Paineurope: Issue 4, 2004. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Researchers at University College London used functional MRI (fMRI) to understand how humans learn to predict conditions that lead to aversive stimulation and pain. Subjects were presented with a series of abstract pictures followed by a 1 second electric shock. While they could not recall the sequence of the images, the imaging indicated that volunteers had learned how to predict the pain-producing conditions. The study concludes that: “The subconscious interpretation of environmental cues, leading to the avoidance of aversive stimuli, may be to the disadvantage (sic) of the persistent pain sufferer.” Dr. Adams Implications: The study conclusions are the just the opposite of what commonsense and casual observation indicate has survival value for any living organism. That is, the ability of lliving organisms to learn to avoid, escpae or terminate the conditions of pain’s occurrence, by effectively modifying the conditions of its occurrence. Clearly this ability provides evolutionary advantage rather than disadvantage to the living organism that learns to manipulate its environment to terminate aversive stimulation. The critical application of this evolutionary skill for CNCP patients is that the ability to effectively escape, avoid or terminate aversive stimulation, technically, is a positive reinforcer and, biochemically, that means systematic release of endorphins. In our program, CNCP patients learn how to avoid aversive stimulation, reinstate release of endorphins, and thereby, as endorphin release is returned to steady state (pre-injury) levels, systematically reduce pain long term.
  • A recent European telephone survey of nearly 6,000 respondents with musculoskeletal pain (MP) and almost 1500 primary care physicians revealed that: (a) the majority of the physicians said they were trying to “improve quality of life” and that they were “aware” of the risks of NSAIDs; while (b) ¼ of the respondents had not sought medical help … those who did often waited for several months before doing so … ¾ had constant or daily pain … just over ½ received a prescription for their pain … however, most felt poorly informed. In 5 of the study countries, only ½ of the respondents “were aware of potential side effects.”  Another survey of 662 patients with peripheral neuropathy conducted by the Neuropathy Trust (UK) revealed that up to ¼ of patients waited at least one year before being referred to a specialist, and 2/3 of the sample “felt they were not being kept under review.” In the UK, there are some 1.4 million people with peripheral neuropathy and around ¾ of these are unable to work because of pain. The article concludes that delays “in assessment and diagnosis can be avoided if primary care practitioners are given advice about recognising and treating neuropathic pain.” Dr. Adams Implications:  Possibly in Europe, if primary care physicians are “given advice about recognizing and treating neuropathic pain,” they will translate it into the action that is needed to expertly care for the 1.4 million Brits with neuropathic pain who are unable to work so that they can return to work and the National Health System can realize the cost savings that this change in practice would bring about. However, based on the US experience, changes in how physicians practice is not driven by “advice” but economics. In the US, even mandated continuing medical education (CME) has not achieved this change in practice. Practitioners of all stripes, since the publication of Bonica’s The management of pain in 1953, continue to practice driven mainly by economic self interest rather than “the right thing to do,” what they are “advised to do” nor, most recently, by what their professional organizations mandate them to do in re. CNCP. In one study – Sohn W, Ismail Al, Tellez M (2004). “Efficacy of educational interventions targeting primary care providers’ practice behaviors: an overview of published systematic reviews” J Public Health Dent, 64(3):164-72 – the authors conclude that “evidence from the included systematic reviews showed that formal continuing medical education (CME) and distributing educational materials did not effectively change primary care providers’ behaviors.” Given the history of inaction on CNCP on both side of the Atlantic, the solution is for CNCP patients to take individual action such as: (1) stop patronizing (read “reinforcing”) non-specialists, (2) put together your own multidisciplinary specialty team, (3) pursue a “restoration of maximum functionality” objective, and (4) if you cannot get the rehabilitative support you need from one doctor, fire that doctor and find another one who will. A half century of inaction is an answer:, and that answer is, “No, we’re not going to do anything about chronic intractable pain.” The best thing CNCP patients can do is get the message and start implementing the 4 steps proposed above. If sufficient numbers of CNCP patients do so, consistent withdrawal of reinforcement, science tells us, will predictably extinguish the undesirable behavior.

