02 September 2010

From Overheard in New York: sphenopalatine ganglioneuralgia

This cautionary tale from Overheard in New York provides me an opportunity to shamelessly boost my Google rating for sphenopalatine ganglioneuralgia (ice cream headache/brain freeze).

Overheard in New York | God Has Played a Cold Joke on Us All.: "God Has Played a Cold Joke on Us All.

Guy #1: Owwww! Fuck! Owwwwwwwww!
Guy #2: You won't get an ice cream headache if you drink it slower.
Guy #1: I'm trying, but it's too delicious!

--9th St. & 3rd Ave

And just for good measure: sphenopalatine ganglioneuralgia

Menstrual cramps even suckier than previously thought

In short, this suggests that menstrual cramps not only suck, they make other pains that happen to be around worse.

Brain morphological changes associated with cyclic menstrual pain: "Volume 150, Issue 3, Pages 462-468 (September 2010)

Cheng-Hao Tuab, David M. Niddambc, Hsiang-Tai Chaod, Li-Fen Chenbce, Yong-Sheng Chenf, Yu-Te Wubeg, Tzu-Chen Yehbe, Jiing-Feng Lirngh, Jen-Chuen HsiehabceCorresponding Author Informationemail addressemail address

Primary dysmenorrhea (PDM) is the most prevalent gynecological disorder for women in the reproductive age. PDM patients suffer from lower abdominal pain that starts with the onset of the menstrual flow. Prolonged nociceptive input to the central nervous system can induce functional and structural alterations throughout the nervous system. In PDM, a chronic viscero-nociceptive drive of cyclic nature, indications of central sensitization and altered brain metabolism suggest a substantial central reorganization. Previously, we hypothesized that disinhibition of orbitofrontal networks could be responsible for increased pain and negative affect in PDM. Here, we further tested this hypothesis....Abnormal decreases were found in regions involved in pain transmission, higher level sensory processing, and affect regulation while increases were found in regions involved in pain modulation and in regulation of endocrine function. Moreover, GM changes in regions involved in top-down pain modulation and in generation of negative affect were related to the severity of the experienced PDM pain. Our results demonstrate that abnormal GM volume changes are present in PDM patients even in the absence of pain. These changes may underpin a combination of impaired pain inhibition, increased pain facilitation and increased affect. Our findings highlight that longer lasting central changes may occur not only in sustained chronic pain conditions but also in cyclic occurring pain conditions."

17 August 2010

The most obnoxious email my hand surgeon has ever received

I managed to badly break my thumb during judo last week. I'm having surgery to repair it this Friday. After spending all this time learning about pain/pain medicine, I've learned just enough about drugs to be dangerous. Today, that danger has manifested in what I'm guessing is the most obnoxious email my hand surgeon has ever received from a patient.

For your enjoyment:

Dear [Dr's assistant],

....The pharmacy has a prescription of Darvocet for me. But, I'd actually like to avoid both the propoxyphene and APAP in Darvocet. I'd appreciate it if you could ask Dr. xxxxxx to cancel that prescription and write me one for something different. He might find the following useful:

The Vicodin prescription [which I had been written for the initial pain of the injury] worked fine. Still, I had forgotten that there is some evidence of an interaction between acetaminophen and xxxxxx. See, for example, [3]. So I'd prefer something without APAP. It's not a big deal, but I'd prefer to keep on the safe side.

I'd prefer to avoid anything containing propoxyphene for two reasons. First, it's somewhat contraindicated with xxxxxxx (propoxyphene can potentiate the xxxxxxxxxx). Second, there are some concerns about its cardiotoxic metabolites. See [1] and [2]. I know it's a tiny risk. But, again, I'd prefer to stay on the safe side wherever possible.

To make things just a bit more complicated: I don't think anything with straight codeine will be very useful. I'm fairly certain that both my mother and my sister are poor metabolizes, so I don't want to trust my CYP2D6's any more than I have to. Moreover, according to Cochrane Reviews [7], with a NNT=12, codeine just doesn't seem very trustworthy.

Finally, just in case this is relevant, I'd prefer to use the narcotics to hit the acute pain hard for 1-2 days and then get off of them as quickly as possible. There seems to be evidence that early aggressive treatment helps cut the overall duration of post surgical pain and, more important to me, reduce the risk of chronic pain (see, e.g., [4], [5], [6], [8]). Thus I'd prefer very few doses of something strong to more of something weaker.

