Psychology of Pain

Pain is top concern in Ohio and the nation

2012-01-27T09:43:00.001-05:00

CLEVELAND, Ohio -- High costs and the alarmingly high number of accidental deaths linked to prescription pain pills have made pain treatment a central issue in health care across Ohio and the nation.

A recent report by the Institute of Medicine underlined the urgency of developing better pain-management strategies in the United States, where chronic pain affects more than 116 million people and costs as much as $650 billion yearly in direct medical treatment and lost productivity.

"Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity," the report stated. "Given the burden of pain in human lives, dollars and social consequences, relieving pain should be a national priority."

Americans make up 4.6 percent of the world population and consume 80 percent of the global opiate supply, including nearly all of the hydrocodone supply, according to the American Society of Interventional Pain Physicians.

In August, an Ohio law went into effect requiring special licensing for pain clinics and doctors with 50 percent or more of patients being treated with controlled substances for chronic pain. The law tightly regulates record keeping on patients and mandates subspecialty certification and continuing education in pain management for physicians. The law also limits how many pills doctors can dispense and establishes a system for collecting unused narcotics.

In Ohio, deaths from unintentional prescription drug overdoses have increased more than 350 percent between 1999 and 2008, making it the leading cause of accidental death in the state since 2007.

With the tightening of regulations, learning the best way to prescribe painkillers, including narcotics, is critical for doctors.

The Institute of Medicine report said more research is needed so that physicians have better data to guide them when treating patients -- especially children and the elderly who sometimes cannot express their needs.

"Pain is something that the U.S. health care system doesn't deal with well," said Dr. Alan Hull, associate dean for curricular affairs in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. "We need to work on recognizing and treating pain appropriately."

Given the restraints on doctors' time during standard appointments, he said, "there certainly is a science and art to being able to read patients and develop a relationship with them."

The Institute of Medicine report recommended that medical education programs expand curriculum about pain.

Limited instruction for medical students

A separate study released last month by researchers from Johns Hopkins School of Medicine found that medical school curriculum addressing pain is limited and often fragmented.

"Health care has undergone dramatic changes in the last 25 years," stated the study published in the American Pain Society's Journal of Pain , "but inadequate treatment of pain has persisted." The study stated that the areas of cancer, pediatric and geriatric pain treatment are unaddressed by the vast majority of medical schools.

Dr. Jennifer Kriegler, associate professor of medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, said unlike when she was receiving her training, schools have been doing a much better job of teaching medical students and residents about pain -- especially chronic pain.

Medical schools throughout Ohio are devoting more time to classroom curriculum on chronic pain -- often linked to cases of drug abuse -- and to student observation of patients.

"Treating pain is much more than giving somebody medication," Kriegler said. "That's what students need to know. It takes a multifaceted approach."

Dr. David Ryan, who runs the pain management program at MetroHealth Medical Center, said doctors have to look at the whole patient. "The best pain physicians take time to listen to the patient and understand their problems, taking into consideration both the physical and emotional complexities," he said.

"Because pain is so complicated, it covers almost the entire spectrum of medical training," Ryan said, "as doctors learn the intricacies of how pain works."

'Not all pain is the same pain'

Research shows that pain tolerance varies from person to person, according to the Institute of Medicine report, which recommended that pain management be tailored to each patient's experience.

Dr. Salim Hayek, division chief of pain medicine at University Hospitals Case Medical Center, said patients -- even those with the same injury or illnesses -- perceive twinging, throbbing, aching or soreness very differently.

Pain is important, he said, because it's the body's signal that something is wrong. And, Hayek said, "Not all pain is the same pain." Acute pain from surgery, for example, eventually goes away, but chronic pain in the lower back may linger for months.

Yet, even if levels of discomfort are similar among people, Hayek added: "The drugs don't work on 100 percent of the patients or 100 percent of the pain." Everyone builds up a tolerance to a pain drug, he explained, but this occurs more quickly with younger patients. Doctors need to keep this and other factors in mind when considering a course of action.

The Institute of Medicine report said that managing pain is a challenge, and more research needs to be done to better understand treating pain.

Research already is revealing the negative effects of underdiagnosing and undertreating pain and that the "wait to see if it goes away" approach could have consequences.

Recent studies show that acute pain -- such as that accompanying burns or kidney stones -- should be treated immediately. Otherwise, there can be changes in the central nervous system and spinal cord that cause the pain to become worse. These changes can result in severe pain that lingers long after the original injury or disease is resolved.

Dependence after an acute condition

Physicians strive to find the balance of keeping patients comfortable and avoiding dependency on these powerful drugs.

"If someone has an acute condition, such as a broken ankle, by all means pain drugs can be safely prescribed for a short period of time -- two to five days," Hayek said.

Doctors said that the vast majority of the patients who need pain medications don't abuse them.

Medical students, Kriegler said, learn to start with where the pain begins and then move to family history and what's going on in the patient's life. "You can't get away from the brain being both an emotional and physiological organ," she said.

Dependence on drugs can occur for many reasons.

"A lot of times people take medication for an acute problem," she said, "but then what happens is, when the pain is gone, they realize the medication helped them in terms of something else -- such as easing their anxiety."

In cases where the injury has healed, other physiological sources have been ruled out and the pain continues, Kriegler said, "we need to treat the problem in the brain because that's where the change has occurred."

Even if there is no obvious source, the pain is very real to the patients. So doctors in training are being taught to find additional means to help patients get some relief.

"If a person says they cannot go to work because of pain," Kriegler said, "then maybe what they need is physical therapy." For other patients, regular exercise may help them begin to feel better, and that's a subject worth discussing.

Counseling could be in order for a patient who, for example, has suffered past abuse or has a fear of illnesses recurring because of family history, she said. "Medical students need to understand that if they cannot help patients, they need to get them to the right specialist who can."

Kathy Cole-Kelly, professor of family medicine at Case Western Reserve School of Medicine, said putting the patient in the center of treatment is key.

Cole-Kelly, who teaches communication skills at the medical school, said students are trained to look at the situation from the patient's perspective. That involves asking questions about a patient's life and listening. A patient with headaches may be worried because his uncle died of a brain tumor.

Family beliefs based on different cultures or heritages could be at the center of a patient's complaints about pain, she said. A patient is more likely to understand his situation if the doctor talks through the beliefs with the patient rather than just dismissing him, she said.

Cole-Kelly said medical students can learn these communication skills just as they learn to recognize physical ailments.

Once medical students get to the hospital floors, Kriegler said, they soon realize how emotional the pain can be for patients and their families.

"If you don't deal with the emotional aspects, you are not going to be a good doctor," Kriegler said.

http://blog.cleveland.com/health_impact/print.html?entry=/2012/01/pain_top_concern_in_ohio_and_t.html

In Rating Pain, Women Are the More Sensitive Sex - NYTimes.com

2012-01-23T21:23:00.001-05:00

Do women feel more pain than men?

It has long been known that certain pain-related conditions, like fibromyalgia,migraine and irritable bowel syndrome, are more common in women than in men. And chronic pain after childbirth is surprisingly common; the Institute of Medicine recently found that 18 percent of women who have Caesarean deliveries and 10 percent who have vaginal deliveries report still being in pain a year later.

But new research from Stanford University suggests that even when men and women have the same condition — whether it's a back problem, arthritis or asinus infection — women appear to suffer more from the pain.

There is an epidemic of chronic pain: Last year, the Institute of Medicineestimated that it afflicts 116 million Americans, far more than previously believed. But these latest findings, believed to be the largest study ever to compare pain levels in men and women, raise new questions about whether women are shouldering a disproportionate burden of chronic pain and suggest a need for more gender-specific pain research.

The study, published Monday in The Journal of Pain, analyzes data from the electronic medical records of 11,000 patients whose pain scores were recorded as a routine part of their care. (To obtain pain scores, doctors ask patients to describe their pain on a scale from 0, for no pain, to 10, "worst pain imaginable.")

For 21 of 22 ailments with sample sizes large enough to make a meaningful comparison, the researchers found that women reported higher levels of pain than men. For back pain, women reported a score of 6.03, men 5.53. For joint and inflammatory pain, it was women 6.00, men 4.93. Women reported significantly higher pain levels with diabetes, hypertension, ankle injuries and even sinus infections.

For several diagnoses, women's average pain score was at least one point higher than men's, which is considered a clinically meaningful difference. Over all, their pain levels were about 20 percent higher than men's.

Unfortunately, the data don't offer any clues as to why women report higher pain levels. One possibility is that men have been socialized to be more stoic, so they underreport pain. But the study's senior author, Dr. Atul Butte, an associate professor at Stanford's medical school, said that explanation probably did not account for the gender gap.

"While you can imagine such a bias," he said, "across studies, across thousands of patients, it's hard to believe men are like this. You have to think about biological causes for the difference."

An extensive 2007 report by the International Association for the Study of Pain cited studies showing that sex hormones may play a role in pain response. In fact, some of the gender differences, particularly regardingheadache and abdominal pain, begin to diminish after women reachmenopause.

Research also suggests that men and women have different responses toanesthesia and pain drugs, reporting different levels of efficacy and side effects. That bolsters the idea that men and women experience pain differently.

One reason for the lack of information about sex differences is that many pain studies, in both animals and humans, are done only in males. One analysis found that 79 percent of the animal studies published in a pain journal over a decade included only male subjects, compared with 8 percent that used only female animals.

In addition, experiments testing pain in men and women have shown that they typically have different thresholds for various types of pain. In general, women report higher levels of pain from pressure and electrical stimulation, and less pain when the source is from heat.

Melanie Thernstrom, a patient representative on the Institute of Medicine pain committee from Vancouver, Wash., said the newest research "really highlights the need for more treatment and better treatment that is gender-specific, and the need for far more research to really understand why women's brains process pain differently than men."

Some researchers believe the pain experience for women may be even more complicated. Women who have given birth, for instance, may have a different threshold for "worst pain ever," causing them to underreport certain types of pain. The bottom line, Dr. Butte said, is that far too little is known about how men and women experience pain and that more study is needed so that, ultimately, pain treatment can be customized to each patient's needs.

"If doctors have a threshold for when they give a dose or start a medication," he said, "you could imagine that the number they are using is too high or too low because a person may be in more pain than they are saying.

"In the end, it comes down to what the brain perceives as pain."

http://well.blogs.nytimes.com/2012/01/23/in-rating-pain-women-are-the-more-sensitive-sex/

Rat helps pinpoint pain molecule : Nature News & Comment

2012-01-23T09:49:00.001-05:00

An uncharted trawl through thousands of small molecules involved in the body's metabolism may have uncovered a potential route to treating pain caused by nerve damage.

Neuropathic pain is a widespread and distressing condition, and is notoriously difficult to treat. So Gary Siuzdak, a chemist and molecular biologist at the Scripps Research Institute in La Jolla, California, and his team decided to take an unusual route to finding a therapy. Their results are published today in Nature Chemical Biology1.

They took rats with surgically damaged paws, who were consequently suffering from neuropathic pain, and instead of analysing changes in gene expression and proteins in the animals, focused on metabolites – the biochemical intermediates and end-products of bodily processes such as respiration and the synthesis and breakdown of molecules. The science that looks at the body's metabolite composition is known as metabolomics. Using mass spectrometry, which can detect many different chemicals simultaneously, the researchers were able to identify the metabolites present in these animals 21 days after surgery.

Surprise finding

The team analysed samples of the injured rats' blood plasma, of tissue near the injured paw, and of tissue from different areas of the spinal column, and compared the metabolites present with that of the same site in healthy rats. One particular area differed markedly between the two cases: the dorsal horn in the spinal column.

"It took me by surprise," says Siuzdak, who had expected to see most differences in metabolite composition near the site of injury.

The researchers then looked more closely at the metabolites and recognized that the ones that were changing the most were associated with the metabolic pathway that synthesizes and breaks down the phospholipid sphingomyelin, a component of cell membranes, and its ceramide precursors.

"It was a huge flare to us that this was something we should home in on," says team member Gary Patti, a chemist at Washington University School of Medicine in St Louis, Missouri.

Using cultures of spinal cord cells the researchers then tried to work out which of the altered metabolites might be responsible for pain. One molecule, the previously unidentified metabolite N,N-dimethylsphingosine (DMS), stood out for the amount of pain signalling it triggered in the cells.

Untargeted screening

To test experimentally whether this molecule was involved in neuropathic pain, the team then injected small amounts of DMS into healthy rats, and sure enough, those rats showed signs of pain.

The team hopes that DMS might prove to be important in the biochemistry of pain, and perhaps offer a target for drug manufacturers. But neuropathic pain expert Andrew Rice at Imperial College London says that in the past 30 years he has seen many targets identified, but virtually none of them has made it into the clinic as an effective pain-relief drug.

Rice lauds the attention shown to neuropathic pain but is concerned that the current animal model for pain is limited: it only corresponds to pain resulting from trauma, and not to the many other sources of neuropathic pain, which include diabetes, HIV infection and stroke. "I'd like to see if this is more than a peripheral nerve damage model," he says.

Siuzdak says his untargeted screening technique could prove useful in identifying drug targets for many other conditions. The more conventional way of using metabolomics is with targeted searches, where the molecule of interest is identified first, before seeing where it might be present. "[Our approach] is more challenging than targeted analyses," he says. "You have to be open to any possibility of what pathways are affected."

When Patti and Siuzdak started to work on this project, their technique was very time consuming, but as methods have improved and their database of metabolites has grown, they are confident that they could use an untargeted metabolite screen in many other scenarios. The potential of this technique, they say, is to find things that would never have been considered before – like that unknown metabolite DMS.

http://www.nature.com/news/rat-helps-pinpoint-pain-molecule-1.9871

Reports of Lost or Stolen Medications: Difficult Conversations - PainEdu.org

2012-01-18T17:09:00.001-05:00

It is not unusual for a patient to report to their prescribing clinician that they have discovered that their prescription pain medication (or the written prescription) has been either lost or stolen, leading them to request a new prescription. It is important to distinguish between lost medications and stolenmedications.

Losing a prescription form or a vial of medications may result from the occasional lapses that all patients may have. If this occurs only once it may not have significant medical implications, and the prescriber may choose to replace it without much concern. Losing a medication more than once, however, may imply that something else is going on. There are many possibilities. Is the patient experiencing some type of cognitive impairment, perhaps one that is being made worse by the medication? Does the patient need a further neurological evaluation? Is the patient impaired by the use of other substances? Should a urine drug screen and some simple labs including CBC, metabolic panel, and thyroid function studies, be done even as early as the first incident of a lost prescription? Is the patient misusing the prescription and running out of it early because they are taking more than prescribed, giving it away, or selling it?

Taking a consistent approach to a lost prescription is made much easier if the provider has reviewed their policy about this with the patient ahead of time. If this has not been done, the first time there is a lost prescription is not too late to create a written patient/provider agreement, outlining each of their roles and responsibilities.

Clinicians in practice with multiple-providers should establish and circulate a uniform, clinic-wide policy among patients and staff, to avoid confusion about what they do. Some practices choose a "one and done" policy, (the first time you lose it I will refill it, but never again), or a stricter policy of zero-tolerance, and no early refills, under any circumstance.

If you are not replacing the lost medication, you will need to inform the patient about the potential for withdrawal, and offer to prescribe medications to help diminish withdrawal symptoms. Prescribing these medications needs to be individualized, based upon the patient's age, presence of other medical problems, use of other medications, and the patient's ability to follow-up.

The problem of reports of stolen prescriptions is more ominous because there is another person involved, and potentially, another person has been put at risk. Medication theft is a situation that requires some form of investigation and should be reported to the appropriate authorities. It is important for the patient to think about who might have stolen the medication.

In my clinical practice I do not provide an early refill for a stolen prescription. Other providers may take a "one and done" approach to stolen prescriptions as well as lost prescriptions. Again, with stolen medication, I will educate the patient about withdrawal symptoms and develop a plan to manage them if they occur.

Repeated medication loss, or theft, is a strong indication that the patient is at high risk and that it is not safe for this patient to remain on this medication. If a medical reason, like cognitive decline, is discovered, this may be successfully addressed so that the patient can continue on the medication. However, if this cannot be done, or if the patient lives in an unsafe environment, the best course may be to taper and discontinue these medications, substituting treatments that are lower risk.

Describing how you address these problems before the patient has begun treatment, and before incidents of lost or stolen medication, is part of your description of the treatment plan, and it demonstrates the principal of shared responsibility.

http://www.painedu.org/articles_timely.asp?ArticleNumber=60&

Compact Clinical Guide to Geriatric Pain Management - An Evidence-Based Approach for Nurses | Ann Quinlan-Colwell / Yvonne D'Arcy

2012-01-18T17:06:00.001-05:00

The care of older adults suffering with pain is a difficult task that calls for understanding as well as compassion. Dr. Quinlan-Colwell has written an excellent book that deals with every facet of the problems that are encountered by caregivers. Elderly people present challenges that call for recognition of the fact that pain affects sleep, appetite, social interactions, and many other facets of life that require attention. Dr. Quinlan-Colwell carries the reader into the lives of elderly people and provides the information necessary to bring psychological comfort as well as knowledge to help people control pains that destroy the quality of their lives. Needless pain is a tragedy that calls for a better understanding of the psychological, social, and medical dimensions of life. This book highlights all of these dimensions and provides the reader with valuable knowledge that will diminish suffering and enrich the lives of people confronting new, often frightening, problems.

The recognition that pain is a multidimensional experience determined by psychological as well as physical factors has broadened the scope of pain therapies. Patients with chronic pain need every possible therapy to battle the pain. Chronic pain is not a symptom but a syndrome in its own right and requires therapists from a wide range of disciplines.

Psychological therapies, which were once used as a last resort when drugs or neurosurgery failed to control pain, are now an integral part of pain management strategies. The recognition that pain is the result of multiple contributions gave rise to a variety of psychological approaches such as relaxation, hypnosis, and cognitive therapies. So too, transcutaneous electrical nerve stimulation and other physical therapy (PT) procedures emerged rapidly, bringing substantial pain relief to large numbers of people. Nursing is an integral part of all therapies and provides the binding unity essential for the elderly patient.

The field of pain continues to develop and there are reasons to be optimistic about its future. First, imaging techniques have confirmed pain-related activity in widely distributed, highly interconnected areas of the brain. An implication of the concept is that neural programs that evolved in the brain to generate acute pain as a result of injury or disease may sometimes go away and produce destructive chronic pain. Future imaging research may reveal the sites of abnormally prolonged activity in chronic pain patients. Second, the detailed knowledge and technical skills developed by scientists for research on the spinal cord can be used to explore brain mechanisms in humans and animals, especially in the brain stem reticular formation, which is known to play a major role on chronic pain. Third, our knowledge of the genetic basis of pain as well as the development of the brain is growing rapidly. Genetic factors are known to contribute to a large number of chronic pain syndromes, and future research will highlight their brain mechanisms. The inevitable convergence of these three approaches will hopefully lead to the relief of pain and suffering now endured by millions of people.

Ronald Melzack, PhD, FRSC

Professor Emeritus McGill University

http://www.springerpub.com/product/9780826107305#.TxdBspiXvoQ

High-dose opiates could crack chronic pain : Nature News & Comment

2012-01-16T21:29:00.001-05:00

Has a cheap and effective treatment for chronic pain been lying under clinicians' noses for decades? Researchers have found that a very high dose of an opiate drug that uses the same painkilling pathways as morphine can reset the nerve signals associated with continuous pain — at least in rats.

If confirmed in humans, the procedure could reduce or eliminate the months or years that millions of patients spend on pain-managing prescription drugs. The results of the study are described today in Science.

"We have discovered a new effect of opiates when they are given, not constantly at a low dose, but at a very high dose," says Jürgen Sandkühler, a neurophysiologist at the Center for Brain Research of the Medical University of Vienna, and a co-author of the paper.

Chronic pain is a nerve condition that lingers long after the immediate, or acute, pain-causing stimulus has receded. It can follow surgery or injury, and is also associated with conditions such as rheumatoid arthritis and cancer.

Sandkühler says that the original stimulus changes how the central nervous system deals with pain over time. In a model known as long-term potentiation, nerves carrying pain signals fire repeatedly, turning on a cellular pain amplifier that causes anything from exaggerated pain to outright agony on a long-term basis.

Opiates such as morphine and heroin remain the 'gold standard' in pain relief, but they work only temporarily for those with chronic pain. Sandkühler and his colleagues decided to push the boundaries of the opiates' action and measure whether the drugs could have any effect on the underlying problem.

The team induced long-term potentiation in 25 rats by exposing nerve fibres known to carry pain signals to low-frequency electrical stimulation. They subjected some of the rats to high-frequency electrical stimulation, or gave them injections of capsaicin, the pain-causing ingredient in chill peppers, as alternative stimuli.

After the pain stimulus ceased, the researchers gave the rats a very high intravenous dose of the opiate remifentanil. As expected, the pain signals slumped at once — remifentanil is an extremely fast-acting painkiller, and was chosen because its effects tend to wear off in rats after just 10 minutes.

When the drug's effects did wear off, the chronic pain was significantly reduced in the rats treated with low-frequency stimulation. A second infusion of the drug an hour later abolished the long-term potentiation and restored these rats' pain levels to normal. A high dose of remifentanil was also effective in reducing the pain of the rats treated with capsaicin or high-frequency stimulation.

Treating the rats with half the dose of remifentanil did not produce the same effect. Sandkühler suggests that a threshold level of the drug is needed to disrupt the movement of calcium signalling ions between nerves and neutralize the long-term potentiation.

"The dose of drugs we use is very high, probably 2–4 times higher than used for normal pain control," says Sandkühler. "The animals almost stop breathing, which is probably one reason why this was not discovered before."

But he adds that the equivalent amount of the opiate for a human is well below a fatal dose. He and his colleagues have conducted pre-clinical experiments that have shown that people can tolerate it.

Michael Serpell, a consultant anaesthetist and pain doctor at the University of Glasgow School of Medicine, UK, is impressed with the paper's methodology. He says the idea has always been that if you hit acute pain hard enough, then you can reduce the chance of it becoming chronic. "It would be appropriate to try this. It could be rolled out into the clinical arena in high-risk patients first," he says.

However, Serpell cautions that a similar approach, applying a pre-emptive analgesic before surgery that was likely to cause chronic pain, produced promising results in animal studies but later trials in humans were "a complete failure".

Treatments are certainly needed for chronic pain, which may affect up to one in six adults across the world; Serpell says that 3–5% of the adult population in the United Kingdom is prevented from working by pain. The condition is the second most common reason for claiming incapacity benefit.

http://www.nature.com/news/high-dose-opiates-could-crack-chronic-pain-1.9796

Resolving Chronic Pain | The Scientist

2012-01-10T07:52:00.001-05:00

Resolving Chronic Pain

The body's own mechanism for dispersing the inflammatory reaction might lead to new treatments for chronic pain.

By Claudia Sommer and Frank Birklein

Inflammation is correctly blamed as one of the root causes of both acute and chronic pain—and more. Not only does chronic inflammation underlie disorders such as rheumatoid arthritis, inflammatory bowel disease, and other autoimmune diseases, it has also been implicated in the pathogenesis of cancer, chronic heart failure, and neurological disorders such as Parkinson's and Alzheimer's diseases. These conditions affect millions, and carry high health-care and socioeconomic costs. And yet, inflammation is an important physiological response that jump-starts tissue repair and more carefully tunes immune reactions. Without it, we could not fight off infection or heal from injury. Why and how does this powerful ally turn into a foe?

