Unraveling the Complexities of Pain

Pain that lasts beyond the expected time after an injury or pain that seems to develop for no apparent reason continues to baffle scientists and pain specialists around the world. This type of pain labeled chronic has been the focus of neuroimaging studies for the last two decades. Neuroimaging has opened our eyes to the changes in the brain that accompany chronic pain. Changes that affect the anatomy, biochemistry, and neurochemistry of the nervous system.

What kinds of studies make up this category of neuroimaging? And what have they shown us? Positron Emission Tomography known as PET scans and Functional Magnetic Resonance Imaging (fMRI) head the list. But other methods include magnetoencephalography (MEG) and the more traditional electroencephalgraphy (EEG). These techniques have made it possible to study the brains of patients with chronic pain compared to individuals without pain. Measuring density of brain tissue, connections between brain structures, brain biochemistry, and location and type of neurotransmitters and their receptors has helped explain more about central pain processing. Central pain processing refers to how pain is processed in the central nervous system (brain and spinal cord).

The question this information brings then is this: is chronic pain a disease? Answering that question is important — both for the millions of people who suffer from chronic pain and because billions of dollars are spent on trying to solve the problem by eliminating (or at least reducing) pain for these folks. Right now, truly effective treatment methods just aren’t available. It seems like a process of trial and error to find what will work with each person — even though the brain scans show similar changes in the structure and function of the nervous system.

Some experts suggest that with visible and measurable changes in the brain, chronic pain fits the medical definition of disease. And that definition is disease is a disorder of structure or function in a human, animal, or plant; especially one that produces specific symptoms. But others call this decision to consider chronic pain a disease into question because it’s not always clear which came first: the pain or the brain changes?

In the case of an injury to the soft tissue or nerves, acute pain is expected. What isn’t clear is why this pain can become persistent (chronic) but only in some people. And what about people who develop chronic pain problems like fibromyalgia, irritable bowel syndrome, and interstitial cystitis (chronic bladder infection) without a traumatic event first? Can stress be considered the triggering trauma? The problem of explaining, describing, and/or categorizing chronic pain as a disease falls into the catch-22 phrase of which came first: the chicken or the egg? In other words, do the painful symptoms develop because of brain changes or do the brain changes occur because of the change in body structure and function?

Right now, we still have more questions than answers. But the current evidence from neuroimaging studies points to chronic pain as a disease state with functional, structural, and chemical brain changes. Chronic pain isn’t just a collection of symptoms that place it in the category of syndrome. With observable changes in the brain, it makes sense to think that the disordered brain function could be considered a disease.

So, where does that leave chronic pain sufferers? Does this change in how we view chronic pain (as a disease state) change anything? Not yet, but maybe it will change the way we treat chronic pain patients and hopefully so in the very near future. Armed with this new information, scientists are changing their focus of study. Now, they are looking at groups of patients with the same problem (e.g., fibromyalgia, irritable bowel syndrome, depression, arthritis) and examining what’s going on in the brain associated with these conditions.

They are finding that common disturbances are present in the brains of people who have the same disorder. For example, patients with knee osteoarthritis have increased brain activity in three areas: the amygdala (survival center), thalamus (relays sensation and motor signals to the main part of the brain), and cingulate cortex (emotion processing and formation). It may be possible to find ways to shift brain activity or change the pain experience through direct brain stimulation. If there are people with a particular pattern of biochemistry more likely to anticipate pain or amplify pain, there may be ways to alter the body chemistry to change their response to pain.

The bottom line is that chronic pain is linked with structural changes and altered neurochemistry in the brain. This information alone gives a focus and direction for research that may ultimately result in changes not only in the way we view chronic pain (disease rather than syndrome), but also in finding more effective ways to treat it centrally (at the brain level). The results of these neuroimaging studies also open the door for changes in treatment for other chronic nervous system-related problems that are currently considered irreversible such as Parkinson disease, post-stroke, and drug addiction (narcotics).

Accurate Diagnosis First Step in Treating Somatoform Disorders

All patients with chronic physical pain are not alike and shouldn’t be treated the same. That’s the basis of this article on somatoform disorders. Somatoform disorders refer to aches and pains that are amplified (blown out of proportion) because of underlying psychologic or emotional distress. Vague complaints of muscle or joint pain, fatigue, stomach problems, numbness and tingling, headaches, and so on are typical physical complaints associated with somatoform disorders. But despite all medical tests and lab work ordered, the physician is unable to find anything wrong. Treatment is general, rather than specific to the problem.

Somatoform disorders include a number of different problems all placed in this one category. These include somatization disorder, conversion disorder, hypochondriasis, body dysmorphic disorder, and factitious disorder. The common feature of all these disorders is symptom amplification. The main symptom is usually, but not always, pain. The lack of any evidence that there’s anything physically wrong to explain these disorders has led some experts to suggest dropping somatoform disorders as a real diagnosis.

But that’s where the authors of this article differ. They suggest that there’s a definite need to look deeper and not only find ways to diagnose these problems but also to treat each one specifically. That’s a concept they refer to as diagnosis-specific and patient specific treatment. And after briefly describing each condition, they offer some treatment guidelines with the hope that someday we will have specific guidelines for each different disorder, rather than general management techniques.

Health care professionals, especially psychologists and psychiatrists, depend on a publication put out by the American Psychiatric Association called the Diagnostic and Statistical Manual or DSM as it is more commonly referred to. The DSM includes criteria for each somatoform disorder such as signs and symptoms and known causes or risk factors. In addition to a brief review of each disorder, the authors added an extensive table comparing each disorder and offering physicians some treatment guidelines for each one.

Here’s a brief summary of the main disorders. Somatization disorder includes vague reports of pain, gastrointestinal problems, sexual problems, and symptoms that suggest a neurologic problem but with no identifiable cause. The problems described by patients last for years and no medical condition can be found to explain them. Conversion disorder describes neurologic symptoms (e.g., numbness, paralysis, blindness, unable to speak) in response to mental, psychologic, and/or emotional stress. Usually, there is a conflict or stress that occurs just prior to the conversion taking place. In the past, conversion was referred to as hysteria. Women are affected more often than men (2:1 ratio).

Most people are familiar with the term hypochondriac — someone who is always sick, afraid of getting sick, and preoccupied with various physical symptoms or bodily functions. Hypochondriasis is a chronic problem that doesn’t go away with time. Men and women are affected equally. Many of these folks have additional disorders such as anxiety, depression, panic, obsessive-compulsive disorders, and high rates of substance abuse.

Body dysmorphic disorder refers to an imagined or exaggerated fault in a person’s physical appearance. Most often, this is displayed by individuals who are obsessively preoccupied with body size and/or shape. Men focus on height, penis size, and body hair while women obsess about their skin, hips, breasts, and legs. And the last disorder in the group: factitious disorder isn’t technically a somatoform disorder but should be considered as a possibility in the differential diagnosis. Factitious disorder describes a situation in which the person pretends to have signs and symptoms and assumes the role of a sick person to gain attention.

The authors encourage all physicians and health care professionals to have a good understanding of each of these conditions based on available information to date. Applying the following suggested treatment guidelines is based on an accurate differential diagnosis (recognizing one disorder from the other). The goals of treatment include reducing emergency department and doctor visits (thereby also reducing costs), improving physical symptoms even if psychologic distress remains unchanged, and/or improving function even if physical symptoms are not relieved.

The use of antidepressants should be restricted to those individuals who have a diagnosed depressive or mood disorder. Just having a somatoform disorder is not sufficient reason to prescribe these medications. Teaching patients how to evaluate their own symptoms (serious versus those that can wait until an appointment is made) is essential. Patients with body dysmorphic disorder should be discouraged from pursuing plastic surgery or skin treatments. There is evidence to show these treatments do not change how the patient views himself or herself and may even result in more dissatisfaction with the defect.

Referral for cognitive behavioral therapy has been shown helpful for somatization disorder, hypochondriasis, and body dysmorphic disorder.
Some disorders such as conversion are unconscious — in other words, the person is not faking or pretending the symptoms. Directly confronting them with the diagnosis and insisting there is no real physical problem doesn’t usually work. It may be better to try and deal with the underlying trigger while reassuring the patient that all will be well in time. Resolving conversion symptoms may take some time but is usually not a permanent health problem. People carrying out a factitious disorder can be directly confronted — gently and with the backup support of friends and family.

The authors suggest that frequent, perhaps regularly scheduled appointments between patient and physician may be helpful with somatoform disorders. Setting the physician or other health care provider up as an ally rather than seeking to confront and change the patient’s view of the situation is a good place to start. The health care provider will have to establish some boundaries to prevent too many visits, phone calls, and requests for various tests, procedures, and treatments. Physicians are advised to avoid ordering unnecessary tests and medical procedures and to encourage patients to consider cognitive-behavioral therapy.

