Over the past few months I have spoken with a number of people who had recent Shingles episodes and the challenges they faced coping with the accompanying pain. For those of you unfamiliar with this painful condition, Shingles is a form of Postherpetic Neuralgia (PHN) affecting the nerve fibers and skin. PHN is a complication of Shingles which is a second outbreak of the Varicella-Zoster virus that initially causes Chickenpox.

After an initial Chickenpox infection, some of the virus remains in the body, lying dormant inside nerve cells. Years later the virus may reactivate causing Shingles. Once reactivated, the virus travels along nerve fibers causing pain. When the virus reaches the skin, it produces a rash and blisters. A case of Shingles (Herpes Zoster) usually heals within a month. But some people continue to feel pain long after the rash and blisters heal — a pain called PHN.

A variety of pain treatments for PHN exist, although patients may not experience complete relief. You can visit the MayoClinic.com website for more information. I have posted some of their treatment recommendations below.

Treatment for postherpetic neuralgia depends on the type of pain you experience. Possible options include:

Antidepressants. Drugs that inhibit the reuptake of norepinephrine and serotonin, including tricyclic antidepressants, such as amitriptyline, desipramine (Norpramin), nortriptyline (Pamelor) and duloxetine (Cymbalta) — may not eliminate the pain. However, they can make it more tolerable.

Certain anticonvulsants. Doctors may prescribe gabapentin (Neurontin), pregabalin (Lyrica) or another anticonvulsant to help control burning and pain.

Injected steroids. Corticosteroid medications injected into the area around the spinal cord may help relieve the persistent pain of postherpetic neuralgia.

Painkillers. Your doctor may prescribe painkillers such as tramadol (Ultram) or drugs containing oxycodone, either in short-acting formulations such as Percocet or in long-acting formulations such as OxyContin. However, these drugs are narcotics and can be addictive. Although this risk is generally low, discuss it with your doctor.

Transcutaneous electrical nerve stimulation (TENS). This treatment involves the placement of electrodes over the painful area. The electrodes deliver tiny, painless electrical impulses to nearby nerve pathways.

Spinal cord or peripheral nerve stimulation. These devices are similar to TENS, but are implanted underneath the skin.

Lidocaine skin patches. These are small, bandage-like patches that contain the topical, pain-relieving medication lidocaine.

However, many patients are not diagnosed within this period. In addition, some acyclovir studies show no improvement in PHN even if started within the 72 hour period. Other treatments such as narcotics, antidepressants, and antiepileptics offer symptomatic control in some patients, but the pain control is frequently inadequate and side effects, such as dizziness, drowsiness, and constipation limit their use. The limited efficacy of current treatments prompted a search for alternative approaches.

PHN is difficult to treat; once it develops, a patient may need a multidisciplinary approach that involves a pain specialist, psychiatrist, primary care physician and other health care providers. In 2004, the American Academy of Neurology (AAN) issued treatment guidelines for postherpetic neuralgia based on an extensive review of published studies. The AAN recommends:

• Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, maprotiline)
• Anticonvulsants (gabapentin and pregabalin)
• Lidocaine skin patches
• Opioids (oxycodone, methadone, morphine)

• Hypnosis
• Topical use of diluted apple cider vinegar
• Acupuncture
• Colostrum (a pre-milk fluid produced by mammals)
• Pantothenic acid (Vitamin B5)

A number of relaxation and stress-reduction techniques may be helpful for managing chronic pain; including meditation, deep breathing exercises, biofeedback, and muscle relaxation. Such techniques may apply to those with severe pain from acute infection and from persistent long-term Postherpetic Neuralgia.

Cognitive Behavioral Therapy is also showing benefit in enhancing patients' beliefs in their own ability to deal with pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives, to the perception that it is a manageable experience. The skill of the therapist is very important to its success.

Many people undergoing chronic pain management face significant challenges in finding ways to relieve their pain. Sometimes medication is not enough which is why most of the latest chronic pain management outcome research is recommending a multidisciplinary team approach for better treatment outcomes. One treatment component that has helped many of my patients over the years is interventional pain management procedures.

When implementing a multidisciplinary team approach the most important member of the team is the patient! In fact, most interventional pain management practitioners emphasize and rely on the full cooperation of their patients throughout the treatment process in order for a successful outcome to be achieved.

According to the American Society of Interventional Pain Physicians (ASIPP), interventional pain management is a "discipline of medicine devoted to the diagnosis and treatment of pain related disorders." Interventional pain medicine utilizes a multidisciplinary approach in which a team of health care professionals works together, to provide a full range of treatments and services for patients suffering from chronic and/or acute pain.

The goals of interventional pain management are to relieve, reduce, or manage pain and improve a patient's overall quality of life through minimally invasive techniques specifically designed to diagnose and treat painful conditions. Interventional pain management also strives to help patients return to their everyday activities quickly and without heavy reliance on medications.

Below is a list of some of the most common pain interventional procedures used in many of the leading pain clinics:

• Epidural injections (in all areas of the spine): The use of anesthetic and steroid medications injected into the epidural space to relieve pain or diagnose a specific condition.

• Nerve, root, and medial branch blocks: Injections done to determine if a specific spinal nerve root is the source of pain. Blocks also can be used to reduce inflammation and pain.

• Facet joint injections: An injection used to determine if the facet joints are the source of pain. These injections can also provide pain relief.

• Discography: An "inside" look into the discs to determine if they are the source of a patient's pain. This procedure involves the use of a dye that is injected into a disc and then examined using x-ray or CT Scan.

• Pulsed Radiofrequency Neurotomy (PRFN): A minimally invasive procedure that disables spinal nerves and prevents them from transmitting pain signals to the brain.

• Rhizotomy: A procedure in which pain signals are "turned off" through the use of heated electrodes that are applied to specific nerves that carry pain signals to the brain.

• Spinal cord stimulation: The use of electrical impulses that are used to block pain from being perceived in the brain.

• Intrathecal pumps: A surgically implanted pump that delivers pain medications to the precise location in the spine where the pain is located.

• Percutaneous Discectomy/Nucleoplasty: A procedure in which tissue is removed from the disc in order to decompress and relieve pressure.

In July 2009 the American Society of Interventional Pain Physicians (ASIPP) announced the release of the updated 2009 Interventional Pain Management (IPM) guidelines. I have posted some excerpts below. To read more please visit the MayoClinic.com website.

Dr. Manchikanti, primary author of the guidelines stated that, "The purpose of the IPM guidelines is to address the issues of systematic evaluation and ongoing care of chronic or persistent pain, and provide information about the scientific basis of recommended procedures. The guidelines are expected to increase patient compliance, dispel miscommunications among providers and patients, manage patient expectations reasonably, and form the basis of a therapeutic partnership between the patient, the provider and payers."

ASIPP first developed treatment guidelines in 2000, and since then there have been four subsequent updates. These guidelines have been developed utilizing a comprehensive, all inclusive approach with systematic assessment of available literature. The guideline authors include various specialists practicing interventional pain management from multiple disciplines, both academic and private practice. ASIPP assessed the strength of evidence by US Preventive Services Task Force criteria. Following a formal process, they also developed multiple systematic reviews along with multiple associated documents describing in detail the process in the literature search and systematic reviews.

Dr. Manchikanti added that, "These guidelines follow the principles laid out by the scientific community including the Institute of Medicine, American Medical Association, and multiple other organizations. Further, we utilized strict criteria of relief of at least six months as short-term, except for certain procedures in which case the relief of one year was considered as short-term."

A word of caution! Like any other pain management component, interventional procedures are not magic or a quick fix. In fact, I tell my patients the role of these procedures is to help them obtain relief so they can start developing other long-term chronic pain management tools that will support them for as long as they are needed. For some patients these procedures are the beginning of a life free from suffering and a much better quality of life as well. Interventional pain management physicians often include other treatments such as physical therapy, occupational therapy, and lifestyle modification (such as exercise, diet, and smoking cessation) to further enhance these procedures.

If you have patients or loved ones suffering from chronic pain who have not been able to find treatment that provides relief, consider recommending an Interventional Pain Management Physician. The comprehensive approach, where the patient is an important team member, may well be the missing pain management component they need.

A Federal Drug Administration (FDA) panel voted narrowly (20 to 17) in June 2009 to recommend a ban on Percocet and Vicodin, two of the most popular prescription painkillers in the world, because of their effects on the liver.

I have mixed thoughts about the efficacy of this proposed ban. On one hand, I have seen the quality of life improve for many people who received adequate pain relief from this type of medication. But I have also worked with people who abused them. Understandably many healthcare providers don't understand the logic behind banning a drug which, when taken as prescribed, won't harm a patient.

The FDA's Drug Safety and Risk Management Advisory Committee said in their report that the agency should ban the two prescription painkillers, Percocet and Vicodin, due to their high levels of acetaminophen and the ease with which patients can become addicted to them. Acetaminophen is also combined with different narcotics in at least seven other prescription drugs, and all of these combination pills will be banned if the Food and Drug Administration heeds the advice of this panel.