A patient who had consulted us earlier about other problems came in complaining of swelling in her right hand, accompanied by incessant pain that left her unable to move her arm very much. An otherwise healthy 47-year-old, she had worked as a bookseller until slipping on ice and fracturing her wrist a few weeks earlier, experiencing what she described as the worst pain of her life. Surgery had been successful, but as she healed, the swelling in her wrist did not resolve. Instead, the swelling had extended to the whole hand, even increasing after her cast was removed, and the hand had become exquisitely sensitive. It appeared to be permanently swollen, reddish in color, and was usually warmer than her other hand. Because of the pain, she was unable to return to her job or perform any exercise, and needed help with many everyday tasks. X-rays did not reveal any pathology that would explain the pain. Treatment with anti-inflammatory drugs like aspirin was ineffective; even morphine provided little relief.

Her doctors finally arrived at a diagnosis of complex regional pain syndrome and she began a multicomponent pain treatment program. Treatment included very specific physical and cognitive therapies that resulted in a 90 percent restoration of hand function and a reduction in pain. Today, complex regional pain syndrome is thought to be initiated by an unusually strong and long-lasting inflammatory reaction to trauma, although its treatment is not always so successful.

Although not all cases of chronic pain involve inflammation, the majority do. Therapy options for chronic pain are complicated because of the ongoing nature of the symptom.

In chronic pain, the inflammatory factors are never completely cleared from the system.
While the causes of chronic pain are many and diverse, the pervasive effect it has on a patient's life—including inability to work, anxiety, depression, and even post-traumatic stress disorder—is universal. Opiates such as morphine are considered among the best medications for relieving pain, but they carry a risk of tolerance and addiction, especially with long-term use. Many doctors thus prefer to prescribe anti-inflammatory drugs such as cyclooxygenase (COX) inhibitors. COX inhibitors, like aspirin or ibuprofen, however, can cause gastrointestinal bleeding and kidney damage when used at high doses, and selective COX-2 inhibitors such as Vioxx have been shown to increase the risk of cardiovascular disease. In addition, these drugs are most effective for mild and moderate pain; they have a "ceiling" beyond which taking more provides no more relief.

One difference between acute inflammation and the persistent inflammation that leads to chronic pain, is that in the latter, the inflammatory factors are never completely cleared from the system. Recent research has revealed that the clearing of these inflammatory factors is an active process rather than a passive one that simply occurs over time. This insight offers the possibility that we might be able to harness resolution factors that clear inflammation and use them to ameliorate the pain that accompanies chronic inflammation.

Reducing inflammation

In 2000, while looking for bioactive molecules derived from the metabolism of omega-3 fatty acids, Charlie Serhan's laboratory at Brigham and Women's Hospital at Harvard Medical School discovered a compound that naturally reduces inflammation after an acute reaction.1,2 Omega-3 fatty acids, which can be found in foods such as fish and flaxseed oil, include eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These two fatty acids have long been known to have beneficial effects in reducing the risk of several diseases, including atherosclerosis, asthma, heart disease, and cancer. The American Heart Association even recommends the consumption of fish rich in omega-3 fatty acids for cardiovascular disease prevention. However, it was not known whether omega-3 fatty acids actively reduced inflammation. The problem was confounded by the fact that many studies investigating the effects included patients who were also taking aspirin, making it difficult to tease apart the anti-inflammatory contribution of each. The Serhan laboratory set out to analyze the interaction of EPA and DHA with aspirin and to identify molecular components derived from the fatty acids.

First, they analyzed the composition of lipid-based compounds that were present in tissues during the resolution of acute inflammation in the mouse. Mice produced fatty acid metabolites that the investigators dubbed "resolvins" for their ability to reduce the inflammatory reaction. Although these compounds appeared to clear the inflammation, the process was different from active suppression of the immune system. The resolvins did not hinder immune cell action; rather, they reduced the inflammatory activity of specific populations of cells and blocked their production of pro-inflammatory chemokines, while increasing the action of immune cells that clear dead tissue.

Serhan's team also showed that these resolving molecules were naturally derived from omega-3 fatty acids—and that aspirin enhanced this conversion. When they then administered the resolvins to animal models of acute and chronic inflammation such as peritonitis, colitis, or asthma, they saw an accelerated return to homeostasis.

The study demonstrated how aspirin could increase the production of the body's own natural inflammation mediators by catalyzing the metabolism of the touted omega-3 fatty acids into chemical forms that diminish inflammation. In addition, it appeared that these newly discovered mediators permitted the aggressive acute inflammation stage to occur, which is so physiologically important, before then subduing the reaction and returning the body to homeostasis. But it was not yet clear whether the reduction in inflammation would also reduce pain.

Inflammation includes a number of processes, not all of which are associated with pain. For example, while systemic infections, like the flu or a cold, spur strong inflammatory reactions, they are only occasionally associated with pain. Pain only occurs when inflammatory cytokines are released near nociceptive, or damage-signaling, nerve fibers. Damaged tissues release their contents during injury or inflammation, flooding the surrounding tissues with prostaglandins (PGs) and bradykinin, which activate the secretion of histamines. Together, these chemicals make blood vessels leaky enough to permit immune cells to enter the damaged tissue from the circulation, releasing PGs creating the swelling that is a cardinal symptom of inflammation. When this process occurs in richly innervated tissues, the inflammatory mediators also cause nearby nociceptors to fire, conveying the sensation of pain.

Resolving the pain

Given that resolvins are derived from omega-3 fatty acids—that is, from essential nutritional factors—and that they are endogenous anti-inflammatory substances, it seemed a likely hypothesis that they would also have an effect on inflammation-related pain. In 2010, the lab of Ru-Rong Ji at Brigham and Women's Hospital in Boston, in collaboration with Serhan, explored this question.3

Using an animal model of pain, investigators injected the paws of mice with formalin, which produces two phases of pain: an immediate reaction, relayed by the peripheral nerves; and a delayed-onset reaction, mediated by inflammation and by spinal cord neurons.3The first phase is characterized by mice licking the injected foot for about five minutes after injection. Then, after a lag of 20–30 minutes, the second phase begins with another bout of foot licking. The researchers administered two different resolvin (Rv) molecules, RvD1 and RvE1, to test their ability to reduce this pain behavior, and found both molecules to be effective when injected either into the paw or directly into the spinal canal. They noted that RvE1 diminished swelling and reduced markers of the inflammatory response, and that, compared to either morphine or COX-2 inhibitors, a much lower dose of the resolvin effectively halted pain behavior. Interestingly, only the second phase of pain behavior—mediated by spinal cord mechanisms that are often associated with chronic pain—was attenuated, indicating that RvE1 and RvD1 were likely acting via a receptor known as ChemR23, a G protein–coupled receptor found on nociceptive neurons in the dorsal root ganglia and the dorsal horn of the spinal cord. These neurons also express the transient receptor potential vanilloid 1 (TRPV1), which is the receptor for the inflammation-producing irritant found in chili pepper, capsaicin. In living mice, RvE1 was able to block the pain induced by capsaicin.

The same researchers looked at another model of inflammatory pain induced by the injection of carrageenan, which also initiates two phases of pain, but is thought to more closely mimic standard muscle pain than the formalin model. When the mice were given RvE1 or RvD1 in the hindpaw before a carrageenan injection, the pretreatment markedly reduced inflammation: the mice showed diminished swelling, fewer immune effector cells called neutrophils infiltrating the damaged tissue, and a reduced level of pro-inflammatory cytokines. Just like morphine, RvE1 did not dull the ability to sense "normal" pain. In other words, the mice did not experience numbing, but rather a more specific alleviation of the pathologic pain associated with inflammation.

Recently, researchers have begun to investigate whether chronic persistent pain might be the result of a learning response in neurons of the spine. Neurons change shape when they are actively involved in learning, both in terms of the number of physical connections between cells and the number of receptors at the synapses of those connections. Researchers have proposed that when pain persists, the neuronal connections relaying that pain strengthen, making it easier to transmit the response—thus lowering the threshold at which something feels painful.

To test whether resolvins might prevent the formation of this learned pain reaction in the spine, researchers took slices of mouse spinal cord and tested how the transmission between neurons changed in the presence and absence of resolvins. Resolvins blocked an increase in the action of tumor necrosis factor-alpha (TNF-α)—a cytokine thought to increase the frequency of synaptic transmission, and thus possibly the likelihood of forming a "pain memory"—without blocking the normal levels of transmission. Then, the authors showed that RvE1 also inhibited glutamate release—required for some types of neuronal learning—by a pathway dependent on the extracellular signal-regulated kinase (ERK). Additionally, RvE1 changed the activity of the glutamate N-methyl-D-aspartic acid receptor (NMDAR), also via the ERK pathway, supporting the concept that blocking the ERK pathway could be a promising therapeutic target for the treatment of pain.

Since the publication of the first paper by Ji and colleagues describing the analgesic effect of resolvins, others have followed. These new studies described positive effects in other pain models, and have uncovered additional mechanisms by which resolvins can diminish pain. For example, RvD1 was shown to reduce, prevent, and transiently attenuate pain associated with operation trauma in a rat model.4 In this study, an oversensitivity to pain, in which a touch that is normally benign feels painful, was reduced or prevented by 20 to 40 nanograms of RvD1 injected into the spinal cord up to 2 days after the surgical trauma. However, if RvD1 was given on postoperative day 9 or 17, the reversal of pain was only transient and incomplete.

In a model of pain that mimics inflammatory arthritis in rats, RvD1 reduced an increased sensitivity to pain. The effect was partially mediated by a decrease in TNF-α and interleukin-1β—cytokines that drive inflammation and are also thought to increase pain hypersensitivity in the central nervous system.5 In this model, systemic injection, rather than spinal administration, of the resolvins was shown to be effective, providing a much more feasible clinical application, as spinal injections themselves are associated with significant pain. Furthermore, in cell culture, RvD1 inhibited other members of the TRP family of receptors.6 Subsequent in vivo experiments demonstrated that injecting RvD1 under the skin was sufficient to attenuate pain caused by direct activation of these TRP receptors in the mouse.

A clearer picture for the future

From the animal data summarized above, it appears that resolvins may be ideal candidates for novel analgesics. Because they are derived from lipid molecules normally produced in the body, resolvins counteract inflammation in a physiological way. Their precursors, the omega-3 fatty acids, have been tested with some success in treating pain conditions,7 although a recent meta-analysis did not show a definitive effect. However, resolvins appear to show effects at concentrations about 10,000 times lower than effective doses of omega-3 fatty acids—an advantage for drug development.

Intriguingly, one of the mechanisms that Ji and colleagues identified for the analgesic action of the resolvins is that they block various TRP receptors (particularly TRPV1) indirectly by blocking the TRPV1-dependent release of glutamate.3 This is particularly interesting insomuch as it may provide a better avenue for blocking TRPV. In fact, recently developed TRPV1 antagonists that have been tested in humans resulted in serious side effects such as high fever. The reason for this side effect is most likely that TRPV1 not only conveys information about pain, but also about temperature. Complete blockade of this receptor, therefore, would also block information about fever from reaching the brain, which would be unable to respond by initiating cooling mechanisms such as sweating. Since resolvins block glutamate rather than directly acting on TRPV1, they might avoid such life-threatening side effects.

Side effects of blocking TRP might be reduced even more with the use of resolvins that act specifically on certain TRP receptors, as recently demonstrated in vitro and in vivo with RvD1, which appears to be specific for TRPV3. This receptor specificity may potentially pave the way to a more tailored treatment for individual pain symptoms such as thermal or mechanical pain hypersensitivity. A further potential advantage of resolvins is that they may have a dual function as both an analgesic and an inflammatory disease-modifying drug. In fact, a number of molecules with this potential have already been investigated, including nerve growth factor and its antagonists in the treatment of nerve lesions, neuropathic pain, or osteoarthritis; erythropoietin in diabetic neuropathy; and cytokine inhibitors in rheumatoid arthritis.8Unfortunately, of these, currently only the cytokine inhibitors have made it to clinical application.

The challenge now, as it is for every promising molecule at the preclinical stage of investigation, will be to develop resolvins into a clinically applicable form. Many of the experimental applications have been via spinal injection, which would limit the use in humans. As drugs, these molecules would need to be stable—so that they could be taken orally, for example—and long-acting. Because they act on the immune system, they might have unwanted side effects, which will need to be investigated further. In addition, although the results reported by Ji and others are impressive and reasonable, the size of the effect on pain behavior in the animals is moderate. Other analgesic drugs, which had even stronger effects than the resolvins in animal models, have failed in human clinical trials because their impact was not sufficiently different from that of placebos. The reason might be that human pain still differs significantly from even the best and most elaborate animal pain models. With all these caveats, testing resolvins in clinical trials will be the best way to determine if alleviating chronic low-grade inflammation, a factor underlying not only pathogenic pain but diseases ranging from cancer to obesity, could reduce morbidity and mortality.

Claudia Sommer is at the University of Würzburg, in Germany, and Frank Birklein is at the University Medical Center of the Johannes Gutenberg University Mainz.

This article is adapted from a review in F1000 Medicine Reports, DOI:10.3410/M3-19 (open access athttp://f1000.com/reports/m/3/19/).

http://the-scientist.com/2012/01/01/resolving-chronic-pain/

How Yoga Can Wreck Your Body - NYTimes.com

2012-01-05T05:50:00.001-05:00

On a cold Saturday in early 2009, Glenn Black, a yoga teacher of nearly four decades, whose devoted clientele includes a number of celebrities and prominent gurus, was giving a master class at Sankalpah Yoga in Manhattan. Black is, in many ways, a classic yogi: he studied in Pune, India, at the institute founded by the legendary B. K. S. Iyengar, and spent years in solitude and meditation. He now lives in Rhinebeck, N.Y., and often teaches at the nearby Omega Institute, a New Age emporium spread over nearly 200 acres of woods and gardens. He is known for his rigor and his down-to-earth style. But this was not why I sought him out: Black, I'd been told, was the person to speak with if you wanted to know not about the virtues of yoga but rather about the damage it could do. Many of his regular clients came to him for bodywork or rehabilitation following yoga injuries. This was the situation I found myself in. In my 30s, I had somehow managed to rupture a disk in my lower back and found I could prevent bouts of pain with a selection of yoga postures and abdominal exercises. Then, in 2007, while doing the extended-side-angle pose, a posture hailed as a cure for many diseases, my back gave way. With it went my belief, naïve in retrospect, that yoga was a source only of healing and never harm.

At Sankalpah Yoga, the room was packed; roughly half the students were said to be teachers themselves. Black walked around the room, joking and talking. "Is this yoga?" he asked as we sweated through a pose that seemed to demand superhuman endurance. "It is if you're paying attention." His approach was almost free-form: he made us hold poses for a long time but taught no inversions and few classical postures. Throughout the class, he urged us to pay attention to the thresholds of pain. "I make it as hard as possible," he told the group. "It's up to you to make it easy on yourself." He drove his point home with a cautionary tale. In India, he recalled, a yogi came to study at Iyengar's school and threw himself into a spinal twist. Black said he watched in disbelief as three of the man's ribs gave way — pop, pop, pop.

After class, I asked Black about his approach to teaching yoga — the emphasis on holding only a few simple poses, the absence of common inversions like headstands and shoulder stands. He gave me the kind of answer you'd expect from any yoga teacher: that awareness is more important than rushing through a series of postures just to say you'd done them. But then he said something more radical. Black has come to believe that "the vast majority of people" should give up yoga altogether. It's simply too likely to cause harm.

Not just students but celebrated teachers too, Black said, injure themselves in droves because most have underlying physical weaknesses or problems that make serious injury all but inevitable. Instead of doing yoga, "they need to be doing a specific range of motions for articulation, for organ condition," he said, to strengthen weak parts of the body. "Yoga is for people in good physical condition. Or it can be used therapeutically. It's controversial to say, but it really shouldn't be used for a general class."

Black seemingly reconciles the dangers of yoga with his own teaching of it by working hard at knowing when a student "shouldn't do something — the shoulder stand, the headstand or putting any weight on the cervical vertebrae." Though he studied with Shmuel Tatz, a legendary Manhattan-based physical therapist who devised a method of massage and alignment for actors and dancers, he acknowledges that he has no formal training for determining which poses are good for a student and which may be problematic. What he does have, he says, is "a ton of experience."

"To come to New York and do a class with people who have many problems and say, 'O.K., we're going to do this sequence of poses today' — it just doesn't work."

According to Black, a number of factors have converged to heighten the risk of practicing yoga. The biggest is the demographic shift in those who study it. Indian practitioners of yoga typically squatted and sat cross-legged in daily life, and yoga poses, or asanas, were an outgrowth of these postures. Now urbanites who sit in chairs all day walk into a studio a couple of times a week and strain to twist themselves into ever-more-difficult postures despite their lack of flexibility and other physical problems. Many come to yoga as a gentle alternative to vigorous sports or for rehabilitation for injuries. But yoga's exploding popularity — the number of Americans doing yoga has risen from about 4 million in 2001 to what some estimate to be as many as 20 million in 2011 — means that there is now an abundance of studios where many teachers lack the deeper training necessary to recognize when students are headed toward injury. "Today many schools of yoga are just about pushing people," Black said. "You can't believe what's going on — teachers jumping on people, pushing and pulling and saying, 'You should be able to do this by now.' It has to do with their egos."

When yoga teachers come to him for bodywork after suffering major traumas, Black tells them, "Don't do yoga."

"They look at me like I'm crazy," he goes on to say. "And I know if they continue, they won't be able to take it." I asked him about the worst injuries he'd seen. He spoke of well-known yoga teachers doing such basic poses as downward-facing dog, in which the body forms an inverted V, so strenuously that they tore Achilles tendons. "It's ego," he said. "The whole point of yoga is to get rid of ego." He said he had seen some "pretty gruesome hips." "One of the biggest teachers in America had zero movement in her hip joints," Black told me. "The sockets had become so degenerated that she had to have hip replacements." I asked if she still taught. "Oh, yeah," Black replied. "There are other yoga teachers that have such bad backs they have to lie down to teach. I'd be so embarrassed."

More ...

http://www.nytimes.com/2012/01/08/magazine/how-yoga-can-wreck-your-body.html?pagewanted=print

A young woman struggles with oxy addiction and recovery - Tampa Bay Times

2011-12-28T20:17:00.001-05:00

ST. PETERSBURG, Florida

When her mom came to pick her up for drug court that morning, Stacy Nicholson was still high.

She staggered to the door, fumbled with the bungee cord that kept it closed, blinked back the sunlight.

"You ready?" asked her mom.

Stacy and two of her cousins had been holed up for months in this rundown house, shooting crushed-up pain pills. Used syringes littered an end table. Stacy's mom had kept telling her: Someone in this house is going to die.

Stacy, then 28, knew she was right. Days before, she had told her mom she was tired of stealing and doctor shopping to get pills. She was in trouble for skipping her last court date, so today, she planned to turn herself in.

"Okay," Stacy said. "Let's go."

She twisted her long, honey-colored hair into a knot. Zipped her sweatshirt. Underneath, she was wearing two bras, a tank top, two white T-shirts and three pairs of panties.

She wanted to be sure she would have a change of underwear in jail.

COURTROOM 10 WAS PACKED when Stacy and her mom, Sherry Alkire, slid into the back row. It was Feb. 1, a Tuesday.

More than 100 women, most 20 to 40 years old, filled the wooden benches. Some were visibly pregnant. Others trailed toddlers. Many of the women struggled to hold up their heads.

Just before 9 a.m., a thin, chestnut-haired woman in a black robe strode through the back door. "All rise!" called the bailiff. "The honorable Judge Dee Anna Farnell presiding."

The judge raised her arms and smiled. "Welcome to Ladies' Day," she said. America's first all-female drug court was in session.

Soon the judge called Stacy's name. Stacy slouched down the aisle, clasped her hands behind her back and hung her head.

Eighteen months earlier, she had been arrested for using a fake prescription to buy oxycodone, the painkiller she had been snorting or shooting for four years. The charge carried a possible five-year prison sentence.

The judge had offered a deal: Plead guilty and go on probation. If you go through rehab, if you go to 12-step meetings and get a job and stay sober, you can stay out of jail — and have your felony record wiped clean.

For a while, Stacy had tried. But then she failed a drug test, stopped going to counseling, started skipping court. Now she faced a sentence of 10 years instead of five.

The judge could send her to a long-term treatment facility or halfway house. Or she could put her in prison for violating her probation.

Farnell asked Stacy about her children. Stacy said her 12-year-old daughter had been staying with her paternal grandparents for almost a year. Her mom was taking care of her 2-year-old son.

"What are you going to test positive for today?" asked the judge.

Stacy shuffled her Air Jordan slides. "Well, I've been smoking and drinking. So marijuana and alcohol." She paused. "And benzos. And maybe …"

The judge shook her head. "Okay," she said. "What do you want to do? Do you want to opt out? Or keep trying?"

Stacy wanted what a lot of addicts want: to get clean, but also to get high. She wanted to have her kids back, but also to have no responsibility. She wanted to feel better, and to feel nothing.

She wiped her nose on her shoulder, looked up and said, "I want to keep trying."

PRESCRIPTION DRUG abuse kills 40 Americans every day. That's more than a threefold increase in the last decade, according to the U.S. Centers for Disease Control and Prevention.

Oxycodone is the deadliest drug of all. An opiate found in such painkillers as OxyContin and Percocet, it's prescribed after surgeries and car wrecks, and to people in chronic pain.

Others take it just for the high. The drug works by blocking the spinal cord's pain receptors. It doesn't make the pain go away, but prevents people from feeling it, creating a sense of euphoria. Soon, they need to take more to get the same pleasurable escape.

Oxy makes junkies out of people who would never buy from a street dealer. It is everyman's high, heroin in a pill.

Of all the oxycodone prescribed in America in the first half of last year, 98 percent was dispensed in Florida. According to the state medical examiner's office, an average of seven Floridians die from prescription drug overdoses every day — more than from car accidents.

In recent years, Pinellas has lost more people to prescription drugs than any other county in the state — 249 just last year. That's an increase of 60 over the year before.

"Everyone knows someone who has gone through this addiction and you just feel so helpless. It's a horrible, vicious disease," said Pinellas County sheriff's spokeswoman Marianne Pasha.

"These aren't Dumpster-diving drug addicts," she said. "These people are getting their pills from doctors. It's the person in line beside you at Publix, the woman next to you in the pew at church."

A few years ago, drug court Judge Farnell started seeing more and more women charged with prescription drug abuse. By 2009, almost half of her drug court defendants were women.

That year, Pinellas County received a $900,000, three-year federal grant to fund substance abuse treatment for women in drug court.

That's how Tuesdays became "Ladies' Day."

Instead of punishing the women, the judge offers them a chance to start over. They come to court once a month. She creates incentives for them: Do yoga, run a 5K, quit smoking, and we'll waive your $52 monthly probation fee. She makes sure they know how to get a bus pass. If she gets a bad vibe about a boyfriend, she'll order a woman to steer clear of him.

She tells defendants, "You can do this. It's going to be hard. But it will be worth it."

When a woman slips, the judge scolds her and sends her back to jail to detox. Then she offers another chance.

About 500 defendants came to court on Ladies' Days this year. St. Petersburg Times journalists attended week after week. They interviewed dozens of women. They followed addicts as they bounced between jail and treatment, stayed in abandoned houses, looked for jobs and stumbled toward recovery or relapse.

One woman let the journalists follow her all year.

Stacy Nicholson grew up in St. Petersburg. A streetwise, Southern-fried tomboy, she loves the Florida Gators, Chevy pickups, Lil Wayne and Toby Keith. She believes in dream catchers and her Gemini horoscope, craves Cocoa Puffs and smokes Newports. She never wears makeup, always spritzes on Victoria's Secret body spray. When it comes to men, she likes the smell of trouble.

Her history of drug use and dysfunction stretches back to puberty. She tried marijuana at 13 and alcohol at 14, had her first baby at 16 and her second, with a different man, at 27.

But the pursuit of the oxy buzz erased any chance of a productive life.

For addicts, using quickly becomes a necessity, not a choice. Getting the next pill becomes more important than work, friends, family, even food. The addict's values shift to justify whatever it takes to get more oxys. Hard workers can no longer hold jobs. Smart students drop out. Good moms neglect their kids, drain their bank accounts, steal from family members.

