TREATING PAIN

1. TREATING PAIN A MAGIC PEN? www.euromedical.co.uk/ Living/paingonepen.html Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 1

2. Pain enters here… Do you think that how we conceptualize pain --PATHWAY vs DYNAMIC DISTRIBUTED SYSTEMS-- influences how we treat pain and the success of those treatments? PAIN PATHWAY Pain Seminar, Lecture #5, PAIN TREATMENTS, p.2

3. PAIN ? Let’s see… Pain Seminar, Lecture #45, PAIN TREATMENTS, p. 3

4. HOW CAN WE ALLEVIATE PAIN? DRUGSSOMATICSITUATIONAL Primary analgesicsSimpleClinician NSAIDS heat/cold education acetaminophen exercise attitude opioids massage clinic arrangement vibration Other analgesicsrelaxationSelf -2 agonistseducation  adrenergic antag. Minimally invas.meditation antidepressants physical therapy diet, herbals anticonvulsants traction art, music, poetry antiarrhythmics manipulation theatre, virtual reality Ca++ channel blockers ultrasound sports, humor cannabinoids TENS gardening corticosteroids acupuncture aroma therapy Cox 2 inhibitors local anesthetics religion GABAB agonists pets serotonin agonists Invasive surgeryInteractive Adjuvantsradiation treatmenthypnosis, biofeedback antihistamines dorsal column stim. support groups laxatives nerve blocks advocacy groups neuroleptics neurectomy networking phenothiazines local ganglion blks self-help groups sympathectomy Routesrhizotomy Structured settings topical, oral DREZ lesions group therapy buccal, sublingual punctate myelotomy family counseling intranasal limited myelotomy job counseling vaginal, rectal commissural myel. cog / behav. therapy transdermal cordotomy psychotherapy i.v., i.m., i.p. brain stimulation multidisipl. clinic epidural, intrathecal brain lesions hospice Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 4

5. DRUGS • All drugs have “side effects” (i.e., multiple actions) • When should drugs be taken? • before… • Regular intervals or on demand? PCAs • (3) How should dose/drugs be adjusted when pain changes? • (4) What are barriers to the use of opiates? (for patients, caregivers, family, pharmaceutical industry, healthcare workers) • (a) fear of side effects (respiratory-children; death-cancer); • (b) fear of addiction; • (c) fear of prosecution Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 5

6. DRUGS (1) The World Health Organization Ladder (2) Changing drugs: Galer BS, Coyle N, Pasternak GW, Portenoy RK. Individual variability in the response to different opioids: report of five cases. Pain 1992;49:87-91. Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 6

7. DRUGS Barrier issues CONSENSUS - April 2001 American Academy of Pain Medicine American Pain Society American Society of Addiction Medicine Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 7

