RSD - Nothing Left To Chance

Speculative Studies - Opioid Use & Cancer Growth?

2010-01-17T13:40:00.000-08:00

January 2010

Does Morphine Encourage Cancer Growth?

"Some recent scary headlines in the lay press hyped a very preliminary study in lung cancer cell lines, suggesting that use of morphine (or other opioids) in advanced cancer patients may hasten death, and that methylnaltrexone, a peripherally acting opioid antagonist, may retard cancer growth. The news reports cite "growing clinical evidence" of this phenomenon. Unfortunately, the "clinical evidence" cited is barely tenuous and the laboratory studies are very preliminary.

The news reports were based on a press release by the University of Chicago press office. It should be noted that methylnaltrexone, which is currently indicated only for opioid-induced constipation in advanced cancer patients, was developed at the University of Chicago and licensed to a pharmaceutical company.

The press release is based on a presentation at a scientific meeting. Even early research findings by well-regarded scientists must be subjected to peer review through publication in reputable scientific journals; this report is yet to be published.

The research was initiated after a small number of patients in a methylnaltrexone study lived longer than expected. Similarly, a very small number of patients with advanced cancer in an intrathecal analgesic study lived a little longer than expected (but did not reach statistical significance, and it was not a study end-point).

Three small, single-institution clinical studies are mentioned (two of them at the same institution in Ireland). Longevity related to opioid use was not a study question in any of these studies. There are multiple other factors that could have contributed to any perceived survival advantage.

There are several small studies which show that well-managed pain (using aggressive opioid treatment) in end-stage disease does not shorten life and may have a slight survival advantage in some cases (these studies did not address the direct affect of opioids on tumor growth, which is the presumed reason for the observed survival effect).

Opioid analgesics have a long and well-documented track record of relieving pain and dyspnea associated with advanced cancer, reducing suffering, and improving quality of life.

Clinical practice in any arena should not be changed based on the findings of a single study, even one that is well-designed and conducted. The findings from these studies are speculative. From a research perspective they raise interesting questions that suggest hypotheses and form the basis for future laboratory research. Based on results of those future studies, clinical trials can then be designed.

There is some fascinating science at work in this, and it will be prudent to follow its progress in the coming years. However, it would be imprudent, at best, to change current pain management practices with opioid analgesics based on this report. Patients and clinicians need to have the news reports put in perspective."

Thomas Quinn, APRN, MSN
Yale Cancer Center

OTC Medication Recall - Motrin, Benadryl, Rolaids

2010-01-15T15:19:00.000-08:00

In consultation with the U.S. Food and Drug Administration (FDA), McNeil Consumer Healthcare has voluntarily recalled certain lot numbers following an investigation of consumer reports of an unusual moldy, musty, or mildew-like odor. The odor was associated with temporary, non-serious gastrointestinal symptoms, including nausea, stomach pain, vomiting, and/or diarrhea.

This recall expands an earlier recall of acetaminophen 100-count bottles with EZ open caps labeled Tylenol Arthritis that began in late 2009. Some of the medications included in this expanded recall are used in the treatment of pain, like:

Children’s Motrin
Children’s Meltaway Tylenol
Benadryl
Extra Strength Tylenol
Regular Strength Tylenol
Motrin IB
Rolaids
St. Joseph Aspirin
Tylenol 8 hour

Specific lot numbers affected by this recall can be found at http://www.mcneilproductrecall.com/
To find if you are in possession of any of the affected products, look on the side of the bottle label for the lot number.

Individuals who may have ANY of these lots in their possession should:
1. Stop taking the medication.
2. Contact your healthcare provider if you have recently taken any of these medications and are experiencing symptoms as listed above or have medically-related questions.
3. Report any adverse reactions to the FDA’s MedWatch Program by:o Fax: 1-800-FDA-0178,o Mail: MedWatch, FDA, 5600 Fishers Lane, Rockville, MD 20852-9787o Internet:(Medwatch website)
4. Contact McNeil Consumer Healthcare for instructions if you wish to obtain replacement medications or a refund and also to receive information about safe disposal of these products.

The public may direct questions to McNeil Consumer Healthcare or 1-888-222-6036 (Monday-Friday, 8:00 a.m. to 10:00 p.m. Eastern time and Saturday-Sunday 9:00 a.m. to 5:00 p.m. Eastern time).

Johnson & Johnson expands voluntary recall of Tylenol Arthritis Pain caplets

Johnson & Johnson, the makers of Tylenol Arthritis Pain caplets, is expanding a voluntary recall of the product because of consumer complaints of a strange, moldy smell that has caused nausea and other ailments. The health care company, based in New Brunswick, N.J., is now recalling all 100-count bottles of the arthritis caplets with the red E-Z Open Cap. Last month, Johnson & Johnson recalled five lots of the pain medicine after consumers complained of a mildew-like odor from the pills that produced nausea, vomiting, stomach pain and diarrhea.

The pills’ musty odor comes from trace amounts of a chemical known as 2, 4, 6-tribromoanisole, according to the company, which is believed to be from the breakdown of another chemical in wooden pallets used to transport and store the drugs.

To date, the health complaints have been “temporary and nonserious,” according to a press release by McNeil Consumer Health Care, the division of J&J that sells Tylenol, although the health effects of the chemical have not been studied.Johnson & Johnson will move production of the caplets to a new facility and return the product to the market by January.

Consumers are advised to stop using the product and call the company at (888) 222-6036 for a refund. Additional information on the recall can be found online at Tylenol's Web site.

Managing Your Pain: How to Use Prescription Drugs Without Becoming Addicted

2009-11-17T13:43:00.000-08:00

While the stories of current and former prescription opioid addicts are frightening, chronic pain experts note that addiction is relatively rare and that these drugs do offer benefits when they are properly prescribed and used. And there is certainly a need for them. Be smart if you take prescription opioids—and find alternative forms of relief

Posted October 26, 2009
Michael Jackson's death has brought renewed attention to prescription drug abuse, which has long been a problem for everyday Americans as well as pill-popping celebrities. About 48 million people, or 20 percent of Americans over age 12, have taken prescription medications—often, the painkillers called opioids—for nonmedical reasons, according to the National Institute on Drug Abuse, and seniors are particularly vulnerable since they often juggle many medications. Those prescription opioids cause more drug overdose deaths than heroin and cocaine combined, according to the Drug Enforcement Administration. (Drowsiness, respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, and coma are among the potential health consequences of abusing the drugs.) Meantime, painkiller-related admissions to state-licensed treatment centers are on the rise, according to a March report.

Michele Braa-Heidner, 47, started taking prescription painkillers in 1995, when she had her wisdom teeth removed. Soon after, she developed a painful spinal condition for which she needed several surgeries—and more medications. The drugs relieved the pain and "made me feel really good," she says. Soon, she found that she couldn't get through the day without them. "You're almost chasing that first high, [but] you never get it anymore unless you take a huge amount," she says.

But while the stories of current and former prescription opioid addicts are frightening, chronic pain experts note that addiction is relatively rare and that these drugs do offer benefits when they are properly prescribed and used. And there is certainly a need for them. More than a quarter of Americans age 20 or older—more than 76 million people—say they've experienced pain that lasted longer than 24 hours, according to the American Pain Foundation, and 42 percent of those sufferers have endured pain lasting longer than a year. For many of these people, prescription opioids like the oxycodone (commonly sold as OxyContin) and hydrocodone (sold most popularly as Vicodin) used by Braa-Heidner, as well as meperidine (sold as Demerol) and others, are very helpful. "I think the fear can be a huge barrier to proper pain control," says Paul Christo, director of the multidisciplinary pain fellowship program at the Johns Hopkins University School of Medicine. So how should you approach using a pain medication to get the relief you need without getting hooked?

First, experts say it's best to stick with one doctor to coordinate your care; that way, she will keep tabs on all the pain medications you're taking. She may also be looking for signs of abuse. Pain specialists can monitor pill use and do urine drug testing to ward off addiction in their patients. They may also require patients to sign treatment agreements that give the doctor permission to take certain steps if he or she suspects addiction—including talking to family members about suspected abuse, says Howard Heit, a pain management and addiction medicine specialist based in Fairfax, Va.

And there are other systemic measures in place to help curb abuse. By July of this year, 40 states had passed legislation to start prescription drug monitoring programs to keep tabs on when, where, and for whom controlled substances, including opioids, are dispensed. There's even a push to fund a federal program, approved by Congress but never put into action, to monitor opioid prescriptions from state to state. Meantime, after being prompted by the Food and Drug Administration, drug companies are trying to do their part to ease the problem by reformulating drugs to make them more difficult to abuse. An FDA advisory panel recently recommended approving a new formulation of OxyContin that would reduce the amount of medication released when tablets are crushed or chewed—common methods used by abusers to boost the impact of the drug. (The FDA typically follows the advice of its expert panels.)

If your pain isn't improving, talk to your physician. It's a bad idea to take medications that haven't been prescribed for you, so don't be tempted to use pills intended for a friend or relative. Instead, see if a different medication or dosing schedule might make things better, and be sure to consider alternative ways of managing pain that might work instead of or in tandem with powerful opioids.

Experts say that injections of steroids or other medications, nerve blocks that interrupt pain signals, physical therapy, and psychological interventions such as cognitive behavioral therapy, biofeedback, and guided imagery, as well as other relaxation techniques can all be beneficial. Acupuncture is another option. It's thought to ease pain by raising the level of endorphins—the body's natural pain relievers—in the body, Christo says. "They are released when the body experiences pain, when you sprain your ankle, cut your finger—in response to injury." The therapy may work for some but isn't a cure-all; a review of 13 studies published in January in the British Medical Journal found that acupuncture offered only a small level of relief for people with low-back pain, migraines, knee osteoarthritis, and postoperative pain.

And while it may sound counterintuitive, people with chronic pain should try to get exercise, both for the same health reasons as everyone else and, specifically, to avoid muscle atrophy. A 2005 study published in the Annals of Internal Medicine found that a supervised, individually tailored exercise program may help both ease pain and improve function. A physical therapist or personal trainer can help.

If you are using prescription opioids, be aware of the different states that your body may experience. Tolerance occurs when the body adjusts to one dosage and needs increasingly more medication over time to achieve the same result. (This also applies to side effects, so if opioids make you itch, for instance, that feeling may go away as your body adjusts.) People should not be overly concerned about developing tolerance to pain medications, because it's a part of taking the drugs, experts say. Users can also experience physical dependence, causing withdrawal symptoms such as diarrhea, perspiration, and abdominal cramping when they abruptly stop taking the medication. It can occur after as few as two days of continuous use; to reduce symptoms, physicians can help you taper off the dosage, says Christo.

Addiction is far more serious. It involves compulsive use of the drug, continued use despite harm to a person or loved ones, and cravings for the substance. Not everyone who takes the medicine will get hooked, even with years of use, and there's no sure way to predict who will. Wonder if you have a problem? The hallmarks of addiction are an inability to keep up with work, school, or family matters as a result of drug abuse, and an inability (or refusal) to stop despite those consequences, says Scott Fishman, professor and chief of pain medicine at the University of California-Davis School of Medicine.

If you suspect that you or a family member might have developed an addiction to prescription opioids, contact a doctor (a personal physician or a local addiction medicine specialist). Some physicians prescribe the medication buprenorphine—a narcotic sold under the brand name Suboxone that makes it easier to withdraw from prescription opioids—for outpatient use. This is not a do-it-yourself project; this medication can also be abused and needs to be used under a doctor's supervision. And be sure there's a plan for ending its use. For more severe cases, people may be referred to treatment centers, which offer detox and treatment.

Patients admitted to the Betty Ford Center in Rancho Mirage, Calif., are first put on buprenorphine, then weaned off the drug quickly. "The drug is only a step to facilitate recovery," says Garrett O'Connor, president of the Betty Ford Institute, the nonprofit arm of the treatment center. Traditional 12-step programs are also necessary, he says, because a "major part of recovery is doing work on character defects and lifestyle problems [such as] grandiosity, antisocial activity, cheating, lying, being unaccountable and irresponsible. They're the things that have to be examined and then put into reverse," says O'Connor.

As for Braa-Heidner, she's stopped using the drugs that got her in trouble. She soon plans to start, with the help of her psychiatrist, slowly tapering off Suboxone. The drug "has helped me in regards to normalizing my life and getting me out of the ups and downs of taking pain meds every four hours, so I am grateful for that," she says. "I am feeling quite good about my life right now, and I am looking forward to succeeding at healing myself and getting off of Suboxone." It's time to put all the drugs aside.

U.S.News & World Report
J. W. P.

Social Security payments shrink in 2010-2011

2009-08-23T13:15:00.000-07:00

For many retirees, Social Security provides the only stable and predictable income in this uncertain economy where shrinking investments, rising food and fuel costs and skyrocketing healthcare expenses make living on a fixed income increasingly difficult. While Social Security remains the bedrock of retirement security, the average Social Security retirement benefit is modest. The trustees who oversee Social Security are projecting there won't be a cost of living adjustment (COLA) for the next two years. Next year, is the first time in a generation that payments would not rise. That hasn't happened since automatic increases were adopted in 1975.

By law, Social Security benefits cannot go down. Nevertheless, monthly payments would drop for millions of people in the Medicare prescription drug program because the premiums, which often are deducted from Social Security payments, are scheduled to go up slightly. More than 32 million people are in the Medicare prescription drug program. Average monthly premiums are set to go from $28 this year to $30 next year, though they vary by plan. About 6 million people in the program have premiums deducted from their monthly Social Security payments, according to the Social Security Administration.

Millions of people with Medicare Part B coverage for doctors' visits also have their premiums deducted from Social Security payments. Part B premiums are expected to rise as well. But under the law, the increase cannot be larger than the increase in Social Security benefits for most recipients. It is predicted Medicare premiums and out-of-pocket expenses will consume nearly $3 of every $10 of the average Social Security benefit.

President Barack Obama has said he would like tackle Social Security next year, after Congress finishes work on health care, climate change and new financial regulations. Social Security is facing long-term financial problems. The retirement program is projected to start paying out more money than it receives in 2016. Without changes, the retirement fund will be depleted in 2037, according to the Social Security trustees' annual report this year.

Lawmakers are preoccupied by health care, making it difficult to address other tough issues. Advocates for older people hope their efforts will get a boost in October, when the Social Security Administration officially announces that there will not be an increase in benefits next year.

Prescription Pain Medication Addiction

2009-08-15T12:58:00.000-07:00

Prescription pain medicine addiction grabs headlines when it sends celebrities spinning out of control. It also plagues many people out of the spotlight who grapple with painkiller addiction behind closed doors. But although widespread, addiction to prescription painkillers is also widely misunderstood -- and those misunderstandings can be dangerous and frightening for patients dealing with pain. Where is the line between appropriate use and addiction to prescription pain medicines? And how can patients stay on the right side of that line, without suffering needlessly?

Here are seven myths they identified about addiction to prescription pain medication.

1. Myth: If I need higher doses or have withdrawal symptoms when I quit, I'm addicted.
Reality: That might sound like addiction to you, but it's not how doctors and addiction specialists define addiction. "Everybody can become tolerant and dependent to a medication, and that does not mean that they are addicted," says Christopher Gharibo, MD, director of pain medicine at the NYU Langone Medical School and NYU Hospital for Joint Diseases. Tolerance and dependence don't just happen with prescription pain drugs, notes Scott Fishman, MD, professor of anesthesiology and chief of the division of pain medicine at the University of California, Davis School of Medicine. "They occur in drugs that aren't addictive at all, and they occur in drugs that are addictive. So it's independent of addiction," says Fishman, who is the president and chairman of the American Pain Foundation and a past president of the American Academy of Pain Medication. Many people mistakenly use the term "addiction" to refer to physical dependence. That includes doctors. "Probably not a week goes by that I don't hear from a doctor who wants me to see their patient because they think they're addicted, but really they're just physically dependent," Fishman says. Fishman defines addiction as a "chronic disease ... that's typically defined by causing the compulsive use of a drug that produces harm or dysfunction, and the continued use despite that dysfunction."

2. Myth: Everyone gets addicted to pain drugs if they take them long enough.
Reality: "The vast majority of people, when prescribed these medications, use them correctly without developing addiction," says Marvin Seppala, MD, chief medical officer at the Hazelden Foundation, an addiction treatment center in Center City, Minn. "I think where it gets really complicated is when you've got somebody that's in chronic pain and they wind up needing higher and higher doses, and you don't know if this is a sign that they're developing problems of addiction because something is really happening in their brain that's ... getting them more compulsively involved in taking the drug, or if their pain is getting worse because their disease is getting worse, or because they're developing tolerance to the painkiller," says Susan Weiss, PhD, chief of the science policy branch at the National Institute on Drug Abuse.

3. Myth: Because most people don't get addicted to painkillers, I can use them as I please.
Reality: You need to use prescription painkillers (and any other drug) properly. It's not something patients should tinker with themselves. Gharibo says that he doesn't encourage using opioids alone, but as part of a plan that also includes other treatment -- including other types of drugs, as well as physical therapy and psychotherapy, when needed.

4. Myth: It's better to bear the pain than to risk addiction.
Reality: Undertreating pain can cause needless suffering. If you have pain, talk to your doctor about it, and if you're afraid about addiction, talk with them about that, too. Fishman remembers a man who came to his emergency room with pain from prostate cancer that had spread throughout his body. "He was on no pain medicine at all," Fishman recalls. Fishman wrote the man a prescription for morphine, and the next day, the man was out golfing. "But a week later, he was back in the emergency room with pain out of control," says Fishman. "He stopped taking his morphine because he thought anyone who took morphine for more than a week was an addict. And he was afraid that he was going to start robbing liquor stores and stealing lottery tickets. So these are very pervasive beliefs."

5. Myth: All that matters is easing my pain.
Reality: Pain relief is key, but it's not the only goal. "We're focusing on functional restoration when we prescribe analgesics or any intervention to control the patient's pain," says Gharibo. He explains that functional restoration means "being autonomous, being able to attend to their activities of daily living, as well as forming friendships and an appropriate social environment." In other words, pain relief isn't enough.

6. Myth: I'm a strong person. I won't get addicted.
Reality: Addiction isn't about willpower, and it's not a moral failure. It's a chronic disease, and some people are genetically more vulnerable than others, notes Fishman. "The main risk factor for addiction is genetic predisposition," Seppala agrees. "Do you have a family history of alcohol or addiction? Or do you have a history yourself and now you're in recovery from that? That genetic history would potentially place you at higher risk of addiction for any substance, and in particular, you should be careful using the opioids for any length of time." Don't share prescription pain pills and don't leave them somewhere that people could help themselves. "These are not something that you should hand out to your friends or relatives or leave around so that people can take a few from you without your even noticing it," says Weiss.

7. Myth: My doctor will steer me clear of addiction.
Reality: Doctors certainly don't want their patients to get addicted. But they may not have much training in addiction, or in pain management. Most doctors don't get much training in either topic, says Seppala. "We've got a naïve physician population providing pain care and not knowing much about addiction. That's a bad combination." Fishman agrees and urges patients to educate themselves about their prescriptions and to work with their doctors. "The best relationships are the ones where you're partnering with your clinicians and exchanging ideas."

Misinformation About Hospice\Palliative Medicine in Health Care Reform Bill

2009-07-31T12:48:00.000-07:00

Help Correct Misinformation About Hospice and Palliative Medicine in Health Care Reform Bill

The American Pain Foundation and the American Academy of Hospice & Palliative Medicine (AAHPM) request your help in correcting misinformation about hospice and palliative medicine in the health care reform bill. Your voice is urgently needed to weigh in on the health care reform debate. Provisions AAHPM worked hard to have included in health care reform legislation are now being attacked, and some members of Congress have been hearing from constituents who've been misinformed. We need you to correct the record!

America's Affordable Health Choices Act (H.R. 3200) contains a provision that would provide coverage under Medicare for people to talk to their doctor about their wishes and care preferences at the end of life. This has prompted some groups to falsely claim that care planning consultations include "euthanasia," that physicians would be required to "recommend a method for death" and that such consultations would be "mandatory every five years." These claims are blatantly false.

The provision included in H.R. 3200 simply allows Medicare to pay for a conversation between a patient and their doctor if the patient wishes to speak about their preferences and values. This benefit would be purely voluntary, and patients do not need to have this consultation with their doctor if they do not wish to do so. The new Medicare benefit would allow doctors to be compensated for these conversations every five years, and more frequently if a patient has a life-limiting illness or health status changes.

Staff for U.S. Rep. Earl Blumenauer (D-OR), who sponsored the original legislation on advance directives, have been reaching out to other Congressional offices in an effort to clarify mischaracterizations of the health care reform legislation. Now they are asking to hear from you. They need quotes from patient advocates and health care providers so they can help correct the record and promote the benefits of advance care planning among the members of Congress.

If you wish to weigh in on this legislation, please forward a quote - no more than a few sentences - to Christa Shively in Sen. Blumenauer's office stating why these provisions in the health care reform bill are important. These should be positive statements about improving patient care and helping families through difficult times. They need your feedback as soon as possible. You may also want to follow up with your own representatives in Congress - let them know that you support this and other hospice and palliative care provisions in the health care reform bills.

Please contact AAHPM Advocacy with any questions.

PLEASE NOTE: Members of Congress will recess and return to their home states for an August work period. AAHPM urges you to make an appointment with your representatives for this time, to discuss the benefits of hospice and palliative care provisions now included in the health care reform bills. Your voice is crucial to ensuring all of these provisions remain in the final version of reform legislation.

Q&A on Acetaminophen and Opioids

2009-07-13T11:56:00.000-07:00

FDA Panel Recommends Market Removal of Opioid plus Acetaminophen Preparations Causing Concern for Individuals Living With Pain
July 1, 2009

Acetaminophen has been on the market for over 50 years and alone is used to treat mild pain and fever. On June 30, 2009, a Food and Drug Administration (FDA) Advisory Committee released recommendations to limit acetaminophen dosages in over the counter (OTC) preparations due to the growing risks of liver damage. This committee was charged to identify ways to lessen this serious health effect associated with acetaminophen, one of the most widely used medications in the U.S. Adult and pediatric OTC formulations of acetaminophen vary in dosing ranges. It is available in a large variety of familiar preparations for minor pain and headache, like regular strength (Tylenol), “extra-strength” (Tylenol ES), a variety of sinus and allergy brands, and cold and cough remedies as well as prescription pain medications for the treatment of mild to moderate pain. This FDA panel of experts voted 36-1 that any preparation on the market should carry a black box warning, the most serious safety label available. Additionally, the panel voted 20-17 for the removal from the market all combination opioid medications that contain acetaminophen. The most common of these preparations are oxycodone+acetaminophen (Percocet, Tylox) and hydrocodone+acetaminophen (Vicodin, Lortab).
Q: Why is acetaminophen combined with opioids in some formulations?
A: Acetaminophen was added to opioid preparations for several reasons:
1. For convenience, because it is easier to take one combined pill rather than two.
2. As a chemical partner so that together pain relief could match what a higher dose of opioid could achieve alone. For example, 7.5 mg of hydrocodone+acetaminophen (classed as a Schedule III Controlled Substance: less restrictive) would equal the effect of one 15 mg dose of hydrocodone (which would be required to be classed as a Schedule II Controlled Substance: more restrictive).
3. It was originally believed that in combination, the medication would be less desirable to substance abusers. However, research has shown that hydrocodone+acetaminophen has ranked highest in the list of misused or abused prescription pain medications over several years. Oxycodone+acetaminophen is not far behind.
Q: Can acetaminophen combined with opioids be risky to my health?
A: At recommended doses acetaminophen does not cause problems, such as stomach discomfort and bleeding, and acetaminophen is considered safe when used according to the directions on its OTC or prescription labeling. However, taking more than the recommended amount can cause liver damage, which can range from abnormal liver function blood tests, to acute liver failure, and even death. Many cases of overdose are caused by individuals who inadvertently take more than the recommended dose (i.e., 4 grams a day) of a particular product, or by taking more than one product containing acetaminophen (e.g., an OTC product and an prescription medication containing acetaminophen). Panel experts cited FDA data that showed approximately 60 percent of acetaminophen-related deaths were related to prescription products.
Liver injury is related to the production of a toxic end-product when acetaminophen is broken down by the body (metabolized). The toxin binds with liver proteins that cause cell injury or cell death. Those with healthy, young and mature livers can remove the toxins more quickly and limit the amount of liver injury as compared to those not so fortunate. Drinking alcohol can slow the removal of toxins even more.
Q: What are the signs of liver failure?
A: Liver failure is a life-threatening condition and demands immediate medical care. Chronic liver failure occurs gradually over time. Acute liver failure occurs suddenly and progresses rapidly (in as little as 48 hours) yet can be difficult to detect initially. The initial symptoms of liver failure are often those commonly seen with a number of conditions, making this challenging to diagnose. Early symptoms include:
* Nausea
* Loss of appetite
* Fatigue
* Diarrhea
As liver failure progresses, the symptoms become more serious.
* Jaundice (Yellow to orange discoloration of the skin and mucous membranes—mouth, eyes. stools)
* Bleeding easily
* Swollen abdomen
* Mental disorientation or confusion (known as hepatic encephalopathy)
* Sleepiness
* Loss of Consciousness and Coma
Q: Could this FDA recommendation be good news?
A: Yes. All medications have some risk and it is important that the benefit outweighs the risk. Though change can be difficult, safety should outweigh convenience. Not knowing if you are taking too much acetaminophen can be dangerous. It is important to use this opportunity to discuss your risk with your pain care provider based on the amount of acetaminophen that you are taking by prescription and over the counter.
Q: I am currently taking Vicodin [Percocet] for the management of my pain. What should I do now?
A: Your first reaction may be “great, now the government is trying to take away my pain medication” or “this is the only pain medication that my doctor will give me” or “I finally found a medicine that works and now it’s gone.”
First: The FDA has not acted on the recommendation from the advisory committee. Right now, they are still available. APF will monitor for their actions.
Second: Plan ahead. You have time to discuss your options with your healthcare professional, should the FDA decide to remove these combination opioid products from the market. This is the time to look at your risks of acetaminophen exposure. You may be surprised at how much you are taking when you add your prescription opioids, OTC headache, allergy or sinus pills, OTC pain relievers for arthritis or minor aches/strains/sprains, etc. Talk with your pain care provider about lowering your exposure to acetaminophen. Take advantage of this opportunity, it may not be a terrible situation as you first thought.
* If you are taking a hydrocodone+acetaminophen product (Vicodin, Lortab, Lorcet), a trial of Vicoprofen or Hycomen might be considered or a change to another opioid or opioid- like medication {unfortunately, there is no plain hydrocodone on the market};
* If you are taking an oxycodone+acetaminophen product (Percocet, Tylox), a trial of plain oxycodone (OxyIR, generic oxycodone, Roxicodone, OxyFast) might be considered or a change to another opioid or opioid- like medication.
* Talk about other treatment options, see: http://www.painfoundation.org/Publications/TreatmentOptions2006.pdf

2009-06-11T12:18:00.000-07:00

More Than a Feeling
New approaches to treating complex regional pain syndrome are helping redefine “mystery pain.”

Max Sokolnicki knows all too well how the pain of complex regional pain syndrome (CRPS) can take over your life. Sokolnicki, 52, of Chesterfield Township, MI, used to be a project manager in a technical training firm in the automotive industry before a botched hip replacement surgery in 2002 damaged his sciatic nerve and triggered CRPS. Today the former soccer player and coach is unemployed, lives on disability, and uses a cane or wheelchair to get around. The pain is centered in his right foot, he says, which feels as if it is surrounded by a block of ice and is often so cold that it burns. That’s only part of the sensation, however; the other part feels like “some kind of small animal chewing at my foot as someone tries to peel my skin back.” While he has found some relief with neurostimulation, he says he is never pain free.

Molly Skipper, who also suffers from CRPS, spent her 16th birthday bedridden, rocking back and forth in pain, terrified that doctors were going to amputate her leg. All because a few months before she'd slipped and fallen, banging her left knee on the handle of a kitchen cabinet. It’s an injury that in most people would have resulted in nothing more than a bruise and some minor discomfort. But for Molly and thousands like her, a bump, fracture, or surgical procedure can turn into intense, unrelenting pain that sends them careening from doctor to doctor in search of relief.

These people have a condition called complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy (RSD) or causalgia (from the Greek words for “heat” and “pain”). Relatively rare—it affects an estimated 26 out of every 100,000 people—CRPS is up to four times more common in women and affects people of all ages, including children as young as three. Traditionally, anesthesiologists and other pain specialists have treated CRPS. But it is first and foremost a neurological condition, according to Anne Louise Oaklander, M.D., associate professor of neurology at Harvard Medical School in Boston and an expert on the disease.

Her research has begun to unravel the specific neurological mechanisms that may be at work in CRPS. Thus, she says, more neurologists need to be trained to diagnose and treat this devastating condition as a neurological condition, not a pain condition. “Having the pain reformulated as a neurologic problem opens the door to the kind of approaches neurologists are expert at,” she says. “Not just giving pain medication but curing the underlying problem.”

WHAT IS CRPS?
The primary symptom of CRPS is pain out of proportion to the initial injury that continues long after the trauma heals. The pain typically occurs in the hands, arms, legs, or feet, but can occur anywhere in the body. Left untreated, it can spread to other parts of the body, most commonly the “mirror limb” opposite the one where the damage first occurred. The pain is sometimes described as “burning,” and may be so bad that patients thrust the affected limb into buckets of ice or drape it in wet, cool cloths to stem the sensation. Others, however, can't tolerate any cold and find their pain worsens in the winter.

Over the years, doctors have used numerous tests to definitively diagnose CRPS, including X-rays, bone scans, MRI, thermography (which measures heat), and electromyogram (which measures nerve conduction). Sometimes these tests can help; but just as often, they can all be negative even in someone with CRPS. Plus, the testing itself can be extremely painful to someone with the condition.

Basically, then, CRPS is diagnosed based on the patient’s description of the symptoms, a comprehensive medical and physical history, and the exclusion of other conditions. That’s one reason the condition remains significantly under-diagnosed even by neurologists and pain specialists, says Joshua Prager, M.D., who directs the Center for the Rehabilitation of Pain Syndrome at the University of California, Los Angeles.

In fact, a survey by the support group American RSDHope (www.rsdhope.org) found that people with CRPS often see five or more doctors before receiving a diagnosis. Patients are often told they are depressed, anxious, or have some other psychiatric condition; suspected of trying to get drugs; or accused of “malingering,” says Dr. Oaklander.

The reality, however, is that the pain itself typically causes mental health issues. The RSDHope survey found that 67 percent of people with CRPS had considered suicide. The best option to ensure you get the correct diagnosis, says Dr. Oaklander, is to see a peripheral nerve specialist, a common neurology subspecialty.

TINY NERVE FIBERS
Every time you touch something hot, bang your shin, or get a paper cut, the communication network of your body switches into high gear. The pain signal travels along axons, fiber-like extensions from neurons that function like individual wires in a large fiber optic cable. The axons use special chemicals called neuropeptides to transmit the pain signal to nearby neurons. Eventually, the signal reaches the spinal cord and shoots up to the brain where it is “read.” All in a split second, of course. Axons come in all lengths, some longer than your leg. Until recently, researchers focused on large axons, the kind covered in fatty sheathing called myelin (hence the name, “myelinated fibers.”) As the tools used to observe nerve fibers have improved, researchers have been able to identify very tiny axonal fibers in peripheral nerves like those in the arms and legs.

More recently, Dr. Oaklander and others examined skin biopsies from patients with CRPS and found significant damage to these small-fiber axons. In some cases, they found, even the slightest injury to these fibers can cause misfiring and the release of excess neuropeptides. Essentially, the nerve fibers become stuck in the “on” position and burn out, leading to the numbness and loss of sensation people with CRPS often describe in the originally injured area. What appears to happen next is that other nearby fibers step in and also begin overfiring, says Dr. Oaklander. The result is hypersensitivity and chronic pain.

Dr. Oaklander’s finding of small-fiber axonal damage is important because it helps convince clinicians that CRPS is a real neurological condition. It also helps patients get approval for disability benefits or even certain medications, something that is difficult if no clear cause for the pain can be seen. “So being able to show damage with an objective test is critical,” says Dr. Oaklander. Functional MRI studies, which image blood flow to different parts of the brain in response to various stimuli, also show underlying changes in people with CRPS. A study published in November 2008 in the journal Neuron found significant alterations in the white matter of the brain, the part that transmits chemical messages between neurons, and shrinkage in the neuronal area, or gray matter. The changes are likely due to the pain itself, says Dr. Oaklander, since other MRI studies find such changes reverse when the pain improves.

INSANE WITH PAIN
One of the earliest written descriptions of CRPS comes from S. Weir Mitchell, a Civil War doctor who was struck by the severe, persistent pain experienced by some soldiers even after their wounds healed—pain that occurred with just the lightest touch. “He is…nervous and hysterical to such a degree that his relatives suppose him to be partially insane,” Dr. Mitchell wrote of a young man who had been shot at Gettysburg. “It is difficult even to examine him properly on account of his timidity, and his whole appearance exhibits the effects of pain…and want of rest.”