Acetaminophen, the ingredient in Vicodin and Percocet that the panel was concerned about, is metabolized by the liver, and in large doses can be toxic. The potential for liver damage rises when acetaminophen is combined with alcohol. Overdoses are estimated to cause about 450 deaths per year, and it is considered toxic when an adult takes about 7,000 milligrams per day, the equivalent of 14 Extra Strength Tylenol tablets.

Yes it is true that patients who take Vicodin and Percocet may develop a tolerance and continue to increase their daily dose that may increase their risk of prescription drug addiction. However, if these two medications are no longer available they would most likely be replaced with other stronger medications—like OxyContin or Oxycodone—that will most certainly increase the serious risk of abuse and medication addiction.

In addition, the FDA announced in July 2009 that it would place a black box warning label on propoxyphene (Darvon) instead of banning it. Darvon also includes acetaminophen, leaving many healthcare providers hopeful that the FDA will go against its advisory board and also keep Vicodin and Percocet on the market. The same FDA panel also voted 36-1 that if the Percocet and Vicodin are not banned from the market; they should be given the black box warning, the FDA's most severe warning label.

Dr. Lewis S. Nelson, a toxicologist from the New York University School of Medicine who served as the panel's acting chairman, said "Experts had been warning of the dangers of combination painkillers like Percocet and Vicodin for years." Still, the recommendation is likely to come as a shock to many patients, who may be unaware of the dangers of high doses of acetaminophen — even if they know the drugs contain the ingredient.

DeAnna DuBose, spokeswoman for Abbott Laboratories, which makes Vicodin, said the combination of acetaminophen and hydrocodone has been available for more than 30 years and said some patients rely on it as part of their recovery. "It is important to balance the need for patient safety and treatment options," DuBose commented. DuBose also stated that there have been precedents of the FDA refusing advice the panel gives and said the company would react to the final decision when one is reached. "At this point it is too early to speculate on next steps until receiving the Agency's guidance," she said.

One of the reasons I am taking this issue so seriously is the impact this proposed ban will have on pain management. Not just for acute pain situations like serious bone breaks, major dental procedures etc., but also in the chronic pain management arena. Many healthcare providers have traditionally prescribed medications like Vicodin and Percocet to address breakthrough pain for people undergoing cancer treatment or other serious types of chronic pain conditions.

Whatever the outcome from the FDA, I believe it is important that anyone undergoing chronic pain management should develop a safe and effective medication management plan if they are on any medications that have serious risk factors, as well as looking at the psychological factors that accompany a pain condition, and what non-medication approaches can be implemented. I recommend this three part approach to developing an effective chronic pain management plan:

1. Medication Management which includes a medication management agreement;

2. Cognitive-Behavioral Treatment that addresses pain versus suffering by learning how to managing thoughts and feelings, as well as changing self-defeating behaviors and problematic social/family reactions; and

3. Nonpharmacological (non-medication) Interventions which supports the development of safer ways to manage pain.

As the number of people in this country living with chronic pain continues to increase, so do the problems people experience as a result of the management of it. One such problem is the use of opiates for chronic pain and the serious problems that develop with long-term use. Some people will develop an addictive* disorder due to prolonged exposure, while others develop tolerance* to the medication and need ever higher doses. Still others may develop a condition known as hyperalgesia*.

Another problem discovered through recent research is that Nerve Growth Factor (NGF) is more prevalent in people with chronic pain. Tissue damage or inflammation induces high levels of NGF secretion. The short-term effect of NGF is to stimulate the release of natural chemicals that increase the sensitivity of nociceptors to pain (e.g. substance P, CGRP, histamine). After this initial phase, the extra stimulation of NGF receptors leads to a remodeling of pain pathways (a neuroplasticity effect), with an increase in the number of nociceptive fibers and pain sensitizing molecules, such as ion channels. These acute and long-term changes cause the chronic pain mechanisms induced by nerve damage, or disease.

As a small secreted protein, NGF induces the differentiation and survival of particular target neurons (nerve cells). It is perhaps the prototypical growth factor, in that it is one of the first to be described — that work by Rita Levi-Montalcini and Stanley Cohen was rewarded with a Nobel Prize.

Eric Voth, MD who practices as an Internist at Cotton-O'Neil Clinic in Topeka, Kansas says clinical trials are underway on new medications that can target the NGF. He also states that studies show people undergoing chronic pain management from a variety of sources, including arthritis, trauma or herniated discs, have elevated levels of the NGF in the area of pain.

The good news is that a substance called monoclonal antibodies appears to be able to suppress the production of NGF. Cotton-O'Neil is participating in clinical trials on some of those medications. Generally, they must be given intravenously or through an injection under the skin. Tissue samples are studied to know where the NGF is active and the drug needs to be delivered.

Initial studies show patients receiving the monoclonal antibodies are getting sustained pain relief. Voth says it's showing very few side effects, the most serious being a slight tingling sensation in some patients. Voth says it's his hope that patients will be able to reduce their dose of more addictive narcotics. The focus now is on getting the dose just right. Voth says certain doses seem to work better than others, and it's unclear exactly how often treatments should be repeated.

Another company, PainCeptor Pharma Corporation, a biopharmaceutical company, also engages in the development of peripherally-active pharmaceuticals for the management of chronic and acute pain. It develops PPC-1807, a nerve growth factor (NGF) antagonist. PainCeptor Pharma Corporation has a strategic alliance with NeuroSearch A/S. The company was founded in 2003 and is based in Saint-Laurent, Canada.

"By focusing on PNS receptors and ion channels we expect to avoid many of the side effects associated with centrally acting pain therapeutics," explained Kazimierz Babinski, PainCeptor's Vice President of corporate affairs. "The idea is to focus on targets at the beginning of the pain cascade." This will not be a magic fix or "Silver Bullet" for the management chronic pain. However, it can become an important tool to add to our chronic pain management treatment plans.

*Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

*Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

*Hyperalgesia is an abnormal state leading to an extreme sensitivity to pain, which in one form can be opiate induced, but it can also be caused by damage to nociceptors (pain receptors) in the body's soft tissues.

Last month we posted an article discussing the challenge of depression that many people with chronic pain face. It's often misdiagnosed because a chronic pain management client does not even realize they are depressed so they don't mention anything to their healthcare providers who often aren't looking for it. And if people who have depression and chronic pain only define their physical problems as it relates to their chronic pain condition, the various symptoms related to depression can be easily ignored.

A good resource for medical related problems is the Harvard Health Publications where I found an article titled Depression and Pain: Hurting Bodies and Suffering Minds Require the Same Treatment. Below are some of the highlights. Please visit Harvard Health Publications if you want to read the entire post.

Medicating Pain and Depression

Almost every drug used in psychiatry can also serve as a pain medication. Relieving anxiety, fatigue, depression, or insomnia with mood stabilizers, benzodiazepines, or anticonvulsants will also ease any related pain. The most versatile of all psychiatric drugs, the antidepressants have an analgesic effect that may be at least partly independent of their effect on depression since it seems to occur at a lower dose. The two major types of antidepressants, tricyclics and selective serotonin reuptake inhibitors (SSRIs), may have different roles in the treatment of pain. Amitriptyline (Elavil), a tricyclic, is one of the antidepressants most often recommended as an analgesic, partly because its sedative qualities can be helpful for people in pain. SSRIs such as fluoxetine (Prozac) and sertraline (Zoloft) may not be quite so effective as pain relievers, but their side effects are usually better tolerated, and they are less risky than tricyclic drugs. Some physicians prescribe an SSRI during the day and amitriptyline at bedtime for pain patients.

Both drug classes act in brain pathways that regulate mood and the perception of pain. Tricyclics heighten the activity of the neurotransmitters norepinephrine and serotonin; SSRIs act more selectively on serotonin. Some researchers and clinicians believe that a newer antidepressant which acts strongly on both neurotransmitters, the so-called dual action drug venlafaxine (Effexor), is superior to both tricyclics and SSRIs for treating pain. So far, the evidence is inconclusive.

Physicians and psychiatrists are also considering the uncertain potential of the anticonvulsant drug gabapentin (Neurontin) and drugs that block the activity of substance P, another neurotransmitter involved in the regulation of both pain and depression. Electroconvulsive therapy, a standard treatment for severe depression, may have independent analgesic effects.

Treating Pain and Depression in Combination

In pain rehabilitation centers, specialists treat both problems together, often with the same techniques, including progressive muscle relaxation, hypnosis, and meditation. Physicians prescribe standard analgesics — acetaminophen, aspirin and other nonsteroidal anti-inflammatory drugs, and in severe cases, opiates — along with a variety of psychiatric drugs (see "Medicating pain and depression" box above). Physical therapists provide exercises not only to break the vicious cycle of pain and immobility but also to help relieve depression. Cognitive and behavioral therapies teach pain patients how to avoid fearful anticipation, banish discouraging thoughts, and adjust everyday routines to ward off physical and emotional suffering. Psychotherapy helps demoralized patients and their families tell their stories and describe the experience of pain in its relation to other problems in their lives.

