Surveys indicate that the American public’s attitude may be shifting toward supporting patients’ right to die and to seek out physician-assisted suicide. Polls of physicians reveal that the profession remains split on this issue.

 highlighted a Harris/BBC World News America poll of more than 2,300 American adults that found large majorities in support of physician-assisted suicide for terminally ill patients in great pain who wish to end their lives in a time, place, and manner of their own choosing. Two-thirds of respondents think that doctors “should be allowed to advise terminally ill patients who request the information on alternatives to medical treatment and/or ways to end their lives.”

 that “a majority of people over 65 now have written directives regarding the type of care they would like to receive, or not to receive, at the end stages of their lives.” However, the likelihood that a patient has created a living will or other written instructions outlining his or her wishes for end-of-life treatment increases with age; only about one-quarter (28%) of all patients have written directives. The survey also reported that 56% of respondents “know someone, living or dead, who has created written directives or documented instructions for the end stages of their lives.”

	Although the greater awareness among patients of the importance of end-of-life planning and directives shown by these survey results is encouraging especially given all of the 

 over “death panels” and advance care planning, the real story is the public’s seeming overwhelming support for the availability and use of physician-assisted suicide in at least some clinical situations. Nearly 70% of surveyed adults agreed that “people who are terminally ill, in great pain and who have no chance of recovery should have the right to choose to end their lives.” The level of support for this issue dropped only slightly among older (over age 65) respondents, 62% of whom were in favor. More than two-thirds (67%) of those surveyed said that “doctors should be allowed to advise terminally ill patients who request the information on alternatives to medical treatment and/or ways to end their lives,” with more than one-quarter (27%) saying this should apply “in all cases” and 40% saying it should apply “only in certain cases” (which were not defined in the survey). Nearly 58% of people surveyed said that “the law should allow doctors to comply with the wishes of a dying patient in severe distress who asks to have his or her life ended.”

	Physicians’ views on this topic are decidedly more mixed than those of the general public, as represented in the Harris/BBC survey. In 

 by Medscape in August-September 2010 that included the question, “Are there situations in which physician-assisted suicide should be allowed?” 45% of physician respondents answered “Yes,” 41% said “No,” and 14% said “It depends.” These results are similar to those produced by 

 in 2005 that asked “Do you think physicians should be given the right to dispense prescriptions to patients to end their life?” In that survey, 59% of physicians answered “Yes” and 41% said “No.” A 2007 survey of attitudes toward assisted suicide among Vermont physicians reported in the 

 found that more than one-third (38%) believed physician-assisted suicide should be legalized, about one-sixth (16%) said it should be prohibited, one-quarter (26%) said that it should not be legislated by the government at all, and another one-sixth (16%) were undecided on the matter. Interestingly, the survey found that physicians who did not care for patients through the end of life were “significantly more likely to favor legalization of [physician-assisted suicide] than physicians who do care for patients with terminal illness,” by a margin of 48% to 33%. A survey of 3,300 oncologists published in 2000 in the 

 found that only 22% of those surveyed “supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain,” a figure the authors at the time noted had decreased by nearly half (from 45%) from a similar survey in 1994.

	These and other survey results reveal a deep divide on the issue of a patient’s right to die and questions about the nature of the medical profession and the proper role of the physician in hastening a patient’s death, with diverse factors such as the wording of survey questions (use of the word “suicide” decreases the likelihood that a respondent will support physician-assisted suicide), physicians’ experience with direct palliative care, physicians’ religious beliefs, and political concerns over further intrusion of the state into the physician-patient relationship coming into play.

15th anniversary of its pioneering Death with Dignity Act

, which “allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose," this issue is increasingly in play in statehouses around the country. As the graphic on page 17 shows, several states are currently considering bills to legalize assisted suicide, with others moving in the opposite direction and taking up bills to explicitly ban the practice. With surveys showing a deepening split between the medical profession’s and the public’s support for physician-assisted suicide, and an aging population that will in coming years likely stretch our already inadequate palliative care services to the limit, it is clear that the issue of who gets to decide when and how a patient’s life journey will end is far from settled.

Should physicians ever take an active role in helping a patient to end his or her life?

	Life itself is a terminal illness. I support allowing competent indiviuals the freedom to determine when and how to end their lives and I support allowing physicians the freedom to advise or assist, depending on their own convictions.

	I don’t believe physicians or patients have the sovereign right to take life. Life is a gift that can involve pain, hardship, and unbelievable challenges. It is not our decision to determine when life shall end.

	Call me old fashioned, but doctors should not be involved with assisted suicide. It’s not our role to play God and decide when a life should end. I am not in favor of “mercy killing” for moral and ethical reasons. It’s one thing to provide palliative care and provide pain meds, or withhold life support measures, but an ethical fine line is crossed when you assist in a patient’s demise or advise them on how to hasten death at their own hands. The Hippocratic oath we all took as physicians is a sacred trust and should not be violated. It’s a slippery slope toward euthanasia if we venture too far down the road toward assisted suicide or hastening the death of the terminally ill. Our job is to keep terminally ill patients comfortable and pain free, and seek the assistance from hospices and others trained in end of life care.

