19 March 2008

Fibromyalgia and pain memory

This is old, but useful.
ScienceDaily (2000-11-01) -- The symptoms of fibromyalgia may be the result of a central nervous system that "remembers" pain sensations for an abnormally long time, according to research presented at the American College of Rheumatology Annual Scientific Meeting Oct. 29 -- Nov. 2 in Philadelphia, Pennsylvania.

18 March 2008

Being realistic about labor pain

ScienceDaily (Mar. 17, 2008) — A pain-free and drug-free labour may be many expectant mothers' dream but a review in the open access journal BMC Medicine reveals that reality hits hard. Most women's labour experiences differ markedly from their expectations. They are often ill-prepared for what might happen and consequently may be disappointed when the birth does not "go to plan".

The study's authors conclude that antenatal programmes should "get real". "People involved in antenatal care should listen to women's hopes for labour whilst also preparing them for what might actually happen during labour," said Joanne Lally of Newcastle University, who led the investigation. "Plans for a labour free of pain relief need to be complemented by preparing women for the possibility that they might need pain relief. Education can help to fill the gap between expectation and experience and thus ensure women are realistically prepared for their birthing experience."

The research team from Newcastle University studied published literature on women's expectations and experience of pain and pain relief in labour. They found that a gap exists between expectations and experience in four key areas: the level and type of pain, access to pain relief, the level of participation in and control over decision--making, and the level of control during labour.

Most of the literature reviewed showed that women underestimate the intensity of the pain they will experience and sometimes hold an unrealistic ideal for a drug-free labour. Indeed, in one study, more than half of the women interviewed who said they would not use pain relief actually did use it.

"Our analysis highlights the importance of antenatal education. It can empower women to have realistic expectations and make informed decisions," notes the author.

"If women can be better educated they can express their preferences but also be aware that things may not always go to plan. They can then be prepared for different eventualities and so make more realistic decisions and have a better experience."

Birth plans or other decision aids can assist women when making decisions about pain relief in labour, but evidence suggests these are not widely used. Recent guidelines published by the National Institute for Clinical Excellence (NICE) call for more research into how health professionals can effectively support pregnant women in making informed decisions about labour.

Journal reference: More in hope than expectation: Women's experience and expectations of pain relief in labour: A review. Joanne E Lally, Madeleine J Murtagh, Sheila Macphail and Richard G Thomson. BMC Medicine (in press)

Adapted from materials provided by BioMed Central, via EurekAlert!, a service of AAAS.


05 March 2008

BLEG: Opiates and renal failure

Hi all,

As I mentioned, I'm suddenly in the position of helping coordinate my grandpa's palliative care. Since I'm not a clinician, I need to get up to speed on some of the pharmacology so that I can have meaningful discussions with the real doctors.

Thus I'd really appreciate it if you could point me in the right direction toward any resources on treating acute pain in patients with severe renal impairment/failure.

Here's an example of the sort of information I'm looking for:

After reading through a bunch of journals early this morning, it seems like there's pretty good reason to not give people with severe renal impairment/failure morphine or hydromorphone. Two of the metabolites don't clear very well and can build up to cause coma or respiratory failure (in fact, at least one of the dangerous metabolites --6MG I think-- doesn't really affect pain, so the danger well outlasts the analgesic effect of the dose).

Codeine is probably even worse. The evidence with oxycodone isn't entirely clear; fentanyl is probably okay. But methadone seems to be all around pretty safe.

These are just my impressions from a bunch of journal articles. But I feel like I can now intelligibly ask his doctors whether they might consider trying methadone instead of giving him morphine for breakthrough pains and then giving him nothing (occasionally APAP) for very long periods. I don't want to second-guess their judgment, but I do want to be able to understand the treatment options....

I'll appreciate anything you can recommend.

Thanks again.

[also, sorry that these posts are pretty sloppy. I'm posting from my phone outside the hospital.]

Well, this sucks....

My 89 year old grandpa has graciously decided to allow me to put my several years of dilettantism with the pain sciences into practice. He's entered the hospital in pretty dire straights. I'm trying to help my parents be involved with decisions about his palliative care (without getting in the real clinicians way).

So, I'll be posting some reflections about his/my experiences with pain care, ethical issues, and other topics, as we go. I'm sure much of this will be naive; especially compared with many of your experiences and backgrounds. But perhaps I'll stumble across something interesting or useful to you.

Also, from time to time I'll probably be soliciting advice on where to find information on certain specialized topics. I'll really appreciate any help I can get.

