A recent May Clinic study surprises practitioners of both systems that they are fundamentally similar despite the differences in approach to treat pain.

Peter Dorsher, MD, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, found in a recent study that at least 92% of common trigger points anatomically correspond with acupoints; that those used to treat pain corresponded more than 95% of the time.

Dorsher points out that myofascial pain treatment was a rediscovery of a system discovered 2,000 years before by the Chinese. Myofascial trigger-point therapy has 255 regions described by the Trigger Point Manual, whereas classic Chinese acupuncture has 361 acupoints that target specific organs or pain problems.

The study was funded by the Mayo Clinic.

Srinivasa Raja, MD, professor of anesthesiology, Johns Hopkins University Medical School, reports that less than 3% of patients with no history of drug abuse will show signs of possible drug abuse when prescribed opioids for chronic pain.

Raja argues that cognitive-behavioral and physical therapies are shown to be effective, but are only part of the solution. In order to address the problem of prescription drug abuse there needs to be a collaboration among the care givers, law enforcement and regulatory agencies, and the pharmaceutical industry. Raja suggest that:

• Law enforcement and regulatory agencies need to develop standardized state-to-state regulatory control of opioids; including a crackdown on illegal Internet pharmacies and prescription thefts and forgeries.
• Pharmaceutical manufacturers need to give priority to developing less addicting pain medication.
• Physicians need to communicate to their patients the benefits and risks of opioids and to screen patients for drug-seeking behavior along with other warning signs of potential abuse.

Raja also suggest patients need to be closely monitored to determine when doses can be lowered.

Katheleen Sluka, PhD, professor Graduate Program in Physical Therapy and Rehabilitation Science, University of Irvine Roy J. and Lucille A. Carver College of Medicine, found that a protein involved in muscle pain works in conjunction with the male hormone testosterone to protect against muscle fatigue.

Sluka, using animal studies, found the differences in fatigue between males and females depends on both the presence of testosterone and the activation of ASIC3 (an acid-activated ion channel protein that is involved in musculoskeletal pain). This suggests that they are interacting somehow to protect against fatigue, which may explain some of the differences we see in chronic pain conditions that include fatigue and why it occurs more often in women.

Michele Crites-Battié, faculty of Rehabilitation Medicine, University of Alberta, studied 147 pairs of identical twins, and 153 pairs of fraternal male twins, to determine what role occupational workloads contributed to degenerative discs. In one example, one of the twins had a sedentary job, while the other’s occupation required heavy physical demands. In another example, one twin routinely engaged in occupational driving, while the other did not. The study’s results were startling.

The study suggest that genetics plays a more significant role in disc degeneration than previously thought. While physical loading–handling heavy loads, bending, twisting, and static work in awkward postures–appears to influence disc degeneration, the effects are very modest. Comparing images of twins side-by-side showed a remarkable similarity in degree of degeneration and the spinal levels involved.

This new understanding of disc degeneration provides a foundation from which to develop a new hypotheses and may help shed light on one of the most common and costly musculoskeletal conditions facing the developed countries of the world.

Researchers are now working to identify the specific genes and biological mechanisms influencing disc degeneration and back pain problems.

Julie Kauer, professor of medical science, Department of Molecular Pharmacology, Brown University, and her co-researchers, treated rat brain tissue from the hippocampus area–the central region of the brain’s learning and memory center–with capsaicin. The researchers found that the capsaicin alone activated TRPV1 channels, which triggered long-term depression in the brain tissue; rats that lacked TRPV1 receptors and treated with capsaicin did not have the same long-term depression.

The researchers point out the potential for new drugs that could prevent memory loss. The study also shows raises the possibility for potential side effects of drugs currently being developed to pain control. Drugs aimed at reducing pain and inflammation by either blocking or activating TRPV1 are in the research pipeline, which means that these drugs may have some unexpected psychiatric side effects.

Richard E. Harris, PhD, research assistant professor, Division of Rheumatology of Internal Medicine, University of Michigan Medical School, believes he has found the link between fibromyalgia pain and the neurotransmitter molecule glutamate.

The glutamate molecule helps convey information between neurons in the nervous system. When glutamate is released from one neuron it binds to the receptors on the next neuron, which causes the the newly attached neuron to become excited (or more active.) Glutamate was targeted for Harris’ study because previous studies using functional magnetic resonance imaging (fMRI), had established that the insula region of the brain in fibromyalgia patients was highly active.

For 4 weeks participants were given either real acupuncture treatments or sham acupuncture treatments to reduce pain. The sham treatment involved using a sharp device to prick the skin in order to mimic a real acupuncture sensation.

After 4 weeks of treatment both the participants receiving the real acupuncture and sham acupuncture self-reported reductions in pain. What is significant is that the patients who reported the greatest reduction in pain also had the greatest reduction of glutamate in the insula region of the brain. Harris’ believes that glutamate may play a role in fibromyalgia and could possibly be used as a biomarker of the disease’s severity.

