Tagged Pain

New Guidelines Cover Opioid Use After Children’s Surgery

Opioids are very effective drugs for managing pain, but they can also be scary drugs, with their potential for misuse and abuse. Given the current opioid epidemic in the United States, some parents worry about whether they are safe for children, while many pain experts worry that fear of opioids among parents and among physicians may contribute to the undertreatment of pediatric pain.

In new guidelines published in November in the journal JAMA Surgery, a panel convened by the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee set out some guidelines for how to think about — and prescribe — opioids for children to relieve pain after surgery. “It’s important to understand that children undergo a lot of painful procedures,” said Dr. Lorraine Kelley-Quon, a pediatric surgeon at Children’s Hospital Los Angeles, who was the lead author on the guidelines. “They have real pain; opioids can help.”

Matthew Kirkpatrick, an addiction expert who is an assistant professor in the department of preventive medicine at the Keck School of Medicine at the University of Southern California, and who was one of the authors of the new guidelines, said, “We don’t want to contribute to scaring parents and to scaring physicians about undertreating pain.” From the data they reviewed, he said, “kids that use these medications as prescribed are at very low risk for abuse and dependence either in the short term or the long term.”

However, the first six statements in the guidelines discuss the risks of adolescents misusing prescription opioids (misuse is anything other than use exactly as directed by the prescriber, or use without a prescription), diverting them (giving them away or selling them), and possibly having a higher risk of problems with opioids in the future. Dr. Kelley-Quon pointed out that many health care practitioners may not be familiar with the addiction literature. But some pain experts warn that heavy emphasis on that risk as a way of framing the issue may frighten both parents and doctors.

Dr. Elliot Krane, the chief of pediatric pain management at Stanford Children’s Health, who was not an author of the new guidelines, said, “the concern is that the paper is going to discourage the appropriate use of opioids, though I know that wasn’t the intent of the authors — the reason I think that’s the risk is they set up their recommendations with a premise which I think is untrue, that kids are dying and becoming addicts” at an increasing rate.

Dr. Krane disputed some of the statements about the risk: “I think the evidence that opioid abuse is increasing in children is very weak; I think the evidence in children that prescription opioids lead to later abuse isn’t there at all.”

Dr. Scott Hadland, a pediatrician and addiction specialist at Boston Medical Center, who was not involved with the guidelines, said, “While I agree with the recommendations, I agree also with the concern from the pain community that risk may be overstated — may not be as large as some of the earlier studies have suggested.”

The guidelines recommend non-opioid medications as first-line postoperative drugs, including the use of regional anesthesia.

But when opioids are used, the guidelines stress careful supervision. “It all boils down to access,” Dr. Kirkpatrick said, and the imperative is to make sure that parents and physicians get the right information “to manage the dispensing of the medication to their kids and the access that their kids have to the medication.” Parents should not be afraid of managing the child’s pain with opioids when they are needed, but should understand the importance of controlling that access in children and through adolescence.

“The parent should be highly engaged in managing the child’s pain, in making sure the child gets the medication to manage the pain, but the child does not have access to the drug on their own.”

Dr. Kirkpatrick said that overprescribing by physicians has contributed to opioid use and misuse in adults. In data from a national survey on drug use and health, he said, kids were most likely to get medication they had misused from friends or family members, but when they were asked where that person had gotten it, it was often from a doctor.

Dr. William Zempsky, the division head of pain and palliative medicine at Connecticut Children’s Medical Center, who was not an author of the guidelines, said that while opioids have been prescribed inappropriately to adults in some settings, there is no clear evidence that it has been a problem in pediatrics.

“We need to do things right, but we don’t need to scare people,” Dr. Zempsky said. “Kids continually are at risk for lack of appropriate postoperative surgical management because of fear of opioid addiction.”

Dr. Eugene Kim, the chief of the division of pain medicine at Children’s Hospital Los Angeles, who was one of the authors of the guidelines, said, “I am aware of the caution that certain pain management experts have,” regarding the dangers of underprescribing and undertreating pain. The guidelines should be the basis for ongoing conversations, he said, as well as for responsible prescribing.

“Parents of children who are undergoing surgeries should be educated as to when to use the medications, how to use the medications, and we, as providers, should be involved in that process from the get-go as far as the education process, as far as responsible prescribing, as far as follow up.”

Some adolescents may be particularly at risk for problems with opioids, especially those who have had substance use problems in the past, and those who have mental health problems.

With patients at higher risk, Dr. Hadland said, such as those with anxiety or depression or those who have had substance abuse issues, opioids can still be prescribed when they’re needed, but “we should take great care.”

