The Impossibility of Being a Pain-Care Expert

In 1970, when Alvin Toffler popularized the phrase “information overload” in his book Future Shock, he was portending an explosion of medical and scientific information that lie ahead — and this was before the Internet. Indeed, the pain management field today is overwhelmed with information, as well as education, research, and news coming from many directions — making it virtually impossible to keep current, let alone become expert in the field. This may explain, at least in part, why millions of people are still being undertreated or mistreated for their pain conditions.

Writing in the December 2010 edition of the British Medical Journal, researchers from the UK note that there are now more than 25,000 journals in science, medicine, and technology, and their number is increasing each year by 3.5% [Fraser and Dunstan 2010]. Specifically in the pain-care field, the number of journals publishing some pain-related articles increased nearly 250% from 1977 (363 journals) to 2007 (972 journals), according to an analysis in the journal Pain Medicine [Robert et al. 2010].

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Cancer Survivors Suffer Burden of Chronic Pain

In a study published online ahead of print in the journal Cancer, researchers at the University of Michigan, Ann Arbor, reported that 43% of cancer survivors had experienced pain since their diagnosis and 20% had current chronic pain related to their conditions [Green et al. 2010]. Furthermore, the pain was worse for black cancer survivors and also for women, who experienced significantly more pain, more pain flare-ups, higher disability related to pain, and more depression.

Study participants consisted of 199 cancer survivors — breast, colorectal, lung, prostate cancer, or multiple myeloma — who were recruited through the Michigan State Cancer Registry. They ranged in age from 57 to 79 years, 31% were black, and 49% were female. At the time of the study, almost all of them were cancer free or in remission (95% of women, 96% of men).

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Analysis Shows NSAIDs Raise Cardiovascular Risks

A new analytical review of research continues the debate about the relative safety of nonsteroidal anti-inflammatory drugs (NSAIDs) commonly used to treat musculoskeletal pain. The conclusion is that most NSAIDs increase risks of cardiovascular events — such as heart attack or stroke — in patients who take them regularly, which should be of concern to all practitioners and their patients.

To examine relative cardiovascular risks of NSAIDs, scientists from Bern University in Switzerland analyzed data from 31 randomized, controlled clinical trials involving patients taking either placebo or one of the following NSAIDs for noncancer pain: naproxen, ibuprofen, diclofenac, or the selective COX-2 inhibitor celecoxib (Celebrex®). They also included trials of the selective COX-2 inhibitors etoricoxib (Arcoxia®), rofecoxib (Vioxx®), and lumiracoxib (Prexige®) — none of which are currently marketed in the U.S. or most other countries. Altogether, the trials enrolled 116,429 patients with more than 115,000 patient years of follow-up. The primary outcome examined was myocardial infarction and, secondarily, stroke, death from cardiovascular disease, and death from any cause [Trelle et al. 2011].

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Data Mining Fallacies in Pain Research Revisited

Why should you care about “data mining” in pain research studies? Simply because this may be a wave of the future and it could produce a flood of misleading “pseudoscience” that might be more of a hindrance than a help in furthering better care for patients with pain.

Writing in a recent edition of the Journal of the American Medical Association (JAMA), researchers from the University of South Florida, Gainesville, remark that legislation in the United States incorporated comparative-effectiveness research (CER) as a fundamental and vital scientific approach for helping to improve health care [Djulbegovic and Djulbegovic 2011]. There is a particular interest in discovering which treatments work best in “real world settings,” and this appears to encourage observational studies that use “data mining” techniques incorporating electronic health records, the authors believe.

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The Trouble with Opioid Treatment Agreements

As the prescribing of opioid analgesics for pain has increased, so have fears about opioid misuse, abuse, and diversion. One measure often presumed to help stem such problems is the Opioid Treatment Agreement. However, a recent report suggests that these documents can be used indiscriminately and seriously harm rather than enhance practitioner-patient relationships.

In April 2010, the Center for Practical Bioethics convened a panel of pain-management professionals to consider the usefulness and the ethical propriety of what they called “Pain Contracts”; more commonly and appropriately known as Pain Treatment (or, Opioid Treatment) Agreements. The meeting focused on professional, patient, and policy issues regarding healthcare providers’ use of these documents when prescribing opioids and/or other medications for pain.

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Study Finds Low Risk of Rx-Opioid-Use Problems

A large study found that the frequency and type of aberrant behaviors associated with strong opioids prescribed for chronic pain were minimal and generally of minor consequence. While this is good news there are some limitations and biases of the study that should be taken into account.