If addicts stop using, they suffer horrible symptoms: vomiting, headaches, intense bone pain. That's why many are afraid to even try to get sober. They need to stay high so they don't crash.

After Stacy got hooked, she lost her personality, spark, motivation. Every new boyfriend was a red flag, but she never saw it. She dragged her kids from bad apartments to cheap motel rooms, and finally gave them up.

In Judge Farnell's court in February, Stacy entered what everyone agreed was a fight for her life. She could get better, or she could become one of Florida's seven a day.

She had a lot going for her: a mother who supported her even after all the times Stacy had broken her heart. Two children who desperately needed her love and attention. A treatment program backed by almost $1 million in taxpayer money. Drug counselors who wanted her to succeed. Other recovering addicts eager to share their experiences at 12-step meetings. An empathetic judge who was willing to give Stacy chance after chance, if only she would try.

Working against her: a little blue pill and Stacy's need to numb herself with it.

More ...

http://www.tampabay.com/features/humaninterest/article1206405.ece

Emergency contraceptives over the counter: Are they more dangerous than other drugs? - Slate Magazine

2011-12-15T16:37:00.001-05:00

Health and Human Services Secretary Kathleen Sebelius overruled the FDA's recommendationthat emergency contraception be made available over the counter to patients of all ages on Wednesday. Her argument was that its effects on 11-year-olds have not been thoroughly studied. Critics pointed out that many over-the-counter drugs are far more dangerous than emergency contraceptives. What's the most dangerous drug you can buy without a prescription?

It's hard to say. As far as the Explainer can tell, no researcher has ever compared the fatality rates of every drug available over the counter—probably because the number of deaths from overdose of antacids and many other products is so small as to make the study a waste of time. There is, however, a large body of research on pain relievers. Analgesic overdoses are pretty common in the United States. In 2000, poison-control centers received more than 130,000 calls from people who believed they had taken a dangerous amount of an over-the-counter painkiller. Nearly one-half of those calls concerned acetaminophen, best known as the active ingredient in Tylenol. Approximately 0.2 percent of those cases ended in death. That's higher than the reported death rate for nonsteroidal anti-inflammatory drugs like Advil (ibuprofen) and Aleve (naproxen), but lower than the fatality rate for aspirin. (Aspirin is technically in the same category, but is often separated for research purposes.)* However, most of the aspirin deaths appear to have been suicides, while accidental overdose is more common than intentional overdose for acetaminophen. Between the years 1990 and 1998, 458 people died from taking too much acetaminophen.*

Pseudoephedrine, a very common cold medication, is also implicated in a number of deaths every year. In 2004, for example, poison-control centers reported 21 deaths in which the chemical was involved. However, most of those patients took a cocktail of drugs—often including acetaminophen—and many of the cases were ruled suicides. It's also not entirely correct to call pseudoephedrine an over-counter drug. A 2005 act of Congress forced retailers to move it behind the counter because of its use in the production of methamphetamine.

Of course, many other drugs can be fatal if you go way overboard. Even Epsom salts, which are commonly used as a laxative, can cause cardiac arrest. A hospital in Scotland reported a case of attempted suicide by Epsom salts in 2009. The woman ingested an incredible 4.4 pounds of the stuff. She suffered some acute cardiac complications, but doctors were able to save her.

It's not easy to determine the fatal dose of over-the-counter drugs. Take the example of acetaminophen. A person's ability to handle the drug depends on a variety of factors, including the condition of their liver, how much they've eaten, and whether they take the pill in conjunction with alcohol. (Bad idea.) Compared to other over-the-counter drugs, acetaminophen has a relatively narrow safety margin—that is, the difference between a safe-but-effective dose and an overdose is relatively small. Doctors have reported liver failure from as little as 2.5 grams in a day, which is 1.5 grams less than the approved limit.

The FDA has considered reducing the approved daily dose (PDF) of over-the-counter acetaminophen, but that wouldn't help in all cases. Many patients don't realize how much of the drug they're taking. Those who are prescribed the painkiller Percocet, for example, might take over-the-counter acetaminophen as an adjunct for different or breakthrough pain. The problem is that Percoset contains acetaminophen, and the combination can easily put them over the dose limit.

What's the fatal dose of emergency contraceptive? Nobody knows. The drug certainly has side effects, like nausea, vomiting, dizziness, fatigue, and the like. Women who use the morning-after pill as their regular form of contraception can also experience some menstrual irregularities. But no one has taken a fatal dose of Plan B.

http://www.slate.com/articles/health_and_science/explainer/2011/12/emergency_contraceptives_over_the_counter_are_they_more_dangerous_than_other_drugs_.html?

Long-Term Study Sheds Light on Jaw Pain Disorders

2011-12-15T16:33:00.001-05:00

People with disorders of long-term jaw pain were much more sensitive to mildly painful sensations elsewhere in the body, more aware of body sensations, and experienced greater heart rate increases under mild stress, according to the first large-scale clinical study of its kind by researchers, including those at the University of Maryland School of Dentistry.

The findings, published in the November issue of the Journal of Pain, provide insights into potential causes of temporomandibular joint disorders (TMJD), and should lead to new methods of diagnosing facial pain conditions, predicting who will be susceptible to them, and new treatment approaches, say the authors.

"There is a real difference. People with TMJ are more sensitive than those without TMJ on parts of the body other than the jaw," says co-author Joel Greenspan, PhD, professor and chair of the School's Department of Neural and Pain Sciences. "To us it means the nervous system for interpreting pain information is now altered. We think that general heightened pain sensitivity is part of the chronic pain problem."

The University of Maryland dental school is one of four testing sites in the study led by William Maixner, DDS, PhD, director of the Center for Neurosensory Disorders at the University of North Carolina School of Dentistry in Chapel Hill. The study is called the Orofacial Pain Prospective Evaluation and Risk Assessment, or OPPERA, in which researchers tracked followed 3,200 healthy volunteers aged 18 to 44 for three to five years to see how many develop the disorder. The other two sites are the University of Florida at Gainesville and the University at Buffalo.

Temporomandibular joint disorders produce pain that radiates from the jaw and surrounding muscles, restricting jaw movement and causing considerable suffering. Although the disorders vary in duration and severity, for some people the pain becomes an unrelenting and long-term feature of their lives.

Genetic factors may also play a role in chronic TMJD. The researchers identified several genes, including some known to influence stress response, psychological well-being, and inflammation that may point to targets for discovery of new drugs to treat TMJD and related chronic pain conditions.

And, the researchers report that the findings provide evidence that chronic TMJD is at least partially linked to a person's perception of and ability to suppress pain, which is determined by the body's physiological regulatory systems.

Greenspan said a principal contribution of the University of Maryland team was to develop the protocols for sensory testing, including development of some of the testing tools. Greenspan has worked in the field of "quantitative sensory testing" for 35 years, including assessments of pain sensitivity in a research setting. He says the results so far cannot distinguish cause and effect. "We cannot say whether a more pain sensitive person is more prone to develop TMJD, or whether chronic TMJD changes the nervous system to enhance pain signals," Greenspan says. "My expectation is more likely the latter, which we plan to evaluate in the future. There is a lot of animal research including studies performed by Dr. Ronald Dubner, a co-primary investigator on the study from the University of Maryland Dental School, showing that a long-term pain state changes the nervous system's responses to subsequent painful events. The question remaining is whether this is what is happening in human clinical conditions."

Adds Maixner: "Previous studies haven't been able to be as conclusive as OPPERA because they've often included fewer participants and didn't follow participants for an extended amount of time. OPPERA is allowing us to study potential biological, psychological, and genetic risk factors over a longer period of time, so we will be able to better evaluate the association of these factors with TMJD. This novel study will also allow us to learn more about pain disorders in general, and will improve our ability to diagnose and treat chronic pain conditions across the board."

The longitudinal study builds on earlier work by members of the multi-university research team, who designed a broad conceptual model to determine the condition's causes. Maixner said the new findings go far toward validating that model, which was first published in 2006.

"The model, like a compass to a traveler, predicts the route ahead in the development of specific persistent pain disorders," Maixner says. "In this case, we predicted that biological and psychological risk determinants, which are modified by both life history and genetic factors, contribute to the onset and persistence of TMJD."

The research team will publish additional findings and insights as they continue to analyze the study data.

http://www.newswise.com/articles/long-term-study-sheds-light-on-jaw-pain-disorders?

American Academy of Pain Management e-Newsletter

2011-12-15T16:31:00.001-05:00

Pain Studies In The News

http://www.aapainmanage.org/pain_management_news/NEW_newsletter/landingpage/studies1211.html

Pain-Topics.org News/Research UPDATES

2011-12-15T16:29:00.001-05:00

These UPDATES are a component of Pain Treatment Topics (http://Pain-Topics.org). Our mission is to serve as a noncommercial resource for healthcare professionals & their patients, providing open access to clinical news, information, research, and education for a better understanding of evidence-based pain-management practices.

http://updates.pain-topics.org/

http://pain-topics.org/

Pain-Topics.org News/Research UPDATES: Is the Shocking Prevalence of Chronic Pain True?

2011-12-15T16:27:00.001-05:00

Many readers have questioned the latest figure that 116 million American adults suffer from chronic pain, which represents more than a third of the total population. Yet, looking at the original source of this data, the evidence seems generally reliable and, furthermore, the U.S. is not unique in the world — chronic pain seems to be a truly huge problem of global proportions.

That 116 million estimation of chronic pain in the U.S. comes from a lengthy Institute of Medicine (IOM) report released last June, 2011: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research [discussed in UPDATE here]. Apparently, many healthcare providers and opinion leaders find that number a bit far-fetched. Where did it come from and can it be trusted as being valid?

More ...

http://updates.pain-topics.org/2011/11/many-readers-have-questioned-latest.html

Staying socially connected while living with chronic pain | painACTION.com

2011-12-15T16:23:00.001-05:00

Living with pain can interfere with quality of life on many levels, one of which is the ability to interact with people and contribute to life in a meaningful way. But being socially connected with others is essential for maintaining and improving productivity, self-esteem, and an overall sense of well-being.

In this lesson, you'll learn how to:

Recognize and manage feelings of isolation.
Take charge of your life.
Maintain old social connections and create new ones.

http://www.painaction.com/members/lesson.aspx?id=5341&utm_source=professionalnewsletter53&utm_medium=email&utm_campaign=Staying+socially+connected+while+living+with+chronic+pain+

How to overcome common fears about chronic pain | painACTION.com

2011-12-15T16:22:00.001-05:00

If you have pain that won't quit, you probably feel worried about it. You might even feel angry, helpless, or afraid. All of these thoughts are normal. These feelings may be especially strong at the time of diagnosis; when a set-back or flare-up occurs; or when a treatment doesn't seem to be working. After all, constant pain is hard on your body and your mind. Your life isn't what it used to be.

Being afraid, though, is one of the most common emotions for people struggling with chronic pain.

This lesson will help you:

Learn about the fears faced by people with chronic pain.
Understand ways to fight those fears.
Get a sense of control over your own fears.

http://www.painaction.com/members/lesson.aspx?id=4751&utm_source=professionalnewsletter54&utm_medium=email&utm_campaign=How+to+overcome+common+fears+about+chronic+pain

Painkillers for N.F.L. Players? Not So Fast - NYTimes.com

2011-12-14T10:58:00.001-05:00

The former professional football player is confused. It is difficult for him to pinpoint, after the pads have come off for good, the precise cause of his aching body and his aching soul. He knows that the game did it. But what part of the game? Was it the physical violence? The psychological warfare? The realization that his life peaked in his 20s? The drugs he took to stay on the field? Whatever the cause, there is always the pain. The pain is constant in football and as a result it is constantly being manipulated.

Last week a group of 12 former National Football League players filed a class-action lawsuit against the league, claiming that the N.F.L. and its teams failed to warn players of the side effects of the drug Toradol, widely administered to players before games to numb pain. The lawsuit contends that the use of the drug masked injuries like concussions and thus further endangered the athletes.

When I played for the Denver Broncos, from 2003 to 2008, Toradol was a popular pregame injection. The night before we took the field, 10 to 20 of us would go into a designated room and stand in line to receive our shots. I don't remember what, if any, specific injury I was nursing on any particular occasion. I do remember that my body was perpetually feeling bad, as were those of my teammates. Our training staff knew this and would encourage us to get a shot. We were told it would make us feel better. So we lined up for the needle.

When I got to the front of the line, I was told that the shot was known to cause internal bleeding in a very small percentage of patients but otherwise was safe. This disclaimer was given with needle in hand and a line of men waiting behind me. There was no hesitation, no trepidation, no point at which I felt that taking Toradol was a risk. I trusted our team doctors. They wouldn't suggest a drug if it was dangerous.

The big risk, in my mind, was not being at my best the next day. The big risk was not taking the shot, playing poorly and being viewed by the staff as unwilling to do what it took to help the team win. The big risk was losing my job.

The N.F.L. is a machine. The operators of the machine pull its levers more frantically every season, pushing it past its breaking point. So the league has stockpiled interchangeable spare parts. The broken ones are seamlessly replaced and the machine keeps rolling. The old pieces are discarded and left to rust in a scrap heap.

This harsh reality is softened by human relationships. Football players spend every day with the members of their team's medical staff. They learn to trust them. The athletic trainers nurse the players back to health when they are injured. The team doctors perform their operations. Friendships are formed and bonds are created. But underneath it all hums the machine.

Athletic trainers are paid to keep the machine humming. The long-term health of the individual player is not their first concern; the health of the team is. The faster a trainer gets his players back on the field, the more likely he'll be to keep his job. Trainers are under pressure to do this by masking a player's pain with drugs and designing a hasty rehabilitation schedule, even if it inevitably trades one injury for the next.

The player rarely if ever has a say in the treatment process. When he is injured, the athletic trainers and team doctors take the necessary X-rays and M.R.I.'s and decide on the course of action among themselves. Only afterward do they tell the player what injury they have found and how they will treat it. If the player seeks a second opinion, which he is technically allowed to do, it is taken as an affront to the medical staff, and he will be treated in the training room like a turncoat. The medical staff issues its reports to the head coach, and is often beholden to him, which is another reason that players don't challenge their diagnoses or treatments.

The player is not told how to access his medical records or whether he even has a right to them. The folder of my medical records was as thick as a dictionary and I never had access to it. Even after I filed a workers' compensation lawsuit against the Broncos a year ago that later included a request for that folder, I still don't have it. The team hasn't released it to me.

If the N.F.L. is serious about protecting its players, it should appoint a league-wide medical body, unaffiliated with any specific team, to oversee players' health. Such an institution would be able to provide care to the athlete without the interests of his team distorting treatment.

Until then, teams will continue to convince players that their bodies and brains are ready for professional football, even when they are not. The injured body needs coaxing. It needs to be stroked, rubbed, heated, stretched and lied to. There are coaches, owners, trainers, fans and a host of media people counting on the players, after all, ready to question their manhood if they decide that the pain is too much to bear.

But the next game, the game that right now feels so important, will pass. In a couple of weeks, few will ever speak of it again. And then it's on to the next one. And the machine will keep humming.

Nate Jackson is working on a book about life in the N.F.L.

http://www.nytimes.com/2011/12/14/opinion/painkillers-for-nfl-players-not-so-fast.html?nl=todaysheadlines&emc=tha212&pagewanted=print

N.F.L Sued by Ex-Players Over Painkiller Toradol - NYTimes.com

2011-12-06T04:34:00.001-05:00

In the latest lawsuit based on medical issues against the N.F.L., a dozen former players have accused the league and its teams of repeatedly administering the painkiller Toradol before and during games, worsening high-risk injuries like concussions.

The players also contend that the league and its teams failed to warn them of the consequences of taking the drug, a blood thinner that, according to the suit, "can prevent the feeling of injury" and therefore made it harder for players to recognize when they had concussions.

"The plaintiffs have described the situation as one of being in a pregame locker room with players lining up to receive injections of Toradol in a 'cattle call' with no warnings of any sort being given, no distinguishing between different medical conditions of the players, and regardless of whether the player had an injury of any kind," the suit alleges.

The dozen retired players, including Joe Horn, Matt Joyce and Jerome Pathon, played in the late 1990s and early 2000s and say they now have anxiety, depression, short-term memory loss, severe headaches, sleeping problems and dizziness, according to Christopher A. Seeger, the lead lawyer for the plaintiffs.

"We took it like clockwork," said Horn, a receiver who played 12 years with the Kansas City Chiefs, the New Orleans Saints and the Atlanta Falcons and who says he now experiences bouts of dizziness and blackouts. "They don't meet with you to tell you what will happen five years later. Had I known that there were going to be complications, I wouldn't have taken the shots."

In accusing the league of negligence, fraud, fraudulent concealment, negligent misrepresentation and conspiracy, the former players are seeking an unspecified amount of compensatory and punitive damages, and the reimbursement of their legal costs.

The league disputed the suit's claims.

"The N.F.L. has long made player safety a priority and continues to do so," Greg Aiello, a league spokesman, said in a statement. "Any allegation that the N.F.L. intentionally sought to mislead players has no merit. It stands in contrast to the league's actions to better protect players and advance the science and medical understanding of the management and treatment of concussions."

The suit, which was filed in United States District Court in New Jersey, also alleged that the N.F.L. was late to acknowledge the problems raised by repeated concussions, and its efforts to combat the issue were half-hearted.

In recent years, the league has instituted a number of changes to protect players, including penalizing helmet-to-helmet hits. Commissioner Roger Goodell said he would not rule out other rule changes to minimize the potential for head and neck injuries.

In October, the league said it would broaden its study of the effects of concussions after an earlier study was scrapped because of problems in how the data was collected. The new study will include about 1,400 people, from 45 to 59 years old, and divided into three groups. The first group will be retired N.F.L. players; the second will be people who played college football but no professional football; and the third will be a control group of nonathletes who have some medical commonalities with the first two.

http://www.nytimes.com/2011/12/06/sports/football/nfl-sued-by-ex-players-over-painkiller-toradol.html?pagewanted=print

New pain sensors explain why snake bites hurt - Technology & science - Science - LiveScience - msnbc.com

2011-12-03T22:41:00.001-05:00

The Texas coral snake may seem benign enough, with crayon-colored rings adorning its body, but this serpent packs a mighty punch in its toxin-laden venom. And new research finds these toxins trigger a previously unknown pain mechanism in humans.

There are many different types of pain, said study researcher David Julius, of the University of California, San Francisco. Some respond to changes in heat or pressure; for example, if you burn your finger or get punched. Others respond to different chemicals, such as acids. Your body senses the painful trigger with a receptor on a pain-sensing nerve in your skin. That nerve signals the brain, which then tells the body that the pot is hot or the acid is burning you.

It seems the coral snake triggers a novel pain receptor on nerves. The finding could help researchers develop drugs to treat snakebites or other painful phenomena in a targeted fashion without having to use opiates. [ 5 Facts About Pain ]

"We find natural products from animals or plants that generate pain sensations and find out what they target on the cells," Julius told LiveScience. "In the future, these kinds of toxins will help us understand how these [pain-sensing] molecules are activated… that sort of information is important for producing drugs to reverse the action."

Julius and his colleagues screened a wide variety of snake venoms, looking specifically at their ability to activate certain pain-relaying nerve cells in rats. The Texas coral venom activated some of these nerve cells, a type of chemical-based pain-sensing cell that communicates the conditions of the body to the brain.

In that venom, the researchers found a toxin they named MitTx, which opens a channel on the outside of the skin's nerve cells, sending a signal up to the brain. Oddly, even though MitTx isn't acidic, it turned on a channel related to those that usually respond to acids.

The channels' acid-sensing relatives produce pain when tissues are deprived of blood and oxygen, but MitTx is specific for a channel that hasn't been implicated in pain sensation before.

"The one [pain pathway] that we've identified with this toxin isn't the one that people have paid the most attention to," Julius said. "This is an important site of action, and we should look at it more closely in how it produces pain."

The Texas coral snake (Micrurus tener tener) is about 2 feet long and is usually shy and secretive, as well as nocturnal, so it's not often you run across one.

They don't usually bite humans unless provoked, but their venom is a powerful neurotoxin and without treatment the bites are fatal about 10 percent of the time. Luckily, no deaths from coral snake bites, the Texas variety or others, have been reported in the United States since coral snake anti-venom has been available to hospitals. Even when not fatal, however, the venom of the Texas coral snake causes extreme pain that can last for hours.

Because this pain is mediated through this newly discovered pathway, it's possible that traditional pain relievers such as aspirin, which work through different receptors, wouldn't help the pain. The bites, if painful enough, are usually treated with opiate pain relievers, like morphine, but a more targeted and less addictive reliever would be beneficial, according to the researchers.

"Different types of injuries mediate pain through different types of mechanisms," Julius said. "That's the secret — figuring out what the mechanism is for different types of pain, so you can eventually target the right kinds of therapeutics for that."

The study is published in the Nov. 17 issue of the journal Nature.

http://www.msnbc.msn.com/id/45329172/ns/technology_and_science-science/#

Older ER Patients Less Likely to Get Pain Meds, Data Shows - Health News - Health.com

2011-11-22T08:38:00.001-05:00

Elderly patients are less likely than middle-aged patients to receive pain medications in U.S. hospital emergency departments, even when they have severe pain.

That's the finding of researchers who analyzed data collected from U.S. emergency departments between 2003 and 2009.

Among patients with a primary complaint of pain, an analgesic (such as morphine, oxycodone or ibuprofen) was given to 49 percent of patients 75 and older, and 68 percent of patients aged 35 to 54.

An opioid (such as morphine or oxycodone) was given to about 35 percent of elderly patients and 49 percent of middle-aged patients, the investigators found.

Age-related differences in the use of pain medications remained even after the researchers adjusted for factors such as sex, race/ethnicity and pain severity. Elderly patients were nearly 20 percent less likely to receive an analgesic and 15 percent less likely to receive an opioid than middle-aged patients.

Even among those with severe pain, elderly patients were less likely to receive pain medications than middle-aged patients (67 percent versus 79 percent, respectively).

The study was published online ahead of print in the Annals of Emergency Medicine.

The reasons why elderly patients are less likely to receive pain medications aren't clear but doctors may be concerned about potential side effects in older patients, suggested lead author Dr. Timothy Platts-Mills, an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill School of Medicine.

"To us, the gap we observe in pain management for older patients highlights the need to better understand how best to manage pain in older patients and understand the barriers to doing this. All patients, regardless of age, deserve to have relief from pain, especially when it is severe," he said in university news release.

Each year in the United States, patients 65 and older make more than 20 million visits to hospital emergency departments and nearly half of those visits are pain-related.

http://news.health.com/2011/11/16/older-er-patients-less-likely-to-get-pain-meds-data-shows/#

Navigating the Long Road to a Sjogren's Diagnosis - ABC News

2011-11-22T06:55:00.000-05:00

Suffering for over six years with widespread, unidentifiable pain and fatigue is a test of patience. For me, the answer came years after seeing dozens of doctors shrug their shoulders at my condition or say I was in excellent health since I looked well.

After enduring endless exams, rounds of blood drawing, body and brain scans, all for no diagnosis at all, I was determined to get answers somewhere else and that's what landed me mid-country. I finally found my diagnosis in the Midwest, thousands of miles away from my home in Massachusetts.

This specialist asked me to describe everything of concern. Then he examined me and began to write his note. Every few sentences, he stopped, turned the computer screen in our direction, and asked me and my husband whether he had captured my problem accurately. We were amazed since no other specialist had ever double checked with us before. No other doctor outright explained my care as a team effort.

And then, a week later, the diagnosis: Sjogren's syndrome -- an often overlooked but serious autoimmune disorder.

