Feb. 19, 2008 The public health problem that needs to be addressed next is the epidemic of pain, according to pain medicine physicians who have come together to discuss the latest in pain research and treatment at the 24th Annual Meeting of the American Academy of Pain Medicine, February 12-16 at the Gaylord Palms in Florida.
"In recent decades, Americans, with the help of their physicians, have been asked to stop smoking and lose weight. Now it is time to focus our efforts on undertreated pain," says B. Todd Sitzman, MD, MPH, AAPM President and medical director of Advanced Pain Therapy, PLLC, a comprehensive pain clinic affiliated with Forrest General Hospital Cancer Center in Hattiesburg, Miss.
An estimated 60 million Americans live with chronic pain, a condition that is more prevalent among the elderly. As the 75 million Baby Boomers move toward retirement, more and more Americans are expected to have untreated or undertreated pain. Pain is vastly undertreated for a variety of reasons including misconceptions regarding opioid addiction, lack of access to care, cultural norms, and physician concerns about prescribing pain medications for chronic pain.
Pain Medicine is a medical specialty which utilized multiple modalities to diagnosis and effectively manage chronic pain. Additionally, pain medicine physicians deliver comprehensive care by combining techniques from several medical specialties. For instance, physical medicine techniques can be complemented by psychiatry and neurosurgery skills. "We treat pain aggressively to help our patients live fulfilling, productive lives," Sitzman adds.
A selection of discussions from the meeting are presented below.
Pain as a disease
Persistent pain is a disease in its own right; this concept is now leading to new specific treatments aimed at physical, psychological, and environmental components of this major disease, including genetic predisposition, Michael Cousins, MD argues.
"Chronic pain is different from acute pain," explained Dr. Cousins. "If pain persists despite reasonable treatment from a primary care physician and other specialists, the advice of a pain medicine specialist should be sought. The earlier such help is obtained the greater the chance of returning to a reasonable range of life activities."
According to the National Center for Health Statistics more than one-quarter of Americans (26%) age 20 years and over - or, an estimated 76.5 million Americans - report that they have had a problem with pain. Studies from the Pain Management Research Institute reveal an annual cost of $1.85 billion per 1 million people.
"In the near future, diagnosis and treatment of persistent pain will be markedly different," Dr. Cousins stated. "Drugs such as morphine that provide only symptomatic relief will be replaced by or supplemented with a new generation of therapies targeted at the disease process."
"Medical specialists have recognized that additional specialist training in pain is needed," says Cousins. "Too few pain medicine specialists are being trained, and not enough patients are getting access to effective treatments. Pain management needs to become a fundamental human right: a bundle of initiatives will be needed in medicine, law, ethics, politics," concludes Cousins.
Michael J Cousins AM, MD, DSc, professor and director of the Pain Management Research Institute at the University of Sydney, Royal North Shore Hospital, in Australia, presented the Decade of Pain plenary session on February 14, 2008.
Altered Central Nervous System Processing in Chronic Pain
"Chronic pain is associated with changes in the brain and can lead to premature aging of the brain, with an accelerated loss of gray matter," Catherine Bushnell, MD comments. "Similar changes are found in other stress-related disorders, such as post-traumatic stress disorder." She adds that chronic pain patients also have neurochemical changes in the brain.
"Many chronic pain patients complain of problems with concentration and memory. These complaints could be related to the structural and chemical changes that appear to take place in the brains of chronic pain patients. Patients should be aware that chronic pain may have an impact on their lives that extends beyond just the direct effects of living with pain," concludes Bushnell.
Opioid analgesics can increase pain under certain clinical conditions, which is referred to as opioid-induced pain. According to Jianren Mao, MD, PhD, opioid analgesics can activate the cellular mechanisms responsible for pathological pain. He says there is a cross-talk between mechanisms of pain and opioid-induced pain, and opioid-induced pain can contribute to chronic pain conditions.
"Opioid-induced pain is an unwanted adverse consequence from opioid therapy, which hampers the opioid analgesic effect for chronic pain management," remarks Mao. "Rational use of opioid analgesics may minimize the impact of opioid-induced pain and improve clinical outcomes of opioid therapy. More clinical and preclinical studies are needed to understand the mechanisms of opioid-induced pain and to guide clinical use of opioid analgesics."