Pain specialists can improve their practice by learning more about the interactions among psychological, neurological, and hormonal influences that link pain and depression. Why do some people recover from injuries without pain while others develop chronic symptoms, and how is that process related to depression and anxiety? How do psychotherapy and antidepressant drugs affect brain function in depressed people with chronic pain? What kinds of psychotherapy are helpful for them and how long should psychotherapy continue? In investigating these questions, and in all treatment of both pain and depression, the goal is not just comfort or the absence of symptoms but restoring the capacity to lead a productive life.

In 2007 I published an article titled "War on Drugs—War on Pain Management." Not a lot has changed in the past two years. When I talk about this problem at my Addiction-Free Pain Management® trainings the common response is "sure this isn't right, but what can we do?" For starters let's become better educated about the problem of the Law Enforcement dictating medical treatment. Then talk about the issue with friends and colleagues, as well as writing to your elected officials and letting them know that in their effort to stop the illegal sale and distribution of prescription drugs, their focus on pain management physicians and chronic pain patients is misdirected and needs to stop.

Too much is at stake. In 1999 the adult population of the United States was about 247.2 million. Approximately 86 million of those people suffered from moderate to severe chronic pain caused by back injuries, arthritis, and other non-cancer conditions. By 2006 there were about 80-100 million American adults suffering—or who had suffered—with chronic pain conditions. If the Drug Enforcement Agency (DEA) policies continue as they are, or worsen, it could mean that many more people might not receive adequate pain management care.

Now the Federal Drug Administration (FDA) is getting involved but unlike the DEA the FDA is attempting to provide safety and common sense guidelines—not declare war. I just want to clarify here that in my opinion there is no such thing as a "bad" medication—as long as it meets safety and efficacy standards—there are only good or bad consequences related to who used it, what they used it for, and how they used it.

In April of 2009 the FDA mandated that generic prescription drug companies must stop making unapproved versions of morphine, hydromorphone, and oxycodone within 60 days and stop all shipments within 90 days. The FDA also warned drug companies like Glenmark Pharmaceuticals to stop making the unapproved medications. The federal government's health and law initiative is geared to eliminate medications being sold to American consumers which have not been properly cleared and approved by the FDA. Mismanaged narcotic pain medications, and drugs with versions of the above generic formulas, have caused widespread injuries, illnesses, addictions, and even deaths across the nation.

I ran across a recent article on JusticeNewsFlash.Com titled "FDA Addresses Pain Medication Injuries" regarding Darvocet deaths in the United States and what they are recommending. Here are some excerpts from that article. You can read the entire post at Justice News Flash.

The U.S. Food and Drug Administration (FDA) http://www.fda.gov announced on July 7, 2009, the governmental agency is making strides to help reduce the risk of overdose from pain medications like Darvon and Darvocet. The two pain medications contain the drug propoxyphene, which has been linked to accidental deaths from overdoses.

Although the FDA has found propoxyphene effective in pain management treatments, it poses potentially hazardous risks. The FDA is asking the manufacturers and retail companies of propoxyphene to supply more information to aid physicians and patients, in the determination of whether the pain killer component is an appropriate treatment for the patient and their medical issue. Propoxyphene reportedly has been on the market since 1957, to treat mild to moderate pain. Some side effects of propoxyphene have been linked to lightheadedness, dizziness, sedation, nausea, and vomiting.

The FDA has released several actions in which will combat deaths from overdoses:

• Manufacturers and makers of propoxyphene-containing medicines are required to strengthen the warning label on the medication box to indicate the high risk for overdose when consuming the product.
• Manufacturers are required to provide an FDA-approved medication information guide to each patient to emphasize the importance of consuming the pain medication only as directed by their health care provider.

• The FDA has mandated a new safety study to research the effects of propoxyphene on the heart when used at higher than recommended dosages.

• The FDA is planning on joining forces with other federal agencies, like the Centers for Medicare and Medicaid Services and the Department of Veterans Affairs, to produce additional studies to determine the safety of propoxyphene-containing products compared to other commonly used pain medicines.

• The FDA has assured they will further evaluate propoxyphene and its safety, and will implement regulatory action if needed.

Doctors and other professionals who prescribe narcotics in Maine have begun to develop new rules aimed at reducing the amount of prescription painkillers available for abuse and diversion. The group, which met Tuesday at the Augusta offices of the Maine Board of Medical Examiners, will expand existing guidelines for medical doctors to be used by other prescribers in managing both chronic and acute pain.

For treating chronic pain, the expanded guidelines may include the use of a formal contract between the patient and the prescribing clinician, random urine checks and pill counts to detect abuse or diversion. They also call for improved assessment, revision and documentation of the patient's pain and the effectiveness of the treatment.

Randal Manning, executive director of the Maine Board of Medical Examiners, said Tuesday that the initial meeting "went off well," with general agreement reached that tightening up prescribing protocols will help rein in rates of illicit drug use, overdose and crime.

The group will meet several times over the coming months to refine a standard protocol for all prescribers, he said,

The rule will be written to allow physicians and other prescribers "great discretion" in treating chronic pain while still providing guidelines for identifying drug-seekers, preventing patients from getting prescriptions from multiple providers, and referring long-term patients periodically to pain management specialists for evaluation, according to Manning.

One of the most frustrating pain symptoms to manage for people suffering with chronic pain conditions is neuropathic pain. According to Wikipedia neuropathy is defined as "disorders of the nerves within the peripheral nervous system (specifically excluding encephalopathy and myelopathy, which pertain to the central nervous system.) It is usually considered equivalent to peripheral neuropathy, which is defined as deranged function and structure of peripheral motor, sensory, and autonomic neurons, involving either the entire neuron or selected levels. According to some sources, a disorder of the cranial nerves can be considered a neuropathy."

Unfortunately for people living with neuropathic pain, they are often prescribed opiates, which in most cases are contraindicated for this type of pain symptom. I recently discovered a new internet resource called RedOrbit.com. The RedOrbit Knowledge Network is an online community specifically for those with an interest in science, space, health and technology. On that site I found an article titled Engineered Viral Vectors Target Painful Nerve Diseases. Excerpts are posted here and if you wish to review the entire article, visit the RodOrbit.com site.

Specially designed virus-derived vectors – engineered not to cause disease – can take therapeutic genes to the malfunctioning peripheral neurons outside the spinal cord and brain, alleviating the pain and other dysfunction that can result from a chronic disease or drug treatment, said researchers from Baylor College of Medicine and the University of Glasgow in a report in the current issue of the Journal of Clinical Investigation.

"The challenge is to deliver the beneficial genes specifically to the diseased nerve cells, or 'neurons', and not to the neighboring unaffected cells or tissues," said Chan. To correct this problem, Chan and his colleagues generated special "helper-dependent" adenoviruses that attach only to dorsal root ganglion neurons. He and his colleagues found that their adenovirus took the missing Hexb gene to the malfunctioning nerves and corrected the problem with high efficiency.

Many pain management practitioners use certain antidepressants e.g. tricyclics and selective serotonin-norepinephrine re-uptake inhibitors (SNRI's), anticonvulsants, especially pregabalin (Lyrica) and gabapentin (Neurontin), and topical lidocaine. Opioid analgesics and tramadol are sometimes used, but are not recommended as a first line of treatment. Many of the pharmacologic interventions for chronic neuropathic pain decrease the sensitivity of nociceptive receptors, or desensitize C fibers such that they transmit fewer signals. Below is some information that I found at Diabetes.WebMd.com. Visit them to see the entire post titled "Diabetic Neuropathy Treatment Overview."

People with peripheral neuropathy often have mild to severe pain in specific parts of their bodies. Talk with your doctor about treatment that can reduce your pain and improve your physical functioning, mood, and mental well-being. These treatments may include:

• Medicines such as pain relievers or creams to relieve pain. Prescription medicines often used to reduce pain from diabetic neuropathy may include medicines that are more commonly used to treat depression, such as tricyclic antidepressants and the antidepressant duloxetine hydrochloride, and medicines that control seizures, such as pregabalin and gabapentin. These medicines may be tried to reduce your pain even though you do not have depression or seizures.

• Complementary therapies such as acupuncture. Acupuncture has not been well studied as a treatment for diabetic neuropathy. But some studies show that it may help with pain.

• Physical therapy such as exercises, stretching, and massage. If you are told to use heat or ice, be careful. Neuropathy can make it hard for you to feel changes in temperature.

• Transcutaneous electrical nerve stimulation (TENS), which is a type of therapy that attempts to reduce pain by applying brief pulses of electricity to nerve endings in the skin.

In June of 2008 the Food and Drug Administration (FDA) approved duloxetine HCl delayed-release capsules (Cymbalta an SNRI) 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 as well as 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.

Posted below are some 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%; 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.

