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Pain affects everyone. Not only can it be emotionally and physically debilitating for patients, but their families, and the economy at large, suffers as well. Studies show the annual cost of chronic pain in the United States, including healthcare ...
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Global Winnipeg
A growing number of doctors are choosing not to prescribe some pain killers over fears of drug abuse. Living with chronic pain is not easy, but for some patients it's become unbearable. A growing number of doctors are choosing not to prescribe some...
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Warning that patients shouldn’t assume their doctor has knowledge to treat pain, a national panel of experts has called on medical schools to train doctors and nurses on the basics of pain care, and address pain as a public health crisis. The group insists that without health reforms and better training to diagnose and treat pain properly, people with untreated pain may face a lifetime of pain as a chronic illness—which often leads to job loss, depression and in a number of cases suicide.

“Doctors, who don’t lack for compassion or medical skills, often offer only limited treatments to patients disabled by chronic pain,” said Lonnie Zeltzer, M.D., co-chair of the panel. “With little or no specific training in pain management, and working systems that make it easier to treat common conditions like high blood pressure than a complex problem like pain, doctors may intend to help but leave most patients under-assessed and under-treated. Women, children and minorities often face the highest risk of under-treatment.”

The panel, included anesthesiologists, neurologists, primary care doctors, pediatricians, emergency physicians, nurses, psychologists, pharmacists and patient advocates and was sponsored by the Mayday Fund. After a conference in Washington, D.C. and deliberations over several months the panel’s report, A Call to revolutionize Chronic Pain Care in America: An opportunity in Health Care Reform, says pain is a huge public health problem. They developed a number of recommendations that need to be addressed, by government and the medical community. The report and recommendations have been endorsed by more than 30 organizations, and numerous other signatories from Canada and the U.S. “As we get closer to the possibility of health care reform, the frontlines of medicine—adult and pediatric primary care—could face enormous strains from millions of new patients seeking care for pain,” says Russell K. Portenoy, M.D., panel co-chair and the chairman of Pain Medicine and Palliative Care at the Beth Israel Medical center in New York. “Primary care is the first stop for people in pain, and both the training received by clinicians and the system of care should facilitate best practices in pain care, but this is not the way it is.” The committee writes that chronic pain should be reframed as a chronic illness since “the burden of chronic pain is greater than that of diabetes, heart disease and cancer combined.” People in chronic pain can have longer hospital stays, and many duplicative tests and unproven treatments-all of which drive up costs. Chronic pain costs the nation more than $100 billion a year in lost productivity and direct medical costs, the report said. “This is a wasteful system,” Portenoy adds. “Major reforms in health care are needed if we want to improve the quality and cost-effectiveness of care of chronic illnesses, and pain is as much a chronic illness as diabetes and heart disease.” Although the impact of pain on patients and on society is among the most serious of public health concerns. Chronic pain has been largely left out of the current debate on health reform, the panel writes. According to the report , about “one-third of people in pain report their pain is disabling and has a high impact on their ability to function in daily life. Research suggests that the high cost of under-treated pain includes lost productivity. Pain is the second-leading cause of medically-related work absenteeism, resulting in more than 50 million lost workdays.” If doctors do not recognize chronic pain as a serious illness, or as serious as others, or they perceive that pain complaints cannot, or should not, be treated, persistent chronic pain is the result. In some cases, such as pain in young children and adults with dementia, patients may not report their pain, and under-assessment drives under-treatment. “The tragedy of this system is that it leaves many people suffering from unrelenting pain,” says Zeltzer. “Pain that goes untreated may permanently change the body’s nervous system and may lead to pain that can be managed but never goes away.”

Policymakers have recognized the impact pain has on individuals and the health care system and have recently included provisions in health reform proposals. A bill calls for an Institute of Medicine Conference on Pain; increased funding for the National Institutes of Health to collaborate across institutes to find more effective treatments for pain and to better understand the biology of pain; a grant program to improve health professionals’ understanding of and ability to assess and treat pain; and better public education so that consumers understand the danger of letting pain go untreated. “Remarkably, less than one percent of the NIH budget was devoted to pain in 2008,” Zeltzer said. “This amount is not commensurate with a public health problem of this magnitude.” The situation is no different in Canada with less than 1% of medical research dollars going to pain researchers.