8. DRUGS OXYCONTIN (“Hillbilly Heroin”) New Painkiller Sparks Debate; Manufacturer Mounts Defense Hurwitz Case Goes To Jury The federal criminal prosecution of northern Virginia physician Dr. William Hurwitz went to the jury in early December, 2004. As reported by the Richmond Times-Dispatch on Dec. 9, 2004 , "A federal jury was asked yesterday to decide between two widely disparate descriptions of a prominent Northern Virginia doctor accused of fueling a black market in potent prescription drugs. Did Dr. William E. Hurwitz, as prosecutors alleged in closing arguments, look the other way when he learned some of his patients were selling and abusing the medications he prescribed for them? Or, as defense lawyers contended, is Hurwitz a caring, courageous physician who was duped by a small number of patients enrolled in a practice that helped hundreds of other people deal with their chronic pain? After a six-week trial and hearing from more than 75 witnesses, the jury is to begin deliberations this morning on a 62-count indictment against Hurwitz. If convicted of the most serious charges, the McLean doctor could be sentenced to life in prison." The Times-Dispatch noted that "The charges against Hurwitz stem from a two-year federal investigation into doctors, pharmacists and patients who allegedly marketed in potent prescription drugs, primarily OxyContin, a widely abused and highly addictive painkiller." In a story published Dec. 7, 2004, the Times-Dispatch reported that "William E. Hurwitz, on trial in U.S. District Court, acknowledged that he prescribed massive amounts of opiates for some of his patients but said he always had a medical reason for doing so. Hurwitz testified that he knew some of his patients were drug abusers who were illegally taking cocaine or abusing his prescriptions. But he said he felt compelled to continue treating them with drugs such as OxyContin - or at the very least to refrain from abruptly canceling their prescriptions - because of the withdrawal they would suffer after taking such high doses. 'Abrupt termination of these medicines is tantamount to torture,' Hurwitz testified. According to the Times-Dispatch, "Some of Hurwitz's patients were using the prescriptions they received to deal drugs; many have struck plea bargains and testified against him at trial. Prosecutors have played audiotapes to the jury that they say are proof that Hurwitz knew these patients were dealing drugs and that he turned a blind eye. Hurwitz testified that he did not know any of his patients were dealing drugs. Expert witnesses have testified for both prosecutors and the defense, differing on whether Hurwitz's prescriptions were medically justified. Among the doctors to testify on Hurwitz's behalf was Russell Portenoy, chairman of the pain management department at Beth Israel Medical Center in New York and considered one of the world's leading experts on pain management. In addition, as the Times-Dispatch reported in a Dec. 8, 2004 story, "They also charge that two patients who came to him seeking legitimate pain treatment were prescribed such massive amounts of drugs that he is to blame for their overdose deaths. Hurwitz's lawyers contend those patients died of other causes. They acknowledge that at times Hurwitz prescribed massive amounts of opiates to the patients enrolled in his clinic, but say it was part of an emerging medical trend that encourages high-dosage opiate treatment for pain management." The case has repercussions in the policy world as well. The Washington Post reported on Oct. 21, 2004 that "Advocates for aggressive pain management said the DEA's decision appears to have been triggered when defense lawyers tried to introduce the guidelines in the upcoming drug-trafficking trial of William Hurwitz, a McLean physician. In late September, Hurwitz's defense team sought to introduce them as evidence. Several weeks later, the DEA took the document off its Web site and said it was not official policy. Twelve days after that, U.S. Attorney Paul J. McNulty, who is prosecuting Hurwitz, filed a motion in the case asking that the guidelines be excluded as evidence, again saying that they do 'not have the force and effect of law.' 'It seems pretty clear that they felt they had to try to get rid of the guidelines because they supported so many parts of our case,' said Hurwitz's defense attorney, Patrick Hallinan. 'If the Justice Department followed the guidelines, there would be no reason to arrest and charge Dr. Hurwitz.'" Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 8

9. DRUGS OXYCONTIN (continued) December 17, 2004 Pain Doctor William Hurwitz Found Guilty “If it wasn't so before, it is now essentially professional suicide to provide pain-management services to one's patients -- a fact that will needlessly cost the lives of many of society's most sick and vulnerable,” said Baylen Linnekin on DrugPolicy.org. Dr. Hurwitz, a prominent pain management caregiver, was charged with over-prescribing medications such as OxyContin to patients around the country, many of whom suffered from cancer, chronic back pain, arthritis, or diabetes. While pain medications can be abused in this way, many pain treatment specialists believe that the arrest of Dr. Hurwitz and others is unwarranted. Data shows that the under-treatment of pain is causing an epidemic of undue suffering and pain. As the nation’s largest health problem, an estimated 50-75 million suffer from pain each day, resulting in more lost days from work than heart disease and cancer combined. Under-treatment of pain largely stems from heavy-handed Drug Enforcement Administration (DEA) monitoring of prescriptions. Those considered to over-prescribe are arrested, leaving many physicians afraid to appropriately treat their patients with strong pain medications. The DEA has “an unprecedented amount of control over the behavior of physicians” says Siobhan Reynolds, Executive Director of the Pain Relief Network. As a result they “control a doctor’s ability to make a living.” There has been an 800% increase in physician prosecutions over the past three years. Recently, the DEA has aggressively focused on the pain killer OxyContin – an opioid analgesic that is among the safest and most effective treatments for pain. Doctors now fear arrest and are prescribing the medication less often and in smaller doses – what Reynolds calls “tapering the patient down”. Concerns about the number of people left under-treated or even untreated have led pain management groups to call for a moratorium on arrests and Congressional investigations into the validity of the DEA’s crackdown. In a blow to the DEA’s campaign to control pain management, a Food and Drug Administration (FDA) panel [last year] voted down a DEA proposal to further restrict patient access to OxyContin. Content courtesy of the Drug Policy Alliance (www.drugpolicy.org). Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 9

