There has been a tremendous amount of controversy about the use of narcotics (also referred to as opiates) for long-term chronic pain management. Some sources and research say it's not safe, others say it is safe with precautions. For the vast majority of people suffering with chronic pain, I believe long-term opiate use can be safely used with adequate precautions, but for 10 to 15% of the people, the usual precautions will not be enough. This month we have added my new article on our Articles Page titled "Addressing the Problem of Prescription Drug Abuse/Addiction," that I encourage you to review.

I came across a new resource I wanted to bring your attention to called eOrthopod and one of the postings caught my attention: Who's at Risk for Narcotic Abuse? You have to register to access this site, but it does have a free site Open eOrthopod with great patient information.

The posting was taken from a research article by Dennis C. Turk, PhD, et al. Predicting Opioid Misuse By Chronic Pain Patients. In The Clinical Journal of Pain. July/August 2008. Vol. 24. No. 6. Pp. 497-508. Here are excerpts outlining the risk factors:

Probably the strongest predictor of drug misuse is a history of previous alcohol or other drug use. A family history of substance abuse may also be predictive. But this hasn't been studied enough to say for sure. When used as prescribed, narcotic medications can be very effective without creating dependence and/or addiction. Signs that there may be a problem with misuse and/or abuse include:

• Seeking drugs from multiple doctors
• Losing the prescription (more than once)
• Stealing or borrowing similar drugs
• Forging prescriptions

Sometimes what looks like drug addiction is really just poorly controlled pain. If the patient is using more drug than was prescribed, hoarding drugs, or complaining about the need for more medication, then a follow-up evaluation with the physician is needed.

Other possible predictors include a history of car accidents, driving under the influence (DUI), and prior drug convictions. Mood disorders (such as depression) aren't as likely to be present before the pain problem developed. But depressive disorders are five times more likely after disabling pain occurs. And ten times as many patients with opioid dependence develop a major depressive disorder after their injury.

The authors conclude that identifying patients who are at risk for drug misuse is a difficult challenge. There isn't a good screening tool to use at present. More research is needed to find a reliable and valid way to measure all patients regardless of age, gender, or race. Until then, physicians must continue to monitor patients closely.

To help reduce the risk posed by the misuse or abuse of opioid medication, I have developed an instrument called the Red Flags Checklist that I use to help determine whether there may be problems with medication management. If you'd like to obtain a free copy of this exercise please go to our Contact Page to request my Brief Red Flags Checklist and we will be happy to email it to you. For more information about managing prescription medication, check out our publication: APM™ Module Two-Examining Your Potential Medication Management Problems.

Several of my patients over the past ten years have mentioned their desire to use Botox (botulinum toxin Type A) to help them with their pain management. The first time this came up I was caught unprepared as I had only thought of Botox for cosmetic surgery applications. I soon discovered there has been significant debate regarding the efficacy of using Botox for chronic pain management.

One opposing view is Anne Asher who writes for About.com. I have included some excerpts below from her recent posting "Is Botox Effective for Chronic Back Pain Management?"

Despite the increase in popularity of this treatment, no convincing evidence of its effectiveness has been found. In fact, the Cochrane Collaboration, an independent organization that reviews medical literature to learn about the validity of treatments, noted that Botox injections appear to be no better than injections of saline solution for decreasing pain or disability due to mechanical neck disorders. And, in a physician review of medical literature, meant to help guide doctors' practices, Botox was not recommended as a treatment of chronic pain.

In the hands of the wrong person, Botox can have devastating effects on the nervous system. This is because, until it is properly diluted and prepared, it remains poisonous. If Botox is used as a treatment for back or neck pain, it should be administered by a licensed medical doctor with experience working with the substance as a medicine.

On the other side of the question, I came across a report discussing 2007 research discussing positive outcomes using Botox for shoulder pain in patients with osteoarthritis. I will include highlights of this research below, but you can read the entire posting here.

A single injection of intra-articular botulinum toxin Type A may significantly decrease pain and improve shoulder function in osteoarthritis sufferers, according to researches presented this week at the American College of Rheumatology Annual Scientific Meeting in Boston, Mass.

Osteoarthritis is the most common joint disease affecting middle-age and older people. It is characterized by progressive damage to the joint cartilage -- the slippery material at the end of long bones -- and causes changes in the structures around the joint. These changes can include fluid accumulation, bony overgrowth, and loosening and weakness of muscles and tendons, all of which may limit movement and cause pain and swelling.

Injection of botulinum neurotoxin (commonly referred to by the brand name Botox) into joints is a promising new approach for treating sustained shoulder pain brought on by arthritis. An injection of neurotoxin in the joint may work by decreasing the release of certain proteins from the nerves in the joints -- thereby decreasing the pain sensation in the joint.

"This study provides the initial 'proof of concept' of effectiveness of botulinum toxin injection for relief of shoulder joint pain," says investigator in the study, Jasvinder Singh, MBBS, MPH; staff physician, Minneapolis VA Medical Center; assistant professor of medicine, University of Minnesota; visiting scientist and K -12 scholar, Mayo Clinic School of Medicine.

An online report by ABC News On Call, titled Botox Jabs: A New Weapon Against Chronic Pain, discussed the use of Botox. A few paragraphs of that report follow below. You can read the entire report here.

Dr. Joshua Prager, director of the Center for the Rehabilitation of Pain Syndromes at UCLA Medical Plaza, started using botulinum toxin in 1994, eight years before it was approved for cosmetic wrinkle removal. Back then botulinum toxin was used to treat muscle spasms responsible for crossed eyes, as well as rare neurological disorders with involuntary muscles spasms called dystonia. "If it relaxes muscles when you have dystonia, it's going to relax your muscles anytime," Prager recalled thinking.

Dr. Prager says that people suffering from intense pain often have a combination of nerve pain and muscle pain. Therefore, reducing muscle pain may either stop a spiraling cycle of pain, or at least relieve it temporarily. Dr. Prager estimates he's treated muscle pain with Botox close to 1,000 times over the years. Though he says that the procedure is safe and that he's never seen any major side effects in his patients, he has heard tales where botulinum toxin injections for pain have gone wrong.

For now, at least, the risks of side effects are only part of the list of considerations for patients. Until botulinum toxin gets FDA approval for use in pain relief, the price of treatment might be more painful than the pain.

As with any other chronic pain intervention using Botox could be explored as long as the recipient is well aware of the pros and cons of this type of medication. Just a word of caution when thinking about suggesting Botox, or using Botox for yourself—it is not approved by the U. S. Food and Drug Administration (FDA) for pain management. It is only FDA approved for treatment of wrinkles and a handful of rare medical conditions, not including muscle pain. A patient must decide whether ending the pain is worth the risk of going "off label," not to mention the $600-per-bottle price tag rarely covered by insurance.

Having worked with people living with chronic pain and coexisting psychological disorders including addition for the past 25 years, I have seen many people use and abuse their pain medication in some very self-destructive—and even lethal—ways. This month we have added a new article on the Articles Page titled "Addressing the Problem of Prescription Drug Abuse/Addiction," that I encourage you to review.

According to researched published in Pain Physician Journal (2006), 90 percent of people in the US receiving treatment for pain management are prescribed opiate medication. Of that number 9 percent to 41 percent had opiate abuse/addiction problems. This research also stated that in this study as few as 16% of pain management patients used illicit drugs along with their prescribed medication, but in other research they reviewed it was as high as 34%.

I recently came across an abstract by David P. Phillips, PhD; Gwendolyn E. C. Barker, BA; and Megan M. Eguchi titled "A Steep Increase in Domestic Fatal Medication Errors with Use of Alcohol and/or Street Drugs" that validates this increasing problem. I am posting this abstract below, but if you want to read the entire article along with the research citations, you will need to sign up for it with the publisher at the Archive of Internal Medicine; Arch Intern Med. 2008;168(14):1561-1566.

Background: Increasingly, medications are consumed outside of clinical settings, with relatively little professional oversight. Despite this trend, previous studies of medication errors have focused on clinical settings.

Methods: We examined all US death certificates from January 1, 1983, to December 31, 2004 (N = 49 586 156), particularly those with fatal medication errors (FMEs) (n = 224 355). We examined trends in 4 types of FMEs that vary according to the relative importance of alcohol/street drugs and the relative likelihood of professional oversight in the consumption of medications.

