Pain

Updated 4:15 pm: In his ongoing effort to push for a public health campaign to battle our country’s pain epidemic, Philip Pizzo, MD, dean of the School of Medicine, traveled to Washington D.C. to speak before the U.S. Senate Committee on Health, Education, Labor & Pensions today.

During the hearing, Pizzo highlighted the results of last June’s Institute of Medicine Committee report on pain, which concluded that the effective treatment of pain demands a “cultural transformation” on the part of patients, physicians and researchers. Pizzo chaired the committee that issued the report.

The total costs of treating pain are higher than the costs of cancer, cardiovascular diseases and diabetes put together, while the treatments still leave many patients suffering needlessly. In order to battle this epidemic, the government needs to support a public health campaign that includes improving education of providers, patients and communities, Pizzo and his co-authors concluded.

“The magnitude is simply astounding,” Pizzo told the committee. While the report focused on the public health implications of this epidemic and recommendations for change, the authors also understood that “it’s the individual human impact of pain that underscores why this is such an important issue…”

The effect on the individual was brought into stark focus by speaker Christen Veasley, an advocate for pain research who had a near-fatal accident 15 years ago and has suffered from residual back and neck pain ever since.

“For many of us, we wake up and the first thing we feel is pain,” she said. “It feels like you live with a veil over your face. As patients, we’ve been left completely disillusioned… This report has brought us renewed hope.”

Also testifying were John Sarno, MD, professor at New York University School of Medicine and William Maixner, PhD, director of the Center for Neurosensory Disorders at the University of North Carolina at Chapel Hill.

Previously: A call to fight chronic-pain epidemic and Relieving Pain in America: A new report from the Institute of Medicine

When you ask someone to describe the physical sensation of love, chances are you’ll get an answer like falling head-over-heels, having butterflies in the stomach or walking on sunshine. As it turns out, and as described in a recent Stanford study, those intense, consuming feelings of love can do more than make you happy: They appear to block pain in ways similar to painkillers or illicit drugs.

In honor of Valentine’s Day, we’ve asked Sean Mackey, MD, PhD, senior author of that study, to respond to your questions about the analgesic effects of love – and he’s happy to answer general questions about pain research, too.

Mackey’s research is focused on explaining the mechanisms of pain perception and control using neuroimaging techniques such as virtual reality and functional magnetic resonance imaging (fMRI). He has shown that chronic pain sufferers may be able to reduce pain levels by studying their own live brain images, and he is working with colleagues to develop a diagnostic tool that uses patterns of brain activity to give an objective assessment of whether someone is in pain. He also recently served on an Institute of Medicine committee that issued a report calling for coordinated, national efforts to tackle the chronic-pain epidemic.

To submit your questions to Mackey about the pain-relieving effects of love and the science of pain, send an @reply message to @SUMedicine and include the hashtag #AskSUMed in your tweet. (Not a Twitter user? Then please submit a comment below.) We’ll collect questions until Friday at 5 pm. In submitting questions, please abide by the following ground rules:

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Twitter handles and/or names may be used in the responses

Medical school experts taking questions on the @SUMedicine feed will answer a selection of the questions submitted, but not all of them.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: A call to fight chronic-pain epidemic, Stanford scientists work towards developing a “painometer”, Stanford’s Sean Mackey discusses recent advances in pain research and treatment, Relieving Pain in America: A new report from the Institute of Medicine, Long-term love may dull pain, study shows, Love blocks pain, Stanford study shows and Oh what a pain
Photo by Ryan Weisgerber

Findings recently published in the journal Obesity offer new insights into the link between obesity and chronic pain.

In the study (subscription required), researchers analyzed responses from 1,010,762 men and women who answered health survey questions during a telephone interview by the Gallop Organization between 2008 and 2010. Participants’ body mass index (BMI) was calculated based on questions regarding their height and weight. Respondents also answered questions about pain, such as if they “experienced pain yesterday.” Science Daily reports:

Sixty three percent of the 1,010,762 people who responded to the survey were classified as overweight (38 percent) or obese (25 percent). Obese respondents were further classified into one of three obesity levels as defined by the World Health Organization. In comparison to individuals with low to normal weight, the overweight group reported 20 percent higher rates of pain. The percent increase of reported pain in comparison to the normal weight group grew rapidly in the obese groups: 68 percent higher for Obese 1 group, 136 percent higher for Obese 2 group, and 254 percent higher for Obese 3 group.

