Heroin Addiction Explained: How Opioids Hijack the Brain - The New York Times

THE OPIOID EPIDEMIC is devastating America. Overdoses have passed car crashes and gun violence to become the leading cause of death for Americans under 55. The epidemic has killed more people than H.I.V. at the peak of that disease, and its death toll exceeds those of the wars in Vietnam and Iraq combined. Funerals for young people have become common. Every 11 minutes, another life is lost.

So why do so many people start using these drugs? Why don't they stop?

Some people are more susceptible to addiction than others. But nobody is immune. For many, opioids like heroin entice by bestowing an immediate sense of tranquility, only to trap the user in a vicious cycle that essentially rewires the brain.

Getting hooked is nobody's plan. Some turn to heroin because prescription painkillers are tough to get. Fentanyl, which is 50 times more potent than heroin, has snaked its way into other drugs like cocaine, Xanax and MDMA, widening the epidemic.

To understand what goes through the minds and bodies of opioid users, The New York Times spent months interviewing users, family members and addiction experts. Using their insights, we created a visual representation of how the strong lure of these powerful drugs can hijack the brain.

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https://www.nytimes.com/interactive/2018/us/addiction-heroin-opioids.html

This Chemical Is So Hot It Destroys Nerve Fibers—in a Good Way - WIRED

In Morocco there grows a cactus-like plant that's so hot, I have to insist that the next few sentences aren't hyperbole. On the Scoville Scale of hotness, its active ingredient, resiniferatoxin, clocks in at 16 billion units. That's 10,000 times hotter than the Carolina reaper, the world's hottest pepper, and 45,000 times hotter than the hottest of habaneros, and 4.5 million times hotter than a piddling little jalapeno. Euphorbia resinifera, aka the resin spurge, is not to be eaten. Just to be safe, you probably shouldn't even look at it.

But while that toxicity will lay up any mammal dumb enough to chew on the resin spurge, resiniferatoxin has also emerged as a promising painkiller. Inject RTX, as it's known, into an aching joint, and it'll actually destroy the nerve endings that signal pain. Which means medicine could soon get a new tool to help free us from the grasp of opioids.

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https://www.wired.com/story/resiniferatoxin/

Pain treatment complicated by doctors' opioid fears - The Washington Post

I felt a shake and opened my eyes. The clock read 1:30 a.m.

"We need to go to the hospital," my mother whispered in my ear, clutching her stomach.

She knew; it was the same pain she had experienced many times before.

We were in California, many miles from home, many miles from my father (a doctor), who always knew what to do. At the time, I was early in my medical school training, although I knew all the intricate details of my mother's medical history and realized she needed to get medical attention.

When we arrived at the local emergency room in an affluent neighborhood, my mother was placed in a wheelchair and taken to the waiting room. She curled up on the cold barren hospital floor, the only position she could find comfortable. Although my mother usually puts on lipstick and high heels to go to the grocery store, this time, her hair was unkempt and her pajamas worn out. Her knees were tucked into her chest and her belly was distended.

It should have been clear to onlookers that she was in agonizing pain, but people were hesitant, skeptical even.

"Ma'am," someone yelled. "Ma'am, we can't have you lying on the floor. Get up."

My mother lay still.

"Get up, ma'am," she was told again, again more forcibly.

They helped her back into the wheelchair.

"Help me," she said. "The pain is unbearable."

Reluctantly, they put her in a stretcher and prepared to place an IV in her arm. To convince them the pain was real, we asked them to call my father, who could fill in all of the medical details: her multiple prior hospitalizations, surgeries and diagnoses.

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https://www.washingtonpost.com/national/health-science/my-mother-was-in-unbearable-pain-but-the-er-staff-didnt-seem-to-believe-her/2018/09/28/1acf1404-abae-11e8-8a0c-70b618c98d3c_story.html?

Illusions as Painkillers: the Analgesic Value of Resizing Illusions in Knee Osteoarthritis - Scientific American

Research has shown that the experience of pain is highly subjective: people feel more or less pain, in identical physical situations, as a function of their mood and attention. This flexibility showcases the potential for cognitive manipulations to decrease the pain associated with a variety of pathologies. As an example, the virtual-reality game "Snow World" (in which game in which players shoot snowballs to defeat snowman Frosty and his penguins) reportedly works better than morphine at counteracting the pain of patients in burn units. Other studies have indicated that virtual reality manipulations of the patient's own body can also help ameliorate pain: an experiment conducted by neuroscientist Maria Victoria Sanchez-Vives and her team at the University of Barcelona in Spain showed that heat applied to experimental participants' wrists felt more painful when their virtual arms turned red than when they turned blue or green.

Following on this tradition, a study published PeerJ last month showed that visuotactile illusions can help the pain experienced by patients suffering from knee osteoarthritis.