Writing in the January 2011 edition of the Journal of Pain and Symptom Management researchers retrospectively examined accumulated data from 5 clinical trials of patients taking daily opioids for chronic noncancer pain (≥60 mg/day oral morphine equivalent) and also prescribed immediate-release (IR) fentanyl buccal tablets (FBT) for breakthrough pain [Passik et al. 2011]. The studies, which were primarily to assess FBT safety and efficacy, incorporated up to 18 months of case-report data coded for abuse, overdose, and/or various aberrant behaviors. A total of 1,160 patients were evaluated; 57% women, 93% white, 94% aged ≤65 years. Aberrant behaviors were categorized as those involving FBT (such as, overuse, lost or stolen study drug, and others) and those not involving FBT (eg, patients seeking prescriptions from other sources, not returning for follow-up, etc.).

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Fibromyalgia Linked to Obesity — A Myth?

For the second time in less than a year, research has been published promoting a link between obesity and disabling symptoms of fibromyalgia syndrome (FMS) in women. The mass media widely reported on this without criticism. However, the research needs to be carefully interpreted and understood to avoid a derogatory myth that FMS is primarily a disease of middle-aged, white, fat women.

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FDA Puts the Brakes on Acetaminophen

On January 13, 2011, the U.S. FDA announced that it is requiring manufacturers of prescription pain relievers containing acetaminophen to limit the amount of this ingredient to no more than 325 mg (milligrams) in each tablet, capsule, or other dosage unit. This action will effectively eliminate more than half of such analgesics from the marketplace, although the FDA does not expect that this will be a hindrance for prescribers or persons with pain.

“FDA is taking this action to make prescription combination pain medications containing acetaminophen safer for patients to use,” said Sandra Kweder, MD, in a news release. She is deputy director of the Office of New Drugs in FDA’s Center for Drug Evaluation and Research (CDER). “Overdose from prescription combination products containing acetaminophen account for nearly half of all cases of acetaminophen-related liver failure in the United States; many of which result in liver transplant or death,” she added. "The risk of liver injury primarily occurs when patients take multiple products containing acetaminophen at one time and exceed the current maximum dose of 4,000 milligrams within a 24-hour period.” Drinking alcohol while taking APAP-containing products also increases the risk for liver injury.

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Study Finds Placebo Works Great for IBS! Why?

Understanding Evidence-Based Pain Management (EBPM)

In a novel experiment, patients given a placebo, and told it was merely a placebo, showed remarkable improvement in their IBS (irritable bowel syndrome) symptoms. However, more than anything, this study demonstrates the power of positive suggestion, and the researchers overlooked another factor that may affect pain research outcomes and clinical interactions — the Hawthorne effect.

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Chronic Back Pain Affects Memory, Concentration

Almost all persons (80%) experience lower back (lumbosacral) pain at some time in their lives, and consequences for the 10% to 20% in whom this condition becomes chronic can extend beyond the pain itself. Recent research observes that people living with persistent spinal pain experience difficulties with mental concentration and remembering information.

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Practitioners Ignore Osteoarthritis Guidelines

A new report in the January 2011 issue of the journal Arthritis Care & Research observes that clinicians who care for patients with osteoarthritis (OA) often do not follow standard care guidelines based on current medical evidence. For example, practitioners are prescribing medications for pain and inflammation, or opting for surgical interventions, rather than recommending weight loss plans or exercise programs to patients with OA.

OA disability is quickly becoming a major public health concern, with experts suggesting that by 2020 the number of people with OA will have doubled due to growing obesity prevalence and aging of the “baby boomer” generation. David Hunter, MBBS, PhD, from the University of Sydney in Australia and New England Baptist Hospital in Boston, Mass., and colleagues reviewed how standard clinical practice diverges from evidence-based recommendations in the management of OA [Hunter et al. 2011].

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Is There a Role for Topical Opioids in Pain Care?

Topical medications have been used for ages and are delivered via a variety of dosage formulations including creams, ointments, gels, lotions, solutions, pastes, and sprays. Agents applied topically specifically for analgesia have traditionally included various NSAIDs, capsaicin, local anesthetics (eg, lidocaine), rubefacients or counterirritants (eg, menthol, camphor, others), and herbal products (eg, arnica, comfrey, and others). For unknown reasons, the topical application of opioids has been largely overlooked; yet, such formulations might be a safe and effective alternative for the better care of many acute and chronic pain conditions.

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Why Practitioners Dislike Chronic Pain Patients

While many studies have looked at the treatment of chronic pain from patients’ perspectives, recent research reported in the journal Pain Medicine suggests that treating these patients can be a pain for healthcare practitioners. Accordingly, improving the delivery of effective pain management should consider the needs and concerns of practitioners, especially primary care providers.

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Top 10 “Hit Parade” Postings for 2010

The 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.

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