These are just some very weak preferences based on my rudimentary understanding of pain management protocols. I trust your judgment completely.


[1] http://www.citizen.org/publications/publicationredirect.cfm?ID=7420


[3] Miners JO, Attwood J, Birkett DJ. Determinants of acetaminophen metabolism: effect of inducers and inhibitors of drug metabolism on acetaminophen's metabolic pathways. Clin Pharmacol Ther. 1984; 35:480-486.

[4] Leibeskind, J. C. (1991). "Pain Can Kill." Pain 44: 3-4.

[5] Merskey, H. (1999). Pain and Psychological Medicine. Textbook of Pain. P. D. Wall and R. Melzack. Edinburgh, Churchill Livingstone: 929-949.

[6] Harman, K. (2000). "Neuroplasticitiy and the Development of Chronic Pain." Physiotherapy Canada 52(64-71).

[7] Derry, S., R. A. Moore, et al. (2010) "Single dose oral codeine, as a single agent, for acute postoperative pain in adults." Cochrane Database of Systematic Reviews DOI: 10.1002/14651858.CD008099.pub2.

[8] Kehlet, H., T. S. Jensen, et al. (2006). "Persistent postsurgical pain: risk factors and prevention." Lancet 367(9522): 1618-1625.
Acute postoperative pain is followed by persistent pain in 10-50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2-10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain.

29 May 2010

Meditation science

UCLA center

Physiological effects of meditation

Control over body temperature

28 May 2010

Aerobic exercise: More pain now for less later

A useful bit from The Well's interview with sports medicine specialist Dr. Vijay Vad

Q: What else can someone do to relieve pain besides take a prescription pain reliever or undergo a procedure?

A: There are so many self-help things you can do. Something as simple as trying to do 30 minutes of aerobic exercise can help. With pain, you’re in a vicious cycle – you take more narcotics, your REM sleep decreases, and then you’re tired and you don’t want to exercise. If you can get through the first week or two of extra pain by doing the proper exercise, like 30 minutes of walking daily, long term that’s going to have an impact. Most people give up on simple walking, but it can have a huge impact long term.

Q: For people treating pain with exercise, do you have to be willing to get worse in order to get rid of pain eventually?

A: In the case of exercises, that’s true. If the pain goes up four-fold, you’re doing something wrong, but proper exercise will make you a little worse for a while before it makes you better. It’s a pain desensitization period. Think about if you have raw skin on your knuckle and you tap it. At first it hurts, but if you tap it more and more it will get desensitized. You’re doing the same to your chronic pain structure when you exercise. There is so much data on this with rehabilitation for back pain, for instance. You become pain desensitized by proper exercise with gradual increases in stress. The overall consensus for exercise therapy is that it has a positive impact. It can be something simple — it doesn’t have to be fancy machines or stretches.

19 May 2010

Torture's effect on society



13 May 2010

Heat therapy for abdominal pain

ScienceDaily (Jul. 5, 2006)The old wives’ tale that heat relieves abdominal pain, such as colic or menstrual pain, has been scientifically proven by a UCL (University
College London) scientist, who will present the findings today at the
Physiological Society’s annual conference hosted by UCL.

Dr Brian King, of the UCL Department of Physiology, led the research
that found the molecular basis for the long-standing theory that heat,
such as that from a hot-water bottle applied to the skin, provides
relief from internal pains, such as stomach aches, for up to an hour.
Dr King said: “The pain of colic, cystitis and period pain is caused
by a temporary reduction in blood flow to or over-distension of hollow
organs such as the bowel or uterus, causing local tissue damage and
activating pain receptors.

“The heat doesn’t just provide comfort and have a placebo effect –
it actually deactivates the pain at a molecular level in much the same
way as pharmaceutical painkillers work. We have discovered how this
molecular process works.”
If heat over 40 degrees Celsius is applied to the skin near to where
internal pain is felt, it switches on heat receptors located at the
site of injury. These heat receptors in turn block the effect of
chemical messengers that cause pain to be detected by the body.