Nearly 4 million Americans suffer from Sjogren's, and 90 percent of whom are women. As I looked through the symptoms for Sjogren's, I found myself identifying with most characteristics I saw on the list – symptoms like widespread muscle soreness, joint pain, brain fog that ways so extreme I had trouble sorting through the mail. I also felt fatigue so extreme that I felt like I got hit by a truck.

More importantly, my pain had a name. And a name meant I would finally get the right treatments.

But coming to the diagnosis required a Herculean effort.

My medical file was stacked high with referral notes and test results, which translated into months of pain unexplainable by doctors, and a growing sense of hopelessness that I would ever be diagnosed, or recover. Five rheumatologists, two neurologists, two immunologists, one infectious disease specialist, several endocrinologists, two psychiatrists, three integrative medicine doctors, two functional medicine doctors and multiple primary care physicians later, I was fed up playing the medical pinball machine.

"She looks well and in excellent health," one part of my file read. "Would benefit from stress reduction dealing with the natural effects of aging, a little tucking in around the edges."

But I knew I wasn't well.

Another part of my file read that I was "doctor shopping," a term used to describe pain pill addicted patients who are fishing for a diagnosis just to get prescribed more pills.

As a PhD clinical psychologist and board member of one of Massachusetts's leading medical systems, I am involved in broader discussions about how patients can better navigate the system more efficiently to get the right diagnosis and treatment faster.

I never thought of health care as a maze until I found myself on the opposite side of one of the top healthcare systems in the nation, this time as a patient suffering from progressively debilitating pain. That may have been one the greatest eye openers on medical system operations than board meetings could offer.

More than 80 million people in the United States suffer from chronic pain, most of whom are women, according to the American Chronic Pain Association. And each year, nearly $100 billion is wasted due to reduced productivity, sick time and medical costs associated with chronic pain.

For the first time, these statistics made personal sense. I imagined that if I did not have the credentials or the backstage pass into the health care system -- if I was "the average patient" -- perhaps nothing could have navigated me through getting the right diagnosis and treatment for my pain.

I had been bounced from specialist to specialist in the greater Boston area where, despite my significant contacts were dismissed summarily to other specialists when my symptoms were confounding, and endured innumerable repetitions of paperwork, exams and lab protocols, many duplicating those done only days earlier.

I had experienced the emotional distress of a first-hand look at healthcare systems gone awry; even within the same healthcare system, clinicians had not consulted with each other, clinical record errors were passed on and further misconstrued, and countless dollars were unnecessarily expended.

Worse, no one seemed the least bit concerned. If I occasionally pointed out the lack or break in process, I was frequently met with a blank stare. It was almost as if no one cared, as if they themselves were not part owners of the process that was operating.

This problem persists in more places across the nation that just my neighborhood. Online patient chat boards echo the same story, and many chronic disease advocacy organizations, besides those dedicated to Sjogren's, spend entire meeting sessions dedicated to helping their members navigate a difficult to diagnose condition.

There's no cure or Sjogren's, but there are treatments to manage the symptoms. While it may be difficult for many of us, except for researchers, to curb the prevalence of chronic conditions like Sjogren's syndrome, there are certainly ways to reduce the personal cost burden and the frustration.

First, write a simple timeline of your problem connecting dates and symptoms. I tried to keep my timeline as concise and accurate as possible. Second, carry copies of your records with you for any visit. Despite electronic medical records, many doctors still aren't using them and, in any case, they usually can't see things across different healthcare systems. I owned my medical chart and it helped me understand my condition better throughout the process.

Third, persist. Don't discount your feelings if you think something is wrong. Experts are highly skilled and deserve the same respect given to you, but even they can't keep up with the flood of new discoveries being made. Be sure to put your most important questions first, in case the doctor and you run out of time.

Finally, for a perplexing or very serious problem, seek out a medical center of excellence, preferably one that explicitly advertises itself as putting patients first. The system in the Midwest had this motto written everywhere, and it actually turned out to be the way people treated each other.

Diagnosis of what can be a progressive disease is a bittersweet experience. I learned that being an expert did not automatically make me an informed patient. Until bigger changes are made among healthcare stakeholders and experts -- the implementation of electronic medical records, more emphasis on patient-provider communication – it's up to patients to find shortcuts in the maze, and share those pearls of wisdom with those of us who took the long way to better health.

Jessica Wolfe, MPH, PhD, has been an entrepreneur, behavioral researcher, and executive in healthcare, health sciences, and public health for over 30 years.

http://abcnews.go.com/Health/PainManagement/navigating-long-road-sjogrens-diagnosis/story?id=15000165&singlePage=true#.TsuNo2D0vms

Hurt All Over - Diagnosis - Dr. Lisa Sanders - NYTimes.com

2011-11-11T20:21:00.000-05:00

'Will you please see my sister?' the young woman asked Dr. David Podell, who was a friend of a friend and had a reputation as a kinder version of TV's Dr. Gregory House. People told her that Podell was a doctor who specialized in diagnosing odd diseases, and she hoped he might finally solve the puzzle of her older sister's mysterious illness.

1. THE PATIENT'S STORY

Over the past 10 years, the patient — now 33 — became completely disabled by strange pains and odd episodes of weakness that no one could explain. The sister handed Podell a letter from the patient. "I am very desperate for help," she wrote, "and I am struggling every day all day without relief. I have heard you are the best, and if there is help out there, you are the one who will find it. . . . Please give me back my future."

Podell wasn't sure he could help but wanted to try. The patient, however, lived in Ohio, and Podell was in Middlebury, Conn. If she were going to travel, Podell told the sister, he wanted to make sure that he could do something for her. He would need copies of her medical records and recent test results, and he would need to talk with her before he saw her.

That weekend, Podell called the woman. Her voice was soft and high-pitched and sounded younger than her 33 years. She told him that her whole life had been one of near-constant pain. It became unbearable when she was pregnant and developed crippling back pain. Now, seven years after her daughter was born, her entire body ached almost all the time.

2. SYMPTOMS

Her joints hurt, she told him. So did her muscles, even her skin. She was tired yet couldn't sleep. She had frequent migraine headaches. She had irritable bowel syndrome. She was severely depressed. She had fibromyalgia, anemia, endometriosis.

Recently she had episodes during which she would lose her strength on one side of her body. The first time it happened, it was just her left arm. She went to the emergency room, where a doctor was worried that she'd had a stroke. But a CT scan of her head was normal. Her strength returned within days. She had seen so many doctors, and no one knew what was wrong. Her voice broke on the phone. He could hear her sobbing quietly.

3. THE DOCTOR'S STORY

Podell is a rheumatologist — a specialist in diseases of the tissues that hold the body together — bones, muscles, tendons. He sees a lot of people who have pain all over their bodies. But he was worried about seeing this patient. "She'd put all her eggs in my basket," he told me. "And I didn't want to drop it." So in addition to having her doctor send him all the studies she had so far, he wanted her to get other tests — lots of tests. He was determined not to miss this diagnosis. "I went for the zebras," he said, meaning rare diseases, "because frankly, after all the doctors she's seen, I was pretty sure all the horses had already been looked at."

4. POSSIBLE DIAGNOSIS

Podell has a list of unusual diseases that he considers in patients who have this kind of diffuse pain. The list includes hepatitis B and C; Lyme disease; Sjogren's syndrome (which affects the glands that produce tears and saliva); lupus and other diseases of the connective tissues; H.I.V.; thyroid disease; celiac disease (which affects the digestive system and is triggered by foods containing gluten).

5. TEST RESULTS

The patient's doctor in Ohio sent records from the past two years. The patient had seen two pain specialists, a gastroenterologist and an allergist. She had been scoped, X-rayed and CT scanned. She'd been stuck for blood and pricked for allergies. Most of the tests were unrevealing. But two stood out: in 2009, two blood tests were performed for celiac disease, and both were positive.

Then results from tests that Podell ordered started to arrive. As before, most were unrevealing, with the sole exception of those testing for celiac disease, which were strongly positive. Podell was excited, but a blood test is not a diagnosis, he knew. False positives are not unusual, so generally a biopsy of the small intestine is recommended. The patient hadn't had one. In addition, the patient saw a gastroenterologist earlier that year, and he didn't even mention celiac in his note. Had it already been ruled out somehow?

6. THE EXAM

Three weeks after they spoke on the phone, the patient came to Podell's office, accompanied by her mother and the sister who had made the arrangements. As they exchanged pleasantries, Podell quietly began his examination. The first thing he noticed was that the patient was much smaller than her sister and mother. She was only 4-foot-9. Otherwise she looked well. He listened carefully as the three women told him about the woman's years of pain.

7. RESEARCH

While the patient undressed for the physical, Podell hurried to his office to read up on the ways celiac disease affects the body. He knew that short stature, abdominal pain and diarrhea were associated with the disease. What else? The list he found was long: neuropathic pain, headaches, psychiatric disorders, iron deficiency, vitamin D deficiency — she had all of these.

Podell examined the woman, and she was extremely tender; everywhere he touched was painful — especially her muscles and skin.

Podell then asked what might have been his most important question: Had she ever tried a gluten-free diet? If she had but hadn't improved, that would make celiac disease very unlikely. The patient said she had tried the diet. After the positive test two years earlier, she gave up pasta and bread for a month or so. But she didn't feel any better, so her doctor said to forget it. Podell smiled. She hadn't really been on a gluten-free diet. Even small amounts of gluten in, say, cereal or baked goods would make her sick. This was celiac disease. He would bet on it.

8. CELIAC DISEASE

Celiac is an inherited disease of the small intestine that causes abdominal pain, diarrhea and an inability to absorb nutrients. When affected individuals are exposed to gluten — a very common protein found in cereals and grains — they develop antibodies that attack the lining of the small intestine. Once the absorptive lining is injured, the small intestine can't do its job of taking up nutrients from food. The undigested foods go on to cause abdominal pain, bloating and diarrhea. This patient had some of these digestive symptoms, but mostly she had pain — nerve pain, muscle pain, headaches, depression. These are also seen in patients with celiac disease. What causes these other symptoms isn't known.

9. TREATMENT

Podell sent the patient to a nutritionist to learn the fundamentals of the celiac diet. She has been disciplined about eating gluten-free for nearly three months. She has more energy and less pain, and she's back at work — not quite full time, but she's getting there.

I asked Podell why the patient did so much better this time than she did two years ago, when celiac was suggested as a possibility. He said that maybe her doctors didn't really think she had celiac, and so she didn't think she had it either. "I was very enthusiastic about this diagnosis. And I thought she really had it. So maybe it was the nonscientific component — the salesmanship — that made her try and stay with it."

This case is a reminder of an important precept in medicine: a diagnosis isn't really final until it is embraced by both the patient and the doctor. That's the real art of diagnosis and an essential part of the cure.

http://www.nytimes.com/2011/11/13/magazine/diagnosis-hurt-all-over.html?pagewanted=all

Are Doctors Really to Blame for the ‘Overdose Epidemic’? | TIME Healthland

2011-11-07T06:07:00.001-05:00

Forty people die each day from what Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention (CDC), calls an "epidemic" of prescription drug overdose. Frieden largely attributes the rise in overdose deaths, which have tripled since 1999, to overprescribing by doctors. But the reality is much more complicated.

At Tuesday's teleconference announcing the release of new CDC data on the problem, Frieden said, "In fact, now the burden of dangerous drugs is being created more by a few irresponsible doctors than by drug pushers on the street corners."

Such hyperbole is unlikely to lead to effective solutions for an extremely complex problem. Panics over addiction have always tended to focus relentlessly on supply, while failing to understand demand. In this case, unnecessary hysteria may also serve to reduce legitimate patients' access to needed pain treatment.

MORE: U.S. Aims to Reduce Overdose Deaths, But Will the New Plan Work?

Let's start with the facts: the vast majority of people who misuse prescription painkillers — 7 out of 10, according to drug czar Gil Kerlikowske — get them from family or friends, not directly from doctors. Secondly, most people addicted to these medications have used illegal drugs previously; they do not become addicted while being treated for pain.

A 2007 study of nearly 1,400 people addicted to OxyContin, who were treated at rehabs across the country, found that 78% had never been prescribed the drug themselves; the same percentage had been in rehab for a previous drug problem. Earlier data found that 80% of those addicted to OxyContin had previously used cocaine, a rate many times that seen in the general population.

That overlap is not likely to be attributed to pain patients who suddenly decide to try cocaine. The more probable explanation is that painkiller addiction is primarily affecting people with current or previous drug problems, not innocent patients being treated by pill-happy doctors.

Indeed, it is impossible for a doctor to "make someone" into an addict. Even if the doctor tied the person down and injected him or her daily with heroin or other strong opioids, only physical dependence could be created. That means the person would suffer withdrawal symptoms when the doctor stopped, but whether such victims genuinely became addicted would be determined by their own actions after that point.

MORE: Fueled by Growing Painkiller Use, Overdose Deaths and Child Poisonings Are on the Rise

If the research data is anything to go by, most people who use illegal drugs don't subsequently go looking for dealers or rob their grandmothers to get money to buy more. Of those who try heroin, more than 80% do not become junkies. Likewise, among adults who are legitimately prescribed opioid painkillers and who do not have past histories of drug problems, more than 97% don't develop new addictions.

Normal, healthy people given these drugs tend to find them unpleasantly numbing, not overwhelmingly attractive. Even among soldiers who served in Vietnam — 45% of whom tried opium or heroin while serving — just 1% developed ongoing heroin addictions that persisted after they came home.

Addiction doesn't just "happen": it requires people to choose repeatedly to use drugs to get high or to escape. By definition, this behavior must occur despite ongoing negative consequences; otherwise, it is not classified as addiction.

Moreover, although people with addiction often have genetic predispositions or exposures to traumatic experience that make drugs especially attractive to them, and although continued use itself can impair decision-making, they are not automatons with no free will. Their ability to choose not to take drugs may be reduced as they get hooked, but it's not eliminated: after all, no one shoots up in front of the cops.

MORE: Should an Overdose Antidote Be Made More Accessible?

The fact that addiction is not just about access to drugs is why talk of drug "epidemics" rarely changes their course. Supply-side efforts have had little effect on addiction rates. The exponential growth on such spending since Ronald Reagan declared war on drugs in the 1980s has no correlation whatsoever with rates of drug problems. The recent crackdown on prescription opioids began in the mid-2000s, with intense concern over OxyContin misuse — and yet overdose deaths continue to rise.

If we want to reduce opioid addiction, it might help to try to figure out why so many people feel the need to escape. And if we want to reduce opioid overdose, it might make sense to distribute the antidote, naloxone (Narcan), with prescriptions and make it available over the counter. Unlike efforts to restrict prescribing, this won't hamper appropriate pain care, and unlike rhetoric about epidemics and associated crackdowns on supply, there's actually a growing body of literature suggesting that Narcan saves lives.

Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland's Facebook page and on Twitter at @TIMEHealthland.

http://healthland.time.com/2011/11/02/are-doctors-really-to-blame-for-the-overdose-epidemic/print/

Academy of Pain Medicine Announces Two-Day Course for Safe Prescribing for Your Primary Physician - PRNewswire

2011-11-06T17:17:00.001-05:00

On the cusp of the recent Centers for Disease Control and Prevention (CDC) report about the growing death toll from prescription drug deaths, the physician leadership of the American Academy of Pain Medicine (AAPM) announced its plans to roll-out a new education initiative: Safe Opioid Prescribing: Reversing the Trends.

Debuting as a two-day course that will be held in Palm Springs, CA, in February 2012, the Safe Opioid Prescribing program is based on clinical research and data in the field of pain medicine that has been effective in minimizing the risks and reducing the number of deaths associated with opioid prescribing for chronic pain by educating family physicians, internists and other primary care clinicians.

"We have been deeply concerned about the serious public health problem of unintentional overdose deaths from prescription medications. The Safe Opioid Prescribing program is one way we are actively seeking to make a difference in this issue by sharing our expertise with other clinicians, who may not be as aware of the most relevant information in prescribing and the practice of pain medicine," President Perry G. Fine, MD said.

As the lead clinical experts in the specialty of pain, the physician leaders from the American Academy of Pain Medicine have dedicated countless hours to problem-solving on this issue, including:

Collaborating with the Office of National Drug Control Policy (ONDCP).
Working with Senator Jay Rockefeller (D-WV) and others to seek better pain care.
Providing clinical testimony to the Food and Drug Administration (FDA) around the Risk Evaluation and Mitigation Strategy (REMS) for long-acting and extended-release opioid drugs.
Collaborating with the Federal State Medical Boards (FSMB) to effect responsible prescribing patterns among all physicians of every specialty.
Accrediting a second edition of AAPM's Past President's Scott Fishman, MD's "Responsible Opioid Prescribing" publication, which has become an authoritative reference for safe prescribing.
Ongoing education to the medical community about the latest science and treatments for pain. The June 2011 issue of the Academy's journal, Pain Medicine published a series of manuscripts describing the complexities of the problem of safe prescribing, but also identified where significant progress has been made to curb and reverse this serious issue.

"We strongly believe that prescribers, policymakers, and our communities must work collaboratively to ensure all patients who need prescription medication have access to them but are safely and appropriately prescribed and consumed," Dr. Fine added.

These efforts align perfectly with the recently released CDC report, which concludes "Improving the way prescription painkillers are prescribed can reduce the number of people who misuse, abuse or overdose from these powerful drugs, while making sure patients have access to safe, effective treatment."

The Academy's Safe Opioid Prescribing Program has the statistical base of proof that reversing the trends is indeed possible. It is based on a successful pilot program that was launched in 2007 in Utah through the Utah Department of Health (UDOH), when a public awareness and provider educational program effectively reversed trends of unintentional drug deaths in the state.

"After the first year of the 2007 campaign, the state experienced its largest decreases in prescription drug deaths since 1994," AAPM Board Member Lynn Webster, MD said, citing the UDOH findings.

"These findings were remarkable," Webster said. And, that is when he began building the foundation of what is now the AAPM's Safe Opioid Prescribing curriculum that uses the experts in pain and the science of prescribing to help inform clinicians and ultimately patients and their families how to safely prescribe, use pain medications and to find ways to reverse the trends of overdose, death and diversion."

"It's a well-known axiom: if you want the most trusted and reliable information, go to the most reliable resource," said Dr. Webster. "We have invested so much time and energy researching and preparing to share our success and expertise with others for the good of society. This is a program that every physician should plan to attend," Webster said.

More information about the Safe Opioid Prescribing: Reversing the Trends Course, as well as the other programs of the Academy will be posted on the AAPM website when available at www.painmed.org.

http://www.prnewswire.com/news-releases/academy-of-pain-medicine-announces-two-day-course-for-safe-prescribing-for-your-primary-physician-133225448.html

CDC seeks data to help curb overdose deaths | Business Insurance

2011-11-06T17:14:00.001-05:00

Those and other CDC recommendations accompanied a report concluding that U.S. deaths from prescription pain-killers more than tripled during the past 10 years, with more than 40 overdose deaths occurring daily.

The U.S. Centers for Disease Control and Prevention last week called for tapping workers compensation claims data and cracking down on "pill mills" to avoid an epidemic of prescription pain medication overdose deaths.

While some insurers, self-insured employers and state agencies already track prescription data to prevent abuse and misuse of prescription narcotics known as opioids, others could undertake such measures or refine their practices, said Christopher Jones, a health scientist for the CDC in Atlanta.

"We want to make sure that it's a concerted effort for all the companies out there, whether they are health insurers, pharmacy benefit managers...or workers comp claims programs," Mr. Jones said. "Because, one, they can save money, but it also can save lives."

The growing issue of prescription painkiller abuse is the subject of Business Insurance's newly launched workers comp channel solution arc at www.businessinsurance.com.

Other federal and state efforts, meanwhile, are focusing on arresting pill mill operators.

The law enforcement efforts have been particularly focused in Florida, although other states are not immune from pill mill operations.

Pill mills tend to be storefront operations, often operated by "rogue doctors" who "are in fact drug dealers," and Florida is "ground zero" in the fight against them, the U.S. Drug Enforcement Agency said in a June statement.

Florida's pill mills "are now the primary source of drug diversion in the Eastern United States," according to a statement from the state attorney general's office.

"Florida leads the nation in diverted prescription drugs, resulting in seven Floridians dying every day and countless others throughout the nation," according to the attorney general's office. "Our state has become the destination for distributors and abusers through the proliferation of pill mills."

Observers say Florida became a pill mill haven because of the state's history of lax prescription drug enforcement, which officials are working to change.

One operation spearheaded by the DEA against illegal drug dispensaries in Florida was dubbed "Pill Mill Nation." It coordinated the efforts of federal and state agencies including the Florida Department of Financial Services' Division of Workers' Compensation, to help monitor any insurance billing.

But the pill mills typically require payments in cash, sources said.

Because of that and other reasons, it's likely that workers comp claims payers have not substantially contributed to their revenue, state and federal sources said. And it is possible that workers comp claimants who have become addicted to opioids through treatment provided for their workplace injuries may find their way to pill mills.

However, studies to determine the extent of such behavior have not been conducted, the sources added.

"I am not aware of any data specifically tracking patients who were at one time in a workers comp program subsequently receiving their prescriptions from pill mills," the CDC's Mr. Jones said. "Certainly, we know people who are suffering with addiction to prescription painkillers may seek drugs at a pill mill."

According to last week's CDC report, "prescription painkiller sales per person were more than three times higher in the highest state, Florida, than in the lowest state, Illinois."

But Florida is not the only state grappling with the problem.

A health care fraud team for Ohio's Bureau of Workers' Compensation has been investigating and prosecuting doctors operating pill mills, although the mills are not the only problem, a bureau spokeswoman said.

Ohio's bureau also has publicized its recent prosecutions of claimants for "deception to obtain a dangerous drug," or visiting several doctors to fill the same prescription.

In one among several such cases, an Ohio claimant pleaded guilty after investigators found that he provided his adult granddaughter with narcotics prescribed by his workers comp doctor. The granddaughter sold his Opana for $50 per pill and his Percocet for $12 per pill on the street and split the profit with the claimant, according to the bureau.

To stem the use of prescription pain medication nationwide, the CDC wants state health and insurance regulators to encourage "use (of) prescription drug monitoring programs, public insurance programs and workers compensation data to identify improper prescribing of painkillers."

In its "Vital Signs" report, the CDC also encouraged state regulators to adopt and enforce laws that prohibit pill mills and doctor shopping. It also encouraged licensing boards to "take action against inappropriate prescribing."

In total, opioid pain relievers were involved in 14,800 U.S. deaths in 2008, or 73.8% of the all prescription drug overdose deaths, the CDC reported.

"The take-home point—and this is why we are calling on insurers and others to take action—is to improve how the drugs are prescribed," Mr. Jones said. "And certainly insurers have influence on how practitioners practice. They have reimbursement mechanisms, they have claims review processes; and we think that they can help positively impact the ways prescribers are using these drugs, which in turn helps make sure that patients that need these drugs can get them, but it also reduces the number of people that are abusing them and dying," he said.

http://www.businessinsurance.com/article/20111106/NEWS08/311069992?tags=|79|342|304|92

More Deaths From Opioids Than Cocaine, Heroin Combined - Medscape

2011-11-01T21:34:00.001-04:00

The number of overdose deaths from opioid prescription pain relievers (OPRs) in the United States has reached epidemic proportions and is now greater than fatalities from heroin and cocaine combined, according to a new report released by the Centers for Disease Control and Prevention (CDC).

According to CDC director Thomas Frieden, MD, MPH, 1 out of every 20 adults in the United States — 12 million individuals — has a history of inappropriate narcotic use, a problem that largely stems from inappropriate prescribing.

Data from the Drug Enforcement Administration shows sales of OPRs to pharmacies and healthcare providers have increased by more than 300% since 1999.

According to the report, enough prescription painkillers were prescribed in 2010 to medicate every American adult around the clock for a month. Although most of these pills were prescribed, many were diverted and ended up being abused.