Because the study involved a small number of participants, Harris feels additional studies need to be done to verify the role of glutamate in fibromyalgia.

Fentanyl is powerful narcotic that is opium derived and nearly 100 times stronger than morphine. Of the four main types of fentanyl in use today, the most common type is used in treating chronic pain and sold with the Duragesic Transdermal Patch. The patch is applied to the skin and releases a specific quantity of the drug hourly.

In some circumstances the patch can cause vision loss or impaired breathing. Other side effects include: death, hypoventilation, and fentanyl overdose.

Janssen Pharmeceutica discovered their popular Duragesic Transdermal Patch could lead to dangerous overdose of fentanyl. The manufacture speculates over 2.2 million patches were manufactured during the period in question. It is estimated that 22% of those patches are still in use today.

The Federal Drug Administration (FDA) recommends:

• Anyone with 25 mcg/hr DURAGESIC patches being recalled should call 800-547-6446.
• Anyone with 25 mcg/hr Sandoz Inc. patches being recalled should call 800-901-7236.
• Patients using fentanyl patches who have medical questions should contact their health-care providers.

The FDA recalled Duragesic® or Sandoz patches on February 12, 2008.

The FDA recalled certain Actavis patches on Februrary 17, 2008.

Dan Ariely, behavioral economist, Duke University, and a team of collaborators at the Massachusetts Institute of Technology, administered mild electric shocks to 82 test subjects. Before and after the shock subjects were given a placebo and were told it was a newly approved pain-killer. All subjects were given a brochure about the new drug that indicated the ‘new’ pain-killer cost $2.50 per dose–except half of the brochures indicated that the per dosage cost had been marked down to 10 cents.

Of subjects who were led to believe the dosage cost was $2.50 experienced a reduction in pain 85% of the time after taking the placebo. The subjects who believed the dosage rate was 10 cents experienced a reduction in pain at the rate of 61%.

Although the number of subjects was relatively small it does demonstrate how people perceive quality and they anticipate therapeutic effects. Researchers could not help but to wonder what implications their study has on how generic medications are perceived. The question raised is if people who use cheaper generic drugs have the same belief that the drug works as those who are paying more for the brand name drug.

The researchers suggest that at the very least, physicians should use their enthusiasm for a drugs efficacy whether it be a brand name drug or of the generic variety.

Dr. Scott Haldeman, clinical professor of neurology, University of California-Irvine, found in his study of neck pain that it is a widespread experience that is a persistent and recurrent condition for the majority of sufferers. Neck pain disables approximately 2 out of 20 people, which affects their ability to carry on with daily activities.

The study recommends that neck pain (including whiplash related pain) be classified and treated in a common 4-grade system:

1. neck pain with little or no inference with daily activities
2. neck pain that limits daily activities
3. neck pain accompanied by radiculopathy (“pinched nerve” — pain weakness and/or numbness in the arm)
4. neck pain with serious pathology, such as tumor, fracture, infection, or systemic disease.

Haldeman and his task force found that most neck pain falls into grades 1 or 2.

The task force also studied the association between chiropractic care of the neck and stroke. They found that patients who visit a chiropractor are no more likely to experience a stroke than are patients who visit a family physician. The type of stroke associated with chiropractic manipulation can be caused by ordinary neck movements like checking when backing up a car or by looking up at the sky.

The minority of those who experience grade 3 neck pain found that corticosteroid injections may provide temporary relief.

Surgery is a last resort and should be considered only if accompanied by arm pain that is persistent or if the person is experiencing grade 4 pain due to serious injury or systemic disease–according to researchers.

The researchers recommend:

• Stay as active as you can, exercise and reduce mental stress.
• Don’t expect to find a single “cause” for your neck pain.
• Be cautious of treatments that make “big” claims for relief of neck pain.
• Trying a variety of therapies or combinations of therapies may be needed to find relief.
• Once you have experienced neck pain, it may come back or remain persistent.
• Lengthy treatment is not associated with greater improvements; you should see improvement after 2-4 weeks, if the treatment is the right one for you.
• There is relatively little research on what does or does not prevent neck pain; ergonomics, cervical pillows, postural improvements etc. may or may not help.

Michael J Counsins AM, MD, DSc, professor and director of the Pain Management Research Institute, University of Sydney, Royal North Shore Hospital, Australia suggest that if pain persists despite reasonable treatment from a primary care physician and/or other specialists, then a pain medicine specialist should be sought. The earlier a patient gets help for their pain the greater their chance of returning to a reasonable range of life activities.

Counsins feels the future of diagnosis and treatment of persistent pain will be markedly different. Drugs that are used to provide symptomatic relief, like morphine, will be replaced by–or supplemented with–a new generation of therapies targeted at the disease process. He feels that not enough pain specialists are being trained leaving pain patients with insufficient access to effective treatments.

According to Counsins, pain management needs to become a fundamental human right; a bundle of initiatives well be needed in Medicine, Law, Ethics, and Politics to accomplish this goal.