Wednesday, May 22, 2019
In 2006, I wrote about gabapentin after discovering accidentally that it could counter hot flashes.
The drug was initially approved 25 years ago to treat seizure disorders, but it is now commonly prescribed off-label to treat all kinds of pain, acute and chronic, in addition to hot flashes, chronic cough and a host of other medical problems.
The F.D.A. approves a drug for specific uses and doses if the company demonstrates it is safe and effective for its intended uses, and its benefits outweigh any potential risks. Off-label means that a medical provider can legally prescribe any drug that has been approved by the Food and Drug Administration for any condition, not just the ones for which it was approved. This can leave patients at the mercy of what their doctors think is helpful.
Thus, it can become a patient's job to try to determine whether a medication prescribed off-label is both safe and effective for their particular condition. This is no easy task even for well-educated doctors, let alone for desperate patients in pain.
Two doctors recently reviewed published evidence for the benefits and risks of off-label use of gabapentin (originally sold under the trade name Neurontin) and its brand-name cousin Lyrica (pregabalin) for treating all kinds of pain.
(There is now also a third drug, gabapentin encarbil, sold as Horizant, approved only for restless leg syndrome and postherpetic neuralgia, which can follow a shingles outbreak.)
The reviewers, Dr. Christopher W. Goodman and Allan S. Brett of the University of South Carolina School of Medicine, found the drugs, called gabapentinoids, wanting in most cases for which they are currently being prescribed.
Monday, May 20, 2019
It was "this low-grade kind of menacing pain that ran through my spine and mostly my lower back and my upper right shoulder blade and then even into my neck a little bit," Witt says.
The pain was bad. But the feeling of helplessness it produced in him was even worse.
"I felt like I was being attacked by this invisible enemy," Witt says. "It was nothing that I asked for, and I didn't even know how to battle it."
So he channeled his frustration into music and art that depicted his pain. It was "a way I could express myself," he says. "It was liberating."
Witt's experience is typical of how an unpleasant sensation can become something much more complicated, scientists say.
Thursday, May 16, 2019
Then he had one more operation, a spinal fusion, the most complex of all, in 2017. And last month he won the Masters, playing the way he used to.
An outcome like his from fusion surgery is so rare it is "like winning the lottery," Dr. Sohail K. Mirza, a spine surgeon at Dartmouth, said.
The idea behind spinal fusion is to remove a disk — a ring of fibers filled with a nerve-cushioning jelly that joins adjacent spine bones — and fuse the spine together, a procedure that almost inevitably means trading flexibility for stability and, the patient hopes, an existence with less pain.
That was all Woods was looking for when he decided to go ahead with fusion as a last resort — a "normal life" is how he put it. He got that and much more, including a new green blazer, though the lesson that most surgeons say Woods's experience teaches isn't that fusion surgery is a panacea but how much active rehabilitation and physical therapy the procedure requires for it to work.
"If you look at it simplistically, what does fusion do? It provides mechanical support," said Dr. Charles A. Reitman, co-director of the Spine Center at the Medical University of South Carolina. "If they are missing mechanical support and that is the pure cause of the problem, then they will get better."
People with a broken spine, for example, or scoliosis, which is severe spinal curvature, or spondylolisthesis, in which vertebrae slip out of place, tend to have terrific results, he said.
But those are a tiny minority of fusion patients. The vast majority of fusion procedures are performed on patients with one or more degenerated disks, disks that are worn out, dehydrated, stiff and friable. And when those disks move, patients' backs can ache.
Monday, April 29, 2019
At the time, I failed to appreciate the wisdom of his advice. Now, four decades later, a sophisticated distraction technique is being used to help patients of all ages cope with pain, both acute and chronic. The method, called Virtual Reality Therapy, goes beyond simple distraction, as might result from watching television. Rather, it totally immerses the patient in an entertaining, relaxing, interactive environment that so occupies the brain, it has no room to process pain sensations at the same time.
"It's not just a distraction — it's like an endogenous narcotic providing a physiological and chemical burst that causes you to feel good," said Jeffrey I. Gold, director of the pediatric pain management clinic at Children's Hospital Los Angeles. "It's different from reading a book or playing with a toy. It's a multisensory experience that engages a person's attention on a much deeper level."
Virtual Reality Therapy is the new kid on the block for pain management, now gradually growing in use as the opioid epidemic continues to soar and the price of the needed equipment has plummeted. VR, as it is called, has been most widely and successfully used so far to help children and adults weather acute pain, as can accompany an IV insertion or debridement of burns. But it can also enhance the effectiveness of established techniques like physical therapy, hypnosis and cognitive behavioral therapy to treat debilitating chronic pain.
Sunday, April 14, 2019
Wednesday, April 03, 2019
At McGill University in Montreal, Canada, Sorge was investigating how animals develop an extreme sensitivity to touch. To test for this response, Sorge poked the paws of mice using fine hairs, ones that wouldn't ordinarily bother them. The males behaved as the scientific literature said they would: they yanked their paws back from even the finest of threads.
But females remained stoic to Sorge's gentle pokes and prods1. "It just didn't work in the females," recalls Sorge, now a behaviourist at the University of Alabama at Birmingham. "We couldn't figure out why." Sorge and his adviser at McGill University, pain researcher Jeffrey Mogil, would go on to determine that this kind of pain hypersensitivity results from remarkably different pathways in male and female mice, with distinct immune-cell types contributing to discomfort2.