Paineurope: Issue 2, 2005. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Drawing on a survey of some 30,000 people, about 17 million Japanese suffer from chronic pain. The prevalence of chronic pain was 13.4%, in ¾ of whom pain is perceived to be poorly controlled. Despite this, almost 90% of patients were satisfied by the treatment provided by their physician. Half of those surveyed believed that their pain would last forever.
  • A Medical Research Council team in the UK has outlined an effective strategy for managing low-back pain. A large study compared standard primary care support with either physiotherapy or spinal manipulation. A third group received both interventions to support treatment from their general practitioner and reported the greatest improvement. Although benefits were modest, the prevalence of back pain is such that the combined approach is likely to be cost effective.
  • According to a study published in the Journal of Neuroscience (2004; 24:10410-15), chronic pain may cause loss of brain tissue, which may be irreversible. Using MRI data, US researchers studied 26 patients with low-back pain and 26 matched controls. Those with pain were divided into groups with neuropathic or non-neuropathic pain. Patients with neuropathic pain demonstrated shrinkage of neocortical areas (prefrontal cortex and thalamus) by as much as 11%, equivalent to grey matter loss occurring with 10-20 years of normal aging. Amount of tissue loss correlated with the length of time patients had had their pain.  The findings agree with other imaging studies that show decreased brain activity – and apparent atrophy – of the affected areas.

Paineurope: Issue 1, 2005. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Self-help advice may be enough to treat back pain: Researchers in Warwick and Oxford in the UK suggests that traditional physiotherapy, alone, may be no more useful for treating back pain than appropriate advice about self-management and modifying beliefs and behavior (http://bmj.com/cgi/content/full/329/7468/708). The study concluded that a single advice session from a physiotherapist was as effective as traditional physiotherapy treatments. Researchers stress that since there is no magical cure for back pain, the need is for better symptom self-management. Dr. Adams Implications:  Our data fully supports that effective pain treatment is multidisciplinary.
  • Also in the UK, researchers have shown that topical anti-inflammatory drugs used for the treatment of osteoarthritis have little benefit if used beyond 2 weeks. Osteoarthritis is a long-term, usually lifelong problem and sufferers need drugs that demonstrate sustainable efficacy. Dr. Adams Implications: at the present time, all pain drugs lack the longitudinal research that supports their use for the average 7 years that the majority of CNCP patients have had their pain. Therefore, CNCP patients should know the side-effect profile of each of their medications, and take personal responsibility for discontinuing problematic ones any time personally risky symptoms arise.
  • European pain specialists have organized to help improve their CNCP knowledge and skills.  The Pan European Pain Specialist  (PEPS) program met in The Netherlands, Sweden and Switzerland during 2004. The purpose was to enable pain specialists to meet, share ideas and experience clinical practice within a variety of European countries. Each meeting has a multi-country delegation of about 20 pain specialists, and consists of a 3-day program of seminars and tours of local pain clinics. The meetings have offered many pain specialists a unique insight into pain management around Europe and provided them with an opportunity to visit some of the world’s leading institutions. Dr. Adams Implications: clearly how pain treatment takes place depends on the healthcare conditions of which it is a function. The impact that the solo practitioner mindset (personal self interest) to treating pain in the US, vs. the national health system mindset (system-wide reduction of costs) in Europe is apparent. Europeans are far ahead of the US in organizing against pain and using the multidisciplinary interventions that have proven more effective for treating CNCP. Two simple factors seem to account for this: self interest is systematically less reinforced in Europe, and the reduction of costs is more reinforced.

Eisenberg, Elon (2004). New online resource for physicians. Paineurope, 4:1

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

“The Opioids and Pain European Network of Minds (OPENMinds), formerly the European Expert Group for the Appropriate Use of Opioids in Pain Management (EEG), have officially launched a European pain and opioids website, www.openmindsonline.org,” coinciding with the European Week Against Pain. “The website aims to assist healthcare professionals in learning about the role of opioids in managing persistent pain and hopes to improve the shared knowledge base on the use of opioids in pain management.” The website “provides visitors with access to in-depth wide-ranging information on the general principles of opioid use in persistent pain management and information on best practice. It also covers various patient subgroups, side-effects, dependence, tolerance (and problem drug users), as well as regulatory and legal issues such as differences in prescribing regulations across Europe. There is also an opportunity for visitors to provide comments and feedback, as well as to ask the OPENMinds group for their expert opinion on key opioid- and pain management-related issues. Healthcare professionals are invited to register for free use of this important new resource at www.openmindsonline.org and are reminded to watch out for updates in paineurope, the official publication of OPENMinds.” Dr. Adams Implications: Offers evidence of the lack of interest in the US of government, the professions and business to take concerted action on chronic pain.