When a patient of his, a young adult who had alcohol use disorder, needed surgery, Dr. Hadland said, “I and the patient themselves were both concerned about the potential misuse of opioids because of the history of addiction.” He and the surgeon partnered, he said, and agreed that Dr. Hadland would do the postoperative pain management because he was more readily available and more comfortable working with a patient who had this history. He prescribed very small amounts of oxycodone, he said, discussing at every stage with the patient how it felt to be taking the medication. “We had open communication around it and things went really well.”

The guidelines go beyond the discussion of when opioids should be used and cover the importance of educating both children and their parents and caregivers about the possible side effects of opioids (oversedation and respiratory depression), about the importance of following medical instructions carefully, about the need for storing these medications securely (that is, in a locked area) and getting any unused doses out of the home in a safe and secure way (they should be returned to a secure opioid disposal bin).

None of the other specialists I spoke with suggested changing the specific recommendations for multimodal pain relief, for using opioids when other drugs are insufficient for effective pain control, and for good parent education leading to careful oversight, locked storage and safe disposal of unused doses.

“The spirit behind these guidelines is correct,” Dr. Hadland said. “Prescribing the lowest effective dose for the shortest period of time, use only short acting formulations, and talk to families about risks and monitoring dosing and locking up medication.”

Parents and physicians can feel safe that if kids are using these medications as prescribed to manage their pain, Dr. Kirkpatrick said, they are “not at significantly greater risk for developing opioid use related problems.”

“If your child needs surgery, talk to your doctor, ask questions about what pain should be expected,” Dr. Kelley-Quon said. Ask if opioids will be used, and if so, how should they be used, and how can they be safely disposed of, she said. “We want to be at the sweet spot, treating pain appropriately, maximizing benefit and minimizing risk.”

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


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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Sometimes Pain Is a Puzzle That Can’t Be Solved


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.

Mind-Based Therapies May Ease Lower Back Pain


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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Think Like a Doctor: Hurting All Over

The Challenge: Can you figure out what is wrong with a 36-year-old man who has had body aches for many years?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try to figure out a real-life diagnostic mystery. Below you will find the details of a case involving a middle-aged man with pains that seem to migrate from one joint to the next with no visible sign of injury.

The route to the final diagnosis was particularly circuitous. Below, I provide most of the records that were available when the diagnosis was made. As usual, the first person to solve the case gets a signed copy of my book, “Every Patient Tells a Story,” and the pleasure of puzzling out a difficult mystery.

Making a List

“Why don’t we make a list?” the young man’s wife suggested. Her husband, tall and slender, had been moving restlessly around the kitchen, but when he heard her words, he came and sat next to her. He was 36 and, for the past 20 years, had been plagued by pains that moved from one joint to the next. Sometimes it was an ankle; sometimes a knee. It could be his back or his hand or his wrist. And sometimes it was all of the above.

Over the years he’d seen a phalanx of doctors. They’d look him over, order an X-ray and then, seeing nothing, refer him to physical therapy. And he’d get better.

But then, within days or occasionally even weeks, something else would start up.

It didn’t seem right, his wife had said, over and over, during their years together. There had to be something else going on. Something bigger than whichever joint was hurting at the moment.

The Patient’s Story

The man had seen internists, orthopedists, rheumatologists. But after various thoughts and tests, none had seen a pattern that suggested anything more than the misfortune of frequent exercise-related injuries.

His wife had Googled his symptoms many times, but the only diagnosis she ran across regularly was fibromyalgia, a chronic pain syndrome. When she read up on that condition, though, it just didn’t seem to fit. Her husband sometimes had muscle pain, a characteristic of fibromyalgia, but most of the time his pain was in the joints themselves.

The patient had resigned himself to these aches and pains. His wife, however, had not. A friend of hers who’d suffered a lifetime of joint pain was recently given a diagnosis: rheumatoid arthritis. And that friend had enthusiastically recommended the doctor who had figured it out, a specialist in inflammatory diseases at Mount Sinai Hospital in Manhattan. Call her, her friend urged. She figured out a diagnosis that had puzzled others for years.

So she called. When her husband’s appointment was a week away, she suggested that they put together a list of everything odd that had happened to him. She could start the list, and he could add anything she left out.

An Expert Opinion

The day of the appointment, the wife tore the list out of her notebook and handed it to her husband. Don’t forget to show this to the doctor, she urged.

The man looked up when he heard his name called in the waiting room. The doctor smiled warmly as she walked toward him. She introduced herself and led him into the tiny exam room in the back. When she asked him about his medical history, he brought out his list.

