs relieved their pain by 27% more than did a placebo. But by 2013, that gap had slipped to just 9%. The phenomenon is driven by 35 US trials; among trials in Europe, Asia and elsewhere, there was no significant change in placebo reponses.The analysis is in press in the journal Pain1.

Only in America

This effect would explain why drug companies have trouble getting new painkillers through trials, notes neuroscientist Fabrizio Benedetti, who studies placebo responses at the University of Turin, Italy. Over the past ten years, he says, more than 90% of potential drugs for treatment of neuropathic and cancer pain have failed at advanced phases of clinical trials.

But the finding that placebo responses are rising only in the United States is the most surprising aspect of the latest analysis. One possible explanation is that direct-to-consumer advertising for drugs — allowed only in the United States and New Zealand — has increased people's expectations of the benefits of drugs, creating stronger placebo effects. But Mogil's results hint at another factor. "Our data suggest that the longer a trial is and the bigger a trial is, the bigger the placebo is going to be," he says.

Longer, bigger US trials probably cost more, and the glamour and gloss of their presentation might indirectly enhance patients' expectations, Mogil speculates. Some larger US trials also use contract research organizations that can employ nurses who are dedicated to the trial patients, he adds — giving patients a very different experience compared to those who take part in a small trial run by an academic lab, for instance, where research nurses may have many other responsibilities.

No pain, no gain?

Mogil's data also challenge one of the fundamental principles of placebo-controlled trials — that comparing a drug against placebo tells us how well a drug works. A basic principle of these trials is that drug and placebo effects are additive: our total response to any drug we take is equal to the placebo response plus the drug's biochemical effect. But Mogil found that although placebo responses have increased over time, drug responses haven't risen by the same amount.

That suggests placebo and drug responses may not always be strictly additive. This isn't entirely unexpected, Mogil argues, because both placebos and pharmaceutical painkillers tap into similar biological mechanisms — such as the release of endorphins in the brain. But if true, it suggests that growing placebo responses are masking real painkilling effects. "There are a lot of people in the pain field who believe the drugs that are failing clinical trials actually work, it's just that the trials can't show it," he says.

For companies trying to develop treatments, one remedy might be to compare new drugs against their best competitors instead of against placebo — or to go back to conducting smaller, shorter trials. Benedetti is not convinced, however. "I don't think that controlling the placebo response will increase the number of successful trials," he says. "What drug companies have to do is to find more effective drugs."

Mogil suggests it is also worth investigating the elements that generate the more powerful placebo response in US trials, and then incorporating those elements (such as the relationship between patient and nurse) into patient care. Ted Kaptchuk, director of placebo research at Harvard Medical School in Boston, Massachusetts, agrees. "If the major component of a drug in any particular condition is its placebo component, we need to develop non-pharmacological interventions as a first-line response," he says.

Tuesday, October 06, 2015

16th World Congress on Pain - IASP - September 26 – 30, 2016 in Yokohama, Japan

The World Congress on Pain provides a state-of-the-art overview of a wide range of topics in pain research and treatment. It offers networking opportunities with thousands of the world's leading experts who are eager to share their thoughts, research, and findings. Whether you are a trainee entering the field, a clinician interested in updating your knowledge, or a researcher announcing promising new results, you will discover new information in plenary sessions, refresher courses, topical workshops, and poster sessions that define the cutting edge of pain research and treatment.

#IASPCongress2016 hashtag on Twitter

PAIN Reports - an international, peer-reviewed, online-only journal focused on pain research and management

Scheduled to launch in July 2016, PAIN Reports is an international, peer-reviewed, online-only journal focused on pain research and management. It is multidisciplinary in scope, covering subjects appealing to basic and applied researchers and practitioners worldwide. With a dedicated focus on publishing brief original reports, communications, and full-length articles, PAIN Reports will support IASP's mission to "...bring together scientists, clinicians, health-care providers, and policymakers to stimulate and support the study of pain and translate that knowledge into improved pain relief worldwide."

All content published within PAIN Reports is openly available online immediately upon publication. Open-access publishing provides unrestricted access via the Internet to peer-reviewed scholarly research. Authors retain copyright of their articles, with content licensed under several Creative Commons licenses. The journal is funded through Author Processing Charges (APCs), which are paid by authors, funders, institutions, or sponsors of accepted articles. Because open-access journals are freely available online, there are no subscriptions. Furthermore, there are no maximum limitations on the number of papers or pages that can be published in the journal.