Results: The overall FME death rate increased by 360.5% (1983-2004). This increase far exceeds the increase in death rates from adverse effects of medications (33.2%) or from alcohol and/or street drugs (40.9%). The increase in FMEs varies markedly by type. Type 1 (domestic FMEs combined with alcohol and/or street drugs) shows the largest increase (3196%). In contrast, type 4 (nondomestic FMEs not involving alcohol and/or street drugs) shows the smallest increase (5%). Types 2 and 3 show intermediate increases. Type 2 (domestic FMEs not involving alcohol and/or street drugs) increased by 564%. Type 3 (nondomestic FMEs combined with alcohol and/or street drugs) increased by 555%. Thus, domestic FMEs combined with alcohol and/or street drugs have become an increasingly important health problem compared with other FMEs.

Conclusions: These findings suggest that a shift in the location of medication consumption from clinical to domestic settings is linked to a steep increase in FMEs. It may now be possible to reduce FMEs by focusing not only on clinical settings but also on domestic settings.

Author Affiliations: Departments of Sociology (Dr Phillips and Ms Barker) and Biology (Ms Eguchi), University of California at San Diego, La Jolla.

Since the 1970's, acupuncture has been practiced in the United States by licensed acupuncturists, physicians, dentists, and other practitioners. It has been used to treat a wide variety of health conditions, as well as to maintain an optimal state of health. Based on clinical experience, the World Health Organization lists more than 40 conditions for which acupuncture might be considered, including a variety of digestive, gynecological, neurological, respiratory, and psychological conditions.

Recently I came across an article by Alan Spira titled "Acupuncture: A Useful Tool for Health Care in an Operational Medicine Environment." I am including excerpts from this article below but if you want to read the entire article along with the research citations go to: www.redorbit.com.

Using acupuncture reduces or eliminates the need for expensive medications and the potential risk of adverse events resulting from medications, with cost savings and health benefits to patients. During a deployment of naval combat engineers to Iraq in support of Operation Iraqi Freedom, acupuncture was used in the health care of sailors, Marines, and soldiers. It objectively and subjectively improved the health of troops in the field. Troops were able to function while being treated, reducing or avoiding sick in quarters or light limited duty status and saving operational man-days. Acupuncture in the right hands can serve as a health force multiplier (amplifying a provider's clinical impact) and can be integrated into routine health care, whether in garrison or in the field . . .

Five hundred sailors in Naval Mobile Construction Battalion Eighteen deployed to Iraq during Operation Iraqi Freedom from September 2006 through March 2007. Sailors, Marines, soldiers, and Special Forces personnel located on the assigned bases were also seen for acupuncture care. Patients were verbally offered acupuncture care in lieu of or in conjunction with allopathic medical care and were informed about the process, as well as the potential risks and benefits. The medical officer, who was board- certified in emergency medicine, was also board-certified in medical acupuncture by the American Academy of Medical Acupuncture and had practiced acupuncture for nearly a decade. The Force Medical Officer at the division level supported the use of acupuncture for patient care. Patients were seen primarily in the BAS at Al Asad Marine Corps Air Station in Al Anbar Province, Iraq, or at the shock trauma platoon located at the base hospital; treatments were also performed in the BAS at Camp Fallujah and at forward operating bases and combat outposts . . .

Conclusion: Acupuncture is a valuable tool that can be safely used to augment the health care of troops in operational field environments. Acupuncture helps save commanders man-days by reducing lost work time and shortening the interval from injury or illness to return to duty. It is inexpensive, carries little overhead, can be used nearly anywhere, and saves money. Providing acupuncture services in garrison and during deployment is beneficial for both troops and commands.

In June of 2008 the Food and Drug Administration (FDA) approved duloxetine HCl delayed-release capsules (Cymbalta) for the management of fibromyalgia. Previously, only pregabalin (Lyrica; Pfizer, Inc) was approved to treat this painful condition. Some see this as a major victory in validating fibromyalgia as a legitimate diagnosis while others see this as a greed-driven pharmaceutical ploy. Having worked with many patients who were diagnosed and living with the pain and problems of fibromyalgia I am firmly in the first camp.

Cymbalta offers relief from both the emotional and physical symptoms that are associated with depression. Cymbalta (duloxetine) is a drug that has been approved by the FDA to treat major depression and also to treat the pain of diabetic peripheral neuropathy (nerve damage in the hands and feet). Cymbalta, a dual reuptake inhibitor, targets two chemical messengers in the body, serotonin and norepinephrine, which play a role in both depression and pain perception.

The symptoms of fibromyalgia can overlap with autoimmune diseases and other musculoskeletal conditions making it difficult to diagnose. The defining symptoms of fibromyalgia are often associated with other subjective and objective symptoms which occur in combination. It is estimated that fibromyalgia affects about 2-6 percent of the U.S. population.

Fibromyalgia can be difficult to diagnose. Combinations of symptoms can occur which overlap with other autoimmune diseases. There are symptoms which are considered "defining" of fibromyalgia. There are also symptoms considered "non-defining" but they often occur as part of fibromyalgia syndrome. Although there is no known cure for the condition, its symptoms can be managed with a multidimensional approach that includes patient education, medication, and lifestyle changes. Some basic tips for managing Fibromyalgia:

• Aerobic exercise, such as swimming and walking, improves muscle fitness and reduces muscle pain and tenderness.
• Heat and massage may also give short-term relief.
• Antidepressant medications may help elevate mood, improve quality of sleep, and relax muscles.
• Patients with fibromyalgia may benefit from a combination of exercise, medication, physical therapy, and relaxation.

Below I am posting some of the research findings from studies that led to FDA approval for Cymbalta to be prescribed for fibromyalgia treatment. I found this information on Medscape which was published by News & CME Author: Yael Waknine in Medscape Medical News. If you want to see the entire report, please go to the Medscape website and search for "Cymbalta Approved for Fibromyalgia."

The [FDA] approval[for Cymbalta] was based on data from 2 pivotal double-blind, fixed-dose, randomized, phase-3 clinical trials of patients meeting the American College of Rheumatology criteria for primary fibromyalgia, including a history of widespread pain for 3 months and pain present at 11 or more of the 18 specific tender point sites. Study 1 enrolled women only (n = 354) and was 3 months in duration; study 2 enrolled both men and women (n = 520) for a period of 6 months.

Both studies compared duloxetine 60 mg or 120 mg once daily (as divided doses in study 1 and a single dose in study 2) with placebo; study 2 also evaluated the benefit of duloxetine therapy at 20 mg/day vs placebo during the initial 3 months of the 6-month study.

The mean baseline pain score was 6.5 on an 11-point Brief Pain Inventory (BPI) 24-hour average pain scale ranging from 0 (no pain) to 10 (worst possible pain); approximately 25% of participants had a comorbid diagnosis of major depressive disorder.

For the first study, results at 3 months showed that treatment with duloxetine 60 mg/day yielded clinically significant pain relief, defined as a 30% or greater reduction in BPI scores from baseline (55% vs placebo, 33%; P < .001). No additional benefit was observed in patients receiving 120 mg vs 60 mg of duloxetine daily (55% vs 54%).

These findings were supported by those of the second study, which showed that duloxetine 60 and 120 mg/day was similarly effective for achieving a 30% or greater reduction in BPI scores from baseline at 3 months (50.7% and 52.1% vs placebo, 36%; P = .016 and P = .008) and for achieving a 50% or greater decrease at 6 months (32.6% and 35.9% vs 21.6%, P = .045 and P = .0009).

According to data pooled from 4 studies of fibromyalgia, the most commonly observed adverse events in duloxetine-treated patients (incidence = 5% and occurring at least twice as often vs placebo) were similar to that observed in other studies and included nausea (29% vs placebo, 11%), dry mouth (18% vs 5%), constipation (15% vs 4%), decreased appetite (11% vs 2%), somnolence (11% vs 3%), hyperhidrosis (7% vs 1%), and agitation (6% vs 2%).

Duloxetine[Cymbalta] previously was approved for the treatment of diabetic peripheral neuropathic pain, depression, and generalized anxiety disorder.

Hypnosis has been an effective tool for many medical conditions including chronic pain management. However, there are significant mistaken beliefs about this procedure. One comes from the movie industry's portrayal of hypnosis as entertainment and deception. In reality, the facts bear out that hypnosis is a well respected clinical tool throughout the medical field as demonstrated by the 50th Anniversary of American Society of Clinical Hypnosis (ASCH) last year and the report below by one of their members, Dr. Mark B Weisberg. The report is titled "50 Years of Hypnosis in Medicine and Clinical Health Psychology: a Synthesis of Cultural Crosscurrents."

The conclusion of that report is posted below. If you want to read it in its entirety, including impressive research references, please go to http://www.redorbit.com.

