06 December 2012

Quench the Fire Run

Quench the fire flyer

Dear SoCal friends,

Causalgia (aka CRPS II or RSD) should be very high on your list of things that you do not want. If you're the sort who runs without being chased, come out this Sunday and support the USC Pain Center.

Quench the Fire Run

Also, MacGyver will be there!



02 November 2012

Malingering in people with pain

Blackwell Synergy - Pain Medicine, Volume 1 Issue 3 Page 280-282, September 2000 (Article Abstract
Volume 1 Issue 3 Page 280-282, September 2000
(2000) A Case of Malingering: Feigning a Painful Disorder in the Presence of True Medical Illness
Pain Medicine 1 (3) , 280–282 doi:10.1046/j.1526-4637.2000.00028.x
The potential for malingering must always be considered among patients presenting with pain. When malingering is identified, care may be discontinued. This case report describes a patient who feigned sickle cell crisis, a painful condition, in the presence of other identifiable and potentially painful medical illnesses.

26 August 2012

Tierney on drugs

Tierney on drugs


24 July 2012

Nocebo effects

Here's a nice post on some of the latest research on nocebo effects --the placebo's evil twin.

Are Warnings About the Side Effects of Drugs Making Us Sick? | NeuroTribes

I haven't looked into the nocebo effects for pain in too much detail. But I've profited immensely from carefully working through the placebo effect literature. I expect this could be similarly useful, especially in the differences between placebos and nocebos

I'd love to hear about any good philosophical work on nocebos.

05 July 2012

Addiction in pain patients estimation

David A. Fishbain, MD, FAPA, Brandly Cole, PsyD, John Lewis, PhD, Hubert L.
Rosomoff, MD, DMedSc, FAAPM, and R. Steele Rosomoff, BSN, MBA
Pain Medicine, 
doi: 10.1111/j.1526-4637.2007.00370.x

27 June 2012

More Sphenopalatine Ganglioneuralgia

I'm not yet over losing my ranking as the internet's number one source for all things sphenopalatine ganglioneuralgia. So, in a futile attempt to reclaim my crown, I share this little bit about ice cream headaches:

01 June 2012

ScienceDirect - Pain : Nicotine differentially activates inhibitory and excitatory neurons in the dorsal spinal cord

ScienceDirect - Pain : Nicotine differentially activates inhibitory and excitatory neurons in the dorsal spinal cord:

Matilde Cordero-Erausquin, Stéphanie Pons, Philippe Faure and Jean-Pierre Changeux,

Récepteurs et Cognition, CNRS URA2182, Institut Pasteur, 25 rue du Dr Roux, 75724, Paris Cedex 15, France


Nicotinic agonists have well-documented antinociceptive properties when administered subcutaneously or intrathecally in mice. However, secondary mild to toxic effects are observed at analgesic doses, as a consequence of the activation of the large family of differentially expressed nicotinic receptors (nAChRs). In order to elucidate the action of nicotinic agonists on spinal local circuits, we have investigated the expression and function of nAChRs in functionally identified neurons of neonate mice spinal cord. Molecular markers, amplified at the single-cell level by RT-PCR, distinguished two neuronal populations in the dorsal horn of the spinal cord: GABAergic/glycinergic inhibitory interneurons, and calbindin (CA) or NK1 receptor (NK1-R) expressing, excitatory interneurons and projection neurons. The nicotinic response to acetylcholine of single cells was examined, as well as the pattern of expression of nAChR subunit transcripts in the same neuron. Beside the most expressed subunits 4, 2 and 7, the 2 subunit transcript was found in 19% of neurons, suggesting that agonists targeting 2* nAChRs may have specific actions at a spinal level without major supra-spinal effects. Both inhibitory and excitatory neurons responded to nicotinic stimulation, however, the nAChRs involved were markedly different. Whereas GABA/glycine interneurons preferentially expressed 462* nAChRs, 327* nAChRs were preferentially expressed by CA or NK1-R expressing neurons. Recorded neurons were also classified by firing pattern, for comparison to results from single-cell RT-PCR studies. Altogether, our results identify distinct sites of action of nicotinic agonists in circuits of the dorsal horn, and lead us closer to an understanding of mechanisms of nicotinic spinal analgesia."

10 February 2012

Labor pain

ScienceDaily (Jun. 4, 1997) — For almost 20 years, researchers have been examining a centuries-old phenomenon -- women helping women through childbirth. Continuous support from an experienced female companion, called a "doula" from the Greek word for servant, has been demonstrated to have impressive benefits, including shorter labors, less need for analgesia, and reduced likelihood of cesarean delivery. These findings about a time-proven, risk-free method come at a time when the focus in childbirth is on increased use of technology and medical intervention.

