Forty-six percent of Americans want marijuana to be legalized (

). Seventy percent of Americans support the legalization of medical marijuana. The large gap between these two figures provides just enough wiggle room for politicians lacking in backbone to squeeze through and try to make everyone happy. The problem is that they are using physicians as a Trojan horse to do it -- and pain physicians should be up in arms.

	It’s surprising to find this level of agreement on such a contentious topic; 46% of Americans don’t agree that the sky is blue. Support for complete legalization has been slowly rising for years and may ultimately get to a majority (

). When does political backbone begin to form? I’m not certain that the additional 30% of Americans who support medical marijuana are particularly well informed on the quality of clinical data on the subject. Instead, they are probably simply trying to be charitable to the sick, planning for their own old age and infirmity when they might want or need pain relief, or simply view marijuana as harmless enough that the risk—benefit ratio favors availability for those who are suffering. Still, others might want to be empowered to use marijuana as a reaction against their fear that their doctors aren’t skilled enough and/or their medicines are not powerful enough to relieve pain, nausea, wasting, and other forms of suffering in advanced disease. Perhaps some are cynical enough to view medical marijuana as step one in a strategy moving toward legalization, but I doubt that they’re the majority.

	In my opinion, if Americans want legal marijuana then it should be legal (as long as some of the revenue generated is targeted at improved substance-abuse treatment for those vulnerable individuals who might be harmed by this increased access). If, once marijuana is legal, there is a desire to develop special access programs for the medically ill or even grow particularly pure or potent plants, so be it. Perhaps better safety and efficacy studies would follow. The present confusion between medical marijuana laws on a state level (which of course is not truly legal) and federal laws is the worst of both worlds (

	Medical marijuana is a compromise that hurts the already troubled image of the pain doctor and threatens pain management (

). Pain physicians are engaged in an ongoing struggle trying to keep already-legal, higher-quality medications--many of which are controlled substances--safe and available for people in pain. All this while the media paints the drugs as killers and the physicians as little more than dealers. Add to this the collateral credibility damage done by the cynical scams that arise around medical marijuana: A sudden epidemic of social phobia among college students and such; coached patients faking a variety of maladies to gain access to marijuana using a physician as the sympathetic gate keeper; etc. Often, such physicians are taking a political stance in such prescribing rather than a medically based one.

	If marijuana were 100% legal, as a pain psychologist, I would still have my qualms about its use in some of my chronic pain patients, in much the same way that I don’t want my patients to smoke tobacco, overuse alcohol, overeat, and be sedentary (all of which are legal vices that nevertheless make it harder for patients to live a full and meaningful life with their chronic disease). Legalization wouldn’t overcome the need for pain patients to strive toward a healthy lifestyle--an area in which many of them struggle. And even for those whose pain improves on medical marijuana, is that likely to help promote the other changes? However, medical marijuana does remove the specter of diversion that surrounds the obtaining of an illegal substance when one is being treated with a controlled substance that can be a commodity in such interactions (but not nearly enough to justify medicalization, in our view).

	Indeed, some studies seem to show that marijuana provides only dubious benefits that at times throw the legitimacy of “medical marijuana” into question. As a sleep aid, marijuana has limited application because it disrupts the natural REM cycle (

); during withdrawal from marijuana, users may experience reduced sleep (

	The primary difficulty in use of marijuana is its potential for abuse. When delivered via smoking, the dose can be titrated and provides nearly instant relief, but there are obvious problems with usage of smoking for prolonged treatment of an illness. As THC, the active ingredient, is not water soluble, oral formulations have their own share of difficulties. Ingested THC does not absorb well, takes one to two hours to take effect, and tends to produce more drowsiness and confusion—psychological side effects nonrecreational users do not seek.

	In addition, there have been studies comparing THC and codeine to determine which has greater efficacy in respect to pain relief (

). This study by Noyes et al. concluded that marijuana’s efficiency, at high doses, is comparable to high doses of codeine. However, there are strong psychological side effects that may limit THC’s viability as a pain reliever, while codeine causes much less mental clouding and does not impair users to the extent that marijuana use does. The NIH 1997 workshop on the medical utility of marijuana concluded that “Since the approval of dronabinol in the mid-1980s for the relief of nausea and vomiting associated with cancer chemotherapy, more effective antiemetics have been developed, such as ondansetron, granisetron, and dolasetron, each combined with dexamethasone. The relative efficacy of cannabinoids versus these newer antiemetics has not been evaluated. Smoked marijuana was tested in one trial in patients who previously had no benefit from older antiemetic agents. Nearly one-quarter of patients who initially agreed to participate later declined, citing bias against smoking, the harshness of smoke, and preference for dronabinol. Among the remaining 56 patients, 78% rated smoked marijuana very effective or moderately effective. Sedation was seen in 88% and dry mouth in 77%. It is not known whether smoked marijuana would benefit patients’ refractory to the current generation of antiemetic therapy” (

	Marijuana’s proponents frequently cite “appetite stimulation” as one of its redeeming qualities, and it does appear to help combat AIDS-related wasting. In one study, small doses of dronabinol were reported to be effective in appetite stimulation without confounding mental acuity, while high doses of dronabinol (10 mg 4x daily) appeared correlated to compromised acuity. However, the weight gained was not lean body mass, indicating that marijuana’s use as an appetite stimulant may be limited (

	Indeed, marijuana seems to be neither a panacea nor a deadly toxin. A recent population-based-case-control study seems to indicate no increased risk of lung cancer and a possible mild protective effect (

), although there appears to be a possible synergistic effect between tobacco and marijuana use in the form of increased risk for lung cancer as compared to smokers of only tobacco (

). The data supporting medical marijuana are too weak, in our opinion, to offset the other potential damage to pain management.