	A person should have freedom of will due to all of the arguments given. Mainly, if the quality of life is not there and the person endures great pain, their end-of-life directives should be honored and the family and attending physicians should by law have restricted rights to end their life.

	Providing patients with a means to kill themselves is not something health care providers should be doing. You wouldn’t place a loaded gun on the bedside of a desperate patient. Palliative care can help ease pain and give time for families to come together, to care and support. Often much healing of relations can take place during even the most difficult times. When the option of physicians ordering medications to kill a patient is legally available, some patients may feel that the family expects them to choose that option or put pressure on them to commit suicide. It also sends a message that because you have suffering in your life, it is no longer worth living.

Do you support a patient’s right to choose the time, place, and manner in which his or her life ends? Are you in favor of physicians offering advice to patients who seek to end their own life?

Are you in favor of physicians actively assisting patients who wish to end their own life, whether by prescribing medications or some other method or intervention?

Does your opinion on this matter change in cases involving terminally-ill patients for whom adequate pain relief is not possible?

Have you been asked by a patient or relative of a patient for advice and/or assistance regarding ending a patient’s life?

Have you noticed an increase in the number of patients with written directives or documented instructions for end-of-life care?

What are the key concerns and consequences of allowing physicians to discuss assisted suicide or other options with their terminally ill patients?

Articles

Cover Story

Surveys indicate that the American public's attitude may be shifting toward supporting patients' right to die and to seek out physician-assisted suicide. Polls of physicians reveal that the profession remains split on this issue.

Deciding When and Where the Journey Ends

The last thing physicians need is another government “solution” that requires them to give up more pay.

	For years, physicians have complained that their reimbursement was determined in large part by unaccountable Medicare bureaucrats who were more interested in controlling spending than in providing quality patient care. Now, with the passage last year of the Affordable Care Act (ACA), that lament is truer than ever. Tucked away inside the 2,000-plus pages of the ACA is a provision calling for the creation of the Independent Payment Advisory Board (IPAB), a panel of 15 unelected bureaucrats tasked with reducing the rate of growth in Medicare without affecting coverage or quality. Beginning in 2015, the IPAB must submit proposals to reduce costs when Medicare spending exceeds a targeted level. Physicians should be in favor of this, right? After all, Medicare spending growth is a budget-busting drag on the economy that needs to be reined in.

	The problem is that the IPAB will most assuredly seek to “fix” Medicare on the backs of the physicians who deliver the care. By law, the IPAB is specifically prohibited from proposing to ration care, raise revenues or Medicare premiums, increase Medicare beneficiary cost sharing, restrict benefits, or modify eligibility criteria. Thus, the only method open to the IPAB for reducing the growth of Medicare is to propose reductions to reimbursement rates.

	James C. Capretta, former associate director at the White House Office of Management and Budget, addressed this issue last year in a 

. In order to “hit its budgetary targets, the IPAB is strictly limited in what it can recommend and implement. It can’t change cost-sharing for covered Medicare services. Indeed, it can’t change the nature of the Medicare entitlement at all, or any aspect of the beneficiary’s relationship to the program. The only thing it can do is cut Medicare payment rates for those providing services to the beneficiaries,” Capretta wrote.

	“This wasn’t an accident. It reflects the cost-control vision of those who wrote the bill. They believe the way to cut health care costs is with stronger federal payment controls. They envision the IPAB coming up with new payment models which will push hospitals and physicians to emulate today’s most efficient delivery models. Call it ‘government-driven managed care,’” he added.

	Of course, more and deeper cuts to physician reimbursement cannot on their own lead to long-term solutions to out-of-control Medicare cost growth. The supporters of this approach know this, but abandoning this reckless approach in favor of more consumer-driven reforms would mean less government interference and control in the health care marketplace, which is anathema to the president and other supporters of the ACA.

	IPAB is an unaccountable board “whose sole job is to make care decisions on the basis of a budget … it does not have a mandate to improve patient care—it has a mandate to meet a budget, and that harms patient care,” according to 

HR 452 (the Medicare Decisions Accountability Act of 2011)

, a bill that would strip the IPAB provision from the ACA.

	Roe has been joined in his calls for repeal of the IPAB by 

more than 75 medical societies and organizations

, including the Cardiology Advocacy Alliance, which opposes the IPAB because it “minimizes the role of Congress, creates a payment authority that has tremendous power but is not accountable to anyone but the President (who appoints IPAB members), and most likely will result in significant Medicare payment cuts based on ivory tower analyses that do not take into account real-world situations."

	At a time when physicians everywhere are already facing the twin pressures of rising business costs and declining reimbursement, the last thing they need is another government “solution” that requires them to give up more pay to fix a mess they didn’t create. This particular board review definitely gets a failing grade.

Columns

The last thing physicians need is another government "solution" that requires them to give up more pay.

ACA Payment Review Board Gets Failing Grade

	A group of apps for kids called Touch Pets-Dogs, -Dogs 2, -Dogs Care, -Dogs Earth, and Touch Pets -Cats are free to download. However, you have to pay real money to buy bones, dog food, cat food, and coins. The game isn’t much fun if you can’t buy these items, so it’s really a scam. Many parents have found bills for $50-$100 from the iTunes store and found out this way that their children were innocently buying these items not knowing they were spending real money! Parents who let their child use their iPhone or iPod Touch should turn off in-app purchases!