Sorge and Mogil would never have made their discovery if they had followed the conventions of most pain researchers. By including male and female mice, they were going against the crowd. At the time, many pain scientists worried that females' hormone cycles would complicate results. Others stuck with males because, well, that's how things were done.
Today, inspired in part by Sorge and Mogil's work and spurred on by funders, pain researchers are opening their eyes to the spectrum of responses across sexes. Results are starting to trickle out, and it's clear that certain pain pathways vary considerably, with immune cells and hormones having key roles in differing responses.
Tuesday, April 02, 2019
A major challenge in pain management is preventing chronic pain from occurring after an acute pain event. For most people, acute pain resolves as the injury or trauma that caused it heals. Yet in many other people, acute pain from injury, surgery, or disease persists beyond the initial insult, and can last for years or throughout life. Many drugs, while effective early on, lose efficacy over time and make the transition from acute to chronic pain worse. In those who transition to chronic pain, maladaptive changes occur throughout the nervous system. Our ability to reverse these changes is very limited. Our lack of understanding of the mechanisms of transition to chronic pain is a major gap in knowledge that limits development of effective preventive therapies. The ability to identify those at risk for transitioning to chronic pain could inform future clinical trials, improve success of trials, and transform acute pain treatment approaches for prevention of chronic pain.
The Acute to Chronic Pain Signatures program will use advances in imaging, high-throughput biomedical experiments ('omics), sensory testing, and psychosocial assessments to explore a range of characteristics from patients who transition or are resilient to chronic pain. The study will follow two groups from the time of acute pain event over a period of six months. One group will have post-operative pain and the other will have musculoskeletal trauma. The key deliverable of the program is a comprehensive data set for the research communities that should reveal "signatures" predictive of transition versus resilience to chronic pain.
NIH seeks input from the scientific community on specific candidate molecules, tests, patient reported outcomes, psychosocial factors, health record data, and/or other characteristics that could potentially serve as high value biomarkers for predicting acute to chronic pain transition and/or resilience which should be considered for inclusion as outcome measures to collect in the studies. All recommendations should be backed up with a rationale and citations from peer reviewed literature or other justification. Potential candidates could include, but are not limited to, the following:
• Specific electronic health record information, including co-occurring conditions, prescription information, etc.
• Specific patient reported outcomes (e.g., PROMIS measures)
• Candidate psychosocial factors
• CNS or other imaging features
• Sensory tests for mechanical, temperature, or other types of pain
• Actinography for sleep and circadian rhythms and locomotor activity
• Molecules that can be obtained in patient blood, serum, or other non-invasively collected fluids
• Candidate genetic variants
Sunday, March 31, 2019
The notion that the same gene could be responsible for the way a person processes physical and psychological pain left many perplexed: Aren't they totally different? Or does her story hint that sensitivity to one type of pain might be intertwined with sensitivity to another?
Childbirth, Ms. Cameron said, felt like "a tickle." She often relies on her husband to alert her when she is bleeding, bruised or burned because nothing hurts.
When someone close to her has died, she said, she has felt sad but "I don't go to pieces." She cannot recall ever having been riled by anything — even a recent car crash. On an anxiety disorder questionnaire, she scored zero out of 21.
"I drive people mad by being cheerful," she said.
Here's a bit about what's known.
"I could feel that my body was changing, but it didn't hurt me," recalled the woman, Jo Cameron, who is now 71. She likened it to "a tickle." Later, she would tell prospective mothers, "Don't worry, it's not as bad as people say it is."
It was only recently — more than four decades later — that she learned her friends were not exaggerating.
Rather, there was something different about the way her body experienced pain: For the most part, it didn't.
Scientists believe they now understand why. In a paper published Thursday in The British Journal of Anaesthesia, researchers attributed Ms. Cameron's virtually pain-free life to a mutation in a previously unidentified gene. The hope, they say, is that the finding could eventually contribute to the development of a novel pain treatment. They believe this mutation may also be connected to why Ms. Cameron has felt little anxiety or fear throughout her life and why her body heals quickly.
Monday, March 18, 2019
This has forced many to take a step back and ponder the very nature of pain, to understand how best to alleviate it.
The ancient Greeks considered pain a passion — an emotion rather than a sensation like touch or smell. During the Dark Ages in Europe, pain was seen as a punishment for sins, a spiritual and emotional experience alleviated through prayers rather than prescriptions.
In the 19th century, the secularization of Western society led to the secularization of pain. It was no longer a passion to be endured but a sensation to be quashed.
Sunday, March 10, 2019
In the before, it was a relatively normal night. The kind of night any 14-year-old girl might have.
Devyn ate dinner, watched TV and had small, unremarkable interactions with her family. Then, around 10 o'clock, she decided to turn in.
"I went to bed as I normally would, and then all of a sudden ... my hips... they just hurt unimaginably!" Devyn says. "I started crying, and I started shaking."
It was around midnight, but the pain was so intense she couldn't stop herself — she cried out so loudly she woke her mother, Sheila. Together, they did everything they could to neutralize the pain — stand up, lie down, hot bath, pain medication. But there was no escape, not for Devyn, and so not for Sheila.
"You go to cancer first, right? It's like, 'OK, maybe you have cancer, maybe it's a tumor?' " Sheila says.
When she was calm enough to reason with herself, Sheila decided cancer was improbable but wondered what was going on? The only thing they could think of was that the hip pain was somehow related to the minor knee surgery Devyn had gotten a few months before — she had broken the tip of her distal femur one day during dance practice.
So as usual, Sheila snapped to attention to solve the problem. It was 2016 — surely modern medicine could fix this. (NPR is not using Devyn's or Sheila's last name to protect Devyn's privacy as a minor discussing her medical treatment.)