Niv, David (2004). Global experts unite in the fight against pain. Paineurope, 4:1

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

Exceptional gathering of the European community of pain specialists with the purpose of taking concerted action on reducing the problem of unrelieved pain. “The European Week Against Pain started in earnest on 11 October with the resounding success of the second Global Day Against Pain. The meeting, held in Geneva on October 11, 2004, was a joint effort between the International Association for the Study of Pain (IASP) and the European Federation of IASP Chapters (EFIC) and was endorsed by the World Health Organization (WHO). “The global focus of the meeting was reinforced… by a live worldwide web-cast, timed so that every continent could view the proceedings first hand. The afternoon sessions covered pain as a global concern, innovation in research and treatment, pain and quality of life and major pain problems in low-income countries.” Dr. Adams Implications: The event contrasts sharply with (1) the minimal efforts being taken in the US to implement national-level action about reducing chronic pain, and (2) why it’s so important that individual CNCP patients get the message that no action probably ever will take place in the US from either government, the medical community, individual physicians or insurance carriers and that every pain patient should get the message and learn to create the conditions that allow them to self manage their pain more effectively, and long term rather than short term.

Puig, Margarita (2005). Drug combinations in pain management. Paineurope, 1:4-5

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

Discusses “multi-modal therapy” – combining 2 or more analgesics with different mechanisms in an effort to improve treatment efficacy while minimizing adverse events. Explains decision logic needed to produce drug interactions with additive, synergistic or antagonistic effects. Shows how isobolograms guide drug interaction decision making. Yet, notes that while in cancer pain, the combination of opioids and NSAIDs “slightly improves analgesia,” in CNCP – the subspecialty pain of interest here – “there are insufficient data demonstrating the advantages of analgesic drug combinations,” because “there are less inflammatory components and the pain mechanism of each case should be investigated to find the correct drug combination.” Dr. Adams Implications: This makes the use of multiple drugs a dead issue in chronic non-cancer pain since, “in chronic musculoskeletal pain… monotherapy is often the rule” and, our CNCP patients with neuropathic pain stated that the addition of “antidepressants, anticonvulsants and other adjuvants” simply complicated treatment by: (1) delaying restoration of function, (2) complicating the management of side effects and (3) creating risk of “paradoxical pain,” where random increases in pain amplitude and frequency have been seen in cancer patients on opioids. Our data clearly show that the more medications that are used, especially at the start of treatment, the greater the risk of “paradoxical pain.”

Müller-Schwefe, Gerhard (2005). Back pain intensity underestimated. Paineurope, 1:1

December 22, 2009 | Filed Under: Latest Readings | Comment(1)

According to research conducted by the German Pain Society, physicians and physiotherapists who lack specialty training in CNCP frequently underestimate the intensity of chronic low back pain in their patients. This affects the ability of patients’ ability to follow standardized rehab programs (SRP) which are an important predictor for effective outcomes. In over 50% of the cases, the pain was underestimated and did affect outcomes negatively in their SRPs. 10% of the patients reported severe pain-related restrictions, yet this was never reviewed nor treated with the appropriate medications. The implication is that there is risk for CNCP patients if they do not include a pain specialist in the team of specialists that should be treating the multiple causes of their CNCP.

Vielvoye-Kerkmeer, Ans (2005). Confusion remains after withdrawal of rofecoxib. Paineurope, 1:1.

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

Of all Europeans who say they suffer from CNCP, 21% have had their chronic pain for more than 20 years. Chronic musculoskeletal pain is the most frequent type of pain suffered, followed by arthritis pain.  Vioxx is a “Cox2 inhibitor” prescribed for musculoskeletal and arthritis pain below 5, on a scale from 1 to 10, where 10 is “the worst pain imaginable.” While Cox2’s reduce GI risk, Vioxx had to be voluntarily withdrawn from the market when a higher-than-usual cardiovascular risk and number of “adverse events” was discovered. However, 2 other Cox2’s – Bextra and Celebrex – remain on the market. Yet, no pain drug has the long-term studies that will support their use without adverse events for the average 7 years that most CNCP patients have had their pain. Going back to using NSAIDs (the “non-steroidal anti-inflammatories”) chronically creates the same GI risk, tinnitus and the need for discontinuing the drug, so going back to less-strong medications is not a good long-term option. The issue now is, Will the demise of the Cox2’s lead to increased use of opioids, with the long-overdue deregulation for legitimate CNCP patients?