The team found that the heat receptor, known as TRPV1, can block
P2X3 pain receptors. These pain receptors are activated by ATP, the
body’s source of energy, when it is released from damaged and dying
cells. By blocking the pain receptors, TRPV1 is able to stop the pain
being sensed by the body.

Dr King added: “The problem with heat is that it can only provide
temporary relief. The focus of future research will continue to be the
discovery and development of pain relief drugs that will block P2X3
pain receptors. Our research adds to a body of work showing that P2X3
receptors are key to the development of drugs that will alleviate
debilitating internal pain.”

Scientists made this discovery using recombinant DNA technology to
make both heat and pain receptor proteins in the same host cell and
watching the molecular interactions between the TRPV1 protein and the
P2X3 protein, switched on by capsaicin, the active ingredient in
chilli, and ATP, respectively.

Adapted from materials provided by University College London.
University College London (2006, July 5). Heat Halts Pain Inside The Body. ScienceDaily. Retrieved March 19, 2008, from http://www.sciencedaily.com­ /releases/2006/07/060705090603.htm

11 May 2010


As always I'm super late on this, but the April pain blog carnival is up at How to Cope With Pain:

Definitely check it out.


Our friends at How to Cope With Pain are having a contest. The winners get the opportunity to write a guest post at the site. This is an excellent opportunity for those of you looking to bring your voice to a wider audience.
The contest details are here:

The deadline is 16th May, so hurry......

29 April 2010

Aquinas on privation

Because evil is the privation of good, and not a mere negation, as was said above (A[3]), therefore not every defect of good is an evil, but the defect of the good which is naturally due. For the want of sight is not an evil in a stone, but it is an evil in an animal; since it is against the nature of a stone to see. [ST]

As was said above (A[1]), evil imports the absence of good. But not every absence of good is evil. For absence of good can be taken in a privative and in a negative sense. Absence of good, taken negatively, is not evil; otherwise, it would follow that what does not exist is evil, and also that everything would be evil, through not having the good belonging to something else; for instance, a man would be evil who had not the swiftness of the roe, or the strength of a lion. But the absence of good, taken in a privative sense, is an evil; as, for instance, the privation of sight is called blindness. Now, the subject of privation and of form is one and the same---viz. being in potentiality, whether it be being in absolute potentiality, as primary matter, which is the subject of the substantial form, and of privation of the opposite form; or whether it be being in relative potentiality, and absolute actuality, as in the case of a transparent body, which is the subject both of darkness and light. It is, however, manifest that the form which makes a thing actual is a perfection and a good; and thus every actual being is a good; and likewise every potential being, as such, is a good, as having a relation to good. For as it has being in potentiality, so has it goodness in potentiality. Therefore, the subject of evil is good.

08 April 2010

NY Times Patient Voices series

I just happened across the NY Times' Patient Voices series. Check it out.
Here're some of the pain related ones:

Patient Voices: Rheumatoid Arthritis

Patient Voices: Migraine

Patient Voices: Fibromyalgia

01 April 2010

Review of David Biro's The Language of Pain

Cover of Biro's Language of Pain

Short story: David Biro's The Language of Pain: Finding Words, Compassion and Relief is very good.
Go buy it.

Longer story: The publisher sent me an advance copy of Biro's The Language of Pain a few months ago. I've read it several times and been working on a review to share with y'all. But the review is getting too long and though I think I agree with most of his conclusions, I'm still not entirely sure what I think about about several of his arguments. Nonetheless, I've certainly profited from engaging with them.

Thus in the interest of posting something while the book is still (somewhat) fresh, I've pasted some of the early parts of the review below. I may post the rest later, or I may work it into something for a more formal venue. I'm omitting the philosophical discussion of the arguments. Though I will list a couple of the topics that concern me. I'm sure the list won't make sense until you've read the book. But perhaps they'll serve as discussion-starters

Those interested in learning about pain can profit from David Biro’s The Language of Pain: Finding Words, Compassion and Relief. It will probably be the most useful to people with chronic pain and those close to them. At the very least, the vast array of nuanced metaphors and literary sources he canvases can serve as raw material for their attempts to communicate and understand the experience of pain. But I expect that his lucid exploration of the structure of these metaphors will provide important conceptual tools for crafting more systematic and effective narratives. Though the applicability of some of his particular insights may be limited by culture and language.