	Legalize it first, medicalize it second.

Steven D. Passik, PhD, is a clinical psychologist at Memorial Sloan-Kettering Cancer Center, New York, NY. His areas of expertise include the psychological aspects of cancer with an emphasis on pain, depression, nausea, and fatigue. Passik is a consultant and speaker for Cephalon, Purdue, King, and PriCara.

Sharang Tickoo is a biology major at Occidental College in California.

Articles

Cover Story

Patients want it. Law enforcement officials are granting it. But could prescribing medical marijuana be more trouble than it's worth?

Medical Marijuana is a Trojan Horse that Pain Physicians Should Refuse

	Although more people than ever use their smartphones to access the Internet, few take the time to think about issues of mobile Internet safety.

	At a recent Health Activist Meetup in Boston, participants were asked to create three action items for their presentations. The idea worked so well for the event, I have decided to try it out in print. So, starting with this month’s column, I will provide three action items to help you structure your approach to getting the most out of social media.

	This month, I want to tackle the topic of portability and the Internet. In the not-too-distant past, cell phones were just phones—for the most part, all they did was make phone calls. Nowadays, however, I’m not even sure that calling them “smartphones” does justice to all of the capabilities they offer. By enabling mobile access to the Internet, these mini-computers have been a game changer for all of us. Yet this increased access and connectivity also carries with it some very real dangers. No longer merely communication devices, these handheld gizmos expose us to the same privacy and security risks as our desktop computers. Few of us consider these risks or take steps to protect ourselves against them.

	According to the 2010 Online Safety Study released last month by the National Cyber Security Alliance and the Symantec Corporation (

), we are more connected online than ever before via not only desktop computers but also televisions, game systems, laptops, and smartphones. Interestingly, although most people understand they must take certain safety precautions (firewalls, backups, password protections, etc) when accessing the Internet from a “real” computer, they often fail to protect themselves when using smartphones.

	Offline, we would never allow ourselves or our loved ones to be in such a vulnerable situation. Yet, when we’re online, we frequently tempt fate, even in the face of known risks and threats. Just because a threat seems faceless or anonymous, making it hard for us to see the imminent danger, doesn’t make it any less real. Ignoring it is not a healthy message to send to children.

	We must admit that cyber safety is up to us. If we want to prevent identity theft, cyberbullying, sexting, and other threats, we have to start by putting in place the right safeguards in our own lives and teaching our kids to do the same in their online and mobile lives.

	In our offices, we see mobile culture every day. We see parents checking e-mail and touching base with their children. We see teens texting friends and updating Facebook. And, now and again, we see a patient surfing the Web to confirm some medical information or advice we just gave. These are all teachable moments that provide the opportunity to ask people about their mobile Internet safety habits. Do they backup their data? Do they use passwords or Wi-Fi from their cell phones? Do they talk to their kids about mobile Internet safety and online game and social networking safety?

	Everything that kids do online has potential safety implications, and parents may not be aware of what’s on their kids’ phones. We can help the parents in our practices by asking them about these issues and alerting them to trends and applications they may not know about. For example, I recently caught wind of an application called the “Ugly Meter” (

). This app is just as mean spirited as its name implies. You upload a photo, and the Ugly Meter spits out a rating of 1-10 on the “Ugly Scale.” The implications for harm are gigantic and can go well beyond hurt feelings to outright cyberbullying. This isn’t funny or even child’s play, and it’s available for anyone to download for $0.99 on iTunes.

	Tipping parents off about this application is a great way of introducing the concept of mobile Internet safety and emphasizing why it is important to talk to kids about these topics.

Gwenn Schurgin O’Keeffe, MD, FAAP, (aka “Dr. Gwenn”) is a pediatrician, health journalist, parenting and social media expert, and is CEO and Editor-In-Chief of Pediatrics Now (

), an online health and communications company dedicated to providing reliable information for today’s busy families. She also writes the blog Dr. Gwenn

Columns

Although more people than ever use their smartphones to access the Internet, few take the time to think about issues of mobile Internet safety.

 Mobile Users are Moving Targets in a Dangerous Online World

	During the debate about tax cuts and the estate tax, a type of trust known as a “dynasty trust” has received a barrage of criticism from those who claim that the wealthy are not paying their fair share of taxes. A recent op-ed in The New York Times (

) complained that dynasty trusts create a powerful new aristocracy whose wealth is protected and untaxed for generations into the future. Sounds appealing right? A closer look at the available benefits of these trusts can help you determine whether they have a role to play within your overall estate plan.

	Many states have recently adopted legislation abolishing the “rule against perpetuities” (

) that eliminates legal restrictions on the period of years that a trust may last. In these states, a trust is now permitted to exist for whatever term is chosen, even if it reaches far-off generations many years in the future (in Nevada, a dynasty trust is permitted to last for up to 365 years).

	Estate plans often include some type of trust to take care of the needs of minor children upon the death of the parents%u2011%u2011usually lasting until the children reach age 20-25. It makes sense to limit the term to a relatively short period if the trust fund contains only enough money for the child’s basic living needs or for the expenses of college and higher education. If there is not going to be anything left over after covering the child’s basic needs, an extended term trust would not make sense.