Rhodin, Annica (2005). Opioid prescribing for pain in Europe: identifying barriers and taking action. Paineurope, 1:3.

December 22, 2009 | Filed Under: Latest Readings | Comments(3)

Although 20% of the adult population in Europe has CNCP, the “treatment of chronic non-malignant pain remains a controversial issue” as it does in the U.S. However, a group of pain specialists from 15 European countries – the Opioids and Pain European Network of Minds (OPENMinds – available at www.openmindsonline.org) – has started addressing the issue by investigating barriers to more effective opioid prescribing. Data is being gathered via questionnaires, which are sent to group members, patient networks and local pharmaceutical companies.  Some of the preliminary findings of their effort are:

  • Writing prescriptions for opioids in Europe is a major problem. Prescription pads vary by country, rather than being standardized. Some countries require that Rx’s be written in triplicate, others make the doctors get them personally from the authorities, and still others require they get them from the national bank! The consequences of the situation is: it discourages doctors from writing Rx’s for opioid Rx’s; it’s a clear stigma for Pts; and, it adds so much additional paperwork that it further discourages doctors from prescribing opioids;
  • The amounts that can be prescribed also vary: in some countries there are no limits, in most others, doctors can only prescribe a 1 week supply of opioids;
  • Reimbursement varies: some countries reimburse the total cost of opioids, others not at all. So, generics or inappropriate strength meds are used, often with inappropriate clinical effect;
  • Doctors’ fear of costly litigation, prosecution or loss of their license are the same as in the US;
  • Low physician awareness of CNCP and the appropriate use of opioids is the same as it is in the US: most physicians are well intentioned, but lack the training or experience in CNCP, familiarity with the different opioids and their modes of delivery, and how to integrate them into the comprehensive multidisciplinary programs that are the global standard of care for CNCP.

The consistency of the pattern worldwide has clear implications for CNCP patients: Do not wait for government, medical associations or individual doctors to give any different a message than the inaction they’ve provided for the past half century (1953) when JJ Bonica published The management of pain. The message: “We’re not going to do anything about your chronic pain.” The alternative is for CNCP patients to take personal action: to become highly aware about CNCP; to screen and locate pain specialists in your own home town; to become familiar with the type of multidisciplinary program that works and to do it, if needed, on your own; and, finally, get over the expectation that there is an easy “fix” for CNCP and move on with creating the multiple conditions that will increase your functionality as much as possible.

Rhodin, Annica (2004). The rise of opiophobia: Is history a barrier to prescribing? Paineurope, 4:3

December 22, 2009 | Filed Under: Latest Readings | Comments(0)

Dr. Rhodin is an anesthesiologist who is also a pain clinician in Uppsala, Sweden, where considerable basic science research has been produced. This is one of those historical reviews of opium that you keep in a special folder because when you need a need a review like this for a talk on CNCP you just can’t find one. This brief review ranges from some 30,000 years ago when Neanderthal Man first planted the opium poppy to deal, no doubt, with some very serious CNCP, to its present use (or non-use) in for treating chronic pain in medicine.  Dr. Adams Implications: I have only one point of disagreement with Dr. Rhodin. She states that “the use of opioids in chronic non-malignant pain remains controversial.” I disagree, in the same way that I disagree that, among those who specialize in interventional cardiology, how to treat mitral valve prolapse “remains controversial.” Among those who specialize in CNCP, there is probably as much consensus about how opioids should be used and for what rehabilitative purpose as there is, among interventional cardiologists, about how mitral valve prolapse should be used and for what cardiac rehabilitative purpose. In Court, the opinions of those who do not satisfy the Federal Rules of Evidence to qualify as “expert witnesses” are summarily dismissed. If we did likewise, we would soon see that, among those who qualify as “experts,” there is no “controversy” about the use of opioids in CNCP.