"The burden of dangerous drugs is being created more by a few irresponsible doctors than drug pushers on street corners," Dr. Frieden told reporters attending a press briefing.

Fastest-Growing Drug Problem

The issue of prescription opioid abuse has been front and center for some time and garnered particular attention in April 2011 when the Drug Enforcement Administration (DEA) announced a comprehensive action plan to stem the United States' national drug epidemic.

Among other initiatives, the federal plan called for pharmaceutical companies to pay for targeted educational initiatives for prescribers and included support for the expansion of state-based prescription drug monitoring programs and support for law enforcement efforts that reduce the prevalence of "pill mills" and doctor shopping.

"Prescription drug abuse is our nation's fastest-growing drug problem... and the facts as outlined are truly devastating," said Gil Kerlikowske, director of National Drug Control Policy.

Kerlikowske added that state laws and policies can make a major difference to curbing the prescription drug problem in the United States. So far, 48 of 50 states have implemented state-based monitoring programs designed to reduce medication diversion and doctor shopping.

In addition, the Department of Justice has conducted a series of takedowns of rogue pain clinics operating as "pill mills."

The Obama Administration has also signed into law the Secure and Responsible Drug Disposal Act, which will allow states and local communities to collect and safely dispose of unwanted prescription drugs and support the DEA's efforts to collect unneeded or expired prescription drugs.

Wide Variation in Mortality Rates

To better understand the scope of the problem, the CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions.

The investigators found that in 2008 drug overdoses in the United States caused 36,450 deaths. Of the 20,044 prescription drug overdose deaths, OPRs were involved in 14,800 (73.8%) — more than 3 times the rate in 1999.

Sales of OPRs quadrupled between 1999 and 2010, and the researchers found that nearly half a million emergency department visits in 2009 were due to misuse or abuse of prescription painkillers.

Further, death rates varied 5-fold by state. For instance, they ranged from a high of 27 deaths per 100,000 population in New Mexico to a low of 5.5 deaths per 100,000 in Nebraska.

Perhaps not surprisingly, the study also showed that states with lower death rates had lower rates of nonmedical use of OPRs and OPR sales.

With a rate of prescription opioid sales of 12.6 kg per 10,000 population, Florida had the highest rate of OPR sales. Illinois had the lowest rate of OPR sales, at 3.7 kg per 10,000 population.

The CDC estimates that nonmedical used of prescription painkillers costs health insurers up to $72.5 billion annually in direct healthcare costs.

Treatment of Last Resort

According to Dr. Frieden, opioids should be used only when all other treatments fail. It is possible, he said, to provide patients with adequate pain relief without necessarily resorting to narcotics. Such strategies range from addressing mood disorders to prescribing physical therapy for pain relief.

"There are many things that can be done to increase patients' comfort and functionality without risking a lifetime of addiction," he said.

In cases where narcotics are necessary, he added, physicians should prescribe only the quantity of pain medications needed based on the expected length of pain.

"For example," said Dr. Frieden, "if someone comes in with acute pain, 3 days rather than 30 days [of OPR] should be the standard."

He noted that many hospital emergency departments around the country are rethinking their use of long-acting narcotics, recognizing that perhaps the clinician who provides the patient's ongoing care is the best source for these types of highly addictive medications.

Patient education is also critical, said Dr. Frieden, and it is important for them to understand the risks of opioids and how to use, store, and dispose of them safely.

"Nonmedical use of prescription pain killers costs the healthcare system an estimated $70 billion a year, but there are measures that can be taken, particularly by states, where we have a huge variation in the rate of prescriptions and the rate of prescription overdose and overdose deaths.

"Through better monitoring and by taking appropriate action for patients and providers that are using these medications inappropriately; by cracking down on pill mills and doctor shopping and doctors who are prescribing inappropriately and by promoting good medical practice...it is possible to make a big difference and reduce this epidemic to controllable levels," said Dr. Frieden.

http://www.medscape.com/viewarticle/752700

Report:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w

Wireless Headache Intervention Study - Track your pain with an electronic diary for your iPhone

2011-10-26T10:27:00.001-04:00

Want to learn more about your headaches? Track your pain with an electronic diary for your iPhone!

Keeping a headache diary is often recommended by healthcare providers if you are living with recurrent headaches. It helps you track precise information about the headache you are experiencing, allows you to identify what triggers your headache, informs you what may help to alleviate your pain or made it worse, and gauge how much headaches impact your life. This information may help you to manage your headaches better.

To make it easier to keep a diary, a research team lead by Drs. Patrick McGrath and Anna Huguet at the IWK Health Centre in Halifax, Nova Scotia, Canada is developing an electronic headache diary for the iPhone. To learn more about this diary, read more details about the application. This application is not providing treatment and is not a substitute for your current medical treatment.

If you are interested in participating in the study, apply now to see if you meet the study criteria.

http://www.bringinghealthhome.com/whi/index.php

Unbearable itch may no longer be a pain in anaesthesia - New Scientist

2011-10-25T11:02:00.001-04:00

The intimate link between itch and pain has been teased apart for the first time - a development that could lead to powerful anaesthetics without any of that intolerable itching.

Itch is one of the most common side effects of the anaesthetics used in procedures such as epidurals. One explanation is that itch and pain receptors are intrinsically connected. "Itch and pain are two sensations that antagonise each other," says Zhou-Feng Chen from Washington University in St Louis, Missouri. "By scratching you create a kind of mechanical pain and suppress the itch. Conversely, if you suppress pain you see more itching."

To understand this mechanism better, Chen used mice to study the action of morphine, a painkiller that can cause itching. Morphine works through a receptor called MOR, and Chen suspected that different variants of the receptor might be responsible for the itch and pain responses. His team bred mice lacking one form of this receptor, called MOR1D. These mice did not scratch themselves when given morphine, though they still felt its painkilling effect (Cell, DOI: 10.1016/j.cell.2011.08.043).

"It's quite exciting that we are able to segregate the two," says Cheng, who believes that separate pathways for pain and itch exist in humans too. "Our study suggests there are different ways that you can inhibit itch without interfering with analgesia."

Another puzzle is that some itches do not respond to anti-itch drugs called antihistamines, and a study published this week suggests why. Antihistamines have proved effective against the itch of mosquito bites, for example, but they do little to soothe the itching caused by kidney failure, liver disease or burns, says Matthias Ringkamp at Johns Hopkins University in Baltimore, Maryland.

Antihistamine-sensitive itches have been shown to activate nerve fibres called unmyelinated C-fibres. Ringkamp suspected that itches that do not respond to the drugs might be mediated by a different type of fibre called myelinated A-fibres.

The spines of a tropical plant called cowage can irritate the skin and produce an itch that does not respond to antihistamines. To find out if the cowage itch signal passes through the myelinated A-fibres, Ringkamp and his team placed a weighted band over volunteers' wrists to cut off conduction in the small A-fibres. When the team inserted cowage spines into the volunteers' fingertips, they found that itch was dramatically reduced in many - but not all - of them (Journal of Neuroscience, DOI: 10.1523/jneurosci.3005-11/2011).

"It is fascinating that this happens in some people and not others," says Glenn Geisler at the University of Minnesota in Minneapolis. "In future, drugs to treat itch would have to treat A and C fibres."

http://www.newscientist.com/article/mg21228355.000-unbearable-itch-may-no-longer-be-a-pain-in-anaesthesia.html

Pain Management News and Video - FOX News Topics

2011-10-25T09:29:00.001-04:00

http://www.foxnews.com/topics/health/wellness/pain-management.htm

Study: Imagined Smells Can Precede Migraines | Fox News

2011-10-17T09:08:00.001-04:00

Hallucinated scents such as a burning or rotten smell, or even the scent of foie gras, can be a part of the "aura" that some people perceive before a migraine attack, although it is rare, according to a U.S. study.

About 30 percent of people with recurrent migraines have sensory disturbances shortly before their headache hits, known as aura, but these are usually visual, such as flashes of light or blind spots. Tingling sensations or numbness, or difficulty speaking or understanding language, may also appear.

But the study, conducted by Matthew Robbins and colleagues at the Montefiore Headache Center in New York, found that a small number of people described smelling scents in conjunction with their headaches.

"It's uncommon, but distinctive," said Robbins, noting that disturbances in the sense of smell, known as olfactory hallucinations, have not been covered in a systematic review of medical literature before.

Researchers reviewed 25 reported cases of patients with headaches, migraines in most cases, and olfactory hallucinations. They also examined records from more than 2,100 patients seen over 30 months. Fourteen people, or just under 0.7 percent, had described smelling scents ahead of their headaches.

"The most common was of the burning or smoke variety," Robbins said.

Some sufferers described a general burning smell. others said they smelled cigar smoke, wood smoke or burned popcorn.

"Decomposition" odors, such as garbage or sewage, were the next most common smell reported. A few people described pleasant odours, including the scent of oranges, coffee or, in one case, foie gras.

About 11 percent of the world's population suffers from migraines, so even though olfactory hallucinations are an unusual part of aura, there could still be a fairly large number of people who experience them, Robbins said.

It's not clear why the hallucinated odors are most often unpleasant, or why they are only rarely part of migraine aura.

But aura symptoms are thought to involve a phenomenon called "cortical spreading depression," where a wave of increased electrical activity in nerve cells of the brain is followed by a wave of depressed activity, Robbins said.

That same phenomenon might underlie olfactory hallucinations -- and because the brain's smell centers occupy much less space than its sight centers, that could, in theory, explain why phantom scents are so much less common, he added.

It is also possible that some people with migraines and olfactory hallucinations do not recognize the phenomenon, he added. People know something is wrong when they see zigzag lines, but it is easy to assume a small is actually coming from somewhere.

Since some disorders, such as Parkinson's disease, can cause a person to smell scents that are not present, any such hallucinations without an accompanying headache should be checked out, he warned.

http://www.foxnews.com/health/2011/10/17/study-imagined-smells-can-precede-migraines/

International Association for the Study of Pain | Global Year Against Headache

2011-10-14T11:29:00.005-04:00

SEATTLE, October 17, 2011 – The Global Year Against Headache launches today, bringing global attention to one of the most common, painful and disabling conditions affecting people throughout their lives. Sponsored by the International Association for the Study of Pain (IASP), and working in close cooperation with the International Headache Society, the 12-month campaign focuses on education for health care professional and government leaders as well as public awareness.

Headache disorders are the most prevalent of the neurological conditions and among the most frequent of medical complaints seen in general practice. They take many forms, including migraine, tension-type headache, trigemino-autonomic cephalalgia (cluster headache), primary stabbing headache, primary sex headache, or rarer conditions such as trigeminal neuralgia or persistent idiopathic facial pain. Half of the general population experience headache during any given year, and more than 90% report a lifetime history of head pain. The most severely disabled 3% experience a headache such as chronic migraine and chronic tension-type headache at least 15 days per month. Headache disorders contribute to a considerable loss of work time and productivity.

Led by headache experts Jean Schoenen, MD, PhD (Belgium), Peter Goadsby, MD, PhD (USA), and Arne May, MD, PhD (Germany), the initiative will mobilize IASP's 7,000+ members and 86 national chapters, and forge partnerships with other organizations, to:

• disseminate information about headache worldwide;
• educate pain researchers as well as health care professionals who see the issues associated with headache firsthand in their interactions with patients;
• increase awareness of headache among government officials, members of the media, and the general public worldwide; and
• encourage government leaders, research institutions, and others to support policies that result in improved pain treatment for people with headaches.

As part of the Global Year Against Headache, IASP offers, in cooperation with the International Headache Society (IHS), a series of fact sheets for clinicians and health care professionals that cover specific topics related to headache, including epidemiology of headache, different headache types and classifications, genetic factors leading to headache, headache in childhood and adolescence, hormonal and vascular changes associated with headache, approaches to study and treatment, and more. These fact sheets are translated into multiple languages and available for free download from the IASP website. Also available on the web to download are posters promoting the Global Year. The association and its chapters will also sponsor meetings, symposia, pain camps, media interviews, publications, and other efforts to promote education on issues surrounding headache. For more information, visit: www.iasp-pain.org/GlobalYear/Headache.

About IASP: IASP brings together scientists, clinicians, health care providers, and policy-makers to stimulate and support the study of pain and translate that knowledge into improved pain relief worldwide. IASP holds a biennial World Congress on PainÂ®, sponsors grants, symposia, and programs to support pain research, and publishes books and a scientific journal, PAINÂ®. IASP is a non-profit international organization based in Seattle, USA, and is recognized as an NGO by the World Health Organization (WHO). On the third Monday of October, IASP launches an annual Global Year campaign to raise awareness of different aspects of pain. www.iasp-pain.org

About IHS: Founded in 1981, the International Headache Society is an international professional organization working with others for the benefit of people affected by headache disorders. The purpose of IHS is to advance headache science, education, and management, and promote headache awareness worldwide. www.i-h-s.org

http://www.iasp-pain.org/Content/NavigationMenu/GlobalYearAgainstPain/GlobalYearAgainstHeadache/Fact_Sheets4/default.htm

Pain of Unpleasant People is Discredited - WSJ

2011-10-13T16:46:00.001-04:00

Observers rate the pain of unpleasant people as lower than that of likeable people, a new study finds.

Researchers had 40 people looked at head shots of patients, all of whom had shoulder problems, paired with adjectives that were positive, neutral, or negative ("honest," "reserved," or "arrogant," for example). They then watched clips of the patients undergoing physiological examination, in which the patients manifested no pain, moderate pain, or severe pain.

The observers then rated the pain's intensity by marking a spot on a visual scale 100 millimeters long.

In the case of high-intensity pain, the participants rated the pain of "disliked" patients as lower than that of the other patients—on the order of 7 points lower, on the 100-point scale. There was no difference on the moderate pain. (To explain the difference, the researchers suggested that the relatively extreme grimaces and grunts that intense pain inspires might cause distinctive reactions: You might think, for example, that someone you dislike is being overly dramatic or self-centered.)

This layman's conclusion was that you should be nice to your nurse. But one author cautioned that the study involved ordinary observers, not health-care professionals, so it would be unfair to assume their judgment is clouded by your likeability—or lack of same.

Source: "When You Dislike Patients, Pain Is Taken Less Seriously," Lies De Ruddere, and six other authors, Pain (October)

http://blogs.wsj.com/ideas-market/2011/10/13/pain-of-unpleasant-people-is-discredited/

BBC News - Targeted back pain care 'cheaper and better for patients'

2011-10-04T12:16:00.001-04:00

More targeted treatment for back pain improves care and "substantially" reduces healthcare costs, say scientists.

Instead of a "one size fits all" approach, different treatments were offered depending on the severity of the condition.

Writing in the Lancet, researchers said the findings would have "important implications" for back pain patients.

Other doctors said the findings were "very promising".

Estimates for the UK suggest back pain is very common with between 6% and 9% of adults visiting their GP with the condition each year. Up to 80% say they still have pain a year later.

The report's authors argued that current care, such as advice, painkillers or referral to a physiotherapist, was based on "intuition" which was "inefficient and inconsistent".

In the study, 283 patients were treated normally and 568 were assessed as having low, medium or high risk of long-term and disabling back pain.

Low-risk patients were given advice by a physiotherapist. Medium-risk patients received intensive physiotherapy. High-risk patients had physiotherapy and help to overcome psychological barriers to recovery, which can occur in chronic conditions.

After 12 months, the targeted groups showed significantly more improvement than the traditional treatment group.

The study said the benefit was achieved at lower cost - saving more than £30 per patient on average.

Lead researcher Prof Elaine Hay, of Keele University, said: "The problem for GPs and other health professionals is spotting who, amongst the patients they see with back pain, is likely to get better with simple advice and reassurance, and who might benefit from further treatment from a physiotherapist."

She said 50 centres in the UK had already adopted the new approach: "The data shows that it is having a substantial beneficial impact where it is being implemented."

The study was funded by Arthritis Research UK. Its medical director Prof Alan Silman said there had been many studies into the effectiveness of exercise and physiological treatments, but: "This research is novel because it shows how to take the best of these two approaches, and make a real difference to large numbers of patients."

Dr Bart Koes, of Erasmus University Medical Centre in The Netherlands, said in an accompanying article that "further improvements are desirable" but "these results are indeed very promising".

He added: "The economic assessment showed that the new approach was cost effective so there is no financial reason not to implement."

http://www.bbc.co.uk/news/health-15089355

Hyperbole and a Half: Boyfriend Doesn't Have Ebola. Probably.

2011-09-25T15:28:00.001-04:00

I took Boyfriend to the Emergency Room last night because he was vomiting up vast quantities of what I thought was blood but actually it was just Craisins. You guys, if you feel like you may become violently ill in the near future, stay away from red food. Failure to do so may create an atmosphere of unnecessary panic and chaos.

Anyway, the doctor wanted to make sure that Boyfriend didn't have SARS or stomach AIDS or something, so he had to poke him a lot. While he was doing this to Boyfriend, he pointed to a little reference chart on the wall and asked Boyfriend to rate his pain::

You've probably seen some version of that chart before. You may also have noticed how inadequate it is at helping you. Based on the faces, this is my interpretation of the chart.

More ...

http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

From Pain to Suffering - Marvin Minsky, MIT

2011-09-17T17:56:00.000-04:00

This is a draft (July 27, 2005) of Chapter III of The Emotion Machine by Marvin Minsky (MIT).

What happens when you stub your toe? You've scarcely felt the impact yet, but you catch your breath and start to sweat—because you know what's coming next: a dreadful ache will tear at your gut and all other goals will be brushed away, replaced by your wish to escape from that pain.

Why does the sensation called pain sometimes lead to what we call suffering? How could such a simple event distort all your other thoughts so much? This chapter proposes a theory of this: if a pain is intense and persistent enough, it will stir up a certain set of resources, and then these, in turn, arouse some more. Then, if this process continues to grow, your mind becomes a victim of the kind of spreading, large-scale "cascade" that overcomes the rest of the mind.

More ...

http://web.media.mit.edu/~minsky/eb3.html

Audio lecture from The Society of Mind course at MIT

http://itun.es/iBd6RV

Tell Me Where It Hurts by Heather Kovich - Guernica

2011-09-16T06:58:00.001-04:00

A former examiner of Social Security disability applicants had forty minutes to determine a claimant's fate.

Doug Stanton enjoyed cooking as much as he enjoyed anything. Late in his life, he made dinner most nights with his ex-wife Laurel, who lived in an identical apartment one floor below his at their motel-style complex in a working-class suburb of Seattle. He told me his favorite dish was Tuna Helper. "We put in two cans of albacore tuna—the good stuff—and then we put in a half a cup of frozen peas and some onions, all the while trying to keep the noodles al dente." At the time, Doug didn't have any teeth. He liked to add "three-quarters of a cup of sour cream to make it, you know, good and fatty, but it makes it really tasty." He said this with a self-deprecating smile. He weighed 345 pounds. "We don't usually have leftovers with that."

I was Doug's doctor when I was a resident in family medicine at the University of Washington and I looked forward to chatting for a few minutes at each visit. He had wide ranging interests: the Large Hadron Collider, the Seahawks, and whatever hot topic there was in national politics. Doug's medical problems were complex, and frustrating to both of us, but we always enjoyed the conversation. (This story alters several names and identifying details.)

I called Doug again about a year after I'd graduated from residency. He was no longer my patient but he agreed to meet me for a series of interviews about his life before disability and his experience with the disability system. I'd taken a job doing physical examinations for Social Security disability applicants. The job had a flexible schedule, which, at the time, was worth its low prestige. There is a stereotype of people who apply for disability: they don't take care of themselves and don't want to work, exaggerating their maladies for a meager check. There is also a stereotype of the doctors who do this work: lazy and disinterested. I found the job fascinating. The more I learned about the disability system, the more I pondered its complexities: it provides a safety net but keeps people mired in poverty. Helpful services, including job retraining, are available, but aren't advertised. And the system rests on a deeply flawed premise—that there is a way to objectively determine who is able to work and who is not. The claimants I met through the job were certain that obtaining disability benefits was going to improve their lives, and they were desperate to tell me their stories. Doug had been subsisting on Social Security Disability Income (SSDI) since 2002, before I met him, and I wanted to hear his.

Payments to the disabled and their families make up about 20 percent of new Social Security awards every year, with retirement benefits constituting most of the rest. Even though Social Security remains in surplus, with the amounts taken in from taxpayers exceeding the amount owed to them, American politicians fret about the impending bankruptcy of Social Security and blame the aging baby boomer generation. Annual awards to disabled workers, however, are increasing. According to the Wall Street Journal, in 2010 one of the two Social Security programs paid out $124 billion in benefits to 10.2 million people.
In the 1980s, before Doug's life unraveled, he was making a good salary at an engineering firm in Seattle. His work was complex: he helped build a crane for NASA that assembled orbiters at Kennedy Space Center and an underwater crane for nuclear submarines. He and Laurel married in 1983 and she brought three children into the marriage. Doug quickly came to consider them his own. They owned a house in the working-class suburbs south of Seattle. But in the winter of 1996, when the tingling started, Doug's life started to fall apart.

He felt it first in his right arm: little electrical pinpricks in the tips of his fingers that shot up to his elbow, causing an aching heaviness at his shoulder. After months of physical therapy the pain had only worsened and spread. An MRI showed the cause of the problem: his spine was collapsing around his spinal cord, crushing many of the nerves, and strangling the cord itself: cervical spinal stenosis. It was bad luck—there was no injury that caused it, no family history that would have predicted it. A neurosurgeon operated to stabilize the vertebrae and take pressure off the spinal cord, but the cord had suffered permanent damage and the pain never lessened. He started drinking to dull it, the drinking affected his work. Eventually he lost his job.

He spent his severance on a drafting table so that he could continue to do part-time work from home. Then, too disabled to support himself completely, he applied for Social Security Disability Insurance.
Before 1956, when Social Security expanded to include disability benefits, disabled workers had to rely on their families or on state welfare for financial subsistence. The 1956 federal bill was controversial—it was expensive, and many politicians thought that paying the disabled not to work would lead to laziness. But Henry Jackson, a senator from Washington, passionately argued for the benefit: "It should be clear to all of us that no matter at what age a person becomes totally and permanently disabled, he needs Social Security payments worse than a person who retires at sixty-five in good health. The worker who is disabled early in life usually has accumulated less savings than has an older person. He has more dependents to care for than has an older worker whose family has grown up and left home… Retirement after one's working years can be planned for. Disability strikes without warning." President Eisenhower signed the bill, giving rise to SSDI, which allowed workers to collect their Social Security prior to age sixty-five if they became disabled. In 1974 the program added Supplemental Security Income, or SSI, which provided minimal payments to the disabled, including children, who had not contributed enough to Social Security to qualify for SSDI.

Doctors were leery of the bill. They worried that they would be put in the uncomfortable position of deciding whether their patients, people they may have known for years, were eligible for this income. To deal with this concern, applicants are now often sent to doctors who work for private staffing firms that contract with the government. This was my job, "independent medical examiner." On the basis of a forty-minute interview and examination, I was supposed to determine how disabled an applicant or "claimant" was.

My first day was a Saturday, in Spokane, Washington. The receptionist showed me around the office, and pointed out where I could discreetly watch the claimants walk back out to their cars. This was so I could see if a limp disappeared, or a wheelchair went unused, once the claimant had left the office. "I'm sorry to say it but you'll meet the scum of the earth doing this job," she explained.
I did hundreds of disability exams over the next year, and while I did meet two people who were obviously faking, for the most part the stories I heard were heartbreaking: car accidents, massive strokes, lost jobs, dead spouses. Many people who apply for disability have lived through a tragedy. But the stories also told of the inefficiencies of the disability system. That first day in Spokane I met a man who had worked in manual labor his whole life, but for years had been getting crushing chest pain after walking a few blocks. His blood pressure was dangerously high. His condition was obviously treatable, but he did not have insurance so he had not been to a doctor in years. He knew that if he qualified for permanent disability he would eventually get Medicare or Medicaid and get proper treatment. He had no idea he could go to a community health center, a federally financed clinic where he could pay on a sliding-scale basis. With the right treatment and a less strenuous job, he would probably have not needed disability.

