Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Evil weed or useful drug?

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The pros and cons of medical marijuana

Marcy Duda, a former home health aide with four children and two granddaughters, never dreamed she’d be publicly touting the medical benefits of “pot.”

But marijuana, says the 48-year-old Ware resident, is the only thing that even begins to control the migraine headaches that plague her nine days a month, which she describes as feeling like “hot, hot ice picks in the left side of my head.”Duda has always had migraines. But they got much worse 10 years ago after two operations to remove life-threatening aneurysms, weak areas in the blood vessels in her brain. None of the standard drugs her doctors prescribe help much with her post-surgical symptoms, which include nausea, vomiting, loss of appetite, and pain on her left side “as if my body were cut in half.”

With marijuana, however, “I can at least leave the dark room,” she says, “and it makes me eat a lot of food.”

The culture wars over marijuana, for recreational and medical use, have been simmering for decades, with marijuana (cannabis) still classified (like heroin) as a Schedule I controlled substance by the US government, meaning it has no approved medical use. (There is a government-approved synthetic form of marijuana called Marinol available as a prescription pill for treating nausea, vomiting, and loss of appetite, though advocates of the natural stuff say it is not as effective as smoked pot.)

Some, like David Evans, special adviser to the nonprofit Drug Free America Foundation of St. Petersburg, Fla., applaud the government’s view, saying marijuana has not gone through a rigorous US Food and Drug Administration approval process.

But that skepticism frustrates leading marijuana researchers like Dr. Donald Abrams, a cancer specialist at San Francisco General Hospital.

“Every day I see people with nausea secondary to chemotherapy, depression, trouble sleeping, pain,” he says. “I can recommend one drug [marijuana] for all those things, as opposed to writing five different prescriptions.”

The tide seems to be turning in favor of wider medical use of marijuana. The Obama administration announced in March that it will end the Bush administration’s practice of frequently raiding distributors of medical marijuana. Thirteen states, including Vermont, Rhode Island, and Maine, now allow medical use of marijuana, according to Bruce Mirken, spokesman for the Marijuana Policy Project, which advocates legalization of pot. Last week, however, New Hampshire Governor John Lynch vetoed legislation that would have legalized medical marijuana in that state.

Research on medical marijuana is hampered by federal regulations that tightly restrict supplies for studies. But there is a growing body of studies, much of it supportive of the drug’s medical usage, though some of it cautionary. Given the intense politics involved, it’s true, as Abrams puts it, that “you can find anything you want in the medical literature about what marijuana does and doesn’t do.”

With that in mind, here’s an overview of what the research says about the safety and effectiveness of using marijuana to treat various ailments.

Pain: Marijuana has been shown effective against various forms of severe, chronic pain. Some research suggests it helps with migraines, cluster headaches, and the pain from fibromyalgia and irritable bowel syndrome because these problems can be triggered by an underlying deficiency in the brain of naturally-occurring cannabinoids, ingredients in marijuana. Smoked pot also proved better than placebo cigarettes at relieving nerve pain in HIV patients, according to two recent studies by California researchers. Marijuana also seems to be effective against nerve pain that is resistant to opiates.

Cancer: The active ingredients in cannabis have been shown to combat pain, nausea, and loss of appetite in cancer patients, as well as block tumor growth in lab animals, according to a review article in the journal Nature in October 2003. But there’s vigorous debate about whether smoking marijuana increases cancer risk.

Some studies that have looked for a link between cancer risk and marijuana have failed to find one, including a key paper from the University of California-Los Angeles and the University of Southern California published in 2006. “We had hypothesized, based on prior laboratory evidence, including animal studies, that long-term heavy use of marijuana would increase the risk of lung and head and neck cancers,” said Hal Morgenstern, a coauthor and an epidemiologist at the University of Michigan School of Public Health. “But we didn’t get any evidence of that, once we controlled for confounding factors, especially cigarette smoking.”

Research published by a French group this year and by Kaiser Permanente, a California-based HMO, in 1997 came to a similar conclusion.

But a state health agency in California, the first state to legalize marijuana for medical use in 1996, recently declared pot smoke (though not the plant itself) a carcinogen because it has some of the same harmful substances as tobacco smoke. The active ingredient in marijuana can increase the risk for Kaposi’s sarcoma, a common cancer in HIV/AIDS patients, Harvard researchers reported in the journal Cancer Research in August 2007. And British researchers reported in May 2009 in Chemical Research in Toxicology that laboratory experiments showed that pot smoke can damage DNA, suggesting it might cause cancer.