When Molly Skipper was in the midst of her CRPS episode, she was lucky if she averaged four hours of sleep a week. Her pain began about a week after she fell, just as she started her dream job at a newspaper in Meridian, MS. Within a few days she was on crutches. Then she couldn't walk at all. “I couldn't touch my leg, it was so painful,” she recalls. She saw numerous doctors, including a psychiatrist. Initially, the doctors thought she was imagining the pain. They came to believe it was real, however, when she was still in agony even after five nerve blocks, a procedure in which a local anesthetic is injected near the nerve. At one point she was taking 13 different medications and still found no relief. Doctors told her she would never walk again.

Finally, in the spring of 2006, her father’s coworker learned about Dr. Oaklander and her practice at Massachusetts General Hospital. Molly’s mother, Leslie Doolittle, called the doctor’s office and left a message. Dr. Oaklander returned the call on a Saturday morning and, after listening to a description of Molly’s condition, said, “I think I can help your daughter.” Molly’s mother burst into tears. This initiated a months long stay in Boston. Because Molly’s foot had shifted into an odd, painful position, Dr. Oaklander had a cast put on it, shifting the cast over time to gradually move the foot back into its normal position. She also weaned Molly off all medication and began a regimen of occupational and physical therapy designed to reduce the swelling, desensitize the leg, and gradually strengthen it and increase its use. By the time the cast was removed three months later, Molly’s foot was in a normal position and the pain was gone.

This multidisciplinary approach offers the best track record for treating CRPS, says Dr. Prager. “If you don't treat pain as a multidisciplinary problem then you can't rehabilitate the patient,” he explains. The essence of CRPS treatment is therapy—physical, occupational, and psychological. And not just an hour or two a day, but six or more hours a day of intensive physical and occupational therapy. It might begin with very simple steps, such as learning to tolerate the sensation of open air on the painful area. This desensitization escalates in a step-wise approach until eventually patients are able to actually scrub the region with a brush. The therapy may also involve hypnosis, biofeedback, and intensive physical therapy with range-of-motion exercises to strengthen the affected muscle and limb.

The psychological therapy used is called cognitive behavioral therapy. This form of therapy educates patients about their condition, helps them avoid “catastrophizing” (in which their perception of the pain makes it worse than it is), and teaches them techniques to better manage the pain and their response to it.

People with CRPS may also require medication or other options to bring the pain to a manageable level so they can even begin thinking about physical therapy and rehabilitation.

Although narcotics can be used, the condition tends to respond better to drugs used to treat other neurologic conditions:anticonvulsants like gabapentin, phenytoin, and carbamazepine; low-doses of antidepressants like nortriptyline, doxepin, desipramine, and trazodone, which block nerve impulses; and corticosteroids, which stem inflammation. Topical pain relievers like EMLA anesthetic cream (which contains lidocaine and prilocaine) and lidocaine patches may also help. Some doctors try bisphosphonates or calcitonin, drugs typically used to treat osteoporosis and cancer-related bone pain. There is some evidence they can relieve the pain of CRPS, most likely by reducing painful bone breakdown.

One approach that Dr. Oaklander says patients should avoid is the nerve blocks that Molly underwent. Not only is the relief temporary, wearing off when the anesthetic wears off, but repeated nerve blocks can result in even more nerve damage.

One approach that is being evaluated in clinical trials involves the infusion, over several days, of ketamine, an anesthetic that blocks receptors for glutamate. Glutamate is a neuropeptide used to convey messages from neuron to neuron; if the chemical doesn't clear out quickly after delivering its message, it can damage nerves. Studies find high amounts of glutamate and glutamate receptors in people with CRPS, suggesting some underlying contribution to the condition.

Some patients travel to Germany or other countries where they are put into a five-day “ketamine coma” to end the pain. But ketamine can have significant side effects, including hallucinations and delirium. Ketamine can also trigger changes in blood pressure and heart rate, as well as breathing problems. Dr. Prager also noted at least two significant complications with the ketamine coma, including one patient who needed a tracheostomy to breathe and another who died. “But the results are fairly miraculous,” he says, particularly since the approach is only used in those for whom nothing else has worked. One study in which 20 patients with intractable CRPS pain were given doses of ketamine similar to what is used during anesthesia for five days found that all were pain free a month after treatment, 17 were still pain free at three months, and 16 remained pain free at six months. Although there are no published results from randomized controlled trials on the use of ketamine in people with CRPS, one trial is currently ongoing.

None of these medications have been approved for CRPS and studies are few and far between on their effectiveness. However, insurance covers most treatments except the ketamine infusion, says Dr. Prager.

Some patients find relief from neurostimulation, in which a small electrical device implanted in the spine sends regular signals to nerves in the affected area, blocking the transmission of pain signals to the brain. “I believe in it,” says Dr. Prager, who implants about 100 devices a year. Plus, it’s fully reversible. “But I also believe that as a single solution it’s not good,” he adds. Case in point: He had one patient whose pain was completely relieved with neurostimulation but who then tried to commit suicide. Why? Because after living for years with the pain she had no job, no friends, and no support. Now the pain was gone, but she still had no job, no friends, and no support.

That’s why people with CRPS—indeed, any type of chronic pain—require a multidisciplinary approach to treatment, one that also involves psychological therapy. “The idea of treatment of CRPS is functional rehabilitation beyond the pain,” says Dr. Prager. “It’s better to get rid of the suffering from the pain than to just get rid of the pain.” Suffering from the pain differs from the pain itself, he explains, and it is the suffering—the way the pain takes over your life and affects all that you are—that accounts for much of the condition’s debilitation.

TAKING CONTROL
In the past year, Max Sokolnicki made a conscious decision to view his pain differently. “Instead of the pain having me, I'm saying that I have the pain,” he explains. It might seem like a small distinction, but it puts him in control of the pain, and control is an important thing when you are disabled and spend your days in pain. “I don't let the pain become a character in my life and define who I am anymore,” he says. Today Sokolnicki volunteers at a hospice, runs a chronic pain support group, and has begun writing about his experiences.
“People feel they are alone with this, and that keeps them from healing,” he says, explaining why he started the group. “But even if the pain doesn't go away, it can get better, and that’s what the pain group helps with.”

As for Molly, who is now 18, she just finished backpacking through Europe with her boyfriend. She worked as a paid intern for an international news organization and followed the Pope as he toured Ground Zero and Yankee Stadium in New York City. Later that day she flew to North Carolina to work on the Obama presidential campaign. As she recalls: “It was a pretty great birthday!”

Clinical Trials on CRPS
At least 20 clinical trials into CRPS treatments are currently ongoing, many of which are still recruiting patients. Doctors at Drexel University in Philadelphia, PA, are conducting a clinical trial on the benefits of 10 days of outpatient ketamine infusions for four hours a day. For information about the trial, contact Robert J. Schwartzman, M.D., at 215-762-7090 or rschwartz@drexelmed.edu. To view a full list of current trials, visit clinicaltrials.gov and search for “CRPS.”

Neurology now • March/April 2009
By Debra Gordon, M.S.

National Fibromyalgia Awareness Day – May 12th!

2009-05-12T17:17:00.000-07:00

Fibromyalgia is a chronic pain disorder that affects an estimated 6-10 million people in the United States, yet half might not know they have it. In recognition of Fibromyalgia Awareness Day, APF is launching new information, special chats on that day, and other awareness activities, as well as highlighting existing fibro spotlight activities and materials. Click here and join others across the country to raise awareness about fibromyalgia or find out if your pain might be caused by this disorder.

Fibromyaliga sufferers fight pain, misconceptions read article here by Carrie Thompson

H1N1 influenza virus (swine flu)

2009-05-01T10:57:00.000-07:00

The recent emergence of a new human-to-human strain of an H1N1 influenza virus (swine flu) has made headlines in recent days. While the disease should be taken seriously, and coordinated efforts are under way to contain its spread, there are simple and common steps you can take to protect your health.

Try to avoid close contact with sick people.

Influenza is thought to spread mainly person-to-person through coughing or sneezing of infected people.
If you get sick, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

There are everyday actions people can take to stay healthy.

*Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
*Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hands cleaners are also effective.
*Avoid touching your eyes, nose or mouth. Germs spread that way.

The California Department of Public Health (CDPH) has activated a toll-free swine flu hotline in English and Spanish. Assistance in other languages is also available. The phone number is 1-888-865-0564

QUESTIONS & ANSWERS

1 May 2009 -- The situation continues to evolve rapidly. Today, 11 countries have officially reported 331 cases of influenza A(H1N1) infection.

The United States Government has reported 109 laboratory confirmed human cases, including one death. Mexico has reported 156 confirmed human cases of infection, including nine deaths.

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (34), Germany (3), Israel (2), Netherlands (1), New Zealand (3), Spain (13), Switzerland (1) and the United Kingdom (8).

Further information on the situation will be available on the WHO website on a regular basis. WHO advises no restriction of regular travel or closure of borders. It is considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention, in line with guidance from national authorities.

PORK
There is also no risk of infection from this virus from consumption of well-cooked pork and pork products. Individuals are advised to wash hands thoroughly with soap and water on a regular basis and should seek medical attention if they develop any symptoms of influenza-like illness.

FAQ

Gripe Porcina, en Español

There are a number of steps consumers can take to protect themselves from the threats posed by Tamiflu drug counterfeiters on the internet. Go here for instructions on: How to recognize counterfeit oseltamivir phosphate. You can also report your suspicions to the FDA's MedWatch program at 1–800–332–1088
If you have any specific questions regarding TAMIFLU contact: Roche Pharmaceuticals Service Center at 1–800–526–6367

Let's review RSD!

2009-04-02T11:11:00.000-07:00

What is CRPS?
Complex Regional Pain Syndrome (CRPS), also called Reflex Sympathetic Dystrophy Syndrome (RSD) is a chronic neurologic disease characterized by intense and persistent pain. Although CRPS is still classified as a rare disorder (affecting less than 200,000), a newer epidemiological study conducted by de Mos et al** reported that there may be up to 50,000 new CRPS-1 cases annually in the United States. People with the syndrome typically see several physicians before being diagnosed. We are, however, making progress in understanding this little-known and poorly understood syndrome.

CRPS occurs when part of the nervous system and the immune system malfunction as they respond to tissue damage from trauma, such as an injury or a medical procedure. The nerves misfire, sending constant pain signals to the brain. There are two types of CRPS: Type I (RSD) and Type II (Causalgia), which has definite nerve damage.

CRPS is a Physical Disease
Many of the symptoms of CRPS are not visible to others, and often people with the syndrome don’t look sick. It has not been unusual for medical professionals to suggest that people with CRPS exaggerate their pain for psychological reasons. However, research has proven that CRPS is a very real condition.

Telltale Signs and Symptoms of CRPS
CRPS is a diagnostic consideration for people who have moderate-to severe pain that is disproportionate to any inciting event (sprain, fracture, surgery, etc.) and has some of the following characteristics:
* Pain which is described as deep, aching, cold, burning, and/or increased skin
sensitivity
* The presence of an initiating noxious event (sprain, fracture, etc.)
* Continuing pain (moderate to severe) associated with allodynia (pain resulting from a stimulus that normally does not cause pain, such as the touch of clothing or water from a shower), or hyperalgesia (heightened sensitivity to painful stimulation).
* Abnormal swelling in the affected part
* Abnormal hair or nail growth
* Abnormal skin color changes
* Abnormal skin temperature (greater than 1°C asymmetry)
* Abnormal sweating
* Limited range of movement, weakness, or other motor disorders (paralysis, dystonia etc.)
* CRPS is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

http://www.rsdsa.org
**de Mos M, de Bruijn AGJ, Huygen FJPM, Dieleman JP, Stricker BHCh, Sturkenboom MCJM. The incidence of complex regional pain syndrome: A population-based study. Pain. 2007; 129:12-20.

Manage Your Pain

2009-03-28T11:09:00.000-07:00

Why is managing your pain important?

Persistent pain can interfere with your enjoyment of life. It can make it hard to sleep, work, socialize with friends and family and accomplish everyday tasks. When your ability to function is limited, you may become less productive. You may also find yourself avoiding hobbies and other activities that normally bring you happiness in order to prevent further injury or pain. Ongoing pain can cause you to lose your appetite, feel weak and depressed. Try not to allow your physical illness or pain to take over your life.

Pain is a part of you, but it is not YOU. It is not who you are.

Managing your pain is an important step to reclaim your life and ensure it does not control you.

Fibromyalgia - "Invisible" No longer

2008-12-11T11:46:00.000-08:00

Fibromyalgia Can No Longer Be Called The "Invisible" Syndrome
November 4, 2008

Using single photon emission computed tomography (SPECT), researchers in France were able to detect functional abnormalities in certain regions in the brains of patients diagnosed with fibromyalgia, reinforcing the idea that symptoms of the disorder are related to a dysfunction in those parts of the brain where pain is processed.

"Fibromyalgia is frequently considered an 'invisible syndrome' since musculoskeletal imaging is negative," said Eric Guedj, M.D., and lead author of the study. "Past imaging studies of patients with the syndrome, however, have shown above-normal cerebral blood flow (brain perfusion) in some areas of the brain and below-normal in other areas. After performing whole-brain scans on the participants, we used a statistical analysis to study the relationship between functional activity in even the smallest area of the brain and various parameters related to pain, disability and anxiety/depression."

In the study, which was reported in the November issue of The Journal of Nuclear Medicine, 20 women diagnosed with fibromyalgia and 10 healthy women as a control group responded to questionnaires to determine levels of pain, disability, anxiety and depression. SPECT was then performed, and positive and negative correlations were determined.

The researchers confirmed that patients with the syndrome exhibited brain perfusion abnormalities in comparison to the healthy subjects. Further, these abnormalities were found to be directly correlated with the severity of the disease. An increase in perfusion (hyperperfusion) was found in that region of the brain known to discriminate pain intensity, and a decrease (hypoperfusion) was found within those areas thought to be involved in emotional responses to pain.

In the past, some researchers have thought that the pain reported by fibromyalgia patients was the result of depression rather than symptoms of a disorder. "Interestingly, we found that these functional abnormalities were independent of anxiety and depression status," Guedj said.

According to Guedj, disability is frequently used in controlled clinical trials to evaluate response to treatment. Because molecular imaging techniques such as SPECT can help predict a patient's response to a specific treatment and evaluate brain-processing recovery during follow-up, it could prove useful when integrated into future pharmacological controlled trials.

"Fibromyalgia may be related to a global dysfunction of cerebral pain-processing," Guedj added. "This study demonstrates that these patients exhibit modifications of brain perfusion not found in healthy subjects and reinforces the idea that fibromyalgia is a 'real disease/disorder.'"

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, fibromyalgia syndrome is a common and chronic disorder characterized by widespread muscle pain, fatigue and multiple tender points. Tender points are specific places - for example, on the neck, shoulders, back, hips, and upper and lower extremities - where people with fibromyalgia feel pain in response to slight pressure. The syndrome is one of the most common causes of musculoskeletal pain and disability and affects three to six million, or as many as one in 50, Americans. Between 80 and 90 percent of those diagnosed are women.

Although fibromyalgia is often considered an arthritis-related condition, it does not cause inflammation or damage to the joints, muscles or other tissues. Like arthritis, however, the significant pain and fatigue caused by fibromyalgia can interfere with a person's ability to carry out daily activities.

Coauthors of "Clinical Correlate of Brain SPECT Perfusion Abnormalities in Fibromyalgia" include Eric Guedj, Serge Cammilleri and Olivier Mundler, Service Central de Biophysique et de Médecine Nucléaire, AP-HM Timone; Jean Niboyet, Patricia Dupont, Eric Vidal and Jean-Pierre Dropinski, Unité d'Etude et de Traitement de la Douleur, Clinique La Phocéanne, all of Marseille, France.

About SNM: Advancing Molecular Imaging and Therapy

SNM is an international scientific and medical organization dedicated to raising public awareness about what molecular imaging is and how it can help provide patients with the best health care possible. SNM members specialize in molecular imaging, a vital element of today's medical practice that adds an additional dimension to diagnosis, changing the way common and devastating diseases are understood and treated.

SNM's more than 16,000 members set the standard for molecular imaging and nuclear medicine practice by creating guidelines, sharing information through journals and meetings and leading advocacy on key issues that affect molecular imaging and therapy research and practice.
Society of Nuclear Medicine, Inc.

Juices block drugs used to treat high blood pressure.

2008-11-23T15:29:00.000-08:00

Fruit Juices Block Common Drugs

Grapefruit, Orange, Apple Juices Decrease Absorption of Many Often-Used Drugs

WebMD Health News
Reviewed by Louise Chang, MD
Aug. 19, 2008 -- Grapefruit, orange, and apple juices block drugs commonly used to treat infections, allergy, transplant rejection, cancer, and high blood pressure.

In 1991, David G. Bailey, PhD, and colleagues found that grapefruit juice increased blood concentrations of the blood pressure drug Plendil to possibly dangerous levels. Grapefruit juice, they later learned, slows down a key liver enzyme that clears Plendil -- and about 40 other drugs -- from the body.

Now Bailey reports that grapefruit, orange, and apple juices decrease the absorption of several important medications:

The allergy drug Allegra, available generically as fexofenadine
The antibiotics ciprofloxacin (Cipro, Proquin), levofloxacin (Levaquin), and itraconazole (Sporanox)
The beta-blocker blood pressure drugs atenolol (Tenormin), celiprolol, and talinolol
The transplant-rejection drug cyclosporine (Gengraf, Neoral)
The cancer chemotherapy etoposide (Toposar, Vepesid)
"This is just the tip of the iceberg. I'm sure we'll find more and more drugs that are affected this way," Bailey says in a news release.

Bailey revealed the new findings in a report to the 236th annual meeting of the American Chemical Society.

A substance in grapefruit juice called naringin seems to be the culprit. The compound apparently blocks OATP1A2, a transporter molecule in the gut, which carries some drugs from the small intestine into the blood. Orange juice contains hesperidin, a naringin-like substance. The culprit in apple juice remains unidentified.

"The concern is loss of benefit of medications essential for the treatment of serious medical conditions," Bailey says.

In their studies, Bailey and colleagues had healthy volunteers take fexofenadine with either a glass of grapefruit juice, a glass of water mixed with naringin, or pure water. Taking the drug with grapefruit juice or the naringin mixture halved the amount of drug that reached the bloodstream.

People should take their pills only with water, advises Bailey, a professor of clinical pharmacology at the University of Western Ontario, London, Canada. He suggests that people taking medications should check with their doctor or pharmacist before taking medications with fruit juices or whole fruits.
By Daniel J. DeNoon

Obecalp-placebO

2008-11-19T12:01:00.000-08:00

Half of Doctors Routinely Prescribe Placebos

October 24, 2008
The New York Times

Half of all American doctors responding to a nationwide survey say they regularly prescribe placebos to patients. The results trouble medical ethicists, who say more research is needed to determine whether doctors must deceive patients in order for placebos to work.

The study involved 679 internists and rheumatologists chosen randomly from a national list of such doctors. In response to three questions included as part of the larger survey, about half reported recommending placebos regularly. Surveys in Denmark, Israel, Britain, Sweden and New Zealand have found similar results.

The most common placebos the American doctors reported using were headache pills and vitamins, but a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.

In most cases, doctors who recommended placebos described them to patients as “a medicine not typically used for your condition but might benefit you,” the survey found. Only 5 percent described the treatment to patients as “a placebo.”

The study is being published in BMJ, formerly The British Medical Journal. One of the authors, Franklin G. Miller, was among the medical ethicists who said they were troubled by the results.

“This is the doctor-patient relationship, and our expectations about being truthful about what’s going on and about getting informed consent should give us pause about deception,” said Dr. Miller, director of the research ethics program in the department of bioethics at the National Institutes of Health.

Dr. William Schreiber, an internist in Louisville, Ky., at first said in an interview that he did not believe the survey’s results, because, he said, few doctors he knows routinely prescribe placebos.

But when asked how he treated fibromyalgia or other conditions that many doctors suspect are largely psychosomatic, Dr. Schreiber changed his mind. “The problem is that most of those people are very difficult patients, and it’s a whole lot easier to give them something like a big dose of Aleve**,” he said. “Is that a placebo treatment? Depending on how you define it, I guess it is.”

But antibiotics and sedatives are not placebos, he said.

The American Medical Association discourages the use of placebos by doctors when represented as helpful.

“In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient,” the group’s policy states.

Controlled clinical trials have hinted that placebos may have powerful effects. Some 30 percent to 40 percent of depressed patients who are given placebos get better, a treatment effect that antidepressants barely top. Placebos have also proved effective against hypertension and pain.

But despite much attention given to the power of placebos, basic questions about them remain unanswered: Are they any better than no treatment at all? Must people be deceived into believing that a treatment is active for a placebo to work?

Some studies have hinted at answers, but experts say far more work is needed.

Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch, in Galveston, said the popularity of alternative medical treatments had led many doctors to embrace placebos as a potentially useful tool. But, Dr. Brody said, doctors should resist using placebos, because they reinforce the deleterious notion that “when something is the matter with you, you will not get better unless you swallow pills.”

Earlier this year, a Maryland mother announced that she would start selling dextrose tablets as a children’s placebo called Obecalp, for “placebo” spelled backward.

Dr. Ezekiel J. Emanuel, one of the study’s authors, said doctors should not prescribe antibiotics or sedatives as placebos, given those drugs’ risks. Use of less active placebos is understandable, he said, since risks are low.

“Everyone comes out happy: the doctor is happy, the patient is happy,” said Dr. Emanuel, chairman of the bioethics department at the health institutes. “But ethical challenges remain.

(**A 2004 study has found that Aleve, a popular over-the-counter painkiller made by Bayer, could increase heart problems, and federal officials are warning patients not to exceed the recommended dose of two 200-milligram pills a day or continue therapy for more than 10 days without consulting a physician. It was the fourth big-selling pain medicine in recent months to be suspected of hurting the heart, and federal drug officials said that similar drugs, like Advil, might also increase heart risks. The study, sponsored by the National Institutes of Health, was intended to measure whether Aleve and Celebrex, made by Pfizer, might prevent Alzheimer's disease. Nearly 2,500 patients were given one of the two drugs or a placebo and were followed for three years. Those taking Aleve had a 50 percent greater rate of heart problems - including heart attacks and stroke - than those given a placebo.)

By Gardiner Harris

Why opioid pain killers don't work.

2008-03-07T12:46:00.000-08:00

People who have the common chronic pain condition fibromyalgia often report that they don't respond to the types of medication that relieve other people's pain.

New research from the University of Michigan Health System helps to explain why that might be: Patients with fibromyalgia were found to have reduced binding ability of a type of receptor in the brain that is the target of opioid painkiller drugs such as morphine.

The study included positron emission tomography (PET) scans of the brains of patients with fibromyalgia, and of an equal number of sex- and age-matched people without the often-debilitating condition. Results showed that the fibromyalgia patients had reduced mu-opioid receptor (MOR) availability within regions of the brain that normally process and dampen pain signals -- specifically, the nucleus accumbens, the anterior cingulate and the amygdala.

Fibromyalgia patients had reduced mu-opioid receptor (MOR) availability within regions of the brain that normally process and dampen pain signals – specifically, the nucleus accumbens, the anterior cingulate and the amygdala.

"The reduced availability of the receptor was associated with greater pain among people with fibromyalgia," says lead author Richard E. Harris, Ph.D., research investigator in the Division of Rheumatology at the U-M Medical School's Department of Internal Medicine and a researcher at the U-M Chronic Pain and Fatigue Research Center.

"These findings could explain why opioids are anecdotally thought to be ineffective in people with fibromyalgia," he notes. The findings appear in The Journal of Neuroscience. "The finding is significant because it has been difficult to determine the causes of pain in patients with fibromyalgia, to the point that acceptance of the condition by medical practitioners has been slow."

Opioid pain killers work by binding to opioid receptors in the brain and spinal cord. In addition to morphine, they include codeine, propoxyphene-containing medications such as Darvocet, hydrocodone-containing medications such as Vicodin, and oxycodone-containing medications such as Oxycontin.

The researchers theorize based on their findings that, with the lower availability of the MORs in three regions of the brains of people with fibromyalgia, such painkillers may not be able to bind as well to the receptors as they can in the brains of people without the condition.

Put more simply: When the painkillers cannot bind to the receptors, they cannot alleviate the patient's pain as effectively, Harris says. The reduced availability of the receptors could result from a reduced number of opioid receptors, enhanced release of endogenous opioids (opioids, such as endorphins, that are produced naturally by the body), or both, Harris says.

The research team also found a possible link with depression. The PET scans showed that the fibromyalgia patients with more depressive symptoms had reductions of MOR binding potential in the amygdala, a region of the brain thought to modulate mood and the emotional dimension of pain.

The study subjects were 17 women with fibromyalgia and 17 women without the condition.

The senior author of the paper was Jon-Kar Zubieta, M.D., Ph.D., the Phil F. Jenkins Research Professor of Depression in the U-M Department of Psychiatry and a member of U-M's Molecular and Behavioral Neuroscience Institute, Depression Center and Department of Radiology. Other authors were Daniel J. Clauw, M.D.; David J. Scott, Ph.D.; Samuel A. McLean, M.D., MPH; and Richard H. Gracely, Ph.D.

Reference: The Journal of Neuroscience, Sept. 12, 2007, 27(37):10000--10006.
ScienceDaily (Oct. 3, 2007)

Chronic Pain Patients, CRPS 1 & 2

2008-02-29T11:17:00.000-08:00

A debate is currently raging as to whether diagnoses, such as fibromyalgia and complex regional pain syndrome 1, can be classified as neuropathic. Our NPS cut-off score results suggest that these diagnoses may have a neuropathic pain component. The reliability and validity of our NPS method will need to be tested further in other neuropathic pain models, such as diabetic peripheral neuropathic pain.

Study Suggests Fibromyalgia Pain is Neuropathic

In the March issue of the journal Pain Medicine, researchers at three institutions in Florida conducted a study to determine whether the neuropathic pain scale (NPS) can be used to classify chronic pain patients (CPPs) as having primarily neuropathic vs non-neuropathic pain, as well as to determine whether there is a cut-off score that can be used reliably to make this distinction between types of pain. This study evaluated 305 chronic pain patients (CPPs) admitted to The Rosomoff Pain Center (Miami, FL). All were administered the NPS, a diagnostic tool designed to assess the distinct pain qualities associated with neuropathic pain, and were given a diagnosis on the basis of a physical examination and all available test results.

Using patients known to have neuropathic or non-neuropathic pain conditions as a reference, esearchers were able to derive "an NPS cut-off score above which CPPs would be classified as having neuropathic pain." Patients who had diagnoses of myofascial pain syndromes, spinal stenosis, epidural fibrosis, fibromyalgia, complex regional pain syndromes, and failed back surgery syndrome, a predicted NPS score was calculated and compared with the cut-off score.

The NPS appeared to be able to separate CPPs into neuropathic pain vs non-neuropathic pain subtypes. The cut-off score the researchers derived was 5.53 on the NPS. Myofascial pain syndrome and spinal stenosis had scores lower than this cut-off score at 3.81 and 4.26, respectively - Therefore they did not meet the criteria for neuropathic pain. Epidural fibrosis, fibromyalgia, complex regional pain syndromes, and failed back surgery syndrome had predictive scores higher than the cut-off score at 6.15, 6.35, 6.87, 9.34, and 7.19, respectively. Thus, these syndromes did meet the qualifications for neuropathic pain according to this study's criteria. The researchers conclude that the NPS does appear to be able to discriminate between patients experiencing neuropathic and non-neuropathic pain.

Pain Medicine, Vol. 9, No. 2. (March 2008), pp. 149-160.

David A. Fishbain MDFAPA, John E. Lewis PhD, Robert Cutler PhD, Brandly Cole PsyD, Hubert L. Rosomoff MDDMedScFAAPM, Rennée S. Rosomoff BSNMBA (2008)
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1526-4637.2007.00302.x

Insomnia, Depression, Anxiety, Mood disorders

2008-02-07T11:32:00.000-08:00

Insomnia Patients Often Denied Sleep Treatment When They Have Mental Health Conditions

ScienceDaily (2008-02-07) -- Patients with insomnia who are diagnosed with accompanying mental health ailments often are not prescribed medication that will help them sleep -- which could then make related anxiety or depression worse, new research suggests. Scientists examining treatment patterns for insomniacs say that their findings suggest that many doctors appear to be reluctant to prescribe sleep aids, even those that pose no risk of dependence, if patients also have depression, anxiety or mood disorders. ... > read full article

Alphabet Soup - CRPS (RSD) FMS & WBC's

2008-02-04T16:51:00.000-08:00

Immunological Changes in Fibromyalgia & Other Chronic Pain Conditions?

The newest issue of the medical journal Neuroimmunomodulation [2008 Feb 1;14(5):272-280] includes the results of a study conducted by Department of Anesthesiology of Ludwig Maximilians University, Munich, Germany.

The study address immunological changes in chronic pain patients, specifically complex regional pain syndrome (CRPS) and fibromyalgia (FMS), both of which the researchers describe as "chronic pain syndromes occurring in highly stressed individuals.

"Despite the known connection between the nervous system and immune cells, information on distribution of lymphocyte subsets under stress and pain conditions is limited. Lymphocytes are white blood cells that play a critical role in the body's defenses. They include T cells, B cells, and natural killer cells. They also modulate the activities of other cells.

The researchers performed a comparative study of 15 patients with CRPS, 22 patients with FMS and 37 age- and sex-matched healthy controls. Their aim was to investigate the influence of pain and stress on lymphocyte number, subpopulations and the Th1/Th2 cytokine ratio in T lymphocytes.

Lymphocyte numbers did not differ between the groups studied. However, when the subtypes of lymphocytes were studied using quantitative analyses, it became evident that there was "a significant reduction of cytotoxic CD8+ lymphocytes in both CRPS... and [fibromyalgia]... patients as compared with healthy controls. Additionally, CRPS patients were characterized by a lower percentage of IL-2-producing T cell subpopulations reflecting a diminished Th1 response in contrast to no changes in the Th2 cytokine profile."

The article concludes that future studies are necessary in order to answer "whether such immunological changes play a pathogenetic role in CRPS and [FMS] or merely reflect the consequences of a pain-induced neurohumoral stress response, and whether they contribute to immunosuppression in stressed chronic pain patients."

Monday, February 04, 2008

Beating Back the Stigma of Pain Treatment

2008-01-16T17:33:00.000-08:00

Paula Abdul's Stardom May Help Cut Negative Perceptions About Chronic Pain, Painkiller Use

By LAUREN COXABC News Medical Unit
Jan. 16, 2008 —

If celebrity gossip were the stock market, Paula Abdul's shares would be on a solid uptick.
Her hit program "American Idol" started Tuesday with no writers needed and TVguide.com reports that she's in talks to sing at the Super Bowl halftime show. Abdul, who has endured more than her share of bad Hollywood gossip, also has a condition not shared by many fellow celebrities. She's one of millions of Americans who suffer from chronic pain.

Acknowledging Her Pain
In a 2005 interview, Abdul was straight up with People magazine, confirming that she had taken powerful drugs before Oxycontin, Vicodin, Soma but all in an excruciating trial-and-error process to beat her chronic pain.

Abdul claimed to suffer from a condition called Regional Sympathetic Dystrophy, or Complex Regional Pain Syndrome. The condition, she said, started with a cheerleading neck injury that sent her body into a mysterious chain reaction of pain symptoms that spiraled into intolerable pain over decades.

Chronic pain may be mysterious, but it's not uncommon. About 10 percent of people suffer from pain that lasts longer than a year, according to 2002 statistics from the American Pain Foundation. For people with neuropathy, spinal cord injuries, rheumatoid arthritis and other diseases, chronic pain can last for decades and sometimes require drugs with side effects that can leave people drowsy, nauseous, or suffering from memory lapses to make life tolerable.
Getting Acceptance

"We don't want sympathy at all, we just want empathy; we want understanding," says Mike K. Buckley, 51, a retired firefighter in Massachusetts who suffers from chronic pain. In the summer of 2002, Buckley pulled a fire hose toward a blaze in full gear. With just one unnatural turn, two discs in the middle of his back bulged into his spinal cord. This single injury has sent him to the emergency room 20 times in the past four years, every time in a bout of excruciating pain.

Buckley stayed at work for three years, even after a T-bone car accident injured a third disc in his spine, making his chronic pain condition inoperable.

"Oh you're taking Oxycontin? Are you addicted?" Buckley remembers his fellow firefighters asking. "I used to joke with people: I wished I was just getting high off of this!"
In fact, most chronic pain patients won't get high with a well-managed dose of opioids like Oxycontin, says Dr. Elliot Krane, professor of anesthesia and pediatrics at Stanford University in Palo Alto, Calif.

"All of us have had patients on grams and grams rather than milligrams of morphine or hydropmorphone, for example, who have been very functional," said Krane, "whereas the same dose would render the opioid-naïve patient comatose."

Prescription Woes
Prescriptions for opioids took off in the 1980s and 1990s with the realization that short-term painkillers could help chronic pain patients in the long term, says Dr. Joe Shurman, chairman of pain management at Scripps Memorial Hospital in La Jolla, Calif.

Unfortunately, in the late 1990s, the drug Oxycontin left a wake of reports of prescription painkiller overdoses and abuses skyrocketed.

"It gives everybody with pain a bad rap," said Buckley, whose doctors have tried Vicodin, Oxycontin and epidural injections to fix his pain before finally finding a prescription for methadone, which he says works. Each time a chronic pain patient switches drugs, he or she may take a couple of weeks to adjust to the mental and physical side effects.