	It is a different matter when family wealth consists of substantial accumulated savings, a valuable business, or a large insurance policy. In these cases, the issue of how long a trust should last assumes much greater significance, and specific questions must be addressed. At what age do we want a child to receive a full distribution of substantial trust funds? Should we make large sums of money available to the child when he or she is young, or do we want to control and limit the distributions based on whatever standards we define for need, responsibility, and maturity? These are not easy questions to answer, especially for children who are young when the trust is formed.

	The answer to the question of how long the trust should last is often based on two key considerations: the estate tax consequences of the plan and the possible need for asset protection.

	A dynasty trust can create substantial estate tax savings. Each time wealth is passed to a younger generation, a new estate tax is imposed. At a 50% estate tax rate, a dollar in wealth is reduced to 50 cents when you pass it on to your children. The remaining 50 cents is further taxed so that grandchildren would receive only 25 cents of the original dollar, and so on until there is nothing much left. This is not a problem for people whose total assets are under the estate tax exemption amount (currently scheduled at $1 million for 2011). Those who have accumulated assets in excess of the exemption amount, or who have large insurance policies and wish to maximize and preserve these funds for future generations, can significantly reduce estate taxes with a properly structured dynasty trust.

	The provisions in the tax law that allow these benefits are long standing and well established. Briefly stated, if assets are left to children or any younger generation and the beneficiary’s rights to the property are limited by certain defined standards, the trust property is not subject to estate tax as it passes to a younger generation of beneficiaries. For example, if you leave $1 million in a trust for your child, and he or she has the right to the income from the trust and also a right to principal for “health, education, maintenance and support,” the trust assets will not be included in your child’s estate on death and can then pass to your grandchildren free of estate taxes. The trust can continue, subject to these same provisions, and there will never be an estate tax imposed as it passes from children to grandchildren and so on. Depending on the amount of trust assets and whether income is accumulated or distributed, wealth that is not subject to estate tax can be maintained or even increased over time as succeeding generations of family members become beneficiaries. As with the estate tax itself, the total amount that can be passed through the generations is subject to a generation-skipping tax on amounts in excess of an exemption amount that has yet to be determined by Congress. Stand by for future developments.

Protecting your children from divorce and lawsuit risk

	Whether or not you have a need for estate tax savings, the dynasty trust is a popular strategy to help protect children from the risks of divorce and creditors’ claims that they may face in their personal life and business careers. Possible claims by a child’s current or future spouse is always a paramount concern in every estate-planning discussion. Facing hard facts, a 50% divorce rate means that there is a substantial financial risk of losing assets to a spouse at some point. Dynasty trusts are often designed to specifically address this issue to make sure that amounts intended to be the separate and protected property of a child are not available to a future claim by a divorcing spouse.

	The same logic applies to other potential creditors that may arise during a child’s lifetime. Some common examples of these risks include student loan debt that is almost impossible to discharge, personal guarantees on loans and debts from bad business decisions, or just plain bad luck that can cause lasting financial hardship and burdens. The point of the dynasty trust is to make sure that a nest egg is preserved for the child that is not subject to lawsuit and liability claims, no matter what happens in the future.

	Depending on the outcome of the estate tax legislation proposed in Congress, your estate may be subject to significant estate taxes as it is passed to your children or grandchildren. A dynasty trust may be useful in reducing or eliminating these taxes as well as preserving family assets from future claims and liabilities. These issues are complicated from a legal and tax perspective%u2011%u2011as always, you should discuss your personal situation and the possible benefits and drawbacks of this planning with your professional advisors.

Robert J. Mintz, JD, is an attorney and the author of the book Asset Protection for Physicians and High-Risk Business Owners. To receive a complimentary copy of the book call 800-223-4291 or visit 

Depending on your financial situation, a dynasty trust may be a valuable part of your asset-protection strategy.

Taking the Long View When it Comes to Asset Protection

Researchers are studying a compound that can treat and prevent neuropathic pain, potentially addressing a significant unmet pain management need for several patient populations without the adverse effects of marijuana.

	Marijuana’s anti-inflammatory properties have been touted as a possible cure for everything from Crohn’s disease to Tourette syndrome. But the negative side effects, including impaired perception, diminished short-term memory, loss of concentration and coordination, and hallucinations, suggest that it’s far from being a perfect drug. Based on recent findings on CB2 receptors—one of two cannabinoid receptors in the body&mdash;new drugs capable of delivering the anti-inflammatory properties of marijuana without the negative side effects may one day become a real option.

	For six years, Mohamed Attala Naguib, MD, and colleagues have been researching potential targets for CB2 receptors in treating neuropathic pain. MDNG: Pain Management spoke with Naguib, a faculty member in the general anesthesiology department at the Cleveland Clinic in Ohio, about his research efforts.

What sparked your interest in this area of research?

	I have a working hypothesis regarding neuropathic pain and neuroinflammation. For years, there were many conflicting views about the origin of neuropathic pain and how to treat it. Putting the pieces together from the last decade, I was able to create a working hypothesis, which helped me better understand the role of cannabinoid receptors in modulating neuropathic pain and other neuroinflammatory conditions.

What is your hypothesis regarding CB2 agonists and the inflammatory process?