Over the past few months I've been hearing about more and more people being diagnosed with Central Pain Syndrome. Central Pain Syndrome is a neurological condition caused by dysfunction that specifically affects the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. It's a form of pain experienced by more than 250,000 Americans and affects more than 50 percent of spinal cord injury patients, 30 percent of multiple sclerosis patients, and 10 percent of stroke patients.

Central Pain Syndrome occurs in people who have — or who have experienced — strokes, multiple sclerosis, limb amputations, brain injuries, or spinal cord injuries. In some cases CNS didn't develop until months or years after the injury or initial nerve damage. Central Pain Syndrome is not a fatal disorder, but the syndrome causes disabling chronic pain and suffering among the majority of individuals who have it. Central Pain Syndrome is characterized by a mixture of pain sensations, the most prominent being a constant burning. The steady burning sensation is sometimes increased by light touch. Pain also increases in the presence of temperature changes, most often cold temperatures. A loss of sensation can occur in affected areas, most prominently on distant parts of the body, such as the hands and feet. There may be brief, intolerable bursts of sharp pain on occasion.

The pain of Central Pain Syndrome can begin within days of the causative insult, or it can be delayed for years (particularly in stroke patients). While the specific symptoms of Central Pain Syndrome may vary over time, the presence of certain symptoms is essentially continuous once they begin. The pain is usually moderate to severe in nature and can be very debilitating. Symptoms may be made worse by a number of conditions, such as temperature change (especially exposure to cold), touching the painful area, movement, and emotions or stress. The pain is often difficult to describe.

Because healthcare providers cannot find a cause for the pain their patients are reporting, they are often accused of exaggerating or making up their symptoms; especially in cases where the condition doesn't manifest for months or years after an injury or after another medical condition is resolved. Prior to being diagnosed with Central Pain Syndrome patients doubted their own reality; some contemplated or even committed suicide.

So what can be done for someone living with central pain syndrome? The main goal of treatment is to increase quality of life and provide pain relief. Unfortunately, common analgesics including opiates are usually not helpful, but are often prescribed anyway. For many people this leads to serious problems including addiction. Many sources report some of the more helpful treatment approaches that I've listed below:

• Tricyclic antidepressants like nortriptyline (Elavil®) are one of the most commonly prescribed drugs.

• Antidepressant medications especially Cymbalta (an SNRI) and other SNRIs and SSRIs can also be helpful.

• Anticonvulsant medication especially Gabapentin and Carbamazepine are also helpful. In addition, Lyrica (pregabalin) is often effective for neuropathic pain and is FDA approved for neuropathy and fibromyalgia and has been proven effective for spinal cord injuries. Some of the other anticonvulsant medications are: Depakote, Neurontin, Topamax, Tegretol plus several others.

• Lowering stress levels also helps to decrease the pain. Teaching patients simple relaxation response exercises and possibly biofeedback can be very helpful.

As with most chronic pain conditions it is always best to use a multidisciplinary treatment team. Neurologists will usually be the mainstay for treating central pain syndrome. Physical and occupational therapists may help an individual facing central pain syndrome obtain maximal relief and regain optimal functioning. Psychiatrists or psychotherapists may be helpful for supportive psychotherapy, particularly in patients who develop depression or other coexisting disorders related to their chronic pain.

For most people, living with chronic pain can be very difficult, especially when they also have a coexisting addiction or other psychological disorders. Given the biopsychosocial nature of chronic pain it is essential to utilize a multidisciplinary treatment plan that incorporates nonpharmacological interventions. The Addiction-Free Pain Management® (APM) System addresses the whole person with implementation of treatment plans for the biological, psychological, social, and spiritual domains.

The APM System consists of three major components: (1) A medication management plan—in consultation with an addiction medicine specialist; (2) A cognitive-behavioral treatment plan addressing pain versus suffering, treating family system issues and changing self-defeating behaviors, using eight Core Clinical Exercises from the Addiction-Free Pain Management® Workbook; and (3) A nonpharmacological pain management plan—developing safer medication-free ways to manage pain. Most pain patients need a strategic combination of all of the above.

One nonpharmacological intervention that has been successfully implemented in many treatment programs is Tai Chi which originated in China as a martial art. As a mind-body practice in complementary and alternative medicine (CAM), Tai chi is sometimes referred to as "moving meditation" where practitioners move their bodies slowly, gently, and with awareness while breathing deeply.

During my research I found several mentions of Tai Chi that I believe important to share. MedicineNet.com posted an article titled Moving Meditation: Tai Chi for Arthritis Relief. Excerpts are noted below. Please visit MedicineNet to read the entire article.

While many of today's Tai Chi movements have roots in martial arts, the goal is indeed therapeutic. Progress is measured in terms of coordination, strength, balance, flexibility, breathing, digestion, emotional balance, and a general sense of well-being.

Tai Chi and other types of mindfulness-based practices "are intended to maintain muscle tone, strength, and flexibility, and perhaps even spiritual aspects like mindfulness - focusing in the moment, focusing away from the pain," says Raymond Gaeta, MD, director of pain management services at Stanford Hospital & Clinics.

Parag Sheth, MD, assistant professor of rehabilitation medicine at Mt. Sinai Medical Center in New York, saw the popularity of Tai Chi on a visit to China 15 years ago. "We saw it every morning - thousands of people in the park doing tai chi, all of them elderly," he tells WebMD.

"There's logic in how Tai Chi works," Sheth says. "Tai Chi emphasizes rotary movements -- turning the body from side to side, working muscles that they don't use when walking, building muscle groups they are not used to using. If they have some strength in those support muscles - the rotators in the hip -- that can help prevent a fall."

"I'm an absolute huge fan of Tai Chi," says Jason Theodoskais, MD, MS, MPH, FACPM, author of The Arthritis Cure and a preventive and sports medicine specialist at the University of Arizona Medical Center. Any type of motion helps lubricate the joints by moving joint fluid, which is helpful in relieving pain, he says. "Tai Chi is not a cure-all, but it's one piece of the puzzle. What's good about Tai Chi is that it's a gentle motion, so even people who are severely affected with arthritis can do it. Also, Tai Chi helps strengthen the joints in a functional manner? You strengthen muscles in the way your body normally uses the joints."

Researchers in Australia conducted a systematic review of Tai Chi studies and found it produces positive effects in those suffering from arthritis. The researchers termed the trials small and of low methodological quality, but they found the outcomes for improvement in level of tension and for satisfaction with general health were statistically significant.

Tai Chi is a form of exercise that has recently been gaining popularity as a way to relieve and/or manage back pain and neck pain. It is often easy to associate Tai Chi with groups of people in parks or gyms moving slowly and deliberately in synchronization. These people are using the same Tai Chi principles and movements created in ancient China and still practiced all around the world as a healing exercise. Tai Chi has demonstrated usefulness in the prevention and treatment of certain problems such as back pain. Importantly, Tai Chi is non-invasive, relatively inexpensive, and gentle on the spine, so many people with back pain are starting to try it as an adjunct to (or sometimes instead of) traditional medical approaches to manage back pain. Furthermore, Tai Chi does not require any expensive equipment and can be practiced anywhere.

As life expectancy in the developed world increases and the population ages, the incidence and associated morbidity of chronic and acute pain is increasing and placing a higher level of emphasis on pain management as a quality-of-life issue for patients and their families. Because it has the potential to improve drug therapy compliance, transdermal delivery addresses a key healthcare issue—one that is particularly problematic in aging populations and developing economies. The irony of pain management drugs is that they almost universally cause pain in their administration.

A transdermal pain management system enables low side effect administration and avoids stomach irritation. Many narcotic analgesics carry dose-dependent side effects when delivered systemically. Transdermal administration can often accomplish the drug's effect with a dose beneath the level likely to cause side effects. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) all carry a risk of significant gastric irritation and liver toxicity, particularly when mixed with other drugs or dietary elements like alcohol. Transdermal pain management enables the bypass of both stomach and liver and accomplishes its effect at about a third of the required oral dose.

While there are many specific diagnoses for which transdermal pain medication may be ideal, the following are some of the most common:

• Arthritis
• Localized or acute injury
• Chronic muscle and joint pain
• Chronic nerve pain

There are many types of medications that can be delivered by transdermal systems. Some of the common ones are listed below:

• Fentanyl, an analgesic for severe pain.
• Lidocaine patches, marketed as Lidoderm, relieve the peripheral pain of shingles (herpes zoster).
• Flector (Diclofenac epolamine) patch is an NSAID topical patch for the treatment of acute pain due to minor strains, sprains, and contusions. It is also being used in the treatment of chronic conditions benefiting from NSAIDs, including fibromyalgia and arthritis.
• Clonidine for treatment of some types of neuropathic pain.

A transdermal patch is classified by the U.S. Food and Drug Administration as a combination product, consisting of a medical device combined with a drug or biological product that the device is designed to deliver. Prior to sale in the United States, any transdermal patch product must apply for and receive approval from the Food and Drug Administration (FDA), demonstrating safety and efficacy for its intended use.

