• chronic pain

    Pain Assessment – What is your Profile?

    by  • 22 May 2014 • abdominal pain, aches and pains, Assessment, back hurts, back pain, chronic pain, chronic pain acceptance, chronic pain management, Communication, coping with chronic pain syndrome, dealing with pain, Doctor Patient Communication, living with pain, pain assessment, Pain News

    When you think about your own pain experience, you may first think about how much you hurt. But, the full pain experience is actually broader than “how much”. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) […]

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    Living With Pain: Chronic Pain Acceptance

    by  • 12 March 2014 • back hurts, back pain, chronic pain, chronic pain acceptance, chronic pain management, Coping, coping with chronic pain syndrome, coping with pain, living with pain, managing pain, Pain Acceptance, Pain News, severe pain

    You may have heard the term “chronic pain acceptance”.  At first, it may sound a little sad – as though you are being asked to simply give up. But that is not what is meant by the term. It has […]

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    Talking About Chronic Pain

    by  • 27 February 2014 • abdominal pain, aches and pains, back hurts, back pain, chronic pain, chronic pain management, Communication, coping with chronic pain syndrome, dealing with pain, living with pain, Pain News, Relationships, Social Support, social support and pain

    People with chronic pain often say that their partner, family, friends, co-workers, or boss don’t seem to understand their pain problem or what it is like to live with pain. You may wonder if  others understand the impact of chronic […]

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    Another Book About Pain; Only Much Better

    by  • 1 January 2014 • book review, chronic pain, complementary-alternative med, exercise, marijuana, opioids, Pain News, pediatrics

    A Nation in PainOf nearly 240 million adults in the United States, more than 4 in 10, or about 100 million, live with chronic pain of some sort. Yet, the professional and popular news media focus more on abuses of pain medications than the dreaded conditions the drugs are intended to treat. Meanwhile, the suffering of untreated or mistreated patients with pain is largely overlooked.

    In her new book — A Nation in Pain: Healing Our Biggest Health Problem — author Judy Foreman provides a deeply researched account of today’s chronic pain crisis and reasons behind it, and she discusses some solutions that could be within reach. Far more than just a symptom, Foreman explains, chronic pain can be a disease in its own right, and the failure to manage pain better in the U.S. and other countries worldwide may be tantamount to torture.

    A great many (perhaps, too many) books have been written on the subject of pain; all are well-intentioned and often they are self-published. While some of the books are of interest, most appear to be riddled with personal opinion, biased perspectives, and/or misinformation rather than being guided by facts and solid evidence. As a journalist and investigative health reporter, Foreman has done a noteworthy job of crafting easy-to-read text that also is excellently documented with enough citations of her evidentiary sources to satisfy even the most skeptical readers — which is quite rare for a book intended for both lay and professional audiences, as is A Nation in Pain.

    The 464 page book, published by Oxford University Press, is ambitious in scope, covering in a mere 14 chapters subjects ranging from the nature of pain to genetic, age, gender, immune system, and mind-body influences. Foreman also examines various traditional, newly discovered, and alternative therapies for chronic pain.

    She says that her research for A Nation in Pain spanned 5 years, during which time Foreman consulted a library of books and hundreds of scientific papers on pain. She also interviewed nearly 200 scientists and physicians, as well as countless patients, a few lawyers, and a handful of government officials. [Full disclosure: This writer was one of those persons consulted, and we can attest to the depth and relentless probing of her inquiries.]

    A most appealing approach of the book is that it is simultaneously a textbook providing research insights and hard evidence, an investigative report replete with stories of affected patients and their families, and a personal memoir relating Foreman’s own experiences with chronic pain and its treatment. Certainly, this juggling was no easy task, but the genre makes for fast-paced, informative reading while captivating even a casual reader.

    Overall, Foreman suggests that there is an appalling mismatch between what people in pain need and what healthcare providers know about pain and its treatment — chronic pain in particular. She found that physicians in the U.S. typically receive only about 9 hours of education specifically on pain during 4 years of medical school — even veterinarians are better educated on pain management.

    Systematic failure is equally evident at the federal government level; for example, in 2012 the U.S. National Institutes of Health spent only about 1% of its vast $30.8 billion budget on pain research, Foreman states, despite the fact that chronic pain was (and still is) a bigger problem than heart disease, cancer, and diabetes combined. At the same time, chronic pain in the U.S. conservatively costs as much as $650 billion per year in direct medical costs and lost productivity. Shamefully, there is no National Institute of Pain; yet, there are other Institutes addressing diverse health conditions that are important, but affect far fewer citizens and with less burden on the economy.