	A product of the Texas Medical Associations’ Physician Oncology Education Program, this app was created specifically to allow primary care physicians quick and easy access to the currently recommended cancer screening guidelines for the top 25 cancers. Information covers risk factors, nutrition and chemoprevention stats, and available imaging tests. The only two reviews in the app store at writing gave CanSearch five stars, saying “Lots of good information here, and searching through it is very easy,” and “A great resource for health care professionals and patients alike.”

	Use this app as a dashboard for containing, managing, and connecting to all the health and wellness apps and resources that currently exist in isolation on your device of choice. Be sure to tell your patients about it too, as they can use it to “identify and define the apps and electronic health record systems that best enhance [their] personal health & wellness.” With WellComm, users can create surveys, questionnaires, and assessments for capturing data, track and monitor health and wellness information, and securely store information from any other medical app on their device in a third party personal health record system.

	Most states now have laws on the book that forbid texting while driving, and it’s probably not a good idea to text and drive in any state. Enter this app, which can set custom or pre-made autoresponses to send to those who text you while this app is turned on, letting them know that there’s a reason why you’re not getting back to them right away—you’re driving, with a patient, in a grand rounds meeting, or on the golf course. The app takes safety one step further by reading aloud those texts you do receive while driving and making quick calls to saved contacts as desired. Reviews are all positive: “I love that this doesn’t run in the background,” “This is an excellent app for anyone on the go,” and “Awesome app works great.”

	Funded by the Cancer Prevention and Research Institute of Texas, CanQuit provides a text-based resource application to help health care providers with the difficult task of approaching smoking cessation. Smoking cessation has gone from an occasional suggestion to an important healthcare intervention, as important to a patient’s health as controlling their blood pressure or cholesterol level. CanQuit offers healthcare professionals a simple and organized outline to follow in order to provide information, motivation, and reassurance to a patient who is considering smoking cessation. Sections are divided into screening questions, motivational interviewing, pharmacotherapies, and important information about special populations. Additional resources are noted in the application, but a search function for local smoking cessation resources would be a helpful update. Smoking cessation is a difficult process for a patient and an intimidating task for a healthcare provider. With CanQuit, the process at least has a beginning framework to build upon, making it a recommended addition to your electronic medical bag.

 iPhone, iPod touch, iPad, (Android coming soon)

	Designed to help physicians decide whether a test will be useful by allowing on-the-fly calculations of post-test probabilities for over 100 tests from its preexisting database, this app also allows users to add sensitivity/ specificity data for their own favorite tests. By demonstrating the potential for false-positive and false negative results, this app facilitates better decisions, improves patient education and family discussions, and clarifies the risks of over- and under-testing. With an intuitive graphical representation of the calculations, Rx-Bayes makes Bayesian analysis fast and easy, so it can be done at the point of care. Its interactive design and thorough information page make it a great learning/teaching tool for clinicians who are unfamiliar with Bayesian theory.

Staff- and physician-written reviews of mobile medical apps for the iPhone, iPad, and Android devices.

App Wrap for March 2011

News and the latest updates on developments in alcohol and drug testing.

Center for Health Enhancement Systems Studies

 is putting the efficacy of mobile health care technology to the test by offering recovering alcoholics access to a smartphone app that will provide consistent “24-hour, in-home (or anywhere) access” to a relapse prevention system.

	Researchers posit that “cost, geographic distance, lack of time, and peer support can reduce participation” in aftercare programs, and also that ready access to the resources that this tool can provide “will improve competence, relatedness, and autonomy which will reduce the days of risky drinking over a 12-month period.” The Addiction Comprehensive Health Enhancement Support System (ACHESS) includes:

		Communication with peer support groups and addiction experts

		Timely monitoring to assess risk of relapse

		Reminders and alerts to encourage adherence to therapeutic goals

		One-touch communication with a care manager

	The trial is recruiting 280 patients from CAB Health and Recovery Services, Boston, MA, and Fayette Companies, Peoria, IL. The system will also be tested as part of a 

 involving 30 offenders in the Ayer Concord Drug Court Program (ACDCP) in Massachusetts. “Being able to reach out during times of risk can be a key factor in maintaining sobriety, and this tool can make that call for help much easier,” said ACDCP program director Hilary Curtis.

Are Some Patients Aware They Are Being Drug Tested without Consent?

	Testing for illegal drugs in the ER may seem routine to you, but your patients may not even be aware of this widespread practice, or that it could be done to them without consent. An excellent explanation of why such testing is standard operating procedure, is presented in a 

 by Zachary F. Meisel, MD, an emergency physician at the University of Pennsylvania.

	Meisel wrote that testing for illicit-drug use “is something we can and often do. And in many cases, it’s done for a good reason.” Confusion, excessive sleepiness, or unexplained “flipping out” require that doctors know “right now” whether these symptoms are the result of alcohol use, stroke, or seizure.

	The basic need for ER drug screens is evident, but Meisel doesn’t approve of the practice with a paternalistic rubber stamp. He also highlighted the ethical implications of their overuse, which can blind practitioners to the downsides of the tests.