Although not yet FDA approved in the United States, transdermal formulation of buprenorphine has been available in Belgium for 3 years, during which time the Pain Clinic of St. Elisabeth of Verviers Hospital has gained experience in the use of transdermal buprenorphine for the treatment of moderate-to-severe pain. They published a paper that focused on four cases of chronic, non-malignant pain, and one case of chronic cancer pain.

By starting patients on low doses and slowly titrating upwards, transdermal buprenorphine matrix patches provided effective analgesia and were well tolerated. Low doses of transdermal buprenorphine were created by cutting the smallest available matrix patch (35 µg/h) into halves or quarters. The initial dose was then gradually titrated upwards to the dose needed for optimum pain relief by the patients. No problems were encountered in switching patients from prior analgesic therapy with other opioids to transdermal buprenorphine. You can learn more about Buprenorphine on another posting this month.

Music hath charms to soothe the savage breast, to soften rocks, or bend a knotted oak. —William Congreve (1670–1729).

Many people have heard this quote and now studies show how music can also soothe chronic pain. As someone living with chronic pain for over two decades I have used music as a soothing agent when experiencing a pain flare up and have recommended it to many of my patients who also found this nonpharmacological intervention beneficial. I sometimes call this technique Avoidance by Distraction.

A recent study done at Glasgow Caledonian University (Scotland) found that people who were listening to their favorite music felt less pain and could stand pain for a longer period. Pain researcher Laura Mitchell has measured how people respond to pain with various forms of distractions, including relaxing music, listening to humorous audio tapes, doing math puzzles and looking at art.

I found this information as I was conducting international research on pain management and came across the Canadian Broadcasting Corporation (CBC)—Canada's national public broadcaster online. Excerpts from the report are posted below. Visit the CBC to review the entire report.

Music may be the analgesic of the art world

In January, pain researcher Laura Mitchell published a study in the journal Psychology of Aesthetics, Creativity, and the Arts, showing the significant effects of music on pain. She used a test that involves asking people to dunk their hand, up to the wrist, in frigid water, and keep it there as long as they can stand it. The test is only done on healthy people and there is an upper limit on the amount of time they keep their hand in the cold bath.

"We were looking to see whether music would have an effect on people's tolerance of pain — to how long they could tolerate some kind of painful stimulus and also whether it would reduce the actual feeling, their actual pain perception for them and whether it would reduce the anxiety of human pain and whether it would help them feel a bit of control over pain they're going through," she said.

People reported their ability to distract themselves from pain more than doubled if they were listening to their favorite music, while their perception of the amount of pain they felt fell significantly. Mitchell, who's been studying art and pain management for eight years, believes it's the emotional associations of music that lessen human perception of pain.

Another interesting posting I found was on Bio-Medicine.org. This article cited research findings that demonstrated music reduced the symptoms of chronic pain and depression. Excerpts from that article are below and if you would like to read the entire article please visit Bio-Medicine.org.

New research on music therapy found that up to 21 percent of chronic pain and depression by up to 25 percent were reduced by music therapy. Music listening, controls pain and makes people feel more comfortable, less disabled by their condition.

Listening to music an hour / per day for 7 days was found to improve physical and psychological signs when compared to the control group. 'The people who took part in the music groups listened to music on a headset for an hour a day and everyone who took part, including the control group, kept a pain diary', explained researcher, Dr Sandra L. Siedlecki of the Cleveland Clinic Foundation in Ohio.

For many people acupuncture can be a crucial component of an integrative chronic pain management plan. Although acupuncture has been used in the USA since the 1970s and in China for over 3,000 years, it is still met with skepticism and even fear. I recently discovered a new resource at www.healingchronicpain.org, for chronic pain management information that I would like to pass on. Below is an excerpt from one of their postings on acupuncture. Visit Healing Chronic Pain to read the entire article.

Recent research has elucidated some of the physiologic and biochemical bases of acupuncture. Acupuncture stimulation has been shown to release central nervous system endorphins and spinal cord dynorphins, explaining part of its mechanism of action. It has also been shown to promote the release of the chemical that activates the adrenal glands (adrenocorticotrophic hormone or ACTH), affect chemicals that are known to be involved in mood and pain perception (serotonin, GABA, catecholamines, dopamine, etc), and influence one of the body's pain-generating messengers (substance P). While its effects have traditionally been explained in terms of energy flow dynamics (Qi or Chi), science has shown that acupuncture may work at least partly by directly affecting the function of the nervous system (Han, 1986; Kaptchuk, 2002; Wu, 1999).

More recent studies and reviews have supported the use of acupuncture for migraine and tension headaches (Melchart, 2001), chronic neck pain (Irnich, 2001), and low back pain, neck pain and soft-tissue injuries of the peripheral joints (Kerr, 2001). 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 (Xu X, 2001).

One form of care being used increasingly to treat the symptoms associated with fibromyalgia is acupuncture, although the current evidence supporting acupuncture in the treatment of fibromyalgia appears mixed. The 1997 NIH Consensus Statement on Acupuncture, for example, cited fibromyalgia as one of dozens of conditions for which acupuncture could be "useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program." Studies published in 1998 and 20002 concluded that acupuncture could reduce pain levels and be effective in treating fibromyalgia, while a randomized clinical trial published in July 2005 suggested true acupuncture was no better than a sham treatment in relieving fibromyalgia pain.

One of the most recent investigations into the effectiveness of acupuncture for fibromyalgia was presented at the 11th World Congress on Pain in Sydney, Australia in August, 2005. The trial, conducted by researchers at the Mayo Clinic, found that acupuncture provided significant improvements in a variety of symptoms associated with fibromyalgia, with the effects of care often lasting several months.

"This study shows there is something real about acupuncture and its effects on fibromyalgia," said Dr. David Martin, the study's lead investigator, in a news conference held during the congress. "Our study was performed on patients with moderate to severe fibromyalgia. It's my speculation that if acupuncture works for these patients with recalcitrant fibromyalgia - where previous treatments had not provided satisfactory relief - it would likely work for many of the millions of fibromyalgia patients."

I also found information on Web MD detailing how acupuncture has proven to be an effective intervention for chronic headache pain including migraines. Please visit Web MD to read the entire posting.

Researchers found that compared with standard medical care, acupuncture offers substantial benefits in preventing headaches and improving the quality of life for people who suffer from frequent headaches, especially migraines.

Acupuncture is commonly used to treat other types of chronic pain, but researchers say this is the first large-scale study to examine the effectiveness of acupuncture under real-life conditions. They say the results indicate that health insurance coverage of acupuncture services should be expanded to include the treatment of chronic headaches and migraine. In the study, published in the March 15 issue of the British Medical Journal, researchers randomly divided 401 adults aged 18-65 years old with chronic headache (at least two headaches a month) — into two treatment groups. Participants had a history of having mostly migraine headaches.

In a related study published in the same journal, British researchers found that acupuncture improves the quality of life for people with chronic headaches at a small additional cost. They say the findings show that acupuncture is a relatively cost-effective headache therapy compared with other treatments covered by the National Health Service of the United Kingdom.

For many years I've been proposing collaboration not competition through the use of a multidisciplinary team approach when working with people living with chronic pain and coexisting disorders including addiction. I believe it is imperative for pain management physicians to work hand-in-hand with other healthcare disciplines in order to provide the best treatment outcomes for this population.

Today I ran across a report validating my position in the online US News and World Report regarding a recent study posted in the May 2009 Journal of the American Medical Association which states that collaborative care helps ease chronic pain. I'm including some excerpts below and if you want, you can read the entire report at US News.

In a study including more than 400 U.S. veterans, researchers found that a collaborative strategy for chronic pain management -- one that included education for patients in pain and their primary care doctors, as well as frequent reevaluation of how the pain plan was working – provided better relief of pain compared to standard care.

"We did a randomized trial comparing collaborative care for chronic pain to people getting usual care. We did this because chronic pain is common, especially in the primary care setting, and most treatment is provided by primary care doctors," said the study's lead author, Dr. Steven K. Dobscha, acting chief of psychiatry in the mental health and behavioral neurosciences division at the Portland VA Medical Center in Oregon.

The good news from the study, said Dobscha, is that "even if you've had years of pain and multiple pain problems, there's hope." Results of the study are published in the March 25 issue of the Journal of the American Medical Association.

"This was a very positive study. These patients had a level of care that is nearly parallel to a pain care center in a primary care setting," said Dr. Christopher Gharibo, medical director of pain management at the New York University Hospital for Joint Diseases in New York City. This type of collaborative care "can certainly reach out to a much greater number of people, may be more convenient for the patients and can help decrease health care costs," he said.

We know that diet/nutrition plays an important role is some chronic pain conditions. For example with migraine sometimes just changing your diet may resolve the problem. Another condition, gout (high uric acid levels) can also be triggered or exacerbated by some foods and alcohol. In this section I want to share the research I discovered on the role of Vitamin D and some chronic pain conditions.