    One of the more startling chapters in A Nation in Pain discusses the mismanagement of pain in pediatrics. Among other revelations, Foreman discloses how as recently as the mid-1980s in the U.S. healthcare professionals believed that young children, especially newborns and infants, seldom needed medication for pain relief and tolerated discomfort well. She recounts the particularly disturbing story of a newborn boy who was subjected to open-heart surgery without anesthesia — a practice that apparently was commonplace at the time, but somewhat of a dark secret known only among medical insiders. In general, management of pain in children of all ages has been deficient worldwide, as Foreman reveals in an examination of the research evidence.

    Foreman devotes 2 chapters to the destructive “Opioid Wars,” which have led to a misguided demonization of prescription opioid analgesics. Her discussion of this highly controversial topic is among the most fairly-balanced and evidence-based that we have seen. She observes that there are 2 separate public health “emergencies,” sometimes called “epidemics”: (a) undertreated pain influenced by some degree of limited access to opioids, and (b) the abuse of opioid analgesics for illegal or nonmedical purposes. She stresses, “whether the term ‘epidemic’ truly applies here is debatable.”

    Foreman recognizes that there are many sides to the ongoing debate and relatively little hard evidence one way or the other. As she states, “The complex truth is that opioids, especially opioids for long-term use in chronic non-cancer pain, are probably both under-prescribed for some patients and overprescribed for others.” Opioids are not a solution for all patients or all types of severe pain, she acknowledges, and at best the pain relief they afford is only partial. She accordingly emphasizes:

    “Opioids, in other words, may be necessary, but they are rarely sufficient. What I am saying is that government drug policy seems to be lopsided, politicized, stacked against legitimate pain patients, and fueled by public hysteria over abuse of prescription pain relievers. That hysteria, in turn, is fueled by often-misleading media coverage.”

    Those few sentences say a great deal about what has gone awry with concerns about opioid analgesics today. In support of those statements, Foreman laces her discussion with references to relevant research studies, while also distinguishing between good- versus poor-quality evidence — an objectively analytical perspective that is missing in most other books and articles on the subject.

    As Foreman observes, the controversy over prescription analgesics is a “highly emotional struggle in which much of the ‘debate’ is driven not by scientific facts but by dueling anecdotes of horror.” She aptly denounces a misguided popular press, prejudiced bureaucrats, and a small cadre of fear-mongering medical professionals for trying to foist a negatively slanted view of opioid pain relievers on the public as well as on the healthcare community at large. In balance, Foreman also tells how over-exuberant marketing by drug manufacturers has contributed to problematic analgesic prescribing and use.

    Throughout the book various therapeutic approaches for managing chronic pain are discussed, including new developments still in preclinical or clinical trial stages. Additionally, a whole chapter is devoted to marijuana (“The Weed America Loves to Hate”) and another focuses on exercise (“The Real Magic Bullet”). A range of CAM (Complementary & Alternative Medicine) therapies also are covered, with balanced discussions of pro and con research evidence for each.

    Challenges of effective chronic-pain management are complex, with many obstacles to overcome on the path to finding practical solutions. As the diverse stories of patients with pain in the book demonstrate, pain often cannot be extinguished altogether; yet, it almost always can be better managed and patients can live more fulfilling lives. Foreman offers some suggestions for action — such as expanded pain education in medical schools, reforms of federal policies across the board, and increased funding for pain research — but it would require a separate book to do justice to such proposals. Meanwhile, for healthcare providers, researchers, policy makers, and patients and their loved ones, A Nation in Pain is highly recommended reading.

    Here is ordering information…..

    A Nation in Pain: Healing Our Biggest Health Problem
    Judy Foreman; Oxford University Press; ISBN-10: 0199837201 | ISBN-13: 978-0199837205

    Release Date: January 29, 2014
    Hardcover (464 pages); List Price $29.95 USD (discounts often available).
    Prepublication ordering available at Amazon.com (here) or at other booksellers.
    See video trailer here: http://judyforeman.com/books/a-nation-in-pain/trailer/
     

    Judy ForemanAbout the Author… Judy Foreman is a nationally syndicated medical journalist with 40 years’ experience. She was a staff writer at The Boston Globe for 23 years, from 1978 through 2000, and a medical specialist and science writer since 1985, covering diverse health issues: fitness, aging, cancer, heart disease, pain, nutrition, and basic biological sciences.

    Foreman graduated Phi Beta Kappa from Wellesley College in 1966. After 3 years in the Peace Corps in Brazil, she earned a Master’s degree in Education for General Purposes from Harvard University Graduate School of Education. Through the years, she has won more than 50 journalism awards from groups such as the American Society on Aging, the American Heart Association, and the Arthritis Foundation, among others. She won a Knight Science Journalism Fellowship at the Massachusetts Institute of Technology in 1989-1990, was a Lecturer on Medicine at Harvard Medical School, and a consultant/patient advocate at Beth Israel Deaconess Medical Center from 2001 to 2004.