"A lot of us just take it to get through the day, and a lot of times the pain wins," said Buckley.
Buckley had to retire in January of last year after a fall down some stairs, which Buckley says weren't compliant with the fire code. Though he says he still spends most of his days at a seven on the 1-10 pain scale used by doctors, Buckley may have been lucky that doctors even believed he was in pain.

Convincing Peers and Doctors
"I guess I wasn't screaming enough; I told them I was in pain, but I guess I should have been yelling at them," said Janice Dallas, a Type 1 diabetic who suffers from "fire and lightning" pain due to a degenerative nerve disease called neuropathy.

"It started out in '94 with neuropathy, it wasn't diagnosed until 2000," said Dallas. Part of Dallas' six-year wait for a diagnosis was an odd condition: She felt pain in her trunk, as opposed to the more common areas of hands and feet.

But part of Dallas' challenge to get diagnosed might have also been doctors' heightened scrutiny of anything that might resemble drug-seeking behavior.

In response to the rising Oxycontin abuse, the U.S. Drug Enforcement Administration started the official Action Plan to Prevent the Diversion and Abuse of Oxycontin in 2003.
The plan led to high-profile cases of doctors going to jail for prescribing certain opioids. Now doctors are hesitant to prescribe heavy-duty pain killers like Oxycontin. "It's shifting to being underprescribed," said Shurman.

But perhaps high profile cases of chronic pain like Abdul's could eventually help normalize the stigma and fear that come along with the proper use of prescribed painkillers.

"Unless you've really experienced pain you can't get rid of, you don't understand our world," Buckley said.

Unlike Buckley, Abdul had a chance of ending her world of pain. In her interview with People, Abdul says after more than 25 years of unsuccessful treatments she's feeling better than ever. According to the Associated Press, Abdul and her doctor report she's only taking low-side effect medication of Enbrel for arthritis and Pamidronate for complications of her chronic pain.
Buckley still feels supportive of Abdul's trial in the spotlight.

"When it comes down to it celebrities are people just like us and have to deal with this pain that changes their whole world."

Questions about your medication?

2007-10-11T16:43:00.000-07:00

Look in the medicine chest of 2,500 medications!

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http://www.askapatient.com

Do you have something to say about a medication you're taking? Rate your medicine!

Patient questions you might have? Try the research assistant!

http://www.askapatient.com/index.asp

Shop online and support RSDSA!

2007-01-16T15:43:00.000-08:00

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Ugly Aging

2006-11-24T17:22:00.000-08:00

Wellness and the buzz about General Metabolic Syndrome (GMS)
By Michael W. Loes, M.D.

We all want to live well and reasonably long – and without pain. We quest for great health, even optimal, enviable health, a term I like to call salubrity. Should our time come to die, most of us would prefer to die quickly, quietly, and comfortably.

Sounds nice, but in reality this is not what generally happens. We, as a society, are not aging gracefully. In fact, we are degenerating at a remarkably fast rate. The life expectancy tables look pretty stable but in reality ugly aging is out of control.

We go for a check-up and your doctor gives you the bad news. You – yes you - have one or more of the following:

* Diabetes – Type I or Type II
* Arthritis – Mostly Osteoarthritis, but Rheumatoid is on the rise
* Heart Disease & Stroke – Atherosclerosis
* Lung Disease – Bronchitis, Asthma, Emphysema
* Deep Venous Phlebitis – Blood Clots in your Legs
* Liver Disease – Cirrhosis and Fatty Liver
* Kidney Disease – Fibrosis and Chronic Renal Failure
* Cancer – Usually Lung, Colon, Breast, Uterus, Ovarian

All of these illnesses start with soft symptoms called “dys-ease.” You don’t feel great –but you are not sure why. The new buzz word for this is General Metabolic Syndrome (GMS). There is hardly a journal that crosses my desk that does not discuss this, mainly because this is the new concept that physicians are now examining, particularly as it relates to the avalanche of early diabetes that we now see. Doctors are able to identify GMS early if they are actively looking for it, and perhaps in doing so, warn you to wake up and change. What you need to understand is that if you have GMS, you are at risk for the whole gamut of degenerative diseases listed above.

There are various blood markers that are helpful in identifying GMS, such as homocysteine, glyco-hemoglobin (also known as HbA1C), ferritin, asymmetric-methyl-D-aspartate (AMDA), total and LDL cholesterol, sedimentation rates and C-reactive protein (CRP). The markers often show up early. You may be at the top of your life activity, experiencing only minor symptoms. You may be comfortably seated, like a child at the top of a slide, experiencing merriment. But, if you have GMS, the descent is likely into the chaos of chronic disease.

Does this scare you? It should. In 2004, more than 35% of Americans were more than 30 pounds overweight. The British come in second at 23%, followed by the Finnish at 19% and the Spaniards are 13%. While weight alone is not the main expressed risk factor for GMS, it factors into what is known as the body mass index (BMI), a combined measure of your weight, height and girth. When this merged number is high, the recipe for disaster is cooking. As this number goes up, you are losing the grip on your life.

In the United States, the incidence of GMC is now 24%.1 Can GMS be prevented? Of course it can, but it’s tough. We all know that losing weight is very hard, but it can be done. Surgical treatment of obesity can be effective when required. Structured supervised diet programs, some using medications for obesity, may be necessary when coupled with accountability measures.

Start doing what the “doctor within you” tells you that you must do to get back on track. Watch the food. Take your exercise program seriously. Consider taking some supplements that may be helpful such as anti-oxidants, herbal anti-inflammatories, and agents to reduce or stabilize blood sugar. Be sure and ask your doctor first.

And then you walk, and walk some more and do it again. I tell patients to exercise eight days a week and keep that pedometer on (a little device that counts steps). Try to get in 4000-5000 steps per day. Please understand that every one of the aging diseases can cause pain. Take this advice very seriously. Learn about healing and enhance your healing response by taking care of yourself.

1. Statistics from the Journal of the American Medical Association as reported in American Journal of Family Practice

Research - Potent Pain Reliever

2006-11-20T13:12:00.000-08:00

A New Target for Painkillers

Snail Toxins Reveal Novel Way to Fight Severe Nerve Pain

Nov. 13, 2006 -- A brand new approach to treating severe nerve pain – by aiming drugs at a previously unrecognized molecular target – has been discovered by University of Utah scientists who study the venoms of deadly, sea-dwelling cone snails.

"We found a new way to treat a chronic and debilitating form of pain suffered by hundreds of millions of people on Earth," says J. Michael McIntosh, a University of Utah research professor of biology, and research director and professor in the Department of Psychiatry. "It is a previously unrecognized mechanism for treating pain."

The findings are being published the week of Nov. 13 in the online edition of the journal Proceedings of the National Academy of Sciences.

The study in rats found that cone snail toxins named RgIA and Vc1.1 can treat nerve hypersensitivity and pain by blocking a molecule in cells known as the "alpha9alpha10 nicotinic acetylcholine receptor."

"The numerous analgesic compounds currently available are largely ineffective" for chronic nerve pain, McIntosh and colleagues write. "Our findings not only suggest a previously unrecognized molecular mechanism for the treatment of neuropathic pain, but also demonstrate the involvement of alpha9alpha10 nicotinic receptors" in nerve injury.

McIntosh emphasized neither substance will be on the market soon. Vc1.1, also known as ACV1, is being developed by an Australian company, Metabolic, and is undergoing trials of its effectiveness in human patients. While Metabolic has said the drug targets nicotinic receptors, McIntosh says alpha9alpha10 nicotinic receptors have not been reported previously as a target for any kind of painkilling medication. McIntosh says Vc1.1 is administered by subcutaneous (under the skin) injection.

McIntosh hopes the new findings make it feasible to develop a painkiller based on RgIA that could be taken orally, but he believes that will take at least 10 years.

McIntosh co-authored the study with two colleagues in the University of Utah Center for Neuropeptide Pharmacology – Baldomero "Toto" Olivera, a distinguished professor of biology, and Michael Ellison, a postdoctoral fellow in biology – and with Michelle Vincler, Shannon Wittenauer and Renee Parker at the Wake Forest University School of Medicine in Winston-Salem, N.C.

The research was funded by the National Institutes of Health.

A Pain in the Nerves

The study dealt with what is known as neuropathic pain, which is chronic pain due to injury to the nerves, spinal cord or brain.

Such pain can result from diabetes damage to nerves in the feet or elsewhere, spinal injury, degenerative disc disease, alcoholism, failed low-back surgery, tumors compressing nerves, spinal tumors, repetitive motion disorders, multiple sclerosis, infection, stroke, traumatic brain injury, shingles, nerve toxins and electrical or other damage to peripheral nerves. Sometimes, doctors are unable to find a cause.

Symptoms can include numbness and pain that feels like constant burning, "pins and needles," sharp shooting pain, electricity or electrical shock, or tingling. People with neuropathic pain often are hypersensitive to previously innocuous stimuli – for example, feeling pain from a foot rubbing against the inside of a shoe – and feel an exaggerated response to things that are painful.

Common pain medicines like aspirin, ibuprofen and acetaminophen often fail to relieve neuropathic pain. Morphine-like opiods such as oxycodone sometimes are used, but can cause constipation, nausea and a spaced-out feeling.

Anticonvulsant drugs for epilepsy sometime are used to reduce the pain by decreasing nerve cell excitability, but have side effects such as lethargy, fatigue, clouding of mental state and weight gain, McIntosh says. Antidepressants and muscle relaxants have been used, but they can cause weight gain, nausea and sexual dysfunction.

Topical treatments include capsicum cream derived from chili peppers, but they usually are not very effective.

"There really is no highly effective treatment available for this kind of severe pain, so having a new way to treat it is exciting," McIntosh says. If the new discovery eventually leads to a new pain drug that is combined with existing treatments, "you may be able to reduce the pain to a lower level than ever before. No one drug is going to fully treat all pain, so having a new way is like having a backup catcher if the first catcher misses the ball."

How the Study was Performed

The toxins in the study come from two cone snail species that eat worms, unlike relatives that eat fish or snails and occasionally deliver a fatal sting to a human fisherman.

* RgIA is from the species Conus regius, which measures 1.6 to 2.8 inches in length and lives from Georgia southward along Central America to Brazil's central coast.
* Vc1.1 is from the species Conus victoriae, which measures 1.4 to 2.8 inches long and lives off portions of Australia.

RgIA and Vc1.1 fit like keys into lock-like alpha9alpha10 nicotinic acetylcholine receptors, which are found on nerve cells and are in the family of receptors activated by nicotine from cigarette smoking.

Alpha9alpha10 nicotinic receptors are found in a variety of body tissues, including white blood cells and the dorsal root ganglia – a group of nerve cells near the spine and involved in pain transmission.

The new study showed alpha9alpha10 nicotinic receptors provide a previously unknown route to pain relief. McIntosh says a patent is pending on this new mechanism.

One form of severe nerve pain is known as sciatica, and occurs when a herniated disk in the lower back causes pain to one or both sciatic nerves, which extend from the lower back to the hips, buttocks and back of the thighs.

For the study, the North Carolina co-authors tied sutures loosely around one of each rat's two sciatic nerves to mimic nerve compression and injury from sciatica. That made the rats overly sensitive to touch on one hind paw but not the other. Each rat's sensitivity was assessed by measuring how much pressure could be applied to a hind paw with a blunt Teflon tip before the rat pulled away the paw.

Normal rats could withstand 4.7 times more pressure before withdrawing their paws, compared with rats with sciatica. When cone snail toxin RgIA was injected, the rats with sciatica were able to tolerate a stronger touch from the tip – both four hours and 24 hours after the drug was given. The highest dose completely reversed the hypersensitivity caused by sciatica, with no adverse effects. Daily injections "produced a sustained analgesic effect," the researchers wrote.

RgIA was such a potent pain reliever that "about 10 billionths of an ounce reversed the hypersensitivity to pain," McIntosh says.

Vc1.1 had a similar effect – replicating studies by other researchers – allowing rats with sciatica to tolerate touch with greater pressure.

The new study is not McIntosh's first involving chronic pain. As an incoming college freshman working in Olivera’s lab in 1979, McIntosh discovered in cone snails the natural form of a drug now used against severe nerve pain. It is Prialt, which must be injected into fluid surrounding the spinal cord as a treatment for severe pain due to cancer, AIDS, injury, failed back surgery and certain nervous system disorders.

The shell of the sea-dwelling cone snail Conus regius, which uses its venom to kill worms so it can capture and eat them. A toxin from Conus regius venom helped University of Utah researchers identify an entirely new way to treat severe pain caused by injury to the nervous system.

Research - Opiates

2006-11-20T12:25:00.000-08:00

Prolonging Painkillers
By Mary Beckman

Morphine and other opiates dull pain, but they don't stick around for long. Almost immediately, a class of enzymes known as peptidases burst onto the scene and degrade these painkillers. Now researchers have identified a naturally occurring molecule in humans that blocks this process, prolonging the effect of opiates. The findings, say the researchers, may lead to new ways to combat pain.

Three years ago, researchers got their first hint that animals could block opiate-destroying enzymes. When neuroendocrinologists stressed rats, they found a small protein or peptide called sialorphin inhibited the action of neutral endopeptidase (NEP), which breaks down a natural opiate known as enkephalin. Do humans make a similar peptide?

Neuroendocrinologist Catherine Rougeot of the Institut Pasteur in Paris suspected so. Previous work hinted that people secrete a mystery molecule in their mouths that could inhibit NEP, so Rougeot and colleagues started isolating peptides from saliva. The team identified a peptide that was five amino acids long and could block NEP in a test tube. Calling it opiorphin, the team modified it slightly to make it easier to work with in rats, naming the new peptide YQRFSR. Then the researchers injected YQRFSR into the bloodstreams of rats and, 15 minutes later, injected a compound that stimulates painful inflammation into the rats' hind paws. Rodents without YQRFSR licked their paws in discomfort for more than 2 minutes, but rats that got the small molecule only tended their paws for a little over a minute and a half, indicating less pain.

© 2006 American Association for the Advancement of Science

Depression & Osteoporosis - A Study

2006-11-18T14:59:00.000-08:00

October 31, 2006

Feeling down? Depression may cause bone loss. Scientists say antidepressants could offer treatment for osteoporosis

“The new findings ... point for the first time to depression as an important element in causing bone mass loss and osteoporosis,” Hebrew University professor Raz Yirmiya, who took part in the study, said in a statement.

JERUSALEM - Depression can lead to brittle bones, Israeli scientists found in a new study released on Monday that also suggested antidepressant drugs could be used to treat osteoporosis.

The scientists, at Jerusalem’s Hebrew University, said mice that were given drugs to induce behavior similar to human depression suffered from a loss of mass in their bones, mainly their hips and vertebrae.

After being given antidepressants, the bone density of the mice increased, along with their level of activity and social interaction, the scientists said.

Depression activates the “sympathetic nervous system”, which responds to impending danger or stress, causing the release of a chemical compound called noradrenaline that harms bone-building cells, the study showed.

Antidepressant drugs block noradrenaline and reverse its negative effects, according to the findings, which will be published this week in the American journal PNAS (Proceedings of the National Academy of Sciences).

A study published earlier this month by the Forsyth Institute in Boston found that fluoxetine, used in the popular anti-depressant drug Prozac, also increased bone mass in mice.

Osteoporosis weakens bones and makes them more likely to fracture. It is treatable but affects millions and is most prevalent among postmenopausal women.

Copyright 2006 Reuters Limited

Fundraiser for RSDSA!

2006-09-23T15:01:00.000-07:00

Can't find time to donate to a worthy cause?

When you search the Internet, you can earn money for the
Reflex Sympathetic Dystrophy Syndrome Association!

Say good-bye to Google.

It's easy - here's how!

http://www.goodsearch.com/
Enter: RSDSA in the box: "I'm supporting"
Click: "Verify"
Search the Internet from the box located above.
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Bookmark it!
GoodSearch is a Yahoo-powered search engine that gives 50% of its advertising revenue to the nonprofits and schools that our users choose. Use this search link and raise money for RSDSA!

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Thank you from RSD'ers all over the world!

Public Comment on Proposed Rule - DEA

2006-09-19T14:32:00.000-07:00

DEPARTMENT OF JUSTICE
Drug Enforcement Administration

21 CFR Part 1306 [Docket No. DEA-287N] RIN 1117-AB01

Issuance of Multiple Prescriptions for Schedule II Controlled Substances
AGENCY: Drug Enforcement Administration (DEA), Justice.
ACTION: Notice of proposed rulemaking.
--------------------------------------------------------------------------------
SUMMARY: DEA is hereby proposing to amend its regulations to allow practitioners to provide individual patients with multiple prescriptions, to be filled sequentially, for the same schedule II controlled substance, with such multiple prescriptions having the combined effect of allowing a patient to receive over time up to a 90- day supply of that controlled substance. DEA is requesting public comment on this proposed rule.

DATES: Written comments must be postmarked, and electronic comments must be sent, on or before November 6, 2006.

ADDRESSES: Please submit comments, identified by "Docket No. DEA- 287N,'' by one of the following methods:

1. Regular mail: Deputy Administrator, Drug Enforcement Administration, Washington, DC 20537, Attention: DEA Federal Register Representative/ODL.
2. Express mail: DEA Headquarters, Attention: DEA Federal Register Representative/ODL, 2401 Jefferson-Davis Highway, Alexandria, VA 22301.
3. E-mail comments directly to agency: dea.diversion.policy@usdoj.gov.
4. Federal eRulemaking portal: http://www.regulations.gov. Follow the on-line instructions for submitting comments.

Anyone planning to comment should be aware that all comments received before the close of the comment period will be made available in their entirety for public inspection, including any personal information submitted. For those submitting comments electronically, DEA will accept attachments only in the following formats: Microsoft Word; WordPerfect; Adobe PDF; or Excel.

FOR FURTHER INFORMATION CONTACT: Mark W. Caverly, Chief, Liaison and Policy Section, Office of Diversion Control, Drug Enforcement Administration, Washington, DC 20537; Telephone: (202) 307-7297.

SUPPLEMENTARY INFORMATION:
I. Background
On August 26, 2005, DEA published in the Federal Register a "Clarification Of Existing Requirements Under The Controlled Substances Act For Prescribing Schedule II Controlled Substances.'' 70 FR 50408. That document addressed the situation of patients who have been receiving prescriptions for schedule II controlled substances for legitimate medical purposes (for example, for the treatment of severe pain or attention deficit hyperactivity disorder (ADHD)) and have settled into a routine of seeing their physician once every three months. The document was intended to address the concerns of many such patients who were under the mistaken impression that, because of DEA's November 16, 2004, Interim Policy Statement (69 FR 67170), they had to begin seeing their physicians every month to obtain their schedule II prescriptions. As the August 26, 2005, clarification document noted: "DEA wishes to make clear that the Interim Policy Statement did not state that such patients must visit their physician's office every month to pick up a new prescription.'' The clarification document further explained some of the possible ways in which, under appropriate circumstances, patients can continue to receive schedule II prescriptions without visiting their physicians' offices every month.\1\1\ The clarification document stated, among other things, that a lawfully issued prescription may be mailed by the physician to the patient or pharmacy.

Read more here: http://www.deadiversion.usdoj.gov/

National RSDS/CRPS Conference Info!

2006-09-19T12:49:00.000-07:00

If you had thought about coming to an RSD conference, this is the year to come. We won't be holding one in 2007 and possibly not in 2008 so don't put it off until next time!

November 3 - 4, 2006
Sheraton Hotel
South Portland, Maine

Cost is only $65 per person
WHAT DOES THAT INCLUDE? It includes the workshops on Friday and the main conference on Saturday. It includes sandwiches/chips/drinks/etc. on Friday night for those arriving before the workshops. Included is a buffet breakfast on Saturday as well as a hot/cold buffet lunch and snack breaks! You will receive all of the hand-outs, work-sheets, and even a free copy of the book "PERSISTENCE IS POWER, A REAL WORLD GUIDE FOR THE NEWLY DISABLED WORKER" By Jeanne Lazo and Carol Amato.

In addition, there will be some giveaways including over 20 books dealing with: Coping with Chronic Pain, sweatshirts and teddy bears!

You can register for the conference by going to our website http://www.rsdhope.org/

We have some fantastic speakers too; Doctor Ronald Harbut who, with Doctor Correll, developed the low-dose ketamine infusion method to treat RSD, will be presenting the latest information on ketamine and RSD as well as his latest patient treatment results. He will also present an overview of exactly how ketamine works with RSD to decrease the pain. Doctor Harbut has had papers published in peer-reviewed journals like the Journal of Pain Medicine and recently spoke at the AAPM's national meeting in San Diego, CA.

Doctor Allan Chino, author of "Validate Your Pain!: Exposing the Chronic Pain Cover-Up," will be focusing on "Beyond the Biomedical: Chronic Pain as a (Hidden) Signaling System". Currently in private practice near Portland, Oregon, Dr. Chino, Ph.D., ABPP is board certified in Clinical Health Psychology and Past President of the American Academy of Clinical Health Psychology. He serves on the Oregon Pain Management Commission which is charged with providing the legislature with recommendations for improving and removing barriers to the provision of effective, high-quality pain management services.

The conference will begin with Keith Orsini, one of the Directors of American RSDHope, as well as a 32 year survivor of RSD. Keith will be speaking about "Living Beyond Your Pain", focusing on how to live the life you want in spite of the pain. In our daily battle with pain we lose a little ground every day and in doing so we lose a little bit of ourselves. Pretty soon the life we have left isn't much of a life and is nothing like the life we wanted or intended for ourselves. Keith is going to show you some ways to change that!

There are also workshops on Friday evening, one for patients led by Doctor Chino and one for loved ones and friends led by some of our loved ones!

Medical professionals are free to attend either workshop of course. And don't forget, the RSD Documentary film crew will be there! This is going to be the best conference we have ever had and we have had 8 before this one! Less than 55 spots are left as of September 17, 2006, out of 200.

The weather is not bad the first weekend in November here, about 50 degrees during the daytime, besides, you will be indoors! Drive up and see the foliage along the way! Or fly in, Portland Jetport services many airlines including the discount airline JETBLUE! You can even take Amtrak to Portland now! Check out all of the details by going to our conference webpage: http://www.rsdhope.org/
We want a full house!
Peace,
Keith Orsini
American RSDHope

A pill for this - a pill for that

2006-08-15T17:05:00.000-07:00

Capricorn Sister's Compendium of Capsules: A Chemical Cheat-Sheet

Insomnia is characterized by complaints of difficulty in falling asleep, frequent nocturnal awakenings, and/or early morning awakenings. The following information is intended to guide you in the safe use of medicine for pain. It is not meant to take the place of your doctor's instructions. Some people have chronic sleep problems that may require prolonged use of sleep medicine. However, you should not use these and pain medicines for long periods without taking with your doctor about the risks and benefits of prolonged use.

Ambien (zolpidem tartrate) is used to treat sleep disorders such as insomnia. Ambien is a non-benzodiazepine hypnotic of the imidazopyridine class and is available in 5 mg and 10 mg strength tablets for oral administration. It’s non-narcotic; however, like most sleep medicines it has some risk of dependency.
http://www.ambien.com

Ambien CR (zolpidem tartrate extended-release) is available in 6.25 mg and 12.5 mg strength tablets for oral administration. Swallow this medication whole. Do not crush or chew the tablets. When taken with food or immediately after a meal, it may take you longer to fall asleep.
http://www.ambiencr.com

Lunesta (eszopiclone) tablets are supplied in 1 mg, 2 mg and 3 mg strengths. Eszopiclone is a nonbenzodiazepine hypnotic that is a pyrrolopyrazine derivative of the cyclopyrrolone class with a chemical structure unrelated to pyrazolopyrimidines, imidazopyridines, benzodiazepines, barbiturates, or other drugs with known hypnotic properties. Lunesta is sometimes used to treat sleep disorders. The effects of Lunesta on sleep onset may be reduced if it is taken with or immediately after a high-fat/heavy meal.
http://www.lunesta.com/

Sonata (zaleplon) is a non-benzodiazepine hypnotic from the pyrazolopyrimidine class. Sonata is indicated for the short-term treatment of insomnia. Hypnotics should generally be limited to 7 to 10 days of use. Taken orally, zaleplon reaches full concentration in approximately one hour.
http://www.sonata.com/

Restoril (temazepam) is an hypnotic agent. Temazepam belongs to a group of medicines known as "benzodiazepines". Restoril capsules are supplied in 7.5 mg 15 mg and 30 mg capsules for oral administration. Temazepam is indicated for the short-term treatment of insomnia (generally 7-10 days). Tell your doctor and pharmacist if you are allergic to temazepam, alprazolam (Xanax), chlordiazepoxide (Librium, Librax), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), lorazepam (Ativan), oxazepam (Serax), prazepam (Centrax), triazolam (Halcion), or any other drugs.
http://www.restoril.com/

Skelaxin (metaxalone) is sometimes used to relieve pain and relax muscles. Metaxalone is available as 400 mg and 800 mg tablets.
http://www.skelaxin.com/

Flexeril (cyclobenzaprine hydrochloride) is supplied as a 5 mg and 10 mg tablet for oral administration. Flexeril is sometimes used to treat sciatica and relieves skeletal muscle spasm of local origin without interfering with muscle function.
http://www.flexeril5mg.com/

Soma (carisoprodol) is sometimes used to treat sciatica, lower back pain and for the relief of discomfort associated with acute, painful, musculoskeletal conditions. Soma is available as 350 mg tablets and may have sedative properties.
Desyrel or Deprax (trazodone hydrochloride) is sometimes used to treat anxiety and depression. Trazodone hydrochloride is available in 150 mg 300 mg tablets for oral administration.

Zanaflex (tizanidine hydrochloride) is a short-acting muscle relaxant drug for oral administration. The 2 mg, 4 mg and 6 mg capsules are not interchangeable with tizanidine or the Zanaflex tablet formulation.
http://www.zanaflexcapsules.com/

Parafon Forte DSC or Paraflex (chlorzoxazone) is indicated for the relief of discomfort, associated with acute painful musculoskeletal conditions. Available in 500 mg caplets, chlorzoxazone is a muscle relaxant with sedative properties. It is used in combination with rest and physical therapy to relieve acute, painful muscles, like those caused by sprains, strains or other injuries.

Xanax (alprazolam) is sometimes used to treat anxiety. Xanax is a triazolo analog of the 1, 4 benzodiazepine class of central nervous system-active compounds. Each Xanax tablet, for oral administration, contains 0.25 mg, 0.5 mg, 1 mg or 2 mg of alprazolam.
http://www.xanax.com/

Klonopin (clonazepam) a benzodiazepine, is sometimes used to treat seizures (epilepsy) and panic attacks. Clonazepam is available as tablets containing 0.5 mg, 1 mg or 2 mg. It is also used to relieve anxiety.

Ativan (lorazepam) is sometimes used to treat nervousness and depression with sedative effects. Each Ativan tablet, a benzodiazepine, is to be taken orally, and contains 0.5 mg, 1 mg or 2 mg lorazepam. Ativan is a prescription drug that helps with general anxiety disorder and sleeping problems. One can become physically and psychologically dependent on lorazepam.

Valium (diazepam) is a benzodiazepine derivative and is sometimes used for relief of acute anxiety and as pre-medication in patients undergoing surgical procedures. Valium is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety. Diazepam is a useful adjunct for the relief of skeletal muscle spasm due to reflex spasm to local pathology (such as inflammation of the muscles or joints or secondary to trauma). Valium is sometimes used to treat stress and is available for oral administration as tablets containing 2 mg, 5 mg or 10 mg diazepam.
http://www.rocheusa.com/products/valium/

Neurontin (gabapentin) is sometimes used to treat neuropathy and is indicated for the management of postherpetic neuralgia in adults. Patients should be informed that, should they break the scored 600 mg or 800 mg tablet in order to administer a half-tablet, they should take the unused half-tablet as the next dose. Half-tablets not used within several days of breaking the scored tablet should be discarded. Tablets are supplied with 100 mg, 300 mg, 400 mg, 600 mg and 800 mg of gabapentin.
http://www.neurontin.com/

Ultram or Tramal (tramadol hydrochloride) is indicated for the management of moderate to moderately severe pain in adults. Tramal 50 mg to 100 mg is an analgesic.
http://www.ultram-er.com/

Celexa (citalopram hydrobromide) is sometimes used to treat anxiety and depression. Celexa is an orally administered selective serotonin reuptake inhibitor (SSRI) with a chemical structure unrelated to that of other SSRI's or of tricyclic, tetracyclic, or other available antidepressant agents. Citalopram is available for oral administration as tablets containing 10 mg, 20 mg or 40 mg.
http://www.celexa.com/

Topamax (topiramate) is a sulfamate-substituted monosaccharide anticonvulsant drug. Topiramate tablets are available as 25 mg, 50 mg, 100 mg and 200 mg tablets for oral administration. Topiramate is indicated for adults for the prophylaxis of migraine headache and epilepsy.
http://topamax.com/

This list is intended as an educational aid only. It is not intended as medical advice for individual conditions or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professionals. Talk to your doctor, nurse or pharmacist before taking any prescription or over the counter drugs (including any herbal medicines or supplements) or following any treatment or regimen. Only your doctor, nurse, or pharmacist can provide you with advice on what is safe and effective for you.

Elavil (amitriptyline hydrochloride) a tricyclic antidepressant drug, is sometimes used to treat fibromyalgia. It may be prescribed for other conditions such as insomnia, chronic pain, postherpetic neuralgia (persistent pain following a shingles attack), interstitial cystitis, irritable bowel syndrome and as a preventative (prophylaxis) for patients with frequent migraines. Elavil is supplied as 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg tablets for the relief of symptoms of depression. A sedative effect may be apparent before the antidepressant effect is noted, but an adequate therapeutic effect may take as long as 30 days to develop.
http://www.elavil.com/

Atarax (hydroxyzine hydrochloride) is unrelated chemically to the phenothiazines, reserpine, meprobamate, or the benzodiazepines. Supplied in 10 mg, 25 mg, and 50 mg tablets - it is used for the symptomatic relief of anxiety. It is also useful in the management of pruritus due to allergic conditions and as a sedative when used as pre-medication and following general anesthesia. Hyroxyzine HCl has an antiemetic effect for symptomatic relief of anxiety and tension associated with psychoneurosis and as an adjunct in organic disease states in which anxiety is manifested. Hydroxyzine belongs to the class of medications called antihistamines which reduce itching, swelling and dry up secretions from the nose, eyes and throat.

Duragesic (fentanyl transdermal system) contains a high concentration of a potent Schedule II opioid agonist, fentanyl. Schedule II opioid substances which include fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone have the highest potential for abuse and associated risk of fatal overdose due to respiratory depression. Fentanyl is indicated for management of persistent, moderate to severe chronic pain that: requires continuous, around-the-clock opioid administration for an extended period of time and cannot be managed by other means such as non-steroidal analgesics, opioid combination products, or immediate-release opioids. Duragesic is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. Duragesic patches are intended for transdermal use on intact skin only.
http://www.duragesic.com/

Cymbalta (duloxetine hydrochloride) is sometimes used to treat anxiety. Duloxetine hydrochloride is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) for oral administration. Cymbalta is indicated for the treatment of major depressive disorder and for the management of neuropathic pain associated with diabetic peripheral neuropathy. Duloxetine hydrochloride delayed-release capsules are available in 20 mg, 30 mg and 60 mg strengths.
http://www.cymbalta.com/

Ultracet (tramadol hydrochloride/acetaminophen) tablets combines two analgesics - tramadol 37.5 mg and acetaminophen 325 mg. Ultracet is sometimes used to treat pain. Acetaminophen is an analgesic and antipyretic agent for oral administration. Tell your doctor and pharmacist if you are allergic to tramadol or other narcotic pain medications such as meperidine (Demerol), morphine, codeine (or medications that contain codeine such as Tylenol with Codeine), hydrocodone (e.g., Vicodin), hydromorphone (e.g., Dilaudid), oxycodone (e.g., Percocet), propoxyphene (e.g., Darvon, Darvon N), any other medications, or corn. Tramadol, a centrally acting synthetic opioid analgesic, can be habit-forming.

Lidoderm (lidocaine patch, 5%) is comprised of an adhesive material containing 5% lidocaine, which is applied to a non-woven polyester felt backing and covered with a polyethylene terephthalate (PET) film release liner. The release liner is removed prior to application to the skin. The size of the patch is 10 cm x 14 cm. Lidoderm is indicated for relief of pain associated with post-herpetic neuralgia. It should be applied only to intact skin.
http://www.lidoderm.com/

Lyrica (pregabalin) is indicated for management of pain caused by nerve damage due to diabetes (neuropathic pain associated with diabetic peripheral neuropathy) and shingles (herpes zoster) infection (postherpetic neuralgia). It is also used with other medications and is indicated as adjunctive therapy for adult patients with partial onset seizures. Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use. Advise your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-anxiety drugs (e.g., diazepam), anti-seizure drugs (e.g., carbamazepine), medicine for sleep (e.g., sedatives), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., phenothiazines such as chlorpromazine, or tricyclics such as amitriptyline), tranquilizers.
http://www.lyrica.com/

Dolobid (diflunisal) is used to relieve mild to moderate pain from various conditions. It also reduces swelling and joint stiffness caused by arthritis. Diflunisal is available in 250 mg and 500 mg tablets for oral administration. Dolobid is a non-steroidal drug with analgesic, anti-inflammatory and antipyretic properties. It is a peripherally-acting, non-narcotic drug.