Researchers suggested several explanations for the close relationship between obesity and pain including: the possibility that having excess body fat triggers complex physiological processes resulting in inflammation and pain; depression, often experienced by obese individuals, influences pain; and medical conditions that cause pain, such as arthritis, might result in reduced levels of exercise leading to weight gain.

Although more study is needed, the findings are notable and add to the evidence showing that overweight patients are at greater risk for chronic pain.

Previously: More than three-quarters of Americans projected to be overweight, obese by 2020, Behavioral therapy for weight loss may also benefit family members, Study finds family members of weight-loss-surgery patients also shed pounds, Stanford researchers, clinicians and academics gather for Obesity Summit 2, Study shows U.S. obesity rates will expand over next 40 years and Experts weigh in on the most effective approach to fighting obesity
Photo by Tony Alter

Working in media relations, I always get excited when one of our studies gets so much attention in the press. That was certainly the case this week, when oodles of reporters and bloggers wrote about a Stanford study of electronic medical records that found women reported more-intense pain than men may in virtually every disease category. (My only beef? The few headlines that implied that women “can’t handle pain.” That was not one of the findings – and if it were the case, babies would cease to be born!)

If you haven’t heard much about the study, or are interested in the topic of pain, this Forum show is one to listen to. Study co-author Martin Angst, MD, was one of the guests, and he and two other pain experts (including Stanford’s Sean Mackey, MD, PhD) discussed the findings and examined the causes and treatments for pain.

Previously: Women report feeling more pain than men, huge EMR analysis shows, A call to fight chronic-pain epidemic, No pain, no gain. Not!, Relieving Pain in America: A new report from the Institute of Medicine, Elliot Krane discusses the mystery of chronic pain, Researching ways to “heal the hurt”, Stanford’s Sean Mackey discusses recent advances in pain research and treatment and Oh what a pain

I’ve mentioned before that I rarely wear flat shoes. Even two pregnancies couldn’t get me to abandon my heels: I pulled on a pair of Skechers before heading to the hospital to deliver my daughters, but I can’t remember reaching for them before that. (I considered this a sort of badge of honor at the time; in retrospect it was probably pretty foolish.)

A few studies have shown that wearing high heels may lead to pain and knee and joint problems, but as Gretchen Reynolds writes on Well today, whether these shoes “affect the wearer’s biomechanics and injury risk has received scant scientific attention.” In her piece, she discusses a new Australian study that found wearing heels “may compromise muscle efficiency in walking” and may increase the likelihood of strain injuries. And she offers advice from Neil J. Cronin, PhD, the researcher who led the work, for readers who can’t kick (sorry, couldn’t resist) their heel habit:

So, if you do wear heels and are at all concerned about muscle and joint strains, his advice is simple. Try, if possible, to ease back a bit on the towering footwear, he says. Wear high heels maybe “once or twice a week,” he says. And if that’s not practical or desirable, “try to remove the heels whenever possible, such as when you’re sitting at your desk.” The shoes can remain alluring, even nestled beside your feet.

Previously: Do pretty shoes lead to ugly problems?, Study links high heels to osteoarthritis and joint problems and Ouch! How high heels can shrink leg muscle, cause pain
Photo by NessieNoodle

Although electronic medical records, or EMRs, are used only by about one percent of hospitals in the U.S. today, they are routinely produced and updated during patient visits to two Stanford-affiliated hospitals. Stanford’s nurses have been rigorously trained in the importance of reporting these patients’ pain - typically in the form of scores on a scale of 0 to 10 (where “0″ means “none at all” and “10″ means “the most imaginable”) – on those EMRs.

Henry Lowe, MD, director of Stanford’s Center for Clinical Informatics, and his colleagues have found a way to aggregate all of this clinical data into a searchable database that researchers can use, if they get approval.

Using de-identified patient data from EMRs, Stanford information-systems maven Atul Butte, MD, PhD, retrieved some 160,000 pain reports from over 72,000 patients, corrected for various confounders, crunched the numbers, and came up with an astonishing result: Across the board, for virtually any given disease men and women both get, women report higher pain scores than men do.