The federal government’s National Institute on Drug Abuse says that it is “not yet determined” whether marijuana increases the risk for lung and other cancers.

Respiratory problems: Smoking one marijuana joint has similar adverse effects on lung function as 2.5 to 5 cigarettes, according to a New Zealand study published in Thorax in July 2007. A small Australian study published in Respirology in January 2008 showed that pot smoking can lead to one type of lung disease 20 years earlier than tobacco smoking.

Addictive potential: The National Institute on Drug Abuse says “repeated use could lead to addiction,” adding that some heavy users experience withdrawal symptoms such as irritability and sleep loss if they stop suddenly.

Mental effects: Cannabis may increase the risk of psychotic disorders, according to a 2002 study in the American Journal of Epidemiology. And the national drug abuse agency warns that “heavy or daily use of marijuana affects the parts of the brain that control memory, attention, and learning.” A study of 15 heavy pot smokers published in June 2008 in the Archives of General Psychiatry showed loss of tissue in two areas of the brain, the hippocampus and amygdala, regions that are rich in receptors for marijuana and that are important for memory and emotion, respectively.

Vaporizing vs. smoking: The push now among proponents of medical marijuana is toward inhaling the vapor, not smoking. Vaporizing is a safe and effective way of getting THC, the active ingredient, into the bloodstream and does not result in inhalation of toxic carbon monoxide, as smoking does, according to a study by Abrams published in 2007 in Clinical Pharmacology and Therapeutics.

Bottom line: From a purely medical, not political, point of view, my take is that if I had medical problems that other medications did not help and that marijuana might, I’d try it – in vaporized form.

Just as Marcy Duda does. “You use it as you need it. You can be normal. You can function,” she says. “I don’t get high. I get by.”

When pain arrives – and help does not

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I never knew such pain existed.

This past spring, my neck suddenly went bonkers — a long-lurking arthritic problem probably exacerbated by hunching over my new laptop.

On a subjective scale of 1 to 10 (there is no objective way to measure pain), the slightest wrong move, such as turning my head too fast or picking something up from the floor, would send my pain zooming from zero to a sobbing, gasping, tears-pouring-down-the-face 10.During these episodes, which happened many times a day for months, it became impossible to talk, and impossible not to yell.  A series of MRIs showed several problems: herniated discs, vertebrae sliding forward over each other, and bone spurs stabbing my nerves.  

These irritated nerves kept firing, causing my shoulder muscles to spasm, which made my head to twist bizarrely to one side, where it would stay “frozen” for a half hour or more.  I couldn’t exercise, work or socialize.  Just going from sitting to lying down was agony.

So new, shocking and self-absorbing was this pain that I felt utterly alone, convinced no one had ever felt like this before. I also became convinced that the medical establishment is nowhere close to adequately addressing chronic pain.

The first point, of course, is completely wrong.

Indeed, in a survey of nearly 4,000 Americans published in May in the journal The Lancet, 29 percent of men and 27 percent of women reported they were in pain  in one given 24-hour period.

Some of this suffering comes from neuropathic pain, that is, pain from nerves damaged by such things as shingles or diabetes. Some comes from inflammation, as in arthritis. And some from diseases such as cancer.

Not only are more than a quarter of Americans living in chronic pain, “nearly 30 percent of them are partially or fully disabled by it,” said Dr. Russell Portenoy, chair of the department of pain medicine and palliative care at Beth Israel Medical Center in New York. And pain carries a significant price tag for the country, he said, in lost productivity as well as treatment costs.

Yet less than one percent of the budget of National Institutes of Health is devoted primarily to pain research. In fact, the allocation of public money for pain research has declined in recent years, said David Bradshaw, an anesthesiology researcher at Utah and author of a new report on pain research funding due out in the fall.

“We have gone backwards in treating patients with pain,” said Dr. Perry Fine, an anesthesiologist at the Pain Research Center at the University of Utah. “It’s a huge problem and it won’t go away…. What we need is an interdisciplinary model where we can work on the mind-body connection, on the whole person, not just on medical interventions like drugs and injections that provide only symptomatic relief and don’t necessarily help people get on with their lives.”

This month, the National Institutes of Health is announcing a $375 million-5-year plan to boost funding in six neglected areas, including pain. But for pain patients like me slogging through “the system,” that may not be enough.

