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And now let's hear what the experts have to say!
(Print this out and have it ready for the next person who tells you it's
"ALL IN YOUR HEAD"

IS FIBROMYALGIA REAL???
WHAT A RESEARCHER HAS TO SAY:
Ordinary touches multiply into severe pain for fibromyalgia patients
By Eric Benjamin Lowe

Imagine living every day in excruciating pain. The millions of Americans who suffer from fibromyalgia must cope with this as well as the doubts of many who dismiss it as a made-up illness invented by a troubled mind.

But researchers at UF and elsewhere are beginning to piece together clues that reveal the physical basis of the puzzling syndrome that causes severe fatigue and aches, and has defied easy diagnosis.

UF scientists have found an abnormal central nervous system reaction in those with fibromyalgia-the body magnifies ordinary repetitive stimulation into an experience of crippling pain.

"This is particularly important because it has been unclear if fibromyalgia was just an imagined illness or a real syndrome," said Roland Staud, M.D., an associate professor of medicine at UF's College of Medicine who also is affiliated with the UF Brain Institute. "We now have good evidence that shows that it's not a psychological abnormality, but that there is a neurological abnormality present."

Staud, who presented his research findings at the annual meeting of the American College of Rheumatology last November, recently was awarded a National Institutes of Health grant worth nearly $800,000 to continue his studies for the next four years. Donald Price, Ph.D., a professor of oral and maxillofacial surgery in the College of Dentistry, and Charles Vierck, Ph.D., a professor of neuroscience, are collaborating on the research. Their goal is to develop a better understanding of the condition, with an eye toward improving diagnostic tests and treatments.

An estimated 3.7 million people in the United States - primarily women who are diagnosed during their 30s and 40s - have fibromyalgia, according to the NIH. A chronic illness with no known cure, its cause also is not known. Researchers have theorized that an injury to the central nervous system or an infectious agent might be responsible for triggering it in people who have inherited susceptibility. Symptoms include persistent and widespread musculoskeletal pain, fatigue and tenderness in the neck, spine, shoulders and hips.

Staud and colleagues found the central nervous system abnormality by conducting a series of repetitive stimulation tests on people with the syndrome as well as healthy research participants. The tests involved repeatedly placing warm plates on their hands and arms. The healthy participants felt the sensation but did not report it as pain.

For those with fibromyalgia, however, the sensation would magnify with each repetition into an experience of crippling and unbearable pain.

"When a sensation signal reaches the spinal cord, the signal can be omitted, changed or augmented," Staud said. "If it is augmented, then something that is innocuous, such as pressure on the skin, can then be perceived as a painful stimulus."

Jessica LeMay, one of Staud's patients, has been battling fibromyalgia since 1993. The 30-year-old Lake City resident said the pain starts in one area and usually spreads, sometimes becoming overwhelming.

"I imagine if someone had taken a baseball bat and beaten me with it, that's got to be what it feels like," she said. "Depending on the day, I'll just move out of the way if someone tries to touch me."

LeMay said many people dismiss her condition, not understanding the "huge difference" between her severe fatigue and the healthy person's occasional tiredness.

"When this fatigue would come about, it's almost like a weight being dropped on you, and you can't function anymore," she said.

LeMay said she is hopeful that Staud's research will lead to more effective treatment for fibromyalgia patients and better understanding by the general public.

"In our society, you either get better or you die, and fibromyalgia patients don't do that," she said. "We don't fit in the mold, so people don't know what to do with us."

Information for your health care providers

Information for Physician's sheets
This gives information for everyone on your health care team.
A PROFILE OF FIBROMYALGIA IN OCCUPATIONAL ENVIRONMENTS
This is a definition of the physical capabilities of a person with FMS in the workplace from the American Journal of Physical & Rehabilitative Medicine.

Fibromyalgia: The Muscle Pain Epidemic  Is it ME by Another Name? 
Understanding and Treating Chronic Fatigue and Fibromyalgia
Chronic Fatigue/Fibromyalgia: The Brain/Sleep Connection 
What Treatment Seems Most Effective in Treatment of Fibromyalgia
This is a collection of 4 very informative articles written by Leon Chaitow N.D., D.O., MRO Senior Lecturer, University of Westminster
Devin's Diagnostic: a brief guide to arriving at a likely diagnosis of Fibromyalgia and/or Chronic Myofascial Pain Syndrome

Aches and Pains Forecast Help

Aches & Pains Index

This index forecasts the potential for weather-related aches and pains, especially in people with chronic health conditions (such as migraines or arthritis) that might make them sensitive to changes in weather conditions. "10" represents the highest risk of weather-related aches and pains. "1" represents the lowest risk.

The Aches & Pains Index is calculated using barometric pressure, absolute humidity, chance of precipitation, temperature and wind. Areas of quiet, dry weather during warmer times of the year are generally associated with lower levels of aches and pains. Approaching areas of low pressure or strong frontal systems, both leading to stormy weather, may cause higher levels of aches and pains.

The scale for the Aches & Pains Index is: Very High (9, 10), High (7, 8), Moderate (5, 6), Low (3, 4), Minimal (1, 2)

For more information about the relationship between weather and well-being, see Aches & Pains 101.

Chance of Precipitation

Precipitation includes not only rain, but also snow, sleet, hail or any other form of water that reaches the ground. It is considered a factor in aches and pains because rainy weather accompanies changes in barometric pressure and humidity. For those who are sensitive to hot weather, rain can cool the atmosphere and may bring some relief.

Humidity Change

Humidity is the amount of water vapor in the air. An increase in absolute humidity (the amount of water vapor per unit of air), especially in the summer, is commonly associated with an increased potential for aches and pains. Some research also finds a correlation between dry, cold air and migraine headaches.

The four levels of the Humidity Change scale are: Steady, Slight, Moderate, Significant

Temperature Change

Rapidly rising or falling temperatures are a hallmark of big weather changes, indicating underlying shifts in barometric pressure. Extremes in temperature, not just changing temperatures, can also affect the potential for feeling aches and pains. Low temperatures may trigger migraine headaches, exacerbate circulatory conditions and contribute to arthritic joint stiffness. Cold weather has also been associated with an increase in asthma-related hospital admissions.

The four levels of the Temperature Change scale are: Steady, Slight, Moderate, Significant

For more about weather conditions and health, see Aches & Pains 101.

Health Conditions

Definitions Related to the

Use of Opioids for the Treatment of Pain

The American Academy of Pain Medicine, The American Pain Society and the American Society of Addiction Medicine

Consensus Document

BACKGROUND

Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals.

Many medications, including opioids, play important roles in the treatment of pain. Opioids, however, often have their utilization limited by concerns regarding misuse, addiction and possible diversion for non-medical uses.

Many medications used in medical practice produce dependence, and some may lead to addiction in vulnerable individuals. The latter medications appear to stimulate brain reward mechanisms; these include opioids, sedatives, stimulants, anxiolytics, some muscle relaxants, and cannabinoids.

Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. Since their clinical implications and management differ markedly, it is important that uniform definitions, based on current scientific and clinical understanding, be established in order to promote better care of patients with pain and other conditions where the use of dependence-producing drugs is appropriate, and to encourage appropriate regulatory policies and enforcement strategies.