    While at The Boston Globe, Foreman’s weekly Health Sense column was syndicated internationally. Since 2000, working as a freelancer, the column has been featured in The Boston Globe, The Los Angeles Times, The Dallas Morning News, and many other media outlets, including foreign distribution. She has also appeared on WBUR radio, the NPR affiliate in Boston, and has been the host of a weekly, call-in webcast on health issues for Healthtalk.com. She now blogs regularly for WBUR’s Cognoscenti and Commonhealth Websites. Foreman’s own website can be visited at http://JudyForeman.com.

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    Is 5,000 IU/Day of Vitamin D Enough for Pain?

    by  • 20 December 2013 • chronic pain, complementary-alternative med, dietary supplements, musculoskeletal pain, Pain News, vitamin D

    Super DIn a recent article, John Cannell, MD — Executive Director of the nonprofit Vitamin D Council — explains how the organization arrived at its recommendation that all adults should take at least 5,000 IU/day of vitamin D for the rest of their lives [see blogpost here]. Previously, we had described research surrounding the potential benefits of oral vitamin D3 supplementation for various pain conditions; however, some may believe that 5,000 IU/day is too much, while it could actually be inadequate for many patients with chronic pain.

    As Cannell acknowledges, the U.S. Institute of Medicine’s Food and Nutrition Board claims that merely 600 IU/day of vitamin D is enough for most adults, while the Endocrine Society says 2,000 IU/day is sufficient. However, he notes, “We think the safest thing to do while all the research is going on is to maintain natural vitamin D levels.”

    By “natural,” Cannell is recommending vitamin D levels obtained by persons with daily sun exposure, such as lifeguards, some construction workers and gardeners, and others who regularly work outside, exposing significant areas of their skin to sunshine. “This is how our ancestors behaved throughout our evolutionary history,” Cannell observes.

    Cannell references a relatively good study examining the vitamin D levels of people who get plenty of sun exposure, which was published by Luxwolda et al. [2012] in the British Journal of Nutrition. The researchers discovered that healthy persons with traditional outdoor lifestyles, living around the African equator (the “cradle of mankind”), have average circulating vitamin D levels — ie, 25(OH)D — of 46 ng/mL (115 nmol/L).

    Cannell remarks that most people do not have their blood tested regularly for vitamin D, so a recommended daily dose of supplemental vitamin D is needed that (a) is easy to obtain at pharmacies, (b) will get at least 97% of people above 30 ng/mL of 25(OH)D and most persons at 40-to-50 ng/mL, and (d) will not cause anyone to reach toxic levels. Besides those 4 goals, Cannell also takes into account body weight; since, apart from genetics, body weight is a significant determinant of vitamin D levels. The more a person weighs, the more vitamin D they need to take.

    In support of this, Cannell describes a large study by Robert Heaney and colleagues that examined the relationship of body size and vitamin D status [see, Drincic et al. 2012]. These investigators found that, for a normal weight adult, 5,000 IU/day of total vitamin D input was needed to obtain a 25(OH)D level of 40 ng/mL. Cannell emphasizes that this pertains to an “average adult” and the final vitamin D level obtained by any dose also depends on baseline level, sun exposure, diet, and genetics.

    More specifically, the researchers calculated from their data that a total input of 70-80 IU/day/kg-of-body-weight is needed to achieve 25(OH)D of 40 ng/mL. That works out to be about 35 IU/day/pound; so, a 100 pound woman would need 3,500 IU/day of total input, whereas a 300 pound man would need 10,500 IU/day. Note: this is total input from all sources, including sunlight, diet, and supplements.

    Taking all of the above factors into account — and considering that most persons in modern society do not acquire much vitamin D from sunlight or diet — Cannell concludes that 5,000 IU/day of vitamin D supplementation is about right for the average adult.

    CLINICAL COMMENTS:

    Vitamin D for PainIn his brief article, Cannell does not address specific health or medical benefits to be gained by more optimal 25(OH)D levels; although, from an evidence-based perspective, his organization has explored the potential of vitamin D in a variety of preventative and therapeutic roles. Additionally, he does not state whether vitamin D3 or D2 is preferred, but in prior writings oral vitamin D3 supplements, taken daily, have been emphasized by Cannell (as well as by our own research on the subject).