In summary, with a careful evaluation and working knowledge and understanding of somatoform disorders, the physician can accurately identify underlying somatoform disorders. Treatment should be directed toward both the disorder and the patient specifically. The physician should avoid jumping to conclusions that the patient’s symptoms are all in their head and that he or she needs to see a shrink. Instead, it’s important to make sure there isn’t a more serious disease going on.

If there isn’t an organic disease present, then after establishing a collaborative relationship with the patient, the physician can recommend referral to a psychologist. The physician can avoid doing so in a way that suggests rejection of the patient — perhaps as a one-time appointment to learn ways of reducing stress, learning relaxation techniques, and/or pain management skills. More studies are needed to help us expand the limited knowledge we have of these disorders. Applying a one-treatment-fits-all approach may not be in the best interest of those affected by somatoform disorders.

Doctors May Do Better With Clearer Understanding of Somatisation

Somatisation (also spelled somatization) is the process of a mental or emotional feeling or stress becoming a physical feeling. Researchers often wonder about somatisation and psychosomatic behavior because it’s a puzzling part of the human body and mind. Not only is it puzzling, it’s very common. Many people experience somatisation at some point, with fatigue and nausea for example.

Many times, a patient sees a doctor for a problem, such as pain or nausea, but for which a cause can’t be identified. It is then not unusual for the doctor to refer to the problem as idiopathic, or of unknown origin. However, it is possible that some of these are somatic, not physical and then the problem may be labeled as somatic. However, by labeling the pain, is the patient getting the proper type of treatment? To look into this more, the researchers of this article wanted to review if studies have been done on somatisation and its relationship to pain, and how effective the studies were.

The researchers searched through the medical literature and found 116 studies that fit their requirements. This meant the studies were in English, were published in 1989 or later, had at least 20 study participants who were adults, had independent measurements of somatisation and pain, and investigated the relationship between somatisation and pain.

What the researchers found was that the primary purpose of the studies did not often even include somatisation. In fact, the majority of the studies did not define the word. The researchers also found that when the authors of the studies looked at somatisation, they were only looking at multiple (more than one) physical complaints. And finally, the studies did not report if people who had somatic complaints received help for them. There were no clear cut outlines to define or measure a somatic complaint.

In order to measure somatisation, most of the studies relied on the subjects filling out a questionnaire, most often the Symptom Checklist or the Brief Symptom Inventory. Only five studies used a structured interview to find out if the subjects had somatisation. Very few studies followed up to see if something physical could be causing the subjects’ pain and only one study of all 116 asked if the subjects were getting help for their symptoms. The authors of this study also wrote, “None of the studies reported of having addressed the last criterion of somatisation, namely whether people attribute the complaint to a physical cause.”

The authors concluded that using the terms somatisation leads to misuse in many cases due to a lack of research and understanding. According to the authors, using the term somatisation could, unknowingly, lead doctors into treating patients only with the somatisation in mind, without investigating further into the physical issues that could be contributing to pain.

Should Somatization Be Removed as Diagnosis?

Somatization occurs when you feel something physical as a result of an emotional or stressful feeling, but some doctors feel that the term is being used too much and not appropriately. In fact, many doctors believe that the term does not belong in medical terminology.

The term was first used by a psychoanalyst (Stekel) who used somatization to describe physical pain or discomfort that was caused by a psychological cause – hysteria being the most common. In fact, the term hysteria was used quite frequently over 2000 years of medicine.

Many of the illnesses that were first labeled as hysteria (or somatization) were figured out, there still remained a many patients who had physical complaints but no clear-cut or obvious reason for them. These patients were all lumped together and they could be either labeled as somatization or, in some cases, as hypochondriacs, people who believe they are ill when they aren’t.

A lot of study went into somatization and the diagnosis of somatization was included in what is considered to be psychiatric bible, the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V), in 1980. Unfortunately, by determining diagnosis such as somatization, many patients’ complaints were not investigated further, especially if the complaint was for pain. Yet, in the 21st century, some doctors are still making the diagnosis of somatization.

The author of this article believes that the term should be dropped from the upcoming DSM-V version because somatization does not have a place in diagnosis.

Fear of Re-Injury Makes Injury Last Longer, Delays Return to Work

When people experience a musculoskeletal injury, one that involves muscles or bone, recovery depends on many things ranging from the obvious (treatment) to the not-so-obvious (fear of movement causing pain). While most people who are injured at work are able to return to their position within a reasonable amount of time, up to 20 percent do not recover quickly and live with prolonged pain and disability, resulting in a delayed return to work.

Fear avoidance includes catastrophizing (fearing the worst) and fear of movement. Many studies have been done to understand who develops fear avoidance and why. By finding a fear-avoidance model, researchers hope to be able to identify those who may fall into this group and intervene before the situation deteriorates.

The authors of this study analyzed the relationships identified by the fear-avoidance model by measuring levels of catastrophizing, fear of movement, depression and pain severity. Researchers identified 401 people who were unable to work because of injury and they were attending a community-based disability reduction program. The researchers chose the people with the highest measures of pain catastrophizing and fear of movement, leaving them with 121 people (82 men, 32 women) for the study.

The injured workers had been off work for at least six weeks and had sustained a soft tissue injury, most frequently back pain. Their average age was 41.9 years. The 10-week program was run by psychologists and they worked with the workers on strategies and targeting risk factors, such as fear of movement. The workers did not have to complete the full 10 weeks if they were ready to return to work earlier and this happened with many who had begun the program not long after their injury.

The workers’ pain was measured using the McGill Pain Questionnaire, pain catastrophizing was measured through a self-reporting questionnaire called the Pain Catastrophizing Scale, as was the fear of movement using the Tampa Scale for Kinesiophobia. Depression was also measured, using the Back Depression Inventory.

The researchers compared questionnaire scores from before and after treatment, and how quickly the patients returned to work to come up with their findings. The results showed that although neither the sex of the patient nor the length of time affected how quickly they returned to work, higher scores on fear of movement and pain severity at the start of the study did mean it would likely take longer. This finding was not all that different from what previous studies have found as well. The study also showed that when it took a long time to adjust catastrophizing, there were higher levels of depression.

The authors concluded that research should be done on finding ways to lower catastrophizing levels among patients with this type of injury. By lowering the level, the workers could usually return to work more quickly.

Topical Ketamine Promising in Relieving Allodynia from Complex Regional Pain Syndrome

Complex regional pain syndrome is a little understood but very painful syndrome that can begin after a seemingly minor injury. What makes this syndrome even more puzzling is the allodynia, severe pain results from a relatively harmless action, such as brushing lightly against the affected limb. Because it is neuropathic, or nerve pain, it is particularly hard to treat. Many of the medications that are tried have side effects that may make them unbearable for the patient, regardless of the ability to relieve pain. For this reason, researchers are constantly working on finding an alternative for people living with this disorder.

Ketamine is a powerful anesthetic that is used mostly by veterinarians, but may be used for humans. It causes the person to feel as if he or she isn’t part of the pain, it’s often called a dissociative anesthetic. Using smaller doses, not enough to induce unconsciousness, may help relieve some types of pain, most often after surgery, but also chronic pain. But it is still not a commonly used medication.

The authors of this study wanted to determine if topical ketamine, ketamine that is placed on top of the skin, rather than ingested or injected, could help patients with complex regional pain syndrome. To do this, researchers recruited 20 patients (14 female) who had been diagnosed with the syndrome. Twelve had developed it in the arm and eight in the leg. Five patients developed it after a fracture, six after a sprain or soft tissue injury, three patients after surgery or receiving a injection, and four after an infection, clotting, electric shock, or anaphylaxis (allergic reaction).

All patients were tested for their sensation, their ability to feel a light touch, their pain-pressure threshold, sharpness stimulation, light brushing sensation, and cold and heat thresholds. The patients were evaluated at the time the cream was applied to both their affected limb and their non-affected limb – and then again 30 minutes later, in two sessions, one week apart. What the researchers found was that although the ketamine cream didn’t decrease the actual pain from the complex regional pain syndrome, it reduced the allodynia and this could be an important finding. Allodynia is reported as one of the most frustrating parts of the disorder. The authors of this article hope that these findings will lead to more research into using ketamine for complex regional pain syndrome.