Not only is this difference statistically significant, it’s clinically significant: “In many cases, the reported difference approached a full point on the 1-to-10 scale,” Butte told me. “How big is that? A pain-score improvement of one point is what clinical researchers view as indicating that a pain medication is working.”

Butte, et al.’s results (described in this release) were just published in The Journal of Pain.

Okay, let’s get this out: Do women actually feel more pain than men, or do they just (to say it tactfully) report it more readily? That question, which husbands and wives have been arguing about for at least a few millennia, is unanswerable on the basis of this study.

Butte and his colleagues, however, are going to try to get to the bottom of it. They intend to rifle through those EMRs again to see if they can find any objectively measurable factor that correlates highly with reported pain.

Previously: A call to fight chronic-pain epidemic, How light exercise can help prevent arthritis from getting worse and Study shows poor sleep may increase risk of fibromyalgia among women
Photo by University of Salford

During my years working as a health writer, I’ve interviewed a wide variety of frustrated – and often depressed – chronic pain sufferers who, after years of searching, were at a complete loss as to where to find help. The causes of the pain were many and varied – from ongoing back problems to autoimmune disorders to accident injuries – but the frustrations were similar.

You could see the pain etched into these patients’ faces, reflected in their movements. Often, they felt misunderstood or not believed or condemned for not “sucking it up” and complaining too much. Living with ongoing pain had become a way of life.

The number of these pain sufferers, who often go ontreated and suffer needlessly, has reached epidemic proportions in the the United States, and now the dean of Stanford’s School of Medicine is calling for a public health campaign to fight the problem. In a New England Journal of Medicine perspective piece published today, Philip Pizzo, MD, and co-author Noreen Clark, PhD, write:

We recommend expanding and redesigning education programs to transform the understanding of pain, improving education for clinicians, and increasing the number of health professionals with advanced expertise in pain care.

The co-authors describe both the “astounding” magnitude of pain – up to 116 million Americans suffer – and the need to better educate health care practitioners and the public as a whole about the problem:

Sadly, many physicians are viewed as poor listeners by people living with chronic pain. Some physicians over-prescribe medications including opioids, while others refuse to prescribe them at all for fear of violating local or state regulations… Often, an initially supportive community becomes intolerant or inattentive as the pain persists, which leads many people with chronic pain to give up, resulting in depression.

Last June, an Institute of Medicine report concluded that the effective treatment of pain demands a cultural transformation on the part of patients, physicians and researchers; Pizzo chaired the committee that issued that report.

Previously: No pain, no gain. Not!, Relieving Pain in America: A new report from the Institute of Medicine, Elliot Krane discusses the mystery of chronic pain, Researching ways to “heal the hurt”, Stanford’s Sean Mackey discusses recent advances in pain research and treatment and Oh what a pain
Photo by SashaW

We’ve written in the past about the country’s growing problem with oxycodone abuse; Kentucky, Florida and West Virginia are three states that have been particularly hard-hit. Now comes a concerning report on the dramatic increase in painkiller use in our third-most populous state. From a New York Attorney General report (.pdf):

In New York, the number of prescriptions for all narcotic painkillers has increased from 16.6 million in 2007 to nearly 22.5 million in 2010 – prescriptions for hydrocodone have increased 16.7 percent, while those for oxycodone have increased an astonishing 82 percent. In New York City, the rate of prescription pain medication misuse among those age 12 or older increased by 40 percent from 2002 to 2009, with nearly 900,000 oxycodone prescriptions and more than 825,000 hydrocodone prescriptions filled in 2009.

The report goes on to outline the problems attached to these numbers – overdoses, addiction-related violence, increased government spending – and advocates for the establishment of  a controlled substance reporting system. The ultimate goal would be to ensure these drugs are given to people “who truly need them.”

Previously: Governors to Congress: Help us fight prescription-drug abuse, Florida’s prescription-drug problem, The Florida Governor’s questionable actions on drugs and How to combat prescription-drug abuse
Via Daily Intel

Okay, well, not just Adele, but it turns out that providing patients with a set of headphones and allowing them to listen to music may help alleviate their pain and anxiety during certain medical procedures, according to a pair of recently published studies.