PAIN Reports will encourage and consider direct submissions. The submission system for PAIN Reports may be linked to the submission system for PAIN, allowing authors of manuscripts not accepted in PAIN to indicate that they wish to transfer their manuscripts directly to PAIN Reports for consideration

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News about #pain on Twitter

The Centre for Pediatric Pain Research | Science Helping Children

International Forum on Pediatric Pain (IFPP)

10th International Forum on Pediatric Pain

October 1 – 4, 2015

White Point Beach Resort, Nova Scotia

One Size Doesn't Fit All: Personalized Approaches to Pediatric Pain Management

At this meeting you experienced a multidisciplinary, stimulating, and educational lecture series led by an international panel of invited speakers. We also brought together scientists and clinicians from around the world to present poster abstracts on the most cutting edge pediatric pain research.

Monday, October 05, 2015

Less Pain, Less Joy: A New Look at Acetaminophen - WSJ

Consider this trade-off the next time you have a headache: Would you take a medicine that didn't just ease the pain but muffled your happiness too?

A recent study suggests that acetaminophen—found in Tylenol, Excedrin and a host of other medications—is an all-purpose damper, stifling a range of strong feelings. Throbbing pain, the sting of rejection, paralyzing indecision—along with euphoria and delight—all appear to be taken down a notch by the drug. 

For most people, this over-the-counter palliative doesn't demand much thought: Take the right dose and the pain goes away. But it may not be that simple.

In 2010, the psychologists Naomi Eisenberger and Nathan DeWall discovered that a three-week course of acetaminophen soothed social pain, like feelings of exclusion or ridicule. The drug also assuaged the agony of indecision, Dr. DeWall found earlier this year. 

Building on this research, a new study, published in June in the journal Psychological Science, shows that acetaminophen affects not just how we perceive physical and psychological pain but how the brain processes strong feelings in general. Though the study was small and limited to college students as subjects, the researchers designed it to meet the high standards of pharmaceutical testing and were able to replicate it.

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Saturday, September 26, 2015

NIH Pain Consortium - Task Force on Research Standards for Chronic Low Back Pain

In 2012, NIH convened a Task Force on Research Standards for Chronic Low Back Pain, comprising 16 invited experts from varied disciplines and from scientific and research institutions outside NIH. The NIH Pain Consortium's charge to this group included developing a set of standards to increase the consistency of future clinical research on cLBP.


In April 2014, the Task Force began to release publications on its work, including a full report with recommendations on standards, an executive summary, journal articles, and a uniform minimal dataset. The Task Force's recommendations, considered a dynamic document, are intended to help advance the field, resolve controversies, and ease the way in future cLBP research.

PROMIS Pain-Related Measures: An Overview

PROMIS Pain-Related Measures: An Overview

The National Institute of Health created PROMIS to develop and evaluate measures to target important health outcomes across various chronic diseases. The pain-related domains include items for pain intensity, interference, behavior, and quality.

Friday, September 25, 2015

CVS won't require prescriptions for heroin life-saver |

CVS pharmacies has made the drug naloxone, which can reverse a heroin or painkiller overdose, available without a prescription in 12 states including Pennsylvania.

The move comes amid a national epidemic of overdoses involving opiates, a category of drug that includes prescription painkillers such as OxyContin and heroin.

Naloxone, which comes in injectable and nose-spray forms, has increasingly been carried by first-responders such as police, and has gained widespread attention for its ability to save addicts. While the drug does nothing to stop their addiction, it give addicts a chance at obtaining treatment and recovering.

Last year, Pennsylvania changed state law to make naloxone available to non-medical first responders and families. It has long been used by hospitals and ambulance crews.

A CVS spokesman couldn't immediately be reached Thursday to say how much naloxone will cost in the midstate.

Naloxone is commonly sold under the brand name Narcan. According to recent news reports, the price of naloxone has recently doubled, apparently because of the growing demand.

Sunday, August 02, 2015

The Washington Post: The genius inventor who says he’ll eliminate chronic pain with a simple device

At exactly 1:45 p.m. on a Tuesday, one of the nation's most prolific inventors arrives at an International House of Pancakes via sports car. It gleams quicksilver in the afternoon sun. "They call this a Jaguar," purrs Robert Fischell, who's credited with saving tens of thousands of lives and ushering in the modern era of satellite navigation. "I think it's named after a cat."

