Salute Press :: Archives :: June 2007 Issue


	HEADLINES ARCHIVES MEDIA CENTER

June 2007 Issue

• Managing Pain
• Treat the Pain First
• Health Briefs: Obesity, Toothpaste and Anxiety
• Shortened Timeline for Anticancer Drug Development

Managing Pain

Ilene Raymond
Editor-in-Chief
1 June 2007

Fifty million or more Americans are partially or totally disabled by pain, according to the American Pain Society, a figure certain to rise with the aging of the U.S population. According to the U.S. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), a third of Americans will experience chronic pain at some point in their lives.

Marco Pappagallo, M.D., has devoted his career to understanding and solving the riddle of chronic pain. A professor at the Department of Anesthesiology and Pain Medicine at Mount Sinai School of Medicine in New York, Dr. Pappagallo is the recipient of a number of awards, including being named as one of America's Top Physicians by the Consumers' Research Council of America, Washington, DC in 2005 and 2006. He serves as an editorial board member of Pain Medicine, Journal of Terminal Oncology, The Journal of Neuropathic Pain and Symptom Palliation. He is also the Founder of the Pain Medicine Cooperative: Italy-USA, a non-profit educational organization.

What characterizes chronic pain?

Pain is always subjective. Chronic pain is often defined as pain that doesn't resolve after the normal time for healing, about 3 months. We often rely on a scale of one to 10, with a scale of over four indicating chronic, severe pain. At the present time, there is no systematic tool for pain imaging: You can't locate pain on an MRI. Many of the changes that cause pain occur on the microscopic level.

What is least understood about chronic pain?

Chronic pain doesn't stem from a single event. It's the result of a mixture of pain mechanisms and, therefore, there is no simple formula available to manage these complex pain states. For this reason, treating chronic pain is a multidisciplinary and multi-professional approach.

Chronic pain is a disease that requires complex medical care that the average physician is not well equipped to handle. Working with people who have chronic pain takes time - in part because they also suffer a host of other symptoms, including depression, insomnia, and a general loss in the quality of their lives. The combination of these factors can be a clinical burden for the average physician. When a patient comes into my office, for example, I often spend two hours analyzing the disability, as opposed to the 15 minutes an average internist may allot for each patient.

Why aren't more physicians schooled in handling pain?

In a way, it's ironic: doctors often enter medical school thinking that they want to cure pain, but when they find out that some kinds of pain can't be cured, they don't want to treat it. Medical schools don't spend a great deal of time on it, and at present, despite the high rates of patients in pain, the medical system doesn't make pain a priority. Part of it is you can't really 'see' pain and there is a fear of getting involve with issues that may involve psychological factors. For these reasons and others, we currently have a shortage of pain doctors - in the U.S. there are about 4 specialists per 100,000 people.

So how do you treat chronic pain?

Although there have been great breakthroughs in treating pain, people still tend to avoid the most successful cures for chronic pain -opioid medications, morphine or methadone. The correct use of opioids can bring real relief and let people regain normal function and resume their quality of life.

One barrier to solving chronic pain are worries about addiction, a worry that can prevent doctors from prescribing adequate pain medication, or patients from taking it - both groups often share an opioid 'phobia'.

In truth, very few patients will become addicted to pain medication. While there will always be some percentage of patients who abuse pharmacological drugs, very few people actually become drug addicts and the number of these people remains relatively stable -- about five to ten percent of the population at a given time. Addiction has much more to do with factors unrelated to chronic pain: genetics, environment, social group, and age.

Have there been any breakthroughs in pain research?

Understanding how chronic pain operates on the molecular level will eventually bring new strategies for treatment, to improve function and quality of life.

Researchers are looking at pain in peripheral nerves, and the central nervous system. One possibility is that with chronic pain, tissue heals from an injury, but the nerves are damaged in a way that the pain never goes away. Why is this? One theory is that the injury - such as osteoarthritis - may create changes in the pain nerves at a microscopic level.

In animal models, we see that after an initial trauma, triggers in some individual pain receptors become more acute. In some cases the phenotype may actually shift and create an increased density of receptors that activate nerves and create pain.

In other research, we hope there will one day be biomarker tests to diagnose pain, blood tests to locate where the disturbed nerves are located, neurostimulation medications, techniques and procedures that cure underlying diseases, better knowledge of pain syndromes, better treatment of symptoms, and improved palliative care for depression.

