Chronic Pain is Considered a "Crisis" in the U.S.

Medical topics with questions, information and discussion related to Lyme disease and other tick-borne diseases.
RitaA
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Chronic Pain is Considered a "Crisis" in the U.S.

Post by RitaA » Sat 2 Mar 2013 21:56

Instead of getting too far off topic in the thread "PTLS and Central Sensitization" (see http://www.lymeneteurope.org/forum/viewtopic.php?t=4596 ) in the Science section, I created this thread about chronic pain syndrome in the Medical section.

Unfortunately, the information I retrieved from Medscape -- which is geared toward medical professionals -- appears to be grossly out of date. That's why I decided to remove it.

This thread started out as "Chronic Pain Syndrome", but I've changed the subject to "Chronic Pain is Considered a Crisis in the U.S." given the following post.
Last edited by RitaA on Mon 4 Mar 2013 6:30, edited 2 times in total.

RitaA
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Joined: Thu 1 Jul 2010 8:33

Re: Chronic Pain Syndrome

Post by RitaA » Sat 2 Mar 2013 22:20

Shifting gears slightly, there is an acknowledged chronic pain "crisis" in the U.S. :

http://journals.lww.com/neurotodayonlin ... ain.5.aspx
Neurology Today:
17 November 2011 - Volume 11 - Issue 22 - pp 19-21,23
doi: 10.1097/01.NT.0000408566.58098.8d

Features

IOM: Systemwide Changes Advised for Chronic Pain ‘Crisis’ in US

Samson, Kurt

ARTICLE IN BRIEF

An IOM report called for increased spending for research as well as steps to improve physician education and training in the management and treatment of chronic pain. The panel calls for the development of a comprehensive plan for improving chronic pain care by the end of 2012.

A report by the Institute of Medicine (IOM) commissioned by the NIH has proposed a game plan for improving and heightening awareness of chronic pain — including a timetable for swift changes for consolidating and coordinating research and data collection by federal health agencies as well as taking steps to raise awareness of the problem.
The IOM report, which was featured at the American Public Health Association's annual meeting in Washington, DC, on Nov. 2, said chronic pain should be “a national priority” given its scope and related costs; it affects one out of every three Americans and costs the country upwards of $600 billion each year.

The report called for increased spending for research as well as steps to improve physician education and training. More controversially, the IOM panel recommended that the NIH shift responsibility for pain research to a single institute rather than having each institute study pain as it pertains to different medical disorders, and develop a comprehensive plan for improving chronic pain care by the end of 2012.

“Reliable data are lacking on the full scope of the problem, especially among those currently under-diagnosed and under-treated, including racial and ethnic minorities; people with lower levels of income and education; women, children, and older people; military veterans; surgery and cancer patients; and people at the end of life; among others,” according to the report. To improve this, it said federal and state agencies, as well as private organizations, should accelerate collection of data on pain incidence, prevalence, and treatments.

“Many of us see this as a crisis in health care that needs to be addressed,” commented IOM committee member Robert D. Kerns, PhD, professor of psychiatry, neurology and psychology at Yale School of Medicine, and national program director for pain management at the Veterans Health Administration VA Connecticut Healthcare System in New Haven, CT.

“I don't think we would have made any recommendations that we felt were unfeasible, but this will take continued input from, and action by, all stakeholders, including advocacy groups, in order to promote the changes,” he told Neurology Today in a telephone interview.

And because neurologists play a central role in how chronic pain is treated, cooperation with other related specialties is an integral component in improving patient care, he said.

“We understand that pain is a broad concept and covers a range of bio-psycho-social factors, which is why we recommend a multidimensional, multimodality, and interdisciplinary approach to treatment and management. In this, neurologists play a very important part, especially as educators. They will be training the next generation of students who will see these patients.”

Neurology is also one of only four specialties at the residency level for which advanced fellowships are available for training in pain management, he said.

“I feel that the future is bright for chronic pain research. The report's reception by NIH seems quite favorable, and even though the report's recommendation that a single institute be charged with carrying the agenda forward is somewhat provocative, I feel confident that there will be more discussions.”

NEUROLOGY'S ROLE

Anne Louise Oaklander MD, PhD, associate professor of neurology at Harvard Medical Schools and Massachusetts General Hospital in Boston, said the wider issue is why many neurologists are not as involved in treating patients with unexplained chronic pain.