During the first study (subscription required), a team of researchers at the University of Utah Pain Research Center instructed 143 participants to perform music tasks, such as following the melodies and identifying deviant tones in songs, while receiving experimental pain shocks with fingertip electrodes. Science Daily reports:

The findings showed that central arousal from the pain stimuli reliably decreased with the increasing music-task demand. Music helps reduce pain by activating sensory pathways that compete with pain pathways, stimulating emotional responses, and engaging cognitive attention. Music, therefore, provided meaningful intellectual and emotional engagement to help reduce pain.

Among the study subjects, those with high levels of anxiety about pain had the greatest net engagement, which contradicted the authors’ initial hypothesis that anxiety would interfere with a subject’s ability to become absorbed in the music listening task. They noted that low anxiety actually may have diminished the ability to engage in the task.

In the second study, a Duke Cancer Institute research team randomly assigned 88 men undergoing a prostate biopsy to three groups: wear no headphones, wear noise-cancelling headphones without listening to music and wear headphones playing Bach concertos. The participants’ blood pressure was taken before and after the biopsy. According to a Duke University release:

Among study participants in both groups with no musical intervention, diastolic blood pressure remained elevated after the procedure, compared to before. But the men who wore the headphones and listened to Bach had no such spike in blood pressure. Diastolic blood pressure often rises as a function of stress and anxiety.

Study participants who had the music also reported less pain, as measured by questionnaires.

The studies add to a body of research showing music therapy may ease various types of pain, including chronic pain and post-surgical pain.

Previously: Can music benefit cancer patients? and Prescription playlists for treating pain and depression?
Photo by Kashirin Nickolai

There’s an interesting overview in Science today of a recent Swedish study that aimed to determinine how the thermal grill illusion tricks the mind.

The thermal grill illusion, for those not familiar with the term, describes the pain sensation of feeling burning heat when placing your hand on a surface with alternating warm and cold bars. In the study, researchers used functional magnetic resonance imaging (fMRI) machines and a grill-like device comprised of silver bars that every 20 seconds were either warmed to 41*C, cooled to 18*C, or warmed and cooled in an alternating pattern. The magazine reports:

[Neuroscientist Fredrik Lindstedt and colleagues at the Karolinska Institute] tested every pattern on 20 people, and as expected the volunteers found the illusion more unpleasant or painful than normal hot and cold. The fMRI showed that those experiencing the illusion had a particularly busy thalamus, a relay station in the brain through which sensory impulses pass, and part of the pain matrix, a collection of brain regions that manage pain. The thalamus is also active during pain caused by cold allodynia, a neurological disorder in which even normal levels of cold hurt.

Building off these findings, the research team, whose long-term goal is to ease pain disorders, plans to repeat the experiment with allodynia patients. Researchers say the results of future studies could yield new insights into where and how the brain transforms feelings of temperature into pain.

Previously: Long-term love may dull pain, study shows
Photo by NIH Image Bank

With three days until Thanksgiving there’s no denying it: the holiday season is upon us. But while many of us are looking forward to celebrating the season with loved ones, an estimated 30 million Americans suffering from migraine are cringing at the thought of holiday crowds, travel delays, stress and other triggers that can result in headache pain.

In an effort to better understand how to manage headache disorders during the holidays, I turned to Robert Cowan, MD, director of the new Stanford Headache Clinic. Below Cowan discusses why headaches and migraines can be more common during the holidays and tips for preventing the pain.

During the holidays, some people may find that their headaches and migraines occur more frequently. Why?

For some people, the holidays are a perfect storm of triggers: stress, changes in sleep pattern, travel, special foods, special events and the list goes on. Of course, not every migraine sufferer has the same triggers but some of the most common ones tend to show up at the holidays. To make matters worse, we have less control over our lives during the holidays. Plans are hard to change, house guests occupy our time and all around us are smells, noise and lights. All this makes it hard to retreat from the environment to that cool, quiet, dark place where a migraine can cool off.

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Women who have trouble sleeping may have a higher risk of developing fibromyalgia, according to findings published online this week in Arthritis & Rheumatism.