    In 2008, we published ground-breaking research review papers focusing extensively on the potential benefits of vitamin D supplementation in patients with various chronic pain conditions, particularly those musculoskeletal in nature. These papers have now been archived and are still accessible as follows:

    RedStarVitamin D – A Neglected ‘Analgesic’ for Chronic Musculoskeletal Pain:
    An Evidence-Based Review & Clinical Practice Guidance
          > Full Report [50-pages; PDF Here]
          > Practitioner Briefing [7-pages; PDF Here]

    RedStarPPM Journal Article: Vitamin D for Chronic Pain [13-pages; PDF Here]

    RedStarVitamin D: A Champion of Pain Relief — Patient Brochure [6-pages; PDF Here]

    Since publication of those papers, a number of followup Pain-Topics UPDATES articles have examined and summarized the latest relevant research findings and commentary on the subject [click here for a listing of those articles]. Several points are worth repeating…..

    • Vitamin D deficiencies have been associated with a variety of chronic pain conditions, such as back pain, osteoarthritis, fibromyalgia, inflammatory bowel disease, and others. In many cases, research has demonstrated the efficacy and safety of vitamin D3 supplementation in helping to alleviate pain and to improve functionality and quality of life.

    • At the same time, much of the research has been of relatively poor quality and biased in one way or another. Larger-scale, randomized, controlled trials with higher vitamin D dosing and adequate followup times are still needed.
    • Unfortunately, there are inconsistencies in the quality and quantity of vitamin D content in over-the-counter supplements, and higher oral dosages (eg, 1,000 IU D3 tablets) are not available in some countries. Daily oral dosing of vitamin D is more consistent with “natural” intake than once-weekly or less frequent megadoses administered orally or via injection.
    • The optimal dose of vitamin D3 supplementation and subsequent 25(OH)D levels in persons with pain have not been determined. While the 5,000 IU/day and ≥40 ng/mL 25(OH)D recommended above by Cannell may be adequate for healthy persons, this could be suboptimal in most cases for helping to ameliorate painful conditions. Research to date has not fully explored effects of more adequate dosing, long-term in pain management.
    • Blood tests for vitamin D — ie, 25(OH)D serum-level assay — can be costly and inconsistent from one laboratory to another, but this test is the only way to know if supplementation frequency and amount are adequate for individual patients.
    • Aside from the other factors that may ultimately influence 25(OH)D levels, possible interactions with medications — eg, antacids, anticonvulsants, corticosteroids, and others — may reduce the potency of vitamin D. Malabsorption syndromes and bariatric procedures have been associated with vitamin D insufficiency, as have alcohol consumption and tobacco smoking.
    • Most persons get adequate calcium from their diet and do not need extra calcium in conjunction with vitamin D supplementation, unless specifically indicated.

    Clearly, there is still much to learn about the role of vitamin D supplementation as an adjunct in the management of chronic pain conditions, which can only be answered by high-quality research trials. Meanwhile, there is ample credible evidence for practitioners and patients to learn more and consider this relatively safe and inexpensive therapy.

    REFERENCES:
    > Drincic AT, Armas LA, Van Diest EE, Heaney RP. Volumetric dilution, rather than sequestration best explains the low vitamin D status of obesity. Obesity. 2012;20(7):1444-1448 [abstract here].
    > Luxwolda MF, Kuipers RS, Kema IP, et al. Traditionally living populations in East Africa have a mean serum 25-hydroxyvitamin D concentration of 115 nmol/L. Br J Nutr. 2012;108(9):1557-1561 [abstract].

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    The 6 Worst Words in Evidence-Based Medicine

    by  • 14 December 2013 • chronic pain, complementary-alternative med, EBPM, Making Sense of Pain Research, opioids, Pain News

    Language MattersWriting in the November 2013 edition of the Journal of the American Medical Association, R. Scott Braithwaite, MD, MS, from New York University School of Medicine, comments on a deceptive 6-word phrase often used in evidence-based medicine (EBM) that frequently leads to dangerously false inferences for clinical decision making [Braithwaite 2013]. We further contend that, applied to the interpretation and application of pain research — such as relating to the use of opioids analgesics for chronic pain — those 6 words also can encourage poor quality pain management and inexcusable patient suffering.

    What are the offending 6 words? They are quite simply, “There is no evidence to suggest….” Braithwaite proposes that this phrase should be banished from the lexicon of EBM and, while this could be important, we also recognize that it could foster uncertainty and doubt that could be discomforting to many professionals and patients in the pain field.

    Untested Hypotheses

    Braithwaite provides the following statements as examples of nefarious usage of the phrase:

    • “There is no evidence to suggest that hospitalizing compared with not hospitalizing patients with acute shortness of breath reduces mortality.”

    • “There is no evidence to suggest that ambulances compared to taxis to transport people with acute GI bleeds reduces prehospital deaths.”
    • “There is no evidence to suggest that looking both ways before crossing a street compared to not looking both ways reduces pedestrian fatalities.”

    As Braithwaite maintains, all of the statements are absurd as a basis for decision making, yet each statement is technically correct since its underlying hypothesis has not been suitably tested to establish contradictory evidence. This presumes a definition of “evidence” that requires formal hypothesis testing in an adequately powered (eg, large sized) and well-designed (eg, randomized, controlled) research study.