For one thing, there’s still too much pressure on doctors to see more patients in less time. My first pain specialist literally told me that we had 10 minutes, during which we could either talk or I could get “trigger point” injections for my spasms. So much for empathy! I got the injections (they didn’t help much) and dumped the doctor,

For another, we’re still caught in the culture wars over painkilling drugs.  Yes, I tried acupuncture, physical therapy, meditation, and it was not enough. Millions of people legitimately need opioid drugs such as Percocet (oxycodone)and Vicodin (hydrocodone).

Even when used properly, these drugs are no picnic. Tramadol, a painkiller, gave me night sweats. Skelaxin, a muscle relaxant, made me sleepy and nauseous. Percocet worked fairly well, but only for three hours at a time.  Even the over-the-counter pills have their problems. Ibuprofen can cause serious bleeding,  Tylenol, liver damage.

Prescription painkillers also raise the thorny issue of abuse. Nobody knows how big the problem really is because the government does not track abuse of prescription painkillers separately from use of illicit street drugs. Beyond abuse, there’s the fear of  “addiction,” which often leads both doctors and patients to under treat pain.  Opioids do create physical dependence, which means that if you abruptly stop taking a drug such as Percocet, you will get withdrawal symptoms such as nervousness, nausea and diarrhea, said Dr. Kathleen Foley [cq], a pain specialist and attending neurologist at Memorial Sloan-Kettering Cancer Center in New York.

But that’s different from genuine addiction, which is the behavioral tendency to take a drug despite harm, to take more than is prescribed, to take it for reasons other than pain relief, such as to get high, and wind up “lying around dysfunctional,” Foley said.

Treating pain can be a nightmare. As Foley put it, “Pain wears away your personality. It limits your activities. It makes you find no joy in life. And when patients don’t respond to the treatments we give them, we start to blame their psychological state. We start to stigmatize every pain patient as having significant emotional problems.”

As for me, I went on to see a total of seven doctors, plus two physical therapists, an acupuncturist and an ergonomics consultant, who got me to buy all new office furniture.

I began to get better when I landed at New England Baptist Hospital where the doctors gave me time, understanding, cortisone shots in my cervical spine and rigorous physical therapy. At Beth Israel Deaconess Medical Center, I got Botox injections into my shoulders, which helped reduce the spasms.

So what did I learn from my ordeal? That a doctor’s kindness, always important, is especially important when you’re in pain.

I learned, too, that the immediacy of pain makes it agony to wait weeks for an appointment or an MRI — and that communicating that effectively to your doctor can save you weeks of suffering.  

And I learned that you can’t go it alone. Support from family and friends is not a nice, little luxury – it’s absolutely essential.

Today, I’m still fighting with my insurer to cover continuing physical therapy. I am nowhere near cured, though I am better. But as for the millions of other pain patients, as well as those lucky folks who have yet to encounter severe, chronic pain, I’m afraid that getting help is still a crapshoot. And that really hurts.

Expensive Arthritis Pills Have Not Lived Up to the Hype

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Seduced by hundreds of millions of dollars in advertising, Americans spend $6 billion a year for the arthritis pain-killers Vioxx and Celebrex, said to be as good as over-the-counter drugs — and easier on the stomach.

But the two have not lived up to their hype, according to published research and interviews with arthritis doctors and drug specialists. Vioxx, which may be better for the stomach, appears to have a far worse side effect than over-the-counter drugs: an increased risk of heart attacks.

For reasons doctors don’t yet understand, Celebrex does not seem to be linked to heart problems, but there’s conflicting evidence whether it has any benefit for the stomach.

There’s also no evidence that these drugs are any better at fighting pain than comparable doses of older medications like ibuprofen — though they cost six times as much. At CVS, a month’s supply of ibuprofen at the doses people with arthritis normally take costs $17.55; a comparable supply of Celebrex costs $107.99, and Vioxx, $110.99. Depending on copays, the consumer may actually end up paying the same amount or even more for over-the-counter drugs, though, because insurance doesn’t defray costs for non-prescription medications.

Vioxx and Celebrex, like their lesser-known cousins Bextra and Mobic, are in a relatively new class of drugs called Cox-2 inhibitors.