02 March 2008

Was torture part of the pep talk?
Suit alleges waterboarding used as motivational technique
By Erin Alberty
The Salt Lake Tribune
Salt Lake Tribune

A supervisor at a motivational coaching business in Provo is accused of waterboarding an employee in front of his sales team to demonstrate that they should work as hard on sales as the employee had worked to breathe.
In a lawsuit filed last month, former Prosper Inc. salesman Chad Hudgens alleges his managers also allowed the supervisor to draw mustaches on employees' faces, take away their chairs and beat on their desks with a wooden paddle "because it resulted in increased revenues for the company."
Prosper President Dave Ellis responded that the allegations amount to "sensationalized" versions of events that have gone uncorroborated by Hudgens' former coworkers.
"They just roll their eyes and say, 'This is ridiculous . . .. That's not how it went down,' '' Ellis said.
The suit claims that Hudgens' team leader, Joshua Christopherson, asked for volunteers in May for "a new motivational exercise," which he did not describe. Hudgens, who was 26 at the time, volunteered in order to "prove his loyalty and determination," the suit claims.
Christopherson led the sales team to the top of a hill near the office and told Hudgens to lie down with his head downhill, the suit claims. Christopherson then told the rest of the team to hold Hudgens by the arms and legs.
Christopherson poured water from a gallon jug over Hudgens' mouth and nostrils - like the interrogation strategy known as waterboarding - and told the team members to hold Hudgens down as he struggled, the suit alleges.
"At the conclusion of his abusive demonstration, Christopherson told the team that he wanted them to work as hard on making sales as Chad had worked to breathe while he was being waterboarded," the suit alleges.
Ellis said the exercise was a dramatization of a story in which a young man asks Socrates to become his teacher. Socrates responds by plunging the student's head underwater and telling him he will learn once his desire for knowledge is as great as his desire to breathe.
However, Ellis said Christopherson explained the exercise before Hudgens volunteered, no one held Hudgens down and Hudgens was free to get up if he was uncomfortable.
"It was meant to be a team-building exercise," Ellis said. "Everybody was . . . involved and enthusiastic."
Hudgens claims he complained to Prosper managers about the exercise, but no action was taken against Christopherson until Hudgens left Prosper.
Prosper attorney George Brunt said Hudgens lodged the complaint six weeks after the exercise; in the meantime, Hudgens joined his team on a water skiing retreat and drove the boat, Brunt said. Ellis said Christopherson was suspended for two weeks while managers investigated Hudgens' complaint. Christopherson returned to work and remains the sales team leader, Ellis said.
"It's incredible to even suggest that he would put anyone under a level of discomfort," Ellis said. "He's a really nice, pleasant, polite young man. He's very dedicated and takes his job very seriously."
However, the suit claims Christopherson "intentionally engaged in physically and emotionally abusive conduct" to punish workers who did not meet company performance goals.
"Prosper's management passed by and through Christopherson's team area and was able to see mustaches on its employees, missing chairs and Christopherson's paddle," the suit alleges. Ellis said no managers have said they saw the activities described in Hudgens' suit, and the employees reported they are "more along the lines of fun."
"It's voluntary, it's humorous, it's team and camaraderie-building," Ellis said.
Hudgens left Prosper because of sleeplessness, anxiety and depression he experienced after the waterboarding, the suit claims. He required psychological counseling for emotional trauma, the suit claims.
The suit accuses Christopherson and Prosper of assault and battery, intentional infliction of emotional distress and wrongful termination. It accuses Christopherson of interfering with Hudgens' employment relationship with Prosper.
Prosper "provides executive-level coaching for individuals," according to its Web site. Personal coaches offer mentoring that focuses on business and finance.
"Our mission is to provide our students with the education and hands-on experiences they need to achieve their personal and professional goals," the Web site claims. "We strive to make the road to personal achievement meaningful, rewarding, and enjoyable."

Might it be that the normalization of torture in our culture has not really been a good thing?

The Catholic Church on torture

Also from the same Harpers article, the official Catholic Church position on torture:

Respect for bodily integrity.

[2297.] Kidnapping and hostage taking bring on a reign of terror; by means of threats they subject their victims to intolerable pressures. They are morally wrong. Terrorism threatens, wounds, and kills indiscriminately; it is gravely against justice and charity. Torture which uses physical or moral violence to extract confessions, punish the guilty, frighten opponents, or satisfy hatred is contrary to respect for the person and for human dignity. Except when performed for strictly therapeutic medical reasons, directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law.

[2298.] In times past, cruel practices were commonly used by legitimate governments to maintain law and order, often without protest from the Pastors of the Church, who themselves adopted in their own tribunals the prescriptions of Roman law concerning torture. Regrettable as these facts are, the Church always taught the duty of clemency and mercy. She forbade clerics to shed blood. In recent times it has become evident that these cruel practices were neither necessary for public order, nor in conformity with the legitimate rights of the human person. On the contrary, these practices led to ones even more degrading. It is necessary to work for their abolition. We must pray for the victims and their tormentors.


Scalia on torture

Sometimes its obvious why I'm not cut out for the judiciary. My little mind is not capable of such genius:

From Harpers:

Justice Scalia said it was “extraordinary” to assume that the ban on “cruel and unusual punishment”—the US Constitution’s Eighth Amendment—also applied to “so-called” torture. “To begin with the constitution… is referring to punishment for crime. And, for example, incarcerating someone indefinitely would certainly be cruel and unusual punishment for a crime.”

Justice Scalia argued that courts could take stronger measures when a witness refused to answer questions. “I suppose it’s the same thing about so-called torture. Is it really so easy to determine that smacking someone in the face to determine where he has hidden the bomb that is about to blow up Los Angeles is prohibited in the constitution?” he asked.

“It would be absurd to say you couldn’t do that. And once you acknowledge that, we’re into a different game. “How close does the threat have to be? And how severe can the infliction of pain be?”

Just so we're clear. We've now learned that the 8th Amendment is only about punishment. It does not cover what the state can do to you before they get around to punishing you.