    Taking this further, based on a prior review article [Smith and Pell 2003], we would add the following statement: There is no evidence to suggest that jumping from an airplane in flight without a parachute as compared with using a parachute is fatal. As the review authors note (somewhat satirically), while there have been anecdotal accounts of persons without parachutes surviving falls from airplanes, it is extremely difficult to recruit subjects for good-quality randomized controlled trials comparing parachute use with no parachute in such circumstances; so, the statement is technically correct, but unproven and misleading.

    Based on his observations, Braithwaite proposes that “there is no evidence to suggest” has become a mantra for EBM practitioners in a wide variety of settings. And, he says, rarely is the statement followed by the clarifying aphorism “absence of evidence is not evidence of absence” [also see Altman and Bland 1995] or discussions of more inclusive definitions of “evidence” for affirming the hypotheses in question.

    Seeking Clarity & Precision

    Braithwaite proposes that, when an intervention potentially may incur significant harm or require large commitments of resources, deciding not to intervene when “there is no evidence to suggest” the favorability of the intervention can be prudent. “However, deciding to intervene when ‘there is no evidence to suggest’ also may make sense,” he writes, “particularly if the intervention does not involve harm or large resource commitments, and especially if benefit is suggested by subjective experience (eg, the qualitative analogue of the Bayesian prior probability).”

    SideNote50wBayesian theory applied to medical research is regaining popularity — albeit, it is difficult for most people to understand —  and it provides a mathematical framework for inference or reasoning using probability estimates. The approach can be particularly helpful in judging the relative validity of hypotheses in the face of sparse or uncertain data. While actual calculations can be complex, to evaluate the probability of a hypothesis being “true” an investigator specifies a prior probability — based on current observation/experience, past research, or scientific principles — which is then updated in the light of new, relevant research data to provide a posterior probability (ie, outcome result). An important feature of a Bayesian approach is that it takes into account what already is known or can be estimated, either quantitatively or qualitatively, about the likelihood of research outcomes being valid; if there is absolutely no (zero) prior probability to support a hypothesis, then research outcomes — whether favorable or unfavorable — are usually unlikely to be valid and reliable. In many respects, this might be viewed as a statistical application of the “Bradford Hill Criteria” for establishing cause-effect relationships [as discussed in Part 11 (here) of our series on “Making Sense of Pain Research].

    Braithwaite further maintains that a fundamental problem with the phrase “there is no evidence to suggest” is that it is “ambiguous while seeming precise.” What does “there is no evidence to suggest” really mean when used to argue against some intervention?

    Does it mean that the intervention has been proven to have no benefit? That some evidence does exist, but it is inconclusive or insufficient? That outcomes are somewhat equivocal, with risks exceeding benefits for some patients but not others? Each has a subtly different meaning affecting decision making; whereas, simply stating “there is no evidence to suggest” circumvents the experience or clinical intuition of healthcare providers. Furthermore, as Braithwaite notes, many decisions are particularly sensitive to patient preferences and, when the favorability of an intervention is unclear, “there is no evidence to suggest” may “inhibit shared decision making and may even be corrosive to patient-centered care.”

    According to Braithwaite, most practitioners make patient-centered decisions every day without high-quality (eg, randomized controlled trial) evidence as a guide, and those decisions are not always wrong. Furthermore, principles of EBM make it clear that an evidence-based approach was never intended to entirely exclude information derived from clinical experience and intuition — which amounts to a qualitative prior probability in a Bayesian sense.

    He recommends that practitioners and researchers make concerted efforts to banish “there is no evidence to suggest” from their professional vocabularies. Instead, they could substitute one of the following 4 phrases, each of which has clearer implications for decision making:

    1. “Scientific evidence is inconclusive, and we don’t know what is best” (corresponding to an uninformative or ambiguous Bayesian prior probability).

    2. “Scientific evidence is inconclusive, but my experience or other knowledge suggests ‘X’” (corresponding to an informative, qualitative Bayesian prior probability supporting ‘X’).
    3. “This has been proven to have no benefit” (if valid evidence indeed exists to confirm this).
    4. “This is a close call, with risks exceeding benefits for some patients but not for others.”

    Braithwaite asserts that each of the 4 statements would lead to distinct inferences for decision making and could improve clarity of communication with patients. Finally, he says, “Informed implementation of EBM requires clearly communicating the status of available evidence, rather than ducking behind the shield of 6 dangerous words.”

