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Cancer, Mental Health, Pain, Patient Care, Public Health

Coping with depression: A free online resource for cancer patients and their families

Coping with depression: A free online resource for cancer patients and their families

4523771529_0431b725aa_z-2If you or someone you know has cancer you’ve probably discovered that the disease can affect more than your physical health: It can alter your mood, your relationships with others and your relationship with yourself.

Many patients and their loved ones also experience feelings of depression and helplessness when faced with a cancer diagnosis, and this common and complex issue is addressed in an excerpt from Everyone’s Guide to Cancer Supportive Care found in the resource section of the Ernest and Isadora Rosenbaum Library at Stanford’s Center for Integrative Medicine.

The “Coping With Depression” piece, written by clinical psychologist Andrew Kneier, PhD, walks the reader through various aspects of the topic, touching on ways cancer and depression are related, what you can do to protect yourself from negative feelings, and how to overcome such feelings. Perhaps one of the most interesting and helpful parts of the piece is its examination of how depression linked to cancer differs from other forms of depression:

Cancer patients often get depressed simply because having cancer can be a depressing experience. However, there is usually more to it than that. Most cancer patients are not clinically depressed. To varying degrees, they are frightened and upset, but this is not depression. When cancer causes depression, there are psychological or biological reasons for it. These causes are understandable, and they are treatable.

Whether you have cancer or not, the piece is worth a read.

Previously: Ernest and Isadora Rosenbaum Library: A free, comprehensive guide to living with cancerLooking at cancer as a chronic illnessEmotional, social support crucial for cancer patients and Stanford psychiatrist David Spiegel’s path west
Photo by Fiona Cullinan

Ask Stanford Med, Pain, Patient Care

Headache 101: On migraines, pain medicine and when to visit a doctor

Headache 101: On migraines, pain medicine and when to visit a doctor

stress-543658_1280I’m a stomachache gal; when something is troubling me, my tummy lets me know. So I’ve always felt a mixture of curiosity and puzzled empathy for those who suffer from frequent headaches or migraines — how odd and awful that must be.

As the founding director of Stanford’s Headache and Facial Pain Clinic, and a migraine sufferer himself, Robert Cowan, MD, is well-positioned to offer headache guidance (and insight for outsiders like me).

He recently chatted with writer Sara Wykes for an Inside Stanford Medicine piece on migraines, pain medicine and more. Here’s Cowan:

A migraine is much more than a headache. It occurs on average one to four times a month. Unlike a tension headache, it is often accompanied by nausea or vomiting. Its pain is intensified by physical activity and is so severe it interferes with daily activities. About 30 percent of migraineurs — people with migraine — have a warning that consists of neurologic signs, or auras, they experience before the migraine episode begins. The most commonly experienced aura is visual, during which patients see small, colored dots, flashing bright lights or multicolored zigzag lines that may form a shimmering crescent-like shape.

The best way to cope with migraines and other headaches is not to keep pounding pills, Cowan cautions:

The vast majority of headaches should not be treated with opioids or any other pain medications. It depends upon what kind of medicine you are taking, of course, but a good rule of thumb is not to take any pain medication more than two days in any week, and no more frequently than recommended on the label or as prescribed. If you need more medication to control pain, you should consult a physician. Overuse of acute medications can actually increase the frequency of your headaches.

Cowan says the best approach to minimizing headaches may be to pay attention and log symptoms such as irritability or a food craving that may appear right before a headache starts. “You may begin to see patterns that were not readily obvious,” he advises.

Previously: Study examines trends in headache management among physicians, More attention, funding needed for headache care and Director of Stanford Headache Clinic answers your questions on migraines and headache disorders
Photo by geralt

Cancer, Pain, Palliative Care, Patient Care, Public Health, Stanford News

Ernest and Isadora Rosenbaum Library: A free, comprehensive guide to living with cancer

Ernest and Isadora Rosenbaum Library: A free, comprehensive guide to living with cancer

Spiegel in office - 600“What’s it like to be told you have cancer?” I asked a friend recently. She told me she was shocked to have received the news, and that this shock quickly gave way to a seemingly endless string of questions. How did I get cancer? What’s the best treatment? What will my care be like? What will the rest of my life be like?

As we talked, I learned that getting her the best care possible, although important, wasn’t the only thing she needed to survive. An equally important need was the peace of mind she regained when her doctors, caregivers and loved-ones helped her tackle her unanswered questions.

Addressing the questions and needs of cancer patients, like my friend, is the primary aim of the web-based Ernest and Isadora Rosenbaum Library at Stanford’s Center for Integrative Medicine.

