Tagged Pain-Relieving Drugs

When It’s Not Just a Boo-Boo: The Push to Treat Children’s Pain

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Credit Sally Deng

It began with a roller-skating accident three years ago. Taylor Aschenbrenner, then 8 years old, lost her balance amid a jumble of classmates, tumbled to the floor and felt someone else’s skate roll over her left foot. The searing pain hit her immediately.

The diagnosis, however, would take much longer. An X-ray, M.R.I.s, a CT scan and blood tests over several months revealed no evidence of a break, sprain or other significant problem. Taylor’s primary symptom was pain — so severe that she could not put weight on the foot.

“Our family doctor first told us to give it some time,” said Taylor’s mother, Jodi Aschenbrenner, of Hudson, Wis.

But time didn’t heal the pain. After about a month, an orthopedist recommended physical therapy. That didn’t end the problem, either. “I couldn’t walk or play outside or do anything,” Taylor said.

After she had spent a year and a half on crutches, her orthopedist suggested she see Stefan Friedrichsdorf, the medical director of pain medicine, palliative care and integrative medicine at Children’s Hospitals and Clinics of Minnesota. He and his team promptly recognized Taylor’s condition as complex regional pain syndrome, a misfiring within the peripheral and central nervous systems that causes pain signals to go into overdrive and stay turned on even after an initial injury or trauma has healed.

He came up with a treatment plan for Taylor that included cognitive behavioral therapy, physical therapy, mind-body techniques, stress-reduction strategies, topical pain-relief patches and a focus on returning to her normal life and sleep routine.

“That turned things around so fast, if I didn’t see it myself, I wouldn’t have believed it,” Mrs. Aschenbrenner said. “I thought, ‘finally, someone understands what this is, has experience with it, and knows how to fix it!’”

But why did it take so long for a child in unbearable pain to find relief? Experts say children’s pain is, for the most part, grossly underrecognized and undertreated.

“Unfortunately, in 2016 pain management in the United States and all Western countries is still abysmal,” said Dr. Friedrichsdorf, who noted that pediatric pain receives the least attention. “Data shows that adults with the same underlying condition will get two to three times as many pain medication doses as children.”

There are effective treatments. But pediatricians, specialists and even parents have been slow to turn to them because pain in children has long been misunderstood and medical training in pain management is scant. Veterinary schools require “at least five times more education on how to handle pain” than medical schools, Nora D. Volkow, the director of the National Institute on Drug Abuse, said..

As recently as the 1980s, babies would routinely undergo invasive medical procedures, including open-heart surgery, without anesthesia or analgesics because physicians believed that infants’ brains were not developed enough to feel the pain. And it was thought that even if babies did feel pain, it wouldn’t ultimately matter because they wouldn’t remember it later on.

The emphasis in Western medicine has traditionally been on “saving lives and executing medical procedures effectively, while pain has been pushed way down on the priority list,” said Christine Chambers, a professor of pediatrics, psychology, neuroscience and pain management at Dalhousie University in Halifax, Nova Scotia.

Many doctors and parents also fear that pain medications will have dangerous side effects, like developmental problems and addiction. But current scientific evidence supports a different conclusion.

“Research shows that poorly managed pain exposures early in life can actually change the wiring in the brain and prime children to be more sensitive to it later on, putting them at risk for developing chronic pain in childhood and adulthood,” said Anna C. Wilson, a child psychologist and assistant professor of anesthesiology at the Pediatric Pain Management Center at Oregon Health & Science University. And while babies or young children may not consciously remember it, their nervous systems will.

There is, however, reason for optimism. Contrary to previous conventional thinking, the effective use of pain medication for children does not hinder brain development, according to several studies.

Research has also shown that the appropriate medical use of prescription pain medications, such as opioids, when properly monitored, does not lead to addiction in young children and adolescents, Dr. Friedrichsdorf said.

A host of other behavioral interventions have been shown to prevent and treat pain as well. Pain experts say these can and should be used even during seemingly minor medical procedures, such as vaccinations. Parents can hold their children during the procedure, breast-feed or give them a sweet solution to suck on, distract them with a song or breathing exercises, and use a topical numbing cream.

One recent study also found that a parent’s behavior and approach to their children’s vaccinations can affect a child’s response to needles.

“That vaccination at age 5 might not seem like a big deal to you, but if it goes wrong and causes a lot of pain, then the child becomes fearful,” Dr. Chambers said, which can perpetuate a cycle of fear and pain over medical care.

“One of the best ways to address the epidemic of chronic pain in this country is to stop it before it starts,” Dr. Wilson at Oregon Health & Science University said.

“If we could reduce painful experiences and problems in childhood, we might be able to reduce chronic pain in the next generation.”