According to lead author Tasha Stanton, from the University of South Australia, the idea for the study originated from her observation that "people with knee osteoarthritis have an altered perception of their own body. [Their affected knee] often feels too big, and they also have changes to the way that touch and movement information is represented in the brain." She hypothesized that patients may "respond to illusions that change the way their knee looks."

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https://blogs.scientificamerican.com/illusion-chasers/illusions-as-painkillers-the-analgesic-value-of-resizing-illusions-in-knee-osteoarthritis/

Pain Narrative Videos | Pain Education and Advocacy | University of New England

UNE's Center for Excellence in Neurosciences and Interprofessional Education Collaborative have partnered to create this collection of pain narrative videos as part of a group of interprofessional training materials. These materials were crafted to aid future practitioners in providing the highest quality of care to patients experiencing chronic pain. They highlight the importance of working interprofessionally and approaching the patient as a whole person when in treatment. Included are outcomes from a project funded in part by the Maine Cancer Foundation to examine cancer pain from an interprofessional perspective and shed light on a wide variety of obstacles that cancer pain patients face over the course of their treatment and life after treatment.

The pain narrative videos collected here give unique insight into the lives of patients experiencing chronic pain. Their intended use is as educational material or for patient advocacy, in pieces or as a whole.

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https://dune.une.edu/pain_videos/

Too Good to Be True? A Nonaddictive Opioid without Lethal Side Effects Shows Promise - Scientific American

With nearly 50,000 drug overdose deaths from opioids last year and an estimated two million Americans addicted, the opioid crisis continues to rage throughout the U.S. This statistic must be contrasted with another: 25 million Americans live with daily chronic pain, for which few treatment options are available apart from opioid medications.

Opioid drugs like morphine and Oxycontin are still held as the gold standard when it comes to relieving pain. But it has become brutally obvious that opioids have dangerous side effects, including physical dependence, addiction and the impaired breathing that too often leads to death from an overdose. Researchers have long been searching for a drug that would relieve pain without such a heavy toll, with few results so far.

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https://www.scientificamerican.com/article/too-good-to-be-true-a-nonaddictive-opioid-without-lethal-side-effects-shows-promise/

Body in Mind - Research into the role of the brain and mind in chronic pain - University of South Australia

Here is our vision: To provide a credible and reliable channel through which clinical pain scientists can bring their scientific discoveries straight into the real world. We reckon that the communication bit of science is the bit that often drags the chain of knowledge development and transfer. We want to communicate our science better. We want to side-step, or perhaps leap-frog, the arduous journey that new discoveries make before they have the opportunity to influence the real world. We want people to share in our fascination with the fearful and wonderful complexity of the human; we want people to understand the scientific discoveries as they occur, not 20 years later, to grasp their significance and potential relevance to everyday life, but to also become astute sifters of the wheat from the chaff. We want to be a reliable go-to web space for the latest developments in the science of pain.

https://bodyinmind.org/

Most Doctors Are Ill-Equipped to Deal With the Opioid Epidemic. Few Medical Schools Teach Addiction. - The New York Times

To the medical students, the patient was a conundrum.

According to his chart, he had residual pain from a leg injury sustained while working on a train track. Now he wanted an opioid stronger than the Percocet he'd been prescribed. So why did his urine test positive for two other drugs — cocaine and hydromorphone, a powerful opioid that doctors had not ordered?

It was up to Clark Yin, 29, to figure out what was really going on with Chris McQ, 58 — as seven other third-year medical students and two instructors watched.

"How are you going to have a conversation around the patient's positive tox screen results?" asked Dr. Lidya H. Wlasiuk, who teaches addiction awareness and interventions here at Boston University School of Medicine.

Mr. Yin threw up his hands. "I have no idea," he admitted.

Chris McQ is a fictional case study created by Dr. Wlasiuk, brought to life for this class by Ric Mauré, a keyboard player who also works as a standardized patient — trained to represent a real patient, to help medical students practice diagnostic and communication skills. The assignment today: grappling with the delicate art and science of managing a chronic pain patient who might be tipping into a substance use disorder.

How can a doctor win over a patient who fears being judged? How to determine whether the patient's demand for opioids is a response to dependence or pain?

Addressing these quandaries might seem fundamental in medical training — such patients appear in just about every field, from internal medicine to orthopedics to cardiology. The need for front-line intervention is dire: primary care providers like Dr. Wlasiuk, who practices family medicine in a Boston community clinic, routinely encounter these patients but often lack the expertise to prevent, diagnose and treat addiction.

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https://www.nytimes.com/2018/09/10/health/addiction-medical-schools-treatment.html

A New Arizona Law Limits A Doctor's Freedom To Prescribe Painkillers : Shots - Health News : NPR

It started with a rolled ankle during a routine training exercise.

