On July 26, Todd Graham, 56, a well-respected rehabilitation specialist in Mishawaka, Indiana, lost his life. Earlier that day, a woman complaining of chronic pain had come to Graham's office in hope of receiving an opioid such as Percocet, Vicodin, or long-acting OxyContin. He reportedly told her that opioids were not an appropriate first-line treatment for long-term pain—a view now shared by professionals—and she, reportedly, accepted his opinion. Her husband, however, became irate. Later, he tracked down the doctor and shot him twice in the head.
This horrific story has been showcased to confirm that physicians who specialize in chronic pain confront real threats from patients or their loved ones, particularly regarding opioid prescriptions. But Graham's death also draws attention to another fraught development: In the face of an ever-worsening opioid crisis, physicians concerned about fueling the epidemic are increasingly heeding warnings and feeling pressured to constrain prescribing in the name of public health. As they do so, abruptly ending treatment regimens on which many chronic pain patients have come to rely, they end up leaving some patients in agonizing pain or worse.
Last month, one of us was contacted by a 66-year old orthopedic surgeon in Northern California, desperate to find a doctor for herself. Since her early 30s, Dr. R suffered from an excruciating condition called Interstitial Cystitis (IC). She described it as a "feeling like I had a lit match in my bladder and urethra." Her doctor placed her on methadone and she continued in her medical practice on a relatively low dose, for 34 years. As Dr. R told one of us, "Methadone has saved my life. Not to sound irrational, but I don't think I would have survived without it." Then a crisis: "Unfortunately for me, the feds are clamping down on docs prescribing opiates. My doctor decided that she did not want to treat me anymore, didn't give me a last prescription, and didn't wait until I found another pain doctor who would help me." For the past 30 years, Dr. R has been an advocate for better treatment of IC and reports "many suicides in the IC patient population due to the severity of the pain."
More ...
http://www.slate.com/articles/health_and_science/medical_examiner/2017/08/cutting_down_on_opioids_has_made_life_miserable_for_chronic_pain_patients.html?
Wednesday, August 30, 2017
Tuesday, August 29, 2017
The Conversation Placebo - The New York Times
In my daily work as a primary care internist, I see no letup from pain. Every single patient, it seems, has an aching shoulder or a bum knee or a painful back. "Our bodies evolved to live about 40 years," I always explain, "and then be finished off by a mammoth or a microbe." Thanks to a century of staggering medical progress, we now live past 80, but evolution hasn't caught up; the cartilage in our joints still wears down in our 40s, and we are more obese and more sedentary than we used to be, which doesn't help.
So it's no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.
What's often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.
In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.
Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients' situation and offered words of encouragement about getting better.
Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.
More ...
https://www.nytimes.com/2017/01/19/opinion/sunday/the-conversation-placebo.html
So it's no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.
What's often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.
In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.
Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients' situation and offered words of encouragement about getting better.
Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.
More ...
https://www.nytimes.com/2017/01/19/opinion/sunday/the-conversation-placebo.html
Thursday, August 24, 2017
A New Brain Measure of Nociception in Infants | Pain Research Forum
Unlike adults, infants can't tell you if they're in pain. Instead, clinicians must interpret behaviors such as crying and physiological measures such as heart rate to determine what a newborn is experiencing. Since these can occur for reasons unrelated to nociception, the pain field has long sought more objective ways to measure pain in this nonverbal population. Now, in a new study, investigators have identified pain-related brain activity in infants that could be measured with a simple electroencephalogram (EEG) recording and used the activity to create an EEG template that allowed them to test the efficacy of an analgesic.
A team led by Rebeccah Slater, University of Oxford, UK, found that the EEG template of brain activity correlated with the presence and intensity of pain-related behavior and validated the template across four independent samples of infants. Intriguingly, a topical analgesic dampened the brain signal, showing how the new approach could be used to assess the effect of pain medications in infants undergoing painful procedures.
More ...
http://painresearchforum.org/news/82405-new-brain-measure-nociception-infants
A team led by Rebeccah Slater, University of Oxford, UK, found that the EEG template of brain activity correlated with the presence and intensity of pain-related behavior and validated the template across four independent samples of infants. Intriguingly, a topical analgesic dampened the brain signal, showing how the new approach could be used to assess the effect of pain medications in infants undergoing painful procedures.