They started by calling Devyn's surgeon, but the surgeon had no explanation for the pain. He renewed Devyn's prescription for Percocet and wrote a new prescription for tramadol. But the pain only got worse, so they lined up more appointments: their pediatrician, a naturopath, a pain specialist, a sports medicine doctor.
Every doctor's visit was the same. The doctor would ask Devyn about her pain: Where was it, and what was her pain number on a scale from 1 to 10? Then the doctor would order some tests to find the pain's cause.
But no matter where the doctors looked in Devyn, all they saw was a perfectly normal body.
"You are healthy. Nothing is wrong." Those are the words the doctors said to Devyn and Sheila over and over again. It made no sense. And it felt, paradoxically, like the more attention they gave to the pain, the bigger the pain grew.
Friday, February 01, 2019
But today's parents may be shocked to learn that was not always the case. As recently as the early 1980s, the pain of children and infants was thought to be different from that of adults and was sometimes treated differently, or sometimes not treated at all.
Change doesn't always come easily in medicine, so there's a certain onus on parents to make sure that their children get state-of-the-art pain management around procedures, large and small. That means preparation before any planned surgery,ideally with a child life specialist, and it means careful attention to the child's pain afterward, with parents well backed up by medical specialists.
Thursday, January 24, 2019
The treatments, which involve injecting bone cement into broken vertebrae, relieve pain no better than a placebo does, according to an expert task force convened by the American Society for Bone and Mineral Research.
The task force noted that the pain goes away or diminishes within six weeks without the procedure. Patients should take painkillers instead, the experts said, and maybe try back braces and physical therapy.
Sunday, January 20, 2019
In experiments, in mice they used a heat probe that created an mild level of heat on the mouse's feet. Then they gave the mice a dose of vinegar to upset their stomachs. The mice, unsurprisingly, didn't like it.
The suprise came when they they repeated the experiment. The male mice showed more stress when brought back to the location of the experiment, and had stronger responses to the heat stimuli - they were more sensitivity to the pain. The female mice showed no extra stress or sensitivity.
Researchers shone a mild heat probe at the mice's feet to induce a slight pain in the experiment. (Sana Khan)
They then ran a similar experiment on humans.
They used the same combination of stimuli - heat on the forearm, and an uncomfortably tight blood pressure cuff over the bicep. They left the cuff on for about 20 minutes and had the participants do arm exercises to increase the pain.
The participants came back the next day and were sent to the same environment where they wore the blood pressure cuff to repeat the heat probe experiment. This time, the men reported feeling more pain from the heat probe, while nothing changed for the women. It was the same sex difference that they'd seen in the mice.
Monday, January 14, 2019
But today's parents may be shocked to learn that was not always the case. As recently as the early 1980s, the pain of children and infants was thought to be different from that of adults and was sometimes treated differently, or sometimes not treated at all.
Change doesn't always come easily in medicine, so there's a certain onus on parents to make sure that their children get state-of-the-art pain management around procedures, large and small. That means preparation before any planned surgery, ideally with a child life specialist, and it means careful attention to the child's pain afterward, with parents well backed up by medical specialists.
Thursday, December 20, 2018
THE OPIOID EPIDEMIC is devastating America. Overdoses have passed car crashes and gun violence to become the leading cause of death for Americans under 55. The epidemic has killed more people than H.I.V. at the peak of that disease, and its death toll exceeds those of the wars in Vietnam and Iraq combined. Funerals for young people have become common. Every 11 minutes, another life is lost.
So why do so many people start using these drugs? Why don't they stop?
Some people are more susceptible to addiction than others. But nobody is immune. For many, opioids like heroin entice by bestowing an immediate sense of tranquility, only to trap the user in a vicious cycle that essentially rewires the brain.
Getting hooked is nobody's plan. Some turn to heroin because prescription painkillers are tough to get. Fentanyl, which is 50 times more potent than heroin, has snaked its way into other drugs like cocaine, Xanax and MDMA, widening the epidemic.
To understand what goes through the minds and bodies of opioid users, The New York Times spent months interviewing users, family members and addiction experts. Using their insights, we created a visual representation of how the strong lure of these powerful drugs can hijack the brain.
Thursday, November 15, 2018
But while that toxicity will lay up any mammal dumb enough to chew on the resin spurge, resiniferatoxin has also emerged as a promising painkiller. Inject RTX, as it's known, into an aching joint, and it'll actually destroy the nerve endings that signal pain. Which means medicine could soon get a new tool to help free us from the grasp of opioids.
Saturday, September 29, 2018
"We need to go to the hospital," my mother whispered in my ear, clutching her stomach.
She knew; it was the same pain she had experienced many times before.
We were in California, many miles from home, many miles from my father (a doctor), who always knew what to do. At the time, I was early in my medical school training, although I knew all the intricate details of my mother's medical history and realized she needed to get medical attention.
When we arrived at the local emergency room in an affluent neighborhood, my mother was placed in a wheelchair and taken to the waiting room. She curled up on the cold barren hospital floor, the only position she could find comfortable. Although my mother usually puts on lipstick and high heels to go to the grocery store, this time, her hair was unkempt and her pajamas worn out. Her knees were tucked into her chest and her belly was distended.
It should have been clear to onlookers that she was in agonizing pain, but people were hesitant, skeptical even.
"Ma'am," someone yelled. "Ma'am, we can't have you lying on the floor. Get up."
My mother lay still.
"Get up, ma'am," she was told again, again more forcibly.