    False Arguments Over Opioids for Chronic Pain

    For quite some time, a very outspoken and opinionated group of healthcare professionals in the United States has been arguing against the long-term use of opioids for chronic noncancer pain, based essentially on the premise “there is no evidence to suggest that the benefits of this therapy outweigh its potential risks.” In fact, going further — by relying on similar logic and bolstered by low-quality, invalid, or misinterpreted evidence — they assert that overwhelming risks negate any benefits. The group also went so far as to petition the FDA to make the labeling of all extended-release (ER) and long-acting (LA) prescription opioids more restrictive [first discussed in an UPDATE here]. Even though the petition’s demands were largely rejected by the FDA in updated product-labeling [see UPDATE here], opioid opponents have persisted in their campaign.

    Indeed, it is acknowledged that there is virtually no clinical research evidence of good quality examining the efficacy and safety of opioid analgesics prescribed long-term for chronic pain. And, in their labeling-change mandates, the FDA also requires manufacturers to conduct longer duration trials of ER/LA-opioids, including evaluations of serious risks, such as misuse, abuse, addiction, overdose, and death, as well as the risks of developing increasing sensitivity to pain (hyperalgesia).

    Meanwhile, the opioid opponents have been using the current lack of evidence as evidence itself to support what might be called argumenta ad ignoratum, or “appeals to ignorance,” as discussed in Part 12 of our “Making Sense of Pain Research” series [here]. In the absence of any high-quality research evidence to the contrary, the opponents have used their own interpretations of data on opioid-related abuse, addiction, deaths, and other risks to arrive at an artificial Bayesian prior probability of harm — and have successfully foisted fallacious inferences on the public.

    Additionally, they are most likely driven by a personal set of prior probabilities — coming from likeminded peers or individual experiences with select patients — that help guide the calculus of their conclusions. Essentially, they have fabricated their own rendition of Braithwaite’s second statement above to claim, “Scientific evidence is inconclusive, but my experience or other knowledge suggests that opioids are ineffective and unsafe in the treatment of chronic noncancer pain.”

    However, using similar evidence deficits and prior probabilities informed merely by empiricism (eg, anecdotal observations), there are other important arguments about opioids for chronic pain that can be stated:

    • There is no evidence to suggest that opioid-induced hyperalgesia is a frequent clinical occurrence in human subjects administered opioids long-term for any type of pain, or which patients might be most affected.

    • There is no evidence to suggest that there is an inordinately high incidence rate of de novo, iatrogenic addiction among patients with chronic pain prescribed long-term opioid analgesics.
    • There is no evidence to suggest that significant numbers of patients with chronic pain do not or cannot benefit from opioid analgesia.

    Other, similar, arguments could be expressed that cast doubts on concerns about the efficacy and safety of opioids for chronic pain. But, in all cases, such doubts are motivated by uncertainty — or, an “ambiguous Bayesian prior probability” — and a most objective and unbiased premise could be a variation of Braithwaite’s first statement above; “Until there is good-quality evidence available we cannot reach definitive conclusions.” Meanwhile, using a lack of evidence to argue for or against opioids for chronic pain becomes a cruel game of sorts in which nothing is scientifically established and patients who presently do or prospectively could benefit from such therapy are the losers.

    Ubi Dubium, Ibi Intellectum

    If we accept Braithwaite’s proposal to eschew the use of “there is no evidence to suggest” as a valid argument against a therapy or intervention, it also raises nagging doubts about the legitimacy of rejecting certain questionable modalities for pain management because they have little if any high-quality evidentiary support. A number of complementary and alternative medicine (CAM) modalities immediately come to mind: eg, homeopathy, reflexology, energy-field therapies (eg, Reiki, etc.), biomagnetic therapy, some variations of acupuncture, and others.

    In most cases, high-quality clinical trials are absent and we are left with observational or anecdotal evidence at best. With certain approaches (eg, homeopathy, Reiki, and others), there is no presently-known biological rationale or plausibility to serve as a prior probability of efficacy. Still, there are ample examples of patients with pain being helped by each of the treatments — an informative prior probability — even if the outcomes are primarily due to placebo effects. So, should those CAM approaches be rejected outright as worthless on the basis of “there is no evidence to suggest that they are clinically effective for pain”?

    Indeed, many critics have made strong, rational arguments for unequivocally rejecting most CAM approaches on the basis of absent or inadequate supportive evidence and/or the lack of biological plausibility [eg, see Science Based Medicine blog]. Despite those contentions, and in view of Braithwaite’s perspective, it would appear that less absolutist and more definitive statements are needed. And, these must not rely primarily on the absence of evidence as evidence against CAM approaches and any prior probabilities must be taken into account, including those based on limited observational or anecdotal data.