In addition to his migrating joint pain, he’d had several other unusual medical problems that might be related. Most recently he’d been given a diagnosis of von Willebrand disease, a disorder of the blood coagulation system. He found that out after nearly bleeding to death following a colonoscopy.

He also had something called a geographic tongue. It wasn’t painful but looked odd. Areas of the tongue surface somehow are injured, leaving smooth, red, angry-looking patches amid the tongue’s normally velvety pink surface. Someone had told him that geographic tongue was a sign of psoriasis, but psoriasis typically causes a scaly skin rash, and he’d never had that. Plus he had scoliosis, or a curvature of the spine. He also had osteoporosis, even though everyone agreed he was way too young.

His symptoms dated back some 20 years. As a teenager, his lung had suddenly ruptured, a condition known as a pneumothorax. Doctors had fixed the collapsed lung, but then it happened again. That second time they’d fixed it permanently. No one could explain why that happened.

Indeed, no one could explain any of his weird medical problems.

Other people in his family were sick, but not in the same way. His mother and brother had Crohn’s, a form of inflammatory bowel disease. Crohn’s disease usually causes bloody diarrhea, but it can also make your joints and muscles ache, so one of his doctors suspected he might have it too. That’s why the patient had been given that colonoscopy that had gone wrong. But it turned out he didn’t have Crohn’s.

Normal Joints

Any redness or swelling in his painful joints?, the rheumatologist asked. Never, he told her.

Any joint stiffness in the morning? None.

Had he ever been tested for arthritis?, she asked. Oh, many times, he replied. The tests had all been negative.

He never smoked, never drank, never used any illegal drugs. He hardly even took Tylenol. He was vegan and took vitamin B12 daily to make certain he didn’t run out of this essential nutrient, which is found in meats. He was married, had two children (both pretty healthy) and worked as a lawyer. He exercised most days, even when his joints hurt.

On exam, the doctor found a few clues. There was the geographic tongue he’d already told her about. And his fingernails had tiny longitudinal ridges, something that can be normal but that is also seen in certain types of arthritis. However, his joints, the source of his main complaint, seemed completely normal. There was a little bit of tenderness in the sacroiliac joint, where the two bones that make up the hip girdle meet. However, even here there was no redness, no swelling, nothing abnormal.

A Confusing Picture

Whatever the patient had, it certainly wasn’t obvious, the rheumatologist told him once he’d gotten dressed.

One possibility she was considering was a condition called psoriatic arthritis, or PsA, an unusual and aggressive type of inflammatory arthritis that can affect people with psoriasis. The geographic tongue, the ridged nails, the family history of Crohn’s disease were all seen in psoriatic arthritis. And in PsA, the usual tests for arthritis will be negative.

But it wasn’t a slam dunk. The patient clearly didn’t have psoriasis — at least not yet. But the arthritis could precede the skin rash, sometimes by years. And although most people with psoriatic arthritis have pain, swelling and redness as well as severe bone destruction, some have only mild symptoms, like this man.

She’d get some blood tests to look for inflammation, she told the patient, and gets X-rays to look for the kind of bony destruction psoriatic arthritis can cause. But even if those tests weren’t informative, she planned to start him on a very gentle medicine that was effective in reducing the pain and joint destruction.

A Drug Trial

The blood tests and X-rays were unrevealing, and so at the next visit she started the patient on sulfasalazine, one of the oldest drugs used to treat both inflammatory arthritis and inflammatory bowel diseases (like Crohn’s).

He took the drug for three months. No relief. She gave it another few weeks. Still, nothing. Perhaps this wasn’t an inflammatory arthritis after all.

There was one final treatment she could try. If he didn’t respond to a week of daily prednisone, a steroid pill, he wasn’t likely to respond to any of the other anti-inflammatory medications used in the treatment of these diseases.

The steroid did nothing but keep him awake at night. The constant roving joint pains continued unabated.

The doctor was disappointed but clear. Whatever he had, it wasn’t an inflammatory disease. She was sorry, but she didn’t think she could help him.

You can view the rheumatologist’s notes here.

Rheumatology Notes

These are the doctor’s notes.

You can view the lab results here.

The Patient’s Labs

Here is a copy of the lab report.

Solving the Mystery

The patient was discouraged but not surprised. Yet another doctor was unable to figure out why he had all these weird problems. His wife was crushed. This doctor had figured out what was wrong with her friend; why not her husband? Maybe it was just fibromyalgia. Or just really bad luck.

But the patient did end up getting a diagnosis. From an unexpected quarter. Can you figure out what this patient has?

The first person to figure out the diagnosis will get a signed copy of my book, and that great feeling you get which you solve a tough case.

I’ll post the answer tomorrow.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.