Shannon Hubbard never imagined it was the prologue to one of the most debilitating pain conditions known to exist, called ­­­­­­­complex regional pain syndrome.

It's a condition that causes the nervous system to go haywire, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.

For Hubbard, it manifested several years ago following surgery on her foot. That's a common way for it to take hold.

"My leg feels like it's on fire pretty much all the time. It spreads to different parts of your body," the 47-year-old Army veteran says.

Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It's red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.

"That started as a little blister and four days later it was like the size of a baseball," she says. "They had to cut it open and then it got infected and because I have blood flow issues, it doesn't heal."

She knows that soon it will happen again.

"Over the past three years, I've been prescribed over sixty different medications and combinations, none have even touched the pain," she says.

She holds up a plastic bag filled with discarded pill bottles — evidence of her elusive search for a solution to the pain.

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https://www.npr.org/sections/health-shots/2018/07/08/622729300/patients-with-chronic-pain-feel-caught-in-an-opioid-prescribing-debate

The Neuroscience of Pain | The New Yorker

On a foggy February morning in Oxford, England, I arrived at the John Radcliffe Hospital, a shiplike nineteen-seventies complex moored on a hill east of the city center, for the express purpose of being hurt. I had an appointment with a scientist named Irene Tracey, a brisk woman in her early fifties who directs Oxford University's Nuffield Department of Clinical Neurosciences and has become known as the Queen of Pain. "We might have a problem with you being a ginger," she warned when we met. Redheads typically perceive pain differently from those with other hair colors; many also flinch at the use of the G-word. "I'm sorry, a lovely auburn," she quickly said, while a doctoral student used a ruler and a purple Sharpie to draw the outline of a one-inch square on my right shin.

Wearing thick rubber gloves, the student squeezed a dollop of pale-orange cream into the center of the square and delicately spread it to the edges, as if frosting a cake. The cream contained capsaicin, the chemical responsible for the burn of chili peppers. "We love capsaicin," Tracey said. "It does two really nice things: it ramps up gradually to become quite intense, and it activates receptors in your skin that we know a lot about." Thus anointed, I signed my disclaimer forms and was strapped into the scanning bed of a magnetic-resonance-imaging (MRI) machine.

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https://www.newyorker.com/magazine/2018/07/02/the-neuroscience-of-pain

HEAL Initiative | National Institutes of Health (NIH)

In April 2018, NIH launched the HEAL (Helping to End Addiction Long-term) Initiative, an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid public health crisis. This Initiative will build on extensive, well-established NIH research, including basic science of the complex neurological pathways involved in pain and addiction, implementation science to develop and test treatment models, and research to integrate behavioral interventions with Medication-Assisted Treatment (MAT) for opioid use disorder (OUD). Successes from this research include the development of the nasal form of naloxone, the most commonly used nasal spray for reversing opioid overdose, the development of buprenorphine for the treatment of OUD, and evidence for the use of nondrug and mind/body techniques such as yoga, tai chi, acupuncture, and mindfulness meditation to help patients control and manage pain.

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https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative

How health insurers are making America’s opioid epidemic worse - Vox

Mandy has now been in recovery from her opioid addiction for more than two months — and she's ready to keep that going. But the 29-year-old in the Chicago area is now dealing with a big obstacle: her health insurer.

Mandy, who asked I use only her first name, said she struggled with addiction for six years. It started with back pain, which a doctor tried to treat with Vicodin. 

"I had tried [opioids] in high school," she said. "I had an older boyfriend, and I tried some of his wisdom teeth painkillers to get high off of. And I was like, 'Whoa, this is awesome.' When I got a Vicodin prescription for my back, I was like, 'Oh, I remember these being really great.'"

Mandy took the drugs as prescribed at first. But every once in a while, she would sneak in an extra pill or two to help deal with a bad day. Then she started taking extras on good days, and, finally, at work.

"It got to the point where I started using them recreationally," Mandy said. "But then I started using them to not get sick" — a typical experience for people addicted to opioids, who over time begin to use the drugs not to get high but to avert cravings and withdrawal.

In March, Mandy decided she had enough. She got into an intensive outpatient addiction treatment program for eight weeks and was prescribed buprenorphine, a medication for opioid addiction that staves off withdrawal and cravings without producing the kind of high that, say, heroin or painkillers might. She's remained on the medication as she's transitioned to less intensive treatment.

There's just one problem: Her insurer, Blue Cross and Blue Shield of Illinois, won't pay for the buprenorphine. That's left Mandy to foot the bill. Her latest bill — for a 28-day supply — was priced at $294 out of pocket, although she got it down to $222.69 with a discount. With the discount, similar bills throughout a full year would add up to nearly $2,900.

