Researchers map human sensory neurons, pursue chronic pain cure

by University of Texas at Dallas

Credit: CC0 Public Domain

An investigation into how human nerve cells differ from animal cells has provided researchers from The University of Texas at Dallas' Center for Advanced Pain Studies (CAPS) with important clues in the pursuit of more effective treatments for chronic pain.

01 may 2022--Dr. Ted Price BS'97, Ashbel Smith Professor of neuroscience in the School of Behavioral and Brain Sciences (BBS) and CAPS director, leads a team that is analyzing the origins of how pain is generated by nociceptors—pain-sensing nerve cells—in human dorsal root ganglia (DRG) neurons. Price is co-corresponding author of a study, featured on the cover of the Feb. 16 issue of Science Translational Medicine, that charts the full range of messenger RNA (mRNA) strands—a grouping called the transcriptome—produced in these cells.

Because mRNA is a single-stranded copy of a gene that can be translated into protein, the findings provide neuroscientists with a much better understanding of which genes are expressed in DRG neurons. The study also reinforces the value of studying human tissue—as opposed to animal cells—in the search for pain treatments.

DRG neurons are specialized nerve cells clustered near the base of the spine. Very little work has been done previously with these cells from humans due to the scarcity of their availability for research.

"We're one of the few groups in the country with access to human donor DRG tissue acquired specifically for research," said Stephanie Shiers Ph.D.'19, neuroscience research scientist and a joint first author of the paper.

Shiers' prior research made the case in broad terms that significant differences exist between the nociceptors in mice and humans. That work explained why proposed pain treatments that succeed in mice fail in humans.

"This paper is the next step, clearly demonstrating the profound scale of those differences," Price said. "An entire set of nociceptors that many people study in mice just aren't found in humans. There are subtypes in humans that don't exist even in nonhuman primates.

"It's not that we should abandon all existing nonhuman models of pain. But some are really good, while others aren't, depending on what you want to study. When it comes to this aspect of pain, our work shows which is which."

To profile all the gene activity in a DRG tissue sample, the research team used an advanced technique called spatial transcriptomics, which has enhanced capabilities compared with single-cell RNA sequencing.

"It's rare to have access to both the human tissue we used and to the technology," said Dr. Diana Tavares-Ferreira, also a co-first and co-corresponding author of the study and a CAPS fellow. "Spatial transcriptomics allows us to overcome the large size of these neurons and to see with a degree of certainty where and how a gene is expressed in human nociceptors.

"Our main goal was to fully characterize the whole transcriptome of human DRG neurons because so much of the work that's been done to find new pain therapeutic targets has been in mice. Our results help clarify why those efforts struggle to produce results."

By describing the neuron types present in human DRG and detailing their gene expression, the team has a much better picture of what the physiological functions are for each gene, Price said.

"With that knowledge, not only can anybody use our data to seek drug targets that they couldn't have sought before, but in some cases we also don't need to use the mice at all now. We can use the human information," he said.

Price called removing that reliance on animal models "a fundamental change," because it allows scientists to explore how any cell type might interact with any neuron in the human peripheral nervous system.

"We're now able to approach developing pain therapeutics in a more specific way and to think about how chronic pain happens in people in a different way," Price said. "My hope is that our findings can change the way people do research in our field. It's a road map that we will use, and others are welcome to follow."

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More information: Diana Tavares-Ferreira et al, Spatial transcriptomics of dorsal root ganglia identifies molecular signatures of human nociceptors, Science Translational Medicine (2022). DOI: 10.1126/scitranslmed.abj8186

 

Definition of pain updated for first time in four decades to make it more inclusive

by Johns Hopkins University School of Medicine

Credit: CC0 Public Domain

Johns Hopkins Medicine pain experts have joined the International Association for the Study of Pain (IASP) and collaborators worldwide to make a subtle but important update to the definition of "pain" for the first time in 40 years. With this change, the experts aim to make pain diagnosis and management more inclusive of all people who experience it.

16 september 2020--The revised definition is published in the September 2020 issue of the journal Pain.

"Pain is not just a sensation or symptom. It is a much more complex condition that is important to acknowledge properly to guide basic science research, patient care and public policy," says Srinivasa Raja, M.B.B.S., professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and chair of the IASP task force that created the revised description.

According to the researchers, the new pain definition—the first update since 1979—features a key phrase (shown in boldface): "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."

The phrase is important, say the researchers, because it includes types of pain not well understood 40 years ago, such as nociplastic—where pain receptors are stimulated without evidence of the cause, such as with fibromyalgia—and neuropathic pain caused by a sensitized or maladaptive nervous system, commonly associated with chronic pain conditions such as persistent pains after surgery, nerve injuries and limb amputations (commonly called "phantom limb pain").

The revised definition also is more inclusive of people who cannot express their pain in words. According to Raja, the previous definition used the word "described," which excludes non-verbal behaviors to indicate pain in animals and certain vulnerable individuals.

"Changing this language enables physicians to adequately account for pain in disempowered and neglected populations such as children, the elderly and people with disabilities," he says.

The updated definition can ultimately have an impact on access to health care, if adopted by insurance providers. A 2016 survey by the U.S. Centers for Disease Control and Prevention estimates that 20.4% of U.S. adults live with chronic pain and approximately 20 million reported that pain limits the ability to accomplish tasks in their work and daily life.

"When pain affects peoples' function, psyche and their social well-being, it needs to be recognized by insurance carriers that dictate who gets care and what aspects of their multidisciplinary care are reimbursed," says Raja.

Overall, the IASP task force says the revised definition has provided a starting point to integrate more evidence-based and holistic pain management into medical and mental health care.

"Pain cannot be simplified to a 0 to 10 scale. Assessments instead need to look at the whole person, accounting for the cognitive, psychological and social factors that are critical to treating pain," says Raja.

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Provided by Johns Hopkins University School of Medicine 

Vitamin D deficiency tied to neuropathic pain

Vitamin D deficiency may be associated with increased neuropathic pain (NP) in patients with rheumatoid arthritis (RA), according to a study published online Aug. 31 in the International Journal of Rheumatic Diseases.

14 sept 2017--Hilal Yesil, from Afyon Kocatepe University in Turkey, and colleagues used the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaire to evaluate NP in 93 patients with RA. Other data were obtained from medical records and interviews.
The researchers found that 80 percent of patients were female and one-third were diagnosed with NP according to the LANSS. There was a negative correlation between vitamin D levels and the LANSS score (P = 0.001). Among patients with serum vitamin D levels <20 0.71="" 5.8="" a="" area="" curve="" d="" diagnoses="" good="" higher="" in="" levels="" ml.="" ml="" ng="" np="" of="" p="" patients="" predictor="" prevalence="" ra="" serum="" than="" the="" times="" under="" vitamin="" was="" were="" with="">"Although further research is needed to clarify the association between serum vitamin D levels and NP, our study raises awareness of the need to screen for vitamin D deficiency in RA patients with NP," the authors write.

More information: Abstract
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Research shows typical American diet can worsen chronic pain

“We need to be concerned about the consequences our diet has on our bodies, and not just immediately with problems like weight gain, but also with long-term complications. That’s what we set out to investigate in this study.”

Sufferers of chronic pain are more susceptible to prolonged and pronounced health issues when practicing poor diet habits, according to new research published by University of Alabama at Birmingham researcher Robert Sorge, Ph.D., and team in the Journal of Pain.