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Opioids Often Ineffective for Low Back Pain

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People with chronic low back pain are sometimes prescribed opioids for pain relief, but a review of studies has found them generally ineffective.

The analysis, in JAMA Internal Medicine, pooled data from 20 high-quality randomized controlled trials that included 7,295 participants. The studies tested various narcotics; most of the studies were funded by pharmaceutical companies. Seventeen of the studies compared the opioid with a placebo, and three compared two opioids with each other. None had a follow-up longer than 12 weeks.

The drugs relieved pain slightly, but the effects were not clinically significant, and the medicines did little to improve disability. There was some evidence that larger doses worked better, but most trials had high dropout rates, some up to 75 percent, because of adverse side effects or inefficacy.

Measured on a 100-point scale, the magnitude of relief did not reach the 20-point level the researchers defined as clinically effective, little different from Nsaids like aspirin.

The lead author, Andrew J. McLachlan, a professor of pharmacy at the University of Sydney, said that often the solution for back pain is exercise regimens, staying active and reassurance from the doctor that the pain will go away.

“All these trials point in the same direction,” he said, “and this gives us the information to make decisions about clinical care. The first question is: Will these medicines help, and will they be safe?”

Sometimes Pain Is a Puzzle That Can’t Be Solved

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Credit Brian Stauffer

My elbow is killing me.

I mean that quite literally. Yes, it hurts, but it is also destroying me, the me as I was without a bad elbow, a happily balanced collection of parts all working modestly, silently, efficiently toward a common good. Kidneys, liver, knees, elbows — what a great team we were. I put my hands in my pockets without wincing, typed without thinking, sat at work judiciously evaluating everyone else’s distress.

My elbow is erasing all those iterations of me.

It’s a common problem: extensor tendinitis, otherwise known as tennis elbow. I do not play tennis; my mistake was painting two dozen bookcases all by myself a few years ago. The back and forth of brush and roller apparently tore enough fibers in my tendon that almost anything makes the left elbow throb now — leaning on it, twisting it, sleeping one degree off the angle it prefers, the little tyrant.

I am ruled by my elbow. The days it feels good are rare and happy. Otherwise, it is my constant companion, whimpering and tugging at my sleeve.

At work, we are in the middle of a giant paradigm shift in pain treatment. I listen to the plaints of patients trapped in the new normal. Some past doctor, in the spirit of times gone by, once decided to eradicate their pain with whatever it took. Now I am supposed to remove them from the substantial quantity of opioids that, apparently, was what it took.

“Nothing else works!” they scream. “My back (or neck or leg) is killing me!”

Meanwhile, the elbow and I struggle on. No opioids for me, not now or ever. I never liked those drugs, have never taken them, and prescribed them sparingly even back in the day.

But I do understand the vagaries of pain treatment. Anti-inflammatories like naproxen and ibuprofen might as well be cornflakes, for all the good they do my elbow. Tylenol is remarkably effective, but a steady diet can’t be healthy, so I try to be sparing.

The counterirritant capsaicin cream is oddly helpful too, replacing that gnawing ache with a superficial burn that is far easier to ignore.

But the hands-down single best treatment for my elbow is a drink. One large glass of wine, and the pain vanishes. Then I am myself again, whole and unencumbered as the elbow sleeps peacefully by my side.

Were I a manual laborer, I would have headed for steroid injections or surgery long ago. Were I less risk-averse, I’d be heading there right now. Were I genetically predisposed or cursed with a lower pain threshold, I might have just a smidgen of an alcohol problem.

And were I a different socioeconomic version of myself, I suspect that my Tylenol might be Percocet and my alcohol might be heroin, and at this very moment, I would be screaming at some poor doctor that nothing else works.

Medical fashions change all the time. Rarely has the U-turn been as tight as it has been with pain control.

First we were zooming along in one direction: “When Will Adequate Pain Treatment Be the Norm?” a 1995 editorial in The Journal of the American Medical Association demanded. Now we are inching along in the opposite way: “Zero Pain is Not the Goal,” an editorial published in the same journal last month affirmed.

We know more about the tangled neural circuits of pain, pleasure and addiction than we used to. We also know more about the tangled social circuits that turn pain pills into gateway drugs.

Unfortunately, none of this knowledge has translated into new treatments. We have the usual handful of alternatives, often just so many cornflakes to the opioid-experienced. Nonpharmaceutical approaches to pain treatment (Exercise! Stretch! Be mindful!) generally just don’t fly.

I suspect neither the pain control mantras of the 1990s nor the ones I hear today are entirely true. No, we cannot eradicate all pain, nor should we try.

But yes, it is possible for some people to live normal, law-abiding lives on long-term opioids for pain control.