In the study (.pdf), Norwegian researchers recruited 12,350 women aged 20 and older and followed them for a 10-year period. Participants were part of a large nationwide health survey that involved completing questionnaires and physical exams first between 1984 and 1986 and again between 1995 and 1997. None of the volunteers had chronic musculoskeletal pain upon enrolling in the study. Medpage Today reports:

A total of 327 women reported having been given a diagnosis of fibromyalgia at follow-up, which represented an incidence proportion of 2.6%.

Women ages 20 to 44 had an incidence proportion of 3.2%; the incidence proportion for those 45 and older was 1.7%.

In analyses that adjusted for smoking, education, physical exercise, body mass index, and education, the researchers found that women 45 and older who had frequent sleep difficulties had a rate ratio for fibromyalgia of 5.41, while the younger cohort had a rate ratio of 2.98.

[Researchers] then compared the 3,949 women who reported sleep problems of any frequency with the 8,401 who had no sleep disturbances, and found a rate ratio for fibromyalgia of 2.10

Previously: How to cope with an “invisible illness” and Can yoga help women suffering from fibromyalgia?
Photo by Ben Seidelman

On Monday morning, Stanford pain expert Sean Mackey, MD, PhD, will deliver a lecture at the National Institutes of Health on the role of neuroimaging in understanding pain. The talk will begin at 6 a.m. Pacific time and be webcast live here.

This year’s featured speaker for the annual Stephen E. Straus Distinguished Lecture in the Science of Complementary and Alternative Medicine, Mackey will discuss how neuroimaging offers insight into the key mechanisms involved in how the brain processes and perceives pain as well as forms neural connections. Additionally, he’ll talk about the role of neural reward systems in regulating pain and the future potential for non-pharmacological strategies to reduce the experience of pain.

To find out more about how pain fundamentally alters the nervous system and about the latest advances in pain research and treatment, listen to this recent 1:2:1 podcast with Mackey.

Previously: Stanford’s Sean Mackey discusses recent advances in pain research and treatment, Love blocks pain, Stanford study shows, Image of the week: Your brain on love and Stanford research provides insight on pain, love

I’ve written before about a quandry facing many new parents: Should they put a bumper in their baby’s crib or not? Now comes from the definitive answer from American Academy of Pediatrics: No. In case you haven’t heard the news this morning, the organization is now saying bumpers should never be used. CNN.com reports:

This recommendation, issued as part of an updated and expanded set of guidelines on safe sleep and SIDS prevention for babies, is the first time the AAP has officially come out against the use of crib bumpers. According to the AAP, there is no evidence that crib bumpers protect against injury, but they do carry a potential risk of suffocation, strangulation, or entrapment because infants lack the motor skills or strength to turn their heads should they roll into something that obstructs their breathing.

Previously: Pediatric experts: Skip the bumper in Baby’s crib

The day I turned 60, I hiked up to a place in Yosemite called Cloud’s Rest. It’s nearly 10,000 feet tall, with some very big boulders to boot. I was grateful that all that time I spent in the gym and on local trails prepared me for the 15 miles I trod that day. My aging feet were safely supported in well-cushioned hiking boots.

Back in the real world, professional attire does not allow comfy hiking boots to substitute for the youthful fatty padding my vintage bones have lost through nature’s wear and tear. When I read recently about some new, biomechanically-engineered, arthritis-assuaging shoes designed by Tom Andriacchi, PhD, at Stanford’s BioMotion Lab – and available at retail stores – I stood up and cheered. Another option to maintain my mobility!

Andriacchi, a world-class expert on gait and osteoarthritis, was persuaded by Laura Carstensen, PhD, founding director of the Stanford Center on Longevity, to apply his knowledge and creativity to the challenge of therapeutic footwear. She saw the opportunity to break out of the classic thinktank syndrome with a breakthrough bench-to-bedside project. She explains:

This is the poster child for us. There are an awful lot of important ideas that academics generate and then sit back and hope someone adopts. Most researchers are not trained to move ideas past the conceptual stage. What we do at the center is to show how and where those ideas can be useful. We help to move practical ideas, based on science, forward to a place where they can positively affect peoples’ lives.

On behalf of my age group and up, I am grateful for that thought.

Previously: Exercise may alleviate symptoms of arthritis regardless of weight loss