The three top causes of chronic pain are low back pain, headaches and knee pain. Low back pain remains a particular problem - ninety percent of people do not know the cause of nonspecific back pain and MRI's do not correlate with the pain. One theory is that they may be from bone pain. Bones have always been thought of as dead tissue, but what if that wasn't true, and that bones next to discs contain nerves that become sensitive after an injury. One promising clue is that 95 percent of those with back pain may have a vitamin D deficiency, which might make the bones more pliable and prone to pain.

What brought you to this specialty?

As a young child I was interested in understanding medicine as a way to relieve suffering. I find the study of pain organically, physically, psychologically, and intellectually stimulating.

I also have a personal story - when I was a young boy in Italy, my grandmother had a disc herniation that caused very painful sciatica when she was about 79 years old. To fix the condition, she had surgery, which was a disaster, and she returned home with severe neuropathic pain that was both intermittent and excruciating. She took a great deal of aspirin and Tylenol but nothing worked except for the eight tablets of morphine her doctor gave her to ration over a month to help the pain. Even as a very young child I could see that when she took the morphine she improved dramatically. Only with the morphine did she have the pain under control.

Has pain management changed over the years in Italy?

It's better, but we still need to catch up. Many doctors have limited experience with injections and the medical aspect of pain medication, but we're trying to boost and expedite education to help people in pain. Italy has a culture of Catholic suffering, but gradually we must move a more modern and compassionate vision of healing and relief.

Print Article E-Mail Article

June 2007

Treat the Pain First

Debora Muresu, M.S.
Clinical Psychology
1 June 2007

As a psychologist who treats cancer patients, the objective of psychological care --- with the related clinical interviews and psycho-diagnostic tools available to the psychologist -- is to improve the quality of life.

Similarly pharmacological pain therapy, which controls the symptoms of pain and all the changes which could develop from the psycho-physical standpoint, is used to achieve the same purpose: to improve the patient's “quality of life.”

Personally, I feel that when there is the possibility of choosing a multidisciplinary approach that integrates both psychological and pharmacological support systems, patients can receive stronger support during the course of their illness, with the concrete possibility of achieving, in a more complete manner, improvement.

Pain is an individual and subjective experience. All patients differ in their response to therapeutic aspects as well, both in terms of one's own subjectivity as well as the different situations or stages of the illness in which one finds oneself.

Based on my observations and those in clinical literature concerning a patient with a cancer diagnosis under my care at the Jefferson University Hospital, I find that from the first stage, the main difficulties of illness were closely linked to the onset of physical pain and the inability to control the major and intense changes created by illness. Increasing pain symptoms were accompanied by intense anxiety and depression experienced by the patient, thus rendering more complex the patient's planned psychological care.

To deal with this, the decision was made to accept the aid and support received from pharmacological pain therapy. This resulted in the control and significant decrease of the pain symptoms as well as the associated stress, thereby reducing, to a certain measure, the patient's stress and in turn maximizing the overall effectiveness of the pain therapy. It also made it possible for psychological care and intervention to take place under more favorable conditions.

Illnesses always bring suffering, anxiety and stress -- particularly those that involve prolonged exposure to chronic-type pain, such as in the case of end-stage cancer patients.

When the pain is intolerable, the possibility of implementing a psychological support network for the psychological care needed to cope with and meet the illness face to face (including more personal and internal aspects to rebuild the Self) become impossible.

In fact it would seem difficult to accept an illness condition without the need to reorganize, in some way, that which the illness itself has destroyed, i.e., one's interior image.

It is important to remember that pain is total and overall, in the sense that it is both physical as well as psychological and that the pain and the suffering must be treated even when it is impossible to eliminate them completely.

Print Article E-Mail Article

June 2007

Health Briefs

Pierpaolo Basso
Editor
1 June 2007

Obesity Increases Job Injury Risk

A body mass index (BMI) in the overweight or obese range increases the risk of traumatic workplace injury, say researchers at the Johns Hopkins University's Bloomberg School of Public Health's Center for Injury Research and Policy.

The researchers used medical and injury surveillance data on hourly workers employed in eight plants of the same aluminum manufacturer to determine whether increased BMI was a risk factor for workplace injury. Employees were grouped into five categories: underweight, normal, overweight, obesity levels I and II and obesity level III.

Of the 7,690 workers included in the study, 29 percent were injured at least once between January 2, 2002, and December 31, 2004. Approximately 85 percent of the injured workers were classified as overweight or obese.

www.NewsWise.com >>

Chocolate Toothpaste?

An extract of cocoa powder that occurs naturally in chocolate, tea, and other products might prove more effective than fluoride in fighting cavities, according to a Tulane University researcher.