RECOMMENDATIONS

The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definitions and recommend their use:

ADDICTION

Addiction is a primary, chronic, neurobiologicneurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

PHYSICAL DEPENDENCE

Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

In the case of sedative drugs, spontaneous withdrawal may occur with continued use. Tolerance Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

DISCUSSION

Most specialists in pain medicine and addiction medicine agree that patients treated with prolonged opioid therapy usually do develop physical dependence and sometimes develop tolerance, but do not usually develop addictive disorders. However, the actual risk is not known and probably varies with genetic predisposition, among other factors. Addiction, unlike tolerance and physical dependence, is not a predictable drug effect, but represents an idiosyncratic adverse reaction in biologically and psychosocially vulnerable individuals. Most exposures to drugs that can stimulate the brain's reward center do not produce addiction. Addiction is a primary chronic disease and exposure to drugs is only one of the etiologic factors in its development.

Addiction in the course of opioid therapy of pain can best be assessed after the pain has been brought under adequate control, though this is not always possible. Addiction is recognized by the observation of one or more of its characteristic features: impaired control, craving and compulsive use, and continued use despite negative physical, mental and/or social consequences. An individual's behaviors that may suggest addiction sometimes are simply a reflection of unrelieved pain or other problems unrelated to addiction. Therefore, good clinical judgment must be used in determining whether the pattern of behaviors signals the presence of addiction or reflects a different issue.

Behaviors suggestive of addiction may include: inability to take medications according to an agreed upon schedule, taking multiple doses together, frequent reports of lost or stolen prescriptions, doctor shopping, isolation from family and friends and/or use of non-prescribed psychoactive drugs in addition to prescribed medications. Other behaviors which may raise concern are the use of analgesic medications for other than analgesic effects, such as sedation, an increase in energy, a decrease in anxiety, or intoxication; non-compliance with recommended non-opioid treatments or evaluations; insistence on rapid-onset formulations/routes of administration; or reports of no relief whatsoever by any non-opioid treatments.

Adverse consequences of addictive use of medications may include persistent sedation or intoxication due to overuse; increasing functional impairment and other medical complications; psychological manifestations such as irritability, apathy, anxiety or depression; or adverse legal, economic or social consequences. Common and expected side effects of the medications, such as constipation or sedation due to use of prescribed doses, are not viewed as adverse consequences in this context. It should be emphasized that no single event is diagnostic of addictive disorder. Rather, the diagnosis is made in response to a pattern of behavior that usually becomes obvious over time.

Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may "clock watch," and may otherwise seem inappropriately "drug seeking." Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

Physical dependence on and tolerance to prescribed drugs do not constitute sufficient evidence of psychoactive substance use disorder or addiction. They are normal responses that often occur with the persistent use of certain medications. Physical dependence may develop with chronic use of many classes of medications. These include beta blockers, alpha-2 adrenergic agents, corticosteroids, antidepressants and other medications that are not associated with addictive disorders.

When drugs that induce physical dependence are no longer needed, they should be carefully tapered while monitoring clinical symptoms to avoid withdrawal phenomena and such effects as rebound hyperalgesia. Such tapering, or withdrawal, of medication should not be termed detoxification. At times, anxiety and sweating can be seen in patients who are dependent on sedative drugs, such as alcohol or benzodiazepines, and who continue taking these drugs. This is usually an indication of development of tolerance, though the symptoms may be due to a return of the symptoms of an underlying anxiety disorder, due to the development of a new anxiety disorder related to drug use, or due to true withdrawal symptoms.

A patient who is physically dependent on opioids may sometimes continue to use these despite resolution of pain only to avoid withdrawal. Such use does not necessarily reflect addiction.

Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects. For example, in the case of opioids, tolerance usually develops more slowly to analgesia than to respiratory depression, and tolerance to the constipating effects may not occur at all. Tolerance to the analgesic effects of opioids is variable in occurrence but is never absolute; thus, no upper limit to dosage of pure opioid agonists can be established.

Universal agreement on definitions of addiction, physical dependence and tolerance is critical to the optimization of pain treatment and the management of addictive disorders. While the definitions offered here do not constitute formal diagnostic criteria, it is hoped that they may serve as a basis for the future development of more specific, universally accepted diagnostic guidelines. The definitions and concepts that are offered here have been developed through a consensus process of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine.

 