“Right now, lack of neurological input is part of the problem,” she told Neurology Today in a telephone interview. “Many patients with unexplained ‘mystery’ pain have an underlying rheumatological or neurological cause that needs to be diagnosed and treated. If the origin of their pain is unclear most will receive only symptomatic treatment, typically with pain medications. But these don't work that well. For instance, small-fiber polyneuropathy, often caused by treatable diseases including diabetes, should be considered in patients with unexplained widespread chronic pain. Neurologists, for the most part, are missing in action.”

The reasons are unclear, but a host of clinical and social issues are involved, said Dr. Oaklander, who serves on the editorial advisory board for Neurology Today.

Part of their hesitancy might be concerns about having to prescribe opioids, even though non-opioid medications are also effective, including tricyclic antidepressants and gabapentin-type drugs that help neuropathic pain. Moreover, she said neurologists, like other physicians, “have an underlying suspicion” that unexplained chronic pain may be caused by psychiatric issues. In her experience, this is no more common than in other areas of neurology, such as epilepsy.

Today other types of specialists treat most chronic pain patients — even those with clear neurological causes such as post-herpetic neuralgia or nerve problems, she noted.

“They have stepped into the breach, but current techniques for treating acute and perioperative pain, especially nerve blocks and high-dose opioids, are not necessarily best for chronic pain and non-neurologists may struggle with difficult diagnoses.”

Most patients with complex regional pain syndrome, for instance, have underlying nerve injury, but few of these patients ever see a nerve specialist or have electrodiagnostic testing, she told Neurology Today. Unexplained chronic pain is one of the cardinal symptoms of diseases of the nervous system and should be treated as such,” she said.

CHALLENGES AHEAD

“There is a real challenge moving forward on how chronic pain is treated,” added IOM committee member John T. Farrar, MD, PhD, associate professor of epidemiology and neurology at the University of Pennsylvania in Philadelphia.

“We need a change in the current paradigm on how the health care system approaches chronic pain, especially neuropathic pain, while at the same time educating the public and physicians. Given the extent of the problem, there is a also disproportionately small amount of research,” he told Neurology Today in a telephone interview.

Part of the problem is how to help patients gain better access to multiple components of health care that might help.

Another challenge will be finding new treatments, he continued. “Even though there have been some advances in neuroactive agents, from amitriptyline to gabapentin, pregabalin, and duloxetine, we still do not have drugs that will work well for many patients and their doctors. There is a tremendous need for basic, translational, and clinical research, which presents a tremendous opportunity for neurologists and neuroscientists.”

THE IOM report recommended that the Department of Health and Human Services develop a comprehensive plan with specific goals, actions, and timeframes. Among strategies they proposed to be implemented before the end of 2012:

* create a comprehensive population health-level strategy for pain prevention treatment, management and research;
* develop strategies for reducing barriers to pain care;
* support collaboration between pain specialists and primary care clinicians, including referral to pain centers, when appropriate
* designate a lead institute at the NIH to move pain research forward

Moreover, the panel recommended that the National Center for Health Statistics, Agency for Healthcare Research and Quality (AHRQ), other federal and state agencies, and private organizations should accelerate the collection of data on pain incidence, prevalence, and treatments. Data should be collected at regular intervals using standardized questions, protocols for surveys, and electronic medical records to identify the following information:

* subpopulations at risk;
* characteristics of acute and chronic pain;
* profound health consequences of pain, including death, disease, and disability; and related trends over time.

For more on the report, visit http://bit.ly/k5qXoc.

RitaA
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Joined: Thu 1 Jul 2010 8:33

Re: Chronic Pain Syndrome

Post by RitaA » Sun 3 Mar 2013 0:35

As shown in the post above, Anne Louise Oaklander MD, PhD, associate professor of neurology at Harvard Medical Schools and Massachusetts General Hospital in Boston, said the following:
“Unexplained chronic pain is one of the cardinal symptoms of diseases of the nervous system and should be treated as such,” she said.
That statement led me to the following link. Although the primary focus of this article is on chronic pain associated with neurological disorders, I think it contains a lot of valuable information:

http://brain.oxfordjournals.org/content ... wr271.full
Neurological diseases and pain

David Borsook

Center for Pain and the Brain, Harvard Medical School, USA

Received March 3, 2011.
Revision received August 18, 2011.
Accepted August 21, 2011.
There is a more recent version available here, however it's only a summary. I wanted to read the full article (which was only available on the link above): http://brain.oxfordjournals.org/content/135/2/320

Here are some snippets from the older version of the full article:
Introduction

Recent advances in basic and clinical neuroscience suggest the brain plays a pivotal role in the chronic pain state. Recent advances in pain research, fuelled by neuroimaging studies, have engendered a transformation in our understanding of how pain affects the brain. As a result, the notion that changes in sensory systems are the predominant process in chronic pain has been replaced by a conceptualization of chronic pain as a very complex CNS state in which patterns of sensory system activation are integrated aberrantly with activity in other brain systems, including emotional, cognitive and modulatory processes.