Clinicians and scientists should be impressed by the conceptual structure that Biro uncovers in the language many sufferer's use to describe their pains. He succeeds in showing that this metaphorical talk, while necessarily imprecise and often obscure, must be taken seriously. In his wake, the same cannot be said for those who dismiss or deride these ways of talking about pain.

At a minimum, researchers interested in developing pain measurement tools and many philosophers will find in it a rich repository of examples and ideas to use in their work.

Philosophers should also find much to be intrigued by in Biro’s arguments. Here are a few of points that I think are worth engaging with:
  • Chapter 2 is occupied with a theoretical response to the charge that pain is completely resistant to language. This is unnecessary. The main thrust of the book is an empirical argument that, in several important ways, pain is in fact amenable to language.
  • The Wittgensteinian argument of chapter 2 can at best show that we must be able to communicate that we are in pain. But his project is to show that we can communicate what it is like to be in pain. He's not confusing the two in chapter 2. He wants to use the former as a wedge to open the door for the latter. But later on they sometimes seem to get run together in significant ways.
  • His discussion of the language/metaphors of agency does a lot to support and build on Elaine Scarry's articulation of the concept (I profited a great deal from this part since the pain-agency connection is important in my own work). The discussions of the x-ray and mirror metaphors/language are much weaker. Indeed, I'm not convinced that these can't be folded into the agency metaphor. [Unlike the others, this concern has significant philosophical consequences for our understanding of pain]
  • I'm probably being overly picky --but, hey, that's what analytic philosophers are for-- but his project is about language (hence the title and the claim to be constructing a 'rhetoric'). I usually think of language as propositional. His discussions using art to express pain thus seem incongruous. This is probably innocuous. At most it's a concern about whether the thesis should be framed in terms of language or more broadly in terms of our ability to meaningfully communicate. Though I sometimes think that there may be something lurking here that's related to the more substantive questions about whether the x-ray and mirror metaphors are really separate from the agency metaphors.
  • I'm betting that analytic philosophers of language who work on metaphor will find a great deal to disagree with in some of his arguments. Though I myself don't know enough about these issues to have more than hazy suspicions at various points.

Like I said, I'm not entirely sure what I think about these and other points. But I've certainly profited from thinking about them. And in any event, none of them undermine the practical import of the book or the philosophical suggestiveness of the overall picture. Indeed, his subtle discussions of pain language’s structure do not require the conceptually strong thesis that the experience of pain is necessarily expressible. By weaving together art, literature, personal experience, and patient testimony, he has demonstrated that many aspects of many pain experiences can, to a practically useful degree, be meaningfully shared.

A critique and new version of the Wong-Baker Pain Faces Scale

I'm passing along this excellent critique and suggestion from Allie at Hyperbole and a Half: Hyperbole and a Half: Boyfriend Doesn't Have Ebola. Probably. *UPDATED*

We're all familiar with the Wong-Baker Pain Faces Scale.
Wong-Baker Pain Faces Scale

But as our Hyperbolic critic notes, this is easily misunderstood. For example, she interprets it as
0: Haha! I'm not wearing any pants!

2: Awesome! Someone just offered me a free hot dog!

4: Huh. I never knew that about giraffes.

6: I'm sorry about your cat, but can we talk about something else now? I'm bored.

8: The ice cream I bought barely has any cookie dough chunks in it. This is not what I expected and I am disappointed.

10: You hurt my feelings and now I'm crying!

Thus she has come up with a better scale:
0:  Hi.  I am not experiencing any pain at all.  I don't know why I'm even here.

1:  I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth.

2:  I probably just need a Band Aid.

3:  This is distressing.  I don't want this to be happening to me at all.

4:  My pain is not fucking around.

5:  Why is this happening to me??

6:  Ow.  Okay, my pain is super legit now.
7:  I see Jesus coming for me and I'm scared.   

8:  I am experiencing a disturbing amount of pain.  I might actually be dying.  Please help.

9:  I am almost definitely dying.

10:  I am actively being mauled by a bear.

11: Blood is going to explode out of my face at any moment.

Too Serious For Numbers:  You probably have ebola.  It appears that you may also be suffering from Stigmata and/or pinkeye.