A press release from PR Newswire discussed a research study out of the Mayo Clinic showing a correlation between inadequate vitamin D levels and the amount of narcotic medication taken by patients who have chronic pain. Some excerpts are posted below:

According to the Centers for Disease Control and Prevention, chronic pain is the leading cause of disability in the United States. These patients often end up taking narcotic-type pain medication such as morphine, Fentanyl or Oxycodone.

This study found that patients who required narcotic pain medication, and who also had inadequate levels of vitamin D, were taking much higher doses of pain medication -- nearly twice as much – as those who had adequate levels. Similarly, these patients self-reported worse physical functioning and worse overall health perception. In addition, a correlation was noted between increasing body mass index (a measure of obesity) and decreasing levels of vitamin D. Study results were published in a recent edition of Pain Medicine.

"This is an important finding as we continue to investigate the causes of chronic pain," says Michael Turner, M.D., a physical medicine and rehabilitation physician at Mayo Clinic and lead author of the study. "Vitamin D is known to promote both bone and muscle strength. Conversely, deficiency is an under-recognized source of diffuse pain and impaired neuromuscular functioning. By recognizing it, physicians can significantly improve their patients' pain, function and quality of life."

"Though preliminary, these results suggest that patients who suffer from chronic, diffuse pain and are on narcotics should consider getting their vitamin D levels checked. Inadequate levels may play a role in creating or sustaining their pain," says Dr. Turner.

"Physicians who care for patients with chronic, diffuse pain that seems musculoskeletal -- and involves many areas of tenderness to palpation -- should strongly consider checking a vitamin D level," he says. "For example, many patients who have been labeled with fibromyalgia are, in fact, suffering from symptomatic vitamin D inadequacy. Vigilance is especially required when risk factors are present such as obesity, darker pigmented skin or limited exposure to sunlight."

I've posted some excerpts below from another interesting article at PainTopics.org that touts Vitamin D as a treatment for chronic pain syndromes.

According to peer-reviewed clinical research, inadequacies of vitamin D have been linked to chronic musculoskeletal pain of various types, muscle weakness or fatigue, fibromyalgia syndrome, rheumatic disorders, osteoarthritis, hyperesthesia, migraine headaches, and other somatic complaints. It also has been implicated in the mood disturbances of chronic fatigue syndrome and seasonal affective disorder.

Current best evidence demonstrates that supplemental vitamin D can help to resolve or alleviate chronic pain and fatigue syndromes in many patients who have been unresponsive to other therapies. Vitamin D therapy is easy for patients to self-administer, is well tolerated, and is very economical.

Research on vitamin D is still an emerging field, and there are divergent opinions among experts regarding many aspects of vitamin D pharmacology, function, and adequate intake needed for good health. While further research is needed, the clinical evidence to date recommending vitamin D supplementation for musculoskeletal pain and associated symptoms seems convincing. In 22 clinical investigations reviewed for this report – which included a total of 3670 patients with musculoskeletal pain – significant vitamin D inadequacies were found in 48% to 100% of the subjects. When supplementation was provided for improving vitamin D status, pain and/or muscle weakness were resolved or at least subsided in most cases, and there were associated improvements in physical functioning.

Relationship of Vitamin D to Pain Syndromes
The process that links vitamin D to musculoskeletal pain is presumed to begin with a lack of circulating calcium (hypocalcemia) due to inadequate vitamin D. This calcium deficiency stimulates increased parathyroid hormone secretion and sets in motion a cascade of biochemical reactions negatively affecting bone metabolism. Even mild hypocalcemia results in an elevation of parathyroid hormone that can diminish bone density (osteopenia) and/or more severely affect bone architecture (osteoporosis).

The effect relating most closely to musculoskeletal aches and pains is that the increase in parathyroid hormone levels can lead to a softening of bone surfaces – or osteomalacia – which generates pain in periosteal tissues covering the skeleton. Osteomalacia has been proposed as an explanation of why many patients with vitamin D inadequacies may complain of dull, persistent, generalized musculoskeletal aches and pains. Myopathy also is part of the osteomalacic complex, so fatigue or decreases in muscle strength, usually in lower limbs, may appear prior to any pain.

In many cases involving pain and myopathy, defects of bone metabolism and osteomalacia may not be clinically detectable but are nonetheless present, or "subclinical." Such disorders are considered to be nonspecific or idiopathic in that an explanatory injury, bone pathology, or anatomical or neurological defect is not evident. This may occur in a significant number of chronic musculoskeletal pain cases that have been resistant to treatment, and, according to the research, many of the problems can be attributed to inadequate vitamin D.

Many people who have been taking opiates for chronic pain may develop serious problems with long-term use. Some of them may develop an addictive disorder due to prolonged exposure to their medication, while others develop tolerance to the medication and need ever increasing doses. Still others may develop a condition known as hyperalgesia.

Although you may already know what hyperalgesia is, I'm including a definition of opiate-induced hyperalgesia from Wikipedia for anyone unfamiliar with this phenomenon.

Opioid-induced hyperalgesia or opioid-induced abnormal pain sensitivity is a phenomenon associated with the long term use of opioids such as morphine, hydrocodone, Oxycodone, and methadone. Over time, individuals taking opioids can develop an increasing sensitivity to noxious stimuli, even evolving a painful response to previously non-noxious stimuli (allodynia). Some studies on animals have also demonstrated this effect occurring after only a single high dose of opioids.

Although tolerance and opioid-induced hyperalgesia both result in a similar need for dose escalation, they are nevertheless caused by two distinct mechanisms. The similar net effect makes the two phenomena difficult to distinguish in a clinical setting. Under chronic opioid treatment, a particular individual's requirement for dose escalation may be due to tolerance (desensitization of antinociceptive mechanisms), opioid-induced hyperalgesia (sensitization of pronociceptive mechanisms), or a combination of both.

Identifying the development of hyperalgesia is of great clinical importance since patients receiving opioids to relieve pain may paradoxically experience more pain as a result of treatment. Whereas increasing the dose of opioid can be an effective way to overcome tolerance, doing so to compensate for opioid-induced hyperalgesia may worsen the patient's condition by increasing sensitivity to pain while escalating physical dependence.

If an individual is taking opioids for a chronic non-cancer pain condition, and cannot achieve effective pain relief despite increases in dose, they may be experiencing opioid-induced hyperalgesia. In this case, they may benefit from complete withdrawal from opioid therapy. Many individuals report reduced pain levels when opioids are withdrawn.

Long-term use of opioids to manage chronic pain increases a patients' sensitivity to certain types of pain, and similar hyperalgesia develops with methadone-maintained drug abusers, researchers from the University of Adelaide, in Australia, report. The observational study by Justin L. Hay, MD and colleagues is in the March 2009 issue of the Journal of Pain, the abstract of which is posted below.

Hyperalgesia in opioid-managed chronic pain & opioid-dependent patients. By: Hay JL, White JM, Bochner F, Somogyi AA, Semple TJ, Rounsefell B

This observational study aimed to determine whether pain sensitivity in patients with noncancer chronic pain, taking either methadone or morphine, is similar to patients maintained on methadone for dependence therapy, compared with a control group. Nociceptive thresholds were measured on a single occasion with von Frey hairs, electrical stimulation, and cold pressor tests. In all subjects receiving methadone or morphine, nociceptive testing occurred just before a scheduled dose. Cold pressor tolerance values in patients with noncancer, chronic pain, treated with morphine and methadone, were 18.1 +/- 2.6 seconds (mean +/- SEM) and 19.7 +/- 2.3 seconds, respectively; in methadone-maintained subjects it was 18.9 +/- 1.9 seconds, with all values being significantly lower than opioid-naïve subjects (30.7 +/- 3.9 seconds). These results indicate that patients with chronic pain managed with opioids and methadone-maintained subjects are hyperalgesic when assessed by the cold pressor test but not by the electrical stimulation test. None of the groups exhibited allodynia as measured using the von Frey hairs. These results add to the growing body of evidence that chronic opioid exposure increases sensitivity to some types of pain. They also demonstrate that in humans, this hyperalgesia is not associated with allodynia. PERSPECTIVE: This article presents an observational study whereby the pain sensitivity of patients with chronic pain managed with opioids and opioid-maintained patients were compared with opioid-naïve patients. The results suggest that opioid use may contribute to an increase in the sensitivity to certain pain experimental stimuli. David Clark, MD, from the Palo Alto VA Health Care System, in California, has also studied opioid-induced hyperalgesia and adds his comments regarding this study. According to Dr. Clark, "An important finding in this study was that not only addicts have this type of sensitization. Chronic-pain patients have it as well, so this problem goes beyond the boundaries of what is unique to drug abusers."

Dr. Clark said the finding that long-term use of opioids might sensitize patients to pain itself suggests factors that could both limit the clinical utility of opioids used to control chronic pain and add to pain problems in those being treated for addiction. "The emerging experience regarding the long-term use of opioids for chronic pain is not terribly encouraging, and opioid-induced hyperalgesia is one explanation for why this therapy might have limited success."