	As you know, there are at least two cannabinoid receptors in the body: Cannabinoid 1 (CB1) and Cannabinoid 2 (CB2). CB1 was discovered and cloned first from the central nervous system (CNS) in 1990, and it mediates the effect of marijuana. CB2 was discovered and cloned in 1993 from the peripheral immune cells; normally, you don’t see CB2 expressed in the CNS unless there’s some form of insult or neuroinflammatory condition in the CNS. CB2 expression helps to modulate the neuroinflammatory processes and prevent it. My working hypothesis is that stimulating CB2 receptors with an endogenous CB2-agonist will shut down the inflammatory process and facilitate recovery.

What are some of the key findings of the study (Pharmacological Characterization of a Novel Cannabinoid Ligand, MDA19, for Treatment of Neuropathic Pain; 

on MDA19? Is that compound one of your chief targets?

	MDA19 is one compound among over 100 compounds that we discovered and patented at the University of Texas MD Anderson Cancer Center. MDA19 is not really our lead compound; our lead compound is called MDA7, which is highly selective for the CB2-receptor. This is important because CB2 agonists are not known to have any psychoactive effects. We have conducted animal studies with MDA7 showing that we can both treat and prevent neuropathy. MDA19 has some CB1 activity in vitro, but not for in vivo testing.

What are the clinical implications of this research?

	It can be useful because millions of diabetic, shingles, and cancer patients suffer from neuropathy. If we are right, CB2 agonists could prevent neuropathy without the addictive psychoactivity side effects of marijuana or other CB1 active compounds.

	Were there any surprising results or unexpected difficulties during the studies?

	With the MDA19 studies there was no problem, but it was intriguing to find, initially, different responses of MDA19 in different in vitro assays. We had to confirm the data many times until we were sure that it wasn’t technical error, and to reveal that MDA19 was a protean agonist. Depending on the cell context, a protean agonist ligand can be an agonist, neutral antagonist, or inverse agonist at the same receptor type. In different in vitro assays, it can behave as an agonist, or antagonist, or without any activity.

	No. Actually, the whole process was interesting and challenging, especially trying to confirm the data we were getting from different assays. We were happy with the results.

	MDA7 is our lead compound. We have some data published in the literature about this molecule. It’s a highly selective CB2 agonist that exhibits no CB1 agonistic activity. We have done some toxicity work, and so far, the drug does not appear to have any major toxicity. So, the goal is to proceed with this compound to applicable studies required by the FDA to move the drug toward clinical studies. We have shown that MDA7 can be used to do more than treat neuropathic pain; we went beyond that and we asked the question, “Can we actually prevent the development of neuropathic pain by using MDA7?” Prevention of peripheral neuropathy is a huge unmet need for patients, especially for those receiving chemotherapy, where neuropathy is a key dose-limiting toxicity. It’s been shown in different studies that in patients with cancer, increasing the dosage of paclitaxel can result in a better outcome. But some patients develop severe neuropathies even within the classic drug schedule, and they cannot continue with the treatment. What we have shown is that we can prevent the development of paclitaxel-induced neuropathy in the animal model. We looked at the molecular mechanism and the data is going to be submitted to a major journal for publication.

And part of the reason why you focused on CB2 receptors is because with these receptors you don’t have the motor effects that are associated with CB1?

	Not only this, CB2 has no CNS psychoactivity, catalepsy, or decreased motor coordination, which are good points. Actually, CB2 receptors are involved in the modulation of central neuroinflammation, and this was the reason.

What is the likelihood that a drug based on these CB2 agonists may hit the market within the next five years?

	With proper funding, an approval in 5-6 years is possible. For me, it’s a matter of securing funds for further development: pre-clinical, Phase I and Phase II, etc. But, I’m very optimistic that CB2 agonists will have a major effect on central neuroinflammatory conditions, such as peripheral neuropathy, Alzheimer’s, and multiple sclerosis.

	Have you seen any complications so far with CB2 agonists?

	We have given the drug to animals repeatedly, daily, for weeks, and we have not seen any negative effects. That said, like any other chemical entity, when we conduct FDA required toxicological studies, we may find something.

Feature Articles

Marijuana-like Drugs without the Side Effects

	This site is dedicated to all things knee pain. Whether the knee pain is a result of osteoarthritis of the knee, runner’s knee, water on the knee, or more, patients can learn about the common symptoms related to these conditions and treatments exercises that can help. Clicking on one of the conditions on the left provides an in-depth, detailed look at what is happening in the knee. For example, clicking on Osgood-Schlatter Disease, describes it as “a common overuse condition causing inflammation of the tibial tuberosity” in teenagers. It goes on to explain that the condition occurs when the “front thigh muscle pulls on the patellar tendon, which pulls on the tibial tuberosity,” usually after activities that include running and jumping. This section discusses the diagnosis, symptoms, treatment, and long-term consequences.

	Parents of patients can check out this site to learn more about the specific knee injuries that are common to adolescents and children and ways to treat these conditions. The article “Common Adolescent Problems — Knee Pain” highlights knee conditions such as Parapatellar knee pain syndrome, Osteochondritis dissecans, Patellar dislocation, Collateral ligament injury, Meniscal injuries, and more. Other related articles highlight treatments for these conditions and common injuries that trigger the issues. The site also features a number of articles on pediatric conditions, parenting advice, and more.