More ...

http://www.guernicamag.com/features/3074/kovich_9_15_11/

NIH Common Fund Strategic Planning | Chronic Pain Conditions: A Transformative Classification for Stimulating Research, Improving Diagnosis, and Personalizing Treatment

2011-09-14T14:54:00.002-04:00

Major obstacle/challenge to overcome: Chronic pain conditions afflict as many as one-third of the US population and incur $560-635 billion per year in incremental healthcare costs and lost productivity (IOM Report June 29, 2011). The long term clinical goal in alleviating chronic pain is to develop targeted therapies and identify patients responsive to these therapies, both of which are supported by etiological- and mechanism-based case definitions and diagnostic criteria of disease. A major challenge in the field is the lack of a mechanism-based case definition and diagnostic criteria for multiple chronic pain conditions. Common Fund investments could facilitate the development of a new objective, biopsychosocial classification system for chronic pain disorders to overcome this major obstacle. This new system will accelerate research by standardizing research diagnoses used across laboratories, enhance clinical diagnoses by developing more objective, mechanism-based measures of disease, and identify subjects responsive to new therapies by developing novel biomarkers of disease and clinical outcomes.

Emerging scientific opportunity ripe for Common Fund investment: We propose a research program to develop a new, comprehensive, mechanism-based, biopsychosocial classification of chronic pain conditions. Three opportunities are ready for Common fund investment. This proposal endorses the ideas and sharpens the focus of "Molecular Classification of Disease", a topic that emerged from the Innovation Brainstorm meeting, and takes on sophisticated data management and analysis elements of the topics on "Beyond GWAS" and "Cross-Cutting Issues in Computation and Informatics".

Common Fund investment that could accelerate scientific progress in this field: This program would create a centralized data bank/repository containing information from a large chronic pain cohort to include study subjects with Temporomandibular Joint Disorders, Fibromyalgia, Chronic Fatigue Syndrome, Vulvodynia, Endometriosis, Irritable Bowel Syndrome, Interstitial Cystitis, Headache, Low Back Pain, Arthritis, etc., recruited and identified using today's best diagnostic criteria. Many of these subjects will have multiple, comorbid chronic pain conditions. This cohort would be genotyped as well as phenotyped extensively using molecular, imaging and psychosocial methodologies. All data would be agnostically analyzed via pathway analyses and new algorithms for lumping and splitting in order to subtype and re-classify these chronic pain patients. Results emerging from the Common Fund incubator space would lead to a breakdown in the current "walls" separating these disorders (and researchers) and a transformation of diagnostic criteria based on a completely new classification of chronic pain conditions. After an intense 5 year effort, the data bank/repository and analytical tool set would become self sustaining with support from Pharma, the genotyping industry, and the NIH Pain Consortium.

Potential impact of Common Fund investment: The outcome of this project will be a completely new way of discovery and management of chronic pain conditions: researchers currently housed in different laboratories collaborating in multidisciplinary teams to study pain, rapid discovery of therapeutic targets, development of novel analgesic therapies based on common mechanisms of disease, introduction of individualized medical treatments and identification of those likely to respond to therapy. Ultimately, results from this project will lead to an overall reduction in the burden of chronic pain, currently $560-$635 billion/year in the US in incremental healthcare costs and lost productivity.

Chronic pain should be thought of as a disease unto itself like other chronic conditions such as diabetes and heart disease, and not merely a symptom of disease. Research approaches to and management of chronic pain conditions must consider that, like other chronic conditions, disease progression and complexity, early identification and intervention, and effective therapies, all influence patient burden and economic costs of disease. A transformative classification of chronic pain conditions will ultimately reduce long-term morbidity and decrease the economic impact of these wide-spread conditions.

http://commonfund.nih.gov/InnovationBrainstorm/post/Chronic-Pain-Conditions-A-Transformative-Classification-for-Stimulating-Research-Improving-Diagnosis-and-Personalizing-Treatment.aspx

NIH Common Fund Strategic Planning | Biomarkers for chronic pain using functional brain connectivity

2011-09-14T14:54:00.001-04:00

Major obstacle/challenge to overcome: Chronic pain is a debilitating condition affecting at least 116 million American adults, resulting in significantly reduced quality of life and an estimated annual cost of $560 – 635 billion ¹. Unfortunately, its assessment is based solely on subjective self-report, using limited scales or measures, which are unsuitable for elucidating the different types and causes of pain (i.e., pain endophenotypes) and for rigorously evaluating the impact of targeted interventions. Self-report measures also hamper progress in the monitoring required to precisely dose a medication and then evaluate its comparative effectiveness among different individuals. Also, importantly, the field of pain management has been long challenged by the twin fears of undertreating pain in those who are suffering vs. triggering or facilitating a drug problem. Because of all these obstacles, there is a pressing need for a standardized, brief and simple measurement that can translate, or at least reproducibly correlate, subjective pain experience into objective and quantitative readings for both clinical and research purposes.

Emerging scientific opportunity ripe for Common Fund investment: In functional neuroimaging, there has been a recent explosion of findings on functional connectivity (FC) between brain regions, especially in the resting-state (RSFC), which is defined as the signal coherence between discrete brain regions in the absence of a cognitive task. RSFC has uncovered discrete functional networks, where the strength or activity coherence can be quantified. Based on recent reports of differences in intrinsic brain network connectivity between patients with chronic pain and controls, it has been suggested that RSFC could be a suitable platform to develop objective biomarkers of pain. Moreover, recent expansion of neuroimage data-sharing, especially of RSFC data in the 1000 Functional Connectomes Project, has demonstrated that data from different sources can be pooled to define subtypes of populations stratified by age, gender, medical conditions, and other variables, to enhance statistical power for discovery. If this level of between-labs consistency turns out to also apply to pain related measurements, RSFC could revolutionize the field of pain research and management.

Common Fund investment that could accelerate scientific progress in this field: Chronic pain is a clinical condition characteristic of a wide range of physical syndromes that collectively span the programmatic purview of many different ICs. A request for applications (RFA) on this topic to fund five or six research project grants would enable multi-disciplinary teams (comprised of pain clinicians, functional neuroimagers, and computational/network neuroscientists) to 1) develop techniques for image time-series analysis to identify brain RSFC signatures of different types of chronic pain, and 2) test the value of said signatures in a clinical context. For example, R21/R33 phased-innovation awards would enable initial collaborations to assess basic cross-sectional differences between controls and patients with different syndromes of chronic pain, and to develop and optimize new analytical tools for better identification of sensitive and specific RSFC biomarkers of pain. The common fund program concept would also enable comparative effectiveness research, data harmonization across funded projects, foster a consortium on pain RSFC biomarkers, and inform prospective evidence-based, personalized care of pain.

Potential impact of Common Fund investment: Advances in image acquisition and data analytic approaches could yield a level of objectivity, sensitivity, and specificity that would be unprecedented for chronic pain. In theory, a single resting-state functional MRI scan could serve as a diagnostic procedure akin to a head MRI for brain cancer or other neurological diagnoses. Data derived from that scan may not only provide an objective and reliable marker, but also help identify optimum therapeutic approaches, lowering the costs and loss of productivity associated with ineffective pain treatments. Validation of pain biomarkers is critical in the development of pain medications and for the adequate use of prescription analgesics matched to the needs of individuals. When the proposed program achieves its objectives, the collaborative effort among funded projects will complete the characterization and validation phase of functional brain connectivity as biomarkers for chronic pain, helping to bring evidence-based, personalized management of pain closer to reality.

http://commonfund.nih.gov/InnovationBrainstorm/post/Biomarkers-for-chronic-pain-using-functional-brain-connectivity.aspx

Does that hurt? Objective way to measure pain being developed at Stanford - Stanford University School of Medicine

2011-09-14T07:08:00.001-04:00

Researchers from the Stanford University School of Medicine have taken a first step toward developing a diagnostic tool that could eliminate a major hurdle in pain medicine — the dependency on self-reporting to measure the presence or absence of pain. The new tool would use patterns of brain activity to give an objective physiologic assessment of whether someone is in pain.

The scientists used functional magnetic resonance imaging scans of the brain combined with advanced computer algorithms to accurately predict thermal pain 81 percent of the time in healthy subjects, according to a study that will be published Sept. 13 in the online journal PLoS ONE.

"People have been looking for a pain detector for a very long time," said Sean Mackey, MD, PhD, chief of the Division of Pain Management and associate professor of anesthesiology. "We're hopeful we can eventually use this technology for better detection and better treatment of chronic pain."

Researchers stressed that future studies are needed to determine whether these methods will work to measure various kinds of pain, such as chronic pain, and whether they can distinguish accurately between pain and other emotionally arousing states, such as anxiety or depression.

"A key thing to remember is that this approach objectively measured thermal pain in a controlled lab setting," Mackey said. "We should take care not to extrapolate these findings to say we can measure and detect pain in all circumstances."

The need for a better way to objectively measure pain instead of relying on the current method of self-reporting has long been acknowledged. But the highly subjective nature of pain has made this an elusive goal.

Advances in neuroimaging techniques have re-invigorated the debate over whether it might be possible to measure pain physiologically, and, in fact, led to this current study.

"We rely on patient self-reporting for pain, and that remains the gold standard," said Mackey, senior author of the study. "That's what I, as a physician, rely on when I take care of a patient with chronic pain. But there are a large number of patients, particularly among the very young and the very old, who can't communicate their pain levels. Wouldn't it be great if we had a technique that could measure pain physiologically?"

A study released by the Institute of Medicine in June reported that more than 100 million Americans suffer chronic pain, costing around $600 billion each year in medical expenses and lost productivity. (Mackey was a member of the committee that produced the report.) What's more, it found that cultural bias against chronic pain sufferers as being weak or even worse — they are often perceived as lying about their pain — complicates the delivery of appropriate treatment. Similar biases crop up in the legal field, with hundreds of thousands of cases each year that hinge on the existence of pain, said Stanford law professor Hank Greely, an expert on the legal, ethical and social issues surrounding the biosciences.

"A robust, accurate way to determine whether someone is in pain or not would be a godsend for the legal system," said Greely, who did not participate in the study.

The idea for this study germinated at a 2009 Stanford Law School event organized by Greely that brought together neuroscientists and legal scholars to discuss how the neuroimaging of pain could be used and abused in the legal system. Mackey and two of his lab assistants attended.

"At the end of the symposium, there was discussion about the challenges of creating a 'painometer.' I discussed hypothetically how we could do this in the future," Mackey said. "These two young scientists in my lab came up to me after and said, 'We think we can do this. We would like to try.' I was skeptical."

The two scientists — Neil Chatterjee, currently a MD/PhD student at Northwestern University, and first author of the study Justin Brown, PhD, now an assistant professor of biology at Simpson College — came up with the concept in a discussion after the symposium.

"It was very much on a whim," said co-author Chatterjee. "We thought, maybe we can't make the perfect tool, but has anyone ever really tried doing this on a very, very basic level? It turned out to be surprisingly simple to do this."

Researchers took eight subjects, and put them in the brain-scanning machine. A heat probe was then applied to their forearms, causing moderate pain. The brain patterns both with and without pain were then recorded and interpreted by advanced computer algorithms to create a model of what pain looks like. The process was repeated with a second group of eight subjects.

The idea was to train a linear support vector machine — a computer algorithm invented in 1995 — on one set of individuals, and then use that computer model to accurately classify pain in a completely new set of individuals.

The computer was then asked to consider the brain scans of eight new subjects and determine whether they had thermal pain.

"We asked the computer to come up with what it thinks pain looks like," Chatterjee said. "Then we could measure how well the computer did." And it did amazingly well. The computer was successful 81 percent of the time.

"I was definitely surprised," Chatterjee said.

http://med.stanford.edu/ism/2011/september/pain.html

Laughter Produces Endorphins, Study Finds - NYTimes.com

2011-09-13T22:40:00.001-04:00

Laughter is regularly promoted as a source of health and well being, but it has been hard to pin down exactly why laughing until it hurts feels so good.

The answer, reports Robin Dunbar, an evolutionary psychologist at Oxford, is not the intellectual pleasure of cerebral humor, but the physical act of laughing. The simple muscular exertions involved in producing the familiar ha, ha, ha, he said, trigger an increase in endorphins, the brain chemicals known for their feel-good effect.

His results build on a long history of scientific attempts to understand a deceptively simple and universal behavior. "Laughter is very weird stuff, actually," Dr. Dunbar said. "That's why we got interested in it." And the findings fit well with a growing sense that laughter contributes to group bonding and may have been important in the evolution of highly social humans.

Social laughter, Dr. Dunbar suggests, relaxed and contagious, is "grooming at a distance," an activity that fosters closeness in a group the way one-on-one grooming, patting and delousing promote and maintain bonds between individual primates of all sorts.

In five sets of studies in the laboratory and one field study at comedy performances, Dr. Dunbar and colleagues tested resistance to pain both before and after bouts of social laughter. The pain came from a freezing wine sleeve slipped over a forearm, an ever tightening blood pressure cuff or an excruciating ski exercise.

The findings, published in the Proceedings of the Royal Society B: Biological Sciences, eliminated the possibility that the pain resistance measured was the result of a general sense of well being rather than actual laughter. And, Dr. Dunbar said, they also provided a partial answer to the ageless conundrum of whether we laugh because we feel giddy or feel giddy because we laugh.

"The causal sequence is laughter triggers endorphin activation," he said. What triggers laughter is a question that leads into a different labyrinth.

Robert R. Provine, a neuroscientist at the University of Maryland, Baltimore County, and the author of "Laughter: A Scientific Investigation," said he thought the study was "a significant contribution" to a field of study that dates back 2,000 years or so.

It has not always focused on the benefits of laughter. Both Plato and Aristotle, Dr. Provine said, were concerned with the power of laughter to undermine authority. And he noted that the ancients were very aware that laughter could accompany raping and pillaging as well as a comic tale told by the hearth.

Dr. Dunbar, however, was concerned with relaxed, contagious social laughter, not the tyrant's cackle or the "polite titter" of awkward conversation. He said a classic example would be the dinner at which everyone else speaks a different language and someone makes an apparently hilarious but incomprehensible comment. "Everybody falls about laughing, and you look a little puzzled for about three seconds, but really you just can't help falling about laughing yourself."

To test the relationship of laughter of this sort to pain resistance, Dr. Dunbar did a series of six experiments. In five, participants watched excerpts of comedy videos, neutral videos or videos meant to promote good feeling but not laughter.

Among the comedy videos were excerpts from "The Simpsons," "Friends" and "South Park," as well as from performances by standup comedians like Eddie Izzard. The neutral videos included "Barking Mad," a documentary on pet training, and a golfing program. The positive but unfunny videos included excerpts from shows about nature, like the "Jungles" episode of "Planet Earth."

In the lab experiments, the participants were tested before and after seeing different combinations of videos. They suffered the frozen wine sleeve or the blood pressure cuff in different experiments and were asked to say when the pain reached a point they could not stand. They wore recorders during the videos so that the time they spent laughing could be established. In the one real-world experiment, similar tests were conducted at performances of an improvisational comedy group, the Oxford Imps.

The results, when analyzed, showed that laughing increased pain resistance, whereas simple good feeling in a group setting did not. Pain resistance is used as an indicator of endorphin levels because their presence in the brain is difficult to test; the molecules would not appear in blood samples because they are among the brain chemicals that are prevented from entering circulating blood by the so-called blood brain barrier.

Dr. Dunbar thinks laughter may have been favored by evolution because it helped bring human groups together, the way other activities like dancing and singing do. Those activities also produce endorphins, he said, and physical activity is important in them as well. "Laughter is an early mechanism to bond social groups," he said. "Primates use it."

Indeed, apes are known to laugh, although in a different way than humans. They pant. "Panting is the sound of rough-and-tumble play," Dr. Provine said. It becomes a "ritualization" of the sound of play. And in the course of the evolution of human beings, he suggests, "Pant, pant becomes ha, ha."

http://www.nytimes.com/2011/09/14/science/14laughter.html?_r=1&src=tp&pagewanted=print

Gene that controls chronic pain identified - Research - University of Cambridge

2011-09-13T12:08:00.001-04:00

A gene responsible for regulating chronic pain, called HCN2, has been identified by scientists at the University of Cambridge.

The Biotechnology and Biological Sciences Research Council (BBSRC) and EU funded research, published last week (09 September) in the journal Science, opens up the possibility of targeting drugs to block the protein produced by the gene in order to combat chronic pain.

Approximately one person in seven in the UK suffers from chronic, or long-lasting, pain of some kind, the commonest being arthritis, back pain and headaches. Chronic pain comes in two main varieties. The first, inflammatory pain, occurs when a persistent injury (e.g. a burn or arthritis) results in an enhanced sensitivity of pain-sensitive nerve endings, thus increasing the sensation of pain.

More intractable is a second variety of chronic pain, neuropathic pain, in which nerve damage causes on-going pain and a hypersensitivity to stimuli. Neuropathic pain, which is often lifelong, is a surprisingly common condition and is poorly treated by current drugs. Neuropathic pain is seen in patients with diabetes (affecting 3.7m patients in Europe, USA and Japan) and as a painful after-effect of shingles, as well as often being a consequence of cancer chemotherapy. Neuropathic pain is also a common component of lower back pain and other chronic painful conditions.

Professor Peter McNaughton, lead author of the study and Head of the Department of Pharmacology at the University of Cambridge, said: "Individuals suffering from neuropathic pain often have little or no respite because of the lack of effective medications. Our research lays the groundwork for the development of new drugs to treat chronic pain by blocking HCN2."

The HCN2 gene, which is expressed in pain-sensitive nerve endings, has been known for several years, but its role in regulating pain was not understood. Because a related gene, HCN4, plays a critical role in controlling the frequency of electrical activity in the heart, the scientists suspected that HCN2 might in a similar way regulate the frequency of electrical activity in pain-sensitive nerves.

For the study, the researchers engineered the removal of the HCN2 gene from pain-sensitive nerves. They then carried out studies using electrical stimuli on these nerves in cell cultures to determine how their properties were altered by the removal of HCN2.

Following promising results from the in vitro studies in cell cultures, the researchers studied genetically modified mice in which the HCN2 gene had been deleted. By measuring the speed the mice withdrew from different types of painful stimuli, the scientists were able to determine that deleting the HCN2 gene abolished neuropathic pain. Interestingly, they found that deleting HCN2 does not affect normal acute pain (the type of pain produced by a sudden injury– such as biting one's tongue).

Professor McNaughton added: "Many genes play a critical role in pain sensation, but in most cases interfering with them simply abolishes all pain, or even all sensation. What is exciting about the work on the HCN2 gene is that removing it – or blocking it pharmacologically- eliminates neuropathic pain without affecting normal acute pain. This finding could be very valuable clinically because normal pain sensation is essential for avoiding accidental damage."

http://www.cam.ac.uk/research/news/gene-that-controls-chronic-pain-identified/

The Schmidt Sting Pain Index

2011-09-13T07:14:00.002-04:00

The Schmidt Sting Pain Index (a.k.a. the Justin O. Schmidt Pain Index) is a pain scale rating the relative pain caused by different Hymenopteran stings. It is mainly the work of Justin O. Schmidt, an entomologist at the Carl Hayden Bee Research Center in Arizona. Schmidt has published a number of papers on the subject and claims to have been stung by the majority of stinging Hymenoptera.

http://en.wikipedia.org/wiki/Schmidt_Sting_Pain_Index

Maldynia: pathophysiology and management of neuropa... [Pain Med. 2010] - PubMed - NCBI

2011-09-07T14:04:00.001-04:00

Maldynia: pathophysiology and management of neuropathic and maladaptive pain--a report of the AMA Council on Science and Public Health.

Abstract

BACKGROUND:

Because of disparate taxonomic arrays for classification, the American Academy of Pain Medicine has proposed categorizing pain on a neurobiologic basis as eudynia (nociceptive pain), Greek for "good pain," or maldynia (maladaptive pain), Greek for "bad pain." The latter has been viewed as maladaptive because it may occur in the absence of ongoing noxious stimuli and does not promote healing and repair.

OBJECTIVE:

To address recent findings on the pathogenesis of pain following neural injury and consider whether the development of maladaptive pain justifies its classification as a disease and to briefly discuss the scope of pharmacologic and non-pharmacologic approaches employed in patients with such pain.

METHODS:

English language reports on studies using human subjects were selected from a PubMed search of the literature from 1995 to August 2010 and from the Cochrane Library. Further information was obtained from Internet sites of medical specialty and other societies devoted to pain management.

RESULTS:

Neural damage to either the peripheral or central nervous system provokes multiple processes including peripheral and central sensitization, ectopic activity, neuronal cell death, disinhibition, altered gene expression, and abnormal sprouting and cellular connectivity. A series of neuro-immune interactions underlie many of these mechanisms. Imaging studies have shown that such damage is characterized by functional, structural, and chemical changes in the brain. Such pain is maladaptive in the sense that it occurs in the absence of ongoing noxious stimuli and does not promote healing and repair.

CONCLUSION:

As defined, maldynia is a multidimensional process that may warrant consideration as a chronic disease not only affecting sensory and emotional processing but also producing an altered brain state based on both functional imaging and macroscopic measurements. However, the absolute clinical value of this definition is not established.

http://www.ncbi.nlm.nih.gov/pubmed/21044254

Faces of Fibromyalgia | H.O.P.E.

2011-08-21T10:23:00.001-04:00

Welcome to the Faces of Fibromyalgia. Every day these Michiganders struggle with pain, exhaustion and cognitive difficulties. But through these videos we hope to inspire each other, and you, through this life-long journey. These are real people who understand what it is like to live with chronic pain and offer, "hope." This mom, teacher, nurse, and retired high school principal are "The Faces of Fibromyalgia."

http://www.hffcf.org/patient-support/faces-of-fibromyalgia/

H.O.P.E. | Fibromyalgia Awareness, Education & Support

2011-08-21T10:02:00.001-04:00

Fibromyalgia is one of the most common rheumatologic disorder, second only to osteoarthritis. It is the number one cause of severe, generalized musculoskeletal pain, surpassing even back pain. In the United States alone, 2.5% of all adults suffer with fibromyalgia. In real numbers, this means that approximately 10 million people in the United States deal with fibromyalgia on a daily basis. This is not a small, marginalized part of our population; the faces of fibromyalgia can be found in our neighbors, our coworkers, our families, and our friends. H.O.P.E. speaks out on behalf of those members of our community, fighting for their opportunity to become fully involved once again and live a life free of suffering.

Helping Our Pain and Exhaustion, Inc., is a 501(c)(3) non-profit organization whose mission is to develop and implement programs dedicated to improving the quality of life, for people with fibromyalgia.

http://www.hffcf.org/

Better chronic pain management - Canadian Medical Association Journal

2011-08-19T19:03:00.003-04:00

Pain care management needs to be improved, with health care professionals committing to improve care as well as a retooling of the health care system to help people who are suffering, states an editorial in CMAJ (Canadian Medical Association Journal) (pre-embargo link only) http://www.cmaj.ca/site/embargo/cmaj111065.pdf.

According to a recent analysis, chronic pain affects people of all ages, with an estimated 500,000 Canadians aged 12 to 44 years, 38% of seniors in long-term care institutions and 27% of seniors living at home experiencing regular pain.

"Experts agree that much can be done now with newer analgesics, nonpharmacologic techniques such as nerve blocks and physical therapies, as well as spiritual and supportive care," write Drs. Noni MacDonald, Ken Flegel, Paul Hébert and Matthew Stanbrook. "Availability of quality care for pain is the major problem. Health professionals have not mounted a response commensurate with the magnitude of the problem."