Then Fischell, in a collared shirt unbuttoned low, puts the Jag into action, weaving it through traffic on his way toward the University of Maryland. He has a meeting there at 2 p.m., and it looks to be an important one. The tech guys are rolling out his newest invention. And this one — a contraption he says could cure chronic pain — should be a doozy.

The life of Robert Fischell has been one of doozies. A space scientist turned inventor, Fischell has authored more than 200 patents that range from the grave to the quirky. He has invented a rechargeable pacemaker, an implantable cardiac defibrillator, a device that warns of epileptic seizures, an insertable insulin pump and a gizmo that zaps migraines before they start. He has also fashioned a bevy of penile prosthetics to cure erectile dysfunction as well as something called a "bowl for keeping cereal crispy."

But this invention, he says, is his most ambitious yet. "Chronic pain costs the American people $600 billion every year," Fischell says in a lilting staccato flecked with traces of his Bronx youth. "Six. Hundred. Billion. Dollars."

Still, Fischell is not a young man. He's 86. He's had two surgeries for cataracts in the last six weeks. He has an artificial left knee.

Fischell, who grimaces when mortality arises in conversation, knows more days are behind him than ahead. So he keeps a frenetic pace. He clocks 10-hour days at his office. He drives his Jaguar fast. He drinks unsweetened tea by the quart. This could be his last great invention. He has to finish it soon.
It's now 1:55 p.m. Fischell slams the Jaguar into a parking space. He hustles into the Fischell Institute for Biomedical Devices, arriving at a conference room. Fischell looks around. It's empty. He's early.

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Thursday, July 23, 2015

These Superhumans Are Real and Their DNA Could Be Worth Billions - Bloomberg Business

Steven Pete can put his hand on a hot stove or step on a piece of glass and not feel a thing, all because of a quirk in his genes. Only a few dozen people in the world share Pete's congenital insensitivity to pain. Drug companies see riches in his rare mutation. They also have their eye on people like Timothy Dreyer, 25, who has bones so dense he could walk away from accidents that would leave others with broken limbs. About 100 people have sclerosteosis, Dreyer's condition.

Both men's apparent superpowers come from exceedingly uncommon deviations in their DNA. They are genetic outliers, coveted by drug companies Amgen, Genentech, and others in search of drugs for some of the industry's biggest, most lucrative markets.

Their genes also have caused the two men enormous suffering. Pete's parents first realized something was wrong when, as a teething baby, their son almost chewed off his tongue. "That was a giant red flag," says Pete, now 34 and living in Kelso, Wash. It took doctors months to figure out he had congenital insensitivity to pain, caused by two different mutations, one inherited from each parent. On their own, the single mutations were benign; combined, they were harmful.

Dreyer, who lives in Johannesburg, was 21 months old when his parents noticed a sudden facial paralysis. Doctors first diagnosed him with palsy. Then X-rays revealed excessive bone formation in his skull, which led to a diagnosis of sclerosteosis. Nobody in Dreyer's family had the disorder; his parents both carried a single mutation, which Dreyer inherited.

Dreyer and Pete are "a gift from nature," says Andreas Grauer, global development lead for the osteoporosis drug Amgen is creating. "It is our obligation to turn it into something useful."

What's good for patients is also good for business. The painkiller market alone is worth $18 billion a year. The industry is pressing ahead with research into genetic irregularities. The U.S. Food and Drug Administration is expected to approve a cholesterol-lowering treatment on July 24 from Sanofi and Regeneron Pharmaceuticals based on the rare gene mutation of an aerobics instructor with astoundingly low cholesterol levels. Amgen has a similar cholesterol drug, based on the same discovery, and expects U.S. approval in August. The drugs can lower cholesterol when statins alone don't work. They are expected to cost up to $12,000 per patient per year and bring in more than $1 billion annually.

"Before a lot of us participated in these projects, very little about pain itself was known"

Thursday, July 16, 2015

Experts Urge Sparing Use of Nonaspirin Painkillers - The New York Times

The Food and Drug Administration warned last week that the risk of heart attack and stroke from widely used painkillers that include Motrin IB, Aleve and Celebrex but not aspirin was greater than it previously had said. But what does that mean for people who take them?