info@overcomingpain.com Ten Steps To Overcoming Chronic Pain  by Mark Grant MA Chronic pain is a serious problem but is often made worse by misinformation, negative attitudes and beliefs, outdated ideas, negative emotions. It is recognised that chronic pain is often mismanaged, not because we lack adequate treatments, but because of fear and ignorance. These steps are designed to help you mentally cope with chronic pain in the best way possible. 1. Make sure you understand what kind of a problem pain really is. Chronic pain is different to other medical problems, which can often be treated relatively easily and successfully. Chronic pain is a complex illness, caused and maintained by a combination of physical, psychological and neurological factors. These multiple causes make it difficult to pinpoint any one cause for pain, or any one treatment. Pain is also often dismissed or poorly treated because of the 'baggage' of old ideas about pain - for example, pain where the physical cause is unknown is often undertreated. This is despite the fact that the role of neurological factors means pain can occur in the absence of external causes and that such pain should not be dismissed or considered abnormal. The medical establishment has struggled to meet the challenge of pain, and now recognises that this problem cannot be overcome without combining input from other disciplines such as psychology and physical therapies. Pain is also a subjective experience which is impossible to accurately measure. Pain involves a range of emotional reactions including anxiety, fear and depression. 2. Acceptance Chronic pain is so awful that sometimes it's easier to escape into wishing it had never happened, or hoping for a miracle cure. If persistent, these common reactions to pain can actually become a bit of a trap. You need to face the reality of what's happened, and find constructive ways of dealing with it. Acceptance means more than just intellectually knowing that you have pain, it means actually allowing yourself to feel the anxiety, fear, anger and grief that go with pain. Acceptance is a process, which requires progressively acknowledging all your feelings, and getting your physical and emotional needs. In order to accept and go through the negative emotions associated with chronic pain, you must have adequate safety and support. Safety means having adequate control over your pain through the right combination of medical, physical and psychological treatment inputs. Support means having adequate emotional support from family and friends giving you a feeling of containment and security. The end product of acceptance is reduced pain, inner peace, less anxiety and better coping.   3. Take Control. After many months or even years of pain and failed treatments, its easy to slip into feeling hopeless and that nothing can be done. Pain sufferers are often the butt of negative treatment and it's easy to end up feeling angry and victimized. They often have some justification for feeling this way. Maybe you didn't cause the pain, and maybe you aren't happy with some aspects of your treatment, but guess what? - life isn't fair. Blaming others for your problems, however well-justified, turns you into a victim and is like giving away control of your life. You are allowing yourself to be led by your emotions, but you do have a choice. Take the easy path (which isn't really so easy) and simply blame others, or take control and get information, communicate assertively with your doctor, practicing pain-management strategies such as regular exercise, pacing and relaxation and stress-management. You need to decide whether you want to be a victim or a survivor, a passenger or a driver. Your pain is no-one else's problem but your own. You do have rights and even responsibilities as a health consumer and a patient. Because chronic pain is difficult to detect or measure, you need to be an informed, active participant in your treatment. Don't be afraid to ask questions, don't be afraid to tell the doctor what you think and what you want, don't be afraid to ask for stronger pain relief. 4. Have a good working relationship with your doctor. An open and trusting relationship with your doctor is essential. This means being able to tell your doctor how you feel, ask questions and feel listened to and understood. The doctor-patient relationship must be a two-way street. Although you rely on your doctor's "expert" opinion for treatment advice, he depends on you for accurate information on which to base his decisions. It is your responsibility to describe your symptoms as accurately as possible and to report back regarding treatment outcomes, even if unfavourable. Under-reporting of pain has been identified as one of the biggest causes of mismanagement of pain. The doctor-patient relationship can be undermined by bad communication, ignorance, arrogance and fear. For example, many people are actually afraid to tell their doctor how they are feeling for fear of being labelled as weak or a complainer. Other patients report down-playing the severity of their pain because they don't want their doctor to feel like a failure! You should feel that you can talk to your doctor, that he listens and respects you, and be satisfied that he is working competently and thoroughly on your behalf. You also have a right to change doctors if you are dissatisfied. 5. Never ignore pain. In the treatment of chronic pain it has become fashionable to recommend ignoring pain (after medical investigations are complete) in the belief that it is only pain and there is nothing physically wrong. This approach represents a pendulum-swing away from the old fashioned notion of prescribing bed-rest in favour of maintaining activity. The idea is that inactivity only leads to depression and does not help the problem anyway. However, with certain types of pain, this can lead to a cycle of aggravation, sleep deprivation, exhaustion and increased pain and suffering, particularly if you are someone who typically ignores pain (ignoring pain is of course, what causes most repetitive strain injuries). The other problem with ignoring pain is that every time pain occurs, it leaves an imprint in your nervous system, a kind of 'pain memory'. These repetitive pain experiences lead to overstimulation of the nervous system and the generation of spontaneous pain signals, leading to a cycle of stress and pain. There are thus sound reasons for wanting to avoid pain, but again, total inactivity is not the answer. The best approach is a balanced one with paced activity levels and avoiding undue aggravation of the pain. 6. Have a balanced approach to physical activity. It can be tempting to adopt a "do nothing" approach, in the hope that you may avoid further pain. As we have indicated, since chronic pain is partly caused by neurological changes, avoiding activity will not stop the pain. Avoiding activity also leads to muscle wasting and a build-up of waste-products in the tissues, which can actually exacerbate pain. At other times, you may feel frustrated and force yourself to complete relatively major tasks (eg mowing the lawns) knowing that it will hurt later. This may cause you to have to take two days of bed rest to recover. This "all or nothing" approach is inappropriate and ineffective in the long run. You need to pace activity levels. You can do this on your own, via "trial and error" or with a bit of 'coaching' in the form of professional help. The support and guidance of a sympathetic health professional is highly desirable to maintain motivation and deal with fears and obstacles along the way. 7. Sleep! Loss of sleep caused by inadequately managed pain can lead to a cycle of fatigue, depression and irritability. Inability to sleep, or waking up feeling tired, are signs that your pain is not being managed properly. Developing a restful sleep pattern is essential to coping with chronic pain. Improving your sleep will give you more energy and help you feel more able to cope. There are many things you can do to get better sleep including relaxing, perhaps by taking a hot bath, listening to music or playing a favourite relaxation tape before going to sleep; self-hypnosis; a good mattress; posture; medication; and good overall stress-management. 8. Make sure you have adequate support. Many chronic pain sufferers become isolated, alienated from loved ones, their work-mates and society. Inadequate social or emotional support can lead to isolation, depression, and increased risk of suicide. People who normally pride themselves on being independent and not needing others are particularly 'at risk'. Unfortunately, the negative reactions of others can discourage chronic pain sufferers from talking about their problems or seeking help. The unhelpful reactions of people you thought you could rely on can be very disappointing, it's another thing that falls into the 'life isn't fair' basket. The reality is it's simply ridiculous to expect yourself to be able to cope on your own with a chronic illness that robs you of your ability to work love and play. Having adequate emotional support greatly increases your ability to cope. Talking to close family and friends is vital. A family talk with your doctor of psychologist can also help by enabling them to learn more about your condition and talk about things in a neutral environment. 9. Don't expect people who don't have pain to understand what it's like. It's frustrating, and easy to get angry when others don't seem to understand. However, because chronic pain sufferers often have no visible injury, it is easy for family and friends, and especially children, to forget there is anything wrong. They may also 'forget' because it is hard for them to have to live with the knowledge that a loved one is in pain. So don't expect people who don't have pain to understand what it's like and be prepared to have to remind others about your limitations. Children especially cannot be expected to understand the implications of a condition like chronic pain. It's a lesson that has to be repeated many times.   10. Forgive yourself. The lost ability to work, love and play caused by chronic pain can create feelings of guilt and failure. Become aware of your own expectations, and any feelings of shame or guilt and examine them critically. Chances are you didn't ask to be in pain. Repressed feelings of shame lead to resentment and later emerge as anger. Feeling guilty can also be a subtle form of self-indulgence - when you engage in self-blame you are really wallowing in self-pity. Forgiveness and letting go of guilt will be easier if you choose a proactive approach by adopting these 10 Steps. This information is provided by Mark Grant to assist you to participate actively in your treatment and cope with chronic pain in the best way possible.Mark Grant is a psychologist, specializing in the management of chronic pain and trauma. His advice is based on many years of clinical experience working with persons affected by chronic pain and trauma.Mark has also conducted research regarding a multi-modal approach to pain management. He is the author of two self-help tapes which use accelerated learning principles for sufferers of chronic pain and stress: Calm and Confident based on EMDR and Pain Control, based on EMDR. He has also spoken at numerous international conferences and workshops about pain management.

 

 