Recently, I had the opportunity to talk about the library with the center’s medical director, psychiatrist David Spiegel, MD. Spiegel first came to know the late Ernest Rosenbaum, MD, through Rosenbaum’s work at San Francisco’s Mt. Zion Hospital. Rosenbaum treated cancer by addressing the patient as a whole – considering not just patients’ physical needs, but their emotional ones as well – and, at the time, his approach was groundbreaking. He wrote Everyone’s Guide to Supportive Cancer Care, Everyone’s Guide to Cancer Therapy and The Inner Fire decades before such support was recommended by the Institute of Medicine in its report, Lost in Transition, long before the National Cancer Institute had an Office of Cancer Survivorship, and before palliative care was widely talked about.

When Spiegel opened the Stanford Center for Integrative Medicine in 1998, Rosenbaum brought his cancer supportive care program to Stanford. There, Rosenbaum and colleagues gave and recorded talks and penned articles that address the many scientific and emotional aspects of cancer care.

Ernie and IzzyRosenbaum bequeathed his writings to Stanford when he passed away in 2010. Volunteer Vahe Katros did the hard work of bringing this material to the web, donating hundreds of hours to bring the website to life. “Vahe represents the best in those who volunteer to help cancer patients, and he shows how we can all help one another,” Spiegel said.

Visitors to the online library will find information on such things as coping with cancer, sources of support, the value of forgiveness and the role of creativity – “topics [that] Rosenbaum selected due to his being personally being involved in the struggles of thousands,” Spiegel explained. The library contains excerpts from Rosenbaum’s book, The Inner Fire, and will be expanded in 2016 to include writings from his unpublished final work and additional content.

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Addiction, Medicine and Society, Pain, Research, Stanford News

Overprescribing of opioids is not just limited to a few bad apples

Overprescribing of opioids is not just limited to a few bad apples

8592523799_0cb9d8f3ff_zMore Americans are now dying of drug overdose each year than car accidents. And the biggest killer among those accidental deaths is prescribed opioids, according to the Centers for Disease Control and Prevention.

The CDC reports the amount of painkillers prescribed and sold in the United States has nearly quadrupled since 1999, yet there has not been an overall change in the amount of pain that Americans report.

With this public health epidemic of opioid overprescribing and overdose deaths, research has implied the problem is rooted in a small population of prolific prescribers operating out of corrupt “pill mills.”

A California physician was even recently convicted of second-degree murder in connection with the overdose deaths of three patients, in what prosecutors said was the first time a doctor was found guilty of murder for recklessly prescribing drugs.

The California Workers’ Compensation Institute found that 1 percent of prescribers accounted for one-third of schedule II opioid prescriptions and 10 percent accounted for 80 percent of prescriptions.

In a  research letter to JAMA Internal Medicine, the focus of a recemt press release, Stanford researchers investigate whether such disproportionate prescribing of opioids — such as morphine, oxycodone and hydrocodone — occurs in the national Medicare population as well.

The Stanford researchers examined individual prescriber data from the 2013 Medicare Part D (prescription drug coverage) claims data set created by the Centers for Medicare and Medicaid Services. Part D covers about 68 percent of the roughly 50 million people on Medicare, the federal insurance program for Americans who have certain disabilities or are 65 years or older.

While they found that up to 60 percent of opioid prescriptions do come from the top 10 percent of prescribers, they note this is no more skewed than Medicare prescriptions for any other drug.

Opioid prescriptions are concentrated among specialty services for pain, anesthesia, physical medication and rehabilitation. By sheer volume, however, the authors found that general practitioners dominate total prescriptions.

“High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions,” writes lead author Jonathan C. Chen, MD, PhD, a Stanford Health Policy VA Medical Informatics Fellow; psychiatrist Anna Lembke, MD; psychiatrist Keith Humphreys, PhD and Nigam H. Shah, MBBS, PhD, a biomedical informatics specialist.

“Efforts to curtail national opioid overprescribing must address a broad swatch of prescribers to be effective,” the authors write.

Previously: Unmet expectations: Testifying before Congress on the opioid abuse epidemic, The problem of prescription opioids: “An extraordinarily timely topic” and Assessing the opioid overdose epidemic
Image by Trevor Butcher

Genetics, Pain, Pediatrics, Precision health, Stanford News

Newly identified gene mutation explains why one family experiences unusual pain response to cold

Newly identified gene mutation explains why one family experiences unusual pain response to cold

snowy-handprintIf you’ve ever plunged your hand into a tub of ice water, you know about the overlap between cold and pain: that deep, biting ache makes you want to get your hand out of the water – fast. But while the protective value of that sensation is obvious, scientists have always been a bit mystified by how pain-sensing nerves register cold temperatures.