Two Thumbs Up for Computerized Pain Assessment Tool

Pain is a very difficult thing to measure. There’s no lab test that can put it into an absolute number like a white blood cell count. Yet with 50 million chronic pain sufferers in the United States alone, there’s got to be a better way to measure pain than the visual analog scale (VAS). Using this scale, patients assign a number from zero to 10 to rate their pain (zero is no pain, 10 is the worst pain). This is so subjective, even the patients can’t tell if a rating of three today is better or worse than yesterday’s three.

Efforts are being made by pain researchers to develop an interactive, intuitive computer program that will help quantify (put into numbers) variable describing and defining pain (e.g., location, intensity, duration). There is also a need for some kind of chronic pain assessment tool that can measure improvement in pain levels. Being able to measure improvement would help researchers identify which treatment approaches are working best.

In this study, researchers from the National Research Centre for the Working Environment teamed up with the QualityMetric Incorporated company to develop a computerized prototype of an adaptive test for chronic pain. They actually conducted the research in two steps and report on the results of those two studies in this report.

In the first step, they selected a variety of test items from several other pain scoring tools (e.g., SF-36, Nottingham Health Profile, Oswestry Low Back Pain, Brief Pain Inventory, Fibromyalgia Impact Questionnaire) and put them all together in what they called a Chronic Pain Item Bank. There were 45 items covering everything from the frequency and intensity of pain to the effects pain has on function and sense of well-being. The scoring was set up for the test bank so that low scores would indicate a low level of function and high scores would mean the patient had a higher level of function. This type of scoring helps show the impact pain has on function.

The computer program was set up so that the computer chose the next question for each person taking the survey based on the answer given to the first question. The program allowed the computer to select the next question to ask each person depending on the answer (and score) for the previous question. The first question was always, How much pain have you had during the past four weeks?

The test had a cut-off point so that patients didn’t end up answering all 45 questions in the bank. The cut-off point was different for each person but based on a concept called precision levels or precision rule. The program was set up to make sure each person was asked questions in all four areas of content (e.g., pain location, intensity, duration, and impact). This method is called content balancing. With the precision rule and content balancing, most people taking the test answered between two and seven questions. Using these two programming methods, when a longer assessment was needed, the computer would present more questions.

Once the survey was pilot tested and ready to go, the second study was carried out. One hundred adults from the Dartmouth-Hitchcock Medical Center Pain Clinic were recruited to take the test. The people in the study completed the full 45-item test bank (a static test) also and took the computerized adaptive survey (a dynamic test). The scores were analyzed and compared between the static and dynamic test methods to find out how the two methods compare in measuring and describing pain and its impact on daily function.

They also looked at how long it took each person to complete both types of surveys. The computer program took an average of one and a half minutes to complete, whereas the full test bank took 10 minutes. The dynamic computer survey was just as accurate as the static full survey with fewer items and taking less time. The scores for all four content areas (pain location, intensity, duration, and impact) were equivalent between the two tests. This shows that the faster, shorter computerized method works just as well as the longer, more cumbersome full test procedure.

Most of the test participants reported no difficulty in completing the computer program using a table type personal computer (PC) and stylus (handheld tool used to touch the screen to answer questions). And they said the results were an accurate reflection of their pain experience. The participants were given a chance to make some suggestions for how to improve the test procedures. Their comments helped the researchers see that left-handed people, anyone with a visual impairment, and those using a wheelchair had some trouble using the table PC.

All in all, this computerized prototype for standardizing data collected on chronic pain has some merit. Fast and easy to use, this dynamic adaptive computer program can replace the longer surveys currently in use. Since this was a feasibility study with a small sample size, further testing with more people will be required before this tool can be released for general use. For now, it’s two-thumbs up for this dynamic pain assessment system that yields an accurate picture of pain patterns and the impact of pain on function.

Good News For Pain Sufferers

Good news for pain sufferers! Health care professionals have an improved tool to use when assessing your pain and helping you to find ways to manage your pain. A very well-known pain researcher from McGill University in Canada, Dr. Ronald Melzack continues to improve his famous McGill Pain Questionnaire.

Once a very long and involved survey of pain, function, and limitations, Dr. Melzack and his collaborators have found a way to trim the original questionnaire down to just 22 pain descriptors. Patients circle a number from zero (none) to 10 (worst possible) for items such as throbbing pain, itching, numbness, and electric-shock pain. Other choices include hot-burning pain, aching pain, punishing-cruel pain, and cold-freezing pain.

This type of pain descriptor scale with the numbers from zero to 10 is called a numerical rating scale. This particular scale is called the Short-Form McGill Pain Questionnaire (SF-MPQ-2). It is designed to measure all kinds of pain — both neuropathic (nerve pain) and nonneuropathic. Some examples of nonneuropathic pain problems are fibromyalgia, migraine headaches, and low back pain.

Each word descriptor included in the SF-MP-2 has a particular meaning. For example, pain that is amplified by emotions is often described by words such as fearful, sickening, tiring-exhausting, or punishing-cruel. High ratings of these questions would categorize the pain as nonneuropathic. This particular subscale is categorized as affective.

Nerve pain is more often described as shooting, hot-burning, numbness or tingling, or electric-shock. This sensory-based category is the neuropathic subscale. Some of the other descriptors look for a musculoskeletal cause (aching, cramping, heavy, tender) or an underlying cardiovascular cause (throbbing pain). Two other categories that developed out of the preliminary research included continuous (constant) and intermittent (comes and goes) pain experiences.

The process of developing the SF-MPQ-2 involved many steps. Focus groups of patients with chronic pain were gathered together and interviewed. Their ideas and opinions about pain and related-symptoms were incorporated into this revised questionnaire. The survey was given to a group of patients (again, all who had chronic pain) in order to further refine the choice of words and to pretest the questionnaire for ease of use and outcome measures.

When it was all ready to go, this study was done in order to validate the questionnaire (i.e., make sure it is a true measure of neuropathic and nonneuropathic pain). The authors gave the questionnaire over the Internet to 882 people with a wide range of chronic pain syndromes. And they gave the questionnaire to 226 patients with painful peripheral neuropathies caused by diabetes. Neuropathy is another word for nerve pain. Peripheral neuropathy is a condition of nerve damage or irritation of the nerves to the hands and feet. Pain numbness and tingling are the main symptoms of this condition.

The authors make it clear that their intention was NOT to find a way to screen patients for neuropathic versus nonneuropathic pain. They are really just looking for a way to help all chronic pain sufferers better describe their pain. By comparing the answers of patients with neuropathic pain against the answers of patients with nonneuropathic pain, they were able to find new words to describe neuropathic pain. A survey like this also makes it possible to evaluate patients who have mixed (both neuropathic AND nonneuropathic) pain.

They also point out that this tool is meant to be used as a single measure of all types of pain — a questionnaire that is reliable and valid. Such a tool can be used for various types of research on the mechanisms of pain and response to treatment. There’s still much to be done before this new revised short form of the McGill Pain Questionnaire is ready for that type of use.

For example, before using this questionnaire to evaluate before and after results of treatment, a pilot study should be done to validate its use for that purpose. The fact that the people who took the survey did so via the Internet suggests a certain group of individuals who may not reflect the general population. They are more likely to be younger, Caucasian, and well-educated. More study must be done to confirm these results with a broad base of individuals with chronic pain who are from all walks of life and circumstances. And there’s no way to know if the person in pain was the one to fill out the form or if perhaps, a partner or family member did so for them.

In summary, the Short-Form McGill Pain Questionnaire is an all around good measure of neuropathic and nonneuropathic pain intensity and quality. The questionnaire is an expanded and revised version of a previous short-form McGill Pain Questionnaire — that’s why they gave it the number two after the name: SF-MPQ-2. Even though more study will be done on this tool, for right now, it’s ready to be used in clinical research and practice.

Reporting on Complex Regional Pain Syndrome From Start to Finish

Every illness, disease, or medical condition has what we call a natural history. The natural history describes what typically happens for that patient with a particular problem. Natural history may include how quickly the disease advances or progresses. It also includes what signs and symptoms develop at each stage. Prognosis and what to expect at different time points of disease are also part of the natural history.

In this study, the natural history of a condition called complex regional pain syndrome (CRPS) is reviewed and analyzed to help us better understand this condition. Complex regional pain syndrome or CRPS is a painful condition that affects the arm and hand or leg and foot. It usually occurs after trauma of some sort, including surgery.

Complex regional pain syndrome (CRPS) comes with a wide range of symptoms. Most people report a cutting, sharp, or stabbing pain. It’s intense and it’s constant. They may also notice increased or decreased sweating of the area. Hair patches or hair loss (or both) are common. Muscle spasm and weakness are part of the clinical picture early on for most patients.