In addition to medical school reforms and expanded funding for pain management programs, the panel cited specific measures that would ease this public health crisis. Among them:

• Health care providers, insurers and government agencies should eliminate disparities in access to pain care related to race, gender, age and socioeconomic status. Everyone should be offered timely and effective treatment for their pain.
• Government, health care payers and providers should develop coordinated health information technology (IT) systems to track pain disorders and treatments. Computerized IT systems can boost physicians’ knowledge about the best treatment for pain providing them with best practice information quickly.
• There should be a reform of reimbursement to eliminate current incentives that drive pain care toward procedures or unproven treatments. Primary care doctors should be reimbursed for the time it takes to provide comprehensive pain care to patients who are disabled by chronic pain—a system that can cost more up front, but often reduces the cost of treating pain over the long haul.
• · Mount a public education campaign to inform the public about the risks associated with under-treated pain. Consumers should understand that if they wait too long to treat acute pain they run the risk of developing a chronic syndrome, one that’s costly to treat and potentially disabling.
  

“Reducing the burden of uncontrolled chronic pain is a societal necessity, a medical challenge and an economic requirement,” the panel stated. Source: The Mayday Fund.

Most of us have heard about the ability of acupuncture to help alleviate pain, as acupuncture has been used in East-Asian medicine for thousands of years, perhaps by activating our body’s own natural painkillers. But how it actually works at the cellular level is largely unknown.

In a recent University of Michigan study, using brain imaging some of these some of these unknowns have come forward. The study is the first to provide evidence that traditional Chinese acupuncture affects the brain’s long-term ability to regulate pain. The results are published in the September issue of the Journal of NeuroImage. In the study, researchers at the U-M Chronic Pain and Fatigue Research Center showed that acupuncture increased the binding availability of mu-opioid receptors (MOR) in regions of the brain that process and dampen pain signals—specifically the cingulated, insula, caudate, thalamus and amygdala. Opioid painkillers, such as morphine, codeine and other medications, are thought to work by binding to these opioid receptors in the brain and spinal cord.

“The increased binding availability of these receptors was associated with reductions in pain,” says Richard E. Harris, Ph.D., a researcher at the U-M Chronic Pain and Fatigue Research Center and also a research assistant professor of anesthesiology at the U-M Medical School. One implication of this research is that patients with chronic pain treated with acupuncture might be more responsive to opioid medications since the receptors seem to have more binding availability, Harris says. These findings could spur a new direction in the field of acupuncture research following recent controversy over large studies showing that sham acupuncture is as effective as real acupuncture in reducing chronic pain.

“Interestingly both acupuncture and sham acupuncture groups had similar reuctions in clinical pain,” Harris says. “But the mechanisms leading to pain relief are distinctly different.”

The study participants included 20 women who had been diagnosed with fibromyalgia, a chronic pain condition, for at least a year, and experienced pain at least 50 percent of the time. During the study they agreed not to take any new medications for their fibromyalgia pain. Patients also had position emission tomography, or PET, scans of the brain during the first treatment and then repeated a month later after the eighth treatment.

Additional authors were Jon-Kar Zubieta, M.D., Ph.D., David J. Scott, Vitaly Napadow, Richard H. Gracely, Ph.D., and Daniel J. Clauw, M.D.. Funding of the project was supplied by the National Institutes of Health and the Department of Army. § Source: University of Michigan Health System.

Sciatica is pain resulting from irritation of the sciatic nerve. Sciatica pain is typically felt from the low back to behind the thigh and radiating down below the knee. The sciatic nerve is the largest nerve in the body and begins from nerve roots in the lumbar spinal cord in the low back and extends through the buttock area to send nerve endings down the lower limb. While sciatica is most commonly a result of a disc herniation directly on the nerve, any cause of irritation or inflammation of this nerve can reproduce the symptoms of sciatica. These causes include irritation of the nerve from adjacent bone, tumors, muscle, internal bleeding, infections, injury, and other causes.

Sciatica causes pain, burning sensation, numbness, or tingling radiating from the lower back and upper buttock down the back of the thigh to the back of the leg. Severe sciatica can make walking difficult if not impossible. Sometimes the symptoms of sciatica are aggravated by walking or bending at the waist and relieved by lying down. Sciatica is diagnosed with a physical exam and medical history. The typical symptoms and certain examination maneuvers help your doctor in diagnosing sciatica. Sometimes, x-rays, films, and other tests, such as a CAT scan or MRI scan and electromyogram, are used to further define a cause of sciatica.