Which she interprets as:
0: Hi. I am not experiencing any pain at all. I don't know why I'm even here.

1: I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth.

2: I probably just need a Band Aid.

3: This is distressing. I don't want this to be happening to me at all.

4: My pain is not fucking around.

5: Why is this happening to me??

6: Ow. Okay, my pain is super legit now.

7: I see Jesus coming for me and I'm scared.

8: I am experiencing a disturbing amount of pain. I might actually be dying. Please help.

9: I am almost definitely dying.

10: I am actively being mauled by a bear.

11: Blood is going to explode out of my face at any moment.

Too Serious For Numbers: You probably have ebola. It appears that you may also be suffering from Stigmata and/or pinkeye.

I expect to see this written up in Pain shortly.

14 March 2010

Mutations in the SCN9A gene and pain sensitivity

The article emphasizes the genetics, but I'm more interested in the implication that the heightened sensitivity relates to the speed at which sodium channels close in nociceptive neurons.

Gene Linked To Pain Perception - Science News: "Gene linked to pain perception
Common genetic variant makes some people more sensitive
By Laura Sanders
Web edition : Monday, March 8th, 2010

The team found that people who reported higher levels of pain were more likely to carry a particular DNA base, an A instead of a G, at a certain location in the gene SCN9A. The A version is found in an estimated 10 to 30 percent of people, Woods says, though its presence varies in populations of different ancestries.

The same trend — higher pain levels reported by people who carried the A — held true in cohorts of people with other painful conditions including sciatica, phantom limb syndrome and lumbar discectomy.

The genetic variation affects the structure of a protein that sits on the outside of nerve cells and allows sodium to enter upon painful stimuli. The sodium influx then spurs the nerve cell to send a pain message to the brain.

This channel protein is a promising target for extremely specific and effective pain drugs, Waxman says: ‘Given that this channel has been indicted, it would be nice if we could develop therapeutic handles that turn it off or down.’

Researchers already knew that people with mutations in SCN9A can have extreme pain syndromes. Genetic changes that render the protein completely inactive can leave a person impervious to pain, although otherwise healthy. Other mutations can lead to conditions such as ‘man on fire’ syndrome, in which people experience relentless, searing pain.
In additional laboratory studies, the researchers found that nerve cells carrying the A variant of the gene took longer to close their sodium gates, allowing a stronger pain signal to be sent to the brain. Nerve cells carrying the more common G version of the gene snapped shut faster, stopping the pain signal sooner. "

19 February 2010

Placebo effect video

Here's a nice summary of some of the current understanding of the placebo effect. I'm also a fan of the fact that the efficacy of a placebo pill increases with the geometric complexity of its shape.

Also, the point at the end about using the research on placebos is bolstered by research on the nocebo effect -where contextual cues make the condition worse (though the nocebo effect lacks much of the placebo effect's nuance).

17 February 2010

My mom must be proud

According to Alexa.com this site is the #1 place on the internet to find answers to the age old question:
Do opiates decrease telepathic abilities?
I hope the 5 people arriving from 3 different countries found the answers they were looking for.

15 February 2010

Fetal pain

I think this sort of debate runs together two separate questions:
(1) Is the neurophysiology upon which pain-involving mental states supervene present in fetuses of x weeks?
(2) Is fetal pain --if it exists-- bad for the fetus?
Here's two reasons for thinking they come apart.

First, it's worth remembering that the aversiveness of pain is to some extent learned (see, for example, the famous McGill dog study). It might be that there is a pain sensation, but that the fetus has not learned to experience it as something bad. There might be evidence for or against this. But it probably wouldn't come from the fetus exhibiting near-reflex escape behaviors. IIRC, in adults many such behaviors are triggered very early in pain processing, even before much of the emotional processing occurs.

Second, there's the very hard question of whether fetuses are yet the sort of creatures that can have things be bad for them. Though I'm obsessed with the general problem (what makes something the subject of agent-relative value) I won't even try to articulate this one here. Especially because it actually a complex of several different super-hard issues.

Omaha.com - The Omaha World-Herald: Metro/Region - When can fetus feel pain?: "Knowing when a fetus first feels pain is like many scientific endeavors: It involves speculation and disagreement.