The developments of the last 50 years have profoundly influenced the practice of hypnosis today. In response to the progress in the field, our assumptions about what can be accomplished clinically have also changed, as have our understanding of the mechanisms responsible for the changes we seek on behalf of our patients. A substantial body of research demonstrates the efficacy of hypnosis as part of the integrative treatment of many conditions that traditional medicine has found difficult to treat. For some disorders (such as irritable bowel syndrome) the evidence for the efficacy of hypnosis is so robust that it could be argued that it is unethical not to inform patients about this treatment modality.

Better evidence exists now supporting the use of hypnosis to relieve discomfort associated with many diagnostic and invasive procedures. The emergence of the PNI literature informs us that modalities such as hypnosis may not only enhance comfort, but may also alter physiological parameters in many conditions. The advent of increasingly sophisticated brain scanning technology has revealed new insights about how various types of hypnotic suggestion changes the activity of specific brain structures. The progression from alternative to integrative medicine cautions us to be open to new therapeutic developments, but not without good empirical support. The debate over hypnosis and possible memory distortion reminds us to remember the fallibility of memory, but also not to throw out the baby with the bathwater.

What's in store for the next 50 years? What will the retrospective on healthcare reveal in 2058? Most well publicized predictions focus on anticipated advances in technology. Improved genetic screening and treatments of everything from cancer to heart disease will be available. Pill cameras will become more commonplace, replacing x-rays and implants. Implanted monitors and drug dispensers are predicted to normalize the lives of diabetics. Physicians will increasingly use telemedicine to make house calls. Our pharmacopoeia will become increasingly customized, aided by new genetic discoveries.

I also predict that the next half century will bring a more comprehensive understanding of the neurobiological mechanisms that allow us to heal naturally. The newest, most advanced technology will increasingly confirm the efficacy of centuries-old health practices. These developments will enhance our capacity to catalyze patients' untapped potential for selfhealing. Hypnosis speaks profoundly to every level of our psychophysiological functioning. Applications of hypnosis in healthcare will continue to expand as the emerging science proves its efficacy in greater detail.

Question: How is hypnosis used to treat chronic pain and is it really scientifically proven?

Answer: Hypnosis is a widely practiced and time-tested method for managing pain. Hypnosis has been around for centuries, and was first utilized by physicians over 100 years ago as a way to help patients in pain. The word "hypnosis" – is derived from the Greek word "hypnos" which means asleep. Early pioneers in the area of hypnosis used it to block the pain of amputations, before chemical anesthetics were available. Although hypnotism has been utilized by many as a form of alternative medical therapy for many centuries, it remains today under close scientific scrutiny within the medical community.

My colleague, Dr. Daniel Rockers, a clinical psychologist who uses hypnosis for pain control, says that although hypnosis was called "sleep" by the Ancient Greeks, hypnosis is not exactly like sleep; although it may truly look like sleep to an observer. When a patient is hypnotized, the mind is in a state of focused awareness. This focused state has been used to alleviate many different kinds of pain: pain from childbirth, dental work, burns, migraine headaches, cancer pain, arthritis and nerve pain.

He notes that the exact way hypnosis works is not fully understood. There are, however, several possible ways that hypnosis could work to block, reduce, or eliminate pain. One is that hypnosis decreases the amount of pain signal that gets sent to the brain. Another way that hypnosis may work is that it redirects one's attention to something other than the pain. Still another way, is that hypnosis may help our mind to know that the pain is there, but not to feel it.

Dr. Rockers also believes that patients can learn to relax so deeply that their pain is reduced, or they can learn to put their hand to sleep and then transfer that numbness to a painful body part, thereby decreasing pain. There are many other hypnotic suggestions that help reduce pain as well.

Many of Dr. Rockers' patients ask him if hypnosis really works. This is because they have often seen it used for entertainment, in which people do silly things in front of others. He reminds his patients that medical hypnosis truly does work; studies have shown that nearly all patients with pain can benefit from hypnosis in some way. Dr. Rockers often cites a well-known study of 86 women with metastatic cancer; the women using self-hypnosis reported half as much pain as those who did not use hypnosis.

When I first started working with people with chronic pain there was serious stigma attached to someone complaining of under-medicated pain conditions. Most of the time they were accused of exhibiting drug seeking behavior and that the pain was all in their head. If healthcare providers couldn't find any physical tissue damage, they decided that the patient's pain wasn't real. Fortunately we now know better.

Today I discovered an interview with one of the leading experts in the pain management field, Scott M. Fishman, MD, president of the American Pain Foundation. The interview was conducted for Web MD by Michael W. Smith, MD. I will be posting some highlights of that interview below. If you want to read the entire interview, click here.

As recently as 20 years ago, people with chronic pain were too often dismissively told that their problem was "in their heads" or that they were hypochondriacs. But in the last decade, a handful of dedicated researchers learned that chronic pain is not simply a symptom of something else -- such as anxiety, depression, or a need for attention -- but a disease in its own right, one that can alter a person's emotional, professional, and family life in profound and debilitating ways. Today, doctors have yet to fully apply this knowledge.

Some 50 million Americans have chronic pain and nearly half have trouble finding adequate relief. But the outlook is good: Ongoing research is revealing the promise of novel treatments, including new medications, devices and injections, alternative therapies such as biofeedback and acupuncture, and an all-encompassing mind/body approach. The point? If patients' whole lives are affected by pain, the treatment must address their whole lives.

I sat down with Scott M. Fishman, MD, to find out what's new in pain management -- and what doctors still need to learn to help their patients. Fishman is the president and chairman of the American Pain Foundation; he is also the chief of the division of pain medicine and professor of anesthesiology at the University of California, Davis. He wrote The War on Pain: How Breakthroughs in the New Field of Pain Medicine Are Turning the Tide Against Suffering. A University of Massachusetts Medical School graduate, he is board-certified in internal medicine, psychiatry, and pain and palliative medicine.

Q: About chronic pain: have researchers learned anything new about the origins of chronic pain that might lead to better diagnosis or treatment?
A: Absolutely -- we know exponentially more today than we knew even 10 years ago and much more than we knew 50 years ago. For one, we've learned a great deal about how pain is produced and transmitted and perceived. Fifty years ago, when someone hurt, we thought it was just a symptom of something else. But we now know the symptom of pain can become a disease in and of itself, and that disease is similar to other chronic conditions that can damage all aspects of someone's life.

New information has emerged in the last 10 years from one of the most active areas of pain research, neuroimaging. Functional MRI (magnetic resonance imaging) scans that look at brain activity when it's in pain or when it's receiving a pain reliever now tell us that when someone is in chronic pain, the emotion centers of the brain are more activated than the brain's sensory centers, which are more involved in acute, not chronic, pain. That's why pain is likely an emotional experience.

For all we've learned, however, we have not translated most of these advances to the frontline of medicine. Every time we take one of these discoveries and treat accordingly, we find unwanted side effects because pain is so pervasive. For instance, it's very hard to give someone pain relief without making them sleepy. It's very hard to turn off the nerves that transmit pain without producing the risk of seizure or heart rhythm problems.

But we're making advances. We're learning more about the electrical channels involved in nerve function. And we have many more candidates to target, and we're very hopeful that's going to translate into drugs with far fewer side effects.

Q: What new chronic pain treatments are you particularly excited about?
A: One has to do with teaching patients how to overcome their pain. We know that the human mind can create pain but that it also has enormous power to take it away; we can teach people skills that were known to Buddhists hundreds or thousands of years ago.

It's the same focusing technique athletes use to help them improve their performance. Take Lance Armstrong on that last hill of the Tour de France. Even though his legs are burning, he can divert his attention from the pain to the goal of performance. And you can do this with many different techniques. In this case, he's used a cognitive technique to change the internal message, "I'm hurting, I better stop" to"I better keep going but perform differently." A pain psychologist teaches these techniques. What I tell my patients is that pain psychologists are really coaches. They're not there to diagnose an illness but to help you learn techniques to use your brain better -- just like you would go to a physical therapist to learn techniques to use your body better. It's the same thing.

Q: You're describing a mind/body way of dealing with chronic pain.
A: Yes. You can't have pain without a mind, so it's all connected. My patients are always afraid I'm going to think their pain is all in their head, that they have a mental illness rather than a physical illness, and ignore the real problem. I try to counsel them that it's quite the opposite, that any pain requires a mind and you can't have pain without a head; so recognizing that opens up all sorts of opportunities to help cope and reduce suffering.

I think of mind/body approaches as techniques that tap into the body's own pharmacy. Things like mindfulness and biofeedback and cognitive behavioral retraining, or guided imagery, even self-hypnosis. Things like acupuncture and massage. We don't know how these things work but we're certain they're helpful.