[snip]

The changes in brain activity that underlie chronic pain may result in changes in central circuits that manifest as pain in the absence of the peripheral trigger. ‘Centralization’ of pain, here defined as ‘the persistent static or dynamic brain functional state that contributes to or causes the behavioural responses to pain (e.g. depression increased sensitivity to stimuli, ongoing pain)’, occurs as a result of altered brain dynamics not only in specific sensory systems, but also in other brain systems including emotional, cognitive and motor systems. This altered state results in a cognitive, sensory and emotional experience of pain, whether the initial instigating process is in the peripheral (perhaps including muscle) or CNS, as a result of primary brain disease, or secondary to afferent input as a result of nerve or spinal cord damage.

[snip]

Complex regional pain syndrome

Perhaps no pain condition represents the centralization of pain more clearly than complex regional pain syndrome (CRPS; Janig and Baron, 2002; Bruehl, 2010). Following a peripheral nerve injury, usually trivial, a series of progressive changes may take place that include some or all of the following: (i) spreading pain that may cross the midline and involve the whole body, suggestive of centralization of sensory processing at the thalamus or higher centres (Maleki et al., 2000); (ii) autonomic changes suggestive of hypothalamic changes (Gradl and Schurmann, 2005); (iii) neglect-like symptoms suggestive of parietal lobe dysfunction (Galer and Jensen, 1999); and (iv) in some cases, dystonias or other motor changes suggestive of potential basal ganglia involvement [see review by Maihofner et al. (2010)]. Taken together, these findings implicate alterations in CNS processing, a notion supported by functional brain imaging studies that demonstrate reproducible alterations in adult (Geha et al., 2008; Maihofner et al., 2010) and paediatric (Lebel et al., 2008) patients with CRPS.

In CPRS, persistent pain and subsequent progressive changes in the brain (namely automonomic, cognitive, central sensitization, hemineglect) are observed following mild peripheral nerve injury. This and other brain imaging studies suggest that all patients with neuropathic pain have alterations in brain systems that may result in cognitive and other behavioural changes, which may go unrecognized because they are not as prominent as the pain symptoms. Longitudinal MRI studies of paediatric patients with CRPS indicate that the brains of these children continue to exhibit significant differences from normal controls after symptoms resolve (Lebel et al., 2008).

[snip]

Brain-based restorative approaches for chronic pain

Despite trials of a number of approaches, chronic pain is largely refractory to treatment. Chronic pain associated with neurological disease has varied presentations and temporal profiles (Fig. 5) that add to the complexity of treatment approaches. Below, I discuss therapeutic approaches that may be more logical in light of the new understanding that chronic pain is a disease of the brain. The over-riding goal of these approaches is to restore brain networks to states that are adaptive. This discussion is not meant to suggest specific therapies for pain in particular neurological diseases, but rather to spur further exploration of new chronic pain treatment options that represent a fairly radical departure from our previous therapeutic approach.

[snip]

Brain stimulation

[snip]

A relatively recent approach is the use of transcranial magnetic stimulation for chronic pain (Lefaucheur, 2008), migraine (Lipton and Pearlman, 2010), spinal cord injury pain (Defrin et al., 2007) and traumatic neuropathic pain (Schwenkreis et al., 2010). Transcranial magnetic stimulation is currently US Food and Drug Administration (FDA) approved for depression (Schonfeldt-Lecuona et al., 2010).

[snip]

Centrally active drugs developed for neurological disease and their potential role in pain therapeutics

Specific pharmacotherapies developed for many of these neurological conditions have been assessed for their ability to treat chronic pain (Finnerup et al., 2010; Haanpaa et al., 2011). The most notably successful are the anti-epilepsy drugs, but antidepressants, membrane stabilizers and opioids have also been used to treat chronic pain, with varying levels of success. Given our new understanding that alterations in grey matter volume correlate with chronic pain, recent trials have investigated drugs with the potential to modify putative underlying disease mechanisms. The major categories of drugs that have been assayed are neuroprotectants, including the excitatory neurotransmitter antagonists (e.g. NMDA), and agonists of inhibitory neurotransmitter systems (e.g. γ-aminobutyric acid, glycine).