A bill before the Nebraska Legislature, the Abortion Pain Prevention Act, would ban abortions 20 weeks after conception, because it's at that point, Speaker of the Legislature Mike Flood says, that a fetus begins to sense pain.

‘The science is compelling,’ the Norfolk lawmaker wrote on his Web site about the bill that is scheduled for a hearing Feb. 25.

In fact, there still is considerable disagreement among scientists, physicians and other experts. It's fairly common for a person's position on the question to mirror his position on abortion. But it's not clear when the complex communication circuitry in the body, spine and brain are developed enough for pain to be felt.

Nerve fibers designed to sense pain are present in a fetus's skin seven or eight weeks after conception, said Dr. Terence Zach, chairman of pediatrics at the Creighton University School of Medicine.

Surely by 20 weeks, Zach said, a fetus is mature enough to respond to what scientists call ‘noxious stimuli,’ or pain.

‘I believe that — yep,’ said Zach, who described himself as pro-life.

Another Omaha physician, Dr. Robert Bonebrake, agrees with Zach. Bonebrake, a perinatologist at Methodist Hospital, sometimes must give blood transfusions to fetuses or drain fluid from them at 21 or 22 weeks.

Those procedures involve inserting a needle or shunt into the fetus. Bonebrake said the fetus will ‘back away a little bit’ from the needle, indicating to him that it has felt the jab.

‘He or she will try to move away if possible,’ said Bonebrake, who also described himself as pro-life.

But in a review of fetal pain literature, University of California-San Francisco physicians reported in 2005 that ‘fetal perception of pain is unlikely before the third trimester,’ or about 27 weeks into the pregnancy.

The review, published in the Journal of the American Medical Association, said reflex movement isn't proof of pain, because it can occur without the brain being developed enough for conscious pain recognition.

The article also stated that only 1.4 percent of abortions in the U.S. occur at or after 21 weeks.

In Nebraska, fetal age doesn't have to be reported and usually isn't, according to a state health spokeswoman. But in cases where it was reported, none of the abortions that occurred in Nebraska in 2008 involved fetuses of 20 weeks or older.

The American College of Obstetricians and Gynecologists' position is that it ‘knows of no legitimate scientific information that supports the statement that a fetus experiences pain at 20 weeks' gestation.’

A Children's Hospital Boston anesthesiologist and researcher, Dr. Roland Brusseau, has studied the subject to determine whether a fetus undergoing a surgical procedure should have anesthesia. His institution is the main children's hospital of Harvard Medical School.

Brusseau calls discussions of fetal pain ‘complicated and controversial.’

He has suggested a broad timeline for when fetal pain might start: ‘If we are to accept that consciousness is possible by 20 weeks (or more conservatively, 30 weeks), then it also would appear possible that fetuses could experience something approximating ‘pain,'’ he wrote a little more than three years ago.

The possibility, he said, would appear to mandate the use of appropriate anesthesia when performing fetal surgery.

Federal legislation has been unsuccessfully introduced over the past several years to require abortion providers to inform the mother that the fetus could feel pain at 20 weeks and offer anesthesia directly to the fetus.

Six states — Oklahoma, Arkansas, Utah, Georgia, Louisiana and Minnesota — have passed similar legislation, according to the Center for Reproductive Rights in New York.

In Iowa, a bill to that effect in the Legislature failed in 2005.

What makes Flood's legislation different is that its answer to the question of fetal pain is to ban abortions after 20 weeks. Exceptions would be allowed if an abortion is deemed necessary to avoid substantial harm or death to the mother.

Flood said that laws protect animals in slaughterhouses from excessive pain, and that fetuses deserve that level of sensitivity.

He said he based his beliefs that fetuses feel pain at 20 weeks in part on assertions by Drs. Jean Wright and K.J.S. ‘Sunny’ Anand. Wright is former chairwoman of pediatrics at Mercer University School of Medicine's Savannah, Ga., campus and Anand is chief of pediatric critical care at the University of Tennessee Health Science Center.

Flood said experts have found, for instance, that stress hormones spike when fetuses undergo invasive procedures.

Wright couldn't be reached for comment, but Anand, who was reached while doing humanitarian work in Haiti, said fetuses show signs of sensory perception around 20 weeks.