Experts said that the warning reflected the gathering evidence that there was risk even in small amounts of the drug, so-called nonaspirin, nonsteroidal anti-inflammatory drugs, or Nsaids, and that everyone taking them should use them sparingly for brief periods. Millions of Americans take them.

"One of the underlying messages for this warning has to be there are no completely safe pain relievers, period," said Bruce Lambert, director of the Center for Communication and Health at Northwestern University, who specializes in drug safety communication.

But the broader context is important. The relative risk of heart attack and stroke from the drugs is still far smaller than the risk from smoking, having uncontrolled high blood pressure or being obese. At the same time, use of the drugs by someone with those other habits and conditions could compound the risk.

"The additional risk is relatively small, but it could be the straw that breaks the camel's back for someone already at risk," Professor Lambert said. The evidence that the drugs increase the risk of heart attack, stroke and heart failure "is now extremely solid," he said.

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Saturday, July 04, 2015

Latif Nasser: The amazing story of the man who gave us modern pain relief | TED Talk |

For the longest time, doctors basically ignored the most basic and frustrating part of being sick — pain. In this lyrical, informative talk, Latif Nasser tells the extraordinary story of wrestler and doctor John J. Bonica, who persuaded the medical profession to take pain seriously — and transformed the lives of millions.

Sunday, June 07, 2015

Painkillers Resist Abuse, but Experts Still Worry -

Anthony DiTullio would pop a painkiller in his mouth but not just swallow it, as intended. He would chew it for 30 minutes, grinding through its protective coating and waxy unpleasantness, because the only pain he was treating was addiction.

The pill was OxyContin, a painkiller that its manufacturer, Purdue Pharma, says deters abuse by being difficult to chew or liquefy into forms that give addicts stronger highs, orally or through injection. Since adding these features to its original and widely abused OxyContin in 2010, the company has likened the pill to a virtual seatbelt to restrain the nation's epidemic of prescription drug abuse.

But as thousands of addicts still find ways to abuse OxyContin and similar painkillers, called abuse-deterrent formulations, some experts caution that the protections are misunderstood and could mislead both users and prescribers into thinking that the underlying medications are less addictive.

Because abuse-deterrent formulations are relatively new, preliminary data on their public-health implications is limited. Several studies, somesponsored by Purdue, have found that abuse of OxyContin specifically has decreased after its protections were added. Other reports confirmed those findings but also found that many abusers simply moved on to other opioids, as well as heroin, leaving the overall effect on drug abuse open for debate.

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Tuesday, May 26, 2015

The Future of Epigenetics in Pain Research | Pain Research Forum

Epigenetic mechanisms impact gene function without affecting the underlying DNA sequence, and are one way in which the environment can have long-lasting effects on the genome. Epigenetics has been slow to catch on in the pain field compared to many other branches of science and medicine, but that may be about to change. Emerging research is beginning to show how epigenetics can help explain why particular individuals are more vulnerable to chronic pain than others, reveal the mechanisms underlying the transition from acute to chronic pain, and identify new targets for pain therapeutics. So argued co-presenters Stephen McMahon and Franziska Denk, King's College London, UK, in a PRF webinar titled Pain Epigenetics: Current Research and Future Challenges, which took place on April 16. The talk was followed by a panel discussion with Chas Bountra, University of Oxford, UK, and Santina Chiechio, University of Catania, Italy. Laura Stone, McGill University, Montreal, Canada, moderated the event.