	“First there are ethical issues of autonomy and confidentiality,” he wrote. “While the Health Insurance Portability and Accountability Act legally protects all medical information from public disclosure, just ordering the test increases the risk that a breach of confidentiality could expose this sensitive information.” Second, the drug screens result in false-positives and contribute to “cognitive biases [and] mental prejudices on the part of doctors that can interfere with our ability to make the best decisions for our patients.”

	For example, if a patient with stomach pains tests positive for cocaine, “she becomes the ‘drug user in Room 2.’” This is not how “priorities in care should be determined,” he said. An “unbiased assessment of urgency” should rule the day, but personal habit and bias can be notoriously hard to change.

	Unfortunately, Meisel offers just such a solution to the problem, but because he stresses that “legal or regulatory barriers to drug tests are a bad idea,” what other options are there? “Just like everything else we do in medicine, the risks and benefits need to be weighed ahead of time. Drug-testing needs to be put to the same measure.”

Urinary Ethyl Glucuronide and Ethyl Sulfate Testing for Detection of Recent Drinking in an Outpatient Treatment Program

	In this admittedly limited study, researchers indicate “that urinary EtG and EtS testing is a useful tool for objective identification of recent drinking in outpatients treated for alcohol and drug dependence.”

MDMA and Methamphetamine: Some Paradoxical Negative and Positive Mood Changes in an Acute Dose Laboratory Study

	“In the laboratory, acute methamphetamine led to significantly higher positive moods. However, against expectations, MDMA did not generate a significant increase in positive moods.”

Acceptability of Drug Testing in an Outpatient Substance Abuse Program for Adolescents

	Adolescents were willing “to participate in a drug testing program that requires frequent urine specimens and reports results to parents. Future studies should determine how this program affects treatment outcomes and whether this program is feasible in primary care.”

Feature Articles

Drug Screening and Laboratory Testing News

Integrating CAM therapies during pregnancy provides the pain management specialist with an opportunity to become a leading voice in maternal care.

According to a literature review published in the 

, maternity care providers are using complementary and alternative medicine (CAM) to soothe a variety of pregnancy-related complaints including nausea, vomiting, back pain, depression, and perineal and general discomfort.

	The willingness of both health care providers and expectant mothers to integrate CAM therapies into maternal care plans has implications for pain management practitioners because though “recent discussion has identified the need to develop an integrated approach to maternity care … there is a lack of understanding of attitudes and behaviours of maternity care professionals towards these treatments.”

	Pain management specialists are already well-positioned to manage a majority of these complications, and by inculcating respect and understanding of CAM therapies and their use during pregnancy, pain practitioners can establish themselves as an integral and leading voice within the maternal care team.

	The authors focused on 21 research papers published between 1999 and 2009 that highlight CAM practices in maternity care in Australia, Canada, Germany, Israel, New Zealand, the UK, and US. Of the 21 papers, 14 examined recommendation or referral for CAM and “showed that most of their respondents reported practising, recommending or referring pregnant women for complementary therapies or products.” Not only are they practicing, recommending, and referring, “many of these service providers employed or endorsed more than one type of alternative therapy for their clients.” The three German studies revealed “an average of four alternative therapies practiced in each gynaecology and obstetrics clinic/hospital.”

	These therapies include herbal and massage therapy, chiropractic, acupressure, homeopathy, physiotherapy, biofeedback, aromatherapy, bioelectromagnetic therapies, yoga, reflexology, phytotherapy, and hydrotherapy.

	A wrinkle to consider: “The most commonly used alternative interventions by pregnant women did not necessarily correspond to those considered most effective or useful by physicians. This incongruity was explained by the fact that many pregnant women had initiated complementary treatment without first consulting their physicians.”

	The authors noted “geographical variations in the incidence of practice or referral for CAM,” that must “be considered alongside the wider social and cultural contexts of healthcare provision and policy and the training available to providers in different countries.” For example, Canadian midwives referred “more often to naturopaths, massage therapists, and chiropractors,” whereas midwives in New Zealand more often turned to homeopaths, osteopaths, and herbalists.

	Additionally, a documented “divergence between prescriptions of alternative therapies by obstetricians and midwives” must also be taken into account. Multiple studies suggest that “midwives have a more positive view of complementary medicine than obstetricians [who] ... are not fully convinced of the efficacy of CAM methods.” Obstetricians are more likely to attribute benefits from CAM therapy to the placebo effect and insist “on the need for an evidence base for alternative treatment.”

	One study found that 88% of midwives “considered available training of CAM inadequate,” while “many providers identify gaining knowledge about CAM as an important and pressing professional issue and support the idea that CAM teaching should be integrated into conventional medical and healthcare curricula.” It should be no surprise then that many “receive no formal training” and learn about CAM through “self-study, discussions with colleagues or participation in workshops.”

	This lack of formal training could be an opportunity for pain management specialists to lend their expertise to other maternal care providers in order to enhance patient care, satisfaction, and well-being. And vice versa.

	Such developments will be highly important going forward, because without both respect and cooperation, the past, fraught with “users of CAM” hiding it from their doctors and physicians discussing CAM only with great difficulty, will surely repeat itself. “Encouraging constructive debate and discussion on the relative roles of conventional and alternative providers would improve communication between all practitioners and their patients.”

	This, the authors write, “will help reduce the risk of adverse effects and maximize the potential usefulness of therapies.”