But now, research on a family with an extremely unusual gene mutation may help clarify what’s going on. The mutation, whose discovery was reported online this week in Nature, confers a heightened pain response to cold. The research was initiated by Stanford geneticists and expanded by scientists at three universities in Germany who specialize in hereditary pain syndromes.

The story began with a family who brought their young daughter to Lucile Packard Children’s Hospital Stanford to get help for her unusual episodes of pain. When cold, she experiences pain in her joints that radiates out to her arms and legs. The pain lasts 20 to 30 minutes at a time. The little girl’s father, paternal grandmother, paternal aunt and first cousin (the aunt’s daughter) also experience similar pain episodes, as the new paper explains in detail.

“When we saw her, we were really struck by the fact that the pain was going on in multiple generations of the family,” said one of the study’s authors, medical geneticist Jon Bernstein, MD, PhD. The pattern of inheritance made Bernstein suspect an autosomal dominant disease, in which only one bad copy of a gene causes symptoms. Although several hereditary pain syndromes are described in the medical literature, none matched the exact pattern of symptoms this family experienced, so the Stanford clinicians asked the German scientists to figure out what was going on.

The German team looked for rare mutations shared by the little girl and her cousin, finding one in a gene that codes for an electrical channel in nerve cell membranes. (Nerves transmit electrical signals via flow of charged ions through tiny protein tubes embedded in the cell membrane. There are several types of these channels.) The scientists’ experiments demonstrated that they had discovered a gain-of-function mutation – in which the encoded protein, instead of being rendered nonfunctional, instead alters what it does. In this case, there is a substitution of one amino acid for another in the structure of the affected electrical channel. That change causes pain-sensing nerves to fire at cool temperatures most people don’t find painful.

The same electrical channel, Nav1.9, was also identified as “a key determinant of cold pain sensation” in a paper published earlier this year that examined its activity in rats and mice. That study found that the channel was important to setting animals’ threshold for when cold begins to feel painful, and the new findings fit into that picture nicely.

The German team plans to continue studying the channel’s dynamics to help learn more about the normal threshold between cold and pain, Bernstein said. As for him? “I’m very much looking forward to working with the next family whose case is unsolved,” he told me.

Previously: One mutation, two people and two (or more) outcomes: What gives?, Crying without tears unlocks the mystery of a new genetic disease and Exploring the mystery of pain
Photo by Chris Geatch

In the News, Pain, Public Health

Pain: When the professional becomes personal

Pain: When the professional becomes personal

3199296759_e5130dc6c1_zFor 10 long months, Philip Pizzo, MD, suffered from incapacitating nerve pain. Even worse, top medical experts were stumped. He describes his ordeal in a recent essay in STAT News:

I tried everything — medication, physical therapy, deep-tissue massage, acupuncture — but nothing worked. Magnetic resonance imaging of my spine, hip, and pelvis didn’t show anything suspicious.

As a physician, a former dean of the School of Medicine, and chair of an Institute of Medicine panel on pain, Pizzo had known intellectually about the problem of chronic pain. Now he had experienced its unremitting intensity firsthand.

His pain was relieved by an unusual diagnosis and surgery, but Pizzo knows many others aren’t as fortunate.

“Nearly 100 million Americans suffer from chronic pain. We need to do more for them,” he writes.

Previously: Laughing through the pain: A comedy writer’s experience with chronic illness, “People are looking for better answers”: A conversation about chronic pain and  Study: Effects of chronic pain on relationships can lead to emotional distress
Photo by Kevin Dooley


Clinical Trials, Pain, Research, Stanford News

Pain-in-the-neck, begone! Better way to relieve chronic neck and shoulder pain?

Pain-in-the-neck, begone! Better way to relieve chronic neck and shoulder pain?

shoulderHundreds of millions of people worldwide (115 million in the United States alone) suffer from chronic pain. Stanford diagnostic radiologist Sandip Biswal, MD, calls this group “one of the largest populations in the world for medical need of any kind.” But current treatments either aren’t all that great or – in the case of opioids, which are highly effective – put patients at risk for addiction.