‘Whether this happens at 20 weeks or 22 weeks or 18 weeks is still open to question,’ Anand said. Some fetuses might develop more quickly than others, he said.

Anand said he believes the sense of pain in a fetus isn't turned on like a light switch. ‘It's more like a dimmer switch that very slowly — very, very gradually — turns on particular sensory modalities.’

Anand said the chain of connections for pain perception includes nerve fibers, spinal cord circuitry, brain stem and other portions of the brain. It's impossible to know for sure whether a fetus feels pain, he said.

But denying there is pain, he said, means there's no incentive to study it, no reason to work out ways to anesthetize fetuses, and no need for a doctor to consider whether pain is being inflicted.

‘But I think the onus is on us to give the benefit of the doubt,’ he said.

Anand said he believes abortion is appropriate in some instances, such as if a teenager has been raped, and inappropriate in others, such as when a woman has broken up with a boyfriend and then learns she's pregnant.

Arthur Caplan, professor of medical ethics and director of the Center for Bioethics at the University of Pennsylvania, said that ‘on the whole, I don't think science and medicine can be drawn in to support’ Flood's bill.

Caplan, who has a doctorate in philosophy, called himself ‘a conservative pro-choicer.’ He said that there is no consensus among physicians and scientists on the subject of fetal pain and that the notion that pain is felt at 20 weeks is ‘not the mainstream opinion.’

Bellevue abortion provider Dr. LeRoy Carhart, who has said he will perform late-term abortions only in cases when the fetus can't survive outside the womb, said he doesn't believe there is fetal pain before or during his abortions.

Nevertheless, Carhart said when performing abortions in cases where the fetus is 17 weeks or older, he sedates the mother — which sedates the fetus — and then administers another injection to stop the fetus's heart. The abortion typically occurs 24 to 72 hours later, he said.

‘This should be the ‘Put Carhart Out of Business Bill,'’ he said of Legislative Bill 1103.

Flood denied that his bill was directed at Carhart's revenue and said: ‘Dr. Carhart's loss of business pales in comparison to the loss of young lives.’

Dr. Michael Barsoom, director of maternal-fetal medicine at the Creighton School of Medicine, said he has seen fetuses move away from needles when needles are put in or near them.

Whether that's a reaction to pain, though, is unclear, Barsoom said. The fetus might respond reflexively and not as a conscious pain experience, he said.

‘I honestly don't know,’ said Barsoom, who described himself as pro-life. He said he doesn't think anyone can say for sure when a fetus begins to feel pain.

‘I don't think there's any way to find out.’"

Oklahoma restricting injections for chronic pain

Unfortunately, the article doesn't say why this was an issue in the first place

Oklahoma House gets bill restricting injections for chronic pain | NewsOK.com: "
Only physicians would be allowed to administer precise pain management injections under a bill approved Tuesday by a House committee.

The House Public Health Committee approved Senate Bill 1133 by a 14-5 vote. It now goes to the full House.
Rep. John Trebilcock, who took over authorship of the bill, said pain management injections into a patient’s spinal or neck area must be precisely administered.

'Chronic pain medication is medicine and should be practiced by doctors,’ said Trebilcock, R-Broken Arrow.

The measure was carried over from last year after it failed to win passage. Efforts to come up with a compromise among a hospital group, doctors and certified registered nurse anesthetists fizzled. Certified registered nurse anesthetists now administer spinal injections to manage pain.

Trebilcock said the practice of chronic pain management is 'extremely dangerous.’

An injection in the wrong spot could cause paralysis or not effectively treat the pain, he said.

Trebilcock said certified nurse anesthetists would be allowed to continue to give other injections. It’s estimated the chronic pain injections take up only about 4 percent of their duties, he said.

Marvin York, a lobbyist for the Oklahoma Association of Nurse Anesthetists, said the measure would be a hardship to rural patients, because few rural doctors practice in pain management.

'I can’t imagine why any rural legislator ... could possibly be for this bill,’ he said.

Victor Long of Norman, a certified registered nurse anesthetist, said about 80 percent of the spinal injections for pain are administered by certified registered nurse anesthetists. About 500 certified registered nurse anesthetists are in the state, he said.

Rep. Pat Ownbey, R-Ardmore, said he wondered why the bill was necessary because no complaints had been filed against certified registered nurse anesthetists administering chronic pain management injections.