10. Public service ad launched in 2005: http://www.csdp.org/ Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 10

11. Nathan PW. Success in surgery may not require cutting the tracts. Pain 19985;22:317-319. Two patients are described in whom surgical intervention was terminated prior to lesioning of any pathways relevant to pain and yet the surgery relieved the chronic severe pain. SOMATIC • The more invasive, the more helpful? • Placebo (chptr 9 in Wall, 1999) • (3) Barriers? • (a) fear of permanency (invasive)? • (b) scepticism (simple/minimal)? Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 11

12. SOMATIC Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 12

13. SOMATIC Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 13

14. SOMATIC Monday, December 20, 2004 [National Center for Complementary and Alternative Medicine301-496-7790Acupuncture Relieves Pain and Improves Function in Knee Osteoarthritis Acupuncture provides pain relief and improves function for people with osteoarthritis of the knee and serves as an effective complement to standard care. This landmark study was funded by the National Center for Complementary and Alternative Medicine (NCCAM) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), both components of the National Institutes of Health. The findings of the study the longest and largest randomized, controlled phase III clinical trial of acupuncture ever conducted were published in the December 21, 2004, issue of the Annals of Internal Medicine *. The multi-site study team, including rheumatologists and licensed acupuncturists, enrolled 570 patients, aged 50 or older with osteoarthritis of the knee. Participants had significant pain in their knee the month before joining the study, but had never experienced acupuncture, had not had knee surgery in the previous 6 months, and had not used steroid or similar injections. Participants were randomly assigned to receive one of three treatments: acupuncture, sham acupuncture, or participation in a control group that followed the Arthritis Foundation's self-help course for managing their condition. Patients continued to receive standard medical care from their primary physicians, including anti-inflammatory medications, such as COX-2 selective inhibitors, non-steroidal anti-inflammatory drugs, and opioid pain relievers. "For the first time, a clinical trial with sufficient rigor, size, and duration has shown that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee," said Stephen E. Straus, M.D., NCCAM Director. "These results also indicate that acupuncture can serve as an effective addition to a standard regimen of care and improve quality of life for knee osteoarthritis sufferers. NCCAM has been building a portfolio of basic and clinical research that is now revealing the power and promise of applying stringent research methods to ancient practices like acupuncture." "More than 20 million Americans have osteoarthritis. This disease is one of the most frequent causes of physical disability among adults," said Stephen I. Katz, M.D., Ph.D., NIAMS Director. "Thus, seeking an effective means of decreasing osteoarthritis pain and increasing function is of critical importance." During the course of the study, led by Brian M. Berman, M.D., Director of the Center for Integrative Medicine and Professor of Family Medicine at the Univ. Maryland School of Medicine, Baltimore, MD, 190 patients received true acupuncture and 191 patients received sham acupuncture for 24 treatment sessions over 26 weeks. Sham acupuncture is a procedure designed to prevent patients from being able to detect if needles are actually inserted at treatment points. In both the sham and true acupuncture procedures, a screen prevented patients from seeing the knee treatment area and learning which treatment they received. In the education control group, 189 participants attended six, 2-hour group sessions over 12 weeks based on the Arthritis Foundation's Arthritis Self-Help Course a proven, effective model. On joining the study, patients' pain and knee function were assessed using standard arthritis research survey instruments and measurement tools, such as the Western Ontario McMasters Osteoarthritis Index (WOMAC). Patients' progress was assessed at 4, 8, 14, and 26 weeks. By week 8, participants receiving acupuncture were showing a significant increase in function and by week 14 a significant decrease in pain, compared with the sham and control groups. These results, shown by declining scores on the WOMAC index, held through week 26. Overall, those who received acupuncture had a 40 percent decrease in pain and a nearly 40 percent improvement in function compared to baseline assessments. "This trial, which builds upon our previous NCCAM-funded research, establishes that acupuncture is an effective complement to conventional arthritis treatment and can be successfully employed as part of a multidisciplinary approach to treating the symptoms of osteoarthritis," said Dr. Berman. Acupuncture the practice of inserting thin needles into specific body points to improve health and well-being originated in China more than 2,000 years ago. In 2002, acupuncture was used by an estimated 2.1 million U.S. adults, according to the Centers for Disease Control and Prevention's 2002 National Health Interview Survey. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. In recent years, scientific inquiry has begun to shed more light on acupuncture's possible mechanisms and potential benefits, especially in treating painful conditions such as arthritis. Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 14