They helped her back into the wheelchair.
"Help me," she said. "The pain is unbearable."
Reluctantly, they put her in a stretcher and prepared to place an IV in her arm. To convince them the pain was real, we asked them to call my father, who could fill in all of the medical details: her multiple prior hospitalizations, surgeries and diagnoses.
Friday, September 21, 2018
Illusions as Painkillers: the Analgesic Value of Resizing Illusions in Knee Osteoarthritis - Scientific American
Following on this tradition, a study published PeerJ last month showed that visuotactile illusions can help the pain experienced by patients suffering from knee osteoarthritis.
According to lead author Tasha Stanton, from the University of South Australia, the idea for the study originated from her observation that "people with knee osteoarthritis have an altered perception of their own body. [Their affected knee] often feels too big, and they also have changes to the way that touch and movement information is represented in the brain." She hypothesized that patients may "respond to illusions that change the way their knee looks."
Wednesday, September 19, 2018
The pain narrative videos collected here give unique insight into the lives of patients experiencing chronic pain. Their intended use is as educational material or for patient advocacy, in pieces or as a whole.
Too Good to Be True? A Nonaddictive Opioid without Lethal Side Effects Shows Promise - Scientific American
Opioid drugs like morphine and Oxycontin are still held as the gold standard when it comes to relieving pain. But it has become brutally obvious that opioids have dangerous side effects, including physical dependence, addiction and the impaired breathing that too often leads to death from an overdose. Researchers have long been searching for a drug that would relieve pain without such a heavy toll, with few results so far.
Monday, September 17, 2018
Body in Mind - Research into the role of the brain and mind in chronic pain - University of South Australia
Friday, September 14, 2018
Most Doctors Are Ill-Equipped to Deal With the Opioid Epidemic. Few Medical Schools Teach Addiction. - The New York Times
According to his chart, he had residual pain from a leg injury sustained while working on a train track. Now he wanted an opioid stronger than the Percocet he'd been prescribed. So why did his urine test positive for two other drugs — cocaine and hydromorphone, a powerful opioid that doctors had not ordered?
It was up to Clark Yin, 29, to figure out what was really going on with Chris McQ, 58 — as seven other third-year medical students and two instructors watched.
"How are you going to have a conversation around the patient's positive tox screen results?" asked Dr. Lidya H. Wlasiuk, who teaches addiction awareness and interventions here at Boston University School of Medicine.
Mr. Yin threw up his hands. "I have no idea," he admitted.
Chris McQ is a fictional case study created by Dr. Wlasiuk, brought to life for this class by Ric Mauré, a keyboard player who also works as a standardized patient — trained to represent a real patient, to help medical students practice diagnostic and communication skills. The assignment today: grappling with the delicate art and science of managing a chronic pain patient who might be tipping into a substance use disorder.
How can a doctor win over a patient who fears being judged? How to determine whether the patient's demand for opioids is a response to dependence or pain?
Addressing these quandaries might seem fundamental in medical training — such patients appear in just about every field, from internal medicine to orthopedics to cardiology. The need for front-line intervention is dire: primary care providers like Dr. Wlasiuk, who practices family medicine in a Boston community clinic, routinely encounter these patients but often lack the expertise to prevent, diagnose and treat addiction.
Sunday, July 08, 2018
Shannon Hubbard never imagined it was the prologue to one of the most debilitating pain conditions known to exist, called complex regional pain syndrome.
It's a condition that causes the nervous system to go haywire, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.
For Hubbard, it manifested several years ago following surgery on her foot. That's a common way for it to take hold.
"My leg feels like it's on fire pretty much all the time. It spreads to different parts of your body," the 47-year-old Army veteran says.
Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It's red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.
"That started as a little blister and four days later it was like the size of a baseball," she says. "They had to cut it open and then it got infected and because I have blood flow issues, it doesn't heal."
She knows that soon it will happen again.
"Over the past three years, I've been prescribed over sixty different medications and combinations, none have even touched the pain," she says.
She holds up a plastic bag filled with discarded pill bottles — evidence of her elusive search for a solution to the pain.
Monday, June 25, 2018
Wearing thick rubber gloves, the student squeezed a dollop of pale-orange cream into the center of the square and delicately spread it to the edges, as if frosting a cake. The cream contained capsaicin, the chemical responsible for the burn of chili peppers. "We love capsaicin," Tracey said. "It does two really nice things: it ramps up gradually to become quite intense, and it activates receptors in your skin that we know a lot about." Thus anointed, I signed my disclaimer forms and was strapped into the scanning bed of a magnetic-resonance-imaging (MRI) machine.
Tuesday, June 12, 2018
Monday, June 04, 2018
Thursday, May 31, 2018
The decision seemed to run counter to what my records showed. A few weeks earlier, I had ended up in the emergency room with chest pains and a heart rate hitting 220 beats per minute. The ER crew told me it was a panic attack, gave me Xanax and told me to try to sleep.
I'd had panic attacks before. I knew this episode was not one. So I went to my doctor.
He put me on a heart monitor overnight. Bingo: I had another episode, this time recorded. It didn't matter. I still left his office thinking it was perhaps anxiety. And so, listening to the advice, I tried to ignore the pain.
Until it happened again. And again. First every month, then every week. Over the following nine years, I would complain about it and be told again that I was having panic attacks or anxiety, that women don't feel heart pain the way I was feeling it, and that maybe I was just confused.
• To develop a comprehensive and forward-thinking pain research agenda for the NIH - one that builds on what we have learned from our past efforts.