Codalgin or Fludeten or Panadeine Forte (paracetamol 500 mg & codeine 30 mg) This combination of two, fast acting ingredients is used to relieve mild to moderately severe pain, migraine headaches, back pain, arthritis, tension headache, rheumatic muscle pain, neuralgia, toothache, sore throats and period pain. Codeine can be habit-forming. Paracetamol is also known as acetaminophen.

Vicodin or Norco or Lorcet or Zydone (hydrocodone bitartrate and acetaminophen) is supplied in tablet form for oral administration. Acetaminophen and hydrocodone may cause constipation. It is possible become physically and/or psychologically dependent on the medication. Hydrocodone bitartrate is an opioid analgesic, antitussive and is habit forming.
Mobic (meloxicam) is a nonsteroidal anti-inflammatory drug (NSAID) indicated to help relieve the signs and symptoms of osteoarthritis and rheumatoid arthritis. Tablets contain 7.5 mg and 15 mg of meloxicam.
http://www.mobictablet.com

Propox or Darvon (propoxyphene hydrochloride) is a centrally acting narcotic analgesic agent. Propoxyphene is structurally related to methadone. The potency of propoxyphene hydrochloride is from two-thirds to equal that of codeine. One can build up tolerance to and become dependent on this drug if you take them in higher than recommended doses over long periods of time.

Celebrex (celecoxib) capsules can be used to treat osteoarthritis and adult rheumatoid arthritis. Capsules, for oral administration, contain either 100 mg, 200 mg or 400 mg of celecoxib. Celebrex is a non-steroidal anti-inflammatory drug that exhibits analgesic and antipyretic activities.
http://www.celebrex.com/

Wellbutrin XL (bupropion hydrochloride extended-release tablets) an antidepressant of the aminoketone class, is chemically unrelated to tricyclic, tetracyclic, selective serotonin re-uptake inhibitor or other known antidepressant agents. Tablets are supplied for oral administration as 150 mg and 300 mg bupropion hydrochloride. At least one brand of bupropion (Zyban) is used to help people stop smoking by reducing cravings and other withdrawal effects.
http://www.wellbutrin-xl.com/

Paxil CR (paroxetine hydrochloride controlled-release tablets) is an orally administered psychotropic drug with a chemical structure unrelated to other selective serotonin reuptake inhibitors or to tricyclic, tetracyclic, or other available antidepressant or antipanic agents. Paxil is indicated for the treatment of major depressive, panic and social anxiety disorders.
http://www.paxilcr.com/

Effexor XR (venlafaxine hydrochloride) is an extended-release capsule for oral administration. Effexor XR is a structurally novel antidepressant for the treatment of generalized anxiety disorder and social phobia. It is known as an SNRI, or serotonin-norepinephrine reuptake inhibitor. Each 75 mg or 150 mg capsule should be swallowed whole with fluid and not divided, crushed, chewed or placed in water. It may be administered by carefully opening the capsule and sprinkling the entire contents on a spoonful of applesauce.
http://www.effexorxr.com/

Esgic or Fioricet (butalbital, acetaminophen caffeine tablets) is a short to intermediate-acting barbiturate. Acetaminophen is a non-opiate, non-salicylate analgesic and antipyretic. Caffeine is a central nervous system stimulant. Avoid sleeping pills, antihistamines, sedatives and tranquilizers except under the supervision of your doctor. Together, acetaminophen, butalbital, and caffeine are used to relieve complex tension (muscle contraction) headaches.

Relpax (eletriptan hydrobromide) is indicated for the acute treatment of migraine with or without aura, in adults. It is in a class of drugs called serotonin receptor agonists. They are believed to work by causing vasoconstriction (narrowing) of arteries and veins that supply blood to the head. Before taking Relpax, tell your doctor if you are taking Inderal, Celexa, Prozac, Luvox, Paxil or Zoloft. Relpax comes in 20 mg and 40 mg tablets.
http://www.relpax.com/

Zomig-ZMT (zolmitriptan) is indicated in the acute treatment of migraine headaches with or without aura, in adults. Available for oral administration as 2.55 mg and 5 mg tablets - an alternative delivery system is Zomig Nasal Spray, if you experience nausea or vomiting with the migraine. Zolmitriptan, 2.5 mg orally dissolving tablets, is not intended for the prophylactic therapy of migraine or for use in the management of hemiplegic or basilar migraine. Before taking zolmitriptan, tell your doctor if you are taking Inderal or a SSRI such as Prozac, Luvox, Paxil, Zoloft or Celexa.
http://www.zomig.com

Lamictal (lamotrigine) is an antiepileptic drug of the phenyltriazine class and is chemically unrelated to existing antiepileptic drugs. Tablets are supplied for oral administration as 25 mg , 100 mg , 150 mg and 200 mg. Chewable dispersible tablets are supplied for oral administration and contain 2 mg , 5 mg or 25 mg of lamotrigine. Lamictal is indicated as adjunctive therapy for partial seizures in adults and pediatric patients. Lamotrigine is indicated for the maintenance treatment of Bipolar I Disorder to delay the time to occurrence of mood episodes (depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy. The effectiveness of Lamictal in the acute treatment of mood episodes has not been established.
http://www.lamictal.com/

This is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professional. Always seek the advice of your doctor before taking any prescription or over the counter drugs or following any treatment or regiment. Only your doctor can provide you with advice on what is safe and effective for you.

RSD Conference Info - Aug. 19, S.C.

2006-08-11T11:14:00.000-07:00

SCRSDA 13th Annual RSD Conference
August 19, 2006
10am to 4:30 pm
Holiday Inn @ I-85 & Augusta Road
4295 Augusta Road
Greenville, SC 29605
(864) 277-8921

Speakers include Dr. Robert G. Schwartz, Piedmont Physical Medicine and Rehabilitation, who will talk about the role of Thermography in RSD, Dr. Kurt Heitman, who will discuss RSD and the eyes, and Dr. Don Kelley, who will discuss RSD and your teeth.

Tickets: $45 (includes lunch and light refreshments).
Registration and more information is at www.scrsda.org

Synera pain patch

2006-07-27T12:55:00.000-07:00

Synera Approved To Soothe Discomfort After Needle Sticks

Synera™ (lidocaine 70 mg and tetracaine 70 mg) topical patch

The Synera anesthetic patch was approved by the Food and Drug Administration in June 2005 for use in relieving pain after intravenous infusions, blood draws and dermatology procedures and will now be available by prescription.

Synera™ is indicated for use on intact skin to provide local dermal analgesia for superficial venous access and superficial dermatological procedures such as excision, electrodessication and shave biopsy of skin lesions.

The Synera heating component generates a mild warming that is intended to enhance the delivery of the local anesthetic. Synera begins to heat once the patch is removed from the pouch and is exposed to oxygen in the air. Although the patch may increase skin temperature by up to approximately 5ºC, maximum skin temperature will not exceed 40ºC.

Venipuncture or Intravenous Cannulation:
Prior to venipuncture or intravenous cannulation, apply Synera to intact
skin for 20-30 minutes.

Superficial Dermatological Procedures:
For superficial dermatological procedures such as superficial excision or shave biopsy, apply Synera to intact skin for 30 minutes prior to the procedure.

FDA/APF

new Pain Drug - Opana

2006-07-27T12:30:00.000-07:00

Prescription Drug Is Oral Form of Painkiller That Used to Be Injection-Only
By Miranda Hitti

June 23, 2006 -- The FDA has approved a new prescription drug to ease moderate to severe pain.

The drug, called Opana, is an opioid pain reliever taken by mouth. It will come in an extended-release form, called Opana ER, and an immediate-release version, simply called Opana.

"Both products are expected to be commercially available in the U.S. in the coming weeks," states Opana's maker, Endo Pharmaceuticals, in a news release.

The drugs contain oxymorphone hydrochloride, which was previously only available by injection. Endo Pharmaceuticals plans to relaunch the drug's injected version for hospital use under the new trade name.

Extended Release vs. Immediate Release

Opana and Opana ER have different uses.

Opana ER -- the first oral, extended-release version of oxymorphone -- is intended for patients with moderate to severe pain who need "continuous, around-the-clock opioid treatment for an extended period of time," states Endo Pharmaceuticals. Opana ER "is not intended to be used on an as-needed basis," the drug company notes.

Immediate-release Opana is for "moderate to severe acute pain where the use of an opioid is appropriate," states Endo Pharmaceuticals.

Opana ER tablets will come in four doses: 5 milligrams, 10 milligrams, 20 milligrams, and 40 milligrams. Opana's immediate-release tablets will come in two doses: 5 milligrams and 10 milligrams.

Drug's Trials

Fifteen clinical trials of Opana and Opana ER have included more than 3,000 patients. Two of those trials are described in Endo Pharmaceuticals' news release.

In one trial, patients with moderate to severe low back pain took Opana ER or a tablet lacking medicine (placebo) for 12 weeks without knowing which pill was which. Patients taking Opana ER had a greater drop in average pain intensity than those in the placebo group.

In another trial, patients with moderate to severe pain after abdominal surgery received immediate-release Opana or a placebo without knowing which pill they'd gotten. The Opana group took their tablets for less time than those in the placebo group.

Opana's Warnings

Like other opioids, Opana and Opana ER can be abused, warns Endo Pharmaceuticals.

In addition, "patients must not consume alcoholic beverages, or prescription or nonprescription medications containing alcohol, while on Opana ER therapy" due to possible overdose risk, the drug company notes.

According to Endo Pharmaceuticals, the most common adverse effects seen in clinical trials of Opana ER were nausea, constipationconstipation, dizzinessdizziness, vomiting, itchiness, sleepiness, headache, increased sweating, and sedation. The most common adverse effects seen in clinical trials of immediate-release Opana were nausea and fever.

WebMD Medical News Reviewed By Louise Chang, MD
on Friday, June 23, 2006

Have RSD/CRPS & no place to go for help?

2006-07-23T17:09:00.000-07:00

FINDING A FREE CLINIC
by Christin Egelhardt

If you need to see a doctor but cannot afford one, a free or low-cost clinic may be able to help you. Keep in mind that all free clinics have eligibility rules for patients: typically free clinics see only patients who have low income and who do not have insurance for the treatment needed. Depending upon their eligibility rules, not all clinics will be able to treat you. However, there may be some flexibility with the eligibility rules, so even if you think you do not qualify, it may still be worth calling the clinic to ask about your situation. Sometimes the care at a free clinic is not completely free; there may be a small charge, depending upon any income you have. In addition, free clinics are not always able to provide care for complicated conditions like RSD/CRPS, but they still may be of at least some assistance.

If you are searching for a free clinic near you, you may be able to find one through your local phone books. You may also find a free clinic through the Internet and may need to try more than one website before you find a clinic to help you as not all the websites have complete lists. Several state and regional associations have their own websites.

Please cut & paste links in your browser:
*Arkansas Association of Charitable Clinics; http://www.aacclinics.org/
*Free Clinic Association of Pennsylvania; http://www.freeclinicpa.org/
*Free Clinics of the Great Lakes Region (for Illinois, Indiana, Iowa, Michigan, Minnesota, Ohio, Wisconsin); http://www.fcglr.org/directory/directory.htm
*Georgia Free Clinic Network; http://www.gfcn.org/
*North Carolina Association of Free Clinics; http://www.ncfreeclinics.org/mc/page.do
*Ohio Association of Free Clinics; http://www.ohiofreeclinics.org/
*South Carolina Free Medical Clinic Association; http://www.scfmca.org/
*Vermont Coalition of Clinics for the Uninsured; http://www.vccu.net/
*Virginia Association of Free Clinics; http://www.vafreeclinics.org/

If your state does not have its own website, there are three other websites which have information about free clinics across the country. Please cut & paste links in your browser:
1. The National Association of Free Clinics, a non-profit organization, has a list of state and regional associations of free clinics on its website; http://www.freeclinics.us/StateRegionalFreeClinicNews/tabid/72/Default.aspx
Find your state or region’s association, and contact that organization for a list of clinics near you.

2. RxAssist (an information center created by Volunteers in Health Care that helps people find out how to get medications) also has a list of state and regional associations of free clinics on its website;
http://www.rxassist.org/patients/res-free-clinics.cfm
Find your state or region’s association, and contact that organization for a list of clinics near you.

3. Medkind Corporation (which produces software for clinics) has a list of many free clinics on its website;
http://www.medkind.com/Scripts/Modules/Module6/A1.idcCode=1004&NewCode=3895369&Index=3336028
Choose the state that you want, and then click “Search” to get a list of clinics in that state.

You may also contact charities in your area (such as the Salvation Army or Catholic Charities) to see if they offer any health care services. If caregivers at the free clinic need a copy of the RSDSA Treatment Guidelines (published in June 2006), you can download it LINK or contact the RSDSA office to have a copy sent to the clinic.

New York, RSD run/walk, Aug. 6 - Central Park

2006-07-23T16:15:00.000-07:00

District animal control officer to get rolling in fund-raiser for RSD research
By Pamela McLoughlin, Register Staff

Rettig, who now spends most of her days in a living room chair, except when she is moved by wheelchair, was stopped in her tracks in January by reflex sympathetic dystrophy, a nerve disorder that can appear after an injury.

But to help bring awareness to the condition and raise money for research through pledges, Rettig will be in New York City's Central Park Aug. 6 as part of a fund-raising run/walk for the Reflex Sympathethic Dystrophy Syndrome Association of America, which is headquartered in Milford. The RSD team will participate in the Achilles Hope and Possibility 5 mile run/walk, which is also raising money for other causes.

Rettig will do a 2-mile walk in a wheelchair, pushed by her dedicated partner of 30 years, Christine Santoro, a retired West Haven teacher.

"You don't think of a rare disease needing research until you have it," Rettig said. "This can happen to anybody. At any point, our life can take a change."

Though her condition really hasn't improved since January, Rettig hopes to return to work at the district shelter someday because she misses rescuing and caring for animals. Sometimes she visits the shelter to see her four-legged friends, but mostly these days she gets her animal fix on the Internet, looking at pictures of dogs for hours at a time on Petfinder.

"I sit here all day, thinking about animals," said Rettig, who still yearns to catch animals, clean them up and find them homes. Through the years, first in West Haven, Rettig became known among animal lovers for the extraordinary lengths she'd go to help animals any time of the day or night.

Rettig also has been an advocate for needy people, including collecting supplies for the homeless.

Rettig now pours some of that same energy into raising awareness of RSD. She wants to show support for the RSD Association because the organization's executive director, Jim Broatch, has been a wealth of help and information about it.

"I'm looking forward to the walk," said Rettig. "My motivation is also to help others who are suffering."

Since she can't go out to seek walk pledges, Rettig said anyone who would like to pledge on her behalf can send money or checks written to the association.

Rettig's RSD stems from a broken leg in January 2005, when she slid on ice at the shelter. Her right leg and foot are affected, and it has jumped to her wrist - a wrist she broke last week when she was trying to walk with crutches and fell because her bad leg gave out. There is no cure for RSD, only pain management, the disease was redefined by the medical community in 1990 as Complex Regional Pain Syndrome, although the term RSD is still commonly used. The pain is so extreme that most drugs - even oxycontin and morphine - barely take the edge off. The best hope is for remission, which can take years if it happens at all.

RSD causes burning pain disproportionate to the injury and makes the area so sensitive to the touch that even a sheet or pant leg can cause agony. Rettig, who wears a special boot over her affected leg, can't sit through a loud movie because vibrations cause pain. She said her leg feels "as if someone put gas on it and lit a match."

Rettig notes, however, that there are RSD sufferers far worse off than she. Some people have it in numerous limbs or full-body RSD. "I'm still optimistic that I'm going to get better," she said.

Broatch has said that while the medical community classifies the syndrome as "rare," meaning fewer than 200,000 cases exist, his organization believes more than 1 million people in the United States have it and have not been diagnosed.

Spinal Cord Stimulation - RSD/CRPS

2006-06-23T15:30:00.000-07:00

Complex Regional Pain Syndromes (Reflex Sympathetic Dystrophy and Causalgia) and Spinal Cord Stimulation

The complex regional pain syndromes (CRPS I and CRPS II), also known as reflex sympathetic dystrophy and causalgia, have been recognized for the past 2,500 years and believed in for the past 150, but they have yet to be understood. These syndromes can be characterized by discrete sensory, motor, and autonomic findings, but many patients with CRPS continue to suffer for years without a diagnosis. The role of the sympathetic nervous system in maintaining these syndromes and its appropriateness as a target for treatment continue to be subjects of enduring controversy. As might be expected in a group of disorders that we still have trouble naming, much less diagnosing, it has been very difficult to reach a consensus on how to treat people afflicted with the CRPS. Recent insights into how the nervous system responds to injury are beginning to explain some of the "impossible" neurological findings that are characteristic of CRPS. These research findings may soon be translated into specific therapies targeted at the processes of neural inflammation that appear to play an important role in these syndromes. Using currently available techniques of quantitative sensory testing should allow us to improve our approach to diagnosing our patients and monitoring their responses to treatment. Incorporating these diagnostic techniques into clinical studies now promises to improve the utility of clinical research in this field. Case-series studies suggest that spinal cord stimulation is a safe and effective treatment for many people with advanced CRPS who have not obtained adequate relief with other treatments.
Pain Medicine Article

Daniel S. Bennett, MD, DABPM, and Daniel Brookoff, MD, PhD

Anything that can provide relief is to be welcomed

2006-06-23T14:17:00.000-07:00

Music can reduce chronic pain

Research has confirmed listening to music can have a significant positive impact on perception of chronic pain.

US researchers tested the effect of music on 60 patients who had endured years of chronic pain.

Those who listened to music reported a cut in pain levels of up to 21%, and in associated depression of up to 25%, compared to those who did not listen.

The Journal of Advanced Nursing study also found music helped people feel less disabled by their condition.

The patients who took part in the study were recruited from pain and chiropractic clinics.

They had been suffering from conditions such osteoarthritis, disc problems and rheumatoid arthritis for an average of six-and-a-half years.

Most said the pain affected more than one part of their body, and was continuous.

Some listened to music on a headset for an hour every day for a week, while the rest did not.

Among those who listened to music, half were able to chose their favourite selections, the rest had to pick from a list of five relaxing tapes provided by the researchers.

Consistent improvements

Researcher Dr Sandra Siedlecki, of the Cleveland Clinic Foundation, said: "Our results show that listening to music had a statistically significant effect on the two experimental groups, reducing pain, depression and disability and increasing feelings of power.

"There were some small differences between the two music groups, but they both showed consistent improvements in each category when compared to the control group.

"Non-malignant pain remains a major health problem and sufferers continue to report high levels of unrelieved pain despite using medication.

"So anything that can provide relief is to be welcomed."

Professor Marion Good, who also worked on the study, said: "Listening to music has already been shown to promote a number of positive benefits and this research adds to the growing body of evidence that it has an important role to play in modern healthcare."

Previous research published in the same journal found listening to 45 minutes of soft music before going to bed can improve sleep by more than a third.

Complex phenomenon

Dr Cathy Stannard, honorary secretary of the British Pain Society, said other studies had shown music could have a positive impact on the perception of pain.

But she said the effects tended to be relatively small, and there was doubt as to whether they were anything other than very short term.

"The perception of pain is very complicated, and is influenced by factors such as emotion, experience and mood," she said.

"If music makes you feel relaxed and chilled out then one might expect it would affect our perception of pain."

Dr Stannard said it was possible that music simply provided a distraction which stopped people concentrating on their pain.

She said it was not surprising that drugs which had a specific action on the body often had a limited effect on a phenomenon as complex as pain.

"We need to start to think outside the box," she said.

Story from BBC NEWS:

Article - Chronic Regional Pain Syndrome, I & II

2006-06-22T15:13:00.000-07:00

Complex Regional Pain Syndrome

By Steven A. King, MD, MS, Psychiatric Times

June 2006, Vol. XXIII, No. 7

Of all the common pain syndromes, perhaps none is so misunderstood by both physicians and patients as complex regional pain syndrome (CRPS). Types I and II of CRPS are the current names for what were previously called reflex sympathetic dystrophy (RSD) and causalgia, respectively. Because of limited knowledge about these disorders, patients who suffer what is frequently very severe pain often have their condition misdiagnosed and do not receive appropriate treatment.

Although many physicians are still relatively unfamiliar with these disorders, the first in-depth description was made over 140 years ago by the physician often considered the father of American neurology, S. Weir Mitchell, and his colleagues, based on their observations of soldiers wounded in the Civil War. They noted that some soldiers who were wounded in the hand or foot developed a burning pain that was exacerbated by touching the affected body part. This syndrome was named causalgia, Greek for “burning pain.”

Multiple similar conditions were described over the years and received a variety of names, including post-traumatic injuries, algodystrophy, and Sudeck atrophy. In 1953, John Bonica, one of the pioneers in the study of pain, suggested that these disorders be subsumed under “reflex sympathetic dystrophy.” However, the validity of this term has been questioned frequently. One of the major problems encountered in its use is the uncertainty of the role of the sympathetic nervous system (SNS) in this disorder. The fact that there is a great deal of variability in response to sympathetic blocks suggests that in many patients, the pain is not due to a disorder of the SNS.

Because of this and the general confusion over RSD and causalgia, the International Association for the Study of Pain renamed these syndromes in its classification of chronic pain.1 RSD became CRPS type I and causalgia became CRPS type II. The diagnostic criteria for CRPS are shown in the Table (see June 2006 Psychiatric Times, page 9). The difference between types I and II is that in the latter, there is evidence of a definable nerve lesion.

Two terms used to describe the pain, allodynia and hyperalgesia, are notable in the criteria for both types of CRPS. Allodynia is pain due to a stimulus that is not usually painful and is commonly the most dramatic presenting symptom of these disorders. Patients with this problem may wear loose-fitting clothing to limit the amount of contact between it and the skin in the affected area. In more severe cases, patients may complain that even having bedsheets touching the body part can cause severe pain. In hyperalgesia, a normally painful stimulus causes more discomfort than expected. Both allodynia and hyperalgesia are covered by the more general term “hyperesthesia,” an increased sensitivity to stimulation.

The frequency of occurrence of CRPS is unclear. A recent study of patients with fractures of the distal radius reported that CRPS type I developed in 18%.2 Another study of 162 soldiers wounded in the Iraqi war who were seen in pain clinics reported that 4.3% suffered CRPS type II and 1.9%, CRPS type I.3 Based on reports that patients with CRPS often see a number of physicians before their condition is diagnosed correctly, it appears that many cases are never diagnosed. Type I may especially go unrecognized because of the absence of an identifiable peripheral nerve injury and the usual relationship of the disorder to some form of trauma, ranging from an accident-induced injury to surgery or diseases that can cause pain, including myocardial infarction and post-herpetic neuralgia. Since pain is an expected sequela of these events, the possibility of CRPS may not be considered by health care providers for lengthy periods.

Unfortunately, because many patients with CRPS appear “normal” and because pain such as allodynia seems so bizarre and so foreign to most laypeople and even some health care professionals, patients may be mistakenly thought to be either exaggerating their pain for secondary gain or even malingering. One of the saddest things is that these patients may find their pain discounted by so many others and may be stigmatized as falsifying their discomfort.

The cause of CRPS remains a mystery. A variety of physiologic mechanisms have been proposed. The classic view that the pain is due to hyperactivity of the SNS has been discounted, although the SNS appears to be involved in some of the symptoms, most notably the edema, blood flow, and sudomotor changes. Currently, CRPS is believed to be due to a combination of peripheral and central factors.4 Among the peripheral mechanisms that have been proposed are an inflammatory process, peripheral sensitization, and changes in sodium channels. These processes may result in central changes, including an exaggerated response to the peripheral input and a reduction of descending inhibitory pathways.

Because the severity of the original trauma does not appear to be correlated with these disorders, the significance of psychological factors and the possibility that they may play an important role - if not the major role - in the development of the pain have often been the focus of attention. Despite this speculation, there have never been consistent findings of a correlation between preexisting mental disorders and the development of CRPS. However, it has been proposed that there may be changes in the brain, most notably in the primary sensory cortex, secondary to CRPS, and that these can lead to a distorted body image.5,6 What role these changes may play in the pain and other symptoms of CRPS is still the subject of speculation.

Dr King is clinical professor of psychiatry at the New York University School of Medicine.

References
1. Merskey H, Bogduk N, eds.Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle: IASP Press; 1994.
2. Puchalski P, Zyluk A. Complex regional pain syndrome type 1 after fractures of the distal radius: a prospective study of the role of psychological factors. J Hand Surg (Br). 2005;30:574-580.
3. Cohen SP, Griffith S, Larkin TM, et al. Presentation, diagnoses, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom: an epidemiological study conducted At two military pain management centers. Anesth Analg. 2005; 101:1098-1103.
4. McBride A, Atkins R. Complex regional pain syndrome. Curr Orthop. 2005;19:155-165.
5. Moseley GL. Distorted body image in complex regional pain syndrome. Neurology. 2005;65:773.
6. Birklein F, Rowbotham MC. Does pain change the brain? Neurology. 2005;65:666-667.

Worker Compensation Resources - CA

2006-06-19T14:52:00.000-07:00

VotersInjuredatWork.org is committed to effecting changes in the workers’compensation system that will help those who have been injured on the job in California receive appropriate medical treatment and get back on track with their lives. That includes keeping the social safety net intact while recovery occurs and people adjust to what is now a different life, whether it is due to a permanently disabling condition or an increased understanding of the fine line between good fortune and disaster.

Learn about topics that include:
* Fraud
* Enforcement
* Permanent Disability Benefits
* Vocational Rehabilitation Benefits
* Medical Services
* Workers' Compensation Insurance

Need help finding an attorney?
http://www.caaa.org

Need forms?
http://www.dir.ca.gov/dwc/forms.html

Need fact sheets and injured worker's guide?
http://www.dir.ca.gov/dwc/iwguides.html

If you or someone you know and love was injured at work, this web site is for you.

Briefing on Pain - June 13, 2006

2006-06-17T13:10:00.000-07:00

Report on Congressional Briefing on Pain held on June 13, 2006

The Congressional Briefing on Pain held June 13, 2006, on Capitol Hill was attended by over 100 congressional staffers and pain advocates. The room was packed and over-flowing into the hall, as Rep. Mike Rogers, Rep. Charlie Norwood and featured speakers passionately shared the facts about pain, the personal and economic impact of this "silent epidemic," and the critical need for federal pain policy and legislation.

Congressman Rogers welcomed the audience and challenged people to learn about the healthcare crisis of the undertreatment of pain and to join forces in support of H.R. 1020, the National Pain Care Policy Act (introduced by Congressman Rogers). This "silent epidemic" is destroying the lives of over 50 million Americans and costing $100 billion in lost productivity. Congressman Norwood, a co-sponsor of the bill, spoke of his commitment to the millions of people suffering daily, the need for "balanced" pain policy and his concerns about abuse and illegitimate internet sales.

Dr. Howard A. Heit, a physician and person living with chronic pain, dependent on a wheel chair and body brace, shared his personal story and his life's work. Dr. Heit treats both patients with pain and patients with the disease of addiction. Dr. Heit raised the question - "why is pain not treated with medications approved by the FDA and consistent with state and federal regulations?" He discussed the barriers to pain management, such as, the confusion between physical dependence and addiction, inadequate education in pain and addiction, and the fact that the "balance" has been lost between preventing abuse and diversion and ensuring the availability of strong pain medications for medical purposes, "for all patients who need them for the relief of pain."

Dr. Rollin M. Gallagher, the Director of the Center of Pain Medicine, Research and Policy at the University of Pennsylvania School of Medicine and the Director of Pain Management at the Philadelphia Veterans Affairs Medical Center, urged the support of H.R. 1020, the Pain Care Policy Act. He said it will address the "enormous impact of chronic pain on our economy, and the suffering that chronic pain causes people, families and business and yes, taxpayers." He discussed the impact for veterans, trying to restore life, "following blast injuries causing severe tissue and nerve damage that leave them in a state of permanent severe pain" and "it is the pain that prevents them from resuming a reasonable quality of life, a productive life."

Mary Vargas, JD, a disability rights attorney and chronic pain patient who spent the past ten years advocating on behalf of pain patients while struggling to receive care for herself, provided a vivid and moving account of what it really means to be one of the fifty million, whose lives are being ravaged by a pain. She spoke of how statistics are so "sanitized and simplified, and so unimaginable when looking at the impact of untreated or undertreated or inappropriately treated pain in just one of those fifty million." Her journey has included "16 doctors with countless specialties (an average number for pain patients), hospitals in four states, three physical therapy practices, numerous procedures - too many to count," as well as 8 surgeries and thousands of dollars, not covered by health insurance. Vargas spoke of the "fight of her life, just to receive care" and the additional barriers she has encountered, such as a lack of education of healthcare professionals, "their palpable and unabashed fear of enforcement by the DEA," her difficulty in getting prescriptions filled and enduring the stigma of being a pain patient.

All speakers expressed gratitude to Congressman Rogers for introducing the National Pain Care Policy Act and urged all who attended to become active in the fight to assure that healthcare providers are educated and "care is based on solid medicine, not fear", that critically needed research and public awareness are funded, and that everyone of the 50 million Americans with untreated or undertreated pain "deserve to have hope that they will wake up one day to a life that is not dictated by pain".

All attendees received a folder of information with pain facts, statistics, personal stories (from the American Pain Foundation's Voices of People in Pain) and pertinent articles.

Thank you to Congressman Rogers and all individuals and organizations that helped to make this Congressional Briefing on Pain a success. Together we will make a difference!

CRPS/RSD Conference, Chicago

2006-06-11T16:30:00.000-07:00

A Comprehensive Review of Complex Regional Pain Syndrome (CRPS):

Dispelling the Myths & Looking at Emergent Treatment

Chicago September 2006

Northwestern University's Feinberg School of Medicine, the Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) and Rehabilitation Institute of Chicago Academy are sponsoring a 2-day course on Complex Regional Pain Syndrome (CRPS) also known as Reflex Sympathetic Dystrophy Syndrome (RSD).

This course will clarify key issues surrounding this chronic pain condition that continues to baffle healthcare practitioners. Experts will discuss the pathophysiology of CRPS, new diagnostic criteria validation, and the recently revised clinical practice guidelines.

Course Chairs:
R Norman Harden, MD is Director for Pain Studies, Addison Chair, Rehabilitation Institute of Chicago; Associate Professor, Physical Medicine & Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago IL.

Joshua P. Prager, MD, MS is Director, Center for the Rehabilitation of Pain Syndromes (CRPS), Departments of Internal Medicine and Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, CA.

To register visit: http://www.ric.org/education/

Call to Action - American Pain Foundation

2006-05-29T10:47:00.000-07:00

We need your help to generate Congressional support for the passage of H.R. 1020. This is an alert from the American Pain Foundation.

Dear Endorsers of the National Pain Care Policy Act,

By signing the Consensus Statement, your organization has joined with others to show strong support for the National Pain Care Policy Act of 2005 (H.R. 1020) and the pain issues it addresses. The American Pain Foundation and the Pain Care Forum in cooperation with Representative Mike Rogers (R-MI) are pleased to announce:

A Congressional Briefing
THE EPIDEMIC OF PAIN IN AMERICA
June 13, 2006
Noon to 1pm
Cannon House Office Building
Room 121

The purpose of the briefing is to educate Congress on the serious need for federal policy reform affecting pain management. It is critical to generate large Congressional attendance, in order to:

-Increase their awareness of pain as a major public health problem
-Provide an understanding of the extensive barriers to effective pain management
-Educate congress on the critical need to improve access to pain management treatment.
-Provide information about the serious need to increase healthcare professional pain management education
-Alert them to the impact of current pain policy
-Urge congressional support for research about the causes of and treatments for pain
-Increase co-sponsorship of H.R.1020, the National Pain Care Policy Act

This is our opportunity to EDUCATE CONGRESS ON THE TRAGIC PERSONAL AND ECONOMIC EFFECTS OF THE UNDERTREATMENT OF PAIN!

TAKE ACTION NOW!
Contact your Congressional representatives and encourage them to attend this hearing. Please send email to your membership and professional network today and urge them to contact their representative about this briefing. A simple way to assist people to write their representatives is to connect to APF’s Online Advocacy Center.
https://secure2.convio.net/apf/site/Advocacy?pagename=homepage&page=UserAction&id=155&JServSessionIdr002=6ketk6ols1.app14a

Go to www.painfoundation.org and click on Take Action Now!
It is vitally important to impress upon our elected officials that they can make a difference in the lives of millions of their constituents who are currently suffering unnecessarily.

There is strength in numbers! RSDSA, RSDHope & For Grace have endorsed HR 1020. Thank you for being part of this united effort to Eliminate the Undertreatment of Pain!

Survey - Opiod Awareness

2006-05-22T16:37:00.000-07:00

SURVEY OF WI PHYSICIANS SHOWS LACK OF KNOWLEDGE ABOUT OPIOIDS

University of Wisconsin School of Medicine and Public Health, Madison, WI

Opioid analgesics are the drugs of choice for the treatment of moderate to severe acute and cancer pain. Although their role in the management of chronic pain not related to cancer is controversial, there is increasing evidence for their benefit in certain patient populations.