20 dec 2015--Sorge's study highlights the negative effects of poor diet quality with respect to recovery from hypersensitivity and susceptibility to chronic pain. The implications of the research could be significant.
"It is currently unknown whether increased pain is due to greater weight or poor diet quality, or both," said Sorge, an assistant professor in the Department of Psychology in UAB's College of Arts and Sciences. "This study shows us the direct link between poor diet quality and increased pain."
Sorge's team instigated the research looking to further explore the link between obesity and chronic pain. The two medical conditions are often comorbid, and their rates are rising.
In looking into the issue, the team focused on the effects of the Total Western Diet, in particular. TWD foods typically have fewer calories from protein and increased calories from carbohydrates and saturated and monounsaturated fats.
"They call it the Total Western Diet because it's a common pattern in societies in our part of the world—it's a problem particularly here in the U.S.," said Stacie Totsch, the paper's first author and a graduate student in Sorge's lab. "We need to be concerned about the consequences our diet has on our bodies, and not just immediately with problems like weight gain, but also with long-term complications. That's what we set out to investigate in this study."
Mice were fed the TWD so that researchers could investigate the functional and physiological consequences of a nutritionally poor diet in mice. After 13 weeks on the diet, the mice on the TWD showed a significant increase in fat mass and a decrease in lean mass.
Tests run on the mice also revealed increases in pro-inflammatory cytokines, signals that promote systemic inflammation, as well as increases in serum leptin, a hormone secreted by adipose tissue that acts to regulate long-term appetite and energy expenditure.
"Most obese people have increased levels of serum leptin and pro-inflammatory cytokines, so we saw the immediate health effects that the diet had on the mice," Sorge said. "Our next step was to look at how the unhealthy effects of the TWD corresponded to chronic pain. Did it make it any worse, and how?"
After utilizing the TWD, researchers introduced chronic pain to the study in order to better understand their link.
This part of the study showed that hypersensitivity to heat and touch was more pronounced and was significantly prolonged in the TWD-fed mice.
"Poor diet seems to have exacerbated the normal recovery period from this mild inflammatory insult," said Sorge. "Because poor diet heightens hypersensitivity, patients with chronic pain who regularly practice bad diet habits are likely to experience exaggerated pain responses and recovery from injury or surgery."
Specifically, prolonged exposure to poor diet quality resulted in an altered perception of pain through acute nociceptive sensitivity, systemic inflammation and persistent pain following chronic pain induction.
The paper detailing the research, "Total Western Diet alters mechanical and thermal sensitivity and prolongs hypersensitivity following Complete Freund's Adjuvant in mice," was published in the Journal of Pain online in October.
"A complete understanding of the impact of diet can aid in treatment and recovery dynamics in human clinical patients," said Sorge. "Now that we know more about the link between diet and inflammation, we can begin thinking about applications to solve the problem."
More information: Stacie K. Totsch et al. Total Western Diet (TWD) alters mechanical and thermal sensitivity and prolongs hypersensitivity following Complete Freund's Adjuvant in mice, The Journal of Pain (2015). DOI: 10.1016/j.jpain.2015.10.006


Provided by University of Alabama at Birmingham

Pain is in the brain

Chronic pain results from disease or trauma to the nervous system. Damaged nerve fibres with heightened responses to normal stimuli send incorrect messages to pain centres in the brain. This phenomenon, called "peripheral and central sensitization" is one of the key mechanisms involved in the condition which touches people with diabetes, cancer, and those suffering from multiple sclerosis, among others.

12 oct 2015--The study, published in the Sept. issue of The Journal of Neuroscience, provides insights into the role of the hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, which control the transmission of pain signals to a particular region of the brain, the anterior cingular cortex (ACC), identified as the most consistently stimulated region in pain processing.
"We were able to show that reducing hyperexcitability of the ACC by blocking the HCN channels had analgesic effects—basically the feelings of pain were dramatically decreased. Our study has revealed one important mechanism linking chronic pain to abnormal activity of the ACC and it provides a cellular and molecular explanation for the overstimulation of neurons in the prefrontal cortex. This gives us new perspectives on therapeutic strategies that could target the HCN channels to help relieve chronic pain," says Dr. Philippe Séguéla, Professor in the department of Neurology & Neurosurgery and senior author of the study.
Recent neuroimaging studies investigating the role of the prefrontal regions of the brain in neuropathic pain have shown how emotional, psychological and cognitive factors can influence pain perception.
"The ACC has been shown to be a key centre to cognitive functions linked to memory and affective functions involved in feelings and emotions. We know that patients who suffer from chronic pain experience impairment of their working memory, difficulties focusing on certain tasks and may suffer from depression and anxiety. Our findings open new doors to research possible treatment of these debilitating symptoms that are linked to chronic pain." says Dr. Séguéla.
The study, conducted by Philippe Séguéla and collaborators at the Montreal Neurological Institute and the Alan Edwards Center for Research on Pain, was supported by grants from the Canadian Institutes of Health Research, the Fonds de Recherche du Québec- Santé and the Louise and Alan Edwards Foundation.

More information: Peripheral Neuropathy Induces HCN Channel Dysfunction in Pyramidal Neurons of the Medial Prefrontal Cortex, The Journal of Neuroscience, 23 September 2015, 35(38): 13244-13256; DOI: 10.1523/JNEUROSCI.0799-15.2015

Provided by McGill University Health Centre

Altered pain processing in patients with cognitive impairment

People with dementia and other forms of cognitive impairment (CI) have altered responses to pain, with many conditions associated with increased pain sensitivity, concludes a research review in Pain, the official publication of the International Association for the Study of Pain.

01 jun 2015--The available evidence questions the previous notion that people with CI have reduced pain sensitivity to pain. Rather, "It appears that those with widespread brain atrophy or neural degeneration...all show increased pain responses and/or greater pain sensitivity," write Ruth Defrin, PhD, of University of Tel Aviv, Israel, and colleagues.

Differences in Pain Sensitivity with Cognitive Impairment

Dr. Defrin and colleagues analyzed previous studies on pain responses in cognitively impaired patients. The topic is an important one, as many patients with CI—which can result from a wide range of neurological and neurodegenerative diseases, or even normal aging—have "sustained and complex healthcare needs" involving pain.

"However, individuals with CI can have difficulty communicating the features of their pain to others, which in turn presents a significant challenge for effective diagnosis and treatment of their pain," the researchers write. Because of those communication issues, it has even been suggested that cognitively impaired people have reduced pain sensitivity. Dr. Defrin and coauthors believe that understanding the experience and responses to pain in people with CI is "an imperative ethical goal."

Evidence suggests that even normal, healthy aging may be associated with increased vulnerability to pain, as well as slightly reduced cognitive performance. These changes may set up a "vicious circle," with pain leading to a decline in cognitive function and vice versa.

Most studies suggest that the experience of pain is elevated in patients with mild to moderate Alzheimer's disease. Pain sensitivity in late Alzheimer's disease is unclear; Dr. Defrin and colleagues emphasize the need for multi-method approaches to assessing pain in this group of patients.

The effects of other types of neurodegenerative impairment on pain processing appear variable. Pain responses seem to be decreased in patients with frontotemporal dementia (Pick's disease) and Huntington's disease, but increased in those with Parkinson's disease. Effects on pain sensitivity may vary even for diseases affecting similar areas of the brain.

Various developmental disabilities—such as autism, cerebral palsy, and intellectual disability—are also associated with increased pain sensitivity. As in other groups of patients with communication difficulties, alternative ways of assessing pain are needed.

Pain processing also appears to be affected in patients with various types of brain damage, such as stroke and traumatic brain injury. Recent studies have demonstrated brain responses to pain stimuli even in severely brain-damaged patientsin a vegetative state.

Within the limitations of the studies performed to date, the analysis suggests that pain processing is frequently altered in cognitively impaired individuals, often with increased sensitivity to painful stimuli. Dr. Defrin and colleagues hope their review will increase awareness of possible changes in pain perception and processing and promote better approaches to pain management in people living with CI.