• To identify key opportunities in pain research, particularly those that provide for multidisciplinary and trans-NIH participation.
• To increase visibility for pain research - both within the NIH intramural and extramural communities, as well as outside the NIH. The latter audiences include our various pain advocacy and patient groups who have expressed their interests through scientific and legislative channels.
• To pursue the pain research agenda through Public-Private partnerships, wherever applicable. This underscores a key dynamic that has been reinforced and encouraged through the Roadmap process.
Saturday, May 19, 2018
What started off as light throbbing in one wrist 10 years ago quickly engulfed the other. The discomfort then spread, producing a pain much "like slapping your hands against a concrete wall," he says. He was constantly stretching them, constantly shaking them, while looking for hot or cold surfaces to lay them on for relief.
But worse was the deep sense of catastrophe that accompanied the pain. Working in tech-related startups, he depended on his hands to type. "Every time the pain got bad, I would think some variation of, 'Oh no, I'm never going to be able to use computers again; I'm not going to be able to hold down a job; I'm not going to be able to earn a living; and I'm going to be in excruciating pain the rest of my life,'" he says.
Like many patients with chronic pain, Golson never got a concrete diagnosis. For a decade, the 38-year-old Californian went from doctor to doctor, trying all the standard treatments: opioids, hand splints, cortisone injections, epidural injections, exercises, even elective surgery.
Golson's pain was not caused by anything physically wrong with him. But it wasn't imagined. It was real.
After weaning himself off the opioid Vicodin and feeling like he had exhausted every medical option, Golson turned to a book that described how pain could be purely psychological in origin. That ultimately took a pain psychologist, a therapist who specializes in pain — not a physician — to treat the true source: his fearful thoughts. Realizing that psychological therapy could help "was one of the most profoundly surprising experiences of my life," Golson says. No doctor he ever saw "even hinted my pain might be psychogenic," meaning pain that's psychological in origin.
Friday, May 18, 2018
The drug, Aimovig, made by Amgen and Novartis, is a monthly injection with a device similar to an insulin pen. The list price will be $6,900 a year, and Amgen said the drug will be available to patients within a week.
Aimovig blocks a protein fragment, CGRP, that instigates and perpetuates migraines. Three other companies — Lilly, Teva and Alder — have similar medicines in the final stages of study or awaiting F.D.A. approval.
"The drugs will have a huge impact," said Dr. Amaal Starling, a neurologist and migraine specialist at the Mayo Clinic in Phoenix. "This is really an amazing time for my patient population and for general neurologists treating patients with migraine."
Millions of people experience severe migraines so often that they are disabled and in despair. These drugs do not prevent all migraine attacks, but can make them less severe and can reduce their frequency by 50 percent or more.
As a recent editorial in the journal JAMA put it, they are "progress, but not a panacea."
Thursday, May 10, 2018
It can be debilitating. It's a leading cause of disability globally.
And the number of people with the often-chronic condition is likely to increase.
This warning comes via a series of articles published in the medical journal Lancet in March. They state that about 540 million people have lower back pain — and they predict that the number will jump as the world's population ages and as populations in lower- and middle-income countries move to urban centers and adopt more sedentary lives.
"We don't think about [back pain] the same way as cancer or heart attacks. But if you look at disability it causes, especially in middle- and low-income where there isn't a safety net, it impacts half a billion people," says Roger Chou, a physician who is a pain specialist at the Oregon Health and Science University and a co-author of the articles.
Disability from chronic back pain can hurt a person's ability to earn a living. One of the Lancet studies found that among rural Nigerian farmers, half reduced their workload because of back pain — an example of how the disability could contribute to the cycle of poverty in countries that lack benefits such as sick days or a social safety net.
Another study from Australia found that people who retired early because of back pain potentially lost out on hundreds of thousands of dollars of accumulated wealth when compared with healthy people who worked all the way to 65.
An overarching issue with back pain management is that the treatments doctors prescribe are often the wrong ones, the report concludes. Also, in many low-income countries, accessing health care is challenging — and getting appropriate care of back pain, specifically, is even harder. In some poor parts of Asia, pain medications are hard to come by and doctors may not have been trained on the most effective treatments.
Tuesday, April 10, 2018
For four years, her doctor prescribed a wide range of opioids for transverse myelitis, a debilitating disease that caused pain, muscle weakness and paralysis.
The drugs not only failed to ease her symptoms, they hooked her.
When her home state of New York legalized marijuana for the treatment of select medical ailments, Owens decided it was time to swap pills for pot. But her doctors refused to help.
"Even though medical marijuana is legal, none of my doctors were willing to talk to me about it," she says. "They just kept telling me to take opioids."
Although 29 states have legalized marijuana to treat pain and other ailments, the growing number of Americans like Owen who use marijuana and the doctors who treat them are caught in the middle of a conflict in federal and state laws — a predicament that is only worsened by thin scientific data.
Because the federal government considers marijuana a Schedule 1 drug, research on marijuana or its active ingredients is highly restricted and even discouraged in some cases.
Underscoring the federal government's position, Health and Human Services Secretary Alex Azar recently pronounced that there was "no such thing as medical marijuana."
Scientists say that stance prevents them from conducting the high-quality research required for FDA approval, even as some early research indicates marijuana might be a promising alternative to opioids or other medicines.
Patients and physicians, meanwhile, lack guidance when making decisions about medical treatment for an array of serious conditions.
Saturday, April 07, 2018
The last time a surgeon general issued such an urgent warning to the country was in 2005, when Richard H. Carmona advised women not to drink alcohol when pregnant.