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Friday, May 22, 2015

Former Players: NFL Teams ‘Conspired’ To Push Painkillers « CBS Miami

The theory that painkillers were pushed to NFL players to keep them on the field has has circulated for years.
Now hundreds of former players are bringing the issue to court after they filed a lawsuit claiming all 32 NFL teams, their doctors, trainers and medical staffs often illegally obtained and provided painkillers to players.
The lawsuit reprises some of the allegations made in a federal lawsuit last year on behalf of 1,300 former players against the NFL. That complaint was filed in May, 2014 and dismissed in December by Judge William Alsup of the U.S. Northern District in California. Alsup wrote that the collective bargaining agreement between the league and the NFL Players Association was the appropriate forum to resolve such claims. That decision is being appealed.
The new lawsuit was filed Thursday in the U.S. Northern District of Maryland. It names each NFL team individually as a defendant and lists 13 plaintiffs, including Hall of Fame cornerback Mel Renfro of the Dallas Cowboys and Etopia Evans, the widow of Charles Evans, a running back who played eight years with the Minnesota Vikings and the Baltimore Ravens and retired after the 2000 season. Evans died of heart failure in October 2008 at age 41.
"This lawsuit alleges intentional activity by the teams, not negligence," said plaintiffs' attorney Steve Silverman. "It's another part of a unified effort to provide health care and compensation to the thousands of former players who have been permanently injured or died as a result of playing professional football."
Both lawsuits contend NFL teams and their medical staffs withheld information from players about the nature and seriousness of their injuries, while at the same time handing out prescription painkillers, anti-inflammatories and other dangerous drugs to mask pain and minimize lost playing time. Among other claims, the players contend prescriptions were filled out in their names without their knowledge.
The new lawsuit also claims that several former head coaches and assistants — among them, Don Shula, Howard Schnellenberger, Wayne Fontes, Mike Holmgren and Mike Tice — warned players they would be cut from their teams unless they took painkillers and returned to the field.
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Tuesday, May 19, 2015

Solicitation of Public Comments on Draft National Pain Strategy - The Interagency Pain Research Coordinating Committee (IPRC)

A core recommendation of the 2011 IOM Report: Relieving Pain in America  is:  "The Secretary of the Department of Health and Human Services should develop a comprehensive, population health-level strategy for pain prevention, treatment, management, education, reimbursement, and research that includes specific goals, actions, time frames, and resources." The IOM report highlighted specific objectives for the strategy:
  • Describe how efforts across government agencies, including public–private partnerships, can be established, coordinated, and integrated to encourage population-focused research, education, communication, and community-wide approaches that can help reduce pain and its consequences and remediate disparities in the experience of pain among subgroups of Americans.
  • Include an agenda for developing physiological, clinical, behavioral, psychological, outcomes, and health services research and appropriate links across these domains.
  • Improve pain assessment and management programs within the service delivery and financing programs of the federal government.
  • Proceed in cooperation with the Interagency Pain Research Coordinating Committee and the National Institutes of Health's Pain Consortium and reach out to private-sector participants as appropriate.
  • Involve the appropriate agencies and entities.
  • Include ongoing efforts to enhance public awareness about the nature of chronic pain and the role of self-care in its management.

The Department of Health and Human Services charged the Interagency Pain Research Coordinating Committee (IPRCC) with creating a comprehensive population health-level strategy to begin addressing these objectives.

National Pain Strategy: 
A Comprehensive Population Health-Level Strategy for Pain (draft)

Monday, April 27, 2015

Preoperative Efficiency of Conditioned Pain Modulation in Rats Predicts Recovery From Pain After Surgery | Pain Research Forum

Rats with weak conditioned pain modulation (CPM), a measure of endogenous analgesia, experience longer recovery times from mechanical hypersensitivity following surgery compared to rats with stronger CPM, according to a study published in the April issue of Anesthesiology. The research, which is consistent with observations in humans, was led by Christopher Peters, Wake Forest University, Winston-Salem, US, and provides a new method for investigating CPM and postsurgical pain in animals. It also points to one mechanism, noradrenergic signaling, that may be involved in the relationship between CPM and resolution of pain after surgery.


"This is an impressive example of back translation [from humans to animals] in pain research," wrote David Yarnitsky, Rambam Health Care Campus, Haifa, Israel, and Albert Dahan, Leiden University Medical Center, the Netherlands, in an accompanying editorial.


From people to rats

It was Yarnitsky's own clinical work that inspired the current research. Chronic pain following surgery is a major problem that affects at least 10 percent, and possibly as many as 50 percent, of patients who undergo common surgical operations (Kehlet et al., 2006). Suspecting that individual differences in endogenous analgesia may play a role in these adverse outcomes, Yarnitsky has found that patients with lower CPM—lower induction of diffuse analgesia throughout the body following an intense, focal pain stimulus—prior to surgery were more likely to have chronic pain six months after thoracotomy (surgical opening of the chest; Yarnitsky et al., 2008). Preoperative CPM also predicts pain following abdominal surgery (Wilder-Smith et al., 2010).


To further examine the relationship between CPM and postsurgical pain, and to look for mechanisms underlying this association, Peters and colleagues modeled the two phenomena in rats. Overall, the research is an "effort to try to make the studies that we're doing in rodents a little more translatable to humans," said Peters.