Previous studies have shown that physicians hold many misconceptions about these drugs and about the laws and regulations that govern their use. Furthermore, the increase in the abuse of these medicines has added to the uncertainty about the appropriateness of using them for the treatment of chronic pain.

A 32-item survey to assess Wisconsin physicians' knowledge and attitudes toward opioid analgesic use was mailed to 600 randomly selected licensed physicians. The response rate was 37%. Half of
the respondents considered diversion a moderate or severe problem in Wisconsin. A majority considered addiction to be a combination of physiological and behavioral characteristics, rather than defining it solely as a behavioral syndrome. Most physicians felt it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain, but only half held this view if the pain was not related to cancer.

Fewer physicians believed it lawful and generally accepted medical practice if the patient had a history of substance abuse. About two-thirds of physicians were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills, or prescribe a Schedule III or IV rather than a Schedule II opioid. Wisconsin physicians who responded to this survey held many misconceptions about the prescribing of opioids. Such views coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances may result in inadequate prescribing of these drugs with resultant inadequate management of pain.

Abstract 996, Journal of Pain, vol. 7, number 4, supp 2, April 2006
http://www.aacpi.wisc.edu/

Curb Drug Abuse

2006-05-22T16:25:00.000-07:00

RX MONITORING PROGRAMS INEFFECTIVE IN CURBING DRUG ABUSE

Robert Twillman, PhD, immediate past-chair of the AACPI’s Advisory Council, head of the Kansas Pain Initiative, and program director of pain management at the University of Kansas Hospital, recently studied the effects of prescription monitoring programs (PMPs) on retail drug distribution patterns and measures of substance abuse. Twenty-two states currently have a system that tracks the prescribing of controlled substances.

Dr. Twillman presented his findings at the annual meeting of the American Pain Society earlier this month. His evaluation indicates that 1) states with PMPs, compared to those without PMPs, report less prescribing of most C-II opioids, especially morphine and oxycodone, while they report significantly greater prescribing of C-III opioids; and 2) states with PMPs do not report lower rates of abuse of prescription opioids, but in fact, actually report higher rates on one measure of such abuse.

When dividing states according to the type of PMP, those with PMPs that monitor both C-II and C-III opioids do not differ significantly from states with no PMPs in prescribing of any opioid except hydrocodone (with PMP states prescribing 68% more hydrocodone than states without PMPs). The pattern of findings with respect to drug abuse holds for these states. States that monitor only C-II opioids report significantly less prescribing of morphine, oxycodone, and hydrocodone, compared to states that monitor both C-II and C-III opioids.

This study suggests that PMPs are not effective in reducing drug abuse (and by extension, probably not effective in reducing drug diversion), and depending on the schedules monitored by the PMP, may result in "downscheduling" of medications prescribed to patients and in a sharp increase in prescribing of hydrocodone (which is the most commonly abused prescription opioid).

You can view Dr. Twillman’s presentation on the AACPI website at: http://aacpi.wisc.edu/policy.htm

RSD in Women

2006-05-19T11:45:00.000-07:00

Chronic Pain Syndrome Hits Women Harder

Jennifer Wider, M.D.

Society for Women’s Health Research

If you’ve ever been in pain, you know it isn’t easy. Sometimes it can place serious obstacles in your path. But for hundreds of thousands of Americans, mostly women, who suffer from a chronic pain syndrome known as reflex sympathetic dystrophy syndrome (RSD), the pain can be constant and excruciating, making it difficult to even get through the day.

For Tracy Zuckerman who currently resides in Florida, the pain was disproportionate to her injuries. Years ago, she was in a head-on collision and the air bag in her car crushed her left hand and the right-side of her jaw. When her healing time was abnormally prolonged, it became quite clear that something else was wrong. Despite the fact that her hand wasn’t broken, the swelling was so severe that she couldn’t open it.

"My hand was not healing, it was swollen and discolored," Zuckerman said. "Someone would brush by me, barely touch me, and I’d have severe pain. I consider myself lucky because my orthopedic surgeon, who had seen a case in medical school, diagnosed me early on with complex regional pain syndrome."

Sometimes called complex regional pain syndrome (CRPS), RSD results when the nervous system doesn’t function properly. Instead, the nerves send incessant pain signals to the brain and the body reacts accordingly. It usually occurs as a response to a traumatizing incident such as an accident or surgical procedure. Like other chronic pain syndromes, RSD is more common in women.

"Epidemiological studies, and a recent web-based survey that we conducted, indicate that CRPS is more common in women than men," said Srinivasa Raja, M.D., director of the pain medicine division and director of pain research at Johns Hopkins University in Baltimore, Md. "The reason for this gender difference in the prevalence of CRPS is not clear. Such a female preponderance is, however, not unique to CRPS as other chronic pain states are also more frequently observed in females compared to males."

An early diagnosis and aggressive therapy are vital for healing and proper function. Unfortunately, diagnosing RSD can be difficult, because many people and members of the medical community are not familiar with the symptoms. According to the Reflex Sympathetic Dystrophy Syndrome Association in Milford, Conn., patients with this disorder see at least five doctors before receiving a proper diagnosis.

Zuckerman began treatment right away but it took a long time to find the right combination of therapies that worked.

"I tried many different treatments for several years," Zuckerman said. Her treatments included massage therapy, physical and occupational therapy, acupuncture and nerve blocks. "Everything is a combination," Zuckerman said. "It required a multi-disciplinary approach. I developed my own team to support me and guide me through this process, which include doctors and therapists. When it stops working, we change the approach. It’s a lot like cross training."

Echoing Zuckerman’s sentiments, Raja said "optimal treatment of this condition often requires a multi-disciplinary approach that includes physical therapy, diagnostic and or therapeutic nerve blocks and psychological consultations."

Zuckerman has learned to live with her condition, but getting well became a full-time job. "You cannot will yourself to be well," she said. "You need a team of doctors, nurses and a support group. It’s not about just taking a pill. You need to become an advocate for your own body."

New treatments are on the horizon for RSD.

"In recent years, spinal cord stimulation has shown promise as a treatment modality for cases that have not been treated successfully with conservative measures," Raja said. In addition, several academic centers have been studying the potential role of ketamine, a drug that can potentially reduce the heightened sensitivity of brain cells. More research involving ketamine is needed to make conclusions about the long-term benefits.

Canada RSD Network

2006-05-18T12:41:00.000-07:00

The Canadian RSD Network will be hosting our Annual General Meeting and Conference on July 21, 2006 in British Columbia.

We have several guest speakers for this event. Seating is limited and we request people reserve a seat in advance.

This event is free.

Please RSVP 604-505-2934
or
info@canadianrsd.com
Agenda, guest speakers and more will be posted soon at: www.canadianrsd.com

July is RSD/CRPS Awareness Month in Canada!

Pain Control - RSD/Fibromyalgia - Allentown, PA

2006-05-17T11:52:00.000-07:00

Lehigh Valley RSD/CRPS Friends of Hope

Presents

Eric Ratner M.D.
(Pain Management/Anesthesiology)

Saturday, June 3rd, 2006

Sacred Heart Hospital
4th and Chew Streets
Allentown, PA

2nd Floor Conference Center, Reception Rooms A-D

1:00 to 3:00 P.M. promptly

FREE for all attendees

Topic:
Medical Options for Pain Control for RSD/CRPS and Post-trauma Fibromyalgia

Dr. Eric Ratner, formerly of the Jefferson Pain Clinic, is the Medical Director of Pain Care Institute in Reading, PA. He is certified with the Board of Anesthesiology and has additional certifications in pain management. Dr. Ratner will discuss procedures such as epidural steroid-nerve blocks, stellate ganglion nerve blocks, and lumbar sympathetic nerve blocks as adjunctive medical therapies for RSD/CRPS.

Other pain management therapies will also be discussed. Family, friends, and medical professionals are welcome to join us! There will be an open question and answer session after the presentation.

This meeting is open to all those who suffer from chronic pain and our support group supports those specifically with Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome and Post trauma Fibromyalgia

For more information call our Info Line at 610-776-5992

Pain Article NY Times Magazine

2006-05-15T13:25:00.000-07:00

My Pain, My Brain

5/14/06

Who hasn't wished she could watch her brain at work and make changes to it, the way a painter steps back from a painting, studies it and decides to make the sky a different hue? If only we could spell-check our brain like a text, or reprogram it like a computer to eliminate glitches like pain, depression and learning disabilities. Would we one day become completely transparent to ourselves, and - fully conscious of consciousness - consciously create ourselves as we like?

The glitch I'd like to program out of my brain is chronic pain. For the past 10 years, I have been suffering from an arthritic condition that causes chronic pain in my neck that radiates into the right side of my face and right shoulder and arm. Sometimes I picture the pain - soggy, moldy, dark or perhaps ashy, like those alarming pictures of smokers' lungs. Wherever the pain is located, it must look awful by now, after a decade of dominating my brain. I'd like to replace my forehead with a Plexiglas window, set up a camera and film my brain and (since this is my brain, I'm the director) redirect it. Cut. Those areas that are generating pain - cool it. Those areas that are supposed to be alleviating pain - hello? I need you! Down-regulate pain-perception circuitry, as scientists say. Up-regulate pain-modulation circuitry. Now.

Recently, I had a glimpse of what that reprogramming would look like. I was lying on my back in a large white plastic f.M.R.I. machine that uses ingenious new software, peering up through 3-D goggles at a small screen. I was experiencing a clinical demonstration of a new technology - real-time functional neuroimaging - used in a Stanford University study, now in its second phase, that allows subjects to see their own brain activity while feeling pain and to try to change that brain activity to control their pain.

Over six sessions, volunteers are being asked to try to increase and decrease their pain while watching the activation of a part of their brain involved in pain perception and modulation. This real-time imaging lets them assess how well they are succeeding. Dr. Sean Mackey, the study's senior investigator and the director of the Neuroimaging and Pain Lab at Stanford, explained that the results of the study's first phase, which were recently published in the prestigious Proceedings of the National Academy of Sciences, showed that while looking at the brain, subjects can learn to control its activation in a way that regulates their pain. While this may be likened to biofeedback, traditional biofeedback provides indirect measures of brain activity through information about heart rate, skin temperature and other autonomic functions, or even EEG waves. Mackey's approach allows subjects to interact with the brain itself.

"It is the mind-body problem - right there on the screen," one of Mackey's collaborators, Christopher deCharms, a neurophysiologist and a principal investigator of the study, told me later. "We are doing something that people have wanted to do for thousands of years. Descartes said, 'I think, therefore I am.' Now we're watching that process as it unfolds."

Suddenly, the machine made a deep rattling sound, and an image flickered before me: my brain. I am looking at my own brain, as it thinks my own thoughts, including these thoughts.

How does it work? I want to ask. Just as people were once puzzled by Freud's talking cure (how does describing problems solve them?), the Stanford study makes us wonder: How can one part of our brain control another by looking at it? Who is the "me" controlling my brain, then? It seems to deepen the mind-body problem, widening the old Cartesian divide by splitting the self into subject and agent.

But most of all I want to know: Will I be able to learn it?

For most of history, the idea of watching the mind at work was as fantastical as documenting a ghost. You could break into the haunted house - slice the brain open - but all you would find would be the house itself, the brain's architecture, not its invisible occupant. Photographing it with X-rays resulted only in pictures of the shell of the house, the skull. The invention of the CT scan and magnetic resonance imaging (M.R.I.) were great advances because they reveal tissue as well as bones - the wallpaper as well as the walls - but the ghost still didn't show up. Consciousness remained elusive.

A newer form of M.R.I., functional magnetic resonance imaging (f.M.R.I.), used with increasingly sophisticated software, is accomplishing this, taking "movies" of brain activity. Researchers are able to watch the brain work, as the films show parts of the brain becoming active under various stimuli by detecting areas of increased blood flow connected with the faster firing of nerve cells. These films are difficult to read; researchers puzzle over the new images like Columbus staring at the gray shoreline, thinking, India? Most of the brain is uncharted, the nature of the terrain unclear. But the voyage has been made; the technology exists. Pain - a complex perception occupying the elusive space spanning sensation, emotion and cognition - is a particularly promising area of imaging research because, researchers say, it has the potential to make great progress in a short time.

Perhaps more than any other aspect of human existence, persistent pain is experienced as something we cannot control but desperately wish we could. Acute pain serves the evolutionary function of warning us of tissue damage, but chronic pain does nothing except undo us. Pain is the primary complaint that sends people to the doctor. Of the 50-odd million sufferers in the United States, half cannot get adequate relief from their chronic pain. Many do not even have a diagnosis.

Unlike acute pain, chronic pain is now thought to be a disease of the central nervous system that may or may not correlate with any tissue damage but involves an errant reprogramming in the brain and spinal cord. The brain can generate terrible pain in a wound that is long healed, in a body that is numb and paralyzed or - in the case of phantom-limb pain - in a limb that no longer even exists.

Although there have been many theories about how pain works in the brain, it is only through neuroimaging that the process has actually been observed. It is now clear that there is no single pain center in the brain. Rather, pain is a complex, adaptive network involving 5 to 10 areas of the brain transmitting information back and forth.

This network has two pain systems: pain perception and pain modulation, which involve both overlapping and distinct brain structures. The pain-modulatory system constantly interacts with the pain-perception system, inhibiting its activity. Much chronic pain is thought to involve either an overactive pain-perception circuit or an underactive pain-modulation circuit.

Like everyone who suffers from chronic pain, I find it hard to believe that I have a pain-modulation circuit. The aspect of my pain I feel most certain about is that it is not voluntary: I cannot modulate it. And this belief is reinforced every single day that I suffer from pain, which is every day. Yet I know that pain is not a fact, like a broken bone; it's a perception, like hunger, about a physical state ("an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage," as the International Association for the Study of Pain defines it). And it's a mercurial perception; under certain circumstances the pain-modulatory system works like a spell and the brain completely blocks out pain.

Soldiers, athletes, martyrs and pilgrims engage in battles, athletic feats or acts of devotion without being distracted by the pain of injuries. When the teenage surfer Bethany Hamilton's arm was bitten off by a shark, she felt pressure, but "I didn't feel any pain - I'm really lucky, because if I felt pain, things might not have gone as well," she said (articulating one reason the modulatory system evolved: if she had thrashed about in pain, she would have bled until she drowned).

In addition to being activated by stress, the pain-modulatory system is triggered by belief. The brain will shut down pain if it believes it has been given pain relief, even when it hasn't (the placebo effect), and it will augment pain if it believes you are being hurt, even if you aren't (the nocebo effect). The brain's modulatory system relies on endogenous endorphins, its own opiatelike substances. The nature of a placebo has long been a source of speculation and debate, but neuroimaging studies have shown the way a placebo actually helps to activate the pain-modulatory system.

In a recently published study led by Dr. Jon-Kar Zubieta at the University of Michigan Medical School, the brains of 14 men were imaged after a stinging saltwater solution was injected into their jaws. They were then each given a placebo and told that it would positively relieve their pain. The men immediately felt better - and the screen showed how. Parts of the brain that release endogenous opiates lighted up. In other words, fake opiates caused the brain to dispense real ones. Like some New Age dictum, philosophy becomes chemistry; believing becomes reality; the mind unites with the body.

Other studies have shown that opiates and other medications rely on a placebo to achieve part of their effect. When subjects are covertly given strong opiates like morphine, they don't work nearly as well as they do if the subjects are told they are being given a powerful pain reliever. Even real medications require some of the brain's own bounty.

Conversely, thinking about pain creates pain. In studies at Oxford University, Irene Tracey has shown that asking subjects to think about their chronic pain, for example, increases activation in their pain-perception circuits. Distraction, on the other hand, is a great analgesic; when Tracey's volunteers were asked to engage in a complicated counting task while being subjected to a painful heat stimulus, she could watch the pain-perception matrix decrease while cognitive parts of the brain involved in counting lighted up. At McGill University, Catherine Bushnell has shown that simply listening to tones while being subjected to a heat stimulus decreased activity in the pain-perception circuit.

"There is an interesting irony to pain," comments Christopher deCharms, who worked with Mackey designing and carrying out the Stanford study. We were talking in his office at Omneuron, a Menlo Park medical-technology company he founded three years ago to develop clinical applications of neuroimaging. "Everyone is born with a system designed to turn off pain. There isn't an obvious mechanism to turn off other diseases like Parkinson's. With pain, the system is there, but we don't have control over the dial."

The goal of the Stanford technique is to teach people to control their dials - to activate their modulatory systems without requiring the extreme stress of fleeing from a shark or the deception of a placebo. The hope of neuroimaging therapy (as deCharms calls the Stanford technique) is that repeated practice will strengthen and eventually change the ineffective modulatory system to eliminate chronic pain, the way long-term physical therapy can change muscular weakness. The scan would thus be more than a research tool: the scan itself would be the treatment, and the subject his or her own researcher.

Only once do I recall having a glimmer of my own pain-modulatory system at work: a hidden power that emerged, dispensed with pain and then returned to some forgotten fold in my brain, where I have never been able to locate it again. The event did not take place on a battlefield or a marathon course or in a temple; it was in a basement of the Stanford University medical center three years ago. At the time, Mackey had designed an earlier study that did not use imaging technology but focused on how suggestion alters pain perception. Although I was not formally enrolled in the study, I asked if I could undergo a clinical demonstration. My experience illustrated the power of suggestion in an unexpected fashion.

A metal probe attached to the underbelly of my arm heated up and cooled down at set intervals. I was told that although the heat probe would feel uncomfortable, my skin would not be burned. During one exposure, I was instructed to think of the pain as positively as possible, during another to think of it as negatively. After each sequence, I was asked to rate my pain on a 0-to-10 scale, with 10 being the worst pain I could imagine.

Although I discovered that I could make the pain fluctuate depending on whether I was imagining that I was sunbathing or was the victim of an inquisition, I still rated all the pain as low - ranging from a 1 to a 3. If 10 was being slowly burned alive, I felt I should at least be begging for mercy to justify a rating of 5. So I insisted that Mackey turn up the dial so I could get a real response. But even during the moments when I was actively trying to imagine the pain as negatively as possible, it remained in a mental box of "not even burned," which kept it from really hurting: hurting, that is, the way a burn would.

As it turned out, I got a second-degree burn that later darkened into a square mark. Mackey was more than a little dismayed as we watched the reddening skin pucker, but I was thrilled. Naturally the protocol had been carefully designed not to injure anyone, yet in my case that protection had failed because of the very phenomenon it was designed to study: expectation - the effect of the mind on pain or placebo.

I had recently spent several weeks observing Mackey in the university's pain clinic, where he is associate director. I was so convinced that Mackey - then a tall sandy-haired 39-year-old with a deep interest in technology (he got a Ph.D. in electrical engineering before he went to medical school) and an air of radiant integrity - would not burn me that my brain had not perceived the stimulus as a threat and generated pain. I admired him, I trusted him, I was positive that he wouldn't hurt me. And, ipso facto, he hadn't.

Mackey's genius as a practitioner, I thought, lay partly in his ability to similarly inspire patients. "When I started working with pain patients, I realized how much of the treatment involved trying to reverse learned helplessness," he said - to rally them out of the despair ingrained from years of unremitting pain and cajole their minds to chip in its own analgesic to their therapies. "The purpose of this study is to show patients their mind matters," Mackey said.

The mark of the burn is barely visible now, but for a couple of years afterward, at times when my chronic pain was making me miserable, the sight of it would both encourage and reproach me. Here is the ultimate proof that my mind can control pain, I would think, yet I didn't know how to make it wake up and do so. I could take the edge off the pain by conjuring positive images, but the effects didn't last, and I never again had the remarkable placebo response that masked a second-degree burn. In fact, a mild burn from spilling tea on my hand one day brought tears to my eyes.

When the real-time neuroimaging study began, I couldn't wait to try it.

The area of the brain that the scanner focuses on is the rostral anterior cingulate cortex (rACC). The rACC (a quarter-size patch in the middle-front of the brain, the cingular cortex) plays a critical role in the awareness of the nastiness of pain: the feeling of dislike for it, a loathing so intense that you are immediately compelled to try to make it stop. Indeed, the pain of pain, you might say, its defining element, is the way in which the sensation is suffused with a particular unpleasantness researchers refer to as dysphoria. Since pain is a perception, it's not pain if you don't experience it as hurting. You can feel hot or cold or pressure, and note them simply as stimuli, but when they exceed a certain intensity, the rACC kicks in, and suddenly they become painful, riveting your attention and causing you to recoil.

Many pain-reducing techniques aim to manipulate the conscious awareness of pain. Distraction, placebo, meditation, imagining pleasant scenes and hypnosis all result in a reduction of rACC activation when they work. Patients who have undergone a radical surgical treatment occasionally used for pain (as well as for mental illness) called a cingulotomy, in which the rACC is partly destroyed, report that they are still aware of pain but that they don't "mind" it anymore. Their emotional response has receded.

The image I saw while lying in the f.M.R.I. machine at the time of the recent Stanford study was not literally my rACC but a visual analogue of it that is easier to see: a 3-D image of a fire. The flames represent the degree of activation in your rACC: when it is low, the flames are low; when rACC activation is high, the flames flare. The study involves five 13-minute scanning runs, each consisting of five cycles of a 30-second rest followed by a 1-minute interval in which you try to increase rACC activation and then a 1-minute interval in which you try to decrease rACC activation.

Before my scan began, I was prepped in different mental strategies for increasing and modulating my pain. Everyone's brain works a bit differently, though, so subjects have to experiment in the scanner to see what is most effective for them. For some, trying to distract themselves from their pain works best; for others, focusing on their pain - like embracing a Zen koan - seems to be what triggers their pain-modulatory system. When deCharms used neuroimaging therapy on himself to try to alleviate his chronic neck pain, he concentrated on the pain itself and felt it "suddenly melt away." He said that a patient described the feeling as being "like a runner's high" (a state that has been shown to involve the release of endogenous endorphins).

Increase Your Pain, the screen commanded, as the first run began. I tried to recall the mental strategies in which I had been prepped for increasing pain: Dwell on how hopeless, depressed or lonely you felt when your pain was most severe. Sense that the pain is causing long-term damage.

Dwelling on the hopeless loneliness of my pain certainly made the flames of my rACC spark. The mental image that I found increased my pain the most, however, was the one that matched the visual analogue of the rACC: Picture a hot flame on your painful area. Try to make the flame grow in the painful area, and imagine it actually burning your flesh.

Having recently read Ariel Glucklich's extraordinary "Sacred Pain," I had plenty of details of the burning of heretics and witches available to me. I had only to imagine the smell of sizzling hair to make the flames of my rACC explode.

Decrease Pain, the screen commanded.

The suggested pain-reduction strategies, however, did little to quell the flames on the screen. I pictured suffocating the pain with banal positive imagery: flowing water or honey, something soft and gentle, but my mind kept slipping back to the progress of the auto-da-fé, and the rACC fire flared.

Feel that sensation, but tell yourself that it is just a completely harmless, short-term tactile sensation.

Pilgrims and devotees all around the world choose to inflict pain upon themselves during sacred rites - from being nailed to crosses to dangling from hooks. For them, pain is an occasion for euphoria, not dysphoria. There are many historical records of the equanimity saints and martyrs often possessed during torture. The second-century Jewish martyr Rabbi Akiva, for example, continued to recite a prayer with a smile on his lips while the flesh was being combed from his bones. "All my life," he explained to the puzzled Roman general orchestrating his execution, "when I said the words 'You shall love the Lord your God with all your heart, with all your soul, and with all your might,' I was saddened, for I thought, When shall I be able to fulfill this command? Now that I am giving my life and my resolution remains firm, should I not smile?"

As Glucklich writes, the conviction that pain is a spiritual opportunity seems paradoxically anesthetizing - or, as a scientist would say, religious states of conviction can robustly activate the pain-modulatory system.

During my next Decrease Pain interval, instead of trying to picture a vacation, I imagined myself as a martyr, lucidly reciting Though I walk through the valley of the shadow of death while being burned at the stake. My rACC activation - I noted - respectfully quieted. Then I remembered that the 23rd Psalm seems to have Christian associations, and since I was presumably being tortured for being half-Jewish, a Jewish prayer might be more appropriate. Unless, that is, I was being accused of witchcraft, in which case, I might be generally disillusioned with Judeo-Christian prayer. As I tried to settle on a fantasy, I noticed that my rACC stayed low: Irene Tracey's theory of the modulating effects of distraction. By the last run, I had the strategies down - heretic-martyr: rACC down; heretic-victim: rACC up.

The results of the scan, Mackey showed me, revealed significant brain control. A week later, I was scanned again, this time in the offices of Omneuron. I could feel that it was easier to control my rACC with less reliance on elaborate fantasy; I was interacting more directly with my brain.

This learning effect was clearly seen in the recent Stanford study (which was financed in part by the National Institutes of Health). The first phase of the study looked at 12 subjects with chronic pain and 36 healthy subjects. (The healthy participants were subjected to a painful heat stimulus in the scanner and tried to modulate their responses. The chronic-pain patients, however, simply worked to reduce their own pain.) The chronic-pain patients who underwent neuroimaging training reported an average decrease of 64 percent in pain rating by the end of the study. (Healthy subjects also reported a significant increase in their ability to control the pain.)

"One big concern we had, " Mackey says, "is, Were we creating the world's most expensive placebo?" To ensure against that, Mackey trained a control group in pain-reduction techniques without using the scanner (as in his previous study) to see if that was as effective as employing a $2 million machine. Mackey also tried scanning subjects without showing them their brain images or tricking subjects by feeding them images of irrelevant parts of the brain or feeding them someone else's brain images. "None of these worked," Mackey says, "or worked nearly as well." Traditional biofeedback also compared unfavorably; changes in pain ratings of subjects in the experimental group were three times as large as in the biofeedback control group.

The second phase of the study, which is now under way, is designed to assess whether neuroimaging therapy offers long-term practical benefits to a larger group of chronic-pain patients. After the six sessions designed to teach them to regulate their pain, they will be observed for at least six months. The idea is to see whether they can fundamentally change their modulation system so that it can reduce pain all the time without constantly and consciously thinking about it. If so, the technique would not simply provide shelter from the storm of pain; it would bring about climate change.

"I believe the technique may make lasting changes because the brain is a machine designed to learn," deCharms says. The brain is soft-wired (plastic) rather than hard-wired: whenever you learn something new, new neural connections are believed to form and old, unused ones to wither away. (Researchers refer to this as activity-dependent neuroplasticity.) In other words, if you actively engage a certain brain region, you can alter it.

Many diseases of the central nervous system involve inappropriate levels of activation in particular brain regions that change the way they operate (negative neuroplasticity). Some regions experience atrophy, while other regions become hyperactive. (For example, epilepsy involves hyperactivity of cells; stroke, Parkinson's and other diseases involve the atrophy of nerve cells.) With chronic pain, it is believed that additional nerve cells, recruited for transmitting pain, create more pain pathways in the nervous system, while nerve cells that normally inhibit or slow the signaling, decrease or change function.

In addition, chronic pain results in a significant loss of other kinds of brain cells. A. Vania Apkarian at Northwestern University found that while the brain of a healthy person shrinks 2.5 percent a year, in a person with chronic back pain, it shrinks an additional 1.3 percent annually in the areas that involve rational thinking. I know chronic pain interferes with my concentration at times, but I never imagined that it could be truly impairing it! The Stanford technique may mitigate this harm by teaching people how to increase the efficacy of the healthy cells.

Moreover, the technique may offer a particular advantage over drug therapy. It is very difficult to design drugs to fix a problem in a specific region of the brain because the receptors that drugs target, like the opiate receptors, generally appear in multiple systems throughout the brain (which is partly why drugs almost always have side-effects). Neuroimaging therapy, on the other hand, is designed to teach control of a localized brain region.

"The technique gives people a tool they didn't know they had," Mackey says, "cognitive control over neuroplasticity. We don't fully understand how this feedback mechanism is working, but it provides tangible evidence that people can change something in their own brains, which can be very empowering. It takes Buddhist monks 30 years of sitting on a mountain learning to control their brains through meditation - we're trying to jump-start that process." As to how exactly it works - how the decision-making parts of the brain (the prefrontal regions of the cortex) cause the change in the rACC - "Heck if I know!" he says. "How do we get the brain to do anything? We can map out the anatomical circuits involved and the general functions of those circuits, but we can't tell you the mechanism by which any cognitive decision is translated into action."

If neuroimaging therapy could treat pain, could it rewire the brain to fix other diseases, like depression, stroke and learning disabilities, or exercise the brain in ways that would make it cleverer and more adept at certain skills? Neuroimaging has shown, for example, that the part of the brains of London cabdrivers that regulates spatial relations is larger than usual and that learning to juggle creates visible changes in parts of the brain involved with motor coordination during three months of training. I'm constantly getting lost and dropping things. Could I exercise and strengthen those areas more quickly by, say, thinking about maps in the scanner than by driving around London?

"What is the limit to neuroimaging therapy?" deCharms muses. "Could you learn to target the reward or serotonin system and up-regulate happiness? Could you augment psychotherapy by allowing the patient and the therapist to watch the brain?" - an idea Omneuron is already exploring, by bringing therapists and patients to the scanner and imaging patients' brains as they undergo the sessions. "After all, talk therapy is about learning to understand thought processes - to understand neural substrates and change them," he says.

How deep can the insights that functional imaging might offer really go?

What I'd like to do most is not fix problems or improve skills but use imaging as a vehicle for self-transparency. Instead of puzzling about my motivations, I'd like to be able to read my mind completely, like a book: for imaging to be the Plexiglas window through which I could finally see the ghost.

"Hmm," Dr. Scott Fishman, chief of the pain-medicine division at the University of California, Davis, said dubiously when I brought up this notion. "I'm not sure that functional imaging is actually looking at the mind. The mind is like a virtual organ - it doesn't have a physical address that we know about. Functional imaging provides a two-dimensional snapshot of a three-dimensional or a four-dimensional event of this entity of the mind. Right now, imaging is just looking at the brain; we have to be honest about that." Imaging shows the level of activation of different parts of the brain, from which we can extrapolate something about the mind, he points out, "but what we really need to see is how the parts talk to each other - and the complex nuances of their language."

The brain has more than a hundred billion neurons. All functional imaging can tell us now is that a few hundred million of them in various areas become more active at certain times. It's as if you were trying to conduct a symphony by watching a silent film of the concert. You would see the players in the bass section active at one moment, vigorously gesturing, and then the rest of the orchestra would join in, but you couldn't hear the notes or how they form strands of melody and harmony and meld together to create the ethereal experience.

"Consciousness is not neurons firing - consciousness is a transcendent emergent phenomenon that depends on the firing of neurons," says Dr. Daniel Carr, an eminent pain researcher who is now the C.E.O. of Javelin Pharmaceuticals. "The gears of a watch rotate and keep time, but the turning of the gears is not time. The question is, Is neuroimaging a picture of the experience of consciousness or is it a picture of a mechanism associated with that experience? Can there actually be a picture of an experience? Does a picture of a funeral or a wedding show you experiences? Or is there an unbridgeable gap there because you need to already understand the experience in order to interpret the photos? If a higher being told us how consciousness works, could we understand the explanation?"

Melanie Thernstrom is a contributing writer for the magazine. She is working on a book about pain.

Save the Date - Chicago Conference, 9/8/06

2006-05-14T14:31:00.000-07:00

A Comprehensive Review of Chronic Regional Pain Syndrome - Dispelling the Myths and Looking at Emergent Treatment

When: September 8, 2006

Where: Northwestern Memorial Hospital
Conference Center
3rd Floor
201 East Huron
Chicago, IL 60611

Co-directors: R. Norman Harden, MD, Director, Center for Pain Studies, Addison Chair, Rehabilitation Institute of Chicago, Chicago, IL

Joshua P. Prager, MD, MS, Director, Center for the Rehabilitation of Pain Syndromes , Departments of Internal Medicine and Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA

Presented by: The Reflex Sympathetic Dystrophy Syndrome Association
The Rehabilitation Institute of Chicago

http://rsds.org/4/resources/chicago_conference.htm

New Clinical Drug Trial - New York

2006-05-10T17:01:00.000-07:00

Beth Israel's Institutional Review Board has approved an addendum to the original study to allow people with CRPS who are in the Workers Compensation system to participate in the study (if you meet study's inclusion criteria).

RSD/CRPS (COMPLEX REGIONAL PAIN SYNDROME) NEW CLINICAL DRUG TRIAL

If you have received a diagnosis of RSD or CRPS, you may be eligible to participate in a study of a potentially new treatment.

To assess your study eligibility, you will be asked the following questions regarding your painful limb:
o Have you had continuing pain for at least one month?
o Have you experienced increased skin sensitivity to touch or clothing?
o Has your skin felt especially cold or especially warm?
o Has the skin color changed?
o Has there been swelling or unusual sweating?
o Has there been any impairment in the range of motion of your affected joints (eg, fingers, wrist, ankle, foot)?
o Has there been any abnormal change in the skin, nails or hair?

For more information, please contact:
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center, NY
Call JE at 1-212-844-1829
Visit www.stoppain.org

Important Reference - NIH & RSD in Spanish

2006-05-08T16:55:00.000-07:00

From the National Institutes of Health:
http://www.ninds.nih.gov/disorders/spanish/sindrome_de_dolor_regional_complejo.htm

Linking patients to medical research:
http://www.clinicaltrials.gov/ct/show/NCT00109772?order=2

May 15 Medicare Drug Benefit Deadline

2006-05-03T13:07:00.000-07:00

Prescription Drug Coverage for People with Medicare: Enrollment Deadline of May 15 Rapidly Approaching

If you have Medicare whether because you are 65 or older or because you are considered disabled by Social Security you can now get prescription drug coverage through Medicare.