A pair of randomized, double-blinded clinical trials, described in a study co-authored by Biswal, former Stanford visiting scholar Charlie Koo, PhD, and several colleagues and published in Nature Scientific Reports, may point to a potential path toward more pain-free lives. In the trials, patients with chronic neck or shoulder pain were treated with three to six 90-minute sessions of either standard physical therapy – so-called transcutaneous electrical nerve stimulation,  or TENS, along with exercise and both manual and heat treatments – or a protocol designed by Koo, who now runs a facility called the Pain Cure Center in Palo Alto, California.

The new method, which Koo calls Noxipoint therapy, also employs electrical stimulation of painful areas, but in a carefully defined way: electrodes are placed precisely at both of the two attachment points for each muscle in pain, and the electrical-current jolt is brief and just enough to cause local soreness and dull, but not sharp, pain. Patients receiving the novel therapy are also told to take it easy for several days after each treatment.

In both trials, Noxipoint therapy proved superior to conventional physical therapy using TENS by close to an order of magnitude. Four weeks after their last treatment, patients given Noxipoint therapy reported substantial pain reduction, restoration of function (for example, regained range of motion) and improved quality of life, without significant side effects. Those given standard treatment reported no significant lasting improvement.

These trials are preliminary and call for confirmation in larger studies, Biswal told me. Given the pressing need for safe, lasting relief from chronic pain and the apparent success of this new method, it would be nice to see those expanded trials take place.

Previously: “People are looking for better answers”: A conversation about chronic painNational survey reveals extent of Americans living with pain and Stanford researchers address the complexities of chronic pain
Photo by Jason Trbovich

Chronic Disease, Dermatology, Immunology, Pain, Research, Science, Stanford News

Stanford researchers investigate source of scarring

Stanford researchers investigate source of scarring

2570500512_22e7fdcd48_zIf you’ve ever had a piercing that you’ve let grow closed, you’ll know that the healing process isn’t perfect. There’s almost always a little dimple to remind you of that perhaps questionable choice you may (or may not) have made during early adulthood.

Now former Stanford pediatric dermatologist Thomas Leung, MD, PhD, and developmental biologist Seung Kim, MD, PhD, have published some interesting research in Genes and Development regarding the healing and scarring process. Their findings may one day lead to advances in regenerative medicine.

As Leung, who is now an assistant professor at the University of Pennsylvania’s Perelman School of Medicine explained in an email to me:

One of the great mysteries in biology is how salamanders and worms regenerate lost body parts following trauma. In contrast to wound healing, tissue regeneration restores tissue to their original architecture and function, without a scar.  Although less dramatic, a few examples of mammalian tissue regeneration exist, including liver and digit tip regeneration.  These examples suggest that the underlying mechanisms driving tissue regeneration may still be intact in humans and perhaps we may use them for regenerative medicine.

The researchers studied how the ears of mice heal from a hole punched through the thin tissue (much like  ear piercing in humans). In many strains of mice, the holes partially fill but remain visible. In a few others, the holes heal with little perceptible scarring. Leung and Kim found that the strains of mice that heal well lack production of a protein that normally recruits white blood cells to the injury; blocking the ability of the protein, called Sdf1, to signal to the white blood cells resulted in enhanced tissue regeneration and less scarring in mice that would normally have been unable to close the hole.

Because the drug used to block Sdf1 signalling is already used clinically in humans for another purpose, Leung is hopeful that it can quickly be tested in humans struggling to heal  chronic or slow-healing wounds. He is currently designing a clinical trial to test the drug, called AMD3100.

The implications of improved wound healing with less scarring stand to benefit many more people than just those wishing away the physical evidence of a hasty cosmetic decision. Tens of millions of surgical incisions are made every year, and not all heal well. Scar tissue is less flexible than normal skin and can significantly interfere with function. In addition, people with certain medical conditions such as diabetes or poor circulation can face ongoing disability or amputation when wounds don’t heal. But the group that inspired Leung to conduct the research is especially poignant.

As Leung explained:

 The inspiration for this work was driven by our clinical experience.  At Stanford, I co-directed the Epidermolysis Bullosa (EB) clinic.  EB is a rare genetic skin disease (about eight babies are affected per million births in this country), where affected patients lack a protein that binds the skin together, resulting in fragile skin. Incidental trauma like rubbing of skin against clothing tears the skin and leaves a scar.  This endless cycle of trauma and scarring and fibrosis inevitably leads to decreased joint function and complete loss of hand function by teenage years.

My recent article for Stanford Medicine magazine and the accompanying video shed light on this devastating condition. Even a small improvement in the pain these children suffer would be a tremendous step forward. And, although Kim emphasizes that greater feats in regenerative medicine (limb regeneration, anyone?) are still years of research away, this finding shows that we’re making progress.

