Saturday, January 1, 2011

Top 10 “Hit Parade” Postings for 2010

Top 10 in 2010The 138 News/Research UPDATES that we posted during 2010 were viewed 93,000 times by 49,000 visitors to the weblog. Which were the most popular? Here is a recap of the Top 10 in our “Hit Parade” of frequently-viewed pages that visitors found of greatest interest. [Click on the date to read the full UPDATE item, and be sure to also read the comments.]

1. Severe Chronic Pain is a Killer – Study Finds
April 8, 2010 — At the top of the “Hit Parade” (and the most commented-on posting this past year), we noted in this blogpost that previous research demonstrated a clearly negative influence of chronic pain on health. Now, a new study portrays a profound link between severe chronic pain and greater risk of death. Researchers followed a large group of persons during a 10-year period and found a significant association between pain conditions and death from any cause. Particularly troublesome was severe chronic pain — survival among persons with this condition was significantly worse than among those reporting mild or no chronic pain. Even after adjusting for various confounding sociodemographic factors and effects of long-term illness, patients with severe chronic pain had a 49% greater risk of death compared with all-cause mortality and a 68% greater risk of death compared with all deaths due to cardiovascular-disease.

2. Vitamin D for Pain: Update of Research Evidence
January 17, 2010 — In summer 2008 Pain Treatment Topics published ground-breaking research reviews focusing on the potential benefits of vitamin D for patients with chronic pain conditions, particularly musculoskeletal and back pain [see reports here]. This blogpost summarizes relevant research on the subject published since that time. Overall, the conclusion still appears to be that vitamin D inadequacies are prevalent in persons with various chronic pain syndromes and, with sufficient vitamin D supplementation, the pain-relieving effects are sometimes quite dramatic. In those cases where pain is unrelieved or only partially resolved there seems to be no harm done, and most likely some healthful effects are achieved in other ways by more adequate vitamin D levels. New research reported in this blogpost focuses on back pain, chronic pain in general, rheumatoid arthritis, fibromyalgia, PHN/shingles, cancer pain, osteomalacic myopathy, and prevalence studies suggesting that in the United States up to 75% of patients have inadequate levels of vitamin D. While practitioners are generally becoming more alert to the vitamin D needs of their patients for good health, there is still an under-appreciation of the potential linkages between inadequate serum concentrations of 25(OH)D and certain chronic pain syndromes. [Note: for an important report and commentary on new vitamin D recommendations from the U.S. Institute of Medicine, published in November 2010, click here.]

3. Pitfalls of Urine Drug Monitoring in Pain Care
January 21, 2010 — Medical practitioners today often focus on objective assessments via diagnostic procedures for guiding patient care. However, relying on urine drug screening and testing for managing opioid-analgesic therapy in patients with pain is fraught with some important but unrecognized problems and challenges. There have been many cases of patients being mistreated by healthcare providers less skilled in the interpretation of urine screening and testing results. Guidelines on opioid prescribing recommend urine drug screens to confirm adherence to prescribed therapy; however, the authors also concede that “…evidence on accuracy of urine drug screening to identify aberrant drug-related behaviors or diversion is lacking, and no evidence exists that demonstrates that screening improves clinical outcomes….” At the least, drug assay results must be placed within the context of the total clinical picture and providers need to ask themselves in advance what they will do with results, which may or may not depict an accurate portrayal of the patient’s medication use or other drug-use behavior. Healthcare providers need to be cautious about making decisions affecting patients’ lives based solely on laboratory reports; that is, applying test-guided treatment rather than being patient-centered.

4. Pain Management Fails Due to Rx-Drug Abuse Fears
January 8, 2010 — According to recent reviews, millions of Americans with significant acute or chronic pain are being undertreated as physicians fail to provide comprehensive pain treatment. The failure is due to inadequate training of physicians, personal biases and, increasingly, fears of prescription analgesic drug abuse. Kathryn Hahn, PharmD, writes, “We’re in the middle of a storm here and have to figure out some way to navigate through it. We have more sophisticated pain management techniques available now than ever before, but many doctors are not fully informed about all the options available, and also turn patients away because they’re very concerned about the problems with prescription drug abuse. Because of this, many people suffer needlessly with pain that could be treated, and almost 80% of visits to community pharmacies involve pain issues.” Adequate pain treatment has always been a concern, in part because it is neglected during medical training. Long-term solutions will take education and responsibility by all parties involved, Hahn believes, including consumers, physicians, nurses, and pharmacists.

5. Chilling Concept: Chronic Pain as a Brain Disease
June 10, 2010 — This was Part 5 of our ongoing series on “Pain and the Great Brain Robbery!” We described how compelling research evidence suggests that no matter what brings on a chronic noncancer pain condition — acute injury, precipitating disease, or unknown factors — it ultimately manifests as a distinct brain disease, which impacts all aspects of the individual’s life and may become irreversible. Relatively new, noninvasive neuroimaging and electrophysiological technologies have facilitated unprecedented examinations of how pain affects signal processing, metabolic activity, and structural changes in the living human brain. Taken as a whole, the research studies have uncovered 3 trends establishing chronic pain as a brain disease: chemical changes in key brain structures; functional changes in patterns of brain activity; structural changes in brain anatomy that create dysfunction. Appropriate clinical response to these alarming changes could require prompt diagnosis followed by aggressive, multimodal pain management early in the course of disease progression to forestall or ameliorate potentially serious and incapacitating brain damage.