The authors argue for a broad strategy to help increase pain management expertise, including education, technology, and supported self-care and lay coaching.

http://www.eurekalert.org/pub_releases/2011-08/cmaj-bcp080911.php

Fibromyalgia Page - Canadian Institute for the Relief of Pain and Disability

2011-08-19T18:57:00.001-04:00

http://www.cirpd.org/PainManagement/HealthTopics/Fibromyalgia/Pages/Default.aspx

New Webinar Series "Chronic Pain: The Journey Forward"

2011-08-19T18:56:00.001-04:00

We are so excited to announce our new webinar series "Chronic Pain, The Journey Forward". Over the next seven months we will be holding 5-7 free live webinars on various topics that relate to pain management, pain treatments and current research on pain. After the live event has occurred, we will offer the recordings for free on our website.

Our first webinar will be held on August 18^th and will feature Neil Pearson PT, on the topic "Building Hope: the Way Through Pain to Self Management & Recovery".

Some of the proposed topics we are looking to explore are:

Myths & Facts About Sleep & Chronic Pain
Utilizing Science and the Arts to Transform Pain
Work Accommodation & Return to Work for Persons with Chronic Pain & Disability
The Pain Puzzle: Diagnosis and Treatment of Pain in the Elderly
Mindfulness Based Stress Reduction as a Strategy in Reducing Pain

Once we have finalized our schedule, I will announce it here, so stay tuned!!

http://www.cirpd.org/GetInvolved/News/Lists/Posts/Post.aspx?ID=21

IASP e-Newsletter - Chronic Pain: An Integrated Biobehavioral Approach By Herta Flor and Dennis C. Turk

2011-08-19T14:22:00.001-04:00

This month, IASP Press releases its latest book, Chronic Pain: An Integrated Biobehavioral Approach, written by Herta Flor, PhD, of the Central Institute of Mental Health, University of Heidelberg, Germany, and Dennis C. Turk, PhD, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA. We asked the authors to give us a glimpse inside the book:

Q: The book describes how cognitive and behavioral factors play a major role in chronic pain. Can you give an example (from your own clinical experience, perhaps) that shows how powerful memories or expectations of pain can be?

One of our patients, a 48-year-old woman, came to an assessment interview with her husband. As she slowly walked into the room, her husband was carrying her purse. He helped her to sit down, which was accomplished with some difficulty and posturing. The husband was extremely solicitous, encouraging her to move carefully and not "overdo it." He explained that he was carrying her purse because the weight added to her pain. The husband's behavior demonstrated the role of reinforcement contingencies on the patient's behaviors and became an important target of treatment because we did not want him to undermine his wife's plan to increase her activity, which would most likely be accompanied by some behaviors that conveyed distress.

Q: Is this book intended to be a handbook for clinical psychologists? Will other clinicians—physicians or nurses, for example—be able to use the assessment and treatment protocols you provide?

The biobehavioral perspective and many of the assessment methods and treatment principles that we describe can be used by the entire range of health care providers, not just clinical psychologists. Some of the treatment techniques can be used by most clinicians. Specific treatments such as biofeedback or cognitive restructuring, however, do require specialized knowledge and training and would best be provided by clinicians with appropriate behavioral health care training.

Q: Why is it that patients with low back pain, for example, are coming to psychological treatment only after a series of medical treatments have failed?

Several factors contribute to such excessive delays. Health care providers as well as patients tend to believe in what we call an acute illness model, in which the presence of symptoms is an indication of underlying physical pathology. The assumption is that once the cause of the symptoms is identified, it should be removed, or if that is not possible, then treatments should be provided—whether pharmacological or surgical—that cut or block the "pain signals." If pain persists, then a quest begins to find THE treatment that will resolve the problem. Unfortunately, there may not be any treatment that can eliminate all of the pain, yet the futile search drags on and may contribute to even greater disability.

Q: According to the evidence base, would it be better to apply treatments such as relaxation training or operant group therapy earlier on, rather than as a last resort?

Absolutely! The longer the patient continues to seek treatment, going from provider to provider and from treatment to treatment, the greater the chance for excessive disability and depressed mood. In an early study, the pioneer of behavioral pain treatment, Bill Fordyce, and his colleagues once showed that a simple limitation of bedrest, along with taking medication not "as needed" but on a fixed schedule, greatly reduces the chronicity of acute back pain.

Q: What's your philosophy on tailoring a treatment to the individual patient? How can you tell whether behavioral (operant) therapy, cognitive-behavioral therapy, biofeedback, or relaxation training will be most effective?

We strongly advocate customizing treatments to individual patient needs and characteristics. Having said that, we are only just beginning to learn about how to match treatments to individual patients. This is an important area of future research. It is also important to monitor progress and modify treatments depending on how well the patient is accomplishing the goals of pain reduction, functional improvement, and improvement in overall health-related quality of life.

Q: What are the most promising new treatment methods based on new insights about learning-related maladaptive plastic reorganization of the brain?

Recent treatment methods that focus on the reversal of brain changes related to chronic pain attempt to eliminate pain memory traces from the brain. This can be accomplished by a number of methods, including pain extinction training, which focuses on reducing pain-related behaviors and increasing positive pain-incompatible behaviors. Other promising methods include cognitive interventions that divert attention from the pain and treatments such as mirror therapy or virtual reality training that provide feedback of an intact body to the brain. Various types of biofeedback may achieve similar results. They all have the goal of altering maladaptive brain changes by providing "normal feedback" to the brain, which helps to target maladaptive changes and replace them with non-pain-related positive associations.

Q: Are psychological therapies appropriate or feasible in the low-resource setting? What about in war-torn parts of the world?

Not only are they feasible, psychological methods may be the best alternatives for use when sophisticated and expensive interventions are not available. We do need to develop more efficient ways to deliver these treatments, or at least components of these treatments, more efficiently and effectively. Developing technologies from the Internet and smart phones with lower costs are making these approaches more reasonable. A number of studies are beginning to demonstrate potential creative and innovative uses of these technological advances. We expect to see them used much more in the next few years.

Q: This book promises to be very accessible and useful for psychologists as well as pain clinicians. Any final comments?

We have provided a detailed and comprehensive rationale for the biobehavioral approach to the management of patients with chronic pain. We show how assessment should follow this model and guide treatment. We believe this integrated approach will lead to the best outcomes for the majority of patients. We provide detailed clinical protocols for assessment and treatment, and we also include our clinical insights from over 60 (combined) years of experience working in the field of pain management. We present the empirical and evidence-based background for this approach. Of course, we also acknowledge the limitations in our current knowledge. We realize that additional research will surely lead to refinements in assessment methods and treatment methods; however, we believe the perspective on patients that we have presented will continue to guide the evolution of successful outcomes in the future.

http://enews.iasp-pain.org/AM/Template.cfm?Section=August_2011&SECTION=Home,HOME&CONTENTID=14107&TEMPLATE=/CM/ContentDisplay.cfm

Doctors Struggle to Evaluate Whether a Patient's Pain Is Real - WSJ.com

2011-08-16T17:35:00.001-04:00

A patient walks into the examining room and says, "Doctor, my back hurts and nothing works—except my Percocet." Now, the physician must decide: Is this pain for real?

Despite decades of research, doctors have few tools to measure pain objectively. Generally, they ask patients to rate it themselves from one to 10, or point to the cartoon face on the wall chart whose expression best matches how they feel.

"We don't have a pain-o-meter," says Joel Saper, director of the Michigan Head Pain and Neurological Institute in Ann Arbor, which draws about 10,000 patients a year, including some of the nation's toughest migraine cases.

Dr. Saper estimates that 15% to 20% of them are faking—or at least, aren't as incapacitated as they say. Some are dependent on painkillers or seeking to resell them, he says. Some want a doctor to certify that they'll never be able to work again and deserve disability payments. Some, he thinks, don't really want to get well because they subconsciously find power in their pain.

Even when pain is real, it's highly subjective. "Two people can have the same nerve compression, but one guy will be bedridden and the other guy will be saying, 'Nah, I'm fine,' " says David Kloth, an anesthesiologist and past president of the American Society of Interventional Pain Physicians.

Evaluating patients' pain is posing a greater dilemma than ever for doctors, given two colliding health-care trends.

On the one hand, opioid painkillers—the most commonly prescribed medications in America—have become a major drug of abuse. With prescriptions up 48% since 1999, opioids are now the nation's second-leading cause of accidental death, after car crashes, according to the Office of National Drug Control Policy.

On the other hand, the Institute of Medicine, which advises the government on health issues, reported last week that pain is all too often undertreated in the U.S. For many of the 116 million Americans afflicted with chronic pain, help is delayed, inaccessible or inadequate, the IOM found.

Many patients feel stigmatized even asking for help. "I hear from people all the time who say they are at a loss to communicate how bad they feel to their doctors—without being eyed as potential criminals," says Karen Lee Richards, a co-founder of the National Fibromyalgia Association. Like many people with fibromyalgia, a complex disorder in which even mild sensations are interpreted as pain, Ms. Richards was told for years that she was probably just getting older.

Some doctors say they have to look at every patient as a potential drug abuser, since there are no typical ones—although there are suspicious patterns. "Sometimes it's the patients with elegant clothes and three kids who call a week after a filling and say they need pain medication. That's when my radar goes up," says George Kivowitz, a dentist in New York City and Newtown, Pa. Insisting that the patient come in to be re-examined usually ends the conversation, he says.

Some physicians make patients take periodic urine tests and sign treatment contracts, promising to take medications only as prescribed and not seek drugs from other sources, or face expulsion from the practice.

In 38 states, doctors can also check prescription registries to see whether patients are getting similar drugs from other physicians in the state. A nationwide version, passed by Congress and signed by President George W. Bush in 2005, has been stalled by lack of funding.

Several bills before Congress would require doctors to undergo additional training in opioid use and abuse as a condition of renewing their license to prescribe them.

"I always ask a patient, 'How are we going to show that this intervention has helped?' " says Scott Fishman, president of the American Pain Foundation who wrote a widely used guide to responsible opioid prescribing. "The person who is just trying to get opioids will say, 'Ah, later, dude' and go somewhere else."

Experts also say it's critical for primary-care physicians, who treat 80% of pain issues, to take time to know a patient's history and circumstances. The lower-back pain he's experiencing may be magnified by an unhappy work situation or pressures at home.

"The answer may not be a neuropathic pain drug but reassurance and counseling," says Perry Fine, a professor of anesthesiology at the University of Utah and president of the American Academy of Pain Medicine (AAPM). But connecting all those dots is very difficult, he concedes, when the typical office visit lasts less than 12 minutes.

There's growing recognition that acute pain and chronic pain require very different approaches. Acute pain is a warning signal to stop something that's harmful, experts say. In chronic pain, that alarm keeps sounding and producing pain long after the original cause is gone, probably due to a malfunction in the central nervous system.

Chronic pain, in turn, can cause changes in the emotional and attention centers of the brain, and lower pain tolerance even further. Antidepressants are helpful in some cases. There is little evidence that opioids are effective at alleviating chronic pain, yet some doctors keep prescribing them, in ever higher doses.

Many pain-management centers now have a multidisciplinary team including anesthesiologists, neurologists, physical therapists and psychologists evaluate patients. At University of California, Davis, where he is chief of pain medicine, Dr. Fishman says, "We start from the beginning and assess where the pain is, what it's robbed the patient of, and how treatment might help," says Dr. Fishman. "It's not a quick visit."

Some centers typically stop all of a patients' pain medicine and start over. If they protest, "I say, 'If the drugs were working, you wouldn't be here,' " Dr. Saper says.

At his migraine center in Michigan, some patients with intractable pain are admitted and observed around the clock. "We can learn a lot that you don't see in an office visit such as how they party in the cafeteria and how they argue with their spouse," he says. One patient who said her chronic migraines made her unable to work was overheard planning an ambitious honeymoon in Europe. Dr. Saper refused to sign her disability form. "We make some patients angry," he says, "but about 75% of the people who come to us improve and are grateful."

Pain psychologists also play a key role, especially when physicians can't minimize patients' pain and have to help them live with it instead. Therapists often wish they were brought in sooner. "Many patients feel like the doctors are saying to them, 'There's nothing we can do from a medical standpoint, so it must be mental,' " says Robert Twillman, a veteran pain psychologist who is now director of advocacy for the AAPM. He often tells patients that whatever the initial cause, the pain must be taking an emotional toll as well, which is in their own power to change.

Many centers focus on improving function rather than eliminating pain. Sean Mackey, chief of Stanford University's division of pain management, doesn't even ask patients how much pain they are in. Instead, he asks, " 'If I could wave a magic wand and take away all your pain, what would you be doing in a month?' We may not be able to measure a patient's pain, but we can define some goals and work toward them," he says.

Lasting aches

Chronic pain affects 116 million Americans (one-third of the population) and costs $550 billion to $635 billion a year in medical bills and lost productivity. The most common types people reported in a survey:

• Low back pain – 28%

• Knee pain – 20%

• Severe headache or migraine - 16%

• Neck pain – 15%

• Shoulder pain – 9%

• Finger pain – 8%

• Hip pain – 7%

Source: Institute of Medicine; 2011 survey of U.S. adults reporting that they had pain in the past three months

Use and Abuse

Opioids are the most commonly prescribed drugs in the U.S. Hydrocodone (Vicodin) is the No. 1 drug.

• Prescriptions rose nearly 50% from 2000 to 2009; milligrams prescribed per person rose 400% from 1997 to 2007.

• 15% to 20% of doctor visits in the U.S. involve an opioid prescription.

• Four million Americans a year are prescribed a long acting opioid.

• Abuse of opioid pain relievers is the second-leading cause of accidental death in the U.S., after car crashes.

• Fatalities rose from 3,000 in 1997 to 12,000 in 2007.

• Emergency-room visits due to prescription-drug overdose more than doubled from 2004 to 2008, according to the Drug Abuse Warning Network.

Source: Archives of Internal Medicine, 2011; Office of National Drug Control Policy

http://online.wsj.com/article/SB10001424052702304450604576419810283786774.html

A list of top 50 Pain blogs by Blog Rank

2011-08-16T12:17:00.001-04:00

http://www.invesp.com/blog-rank/Pain

The societal impact of pain - 2011 European conference

2011-08-14T11:46:00.001-04:00

http://www.sip-meetings.org/grt-sip/GRT-SIP__en__Home/2011/Programs/173500017.jsp

The Pain Project | InternationalReporting.org

2011-07-27T19:32:00.001-04:00

Anyone who has been given painkillers for a sore back, or a morphine drip after surgery, should consider themselves lucky. While morphine is the standard treatment is most Western hospitals, more than half the countries in the world have little to no access to these drugs. Millions of patients around the globe suffer long-term illnesses in excruciating pain.

Unlike so many global health problems, pain treatment is not about money or a lack of drugs, since morphine costs pennies per dose. The culprits are bureaucratic hurdles and the chilling effect of the global war on drugs.

The International Reporting Program traveled to Ukraine, India and Uganda, to uncover this hidden human rights crisis. The resulting report is "Freedom from Pain," a half hour documentary produced in partnership with Al Jazeera English.

http://www.internationalreporting.org/blog/2011/07/07/the-pain-project/

NIH grant program on Pharmacological Management of Chronic Pain in Older Adults

2011-07-25T21:01:00.000-04:00

Section I. Funding Opportunity Description

The number of Americans age 65 or older currently exceeds 40 million, or about 13% of the US population. Over the next 20 years, this number is expected to reach approximately 70 million, or 20% of the population. The oldest old, those individuals age 85 or older, are the fastest growing segment of the US population, and the proportion of these individuals is expected to more than triple by 2050.

As the age of the population increases, so too will the diseases and conditions that accompany advancing age. Chronic pain is highly prevalent among older adults. Primary causes of chronic pain in this population include musculoskeletal diseases (e.g., osteoarthritis and degenerative disk disease), cancer, and neuropathic conditions (e.g., diabetic neuropathy, post-herpetic neuralgia, and chemotherapy-induced neuralgia). Chronic pain is also associated with a variety of adverse health outcomes such as disability, cognitive deficits, mood disturbance, and impaired sleep.

Current management of chronic pain involves a stepwise approach that frequently includes non-steroidal anti-inflammatory drugs (NSAIDs) and/or opioids for moderate-to-severe pain. A variety of adjuvant drugs, devices, and non-pharmacologic therapies may also be used, often in combination with NSAIDs and/or opioids. Despite this panoply of therapeutic options, however, older adults continue to be undertreated disproportionately, due in large part to lack of evidence, under-recognition of pain, and safety concerns among prescribers, patients, and caregivers.

In 2009, an American Geriatrics Society (AGS) special panel published updated guidelines for pharmacologic management of chronic pain in older adults [1]. Specifically, these guidelines recommended that "[n]onselective NSAIDs and COX-2 selective inhibitors may be considered rarely, and with extreme caution, in highly selected individuals." At the same time, the AGS guidelines also recommended that "[a]ll patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life due to pain should be considered for opioid therapy." While there is a fair amount of evidence supporting contraindications to treatment, there is a much smaller evidentiary base to identify those older adults with chronic pain who may safely benefit from NSAIDs or opioids over months or years of treatment. The evidence base for other classes of drugs, such as adjuvant analgesics, also requires further development.

Consequently, there is a need to generate evidence guiding safe and effective treatment for chronic pain in older persons. In 2010, an "Expert Panel Discussion on Pharmacological Management of Chronic Pain in Older Adults" was convened under the aegis of the NIH Pain Consortium to identify research gaps and suggest approaches to address them. A summary of the research gaps and methods to address them are in press at Pain Medicine with publication expected in the September, 2011 issue. Among many recommendations, panelists noted that a variety of factors may influence the selection and outcomes of treatment, including patient-, medication-, provider-, and system-level factors. A cost-effective approach to investigating these myriad factors may be to examine available datasets or add new measures to existing studies to identify variables associated with successful or adverse outcomes of treatment.

The purpose of this FOA is to support small, self-contained research projects that aim to leverage existing data or longitudinal studies in order to evaluate the safety and/or effectiveness of pharmacological management for chronic pain in older adults. Applicants are invited to submit innovative proposals using administrative databases, health care records, clinical trial datasets, patient registries, cohort studies, or other resources to further our understanding of treatment outcomes from pharmacologic or combination pharmacologic/non-pharmacologic interventions, particularly involving NSAIDs or opioids, in older individuals with chronic pain. Proposed approaches may include, but are not limited to 1) secondary analyses of existing datasets; 2) adding new measures to existing observational or interventional studies; or 3) developing methodologies to facilitate the preceding two approaches.

Examples of aging-related studies that this FOA may support include, but are not restricted to:

Identification of patient-level factors (e.g., cormorbidities, pharmacogenomic profiles, renal function, cognitive function, vulnerabilities), medication-level factors (e.g., initiating dose, titration method, specific pattern of analgesic use, mode of delivery, interactions with alcohol, benzodiazepines, anti-depressants, or other sedatives), provider-level factors (e.g., communication patterns with patients, attitudes and beliefs), and/or system-level factors (e.g., guideline recommendations, care models) associated with outcomes from specific treatment strategies (e.g., pharmacotherapy or combination pharmacotherapy/ non-pharmacologic therapy) in older adults with chronic pain.
Comparative safety and/or effectiveness studies of different treatment approaches in older adults or in specific sub-populations (e.g., individuals with dementia), such as comparisons between primary treatments to reduce pain, co-administered treatments to reduce side effects, or additive treatments to enhance therapeutic effects.
Development of a methodology to link datasets with complementary data elements in order to enable valid evaluations of pain treatment outcomes that would not be possible using datasets individually.
Evaluation of the utility of pain-related measures or indices in guiding treatment initiation, titration, or discontinuation in specific older populations (e.g., individuals with dementia).

Investigators hypothesizing mediatory roles for specific characteristics on treatment outcomes are encouraged to provide an empirical or theoretical rationale for selecting such characteristics. In addition, investigators are encouraged to provide adequate analytic plans to address potential methodological pitfalls of analyzing observational data, especially those collected in non-randomized studies or during clinical care.

Applicants are encouraged to study older subjects with a range of ages. Studies in older subjects with multiple morbidities, vulnerabilities, and those from ethnically diverse backgrounds are particularly encouraged, as these populations are among the most commonly undertreated and understudied patients with chronic pain.

The NIA Database of Longitudinal Studies contains an extensive listing of NIH-supported cohort studies involving older subjects and/or aging research questions. The database can be found at http://nihlibrary.ors.nih.gov/niapopdb/.

The National Institute on Drug Abuse (NIDA) is also interested in applications responsive to this FOA that fall within its scientific mission. NIDA may support such meritorious applications contingent on availability of funds.

References

1. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons: American Geriatrics Society. Journal of the American Geriatrics Society. 2009; 57:1331-1346.

http://grants.nih.gov/grants/guide/rfa-files/RFA-AG-12-006.html

Gut memories: Towards a cognitive neurobiology of irritable bowel syndrome [Neurosci Biobehav Rev. 2011]

2011-07-24T08:36:00.001-04:00

Neurosci Biobehav Rev. 2011 Jul 13. [Epub ahead of print]

Gut memories: Towards a cognitive neurobiology of irritable bowel syndrome.

Kennedy PJ, Clarke G, Quigley EM, Groeger JA, Dinan TG, Cryan JF.

Source

Alimentary Pharmabiotic Centre, University College Cork, Cork, Ireland; Department of Psychiatry, University College Cork, Cork, Ireland.

Abstract

The brain and the gut are engaged in continual crosstalk along a number of pathways collectively termed the 'brain-gut axis'. Over recent years it has been becoming increasingly clear that dysregulation of the axis at a number of levels can result in disorders such as irritable bowel syndrome (IBS). With recent advances in neuroimaging technologies, insights into the neurobiology of IBS are beginning to emerge. However the cognitive neurobiology of IBS has remained relatively unexplored to date. In this review we summarise the available data on cognitive function in IBS. Moreover, we specifically address three key pathophysiological factors, namely; stress, immune activation and chronic pain, together with other factors involved in the manifestation of IBS, and explore how each of these components may impact centrally, what neurobiological mechanisms might be involved, and consider the implications for cognitive functioning in IBS. We conclude that each factor addressed could significantly impinge on central nervous system function, supporting the view that future research efforts must be directed towards a detailed assessment of cognitive function in IBS.

http://www.ncbi.nlm.nih.gov/pubmed/21777613

Behavioral Treatment For Migraines A Cost-Effective Alternative To Meds - Medical News Today

2011-07-21T17:42:00.000-04:00

Treating chronic migraines with behavioral approaches - such as relaxation training, hypnosis and biofeedback - can make financial sense compared to prescription-drug treatment, especially after a year or more, a new study found.

Longtime behavioral therapy researcher and practitioner Dr. Donald Penzien, University of Mississippi Medical Center professor of psychiatry, coauthored the study. He said the costs of prescription prophylactic drugs - the kind chronic migraine sufferers take every day to prevent onset - may not seem much even at several dollars a day.

"But those costs keep adding up with additional doctor visits and more prescriptions," Penzien said. "The cost of behavioral treatment is front-loaded. You go to a number of treatment sessions but then that's it. And the benefits last for years."

Published in the June issue of the journal Headache, the study compared the costs over time of several types of behavioral treatments with prescription-drug treatments. The research team included investigators from Wake Forest University, UMMC and the University of Mississippi.

The researchers found that after six months, the cost of minimal-contact behavioral treatment was competitive with pharmacologic treatments using drugs costing 50 cents or less a day. Minimal-contact treatment is when a patient sees a therapist a few times but largely practices the behavioral techniques at home, aided by literature or audio recordings.

After one year, the minimal-contact method was nearly $500 cheaper than pharmacologic treatment.

"We have a whole armamentarium of behavioral treatments and their efficacy has been proven. But headache sufferers are only getting a tip of these options," said Dr. Timothy Houle, associate professor of anesthesiology and neurology at Wake Forest University, and the study's principal investigator.

