APS Press Room
| For immediate release May, 2006 |
Contact: Chuck Weber (847) 705-1802 |
NEWS SUMMARY
25th Annual Scientific Meeting
American Pain Society
The 25th American Pain Society Annual Scientific Meeting was held May 4-7 at the Henry Gonzalez Convention Center in San Antonio. Some 2,000 pain researchers and pain care clinicians attended. The focus of the meeting is on multidisciplinary pain management and research. Below are news highlights of selected plenary talks, paper presentations and panel sessions.
For further information about scientific presentations at the APS meeting and to arrange interviews with presenters and other meeting participants, contact Chuck Weber (847) 705-1802. In 2007, the APS annual meeting will be held in Washington DC, May 2-5.
IS THERE A RIGHT TO PAIN RELIEF?
Americans enjoy constitutionally protected rights to freedom of speech and religion and due process of law, but are we also entitled to a right to pain relief when we deem it necessary? That question was the subject of lively panel presentation at the 25th Annual Scientific Meeting of the American Pain Society.
On Oct. 11, 2005 the International Society for the Study of Pain (IASP) declared that pain relief is a human right. However, does this mean patients can hold health care organizations responsible if they are not treated satisfactorily for their pain?
Medical ethicist Ben A. Rich, JD, PhD, associate professor of bioethics, University of California Davis, said enforcing one’s right to effective pain care is problematic because this moral right isn’t legally binding. “In the United States, if we’re serious about something, we pass laws,” said Rich. He noted some states have mandatory continuing medical education requirements in pain care for health providers, and California has implemented a pain patient bill of rights. It acknowledges that a right to ask for pain treatment but imposes no obligation to health professionals.
Rich noted that courts have granted awards to patients who claimed their pain wasn’t treated at all. “Juries have held there is a standard of care for pain management that can be established and health care organizations can be found liable.”
He added it’s unclear what would happen legally if customary pain care practices at some institutions fail to keep up with advances in medical science. “Laypersons take the duty to relieve pain and suffering seriously and, in the future, significant monetary awards may be granted for undertreated pain.”
Rich believes that requiring continuing medical education on pain isn’t all that’s needed to achieve behavioral changes in healthcare professionals. “CME and clinical practice guidelines alone don’t change professional behavior,” said Rich. “At the local level, attention must be focused on strategies for coordinating the dissemination and implementation of findings to overcome barriers and resistance to change.”
Even though juries might be setting standards in medicine, shouldn’t the clinical context of the pain condition dictate whatever limits are imposed on patient rights to pain relief? “There are trade-offs in assessing appropriate pain care for different patients, so there is no one right to pain relief,” said Mark Sullivan, MD, PhD, professor of psychiatry, University of Washington. He said patients with acute, post-operative pain have benefited greatly from improvements in attitudes related to overstated fears of addiction, exaggeration and malingering. For these patients, trade-offs to pain relief are medical risks associated with morphine and other analgesics.
Trade-offs for treating pain at the end of life swing heavily toward providing the most effective relief possible. “In palliative care, pain relief rises in importance because disease cannot be stopped, therefore, the right to pain relief is unqualified,” said Sullivan. He added that in these cases physicians must balance pain relief and life preservation, and providers shouldn’t intentionally hasten death.
Perhaps the most problematic cases are relatively healthy and younger individuals who suffer chronic non-cancer pain. “This type of pain occurs in the midst of life, and pain relief may increase overall quality of life or decrease it through side effects, impaired functional capacity or addiction,” said Sullivan. He noted that patients’ rights in clinical settings can counterbalance their traditional passivity and feelings of powerlessness. However, the meaning of a right to pain relief for outpatients still is unclear. “Since pain and suffering cause each other, there are no clear limits to the right to pain relief. The duties to provide pain relief in these patients are undefined,” Sullivan said.
MIGRAINE INTENSITY LINKED TO SEX HORMONES
A panel of noted migraine experts presented data showing that sex hormones, especially estrogen, can influence the frequency and severity of migraine headaches. Some 28 million Americans or 13 percent of the general population are affected by migraine, which is 3-4 times more prevalent in women. Most new cases of migraine occur in women between the ages of 12 and 40 years, which suggests a role for estrogen and other sex hormones in the migraine process.
According to Nabih M. Ramadan, MD, professor and chair, Department of Neurology, Rosalind Franklin University of Medicine and Science, North Chicago, Ill., the highest prevalence of migraine attacks occurs at the time of the menstrual cycle when estrogen levels are rapidly declining. Normally that is just before the first day of menstrual bleeding. Ramadan said there is evidence that declining estrogen levels cause sensitization of the nervous system and up-regulation of inflammatory systems, which in turn activates pain pathways including those involved in migraine.
David M. Biondi, DO, director of clinical research and development for Ortho-McNeil Neurologics, Titusville, NJ, said women who have migraine and take estrogen-based oral contraceptives might experience worsening of their migraines during the blank or placebo tablet week. He advised that women with predictable menstrual-related migraines can try to prevent them before they start by following a short-term prevention strategy of taking scheduled NSAID or triptan dosages two to three days before and continuing through menstrual flow. Some breakthrough headaches might occur but are usually less intense and more easily relieved with acute treatments. Biondi added that long-term prevention might be needed in some cases by taking a medication every day, such as specific beta blockers or anticonvulsants that are FDA approved for migraine prophylaxis in adults. Patients are advised to discuss specific treatment options with their health care professional.