[snip]

Other examples of therapies directed at primary neurological disease that may be useful for pain include: (i) minocycline, a microglial inhibitor that may be a neuroprotective agent. It has been used in preclinical models of Huntington's disease (Smith et al., 2003) but has some effects in pain models as well (Chang and Waxman, 2010);

[snip]

Conclusions

Pain is common in neurological diseases affecting diverse parts of the PNS and the CNS (Fig. 5) that may have subsequent effects on altered brain circuitry and result in pain. Most neurologists treat patients with chronic pain, but few specialize in the discipline. In fact, when neurologists rate their preference for treating diseases, chronic pain ranks low (with the exception of migraine, which ranks high) (Evans and Evans, 2010). The reasons for this may include: (i) lack of formal training in pain management (Galer et al., 1999); (ii) the fact that pain clinics treat such a broad spectrum of syndromes (with the exception of those treating conditions such as migraine); (iii) a sense that there are few viable treatment options; (iv) the notion that patients with chronic pain are complex to deal with; or (v) the lack of financial incentive.

Thus, there is a high unmet need for chronic pain treatment and for more research into the underlying mechanisms of pain diseases. With current technological advances and investigation into mechanism-based treatment approaches (Finnerup, 2008), we are at a critical juncture in pain research. However, progress will remain slow unless we fully recognize pain as a brain disease and increase the involvement of neurologists in the treatment of and research into chronic pain. The first step towards this goal is to include a comprehensive survey of pain conditions, management and research as part of the standard training of new neurologists.

Henry
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Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by Henry » Mon 4 Mar 2013 14:34

Don't forget this article:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250243/

All seem to indicate the direction in which new research efforts should be directed.

RitaA
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Joined: Thu 1 Jul 2010 8:33

Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by RitaA » Mon 4 Mar 2013 14:43

Thanks, Henry!

I meant to include that article in this thread, so I appreciate the reminder.

Lorima
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Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by Lorima » Mon 4 Mar 2013 16:41

Henry,

Could you direct me to Dr. P.J. Baker's academic CV? I can't seem to find any academic history of his, before his involvement with Lyme disease, perhaps because it's a common name. If there isn't anything online, maybe you could give us a brief synopsis, or links to some pre-Lyme-era references.

Thanking you in advance,
Lorima
"I have to understand the world, you see."
Richard Feynman

Henry
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Joined: Thu 10 Nov 2011 18:49

Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by Henry » Mon 4 Mar 2013 18:25

Lorima: No, but I really don't see how that is relevant. No one has asked about your credentials as an expert on Lyme disease and reforming the whole medical profession. How many patients have you treated? It would be more fruitful to focus your attention on the issues at hand and not the personalities.

Lorima
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Joined: Mon 29 Oct 2007 20:47

Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by Lorima » Mon 4 Mar 2013 23:28

Henry, I am posting as a private citizen, albeit an educated one, in a small patient support forum. I have no professional connection with Lyme disease, I am not an MD, and I have not presented myself as such. It is no secret here that I am a caregiver for late LD patients in my family. How many late LD patients have you, or any of your colleagues, had under daily care and observation for more than a decade? 

The opinion piece you linked by Phillip Baker, isn't about science. It focuses on discrediting dissenting MDs and their patients. It seems to me that you are taking the topic into the political arena, not I.

I'm willing to treat your recommendation as a good-faith offering. The trouble is, I don't see any articles by Phillip J. Baker in PubMed that would indicate his area of scientific expertise, in contrast to his policy convictions. Since he is a PhD rather than, say, a practicing physician, he must have studied with someone, written a dissertation, and published a few papers on his dissertation work. I can't find them, perhaps because it's a common name, and it all took place long before the internet existed. In Google, all that comes up, besides his activities on behalf of ALDF, are his comments on anthrax, in the early 2000's. Anthrax doesn't have much biology in common with borrelia, as far as I can see, despite the NIAID's having assigned them both to the same person. 

I would like to see what kind of research Dr. Baker did, back when he did any. Maybe he did some good solid science, relevant to his current subjects, and I just can't find it. (Although it is true, even if he did real science in the past, that wouldn't justify his current activity.) From his public statements about LD so far, one might reasonably suspect that he is repeating what he is told, rather than thinking critically about it. In that case, his opinion has no value, from a scientific perspective. 