info@overcomingpain.com Ten Tips For Communicating With A Person Suffering From Chronic Pain  by Mark Grant MA People with chronic pain communicate differently to well people. Tired, irritable and withdrawn, they are often reluctant or unable to talk about their feelings. Or they may talk in a kind of 'code' and tell you they feel fine when they are really hurting. Sometimes they just don't have the words to describe how they feel. These factors can create frustration and often lead to a breakdown in communication between the pain sufferer those whose mission it is to try and understand them.. The following 'communication tips' are designed to help you recognise and overcome the special obstacles that may occur when communicating with persons suffering from chronic pain or illness. 1. Listen! To really listen is one of the most helpful things you can do for a person in pain. Listening also involves more than just hearing what is being said. A good listener listens with their heart as well as their ears. They are able to read between the lines and interpret unspoken non-verbal pain communications. To be a good listener you must focus your attention completely on the person you are communicating with, and listen to how they are saying it as well as what they are saying. Good listeners are also able to drop their own preconceptions and assumptions and adopt an attitude of genuine and profound curiosity. Repeating and summarizing what is said is also a skill associated with good listening. As Bernard Lown, MD and Nobel prize-winner, notes, 'the majority of people's complaints are relatively straightforward, detectable to the ear cultivated to listen for the inaudible sigh, visible to the eye sensitive to the unshed tear.' 2. Don't Fake It. It can be unpleasant to listen to someone talk about their pain (imagine how it is for them!). Don't ask someone how they're feeling unless you're really prepared to listen. However, it's better to really listen for just five minutes than to pretend - you don't have to have all the answers. People can tell if you're not really interested and it makes them feel like they are a burden. 3. Understand that pain sufferers may be afraid to say how they are feeling. Many chronic pain sufferers are silent about their pain because of fear of ridicule or a feeling of 'what's the point?' or just thinking that if they don't talk about it, maybe it will go away. Others understate their pain for similar reasons. Not expressing or underreporting pain are coping mechanisms which can be misleading to the unsuspecting. So when someone you suspect of being in pain says they feel fine, you can let them know that you're really interested, but you understand if they don't want to talk about it. 4. Look for non-verbal cues. As indicated, chronic pain sufferers often underreport their pain, so look for a 'mismatch' between what is said and how they appear. Some tell-tale symptoms that usually indicate severe and inadequately controlled pain include sweating, irritability, sleep disturbance, restlessness, difficulty concentrating, decreased activity and suicidal thoughts. Many chronic pain sufferers are so accustomed to these negative feelings they do not recognise their significance and so don't volunteer this information unless specifically asked. 5. Believe people when they say they are in pain. When pain sufferers complain about their pain, they are often not believed. There are many reasons for this including a myth that chronic pain sufferers exaggerate their pain in order to gain sympathy or avoid responsibilities. In general, people do not go around pretending they are in pain to get sympathy - research has shown that exaggerating or malingering are actually rare. Remember, "pain is whatever the experiencing person says it is, whenever the experiencing person says it does." 6. Asking 'helpful' questions can stimulate hope. Helpful questions are specific or open-ended questions that convey you understand and are interested in what the pain sufferer is experiencing. For example, you can obtain a rough idea of how much pain they have by asking them to rate their pain on a scale of 0 to 10 where 0 = no pain and 10 = the worst possible pain. Other important areas to ask about include sleep, concentration, sweats, and mood (look for depression, irritability). It's also amazing how rarely chronic pain sufferers are ever asked directly how satisfied they are with their treatment, and whether or not they think their pain is bearable. Being asked the right questions also gives the pain sufferer permission to talk about their pain. 7. Avoid "words that maim". Words are a powerful "two-edged sword" - they can maim or heal. Thoughtless throwaway lines such as "you'll just have to learn to live with it" or "you don't look sick" do nothing to help and make the sufferer feel worse. Elementary psychology teaches that fear is an improper way to motivate constructive behavior. Instead of mobilizing the sufferer's inner resources, such talk dissipates hope. Constructive, carefully chosen words, in the context of a caring relationship, can be a powerful activator of healing resources. Just asking someone who is feeling at the end of their tether "so how have you survived?" can evoke awareness of strengths and determination to survive. 8. Have compassion. Try and put aside your cares and preoccupations even for just a few minutes and listen with an open heart. Compassion is known to be one of the most healing human emotions. As the essayist Anatole Broyard wrote "I wouldn't demand a lot of my doctor's time. I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh to get at my illness, for each man is ill in his own way. Without such recognition I am nothing but my illness." 9. Be honest about the limitations of your own knowledge. IIt is difficult to see a person in pain and not know how to help them. Nobody likes to see someone suffer. It can be tempting to offer well-meaning advice such as "you'll just have to learn to live with it", which, however well-intended, is not actually very helpful. It is better to admit you don't know the answer rather than to say something which may unintentionally destroy hope. 10. Remember, pain is not what you think it is. As you're probably aware, the concept of pain has undergone considerable revision in recent decades. Pain has gone from being thought of in purely physical terms to the realization that it is made up of physical, psychological and neurological factors. However, although it is over 30 years since the International Association for the Study of Pain officially declared that pain is both a mental and an emotional problem, many people still act as though pain can be understood simply as a sign of physical injury. For example, pain sufferers are often met with disbelief (even by trained medical professionals) because they do not have any visible injury. But as pain specialists now realize, the involvement of neurological factors explains why pain can occur in the absence of external causes. It also means that pain in the absence of external causes should not be considered abnormal. Pain is in part a psychological problem involving a range of emotions. The initial response to pain is fear, which is appropriate since pain represents a threat to identity and the ability to work, love and play. However, when pain persists, fear turns into anxiety and depression. The effect of depression is for people in pain to show less emotion, and thus to not appear as though they are in pain. Pain is also very difficult to convey in language, making it even harder to understand what the pain sufferer is experiencing. So to understand a person in pain you have to remember that pain is a highly complex and individual thing. The other thing to remember is that pain is different for everybody, depending on the personality and life history of the person experiencing it. Thus, you cannot know another person's pain. .

 