To study CPM, the researchers used a paradigm in which capsaicin administered to the forepaw increases hind paw withdrawal thresholds to mechanical stimuli. To model postsurgical pain, the researchers performed partial ligation of the L5 spinal nerve. Nerve injury is a proposed risk factor for developing chronic pain, explained Peters, so "we wanted a model that had a neuropathic component … and that we knew would spontaneously recover," he said. To examine the rats' recovery, the researchers measured mechanical withdrawal thresholds in both hind paws until 70 days post-surgery.

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Monday, March 02, 2015

The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention WorkshopEffectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain | Annals of Internal Medicine

Background: Increases in prescriptions of opioid medications for chronic pain have been accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness.

Purpose: To evaluate evidence on the effectiveness and harms of long-term (>3 months) opioid therapy for chronic pain in adults.

Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PsycINFO, and CINAHL (January 2008 through August 2014); relevant studies from a prior review; reference lists; and

Study Selection: Randomized trials and observational studies that involved adults with chronic pain who were prescribed long-term opioid therapy and that evaluated opioid therapy versus placebo, no opioid, or nonopioid therapy; different opioid dosing strategies; or risk mitigation strategies.

Data Extraction: Dual extraction and quality assessment.

Data Synthesis: No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction. Good- and fair-quality observational studies suggest that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction, although there are few studies for each of these outcomes; for some harms, higher doses are associated with increased risk. Evidence on the effectiveness and harms of different opioid dosing and risk mitigation strategies is limited.

Limitations: Non–English-language articles were excluded, meta-analysis could not be done, and publication bias could not be assessed. No placebo-controlled trials met inclusion criteria, evidence was lacking for many comparisons and outcomes, and observational studies were limited in their ability to address potential confounding.

Conclusion: Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms.

Primary Funding Source: Agency for Healthcare Research and Quality.

Friday, February 27, 2015

Use Virtual Reality to Eliminate That Pain in Your Neck | Smithsonian

Tired of reaching for a bottle of pills to quell your chronic pain? Maybe you should strap on a virtual reality headset. In an experiment described last week in Psychological Science, scientists showed how bogus visual feedback created by virtual reality can actually trick the brain into boosting or reducing a person's range of pain-free movement. The study highlights the ways in which sensory perceptions, and not just physical signals, can make us feel pain—and how that effect can be manipulated to design new therapies.

To test this notion, Daniel Harvie at the University of South Australia and his colleagues put chronic neck pain sufferers through a series of twists and turns, first with no equipment and then fitted with Oculus Rift headsets. The headsets were programmed to show indoor and outdoor scenes, and they used gyroscopes to monitor the wearer's head movements. The patients were then told to turn their heads left or right until they felt pain.

When patients turned their heads just a bit, they sometimes perceived that they were moving much further, or vice versa. If participants moved their heads within a normally non-painful range, they experienced pain when the headset's visuals made them think they'd performed a much greater rotation. Similarly, the volunteers often experienced no pain when the headsets made it appear to them that they'd performed smaller, normally pain-free turns—even if they moved into a normally painful pose. The results suggest that chronic sufferers create an association between movement and pain, so that the mere visual suggestion of motion its own signal of danger to the body.

"It is important to recognize here what pain actually is," Harvie says. "Pain is not a linear result of messages from the body. Rather, pain is one of the brain's protective responses, produced when, after evaluating all of the evidence, it decides that body tissue is in danger and that we need warning. In this case, because of the association between pain and movement, learned through past experience, visual signals of movement themselves have become signals of threat to the body and therefore, triggers of pain."

Virtual reality has been used previously for other types of pain research. In 2014 Swedish scientists detailed in the journal Frontiers in Neuroscience how virtual reality helped phantom limb pain, which plagues some 70 percent of amputees. Muscle signals from a patient's stump were recorded by electrodes and processed by a software program that enabled each patient to control a virtual limb just by thinking about it. The treatment caused a reduction in phantom pain, perhaps because the illusion tricked the brain into thinking that the missing limb was again part of the body.

Harvie sees similar potential for developing future pain treatments based on his team's research, such as training the brain to target the cues it interprets as danger signals.

"Movement is a common example of something that is often associated with pain when we have an injury, and might therefore become a 'learned' signal of danger and trigger of pain, even after injury healing," he says. "If we can teach the brain anew that movement and other learned triggers are actually safe, then their ability to contribute to pain will be extinguished."