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https://www.vox.com/science-and-health/2018/6/4/17388756/opioid-epidemic-health-insurance-buprenorphine

BBC - Future - Pain bias: The health inequality rarely discussed

In 2009, my doctor told me that, like "a lot of women", I was paying too much attention to my body. Saying there wasn't an issue, he suggested I just relax and try to ignore the symptoms.

The decision seemed to run counter to what my records showed. A few weeks earlier, I had ended up in the emergency room with chest pains and a heart rate hitting 220 beats per minute. The ER crew told me it was a panic attack, gave me Xanax and told me to try to sleep.

I'd had panic attacks before. I knew this episode was not one. So I went to my doctor.

He put me on a heart monitor overnight. Bingo: I had another episode, this time recorded. It didn't matter. I still left his office thinking it was perhaps anxiety. And so, listening to the advice, I tried to ignore the pain.­­

Until it happened again. And again. First every month, then every week. Over the following nine years, I would complain about it and be told again that I was having panic attacks or anxiety, that women don't feel heart pain the way I was feeling it, and that maybe I was just confused.

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http://www.bbc.com/future/story/20180518-the-inequality-in-how-women-are-treated-for-pain

NIH Pain Consortium

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

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

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

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

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

https://painconsortium.nih.gov/

Chronic pain treatment: Psychotherapy, not opioids, has been proven to work - Vox

When pain settled into Blair Golson's hands, it didn't let go.

What started off as light throbbing in one wrist 10 years ago quickly engulfed the other. The discomfort then spread, producing a pain much "like slapping your hands against a concrete wall," he says. He was constantly stretching them, constantly shaking them, while looking for hot or cold surfaces to lay them on for relief.

But worse was the deep sense of catastrophe that accompanied the pain. Working in tech-related startups, he depended on his hands to type. "Every time the pain got bad, I would think some variation of, 'Oh no, I'm never going to be able to use computers again; I'm not going to be able to hold down a job; I'm not going to be able to earn a living; and I'm going to be in excruciating pain the rest of my life,'" he says.

Like many patients with chronic pain, Golson never got a concrete diagnosis. For a decade, the 38-year-old Californian went from doctor to doctor, trying all the standard treatments: opioids, hand splints, cortisone injections, epidural injections, exercises, even elective surgery.

Golson's pain was not caused by anything physically wrong with him. But it wasn't imagined. It was real.

After weaning himself off the opioid Vicodin and feeling like he had exhausted every medical option, Golson turned to a book that described how pain could be purely psychological in origin. That ultimately took a pain psychologist, a therapist who specializes in pain — not a physician — to treat the true source: his fearful thoughts. Realizing that psychological therapy could help "was one of the most profoundly surprising experiences of my life," Golson says. No doctor he ever saw "even hinted my pain might be psychogenic," meaning pain that's psychological in origin.

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https://www.vox.com/science-and-health/2018/5/17/17276452/chronic-pain-treatment-psychology-cbt-mindfulness-evidence

New Drug Offers Hope to Millions With Severe Migraines - The New York Times

The first medicine designed to prevent migraines was approved by the Food and Drug Administration on Thursday, ushering in what many experts believe will be a new era in treatment for people who suffer the most severe form of these headaches.

The drug, Aimovig, made by Amgen and Novartis, is a monthly injection with a device similar to an insulin pen. The list price will be $6,900 a year, and Amgen said the drug will be available to patients within a week.

Aimovig blocks a protein fragment, CGRP, that instigates and perpetuates migraines. Three other companies — Lilly, Teva and Alder — have similar medicines in the final stages of study or awaiting F.D.A. approval.

"The drugs will have a huge impact," said Dr. Amaal Starling, a neurologist and migraine specialist at the Mayo Clinic in Phoenix. "This is really an amazing time for my patient population and for general neurologists treating patients with migraine."

Millions of people experience severe migraines so often that they are disabled and in despair. These drugs do not prevent all migraine attacks, but can make them less severe and can reduce their frequency by 50 percent or more.

As a recent editorial in the journal JAMA put it, they are "progress, but not a panacea."

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https://www.nytimes.com/2018/05/17/health/migraines-prevention-drug-aimovig.html?

Treatments Prescribed For Lower Back Pain Are Often Ineffective, Report Says : NPR

Chances are, you — or someone you know — has suffered from lower back pain.

It can be debilitating. It's a leading cause of disability globally.

And the number of people with the often-chronic condition is likely to increase.

This warning comes via a series of articles published in the medical journal Lancet in March. They state that about 540 million people have lower back pain — and they predict that the number will jump as the world's population ages and as populations in lower- and middle-income countries move to urban centers and adopt more sedentary lives.

"We don't think about [back pain] the same way as cancer or heart attacks. But if you look at disability it causes, especially in middle- and low-income where there isn't a safety net, it impacts half a billion people," says Roger Chou, a physician who is a pain specialist at the Oregon Health and Science University and a co-author of the articles.