	For patients that might have to undergo total knee replacement, this site is a good resource on what to expect and offers detailed information on which patients are candidates for the surgery and why. The article offers diagrams on knee anatomy, describes the benefits of TKR surgery, and describes who the common patients are: patients age 60 to 80, with strong levels of pain and disability. It goes on to explain what transpires during an orthopedic evaluation, including the physical examination, X-rays, and some blood tests or MRI. In the “Realistic Expectations About Knee Replacement Surgery” section of the page, the site advises what recovery time may look like and which activities should be avoided. The preparing for surgery section of the page offers tips on what may be expected such as the need to prepare the skin and leg, disclosure of medications, urinary evaluations, dental evaluations, and the need for home or social planning, etc. Additionally, there is info on what a stay at the hospital will entail and what to expect when returning home.

segment of the TV show, “The Doctor’s

,” discusses a procedure that may help certain chronic knee pain sufferers. The video can be shared with patients as an additional visual aid. The clip highlights the story of a relatively young chronic knee-sufferer who seeks medical advice on treatments that will help her return to completing common tasks like walking up the stairs, and others that require bending or twisting the knees. The doctors bring in a sports medicine specialist to provide the patient with a series of hyalouronic acid injections after first taking X-rays and an MRI to rule out certain injuries.

	This activity will discuss “a conservative approach to treatment” in older adults, emphasizing “individualized care” and considering “the various aspects of their condition in order to achieve functional improvement.”

Platelet-rich plasma intra-articular knee injections for the treatment of degenerative cartilage lesions and osteoarthritis

Knee surgery, sports traumatology, arthroscopy: Official Journal of the ESSKA

The study was designed to “investigate the persistence of the beneficial effects observed,” in a previous analysis of a 12-month follow-up study that demonstrated positive results in treating patients with knee degeneration with PRP intra-articular injections.

The study evaluated 90 of the 91 patients from the previous study for a two-year follow-up. The patients all presented with a “chronic knee degenerative condition and were treated with three intra-articular PRP injections.” The team took IKDC and EQ-Vas scores. Also recorded were: complications, adverse events, and patient satisfaction. “All of the evaluated parameters worsened at the 24-month follow-up.” Better results were shown in younger patients and “lower degrees of cartilage degeneration.” The researchers concluded that “treatment with PRP injections can reduce pain and improve knee function and quality of life with short-term efficacy.”

Infiltration of Plasma Rich in Growth Factors for Osteoarthritis of the Knee Short-term Effects on Function and Quality of Life

Archives of Orthopaedic and Trauma Surgery

The researchers sought to evaluate alternative and co-adjuvant therapies to improve the quality of life and physical function of affected patients.

The team treated 808 patients with knee pathology with plasma rich in growth factors (PRGF). Of the total patients, 312 had osteoarthritis of the knee and symptoms that lasted for more than three months. “Three intra-articular injections of autologous PRGF were administered at two-week intervals in outpatient surgery.” The results indicate that at six months “following intra-articular infiltration of PRGF in patients with OA of the knee” experienced “improvements in function and quality of life.”

Manual for Guided Home Exercises for Osteoarthritis of the Knee

The researchers sought to “assess the efficiency of a guidance manual for patients with osteoarthritis of the knee in relation to pain, range of movement, muscle strength and function, active goniometry, manual strength test, and function.”

The team studies 38 adults with osteoarthritis of the knee (ages 45 and up). The patients “received guidance for the practice of specific physical exercises and a manual with instructions on how to perform the exercises at home.” The results determined that “the program was effective for improving muscle strength, controlling pain, maintaining range of movement of the knee joint, and reducing functional incapacity.”

Knee Osteoarthritis, Knee Joint Pain and Aging in Relation to Increasing Serum Hyaluronan Level in the Japanese Population

 The researchers sought to “investigate the relationship between serum hyaluronan (HA) level and the presence and severity of radiographic knee osteoarthritis (OA) as well as the degree of knee pain in Japanese population.”

 The study included 616 volunteers. The participants were placed into three groups based on their score on the Kellgren-Lawrence (K-L) grade: normal, moderate and severe. The found that, “Serum HA level has the potential to be useful for the diagnosis of the presence and severity of knee OA.”

Intra-articularInjection of Botulinum Toxin Type

 Minneapolis Veterans Affairs Medical Center

 The study is designed to “determine whether intra-articular injection of botulinum toxin is effective in the treatment of chronic knee pain due to arthritis.”

 There are four main goals: “To examine differences between AA and white patients with knee OA in willingness to consider knee joint replacement;” “to examine the relationship between socio-cultural factors and patient willingness to consider joint replacement;” “To examine how demographic, socio-cultural, and clinical factors mediate the relationship between race and patient willingness;” and “To examine the relationship between patient willingness and referral to orthopedic care for knee OA (secondary aim).”

Study of TG-C in Patients with Grade 3 Degenerative Joint Disease of the Knee

 The researchers seek to examine whether or not they “can safely regenerate cartilage without invasive surgery using a biologic product called TissueGene-C.”

Vimovo (naproxen and esomeprazole magnesium)

	Send your patients to the main Vimovo site to learn more about how the drug works, how to take the medicine, and safety information. Additionally, there is information on the different types of arthritis, facts about arthritis, treatment option information, and pain relief options.

Phase I Study to Evaluate Bioavailability of Naproxen as PN400 Compared to Naproxen as Naprosyn E

Net Guide

A collection of links and resources from across the web focused on one specific condition. These resource range from useful websites to clinical trials. 