6. Followup: Safety of Long-Term Opioid Therapy
February 13, 2010 — The prescribing of opioid analgesics for chronic noncancer pain is still shrouded by some controversy; particularly, when patients are continued on these medications for many years. However, evidence is growing in support of long-term opioid therapy for providing less pain, better function, and improved quality of life in select patients — benefits clearly seem to outweigh risks. In a followup study of 100 patients prescribed opioids for 10 to 35 years, far from becoming debilitated by ongoing opioid therapy, most patients were able to read newspapers and other literature (97%), attend social events (89%), dress themselves (82%), walk unassisted (85%), and even drive a car (74%). Almost half of patients (45%) had been on a stable opioid dose without significant escalation for at least 3 years (range 3 months – 31 years). Patients were taking opioids for spine disease, arthritis, peripheral neuropathy, and headache. No neurologic complications such as hyperalgesia, dementia, tremor, or seizures were noted; nor were hepatic, renal, or gastrointestinal complications, except for minor constipation. The conclusion is that when patients appear to be doing well on opioid therapy for chronic noncancer pain, there is no obvious reason to discourage opioid use no matter how long they have been on such therapy.

7. NSAID Dangers May Limit Pain-Relief Options
March 14, 2010 — Concerns about risks of opioid and acetaminophen analgesics have overshadowed inherent dangers of nonsteroidal anti-inflammatory drugs (NSAIDs). Yet, as a class, ubiquitous NSAIDs may be the most hazardous. An estimated 60 million Americans regularly use NSAIDs, resulting in clinically significant upper GI complications in up to 2% of users (1.2 million cases). GI hemorrhages due to NSAID use result in up to 120,000 hospital admissions annually, and a conservative estimate is that 20,000 or more persons die from NSAID-related GI adverse events each year in the U.S. alone. Based on available data, NSAIDs account for more fatalities each year than from opioid analgesics and acetaminophen-containing products combined. Overall, there are many unresolved questions about the safety of NSAIDs for treating chronic pain conditions, and adverse GI or cardiovascular events associated with NSAIDs often result in benefit-to-risk ratios favoring acetaminophen or opioid analgesics. [For a look at controversial new research suggesting, wrongly we believe, that NSAIDs are safer than opioids, click here.]

8. Coping Skills Essential for Managing Chronic Pain
May 20, 2010 — Speaking at the American Pain Society’s annual scientific meeting in early May 2010, Francis J. Keefe, PhD, from the Pain and Palliative Care Initiative at Duke University Medical Center, suggested that how individuals cope with and appraise disease-related pain, such as from arthritis or cancer, is related not only to their experience with pain but also to their neurobiological and psychological functioning. Of most concern is catastrophizing, or a patient’s tendency to focus on and exaggerate the threat value of painful stimuli and negatively evaluate their ability to deal with pain. From a neurological perspective, intense pain may overwhelm the patient’s ability to call upon cognitive control (or thinking) centers in the cortex to assist in self-managing the pain experience. On the other hand, coping skills training may help patients to rethink the pain experience and gain more control through relaxation, hypnosis, mental distraction, yoga practice, and guided imagery. In summary, Keefe proposed that developing and refining interventions to enhance pain coping can lead to major advances, including improvements in the quality of life and reductions in the suffering of many individuals with disease-related pain.

9. Opioids Relieve Pain with Little Addiction Risk
February 3, 2010 — According to a comprehensive updated Cochrane Review, and contrary to misperceptions among many healthcare professionals, opioid analgesics effectively relieve chronic noncancer pain in most patients and with only a small (though not zero) risk of developing abuse or addiction. Across 7 studies, enrolling a total of 2,613 participants taking opioids for as long as 48 months, serious adverse events were rare and signs of opioid addiction were reported in only 0.27% of participants. However, it must be appreciated that a portion of patients may have inadequate pain relief or develop intolerable opioid side effects. These issues need further and unbiased examination; meanwhile, during everyday practice, iatrogenic (therapy induced) opioid abuse or addiction might be considered as merely a rather rare adverse effect in very select patients.

10. Why Do Patients Dislike Pain Care Providers?
October 2, 2010 — Focused interviews conducted by researchers at the University of Massachusetts, Boston, MA, found that patients report low levels of satisfaction with their pain care providers, the care they receive, and the outcomes. In general, patients felt disrespected and distrusted by their healthcare providers, suspected of drug-seeking, and having their self-reported symptoms dismissed as trivial and/or not warranting medical attention. Participants reported greater satisfaction when they felt the provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. The study authors concluded that implementing more patient-centered approaches and managing chronic pain as would be appropriate for dealing with any chronic disease might improve both patient and provider satisfaction. [For a look at the other side of this issue, see the recent blogpost “Why Practitioners Dislike Chronic Pain Patients” here.]