15. SITUATIONAL • Deliberate use of placebo • “locus of control” • (3) Context important • (a) clinician • (b) patient/individual Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 15

16. SITUATIONAL • Deliberate use of placebo • “locus of control” • (3) Context important • (a) clinician • (b) patient/individual Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 16

17. SITUATIONAL • Deliberate use of placebo • “locus of control” • (3) Context important • (a) clinician • (b) patient/individual Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 17

18. SITUATIONAL • Deliberate use of placebo • “locus of control” • (3) Context important • (a) clinician • (b) patient/individual “You can turn a pelvic pain patient into an acute abdomen by the first question you ask her when she enters the clinic,” said John Slocum, MD, Chair ObGYN, Univ of Colorado, Boulder. Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 18

19. SITUATIONAL • Deliberate use of placebo • “locus of control” • (3) Context important • (a) clinician • (b) patient/individual Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 19

20. SO: How shall we make use of this table? DRUGSSOMATICSITUATIONAL Primary analgesicsSimpleClinician NSAIDS heat/cold education acetaminophen exercise attitude opioids massage clinic arrangement vibration Other analgesicsrelaxationSelf -2 agonistseducation  adrenergic antag. Minimally invas.meditation antidepressants physical therapy diet anticonvulsants traction art, music, poetry antiarrhythmics manipulation theatre, virtual reality Ca++ channel blockers ultrasound sports, humor cannabinoids TENS gardening corticosteroids acupuncture aroma therapy Cox 2 inhibitors local anesthetics religion GABAB agonists pets serotonin agonists Invasive surgeryInteractive Adjuvantsradiation treatmenthypnosis, biofeedback antihistamines dorsal column stim. support groups laxatives nerve blocks advocacy groups neuroleptics neurectomy networking phenothiazines local ganglion blks self-help groups sympathectomy Routesrhizotomy Structured settings topical, oral DREZ lesions group therapy buccal, sublingual punctate myelotomy family counseling intranasal limited myelotomy job counseling vaginal, rectal commissural myel. cog / behav. therapy transdermal cordotomy psychotherapy i.v., i.m., i.p. brain stimulation multidisipl. clinic epidural, intrathecal brain lesions hospice Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 20