Net Guide: Chronic Knee and Joint Pain

	Designed to offer information on addiction across a wide spectrum and offer tips and strategies, this site can be a good starting point for your patients who may suspect they are becoming or are addicted to opioids. Myaddiciton.com provides an overview of opioid addiction and a number of articles on common opioids, opioid withdrawal symptoms, and medical treatments for opioid addiction. In addition there are links to online support groups, and general articles on addiction, including “How Addiction Affects the Brain,” “What is Methadone?,” or “The Genetics of Addiction.” There are also videos, blogs, news, and more.

	Drug addiction can be very isolating. Send your patients here to let them know they are not alone in their struggle. Addiction Survivors is a website that features AddictionSurvivors.org is a “not-for-profit organization dedicated to providing peer support communities for those with addiction disorders and their families and friends.” Featured here are a number of community forums dedicated to opioid addiction, alcohol dependence, stimulant addictions, and gambling addictions.

	This site describes opioids as “the most effective analgesics by far” and goes on to explain what they are and how they work by binding to opioid receptors in the brain. It also described antagonist drugs, such as Naltrexone, and their role in reversing opioid addiction. Further explanation is also given on agonist-antagonist drugs and how they work to trigger certain receptors and block others. The descriptions can help a patient frame the addiction process and better understand what is transpiring within their bodies. The site also describes how opioid treatments are typically selected for the patient and then further delves into “Physical Dependence, Addiction, and Tolerance.” The site explains the difference between physical dependence and addiction. “Addiction is defined by a loss of control over the drug, compulsive use of the drug, and continued use of the drug even if it is harming the person or others,” it reads.

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

	Last updated February 2009, these guidelines can help practicing physicians better manage their patient’s treatment with opioids and may help prevent misuse. Developed by the “The American Pain Society and the American Academy of Pain Medicine,” the guidelines are based on a “systematic review of the evidence on chronic opioid therapy for chronic noncancer pain.” They were also reviewed by a multidisciplinary expert panel. The recommendations discuss risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; patient monitoring; dose escalations, opioid rotation, and much more.

COPE - Collaborative Opioid Prescribing Education

	The program is designed to offer physicians useful tools that they can use at the start of opioid treatment. This program features didactic exercises, video tools, quizzes and “extensive background information.” The latest evidence based practices will be discussed as well.

Appropriate Use of Opioid Therapy For Patients With Pain

	This activity will cover the clinical strategies available to help prevent opioid misuse, abuse, and diversion. It features an expert panel and discusses how to implement the useful strategies. Upon completion, physicians should be able to “Describe how to apply the Universal Precautions to the assessment and management of patients with chronic opioid therapy.” (Hurry up, it expires soon.)

Stemming the Tide of Opioid Abuse and Diversion with Abuse-Deterrent Choices

	This activity focuses on abuse-deterrent choices for pain management treatment and will provide “updated information.”

Critical Issues in Managing Pain with Opioid Therapy

	The activity reviews evidence “that demonstrates the prevalence of chronic pain and its debilitating costly effects when inadequately treated.” It will instruct physicians on how to implement a “pain management plan” that utilizes risk assessment tools and monitors strategies.

Effect of Ultra-rapid Opiate Detoxification on Withdrawal Syndrome

 The study was designed to examine the effect of ultra-rapid opiate detoxification (UROD) “on the presence or absence of withdrawal syndrome in a group of patients with opiate dependency.”

 The study included 173 patients with opiate addiction. The participants were evaluated both before and after UROD “using the Objective Withdrawal Scale.” The most prevalent withdrawal sign before UROD was anxiety. The researchers found that the opioid dependent patients that “underwent UROD showed the highest rate of withdrawal symptoms at one hour after anesthesia. Most of these symptoms subsided after 24 hours.” They concluded that for opioid dependent patients “UROD can be applied for detoxification with safety.”

Characteristics of Prescription Opioid Abusers in Treatment: Prescription Opioid Use History, Age, Use Patterns, and Functional Severity

 The study is designed to examine whether prolonged use of prescription opioid drugs leads to, or is associated with, “abuse of other drugs” and increases “more risky drug-related behavior, and more functional problems.”

 The researchers examined data from the Addiction Severity Index-Multimedia Version Connect system. The team had access to 55,341 client assessments at substance abuse treatment centers. The researchers concluded that “Overall findings supported the hypothesis that length of opioid abuse is associated with higher risk of drug use patterns as well as functional problems.”

A Clinical Trial Comparing Tapering Doses of Buprenorphine with Steady Doses for

Chronic Pain and Co-existent Opioid Addiction

Journal of the American College of Cardiology

 Blondell R, Ashrafioun L, Dambra C, et al

 The study compares the effects of discontinuing opioids and the effectiveness of opioid replacement protocols.

 The team enrolled participants into one of two six-month treatment protocols of buprenorphine/naloxone sublingual tablets. The participants had been treated with opioids for chronic non-cancer pain and had an opioid addiction. One group received tapering doses for detoxification and the other group received “steady doses for opioid replacement.” Based on the results, the researchers concluded that the participants “were more likely to adhere to an opioid replacement protocol.” Additionally, the second group demonstrated “improved pain control and physical functioning.”

Quality of Life Under Maintenance Treatment with heroin versus Methadone in Patients with Opioid Dependence

 The researchers sought to examine health-related quality of life (HRQOL) in patients with “severe opioid dependence” through a longintudinal study.

 The 938 participants were randomly assigned to four groups of medical and psychosocial treatment. The groups were: “heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively.” The results revealed that while both forms of maintenance and psychosocial treatment improved HRQOL during the observation peroid,” maintenance with heroin improvement in HRQOL exceeded maintenance with methadone. Additionally, HRQOL improved HRQOL significantly “in subjects treated with PSE compared with CM.”