As you can see, my name is Dr Patty V (psydchick). I am 43 years old. I am married to a wonderful man that i have known since 1994. We have been married for almost 6 years (July 30, 2000). I was born in Freeport, NY and i lived on Long Island, NY for the first 11 years of my life (no, i don't have my accent still. I graduated high school in 1980 (Birmingham High School in Van Nuys, CA). Upom graduation, i went to college at UCSD. I went there for 1 year. Due to financial difficulties of my family at the time, i did not return to UCSD for a second year. I worked full-time and went to Jr College (LA Pierce College, Woodland Hills, CA). I saved money, applied for financial aid and then started UCLA in 1983. I worked really hard to help my mom pay for school. I got 3 jobs at the beginning of my schooling at UCLA. I worked in a law office as a clerk, worked at a preschool as an assistant teacher and also worked in my dorm at UCLA food service. On may 15, 1983 while i was working in food service, i was helping another worker with the dishes (we worked on converyor belt at the time). This other person was getting behind so i gave him some help of moving a tray of silverware to another location. Unfortunately, they never taught proper body mechanics in those days. I felt a pull in my back. I continued with my shift and after i went to my dorm room to lay down. When i awoke i had severe pain in my back and could barely move. I was told by my roommate (who also worked in food service) to go to the hospital. I felt uncomfortable about making a fuss. I thank the Lord i did. I went to the E.R. that night and i was told i had to stay at bedrest for 2 weeks. I was given some pain medication that made me feel so ill. The first shot of narcotics in my life (Demerol). I told the nurse i was going to be sick. She didn't believe me..lol, so i vomited all over the place. Anyway, i was sent home to rest and employee health got ahold of me and sent me to an orthopedic surgeon 2 weeks after my injury. I had been given meds, went to a chiropractor (which made it hurt more), physical therapy, and then eventually an oil based mylogram. It turned out that what they thought i did (sprain), it was a disk herniation at L5-S1. Since then, i went through my first surgery in August, 1983. It was experimental and they no longer do it in the united states anymore. It was called chymopapain. I felt good for 2 years and then i started having horrible pain again. Then after more tests, going into pain management hospital, attempting to tough it out (also moved to Orange, CA to continue school), i had another surgery in 1986. It was a fusion from L5-S1. In 1987 i had a third surgery which was another fusion from L4-S1 (i had trouble fusing from the first one). After each of these surgeries i had to be at bedrest for 6 months. After the first fusion, i had very little pain for 6 months and only had to take aspirin for the pain. After the second fusion i did not get much relief. I was in a body cast for about 6 more months. I remember graduating from Chapman University with a cast under my cap and gown (cute pic huh? lol). After graduation from my bachelor's degree, i decided to apply for a master's in psychology. I wanted so bad to help others who were suffering from pain like i was. I remembered back several years when i was in pain management talking to the psychologist. She had been trying to tell me how to live my life in pain. I asked her "do you have pain" and she said "no". I said then "how can you tell me how to live my life in pain?" From that time on i realized that nobody could ever tell me that if i was a pain therapist. In 1989, i met an orthopedist who thought he would be able to help me. I was told that i had to lose weight (100 pounds) before he would attempt to do surgery. I had tried everything over the years. In 1989 i had a gastric stapling and a gastric intestinal bypass. I lost a lot of weight, to the point where i was vitamin deficient, and couldn't keep any food down. I also had dumping syndrome several times a day (this is where you have a really bad case of the runs). I lost over 100 pounds in 1 year and i had another back surgery in 1990. This was an anterior and posterior fusion (L3-S1). Here, hardware was placed. I had screws and isola rods. Again, i had trouble fusing. After this surgery, i didn't seem to do much better. Yet i continued to do things in my life. In 1994, after losing so much weight and being in so much pain, i had to go to the hospital because i was quite ill. It was recommended that i go through detox because the docs believed in those days that anyone who had to take narcotics every day was an addict (which is so far from the truth). In February, 1994 i entered the detox unit and live there for 1 month. I was horrible because i was cut off cold turkey. I couldn't sleep, eat, and lord i was in so much pain. The only drug i was given for pain was an anti inflammatory. It was called Dolobid. After leaving the hospital, i attempted to go home and deal with this horrible pain without medications. I felt so alone and frustrated because i was in severe pain and i was brainwashed to belive if i took any more narcotics i would explode. After leaving the detox program i decided i wanted to help others. I went back to the hospital to ask some questions and was asked to volunteer. I thought that it would be a great idea. I wanted to try to get my sitting tolerance up so that i could go back to school. I went to physical therapy in the early am's and went to volunteer in the detox unit right after exercising. I was doing great. Then, one day i got up and felt like i had the flu. I was dizzy, not hungry, just feeling horrid. Within a few days i went to my doc for a checkup and found out the i didn't have the flu and that i should not have been able to get up let alone drive. I had some sort of bleed and my hemoglobin went down to a 3. I was immediately put in the hospital for a transfusion and then went back home for the weekend. I returned back to my volunteer work on Monday and started to feel odd again. I decided it was too soon to come back to work, so I decided to go home. I went to say goodbye to one of the nurses and she wouldn't let me leave. Apparently, i was showing symptoms of bleeding inside. I was sent over to the emergency room and went in to shock pretty soon after getting there. It turns out that the Dolobid i was taking ate a hole through my little stomach pouch and i was bleeding to death. I was told that i would have to reverse the gastric stapling and bypass if i needed to stay on anti inflammatories. This was done soon after going in the hospital. I remember this guy visiting me in the hospital. He was chaiman of the volunteer organization that i was volunteering in. One night he bought this big stuffed bear in to me. He was very nice. When i was recovering with my family he used to call and check on me. We had so much in common, but he was 22 years older than I was. We eventually got really close over the years (Now he is my husband). Anyway, after the surgery i decided to go back to school. I went to a private school to finish my master of arts in psychology. In late 1994, i was on a trip with my friend in stateline nevada and my pain started up really bad again. It turned out that i needed another surgery on my back from L-S1. I had had some broken titanium screws and i had problems fusing again. I had the surgery and attempted to go back to my life. I graduated with my master of arts degree in clinical psychology in 1996 and was scholarshipped for my doctorate, in which i graduated 1 year after my master's because i had a lot of transfer credits. I became a Doctor of Psychology in 1997. I specialized in the assessment, diagnosis and treatment of chemical dependency (thought i may need that knowledge while dealing with pain patients) and pain management. While While i was working as a therapist, i learned that not everything is like what is in the books. In late 1997 i began having pain in my shoulder. I went through many many tests but the docs couldn't figure it out. Finally, during that time, i developed a problem with my left pinkie. It was a bone infection called osteomyelitis. I was in the hospital for a short time and was given high dose antibiotics. About 6 months after, i woke up one morning and could not get out of bed. I screamed for my boyfriend who was living with me at the time. I was taken to the hospital and was told that the infection from my shoulder and pinkie spread to my spine. I had gone through several biopsies and tests just to try to get rid of this infection. I was eventually told by my spinal specialist that there was nothing that could be done. What usually happens is that an individual gets the infection, clears if up with antibiotics and then they have surgery. For me, nothing else could be done. I was told that it was too dangerous to attempt to clean the infection out of my spine and the chances of me surviviing were not good. I was also told that i would fuse in a nonphysiological angle. I never listened to the docs because i felt only God knew what was going to happen. Unfortunately, the doc was right. I am now fused at a 90 degree angle, whereby my chin and brow line are parallel to the floor when i try to stand. I am unable to lay flat on my back or on my left side. I am also unable to sit for more than 10-15 minutes without causing my pain to go wild. I was told the only way to deal with the pain is by medications. I have gone to several pain docs. It turns out that my stomach surgery came up to bite me again. I now have a serious malabsorption problem so that my meds (antibiotics, pain meds) have to be administerd through other means such as intravenous. Since 1997, i married in July 2000. I am now bedbound. I figured out how to adapt to using a computer almost 2 years ago. Since i am unable to sit up straight when using the computer, i balance myself on my right elbow, have pillows between my knees, under my elbow, in back of me and i have a keyboard on my lap to type. I has a laptop, but it finally died. I am attempting to use a desktop because it is not possible to get another laptop right now. I am adjusting toward using a regular mouse. Since 1994 i have had multiple diagnoses or other medical problems that have resulted because of my posture. I was diagnosed with FMS, CFS, Epstein Barr, Rheumatoid Arthritis, Bursitis, Atalectasis (where my right lung doesn't expand well), vitamin deficient, lost weight on my own (over 100+ pounds) because after the reversal of the stapling and bypass i gained the weight and some. I now work in my bed as a pain patient advocate and help others suffering from severe pain. I am very happily married to a wonderful man who takes care of me because he says "it is a labor of love!" I am unable to cook, walk, etc. He brings me meals, cleans me up because it is too difficult to go in the shower, goes to the store, pharmacy, drives me to the docs when needed, and the list goes on. SOME OF YOU HAVE ASKED WHAT OUR SECRET IS TO STAYING SO HAPPILY MARRIED. WELL, IF SOMEONE CARED ABOUT YOU AS MY HUSBAND DOES FOR ME THAT IS ENOUGH. He also suffers from chronic pain and is disabled. So, this is my story, actually the short one. I hope this helps anyone get an idea of who i am and what i do...I will go out of my way to help another person in pain...because i never want anyone to have the feelings that i did and want to take their lives because they feel nobody understands!!!!! God is now bringing us together. Things are done in God's timing not ours!!!