Disability from chronic back pain can hurt a person's ability to earn a living. One of the Lancet studies found that among rural Nigerian farmers, half reduced their workload because of back pain — an example of how the disability could contribute to the cycle of poverty in countries that lack benefits such as sick days or a social safety net.

Another study from Australia found that people who retired early because of back pain potentially lost out on hundreds of thousands of dollars of accumulated wealth when compared with healthy people who worked all the way to 65.

An overarching issue with back pain management is that the treatments doctors prescribe are often the wrong ones, the report concludes. Also, in many low-income countries, accessing health care is challenging — and getting appropriate care of back pain, specifically, is even harder. In some poor parts of Asia, pain medications are hard to come by and doctors may not have been trained on the most effective treatments.

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https://www.npr.org/sections/goatsandsoda/2018/04/05/597505825/report-ineffective-treatment-often-prescribed-for-lower-back-pain

Lack Of Research On Medical Marijuana Leaves Patients In The Dark : Shots - Health News : NPR

By the time Ann Marie Owen, 61, turned to marijuana to treat her pain, she was struggling to walk and talk. She was also hallucinating.

For four years, her doctor prescribed a wide range of opioids for transverse myelitis, a debilitating disease that caused pain, muscle weakness and paralysis.

The drugs not only failed to ease her symptoms, they hooked her.

When her home state of New York legalized marijuana for the treatment of select medical ailments, Owens decided it was time to swap pills for pot. But her doctors refused to help.

"Even though medical marijuana is legal, none of my doctors were willing to talk to me about it," she says. "They just kept telling me to take opioids."

Although 29 states have legalized marijuana to treat pain and other ailments, the growing number of Americans like Owen who use marijuana and the doctors who treat them are caught in the middle of a conflict in federal and state laws — a predicament that is only worsened by thin scientific data.

Because the federal government considers marijuana a Schedule 1 drug, research on marijuana or its active ingredients is highly restricted and even discouraged in some cases.

Underscoring the federal government's position, Health and Human Services Secretary Alex Azar recently pronounced that there was "no such thing as medical marijuana."

Scientists say that stance prevents them from conducting the high-quality research required for FDA approval, even as some early research indicates marijuana might be a promising alternative to opioids or other medicines.

Patients and physicians, meanwhile, lack guidance when making decisions about medical treatment for an array of serious conditions.

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https://www.npr.org/sections/health-shots/2018/04/07/600209754/medical-marijuanas-catch-22-limits-on-research-hinders-patient-relief

Naloxone Stops Opioid Overdoses. How Do You Use It? - The New York Times

The United States surgeon general issued a rare national advisory on Thursday urging more Americans to carry naloxone, a drug used to revive people overdosing on opioids.

The last time a surgeon general issued such an urgent warning to the country was in 2005, when Richard H. Carmona advised women not to drink alcohol when pregnant.

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https://www.nytimes.com/2018/04/06/us/naloxone-narcan-opioid-overdose.html

Medicare Is Cracking Down on Opioids. Doctors Fear Pain Patients Will Suffer. - The New York Times

Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.

Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.

But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.

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https://www.nytimes.com/2018/03/27/health/opioids-medicare-limits.html?

America's War on Pain Pills Is Killing Addicts and Leaving Patients in Agony - Reason.com

Craig, a middle-aged banking consultant who was on his school's lacrosse team in college and played professionally for half a dozen years after graduating, began developing back problems in his early 30s. "Degenerative disc disease runs in my family, and the constant pounding on AstroTurf probably did not help," he says. One day, he recalls, "I was lifting a railroad tie out of the ground with a pick ax, straddled it, and felt the pop. That was my first herniation."

After struggling with herniated discs and neuropathy, Craig consulted with "about 10 different surgeons" and decided to have his bottom three vertebrae fused. He continued to suffer from severe lower back pain, which he successfully treated for years with OxyContin, a timed-release version of the opioid analgesic oxycodone. He would take a 30-milligram OxyContin tablet twice a day, supplemented by immediate-release oxycodone for breakthrough pain when he needed it.

Then one day last May, Craig's pain clinic called him in for a pill count, a precaution designed to detect abuse of narcotics or diversion to nonpatients. The count was off by a week's worth of pills because Craig had just returned from a business trip and forgot that he had packed some medication in his briefcase. He tried to explain the discrepancy and offered to bring in the missing pills, to no avail. Because the pill count came up short, Craig's doctor would no longer prescribe opioids for him, and neither would any other pain specialist in town.

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http://reason.com/archives/2018/03/08/americas-war-on-pain-pills-is

What's in a Name for Chronic Pain? | Pain Research Forum

For decades, pain researchers have set their sights on understanding pain mechanisms—the cellular and molecular machinery underlying chronic pain. In doing so, they became increasingly aware that the terms they used to describe the neurobiological workings of pain did not always match what they had learned.