Some patients’ have a change in temperature, too. The limb may become very hot and sweaty or cold and clammy. It’s not entirely clear what causes this condition or its symptoms. It looks like changes in both the central (brain and spinal cord) and peripheral nervous systems (spinal nerves) are part of the process. Interactions between the nervous system and the immune system may be equally important.

Some recent research has taken a look at the nerves, blood vessels, and hair follicles of patients with CRPS. It appears that tiny nerves to the blood vessels are missing in patients with CRPS. The walls of the arteries become hypertrophied (thicker) cutting down blood flow to the area. Even the layers of the blood vessels are disrupted.

Women are more likely to develop CRPS compared to men, so there may be a neurohormonal factor as well. The interaction between the nervous system and hormones is complex and not well understood. Any number of problems in communication between these two systems could set off a chain reaction that ends in developing CRPS.

All of these changes probably contribute to the symptoms described with CRPS. Most people think the syndrome occurs after healing is complete. But one theory is that there is ongoing inflammation. The inflammation causes nerve endings to become extra sensitive.

Until we have more information about what is actually causing CRPS, describing the natural history can be very helpful. Patients, physicians, physical therapists, and other health care professionals can use this information to plan treatment and help the patient manage their own symptoms.

In this study, over 650 patients with CRPS for at least one-year duration were analyzed. They each completed an in-depth interview by completing a survey answering questions about their experiences with CRPS. They reported on what triggered the development of CRPS, what makes their symptoms better or worse, and how the pattern of pain spread over time.

They also answered questions about work, quality of life, education level, general health, and family history. Each of these factors was examined on a continuum of time. In other words, as the disease changed and progressed (got worse), the researchers looked to see if there was some connection between those changes and any of these parameters.

Here’s what they found. The longer a person had CRPS, the more intense the pain became over time. Pain triggered by touch or made worse by touch got worse over time as the disease got worse. Time of day for the worst pain varied but everyone agreed that pain in the evening and at night was a definite problem. Patients described the effect of their symptoms as more likely to be tiring and exhausting than fearful.

It was very common for patients to report painful symptoms that spread down the arm or leg and from one area to another. For example, symptoms spread from one arm to the leg on the same side or even the opposite side. Sometimes the pain spread over the entire body. There were patterns to the way the pain seemed to spread. The most common pattern was contiguous (slow spread from one area to the next).

There were patterns as to how the painful symptoms responded. Medication, rest, hot weather, and hot or warm water were more likely to provide relief from symptoms. Massage, elevation of the limb, and physical therapy were also reported helpful to some patients. Although these kinds of treatment offered pain relief, there was no obvious time period linked with improvement. In other words, patients who were treated early on had the same relief as patients who were treated much later in the course of their disease. For a small number of people, nothing helped.

Aggravating factors (that is to say, things that could be counted on to make the symptoms worse) included cold, physical activity, and some specific motions. Standing still too long, holding the arms up overhead, being in a car (as driver or passenger) for a long time, and stress were listed as aggravating factors.

When looking at symptoms as they unfolded over time, the authors saw that skin color changes and skin temperature changes were common. Nearly three-fourths of the patients had skin color changes in the first five years of their disease. This percentage increased to 83 per cent after 15 years. Skin temperature changes increased over time. The longer the patient had CRPS, the more likely the patient would report skin temperature changes.

Most other symptoms (e.g., swelling, sweating, abnormal limb position) followed the same pattern of increasing over time with disease duration. The exception to this pattern was weakness and the initiation of movement. Both of those problems were present within the first five years and stayed about the same as time went by.

One important finding was that the number of patients reporting constant, intense pain (or other symptoms) did not increase over time. In other words, symptoms gradually got worse for those who had symptoms. Those who didn’t report specific problems early on did not usually develop them later.

The authors conclude that by looking back over time for many patients (rather than just following one person), they were able to see a pattern of disease progression for CRPS. Most of the bothersome symptoms were present early on. They get worse over time. No one ever had a spontaneous cure or recovery. CRPS can be a very disabling, life-altering illness that only responds moderately to most of today’s treatments.

Scientists are pinning their hopes on finding an effective drug therapy that will minimize the problems seen with CRPS. Right now, research efforts are focused on developing substances that will target the nervous system and/or the immune system.

Scientists Find New Link in Solving the Puzzle of Complex Regional Pain Syndrome

Sometimes after trauma (even minor trauma) to human tissue, a chronic pain condition develops. Once called i>reflex sympathetic dystrophy (RSD), this syndrome is now referred to as complex regional pain syndrome (CRPS).

With CRPS, the pain generated is greater than expected for the degree of tissue trauma that has been sustained. The pain begins early on and spreads from a small, local area to a larger, regional distribution. Patients report a burning sensation that comes on suddenly for no apparent reason. It is intense. Usually, there are other symptoms such as sweating, hair growth, and changes in skin color and texture.

No one knows for sure what causes this to happen. Lab studies of blood and tissue samples appear normal. There is no apparent inflammation of the affected soft tissues (e.g., skin, muscles). There is some evidence that the cellular changes are occuring within the nerve fibers to the affected tissues. Most of what we’ve learned so far has come from animal studies.

Scientists have been able to produce a similar response in rats by causing a bone fracture in such a way as to set up a CRPS response. By doing so, they can then study the tissues to see what’s going on inside the body. The hope is to be able to work their way back to identify causative factors. Then it might be possible to prevent those from happening. In that way, we could prevent CRPS from developing in susceptible people.

In this editorial, two scientists (one American, one German) team up together and report the results of their efforts with this CRPS-induced (animal) fracture model. They report that it looks like it may be possible to inhibit the over reaction of the neurogenic inflammatory process by using a substance to inhibit the release of substance-P.

Substance P is a neuropeptide that acts as a messenger of information in the nervous system. Substance P is released from the ends of specific sensory nerves. It seems to be able to increase the excitability of pain responsive neurons. That may answer some of the questions about why people develop so much pain, but it doesn’t answer the question of why those particular people have this pain response after an injury.

Looking at patients with CRPS as a whole, it has been noticed that these same individuals often have migraine headaches, too. There is a signaling neuropeptide called CGRP that seems to be linked with the overly dramatic nerve response in both migraine headaches and complex regional pain syndrome. This piece of the puzzle supports the idea that there’s a nerve inflammation response going on that the body just can’t seem to regulate.

With this much new information, scientists are back to the drawing board. Now they are trying to understand why there might be a loss of inhibition in the complex cascade of nerve-related inflammatory chemicals. The fact that this response can occur after major or minor trauma suggests it’s not the trauma itself that exaggerates the process, but rather, something has gone haywire in the nervous system’s response to injury.

Each new finding brings us closer to solving the painful puzzle of complex regional pain syndrome — a solution that could bring welcome relief to chronic pain sufferers from this very disabling condition.

Does Dystonia Respond to Baclofen?

Scientists continue to unravel the mystery of complex regional pain syndrome (CRPS). CRPS is a condition that develops after surgery or some other type of trauma. The patient develops exquisite pain and/or tenderness usually of one extremity (arm or leg). Symptoms of sweating, hair growth, swelling, and changes in skin color and temperature develop in that extremity. Changes in nail growth and nail strength are also common symptoms of CRPS.

No one knows exactly what causes CRPS to develop — or why only certain people (usually women) are affected. There appears to be involvement of both the immune system and the nervous system. In one out of five patients affected by CRPS, an additional problem develops: dystonia. Dystonia is the abnormal movement of a body part. The patient experiences involuntary (not under their control) muscle contractions. The arm or leg twists, freezes into one position, or twitches repetitively.

In this study, researchers from the Department of Neurology at Leiden University Medical Center in The Netherlands used baclofen to treat the dystonia. Baclofen is a drug that has been used to reduce spasticity by stopping the messages that go from the muscles to the spine. The baclofen works by inhibiting the GABA receptors in the nervous system. The result is to prevent the release of neurotransmitters. Neurotransmitters are chemicals that send and receive signals between a neuron (nerve cell) and the rest of the body.

To test out the theory that baclofen might help with dystonia, 36 patients with CRPS-related dystonia received an injection of baclofen into the spinal cord. The authors were interested in finding out how much of a dose is needed to be effective and whether such a dose is safe. The baclofen was delivered through a pump into the subarachnoid space of the thoracic spine.

The subarachnoid space refers to an area between a layer of tissue that covers and protects the spinal cord and the spinal cord. Cerebrospinal fluid is contained within the space. The brain and spinal cord float in cerebrospinal fluid. The fluid is designed to act as a cushion or buffer for the nervous system.

From previous studies, the authors learned that continuous infusion of baclofen is needed to get the desired result. The patients were given the baclofen every day until the desired effect was reached. They started with 150 micrograms/day and gradually increased the dosage. This approach is called dose-escalation. If the patient developed side effects, the dose was lowered. The goal of any drug (including baclofen) is to obtain the maximum benefit with the least amount of adverse effects.