Treatment Study Using Depot Naltrexone (1/6) Philadelphia Coord/Data Mgmt Site

The study is designed to “determine whether the addition of a monthly injection of depot naltrexone to treatment as usual (TAU) will significantly improve outcome in parolees and probationers with a history of opioid addiction compared to TAU alone.”

Efficacy of Extended Release Tramadol for Treating Prescription Opioid Withdrawal

 The researchers seek to examine two different doses of extended-release tramadol to treat opioid withdrawal. They will also be evaluating whether or not “tramadol itself produces withdrawal after it is no longer taken.”

Net Guide: Opioid Addiciton

	This site provides a complete overview of central pain syndrome that can be useful for patients newly diagnosed with the condition. Organized by the National Institute of Neurological Disorders and Stroke, the page begins by describing central pain syndrome as a “neurological condition caused by damage to or dysfunction of the central nervous system.” The syndrome - it goes on to explain - can be caused by “stroke, multiple sclerosis, tumors, epilepsy, brain or spinal cord trauma, or Parkinson’s disease.” Additionally, the site highlights treatment options, prognosis, and current research with links to clinical trials.

	Here is a website that is dedicated to providing information solely on or related to Central Pain Syndrome. Patients can come to this site to understand the circumstances in which Central Pain develops. The site explains that often times, most individuals that suffer from neuropathic pain from the central nervous system, “have no idea that their most distressing symptom, intractable central pain, is shared by people with such a wide range of other health conditions.” The site provides information on how damage to sensory nerve cells in the central nervous system is the main criteria in diagnosing central pain. Likewise, the site mentions that the condition may appear to be peripheral neuropathy, which can cause difficulties in diagnosing the condition. Included on the site, are also patient descriptions of what it feels like to have central pain syndrome.

	This site is dedicated to providing resources for those with Central Pain Syndrome and is written specifically with the patient in mind and in simple to understand language. For example, it describes CPS as being “extremely difficult to diagnose, sometimes sending the patient to many doctors to find one that believes them, and/or has even heard of and dealt with and treated this savage pain.” The goal of the alliance is to “encourage the education of sufferers, doctors, therapists, and loved ones.” It was created by a group of CPS sufferers who had acquired the condition after a stroke who wanted to provide one another with support. Featured here is a key article on who gets CPS, news and journal articles, a collection of links to related resources, a message board, and an art gallery of paintings representing the condition.

	Since Central Pain Syndrome is a form of neuropathic pain, this Webpage - based on information found in the Merck Manual - can offer physicians a quick review on the causes of neuropathic pain, the treatment, diagnosis, and more. The site goes into the etiology of neuropathic pain, symptoms, diagnosis, and treatment.

Operculo-insular Pain (parasylvian pain): a Distinct Central Pain Syndrome

 Garcia-Larrea L, Perchet C, Creac'h C, et al

 The researchers sought to investigate whether central pain with dissociated thermoalgesic sensory loss is common in cortical lesions.

 The researchers identified five cases out of 270 patients that were investigated “because of somatosensory abnormalities.” The five cases chosen presented “with central pain and pure thermaologic sensory loss contralateral to stroke.” The team found that “Central pain resulting from posterior parasylvian lesions appears to be a distinct entity.” They proposed that the terms “parasylvian or operculo-insular pain as appropriate labels” be used rather than “‘pseudo-thalamic.’”

Abnormal Activity of Primary Somatosensory Cortex in Central Pain Syndrome

 The researches sought to evaluate whether or not “CPS is associated with increased activity in the primary somatosensory cortex (SI),” which is a “major projection target of PO that plays an important role in processing sensory-discriminative aspects of pain.”

 Using rats with CPS, the team “recorded single units in SI” and found that the SI neurons “exhibited significantly higher spontaneous firing rates.” They concluded that “the excruciatingly painful symptoms of CPS may result…from abnormally increased activity in SI.”

 The researchers sought to “test the hypothesis that CPS is associated with abnormal inhibitory regulation” of posterior thalamus by zona incerta.

 They found that “the spontaneous firing rate and somatosensory evoked responses of ZI neurons were lower in lesioned animals compared with sham-operated controls.” Further findings led them to conclude, “CPS can result from suppressed inputs from the inhibitory nucleus zona incerta to the posterior thalamus.”

Development and Characterization of a Hemorrhagic Rat Model of Central Post-stroke Pain

: The researchers “describe the development and characterization of a rat model of thalamic CPSP.”

 They found that “thalamic hemorrhage produces a confined lesion that destroys the tissue within the initial bleed, with little or no neuron death beyond the hemorrhage core.” The surviving neurons, surrounded by activated glial cells, “likely contribute to neuropathic pain in this model,” the said. They conclude the findings may help researchers develop “therapeutics for central post-stroke pain.”

Safety Study of Deep Brain Stimulation to Manage Thalamic Pain Syndrome (DBS)

 “To determine the safety and efficacy of Deep Brian Stimulation (DBS) of the ventral capsular/ventral striatal as a treatment for patients with Thalamic Pain Syndrome (TPS).”

Effects of Vaporized Marijuana on Neuropathic Pain

 The study is designed to “measure the pain-relieving effects of vaporized marijuana in subjects with neuropathic pain.”