Wednesday, March 28, 2018
Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.
Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.
But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.
Friday, March 23, 2018
But now, official adoption by the International Association for the Study of Pain (IASP) of an IASP terminology task force recommendation for a so-called "third mechanistic descriptor" of chronic pain could move the field forward in its efforts to more fully characterize the known pathophysiological mechanisms of pain. The new term, christened "nociplastic pain," joins "nociceptive pain" and "neuropathic pain" as terms officially adopted by the association to describe the underlying neurobiological basis of chronic pain.
Tuesday, March 13, 2018
Monday, February 26, 2018
“Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain - Pain Research and Management
Thursday, February 08, 2018
The new therapies are based on research begun in the 1980s showing that people in the throes of a migraine attack have high levels of a protein called calcitonin gene–related peptide (CGRP) in their blood.
Step by step, researchers tracked and studied this neurochemical's effects. They found that injecting the peptide into the blood of people prone to migraines triggers migraine-like headaches, whereas people not prone to migraines experienced, at most, mild pain. Blocking transmission of CGRP in mice appeared to prevent migraine-like symptoms. And so a few companies started developing a pill that might do the same in humans.
Monday, February 05, 2018
PAS-18-624: Mechanistic investigations of psychosocial stress effects on opioid use patterns (R01- Clinical Trial Optional)
In light of the current opioid epidemic in the United States, there is an urgent need to understand how psychosocial stress influences the risk for opioid misuse, abuse, and use disorder. According to the 2014 National Survey on Drug Use and Health (NSDUH), over 4 million Americans engaged in non-medical use of prescription opioids in the previous month, and approximately 1.9 million Americans met criteria for OUD. Further, according to the Center for Disease Control (CDC), deaths from drug overdose in the US exceeded 60,000 last year, surpassing the number of AIDS-related deaths at the height of the HIV/AIDS epidemic. Another recent CDC report indicates that areas with the largest number of filled prescriptions for pain medications also have higher rates of poverty and unemployment, implicating psychosocial stressors as factors that exacerbate opioid use patterns across the country. Notably, relatively few mechanistic studies have investigated the relationship between psychosocial stress and substance use disorders, of which only a fraction pertains to OUDs specifically.
This funding opportunity announcement seeks to address two specific mechanistic pathways via which psychosocial stress may modulate opioid use trajectories.The first pathway is through its effects on cognitive and affective systems that are also altered in OUDs. Stressful environments have been linked to impairments in reasoning, memory, inhibitory and cognitive control, and negative affect. Acute poverty, for example, has been shown to immediately impact performance on tasks measuring intelligence and cognitive control. Relatedly, there is substantial co-morbidity between OUD and stress-related affective disorders, including depression, anxiety and PTSD. Many neurobiological substrates and circuits that are thought to mediate cognitive and affective aspects of addiction are impacted by psychosocial stress. Taken together, these findings suggest that more research is warranted on the role of cognitive and affective systems mediating the effects of psychosocial stress on opioid use trajectories.
Psychosocial stress can also influence opioid use trajectories through its effects on pain processing. Of relevance here, adverse childhood experiences have been associated with an increased prevalence of pain-related medical conditions during adulthood and many individuals with stress-related psychiatric disorders have co-morbid chronic pain syndromes. This may be a consequence of overlapping neural circuits or substrates that are engaged by psychosocial stress and pain and that have been implicated in OUD. Recent estimates suggest that the rates of opioid misuse in patients with chronic pain range from 15-26%. Importantly, and germane to the discussion above, negative affect and the reduced ability to cope with negative emotions in pain appear to increase opioid misuse rates. Further research is needed to understand how the effects of psychosocial impacts on cognitive and affective components of pain may influence the opioid use trajectory. This knowledge may advance prevention and treatment strategies in chronic pain populations.
A Doctor’s Painful Struggle With an Opioid-Addicted Patient - Siddhartha Mukherjee - The New York Times
We were living, then, in what might be called the opioid pre-epidemic; the barometer had begun to dip, but few suspected the ferocity of the coming storm. Pain, we had been told as medical residents, was being poorly treated (true) — and pharmaceutical companies were trying to convince us daily that a combination of long- and short-acting opioids could cure virtually any form of it with minimal side effects (not true). The cavalier overprescription of addictive drugs was bewildering: After a tooth extraction, I emerged from an oral surgeon's office with a two-week supply of Percocet.
Saturday, February 03, 2018
Scientists at University College London found they could alleviate pain in animals with a nasal spray that delivered millions of soluble nanoparticles filled with a natural opioid directly into the brain. In lab tests, the animals showed no signs of becoming tolerant to the compound's pain-relieving effects, meaning the risk of overdose should be far lower.
The researchers are now raising funds for the first clinical trial in humans to assess the spray's safety. They will start with healthy volunteers who will receive the nasal spray to see if it helps them endure the pain of immersing one of their arms in ice-cold water.
"If people don't develop tolerance, you don't have them always having to up the dose. And if they don't have to up the dose, they won't get closer and closer to overdose," said Ijeoma Uchegbu, a professor of pharmaceutical nanoscience who is leading the research through Nanomerics, a UCL startup.
If the first human safety trial is successful, the scientists will move on to more trials to investigate whether the nasal spray can bring swift relief to patients with bone cancer who experience sudden and excruciating bouts of pain.
Tuesday, January 30, 2018
Saturday, January 27, 2018
Thanks to modern medicine, my hysterectomy was performed laparoscopically, without an overnight hospital stay. My only concern about this early release was pain management. The fibroids that necessitated the surgery were particularly large and painful, and the procedure would be more complicated.