The pump used to deliver the baclofen was placed in the patient’s abdomen just under the skin. A thin tube called a catheter went from the device to the subarachnoid space in the midthoracic spine. A special X-ray called fluoroscopy was used to help guide the surgeon when putting the device in place. The catheter was put in the same place within the midthoracic subarachnoid space no matter where the patient was having pain/symptoms (arm or leg).

All patients in the study had tried an oral (pill taken by mouth) dose of baclofen but either got no benefit or had too many side effects to use it on a regular basis. Everyone had CRPS from an injury affecting at least one extremity. The majority (62 per cent) had CRPS of all arms and legs. Patients with CRPS-related dystonia from birth injuries and head trauma were not included. The programmable pump-catheter system was left in place and only removed if there were problems.

Every hour for five days, the patients filled out a form rating their pain, mobility, function, and limitations. Everyone was followed for 12 months. The severity of the dystonia was rated before and during treatment using a special tool called the Burke-Fahn-Marsden (BFM) dystonia rating scale. Other questionnaires were used to assess mobility, daily activities, and health-related quality of life. All this information gathered helped show that the treatment was very effective.

Safety was another concern measured by the type, severity, and number of adverse events. This included problems with the pump/catheter system, cerebrospinal fluid leakage, nausea, vomiting, headache, and difficulty sleeping. Many of these problems cleared up by stopping the drug temporarily or by lowering the dose.

There were a total of 89 problems counted in 26 patients. Most of the problems were related to the device. The catheter got kinked or blocked, pain developed around the pump or in the back, or some part of the pump/catheter system failed.

In a few cases, the drug seemed to help but then the patients got worse again. This was always caused by a catheter complication and could be reversed with a little trouble-shooting. Pump migration (movement of the pump) with failure of drug delivery was reported in two obese patients.

In a few cases, depression or psychosis developed but cleared up when the drug was stopped. There were three patients who developed an infection in the pocket where the device was implanted under the skin. In those cases, the pump had to be removed.

Only one patient did not respond to the baclofen. Everyone else seemed to get the maximum benefit using up to 450 micrograms of the drug. A beneficial response to the drug was observed within the first two days. Pain was reduced and function improved. Some patients who had to use a wheelchair before treatment could walk again. There were patients who could walk with a walker or cane before the study who could walk independently after getting the baclofen pump. And some who were bedfast could start using a wheelchair.

Maximum improvement seemed to occur after about three months. Smaller benefits were observed up to six months. After that, the changes seemed to stabilize. The improved ability to use the arm(s) or leg(s), changes in mobility and function, and reduced disability were clear indications that intrathecal baclofen is an effective treatment for CRPS-induced dystonia.

The authors conclude that although dose-escalation intrathecal baclofen is an effective way to treat dystonia, the high rate of complications is a major safety problem. More study is needed to improve the pump/catheter system. It may also be possible to select a more specific subgroup of patients who are less prone to problems.

Craving Could Indicate Potential Opioid Medication Misuse

Managing chronic pain can be quite difficult – to find the right combination of treatment and medications takes a lot of trial and error for many patients. One treatment that is becoming more common is using opioids (controlled drugs, narcotics) to try to lessen the pain. This means more people than ever have access to these medications and increases the potential of abuse.

Currently, it’s estimated that about three to 16 percent of the general public abuse substances of some sort, with a growing number abusing prescription opioids. Unfortunately, healthcare professionals don’t always have the proper training to identify drug addiction and drug-seeking behaviors. Not only can this be a problem by giving drug-abusing patients more of what they want, it can result in patients not being adequately treated because of the physicians’ concern of feeding the addiction. So, there are issues on both sides of the spectrum.

For the most part, patients who take opioids to manage their chronic pain don’t experience euphoria or cravings. Their medication helps relieve the pain. However, there are some people who do experience those euphoric effects. Because of the seriousness of opioid misuse, researchers have been working to see if they could identify which patients would be more vulnerable in order to prevent drug abuse.

Researchers are in general agreement that cravings are in important part of abuse, but they don’t know if the craving means the abuse is inevitable. As well, cravings are an important part of treatment, assessing cravings as they increase, stay steady, or decrease.

Earlier, a questionnaire called the Screener and Opioid Assessment for Patients with Pain (SOAPP) was developed to help patients report their progress, called self-reporting. Using the questionnaire, researchers found that five factors could help predict noncompliance (patients not following the medication regimen) and opioid misuse. They were: history of substance abuse, history of legal problems, craving for medications, heavy smoking, and mood swings.

Using the information gathered for the SOAPP, researchers refined the questionnaire and developed the SOAPP-R. The authors of this article wanted to compare the two studies where the first one did not include cravings while the second one did, looking to see if craving truly was a predictor for addiction or misuse.

Over 600 patients who had chronic pain and who were taking opioids were asked to rate their cravings for medications on a scale of zero to four, with zero being never and four being very often. Their average age was 50 years, ranging from 21 to 89 years). The majority (66.8 percent) had lower back pain. After six months, they were given a questionnaire called the Prescription Drug Use Questionnaire and their urine was tested for drugs. Their own doctors were asked to complete a checklist called the Prescription Opioid Therapy Questionnaire. Other questionnaires were also used to understand the patients’ history. The Brief Pain Inventory looks at the patients’ pain history, intensity, and location, as well as how much it affects their daily life. Zero means not at all and 10 means as much as possible. The Marlowe-Crowne Social Desirability Scale has 13 questions that tells doctors how likely a patient is to tell them what they want to hear versus what their real answer is.

At the end of the study, of the 613 patients, 337 (55 percent) reported that they didn’t have an cravings for the medication while 276 (45 percent) said they did. This group also showed the highest scores on the Prescription Drug Use Questionnaire and had higher ratings on the physician’s questionnaires as well. In addition, they also had a higher rate of abnormal urine test results for drugs. The cravings group had many more men in it than women, they were often unmarried, and many scored low on “social desirability.”

The authors point out that there are some flaws to the study, the first of which is the intent of the study. The authors went into the study meaning to look into assessing and validating the tools that predicted opioid misuse and not to address cravings, as they did in the results. They also felt that their questions were perhaps too vague for some patients to be interpreted the same by everyone. They also didn’t take into account patients who didn’t test positive for drugs in their urine but who still may have been abusing their drugs.

In conclusion, the authors felt that the findings did support the idea that patients who have chronic pain and who take opioids are at higher risk of abusing the drugs if they admit to cravings.

Radiofrequency Denervation for Low Back Pain is Safe and Effective in Select Patients

Surgeons commonly use radiofrequency (heat) energy to cut small sensory nerves around the facet (spinal) joints that are causing patients’ low back pain. The procedure is called a radiofrequency denervation (RFD). The evidence for RFD as a safe and cost-effective treatment method is a bit sketchy. Some say it works well. Others show little or no benefit over sham (pretend) treatment.

In this Canadian study, carefully selected patients were treated with RFD at the pain generating spinal structure. What does carefully selected mean? And how do they know which joint is causing the pain? Both of these questions can be answered by the process used to choose patients for this treatment intervention.

First, everyone had chronic low back pain that had not responded to other conservative care methods. In fact, they all reported back pain lasting more than two years. The facet joints were identified as the primary cause of back pain by using fluoroscopic-guided nerve blocks. In this procedure, the surgeon uses special imaging (fluoroscopy) that allows him or her to see inside the body.

A local anesthetic (numbing agent) was injected around the nerve of the suspected facet joint. If more than 50 per cent of the patient’s pain was relieved, the test was considered positive. A positive test meant that the facet joint tested was causing the low back pain. The diagnostic facet joint block was repeated a second time with the same results before patients were included in this study.

Once the bothersome facet joint was identified, then radiofrequency denervation was carried out. The irritated nerve causing chronic pain signals was burned for 90 seconds at a temperature of 80-degrees Celius (176-degrees Fahrenheit). A special probe was used to burn the nerve in three separate places. The result was to completely denervate (cut) the nerve and interrupt pain messages.

Other studies have been done measuring changes in pain and disability after radiofrequency denervation. This is the first one to look at other measures such as cost-effectiveness, patient satisfaction, employment status, disability, and analgesic intake (use of pain relievers).

Patients were surveyed before to obtain a baseline and then several times after the treatment to assess before and after changes for each of these factors. Commonly used tools such as the Oswestry Disability Questionnaire, visual analogue scale, patient satisfaction survey, and Beck Depression Index were administered.