However, you may be better off not joining a Medicare plan if you already have other drug coverage that is as good or better than a Medicare plan (creditable coverage). If you have prescription drug coverage now through a spouse, for example, or through a former employer, you should have received a letter telling you whether or not the coverage is creditable. If it is creditable, as long as you keep it, you do not have to think about Medicare enrollment deadlines. If it is not creditable or if you do not have any prescription drug coverage now, Medicare's prescription drug plans may benefit you.

Medicare's prescription drug coverage, known as Part D, is a voluntary or optional program. Hence, unless you have Medicaid and Medicare or unless you were in a Medicare Advantage plan with some drug coverage at the end of 2005, you must choose and enroll into a plan if you want the Part D coverage.

The enrollment deadline for 2006 is Monday, May 15. (If you applied for "extra help" or the low-income subsidy through the Social Security Administration or through your state's Medicaid office and did not enroll in a plan, you should have received a letter a few weeks ago telling you what plan you have as of May 1. If that plan does not cover your medications or if for any reason you do not like the plan, you should be able to switch plans at least once before May 15.)

Most people will pay a monthly premium for Part D (just as there is a premium for Medicare Part B which covers many out-patient services). Many people with low incomes and certain limited assets (like a savings accounts) can get help paying the costs of Part D.

There are also numerous plans with very low monthly premiums, though these are not always the best choice for people with high drug costs. There are many plans available around the country, and because there are so many plans with different costs and different lists of drugs covered (formularies) and different rules on prior authorization, quantity limits, and step therapy, it can be extremely difficult to choose a Part D plan that is right for you.

Moreover, under the law, Part D plans cannot cover certain categories of drugs, including the benzodiazepines that are sometimes used by people with RSD (such as clonazepam or Klonopin and alprazolam or Xanax). Yet if you have Medicare and no prescription drug coverage (or limited drug coverage, such as a standard Medigap prescription drug coverage plan), you may still find Part D valuable.

Just remember that if you already have prescription drug coverage that is as good or better than a Medicare plan (creditable coverage), including a retiree plan, signing up for Part D may mean that you and any of your dependents (such as a spouse or a child) on that policy can lose that entire health coverage permanently.

If you do not enroll in a Part D plan by May 15 and you do not now have other drug coverage that is as good or better than a Medicare plan (creditable coverage) and you cannot get a special enrollment period, you will not be able to get drug coverage through Medicare until January, 2007. In addition, the law says that you will pay a penalty higher Part D monthly premiums for as long as you have a Part D plan.

If you have any questions about Medicare's prescription drug coverage, you can contact Christin Engelhardt, who is working on health insurance issues for the RSDSA, at rsdsa-dc@hotmail.com.

AANP News Brief

2006-05-01T16:44:00.000-07:00

Multicultural Pain Management

Health care professionals can benefit from understanding the diverse
cultural attitudes patients have toward pain and tolerance.

By Maureen Sullivan-Tevault, RN, CEN

Despite significant advances in many areas of medicine, many studies, including a landmark investigation of elderly cancer patients and pain management published in JAMA in 1998, indicate pain remains poorly managed and under-treated for many patients.1 Unrelieved pain has been associated with undesirable outcomes, such as delays in postoperative recovery. Thus, health care providers must improve their understanding of pain management.

One of the most challenging aspects of pain management is understanding a patient's culture and how it affects their response to pain. Religious beliefs, cultural influences and diverse personal attitudes toward pain and suffering impact a person's response to pain, and health careproviders have a responsibility to honor their choices, offer them culturally competent care and maximize their pain relief options.

Patients need to be educated about the importance of adequate pain relief, be it delivered via traditional pain medications or, if the patient prefers, through alternative options, such as acupuncture, massage, imagery, meditation, music therapy, relaxation therapy, yoga or herbs.

JCAHO established standards related to pain management in 1999.2 These standards advocate the patient's right to appropriate management of pain and the provider's responsibility to educate patients and their families about the importance of pain management. Also noted in the standards is the need to ensure staff competency in both pain assessment and management to achieve optimal results for patients.

Demographics of Pain

Pediatric patients often are under-treated for pain because they cannot effectively communicate the level of pain they are experiencing. By age 4, however, most children can point to the part of their body causing them pain or identify it on a drawing.

While children's coping skills and developmental levels vary widely, their body language can provide clues to pain they are experiencing. For example, a child lying on his side in bed, with his knees pulled up toward his chest, might have abdominal pain.3

Elderly patients face unique issues regarding pain management, as well. For example, the desire to be a "good patient" often makes them hesitant to mention their pain. They also may fear the addiction potential and other side effects of narcotics. They may decline any pain medication, preferring to "tough it out."

Pain management for the elderly should focus on the different types of pain they suffer, including arthritis, osteoporosis, diabetes-related neuropathy and angina, to name a few examples. And these types of pain all may need to be addressed by different interventions. In addition, pain from different conditions, such as arthritis, may vary throughout the day and depend on activity levels, and can require multiple medications.

Meanwhile, cancer-related pain is another specialized area of pain management. These patients may fear increasing medication amounts can cause side effects worse than the pain, prolong hospitalization and hasten death. Education of staff and patients and their families about cancer pain management is paramount, to not only reduce suffering, but also promote healing.4

Cultural Influences

The influence of cultural upbringing impacts the response to pain, as
well as acceptance of pain medication.

While health care providers cannot know everything about a person's culture, they should be aware of external influences to one's pain experience, including the effects of religious beliefs. They should acknowledge and respect the patient's choices in pain management. In some cultures, pain may be interpreted as a test of one's faith, and the foregoing of pain medication may be viewed as a sign of personal strength and fortitude.

To maintain open, accepting lines of communication, the health care provider should acknowledge and respect a patient's choice to decline pain medication. The provider may enlist chaplain services and educate the patient of various other treatment options that may reduce pain, such as massage, relaxation and even biofeedback. The provider also may offer to pray with the patient, further developing a sense of trust and acceptance.

Life Experience

Pain is a complex phenomenon. A person's response is shaped by his individual life experiences. The health care provider first must understand the patient's pain is unique, and also be aware no two people will respond to pain in precisely the same manner.

Patient education is important to ensure patients receive sufficient pain control to optimize recovery and enhance their quality of life. Patients' family members also should be educated regarding adequate pain management in regard to its positive influence in the healing process.
Many patients, hesitant to ask for "as needed" medications for fear of appearing weak, may respond better to scheduled analgesic administration.

The effective management of pain is multifaceted at best. To maximize patient comfort and trust and to minimize poor outcomes, the health care provider must take into account not only the patient's complaints of pain, but factors influencing the patient's response to it. A willingness to understand the uniqueness of the patient's pain and to respect the patient's pain management choices will greatly improve the success of any interventions.

References

1. Bernabei, R., et al. (1998). Management of pain in elderly patients
with cancer. JAMA, 279(23), 1877-1882.

2. JCAHO. (1999, August 3). Joint Commission focuses on pain
management. Retrieved Feb. 12, 2005 from the World Wide Web:
http://www.jcaho.org/

3. Wong, D.L., & Hockenberry-Eaton, M. (2001). Wong's essentials of
pediatric nursing (6th ed.). St. Louis: Mosby.

4. National Coalition for Cancer Survivorship. (2004). Pain and the
elderly. Retrieved June 13, 2005 from the World Wide Web:
http://www.canceradvocacy.org/resources/essential/pain/elderly_test.aspx

Maureen Sullivan-Tevault works in the pain management department at the VA Medical Center, Bay Pines, FL.

CRPS, 4/29/06, Radio show

2006-04-26T12:56:00.000-07:00

Dr. Anne Oaklander, MD, PhD, director of the Mass. General Hospital (MGH) Nerve Injury Unit, will be interviewed on the Jordan Rich show. The interview will be aired this coming Saturday at 12:30 AM on WBZ, 1030 AM.

Dr. Oaklander led the MGH researchers that found the first evidence of a physical abnormality underlying complex regional pain syndrome-I (CRPS-I). In the February issue of the journal Pain, they described finding that skin affected by CRPS-I pain appeared to have lost some small-fiber nerve endings, a change characteristic of other neuropathic pain syndromes.

According to David Dehart (who suggested to Mr. Rich that he interview Dr. Oaklander), the radio station may be heard between sundown & sunrise in just about all of the states east of the Rocky Mountains. Mr. Dehart suggests that you try to find the station a day or so before the interview.

If you are unable to get the station on AM radio, ANYONE with an Internet connection can hear WBZ for FREE on-line by going to: http://www.wbz.com.

Please register prior to Saturday because it takes time --but it will work and it's free.

CRPS conference - Sept. 8, 2006 - Chicago

2006-04-25T14:30:00.000-07:00

A Comprehensive Review of Complex Regional Pain Syndrome: Dispelling the Myths & Looking at Emergent Treatment

RSDSA is co-sponsoring, with the Rehabilitation Institute of Chicago, a CME conference on September 8th & 9th in Chicago.

There will also be a similar conference for individuals with CRPS on Friday, September 8, 2006 at the same location.

Northwestern Memorial Hospital
Conference Center – 3rd Floor
201 East Huron
Chicago, IL 60611

Medical professionals can register at the following URL:
http://rsds.org/pdf/CME_chicago_flyer.pdf

Please help spread the word.

Free Medication for Medicare Beneficiaries

2006-04-19T13:09:00.000-07:00

Drug Makers Get OK for Charity to Seniors

By KEVIN FREKING
Associated Press Writer
April 18, 2006, 8:12 PM EDT

WASHINGTON -- In a legal opinion that could help many thousands of Medicare beneficiaries, drug manufacturers were told Tuesday that they can continue giving free medicine to poor people even if they're enrolled for the new drug benefit.

Each year, large drug companies routinely give millions of free prescriptions to the poor. However, most of the drug companies had said they would discontinue this practice for senior citizens now that they could get coverage through Medicare.

In particular, the drug companies had concerns that continuing to operate their patient assistance programs for Medicare beneficiaries would violate federal anti-kickback laws. Conceivably, they could use the programs to steer patients to a particular drug and reduce the patients' incentive to locate and use less expensive drugs. Such steering could also raise the costs of the program for taxpayers and participants.

Health and Human Services Inspector General Dan Levinson clarified his position on Tuesday that "lawful avenues exist for pharmaceutical manufacturers to give assistance to financially needy patients, including Medicare beneficiaries."

Levinson told one manufacturer seeking advice, Schering-Plough, that its proposal had two important safeguards that present "minimal risk of fraud and abuse."

First, the company will ensure that no Medicare payment is sought for the free drugs provided to poor beneficiaries. Second, it will ensure that assistance is based solely on financial need, using a methodology that does not take into account an enrollee's choice of a drug plan.

"Taken as a whole, these safeguards substantially mitigate the risk that the free drugs are or will be used to tie Medicare beneficiaries to particular outpatient prescription drugs," Levinson said.

CMS Administrator Mark McClellan said the review could help some beneficiaries save substantially on their medicine by getting free medicine in certain cases when they need help for a certain expensive condition, such as rheumatoid arthritis. Then, they could use the Medicare drug benefit for help dealing with their other illnesses.

"This is excellent news for the many people with Medicare who have relied on these valuable patient assistance programs," HHS Secretary Mike Leavitt said.

The patient assistance programs generally help people whose income is less than 200 percent of poverty. Medicare's low-income subsidy extends only to those with incomes below 150 percent of poverty. So, many beneficiaries face the prospect of paying for something that they had been getting for free.

Just how many seniors and disabled beneficiaries rely on patient assistance programs is unclear. However, the trade association for drug manufacturers said Tuesday that its members provided 35 million free prescriptions last year worth an estimated $5.1 billion.

About a quarter of those people getting the free prescriptions are senior citizens, estimated Ken Johnson, senior vice president for the Pharmaceutical Research and Manufacturers of America.

Johnson said the inspector general's opinion, while effective only for the company that asked for it, would provide guidance to other companies.

"We have sent a copy of the opinion to our members and undoubtedly they are reviewing it and comparing it to their own programs," Johnson said.

Rollin Thoren of L'Anse, Mich., is an example of a Medicare beneficiary who could potentially be helped through continuation of the patient assistance programs. Last year, his wife received free medicine worth more than $19,000 from the Novartis program.

He was told he could no longer get that free medicine now that he could get coverage through Medicare. So they enrolled in the program.

"Please try to throw out this monstrosity," he wrote to his congressman. "The country can't afford it and we certainly can not."

http://oig.hhs.gov/

N.Y. Clinical Drug Trial

2006-04-13T10:44:00.000-07:00

RSD (Reflex Sympathetic Dystrophy Syndrome) - CRPS (Complex Regional Pain Syndrome)
NEW CLINICAL DRUG TRIAL

If you have received a diagnosis of RSD or CRPS, you may be eligible to participate in a study of a potentially new treatment.

To assess your study eligibility, you will be asked the following questions regarding your painful limb:

o Have you had continuing pain for at least one month?
o Have you experienced increased skin sensitivity to touch or clothing?
o Has your skin felt especially cold or especially warm?
o Has the skin color changed?
o Has there been swelling or unusual sweating?
o Has there been any impairment in the range of motion of your affected joints (eg, fingers, wrist, ankle, foot)?
o Has there been any abnormal change in the skin, nails or hair?

For more information, please contact:
The Department of Pain Medicine and Palliative Care
Beth Israel Medical Center, NY.
Call JE at: 1-212-844-1829

Visit: www.stoppain.org

H.R. 1020 stalls in Committee - Help!

2006-04-04T13:15:00.000-07:00

H.R. 1020, The National Pain Care Policy Act of 2005 is stalled in Committee. Only 33 Representatives have signed on as co-sponsors. Is your representative a co-sponsor?

Check: http://thomas.loc.gov/cgi-bin/bdquery/z?d109:HR01020:@@@L&summ2=m&#cosponsors

If your Representative is not a co-sponsor, visit the American Pain Foundation's website and send a message to your Representative: https://secure2.convio.net/apf/site/Advocacy?pagename=homepage&page=SplashPage&id=103

RSDSA, The American RSDHope Group, and For Grace have all endorsed this bill. Help us make a difference!

Important Research Info

2006-03-29T16:19:00.000-08:00

Celgene Corporation has just enrolled its 100th patient with Complex Regional Pain Syndrome in its national Lenalidomide research study. This study is very important to the CRPS community. If this study is completed and recruits 180 patients, other pharmaceutical corporations might also conduct national multicenter, double-blind, placebo-controlled studies.

Individuals who are currently taking medication do not need to discontinue it--"Opioid analgesics, non-opioid analgesics, non-steroidal anti-inflammatory drugs, anticonvulsants, antidepressant drugs and other non-drug therapies may be continued provided that the subject is on stable doses/regimens for at least four weeks prior to the start of the Treatment Phase (Visit 2)."

Learn more about this study and whether a study site is near you:
http://rsds.org/3/research/celgene.html

More information:
http://rsds.org/3/research/index.html

Precious Petal Pushers

2006-03-24T09:21:00.000-08:00

Precious Petal Pushers, an on-line site that sells greeting cards, is donating 10% of its profits to RSDSA.

To view their offerings, please visit http://www.preciouspetalpushers.com

Purchase a set of 12 beautiful cards and help with Reflex Sympathetic Dystrophy research and awareness.

RSD - OT & PT Exeptions

2006-03-21T14:54:00.000-08:00

OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA (Deficit Reduction Act)

RSD has been granted an automatic exception to the limitation below.

Background: Section 4541 of the Balanced Budget Act of 1997 (BBA) required the Centers for Medicare & Medicaid Services (CMS) to impose financial limitations or caps on outpatient physical, speech-language and occupational therapy services by all providers, other than hospital outpatient departments. The law required a combined cap for physical therapy and speech-language pathology, and a separate cap for occupational therapy. Due to a series of moratoria enacted subsequently to the BBA, the caps were only in effect in 1999 and for a few months in 2003. With the expiration of the most recent moratorium, the caps were reinstated on January 1, 2006 at $1,740 for each cap.

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782

New York (Manhattan) Drug Treatment Trial

2006-03-02T13:19:00.000-08:00

Reflex Sympathetic Dystrophy - CRPS (Complex Regional Pain Syndrome)

NEW CLINICAL DRUG TRIAL

If you have received a diagnosis of RSD or CRPS, you may be eligible to participate in a study of a potentially new treatment. To assess your study eligibility, you will be asked the following questions regarding your painful limb:
o Have you had continuing pain for at least one month?
o Have you experienced increased skin sensitivity to touch or clothing?
o Has your skin felt especially cold or especially warm?
o Has the skin color changed?
o Has there been swelling or unusual sweating?
o Has there been any impairment in the range of motion of your affected joints (e.g. fingers, wrist, ankle, foot)?
o Has there been any abnormal change in the skin, nails or hair?

For more information, please contact the Department of Pain Medicine and Palliative Care
Beth Israel Medical Center, NY
You must be able to travel to Manhattan to participate.

Visit: www.stoppain.org

RSD Conference Info - May 13, 2006 - New York

2006-03-02T13:12:00.000-08:00

RSD, CRPS & Chronic Pain State-of-the-Art Practices and Computerized Infrared Imaging

May 13, 2006
NYU Medical Center
550 1st Ave, NY

This course is designed for physicians, dentists and allied health professionals. The cost is $125. Individuals with CRPS can attend the conference for $75.00

http://rsds.org/1/events/brochure%20v%202%2015%2006.pdf

North Carolina Walk-a-Thon benefits RSD Research

2006-02-22T14:09:00.000-08:00

YOU ARE INVITED TO JOIN US!

THE ROWAN COUNTY (NORTH CAROLINA) RSDS WALK-A-THON

SATURDAY, MARCH 4, 2006
DAN NICHOLAS PARK, SALISBURY, NORTH CAROLINA

REGISTRATION: 10:30 AM
WALK-A-THON BEGINS: 11:00 AM
ENJOY FREE LUNCH WITH US FOLLOWING THE WALK-A-THON!

ALL PROCEEDS GO TO THE NATIONAL RSDS ASSOCIATION FOR RESEARCH.

THIS YEAR OUR WALK-A-THON IS NAMED THE DONNA AND JOHN BOGER RSDS WALK-A-THON.

Donna, our president, is affected by RSDS; her husband, John, has Leukemia. John and Donna have been such an inspiration to all of us; they have given us HOPE to live with RSDS.

Suicide Lifeline

2006-02-22T14:02:00.000-08:00

National Suicide Prevention Lifeline available

The National Suicide Prevention Lifeline, 800-273-TALK

(888-628-9454 for Spanish) is the only federally funded hotline for suicide prevention and intervention. Call from anywhere at any time to talk with a trained crisis worker who will listen to and assist callers in getting the help they need. For more information, visit: http://www.suicidepreventionlifeline.org/

Medicare - The Doughnut Hole Program

2006-02-10T16:10:00.000-08:00

Medicare Rx Companies Developing Plan To Provide Discounted Drugs To Fill 'Doughnut Hole' in Medicare Drug Benefit

[Feb 07, 2006]

A group of seven pharmaceutical companies is working on a plan that would provide discounted prescription drugs to Medicare beneficiaries whose annual drug costs fall into the so-called "doughnut hole," or the gap in coverage under the new Medicare drug benefit, the Wall Street Journal reports. Under the drug benefit, Medicare beneficiaries are responsible for all drug costs between $2,250 and $5,100 in total spending, or between $750 and $3,600 in out-of-pocket costs. An estimated 6.9 million Medicare beneficiaries are expected to reach the doughnut hole in 2006, according to the Kaiser Family Foundation, the Journal reports. According to documents filed on Jan. 12 with the HHS Office of Inspector General, the pharmaceutical companies are joining together to provide discounts of at least 50% on their drugs when qualifying Medicare beneficiaries reach the doughnut hole. The Bridge Rx program, which the companies hope to announce in April and launch in May, would have copayments of at least 15%, the Journal reports. Medicare beneficiaries with annual incomes between $14,000 and $18,620 would qualify for the program, as would beneficiaries who have annual incomes lower than $14,000 and assets that make them ineligible for additional financial help under the drug benefit. The projected budget for the program's first year is $30 million, with projected enrollment in 2006 of more than 500,000 Medicare beneficiaries. Companies that plan to participate in the program include AstraZeneca, Johnson & Johnson, Novartis and Bristol-Myers Squibb.

Concerns
According to the Journal, the federal government has said the program could "run afoul of anti-kickback laws unless properly structured." According to the Journal, the small number of participating companies so far "is a potential problem, because the government worries that companies could use the discounts to steer patients to their drugs." The HHS OIG on Jan. 16 in an informal response to the companies' proposal, which the companies sent to HHS on Jan. 12, raised several issues, including the need to provide uniform discounts for all drugs and safeguards to ensure participants do not switch from less-expensive generic drugs to brand-name medications. In an advisory bulletin issued last fall before the plan was presented, the federal government said the "risk" of a kickback "potentially may be reduced" if large numbers of companies participated in such a program and included all of their drugs. CMS Administrator Mark McClellan said the government has been in discussions about the creation of a doughnut hole program, adding that the HHS OIG has said such a plan would work as long as it includes "a broad range of drugs." The HHS OIG is expected to issue a formal opinion on the program by mid-February.

Comments
"It's uncharted waters, so we don't know what" the HHS OIG's office will decide, an unnamed person familiar with the plan said, adding that it is a "good sign" federal officials are in discussions about such a program. The Bridge Rx coalition is working to persuade other large companies, including generic drug makers, to join the group. Pfizer, GlaxoSmithKline and Merck are some of the drug companies that have not yet joined the program. A spokesperson for GSK said the company "is looking at a number of options in terms of ways in which we might be able to help seniors." A spokesperson for Merck said, "[W]e'd certainly see what comes out of" Bridge Rx's efforts and "always examine our options." A Pfizer spokesperson said the company is reviewing the Bridge Rx plan

(Martinez, Wall Street Journal, 2/7).

Need pledges for RSD/CRPS research!

2006-02-10T15:53:00.000-08:00

Mini-marathon runner seeking pledges for Chronic Regional Pain Syndrome research

Lori Camacho, a veteran mini-marathoner with CRPS is participating in the May 6 Indianapolis One America 500 Festival. You may remember Lori and her daughter Cheryl's photo as they crossed the finish line at the 2004 More Marathon in New York in the RSDSA Review.

She is walking the 13.1 course to raise money for CRPS research and is seeking sponsors to pledge a specific amount or per mile.

If you are interested in pledging, please send your pledge to me at:
info@rsds.org

If by chance, you know of someone else who is participating in the mini-marathon, please let us know and we can link them with Lori.

RSDSA Analyzes Results of Internet Survey

2006-02-04T15:01:00.000-08:00

In early January, RSDSA Board members and staff met with Srinivasa Raja, MD and Shefali Agarwal, MPH, to discuss the Web-based Epidemiological Survey of Complex Regional Pain Syndrome (CRPS). The survey, conducted by Johns Hopkins School of Medicine and funded by RSDSA, was hosted on RSDSA's website for six months. A total of 1,829 individuals started the survey and 1,362 completed it. The survey results revealed how devastating and intractable CRPS can become.

Some of the findings include:
respondents were overwhelmingly female (84%)
mean duration of disease was between 40 and 58 months
average pain score reported was 7.9 (based on a rating scale of 1 to 10, 10 being the worst imaginable pain) with 35% reporting a pain score of 10!
94% reported that their pain affected their sleep
47% reported thoughts of ending their life and 15% had acted on the impulse (an average of 2 times)
62% of the respondents rated their general health as poor to fair
60% reported being disabled
41% had suffered a work-related injury
16% reported being employed full time; 6% reported being employed part time

The four predominant precipitating events cited were
surgery (30%)
fracture (15%)
sprain (11%)
crush injury (10%)

CRPS was first diagnosed by
an orthopaedic surgeon (32%)
a pain specialist (19%)
a neurologist (15%)
a physical therapist (4%)
Significantly, CRPS was rarely diagnosed by a general practitioner (3%)
or family practitioner (2%)

Currently, we are evaluating ways to present the information to the survey participants, and the medical, legal, governmental, and insurance communities. The research team, led by Dr. Raja, has presented an abstract of the data at the 2005 annual meeting of the American Society of Anesthesiology. Also, we hope to publish the data in a peer-reviewed journal for primary care physicians; only 5% of the participants had their CRPS diagnosed by these practitioners. A shocking statistic - almost 30 percent developed CRPS after surgery - raises a number of questions. How do we best communicate the risk that CRPS is a potential side effect of certain surgeries?

A lot of relevant information was added by the survey respondents in the areas of treatment cost, experiences with workers' compensation companies, and how individuals with CRPS were treated by emergency medicine practitioners. The survey data is a treasure trove of information that we will use to bring greater attention to this devastating syndrome that should be a major public health concern.

http://rsds.org/3/pdf/Modified%20ASA%20poster-RSDSA.pdf

Together EX Access Card

2006-02-02T17:54:00.000-08:00

Uninsured may qualify for free Rx savings card in minutes

Patients who lack prescription drug insurance and are not eligible for Medicare can determine in minutes if they qualify for the free Together RX Access Card by calling 800-444-4106 or online at http://www.togetherrxaccess.com/.

Most cardholders save 25% to 40% on more than 275 prescription drugs and products, as well as a range of generics. E-mail amyniles@aol.com to request cards for those who may be eligible

Mysterious Pain Syndrome?

2006-01-31T11:28:00.000-08:00

For immediate release: January 30, 2006

Study finds nerve damage in previously mysterious chronic pain syndrome

Reduction in small-fiber nerves may underlie complex regional pain syndrome-I (reflex sympathetic dystrophy)

BOSTON – Researchers at Massachusetts General Hospital (MGH) have found the first evidence of a physical abnormality underlying the chronic pain condition called reflex sympathetic dystrophy or complex regional pain syndrome-I (CRPS-I).

In the February issue of the journal Pain, they describe finding that skin affected by CRPS-I pain appears to have lost some small-fiber nerve endings, a change characteristic of other neuropathic pain syndromes. “This sort of small-fiber degeneration has been found in every nerve pain condition ever studied, including postherpetic neuralgia and neuropathies associated with diabetes and HIV infection,” says Anne Louise Oaklander, MD, PhD, director of the MGH Nerve Injury Unit, who led the study.

“The nerve damage in those conditions has been much more severe, which may be why it’s been so hard to detect CRPS-I-related nerve damage.” Complex regional pain syndrome is the current name for a baffling condition first described in the 19th century in which some patients are left with severe chronic pain and other symptoms – swelling, excess sweating, change in skin color and temperature – after what may be a fairly minor injury.

The fact that patients’ pain severity is out of proportion to the original injury is a hallmark of the syndrome, and has led many to doubt whether patients’ symptoms are caused by physical damage or by a psychological disorder.

Pain not associated with a known nerve injury has been called CRPS-I, while symptoms following damage to a major nerve has been called CRPS-II. Because small-fiber nerve endings transmit pain messages and control skin color and temperature and because damage to those fibers is associated with other painful disorders, the MGH research team hypothesized that those fibers might also be involved with CRPS-I.

To investigate their theory they studied 18 CRPS-I patients and 7 control patients with similar chronic symptoms known to be caused by arthritis.

Small skin biopsies were taken under anesthesia from the most painful area, from a pain-free area on the same limb and from a corresponding unaffected area on the other side of the body. The skin biopsies showed that, the density of small-fiber nerve endings in CRPS-I patients was reduced from 25 to 30 percent in the affected areas compared with unaffected areas.

No nerve losses were seen in samples from the control participants, suggesting that the damage was specific to CRPS-I, not to pain in general. Tests of sensory function performed in the same areas found that a light touch or slight heat was more likely to be perceived as painful in the affected areas of CRPS-I patients than in the unaffected areas, also indicating abnormal neural function.“The fact that CRPS-I now has an identified cause takes it out of the realm of so-called ‘psychosomatic illness.’ One of the great frustrations facing CRPS-I patients has been the lack of an explanation for their symptoms. Many people are skeptical of their motivations, and some physicians are reluctant to prescribe pain medications when the cause of pain is unknown,” says Oaklander.

“Our results suggest that CRPS-I patients should be evaluated by neurologists who specialize in nerve injury and be treated with medications or procedures that have proven effective for other nerve-injury pain syndromes.” She adds that the next research steps should investigate why some people are left with CRPS after injuries that do not cause long-term problems for most patients, determine the best way of diagnosing the syndrome and evaluate potential treatments.

“Investigations that identify the causes of disease are only possible if patients are willing to come to the lab and allow researchers to study them,” she adds. “We are tremendously grateful to these CRPS patients, whose willingness to let us study them – despite their chronic pain – allowed us to make an important step in helping those who suffer from this condition.” Oaklander is an assistant professor of Anaesthesia and Neurology at Harvard Medical School.The study was supported by grants from The Mayday Fund, the National Institute for Neurological Disorders and Stroke, and the American Federation for Aging Research. Coauthors are Julia Rissmiller, Lisa Gelman, Li Zheng, MD, PhD; Yuchiao Chang, PhD; and Ralph Gott, all of the MGH.

Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of nearly $500 million and major research centers in AIDS, cardiovascular research, cancer, cutaneous biology, medical imaging, neurodegenerative disorders, transplantation biology and photomedicine. In 1994, MGH and Brigham and Women’s Hospital joined to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups, and nonacute and home health services.

Contact: Sue McGreevey (617) 724-2764

Chronic Pain Article

2006-01-27T15:21:00.000-08:00

Science Spots New Cause of Chronic Pain

WEDNESDAY, Jan. 25 (HealthDay News) -- In a finding that could alter pain treatment, British scientists have found that undamaged nerve fibers, not injured ones, cause ongoing spontaneous pain.

The unexpected finding that may help in the development of new treatments for back problems and other conditions that involve chronic pain. Previous research into chronic pain focused on nerve fibers damaged due to injury or illness, and largely overlooked intact nerve fibers.

"The cause of this ongoing pain and why it arises spontaneously was not understood before," Sally Lawson, of the University of Bristol, said in a prepared statement. "Now that we know the type of nerve fibers involved, and especially that it is the undamaged nerve fibers that cause this pain, we can examine them to find out what causes them to continually send impulses to the brain. This should help in the search for new analgesics that are effective for controlling ongoing pain."

The findings appear in the current issue of the Journal of Neuroscience.

Lawson and her colleagues identified nerve cells called nociceptors (damage detectors) that, when activated by disease or injury, send out electrical impulses that are sent to the brain. The faster these undamaged nociceptors fire electrical impulses, the stronger the ongoing pain.

The firing of these nociceptors seems to be caused by inflammation within the nerves or tissues, caused by dying or degeneration of the injured nerve fibers within the same nerve, the researchers said.

Yahoo News

Part D from Outer Space

2006-01-27T13:42:00.000-08:00

Another viewpoint on Medicare Part D

Part D From Outer Space
by TRUDY LIEBERMAN
The Nation
January 30, 2006 issue

Despite the best efforts of the Bush Administration's public relations machine, Americans made it clear last year that they were in no mood to privatize Social Security. But the Administration had already won a quieter victory with an equally successful social insurance program, Medicare. Part D, the new prescription drug benefit that took effect January 1, looks like the first step on the way to destroying Medicare as a benefit for all senior Americans.

It's too early to tell whether Medicare Part D will be a flop like its predecessor, a drug discount card program that attracted only 15 percent of eligible seniors. But it may well be. So far only about 1 million have voluntarily signed up--fewer than 5 percent of the 21 million eligible seniors, most of whom have been without prescription coverage. At a carefully scripted press conference just before Christmas, Health and Human Services Secretary Michael Leavitt put a positive spin on the numbers, noting that another 21 million seniors were receiving coverage. But most of those enrollees were low-income people the government automatically enrolled, or those already receiving drug benefits elsewhere. The new plan is not yet reaching most of the people it's designed to help.

Unlike other Medicare benefits, Part D is modeled on the country's dysfunctional commercial health insurance system. With Medicare Parts A and B, which cover hospital services and doctor visits, the government pays providers directly. Under Part D, the government pays some 260 private insurers--including pharmacy benefit managers, HMOs and pharmacies--to provide the coverage. If seniors want the benefit, they must buy it from one of those private carriers. To force them to sign up, Congress imposed a financial penalty (growing more onerous over time) for those who don't get on board by May 15.

Medicare Part D represents the free market run amok. "You don't have to understand every detail and every option," Medicare administrator Dr. Mark McClellan told the Los Angeles Times. "People just need to focus on what they want." Easier said than done. In some counties, seniors have forty or fifty choices of plans--a jumble of insurance options with monthly premiums ranging from zero to more than $60. The government has allowed sellers to mold Part D coverage into hundreds of combinations of deductibles; co-insurance (a percentage of the drug cost consumers pay); drug utilization techniques (such as trying cheaper generic drugs first); and drug tiers, with their own dizzying array of co-payments (the flat amount consumers pay for each drug). Co-payments differ depending on whether people buy generics, preferred brand drugs, non-preferred brand drugs or specialty drugs--and depending on whether they buy from an in-network pharmacy where the insurer has negotiated good discounts or from an out-of-network pharmacy where it hasn't. Adding to the confusion is the fact that there's no standard nomenclature; sellers can use any fanciful name they think will lure buyers to their plan. They can also cover whatever drugs they want to; prescription formularies are not standardized either.