Complementary & alternative medicine

Complementary and Alternative Medicine News: Taking the Pain out of Pregnancy

	As part of the American Academy of Physician Assistants’ (AAPA) Leadership Forum, 200 physicians assistants took to Capitol Hill to drum up support among members of Congress for “removal of barriers for PAs” that AAPA believes will help their members “meet the demands of a 21st century health care system.”

Allow PAs to provide hospice care for Medicare beneficiaries;

Amend the HITECH Act to extend Medicaid EHR incentives to all PAs who meet the required threshold of care for Medicaid beneficiaries;

Amend federal law to allow PAs to prescribe buprenorphine for opioid addiction.

	“It just makes sense to promote a teambased model in which patient care can be strategically coordinated, reducing the burden of unnecessary testing and treatment on patients and the health care system as a whole,” said AAPA president Patrick Killeen. “The removal of these barriers to care will allow PAs to infuse our health care system with much-needed medical expertise as we shift into new models of care.” http://HCP.LV/gM4HwO

	Special Issue of Neuron focuses on addiction

	The February 24 issue of Neuron, dubbed “Reviews on Addiction,” presents a host of research and commentary that will “provide insights into how research has shaped our understanding of the neural underpinnings of addiction and led to more informed treatment strategies, while more societal-focused NeuroViews further highlight the complexities associated with substance abuse and ways in which the field is moving toward addressing such issues.”

	Highlights include a podcast interview with Nora Volkow, MD, director of the National Institute on Drug Abuse, “where she discusses her views of addiction research and policy with Neuron senior editor Kris Dickson;” an essay by Harvard Provost Steven Hyman, MD, in which he dissects the “promises and perils” inherent in the development and use “of biotechnology (drugs, stem cells, brain-machine interfaces) to enhance human cognition, emotion, and executive function…”; and a report detailing how “drug-evoked synaptic plasticity, which outlasts the presence of the drug in the brain and contributes to the reorganization of neural circuits,” may contribute to addictive behavior “with repetitive drug exposure.” http://HCP.LV/gq2BKk

Opioid addiction and dependence

As part of the American Academy of Physician
Assistants' (AAPA) Leadership Forum, 200
physicians assistants took to Capitol Hill
to drum up support among members of
Congress for "removal of barriers for PAs" that
AAPA believes will help their members "meet
the demands of a 21st century health care
system."

Opioid Addiction and Dependence: PAs want to provide hospice care, prescribe buprenorphine

	Studies have shown that pain prevalence and severity is linked to obesity (http://HCP.LV/e6AdnS) and that pain has a greater impact on functionality and quality of life in obese individuals (http://HCP.LV/i26fzr). Analysis of data from the Einstein Aging Study (EAS; http://HCP.LV/feBFFC) has shown that self-reported BMI “was associated with an increased prevalence of chronic pain” among the elderly participants in that study. However, according to the authors of “Mechanisms of Association between Obesity and Chronic Pain in the Elderly,” published in the January 2011 issue of Pain (http://hcp.lv/gqEsbA), the “mechanisms underlying the relationship between pain and obesity remain unclear, particularly in older adults.” To investigate and clarify these mechanisms, the authors looked at data from more than 400 EAS participants, age 70 and older, and examined components of the metabolic syndrome, insulin resistance, high-sensitivity C-reactive protein (hsCRP), and the presence of painful comorbidities. They also looked at comorbid depression and anxiety and the use of NSAIDs “to investigate their potential role as confounders of the pain—obesity relationship.”

	EAS participants undergo annual assessments that include “neurologic and cognitive testing, anthropometric measures, blood pressure, and collection of fasting blood samples.” Subjects were also assessed for insulin, hsCRP, triglycerides, HDL, and depression symptoms. Investigators measured BMI, assessed for metabolic syndrome (according to the National Cholesterol Education Panel’s Adult Treatment Panel III), and assessed for experience of pain in the prior three months to the clinic visit using the Total Pain Index (TPI). More than three-quarters of subjects (76%) reported pain of any severity during the prior three months at one or more locations, with slightly more than half of subjects (52.3%) meeting the criteria for chronic pain.

	The authors reported that chronic pain was significantly associated with depression score among participants, and that both BMI and abdominal obesity were associated with chronic pain, with the likelihood that a subject experienced chronic pain increasing with each unit of BMI. Individuals with abdominal obesity “were twice as likely to report chronic pain.” Roughly one-third of subjects (34%) met the criteria for metabolic syndrome, with prevalence showing “a trend toward greater frequency among those with chronic pain.” Abdominal obesity was the only individual component of metabolic syndrome consistently associated with pain. Higher hsCRP was also associated with higher TPI scores.

	The authors looked at several adjusted models that analyzed individual components of metabolic syndrome to “further examine the role of abdominal obesity as the potential driver of the relationship between metabolic syndrome and pain.” After adjusting for demographic characteristics and other factors, abdominal obesity was the only component that independently significantly predicted pain; subjects with abdominal obesity had an 83% increased likelihood of having chronic pain. Other models that adjusted for fasting insulin level, fasting glucose, a history of diabetes, hsCRP, osteoarthritis, and neuropathy “did not attenuate the relationship between abdominal obesity and pain.”