Motion Preservation: A Paradigm Shift in Spine Surgery
Motion sparing treatment of the spine is rapidly gaining interest. Paul Anderson, MD says that the early results for disc arthroplasty, interspinous process device and dynamic stabilization are encouraging; however, long-term results are lacking and further research is needed.
"The rationale for motion preservation technology is to avoid fusion thereby decreasing the likelihood of adjacent segment degeneration will allow earlier return to activities, maintain viscoelastic properties of the motion segment, reduce surgical morbidity, and decrease postoperative bracing requirements," Anderson explains.
Anderson says that the short-term outcomes of lumbar and cervical arthroplasty are comparable to fusion, while interspinous process distraction has been shown to have significantly better results than epidural steroid injections in spinal stenosis patients.
"Motion sparing technology offers hope that reduced secondary diseases as a result of altered mechanics from surgery will be avoided. Additionally these techniques may be associated with shortened recovery time and earlier return to activities," concludes Anderson.
Who Needs Back Surgery?
Several lines of evidence suggest we may be doing too much back surgery in the United States. The evidence that this may be true includes expert opinion, comparison with other countries, geographic variations in surgery rates within the US, rapid increases in certain types of surgery, patient outcomes in areas with high or low surgical rates, and the preferences of patients when they are well informed.
According to Richard A. Deyo, MD, MPH, surgery offers better relief from leg pain, or sciatica, than from back pain. Whether it helps people who have back pain alone is controversial. "Even in situations where surgery is likely to be of benefit, there is a choice, and reasonable people may choose for or against surgery depending on their own preferences and values," Deyo continues. "Patients should be involved in the decision-making."
"Back surgery is not helpful for everyone with low back pain; only those with some very specific conditions who also have leg pain with their back pain may benefit. Even then, surgery rarely offers a complete cure, and a choice of either surgical or non-surgical treatment is usually reasonable. Patients should understand that even people without back problems/pain often have abnormal MRI scans of the spine, so an abnormality doesn't necessarily mean surgery is going to help. Surgery is only likely to help if the MRI images match up with specific symptoms and findings on a doctor's examination. It's always wise to consider a second opinion when back surgery is recommended," he concludes.
Dark Side of Addiction: Relevance to Pain Medicine
The conceptualization of drug addiction as a disorder that consists of neurobiological adaptive mechanisms involved in emotional processing may be relevant to pain management and addiction vulnerability.
"Addiction has been conceptualized as a syndrome that moves from an impulse control disorder to a compulsive disorder to produce excessive drug intake and loss of control over drug intake. Impulsivity is driven by key neurochemical elements," says George Koob, MD.
Acute withdrawal from all major drugs of abuse produces increases in reward thresholds, increases in anxiety-like responses, and increases in CRF levels in the brain. CRF antagonists block excessive drug intake produced by dependence. "This brain stress response system as hypothesized has a critical role in driving the compulsivity associated with the loss of control over drug seeking behavior and may be a potential site for overlap with the emotional component of chronic pain. These same neurochemical circuits may be a key component of the normal neurocircuity of emotional processing that is vulnerable to disruption in other psychopathology associated with reward function," Koob concludes.
Nature and Nurture of Pain
Pain is associated with much interindividual variability, including the propensity to develop chronically painful pathologies after injury or infection. Genetic-linkage mapping efforts in mice and targeted genetic association studies in humans are beginning to identify the genes underlying much of the variability noted in these traits.
"In our laboratory, we have recently uncovered a number of genes associated with thermal and inflammatory nociception," explains Jeffery Mogil, PhD. "These efforts may lead to new clinical treatments for pain or facilitate the patient-centered, individualized treatment of pain using current pharmaceuticals. In addition, we are now paying greater attention to the identification of environmental factors that affect pain behavior in mice. We have recently observed modulation of pain in mice by purely social factors. These data can be interpreted as providing evidence for the existence of empathy for pain in this subprimate species."
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