But now, official adoption by the International Association for the Study of Pain (IASP) of an IASP terminology task force recommendation for a so-called "third mechanistic descriptor" of chronic pain could move the field forward in its efforts to more fully characterize the known pathophysiological mechanisms of pain. The new term, christened "nociplastic pain," joins "nociceptive pain" and "neuropathic pain" as terms officially adopted by the association to describe the underlying neurobiological basis of chronic pain.

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https://www.painresearchforum.org/news/92059-whats-name-chronic-pain

Handing out naloxone doesn’t fix opioid crisis | Dalla Lana School of Public Health

In the midst of a national opioid crisis, take-home naloxone programs have expanded rapidly. Ontario's Minister of Health and Long Term Care Dr. Eric Hoskins recently announced that naloxone kits will be provided to fire and police departments across the province, but U of T researchers are questioning whether naloxone distribution might distance people from health-care services or worsen health inequities.

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http://www.dlsph.utoronto.ca/2018/02/handing-out-naloxone-doesnt-fix-opioid-crisis/?

“Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain - Pain Research and Management

Background. Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity. Methods. A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach. Results. The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity. Conclusions. Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

https://www.hindawi.com/journals/prm/2018/6358624/

Migraine Relief May Be On The Way With New Therapies In Development : Shots - Health News : NPR

Humans have suffered from migraines for millennia. Yet, despite decades of research, there isn't a drug on the market today that prevents them by targeting the underlying cause. All of that could change in a few months when the FDA is expected to announce its decision about new therapies that have the potential to turn migraine treatment on its head.

The new therapies are based on research begun in the 1980s showing that people in the throes of a migraine attack have high levels of a protein called calcitonin gene–related peptide (CGRP) in their blood.

Step by step, researchers tracked and studied this neurochemical's effects. They found that injecting the peptide into the blood of people prone to migraines triggers migraine-like headaches, whereas people not prone to migraines experienced, at most, mild pain. Blocking transmission of CGRP in mice appeared to prevent migraine-like symptoms. And so a few companies started developing a pill that might do the same in humans.

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https://www.npr.org/sections/health-shots/2018/02/03/581092093/gone-with-a-shot-hopeful-new-signs-of-relief-for-migraine-sufferers?

PAS-18-624: Mechanistic investigations of psychosocial stress effects on opioid use patterns (R01- Clinical Trial Optional)

Psychosocial stress, defined here as socioenvironmental demands that tax the adaptive capacity of the individual (e.g., low socioeconomic status, childhood adversity, bullying), has repeatedly been linked to substance use disorders (SUDs). Neighborhood poverty and social support are shown to influence substance use patterns. Among smokers, multiple psychosocial stressors are associated with relapse, and acute psychosocial stress has been demonstrated to enhance cigarette craving and smoking behavior. Similarly, psychosocial stress has been associated with greater risk of relapse in individuals with alcohol and cocaine use disorders. Recent findings suggest that OUD might also be influenced by psychosocial stress, although the exact relationship and underlying mechanisms remain poorly understood.

In light of the current opioid epidemic in the United States, there is an urgent need to understand how psychosocial stress influences the risk for opioid misuse, abuse, and use disorder. According to the 2014 National Survey on Drug Use and Health (NSDUH), over 4 million Americans engaged in non-medical use of prescription opioids in the previous month, and approximately 1.9 million Americans met criteria for OUD. Further, according to the Center for Disease Control (CDC), deaths from drug overdose in the US exceeded 60,000 last year, surpassing the number of AIDS-related deaths at the height of the HIV/AIDS epidemic. Another recent CDC report indicates that areas with the largest number of filled prescriptions for pain medications also have higher rates of poverty and unemployment, implicating psychosocial stressors as factors that exacerbate opioid use patterns across the country. Notably, relatively few mechanistic studies have investigated the relationship between psychosocial stress and substance use disorders, of which only a fraction pertains to OUDs specifically.

This funding opportunity announcement seeks to address two specific mechanistic pathways via which psychosocial stress may modulate opioid use trajectories.The first pathway is through its effects on cognitive and affective systems that are also altered in OUDs. Stressful environments have been linked to impairments in reasoning, memory, inhibitory and cognitive control, and negative affect. Acute poverty, for example, has been shown to immediately impact performance on tasks measuring intelligence and cognitive control. Relatedly, there is substantial co-morbidity between OUD and stress-related affective disorders, including depression, anxiety and PTSD. Many neurobiological substrates and circuits that are thought to mediate cognitive and affective aspects of addiction are impacted by psychosocial stress. Taken together, these findings suggest that more research is warranted on the role of cognitive and affective systems mediating the effects of psychosocial stress on opioid use trajectories.