More information: "Experimental pain processing in individuals with cognitive impairment: Current state of the science." DOI: 10.1097/j.pain.0000000000000195

Provided by Wolters Kluwer Health

Publication's debut addresses pain among older adults

The first issue of a new publication series from The Gerontological Society of America (GSA) called From Policy to Practice explores pain as a public health problem and takes a look at how various policies impact the care provided to patients in a range of practice settings. It also provides readers with an overview of provisions of the Affordable Care Act that address pain research, education, training, and clinical care—as well as steps taken to implement those provisions.

20 nov 2014--"An Interdisciplinary Look at the Potential of Policy to Improve the Health of an Aging America: Focus on Pain," as this inaugural installment is titled, aims to ensure that researchers, practitioners, educators, and policy makers are aware of major policy issues at federal, state, and local levels that impact the prevention, assessment, and treatment of pain, as well as the social and practical supports required by older adults with pain. Support for the publication was provided by Purdue Pharma.

The issue was assembled by an expert panel chaired by GSA member Mary Beth Morrissey, PhD, MPH, JD, of Fordham University.

"This publication will serve as a resource for policy makers, researchers and practitioners dealing with the complexities of older adults' pain experience in diverse social and cultural contexts," Morrissey said. "It may also help to inform the design of broad-based policy and practice responses that encompass both medical and social services and supports."

Joining Morrissey as faculty for the publication were GSA Fellows Ann L. Horga, PhD, or the University of Florida; Edward Alan Miller, PhD, MPA, of the University of Massachusetts, Boston; and Joshua M. Wiener, PhD, of RTI International.

"This publication addresses how public policy helps to shape responses by medical and long-term care providers to the needs of older people," Wiener said. "My hope is that this publication will draw attention to the regulatory and funding constraints and incentives that currently exist and motivate changes to reduce pain among older people in the community, hospitals and nursing homes, especially at the end of life."

Chronic pain affects about 100 million American adults—and costs the nation up to $635 billion each year in medical treatments and lost productivity, according to the 2011 Institute of Medicine (IOM) report "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research," which went on to identify older adults as a population at risk for inadequate assessment and treatment of pain.

Morrissey called the release of the new GSA publication very timely, as it follows on the heels of the recently released IOM report titled "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life," which recommends integrated financing of medical and social services for individuals with serious advanced illness.

"GSA's primary focus in this 2014 report is bringing attention to the urgent needs of older adults living with pain, especially chronic pain that is often accompanied by multiple chronic illnesses," Morrissey said. "These complex needs call for both person-centered and public health responses."

The new issue of From Policy to Practice goes on to examine current policies in the context of the Affordable Care Act implementation and structural incentives for integrated and coordinated care, and highlight the role of policy in helping to eliminate pain disparities and assure equitable access to appropriate pain care and management for older Americans.

Morrissey additionally emphasized the value of the interdisciplinary approach taken by this publication.

"There is robust evidence showing that pain is a multidimensional experience involving the complex interaction of sensory, cognitive, emotional, social, cultural and spiritual dimensions," she said. "In light of this, it is essential that knowledge and expertise from across the various disciplines—for example, medicine, nursing, social work, psychology, pharmacy, and rehabilitation therapy—be brought to bear on the challenges pain poses for older adults and their family caregivers through interprofessional and interdisciplinary collaboration."

Provided by The Gerontological Society of America

Women report feeling pain more intensely than men: study

Women report more-intense pain than men in virtually every disease category, according to Stanford University School of Medicine investigators who mined a huge collection of electronic medical records to establish the broad gender difference to a high level of statistical significance.

01 feb 2012--Their study, to be published online Jan. 23 in the Journal of Pain, suggests that stronger efforts should be made to recruit women subjects in population and clinical studies in order to find out why this gender difference exists.

The study also shows the value of EMR data mining for research purposes. Using a novel database designed especially for research, the Stanford scientists examined more than 160,000 pain scores reported for more than 72,000 adult patients. From these, they extracted cases where disease-associated pain was first reported, and then stratified these findings by disease and gender.

"None of these data were initially collected for research, but this study shows that we can use it in that capacity," said Atul Butte, MD, PhD, the study's senior author.

The medical literature contains numerous reports indicating that women report more pain than men for one or another particular disease, noted Butte, a professor of systems medicine in pediatrics. "We're certainly not the first to find differences in pain among men and women. But we focused on pain intensity, whereas most previous studies have looked at prevalence: the percentage of men vs. women with a particular clinical problem who are in pain. To the best of our knowledge, this is the first-ever systematic use of data from electronic medical records to examine pain on this large a scale, or across such a broad range of diseases."

The study's first authors were Butte's graduate student Linda Liu and postdoctoral scholar David Ruau, PhD, who splits his time between Butte's group and that of co-author Martin Angst, MD, professor of anesthesia. David Clark, MD, PhD, a professor of anesthesia, was another co-author.

Electronic medical records are deployed in about 1-2 percent of hospitals now, but that should approach 100 percent within the next few years as the United States continues to move toward EMRs, Butte said. Thus, large-scale research using clinically collected data will become increasingly feasible.

In this case, the scientists tapped an existing data archive that has been designed specifically for ease of research: the Stanford Translational Research Integrated Database Environment, or STRIDE. Pioneered by the medical school's chief information officer, Henry Lowe, MD (who is also an associate professor of systems medicine in pediatrics and director of Stanford's Center for Clinical Informatics), STRIDE aggregates clinical data on patients cared for at Stanford Hospital & Clinics and Lucile Packard Children's Hospital, making this data searchable for approved research projects.

Butte's team selected only adult records and looked for gender-related differences in pain intensity as reported on 1-to-10 scales, in which a zero stands for "no pain" and 10 for "worst imaginable." Their search algorithm combed through de-identified EMR data for more than 72,000 patients, and came up with more than 160,000 instances, ranging across some 250 different disease categories, in which a pain score had been reported.

"If someone's reporting that they're in pain, they're probably going to be given medication, which might reduce any subsequently measured pain score," said Butte. To get pain estimates that weren't as confounded by subsequent pain-relief medications or procedures, his group analyzed only the first pain-intensity score reported by a patient per encounter with a hospital-associated health professional.

The search identified 47 separate diagnostic categories for which there were more than 40 pain reports for each gender. The sample included more than 11,000 individual adult patients, of which 56 percent were women and 51 percent of them white. The researchers were able to further analyze these 47 categories by condensing them into 16 disease clusters: "musculoskeletal and connective tissue" (in which the biggest gender differences in reported pain intensity were observed), "circulatory" and so forth.

"We saw higher pain scores for female patients practically across the board," said Butte. Those reported differences were not only statistically significant, but also clinically significant. "In many cases, the reported difference approached a full point on the 1-to-10 scale. How big is that? A pain-score improvement of one point is what clinical researchers view as indicating that a pain medication is working."

While the overall results tended to confirm previous clinical findings — for example, that female fibromyalgia or migraine patients report more pain than their male counterparts — the search also unearthed previously unreported gender differences in pain intensity for particular diseases, for example acute sinusitis and "cervical spine disorders," more commonly known as neck pain.

The study's results come with a few caveats. First, the investigators made the assumption that patients' pain hadn't already been treated—for example, that they hadn't already self-medicated with over-the-counter painkillers — by the time they showed up in the emergency room, doctor's office or neighborhood health clinic (or, equivalently, that the men and women were equally likely to have done so).