For the past twenty-five years I've noticed that most of the chronic pain patients I've worked with reported a history of childhood or adolescent trauma. The trauma fell into several different categories: (a) physical abuse; (b) sexual abuse; (c) emotional abuse; (d) physical neglect; and (e) emotional neglect. We are now starting to see research studies showing a link between sensitivity to chronic pain and unresolved history of abuse.

In order to evaluate for a trauma history, it is crucial that people living with chronic pain receive multidisciplinary assessment and treatment including an in-depth psychological examination. Below is some information posted by Caroline Cassels from the 50th Annual Meeting American Headache Society: Abstract OR 8; Presented June 27, 2008 that lists new research showing the chronic pain and abuse history link. To read the entire report, go to Medscape Psychiatry and Mental Health.

New research suggests migraineurs (people experiencing chronic migraine headaches) who have suffered childhood abuse are much more likely than their counterparts who have not been abused to have comorbid pain conditions, including arthritis, irritable bowel syndrome (IBS), and fibromyalgia. Furthermore, there is a significant dose response, with individuals who have suffered severe abuse experiencing an increased number of pain conditions.

Presented here at the 50th Annual Meeting of the American Headache Society by investigators from the University of Toledo Medical Center, in Ohio, the multicenter study examined the relationship of childhood maltreatment and migraine among individuals seeking treatment at designated headache centers in Canada and the United States.

"Individuals who have migraine plus pain syndromes, besides being more likely to have chronic migraine and psychiatric comorbidities, including depression and anxiety, are also significantly more likely to have a childhood history of maltreatment, including physical and sexual abuse as well as physical and emotional neglect," principal investigator Gretchen Tietjen, MD, told Medscape Neurology & Neurosurgery.

Chronic Pain, Childhood Adversity Linked
According to Dr. Tietjen, comorbid chronic pain conditions are frequent in migraineurs, and chronic illness has been related to childhood adversity. To examine the relationship between childhood maltreatment and chronic pain conditions in individuals with migraine, investigators recruited 1331 diagnosed with migraine based on the International Classification of Headache Disorders, 2nd ed (ICHD-2) criteria.

Of the subjects, 56% had migraine without aura and 39% had migraine with aura. Of the total study group, 88% were women and the average age of participants was 42 years. All subjects completed a self-administered electronic survey to gather information on demographics, headache frequency, disability, and allodynia. Participants also provided information on maltreatment history using the Childhood Trauma Questionnaire (CTQ).

Severity of each of the 5 maltreatment types was quantified as none/minimal, low-moderate, moderate-severe, and severe-extreme. Comorbid pain conditions included IBS, chronic fatigue syndrome (CFS), fibromyalgia, interstitial cystitis, and arthritis. There were 79% of study subjects who reported at least 1 comorbid pain condition, and 10% reported 4 or more.

Emotional Abuse Most Common
Of the 5 different maltreatment types, 37% of the study population experienced emotional abuse, 25% sexual abuse, 21% physical abuse, 38% emotional neglect, and 22% physical neglect. Adjusted analysis confirmed the relationship between the increasing number of pain conditions and severity of comorbid pain conditions and severity of each of the maltreatment types.

The researchers also found that those with 4 or more pain conditions were more likely to report a severe-extreme degree of maltreatment compared with those who reported moderate, low, or no history of abuse or neglect. Individuals with 4 or more pain conditions were much more likely to have suffered some type of abuse, said Dr. Tietjen.

Investigators at the University of Toledo–Health Science Campus found women with migraine who had major depression were twice as likely as those with migraine alone to report having been sexually abused as a child. Furthermore, if the abuse continued past the age of 12 years, women with migraine were 5 times more likely to report depression.

"When sexual abuse carries over into adulthood that is when it is most strongly associated with the migraine/depression complex," principal investigator Gretchen Tietjen, MD, told Medscape. "Our findings contribute to the mounting data showing abuse in childhood has a powerful effect on adult health disorders and the effect intensifies when abuse lasts a long time or continues into adulthood," she said.

Study Highlights

• Women aged 18 years or older attending 1 of 6 specialty headache clinics were eligible for participation. Headache type was defined from criteria established by the ICHD.
• Participants received a questionnaire that inquired about their history of physical and sexual abuse as well as a fear for their lives related to abuse. They also completed assessments of headache severity. The PHQ-9 was used to measure depression.
• The main study outcome was the relationship between migraine headache, depression, and a history of maltreatment.
• 1032 women participated in the study, and 92% were diagnosed with migraine headache. The analysis focused only on subjects with migraine. The mean age was 42 years, and 25% of subjects had migraine along with another headache diagnosis.
• 38% of subjects reported a history of physical or sexual abuse, and 12% of participants reported a history of both physical and sexual abuse. Most cases of abuse occurred during childhood, and there was significant overlap between different types of abuse.
• 40% of women reported headaches on at least 15 days per month (chronic headache), and nearly three quarters of the study cohort rated their headaches as very severe. Approximately one third of the study group had depression and significant somatization.
• Women reporting physical abuse, sexual abuse, and fear for life related to abuse had a higher rate of chronic headache. In addition, a history of maltreatment was associated with more severe headache severity, higher levels of depression, and more somatic symptoms.
• Maltreatment did not affect the age of onset of headache. Women with a history of witnessing abusive behavior between adults or substance abuse by adults also had a higher risk for depression.
• Compared with women without depression, women with migraine and major depression were 4 times as likely to have a history of childhood maltreatment. Women with migraine and less severe depression were twice as likely to have had maltreatment in childhood.
• In examining the timing of childhood maltreatment and the risk for depression, sexual abuse prior to the age of 12 years was a particularly strong risk factor. In addition, women with a history of sexual abuse both before and after the age of 12 years had a 5-fold increase in the risk for major depression.
• The risk for depression also increased among participants who had had multiple types of maltreatment vs a single category of abuse.

Up until recently there was a lack of information and a great deal of misinformation regarding the role of proper nutrition for effective chronic pain management. Recent research studies by the National Fibromyalgia Association (NFA) have confirmed that diet and nutrition play a significant role in the management of pain. The NFA (2006) reports that success relies upon utilizing a multidisciplinary and multidimensional approach, incorporating lifestyle and dietary changes to achieve optimum health and well being.

The NFA also states that nutritional therapy practitioners are successfully using diet to treat and prevent illness, and restore the body to a natural healthy equilibrium. Some healthcare practitioners believe that deficiencies of minerals and vitamins could be responsible for much of the disease and weakness in the body. Examples of conditions resulting from deficiencies include fatigue, lethargy and susceptibility to colds and viruses.

There is also substantial pain management literature emphasizing the importance of nutrition and exercise in the healing process and effective chronic pain management. In fact, Dr. Margaret Caudill (2001) devotes an entire chapter of her book, Managing Your Pain before it Manages You, to nutrition in an effective chronic pain management program.

Harris H. McIlwain, M.D., and Debra Fulghum Bruce, M.S.authors of Pain-Free Arthritis: A 7-Step Program for Feeling Better Again, outline some of the foods and nutritional supplements that are helpful for chronic pain management. I'm including a brief synopsis of their work below. Their book is published by Henry Holt and Company, LLC; September 2003; ISBN# 0-8050-7325-6.

Until recently it's been unclear whether changing your diet may influence the symptoms of a chronic illness like arthritis. Nevertheless, new research continues to pour in touting the healing benefits of certain foods. Perhaps these foods aren't the miracle cure many hoped for, but through scientific studies we do know that certain nutrients can boost immune function and decrease inflammation in those with arthritis. Be sure to include the following suggestions in your pain-free diet to further reduce inflammation and pain.

• Sip Tea: You can now add tea to your list of healing foods. In fact, some experts claim that we should add tea to the list of disease-fighting fruits and vegetables that we should eat daily. Some intriguing information was presented at the Society of Critical Care Medicine in January 2002 on how green tea may help decrease inflammation.
• Serve Vegetables: There is a lot of evidence that a diet high in vegetables can help to decrease inflammation in susceptible people. I've had many patients, particularly those with inflammatory types of arthritis, say a modified vegetarian diet (including fish) helps to reduce symptoms. Journal studies over the past five years have shown that a vegetarian diet causes an extensive change in the profile of the fatty acids of the serum phospholipids. These changes may favor production of Prostaglandins and leukotrienes with less inflammatory activity, which is a bonus for those with inflammatory illnesses.
• Feast on Fish: Studies continue to come in touting the benefits of omega-3 fatty acids, contained in fish, as helping to decrease inflammation. Some research indicates that when fish oils are added to the diet, scientists measure a very significant drop in one of the most inflammatory immune substances - -leukotriene B4, which is an important part of the process of inflammation in many types of arthritis. Researchers suspect that omega-3s may block the production of inflammatory substances linked to autoimmune diseases like rheumatoid arthritis and lupus. In some trials, taking fish-oil supplements for at least twelve weeks resulted in positive improvements in symptoms with less morning stiffness and tender joints.