Psychosocial stress can also influence opioid use trajectories through its effects on pain processing. Of relevance here, adverse childhood experiences have been associated with an increased prevalence of pain-related medical conditions during adulthood and many individuals with stress-related psychiatric disorders have co-morbid chronic pain syndromes. This may be a consequence of overlapping neural circuits or substrates that are engaged by psychosocial stress and pain and that have been implicated in OUD. Recent estimates suggest that the rates of opioid misuse in patients with chronic pain range from 15-26%. Importantly, and germane to the discussion above, negative affect and the reduced ability to cope with negative emotions in pain appear to increase opioid misuse rates. Further research is needed to understand how the effects of psychosocial impacts on cognitive and affective components of pain may influence the opioid use trajectory. This knowledge may advance prevention and treatment strategies in chronic pain populations.

https://grants.nih.gov/grants/guide/pa-files/PAS-18-624.html

A Doctor’s Painful Struggle With an Opioid-Addicted Patient - Siddhartha Mukherjee - The New York Times

I once found myself entrapped by a patient as much as she felt trapped by me. It was the summer of 2001, and I was running a small internal-medicine clinic, supervised by a preceptor, on the fourth floor of a perpetually chilly Boston building. Most of the work involved routine primary care — the management of diabetes, blood pressure and heart disease. It was soft, gratifying labor; the night before a new patient's visit, I would usually sift through any notes that were sent ahead and jot my remarks in the margins. The patient's name was S., I learned. She had made four visits to the emergency room complaining of headaches. Three of those times she left with small stashes of opioids — Vicodin, Percocet, oxycodone. Finally, the E.R. doctors refused to give her pain medicines unless she had a primary-care physician. There was an open slot in my clinic the next morning, and the computer had randomly assigned her to see me.

We were living, then, in what might be called the opioid pre-epidemic; the barometer had begun to dip, but few suspected the ferocity of the coming storm. Pain, we had been told as medical residents, was being poorly treated (true) — and pharmaceutical companies were trying to convince us daily that a combination of long- and short-acting opioids could cure virtually any form of it with minimal side effects (not true). The cavalier overprescription of addictive drugs was bewildering: After a tooth extraction, I emerged from an oral surgeon's office with a two-week supply of Percocet.

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https://www.nytimes.com/2018/02/01/magazine/a-doctors-painful-struggle-with-an-opioid-addicted-patient.html

Natural painkiller nasal spray could replace addictive opioids, trial indicates | The Guardian

A nasal spray that delivers a natural painkiller to the brain could transform the lives of patients by replacing the dangerous and addictive prescription opioids that have wreaked havoc in the US and claimed the lives of thousands of people.

Scientists at University College London found they could alleviate pain in animals with a nasal spray that delivered millions of soluble nanoparticles filled with a natural opioid directly into the brain. In lab tests, the animals showed no signs of becoming tolerant to the compound's pain-relieving effects, meaning the risk of overdose should be far lower.

The researchers are now raising funds for the first clinical trial in humans to assess the spray's safety. They will start with healthy volunteers who will receive the nasal spray to see if it helps them endure the pain of immersing one of their arms in ice-cold water.

"If people don't develop tolerance, you don't have them always having to up the dose. And if they don't have to up the dose, they won't get closer and closer to overdose," said Ijeoma Uchegbu, a professor of pharmaceutical nanoscience who is leading the research through Nanomerics, a UCL startup.

If the first human safety trial is successful, the scientists will move on to more trials to investigate whether the nasal spray can bring swift relief to patients with bone cancer who experience sudden and excruciating bouts of pain.

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https://www.theguardian.com/us-news/2018/feb/01/natural-painkiller-nasal-spray-could-replace-addictive-opioids-trial-indicates?

News Archive | Pain Research Forum

All of our news and discussion content, research resources and member services are provided free to researchers, clinicians and others interested in the problem of chronic pain.

https://www.painresearchforum.org/news/archive

After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea - The New York Times

MUNICH — I recently had a hysterectomy here in Munich, where we moved from California four years ago for my husband's job. Even though his job ended a year ago, we decided to stay while he tries to start a business. Thanks to the German health care system, our insurance remained in force. This, however, is not a story about the benefits of universal health care.

Thanks to modern medicine, my hysterectomy was performed laparoscopically, without an overnight hospital stay. My only concern about this early release was pain management. The fibroids that necessitated the surgery were particularly large and painful, and the procedure would be more complicated.

I brought up the subject of painkillers with my gynecologist weeks before my surgery. She said that I would be given ibuprofen. "Is that it?" I asked. "That's what I take if I have a headache. The removal of an organ certainly deserves more."

"That's all you will need," she said, with the body confidence that comes from a lifetime of skiing in crisp, Alpine air.

I decided to pursue the topic with the surgeon.