'Is this a patient issue or a money issue?’ he asked fellow committee members. 'Make no mistake, this is a turf war.’

Trebilcock said doctors are willing to travel to rural areas to administer the injections.

'Rural Oklahoma shouldn’t have to settle for less than a doctor when they suffer from chronic pain,’ he said."

14 February 2010

Healthcare-Associated Infection

This isn't directly about pain. But I thought I'd pass it along.

The Kimberly-Clark Health Care Company has an informational (and of course promotional) website on healthcare associated infections here Patients who want to get a sense of the problem and what they should keep an eye out for may find some of the links useful.

06 February 2010


Thanks OED:

[a. OFr. anguisse, angoisse (Pr. angoissa, It. angoscia) the painful sensation of choking:{em}L. angustia straitness, tightness, pl. straits, f. angust-us narrow, tight, f. root angu- in ang(u)-{ebreve}re to squeeze, strangle, cogn. w. Gr. {alenisacu}{gamma}{chi}-{epsilon}{iota}{nu}.]

Formerly with pl.

1. Excruciating or oppressive bodily pain or suffering, such as the sufferer writhes under.
c1220 Hali Meid. 35 Hwen hit {th}er to cume{edh} {th}at sar sorhfule angoise. a1300 Pop. Sc. (Wright) 374 The bodi..in strong angusse doth smurte. c1380 Sir Ferumb. 212 Hys wounde..for angwys gan to chyne. 1382 WYCLIF Jer. iv. 31 Anguysshes as of the child berere [1388 angwischis as of a womman childynge; 1611 the anguish as of her that bringeth forth her first child]. c1386 CHAUCER Pars. T. 139 The peyne of helle..is lik deth, for the horrible anguisshe [v.r. angwissh(e, -uysch, -uyssche, -wysshe]. 1485 CAXTON Chas. Gt. 238, I haue suffred many anguysshes of hungre. 1592 SHAKES. Rom. & Jul. I. ii. 47 One paine is lesned by anothers anguish. 1656 RIDGLEY Pract. Physick 150 If there be pain of the Stomach, anguish, heat. 1758 S. HAYWARD Serm. xvii. 520 His [Job's] body was full of anguish. 1880 CYPLES Hum. Exp. iii. 70 The anguish of corns and toothache.

2. Severe mental suffering, excruciating or oppressive grief or distress.
c1230 Ancr. R. 234 In the muchel anguise aros {th}e muchele mede. 1297 R. GLOUC. 177 In gret anguysse and fere Wepynde byuore {th}e kyng. c1325 E.E. Allit. P. C. 325 When {th}acces of anguych wat{ygh} hid in my sawle. 1382 WYCLIF Prov. xxi. 23 Who kepeth his mouth and his tunge, kepeth his soule fro anguysschis. c1450 Merlin 64 Grete angwysshe that he suffred for the love of Ygerne. 1583 STANYHURST Aeneis II. (Arb.) 46 With choloricque fretting I dumpt, and ranckled in anguish. 1611 BIBLE Job vii. 11, I wil speake in the anguish of my spirit. 1678 JENKINS in Pepys VI. 125 An honest man..full of Anguishes for his King and his Country. 1769 Junius Lett. xxiii. 105 You may see with anguish how much..authority you have lost. 1810 SCOTT Lady of L. II. xxxiv, The deep anguish of despair.

25 January 2010

Man experiences intense pain from nail that slid between his toes Boing Boing

There are some experiments in which subjects primed to expect pain experience pain when given an ambiguous stimulus (e.g., a rapidly vibrating emery board). But this is much cooler:

Man experiences intense pain from nail that slid between his toes Boing Boing: ""

Mind Hacks reports that a nail penetrated the shoe of a 29-year-old construction worker, causing great pain. But the hospital workers discovered that the nail had passed harmlessly between his toes.

A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.

Mind Hacks says this is related to "somatisation disorder, where physical symptoms appear that aren't explained by tissue damage."

H/T: Saba

Does Morphine Stimulate Cancer Growth?


GeriPal does yeoman's work in explaining why

Does Morphine Stimulate Cancer Growth? | GeriPal - A Geriatrics and Palliative Care Blog: ""