The authors found that pain intensity was reduced significantly after treatment. The pain relief lasted a full six months but started to come back after that. The use of pain relievers was much less throughout the follow-up period (one full year).

Disability followed the same pattern as pain (decreased at first then slowly increased again). Along the same lines, patients were satisfied with the treatment and treatment results for the first six months. Patients reported being able to work more hours with fewer days absent during the year of the study.

Compared to other studies done in this area, the patients in this study had a much greater reduction in pain intensity. Similar to other studies, the results didn’t last. There were no complications, so it seems the procedure is safe and effective for short-term pain relief. But it is not effective for long-term back pain stability.

The patients felt that even short-term pain relief was worth it. They saved money in how much they paid for pain relievers. They missed fewer days of work. The fact that the effects didn’t last was disappointing and reflected in less overall satisfaction with the procedure.

The authors make several suggestions based on the results of this study. First, it may be possible to get more people back to work full-time (many returned part-time) if the treatment is followed by a formal occupational/vocational rehabilitation program. Second, patients might benefit from a supervised low back fitness program. Core stabilization, muscle flexibility, and aerobic fitness could be customized for each individual for best results.

And third, another study comparing the results with carefully selected patients should be compared with a control group. There was no control group in this study. The control group would include patients with nerve block diagnosis of facet joint-derived back pain who did not receive the radiofrequency denervation. Such a study might help sort out how much improvement occurs as a result of the natural course of time, how much is really from the nerve degeneration, and how much is a placebo effect (the patient expects to get better and does).

New Approach to Sacroiliac Joint Pain

Medical treatment for sacroiliac joint (SIJ) pain has been less than successful. Doctors have tried injecting the joint with a numbing agent and even fusing the joint in severe cases. A new treatment under investigation may change that. New water-cooled radiofrequency technology has been shown very effective in preliminary studies.

The research is being done at the well-known Johns Hopkins School of Medicine in Baltimore. The first study in a series compared two groups of patients. The first group was the treatment group. The second group was the control group. They all received one injection of a numbing agent directly into the SIJ. This type of nerve block has been used to diagnose and treat SIJ in the past.

Then for the treatment group, the surgeon used a radiofrequency probe to cut sensory nerves to the SIJ. The procedure is called denervation. The control group had a placebo denervation. Results were compared between the two groups. Measures of effectiveness included pain relief and improved function. Patients had to have more than 50 per cent improvement in both areas. Otherwise, a less than 50 per cent improvement would be no better than chance if they did or did not improve.

The treatment group had major improvements in all areas compared with the placebo group. And a significant number of patients in the treatment group still had positive benefits six months later. Results in the placebo group only lasted 30-days.

The short-term effects observed are typical in a placebo group. The patients think they had a beneficial treatment. They respond favorably (mind over matter), but the results don’t necessarily last because nothing was really done to change the problem.

This first study was just a start. It’s not really a treatment everyone will try just yet. Because it was done with a small number of patients (28 total), a second study is needed to prove the results weren’t just a fluke. The second study (by the same researchers at Johns Hopkins) with 150 patients is underway.

Besides showing the benefit of this treatment, the authors will also try to narrow down which patients are most likely to respond to radiofrequency denervation for their SIJ pain. One way to sort this out is to divide the study into three groups: 1) radiofrequency denervation without a nerve block, 2) radiofrequency denervation after one block injection, and 3) radiofrequency denervation after two nerve blocks.

The reason for using three different groups is safety and effectiveness. If a patient responds well to a single nerve block and no further treatment is needed, then there’s no point in cutting the nerve. Likewise, there may be patients who respond well to the nerve block after two blocks. The goal is to find out which patients truly need a denervation procedure.

The authors believe that with a tight selection criteria, this new technology will benefit a specific subgroup of individuals who suffer from chronic sacroiliac joint pain. Clearly, the first study showed that the treatment is not a sham. Refining the treatment is the next step before this approach might be available for use in the general population.

Physicians Offered Guidelines in the Use and Monitoring of Opioid Therapy

Understandably, physicians are cautions about giving their patients narcotics (also known as opioids). Worries about misuse, abuse, and addiction are reasonable. In this article, over a dozen highly qualified panel members offer doctors guidelines for the long-term use of opioid therapy. The target patients are those with chronic noncancer pain (CNCP).

Recent studies have shown that although physician concerns about opioid use are important, it’s also true that most patients are able to take these medications without problems. This information has helped open up the use of opioids for chronic pain patients who might otherwise suffer needlessly.

Several tools for clinicians to use in assessing and monitoring patients are provided. The first is the Screener and Opioid Assessment for Patients with Pain (SOAPP). This brief questionnaire helps physicians determine how much monitoring a patient might need who is on long-term opioid therapy.

The second is the Opioid Risk Tool (ORT). Five measures are used to determine a low, moderate, or high risk of problems using opioids. Factors such as personal and family history of substance use, age, history of sexual abuse, and psychological disease contribute to the risk of opioid abuse or misuse.

The third risk assessment tool is called the D.I.R.E. Score. The health care professional completes this tool looking at four main factors. Diagnosis stands for type of pain problem (e.g., fibromyalgia, migraine headaches, back pain) and its natural history (slowly progressive, degenerative).

Intractability looks at what other treatments have been tried, the patient’s level of cooperation, and the patient’s response to those approaches. Risk is based on multiple variables such as patient reliability, patient’s social support, psychologic profile, and use of chemicals such as alcohol or other drugs. And finally, efficacy is assessed, which is a way to score the patient’s pain, function, and quality of life.

Once it looks like the patient is a good candidate for opioid therapy, then it’s important for the physician to monitor pain management, the patient’s response, and results. There are several monitoring tools available to help with this. These tools help the physician determine the risk-to-benefit ratio for each patient. In other words, do the benefits outweigh the risks enough to continue with the drug?

The Pain Assessment and Documentation Tool (PADT) keeps track of pain relief, activity level, and adverse effects of the medications. This checklist also helps the physician (or other health care professional) observe and make note of any potential drug-related behavior.

Another similar monitoring tool is the Current Opioid Misuse Measure (COMM). The COMM is a quick and easy patient self-assessment tool. Patients can still fudge their answers on this survey if they choose to do so. It is designed to be used to see if changes in the treatment plan are needed but it does require the patient’s honesty.

Pain management with chronic opioid therapy (COT) requires patient participation and responsibility. They are educated about the proper use of these drugs and required to sign an informed consent form. What’s expected of the patient is clearly outlined. Risks of adverse effects are reviewed ahead of time. Goals of therapy and how and when the opioids are to be taken are also clearly described.

Patients must understand that COT rarely provides total pain relief. And it’s only one part of a total pain management plan that also includes diet, exercise, behavioral counseling, and stress management.

The treatment guidelines offered in this article cover much more than just patient assessment and monitoring. Choosing the right patient, determining the type and dose of medication, and judging when adverse effects require discontinuation of the drug are important, too. The authors review specific drugs such as methadone, how it works, when to use it, and what to watch for.

COT can be used for high-risk patients (e.g., previous history of drug abuse or mental health problems) and during pregnancy but with frequent and careful monitoring. It’s best not to use it during pregnancy, but sometimes the benefit outweighs the risk.

Other concerns such as recommendations for driving and work safety are also addressed. It’s not that patients on COT can’t drive or work. But if there is any sign of impairment from the medication, they are counseled (for their own safety as well as the safety of others) NOT to drive or engage in dangerous work or recreational activities.

Physicians will be faced with other decisions. What should be done for patients who show drug-related behaviors, who have intolerable side effects of the drug, who make no progress in therapy, or who don’t have insurance coverage or a way to pay for treatment? Weaning a patient can be painful but necessary and requires addiction treatment.

Then there’s the problem of breakthrough pain. The patient’s pain level rises despite usual and standard doses of opioids. Breakthrough pain occurs when the underlying condition is getting worse or when a new, unrelated pain condition is developing. Strategies for approaching this situation are offered. Treatment of the new problem may help. Trying other nondrug treatments is advised before increasing opioid dosage.

Whenever prescribing COT, the physician must be aware of local laws, regulations, and other policies that govern the use of controlled substances. In addition to federal laws, each state has its own regulations that must be followed. Anyone who fails to follow these laws is liable and can be fined or otherwise disciplined.

The panel summarizes the important points of this document by saying first that COT can be used safely and effectively for patients with chronic noncancer pain. The evidence offered in the guidelines is limited but considered the best practice available right now.

Anyone who does not feel qualified to assess, prescribe, and monitor patients should refer them on to a specialist or pain clinic staffed and trained to handle these types of cases. The expert panel agreed that a total management program is needed. No one should just be given opioids without additional nonpharmacologic (nondrug) treatment and social and psychologic support.