Theories Of Pain: Researchers equate pain perception within the networks of free nerve endings in the skin. Pain appears to be generated through a variety of procedures. Intense mechanical stimulation activates a class of high threshold receptors that produce sensation of pain. The painful stimulus causes pain and tissue damage. Besson (1982) suggested that pain is also caused by the release of chemicals by injured cells. When cells are damaged in any way, they quickly synthesize what is called a prostaglandin. These are categories of hormones first discovered and seen in the prostate gland. This chemical sensitizes free nerve endings to another chemical known as histamine. The chemical sensitizes free nerve endings to another chemical known as histamine. Damaged cells also release histamine. An extremely interesting type of pain sensation happens after a limb has been amputated. Once the limb is gone, investigators state that approximately 70% of individuals who have lost lims report that they felt as though the missing limb still existed and hurt often. This phenomenon is referred to as phantom limb pain (Melzack, 1992). An important discovery made by Aberdeen, Scotland investigators lent weight to the general concept of the "gate control" theory of pain. These investigators found small members of proteins known as enkephalins (meaning "in the head"). In time, a larger group of proteins became isolated known as endorphins (meaning "morphine within"). Endorphins are released from nerve cells in the brain, which have been described to inhibit spinal cord cells through direct pathways decending from the brain to the spinal cord.

A functional pain theory includes an explanation of all the possible ranges of pain phenomena. All of the present pain theories leave out a great amount of unknowns and are inadequate when dealing with the vast array of pain phenomena. The majority of contemporary theories have what Weisendberg (1977) referred to as "the neurophysiological structures related to pain". The gate control theory of pain was developed by Ronald Melzack and Patrick Wall in 1973 to account for some of the ways in which pain differs from other sensations. They were particularly interested in the mechanisms by which other cutaneous stimuli and emotional states alter the level of pain felt by a human being. Simply put, Melzack suggests that there is a control mechanism in the spinal cord that acts as a gate. When the gate is open, pain messges will pass to the brain and theperson will feel pain. When the gate is closed, the messages will not pass from cell-to-cell and will not reach the brain. Thus the individual feels no pain. Physiologically described, pain messages are carried from the nerve endings through the nerve fibers (which are held together in bundles) to the spinal cord. If a non-pain stimulus is given to the nerve endings, the message is carried from the nerve endings to the spinal cord. If a non-pain stimulus is activated at the nerve endings that carry the different messages simulataneously as a non-pain message, the non-pain message moves up the the larger nerve bundles quicker than the pain message. Thus, the non-pain message reaches the spinal cord first and the pain message is unable to geet to the brain. The gate control theory also explains what occurs when the brain receives an excess amount of information passing through the gate. A neural mechanism is activated which is responsible for pain experience and control. At this time, a threshold is passed and another system is activated. This system controls reflex reactions such as swelling. This reflex reaction in turn activates the sympathetic nercous system. ***note: Please do not copy without permission from author*** By Dr. Patricia Verdugo, PsyD (1997)