We are now being expertly assisted in the responsible prescribing of opioids with a flurry of new guidelines. So far, none of them has been particularly helpful as we try to distinguish among patients who are physically dependent on the drugs, those who are financially dependent on the proceeds from selling the drugs, and those who just need something for when the pain gets bad.

Not to mention those who are two of the above, or all three.

The elbow has been just about as unhelpful as the guidelines in these adjudications.

“Cornflakes!” it will snort on occasion. “Why don’t you give that poor fellow sufferer something that will actually work?” But it also continually, smugly, silently demonstrates that a person can live a normal, fully functional life with incompletely treated pain.

That accursed elbow is always introducing some nagging doubt into everything I might otherwise be happy to believe. As I said, it is killing me.

Ask Well: Do Pain Relievers Heal Tendinitis, or Just Ease Pain?

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Credit Hiroko Masuike/The New York Times

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Seeking Painkillers in the Emergency Room

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Credit Stuart Bradford

A couple of months ago, a patient well known to the emergency room where I work came in requesting his usual cocktail of narcotic pain medications. It was early Saturday morning, before the usual bustle of patients had begun, and I had some time.

The patient was well documented in the electronic medical record for his frequent emergency room visits for painkillers. To further confirm, I called his pharmacy, and as soon as the pharmacist heard the patient’s name, he sighed loudly, said he knew him well, and began listing the litany of different doctors and hospitals from which the patient had gotten narcotic painkillers.

I then sat down with the patient for a good 25 minutes — a considerably long time in a busy, urban emergency room— and explained why I could not give him what he wanted. It was clearly stated in his medical record that he had an extensive history of opioid abuse, and the shopping-around for prescriptions, as suggested by his pharmacy, further validated that. I knew if I waved him off with another supply of painkillers, I would only perpetuate his addiction problem.

He protested loudly and repeatedly said, “I don’t know why you can’t be like all the other docs and just give me the drugs. Everybody does it.” Finally, realizing that he would not get what he wanted, he stormed out after shouting at me: “If you doctors don’t want me taking the drugs, why’d you all give me all those pills after my surgery last year?”

Patients like him are not uncommon in the emergency room. A 2014 study confirmed that from 2001 to 2010, the percentage of emergency room visits during which opioids were prescribed jumped by 10 percent. My patient’s story stuck with me because I was actually able to spend time counseling him instead of caving to his request — and because he had the insight to know that his addiction started with a doctor’s prescription.

The opioid epidemic is explosive, and laws are being passed to address the problem. Two-thirds of emergency room visits involving overdoses are due to prescription drugs. The highest number of deaths caused by opioid painkillers was in 2014. The data for 2015 has yet to be released.

But, as one of my colleagues whom I greatly respect said to me in the emergency room recently: “Why wouldn’t I give patients a Percocet prescription? It makes their life easier and my life easier.” Another colleague overhead this and wholeheartedly agreed, speaking truth to the fact that the system is set up so that refusing these demands is much more difficult and time-consuming than it is to simply give in to them.

I know it, too. I’ve had patients seeking painkiller prescriptions who kept the hospital administrator’s number in their cellphones and have called pre-emptively before I’ve even had a chance to talk to them. I’ve had patients who’ve had tremendous outbursts in the emergency room, completely disrupting care and taking up the time and attention of many of the hospital staff members, often to the detriment of other patients. This sometimes results in my colleagues asking if I could simply prescribe a couple of pills so the patients would leave.

Several years ago, I even had a patient formalize a letter of complaint to the state health department that I did not give her the opioids she requested. At the very least, I have to worry about patient satisfaction scores, which have come to be valued ever more greatly as they’re now linked to Medicare reimbursements. For individual physicians, low scores may result in a slap on the wrist or decreased pay or, in extreme cases, even be grounds for dismissal.

I appreciate that new safeguards are being implemented. In New York State, where I now work, a higher-level electronic prescribing system is rolling out to closely track and protect against narcotic painkiller over-prescribing; my colleagues and I all went through the training process and are mandated to start the new system on March 27. Under the new system, only digital prescriptions that are electronically transmitted to the pharmacy are allowed, and if a physician wants to prescribe a narcotic painkiller, an additional security verification step is required. In Massachusetts, where I used to work, a law was passed to limit narcotic prescribing to a seven-day supply after a surgery or injury.

But the truth is, a deep cultural shift within our health care system is needed. Physicians need to know that if they don’t prescribe a narcotic because it’s not clinically indicated, or worse yet, because the patient already has an addiction problem, that they have the backing of administrators at every level, from their own department to the head of the hospital all the way up to state officials. If patients are seeking narcotics and have a documented history of doing so — and become combative or refuse to leave after discharge — they may need to be escorted out of the emergency room by security and their treatment terminated to avoid interrupting the care of other patients.