I am merely offering you an opportunity to correct that impression, if it is not accurate. 

Best wishes, 
Lorima
"I have to understand the world, you see."
Richard Feynman

phyfe
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Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by phyfe » Tue 5 Mar 2013 0:51

Lorima wrote:Henry, I am posting as a private citizen, albeit an educated one, in a small patient support forum. I have no professional connection with Lyme disease, I am not an MD, and I have not presented myself as such. It is no secret here that I am a caregiver for late LD patients in my family. How many late LD patients have you, or any of your colleagues, had under daily care and observation for more than a decade? 

The opinion piece you linked by Phillip Baker, isn't about science. It focuses on discrediting dissenting MDs and their patients. It seems to me that you are taking the topic into the political arena, not I.

I'm willing to treat your recommendation as a good-faith offering. The trouble is, I don't see any articles by Phillip J. Baker in PubMed that would indicate his area of scientific expertise, in contrast to his policy convictions. Since he is a PhD rather than, say, a practicing physician, he must have studied with someone, written a dissertation, and published a few papers on his dissertation work. I can't find them, perhaps because it's a common name, and it all took place long before the internet existed. In Google, all that comes up, besides his activities on behalf of ALDF, are his comments on anthrax, in the early 2000's. Anthrax doesn't have much biology in common with borrelia, as far as I can see, despite the NIAID's having assigned them both to the same person. 

I would like to see what kind of research Dr. Baker did, back when he did any. Maybe he did some good solid science, relevant to his current subjects, and I just can't find it. (Although it is true, even if he did real science in the past, that wouldn't justify his current activity.) From his public statements about LD so far, one might reasonably suspect that he is repeating what he is told, rather than thinking critically about it. In that case, his opinion has no value, from a scientific perspective. 

I am merely offering you an opportunity to correct that impression, if it is not accurate. 

Best wishes, 
Lorima
Well Said!!!!!

RitaA
Posts: 2768
Joined: Thu 1 Jul 2010 8:33

Re: Chronic Pain is Considered a "Crisis" in the U.S.

Post by RitaA » Sun 17 Mar 2013 13:30

Thanks for retweeting this, Camp Other.

http://www.nytimes.com/2013/03/17/opini ... =auto&_r=0
Opinion

The Gender Gap in Pain

By LAURIE EDWARDS

Published: March 16, 2013
Some snippets:
TO the list of differences between men and women, we can add one more: the drug-dose gender gap. Doctors and researchers increasingly understand that there can be striking variations in the way men and women respond to drugs, many of which are tested almost exclusively on males. Early this year, for instance, the Food and Drug Administration announced that it was cutting in half the prescribed dose of Ambien for women, who remained drowsy for longer than men after taking the drug.
In some cases, drugs work less effectively depending on sex; women are less responsive to anesthesia and ibuprofen for instance. In other cases, women are at more risk for adverse — even lethal — side effects.
These differences are particularly important for the millions of women living with chronic pain. An estimated 25 percent of Americans experience chronic pain, and a disproportionate number of them are women. A review published in the Journal of Pain in 2009 found that women faced a substantially greater risk of developing pain conditions. They are twice as likely to have multiple sclerosis, two to three times more likely to develop rheumatoid arthritis and four times more likely to have chronic fatigue syndrome than men. As a whole, autoimmune diseases, which often include debilitating pain, strike women three times more frequently than men.
Pain conditions are a particularly good example of the interplay between sex (our biological and chromosomal differences) and gender (the cultural roles and expectations attributed to a person). In 2011, the Institute of Medicine published a report on the public health impact of chronic pain, called “Relieving Pain in America.” It found that not only did women appear to suffer more from pain, but that women’s reports of pain were more likely to be dismissed.
For all the medical advances of the past few decades, we still know shockingly little about pain and how to control it. Sex-based research is a crucial part of understanding not just the underlying mechanisms of pain, but the most effective ways to treat it for men and women alike. The Institute of Medicine report found gaps in research, particularly in terms of effective treatments, as well as in the oversight of pain research. The report recommended that these problems be addressed and that strategies to resolve them be implemented by 2015.
Part of the reason the diagnosis and treatment of women’s pain lag so much is simply the pace of medical research itself, which is slow to move from publication to clinical practice. Unfortunately, if anything, changes in assumptions about gender evolve even more slowly.

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