Intractable Pain Treatment Laws and Regulations California Colorado Florida New Jersey Texas Virginia Washington As demand for better pain management grows in the United States, the public is taking an interest in policies that govern the medical use of opioid analgesics for people with chronic pain. Although the use of opioids in acute and cancer pain is well accepted, their use in chronic noncancer pain has been considered widely to be inappropriate due to concerns about efficacy, toxicity, and addiction (Portenoy, 1990; Turk & Brody, 1991). Indeed, some state medical boards have used their disciplinary authority to reject or discourage the prescribing of opioids for chronic noncancer pain (Oregon Board of Medical Examiners, 1991; Washington State Medical Disciplinary Board, 1987). However, the assumptions behind the belief that opioids should not be used for patients with chronic pain are undergoing a critical reappraisal in an effort to clarify patient selection and appropriate management strategies (Portenoy, 1994). At the same time, state governments have begun to adopt laws that specifically allow the use of opioids for the treatment of intractable pain. Definitions Intractable pain is a term that is used and defined in the federal controlled substances regulations and now in some state laws. The term generally refers to a pain state in which the cause cannot be removed or otherwise treated, and no relief or cure has been found after reasonable efforts (Code of Federal Regulations, 1988). It includes pain due to cancer as well as to other chronic diseases. Intractable pain treatment policy refers to laws, regulations, or other government-issued policies and guidelines that address the legitimacy of the medical use of opioid analgesics to treat patients with intractable pain. These policies vary in the degree to which opioid treatment for intractable pain is accepted or rejected, and they may include specific restrictions and conditions. The focus of this article is federal and state laws and regulations, including the Federal Intractable Pain Regulation (1974); the state laws of Virginia (1988), Texas (1989), California (1990), Colorado (1992), Washington (1993), and Florida (1994); and the state regulation of New Jersey (1984). Federal intractable pain policy Federal regulations established in the early 1970s govern the prescribing of controlled substances (Code of Federal Regulations, 1988, Part 1300). As a general principle, the federal government does not regulate medical practice as this is a function of the states (Joranson, 1990). In 1974, however, Congress adopted a law to prohibit physicians from prescribing opioids to detoxify or maintain opioid addiction (unless they are operating as part of a separately registered narcotic treatment program). Subsequently, to clarify the critical distinctions between the treatment of opioid addiction and the use of opioids to treat pain, the Drug Enforcement Administration (DEA) issued a regulation in 1974 stating that the law was not intended to interfere with physicians who used opioids to treat intractable pain: This section is not intended to impose any limitation on a physician or authorized hospital staff...to administer or dispense [including prescribe] narcotic drugs to persons with intractable pain in which no relief or cure is possible or none has been found after reasonable efforts. (Code of Federal Regulations, 1988, p. 72) The DEA has reiterated and communicated this policy to U.S. physicians through its Physician's Manual (Drug Enforcement Administration, 1990) and its Pharmacist's Manual (Drug Enforcement Administration, 1986). State intractable pain treatment policies In addition to federal regulations, physicians' prescribing is subject to the law and regulations of each state, which sometimes are more restrictive than federal law (Joranson & Gilson, 1994). A physician's prescribing of controlled substances may be reviewed by a number of agencies, including state justice departments, triplicate prescription programs, professional licensing boards, and local law enforcement agencies. Typically, these agencies want to identify physicians who are prescribing outside of legitimate medical practice. Legitimate and illegitimate medical practices are usually defined in state medical practice law and by the regulations and enforcement policies of state medical boards. There are no state laws or regulations that consider the use of opioids for intractable pain to be an illegitimate practice. Indeed, the model for state medical practice laws recommends that state legislatures define the practice of medicine to include the use of drugs to treat pain (Federation of State Medical Boards of the United States, 1988). Further, the model for state controlled substances laws specifically recommends that prescribing opioids for intractable pain be considered legal under state law (National Conference of Commissioners on Uniform State Laws, 1990). Physicians, however, have been investigated and prosecuted for prescribing opioids for chronic pain (Angarola & Joranson, 1993; Joranson & Gilson, 1994). According to a 1991 survey, most of the members of state medical boards of the United States said they would discourage a physician from prescribing opioids for chronic noncancer pain, and approximately one-third of state medical board members said they would investigate the practice as a potential violation of law (Joranson, Cleeland, Weissman, & Gilson, 1992). Although most state laws and regulations still do not specifically recognize the legality of opioids for intractable pain, this is changing. In the last several years, some legislatures have begun to adopt laws to affirm the use of controlled substances for intractable pain. Typically, legislators have been responding to (a) the undertreatment of patients with pain, (b) inappropriate medical board discipline of some physicians, and (c) proposed legalization of physician-assisted suicide. Media coverage of physician-assisted suicide and inadequate pain management as well as the efforts of patients and physicians who are advocating for legislative action to improve pain management are fueling state legislative interest in intractable pain treatment policy. Washington In the state of Washington, the use of opioids for intractable pain became an issue in 1987 when the Washington State Medical Disciplinary Board opposed prescribing opioids for chronic pain: Many cases reviewed by the Washington State Medical Disciplinary Board involve inappropriate prescribing of controlled substances. A significant number of these are related to the use of narcotics as a method to manage chronic pain. During fiscal year 1987 the Board experienced nearly a 100ncrease in disciplinary actions related to prescribing of controlled drugs for chronic pain. The Board does not recognize repeated prescribing of controlled drugs as appropriate therapy for chronic pain [italics added]. (p. 1) The subsequent outcry from physicians resulted in additional policy statements in 1989 and 1992 explaining that the board had not wanted "to interfere with a physician's exercise of appropriate clinical judgment" (State of Washington Department of Health, 1989, p. 1), and that chronic pain is "best not treated with opiates" (State of Washington Department of Health, 1992, p. 1). Concern about the board's position continued, and in 1993, the state legislature enacted a statute that borrowed a provision from a recently developed model for state drug laws developed by medical and legal experts (National Conference of Commissioners on Uniform State Laws, 1990): A practitioner may dispense or deliver a controlled substance to or for an individual or animal only for medical treatment or authorized research in the ordinary course of that practitioner's profession. Medical treatment includes dispensing or administering a narcotic drug for pain, including intractable pain. (Washington Uniform Controlled Substances Act, 1993) Colorado In 1992, the Colorado legislature adopted an intractable pain treatment policy as part of revisions to its controlled substances act. Colorado's approach is similar to that used in Washington state. Virginia In 1988, Virginia enacted a law allowing physicians to prescribe heroin for treatment of terminally ill cancer patients ("Virginia Enacts Law," 1988). (Note: This occurred despite the fact that legislation at the federal level was necessary to make heroin actually available and that Congress had already soundly defeated such a bill.) The Virginia legislature adopted an additional measure to allow prescription of pain medications "in excess of recommended dosage" for patients with intractable pain ("Relieving Intractable Pain," 1988, p. C5; Commonwealth of Virginia, 1988). Both laws exemplify how drug laws can reflect common misconceptions, that is, that heroin has significant analgesic advantages over currently available opioids, and that a physician's prescription cannot legally exceed the dosage recommended in FDA-approved product labeling (Angarola & Joranson, 1995). Texas: The first intractable pain treatment act The first intractable pain treatment act (IPTA) was approved by the Texas legislature in 1989 and has received considerable publicity (Hill, 1992). Physicians in Texas were concerned about board investigations of physicians and ambiguous language regarding opioid prescribing in the state's Medical Practice Act and went to the legislature for relief (Hill, 1992). The purposes of the new act were to clarify legal ambiguities, bring Texas law into conformity with the federal intractable pain regulation, and assure that no Texan requiring narcotics for pain relief, for whatever reason, was denied them because of a physician's real or perceived fear that the state regulatory agency would take disciplinary measures against the physician for prescribing narcotics to relieve pain. (Hill, 1992, p. 70) The Texas IPTA (a) provides a definition of intractable pain that is similar to that of the federal regulation, (b) autliorizes physicians to use controlled substances (not only opioids) for treatment of intractable pain, (c) prohibits healthcare facilities from restricting the use of such drugs for intractable pain, and (d) prohibits the Texas State Board of Medical Examiners from disciplining a physician for using such drugs in the legitimate treatment of intractable pain (Medical Practice Act of Texas, 1989). The Texas IPTA also contains important exclusions. For example, the act does not protect a physician if the pain patient is also being treated for chemical dependency or when the physician should have known that the patient was using drugs in a nontherapeutic manner. Several years after adoption of the IPTA, the Texas State Board of Medical Examiners issued a policy statement in its official newsletter that was drafted by a board member, C. Richard Stasney, MD, and by C. Stratton Hill, MD (1993). The statement endorsed the federal intractable pain regulation and the IPTA and stated that the board would use treatment outcome and not quantity or duration of prescribing as a standard for evaluating cases against doctors. In 1995, Hill, David Rallston, and colleagues are seeking further clarification of Texas policy and have submitted to the Board of Medical Examiners a proposed regulation for the treatment of intractable pain in Texas (C.S. Hill, personal communication). New Jersey The only state of which we are aware that currently has a regulation on intractable pain treatment is New Jersey. The regulation mirrors the federal intractable pain regulation in part. The New Jersey regulation, however, has several conditions that delimit the boundaries of intractable pain treatment: When protracted prescribing [of narcotic drugs] is utilized for the alleviation of intractable pain, practitioners shall remain alert to the availability of new or alternative types of treatment. The practitioner should attempt periodically to either cease the medication or taper down the dosage, or try other medication or treatment modalities in a regular and vigilant effort to reduce the addiction propensity for the patient. (New Jersey Board of Medical Examiners, 1993, p. 64) Regulations have the force of law, and compliance with specified conditions becomes the responsibility of the practicing physician. Indeed, failure to comply with such conditions might constitute a violation. Thus, a New Jersey physician who prescribes opioids for intractable pain should document compliance with the additional conditions in the patient's chart. California In 1990, California became the second state to adopt an IPTA due to the efforts of State Sen. Leroy Greene and Harvey Rose, MD. This legislation was the consequence of professional and public concerns about inadequate pain management, the harsh effects on patients, and physicians' concern about investigations by the state medical board. California's law is essentially identical to the Texas IPTA, although it requires evaluation of the patient by a specialist in addition to the attending physician (California Business and Professions Code, 1990). The adoption of the California IPTA has also served as a catalyst for a number of governmental and professional actions to identify and remove barriers to pain management. For example, other new legislation required examination of alternatives to the triplicate prescription program, distribution of information on pain management and the California intractable pain treatment policy to all physicians by the medical board, and a medical board survey of state medical schools' curricula on pain management. In March 1994, the governor sponsored the Summit on Effective Pain Management: Removing Impediments to Appropriate Prescribing to prepare a strategy for a statewide effort to improve pain management (Angarola & Joranson, 1994; State of California Department of Consumer Affairs, 1994). The licensing and disciplinary boards for medicine, pharmacy, and nursing developed positive guidelines for the appropriate use of opioids in intractable pain. The American Pain Society Board of Directors endorsed the medical board's guidelines (correspondence of APS President J. Campbell to D. Arnett, Executive Director, California Medical Board, January 11, 1995; see page 20 of this newsletter for details). The State of California's actions to make pain management a priority are exemplary. Florida In 1994, following an intense debate on euthanasia and physician-assisted suicide, the Florida legislature instead approved an intractable pain treatment provision. Intractable pain is defined as "pain for which, in the generally accepted course of medical practice, the cause cannot be removed and otherwise treated" (Florida Statutes, 1994, p. 2). A licensed and qualified physician must diagnose intractable pain. The new provision permits use of any controlled substance in Schedules II-V, not only opioids, to treat a person with intractable pain, provided the physician conforms to a standard of care that would be recognized by reasonably prudent physicians under similar circumstances [italics added] (Florida Statutes). (One might ask what this means, given the prevalence of inadequate pain management and the history of discouragement of extended use of strong opioids for chronic noncancer pain.) Florida's intractable pain provision also recognizes that the state does not condone euthanasia and bans the use of intractable pain treatment for such a purpose. Discussion The development of intractable pain treatment laws gives much-needed recognition to the necessity for better treatment of intractable pain and can help to correct past policy, which discouraged any use of opioids. However, the opportunity to develop new legislation merits our careful consideration of both benefits and risks. For example, could there be unintended consequences from making opioid therapy for intractable pain a "treatment of last resort"? Is it medically appropriate to require physicians to demonstrate that every chronic pain problem - whether due to terminal illness or any other chronic condition-is refractory to other therapies before prescribing opioid analgesics? How much time must elapse? How many therapies must be tried, and at what expense to the patient and the healthcare system? Although these questions should be answered by the physician and patient, they may also become legal questions once intractable pain treatment laws and regulations are enacted. Are state intractable pain treatment laws really needed? Although the states have the power to regulate medical practice, the results can be unpredictable when state legislators and other interest groups start writing new laws, especially when the subject is drugs and medical practice - witness, for example, Virginia's approval of heroin in an effort to treat cancer pain. Moreover, after a new law is passed, a state agency may adopt regulations to codify, and perhaps restrict, the treatment of intractable pain, potentially leading to new issues. For example, if intractable pain regulations include conditions and restrictions, as in New Jersey, these may expand recordkeeping requirements and, thus, increase instead of decrease the potential for violations when controlled substances are prescribed for pain. States do not now directly prohibit by law or regulation the use of opioids for intractable pain. If a state medical, pharmacy, or nursing board discourages the use of opioids for intractable pain, this is informal policy and it should be changed. Such a change can occur without legislation-for example, through a cooperative effort of regulatory boards and pain experts to develop and communicate new guidelines (Commonwealth of Massachusetts Board of Registration in Medicine, 1989; Medical Board of California, 1994). If the voluntary development of positive guidelines by a board proves unsuccessful, political action, including lobbying for intractable pain treatment legislation, merits consideration. In Idaho, an intractable pain treatment act was introduced to protect physicians who prescribed opioids for intractable pain from the medical board. Although the bill was not adopted, the medical board has undertaken a review of its policy on prescribing for intractable pain (Idaho State Board of Medicine, 1994). Which language should be used? The Texas and California IPTAs might be useful if the primary goal is to protect physicians from a medical board when, in fact, that threat exists or when the board is reluctant to clarify and communicate its policy. The Texas and California IPTAS, however, also appear to restrict prescribing of opioids to substance abusers, even if they have pain. The laws in Washington and Colorado do not exclude substance abusers and are consistent with the nationally approved model for drug control laws in the United States. On the other hand, they do not establish a legal protection for physicians from their medical boards. Can legislation be an opportunity to initiate action? A new intractable pain law, by itself, probably will do little directly to change practice patterns or improve the management of patients' pain. In California, however, the legislative sponsor and key supporters of the new IPTA have served as powerful catalysts for other positive actions to improve pain management in the state. In addition, either a legislature or a governor can establish a pain commission to study the problem and make recommendations for action. Study commissions can, however, also waste time and energy and actually delay real progress unless there is (a) strong support for implementation of the recommendations; (b) a clear mission focused on better and more cost-effective pain management; (c) willingness to identify and address common myths and barriers; (d) competent and adequate staff resources; and (e) a membership that is balanced, knowledgeable, and committed to the mission. Conclusions Long-held medical beliefs and regulatory traditions have rejected the use of opioids for chronic noncancer pain but are now undergoing reassessment in light of new knowledge, recent clinical experience, and the public attention being given to better pain management. The ultimate goal of a balanced public policy should be to harmonize medical and drug regulation with clinical practice so that physicians are free to use this treatment according to good medical judgment. This harmony can sometimes be promoted through laws and certainly through the development of medical, pharmacy, and nursing guidelines. Such guidelines should encourage pain management and help clinicians select and manage patients and avoid investigation. Guidelines should also continue sanctions against sloppy and unprofessional practices that can contribute to drug abuse. Such guidelines as those issued in Texas and California give medical boards unique opportunity to encourage quality care while at the same time allowing them to focus limited resources on cases in which there is harm to public health. (Note: The second article in this series will discuss state medical boards' development of intractable pain guidelines.) As the development of intractable pain policy proceeds in the United States, we should take care not to oversimplify the complexity of chronic pain and its treatment. We should avoid creating the impression that all prescribing of opioids is appropriate or that any person with chronic pain has a right to opioids. We should also avoid creating the impression that new policies will correct deficits in practitioners' knowledge and attitudes. The appropriate use of a range of therapeutic options, including nonpharmacologic treatments, opioids, and other drugs, depends on careful evaluation and monitoring of results by knowledgeable professionals supported by regulatory policy and practice. Opioids and other individual therapeutic modalities should neither be prescribed nor proscribed by laws, regulations, or policies. Do the differences in today's state intractable pain laws and regulations suggest we are moving toward a balkanized approach to the use of opioids for chronic pain? How can we uniformly raise the quality of pain care if policies differ from state to state? The quality of intractable pain treatment policy at the state level would benefit from a dialogue aimed at acheiving consensus among healthcare professional, regulatory, and patient interests in the United States. One aim of such a dialogue should be to achieve reasonable uniformity of policy among the states; another would be to address the needs of individual patients who have fallen through the cracks. The author would appreciate having readers' perspectives and any additional information about state policies