I brought up the subject of painkillers with my gynecologist weeks before my surgery. She said that I would be given ibuprofen. "Is that it?" I asked. "That's what I take if I have a headache. The removal of an organ certainly deserves more."
"That's all you will need," she said, with the body confidence that comes from a lifetime of skiing in crisp, Alpine air.
I decided to pursue the topic with the surgeon.
He said the same thing. He was sure that the removal of my uterus would not require narcotics afterward. I didn't want him to think I was a drug addict, but I wanted a prescription for something that would knock me out for the first few nights, and maybe half the day.
With mounting panic, I decided to speak to the anesthesiologist, my last resort.
This time, I used a different tactic. I told him how appalled I had been when my teenager was given 30 Vicodin pills after she had her wisdom teeth removed in the United States. "I am not looking for that," I said, "but I am concerned about pain management. I won't be able to sleep. I know I can have ibuprofen, but can I have two or three pills with codeine for the first few nights? Let me remind you that I am getting an entire organ removed."
The anesthesiologist explained that during surgery and recovery I would be given strong painkillers, but once I got home the pain would not require narcotics. To paraphrase him, he said: "Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It's not good for your kidneys. Only take it if you must. Your body will heal itself with rest."
Wednesday, January 24, 2018
Monday, January 22, 2018
These receptors embed themselves in the walls of cells throughout the brain and peripheral nervous system. There, they serve as cellular gatekeepers, unlocking not just the painkilling properties for which opioids are prized, but the severe, addictive, and often lethal side effects that, in 2016, contributed to the deaths of more than 50,000 people in the US.
But it doesn't have to be that way. "The idea in the field for many years has been to make an opioid that provides beneficial analgesic properties without the harmful side effects," says pharmacologist Bryan Roth, a physician researcher at University of North Carolina School of Medicine. Design a drug that kills pain, not people.
To build that drug, though, researchers need to know the shape of its receptor. This week in the journal Cell, Roth and nearly two dozen of his colleagues report for the first time the structure of the kappa opioid receptor while it's bound to a drug molecule, a discovery that could accelerate the discovery of less-addictive—and less deadly—opioids.
In the past few years, these side effects have plagued growing numbers of US citizens, plunging the country into the throes of a devastating opioid crisis in which nearly 100 people die from overdoses every day. Even so, opioids are still among the most effective pain-relief options available. "Over hundreds of years, [opioid receptors] have remained a target," says Laura Bohn, a biochemist at the Scripps Research Institute in Jupiter, Florida. "Therapeutically, it works."
Since the early 2000s, intriguing evidence has emerged suggesting that opioids' useful properties could be separated from their harmful attributes. (See "Pain and Progress," The Scientist, February 2014.) In 2005, Bohn, then at the Ohio State University College of Medicine, and colleagues showed that shutting down one of the signaling pathways downstream of the opioid receptor targeted by morphine not only amped up the drug's painkilling effects in mice, but also reduced constipation and respiratory depression (J Pharmacol Exp Ther, 314:1195-201).
That research opened the door to developing a new type of opioid: a "biased agonist" that could trigger analgesia without tripping the switches on other pathways that cause side effects. Now, more than a decade later, Trevena Inc.'s Olinvo (oliceridine)—a drug based on this principle and designated by the US Food and Drug Administration (FDA) as a breakthrough therapy—has completed Phase 3 clinical trials.
Olinvo is just one of many such drugs under development. From compounds that act only in specific regions of the body to those that engage multiple receptor types, researchers and pharmaceutical companies are trying many different tactics to produce less-dangerous opioids.
Wednesday, December 06, 2017
The emergency room and a series of doctors could do little but scratch their heads and offer her painkillers.
"I was living on oxycodone and very grateful for it," Levine said, then Harvard University's chief patent attorney. But it wasn't enough. "By January, I was on disability, because I was in such pain and could hardly walk."
Her internet search for answers led her to Dr. Anne Louise Oaklander, a neurologist at Massachusetts General Hospital, who was then developing a hypothesis about inexplicable pain disorders like Levine's: What if they were caused by an overactive immune system?
Oaklander treated Levine as if that were the case and the pain—thankfully—disappeared within five days. "I didn't know how I was going to live with that level of pain," Levine said, adding that it returns every time she stops treatment.
Now, Oaklander has published a series of 55 case reports including Levine's, suggesting that a number of people who suffer pain or other neurologic symptoms—which may have been diagnosed as fibromyalgia, chronic fatigue syndrome, mental illness, or a host of other problems.
Oaklander thinks that some percentage of people who have small fiber neuropathy—which can be caused by diabetes, chemotherapy, or other toxins—actually have a previously undiagnosed autoimmune problem.
Wednesday, November 29, 2017
Thursday, November 23, 2017
The doctor will have to take their word for it. And then, all too often, the doctor will prescribe a powerful and addictive opioid painkiller.
It's a longstanding — if imprecise and subjective — way of measuring and treating pain. And it's at least partly responsible for starting an opioid addiction crisis that killed 64,000 people last year.
"One of the things we heard from many physicians is that the pain-specific indicator contributed to this crisis," said White House Counselor Kellyanne Conway, President Trump's top adviser on the opioid crisis.
"We don't think health care by emoji is good idea," she said.
So the Trump administration, which has declared the opioid crisis a public health emergency, is backing efforts to find better ways of measuring and treating pain in the hope of developing precise treatments that would be more effective than opioids — and without the often catastrophic side effects.