Before discussing the role of Neuroplasticity in chronic pain management it is important to have a working definition of the term. Neuroplasticity (variously referred to as brain plasticity or cortical plasticity or cortical re-mapping) refers to the changes that occur in the organization of the brain as a result of learning and experience. A surprising consequence of neuroplasticity is that the brain activity associated with a given function can move to a different location within the brain as a consequence of normal experience or brain damage/recovery.

It is now indicated that this capacity for rewiring of the neuronal synapses to allow for re-development of entire regions of the brain is present in adults as well as children. Newly discovered principles of adult neuroplasticity are at the heart of some of the most revolutionary and groundbreaking brain research.

Pain research presented by the American Society of Anesthesiologists has emphasized the molecular transduction of painful stimuli, the sensitization processes that occur after injury and long-term phenomena such as pain memory. Neuroplasticity after surgery occurs at the transduction process, in the periphery at the sub-cellular level, or in the central nervous system, where central sensitization occurs.

According to Kenneth Sufka in his article published in Brain and Mind Journal in 2004:

Pain that persist long after damaged tissue has recovered remain a perplexing phenomenon. This so-called chronic pain serves no useful function for an organism and, given its disabling effects, might even be considered maladaptive. However, a remarkable similarity exists between the neural bases that underlie the hallmark symptoms of chronic pain and those that serve learning and memory. Both phenomena, wind-up in the pain literature and long-term potentiation (LTP) in the learning and memory literature, are forms of neuroplasticity in which increased neural activity leads to a long lasting increase in the excitability of neurons through structural modifications at pre- and post-synaptic sites.

Research published in Pain Physician Journal (2006) indicated that 90 percent of people in the US receiving treatment for pain management are prescribed opiate medication. Of that number 9 percent to 41 percent had opiate abuse/addiction problems. According to research published in Annals of the New York Academy of Sciences 933:175-184 (2001) titled “Spinal Cord Neuroplasticity following Repeated Opioid Exposure and Its Relation to Pathological Pain;” convincing evidence has accumulated that indicates there are neuroplastic changes within the spinal cord in response to repeated exposure to opioids. Such neuroplastic changes occur at both cellular and intracellular levels. Since so many people living with chronic pain are using opiates these neuroplastic changes need to be better understood.

Since chronic pain is a biopsychosocial condition it makes sense that the treatment plan would include the physical, psychological and social domains as well. One important part of the biological treatment plan for many people living with chronic pain should be physical therapy that can be either active or passive in nature. Active physical therapy for pain treatment involves numerous stretching techniques and specific exercises whereas passive pain therapy may include varying temperature packs are often used as a form of relief. The goal is to heal and prevent injury as well as improve a person’s range of motion.

I have quoted the information below from the International Association for the Study of Pain (IASP) on the role of the Physical Therapist as part of a multidisciplinary chronic pain management treatment team. I have been a member of the IASP since 1999 and have learned a great deal from their research and experience. To learn more about the IASP— and to explore the benefits of membership— please go to their website at www.iasp-pain.org.

Health care has changed in recent decades. Early activity for recovery of function is now encouraged, and the impairment model has broadened to include psychosocial components. A multidisciplinary team approach now includes the patient as an educated and active participant, and physical therapy treatments emphasize activity. The therapist's role has changed from healer to helper.

Therapists help patients address and overcome physical and psychological obstacles, return to activities, and achieve personal goals. Recognition of a broad biopsychosocial model of health (and illness) and the positive role of activity in health and healing, emphasis on function rather than impairment, and reliance upon clinical evidence have transformed physical therapists' practice.

For chronic pain sufferers the process of rehabilitation to a life less dominated by pain can be long and complex. Rehabilitation involves overcoming physical and psychological obstacles. Physical therapists are important to pain management. They help patients address obstacles to rehabilitation and to use information, and provide helpful feedback and reinforcement to guide efforts toward a return to activities and achievement of valued personal goals.

Physical therapists have incorporated cognitive and behavioral principles into rehabilitation and use a comprehensive biopsychosocial model of pain management that is patient-centered, time-limited, and goal-oriented. Their rehabilitative approach and fundamental concern with restoration of movement and function make physical therapists essential to the collaborative approach required for effective pain management. Their rehabilitative approach and focus upon restoration of movement and function make physical therapists essential to the collaborative approach required for effective [chronic] pain management.

The information below is posted with the generous permission of Dr. Eugene G. Lipov, the developer of a new cutting edge process that is helping many people living with severe chronic back pain as a result of failed back surgery. I am posting this information in its entirety in the hope that it may prove beneficial to my readers. I plan to follow Dr. Lipov’s progress and wish him the best in his ongoing development of this breakthrough process.

"Mix of 2 pain-relief procedures can end chronic back and leg pain without drugs"
By Eugene G. Lipov, MD and Jay R. Joshi, MD

FOR IMMEDIATE RELEASE

Combination of 2 implanted nerve stimulators dramatically improves quality of life for those who have had poor results from back surgery

CHICAGO – April 22, 2008 – Help is on the way for patients who have undergone back surgery but who continue to suffer from chronic pain in their backs and legs, thanks to a novel technology pioneered by two Chicago-area pain management specialists.

Called a “hybrid technique,” the procedure combines an implanted electronic device called a dorsal column (spinal cord) stimulator with a newer technology known as peripheral nerve field stimulation (PNFS). This latest development in pain management gives patients drug-free relief from the severe, chronic back and leg pain of failed back surgery syndrome (FBSS), a condition suffered by nearly half of all spine surgery patients.

“Since 1968, physicians have used the dorsal column stimulator to control the leg pain common among patients with FBSS, but it does little to relieve back pain,” explains Eugene G. Lipov, MD, Director of Pain Research at the Northwest Community Hospital, Arlington Heights, Ill. “Recent studies have shown that peripheral nerve field stimulation is very effective in relieving back pain. This is what led us to combine these two technologies. Patients can have the best of both worlds: relief from leg and back pain they can’t get even with the strongest pain medications.”

Narcotics, such as codeine and morphine, don’t work well on nerve pain, which tends to be opiate-resistant. Implantable dorsal column stimulators stop pain signals from reaching the brain. Peripheral nerve field stimulation is a newer technology that is more focused on shutting off pain signals further away from the spinal column. Used together, the dorsal column stimulator and peripheral nerve field stimulation effectively block the body’s pain signals from the legs and back to the brain.

Performed as an outpatient procedure, the hybrid stimulator is implanted subcutaneously (under the skin) in the abdominal wall, side of the back, or in the upper hip area. It is approximately the size of a small cell phone. Typically, three electrical leads connected to the stimulator unit are then implanted in areas of the lower back and leg where the patient has felt the most pain. The patient is then able to control his or her pain by placing a small remote control device over the implanted stimulator. Patients feel their pain replaced by a mild tingling sensation. The hybrid stimulator can be left in place for seven to nine years, at which time a simple surgery is performed to replace the battery only, not the electrical leads.

“Using the hybrid technique we’ve literally seen patients’ quality of life dramatically improve right before our eyes,” says Jay R. Joshi, MD, Dr. Lipov’s research partner. “We have been able to offer hope and significant success to patients who have failed virtually every other treatment, including surgery, spinal injections, physical therapy, and medications. Many of our patients no longer need pain medications, and they quickly return to work and to the activities of daily living pain-free. It is a tremendous cost savings in terms of insurance claims, lost productivity at work, and offers patients an alternative to potentially addictive pharmacologic treatment.”

In 2005, there were 34 million physician visits for back-related symptoms, according to the National Center for Health Statistics. A review article published in The Journal of the American Medical Association earlier this year estimated an $85.9 billion was spent in treating spine problems in 2005, with the greatest cost increase coming from use of prescription pain medications. “Clearly, this is an enormous problem for Americans, physically, emotionally, and economically,” Dr. Lipov says. “But we believe this new procedure will restore quality of life to millions of patients who suffer from back and leg pain and who have not found relief from surgery or drug treatment.”