In a recent study, researchers John Kennell, M.D., and Susan K. McGrath, Ph.D., from the Department of Pediatrics at the Case Western Reserve University (CWRU) School of Medicine, looked at the childbirth experience of women at a Houston maternity hospital. Thirty-nine women were randomly chosen to be supported by a doula. Another 45 first-time mothers were randomly chosen to receive epidural analgesia to help control the pain of labor and delivery but were not supported by a doula. The day after delivery, both groups of women were asked to evaluate their pain levels and ability to cope with pain at three different times during childbirth. They rated their pain as ranging from "no pain" to "maximum pain" at the following times: 1) before receiving pain intervention (epidural analgesia or doula support), 2) after pain relief intervention, and 3) 24 hours after delivery. (Women who delivered by cesarean section were not included in the pain evaluation analysis.)

For women in both groups, pain was rated highest before the pain relief intervention, significantly less after the intervention, and much less again 24 hours after delivery. More importantly, when the pain evaluations from women in the doula group were compared to those from women in the epidural group, the two groups experienced equivalent levels of pain at all three measurement points.

Laboring women supported by a doula (with no pain relief medication) experienced the same levels of pain as women who received epidural analgesia, both during and after labor. Additionally, there were no differences in a laboring woman's ability to cope with pain whether she had an epidural or the continuous emotional support of an experienced doula.

According to the researchers, doula support is an effective, risk-free, non-pharmacologic, and inexpensive pain relief method that may be a viable alternative to epidural analgesia for many women in labor. Without the negative side effects and expense of an epidural, doula support offers the laboring woman a significant reduction in the pain of childbirth while also decreasing the chance for a cesarean delivery. Physicians, midwives, and consumers should consider these results when choosing obstetric pain relief.

The research team also included Vijay S. Varadarajulu, a premedical student at CWRU.

Adapted from materials provided by Johns Hopkins Children's Center.
Need to cite this story in your essay, paper, or report? Use one of the following formats:

Johns Hopkins Children's Center (1997, June 4). Doula Support Found To Be A Risk-Free Alternative For Pain Relief During Childbirth. ScienceDaily. Retrieved March 19, 2008, from http://www.sciencedaily.com­ /releases/1997/06/970604100308.htm

Epidural Leads To Less Pain, More Assisted Deliveries

ScienceDaily (Nov. 22, 2005) — Women who receive epidurals during labor report less pain than those who choose opiates or natural childbirth, according to a systematic review of evidence.

Yet epidurals bring an increased risk of delivery assisted by forceps or vacuum. The pluses and minuses mean that a woman’s decision about pain relief is not clear-cut.

“Each woman will have to weigh how much it means to her to have a spontaneous vaginal delivery versus having more pain in labor,” said lead author Dr. Millicent Anim-Somuah of the Liverpool Women’s Hospital in England.

On a more positive note, mothers who receive the spinal injections are no more likely than others to require Caesarian sections or to suffer chronic backaches. Their infants are equally healthy soon after birth.

Epidural analgesia involves injecting a local anesthetic into the lower back to block pain impulses from the uterus and birth canal. Obstetricians introduced the technique in 1946, and 58 percent of American women now choose this form of pain relief during childbirth, according to the authors.

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The reviewers analyzed 21 studies involving more than 6,000 women. Most of the participants were in the United States, England and Australia.

“It’s always been suspected that epidurals slow down your labor,” said Anim-Somuah. The study confirmed that the nerve block lengthens the stage during which the mother must push the baby through the birth canal. This leads to greater use of medication to stimulate contractions and a 38 percent increase in risk of instrumental delivery.

The precise timing of the epidural injection may be an important factor, says Todd Liu, M.D., a fellow of the American College of Obstetricians and Gynecologists who practices in New Jersey.

“Should you get your epidural when you first feel a contraction or when you are in a strong labor pattern?” Liu asked. “I would guess that there would be a higher [Caesarian section] rate if epidurals are given too early.”

Finally, there are certain “rare but potentially severe adverse effects” associated with epidurals, says the review. These include spinal cord injuries and permanent paralysis in the mother. These are so rare that incidence rates are currently unknown.

Randomized controlled trials like those included in Cochrane reviews are not well-suited to studying such uncommon events, said Anim-Somuah. “There should be some ongoing data collection as to whether these are occurring with epidurals.”

For now, Liu said, “My usual recommendation is that if labor is going to be long (usually with the first baby) and labor pains are very intense … then it is worth getting an epidural and accepting the potential risk.”

A potential weakness of the review is that only one trial studied childbirth without any painkillers at all.

Adapted from materials provided by Center for the Advancement of Health.
Need to cite this story in your essay, paper, or report? Use one of the following formats:

Center for the Advancement of Health (2005, November 22). Epidural Leads To Less Pain, More Assisted Deliveries. ScienceDaily. Retrieved March 19, 2008, from http://www.sciencedaily.com­ /releases/2005/11/051122210414.htm

From Chloroform To Epidurals: New Book By UF Physician Examines History Of Labor Pain Relief

ScienceDaily (Mar. 1, 2000) — GAINESVILLE, Fla.---Is the pain of childbirth an ancient curse, a meaningful passage to the beginning of a new life or simply a bout of agony to be endured with a generous helping of anesthesia?