The extract, a white crystalline powder whose chemical makeup is similar to caffeine, helps harden teeth enamel, making users less susceptible to tooth decay.

www.NewsWise.com >>

Anxiety Hikes Risk of Heart Attack, Death

Worried sick: We've all heard the phrase, but new evidence shows that highly anxious patients with heart disease face nearly twice the risk of heart attack or death when compared to those with a more serene outlook on life. Patients whose anxiety intensified over time were in greatest peril, while those who started out highly anxious but later found inner calm markedly reduced their risk. The research appears in the May 22, 2007 issue of the Journal of the American College of Cardiology (JACC).

“Most patients come in very anxious about their coronary condition,” said Charles M. Blatt, M.D., F.A.C.C., director of research at the Lown Cardiovascular Research Foundation and a clinical professor of medicine at Harvard Medical School, both in Boston. “I'm convinced that spending time with the patient and the family and interacting with them as a caring human being is critically important to clinical outcomes.”

“This study provides further insight into the complex connections between the brain and heart,” said James L. Januzzi, M.D., F.A.C.C., an associate professor of medicine at Harvard Medical School and director of the cardiac intensive care unit at Massachusetts General Hospital, Boston.

www.NewsWise.com >>

Print Article E-Mail Article

June 2007

Shortened Timeline for Anticancer Drug Development

National Cancer Institute
15 June 2007

A new compound, called ABT-888, has passed the first stage of clinical examination using a new model for drug development that promises to shorten -- by up to six to 12 months -- the timeline for taking anticancer drugs from the laboratory to the clinic, according to a team of researchers at the National Cancer Institute (NCI), part of the National Institutes of Health. This result (abstract #3518) was presented June 3, 2007, at the annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago, Ill.

Instead of being tested in the traditional phase I clinical trial, which explores drug safety and tolerance, ABT-888 was tested in a new type of study called an early Phase I trial (also sometimes called a Phase 0 trial). Conducted as part of the pioneering NCI Experimental Therapeutics (NExT) program, this early phase I trial shows that using an approach that adds a focus on the mechanism of action (the specific target in a cell that the drug attacks) can reduce the number of patients required for an early clinical study, and the time necessary to gather critical information for development of the drug.

"With this trial, NCI is doing much more than studying a new intervention; it is blazing a trail for early phase trials, which will hasten our progress across cancer research and drug discovery," said NCI Director John E. Niederhuber, M.D. "Conducting the ABT-888 trial also required close collaboration and consultation with the FDA, in order to negotiate the prototype for a new regulatory process."

"The time from initiation of the trial to the analyses of the data that provided proof-of-concept was less than six months," said Shivaani Kummar, M.D., NCI Center for Cancer Research (CCR), who led the trial.

Just as each patient's physical pathology is individuated, so are the psychological ways that each patient deals with the disease.

For more information about cancer, please visit the NCI Web site at www.cancer.gov, or call NCI's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

The study was conducted by a team of scientists from NCI-Frederick, Md., CCR, and the Division of Cancer Treatment and Diagnosis (DCTD). "Early Phase I trials allow new cancer therapies to be evaluated in clinical trials sooner than what is done currently," Kummar said. The first six patients enrolled in the trial had a variety of cancers and provided the information needed to signal that ABT-888 should proceed to a more comprehensive series of NCI-sponsored Phase I trials, which are expected to start in the next few months.

ABT-888 inhibits an enzyme critical for repairing damage to DNA. In the absence of an active enzyme, tumor cells are more sensitive to the effects of several cancer drugs. Abbott Laboratories, Abbott Park, Ill., developed ABT-888 as part of a clinical trial agreement with NCI to study whether performing an early phase I trial would hasten the overall drug development plan for this agent.

A unique aspect of this trial was the development of a rigorous assay to measure a biomarker affected by ABT-888. The study showed that the compound inhibited its targeted enzyme in tumor cells as well as in circulating white blood cells. This latter finding suggests that white blood cells, which are easily accessible, can be used in subsequent trials as an easy way to measure whether the agent is altering its presumed target.

This early phase I trial was a proof-of-principle study aimed to determine whether this new approach to early drug testing could work and that fits in well with the goals of NExT. "The NExT program requires research resources that are not readily available at most medical centers engaged in anticancer drug development," said James H. Doroshow, M.D., DCTD director, who spearheads the program. "It requires the scientific and clinical infrastructure of the NCI to do this research."

Print Article E-Mail Article

TOP	CONTACT OUR POLICY SHRO CREDITS