Drs. Lipov and Joshi have implanted the hybrid stimulator in 19 patients since August 2007. Patients report 60% to 100% reduction in pain using the stimulator; to date, no patients have had the hybrid stimulator removed. Lipov’s and Joshi’s findings will be presented at the American Society for Stereotactic and Functional Neurosurgery conference in Vancouver, British Columbia, Canada, in June.

When many people think migraine they think only of the pain of migraine. In reality, a migraine episode consists of far more. A typical migraine episode often consists of four parts, referred to as phases or components. It's important to note that not every migraineur experiences all four phases. Also, episodes can vary with different phases experienced during different episodes. The four phases of a migraine episode are:

• Prodrome: This phase is sometimes called pre-headache and it may be experienced hours or even days before a migraine episode. The prodrome may be considered to be the migraineur's "yellow light," a warning that a migraine is imminent.

• Aura: Aura follows the prodrome and usually lasts less than an hour. The symptoms and effects of the aura vary widely. Some can be quite terrifying, especially when experienced for the first time. Some of the visual distortions can be exotic and bizarre and the most common are visual symptoms: flashing lights, wavy lines, spots, partial loss of sight, blurry vision.

• Headache: This is the actual period of pain experienced during the migraine episode. The pain is usually unilateral (affecting one side of the head) although it can change sides or sometimes be bilateral. The pain is usually throbbing or pulsating, and can be aggravated by physical activity.

• Postdrome: This is the period following a bad migraine headache during which a person feels tired. Sometimes called Migraine hangover.

The principles of the new MIPCA guidelines are:

• To arrange specific consultations for headache.

• To institute a system of detailed history taking, patient education and buy-in at the outset of the consultation.

• To utilize a new screening algorithm for the differential diagnosis of headache, which can be confirmed by further questioning, if necessary.

• To institute a process of management that is individualized for each patient, using a new algorithm. Assessing the impact on the patient's daily life is a key aspect of diagnosis and management.

• To prescribe only treatments that have objective evidence of favorable efficacy and tolerability.

• To utilize prospective follow-up procedures to monitor the success of treatment.

• To organize a team approach to headache management in primary care.

Medications used to combat migraines fall into two broad categories:

• Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun.

• Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Ergotamine medications (used as vasoconstrictors for migraine prevention and are sometimes mixed with caffeine) such as DHE and Migranal; they are also FDA approved for Migraine treatment as is Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene). Thus, the issue here is not so much FDA approval of acute medications, but the difference between using “generic pain medications” as opposed to Migraine-specific medications. It’s been my experience that when patients use opiates or other non-FDA approved medications for ongoing Migraine treatment they often experience problems. Migraine patients need to be proactive and see healthcare providers who specialize in Migraine treatment.

Acupuncture is one of the oldest, most commonly used medical procedures in the world. Originating in China more than 2,000 years ago, acupuncture became better known in the United States in 1971, when New York Times reporter James Reston wrote about how doctors in China used needles to ease his pain after surgery. The term acupuncture describes a family of procedures involving stimulation of anatomical points on the body by a variety of techniques.

The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. Acupuncture is often effective in managing certain types of pain; It stimulates the large and small nerve fibers that inhibit pain signaling; and may produce a placebo effect through the release of endorphins and enkephalins. Acupuncture is often used in the treatment of back pain, minor surgery, and other pain conditions.

Research indicates there are areas where acupuncture interventions are very useful. For example, promising results have emerged showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low-back pain, carpal tunnel syndrome, and asthma in which acupuncture may be useful as an adjunct treatment or as part of a comprehensive management program or even an acceptable treatment alternative.

Western medicine’s view is that the placement of acupuncture needles at specific pain points releases endorphins and opioids, the body’s natural painkillers, and perhaps immune system cells as well as neurotransmitters and neurohormones in the brain. Research has shown that glucose and other bloodstream chemicals become elevated after acupuncture.

According to the National Institutes of Health’s National Center for Complementary and Alternative Medicine, there is also evidence that stimulating acupuncture points enables electromagnetic signals to be relayed at a greater rate than under normal conditions. This may increase the flow of healing or pain-killing natural chemicals to injured areas.

When pain is relieved, patients feel a greater sense of well-being overall, physically and emotionally. As a result, they may heal faster. Most acupuncture points coincide with the “trigger points” described by Janet G. Travell, MD, whose textbook, Myofascial Pain & Dysfunction: The Trigger Point Manual, is widely used at pain management centers in the Western world.

Since the 1970's, acupuncture has been practiced in the United States by licensed acupuncturists, physicians, dentists, and other practitioners. It has been used to treat a wide variety of health conditions, as well as to maintain an optimal state of health. Based on clinical experience, the World Health Organization lists more than 40 conditions for which acupuncture might be considered, including a variety of digestive, gynecological, neurological, respiratory, and psychological conditions. In 1997, the National Institutes of Health Consensus Development Conference, a panel of experts, reviewed the scientific evidence on the effectiveness of acupuncture and concluded that acupuncture was effective for postoperative dental pain, and helpful as an additional treatment for headache, menstrual cramps, fibromyalgia, myofascial pain, osteoarthritis, tennis elbow, low back pain, and carpal tunnel syndrome.

More recent studies and reviews have supported the use of acupuncture for migraine and tension headaches, chronic neck pain, and low back pain, neck pain and soft-tissue injuries of the peripheral joints. According to a recent National Institutes of Health study, acupuncture is most frequently used in both China and the U.S. for musculoskeletal pain relief, with other common uses for pain including migraine and peripheral nerve neuralgia.

I am always keeping an eye out for new and interesting information for our website, and recently I came across the website that I’ve never been to before; www.preweb.com. The report I found was titled “Traditional Therapy for Joint Pain - Doing More Harm than Good?” This report published May 4, 2008, focuses on the work of Eric Berg, DC of Alexandria, VA, the developer of the new technique called Dynamic Joint Recovery. I’m including an excerpt from this report below.

Thousands of dollars spend on joint rehab every year; thousands of work hours lost; days, months, sometimes years of lost quality of life from painful joint injuries that never heal. Dr. Berg, DC from Alexandria VA says traditional therapy has it backwards and the approach can actually prolong or worsen the injury. He explains that there is a simple, non-invasive approach to joint pain relief and recover that is faster, safer and cost significantly less and demonstrates his point weekly in free public seminars…

Dr. Berg's new discovery and treatment never touches the painful joint but stimulates and stretches the opposing or reciprocal side to facilitate healing. This treatment has resulted in quick, consistent results. Many of his clients see significant increases in range of motion and loss of pain within minutes, even after a single session. The entire program is just a fraction of the cost of traditional therapy. Dr. Berg's theory is based on research by neurologist Anne Louise Oaklander, MD, PhD, of Massachusetts General Hospital who found physical evidence of communication between nerves on opposite sides of the body. In the May 2004 issue of Annals of Neurology, scientists describe how cutting a major nerve in one paw of a group of rats resulted in a significant decrease in skin nerve endings in the corresponding area of the opposite limb.

According to Dr. Berg, the flaw in the traditional therapy is caused by a lack of understanding in the links between reciprocal or opposing muscles. When one muscle contracts or turns on, the opposing muscle has to relax or turn off. In traditional therapy, when the practitioner is stretching or strengthening a tight injured muscle, nerve stretch receptors get activated and make the muscle even tighter or more painful.

Another resource for joint pain management is www.joint-pain.com. I would encourage you to go to this website as a good starting point for understanding the different types of joint pain. I’m including an excerpt from this site’s home page below.

We are happy to introduce Joint Pain, a resource for osteoarthritis, rheumatoid arthritis and gout sufferers, as well as those with similar chronic pain conditions. Millions of people suffer the painful symptoms of arthritis and related diseases, which include inflammation, swelling, redness, pain and stiffness. Although there are literally hundreds of different kinds of arthritis, osteoarthritis, rheumatoid arthritis and gout are the three most common. As far as treatments are concerned, until recently the most popular have been the NSAIDs, or Non-Steroidal Anti-Inflammatory Drugs, such as Vioxx, Celebrex and Bextra. Unfortunately these prescription medications come with potentially painful side effects. One such medication, Vioxx, was recalled due to increased risk of stroke and heart attack in patients who were taking this drug for an extended period of time. Bextra was also pulled from shelves and Celebrex is currently under fire.

Although these drugs can be helpful in treating symptoms, due to the possible adverse effects more and more people are seeking safer, natural alternatives such as glucosamine, chondroitin, turmeric, SAMe, MSM and fish oil to treat their painful symptoms. You may be surprised to learn that many natural remedies for arthritis can be as effective if not more so than prescription and over-the-counter anti-inflammatory drugs, and as such might be a better solution for those that suffer the debilitating joint pain, swelling and inflammation of osteoarthritis, rheumatoid arthritis and gout.