	A previous study on this topic also produced similar findings. The authors of a study published in the January 2009 issue of the Journal of the American Geriatrics Society (http://HCP.LV/enY32f) that looked at data from the Einstein Aging Study (http://HCP.LV/feBFFC) from more than 800 men and women, age 70 and older, found that “obese individuals were twice as likely to have chronic pain and severely obese individuals were more than four times as likely to have chronic pain, even after adjusting for other risk factors. Individuals in higher BMI categories also had more frequent and more severe pain, along with a higher number of painful bodily locations than those in lower BMI categories.”

	In their discussion, the authors wrote that these results “contribute to the growing body of evidence that pain among community-dwelling, well elderly individuals is associated with obesity.” Although they performed several multivariable analyses to look for “potential mechanistic links between the co-occurrence of obesity and pain … none of these potential mediators fully accounted for the relationship.” Other factors (hsCRP, osteoarthritis, etc.) were associated with pain, but only abdominal obesity was linked to the presence of chronic pain and higher pain scores, with individuals with abdominal obesity estimated to have a 70% increased likelihood of having pain. The authors wrote that the finding that “central adiposity was independent even of painful comorbidities suggests that an alternative pathway accounts for the pain—obesity association, which may be bidirectional.” They suggested that pain “may lead to decreased physical activity, depression, and obesity,” and may also lead to “cortisol secretion that contributes to truncal obesity.” Conversely, “the metabolic derangements of obesity may predispose to pain.”

	Although these results point to a strong relationship between obesity and pain in the elderly, the benefits of one seemingly obvious solution—weight loss&mdash;have yet to be demonstrated. The authors recommend that clinicians advising elderly patients to restrict caloric intake “must take into consideration the potential risk of weight loss in this population,” including the effects of losing lean body mass and bone mineral density (although there are published consensus statements that support weight loss interventions that minimize the loss of lean body mass in obese elderly).

Geriatric pain medicine

Study shows that abdominal obesity is associated with a nearly twofold increase in the probability of chronic pain among elderly individuals.

Obesity Is Associated with Increased Risk of Pain in Elderly Patients

	Although the majority of patients undergoing treatment for cancer experience breakthrough cancer pain, and despite the fact that suboptimal breakthrough cancer pain treatment can have a severe negative impact on patients’ quality of life, diagnosis and treatment of breakthrough cancer pain remain poor due to a variety of factors.

	In “Integrated Strategies for the Successful Management of Breakthrough Cancer Pain,” published in the journal Current Opinion in Supportive and Palliative Care (http://HCP.LV/ g8S9o1), Andrew Dickman, a researcher at the Marie Curie Palliative Care Institute, in the UK, noted that the lack of a clear consensus definition of breakthrough cancer pain, concerns among patients and physicians regarding overmedication and addiction/ dependence, “difficulties among healthcare professionals in differentiating [breakthrough cancer pain] from poorly controlled background pain,” and other barriers conspire to ensure that detection and treatment of breakthrough cancer pain remains less than optimal. Dickman also wrote that control of breakthrough cancer pain using traditional “rescue medications” is also problematic because “the pain relief afforded by morphine and other normal-release oral opioids, such as oxycodone and hydromorphone, does not appear to match the characteristics of the [breakthrough cancer pain] episode itself.”

	The effects of untreated breakthrough cancer pain are pervasive, impacting nearly every aspect of affected patients’ lives. According to a survey conducted by the American Pain Foundation (http:// HCP.LV/dJayy5), “85% of patients who responded stated that breakthrough cancer pain negatively affects their quality of life, including their physical health, interpersonal relationships and ability to engage in certain activities.” A European study of oncology patients (http://HCP.LV/gbSTFf) found that 63% of patients reported breakthrough cancer pain or inadequate pain relief “despite being prescribed analgesics.” More than half of these patients “reported inadequate pain relief all the time, every hour, several times daily, daily or several times per week, and yet, only a third (33%) of them were treated with additional analgesic medication.”

	Effective treatment begins with proper recognition and assessment. Dickman noted that it is important for clinicians to “differentiate patients with uncontrolled background pain experiencing transient exacerbations of that pain from patients with controlled background pain experiencing episodes of breakthrough cancer pain.” When assessing patients for breakthrough cancer pain, “it is important to ascertain the temporal pattern of pain, any precipitating or exacerbating factors, any relieving factors, the response to opioid analgesics and the response to other therapeutic manoeuvres.” Assessment should include a detailed history and physical exam and the use of standard pain measures and questionnaires.

	Barriers to treatment include physicianrelated causes, such as inadequate knowledge of breakthrough cancer pain and underestimating and/or underappreciating the intensity of the patient’s pain, as well as concerns about “side-effects of opioids, prescription of ineffective doses of opioids, and failure to adequately address the undesirable effects of opioids.” Patients also contribute to suboptimal treatment by inadequately communicating to clinicians the extent and/or intensity of their pain, harboring heightened fears of the adverse effects of opioids, and failing to properly adhere to the prescribed medication regimen.

			It is important to distinguish breakthrough cancer pain from end-of-dose pain, “which can occur before a scheduled dose of background analgesic and generally arises due to an inadequate dose of analgesic or extended dosing interval.”