Treatments for sciatica have traditionally advocated bed rest. To study the effectiveness of bed rest in patients with sciatica bad enough severity to justify treatment with bed rest of two weeks, researchers in the Netherlands led by Dr. Patrick Vroomen randomly assigned 183 such patients to bed rest or, alternatively, to watchful waiting for the same period of time. In analyzing the outcome, both primary and secondary measures were examined. The primary outcome measures were the global assessments of improvement after two and twelve weeks by the doctor and the patient. The secondary outcome measures were changes in functional status and in pain scores, absenteeism from work, and the need for surgical intervention. Neither the doctors who assessed the outcomes nor those involved in data entry and analysis were aware of any of the patients’ treatment assignments.

The results, reported in the New England Journal of Medicine, showed that after two weeks, 64 of the 92 (70%) patients in the bed-rest group reported improvement, as compared with 59 of the 91 (65%) of the patients in the control (watch-full waiting) group. After 12 weeks, 87% of the patients in both groups reported improvement. The results of assessments of the intensity of pain, the bother someness of symptoms, and functional status revealed no significant differences between the two groups. The extent of absenteeism from work and rates of surgical intervention were similar in the two groups.

The researchers have concluded that: “Among patients with symptoms and signs of a lumbrosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.” Sometimes conventional wisdom is not as wise as research. Other treatments for sciatica include addressing the underlying cause, analgesic medications to relieve pain and inflammation and relax muscles, and physical therapy. Surgical procedures can sometimes be required for persisting sciatica that is caused by nerve compression at the lower spine. § Source: New England Journal of Medicine.

DID YOU KNOW? Musculoskeletal pain is one of the most frequent complaints reported in health surveys. Around 50% of the population report having musculoskeletal pain in one or more areas for at least one week during the past month. As we age it appears this will only get worse.

We are sure that you are all aware that there is an argument used consistently that the long-term use of opioids has not been validated and remains in a sort of limbo. Even though there is ample anecdotal evidence that opioids do benefit a number of pain sufferers over many years this lack of evidence argument continues. But, now a recent article published in a European journal (Heroin Addict Relat. Clin. Problems), reports on the benefits of long-term use of opioids.

Dr. Forest Tennant, MD, reported on a group of patients who were administered strong opioids for from 10 to 35 years, with all indications that significant pain relief, ongoing quality of life and physical functioning enhancements outweigh any complications of this form of therapy. Any complication that rose were easily managed. The study involved 24 patients aged 30 to 79 years, two-thirds female and suffering from post trauma neuropathies and arthropathies (29%), spinal degeneration (25%), abdominal adhesions or neuropathies (20%), or fibromyalgia (12.5%). They had been on continuous opioid therapy for from 10 to 35 years, taking a long-acting formulation of either morphine, oxycodone, fentanyl, or methadone. One or more short-acting opioids were also prescribed for pain flares or breakthrough pain. The participants were also prescribed muscle relaxants, sleep aids, hormone replacement medications, and/or dietary supplements as were deemed as appropriate.

An overwhelming number (92%) reported their pain was permanently decreased, and the great majority (83%) believed the opioid regimen continued to relieve their pain as well as it did when treatment first began. All patients reported they could perform a variety of activities and physical functions that they could not do prior to opioid therapy. Hormonal abnormalities were a complication in the men, but was managed with hormone replacement therapy. Other complications reported included hypertension, diabetes, tooth decay and weight gain. They were all medically managed, but whether they were pain related, opioid produced, or simply inherent in the patients and/or a result of aging is unclear. No neurologic complications such as hyperalgesia, dementia, tremor, or seizures were note; nor were hepatic, renal, or gastrointestinal complications, except for minor constipation, which was also medically managed. 

Dr. Tennant concluded: “Even though the number of patients evaluated here is small, the great improvement in their quality of life and physical functioning is so positive and the complications of the therapy so easily managed that the long-term opioid therapy should continue to be provided and evaluated.”

Overall, the reported outcomes in this study offer hope for patients who might benefit from long-term opioid therapy for chronic noncancer pain. The study helps confirm the legitimization of pain as a chronic illness in certain patients and opioids as a justifiable long-term therapy. So much of the literature today speaks negatively of long-term use of opioid analgesic therapy and wrongly portrays patients who do well on them as potential drug seekers or abusers requiring intense surveillance. Such a perspective would be unheard of if they were using insulin or antihypertensives for chronic diseases like diabetes or hypertension.

Dt. Tenant acknowledges more studies are needed and is currently developing another study that would include more patients. There is presently another completed study, involving a large number of patients (3,000), showing many of the same results, being readied for publication. This validates much of the anecdotal information. § Source: Heroin Addict Related Clinical Problems.

Discovery Channel recently aired the "Use of Opioids to Treat Chronic Non-cancer Pain. Here's the link to the program.http://discoveryhealthcme.discovery.com/opioidtherapy/program/program.html