He said the same thing. He was sure that the removal of my uterus would not require narcotics afterward. I didn't want him to think I was a drug addict, but I wanted a prescription for something that would knock me out for the first few nights, and maybe half the day.

With mounting panic, I decided to speak to the anesthesiologist, my last resort.

This time, I used a different tactic. I told him how appalled I had been when my teenager was given 30 Vicodin pills after she had her wisdom teeth removed in the United States. "I am not looking for that," I said, "but I am concerned about pain management. I won't be able to sleep. I know I can have ibuprofen, but can I have two or three pills with codeine for the first few nights? Let me remind you that I am getting an entire organ removed."

The anesthesiologist explained that during surgery and recovery I would be given strong painkillers, but once I got home the pain would not require narcotics. To paraphrase him, he said: "Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It's not good for your kidneys. Only take it if you must. Your body will heal itself with rest."

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https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-germany-vicodin.html?

Sourcing Painkillers from Scorpions’ Stings | The Scientist Magazine

Studying scorpions comes with its share of danger, as biologist Bryan Fry of the University of Queensland knows all too well. On a 2009 trip to the Brazilian Amazon, Fry was stung while trying to collect the lethal Brazilian yellow scorpion (Tityus serrulatus), and for eight hours he says it felt as though his finger was in a candle flame. Meanwhile, his heart flipped between racing and stopping for up to five seconds at a time. "At least the insane levels of pain helped keep my mind off my failing heart," Fry writes in an email to The Scientist.

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https://www.the-scientist.com/?articles.view/articleNo/51210/title/Sourcing-Painkillers-from-Scorpions--Stings/

Scientists Just Solved a Major Piece of the Opioid Puzzle | WIRED

When it comes to tackling the opioid crisis, public health workers start with the drugs: fentanyl, morphine, heroin. But biochemists have a different focus: Not the opioids, but opioid receptors—the proteins the drugs latch onto within the body.

These receptors embed themselves in the walls of cells throughout the brain and peripheral nervous system. There, they serve as cellular gatekeepers, unlocking not just the painkilling properties for which opioids are prized, but the severe, addictive, and often lethal side effects that, in 2016, contributed to the deaths of more than 50,000 people in the US.

But it doesn't have to be that way. "The idea in the field for many years has been to make an opioid that provides beneficial analgesic properties without the harmful side effects," says pharmacologist Bryan Roth, a physician researcher at University of North Carolina School of Medicine. Design a drug that kills pain, not people.

To build that drug, though, researchers need to know the shape of its receptor. This week in the journal Cell, Roth and nearly two dozen of his colleagues report for the first time the structure of the kappa opioid receptor while it's bound to a drug molecule, a discovery that could accelerate the discovery of less-addictive—and less deadly—opioids.

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https://www.wired.com/story/scientists-just-solved-a-major-piece-of-the-opioid-puzzle/

The Quest for Safer Opioid Drugs | The Scientist Magazine

Opioid drugs are well-established double-edged swords. Extremely effective at analgesia, they cause an array of harmful side effects throughout the body, including itching, constipation, and respiratory depression—the slowed breathing that ultimately causes death in overdose cases. What's more, the body's interaction with opioids is dynamic: our receptors for these compounds become desensitized to the drugs' activity over time, requiring ever larger doses to suppress pain and eventually provoking severe dependence and protracted withdrawal.

In the past few years, these side effects have plagued growing numbers of US citizens, plunging the country into the throes of a devastating opioid crisis in which nearly 100 people die from overdoses every day. Even so, opioids are still among the most effective pain-relief options available. "Over hundreds of years, [opioid receptors] have remained a target," says Laura Bohn, a biochemist at the Scripps Research Institute in Jupiter, Florida. "Therapeutically, it works."

Since the early 2000s, intriguing evidence has emerged suggesting that opioids' useful properties could be separated from their harmful attributes. (See "Pain and Progress," The Scientist, February 2014.) In 2005, Bohn, then at the Ohio State University College of Medicine, and colleagues showed that shutting down one of the signaling pathways downstream of the opioid receptor targeted by morphine not only amped up the drug's painkilling effects in mice, but also reduced constipation and respiratory depression (J Pharmacol Exp Ther, 314:1195-201).

That research opened the door to developing a new type of opioid: a "biased agonist" that could trigger analgesia without tripping the switches on other pathways that cause side effects. Now, more than a decade later, Trevena Inc.'s Olinvo (oliceridine)—a drug based on this principle and designated by the US Food and Drug Administration (FDA) as a breakthrough therapy—has completed Phase 3 clinical trials.

Olinvo is just one of many such drugs under development. From compounds that act only in specific regions of the body to those that engage multiple receptor types, researchers and pharmaceutical companies are trying many different tactics to produce less-dangerous opioids.

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https://www.the-scientist.com/?articles.view/articleNo/51159/title/The-Quest-for-Safer-Opioid-Drugs/