And what happens when seniors are understandably flummoxed by the overabundance of options? They're sent to a complicated web tool for answers--even though, according to one survey, three-quarters of seniors say they have never gone online.

This teeming marketplace, with its myriad sellers all offering their own versions of Part D, was no accident. The push for private market benefits began in earnest nearly a decade ago, when the right-wing Heritage Foundation proposed a bipartisan commission to look at "reforming" Medicare. In 1997 Heritage got its commission, chaired by then-Louisiana Senator John Breaux. A moderate, business-friendly Democrat, Breaux pushed a plan that would have given beneficiaries a set amount of money to buy health coverage in the private market. In the end it didn't fly. But in late 2003 moderate Democrats and Congressional Republicans, led by then-House majority leader Tom DeLay and Senator Breaux, saw their chance to move toward a privatized Medicare. Public outcry over escalating drug prices had caught the attention of Congress, and a drug benefit desperately needed by many seniors became the justification to pass legislation that took a big step toward privatization.

Think of Part D as Version 2.0 on the way to a Medicare system that relies completely on the private market. (The discount cards introduced in 2004, also provided by private insurers, were Version 1.0.) Congress appropriated $400 billion to finance Part D, a number that Richard Foster, chief actuary at the Centers for Medicare and Medicaid Services, later said was much too low. According to several news reports, Bush Administration officials prevented the agency from disclosing the real cost, then estimated at $550 billion, according to Foster.

While seniors are confronted with an overwhelming number of choices, insurers are benefiting from a massive Congressional giveaway. Insurers got generous payments to offer the coverage. And when the inevitable shakeout occurs among the 260 sellers, a cluster of mega-carriers like Aetna, WellPoint, UnitedHealthcare and CIGNA will reap the most from the Congressional largesse.

The size of these big insurers' marketing and operations budgets for Part D shows how important the new Medicare is to them. UnitedHealth Group is spending $75 million, Aetna $50 million and CIGNA $40 million. Humana, a large regional carrier looking to switch seniors to the company's other products, is spending $80 million. Steve Brueckner, Humana's vice president of senior products, says that Part D offers "an unprecedented opportunity to establish relationships."

Indeed it does. Drug companies are also eyeing new customers, especially among enrollees who could not in the past pay for drugs. They, too, are designing marketing strategies around Part D. Bob Dole, former senator turned Viagra pitchman, is selling the benefit on behalf of Pfizer. AstraZeneca is funneling $10 million to the National Council on the Aging (NCOA) to pay for vans and laptop computers that state insurance counselors can use to sign people up.

For politicians, of course, the goal was not just money but votes. Last summer at a meeting of some fifty healthcare lobbyists, a parade of Republicans, led by cheerleader DeLay, urged the lobbyists to help launch a national advocacy campaign to sell Part D, saying the effort would pay dividends in the 2006 midterm elections. That campaign is roaring across the country with the Medicare Rx Education Network, whose membership roster reads like a Who's Who of the business and medical establishment, leading the promotional charge. The network's star is none other than ex-Senator Breaux, who chairs the effort from his Washington law firm, Patton Boggs, one of the capital's premier lobbying outfits. Breaux has been placing op-eds and letters to the editor in newspapers urging seniors to sign up. The network has sent out six mailings to everyone eligible for Medicare, using the government's Medicare Rx Education logo. These mailings' return address is the US Chamber of Commerce. Seniors who also see the Medicare Rx Education logo on government publications can be forgiven if they are confused about who is sending the message.

In its pro-Part D public relations efforts, Medicare Today--a creation of the Healthcare Leadership Council, an organization of hospitals, drug companies, device makers and academic medical centers--has enlisted more than 300 other organizations, ranging from the Blue Cross Blue Shield Association to Wal-Mart Pharmacies, which have contributed $6 million toward "outreach." Since July Medicare Today has held 1,000 events around the country promoting Part D to seniors, and it has stationed representatives in pharmacies and grocery stores to answer questions and help them use the web tool. "We believe this is the right fix for Medicare and it's the right evolution for the twenty-first century, and we're trying to get people to take advantage of it," explains Michael Freeman, executive vice president of the Healthcare Leadership Council.

the initial reluctance of seniors--despite the fevered push to sign up the 20 million older Americans still eligible but not yet enrolled--may reflect an intuitive wariness of a program that while helping them in the short run may doom Medicare in the long run. At the Christmas press conference, Secretary Leavitt said seniors would "never have to worry about high drug costs in the future." But they do. In the end, a drug benefit based on the free market may kill Medicare. It's bad enough that Congress underestimated the true cost of Part D by at least $150 billion. But in its most devastating concession to Big Pharma, Congress forbade the government to negotiate with pharmaceutical companies over drug prices--a deliberate and crucial omission. In essence, Congress bet on insurance carriers and competition to keep drug prices under control--something the market has done poorly.

With Part D causing a virtual epidemic of headaches and complaints, there will be plenty of pressure on Congress to fix the mess. Representative Jan Schakowsky, a progressive Illinois Democrat, has introduced a bill to standardize benefits and require the government to negotiate prices with pharmaceutical firms. Passing such needed reform will be difficult, if not impossible. But Part D will not work in the long run unless Congress mandates price negotiations and ends the formulary free-for-all. Without standardized formularies, sellers can change the drugs they cover at any time--forcing seniors to pay out of pocket, find another insurer, get their doctors to change their treatment plans or file for an exception.

Even with standardized formularies, runaway drug prices could cause Congress ultimately to conclude that Medicare is simply too expensive--and transform it into a means-tested welfare program that would make doctor, hospital and drug benefits available only to the very poorest seniors. That would end Medicare as we know it. Maybe that was the real goal of Part D all along.

The Part D Perfect Storm

2006-01-27T13:05:00.000-08:00

The Part D Perfect storm:

What To Do If You Can’t Get MEDICATIONS You Need From Your Medicare Prescription Drug Plan

Introduction
The media, and advocates for people with Medicare, are focusing on the problems of dual eligibles who cannot get access to medically necessary drugs because drug plans are not honoring their obligation to provide a transition supply of prescribed medications. Despite statements by the Centers for Medicare & Medicaid Services (CMS), these issues will not go away even as drug plans get their computer and customer service systems up and running. As more people enroll and use their drug plans, problems will persist. They may change, but they will not go away.

Medicare's “Transition” policy only requires a drug plan to fill a prescription for a non-formulary drug or for a drug that requires prior authorization or other plan approval one time when the person first enrolls in a drug plan. After receiving the transitional first-fill, the beneficiary is expected to either go through the process to get the drug paid for by the plan or get a prescription for a different drug that is on the planes formulary from the treating physician. Unfortunately, advocates report that many people are leaving pharmacies without their medications. Even when beneficiaries are able to secure a transitional supply of medications, they are not being told that they must take further action to get their medications next month.

As a result, in February, we can expect people to be told once again by their pharmacy that their Part D plan will not pay for their medications. But next month, the plans will not be required to supply the medications, and most states will not fill in the gaps. This alert is designed to provide Medicare beneficiaries with information about the steps they need to take when they are told theirdrug plan will not pay for their medications.

What to Do When Your Drug Plan Won’t Pay for Your Medicine?
ANY TIME you can’t get your prescription filled, for ANY reason, you (or someone you authorize to act for you) must contact your Part D Prescription Drug Plan and ask for an official “coverage determination” to explain why you can’t get your prescription filled. You need this official explanation before you can take steps to get the drug you need, and it will tell you what to do next.

What happens at the drug store?
When your drug plan does not cover your medicine, your pharmacy should either give you a piece of paper telling you to contact your drug plan or have a sign posted that explains how to get more information. Even if your pharmacy tells you why the drug isn't covered, you still must contact your drug plan.

Your drug insurance card will have the drug plan’s phone number. If you don’t have a drug card, look in the Medicare & You Handbook you received in October or call 1-800-Medicare. (NOTE: Some plan phone numbers were listed incorrectly in the Medicare & You Handbook.)

How long do I have to call my drug plan?
You have up to 60 days to contact the drug plan for an explanation as to why it will not cover your medicine, but the longer you wait, the longer it may take for you to get your prescription. You can also send a written request to the drug plan. There is no special form to use, but you should say you want a “Coverage Determination” when making your request. (Some Coverage Determinations are called “Exceptions.” See below for details.)

What happens when I call my drug plan?
Ask why coverage has been denied for your medication and state that you want a written explanation. The drug plan must issue a written “Coverage Determination” that gives the reasons for the plan’s denial of payment for your prescription, and tells you what you need to do next to challenge the drug plan’s decision. If at all possible, get a letter from your doctor explaining why you need the medication. Submit it to the plan and keep a copy for your records.

The drug plan must issue the written Coverage Determination, within 72 hours of your request. It may have to issue the decision within 24 hours if you ask for, and are granted, “expedited” review. If an expedited decision is important, get a statement from your physician explaining that this is necessary, and why. The plan may have to issue the decision even sooner if your health condition requires a more immediate answer. If you have already paid for the drug yourself, the plan will issue a decision in 72 hours. If the drug plan doesn't issue a decision in time, it is required to send your claim to an outside, independent reviewer.

What can I do if the drug plan denies my request to pay for the drug?
You have 60 days to ask the plan for a “Redetermination” of its original decision. Your drug plan may require you to make a request for a “redetermination” in writing. The unfavorable coverage determination will tell you how to request a redetermination.

If you request a Redetermination, your drug plan must issue a written decision within 7 days or within 72 hours if you are entitled to expedited review. The drug plan may have to make a decision more quickly if your health condition requires a more immediate answer. The plan will issue a decision in 7 days if you have already paid for your drug. If the drug plan doesn't issue a decision in time, it is required to send your claim to an outside, independent reviewer. The written decision will explain the reasons for the drug plan’s decision and tell you what to do next.

What happens if the drug plan continues to say it won’t pay for the drug?
You have 60 days to file a written request for reconsideration with the Independent Review Entity (IRE). The request must be in writing; there is no option to call the IRE to request a Redetermination. The IRE is an independent company that contracts with Medicare to review prescription drug claims. Maximus is currently the company that has been hired by Medicare to perform this job.

The IRE will review the evidence and may contact you or your doctor. It will then issue a written decision that tells you the reasons for the decision and what you need to do next. The decision should be issued within 7 days or within 72 hours if you are entitled to expedited review.

What happens if the IRE denies my claim?
If the value of your claim is large enough, you may request a hearing before an Administrative Law Judge (ALJ). The hearing process for denied drug claims is the same as the process for appeals from denied hospital, nursing home, doctor, and other Medicare claims.

In 2006, your claim must be at least $110 to get an ALJ hearing. This amount may change each year. In determining this amount, Medicare will consider the cost of your drug over the course of the year. For example, if your drug costs $30, and you have 4 refills left, the value of your claim will be $120.

Can I appeal if the ALJ denies my claims?
Yes. You can ask for review by the Medicare Appeals Council (MAC) and even by federal court if the claim is large enough. Your claim must be worth $1090 to file an appeal in federal court in 2006. The written decision from the ALJ and then from the MAC will tell you how to proceed.

Involving Your Doctor in Your Appeal
Your prescribing doctor plays a critical role if your drug claim is denied. In some cases, you cannot get the drug plan to pay for your drug without your doctor’s help.

When is help from my doctor required?
You must have a doctor’s statement when you are requesting a special type of Coverage Determination called an “Exception.” A plan will not grant your Exception request without a statement from your doctor.

When would I ask for an Exception?
You would ask for an Exception:
*When the drug you need is not on your drug plan’s list of covered drugs (formulary),
*When your drug plan requires you to get its approval (prior authorization) before it will pay for your drug,
*When the drug plan wants you to try a less expensive drug before paying for the prescribed drug (step therapy or fail first),
*When the drug plan limits the number of pills you may have (quantity limits), or
*To reduce the co-payment you have to pay to a lower, less expensive tier of co-payments.

How do I ask for an Exception?
You ask for an Exception the same way you would ask for any Coverage Determination. It is important to note that your doctor can ask for an Exception for you. Some drug plans may require your doctor to use a special form when asking for prior authorization or making a different exceptions request. Each drug plan may have its own form or forms. Even if the plan allows the doctor to request an Exception by telephone, the doctor should follow the telephone request with a written statement.

What does the doctor’s statement have to say?
Each drug plan sets its own requirements for the doctor’s statement. You or your doctor should check with the Evidence of Coverage from your drug plan, or directly with the plan itself, to find out its requirements. At a minimum, the doctor’s statement would have to show that you need to take the prescribed drug because taking any of the similar drugs on the plan’s formulary would cause adverse health consequences, would not be as effective, or both.

What happens if the exception request is denied?
As described above, you can ask your drug plan for a redetermination, just as you would if you got any other unfavorable coverage determination. The rest of the appeals process is also the same as that described above.

Are there other times when I should seek help from my doctor?
A drug plan and the Independent Review Entity must grant a request to expedite a coverage determination (including an Exception), a Redetermination, or a Reconsideration if a doctor asks for expedited review. They do not have to grant such a request if you make it yourself.

You should ask your doctor to request expedited consideration when making an Exceptions request. The doctor should indicate that waiting for a decision during the standard time period could seriously jeopardize your health or life or your ability to regain maximum function.

Conclusion
CMS has stated publicly that Medicare beneficiaries will have access to a wide array of drugs, though they may have to use the exceptions and appeals processes to get some of them. Only time will tell whether beneficiaries and doctors find these processes easier to use than the
transition and other processes CMS said would help all beneficiaries get their medicine when the new Part D drug benefit went into effect.

Relieve Chronic Pain!

2006-01-10T11:31:00.000-08:00

New York Times

Let's Get Serious About Relieving Chronic Pain
By JANE E. BRODY

Patients with debilitating pain from chronic illness, accidents, surgery or advanced cancer have long had problems getting adequate medication to control their pain and make life worth living.

Now the federal government, and especially the Drug Enforcement Administration, is working overtime to make it even harder for doctors to manage serious pain, including that of dying patients trying to exit this world gracefully.

In an article in the current New England Journal of Medicine titled "The Big Chill: Inserting the D.E.A. into End-of-Life Care," two specialists in palliative care, Dr. Timothy E. Quill and Dr. Diane E. Meier, state that despite some physicians' commitment to treat pain and despite the effectiveness of opioid drugs like OxyContin and morphine, "abundant evidence suggests that patients' fears of undertreatment of distressing symptoms are justified."

They continue, "Although a lack of proper training and overblown fears of addiction contribute to such undertreatment, physicians' fears of regulatory oversight and disciplinary action remain a central stumbling block."

Obstacles to Relief
In addition to a case before the United States Supreme Court, Gonzales v. Oregon, that threatens to undermine Oregon's Death With Dignity Act, the D.E.A. has recently increased raids on doctors' offices, confiscating files and arresting doctors on charges of overprescribing narcotics to patients who are addicts or drug dealers.

Most of these physicians are compassionate people trying to help suffering patients but are sometimes fooled by clever addicts, drug dealers or undercover agents who fake their pain.
Should the court rule against Oregon, the D.E.A. could turn to all physicians whose patients die while getting prescribed opioids or barbiturates, even if the drugs were administered only to relieve intractable pain, not to hasten death.

Yes, there are bad apples among members of the medical profession. There are some doctors who charge for medical exams that they never do and provide phony patients with prescriptions for narcotics to feed their habits or sell on the street.

But should all physicians be subject to intense scrutiny by the D.E.A. and risk arrest and prosecution, leaving legitimate patients to suffer intensely or scramble to find other doctors willing to risk taking them on?

Doctors have no certain way to measure patients' pain other than to ask them. Patients should be asked to rate their pain, say, on a scale of 1 to 10, with 10 being the most intense they can imagine.

"Model Guidelines for the Use of Controlled Substances for the Treatment of Pain" were established in 1998, and every physician who prescribes narcotics should know them by now. These guidelines emphasize that documentation is critical to proper pain management.
With patients who are prescribed strong painkillers, doctors first are supposed to obtain a medical history, perform a physical examination, ask about addictive behaviors and whether other treatment options have been tried, and fully record what they find.

Prescriptions for controlled substances like narcotics cannot be refilled automatically. When a patient asks for a new one, a well-documented follow-up visit is necessary. The doctor should ask about the kinds and amounts of painkillers being taking, side effects, performance of daily activities and aberrant drug-related behaviors.

Dr. Jennifer P. Schneider, a pain management and addiction medicine specialist in Tucson, gives this example: "Back pain today is 4/10, walks the dog 15 minutes daily, constipation is controlled with Senokot-S, patient is on schedule with his meds." She advises physicians, "If a patient lies about his medical problems and turns out to be a drug abuser, at least you've documented that you were acting in good faith."

A Fear of Prosecution
The growing number of arrests of pain management specialists is exacting high costs for patients, physicians and medical insurers. Some doctors order costly but unnecessary diagnostic tests so they can show the D.E.A. a reason for prescribing strong pain medication.

Many doctors are simply unwilling to prescribe narcotics, no matter how much a patient suffers. Ignorance, as well as a fear of the D.E.A., plays a role. For example, the surgeon who performed my double-knee replacement a year ago told me, in reference to OxyContin, a synthetic opioid: "I don't like to prescribe these drugs. Patients have too hard a time getting off them."
Well, sir, if you never prescribe them, then chances are you never learned how to help patients stop them. Many doctors and patients fail to understand the difference between physical dependence and addiction.

An addict uses a drug to get high, becomes tolerant and needs ever-increasing amounts to maintain that high. Patients taking narcotics for pain don't get high; they get relief from their pain, and when larger doses are needed, it is usually because their pain has become more intense, as often happens in patients with advanced cancer or degenerative diseases.

Physical dependence occurs in almost everyone who takes a narcotic for two weeks or more. The body becomes adapted to the presence of narcotics (that is, becomes physically dependent on them). A patient cannot go off them abruptly without suffering serious withdrawal.

A Gentle Weaning Process
I asked Dr. Schneider how to go off narcotics safely. She suggested cutting back 10 milligrams every three days (the exact amount would depend on the dose a patient is on). If at any point in the weaning process my pain became more intense, I was to go back to the last dose, wait a week, then try to resume the weaning.

As I neared the end, the cutback was five milligrams every three days. Then the dose was down to nothing, and no withdrawal symptoms, either.

Having heard only about those who, like Betty Ford, got hooked on painkillers, many patients are afraid of becoming addicted if narcotics are prescribed. But it is the rare patient who becomes addicted, and it is nearly always someone with a history of addiction, typically to alcohol.

Even with dying patients, the families and physicians often shy away from narcotics for fear of addiction, as if it mattered whether someone near the end of life - in desperate pain or extreme agitation - became addicted to the morphine that could provide almost instant relief.

Proper pain management for dying patients can facilitate important communication between patients and their loved ones and provide what most people would call "a good death."
"Pain is a common symptom in patients nearing the end of life," with up to "77 percent of patients suffering unrelieved, pronounced pain during the last year of life," Dr. Timothy J. Moynihan wrote in The Mayo Clinic Proceedings in 2003.

In their current article, Dr. Quill of the University of Rochester School of Medicine and Dr. Meier of Mount Sinai School of Medicine stated, "Allowing D.E.A. agents, trained only to combat criminal substance abuse and diversion, to dictate to physicians what constitutes acceptable medical practice for seriously ill and dying persons" may make doctors increasingly reluctant to prescribe needed medications and "end up abandoning patients and their families in their moment of greatest need."

Free RSD Seminar!

2006-01-08T16:47:00.000-08:00

FREE SEMINAR

Complex Regional Pain Syndrome
Formerly Known as RSD (Reflex Sympathetic Dystrophy)
CRPS is a chronic neurological disease.

Richard W. Lingenfelter, M.D., and Michael D. Papenfuse, D.O., board certified pain specialists at Matrix Pain Management, will discuss how CRPS impacts men, women, and children of all ages.

• Learn about CRPS: CRPS I and CRPS II
• Causes
• Symptoms
• Diagnosis and Treatment
• Prognosis

WHO SHOULD ATTEND: People affected by, or interested in CRPS

WHEN: Thursday, January 26, 2006 at 6:30PM

WHERE: Matrix Pain Management
4450 Fashion Square Blvd.
Saginaw, MI 48603
Call to 989.792.4090 to register.

Visit our website at www.matrixpain.com to learn more about Matrix Pain Management.

Chronic Multi-Symptom Illness

2006-01-01T12:30:00.000-08:00

MYSTERIOUS CONDITION PLAGUES GULF WAR VETS

FRIDAY, Dec. 30 (HealthDay News) --

Veterans who served in the Persian Gulf War have nearly twice the prevalence of a chronic multi-symptom illness than soldiers who served elsewhere at the same time, a new study shows.

The condition, chronic multi-symptom illness (CMI), is similar to what is often called Gulf War Syndrome. Diagnosis requires at least two symptoms including fatigue, "mood symptoms" or difficulty thinking, and muscle or joint pain, for six months.

It appears that the risk of CMI is greater in those who had depression and anxiety disorders before military service, Dr. Melvin Blanchard, associate chief of medicine at the St. Louis Veterans Affairs Medical Center and an assistant professor of medicine at Washington University School of Medicine in St. Louis, said in a prepared statement.

"We're still not sure whether CMI is due to a single disease or pathological process," he said.
The study, which appears online in the Journal of Epidemiology, is part of a continuing analysis of data in a VA study called the National Health Survey of Gulf War Era Veterans and Their Families, conducted from 1999 to 2001.

The researchers also found that CMI doubles the risk of metabolic syndrome, which includes increased risk of coronary heart disease, diabetes and cirrhosis of the liver.

CMI continues to be much more prevalent in those who served in the war, although some of those veterans appeared to get better over the 10 years since. A study conducted soon after the war in 1995 by the U.S. Centers for Disease Control and Prevention found that nearly 45 percent of the war veterans were diagnosed with the disorder. The new study shows that number now to be 28.9 percent. However, the percentage of other soldiers with the disorder has held steady at about 15 percent.

"Physicians need to be aware of the potential manifestations of CMI and the need to treat them, and metabolic syndrome is a key example," Blanchard said. "There's quite a bit of literature on this condition, and there are steps physicians can encourage their patients to take, such as increased exercise, stress management and dieting to reduce abdominal fat, that can lessen its effects."

-- Meryl Harris
SOURCE: Washington University School of Medicine, news release, Dec. 27, 2005

Copyright © 2005 ScoutNews, LLC. All rights reserved.

MEDICARE 2006 PRESCRIPTION DRUG PLAN

2005-12-24T12:01:00.000-08:00

HHS RELEASE

Date: December 22, 2005
For Release: Immediately
Contact: CMS Public Affairs
(202) 690-6145

Headline: MORE THAN 21 MILLION MEDICARE BENEFICIARIES

TO BE COVERED FOR PRESCRIPTION DRUGS AS OF JANUARY 1, 2006

More than 21 million seniors and people with disabilities will get prescription drug coverage as of Jan. 1, 2006, HHS Secretary Mike Leavitt said today. The number includes more than one million Americans who signed up for the new stand-alone coverage in the first 28 days it was offered. Another 500,000 are expected to be enrolled by the end of January.

"The new prescription drug benefit is off to a strong start," Secretary Leavitt said. "With more than 21 million participating in coverage as of January 1, we are well on the way of meeting our goal of 28-30 million enrolled in the first year of the program. While there is still much work to do, we are encouraged by the early results."

"Interest in the drug coverage is strong, and these numbers do show that people are getting questions answered and making decisions. For people who have decided they want coverage, they should go ahead and enroll now so they can take advantage of this important new protection," said Centers for Medicare & Medicaid Services Administrator Mark B. McClellan, M.D., Ph.D.

Dr. McClellan noted the especially strong response from employers and unions who are planning on keeping their retirees in their current coverage. "We expected an initial spike in enrollment, but the participation in Medicare's new support for retiree coverage is even better than many predicted," Dr. McClellan said. "With more than 11 million retirees keeping the good coverage they have now, the support for retiree coverage provided in the Medicare drug benefit is working."

Medicare beneficiaries will be getting their drug coverage in various ways, including from existing federal and/or military programs. The enrollment figures as of Dec. 13 are:

· Stand-alone Prescription Drug Plans: more than 1 million.

· Medicare/Medicaid: 6.2 million (including 600,000 in Medicare
Advantage plans).

· Medicare Advantage: 4.4 million (plus 600,000 Medicare/Medicaid
beneficiaries).

· Retiree coverage: About 5.9 million retirees are enrolled in the Medicare retiree subsidy, with an additional 600,000 in process. Also, about 1 million retirees are in employer coverage that incorporates or supplements Medicare's coverage. Another estimated 500,000 retirees are continuing in coverage that is as good as Medicare's. (See Attachment A.)

· TRICARE/ FEHB retirees: 3.1 million.

"The holidays are a great time for families to have a conversation with a loved one about signing up for the new prescription drug coverage," Secretary Leavitt said. "The new benefit is the biggest improvement in health care for seniors and Americans with disabilities since Medicare began 40 years ago. We encourage all eligible beneficiaries to enroll so they can start saving right away on the prescription drugs they need to stay healthy -- now and in the future."

The Centers for Medicare & Medicaid Services will be releasing drug coverage enrollment data monthly.

Thank You http://www.RSDHope.org

Beware - Free Medication Scams!

2005-12-14T17:18:00.000-08:00

Watch out for "free medication" scams!

The Federal Trade Commission has filed a complaint in the U.S. District Court against MyFreeMedicine.com, LLC, a company that advertised on television and the radio that they could get free prescription medicine for “eligible” consumers. After paying $195.00 to enroll, consumers were directed to pharmaceutical company-run programs. Many consumers found they were not eligible for all the medications they needed.

The FTC has also published a consumer alert, No Need to Pay for Information on Free (or Low-Cost) Rx Drugs.

Go to http://www.ftc.gov/bcp/conline/pubs/alerts/rxdrugsalrt.htm

Travel in Comfort

2005-12-14T14:35:00.000-08:00

Thursday's Internet Radio Show

Disabled with Pain? Not to Worry.

Travel in Comfort!

Dianne Tuttle has been in the travel industry for over 20 years and specializes in helping people with disabilities make sure they get everything the American with Disabilities Act allows them to have - but often don't get. Helen and Dianne discuss plane travel, car travel, and train travel and the "secrets" to being almost as comfortable as home.

Arrive at your destination not as tired, or in as much pain as you might expect by being prepared and knowing in advance how to plan. Remember, we don't plan to fail, we just fail to plan! Joining Helen and Dianne, a CMT (certified massage therapist) to give you tips on how to self-massage those tired legs, feet, shoulders and other places that may become sore and achy from sitting. Nancy Brown teaches you how to relieve pain, sore muscles, and relax while traveling. This will be a fun show and just in time for the holidays when many will be traveling.

Listen live tomorrow by visiting:
www.health.voiceamerica.com at 5 PM (eastern)

Important Alert!

2005-12-12T10:16:00.000-08:00

You could be at risk for serious and life-threatening events if you have any underlying cardiopulmonary conditions and your healthcare provider uses NeutroSpec [Technetium (99m Tc) fanolesomab] when doing bone scans or other imaging procedures. The manufacturer and the FDA have reported some serious events when a radiodiagnostic agent consisting of a murine IgM monoclonal antibody formulated to be labeled with technetium was used. These events generally occurred within minutes of injection.

Two deaths have been attributed to cardiopulmonary failure within 30 minutes of injection. Additional cardiopulmonary events, including cardiac arrest, hypoxia, dyspnea and hypotension, required resuscitation with fluids, vasopressors, and oxygen.

Although this agent is indicated for scintigraphic imaging of patients with equivocal signs and symptoms of appendicitis who are five years of age or older, some healthcare professionals may be using it for bone scans for people with CRPS (Chronic Regional Pain Syndrome).

If you are using NeutroSpec, you should be closely monitored for at least one hour following injection. Resuscitation equipment and appropriately trained personnel must be readily available during this time. If you have any underlying cardiopulmonary conditions you may be at higher risk for serious complication. You should only use NeutroSpec after carefully considering the known and potential risks and benefits.

You may access this alert, at: http://www.fda.gov/medwatch/safety/2005/safety05.htm#NeutroSpec

The Time to Act is Now!

2005-12-07T17:17:00.000-08:00

RSDSA is supporting H.R. 1020 Bill that will establish an Office of Pain at the National Institute of Health. We have just received word from the American Pain Foundation (APF) that a critical hearing on Chronic Pain, which we anticipated would be in January, is the TOMORROW!

The House Sub-Committee on Health will be holding a hearing this Thursday December 8th at 10 a.m. in the Rayburn Building (HOB 2123) entitled "Improving America's Health: Examining Federal Research Efforts for Pulmonary Hypertension and Chronic Pain." We want the best outcomes from this hearing and are asking you to contact your Congressional representatives (especially members of the Subcommittee on Health) and encourage them to attend this hearing.

Please contact your representative about this hearing. A simple way to to write your representatives is to connect to APF's Advocacy Center:
http://www.painfoundation.org/page.asp?file=Action/intro.htm

The members of the Subcommittee on Health are listed here as well.
If you are able to travel to D.C. on Thursday, we are encouraging as many pain patients, advocates, and professionals to attend the hearing.

Please contact Michelle Lonchar at the APF (410) 783-7292, Ex. 306) if you plan on attending so they are sure to have enough room.

It is vitally important for Congress to hear from everyone who is concerned about improving pain care in America. The time to act is NOW. Do not allow this opportunity to slip away. We may not get another chance to stress how the undertreatment of pain, as a national health crises, is causing undue suffering all around us.

Online Support Group Research Project Summary

2005-11-19T14:10:00.000-08:00

Research Project Summary

Online Support Group Research Project Summary

People affected by pain are invited to take part in a study to learn more about the effectiveness of online support groups for people with chronic pain. Study volunteers must be 18 years or older. This study is sponsored by the American Pain Foundation, whose services for people affected by pain include PainAid, an online support group program. This study will be conducted by Yvette Colón, MSW
Director of Education & Internet Services
American Pain Foundation and Ph.D. Candidate
New York University School of Social Work
(410) 783-7292, ext. 223
yvette@painfoundation.org (as part of a doctoral dissertation)

The Faculty Sponsor is Dr. Martha A. Gabriel
New York University School of Social Work
(212) 998-5977
martha.gabriel@nyu.edu

Volunteers in this study about adults with chronic pain who participate in online pain support groups understand that their participation will include the following:
- Participate in PainAid, the American Pain Foundation's Online Support Group Program
- Use or participate in the online support group at least once a week
- Continue with the online support group for three months
- Complete 2 sets of questionnaires online: one at sign up for the study and one after 3 months (the questionnaires will take approximately 30 minutes to complete each time)
- The right to skip or not answer any questions they prefer not to answer
- The right to refuse to participate or withdraw from part or all of this study at any time
- The freedom to participate or not participate in the study without consequences
- Participation in this study is completely voluntary
- Participants can create a username and a password of their choice
- their real name will not be used, nor will they be identified personally in any way at any time
- If they agree to participate and change their minds, they will not be penalized and may continue to participate in PainAid without being part of this study
- They can continue to receive all services provided by the American Pain Foundation
- They understand that the results of the study will be included in a doctoral dissertation and may also be included in manuscripts submitted to professional journals for publication
- They understand that in appreciation of their participation, they will have the opportunity to download a free pain management relaxation audio file at the completion of the study

Confidentiality of all research records will be strictly maintained and participants' responses will be kept confidential.

There are no known risks associated with participation in this research beyond those of everyday life. Although participants will receive no direct benefits, this research may help the investigator understand the effectiveness of online support groups for adults with chronic pain.

This study has been explained to participants and their questions have been answered. If participants have additional questions or wish to report a research-related problem, they may contact the researcher:

American Pain Foundation
(410) 783-7292, ext. 223
yvette@painfoundation.org
the faculty sponsor at (212) 998-597
martha.gabriel@nyu.edu
New York University School of Social Work
1 Washington Square North
New York, NY 10003
For questions about their rights as a research participant, they may contact:
University Committee on Activities Involving Human Subjects
15 Washington Place
Apt. 1-A
New York, NY
10003-6657
telephone (212) 998-4808
fax (212) 995-4304
email: human.subjects@nyu.edu
website: http://www.nyu.edu/ucaihs

HELP GET RSD ON THE MONTEL WILLIAMS SHOW!

2005-11-19T13:14:00.000-08:00

CREATING AWARENESS, MONTEL WILLIAMS SHOW

How can YOU create Awareness of RSDS?

In the past ten years, many newspaper stories have been written in papers all across America.

Television Shows have had pieces on RSDS, both local and National.

Radio spots on RSD Awareness have been run.

Many individuals have gone to Washington, DC to talk to Congressional Representatives and Senators about raising Awareness and funding for RSDS.

Has legislation been passed in State Governments to help further the education and funding for RSD? Yes. Has much funding actually occurred? No. Not yet.

Has it been enough? Has everyone heard of these efforts? No. Absolutely not.

So what can YOU do to help raise awareness?

UPDATE - NOVEMBER 2005

WE CURRENTLY HAVE ONE OF THE PRODUCERS OF THE MONTEL WILLIAMS SHOW INTERESTED IN DOING A SHOW FEATURING RSD AND FOCUSING ON THE FUNDRAISING EFFORTS OF LYNN MARKLEY AS NOTED IN THE ARTICLE ELSEWHERE IN THIS SECTION. SHE IS THE REMARKABLE YOUNG LADY WHO RAISED OVER $10,000 FOR AMERICAN RSDHOPE'S RESEARCH FUND, IN HONOR OF HER AUNT LORI RUDELITCH.