More ...
http://painresearchforum.org/news/82405-new-brain-measure-nociception-infants
Sunday, August 20, 2017
Women are flocking to wellness because modern medicine still doesn’t take them seriously - Quartz
The wellness movement is having a moment. The more luxurious aspects of it were on full display last weekend at the inaugural summitof Gwyneth Paltrow's lifestyle brand Goop, from crystal therapy to $66 jade eggs meant to be worn in the vagina. Meanwhile, juice cleanses, "clean eating," and hand-carved lamps made of pink Himalayan salthave all gone decidedly mainstream. I myself will cop to having participated in a sound bath—basically meditating for 90 minutes in a dark room while listening to gongs and singing bowls. (I felt amazingly weird afterward, in the best possible way.)
It seems that privileged women in the US have created their own alternative health-care system—with few of its treatments having been tested for efficacy, or even basic safety. It's easy to laugh at the dubious claims of the wellness industrial complex, and reasonable to worry about the health risks involved. But the forces behind the rise of oxygen bars and detox diets are worth taking seriously—because the success of the wellness industry is a direct response to a mainstream medical establishment that frequently dismisses and dehumanizes women.
To be fair, the American health-care system is generally unpleasant for everyone: impersonal, harried, and incredibly expensive. "The doctor-patient relationship has been slowly eroding, not only with specialization and the fact that people now see panels of doctors, but because emergency rooms are slammed, there are insurance-coverage problems, et cetera," Travis A. Weisse, a science historian at the University of Wisconsin, told Taffy Brodesser-Akner in an article for Outside magazine. "It can make a patient feel devalued."
The medical system is even more terrible for women, whose experience of pain is routinely minimized by health practitioners. In the emergency room, women routinely wait longer than men to receive medication for acute pain. At the gynecologist's office, severe period-related pain is often dismissed or underestimated. Ingrained sexism means that doctors may regard women as either earth mothers or hypochondriacs; that is, either women possess deep wellspring of internal pain control that they ought to be able to channel during childbirth, or their pain is psychological in nature—a symptom of hysteria.
Conditions that affect women at higher rates than men, including depression and autoimmune diseases like fibromyalgia, are much more likely to be dismissed as having a psychological rather than a physiological source. Chronic fatigue syndrome sufferers are still instructed to rely on exercise and positive thinking, despite research that indicates these measures do not cure the condition. Many women with autoimmune diseases, endometriosis, or even multiple sclerosis go undiagnosed for years, despite multiple trips to doctors and specialists—all the while being told that their symptoms could just be stress.
More ...
https://qz.com/1006387/women-are-flocking-to-wellness-because-traditional-medicine-still-doesnt-take-them-seriously/
It seems that privileged women in the US have created their own alternative health-care system—with few of its treatments having been tested for efficacy, or even basic safety. It's easy to laugh at the dubious claims of the wellness industrial complex, and reasonable to worry about the health risks involved. But the forces behind the rise of oxygen bars and detox diets are worth taking seriously—because the success of the wellness industry is a direct response to a mainstream medical establishment that frequently dismisses and dehumanizes women.
To be fair, the American health-care system is generally unpleasant for everyone: impersonal, harried, and incredibly expensive. "The doctor-patient relationship has been slowly eroding, not only with specialization and the fact that people now see panels of doctors, but because emergency rooms are slammed, there are insurance-coverage problems, et cetera," Travis A. Weisse, a science historian at the University of Wisconsin, told Taffy Brodesser-Akner in an article for Outside magazine. "It can make a patient feel devalued."
The medical system is even more terrible for women, whose experience of pain is routinely minimized by health practitioners. In the emergency room, women routinely wait longer than men to receive medication for acute pain. At the gynecologist's office, severe period-related pain is often dismissed or underestimated. Ingrained sexism means that doctors may regard women as either earth mothers or hypochondriacs; that is, either women possess deep wellspring of internal pain control that they ought to be able to channel during childbirth, or their pain is psychological in nature—a symptom of hysteria.
Conditions that affect women at higher rates than men, including depression and autoimmune diseases like fibromyalgia, are much more likely to be dismissed as having a psychological rather than a physiological source. Chronic fatigue syndrome sufferers are still instructed to rely on exercise and positive thinking, despite research that indicates these measures do not cure the condition. Many women with autoimmune diseases, endometriosis, or even multiple sclerosis go undiagnosed for years, despite multiple trips to doctors and specialists—all the while being told that their symptoms could just be stress.
More ...
https://qz.com/1006387/women-are-flocking-to-wellness-because-traditional-medicine-still-doesnt-take-them-seriously/
Sunday, August 13, 2017
A comprehensive guide to the new science of treating lower back pain - Vox
Cathryn Jakobson Ramin's back pain started when she was 16, on the day she flew off her horse and landed on her right hip.
For the next four decades, Ramin says her back pain was like a small rodent nibbling at the base of her spine. The aching left her bedridden on some days and made it difficult to work, run a household, and raise her two boys.