"One reason is people think behavioral treatment costs a lot. Now with this study, we know that the costs are actually comparable, if not cheaper, in the long run."

At a time when health-care costs are under national scrutiny, the study offers a framework for comparing costs that researchers can update and use for years to come.

"We thought, 'Wouldn't it be fun to model this and see how it comes out over time?'" Penzien said. "All the figures are there so if someone disagrees with it, they can plug in their own numbers."

The researchers didn't compare the effectiveness of methods, nor did they calculate the costs over time of individual drugs, since dosages and prices vary widely. Rather, they figured the per-day costs of each method based on fees of physicians and psychologists. For the physician group, they added in the cost of prescription beta-blocker drugs at various prices.

For instance, among the psychologists surveyed, one-on-one behavioral sessions cost between $70 and $250 for the intake visit and $65 and $200 for follow-up visits. That put the median intake cost at $175 and median follow-up cost at $125 for a median 10 visits.

The researchers calculated the median cost of pharmacologic approaches at $250 for the intake session and a professional fee of $140 per session. Median time to the first follow-up was 52.2 days, rising to 60 for the second with a median five visits per year.

To get information on behavioral treatments, the researchers surveyed members of the Behavioral Issues Group of the American Headache Society. For figures on pharmacologic treatments, the researchers surveyed a group of Headache Society-member physicians they knew treated substantial numbers of headache sufferers.

The most expensive behavioral treatment method - individual sessions with a psychologist in clinic - cost more than pharmacologic treatment with $6-a-day drugs in the first months. But at about five months, individual sessions become competitive. After a year, they are cheaper than all methods except treatment with drugs costing 50 cents or less a day.

Overall, group therapy and minimal-contact behavioral treatment were cost-competitive with even the cheapest medication treatment in the initial months. At one year, they become the least-expensive headache treatment choice.

http://www.medicalnewstoday.com/releases/230529.php

CRC Press Online - Maldynia - James Giordano, Ed.

2011-07-21T14:49:00.001-04:00

Features

• Provides an overview of the history of pain and its treatment since Hippocrates

• Addresses the neurobiology and experience of chronic pain

• Discusses possible relationships of chronic pain to spirituality

• Details the role and value of narrative and expression, as well as technology in assessing maldynic pain

• Posits the basis for an ethic of pain care

• Explores the problematic nature and implications of pediatric maldynia

• Examines the importance of goal-directed health care

Summary

Whether initiated by injury or disease, induced and sustained by changes in the nervous system, or manifested by society and culture, chronic pain can change one's first-person experience of the body and the world, and ultimately impacts cognitions, emotions, and behavior. Many fine medical books address the causes and management of chronic intractable pain, but rarely do they focus on the ways that such pain creates illness and is experienced and expressed by persons in pain.

Maldynia: Multidisciplinary Perspectives on the Illness of Chronic Pain is about chronic pain that has progressed to a multidimensional illness state in and of itself. Although often dismissed as such, this pain is not imaginary, but rather represents an interaction of neurobiological processes, emotional and behavioral responses, and socio-cultural effects and reactions that become enduring elements in the life and world of the pain patient, and often remain enigmatic for those who provide care.

Taking a comprehensive approach that covers science, humanities, and culture, this volume emphasizes the need for researchers, clinicians, and caregivers to regard the ways in which chronic intractable pain becomes illness and affects a patient's biological, social, and psychological states, as well as his or her sense of self. Edited by neuroscientist and neuroethicist James Giordano, this book contains 17 insightful chapters representing medicine, neuroscience, psychology, philosophy, ethics, history, art, and the ministry, this volume:

• Provides an overview of the history of pain and its treatment since Hippocrates
• Addresses the neurobiology and experience of chronic pain
• Discusses possible relationships of chronic pain to spirituality
• Details the role and value of narrative and expression, as well as technology in assessing maldynic pain
• Posits the basis for an ethic of pain care
• Explores the problematic nature and implications of pediatric maldynia
• Examines the importance of goal-directed health care

This exceptional volume also looks at representations of pain in and through the arts, addresses the assignation of values and meaning in pain assessment and treatment, and considers ways to conjoin the sciences and humanities so as to inform the practice of pain medicine and improve the care of those suffering the illness of chronic pain.

http://www.crcpress.com/product/isbn/9781439836309?utm_source=Real Magnet&utm_medium=Email

What Doctors Don't Know About Pain - NYTimes.com

2011-07-21T14:33:00.001-04:00

Most doctors view pain as a symptom of an underlying problem — treat the disease or the injury, and the pain goes away.

But for large numbers of patients, the pain never goes away. In a sweeping review issued last month, the Institute of Medicine — the medical branch of the National Academy of Sciences — estimated that chronic pain afflicts 116 million Americans, far more than previously believed.

The toll documented in the report is staggering. Childbirth, for example, is a common source of chronic pain: The institute found that 18 percent of women who have Caesarean deliveries and 10 percent who have vaginal deliveries report still being in pain a year later.

Ten percent to 50 percent of surgical patients who have pain after surgery go on to develop chronic pain, depending on the procedure, and for as many as 10 percent of those patients, the chronic postoperative pain is severe. (About 1 in 4 Americans suffer from frequent lower back pain.)

The risk of suicide is high among chronic pain patients. Two studies found that about 5 percent of those with musculoskeletal pain had tried to kill themselves; among patients with chronic abdominal pain, the number was 14 percent.

"Before, we didn't have good data on what is the burden of pain in our society," said Dr. Sean Mackey, chief of pain management at the Stanford School of Medicine and a member of the committee that produced the report. "The number of people is more than diabetes, heart disease and cancercombined."

For patients, acknowledgment of the problem from the prestigious Institute of Medicine is a seminal event. Chronic pain often goes untreated because most doctors haven't been trained to understand it. And it is isolating: Family members and friends may lose patience with the constant complaints of pain sufferers. Doctors tend to throw up their hands, referring patients for psychotherapy or dismissing them as drug seekers trying to get opioids.

"Most people with chronic pain are still being treated as if pain is a symptom of an underlying problem," said Melanie Thernstrom, a chronic pain sufferer from Vancouver, Wash., who wrote "The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering" (Farrar, Straus & Giroux, 2010) and was a patient representative on the committee.

"If the doctor can't figure out what the underlying problem is," she went on, "then the pain is not treated, it's dismissed and the patient falls down the rabbit hole."

Among the important findings in the Institute of Medicine report is that chronic pain often outlasts the original illness or injury, causing changes in the nervous system that worsen over time. Doctors often cannot find an underlying cause because there isn't one. Chronic pain becomes its own disease.

"When pain becomes chronic, when it becomes persistent even after the tissue and injury have healed, then people are suffering from chronic pain," Dr. Mackey said. "We're finding that there are significant changes in the central nervous system and spinal cord that cause pain to become amplified and persistent even after the injury has gone away."

The institute emphasized the importance of prevention and early treatment, a novel concept for many doctors who try to diagnose the source of pain before treating it or advise patients to wait it out in the hope it will go away on its own.

"Having pain that is not treated is like having diabetes that's not treated," said Ms. Thernstrom, who suffers from spinal stenosis and a form of arthritis in the neck. "It gets worse over time."

Ms. Thernstrom compared the effect of chronic pain on the body to the rushing waters of a river carving out a new tributary. Pain, she says, also changes the body's landscape.

"My pain is at the level where it's manageable," she said. "I do wish I had gotten aggressive treatment in the first year. There is a window of time to intervene, because pain changes your nervous system and pain pathways develop."

The report also acknowledged the "conundrum of opioids," noting that doctors are conflicted about how to treat pain because of worries about drug addiction. But the group noted that proper use of the drugs early in a pain cycle can resolve pain problems sooner, and stated that opioids are also particularly useful for pain management near the end of life.

The pain report is only a first step for the community of medical professionals who treat pain. It will be up to medical schools to begin better education of doctors in the treatment of pain, and the National Institutes of Health to decide whether to promote research into chronic pain. Patients, too, need to be educated about the importance of early treatment of pain rather than gutting it out or waiting until it has become severe and chronic.

"Some people were expecting a cure within the report," Dr. Mackey said. "There's no immediate cure. But I've seen a lot of patients who have said, 'Finally they are putting out a report that helps others understand what I'm going through.' "

http://well.blogs.nytimes.com/2011/07/18/giving-chronic-pain-a-medical-platform-of-its-own/

The Genetics of Pain: Science, Medicine, and Drug Development - Miami Beach, February 7-9, 2012

2011-07-21T13:02:00.001-04:00

With this IASP symposium we will:

Discuss key issues in pain research, including promising ongoing research, unanswered questions, emerging concepts
Emphasize translational research as the key to understanding mechanisms of susceptibility to chronic pain, and developing preventative approaches and novel treatment strategies
Explore the latest findings of genetic and genomic mediation of nociception from various models, emphasizing the conservation of pain-related genes, their functions and their advantages
Discuss the role of gene polymorphisms in normal and pathological modulation of pain in models, humans, and as future drug targets
Explore the latest findings from human genome-wide investigation of genomic variability and gene expression on pain and nociception
Review and discuss "gold standard" tools for comprehensive pain phenotyping in humans
Review and discuss current and future genetic and genomic techniques to study genetic contribution to human pain
Summarize the progress of cutting-edge clinical trials and those steps required to translate present research findings to clinical practice
Create a forum for the exchange of ideas on the impact of modern genetics on pain research

http://paingenetics.org/

Michelle Bachmann's headaches: Why are migraines more common in women? - By Brian Palmer - Slate Magazine

2011-07-21T11:24:00.001-04:00

Aides to Republican presidential candidate Michele Bachmann say she suffers from severe migraine headaches that can incapacitate her for days at a time. After Bachmann's campaign denied the claim s, a secondary debate was sparked about whether reporting on the issue is sexist, since migraines are more common in women than men. Why do migraines disproportionately afflict women?

Hormones, probably. About 18 percent of women suffer from migraines, compared with just 6 percent of men. Doctors have proposed several explanations for the disparity, including different levels of external stress and gender-related differences in the psychological response to pain. The best research, however, now suggests that sex hormones are to blame, and loads of circumstantial evidence support this theory. In women, the headaches typically begin after puberty and tend to decrease in both frequency and intensity after menopause. (Migraines are one of the few neurological disorders to subside with age.) They are also more common during menstruation and less common during pregnancy. Intriguingly, doctors treating male-to-female transgendered people have noticed that after their patients begin hormone therapy, they start to experience migraines with the same frequency as genetic females.

Although the research is still unsettled, there is growing scientific evidence that estrogen is the primary culprit. Migraines occur when inflammation around the brain triggers trigeminal nociceptors—cells responsible for pain sensations around the face—to transmit chemical signals. Nancy Berman and Kenneth McCarson, neurology researchers at the University of Kansas Medical Center, have shown that in mice these cells have estrogen receptors. Also, rats exposed to estrogen exhibit significantly worse migraine symptoms—except for nausea, since rats don't vomit—than their estrogen-starved counterparts at the same level of inflammation. At a biochemical level, they've documented changes indicating that pain signals are stronger when estrogen receptors are activated. Such evidence suggests the possibility that men might experience the inflammation associated with migraine just as often as women but their pain receptors have a less forceful response to it.

Charges of sexism have hovered around migraines for years. Advocates point out that the National Institutes of Health will spend $15 million on migraine research in 2011, less than 0.05 percent of its annual research budget. That's peanuts compared with what we spend on some other debilitating but usually nonfatal diseases like arthritis ($253 million) and sleep disorders ($230 million).

http://www.slate.com/id/2299640/

Body in Mind — Research into the role of the brain in chronic pain (The Body in Mind Research Group, Australia)

2011-07-20T18:25:00.000-04:00

The Body in Mind Research Group is based at The Sansom Institute for Health Research at the University of South Australia in Adelaide and Neuroscience Research Australia in Sydney. We have active collaborations with researchers scattered around the world. Together we are seeking a better understanding of the interaction between the body, brain and mind in chronic and complex pain disorders.

http://bodyinmind.org/

rTMS and chronic pain: Our two penny’s worth - O’Connell NE, & Wand BM

2011-07-20T18:21:00.000-04:00

Some of you might have heard of repetitive transcranial magnetic stimulation (rTMS) and its use in chronic pain. Basically rTMS uses magnetic fields to generate electrical currents within the brain. This is a direct way of altering neuronal firing or excitability in the brain and a number of research groups have been investigating whether it might be used to treat chronic pain by altering pain processing in the brain. To get an idea of what it's all about check out this section of the BBC's Horizon programme "The Secret World of Pain".

http://www.youtube.com/watch?v=ERtdvj6cw3w

While that video is emotionally compelling and at face value looks really promising, I lost count of the number of ways in which the placebo effect might be being ramped up in that interaction. In fact I personally felt that the programme did not really offer the viewer enough balance or caveats there. So what does the best evidence tell us about the efficacy of this technique? For a change we get to talk about our own research because after carrying out a Cochrane review on this very topic we have just written a commentary in the journal PAIN® that discusses the current state of the evidence for rTMS in chronic pain management.

Our review found a bunch (19) of small studies of rTMS. Overall the data was quite varied but when pooled it suggested a small effect. When we broke the data into pre-planned subgroups we found a small short-term effect on pain of single doses of high frequency rTMS applied to the motor cortex. Great news - it seemed to work better than sham (placebo) stimulation. But as usual there were reasons to be a tad less cheerful. The effect was small and while it tickled the feet of clinical importance it didn't clearly hit that target. There were also problems with risk of bias, particularly the tricky challenge of effectively blinding the studies, and we know that these issues tend to exaggerate effect sizes.

In fairness to rTMS these were single-dose one-off treatment studies. Maybe more doses would be more effective. Also they almost all recruited patients with severe neuropathic pain that didn't respond to anything else either, so not the easiest pain to influence. When we looked the few studies that delivered multiple doses the results were conflicting and inconsistent and there really aren't enough of them to make a confident judgement.

The point that we make in our commentary is that the evidence does suggest that rTMS might modulate pain, but this data has its problems, the studies are small and the evidence is a mixed bag of quality. There are more small, exploratory studies being published regularly, all justified by and based upon the initial promise of the earlier work but what is really needed is for researchers to take a nice big sample, deliver a good robust course of rTMS treatment using the parameters that look most promising right now (high frequency stimulation to the motor cortex), measure their outcomes over a decent time span, and all of this with good tight methods and better blinding. Sounds easy (but of course it never is)! But without this effort the next time we update our Cochrane review we might still only be able to say "maybe, maybe not".

O'Connell NE, & Wand BM (2011). Repetitive transcranial magnetic stimulation for chronic pain: Time to evolve from exploration to confirmation? Pain PMID: 21703764

http://bodyinmind.org/rtms-and-chronic-pain/

‪Princess on the Pea - Mechanisms of Chronic Pain‬‏ - YouTube

2011-07-20T18:09:00.001-04:00

Today we have a pretty good knowledge of the mechanisms behind chronic pain. This is a presentation of the basic understanding of how chronic pain starts, what causes it and why we most often are not able to see it on x-ray, MRI or other diagnostic procedures despite the fact that the patient are experiencing pain. We comes around allodynia, hyperalgesia, sensitization regulatory pathways and influence of sleep, depression and much more.

http://www.youtube.com/watch?v=RlnRb0sW_FE&feature=channel_video_title

Specificity Versus Patterning Theory: Continuing the Debate - Allan Basbaum | Pain Research Forum

2011-07-15T07:30:00.001-04:00

Does the brain process and interpret innocuous and noxious stimuli by "reading" a pattern of activity across multimodal lines of activity, or are there specific, labeled lines that carry functionally distinct modalities from the periphery to the spinal cord and then rostrally in the neuraxis?

The specificity camp has its origins in the nineteenth-century studies of German neurophysiologists who concluded that there are modality-specific spots on the skin (e.g., touch, cold, etc.), and that a percept is generated by activation of specific neuronal pathways in the periphery and CNS (for reviews, see Craig, 2003; Ma, 2010; and Perl, 2007). This concept was originally articulated by Müller (Müller, 1840), who proposed that the stimulus did not even determine the perception, but rather that connectivity of the afferent and its ultimate projection site in the brain were critical.

The pattern theory, by contrast, proposed that afferent fibers respond to a host of stimulus modalities, and that the ultimate perception depends on the brain's deciphering and interpretation of the patterns of activity across the different nerve fibers. The late Patrick Wall, almost 30 years after coauthoring the Gate Control Theory of Pain in 1965 with Ronald Melzack (Melzack and Wall, 1965), wrote that "…specificity theory has failed to generate any explanation for clinical pains. Worse yet…it has encouraged ineffective, often counterproductive, surgical attempts to destroy the cells or their axons" (Wall, 1996). The poster boy/dartboard for the specificity camp, of course, is Descartes' little boy whose "pain pathway" runs from his foot to a pain center in his brain.

It is of interest that the focus of Melzack and Wall's seminal 1962 article "On the nature of cutaneous sensory mechanisms," which preceded the Gate Control Theory paper by three years, was on the processing of non-noxious thermal and mechanical stimuli, as compared to pain-producing stimuli. The paper dealt much less so, if at all, with the question of the processing of different modalities of noxious/painful stimuli (i.e., heat, cold, mechanical, and chemical pain) (Melzack and Wall, 1962). Pat Wall was, of course, strongly influenced by his discovery, with Lorne Mendell, of the wide dynamic range (WDR) dorsal horn neuron (Mendell and Wall, 1965). The WDR neuron clearly responds to both innocuous and noxious stimulation, which argued against a specific Cartesian "pain" pathway. However, subsequent demonstrations by Ed Perl and colleagues of primary afferents (nociceptors) and lamina I dorsal horn neurons that respond only to noxious stimulation, at least in uninjured animals (Bessou et al., 1971; Christensen and Perl, 1970) provided fodder for the labeled line advocates.

So where are we today? As a student of both Melzack and Wall, I grew up with a firm belief in pattern theory. However, results from our recent studies have encouraged me to reexamine this basic tenet. Just as the ability to record from single fibers made possible the identification of afferents that respond rather exclusively to noxious stimulation, so the molecular revolution has revealed a detailed subclassification of the nociceptors. In fact, nociceptors are remarkably heterogeneous; different subsets express channels that are responsive to different noxious stimulus modalities (e.g., heat [TRPV1], cold [TRPM8], mustard oil [TRPA1], etc.) (Basbaum et al., 2009; Julius and Basbaum, 2001). Of course, there is some overlap of these channels, and there is no question that many of the nociceptors are polymodal, responding to thermal as well as mechanical stimulation. Nevertheless, our studies argue strongly for a modality-specific contribution of subsets of primary afferents to the presumptive pain-generated behaviors evoked by the particular modality, (e.g., heat, cold, mechanical) (Cavanaugh et al., 2009; Scherrer et al., 2009).

Although I have written (in a syllabus for an IASP Refresher course) that "there are no labeled lines….", I now believe that there is behaviorally relevant specificity, at least at the level of the primary afferent. To what extent the behaviorally relevant (pain, and likely itch) information generated by primary afferents is also manifest at the level of circuits in the spinal cord and at higher levels of neuraxis is the critical unanswered question. Yes, there are nociceptive-specific neurons in the dorsal horn, but the WDR neuron cannot be ignored (Price et al., 2003). Indeed, the relative contribution of these two neurons is worthy of continued discussion in this forum.

In their 1962 article, Melzack and Wall proposed that, "A satisfactory theory of somesthesis must be able to provide answers to two essential problems: 1) What is the nature of the information that is sent to the central nervous system when the skin is stimulated, and 2) How do the central cells select or abstract from this information to provide the many different qualities of our sensory experience?" We have come a long way to answering the first question, butclearly, we need more information as to the specificity versus patterning question at the level of CNS circuitry, so that answers to the second question can be generated.

These questions are not merely of interest to the basic scientist, but are relevant to the development of approaches to the clinical management of pain. Are there clinical pain conditions that arise from activity in subsets of nociceptors, and if so, can drugs be developed to block selectively the contribution of those afferents? For example, TRPV1 is generally associated with noxious heat transduction and heat hypersensitivity, but clearly that is not its function in a visceral afferent that innervates the pancreas. Thus, a drug that blocks TRPV1-expressing afferents selectively may have great utility, beyond regulating heat-pain sensibility (which is clearly not a major clinical concern).

The question of specificity is also relevant to ablative procedures. Because attempts in animals are now made to ablate chemically subsets of spinal cord neurons (e.g., with substance P-conjugated to saporin; Nichols et al., 1999), the controversy, unquestionably, has significant clinical implications. Does the preclinical development of these techniques mean that we are poised to go beyond what Pat Wall, as noted above, referred to as "ineffective, often counterproductive, surgical attempts to destroy the cells or their axons" (epitomized by anterolateral cordotomy), or are the new approaches built upon a misunderstanding of the way pain is generated? Should we be concerned that reducing information flow in a specificity-based "pain transmission network" can contribute to the development of central pain syndromes (as can occur post-stroke)?

Finally, and very importantly, this author certainly appreciates that this contemporary perspective on the question of specificity versus patterning relates more to the processing of nociceptive messages, and much less so to the sensory experience/perception of pain. The latter is clearly influenced and in some cases dominated by emotional and cognitive factors. To what extent specificity or patterning or some hybrid model integrates with these factors is not at all clear, and will not be determined by studies directed only at the primary afferent or spinal cord circuits. Studies that integrate an analysis of the pathways through which inputs are transmitted from the cord to the brain, with others directed at identifying where and how emotional/affective and cognitive factors are processed, will require combining psychophysical studies with novel imaging methods that can monitor the process of information transfer from the spinal cord to the brain.

Remember that the original discussion of specificity versus patterning was not a neurophysiological one. Rather, it was a perceptual one: How does the brain generate a pain percept? It is certainly possible that convergence of "specific" inputs at the level of the spinal cord or higher in the neuraxis generates an integrated pattern of activity that is read by the brain, the product of which is the ultimate percept.

References ...

Comment:

Clifford Woolf , Children's Hospital Boston

Although many philosophical questions may ultimately be answered by neurobiology—the nature of self-knowledge and free will, for example—generally the two disciplines live in parallel separate universes. My first exposure in the late 1970s to the Specificity versus Pattern Theory debate, repeated endlessly over too many pints of ale at the Jeremy Bentham pub near University College London, was from Pat Wall. He was passionate in his hostility to Specificity, based I think on his philosophical certainty that the Pattern theory was much more intellectually challenging and interesting than "mere fixed telephone lines," and therefore it just had to be correct, a question of neuroaesthetics. However, in the end, facts are our currency and the accumulated data from the last 30 years demonstrate quite conclusively that at the primary afferent level, there is clear specificity. Sensory neuron subtypes display exquisite selectivity in deconvoluting the external work into defined neural representations by virtue of their specialized transduction processes, extracting information about particular aspects of the sensory environment, its intensity, nature, place, and time. Individual afferents capture enough information from defined stimuli to tempt us to conflate their firing patterns with the sensation generated, leading us into calling them warm, tickle, itch, or pain fibers. However, as Basbaum points out in describing his conversion from the Pattern Theory to the Specificity School, the way in which the CNS represents the sensory information at a systems level and the way in which it is read from neural circuitry as a sensation remains almost a closed book. Is the exquisite specificity engineered in the periphery maintained in the CNS, or is perception the consequence of an interrogation of complex multidimensional information across space and time, the translation of a pattern? Here, due to our lack of data, we can remain, for the moment, philosophical. However, the capacity to silence or activate designated subsets of central neurons, to record activity simultaneously from many neurons in vivo, and the new field of connectomics that will reveal the synaptic wiring diagram of the brain, means that it is only a matter of time before the answer will be revealed. Take your bets. I know mine.

http://www.painresearchforum.org/forums/discussion/7347-specificity-versus-patterning-theory-continuing-debate