Other possible confounders include the setting in which pain was reported, Butte said. "Will an 18-year-old male report the same pain intensity with or without his mom present, or in the presence of a male vs. a female nurse? We can't be sure." But the sheer size of the study probably washes these concerns out at least to some extent, he said.

The third caveat is perhaps the most controversial. "It's still not clear if women actually feel more pain than men do," said Butte. "But they're certainly reporting more pain than men do. We don't know why. But it's not just a few diseases here and there, it's a bunch of them — in fact, it may well turn out to be all of them. No matter what the disease, women appear to report more-intense levels of pain than men do."

To get to the bottom of this, Butte's team plans to search EMRs to see if they can find some objective measurement — an already commonly measured blood-test variable, for instance — that correlates highly with reported pain. "We want to find a biomarker for pain," he said.

Provided by Stanford University Medical Center

First large-scale study of pain reveals risk factors

Millions of Americans are affected by painful jaw problems known as TMD, temporomandibular disorders, but predicting who is at risk has been extremely difficult.

13 nov 2011--Now, for the first time, researchers in the University at Buffalo School of Dental Medicine are publishing a comprehensive set of clinical characteristics that they say will lead to the ability to identify individuals at risk for developing the painful conditions. Their new clinical assessments will help researchers and clinicians better understand TMD and other pain conditions, so as to find ways to better manage and treat them.

Published in the November issue of the Journal of Pain, the UB research results are part of the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) study, available at http://www.jpain.org/issues?issue_key=S1526-5900(11)X0013-5, which followed 3,200 initially pain-free individuals for three to five years. It is the largest clinical study of pain conditions and how they develop that has ever been done.

The UB researchers, led by Richard Ohrbach, DDS, PhD, associate professor of oral diagnostic sciences in the UB School of Dental Medicine, have been studying pain and TMD for several decades. Ohrbach is the lead author on the paper.

"The UB role in the project was to develop well-designed examination procedures to help dentists and other health care providers identify risk factors for TMD," says Ohrbach.

Ohrbach and his co-authors studied 71 different clinical variables in 1,633 controls -- individuals who never had TMD -- and in 185 people with chronic painful TMD. They assessed the individuals through lengthy questionnaires about health histories and current symptoms and through clinical exams. Participants were from Western New York, Maryland, North Carolina and Florida.

The UB researchers found that a very high rate of the variables they assessed, 59 out of 71, were significantly associated with painful TMD. "Our results indicate that individuals with TMD differ substantially from the controls across almost all of the variables we assessed," says Ohrbach.

TMD sufferers tended to have significantly higher levels of the following variables: trauma to the jaw, non-pain symptoms in the facial area, jaw locking and noises, and pain during such jaw movements as chewing, smiling or talking. Ohrbach notes that while the last two findings were clearly expected, very little has been known about the first two findings.

In particular, the UB researchers found that TMD sufferers reported a much higher rate of neural and sensory medical conditions, such as earaches, tinnitus or hearing loss, fainting and dizziness, as well as seizures due to epilepsy and other conditions.

Ohrbach said that the study also confirmed many findings that long have been associated with TMD but which have not, until now, been proven in a comprehensive, large-scale study.

Among these is the finding that any pain disorder, such as headache, backache and abdominal pain, is more likely to occur in TMD patients than in people who do not have TMD.

"Why are other pain disorders more common in people with TMD?" asks Ohrbach. "Is it because those pain conditions predispose them to develop TMD or do they develop TMD first and does TMD lead them to then develop other pain disorders?"

To answer these and other related questions, Ohrbach says he and his colleagues will next look at comorbidity.

"We'll be tracking these multiple pain disorders over time with particular variables," he says.

Ultimately, the findings of the UB researchers and their colleagues on the OPPERA study will be geared toward a better understanding of pain conditions in general.

"How do we understand the pain? How do we establish a reliable and clinically useful marker of pain so that significant pain can be more readily diagnosed?" asks Ohrbach. "To answer these questions, we need to have a model that puts all of the pieces together, that takes the findings from a clinical exam, puts it into a rigorous framework using the right assessment and diagnosis tools in order to chart the nature of multiple physical disorders so that we can ultimately understand how the pain is affecting the individual."

Provided by University at Buffalo

IOM report calls for cultural transformation of attitudes toward pain and its prevention and management

Every year, at least 116 million adult Americans experience chronic pain, a condition that costs the nation between $560 billion and $635 billion annually, says a new report from the Institute of Medicine. Much of this pain is preventable or could be better managed, added the committee that wrote the report.

29 june 2011--The committee called for coordinated, national efforts of public and private organizations to create a cultural transformation in how the nation understands and approaches pain management and prevention. Some of the recommended changes can be implemented by the end of 2012 while others should be in place by 2015 and maintained as ongoing efforts.

"Given the large number of people who experience pain and the enormous cost in terms of both dollars and the suffering experienced by individuals and their families, it is clear that pain is a major public health problem in America," said committee chair Philip Pizzo, dean, Carl and Elizabeth Naumann Professor of Pediatrics, and professor of microbiology and immunology, Stanford University School of Medicine, Stanford, Calif. "All too often, prevention and treatment of pain are delayed, inaccessible, or inadequate. Patients, health care providers, and our society need to overcome misperceptions and biases about pain. We have effective tools and services to tackle the many factors that influence pain and we need to apply them expeditiously through an integrated approach tailored to each patient."

A new analysis undertaken as part of the study finds that the medical costs of pain care and the economic costs related to disability days and lost wages and productivity amount to at least $560 billion to $635 billion annually. Because the range does not include costs associated with pain in children or military personnel, it is a conservative estimate.

Health care providers, insurers, and the public need to understand that although pain is universal, it is experienced uniquely by each person and care –which often requires a combination of therapies and coping techniques — must be tailored, the report says. Pain is more than a physical symptom and is not always resolved by curing the underlying condition. Persistent pain can cause changes in the nervous system and become a distinct chronic disease. Moreover, people's experience of pain can be influenced by genes, cultural attitudes toward hardships, stress, depression, ability to understand health information, and other behavioral, cultural, and emotional factors.

Successful treatment, management, and prevention of pain requires an integrated, approach that responds to all the factors that influence pain, the committee concluded. The majority of care and management should take place through primary care providers and patient self-management with specialty care services reserved for more complex cases. Health care organizations should take the lead in developing innovative approaches and materials to coach and empower patients in self-management.

Training programs for dentists, nurses, physicians, psychologists, and other health professionals should include pain education in their curricula and promote interdisciplinary learning, the report says. Many health care professionals are not adequately prepared to provide the full range of pain care or to guide patients in self-managing chronic pain. For example, a recent study found that only five of the nation's 133 medical schools have required courses on pain and just 17 offer elective courses. Licensing and certification exams should include assessment of pain-related knowledge and capabilities. Programs that train specialists or offer training in advanced pain care need to be expanded.

The report calls on Medicare, Medicaid, workers' compensation programs, and private health plans to find ways to cover interdisciplinary pain care. Individualized care requires adequate time to counsel patients and families, consultation with multiple providers, and often more than one form of therapy, but current reimbursement systems are not designed to efficiently pay for this kind of approach and health care organizations are not set up for integrated patient management.

Due to its significant toll on individuals and society, pain warrants a higher level of attention and resources within the National Institutes of Health. The report recommends that NIH designate a lead institute to move pain research forward and increase the scope and resources of its existing Pain Consortium. NIH, academic researchers, and other public organizations should collaborate with private firms to advance research and development of new and improved therapies.

Provided by National Academy of Sciences

It's a pain to take care of pain

While many studies have looked at the treatment of chronic pain from the patient's perspective, there has been little research on those who provide care for chronic pain.