By 2008, after Ramin had exhausted what seemed like all her options, she elected to have a "minimally invasive" nerve decompression procedure. But the $8,000 operation didn't fix her back, either. The same pain remained, along with new neck aches.
More ...
https://www.vox.com/science-and-health/2017/8/4/15929484/chronic-back-pain-treatment-mainstream-vs-alternative
For the next four decades, Ramin says her back pain was like a small rodent nibbling at the base of her spine. The aching left her bedridden on some days and made it difficult to work, run a household, and raise her two boys.
By 2008, after Ramin had exhausted what seemed like all her options, she elected to have a "minimally invasive" nerve decompression procedure. But the $8,000 operation didn't fix her back, either. The same pain remained, along with new neck aches.
More ...
https://www.vox.com/science-and-health/2017/8/4/15929484/chronic-back-pain-treatment-mainstream-vs-alternative
Surgery Is One Hell Of A Placebo | FiveThirtyEight
The guy's desperate. The pain in his knee has made it impossible to play basketball or walk down stairs. In search of a cure, he makes a journey to a healing place, where he'll undergo a fasting rite, don ceremonial garb, ingest mind-altering substances and be anointed with liquids before a masked healer takes him through a physical ritual intended to vanquish his pain.
Seen through different eyes, the process of modern surgery may look more more spiritual than scientific, said orthopedic surgeon Stuart Green, a professor at the University of California, Irvine. Our hypothetical patient is undergoing arthroscopic knee surgery, and the rituals he'll participate in — fasting, wearing a hospital gown, undergoing anesthesia, having his surgical site prepared with an iodine solution, and giving himself over to a masked surgeon — foster an expectation that the procedure will provide relief, Green said.
These expectations matter, and we know they matter because of a bizarre research technique called sham surgery. In these fake operations, patients are led to believe that they are having a real surgical procedure — they're taken through all the regular pre- and post- surgical rituals, from fasting to anesthesia to incisions made in their skin to look like the genuine operation occurred — but the doctor does not actually perform the surgery. If the patient is awake during the "procedure," the doctor mimics the sounds and sensations of the true surgery, and the patient may be shown a video of someone else's procedure as if it were his own.
Sham surgeries may sound unethical, but they're done with participants' consent and in pursuit of an important question: Does the surgical procedure under consideration really work? In a surprising number of cases, the answer is no.
More ...
https://fivethirtyeight.com/features/surgery-is-one-hell-of-a-placebo/?
Seen through different eyes, the process of modern surgery may look more more spiritual than scientific, said orthopedic surgeon Stuart Green, a professor at the University of California, Irvine. Our hypothetical patient is undergoing arthroscopic knee surgery, and the rituals he'll participate in — fasting, wearing a hospital gown, undergoing anesthesia, having his surgical site prepared with an iodine solution, and giving himself over to a masked surgeon — foster an expectation that the procedure will provide relief, Green said.
These expectations matter, and we know they matter because of a bizarre research technique called sham surgery. In these fake operations, patients are led to believe that they are having a real surgical procedure — they're taken through all the regular pre- and post- surgical rituals, from fasting to anesthesia to incisions made in their skin to look like the genuine operation occurred — but the doctor does not actually perform the surgery. If the patient is awake during the "procedure," the doctor mimics the sounds and sensations of the true surgery, and the patient may be shown a video of someone else's procedure as if it were his own.
Sham surgeries may sound unethical, but they're done with participants' consent and in pursuit of an important question: Does the surgical procedure under consideration really work? In a surprising number of cases, the answer is no.
More ...
https://fivethirtyeight.com/features/surgery-is-one-hell-of-a-placebo/?
Wednesday, August 02, 2017
Almost half of all opioid misuse starts with a friend or family member's prescription | PBS NewsHour
More than half of adults who misused opioids did not have a prescription, and many obtained drugs for free from friends or relatives, according to a national survey of more than 50,000 adults.
Although many people need medical narcotics for legitimate reasons, the National Survey on Drug Use and Health reported Monday that regular access to prescription opioids can facilitate misuse. The results, outlined in the Annals of Internal Medicine, indicate when the medical community overprescribes opioids, unused drugs are then available for abuse.
More ...
http://www.pbs.org/newshour/rundown/opioid-misuse-starts-friend-family-members-prescription/?
Although many people need medical narcotics for legitimate reasons, the National Survey on Drug Use and Health reported Monday that regular access to prescription opioids can facilitate misuse. The results, outlined in the Annals of Internal Medicine, indicate when the medical community overprescribes opioids, unused drugs are then available for abuse.
More ...
http://www.pbs.org/newshour/rundown/opioid-misuse-starts-friend-family-members-prescription/?
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