Dawn Buse, PhD., a psychologist and assistant professor of neurology at Albert Einstein College of Medicine, Bronx, NY, said her review of more than 200 published studies showed conflicting results and did not reveal enough definitive evidence to develop treatment guidelines regarding the use of estrogen-based oral contraceptives in women with migraine. One noteworthy exception is the increase in risk for serious adverse events that include stroke for women who have migraine with aura, take estrogen-based oral contraceptives and use tobacco.
PAIN RESEARCH REQUIRES COLLABORATION AMONG MULTIPLE DISCIPLINES
Linking the Bench and the Bedside
Despite major advances in the last four decades, pain research has yet to foster new approaches to pain management, which still rely on medications that have been available since the early 20th Century, according to noted pain researcher Ronald Dubner, PhD, professor, University of Maryland Dental School, However, he believes there’s hope for significant improvement as the National Institutes of Health is promoting interdisciplinary approaches that will more rapidly translate into clinical research and improved disease management.
Speaking as the Decade of Pain Lecturer at APS annual scientific conference, Dubner said NIH can look to the pain field as the model for interdisciplinary collaboration. “Chronic pain is such a complex condition that it requires expertise from several different disciplines, such as neurology, anesthesiology, psychiatry and others,” he said. “That’s why the merging of ideas and approaches was instrumental in the formation of major pain societies, such as the International Association for the Study of Pain and the American Pain Society. These organizations are truly multidisciplinary.”
Dubner said pain research fits well with the new NIH focus on translational research, in which discoveries in the laboratory are directly applied to clinical problems to study underlying mechanisms of disease. “Transitional research provides the link between the bench and the bedside,” said Dubner. “The new emphasis on translational research at NIH will provide increased funding opportunities for new interdisciplinary approaches to the study of diseases and the translation of basic findings into the clinical arena. The key issue for the pain research community is how can we take advantage of these new funding opportunities?”
Dubner noted that pain research has not been well funded by NIH in the past and cited a study published in The Journal of Pain last year showing that just 1 percent of NIH research dollars are allocated for pain studies, despite widely accepted estimates that 50 million Americans suffer from some type of persistent pain. “It’s clear from the grant-tracking data there are clinical conditions associated with pain that are being overlooked by basic and clinical research scientists and funding agencies,” said Dubner.
Dubner cautioned that researchers, clinicians and patients must realize there will be no cure-all breakthrough for treatment of persistent pain, but advances in genetics and brain imaging should make great strides toward improving our understanding of pain mechanisms. “”Large-scale research projects are the wave of the future and will require collaboration among multiple disciplines, the NIH and industry,” said Dubner. “The NIH roadmap for translational research can provide the merging of innovative ideas to achieve our goal of finding new approaches to pain management during the latter half of the Decade of Pain Control and Research.”
NERVES FROM ABNORMAL GROWTHS HELP EXPLAIN PAINS OF ENDOMETRIOSIS
Endometriosis (endometrial tissue located outside the uterus) can produce a wide range of pain symptoms, from none to pain throughout the body. Surgery to remove the abnormal tissue (implants) relieves the pains in some patients, but in others it fails to provide relief or the pain may recur without evidence of residual or recurrent disease.
Speaking in a plenary session at the APS Annual Scientific Meeting, Karen J. Berkley, PhD, McKenzie Professor, Florida State University Neuroscience Program, reported that the implants allow two-way communication between the growths and wide areas in the central nervous system.
”Our research on these nerves suggests that part of the explanation for the variation in pain symptoms and the failure of surgery to alleviate pain may lie in how the new nerves influence the spinal cord and brain, and the relationship of the nerves to blood vessels in the growths,” said Berkley.
She added that pain intensity, duration and location could reflect variability in a number of factors associated with the implants' nerve and blood supply. They include type of nerves in the implants agents that activate or sensitize them, sites in the central nervous system involved in processing information associated with the implants, and how that information is modulated by estradiol or other hormones.
Berkley said further research holds promise for learning how endometriosis is associated with various pain syndromes. The research strongly supports a multifactorial approach toward pain alleviation.
DOES HYPNOSIS WORK FOR PAIN RELIEF?
Experts in using hypnosis for pain management showed that the technique has yielded good results with severe burn patients and women undergoing lumpectomy or mastectomy.
According to David Patterson, PhD, burn patients who endure extremely painful once or twice a day wound dressing changes can be relaxed and helped with hypnosis to get through treatments with less pain.
Guy Montgomery, PhD, Mt. Sinai School of Medicine, reported that hypnosis is effective in controlling pain, nausea and psychological distress associated with breast cancer surgery. In the Mt Sinai study, a 15-minute script was read to patients by a clinical psychologist prior to surgery. Results showed that hypnosis patients spent less time in the operating room and the hospital realized savings of $727 per patient.
CALL TO IMPROVE PAIN EDUCATION
Former APS President John Loesser, MD, professor of neurology, University of Washington, said that education about pain in US medical schools is inadequate, partly because the curriculum at most medical schools is saturated and leaves no time to add course hours on pain. He noted that most textbooks are deficient in pain information, especially for chronic pain, and cited the example of an 1800-page oncology textbook that dedicates just a page and half to pain.
Loesser recommended that multidisciplinary faculty teams representing several medical school departments should work together to implement better pain content in medical school curricula.