One thing I found very exciting about this site is that it includes both traditional and non-traditional pain management approaches. For example, it covers types of foods and supplements that can help or lead to problems for different joint problems. They also have many “natural” alternatives that many people living with this type of chronic pain can really benefit from.

Meditation is a fairly new phenomenon in our Western culture, but research shows that the origins of meditation go back at least five-thousand years. One type that I've found particularly helpful for my own chronic pain management and that I teach my patients is the Buddhist discipline of "mindfulness meditation." This is a moment-to-moment awareness of what our bodies are doing. The goals of meditation are to understand one's mental processes, develop the power to control these processes and gain freedom from one's mind-set.

Patrick Randolph, Ph.D., and his colleagues, from Texas Tech University, have created a Pain and Stress Management Program (PSMP) based on Eastern meditation techniques, which, when combined with medication, improve patients' pain symptoms significantly better than drug therapy alone. The PSMP is an eight-week regimen that uses the Buddhist discipline of mindfulness meditation.

Neuroscientist Dr. Shanida Nataraja has a more scientific approach to meditation. In her new book, The Blissful Brain, she aims to de-mystify the subject by bringing together findings of recent clinical research on meditation's effects on the mind and body.

Dr. Nataraja collated the results of several studies worldwide, which suggest that meditation reduces stress and heart-rate, lowers blood pressure and cuts the risk of cardiovascular disease. It has also been found to boost immune function, melatonin levels and psychological well-being. This makes it an excellent component of any chronic pain management treatment plan. To see more information regarding Dr. Ntaraja please click here.

Our first Addiction-Free Pain Management® Center of Excellence, Sierra Tucson, utilizes Awareness-Based Sensory Integration (ABSI) as a key approach in breaking the cycle of pain and psycho-emotional reactions. This specific mindfulness technique teaches patients to break down their subjective experience into identifiable parts, making individual sensations less likely to become overwhelming and allowing them to be experienced differently. Additionally, ABSI teaches vital skills and empowers individuals to deal with difficulties in all aspects of their lives.

Dr. Mark Pirtle the Associate Director of the Sierra Tucson's Pain Program teaches patients mindfulness meditation and has developed educational components to help them implement it as an integral component of their pain management treatment plan.

Anyone working in the chronic pain treatment field knows about the importance of physical activity and exercise as an important component of a chronic pain treatment plan. This month I want to share a report that I found on the Mayo Clinic website entitled "Exercise takes the edge off chronic pain."

For the past 25 years I have always included activity pacing and safe, medically approved exercise in the treatment plans I helped my patients develop. I've highlighted here what the Mayo Clinic report calls "the benefits of movement." If you want to see the entire report, go to www.mayoclinic.com and in their search engine type in "Exercise takes the edge off chronic pain."

The Benefits of Movement

As tough as it may be to start an exercise program, your body will thank you. Are you skeptical? Consider the facts. Exercise can:

• Prompt your body to release endorphins. These chemicals block pain signals from reaching your brain. Endorphins also help alleviate anxiety and depression — conditions that can make chronic pain more difficult to control. "Endorphins are the body's natural pain relievers," Dr. Laskowski says. "Endorphins have the potential to provide the pain-relieving power of strong pain medications, such as morphine."

• Help you build strength. The stronger your muscles, the more force and load you'll take off your bones and cartilage — and the more relief you'll feel.

• Increase your flexibility. Joints that can move through their full range of motion are less likely to be plagued with aches and pains.

• Improve your sleep quality. Regular exercise can lower your stress hormones, resulting in better sleep.

• Boost your energy level. Think a walk around the block will wipe you out for the rest of the day? Not likely, and if you do it again tomorrow and the day after, it'll be easier each time. In the long run, regular exercise can actually give you more energy to cope with chronic pain.

• Help you maintain a healthy weight. Exercise burns calories, which can help you drop excess pounds and reduce stress on your joints — another way to improve chronic pain.

• Enhance your mood. Exercise contributes to an overall sense of well-being. It increases blood and oxygen flow to all your tissues, livening up your skin tones and nourishing your brain. These positive effects perpetuate themselves. The better you look and feel, the greater your confidence and motivation to keep exercising.

• Protect your heart and blood vessels. Exercise decreases the risk of high blood pressure, diabetes, heart attack and stroke.

I am always keeping an eye out for new and interesting information for our website, and recently I came across a website I've never been to before; www.health24.com. The report I found there discussed recent research regarding people who were HIV Positive and were experiencing neuropathic pain symptoms. One statistic I found significant was that up to 62 percent of HIV-infected patients develop extensive painful neurological pain extending into the legs that is either due to the disease itself or is a side effect of HIV drug treatment, according to a report in the Journal of Pain and Symptom Management.

I'm including a portion of that research below and if you want to read the entire report please go to www.health24.com and search for "Patch helps brain pain in HIV+."

The patch was applied once to affected areas for 60 minutes. The main outcome measure was the percent change in a pain rating scale score from the start of the study through two to 12 weeks after treatment. Treatment with the patch produced a sustained reduction in pain scores of roughly 40 percent on average over the follow-up period. A treatment response, defined as a 30 percent or greater reduction in pain, was seen in eight patients (67 percent), including four with a 50 percent or greater reduction.

Most patients experienced an increase in pain during the 48 hours after the patch was applied, which resolved in the first week after treatment. The patch gives long-lasting relief except for the expected local pain and redness. "NGX-4010 was tolerated well and no safety concerns were identified," the investigators report.

"The most important finding is that the high-concentration capsaicin patch produced long-lasting (i.e. at least three months), significant pain relief in HIV-associated peripheral neuropathy with a good safety profile," Simpson said. While encouraging, the results will need to be replicated in controlled trials, he added. "This is an exciting time in research of new treatments for neuropathic pain," such as HIV-related pain, shingles and diabetic neuropathy, "with new drugs on the horizon." – (Reuters Health)

While some healthcare providers doubt that fibromyalgia really exists, anyone living with it certainly has a different experience. Unfortunately for both patients and their healthcare providers, treatment can be confusing and frustrating. For example, many general practitioners still use opiates as the only pain management intervention and in my work this type of medication only approach is a big problem. Over the past several years we have seen more evidence that a multidisciplinary approach is best in order to obtain positive treatment outcomes.

One such series of research studies by the National Fibromyalgia Association (NFA) have confirmed that diet and nutrition play a significant role in the management of fibromyalgia pain. The NFA (2006) also reports that success relies upon utilizing a multidisciplinary and multidimensional approach that incorporates lifestyle and dietary changes to achieve optimum health and well being.

The NFA also states that nutritional therapy practitioners are successfully using diet to treat and prevent illness, as well as restore the body to a natural healthy equilibrium. Some healthcare practitioners believe that deficiencies of minerals and vitamins could be responsible for much of the disease and weakness in the body. Symptoms that can result from these type of deficiencies include fatigue, lethargy and susceptibility to colds and viruses.

Another report came out in October 2007 published by ScienceDaily that discussed why painkillers don't work for fibromyalgia and states in part: "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." To read the complete report, click:

http://www.sciencedaily.com/releases/2007/09/070927131357.htm.

I just found another report published by Science Daily (Mar. 10, 2008) that stated "Researchers at the University of Michigan Health System have found a key linkage between pain and a specific brain molecule, a discovery that lends new insight into fibromyalgia, an often-baffling chronic pain condition."

The report goes on to say that "when levels of the brain molecule called glutamate went down in patients with fibromyalgia, their pain decreased. The results of this study, which appears in the journal Arthritis and Rheumatism, could be useful to researchers looking for new drugs that treat fibromyalgia, the authors say." To read this March 10, 2008 report: click here.

The Mayo Clinic suggests that treatment for fibromyalgia includes both medication and self-care. The emphasis is on minimizing symptoms and improving general health. For medication management they discuss finding the best combination of appropriate drugs such as analgesics, antidepressants, muscle relaxants, and pregablin (Lyrica). Fortunately, they didn't stop there and also cited the importance of implementing cognitive behavioral therapy and other nonpharmacological interventions.

Works Cited

University of Michigan Health System (2008, March 10). Pain In Fibromyalgia Is Linked To Changes In Brain Molecule. ScienceDaily.

University of Michigan Health System (2007, October 3). Why Don't Painkillers Work For People With Fibromyalgia? ScienceDaily.

University of Michigan Health System.