			Effective pain management requires a comprehensive, individualized, multidisciplinary approach that may incorporate a combination of pharmacological and nonpharmacological treatment modalities.

			Oral formulations of morphine and opioid rescue medications may not provide optimal responsiveness for breakthrough cancer pain “because the analgesia provided occurs after the [breakthrough cancer pain] has spontaneously subsided.”

			It is important that patients, caregivers, and clinicians receive appropriate education to dispel the fears and myths surrounding opioids.

	Ideally, treatment for breakthrough cancer pain includes “a rescue dose of strong opioid with pharmacokinetic properties that closely match the temporal characteristics” of the patient’s pain. Treatment should provide demonstrable analgesic relief and combine rapid onset of action with a relatively short duration of action, be easy to administer, and have minimal adverse effects (the latter two characteristics especially contribute to improved adherence). Fentanyl preparations may be especially suitable for this role because they are “rapidly absorbed across mucosal membranes, with the promise of a rapid onset that more closely matches the profile of the ideal rescue treatment.” Dickman notes that formulations of fentanyl that use “advanced delivery systems provide efficacious pain therapy with minimal side-effects and are often preferred by patients compared with traditional oral opioids” used for the treatment of breakthrough cancer pain.

	In addition to taking appropriate measures to deter and prevent misuse and abuse of fentanyl products, physicians treating patients for breakthrough cancer pain should combine a “multidisciplinary approach, careful patient assessment, and a treatment strategy tailored for the individual patient that considers the cause and type of [breakthrough cancer pain], as well as patient preferences.”

Cancer pain

Despite the availability of several effective treatment options, including
well-tolerated fentanyl products, researchers report that breakthrough
cancer pain continues to be underrecognized and undertreated.

Clinical Challenges of Treating Breakthrough Cancer Pain

	Although the statute authorizing the creation of the Florida Prescription Drug Monitoring Program (PDMP) “specifically does not allow the use of state appropriations for establishing the PMDP” (http://HCP.LV/ggt194), Florida Governor Rick Scott has called for the cancellation of the program as part of his efforts to reduce state spending, a move that has touched off a wave of protest from the pain medicine community in Florida.

	The Florida Society of Pain Management Providers (FSPMP) responded to the governor’s call for repeal by calling the PDMP “the single most important weapon in the war on Rx drug abuse, not only in Florida but in the other 42 states where legislators have approved their operation” (http://HCP.LV/fQb3o9). Claiming that Florida is “the epicenter of Rx drug abuse” in part because it has delayed implementing the PDMP, the FSPMP news release noted that “without the PDMP system there is no effective way to enforce the law, leaving honest physicians in the precarious position of unknowingly prescribing narcotic medications to a possible abuser or dealer.”

	Citing data from the states that operate PDMPs, the FSPMP estimated that Florida’s PDMP “will need approximately $1.2 million for its first two years of operation,” with an additional $500,000 per year thereafter to run the program. The FSPMP also noted that the program has secured enough money through federal grants and private donations to fund more than two years of operations (http://HCP.LV/goAByQ).

	Opponents have also decried the PDMP as yet another example of government overreach into the private lives of citizens. Florida House Health and Human Services Chairman Rob Schenck called the database “just a big-government, big-brother alternative’’ (http://HCP.LV/i1hSUx). Schenck said in a media release that after eliminating the PDMP, Florida “must examine every step in the supply chain and every strategy intended to stop prescription drug abuse” in order to find out “what really works” (http://HCP.LV/fh8vAl). Saying that Florida needs “a front-end solution” that “stops the problem at its source and stops legalized drug dealers in Florida,” Schenck promised that his committee would soon introduce a bill that would present a solution to Florida’s pill mill problem.

		Prescription Drug Abuse in Florida, by the Numbers

 as many as caused by all illegal drugs combined. The rate of deaths in Florida caused by prescription drugs is increasing five times as fast as the rate of deaths caused by all illegal drugs. Drug-related deaths in Florida increased from 6,767 in 2003 to 8,556 in 2008.

 oxycodone than the national average of dispensing physicians and prescribe

oxycodone pills than all other states combined.

			More oxycodone is distributed in Florida than in any other state (

			In one six-month period in 2008, pill mills in Broward County dispensed more than

			The DEA estimates that the number of pain clinics in South Florida 

 in 2009-2010 (from 60 to more than 150).

: http://HCP.LV/fdnhGN, http://HCP.LV/gqKJsA, http://HCP.LV/hiNHKs

	Relaying the governor’s concerns over potential violations of patients’ privacy, a spokesperson for Scott’s office asked whether it was a legitimate function of government “to track the activities of law-abiding people in order to track a smaller subset of criminal behavior.” Scott himself has called the database “an invasion of privacy” (http://HCP.LV/el8vpa). The governor’s office disputes the claim that the PDMP would not require taxpayer funding, pointing out that at least one bill has been introduced in the legislature calling for more than $1 million in public funding (http://HCP.LV/elvCZP). It attributes the lack of private funding for the database to the fact that “nobody wants to pay for what already exists at all legitimate pharmacy chains already” and that potential funders realize that relying on the physicians who are dispensing the medications to honestly self-report their actions “will do little to stop so-called pill mills.” The governor has said he will seek alternate approaches to dealing with Florida’s prescription drug abuse problem, including stricter fines, regulations, and enforcement.