23 dec 2010--In a study in the November 2010 issue of the journal Pain Medicine, researchers from the Regenstrief Institute, the Indiana University School of Medicine, the IU School of Liberal Arts and the Roudebush VA Medical Center report that chronic pain takes a toll on primary care providers as well as their patients. They conclude that providers' needs should not be ignored if pain care is to be improved.

Most chronic pain is treated by primary care providers and necessitates frequent interactions with the patient. In this study the researchers surveyed 20 primary care providers (15 physicians, four nurse practitioners and one pharmacist) with varying clinical experience in the Roudebush VA Medical Center in Indianapolis. All 10 men and 10 women were asked open-ended questions designed to elicit their experiences with chronic pain management.

"Many providers criticized themselves because they felt unable to treat chronic pain effectively. Many internalized their lack of success with pain treatment, felt stress, and had guilty feelings. These negative feelings were compounded by hostile interactions with some patients, suspicions and distrust of some patients, especially those they suspected might be seeking pain medications for uses other than pain control, or to sell," said study first author Marianne Matthias, Ph.D., a Regenstrief Institute investigator, adjunct assistant professor of communication studies in the IU School of Liberal Arts and a research scientist at the Roudebush VA Medical Center.

Unlike other symptoms, such as elevated blood pressure or cholesterol readings, pain is subjective without any objective tests to confirm. One individual might rate pain a four on a one to 10 pain scale; another might label the same degree of pain a six or a seven. While high blood pressure and cholesterol often can be lowered with medication; successful treatment of chronic pain -- especially pain for which there is no known cause -- can be elusive, which is frustrating to both patients and care providers and can put a strain on their relationship, which can ultimately impact both patients' and providers' well-being.

"The providers often described dread when seeing a patient's name on their clinic schedule, knowing the interaction was going to be unsuccessful at best, difficult or hostile at worst. They described feeling ineffective and unsuccessful in their ability to treat many of their patients with pain. Interestingly, reports of frustration and negative experiences were present throughout the sample. Even those who were generally positive about their relationships with their patients reported difficulties, distrust and other relational issues at times," said Dr. Matthias, who is a health services researcher.

One provider interviewed said, "I beat myself up with it…You want to be liked by your patients. You want to be respected by your peers. You don't want to personally feel like you are being Cruella Deville by denying taking them out of pain. Of course, you want to relieve their pain, so I beat myself up. I feel guilty when these people end up yelling at me, and they do."

The study authors conclude that strategies to ease frustrations and defuse potential hostility in clinical interactions will ultimately improve pain management from the perspectives of both patients and providers. However they also note that potential solutions to difficulties in chronic pain care extend beyond the individual provider. The culture of the organizations -- for example if there is pressure to prescribe or not to prescribe opioids for chronic pain -- in which providers practice play an important role in providers' experiences, potentially making a difference in relationships with chronic pain patients.

"As an internist who frequently treats patients with chronic pain, I know how debilitating and disheartening chronic pain can be for patients. Clinicians need to work with their patients to give them hope that effective treatment of pain is possible," said the paper's senior author, Matthew Bair, M.D., a Regenstrief Institute investigator, assistant professor of medicine at the IU School of Medicine and a research scientist at the Roudebush VA Medical Center.

Provided by Indiana University School of Medicine

Pain is common in the last two years of life, study find

In the first study to look at the prevalence of pain experienced among older people during the last two years of life, researchers at the San Francisco VA Medical Center found that 46 percent of study participants suffered moderate to severe pain during their final four months of life.

04 nov 2010--The researchers also found that more than one quarter of the participants had moderate to severe pain during the last two years of life, and that arthritis was the biggest single predictor of pain, outweighing all eventual causes of death, including cancer.

“The impact of arthritis on the experience of pain among older adults has not been recognized to the extent it should be,” says lead author Alexander K. Smith, MD, MS, MPH, a palliative medicine physician at SFVAMC. He notes that the prevalence of pain in the last month of life was 60 percent among patients with arthritis and 26 percent among patients without arthritis.

“This research tells us that physicians should anticipate that pain will increase among their elderly and dying patients, assess their patients for pain frequently, and prescribe appropriate pain medications at appropriate levels,” says Smith, who is also an assistant professor of medicine in the Division of Geriatrics at the University of California, San Francisco.

Smith recommends that physicians regularly assess and treat pain in their older patients with chronic diseases who are not obviously nearing death. “In other words,” he says, “pain management is not just for hospice patients.” The study appears in the November 2, 2010 issue of the Annals of Internal Medicine.

The authors analyzed data from interviews conducted with 4,703 men and women age 50 and older who died while enrolled in the Health and Retirement Study, an ongoing nationally representative longitudinal study of health, retirement, and aging sponsored by the National Institute on Aging. The interviews were conducted during each participant’s last 24 months of life.

“As physicians, we need to recognize the high burden of pain among our older patients,” says Smith.

Provided by University of California, San Francisco

Depression Can Make Pain Worse

15 jun 2010-- Being depressed can make real physical pain feel worse, British researchers have found.

Noting that pain and depression often occur at the same time, the current observation blends two competing schools of thought, in which some believe that pain is "all in the head" while others contend that pain is "all in the body."

To see how pain and depression might intersect, the research team -- led by the University of Oxford's Dr. Chantal Berna -- used brain imaging to conduct pain tests on healthy participants who were induced to feel sad.

A depressed mood appeared to affect brain nerve circuitry responsible for emotion, resulting in a stronger perception of pain, according to the report published in the June 1 issue of Biological Psychiatry.

"When the healthy people were made sad by negative thoughts and depressing music, we found that their brains processed pain more emotionally, which lead to them finding the pain more unpleasant," Berna said in a news release from the journal's publisher.

Berna's team theorized that one's ability to control the negative emotions linked to pain are short-circuited by depression, leading to a bigger punch when pain hits. In other words, depression may not only be a consequence of being in pain. It might actually exacerbate pain, making it worse than it would be for those in a positive frame of mind.

"Our research suggests depressed mood leads to maladaptive changes in brain function associated with pain, and that depressed mood itself could be a target for treatment by medicines or psychotherapy in this context," Berna explained in the news release.

Following this line of research, the next step would be to study patients with chronic pain, because they often also suffer from depression, the researchers noted. The goal would be to find ways to more effectively treat the millions of people worldwide who experience chronic pain and depression, the authors explained.

More information

For more on pain and depression, visit National Pain Foundation.

Persistent Pain May Accelerate Signs Of Aging By Two To Three Decades In Middle-Aged Adults

18 sept 2009--Younger people with pain look similar in terms of their disability to people who are two to three decades older without pain, according to a study published in this month's issue of the Journal of the American Geriatric Society. The results of the study uncovered that people with pain develop the functional limitations classically associated with aging at much earlier ages.

Functional limitations that impair the ability to live independently increase markedly with age, and to examine the effect researchers looked at the data from the 18,531 participants, aged 50 and older, who took part in the 2004 Health and Retirement Study. The four physical abilities considered were: mobility, for example walking or jogging; stair climbing; upper extremity tasks, and; activity of daily living (bathing, dressing, eating, etc) with or without help.

24% of participants had significant pain (often troubled by pain that was moderate or severe most of the time) and across all four physical abilities looked at, participants with pain had much higher rates of functional limitations than subjects without pain. In the mobility function as an example, of subjects aged 50 to 59 without pain 37% were able to jog 1 mile and 91% were able to walk several blocks without difficulty, compared to only 9% and 50% respectively in those with pain.