We've known for years that back pain is one of the most prevalent complaints people seeking medical attention report. What surprised one group of researchers was how much chronic low back pain has increased in the past fifteen years. Another problem is the dramatic over utilization of the healthcare system because many people living with chronic pain are not receiving appropriate treatment.

According to a report by the University of Wisconsin, back pain costs Americans around $15 billion per year for medical care and disability payments. Mechanical low back pain is one of the most common complaints that emergency physicians in the United States hear, and accounts for more than 6 million cases annually. As a health problem, back pain is the third most expensive disorder after heart disease and cancer.

Occupational injury is a big contributor to the country's back pain woes. According to the Bureau of Labor Statistics, in private industry alone, there were approximately 123,000 work related back injuries in 2004. This is roughly around 10 percent of all on the job injuries reported by private industry. The good news is that the number of back injuries at work is declining: in 2003 there were 132,000 reported cases. Productivity suffers as well. While the specific numbers vary, back problems cost employers many billions of dollars in lost productivity each year.

Recently I found a research review at Health.com and have posted some excerpts below. The findings were published in the Feb. 9, 2009 issue of Archives of Internal Medicine where you can read the entire report. Go to "Chronic Low Back Pain is on the Rise".

A North Carolina study finds that the rate of chronic low back pain has more than doubled in that state since the early 1990s — a statistic the authors say might reflect what's happening in the country as a whole.

"We were actually surprised by what we found," said Dr. Timothy S. Carey, a professor of medicine at the University of North Carolina and the study's lead author… "A major reason for the increase in cost for back pain is not just that people are seeking a lot of care, but that there is a lot of back pain out there," Carey said. "We may need to rethink our way of dealing with this problem."

According to the study, 3.9 percent of North Carolina residents surveyed in 1992 said that they had debilitating, chronic back pain. That number rose to 10.2 percent by 2006, the researchers said.

The methodology of the study didn't enable researchers to ascertain the reasons for the increase in chronic lower back problems, but there are several possibilities, Carey said. One is the increase in obesity. Another is an increase in the prevalence of depression, which has been linked to back pain. Carey said that it's unclear whether back pain causes depression or whether people with pre-existing depression are more likely to develop depression.

What is clear is that chronic lower back problems remain a major public health problem. "While no one dies from mechanical back pain, it is one of the most common reasons for work disability," Carey noted. The bill for lost productivity and back-related health care totals about $100 billion a year, he added. "In one sense, we're all paying for back pain. It ends up being reflected in our health insurance premiums and our Social Security disability costs," he said.

• 629 percent increase in Medicare expenditures for epidural steroid injections;
• 423 percent increase in expenditures for opioids for back pain;
• 307 percent increase in the number of lumbar magnetic resonance images among Medicare beneficiaries;
• 220 percent increase in spinal fusion surgery rates.

Dr. Deyo and his colleagues concluded that "Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain." He notes that these approaches often are applying an acute care model to chronic pain and not acknowledging the current evidence that chronic pain requires a different approach and that there are "no magic bullets." In a "chronic care model" chronic back pain, like diabetes or asthma, "is a condition we can treat but rarely cure." Deyo suggests the solution is that "chronic back pain may benefit from sustained commitment from health care providers; involvement of patients as partners in their care; education in self-care strategies; coordination of care; and involvement of community resources to promote exercise, provide social support, and facilitate a return to work."

Over past several years many of my training participants have wondered what the role of methadone should be in non-cancer chronic pain management. I've also noted many treatment programs are now seeing people who have run into serious problems from the use of methadone as a chronic pain medication. Like any pain management prescription, methadone can be beneficial under certain circumstances or cause problems, sometimes even death. Negative consequences are more likely to occur if a person is taking other medication; especially any of the benzodiazepines.

Methadone is a synthetic opioid with potent analgesic effects. Although it is associated commonly with the treatment of opioid (opiate) addiction, it may be prescribed by licensed family physicians for analgesia. Methadone is listed on schedule II of the Controlled Substances Act. Initially, its use was limited to "detoxification treatment" or "maintenance treatment" within U.S. Food and Drug Administration-approved narcotic addiction programs. This restriction was removed in 1976; all physicians with appropriate Drug Enforcement Agency registration are now allowed to prescribe methadone for analgesia. An indication, such as "for chronic pain," may be added to the written prescription to clarify its purpose. State laws vary regarding this documentation requirement. Not all pharmacies stock methadone because of its association as a treatment for heroin addiction.

Side effects associated with methadone are similar to those incurred with other mu-opioid agonists, including pruritus (an itch or a sensation that makes a person want to scratch), nausea, constipation, confusion, sedation, and respiratory depression. Excess sweating (diaphoresis) and flushing are common with oral methadone dosing. Caution should be taken with initiation of therapy and dosage increases because severe toxicities may not become apparent for two to five days. In a study of patients who converted to methadone therapy in an outpatient setting, 20 of 29 participants experienced some degree of toxicity, most frequently mild drowsiness, during initial titration. Side effects such as sedation and respiratory depression increase when methadone is combined with alcohol or other drugs. An Australian study found benzodiazepines present in 74 percent of deaths related to methadone and urged particular caution when prescribing methadone with benzodiazepines.

This February a new report came out on MedpageToday.com reporting information from The Journal of Pain, (Vol 10, No 2 [February], 2009: pp 113-130) titled Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Excerpts are posted below. You can read the entire report here. You can view a PDF Version of the journal article as well.

Although methadone has become an increasingly popular option for treating chronic pain, it is one of the most unpredictable opioids and should be used cautiously, according to new guidelines issued this week.

The methadone caution was one of 25 recommendations in the guidelines, developed by the American Pain Society and the American Academy of Pain Medicine and published in the February issue of the Journal of Pain.

The guidelines were based on an extensive literature review and analysis, published as separate papers in the journal. They are the first joint guideline effort of the two societies.

"Use of methadone for chronic non-cancer pain has increased dramatically," wrote Roger Chou, M.D., of Oregon Health and Science University here, and colleagues on the guideline panel. But they noted that its pharmacokinetics and clinical effects are highly variable, and the drug has been associated with prolonged[heart] arrhythmias, and an increasing number of deaths.

For these reasons, the guidelines recommend that clinicians start with low doses of methadone -- 2.5 mg every eight hours in opioid-naive patients -- and titrate slowly. Some patients may need 12 days to achieve a steady state, the authors said. They also recommended that methadone never be used for breakthrough pain or be prescribed "as needed."

A California orthopedic surgeon—Dr. Robert England—has received a patent for a process he says can objectively determine whether someone is in chronic pain. This could be a big help for people with chronic pain conditions like fibromyalgia, who sometimes have a hard time convincing others that their pain is real and is severe enough to substantially limit their activities.

People living with chronic pain often receive negative messages from their healthcare providers. They have been told "it's all in your head," "you need to try harder," or maybe "you're making yourself hurt so you can get drugs." Another phrase I have heard from doctors and nurses, as well as mental health and substance abuse counselors, is "they're just drug/med seeking." Early in my career, I used to think this as well. However, I have learned that what people are really seeking is relief from pain—both physical and emotional.

Patients who are not believed often do not receive adequate pain relief which I believe is unacceptable. To learn more about the right to pain relief, check out my article The Right to Quality Chronic Pain Management.

I was intrigued by Dr. England's online news story at www.recordnet.com dated February 16, 2009 about his remarkable patent and have posted excerpts below. I'm not sure how applicable this new pain measurement technology will be since it cannot rate the intensity of pain—only the presence.

England's process involves the use of functional magnetic resonance imaging, or fMRI, to capture an image of the brain. It looks at neuron activity when the patient with chronic pain receives stimulation - such as excessive squeezing of a finger or mild electrical shock - and compares it against the neuron activity in the brains of pain-free people.

The validation and measurement of chronic pain, a controversial issue in medical, legal and insurance circles, is accomplished without any input from the patient - for whom pain is highly subjective.

England sought the patent with the assistance of Physicians Resource Center LLC of Newport Beach. He has no intention of inhibiting further research but felt it was necessary to protect "a valuable piece of information. I am interested in stopping false, fraudulent and embellished claims. It's very important that people in chronic pain be heard."

Over the past 25 years I've noticed that many of the chronic patients I worked with moderate to severe coexisting psychological disorders including addiction, also suffered from moderate to severe unresolved psychological trauma—often dating back to childhood. This month I want to focus on the role of unresolved trauma in the management of chronic pain.

Research published this week in the Australian medical journal, Archives of General Psychiatry, links trauma such as emotional abuse, neglect or sexual abuse as a child, to a six-fold increased risk in developing chronic fatigue syndrome which you can read a summary of Here.

Below I have posted a few excerpts from a review written by Emily Sherlock.