What my patient said to me that Saturday morning is right: We health care providers created the problem. Now it’s up to us to take steps to try to solve it. Beyond these new prescribing laws, on-site drug counseling ought to be in place. Drug rehabiliation programs need to be expanded, and dedicated staff should be available in the emergency room to enroll patients into them directly. But it begins with doctors not jumping immediately to prescribe narcotic painkillers — and a health care system that allows them to say no.

Helen Ouyang is an emergency physician at NewYork-Presbyterian Hospital and an assistant professor of medicine at Columbia University.

Mind-Based Therapies May Ease Lower Back Pain

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Credit Stuart Bradford

Sixty-five million Americans suffer from chronic lower back pain, and many feel they have tried it all: physical therapy, painkillers, shots. Now a new study reports many people may find relief with a form of meditation that harnesses the power of the mind to manage pain.

The technique, called mindfulness-based stress reduction, involves a combination of meditation, body awareness and yoga, and focuses on increasing awareness and acceptance of one’s experiences, whether they involve physical discomfort or emotional pain. People with lower back pain who learned the meditation technique showed greater improvements in function compared to those who had cognitive behavioral therapy, which has been shown to help ease pain, or standard back care.

Participants assigned to meditation or cognitive behavior therapy received eight weekly two-hour sessions of group training in the techniques. After six months, those learning meditation had an easier time doing things like getting up out of a chair, going up the stairs and putting on their socks, and were less irritable and less likely to stay at home or in bed because of pain. They were still doing better a year later.

The findings come amid growing concerns about opioid painkillers and a surge of overdose deaths involving the drugs. At the beginning of the trial, 11 percent of the participants said they had used an opioid within the last week to treat their pain, and they were allowed to continue with their usual care throughout the trial.

“This new study is exciting, because here’s a technique that doesn’t involve taking any pharmaceutical agents, and doesn’t involve the side effects of pharmaceutical agents,” said Dr. Madhav Goyal of Johns Hopkins University School of Medicine, who co-wrote an editorial accompanying the paper.

Dr. Goyal said he sees many patients with chronic lower back pain who become frustrated when they run out of treatments. “It may not be for everybody,” he said, noting that some people with back pain find yoga painful. “But for people who want to do something where they’re using their own mind to help themselves, it can feel very empowering.”

One of the strengths of the study, published in JAMA on Tuesday, was its sheer size. It included 342 participants ranging in age from 20 to 70. They were randomly assigned in equal numbers to either mindfulness-based stress reduction, cognitive behavioral therapy, or to continue doing what they were already doing.

Sixty-one percent of participants who received meditation training experienced meaningful improvement in functioning six months after the program started, slightly more than the 58 percent who improved with cognitive behavioral treatment but far exceeding the 44 percent who improved with their usual care.

Those who got cognitive behavioral therapy had greater improvement when it came to a measure called “pain bothersomeness,” with 45 percent gaining meaningful improvement compared with 44 percent in the meditation group. But both these treatments were more effective than the usual treatment, which led to improvement in only 27 percent of people.

The benefits were limited, but that’s not really surprising, said the study’s lead author, Daniel Cherkin of Group Health Research Institute in Seattle. “There are no panaceas here. No treatment for nonspecific back pain has been found to make a whole lot of difference for many people.” While some treatments may help some people, he said, they don’t work well for others, which is why it’s important to be able to offer lots of options.

Mindfulness-based stress reduction was developed in the 1970s by Jon Kabat-Zinn, a scientist in Massachusetts who adapted Buddhist meditation practices for an American audience. The goal is for meditators to increase their awareness of their experience and of “how it’s affecting them and how they’re responding to it,” said Dr. Cherkin, adding that the idea is for participants “to change their mind-set and, in a way, almost befriend the pain, and not feel it’s oppressing them.”

The new study is the second showing that meditation may help people manage chronic lower back pain. Earlier this month, researchers at the University of Pittsburgh School of Medicine reported in JAMA Internal Medicine that mindfulness meditation helped older adults manage their pain for up to six months, though the improvements in function did not persist.

Access to mindfulness-based stress reduction can be problematic, however. Training by certified instructors is not available everywhere, and may not be covered by health insurance.

But the need is tremendous. Back pain is a leading cause of disability worldwide and the second most common cause of disability for American adults.

One in four adults in the United States has had a bout of back pain within the past month, according to national health figures, and back pain that has no clear underlying cause can be tough to treat, often improving only to flare up again weeks to months later.

Dr. Cherkin said mindfulness-based stress reduction may be particularly helpful for people because even if their use lapses, they develop a skill they can draw on later when they need it.

“That suggests that training the mind has potential to change people on a more lasting basis than doing a manipulation of the spine or massage of the back,” techniques that may be “effective in the short term but lose effects over time,” Dr. Cherkin said. “You can practice it by waiting at the bus stop and just breathing.”

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