	However, many leaders in the Florida law enforcement community disagree with this approach. At the press conference announcing the results of police raids on more than a dozen pill mills across south Florida (http://HCP.LV/gqKJsA), Broward County Sherriff Al Lamberti and several other officials expressed their hope that the governor would reconsider his efforts to repeal Florida’s PDMP. Calling the database a critical weapon in the fight against the state’s flourishing pill mills and illegal prescription pain medication trade, Lambertia said that without the PDMP, “Florida is going to remain a problem state for pill mills. It is a huge step backward to rescind that [system]. We cannot arrest our way out of this problem” (http://HCP.LV/fEX1zk).

Medical/legal issues

Florida Governor Rick Scott's plan to cancel the state's prescription drug monitoring program-because it is too pricey and intrusive-has drawn protests from medical and law enforcement officials.

Proposal to Cancel Florida's Prescription Drug Monitoring Program Meets Strong Resistance

	Unexplained chronic pain (UCP) is quite common in children and adolescents and, according to the authors of “Psychiatric Disorders in Children and Adolescents Presenting with Unexplained Chronic Pain: What is the Prevalence and Clinical Relevancy?” (http://HCP.LV/grkc5R), published in the January 2011 issue of European Child and Adolescent Psychiatry, there is “increasing evidence that psychiatric symptoms and psychiatric disorders are also involved” in this patient population. However, there is relatively little information about the prevalence of psychiatric morbidity in children with UCP and whether the inclusion of a psychiatrist in the diagnostic process produces added clinical benefit. This is a salient question because, as the authors note, although guidelines for UCP “advocate a combination of psychological, physical, and pharmacological treatment,” they focus mainly on pain control, not on managing comorbid psychiatric disorders. Because there is “strong evidence for psychological and pharmacological treatment of child psychiatric disorders,” if it can be established that UCP is indeed associated with psychiatric morbidity, then “identification of children with UCP at risk of psychiatric disorders [will therefore be] required, because it justifies referral for psychiatric assessment and care.”

	To assess the prevalence of clinically relevant psychiatric disorders and their predictors in children with UCP, Dutch researchers looked at data from 134 subjects in the Pain of Unknown Origin in Children study, which enrolled children between the ages of 8 and 18 years who reported experiencing chronic pain for at least three months prior to first visiting the study clinic and who did not receive an explanatory diagnosis from the referring physician. Participants were assessed for the presence of possible psychiatric disorders using the Diagnostic Interview Schedule for Children (DISC)—a “highly structured respondent-based interview for children”&mdash;and the Clinical Interview for Children and Adolescents (SCICA), administered by a child psychiatrist. For this study, the researchers used the parent version of the DISC. Subjects’ degree of psychiatric impairment was assessed using the Children’s Global Assessment Scale (CGAS); the children rated their pain using the Visual Analogue Scale of the Varni/Thompson Pediatric Pain Questionnaire (PPQ-VAS).

	The study authors found that, based on the parental interview, 40% of the children had a psychiatric disorder, but only 21% had a psychiatric disorder that was “clinically relevant.” Anxiety disorder was identified in 18% of the children (including specific phobias, separation anxiety disorders, social phobias, and generalized anxiety disorders). Other disorders identified in this group included affective disorder (in 5% of the children) and disruptive disorder (5%). When looking at SCICA results, the authors found that 53% of the children had a psychiatric disorder, with 29% having a clinically relevant disorder. Nearly 15% of the children had a psychiatric diagnosis according to both DISC and SCICA; nearly 35% had a clinically relevant psychiatric disorder assessed by one or both instruments.

	Demographic factors such as age, sex, and socioeconomic status were not predictive of clinical psychiatric disorders. Analysis of other pain parameters (duration, location, etc.) produced mixed results; however, headache as the primary location of pain “was a significant predictor of a clinical psychiatric diagnosis” in patients assessed by DISC and SCICA.

	Based on these results, the authors concluded that “the high prevalence of clinically relevant psychiatric disorders in this referred sample with UCP has implications for diagnosis and treatment in daily clinical practice. When a child presents with UCP, it is essential to make a careful psychiatric assessment, including a professional child observation and interview, symptom severity, and impairment.”

	The authors recommend that “When a child presents with UCP, it is essential to make a careful psychiatric assessment, including a professional child observation and interview, symptom severity, and impairment. If psychiatric disorders are present, evidence-based child psychiatric treatment should be offered.” Although there has been little research on the pain-management effects of depression treatment in children, studies in adults have shown that successful treatment for depression also has a beneficial effect on patients’ chronic pain. Therefore, because children with UCP “frequently experience limitations and impairments in their daily activities, which interfere with their development,” the authors recommend that “any physical, psychological, or psychiatric treatment able to reduce this interference should be incorporated in a tailored treatment plan.”

Pediatric pain medicine

Research shows that psychiatric morbidity is common in children with unexplained chronic pain. A comprehensive work-up that includes structured interviews with the child and parent, as well as clinical observation and interview of the child by a pediatric psychiatrist, is important to creating a complete diagnostic picture and identifying children who are at risk for treatable psychiatric disorders.

March 2011