Next month, the National Institutes of Health will open proposals for $4 million in small business grants to develop a device or technology to objectively measure pain. That could take the form of a blood test, a device to measure pupil dilation, or software to interpret facial expressions.
NIH Director Francis Collins calls it the "pain-o-meter."
It's not entirely clear what the pain-o-meter would look like, or exactly how it would work. It hasn't been invented — yet.
But the pain-o-meter isn't meant to be the end game. It's actually the first step in understanding the measurable indicators — or "biomarkers" — that can indicate pain. And that, in turn, could pinpoint causes and treatments, bringing precision medicine to pain management.
"There is this issue about whether we'll ever really get where we want to go in terms of developing effective pain management if we just consider pain to be one thing," Collins told the National Advisory Council for Complementary and Integrative Health last month. "Because we know that it's not."
The current tools of measuring pain don't take into account individual pain thresholds, which can be influenced by genetics, past experiences and other conditions. They often don't distinguish different causes of pain, or different pain sensations.
Tuesday, November 21, 2017
The authors had set out to ask and answer a simple question: Does placement of a small wire mesh (called a stent) inside the artery that feeds blood to the heart (the coronary artery) relieve chest pain? One might ask what was novel about this question. The truth is that there was and is nothing novel about the question. The novelty was in the methods the authors used to answer the question: They conducted a prospective randomized controlled clinical trial, or RCT, the gold standard of research. The best RCTs compare the effect of the active intervention to a placebo and the best of the best keep both the subjects and the investigators blind to the intervention. The authors managed to do this for stents and chest pain, something that had never been done before, and in doing so, they had the best chance of preventing the placebo effect from skewing the results.
Friday, November 17, 2017
Countering this lethal side effect without losing opioids' potent pain relief is a challenge that has enticed drug developers for years. Now, for the first time, the U.S. Food and Drug Administration (FDA) in Silver Spring, Maryland, is considering whether to approve an opioid that is as effective as morphine at relieving pain and poses less risk of depressing breathing.
Trevena, a firm based in Chesterbrook, Pennsylvania, announced on 2 November that it has submitted oliceridine, an intravenous opioid meant for use in hospitalized patients, to FDA for marketing approval. The drug, which would be marketed under the name Olinvo, is the most advanced of what scientists predict will be a growing crop of pain-relieving "biased agonists"—so called because, in binding a key opioid receptor in the central nervous system, they nudge it into a conformation that promotes a signaling cascade that kills pain over one that suppresses breathing. And in a paper out this week in Cell, a veteran opioid researcher and her colleagues unveil new biased opioid agonists that could surpass oliceridine, though they haven't been tested in people yet.
Tuesday, November 07, 2017
The results challenge common ER practice for treating short-term, severe pain and could prompt changes that would help prevent new patients from becoming addicted.
The study has limitations: It only looked at short-term pain relief in the emergency room and researchers didn't evaluate how patients managed their pain after leaving the hospital.
But given the scope of the U.S. opioid epidemic — more than 2 million Americans are addicted to opioid painkillers or heroin — experts say any dent in the problem could be meaningful.
Results were published Tuesday in the Journal of the American Medical Association.
Long-term opioid use often begins with a prescription painkiller for short-term pain, and use of these drugs in the ER has risen in recent years. Previous studies have shown opioids were prescribed in nearly one-third of ER visits and about 1 out of 5 ER patients are sent home with opioid prescriptions.
"Preventing new patients from becoming addicted to opioids may have a greater effect on the opioid epidemic than providing sustained treatment to patients already addicted," Dr. Demetrios Kyriacou, an emergency medicine specialist at Northwestern University, wrote in an accompanying editorial.
The study involved 411 adults treated in two emergency rooms at Montefiore Medical Center in New York City. Their injuries included leg and arm fractures or sprains. All were given acetaminophen, the main ingredient in Tylenol, plus either ibuprofen, the main ingredient in Motrin, or one of three opioids: oxycodone, hydrocodone or codeine. They were given standard doses and were not told which drug combo they received.
Patients rated their pain levels before taking the medicine and two hours later. On average, pain scores dropped from almost 9 on a 10-point scale to about 5, with negligible differences between the groups.
Sunday, October 29, 2017
There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).
But take too many and you have a problem. And America certainly has a problem.
Saturday, October 21, 2017
Tuesday, September 26, 2017
The numbers, released by the Centers for Disease Control and Prevention, are provisional and will be updated monthly, according to the agency.
Fueling the rise in deaths is fentanyl, a synthetic opioid up to 100 times more potent than morphine, and fentanyl analogs, or slight tweaks on the fentanyl molecule. This has not always been the case: As the chart below shows, the drivers of the opioid crisis have changed from prescription painkillers to heroin, and then to fentanyl.
As Dan Ciccarone, a professor at the University of California-San Francisco School of Medicine, recently wrote in the International Journal of Drug Policy:
This is a triple epidemic with rising waves of deaths due to separate types of opioids each building on top of the prior wave. The first wave of prescription opioid mortality began in the 1990s. The second wave, due to heroin, began around 2010 with heroin-related overdose deaths tripling since then. Now synthetic opioid-related overdoses, including those due to illicitly manufactured fentanyl and fentanyl analogues, are causing the third wave with these overdose deaths doubling between 2013 and 2014 .
The epidemic is straining the capacity of morgues, emergency services, hospitals, and foster care systems. Largely because of prevalent drug use and overdose, the number of children in foster care nationwide increased by 30,000 between 2012 and 2015.