Study of Gabapentin to Reduce Duration of Postoperative Pain and Opioid Use

The goal of this study is to determine whether administering Gabapentin prior to surgery affects duration of pain and opioid use post-surgery. We aim to compare gabapentin to placebo in a prospective, randomized clinical trial in which patients will be followed post-surgery until pain resolves and opioid use ceases.

Robot-Assisted Post Stroke Therapy Beneficial Even for Late Starters

	A late start to stroke therapy has been thought to be detrimental to getting much benefit out of it, so exercises must begin as soon as possible. A new study, published in the New England Journal of Medicine, has now shown that even late starters can see substantial improvement when using robotically assisted therapy.

US Cost Burden of Ischemic Stroke: A Systematic Literature Review

	This study was featured in our sister publication. It focused on conducting “a systematic literature review to determine current US costs of stroke and to assess if a gap in available information exists.”

Net Guide: Central Pain Syndrome

Average App Store Rating: 4.5 stars (10 ratings)

This app offers a case-based way to cover all the basics of family medicine, using an overview approach that has its strengths and weaknesses. Each topic is organized very logically, starting with a patient story and photos that illustrate the story, then going into epidemiology, pathophysiology, and diagnosis. From there, the topics then cover differential diagnosis and management. Each section is succinct and organized into bullet lists, which makes it easy to go right to the information you are looking for. The authors have added active links to some great resources for both the patient and the provider. I appreciate the evidence-based medicine codes that are added to the management recommendations.

The iTunes description of this app uses two prominent reviews of the BOOK and not the APP; I believe this type of app doesn’t have the same impact as a book. Browsing through pages of a book with excellent (full-size) photos and stories simply doesn’t compare to the experience of browsing through an iPhone or iPad app with excellent thumbnails that you must click on to fully view. Granted, the more than 1,500 photos available are of excellent quality, but when it boils down to sometimes as few as two to five photos per topic, it’s not that many. The app allows for search by keyword or browsing by table of contents or topic. Browsing the table of contents shows only six topics under the heart and circulation heading, illustrating this app’s weakness. Another weakness is the search function, which does not allow for partial word searches.

This text within the app covers basics, making it suitable for a medical student. It would make for a super quick way for a resident to prepare for morning report, for instance. However, I find it too general a reference to rely on in daily practice for a specialist or more seasoned physician.

Because all the photos and information reside on your device, no Internet is required to run this app, but it is helpful if you want to follow the links. I hope they keep updating this app with fresh topics and keep the links up-to-date!

The Color Atlas of Family Medicine provides excellent clinical illustrations and overviews of common family medicine topics, but there aren’t enough topics. However, it’s a unique approach and looks especially great on an iPad!

Developed by a diverse background of medical professionals, Calculate offers physicians a comprehensive calculator database to guide treatment, determine prognoses, stage and classify diseases, and calculate the most commonly used formulas in medical practice. More than 150 calculators and decision support tools are organized into this one application. After selecting a calculator under a certain specialty, the Question Flow engine begins presenting users with questions regarding that calculator. For example, under the “Gastroenterology” tab, there are tabs for “GI Bleed,” “Hepatology,” and “Pancreatitis.” After selecting “Pancreatitis,” the following calculators are displayed: APACHE II, CT Severity Index, and Ranson’s Criteria. By selecting APACHE II, the Calculate application presents questions about all of the parameters of the APACHE II score, calculates answers, and provides the appropriate prognosis and additional information about that score and prognosis. The interface is simple and intuitive, and the wealth of calculators packed into this one application means that many physicians can find use in it, regardless of specialty. I have downloaded many medical calculators, and I replaced all of them by putting Calculate in my electronic medical bag.

Laboratory Gear Medical ~ Lab Values, Differentials & Symptoms

Average App Store Rating: 4.5 stars (13 ratings)

Laboratory Gear Medical, by Med Gears, is a fast and easy-to-use app that includes detailed information on more than 250 common laboratory tests. Lab tests can be found by search, browsing by organ system, and specimen source (blood, urine, CSF, etc.). A favorites list can also be created for commonly reviewed lab tests. Each lab test entry includes information on the reference range (sometimes known as the “normal” range) for the test, a differential diagnosis for test abnormalities, and a description of the utility of the test. Switching from US to SI units is quick and easy. Laboratory Gear currently lacks infectious disease-related tests. Hopefully these will be added in an update.

Use this app to enhance the doctor—patient experience. Physicians can choose from multiple sets of questions and approaches to pain management designed to help adequately categorize the patient’s pain. For example, the app provides guidelines on how to start a conversation on pain, then assess, treat, and monitor patients. Additionally, it features a management flowchart, pain treatment ladder, a terminology of pain management section, and innervation maps. Reviews for the app are almost entirely positive, with reviewers saying “Easy navigation, good content, excellent view in the classic view,” and “It is a great app. It teaches how to manage your pain. Quick access to information saves time.”

If you love your iPhone but don’t love the reception you get with it, look into Line2, the only app that lets iPhone—and iPad and iPod touch&mdash;users call using WiFi, 3G, or cellular with the same number. After setting up a Line2 phone number, users can start making calls right away and text as much as they like. Plus, Line2 lets you listen to music, browse the Web, and make calls using the main number while still receiving Line2 calls and texts. The reviews say it all: “If you have bad AT&T coverage, if you want to save on minutes, if you want extensive control over call settings and features, then Line2 is unquestionably the solution. There’s a free 30 day trial, so you’ve got nothing to lose” and “Best voip app. Great Job developers.”

November 2010