NYTimes: The Evidence Gap. The Pain May Be Real, but the Scan is Deceiving

Gina Kolata has an interesting piece in the NYTimes right now, looking at the gap in evidence between use of scanning technology like MRIs and CAT scans to track down causes of pain, the discovery of a problem, and whether or not fixing the problem found via scan fixes the actual problem.

This hits home for me, because several years ago I went through a long series of scans to see what in the world was possibly causing the severe pain in my right arm. The MRI eventually discovered a disc bulge very high up in my c-spine, at an area that would have significant risks attached to surgery. Thankfully, my primary care physician, anesthesiologist and neurologist held a joint meeting with me and took the time to explain not only how to read MRIs, but the number of people who have something "wrong" with them without that "wrongness" being the cause of their pain.

In my case, terror about the risks associated with surgery high on my spinal column evaporated, and I was left with a different diagnosis and management routine for the disease.

But many people aren't so lucky, and go through unnecessary surgery because they have a pain, a scan shows a deviation, therefore the deviation must be linked to the pain. They have surgery, expecting to feel fine after your typical recovery period, and instead, no dice. (And if someone is unlucky enough to have some kind of pain condition that likes to spread when nerves are injured, things could be made even worse.)

Because of this, it's nice to see people - reporters and medical folks alike - are actually taking a look at the prevalence of "abnormal" scan results. Results that, in the end, are not so abnormal after all. However, it would have been nice to see whether or not doctors who realize that disc bulges or torn meniscus's aren't necessarily related to the pain you're feeling treat the pain, rather than the absence of a fixable issue. Knowing you have arthritis and that's the cause of your pain issues means very little if you're not getting pain relief.

Moving away from a concept of a single norm for the body is good - but hopefully as we make that transition, people recognize that simply because there is not a fixable cause to pain, doesn't mean the pain itself cannot be successfully treated.
-Kelly Hills

Obama election signals change in stem cell fight

A commentary by friend and colleague Art Caplan in his MSNBC column:

'Change' was the horse that Barack Obama's presidential campaign rode to victory. Indeed the 2008 election will be remembered not only for Obama becoming the first African-American president, but also for its impact on core bioethical topics that have long dominated American domestic politics.

Divisive issues such as abortion bans failed to gain traction on state ballot initiatives, while newer bioethical concerns that are likely to dominate American politics for years to come, including physician-assisted suicide, emerged.

The past eight years of the Bush White House have seen stem cell research and the status of embryos at the center of the moral values debate. Obama's election has brought the fight over embryonic stem cell research in the U.S. to an end.

Loosening stem cell research
The state of Michigan passed Proposal 2, loosening restrictions on embryonic stem cell research. This means that in Michigan - whose universities such as Michigan State in East Lansing are major biomedical research powerhouses - scientists will be able to use the excess embryos created at in-vitro fertility clinics as a source of stem cells for research, as long as they have the written consent of the parents who sought treatment.

There are now 10 states that have laws permitting embryonic stem cell research. These 10 are likely to be the recipients of an executive order that the new president will undoubtedly sign shortly after taking office, freeing up federal funds for embryonic stem cell research while laying out new regulatory guidelines.

One of the main arguments against embryonic stem cell research is that all embryos are persons from the moment of conception. The voters of Colorado were given the chance to put that view into law with the proposed Amendment 48. The so-called "Personhood Amendment" sought to define fertilized eggs as human beings, extending them constitutional rights. Coloradoans defeated this amendment by a margin of three to one.

Many, including myself, would argue that the ongoing debate over the morality of stem cell research is really just a stalking horse for the abortion debate. But efforts to further restrict abortion did not fare well at the ballot box, either. California voters rejected a proposition that would have required doctors to notify parents before performing an abortion on a minor. The initiative also would have required a two-day waiting period before minors could get abortions.

In South Dakota a measure that would have banned abortions - except in cases of rape, incest and serious health threat to the mother - also lost. An even tougher version, without the rape and incest exceptions, was defeated two years ago. The 2008 initiative went down to a resounding defeat of 55 percent to 45 percent.

Taken all together this series of votes represents an important moment in public bioethics in America. Like it or not - and I am well aware that many are not ready to let go of these issues - the nation may be starting to move past the endless battles over stem cells, embryos and abortion. Stem cell research in all forms is proceeding. Embryos are not going to be given legal status as persons. Further restrictions on abortion are unlikely.

There will still be plenty to fight over! The most important topic to emerge from this election is how Americans die and treat painful medical conditions.

Michigan became the 13th state to enact an amendment legalizing marijuana use for medical purposes. Proposal 1 passed by a margin of 63 percent to 37 percent. It allows patients with "debilitating medical conditions" to register with the state and, with the permission of a physician, legally buy, grow and use small amounts of marijuana to relieve pain, nausea and appetite loss, among other symptoms. Massachusetts decriminalized possession of one ounce or less of marijuana, shifting the penalty to a $100 fine.