Experiment With Opioid Pain Killers Failed

Opioid (narcotic) medications for pain relief have been in the center of an ongoing controversy for years now. Yes, they provide pain relief for pain sufferers. But they are potentially addictive. And one of the most severe adverse side effects is death from unintentional overdose.

Despite this knowledge, the use of opioids as a treatment for chronic (noncancerous) pain has risen dramatically in the last few years. Along with that increase has been an obvious spike in the number of overdose deaths. The Centers for Disease Control and Prevention report as much as a 371 per cent increase in these kinds of deaths.

A closer look at that figure revealed a large difference based on demographics such as geographical location (urban versus rural), gender (male versus female), and age. What they found was a much higher incidence of opioid-related deaths in rural areas. West Virginia had the highest rates of opioid use in the entire United States. And the rate of unintentional drug overdose was more than twice the national average.

Men were twice as likely to die of a drug overdose than women. And individuals between the ages of 18 and 54 were affected most often. A closer look at the people who died of unintentional opioid overdose revealed a few important facts:

  • Drug abuse was the common denominator in 95 per cent of all deaths caused by drug overdose.
  • More than half of the deaths involved prescription opiates. But less than half of those deaths occurred in people for whom the prescription was written. Giving other people drugs prescribed for yourself is called drug diversion.
  • Almost 80 per cent of the opiate-related deaths involved alcohol and other drugs.
  • One in five people obtained their opioids by doctor shopping (going from doctor to doctor getting prescriptions for the drugs).

    Has the great experiment to extend opioid treatment to people in chronic pain failed? Not necessarily. It may just be there’s a need to adopt a more reasonable approach. Limit the number of prescriptions written to avoid drug diversion. Monitor patient use. That means use urine screening for anyone taking opiates over a long period of time. Assess for a history of alcohol and other drug abuse before prescribing narcotic medications.

    At the same time, we need studies that look for ways to predict two things: 1) prediction of opioid abuse and 2) prediction of opioid effectiveness. Along with these two items, researchers need to identify patients who are well-suited for opioid therapy. Factors that might affect opioid use should be identified. This may include patient age, family history (hereditary factors), gender (male versus female), pain beliefs, psychologic or mental status, and many others.

    For now, it’s a step in the right direction to know that there’s a broad pattern of drug overdose deaths related to drug diversion and/or drug abuse. Such a finding makes everyone take a step back and re-evaluate the use of prescription opiates. No one wants patients to suffer unnecessarily. But death as a potential side effect is not an acceptable outcome either.

  • Chronic Pain Acceptance Questionnaire Useful Tool in Chronic Pain Assessment

    With the ever increasing number of people living with chronic pain, it still appears that those who have chronic pain aren’t always taken seriously by healthcare professionals. This is unfortunate because studies have shown that patients with chronic pain who are understood do much better physically and psychosocially than those who aren’t understood. For example, studies have shown that people with rheumatoid arthritis have fewer painful flare-ups, people with lower back pain have a better quality of life, and people with mixed types of pain conditions can participate in more activities if their pain is understood and accepted than those who don’t have that acceptance.

    Now, physicians use the Chronic Pain Acceptance Questionnaire (CPAQ) as a measurement for how chronic pain affects their patients, but the number of questions used varied according to new ideas about pain surfaced. The author of this study wanted to learn what would be the most useful in the CPAQ to make up a solid assessment for chronic pain.

    Researchers recruited patients with chronic pain and divided 333 into Group 1 and 308 into Group 2. All patients completed self-report questionnaires one week before being assessed by physicians. The questionnaires assessed levels of depression, pain anxiety, disability and medications. The medications were classified as strong opioids (controlled medications for pain relief), weak opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, muscle relaxants, sedatives, anticonvulsants, selective serotonin reuptake inhibitors (SSRIs), which are antidepressants too, and over-the-counter pain relievers. Pain was rated on a scale of zero to 10, with zero being no pain at all and 10 being the worst possible.

    The results of the study showed that the CPAQ could be divided into two sections: Activity Engagement and Pain Willingness, which is consistent with the earlier use of the questionnaire.

    In Activity agreement, this is related to being involved in everyday activities while having pain and Pain Willingness is related to not participating in a certain behavior in order to prevent pain from occurring.

    The patients turned out to fall into one of three clusters, two of which were expected. They were patients who score on either end of the scales, either high or low. The third cluster included patients who were functioning with everyday activities but still had a lot of pain that required pain relief. This group also may be functioning well physically, but reported psychosocial issues.

    The authors of the article pointed out that the third group could benefit from treatment that would help them learn how to better cope with the physical pain so it would be more effectively relieved. They also noted that just because patients scored high on the Pain Willingness scale, it was not a given that they would score low on the Activity Engagement scale. This could be because many patients have the mindset that certain activities need to be done regardless of how much pain they’re experiencing.

    In an earlier study, by Nicholas and Asghari, CPAQ was criticized because it wasn’t efficient in discovering issues like pain self-efficacy, pain-related anxiety, and catastrophizing (fearing the worst when it comes to pain). However, five other research groups didn’t agree with these thoughts.

    The authors conclude that using the CPAQ is useful and reliable in helping assess patients and their levels of pain until more reliable measurements are developed.

    Pain and Inflammation May Be Linked

    In the last 10 years, experts have identified one factor that might predict who will end up with chronic pain. It’s a concept called catastrophizing. A catastrophizer is a person who feels helpless and tends to think the worst when in pain. They seem unable to cope, and they focus on their symptoms in detail. This may be the first study to show a link between pain and inflammation, which may explain what’s happening at a physiologic level to explain the catastrophizing-pain response.

    Participants in the study were all healthy adults. A nurse pre-evaluated everyone to make sure there were no hidden health concerns. Everyone filled out a medical history form, Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS).

    Previous studies have shown that by using these tools, it is possible to predict who will be a high pain catastrophizer. And these folks are at risk for persistent or chronic pain associated with low back pain or prolonged pain after surgery. What makes these people more likely to experience this type of response? That’s the focus of this study.

    Other researchers have suggested a variety of ways catastrophizing might enhance or turn up the pain barometer. There may be social or emotional factors. There might be a specific neural (nerve) pathway that gets turned on. Or, as the results of this study showed, there could be an inflammatory process at the heart of the problem.

    In this study, participants were subjected to pain testing. Pain was created using several different techniques. Three sites were chosen and tested on both sides of the body: 1) the belly of the trapezius (neck) muscle, 2) the thumb joint, and 3) the quadriceps muscle where it inserts (connects) to the knee).

    First, the end of a probe was placed next to each of these three areas. Mechanical pressure was applied until the person felt pain. Second, a heat probe was applied to the same areas. Two temperatures were applied, and the subject rated how painful the stimulus felt from zero (no pain) to 100 (most intense pain possible). And last, the right hand was dunked in a bath of cold water a number of times until the hand was finally left in the tank until pain was perceived by the person being tested.

    Blood samples drawn before and after the testing were analyzed for levels of cortisol and interleukin-6 (IL-6). Cortisol (also known as cortisone) is a stress hormone. It is released in the body in response to stress. It increases blood pressure and blood sugar, and reduces immune responses. IL-6 is a chemical messenger that signals the immune system to launch a response. The end result is tissue inflammation causing joint and muscle pain.

    Results showed that both cortisol and IL-6 were elevated for the first 30 minutes after the pain-inducing procedures. Cortisol levels were back down to normal at the end of one hour. IL-6 remained elevated.

    People who catastrophized had higher levels of IL-6. The results suggest that mental and emotional responses during pain experiences can lead to inflammatory immune responses. And using scores from the Pain Catastrophizing Scale might be a way to predict IL-6 reactivity.

    The authors conclude that in some people, pain appears to cause a release of extra proinflammatory messengers that turn up the nervous system’s sensitivity. The result is an amplified (louder) broadcast of pain messages to the brain. So, we know there may be an inflammatory response as the main mechanism by which catastrophizing shapes pain responses. But we still don’t know the exact way in which catastrophizing turns on the cascade of steps leading to inflammation.

    Clearly, there is a link between psychologic processes and central pain processing. Screening patients for catastrophizing might help identify patients at risk for this immune-based pain response. The next step is finding a way to turn it down or off to prevent a chronic pain response from developing.

    Preparing Healthcare Professionals for Patient Pain Management

    Patient-centered pain management is an important part of every health care professional’s working day. Dentists, doctors, nurses, physical and occupational therapists, and pharmacists address patient concerns about pain each and every day. In this article, faculty from the University of Toronto (Canada) present the Interfaculty Pain Curriculum (IPC) that they developed to help students in these six disciplines prepare for this part of their clinical practice.