The study was led by Dr. Kenneth Covinsky of the Division of Geriatrics at University of California, San Francisco. "We found that the abilities of those aged 50 to 59 with pain were far more comparable to subjects aged 80 to 89 without pain, of whom 4% were able to jog 1 mile and 55% were able to walk several blocks, making pain sufferers appear 20 to 30 years older than non-pain sufferers," surmised Covinsky. "After adjustment for demographic characteristics, socioeconomic status, comorbid conditions, depression, obesity, and health habits, across all four measures, participants with significant pain were at much higher risk for having functional limitations."

This is the first study of its kind to examine the relationship of pain across the age span, and to identify the large magnitude of the association between pain and age related disability. Although the strength of the association between pain and mobility limitation decreased somewhat with increasing age, a strong association between pain and mobility limitations persisted through the 10th decade of life.

"Our study cannot determine whether pain causes disability or whether disability causes pain. We think it is likely that both are true and that pain and disability probably can act together in ways that make both problems worsen in a downward spiral," said Dr. Covinsky. "One implication of our study is that pain and disability may not be fully separate processes, but may often be part of the same underlying process. Patients may be better served if pain and disability are evaluated and treated jointly rather than treated as separate issues."

The editor of the Journal of the American Geriatric Society, Dr. Thomas Yoshikawa, added "The drastic effect that pain can have on sufferer's abilities to carry out everyday tasks in their lives highlights the importance of managing pain and treating it effectively. Last month, we published our annual guidelines on the pharmacological management of persistent pain in older persons, and this study really brings home how essential it is for healthcare providers to be able to improve quality of life through awareness of the best treatments."

This study is published in the September issue of the Journal of the American Geriatrics Society.

Full citations:
Covinsky KE, Lindquist K, Dunlop DD, Yelin E; Pain, Functional Limitations, and Aging; AGS 2009; Volume 57 Issue 9, Pages 1556 - 1561; DOI: 10.1111/j.1532-5415.2009.02388.x View the abstract here.

"Pharmacological Management of Persistent Pain in Older Persons; American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons;" JAGS 57:1331-1346, 2009; DOI: 10.1111/j.1532-5415.2009.02376.x View the abstract here.

About the Author

Kenneth Covinsky, MD, MPH, is based at the Division of Geriatrics, University of California, San Francisco and staff physician at the San Francisco VA Medical Center.

About the Journal

The Journal of the American Geriatrics Society is a comprehensive and reliable source of monthly research and information about common diseases and disorders of older adults.

The Journal of the American Geriatrics Society is a comprehensive and reliable source of monthly research and information about common diseases and disorders of older adults. The journal is published by Wiley-Blackwell on behalf of the American Geriatrics Society. For more information, please visit http://www.blackwellpublishing.com/jgs.

Source
Wiley-Blackwell

FDA Approves Dual-Action Analgesic for Moderate to Severe Acute Pain

By Peggy Peck
ROCKVILLE, 30 nov 2008-- The FDA announced today it has approved a centrally acting oral analgesic, Tapentadol hydrocholoride, for relief of moderate to severe acute pain.
The drug combines mu-opioid receptor agonism with norepinephrine reuptake inhibition in a single molecule.
The FDA approved an immediate release formulation of the drug in 50-mg, 75-mg, and 100-mg doses.
The agency said the approval offered "health care professionals an additional choice for treating moderate to severe acute pain."
The most common side effects reported with Tapentadol were nausea, dizziness, vomiting, sleepiness, and headaches.
The FDA said the Tapentadol label will include warnings about the risk of respiratory depression; addictive depressive effects on the central nervous system when taken with alcohol, other opioids, or illicit drugs; and abuse potential.
The drug is marketed by Johnson & Johnson of New Brunswick, N.J.

Depressed Patients Have Dysfunctional Pain-Processing Network

By Todd Neale
LA JOLLA, Calif.,09 nov 2008 -- Patients with major depressive disorder process pain differently in the brain than healthy individuals, researchers here found.
During exposure to a painful heat stimulus, depressed patients had decreased activity in the area of the brain responsible for pain modulation, Irina Strigo, Ph.D., of the University of California San Diego, and colleagues reported in the November issue of Archives of General Psychiatry.
When the same patients anticipated pain, they had increased activity in the right anterior insular region, dorsal anterior cingulate, and right amygdala, parts of an emotion-processing network.
"The anticipatory brain response may indicate hypervigilance to impending threat, which may lead to increased helplessness and maladaptive modulation during the experience of heat pain," the researchers said.
"This mechanism could in part explain the high comorbidity of pain and depression when these conditions become chronic," they said.
More than three-quarters of patients with depression have chronic pain and 30% to 60% of patients with chronic pain have depressive symptoms, according to the researchers.
But despite the overlap between the two conditions, they said, little is known about the neurobiological basis of how pain is processed in the brains of patients with major depressive disorder.
So they recruited 15 patients with major depressive disorder (12 females; mean age 24.5) and 15 healthy controls with no history of psychiatric disorders (10 females; mean age 24.3) to undergo functional magnetic resonance imaging before and during painful stimulation.
The depressed patients completed the Pain Catastrophizing Scale, which assesses magnification, rumination, and helplessness related to pain.
Both painful and non-painful levels of heat were applied to the participants' forearms as they viewed images that signaled the intensity of heat to come.
The temperatures did not differ significantly between the groups; the painful stimulus was 115.5° F in the depressed patients and 116.4° F for the controls (P=0.08), and the non-painful stimulus was 102.2° F for both groups (P=0.59).
Both groups reported similar subjective ratings of the unpleasantness and intensity of the painful heat.
The depressed patients rated the non-painful heat as significantly more unpleasant (P=0.04), "a finding that is consistent with our previous observations of the increased affective bias in major depressive disorder at non-painful temperatures," the researchers said.
During the anticipation of pain, the depressed patients had increased activation in the right anterior insular region, left anterior insular/inferior frontal gyrus, bilateral dorsal anterior cingulate cortex, right dorsolateral prefrontal cortex, several clusters in the left dorsolateral prefrontal cortex, clusters in the temporal and occipital lobes, and right amygdala.
The increased activity in the amygdala during anticipation was associated with greater levels of perceived helplessness toward pain (P=0.01) and rumination (P=0.02) in the depressed patients only.
During painful stimulation, the depressed patients had increased activity in the left parahippocampal gyrus and occipital cortex and the right amygdala, and decreased activity in the periaqueductal gray matter and the rostral anterior cingulate and prefrontal cortices.
The increased activity in the amygdala during painful stimulation was associated with perceived levels of helplessness (P=0.02) and rumination (P=0.03).
"These findings suggest that increased emotional reactivity during the anticipation of heat pain may lead to an impaired ability to modulate pain experience in major depressive disorder," the researchers said.
Cognitive models suggest that patients with major depressive disorder negatively bias their expectations, perceptions, and memories, which may lead to the development of passive coping styles that promote helplessness and the maintenance of depression, they said.
Past studies have shown that passive coping styles are associated with the enhanced emotional impact of chronic and experimental pain.
The current findings are in line with these models, the researchers said, and "may represent a neural correlate of hypervigilant monitoring of negative information in major depressive disorder," the researchers said.
The authors acknowledged that the study was limited by the "mixed sample of relatively modest size," and that the findings needed to be confirmed using more patients.
The study was supported by grants from the National Institute of Mental Health and by the Barrow Neurological Foundation, the National Alliance for Research in Schizophrenia and Depression, and the University of California San Diego Center of Excellence for Stress and Mental Health.
The authors reported no financial disclosures.
Primary source: Archives of General PsychiatrySource reference:Strigo I, et al "Association of major depressive disorder with altered functional brain response during anticipation and processing of heat pain"Arch Gen Psychiatry 2008; 65: 1275-1284.