    Pain-Topics UpdatesIn many cases, prior probability or plausibility may be so low that the respective CAM approach is still deemed ineffective. But, in other instances, this could encourage “suspended disbelief” until further investigation via high-quality research is possible. Many practitioners and patients may be discomforted or irritated by the degree of uncertainty and doubt this tolerates. And, a dilemma may be that, as with the parachute example above, there may never be definitive research to make strictly evidence-based pain management decisions. However, a fundamental theme of these UPDATES, as well as our “Making Sense of Pain Research” educational series has been Ubi Dubium, Ibi Intellectum, or “Where There Is Doubt, There Can Be Understanding” [click to download series PDF].

    REFERENCES:
    > Altman DG, Bland JM. Absence of evidence is not evidence of absence. BMJ. 1995;311(7003):485 [access here].
    > Braithwaite RS. EBM’s Six Dangerous Words. JAMA. 2013;310(20):2149-2150 [access by subscription here].
    > Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461 [abstract here].

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    Living with Chronic Pain: Discovering Gratitude

    by  • 27 November 2013 • back hurts, back pain, chronic pain, chronic pain acceptance, chronic pain management, Coping, coping with chronic pain syndrome, coping with pain, Emotion, gratitude, Pain Acceptance, Pain News, pictures, severe pain, thankfulness, thanksgiving, treatment for chronic pain, well being

    It can be difficult to feel thankful when you live with chronic pain.  Because pain may interfere with important areas of life, you may have suffered some difficult losses. Over time, you may have become more resentful and less thankful.   […]

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    Chronic Pain Management and Activity Level: The Power of 10%

    by  • 20 November 2013 • aches and pains, Activity, back hurts, back pain, chronic pain, chronic pain management, coping with chronic pain syndrome, coping with pain, exercise, living with pain, Migraine Headache, Pacing, Pain News, walking

    If your back hurts, or you have tension headaches, facial pain, knee pain, migraine headaches, arthritis, or one of the many other chronic pain problems, you may find it difficult to stay active, much less to exercise.  Yet, an important […]

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    Confusion Over Why Youths Misuse Rx Opioids

    by  • 16 November 2013 • abuse-addiction, acute pain, analgesic, chronic pain, language matters, opioids, Pain News, pediatrics

    Teenage Drug AbuseThe misuse of prescription opioid analgesics by young persons has garnered significant news-media coverage and created much concern, but there has been inadequate attention focused on the underlying motives for such behaviors. A new study among adolescent students revealed that most of the alleged medication misuse was for treating legitimate pain; however, there are some confusing aspects of this investigation that muddle the interpretation and usefulness of outcomes.

    Researchers at the University of Michigan surveyed 2,964 students in Detroit, Michigan (grades 7-12; 51% female) during 2011 to 2012 to assess motives for medical misuse of prescription opioids, as well as substance abuse and diversion behaviors [McCabe et al. 2013]. “Medical misuse” of Rx opioids was defined as “the use of prescribed opioids by a patient with a prescription for an opioid analgesic who uses the prescription in a manner not intended by the prescriber (eg, higher or more frequent doses, using intentionally to get high, or coingesting with alcohol or other drugs).” Whereas, “nonmedical use” of the drugs was defined as any use of someone else’s prescription opioids, whether for pain relief, to get high, or in conjunction with other drugs.

    The following results were noted by the researchers:

    • Among all respondents, 13% (n=393) reported that they had been prescribed opioid analgesics during the past-year (although reasons for Rx, such as specific pain disorders, were not captured in the data).

    • Among those legitimately prescribed opioid medications, about 18% of them reported “medical misuse” (eg, using too much of their medication, using it to get high, or using it to increase alcohol or other drug effects).
    • Among the “medical misusers,” the most prevalent motives were “to relieve pain” (84%) and “to get high” (35%). As for “nonmedical users,” taking someone else’s medication, pain relief was cited as the primary motivation by nearly 88%.
    • Multivariate analyses indicated that females were almost twice as likely as males to report past-year “medical misuse” of opioids, but there were no gender differences seen in the prevalence of motives.
    • African Americans were more likely than whites to “medically misuse” opioids, and most of them (3 in 4) said they were motivated by pain relief.
    • “Medical misusers” driven by non–pain-relief motives were more likely to also exhibit substance abuse behaviors; more than 15 times greater odds as compared with nonusers (adjusted odds ratio = 15.2, 95% CI = 6.4–36.2, P<0.001).
    • No such differences in substance abuse behaviors existed between nonusers and appropriate medical users, or between nonusers and “medical misusers” motivated by pain relief only.

    The researchers conclude that their findings improve our understanding of opioid medication misuse among adolescents and indicate a need for better education about appropriate medical use and appropriate pain management, as well as enhanced patient communication with prescribers. But, a most important concern brought out by this study might be the apparent undertreatment or mistreatment of pain in young persons.