Previously: Limb regeneration mysteries revealed in Stanford studyTo boldly go into a scar-free future: Stanford researchers tackle wound healing and Life with epidermolysis bullosa: “Pain is my reality, pain is my normal”
Photo by The Guy with the Yellow Bike

Addiction, Chronic Disease, Pain, Stanford News, Videos

“People are looking for better answers”: A conversation about chronic pain

"People are looking for better answers": A conversation about chronic pain

2048px-Low_back_painChronic pain limits the lives of an estimated 100 million people in one way or another and costs our country half a trillion dollars per year, according to Sean Mackey, MD, PhD, chief of the Division of Pain Medicine. To address the needs of the many people suffering from back pain, the most common kind of chronic pain, Mackey and other doctors and researchers in the division recently held a free Back Pain Education Day.

The event was popular enough that all seats were filled more than a week ahead of time, and a video stream of the day’s speakers was viewed by almost 1,500 people during the conference and in the week following. Recordings of the day’s talks can now be viewed on the Division of Pain’s YouTube channel.

We don’t have a cure for chronic pain. What we have are exceptional ways [to help] people get back their lives

During a recent conversation, Mackey told me the big turn-out reflects the keen interest people living with back pain have in finding solutions. “People are looking for better answers: why they have what they have and what they can do about it,” he said. “We wanted to provide them with real-world tools that they can use to control their pain.”

Speakers at the event covered varied ground, including physical therapy approaches to pain management, new research in using acupuncture to treat pain, self-management strategies, mindfulness-based pain reduction and the important role of sleep in pain. (Recent research has shown that poor sleep can intensify and prolong pain.) One over-riding theme was the role of the brain, Mackey said, not just in terms how people experience pain, but also how it can help turn down or turn up pain.

Mackey cautions that a quick fix often isn’t possible, so people living with chronic pain need to think about long-term management. “It’s a chronic disease, like diabetes. We don’t have cures for diabetes, and we don’t have a cure for chronic pain,” he said. “What we have are exceptional ways to control the disease and ways [to help] people get back their lives.” Speaker Beth Darnall, PhD, the event co-chair, emphasized that pain psychology techniques can empower people to lessen distress and pain, and begin moving toward meaningful life goals.

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Chronic Disease, Events, Pain, Stanford News

Stanford expert on back pain: “The important thing for people to know is that it’s treatable”

BackPainSeptember is Pain Awareness Month and later this month, Stanford will host a Free Back Pain Education Day. The event, sponsored by the Division of Pain Medicine, offers community members the opportunity to come to campus and hear about current back pain management strategies and the latest research. The event will also be live-streamed via YouTube for people unable to make it in person.

In anticipation of the Sept. 13 event, I sat down with Beth Darnall, PhD, a pain psychologist at Stanford’s Pain Management Center, and one of the day’s speakers. I was interested to understand why back pain is such a critical health problem worldwide and what people living with back pain can do to manage their pain.

Back pain is a leading cause of disability in the U.S. and other countries. Why is chronic back pain so common?

I think there are many different reasons why back pain is the number one pain condition. The back seems to be the place that’s really most related to the development of chronic pain and debility from chronic pain. Pregnancy can either trigger or flare back pain, but there are a multitude of reasons: aging (there is degeneration of the spine), obesity (when people gain weight, it puts additional load on the spine), activity levels, and influence of posture. Dr. Sean Mackey will be talking about some of the reasons why back pain is the most prevalent pain condition in the world at the event.

[Back pain] is something that almost everyone will experience at some point in their lifetimes, so it’s really relevant to all of us, whether we have pain now or not.

Why have a community event about back pain now?

There has been increasing global and national attention to chronic pain in terms of its impacts and costs to society. In the United States alone, 100 million suffer from pain on a regular basis, and that is associated with costs of $635 billion dollars annually. That includes treatment costs and loss of productivity.

What we also know is that the incidence and prevalence of chronic pain has been increasing, despite the fact that theoretically, we have better treatments. So then the question is why. While we have a multitude of treatments available, we haven’t been focusing on back pain as comprehensively as we really should. We need a broader approach to the treatment of pain. This was recently outlined in the National Institute of Health’s National Pain Strategy (Note: Mackey co-chaired the oversight committee).

Some people may be under the misconception that the best way to treat back pain is simply with a pill… While medication can be one helpful component, the best way to treat back pain is with a comprehensive approach that involves self-management strategies.

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