Pain a Part of Daily Life for One in Four

By Crystal Phend
PRINCETON, N.J., 04 may 2008-- More than a quarter of all Americans are in pain at any given time during the day, particularly those with lower income and less education, researchers said.In a population-based survey, 28.8% of men and 26.6% of women reported some level of pain during everyday activities at randomly sampled times through the day, according to Alan B. Kruger, Ph.D., of Princeton University, and Arthur A. Stone, Ph.D., of Stony Brook University in Stony Brook, N.Y.Activities associated with the highest average levels of pain were lawn care and caregiving as well as medical care among women and sports and exercise among men, they reported in the May 3 issue of The Lancet.
"If the relation with pain is causal, palliative care could increase the quality of life and range of activities in which people participate," the researchers said.
Even changing the mix of activities could lower a person's level of pain, they added.
So when doing a pain assessment, clinicians might consider asking for information about daily activities, Drs. Kruger and Stone suggested.
Previous studies have found that 17% to 29% of the general population suffers chronic pain, commented Juha H.O. Turunen, Ph.D., of the University of Kuopio in Kuopio, Finland, in an accompanying editorial.
Because little is known about pain prevalence other than chronic or condition-specific pain, such as arthritis, the researchers conducted the Princeton Affect and Time Survey (PATS). The Gallup Organization administered the community-based telephone survey to a nationally representative sample of households.
The 3,982 respondents provided a pain diary for one 24-hour period during which they rated pain on a seven-point scale. The researchers randomly selected three 15-minute intervals during waking hours for each participant.
Overall, respondents averaged 17.8 episodes of any degree of pain during the day before the survey.
Reports were similar from men and women. Race and ethnic origin were likewise not significant predictors of pain.
Pain ratings generally rose with age, although scores tended to plateau from the mid-40s to the mid-70s.
Along with age, education was a strong predictor of pain. Participants with less than a high school diploma had an average pain rating twice that of college graduates (1.21 versus 0.69, P<0.001).
Likewise, average pain ratings were about twice as high for men and women in households with yearly income below $30,000 as for those with an annual income of more than $100,000 (1.27 versus 0.67, P<0.001).
Individuals in the lowest income category spent 34.2% of their time in some degree of pain and 18.5% of their time in more severe pain (pain scores of three or higher on the seven-point scale). Those proportions were 22.9% and 7.7% for those in the highest income category.
The reason for these disparities, the authors suggested, was at least partly related to occupational status. Blue-collar workers had higher average pain ratings both during and outside of work than did white-collar workers (1.00 and 0.84 versus 0.61 and 0.61, respectively).
"Such a disparity emphasizes the need for pain-prevention measures, such as better ergonomics and better availability of occupational health services, in jobs with high physical strains," Dr. Turunen said in his editorial.
Drs. Kruger and Stone also found that disability and lack of satisfaction with life and health status were associated with the highest pain levels (all P<0.001).
Those participants who reported significant pain during much of the day reported spending 24.1% of their time watching television, whereas others spent 16% of the day in front of the TV.
Those individuals also spent more time relaxing and less time working and traveling than others, even when controlling for age and other demographic factors.
However, the researchers cautioned that the survey response rate was low (37%) and noted that the study lacked information on causes, location, and duration of pain, as well as medical conditions and treatments.
Further study is needed to identify groups of patients needing help with pain, Dr. Turunen said, "for example, to enable pain sufferers to obtain quicker and easier access to multidisciplinary pain clinics."
The study was supported by the National Institute of Aging and the Hewlett Foundation. Drs. Kruger and Stone reported being consulting senior scientists to the Gallup Organization. Dr. Stone also reported being associate chair of the scientific advisory board for Invivodata. Dr. Turunen reported no conflicts of interest.

Primary source: The LancetSource reference:Krueger AB, Stone AA "Assessment of pain: A community-based diary survey in the USA" Lancet 2008; 371: 1519-25. Additional source: The LancetSource reference: Turunen JHO "Depicting the pain profile with the diary-day method" Lancet 2008; 371: 1482-83.

Nursing homes undertreat dementia patients' pain

01 may 2008--Nursing home residents with dementia appear to be less likely to receive pain medication than other residents, even though they have just as many painful health conditions, a new study suggests.
Researchers at the University of North Carolina Chapel Hill evaluated data for 551 residents of six nursing homes across the state and found that residents who were cognitively impaired were less likely to receive regular doses of pain medication or to receive pain drugs at all.
This was despite the fact that dementia patients and cognitively healthy patients had similar rates of often-painful conditions like cancer, osteoarthritis and degeneration in the spinal disks.
Pain medications are often prescribed to be taken "as needed," the researchers note. The findings suggest that more nursing home residents with dementia should be on regularly scheduled doses of pain medication, they report in the Journal of Pain and Symptom Management.
This does not mean that undertreatment stems from neglect on the part of nursing home staff, lead author Dr. Kimberly S. Reynolds and her colleagues point out in the report. Instead, it is simply more difficult to recognize pain in dementia patients, who often lack the ability to communicate their symptoms or ask for pain drugs, as cognitively healthy nursing home residents do.
Indeed, the researchers' review of residents' medical records showed that while 34 percent of those with no cognitive impairment had documented pain in the past week, this was true of only 10 percent of residents with the most severe cognitive impairment.
Severely impaired patients were also more likely to have their pain documented as "less than daily" and "mild."
It was not surprising, then, that residents with dementia received pain drugs less often, according to Reynolds' team. Overall, 80 percent of residents with no impairment received pain medication at least occasionally, versus 56 percent of those who were the most severely impaired.
Similarly, 42 percent of cognitively healthy residents were on regularly scheduled doses of pain relievers, compared with only 23 percent of residents with severe dementia.
Yet it is unlikely that dementia patients truly were in less pain than their cognitively healthy counterparts, Reynolds and her colleagues write. In both groups of patients, roughly half had medical conditions likely to cause pain.
Given that severely impaired patients may be unable to complain of pain or ask for medication, the researchers conclude, in many cases it would be "more appropriate" for them to be on scheduled doses of medication.
SOURCE: Journal of Pain and Symptom Management, April 2008.