    They were aware that pre-licensure preparation was limited and lacking in their own program. So they put together a core group of classes to help students in all areas become more knowledgeable in the area of pain management. They wanted the students to understand how to talk with patients about their pain and work together with other team members to help patients manage their pain.

    Over a period of six years, they tested and modified the program. They used students’ comments, feedback from the faculty, and suggestions from clinical instructors and supervisors to refine the design, improve the process, and update the content.

    The 20-hour curriculum is now presented to all pre-licensure students. The material is covered in one three-and-a-half day period of time. The method of instruction is not just lecture, but also patient cases, large group sessions, and small interprofessional student learning groups. Efforts are made to help students understand the physiology of pain while also seeing the personal side of it from the patient’s point-of-view living with chronic pain.

    All kinds of pain types are included such as acute pain, chronic pain, pain in children and teens, cancer pain, arthritis pain, phantom pain after amputation, and other types of neuropathic (nerve) pain. Students are taught how to assess and manage pain. There is an emphasis on a team approach. Topics covered vary a bit from year to year based on current research and evidence from published studies.

    The faculty has worked hard to create a relevant learning experience for the many different student groups. Keeping the main goal in mind (teaching students patient-centered care using an interprofessional approach), the faculty worked together to create a tight program without gaps in content.

    They recognized, discussed, and collaborated on the importance of giving students as much clinical application as possible. Learning by doing with real patient problems is now a key focus of the program. As in real life, the cases involve more than one discipline at a time. The hope is that this will help students early on in their training to see how a team approach benefits the patient.

    The faculty was also able to narrow down what kind of resources are helpful to students during this learning experience. They developed a student manual, list of resource readings, and on-line reference materials. The manual has information on scheduling, group assignments, and a list of the resources to guide the student through the process.

    And, in an effort to continue refining the curriculum design and content, an evaluation is done each year by all students and involved faculty members. The students fill out several different questionnaires designed to measure their beliefs about pain before and after the program. Another set of tests is completed to find out what the students thought about the program.

    As time went on, the faculty was able to find a way to test whether the students were using the knowledge they learned from the course when practicing in the clinic with patients. Transfer of learning can be a difficult concept to measure. This is especially true when there is such a wide range of students.

    For any program considering putting together a similar curriculum, the authors of this article included many details of their own process. They created tables to summarize what they found in terms of learning issues and how they revised the design and content of their curriculum. They developed and share with the readers a Comprehensive Pain Management Plan (CPMP). This tool is used to measure effectiveness of the program and transfer of knowledge.

    Analysis of the data collected from the participating students suggests that the program is effective. Students report increased awareness of patients’ pain, their own unique role in pain management, and an appreciation for what other professionals can offer patients in pain.

    The faculty believes that early education is important to promote positive attitudes in students who will eventually be working with chronic pain patients. They report that their program is comprehensive yet realistic. They strongly recommend continuing the problem-based approach. Using the small interprofessional groups to work on, put together, and present case studies helps make the learning process permanent and transferable to the clinic.

    The authors conclude the Interfaculty Pain Curriculum (IPC) is a successful interprofessional curriculum model on pain education. It uses a variety of learning tools and keeps abreast of changes in clinical practice for the treatment of pain problems. Future efforts will be made to examine the long-term impact of this program.

    Good Oversight May Assure Safety of Analgesia

    Pain is one of the most common reasons why someone goes to the doctor. This is for both acute (sudden) and chronic (long-term) pain. If non-medical treatment doesn’t work, such as rest, ice, exercise, for example, the next step is usually to use medications. Analgesics, medications to relieve pain, are among the most widely prescribed medications because of the high number of people who live with pain. Despite all that researchers have learned about pain management, many people are still experiencing moderate to severe pain, somewhere between 20 percent and 40 percent.

    When treating rheumatoid arthritis, for example, doctors have available topical agents (creams or ointments), non-steroidal anti-inflammatory drugs (NSAIDs), opioids (controlled drugs, also called narcotics), and many other types of medications. Yet, most people with rheumatoid arthritis still experience a high level of pain. Cancer is another illness that can cause severe pain. It’s estimated that half of people with cancer do not receive adequate pain management.

    Many studies that have looked into pain treatment and its effectiveness have been relatively short-term studies and, if the improvement is up to 30 percent, this is considered to be significant, or good. That leaves 70 percent without adequate relief. Understanding how pain management works would help doctors and researchers come up with better pain management strategies. The authors of this article looked into the consequences of finding “profoundly” effective pain relieving treatments.

    When analgesics are used to relieve pain, the medications work to stop the cause of the pain, for example an anti-inflammatory will reduce inflammation and thus reduce pain, or to interrupt the pain messages to the brain, like opioids do. A local anesthetic, like a topical cream or something injected directly into the area numbs the pain so the sensation isn’t transmitted to the brain. The problem with medications is that not all medications work for all types of pain or all people. There are also side effects that can make the medications intolerable for some people.

    Sometimes, an illness or syndrome may cause an altered sensation of pain and this has given researchers a different insight. People with these syndromes may not feel the pain as the body normally does. These conditions are rare, but researchers have found that part of the problem is the way the person’s body has a gene defect that reduces nerve growth factor signaling. Using this knowledge, researchers are working on medications that do the same thing, interfere with the nerve growth factor signaling.

    In one study, done by Cox and colleagues, researchers studied three different families who had a congenital (born with) lack of sensitivity to pain. Although the children in the family were able to feel normal hot, cold, touch and motion, they couldn’t feel pain. Nerve tests didn’t find any abnormality, it just was as if they just did not feel pain.

    Often, in medical reports of people who don’t feel pain, there are a lot of negative issues. For example, from birth, they may hurt themselves on purpose (self-mutilation) and have repeated accidents that can lead to severe injuries. But not all people with lack of pain are born that way either. Some come by this situation later on in life. People with diabetic neuropathy, a condition where people with diabetes have problems feeling their feet and toes properly, can develop severe injuries on their feet. They may not know they even have a blister or cut until it becomes infected and they happen to see it. It’s also been found that people with diabetes can have what is called silent ischemia. Ischemia is a condition where blood flow to the heart is restricted but usually causes chest pain. Silent ischemia means the person has ischemia, but there isn’t any pain. Other people who have altered or no pain sensation are those who have spinal damage that results in paralysis and lack of sensation below the injury.

    So far, there hasn’t been any research in the psychological impact of children who don’t feel pain. Other than self-mutilation, researchers don’t know how lack of pain may affect how they see the world and themselves. However, it is thought that this lack of pain could and would lead to social and psychological disturbances.

    So, knowing the drawbacks of eliminating pain completely, the whole issue of treating pain often comes down to a single problem, how much pain relief does each individual need? Should the ability to feel pain be eliminated completely? Some patients need or want much more pain relief than some others need. Whether this can lead to abuse of the drug or addiction also depends on many things, such as the level of pain, the patient’s pain threshold, the type of pain, and what is causing it, among other issues.

    The potential for abusing some pain relievers, such as opioids, is a constant worry for many healthcare providers and for some patients as well. At this point, researchers haven’t found that profound analgesia, a deep analgesia, given to someone who isn’t in pain causes addiction. They also haven’t found that giving it makes people need more. But, there are concerns about some other issues that can come up with using analgesics to numb pain that hasn’t been experienced yet. This is the potential for people like athletes who want to play through the pain, perhaps causing more injury that can be more severe or even permanent. There is also a concern that the criminal element could get hold of this type of thing and then not think twice about getting hurt, because he or she wouldn’t feel it.

    These concerns are all valid and upfront among researchers who are trying to find better and more effective methods of pain relief. In the search for adequate pain relief, should the goal be complete pain relief or elimination of pain? And if that is available, should this be offered to everyone or to a few people with specific types of pain? How would society be affected if all pain were eliminated?

    The authors of this study wrote that some of the issues to be considered include the study process. They feel that the fewer patients involved in these studies, the better. Researchers would have to carefully watch for signs of accidental injuries and for self-mutilation. One thing to consider is that perhaps patients of limited time, those with cancer or are in palliative care for example, may be the right candidates for total elimination of pain.

    They also wrote that the government would need to be aware of the research and at what level of development the medications are. There will need to be an evaluation as to whether these medications should be considered controlled or restricted medications as are opioids. Once the medications are available to the general public, doctors would need specific guidelines to help them understand which patient groups need this type of treatment and how to go about it.

    In conclusion, the authors believe that although the medical community better understands pain, there’s still a lot of work that needs to be done. However, as we get closer to medications that may be able to eliminate pain, the ethical issue of who, where, and for what reason, will all need to be addressed.