21. Pain enters here… Neural Mechanisms of Pain PAIN PATHWAY Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 21

22. ???--Strategy #1: If one treatment doesn’t work, try another. DRUGSSOMATICSITUATIONAL Primary analgesicsSimpleClinician NSAIDS heat/cold education acetaminophen exercise attitude opioids massage clinic arrangement vibration Other analgesicsrelaxationSelf -2 agonistseducation  adrenergic antag. Minimally invas.meditation antidepressants physical therapy diet anticonvulsants traction art, music, poetry antiarrhythmics manipulation theatre, virtual reality Ca++ channel blockers ultrasound sports, humor cannabinoids TENS gardening corticosteroids acupuncture aroma therapy Cox 2 inhibitors local anesthetics religion GABAB agonists pets serotonin agonists Invasive surgeryInteractive Adjuvantsradiation treatmenthypnosis, biofeedback antihistamines dorsal column stim. support groups laxatives nerve blocks advocacy groups neuroleptics neurectomy networking phenothiazines local ganglion blks self-help groups sympathectomy Routesrhizotomy Structured settings topical, oral DREZ lesions group therapy buccal, sublingual punctate myelotomy family counseling intranasal limited myelotomy job counseling vaginal, rectal commissural myel. cog / behav. therapy transdermal cordotomy psychotherapy i.v., i.m., i.p. brain stimulation multidisipl. clinic epidural, intrathecal brain lesions hospice Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 22

23. ???-OR, possibly: Strategy #2: “All you need is a needle and a bunch of psychologists.” – Tallahassee doctor, 2003. DRUGSSOMATICSITUATIONAL Primary analgesicsSimpleClinician NSAIDS heat/cold education acetaminophen exercise attitude opioids massage clinic arrangement vibration Other analgesicsrelaxationSelf -2 agonistseducation  adrenergic antag. Minimally invas.meditation antidepressants physical therapy diet anticonvulsants traction art, music, poetry antiarrhythmics manipulation theatre, virtual reality Ca++ channel blockers ultrasound sports, humor cannabinoids TENS gardening corticosteroids acupuncture aroma therapy Cox 2 inhibitors local anesthetics religion GABAB agonists pets serotonin agonists Invasive surgeryInteractive Adjuvantsradiation treatmenthypnosis, biofeedback antihistamines dorsal column stim. support groups laxatives nerve blocks advocacy groups neuroleptics neurectomy networking phenothiazines local ganglion blks self-help groups sympathectomy Routesrhizotomy Structured settings topical, oral DREZ lesions group therapy buccal, sublingual punctate myelotomy family counseling intranasal limited myelotomy job counseling vaginal, rectal commissural myel. cog / behav. therapy transdermal cordotomy psychotherapy i.v., i.m., i.p. brain stimulation multidisipl. clinic epidural, intrathecal brain lesions hospice Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 23

24. PAIN ? Neural Mechanisms of Pain Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 24

25. ???--Strategy #3: DELIBERATE COMBINATIONS (A Chinese Menu!) (partnership between patient and clinician) DRUGSSOMATICSITUATIONAL Primary analgesicsSimpleClinician NSAIDS heat/cold education acetaminophen exercise attitude opioids massage clinic arrangement vibration Other analgesicsrelaxationSelf -2 agonistseducation  adrenergic antag. Minimally invas.meditation antidepressants physical therapy diet anticonvulsants traction art, music, poetry antiarrhythmics manipulation theatre, virtual reality Ca++ channel blockers ultrasound sports, humor cannabinoids TENS gardening corticosteroids acupuncture aroma therapy Cox 2 inhibitors local anesthetics religion GABAB agonists pets serotonin agonists Invasive surgeryInteractive Adjuvantsradiation treatmenthypnosis, biofeedback antihistamines dorsal column stim. support groups laxatives nerve blocks advocacy groups neuroleptics neurectomy networking phenothiazines local ganglion blks self-help groups sympathectomy Routesrhizotomy Structured settings topical, oral DREZ lesions group therapy buccal, sublingual punctate myelotomy family counseling intranasal limited myelotomy job counseling vaginal, rectal commissural myel. cog / behav. therapy transdermal cordotomy psychotherapy i.v., i.m., i.p. brain stimulation multidisipl. clinic epidural, intrathecal brain lesions hospice Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 25

26. AN AFTERWORD…………………… Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 26