Views of labor pain have shifted with the times, shaped by culture, but also by advances in medicine. Physicians have found reasonably effective ways of diminishing the most excruciating sensations, yet the 150-year history of anesthesia reveals what a complicated journey it has been, according to a University of Florida anesthesiologist.

"On the surface, it seems to be such a simple issue-there is pain and we can relieve it. Yet there are many philosophical and social ramifications, which have been viewed in very different ways through the years," said Dr. Donald Caton whose recently published book, "What A Blessing She Had Chloroform," delves into the medical and social history of relieving labor pain.

"Childbirth is such a very personal thing, so you see a range of reactions," Caton said. "Today, some women refuse anesthesia outright because they feel pain is part of the birth experience. Some refuse it for biblical reasons, citing the Book of Genesis story and its linking of punishment with childbirth."

And under the banner of feminism, women have alternated between demanding that anesthesia be given or insisting that it not.

The diversity of attitudes has at times caught the medical field off-guard. Caton, a professor of anesthesiology at UF's College of Medicine, says that early in his career he was surprised when some women would refuse his assistance. Now he sees obstetric pain relief as a fascinating case study of how science and culture evolve, influencing each other along the way.

Soon after the first modern anesthetic was introduced in 1846, some women began to push for its use in labor. Physicians, however, had to grapple with issues of safety -- and at a time when they were only beginning to learn how to investigate such questions scientifically.

"In 1820, they still had been learning that the body is composed of earth, air, fire and water and that disease is caused by an imbalance of those elements," Caton said. "So when anesthesia became available, physicians had a lot to sort through. It was first used for surgery, which makes sense because without pain relief, some operations simply couldn't be performed.

"But childbirth was seen as a natural process, and physicians had a very difficult time trying to figure out if the pain of it was a necessary part of that process. They needed to determine whether eliminating or at least diminishing pain would in itself cause labor to stop."

Though it would take into well into the next century to answer those questions, that didn't keep physicians from experimenting. In 1847, Scottish obstetrician James Young Simpson administered ether to a woman in delivery, just a few weeks after a Massachusetts dentist had publicly demonstrated its use for surgery. That same year, Fanny Wadsworth Longfellow, wife of the poet, became the first woman in the United States to give birth with the aid of pain relief.

In England, Queen Victoria was an early recipient. Then in 1859, when her oldest daughter gave birth, the queen offered the phrase that would become the title of Caton's book: "What a blessing she had chloroform."

But while physicians continued to study the effects of labor medications, obstetric anesthesia was far from routine. By the early 20th century, American feminists had become more and more impatient that labor pain relief was not widely available.

They campaigned for a new European technique called Twilight Sleep. Unfortunately, the combination of morphine and a disorienting drug called scopolamine was far from the perfect solution. Pain was still significant, and too high a dose could prove toxic. What little Twilight Sleep had to offer was of dubious value: the possibility that women would forget the birthing experience.

As the 20th century wore on, though, anesthesiologists became adept at relieving pain in a manner they believed to be safe for both mother and child. However, their confidence in its safety led to higher and higher doses, which sparked a backlash. English obstetrician Grantly Dick Read advocated a return to natural childbirth, and later French obstetrician Fernand Lamaze did as well. A new wave of feminism in 1960s and 1970s took up the cause against medicalized childbirth, arguing that physicians were taking away women's right to experience labor and delivery.

Today, Caton believes, the vehemence of the natural childbirth movement has passed. Women appear to have less pressure on them to choose or reject anesthesia. Currently, about 60 percent of women in the United States receive some form of pain relief for vaginal delivery, usually an epidural, a type of regional anesthesia.

"At the same time," Caton points out, "there is this residual idea in the culture as seen through literature, religion and politics that maybe pain has meaning and has important social benefits," such as establishing family bonds, inspiring people to try harder or as a method of controlling criminals.

"In childbirth, you continue to see that for some women, experiencing childbirth pain is extremely important to their personal and social development," Caton said. "But then there are a lot of people who think, 'I have local anesthesia when I go to the dentist's office, I'm certainly going to have it when I have my child.' So most of them do."

Adapted from materials provided by University Of Florida Health Science Center.
Need to cite this story in your essay, paper, or report? Use one of the following formats:

University Of Florida Health Science Center (2000, March 1). From Chloroform To Epidurals: New Book By UF Physician Examines History Of Labor Pain Relief. ScienceDaily. Retrieved March 19, 2008, from http://www.sciencedaily.com­ /releases/2000/02/000228103624.htm