    COMMENTARY:

    As usual, attention-seeking and biased news stories depicted rampant Rx-opioid misuse by youths, which actually was not evidenced by this investigation. Several key points regarding this study by McCabe et al. [2013] are worthy of consideration….

    1. This was a relatively small study of students from a single geographic location; so, as the researchers acknowledge, the external validity of outcomes for a larger, broader population is doubtful. Along with that, relatively small percentages of the total 2,964 respondents were “medical misusers” (1.9%) or “nonmedical users” (4.9%), which decreases the statistical power and practical significance of subgroup analyses.

    2. As with a great deal of other epidemiological research in the pain field, the terminology and definitions used can be more confusing than helpful when it comes to a clear interpretation of the evidence. In this present study, distinctions between “medical misuse” and “nonmedical use” primarily involve opioid analgesics being prescribed for the student/patient (“medical”) as opposed to similar medication prescribed for somebody else (“nonmedical”).

      In either case, however, a student might be using the opioid for a medical reason to treat pain and/or for recreational purposes (eg, to get high or in conjunction with other substances of abuse). So, it becomes difficult to keep track of the differences between what is meant by “medical” vs “nonmedical,” as well distinctions between misuse for medical reasons (eg, pain relief) as opposed to abuse for recreational purposes (eg, to get high).

    3. Despite such linguistic consternations and possible misnomers, it is important to note overall that the most prevalent reason for either “medical misuse” or “nonmedical use” of Rx opioids was to relieve pain. Specifically, 84.2% of “medical misusers” and 87.6% of “nonmedical users” said their motivation was “because it relieves pain.” It is of further interest that when students “misused” Rx opioids for pain relief they were less likely to also use those medications in ways related to substance abuse; only 0.24% of all respondents claimed to be driven by an opioid-addiction problem.

    A similar prior study by McCabe and colleagues [2009; discussed in an UPDATE here] was much larger, examining responses from more than 12,000 high school seniors. They found that only about 1 in 8 of the students (12.3%) had used opioids in ways other than had been prescribed for them. At the same time, however, a large percentage (45%) of those who did misuse opioid analgesics — whether involving their own or someone else’s medication — were trying to relieve physical pain. Also, it was found that when pain relief was a primary motivation for “misusing” opioids the students were less likely to also use other drugs of abuse, including alcohol.

    Another interesting finding in the current study by McCabe et al. [2013] is that, among the 393 students that had been prescribed opioid analgesics in the past year, the most prevalently prescribed drug was codeine (38%), followed in the distance by hydrocodone (18%), oxycodone (9%), and morphine (7%). As reported in an earlier UPDATE [here], an exhaustive Cochrane Systematic Review found codeine to be probably the least effective and most problematic of all analgesics; so, why this medication was so frequently prescribed in this population might be questioned. However, it also should be noted that roughly 31% of the students prescribed opioids did not even know the name of the agent they were taking, which itself is troublesome in suggesting a lack of patient education and communication that accompanies prescribing for adolescents.

    Overall, it is important to emphasize that more than 4 of every 5 (82%) adolescents prescribed opioid analgesics used them appropriately. Among those who used them in an un-prescribed manner, the relief of physical pain was a primary motivating force. While it should not be overlooked that significant percentages (but relatively small absolute numbers) of “medical misusers” and “nonmedical users” were motivated by non-pain-relief choices, a bigger question might be, “Why are so many youths inadequately treated (or mistreated) for pain that they resort to potentially hazardous self-treatment strategies?”

    The data in this and other epidemiological studies on this topic do not provide clear answers. Perhaps, as McCabe et al. suggest, there should be better education and communication when addressing the pain management needs of young patients. However, there also could be access-to-care issues, along with the underdiagnosis and inadequate treatment of pain in adolescents to begin with, accompanied by inappropriate prescribing and insufficient monitoring. In any case, the solutions would most likely center on providing more and better pain relief in youngsters who are identified as needing it, rather than limiting access or setting arbitrary restrictions (unsupported by best evidence) on the prescribing of effective and safe analgesics, whether opioid or nonopioid.

    REFERENCE: McCabe SE, West BT, Boyd CJ. Motives for Medical Misuse of Prescription Opioids Among Adolescents. J Pain. 2013(Oct);14(10):1208-1216 [abstract here].

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    Living with Pain: Goals Matter

    by  • 31 October 2013 • Activity, back pain, chronic pain, chronic pain management, coping with chronic pain syndrome, coping with pain, Goals, living with pain, managing pain, Motivation, pain and goals, pain and motivation, pain coping, Pain News, severe pain, treatment for chronic pain

    Chronic pain can make your goals seem unimportant or unreachable.  Your pain may interfere with your social goals, career goals, or family goals.  Personal goals like exercise, hobbies, reading, or learning something new may have fallen by the wayside too. […]

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