What we need to do now is fuel that interest by sending to the Montel show as many emails and/or postal letters as we can detailing why it is so important and vital that he tell our story. Now, in order to be consistent and to make our voices stand out as one we need to do the following;
In the Subject Line or First Line of your email or Letter, mention American RSDHope and the importantance of raising Research Dollars. Our Research Fund is called "HOPE FOR TOMORROW".
In your email/letter talk bout how our organization and especially the internet has impacted you in your struggle to understand this disease.

We have all heard before how so many shows don't want to hear the horror stories and that they want to hear positive stories. Let's give them what they want. Yes, we have all been negatively impacted by this disease in a severe way; physically and financially. So have millions of victims of a hundred other diseases. We have to share with Montel and his Producers what sets us apart from the rest, what makes us special!

I think what makes our community special is the way we have taken the impact of what is ranked as the most painful Chronic Pain Disease that exists today and gathered together on the internet in groups large and small and supported each other. We have started Support groups to comfort one another, websites to share information as soon as it comes out, National Organizations to hold Conferences and produce Videos and Support Research. We have done all of this and where a decade ago there was practically nothing, today a supportive community thrives!

THIS is our story, this is the positive story we need to share with Montel and the country and with all of the millions of other patients out there who have yet to hear about us, many of whom have yet to be diagnosed and who still live in fear and confusion wondering if they are losing their mind ...if it really IS all in their head...if they really are exaggerating their pain.

PLEASE SHARE OUR WEBSITE WITH THEM SO THEY CAN GET MORE INFORMATION!

AMERICAN RSDHOPE WEBSITE

Write to Montel by going to THE MONTEL SHOW and leave your story on the website and/or send it in via postal mail. Send it in once a week for amonth if needed. Share the site with your family and friends, fellow patients, etc. SPREAD THE WORD! LET'S HAVE OUR VOICES HEARD!

If you need an RSD Informational video to run on your local cable access channel, go to our Awareness Products section. We have many 30 minute videos that were done exclusively for this purpose and have been used for this purpose.

These are wonderful videos that can be shared with not only the tv station but also your local group, Chruch Groups, Civic Groups, and more; to explain all about RSD - who it affects, what it is, etc. as well as an RSD & the Family presentation.

KEEP WRITING AND PASS THE WORD!

Thank You! RSDHope

Wolf Amendment Defeated!

2005-11-10T15:12:00.000-08:00

ALERT

November 8, 2005

WOLF AMENDMENT DEFEATED!

Great news! On November 4, 2005, a U.S. House-Senate conference committee dropped a controversial provision that gave the Drug Enforcement Administration (DEA) authority to review, and potentially block, the sale of all new prescription opioids.

The legislation, promoted by Rep. Frank R. Wolf (R-VA) and attached to a multi-department appropriations bill, passed last year with little notice. This year, however, the Food and Drug Administration (FDA), pharmaceutical manufacturers, doctors who treat people with pain and many others objected to renewing it, and the provision was stripped from the bill. Opponents of the bill believed that the provision was an unwarranted intrusion by a law enforcement agency into the FDA's drug-review system. Pain specialists also said that DEA reviews could jeopardize development of new drugs needed by people with chronic pain.

The Congressional Appropriations Conference Committee decided to remove language from the proposed appropriations bill that would have allowed the DEA to force delays or veto newly approved FDA pain medicines from reaching the market. The troublesome amendment was removed from the final bill.

The American Pain Foundation along with the American Academy of Pain Medicine and others worked to inform the public and the Conferees about the potential harm to people with pain if this amendment were enacted.

http://www.painfoundation.org
Thank you, RSDHope

Sleep & Dreams

2005-11-07T15:45:00.000-08:00

Nighty Night: Unraveling the Mystery of Dreams and Sleep Disorders

Reported by Alexandra L. Woodruff, Ivanhoe Health Correspondent

(Ivanhoe Newswire) -- Sweet dreams are made of these . Dreams have been a constant for all of human kind, but dreams have not always been kind to the humans who try to explain them. Dreams can be a portal into our emotional lives, and opening the door of dreams can be as easy as one, two, dream.

During sleep, people alternate between two stages: rapid eye movement sleep and non-REM sleep. During REM sleep, brain activity is similar to waking levels, and the brain consumes the same amount of energy as during waking hours. Heart rate and breathing become irregular, muscle control is lost, and body temperature is not well regulated and drifts to the ambient temperature. Non-REM sleep, also known as quiet sleep, is characterized by decreased brain activity and regular breathing and heart rate. Most vivid dreaming happens during REM sleep, but new research shows dreaming can actually happen during the non-REM cycle.1

Not all experts agree on the meaning or significance of dreams, but most agree all humans dream, regardless of whether or not they remember the subconscious short stories. People who are deprived of REM sleep will start dreaming in non-REM stages, tend to be more day dreamy during the day, and it's more difficult for them to focus. "Dreaming is a sensory, usually visual, experience during sleep, which has a narrative continuity and occurs without your conscious participation in the selection of that narrative and is a normal part of every human being's sleep," said Rosalind Cartwright, Ph.D., chair of the psychology department at Rush University in Chicago.2

She believes dreams are an integral part of a person's mood and emotional well being. "For the most part, the major effect is on mood regulation. I think that's what dreaming does for us. Its primary function is that it deals with emotional material, and it helps regulate it," Cartwright says.3

She has found patients who are very depressed have bland dreams that lack emotional content. The dreamers don't develop good story lines and don't remember dreams even when awakened during REM sleep. She says the dream system is simply not doing its job of dream regulation. "Some of them do manage over time to get their lives back together, and the dreaming then becomes more rich and interesting and handles the emotion better. Then it's not that they wake up in a depressed state anymore, they wake up with their mood improved as their dream life becomes more vivid and exciting," explains Cartwright.4

During conscious hours, people have so many distractions that emotions are pushed into the periphery. When someone is troubled with psychological disturbances like panic disorders, nightmares or post-traumatic stress disorder, she records their dreams in a sleep laboratory and later goes over them in the office to find relationships between their present life and their dreams. "Sleep is devoted to handling the emotional meaning of our experience and putting it into perspective with our past and our hope for a future." Cartwright says.5

Those who don't have access to a clinical dream therapist can use a few simple steps to help them use dreams to guide them through emotional stumbling blocks. Dream therapy is only useful when you remember dreams, and Cartwright suggests a routine to help conjure up the tales of the subconscious. First, choose a night when you can sleep in and do not have to wake to an alarm. This increases the possibility of waking up during REM sleep when most dreaming takes place. Go to sleep with the intent of remembering the night's dreams. Keep a pen and piece of paper next to your bed. When you wake up, keep your eyes closed, go over your dream's narrative in your head. Give it a title; this will help you remember the dream. Then write down everything you remember about the dream. Also, make notes about possible triggers for the images in the dreams. For example, if you watched a film the night before, those images could be incorporated into your dreams. After you have a collection, go back over the dreams, find patterns, and interpret the dream imagery according to your personal experience.

"You can't really apply any other system to understanding them except help the individual understand their own material, but they can do it pretty quickly, and once they begin to get a clue as to what they're saying to themselves and they're feeling about themselves in the dream life, then you can begin to work with them about how to improve it, how to feel more positive," Cartwright says.6

Sleep Deprived Society:
Insomnia, the most common sleep disorder, affects 20 percent to 40 percent of adults every year. More than 70 million Americans are plagued with sleep disorders, with 60 percent of those suffering from a chronic disorder. Both men and women battle insomnia, but it's more common in females and older adults. The American Academy of Sleep Medicine estimates that sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national health care bill.7

The symptoms include difficulty falling asleep, waking frequently during the night with difficulty falling back asleep, waking up too early in the morning, and feeling unrefreshed from sleep. There are varying levels of the disorder, which include feelings of restlessness, irritability, anxiety, daytime fatigue and tiredness.

Transient and intermittent insomnia: The patient complains of an insufficient amount of sleep and doesn't feel rested after a night of sleep. There is little or no evidence that social and occupational function is impaired. The episodes may not require treatment, as they only last a few days. Chronic insomnia: The patient complains nightly of an insufficient amount of sleep and doesn't feel rested after a night of sleep, but unlike milder forms suffers have severe impairment of social or occupational functioning. These individuals should consult a sleep practitioner for an evaluation and treatment options, which include relaxation therapy, sleep restriction, and reconditioning.8

Addressing insomnia is vital for proper psychological and physical health. "We would say that sleep is just as important for overall health and quality of life as our physical activity and healthy diet," says Carl E. Hunt, M.D., director of the National Center on Sleep Disorders Research, which is part of the National Institutes of Health's National Heart, Blood and Lung Institute.9

But our modern, fast-paced life of round-the-clock operations are keeping proper sleep patterns at arm's reach. Before industrialization and electricity, humans relied on the rising and the setting of the sun to determine their sleep cycles. For thousands of years, humans have adapted their bodies to this simple, somewhat consistent light-dark cycle. "It's not too strong a term to say that our species is facing a biologic challenge associated with 24-7 operations, and this challenge is as strong a challenge as our species faced when they left temperate climates and started to go north and south to seasonal changes where you needed shelter and clothes and you needed to find ways to store food and so on," says Merril Mittler, Ph.D., a program director at the National Institute of Neurological Disorders and Stroke who has researched sleep for 30 years.10

Throughout a 24-hour period, humans' biochemical processes increase and decrease according to the amounts of ambient light. There are literally thousands of these biological processes determining everything from body temperature to reasoning speed to how fast we run and how we secrete. These cycles, called circadian rhythms, have nothing to do with psychology and are biologically mediated. The functions are determined by the master clock in the hypothalamus. Shift work and rapid travel creates an environment where humans are forced to be awake and alert at times when they are programmed to be sleeping.

"We are trying to have these people do these very important tasks at the absolute worst time, and their ability to do these tasks at the worst times does not change by training them better or paying them more or yelling at them if they fall asleep. That does about as much good as telling someone who is 5-foot-2 to grow 6-foot-6 so they can play basketball. We need techniques that can overcome the biological limitations that are associated with our circadian rhythms," said Mitler.11

Researchers do not know how often one can reset the clock or how quickly it can be reset. Mitler says the research and the solutions for dealing with these environmental changes are rudimentary at best. Through light manipulations and artificial environments, researchers can fool the circadian rhythms into believing they're in a different time zone. This could be effective for people involved with shift work, but difficulties arise when they have to leave the controlled environments. Stimulants and other pharmacological medications can be used only as a crutch to mask the difficulties of improper sleep. Scientists are now working to understand how the cells in the master clock communicate. Once this is established, medication or perhaps an implantable device could help alleviate circadian rhythm upsets. Mitler says the consequences cannot be overstated.

"It's not a joke, it's not curiosity science because most of the major transportation and industrial accidents as well as individual passenger vehicle accidents that kill people occur between the hours of midnight and six in the morning. They do not because it's dark out per say but because this period represents a period of increased vulnerability to areas of performance. Not only is the operator hurt or killed, but frequently the vehicle kills other people as well," said Mitler.12

Laboratory testing using genetic manipulations of fruit flies seems to show the need for sleep and the ability to work graveyard shifts is genetically determined. Scientists are working to isolate the genes and hope to eventually use the information to help humans adapt to this relatively new work schedule.

Scientists know sleep is a necessary human function, but they still don't understand exactly why we do it or what it is for. Scientists generally believe sleep is most likely a way for the brain to rest and recover from daily mental activity, similar to the way muscles relax after a physical workout. "The real function of eating is to supply nutrients, and the function of breathing is to take in oxygen and expel carbon dioxide. But we have no comparably straightforward explanation for sleep," wrote Siegel.

More than a decade ago, researchers found rats died with total sleep deprivation. The animals lost weight despite increased food intake and died 10 to 20 days faster than if they were totally deprived of food, but slept normally.13

Untreated sleep apnea puts humans at a greater risk of high blood pressure and its complications which include coronary artery disease, stroke and heart failure.14

"We don't know if insomnia is a risk factor for developing medical and psychiatric disorders, or is it that the insomnia and those other disorders are both a consequence of some other vulnerability or predisposition that's just not been well identified," says Edward Stepanski, Ph.D., from Rush University's Sleep Disorders & Sleep/Wake Research Center.

Extreme sleep deprivation has many consequences including personality changes, decreased memory, and cognitive function. In less severe sleep deprivation, there is a change in the way people address their jobs and job tasks, which leads to degradations in performance. "People feel they can't concentrate as well during the day. Their memory is not as good during the day, those kinds of things and then some mood change is the second major set of changes which are usually people wanting to be more socially withdrawn, being a little more depressed, low energy, irritable," Stepanski says.16

While research shows humans need sleep, it's not exactly clear what kind of sleep they need. Early studies found that people who were deprived of REM sleep became psychotic. These tests were later proved wrong after discovering the researchers used amphetamines to deprive the sleep. It's now believed the subjects were reacting to the amphetamines and not the REM sleep deprivation. Patients who are denied REM sleep don't necessarily exhibit abnormal behavior. The only well-established connection between REM sleep and mental illness is depression. Some antidepressants, in particular MAO (monoamine oxidase) inhibitors, actually suppress REM sleep to treat the disease.

"People on MAO inhibitors have this spectacular suppression of REM sleep where it's almost completely gone, and literally millions of people have been on MAO inhibitors, so if there was some striking or peculiar consequence of loss of REM sleep you would think we would know it from the MAO inhibitor studies. In fact, not much has been reported, certainly not much in the way of cognitive function. These people have normal emotions, normal learning abilities, and side effects are more on the physiological side," Siegel says.17

He suggests some people who suffer from insomnia simply have a decreased need for sleep. Humans who sleep seven hours a night tend to have a longer life span. "Existing evidence indicates that 'helping' people increase sleep time with long-term use of sleeping pills produces no clear-cut health benefit and may actually shorten life span," wrote Siegel.18

Epidemiological studies suggest that taking daily use of hypnotics like valium and other benzodiazepines can decrease your life span as much as smoking a pack of cigarettes a day. "I know of no study showing that hypnotic use prolongs life span and now two studies that suggest that it shortens life span. So, an important health issue is to try to counter the self-serving publicity of drug companies that say if don't get enough sleep you should go see your doctor, which means you should get a hypnotic. Because if it were harmless it would be one thing, but if it's going to shorten your life span then that is a great disservice to the public that may take 20 years to prove," says Siegel.19

Also, the hangover effect of these drugs could be just as detrimental as simply not getting sleep. He says the long-term effects still need to be studied, but there is no evidence to suggest that on a long-term basis these drugs are good for you.

Summoning the Sandman:

The first thing doctors must do for a patient suffering from insomnia is to determine whether there are any underlying medical or psychological problems triggering the insomnia. Behavioral and lifestyle changes are a proven effective way to promote sleep and restfulness without the use of prescription medication.20

Set a rigid sleep schedule seven days a week: It is important to wake up and go to sleep at the same time every day, to help set the internal clock that controls circadian rhythms. Stick to the schedule on weekends. People who struggle with insomnia can start with a reduced time schedule. To start, try sleeping at five-hour intervals every night. Then every week add 15-minutes to the sleep period until you are sleeping enough to feel refreshed in the morning. This sleep deprivation therapy can help reset the body's clock.

Don't waste time in bed: People need less sleep as they get older. Experts say there is no normal amount of sleep for an adult. If you can't sleep, don't stay in bed and worry about not sleeping. The worry and anxiety of sleeplessness can perpetuate the problem. Get up, find another activity, and don't go back to bed until you are drowsy. If stress is always associated with the bedroom, it will make it more difficult for insomniacs to relax and fall asleep.

Sometimes simply not worrying about insomnia can decrease anxiety and induce drowsiness. Set aside quiet time before bed: People with busy schedules often head to bed without sorting out the nuances of the last day and the tasks for the day ahead. Bedtime is the first time these potential stresses are addressed. Experts suggest sitting down an hour or two before bedtime and review anything that is bothering you. Try to work out solutions, so you don't have to deal with them when your head hits the pillow. Exercise not too close to bedtime can also help clear the mind.

Make the bedroom a place for sleep: Modern bedrooms are no longer a place just to sleep, they are a place to watch TV, play video games, work on the computer, and talk on the phone. The bedroom should be a sanctuary for sleep and sex. These other distractions can create an overstimulating environment in a place originally meant for rest.

Avoid stimulants and alcohol after twilight: Don't eat chocolate, coffee and other beverages with caffeine after 4 p.m. Smoking is also a stimulant that should be avoided around bedtime. Alcohol at dinnertime can make you feel sleepy, but it depresses the central nervous systems and will usually disrupt your sleep in the middle of the night. Also, talk to your doctor about certain medications that could interfere with sleep.

Learn and practice relaxation techniques and mechanical aids: Deep diaphragm breathing can slow down breathing and promote relaxation. Relaxation tapes can help guide people through relaxation exercises. Focusing on pleasant thoughts before bedtime can also be beneficial. Earplugs can help block out unwanted noise, and eyeshades can help block out light.

Physical activity before sleep: Walking or other light physical activity in the late afternoon or early evening will fatigue the muscles and raise body temperature. Some researchers have found that sexual activity triggers hormonal mechanisms that help enhance sleep.

Take a warm bath: One theory is that body temperature plays a role in the body's circadian rhythms. Some believe that the body begins to get drowsy as its temperature drops, so taking a warm bath four or five hours before will raise that temperature. When the temperature starts to drop, it will be easier to fall asleep.21, 22

Bright light therapy can help people suffering from a circadian rhythm disorder. People are exposed to bright lights at the beginning of the day to make them believe it is dawn.

"It's actually like a dose-response relationship, so you can get a less bright light for an hour, and you'll get the equivalent change in resetting your biological clock, as you would be getting more intense light for half an hour. Light intensity is measure by lux. We're usually thinking 5,000 lux for an hour, and 10,000 lux for half an hour. The best thing I tell people is just use sunlight as much as possible. Just get outside, get exposure to sunlight, and that's going to be the best light source you'll ever find," says Stepanski.23

Melatonin, which is a naturally occurring brain chemical, is available in most health food stores and has been proven effective in people who are doing shift work and have to fall asleep at odd hours of the day.24

Herbal remedies such as valerian root and kava kava are used to promote sleep, but scientists say there is little or no evidence that they are effective. Stepanski says the only studies that have positive results for the homeopathic remedies have not used a placebo group, so the findings are suspect at best.25

Soporific Strides:

Sleep still remains a mystery to the scientific world, but researchers are making strides to uncover sleep's enigma. Scientists are refining pharmacological medications, and sleeping pills are becoming more specific and refined. "They keep trying to find the perfect sleeping pill, something that will last long enough to keep you asleep the whole night without having any residual sedation into the day," says Stepanski.26

Mitler and his laboratory are studying genetic mutations in fruit flies. They are developing flies that have varying sleep needs. "It allows us to look at these genes, look at the protein products of these genes, and see if there are analogous genes in the human that we might be able to adjust or tweak for therapeutic reasons. I think we're close. I think there's a lot of conservation in the genetic machinery that controls the clock. Once we identify these genes, then we have to find how you experimentally turn them on or off because they do carry over from animal to animal," says Mitler.27

Scientists have also found people who tend towards insomnia have a predisposition to hyper-arousal, which means their body's physiologically ramp up more quickly and easier than others. Their heart rates increase and show other signs of stress like increased cortisol levels. This response does tend to show up in families and is possibly gene related. "What they need to do now is more sophisticated genetic testing to see if they really can identify that that's true. The problem you have with family history is that it could also be learned behavior," says Stepanski.28

A Canadian psychiatrist has found that pumpkin seeds have an unusually high rate of tryptophan and has developed a pumpkin-seed-based supplement to promote sleep. Tryptophan is a naturally occurring chemical that is found in most of the foods we eat. If it is properly metabolized, it will create seratonin in the brain when it is light and melatonin in the brain if it is dark.

Hudson estimates we eat 1,000 milligrams to 1,500 milligrams of tryptophan every day, but only about 3 percent of that ever goes into the brain. Researchers have also found when there is a lot of insulin in the blood, tryptophan can get into the brain more easily. Knowing this he developed a method for tryptophan to be released into an insulin-rich blood stream, which will direct the chemical reactions to create melatonin.29

Tryptophan supplements were banned in the United States in the late '80's after fatalities resulted from using the supplements, but Hudson says his supplement would be excluded from the ban. "We checked with the FDA regulatory person at the time, and they're quite explicit that tryptophan is acceptable in the States provided it's in an intact protein, that was specifically excluded when they banned tryptophan. Tryptophan within protein is acceptable," says Hudson.30

Initial studies show the supplement was effective in helping subjects sleep. The hangover affects in the morning are milder than pure melatonin because once the subject is exposed to light, the body switches and starts creating seratonin.

Blue light may be better than any other wavelength for bright light therapy. Researchers from Brigham and Women's Hospital in Boston and Jefferson Medical College in Philadelphia have found that the body's natural biological clock is more sensitive to the shorter wavelengths of blue light than the longer wavelengths of green light. Researchers exposed 16 healthy subjects to the same amount of blue and green light and found the blue light was twice as effective as green light in resetting the internal biological clock. Researchers believe the relationship could be related to the fact that under normal daytime circumstances humans are exposed to a blue sky.31

As researchers delve deeper in the abyss of dreams and sleep, science gets closer to the understanding the labyrinth of the subconscious. .

This article was reported by Ivanhoe.com, who offers Medical Alerts by e-mail every day of the week.
To subscribe, go to: http://www.ivanhoe.com/newsalert/.

ENDNOTES 1. Siegel, Jerome M. "Why We Sleep," Scientific American, November 2003.
2. Cartwright, Rosalind, Ph.D., Interview on September 3, 2004.
3. Ibid.
4. Ibid.
5. Ibid.
6. Ibid.
7. American Academy for Sleep Medicine. "Insomnia," www.aasmnet.org.
8. Ibid.
9. Hunt, Carl E., M.D., Interview on September 2, 2004.
10. Mitler, Merrill, Ph.D., Interview on September 2, 2004.
11. Ibid.
12. Ibid.
13. Siegel, Jerome M. "Why We Sleep," Scientific American, November 2003.
14. Hunt, Carl E., M.D., Interview on September 2, 2004.
15. Stepanski, Edward, Ph.D., Interview on September 3, 2004.
16. Ibid.
17. Siegel, Jerry, Ph.D., Interview on September 1, 2004.
18. Siegel, Jerome M. "Why We Sleep," Scientific American, November 2003.
19. Siegel, Jerry, Ph.D., Interview on September 1, 2004.
20. Gale Group, Inc., "Sleep Disorders Treatment," National Women's Health Resource Center, January 28, 2004.
21. Ibid.
22. MotherNature.com. "19 Steps to a Good Night's Sleep," http://www.mothernature.com
23. Stepanski, Edward, Ph.D., Interview on September 3, 2004.
24. Ibid.
25. Ibid.
26. Ibid.
27. Mitler, Merrill, Ph.D., Interview on September 2, 2004.
28. Stepanski, Edward, Ph.D., Interview on September 3, 2004.
29. Hudson, Craig, M.D., Interview on September 2, 2004.
30. Ibid.
31. Health & Medicine Week. "Circadian Rhythm: Blue light important for setting biological clock," Health & Medicine Week via NewsRx.com and News.Rx.net, September 29, 2003.

REFERENCES
American Academy for Sleep Medicine. "Insomnia," http://www.aasmnet.org
Church, Michael. "Dream On," The Times Educational Supplement, The Inside Story, no. 4590, July 2, 2004, p. 8.

Cudworth, Laura. "Ticket to Dreamland? Stratford Study Leads to Development of Natural Sleep Aid," Stratford Beacon Herald, March 14, 2003, p.3.

Forna, Aminatta. "About Last Night," Observer Magazine, May 30, 2004, p.20.

Health & Medicine Week. "Circadian Rhythm: Blue light important for setting biological clock," Health & Medicine Week via NewsRx.com and News.Rx.net, September 29, 2003.

James, Steven P., M.D., M.B.A., and Wallace B. Mendelson, M.D., "Herbal and OTC Sleep Remedies; Implications for Pschychiatry," Psychiatric Times, November 1, 2003, p. 72.

Gale Group, Inc. "Sleep Disorders Treatment," National Women's Health Resource Center, January 28, 2004.

Jones, Dr. Hilary. "Sleep Eazzzy," News of the World, July 4, 2004

MotherNature.com. "19 Steps to a Good Night's Sleep," http://www.mothernature.com/ Siegel, Jerome M. "Why We Sleep," Scientific American, November 2003.

Springen, Karen with Pat Wingen. "Anxiety: Sweet, Elusive Sleep," Newsweek, August 9, 2004.

Toto, Christian. "Sleepless nights; Relieving insomnia a restless pursuit," the Washington Times, April 22, 2003, p. B01.

If you would like more information, please contact: Biosential Inc. Craig Hundson, M.D. 416-421-7445 Toll free: 800-725-4538 http://www.biosential.com/

National Center on Sleep Disorders Research
Carl E. Hunt, MD, Director
301-435-0190

The National Institute of Neurological Disorders and Stroke
Merrill Mitler, Ph.D.
301-496-9964

Rush University Medical Center
Media Contact: Chris Martin
Associate Director,
Media Relations
312.942.7820 cmartin@rush.edu http://www.rush.edu/news/media.html

Rosalind Cartwright, Ph.D.
312-942-2020
rcartwri@rush.edu

Edward Stepanski, Ph.D.
312-942-5440

UCLA Dept. of Psychiatry
Neurobiology Research 151A3,
VA GLAHS, North Hills California 91343
Jerry Siegel Ph.D.
818-891-7711 Ext. 7581
JSiegel@ucla.edu
http://www.npi.ucla.edu/sleepresearch/index.htm

Thank You, RSDHope

Market Sales - Chronic Pain Treatments

2005-11-07T15:24:00.000-08:00

Reformulated Drugs Will Drive Market for Treatment of Chronic Pain

Thursday November 3, 8:00 am ET

Market Sales Will Grow to $24 Billion in 2014,
According to a New Report from Decision Resources

WALTHAM, Mass., Nov. 3 /PRNewswire-FirstCall/ --Decision Resources, Inc., one of the world's leading research and advisory firms focusing on pharmaceutical and health care issues, finds that the reformulations of existing drugs for the treatment of chronic pain, including therapies manufactured by Johnson & Johnson, Purdue Pharma, Endo Pharmaceuticals, and Cephalon, will drive major market sales from $15 billion in 2004 to more than $24 billion in 2014.

In addition, the new Pharmacor report entitled Chronic Pain: Key Populations, Market Size, and the Driving Force of Drug Reformulations finds that the antidepressant and antiepileptic drug sectors will also experience significant growth over the next decade as a result of new approvals -- and thus more widespread use -- for chronic pain conditions. Specifically, new drugs like duloxetine (Eli Lilly's Cymbalta), Dov Pharmaceutical's bicifadine, pregabalin (Pfizer's Lyrica), and new formulations of gabapentin (Pfizer's Neurontin, generics) are expected to drive growth in the chronic pain market.

"Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX)-2 inhibitors, which accounted for nearly 50% of the chronic pain market in 2004, will steadily lose market share in the wake of serious long-term safety issues," said Michelle Grady, therapeutic area director, Pain, at Decision Resources, Inc. "Filling the void left by the declining use of NSAIDs and COX- 2 inhibitors, opioid analgesics and antiepileptic drugs will capture leading shares, together accounting for 55% of the chronic pain therapy market in 2014, compared with a projected 18% NSAID/COX-2 market share that year."

About Chronic Pain
Key chronic pain populations include arthritic pain (primarily osteoarthritis and rheumatoid arthritis pain), chronic low back pain, cancer pain, prominent neuropathic pain conditions (i.e., painful diabetic neuropathy, postherpetic neuralgia, and HIV-related neuropathic pain), fibromyalgia, and chronic headache.

About Pharmacor from Decision Resources
Pharmacor is a unique family of studies that assesses a host of market- impacting factors and analyzes the commercial outlook for drugs in research and development.

About Decision Resources
Decision Resources, Inc., (http://www.decisionresources.com) is a world leader in market research publications, advisory services, and consulting designed to help clients shape strategy, allocate resources, and master their chosen markets.

All company, brand, or product names contained in this document may be trademarks or registered trademarks of their respective holders.

For more information, contact:
Elizabeth Marshall
Decision Resources, Inc.
781-296-2563
emarshall@dresources.com
Source: Decision Resources, Inc.

Thank You, RSDHope

Lyrica - New Drug Survey

2005-10-31T12:30:00.000-08:00

Lyrica is a fairly new medication for peripheral neuropathy. RSDHope is conducting an unofficial survey of those who have taken this drug for at least 3 weeks. Please answer the following:

1) What dosage you started on and what side effects you experienced at the different dosage levels?

2) How you feel it has helped you?
For instance, has it helped decrease your pain?
Increased your sleep?
Enabled you to decrease your other medications, and if so, which ones?

3) Have you found a good time to take it in the evening? 6pm? 8 pm? 11pm?

Please send your Lyrica survey reply to:

rsdhope@mail.org

Also, please remember the basic tenets when sharing information about medication online:
1) Never stop or start any medication you hear or read about without checking with your Doctor first.

2) Always try to have ONE Doctor prescribe all of your medications if possible, that way you are less likely to have crossover problems and/or accidental overdoses.

3) Don't buy your medication online unless you know it is from a reputable pharmacy and/or company approved by the FDA.

4) Understand that different patients will react differently to the same levels of medication. Results vary depending on body weight, other medications being taken, other diseases conditions you have known and unknown, allergies you have known and unknown, and many more things.

Bottom line? Take what you read on the Internet as a guide, share it with your Doctor and together decide on a course of action. You might be fortunate enough to find a new medication that does wonders for you! You also may learn things about the medications you are on that could save your life. But remember these are JUST observations made by fellow patients.

Thank You!
http://www.rsdhope.org

For additional information: LYRICA

More Research Information!

2005-10-27T15:05:00.000-07:00

Ongoing Research Studies for People with Chronic Regional Pain Syndrome/Reflex Sympathetic Dystrophy

Please visit: http://rsds.org/3/research/index.html to determine your eligibility to participate in four ongoing clinical research trials.

"Insufficient medical research can be hazardous to your health."Former Surgeon General C. Everett Koop

Please help us spread the word!

No Help from Schwarzenegger in California

2005-10-23T15:40:00.000-07:00

RSD Education Bill Vetoed by the Governor

Public Awareness Campaign Denied Signature for Little Understood Disease that Affects Up to 6 Million Americans

Sacramento, CA, October 7, 2005 – Today, Governor Arnold Schwarzenegger vetoed AB 1648, the Reflex Sympathetic Dystrophy Education and Research Program Act, introduced by Assemblywoman Fran Pavley (D-Agoura Hills). The bill would have authorized the State Department of Health Services to establish and implement a Reflex Sympathetic Dystrophy public awareness campaign using non-public funding. “It is unfortunate that the Governor vetoed AB 1648 since RSD affects more Americans than victims of breast cancer and HIV / AIDS combined.

The RSD and pain community is to be commended for its efforts to raise public awareness since there is no way to detect or cure this painful disease,” said Assemblywoman Pavley. RSD, which is estimated to affect between 1.5 and six million Americans, is a little understood chronic neurological pain condition of the central nervous system characterized by severe, burning pain (often described as being doused with gasoline and lit on fire). Many patients suffer alone in pain because of the stigma and misunderstanding associated with the disease. RSD is typically triggered by a minor injury or trauma.

Cynthia Toussaint, the bill's sponsor and founder of For Grace, a nonprofit dedicated to achieving the ethical and equal treatment of all women in pain, said, "RSD is a devastating illness if not caught and treated early. In signing AB1648, the Governor would have recognized the importance of educating allCalifornians about the consequences of delayed diagnosis and treatment for RSD.

"Toussaint, who suffers from RSD herself, knows all too well the consequences of delayed treatment and misdiagnosis. For 13 years, doctors told her that the chronic pain she felt was "all in my head. "Toussaint testified before the California Assembly and Senate Health committees this year in support of AB 1648, known as "Cynthia's Bill" in Sacramento. “The demise of 1648 is an unfortunate example of the short-sighted politics and economics that rule Sacramento today.

Make no mistake—hundreds of thousands will continue to suffer needlessly due to the ravages of RSD—and that's a terrible shame as the opportunity for change was just a signature away”, concluded Toussaint.

A prisoner in your own home?

2005-10-20T10:56:00.000-07:00

An Alert from the United Spinal Association

"We need YOU to educate your representative in Congress about what
Medicare is doing to YOUR power wheelchair/scooter benefit.

The Center for Medicare and Medicaid Services (CMS) has recently issued
a series of draft and final policy changes to the coding, coverage and
documentation rules for power wheelchairs and scooters. Some of these
changes are scheduled to take effect October 25; some are scheduled to
be effective January 2006. CMS implementation plan for these separate
but related policies is undefined and could mean you might lose your
power wheelchair/scooter benefit and become a prisoner in your own home.

What can you do?

1. Go to www.rightwheelchair.org to educate yourself about this issue.

2. Call the Capitol Switchboard, 202-224-3121 and tell your
representative what Medicare is doing to threaten your independence"