National Fibromyalgia Association (NFA).

The Mayo Clinic.

One of the most challenging types of chronic pain that many people are suffering with is neuropathic pain. In neuropathic pain the peripheral or central nervous systems are malfunctioning and actually become the cause of the pain. Neuropathic pain is usually perceived as a steady burning and/or "pins and needles" and/or "electric shock" sensations and/or tickling. The difference is due to the fact that "ordinary" pain stimulates only pain nerves, while a neuropathy often results in the firing of both pain and non-pain (touch, warm, cool) sensory nerves in the same area, producing signals that the spinal cord and brain do not normally expect to receive.

As anyone living with neuropathic pain knows, the treatment is frustrating and often ineffective. While acute short-term pain is usually easy to manage and most chronic pain conditions can be treated effectively, neuropathic pain is a major treatment challenge for both patients and their healthcare providers. Unfortunately, neuropathic pain often responds poorly to standard pain treatments and occasionally may get worse instead of better over time. For some people, it can lead to serious disability.

The etiology and management of neuropathic pain were discussed in sessions at the annual meeting of the American Pharmacists Association, held March 17-21, 2006, in San Francisco. Here is a brief overview of their findings:

• When considering pharmacologic options to treat chronic pain, we first think of nonopioids (eg, acetaminophen, nonsteroidal anti-inflammatory agents), opioids, and co-analgesics. Generally speaking, the nonopioids are unlikely to provide any significant degree of pain relief in patients with neuropathy. Given the complicated nature of neuropathic pain, it is not surprising to find that, at best, an opioid or co-analgesic agent will effect a 30% reduction in the pain severity rating. In fact, this response is considered to be "clinically important" and, at this level, patients will report "moderate relief" or say they are "much improved." The medications used to treat neuropathic pain commonly cause adverse effects and are frequently involved in drug interactions. Careful analgesic selection and dosage titration are required, as many patients with neuropathic pain are elderly, take multiple medications, and have numerous comorbid conditions.

• At present there are only 5 co-analgesic agents that carry US Food and Drug Administration (FDA)-approved indications for neuropathic pain. These are carbamazepine (Tegretol [Novartis]) for trigeminal neuralgia, gabapentin (Neurontin [Parke-Davis]) and transdermal lidocaine (LidoDerm [Endo]) for postherpetic neuralgia, duloxetine (Cymbalta [Eli Lilly]) for diabetic neuropathy, and pregabalin (Lyrica [Pfizer]) for both diabetic neuropathy and postherpetic neuralgia. However, there is a significant body of literature demonstrating the effectiveness of these and other co-analgesics in treating a wide variety of neuropathic pain states.

• Robert Dworkin and colleagues[12] considered the evidence base of analgesics and co-analgesic clinical trials in the management of neuropathic pain. They concluded that first-line recommendations included gabapentin, the 5% lidocaine transdermal patch, opioid analgesics, tramadol hydrochloride, and tricyclic antidepressants (TCAs). Since that time, Dworkin has published further reports that add the serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants (eg, venlafaxine and duloxetine) and pregabalin as first-line medications for neuropathic pain.[13]

Currently, Lawson Health Research Institute scientists are tackling one of the worst pains for humans in a $1-million, three-year research project. Dr. Dwight Moulin and Dr. Patricia Morley-Forster at London Health Sciences Centre are leading the investigation to find the best way to treat neuropathic pain. I will be very interested to see the results of this project.

Most people will readily agree that regular exercise is good for you, and when combined with a healthy diet will help people gain or lose weight, and generally improve their quality of life. Unfortunately, many people with a chronic pain condition mistakenly believe that they can no longer get the full benefits of exercise. Egoscue (1998) is very adamant that flexibility and mobility are the keys to successful chronic pain management.

I recently found a new study highlighting the benefit of even modest exercise titled Modest Exercise Helps Chronic Pain Patients that was presented on February 15, 2008 at the American Academy of Pain Medicine 24th Annual Meeting. Please see an excerpt below.

• The review aimed to determine the effect of a 3-week aerobic training program on physical conditioning and to assess the acute effects of a brief, 10-minute exercise protocol on pain, mood, and perceived exertion. The final sample of 28 patients — lowered from 54 due to factors such as lack of motivation to exercise and fear of exercise — had an immediate perception change about exercise upon starting the program.

• Measures of heart rate, mood, pain, and perceived exertion were obtained. On average, patients received 5 hours of conditioning per week, in addition to routine daily activities. Results demonstrated significant short- and long-term benefits of exercise. Patients showed a statistically significant reduction in exercise-induced cardiac acceleration from admission to 3 weeks. The brief exercise protocol also produced significant immediate antidepressant and anxiolytic effects. The research suggests that relatively modest exercise leads to improved mood and physical capacity, which has further implications for mortality risk. The review also suggests that brief exercise is a safe, cost-free, nonpharmacological strategy for immediately reducing depression and anxiety [which often accompany living with chronic pain].

Exercise can and should be part of all pain management plans. The type and frequency of exercise is the important factor which requires someone with experience and clinical skills to develop an effective—and safe—program. Rest and immobilization periods (or up-time and down-time), should also be an integral foundation of the plan.

Other important considerations include the style of exercise, the progression of intensity, the frequency or quantity, and the prevention of additional injury. As mentioned earlier, hydrotherapy and water exercises can be very beneficial for people with chronic pain issues.

Caudill (2001) discusses the importance of aerobic exercise at least three times a week to improve health and weight management. Many people with pain are afraid that their pain will increase if they become too active. However, the risks of not exercising far outweigh the fear of what "might" happen as a result of developing an exercise regime. Caudill states that if people are careful and progress slowly, they are not likely to worsen their condition.

Catalano and Hardin (1996) note the fact that people who gradually incorporate exercise into their pain management treatment plan return to a higher level of functioning and maintain more effective pain management. They also recommend a program of exercise that includes proper posture and stretching. Catalano and Hardin also show a secondary gain for exercise—reducing isolation tendencies.

Works Cited

Catalano, E., & Hardin, K. (1996). The chronic pain control workbook: A step-by-step guide for coping with and overcoming pain. Oakland, CA: New Harbinger.

Caudill, M. (2001). Managing pain before it manages you. New York: Guilford Press.

Egoscue, P. (1998). Pain Free: A revolutionary method for stopping chronic pain.
New York, NY: Bantam.

Modest Exercise Helps Chronic Pain Patients (2008). American Academy of Pain Medicine 24th Annual Meeting: Abstract 105.

According to a special report from Pain-Topics.org, practitioners prescribing opioids for pain should be prepared to deal with patients' problems in using the medicines. Patients should not be discharged from treatment if opioid abuse or addiction occurs.

Chicago, IL, January 20, 2008 --(PR.com)-- "Any practitioner prescribing opioids for chronic use should be accountable for having a strategy in place if medication abuse or addiction occurs," says Peggy Compton, RN, PhD. "Providing daily opioid pain relievers without suitable addiction expertise or support in place puts both the pain-management practitioner and patient at risk for poor outcomes." For the full article click:

http://pain-topics.org/clinical_concepts/comments.php#Compton.

Many pain management providers find themselves in a difficult position. They want to provide effective pain management for their patients with chronic pain but are confronted more and more with prescription drug abuse or addiction issues. They are also being scrutinized by government departments such as the Drug Enforcement Agency (DEA) who are looking for over-medicated patients and prescription drug diversion. Because of this, providers are deciding they don't want to deal with this type of pain patient and are discharging them or severely limiting the pain management interventions these patients need and deserve for fear of being targeted.

This can avoided, and patients can get the help they need, if practitioners are diligent about putting certain policies and procedures in place. Pain management providers will have a much better chance of providing the level of care they want, protecting their patients from overdoses and shielding their practice. Below are recommendations by the Federation of State Medical Boards of the United States Inc. This organization has adopted the following criteria to support the physician's treatment of pain, including the use of controlled substances. They recommend the following six guideline areas:

• Evaluation of the Patient
• Treatment Plan
• Informed Consent and Agreement for Treatment
• Periodic Review
• Consultation Model Policy for the Use of Controlled Substances for the Treatment of Pain; page 16 Adopted May 1, 2004
• Medical Records

For a full look at their model policy for the use of controlled substances for the treatment of pain including details of the above six areas please go to: http://www.fsmb.org/RE/PAIN/default.html For more information about how to manage prescription medication abuse and/or addiction issues in your practice, please join us at an upcoming multidisciplinary training, call for a consultation to discuss ways to specifically implement the above guidelines from an Addiction-Free Pain Management® approach, or check out our publications page.