What is pain? Pain is a psychological as well as a physiological phenomenon or process. It is an event that involves the entire nervous system, brain, spinal cord and nerves. When an individual experiences pain, the stimulus is carried from the nerve endings of the site of the painful experience to the brain. The brain registers the experience as being painful and quickly sends messages back to the area that causes the individual to react. Reactions are determined by many factors that are incorporated into us as human beings. The experience and _expression of pain is a purley subjective event that is unique to each person. It is universal, complex and no two people feel pain in the same way. The word pain describes everything from a stubbed toe to malignant cancer pain. Weisenberg (1977) defines pain as "a reaction related to actual or impending tissue damage on the basis of the responses measured to indicate the evidence of its presence". The Agency for Health Care Policy and and Research (1993) defines pain as an "uncomfortable feeling that tells you something may be wrong in your body." Pain is the body's way of sending a warning to the brain. The spinal cord and nerves provide pathways for messages to travel to and from the brain as well as to other parts of the body. Pain is one of the many reasons why indibiduals seek help from the medical profession. Throughout our lives human beings experience many different types of painful stimuli. However, due to the uniqueness of each person's pain, it is extremely difficult to adequately explain to others as well as understand ourselves. One reason why pain is hard to convey to another person is that the description of the pain that is felt is combined with personal emotions that human beings possess. The description a person gives is not the actual sensations of the painful experience, but rather the person's perceptions of the discomfort while experiencing the pain. ***Note this comes from owners dissertation. If you wish to copy, please ask permission. Patricia Verugo, PsyD (1997)

Hello msn, I am new to msn messenger and msn my space.  I have done 2 other pages on yahoo and myspace.  The url's are http://www.360.yahoo.com/psydchick

http://www.myspace.com/psydchick

I also started a group on yahoo for intractable pain.  I am very happy to be acquainted with msn and hope that i will meet some wonderful individuals