Help for terminally ill
Americans are clearly telling Washington that they want dying people to have access to whatever helps make that process less burdensome. It will be interesting to see how the new administration grapples with that message. If no one listens, then a much more controversial option may emerge - physician-assisted suicide.

Perhaps the most startling measure to pass at the state level was in Washington's Initiative 1000, offering terminally ill people the option of physician-assisted suicide. Washington voters decided that adults who are deemed competent and have been given less than six months to live by a physician can legally request and self-administer lethal prescription medicine. The measure passed by a margin of 59 percent to 41 percent.

This surely will not be the last state-level effort to legalize physician-assisted suicide if other policies aimed at minimizing the suffering of the dying are not enacted. While I have my doubts about the wisdom of offering help in ending one's life before offering them health insurance, I suspect it will become a political hot potato in a number of states in the next few years.
An aging population, the increasing cost of medical care and a lack of high-quality palliative and nursing-home care almost guarantee it.

The pundits will spend the next few months analyzing the election, pontificating on what led to the Obama victory and the Democrats taking greater control of Congress. They won't find the answers if they do not pay attention to the clear messages Americans sent concerning critical bioethical questions.

Original article here.

How to keep our children pain-free

By: Jenny Walters

A recent article on Cnn.com entitled How to keep your kids pain-free by Elizabeth Cohen, dealt with 5 ways that a parent can use to help alleviate a child’s pain.

Dr. Jodi Greenwald, a pediatrician in Roswell, Georgia, uses a “secret weapon” for pediatric pain relief, a pinwheel. Dr. Greenwald stated: “Tell them to blow the pinwheel to make it turn, and you’re accomplishing two things…It distracts the child while they’re getting a shot and it makes them take deep breaths, which helps them relax.”[1]

Following giving birth to her son, Jennifer Crain discovered an anti-pain weapon too; a pacifier dipped in sucrose water. Nurses used this during her son’s circumcision. Researchers believe that sucking on sugar water changes the neurochemicals in the brain of the neonate.

Pediatric pain experts report that “sadly, too many children aren’t getting any pain relief, even something as simple as a pinwheel or sugar water.” A recent study in the Journal of American Medical Association, found that “four out of five babies in the neonatal intensive are unit received no pain relief when they had to undergo painful procedures.”

A study in France also found that U.S. doctors do not give pain relief to babies and children as often as they should. According to Dr. Brenda McClain, director of pediatric pain management at Yale-New Haven Children’s Hospital in Connecticut: “We may not see children’s pain as that severe. But pediatric pain needs to be taken seriously. However, most of the time I don’t think we see it that way.”

Below are five techniques that a parent can use to help alleviate a child’s pain:

1. For babies, ask about a pacifier dipped in sucrose water: Doctors say this works wonders in babies. If your pediatrician does not have sucrose water, you can make your own by dipping a pacifier into a mixture of one teaspoon table sugar and four teaspoons water. You can give your baby the pacifier about 30 minutes before a shot or procedure.

2. Ask for a topical pain cream: Creams can help take the sting out of a needle stuck. However, many doctors don’t use the topical creams, because they complain they take too long to work and they have to “sit there and wait until the cream takes effect.” You can ask your doctor for a prescription and apply the cream before you arrive at the doctor’s office. The cream needs to be applied 30 minutes to two hours before the procedure or shot.

3. Distract your child: Talking to your child about anything, but what is going on. Parents make the mistake of saying things like “We’ll get ice cream when it’s over” or “I know it hurts.” Instead it is better to talk to your child about good memories. For example, “Remember the time we went to Disney and you got to meet Mickey Mouse.”

4. Ask about alternative treatments: Acupuncture, music therapy, and hypnosis have all been used to treat children’s pain.

5. Don’t be afraid of opiates: According to pediatric pain experts, opiates can help a child in sever pain, and the risks are small. “It is very rare for children to get more pain medicine than they need or to get addicted to pain medicine” according to pain management program at the Seattle Cancer Care Alliance.

Overall, if your child is not getting enough pain relief, you, as the parent, may have to step in.

This article was not only important to me as a parent, but also as a neonatal intensive care nurse. In the neonatal intensive care unit (NICU), we used a specific pain scales designed specifically for the neonates, and we used sugar water and various pain medications to help alleviate the neonate’s pain.

I have to disagree somewhat with the research findings of “four out of five babies in the neonatal intensive are unit received no pain relief when they had to undergo painful procedures.” Pain was one the biggest concerns in the NICU. We were adamant about preventing and managing the neonate’s pain. Although there are and will always be a hand full of nurses and doctors who do not make pain management their priority, the majority of nurses and doctors are very much so concerned with pain management for neonates and children alike.

[1] Cohen E. How to keep your kids pain-free. July 2008. Available at: http://us.cnn.com/2008/HEALTH/07/10/ep.child.pain/index.html. Accessed on July 18, 2008.