Cortisol is often referred to as a "stress hormone"' and is important in regulating the body's response to stress. Low levels of cortisol may indicate decreased function of the body's main neuro-endocrine stress response system.

Individuals with chronic fatigue syndrome reported higher levels of childhood trauma exposure, the researchers said. Those with the syndrome were also were more likely than the control group to have depression, anxiety and post-traumatic stress disorder.

Cortisol levels were decreased in patients with chronic fatigue syndrome who experienced childhood trauma, but not in those with chronic fatigue syndrome who had not been subjected to trauma. "Our results confirm childhood trauma as an important risk factor of chronic fatigue syndrome,'" the study authors wrote.

The following abstract highlights this need from a report entitled "An emotional exposure-based treatment of traumatic stress for people with chronic pain: Preliminary results for fibromyalgia syndrome," that stresses the importance of treating the trauma as well as the pain. This report was published in Psychotherapy: Theory, Research, Practice, Training. Vol 45(2), Jun 2008, 165-172. I'm posting the Abstract below. There is a charge of $11.95 to read the entire Article.

Abstract
Emotional trauma occurs in many patients with chronic pain, particularly fibromyalgia syndrome (FMS). Current cognitive-behavioral treatments for chronic pain have limited effects, perhaps because the trauma is not addressed, whereas emotional exposure-based treatments improve post-traumatic stress, but have not been tested on chronic pain. The authors present a novel, brief treatment protocol for people with chronic pain and unresolved trauma (Multi- Stimulus, Multi-Technique Emotional Exposure Therapy), which involves detecting avoidance of a range of emotion-related stimuli, implementing exposure techniques tailored to the patient's avoidances, and negotiating the process and therapeutic alliance.

This treatment was pilot tested on 10 women with intractable FMS and trauma histories. Three months post-treatment, the sample showed moderate to large effects on stress symptoms, FMS impact, and emotional distress; and small-to-moderate improvements on pain and disability. Two patients showed substantial improvement, four made moderate gains, two showed modest improvement, and two did not benefit. This pilot study suggests that emotional exposure treatment for unresolved trauma may benefit some patients with FMS. Controlled testing of the treatment for FMS and other chronic pain populations is indicated.

Many people living with chronic pain are looking for treatment approaches that not only work for them but are affordable. And if they're not, they really need to. In the era of HMOs and cost containment, effective treatment has been hard to come by. Unfortunately in the short term, it is more "cost-effective" for a healthcare provider to write a script for pain medication than to make sure the patient receives multidisciplinary interventions; much less be offered alternative (i.e., Holistic or nonpharmacological) approaches such as acupuncture, chiropractic, psychotherapy, Tai Chi, Yoga, etc.

In this posting I want to point out the need for utilizing alternative approaches that are complementary with main stream medical approaches in order to provide the best possible treatment plan for someone living with chronic pain.

I recently read an online article titled "Alternative Medicine to the Rescue" from the San Francisco Chronicle written by Deepak Chopra. Although this article is not specifically about chronic pain, it does make a wonderful point that can be applied to pain management treatment. I'm posting an excerpt from that article below. The entire article can be found at the San Francisco Chronicle.

One of the hidden downturns in the current economic crisis is occurring in medicine. People have stopped going to the doctor in alarming numbers — some hospitals report a 40% cancellation rate in appointments among heart patients. Most of these are follow-up patients who need to be told how to manage their condition, usually after surgery. But faced with high co-payments, it's easier to stay home and remain untreated.

If only this country had a cheap, easily accessible system where wellness and long-term prevention could be attended to? We do have such a system. It's called alternative medicine.

For decades, mainstream medicine has looked on CAM — complementary and alternative medicine, as the government labels it — with barely disguised suspicion. CAM has managed to squeeze into medical school curriculums, just barely. At last count 64% of medical schools, including all the elite ones, offer courses outside mainstream disciplines. But only a fraction of a young doctor's education is devoted to alternative treatment, which should bother the American public, since this small fraction includes minimal hours spent learning about prevention and wellness. To the chagrin of the AMA [American Medical Association], millions of patients have already voted with their wallets, making alternative treatments mainstream.

The second reference I want to cite is from a report I found entitled "Pain Management: Alternative Therapy" which can be read in its entirety at Wed Med.Com.

The term alternative therapy, in general, is used to describe any medical treatment or intervention that has not been sufficiently scientifically documented or identified as safe and effective for a specific condition. Alternative therapy encompasses a variety of disciplines including acupuncture, guided imagery, chiropractic treatment, yoga, hypnosis, biofeedback, aromatherapy, relaxation, herbal remedies, massage and many others.

In the past decade, strong evidence has been accumulated regarding the benefits of mind-body therapies, acupuncture, and some nutritional supplements for treating pain. Other alternative therapies such as massage, chiropractic therapies, therapeutic touch, certain herbal therapies, and dietary approaches have the potential to alleviate pain in some cases.

My final reference is from the Chicago Tribune that reports on a study that examined alternative treatments for chronic pain. From that article you can link to the Federal Report titled Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. I'm posting excerpts of that article below. To read the entire posting visit the Chicago Tribune.

Americans frequently use complementary and alternative medicine (CAM) to deal with chronic pain, according to a comprehensive federal survey. Thirty-eight percent of adults and 12 percent of children use some form of CAM, which is also called "integrative' medicine, according to the report by the National Center for Health Statistics. Unlike alternative treatments, CAM methods are often used in conjunction with conventional treatment practices.

For adults, CAM use has remained steady since the last survey was taken in 2002. But the most recent data shows increases in the use of acupuncture, deep breathing, meditation, massage therapy and yoga.

What the study doesn't reflect is how many people are interested in CAM "but don't know how to pursue it," said Robert Dumont, a Loyola University Health System pediatrician who practices CAM--including Chinese medicine, herbal, acupuncture and homeopathy--and was not involved in the research. Adults used CAM most often to treat pain including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions.

The most commonly used CAM therapies among U.S. adults were:

• Nonvitamin, nonmineral, natural products (17.7 percent) Most common: fish oil/omega 3/DHA, glucosamine, echinacea, flaxseed oil or pills, and ginseng
• Deep breathing exercises (12.7 percent)
• Meditation (9.4 percent)
• Chiropractic or osteopathic manipulation (8.6 percent)
• Massage (8.3 percent)
• Yoga (6.1 percent)

Early in my career I discovered that the clients I worked with who were living with chronic pain fared much better when a multidisciplinary treatment approach was used that included treating the entire person. That is why I developed the Addiction-Free Pain Management® (APM) System; an important component of which is to develop nonpharmacological approaches in addition to medication management to cope with the psychological and emotional components of chronic pain. One such non-pharmacological approach I've used with great success over the years is many different versions of music (acoustical) and art therapy.

Recently I was conducting research and came across a website new to me and found an interesting posting which discusses the use of art and music in pain management. If you want to read the entire posting please visit Science Blogs.Com.

A team led by Laura Mitchell recruited 80 people to bring their favorite song to the laboratory, where they would be paid to dip their hands in frigid water for as long as they could tolerate it. The musical selections they chose ranged from works by Johnny Cash, to The Verve, to Rancid. The volunteers first dipped their hand in warm water to bring it to a consistent 32°C. Then they held it in a circulating cold water bath at 5°C -- close to freezing! This was repeated three times -- once while listing to their favorite song, once while staring at a blank wall, and once while looking at a work of art they selected from 15 chosen by the experimenters. They were told to hold their hand in the water as long as they could stand it, or five minutes, whichever came first. Did listening to the music affect their ability to tolerate pain?

While listening to music was best, participants who viewed the artwork rated their ability to distract themselves from the pain as significantly higher compared to when there was no distraction (again, on a scale of 0-100). Perhaps it was the combination of factors: the music, the scenery, the comfort in being cared for by a family member, which combined to make me feel better at my uncle's office compared to the public clinic. But in any case, it seems clear that allowing patients to choose their own music while experiencing pain does indeed go a long way toward mitigating that pain.

The art part of this experiment tends to validate one of my favorite chronic pain management tools that I call "Avoidance by Distraction." When I work with patients I help them find something rewarding and interesting to focus their attention on experience some relief from the constant pain. One woman said that when she focused on being really present with her grandchild she didn't even notice her pain symptoms. Again, using art, music and other "right-brain" modalities can be a useful addition to any chronic pain management plan.

Researchers found that music brought about a 21% reduction in pain levels as well as a 25% drop in depression linked to pain. The researchers said patients felt the pain less disabling with music therapy. There was no significant difference between those who could chose their own music and those who could select from five recordings given to them.

Dr. Sandra Siedlecki, team leader, said the study showed that music has a significant beneficial effect of pain reduction, less depression, less disability and increased feelings of power. She added that many sufferers of non-malignant pain continue to experience high levels of pain despite using medication. Anything that can provide relief is welcomed. The team concluded that music does have an important role to play in modern healthcare.

News & Research Archive — Here is a history of past Research for 2009, 2008 or 2007