AAPM: Pain Can Make Patients Want to Kill Physicians

By Ed Susman
KISSIMMEE, Fla., Feb. 18 -- Patients in pain are particularly prone to want to take it out on their physicians in one way or another, even to the point of having thoughts of homicide, according to research reported here. "We haven't performed a prospective validity test on our findings -- that is, do their patients carry out their wish," said psychiatrist David Fishbain, M.D., of the University of Miami. "While we don't know if these patients will take you to court or kill you, we do know that healthcare workers are at a significant risk for patient perpetrated violence."
Dr. Fishbain noted that in one study conducted from 1983 through 1990, pharmacists were at greatest risk for work-related homicides -- 16 per 100,000 -- but physicians were a close second at 15 per 100,000.
In scrutinizing study questionnaires used to develop the Battery for Health Improvement test, Dr. Fishbain found questions pertaining to a patient's hostile wish to sue his physician and the hostile wish to kill the doctor. More than 2,200 patients and healthy participants took part in the process of developing the test.
Dr. Fishbain said a logistic regression analysis confirmed that the characterization of the acute and chronic patients was statistically significant (P<0.001).
"Acute pain patients and chronic pain patients were at greater risk than patients without pain for affirming the hostile wish statements," Dr. Fishbain reported at the American Academy of Pain Medicine meeting.
The study found that the chronic pain patient most likely to harbor the hostile wish is involved in litigation -- and most frequently that is a worker's compensation legal tussle. These patients are forced to see physicians against their will -- often because of dictates of the litigation, and patients don't trust the doctors.
For the acute pain patients, the portrait of the person with the hostile wish are those depressed by the state of their health and the tasks they cannot accomplish. Because of this, they are angry with people in general, including the doctor.
In the healthy community, Dr. Fishbain found that about 1.58% of the people expressed the hostile wish to kill their doctor while 1.5% harbored an urge to sue. The relative risk of having the hostile wish to kill increased by 2.8 times in patients who are not healthy and this group's wish to sue is increased by 3.36 times or about 5.5% of the population.
Acute pain patients in rehabilitation under workmen's comp claims are five times more likely to have a wish to kill the doctor than a healthy person and are three times more likely to sue. A chronic pain patient is a little less than five times more likely to hold a hostile wish, and they are more than four times more likely to think about suing.
Remarkably, 22% of the 18 patients identified in the surveys as having acute pain and are in rehabilitation under workmen's compensation rules and are in litigation have thoughts of killing their doctor -- 14 times that of a person in good health. However, they are seven times more likely than a healthy person to think about suing the doctor.
A person with chronic pain, in rehabilitation programs and involved in litigation is 10 times more likely than a healthy person to harbor a wish about killing the doctor, are 8 times more likely to think about suing.
"I think that doctors should try to diffuse the issues when they are involved in a workmen's compensation case," Dr. Fishbain said. "Tell the patients you are there to render an independent evaluation and treatment and you aren't on his side or on the insurance company's side. Get that in the open -- especially among those patients who are assigned to see you."
"These thoughts about killing a doctor or suing him are part of the ripple effect caused by chronic pain," said Rollin Gallagher, M.D., a clinical professor of psychiatry and anesthesiology at the University of Pennsylvania. "These patients may be more inclined to sue and may harbor wishes of violence if they have pain and are in litigation."
Dr. Gallagher, who was not part of the studies, said that pain patients tend to be frustrated and have loss of hope, problems that doctors need to address and be aware of when they are treating these individuals.
He also said the study points out the need for further education of doctors on the complexity of chronic pain and "emphasizes the need for the timely referral of patients to pain specialists."
Dr. Fishbain disclosed possible financial conflicts of interest with Lilly; Dr. Gallagher reported no financial conflicts of interest. The studies were funded through Pearson Assessments.
Primary source: American Academy of Pain MedicineSource reference:Fishbain D, et al "What are the variables that are associated with the patient's wish to sue his physician in patients with acute and chronic pain?" AAMP Meeting 2008; Abstract 102.

7 Pains You Shouldn't Ignore

By Leanna Skarnulis
Whoever coined the term "necessary evil" might have been thinking of pain. No one wants it, yet it's the body's way of getting your attention when something is wrong. You're probably sufficiently in tune with your body to know when the pain is just a bother, perhaps the result of moving furniture a day or two before or eating that third enchilada. It's when pain might signal something more serious that the internal dialogue begins:
"OK, this isn't something to fool around with.""But I can't miss my meeting.""And how many meetings will you miss if you land in the hospital?""I'll give it one more day."Etc.
You need a guide. WebMD consulted doctors in cardiology, internal medicine, geriatrics, and psychiatry so you'll understand which pains you must not ignore -- and why. And, of course, if in doubt, get medical attention.

No. 1: Worst Headache of Your Life
Get medical attention immediately. "If you have a cold, it could be a sinus headache," says Sandra Fryhofer, MD, MACP, spokeswoman for the American College of Physicians. "But you could have a brain hemorrhage or brain tumor. With any pain, unless you're sure of what caused it, get it checked out."
Sharon Brangman, MD, FACP, spokeswoman for the American Geriatrics Society, tells WebMD that when someone says they have the worst headache of their life, "what we learned in medical training was that was a classic sign of a brain aneurysm. Go immediately to the ER."

No. 2: Pain or Discomfort in the Chest, Throat, Jaw, Shoulder, Arm, or Abdomen
Chest pain could be pneumonia or a heart attack. But be aware that heart conditions typically appear as discomfort, not pain. "Don't wait for pain," says cardiologist Jerome Cohen, MD. "Heart patients talk about pressure. They'll clench their fist and put it over their chest or say it's like an elephant sitting on their chest."
The discomfort associated with heart disease could also be in the upper chest, throat, jaw, left shoulder or arm, or abdomen and might be accompanied by nausea. "I'm not too much worried about the 18-year-old, but if a person has unexplained, persistent discomfort and knows they're high risk, they shouldn't wait," says Cohen. "Too often people delay because they misinterpret it as [heartburn] or GI distress. Call 911 or get to an emergency room or physician's office. If it turns out to be something else, that's great."
He tells WebMD that intermittent discomfort should be taken seriously as well. "There might be a pattern, such as discomfort related to excitement, emotional upset, or exertion. For example, if you experience it when you're gardening, but it goes away when you sit down, that's angina. It's usually worse in cold or hot weather."
"A woman's discomfort signs can be more subtle," says Cohen, who is director of preventive cardiology at Saint Louis University School of Medicine. "Heart disease can masquerade as GI symptoms, such as bloating, GI distress, or discomfort in the abdomen. It's also associated with feeling tired. Risk for heart disease increases dramatically after menopause. It kills more women than men even though men are at higher risk at any age. Women and their physicians need to be on their toes."

No. 3: Pain in Lower Back or Between Shoulder Blades
"Most often it's arthritis," says Brangman, who is professor and chief of geriatrics at SUNY Upstate Medical University in Syracuse, N.Y. Other possibilities include a heart attack or abdominal problems. "One danger is aortic dissection, which can appear as either a nagging or sudden pain. People who are at risk have conditions that can change the integrity of the vessel wall. These would include high blood pressure, a history of circulation problems, smoking, and diabetes."

No. 4: Severe Abdominal Pain
Still have your appendix? Don't flirt with the possibility of a rupture. Gallbladder and pancreas problems, stomach ulcers, and intestinal blockages are some other possible causes of abdominal pain that need attention.

No 5: Calf Pain
One of the lesser known dangers is deep vein thrombosis (DVT), a blood clot that can occur in the leg's deep veins. It affects 2 million Americans a year, and it can be life-threatening. "The danger is that a piece of the clot could break loose and cause pulmonary embolism [a clot in the lungs], which could be fatal," says Fryhofer. Cancer, obesity, immobility due to prolonged bed rest or long-distance travel, pregnancy, and advanced age are among the risk factors.
"Sometimes there's just swelling without pain," says Brangman. "If you have swelling and pain in your calf muscles, see a doctor immediately."

No. 6: Burning Feet or Legs
Nearly one-third of the 20 million Americans who have diabetes are undiagnosed, according to the American Diabetes Association. "In some people who don't know they have diabetes, peripheral neuropathy could be one of the first signs," says Brangman. "It's a burning or pins-and-needles sensation in the feet or legs that can indicate nerve damage."

No 7: Vague, Combined, or Medically Unexplained Pains
"Various painful, physical symptoms are common in depression," says psychiatrist Thomas Wise, MD. "Patients will have vague complaints of headaches, abdominal pain, or limb pain, sometimes in combination."
Because the pain might be chronic and not terribly debilitating, depressed people, their families, and health care professionals might dismiss the symptoms. "Furthermore, the more depressed you are, the more difficulty you have describing your feelings," says Wise, who is the psychiatry department chairman at Inova Fairfax Hospital in Fairfax, Va. "All of this can lead the clinician astray."
Other symptoms must be present before a diagnosis of depression can be made. "Get help when you've lost interest in activities, you're unable to work or think effectively, and you can't get along with people," he says. "And don't suffer silently when you're hurting."
He adds there's more to depression than deterioration of the quality of life. "It has to be treated aggressively before it causes structural changes in the brain."