Despite the saturation advertising aimed at the 22 million Americans who suffer from arthritis, “there is no proof that these Cox-2 drugs are better for arthritis pain than traditional ibuprofen, and there is also no proof, except for a certain subset of patients, that these drugs are safer,” said Dr. Neil Minkoff, medical director of pharmacy at Harvard Pilgrim Health Care, which insures 800,000 people in Massachusetts, New Hampshire and Maine.

Some insurers, including Harvard Pilgrim, now insist that doctors get “prior approval” before writing prescriptions for them.

Back in the late 1990s, when the hype over Vioxx and Celebrex began, the excitement seemed well-founded. Researchers had long known that prostaglandins, natural chemicals that are made in cells under the direction of enzymes called cyclooxygenases, were the root cause of pain and inflammation.

But it turned out there were actually two types of cyclooxygenases, dubbed Cox-1 and Cox-2. Cox-1 releases “good” prostaglandins that protect the stomach. Cox-2 releases “bad” prostaglandins that further drive inflammation. The new drugs were hailed for their ability to block only Cox-2 and leave the good prostaglandins intact, something that traditional over-the-counter anti-inflammatory drugs like ibuprofen could not do.Eager to get the pain-killing benefits without stomach-killing side effects like bleeding ulcers, doctors and patients flocked to the new drugs to help dampen the pain of arthritis, as well as migraines, acute pain and menstrual cramps.

Then the bad news began trickling out.

The Cox-2 inhibitors actually “don’t eliminate gastrointestinal side effects, they just reduce them somewhat, and even that is more problematic than first thought,” said Dr. Jerry Avorn, chief of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital, and author of the forthcoming book, “Powerful Medicines” on the subject.

In September, 2000, a study on 8,000 patients showed that people taking Celebrex had fewer ulcer complications than those taking over-the-counter medications. But the study, published in the Journal of the American Medical Association, focused only on figures from six months of drug use, “the most appropriate” time-frame, according to Dr. Gail Cawkwell, worldwide medical team leader for Pfizer, which sells Celebrex.

When a later analysis by the US Food and Drug Administration looked at 12 months’ worth of data, this apparent advantage disappeared, said Dr. Michael Wolfe, chief of gastroenterology at Boston Medical Center.

In November, 2000, a study called VIGOR showed that 50 milligrams a day of Vioxx — a relatively high dose –reduced the risk of serious stomach problems by half, compared to prescription strength naproxen (Aleve). But the study, published in the New England Journal of Medicine also showed, to researchers’ surprise, that the risk of heart attack was two to four times higher for patients on Vioxx.

Since then, the data have been conflicting, with most — but not all — studies showing a link between Vioxx and heart disease. This spring, researchers from Brigham and Women’s Hospital, writing in the journal Circulation concluded that compared to high doses of Celebrex, high doses of Vioxx were linked to a 70 percent increase in heart attack risk in the first 90 days of use.

Dr. Lee Simon, a rheumatologist at Beth Israel Deaconess Medical Center, said that people should realize that it’s not wise to take 50 milligram doses of Vioxx for more than a week, but 12.5 and 25 milligrams a day are safer.

Consumers, shareholders and regulators, not surprisingly, have not been thrilled about these studies.In 2001, the US Food and Drug Administration issued a “warning letter” about Merck & Co., Inc.’s promotional activities for Vioxx, which the agency said was minimizing the potential heart attack link. The FDA also issued a warning letter in 2001 about misleading promotion of Celebrex, particularly its potentially harmful interactions with Coumadin, a commonly prescribed blood thinner.

Pfizer would not comment on the warning letter, or discuss possible litigation over Celebrex, but Merck is clearly on the defensive. Merck officials say they have corrected the problem. Since 2002, Merck has also included heart risk data from three studies on its package labeling, said company spokeswoman Mary Elizabeth Blake.

But in New Orleans, the Kahn Gauthier Law Group, is leading a shareholders’ proposed class action suit against Merck alleging that the company artificially inflated its stock prices based upon false and misleading statements about the safety of Vioxx. In New Jersey and California, lawyers (Seeger Weiss in Newark and Girardi & Keese in Los Angeles) are handling more than 200 personal injury lawsuits claiming that Merck failed to warn consumers about Vioxx’ potential risks. No similar cases have been filed in federal or appeals courts in Massachusetts. 

So where does this leave us? Use over-the-counter medications if they work for you. If they don’t work or if they cause stomach problems, talk to your doctor.

The Science of Pain (This is the second of a two part column on pain)

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Dr. Darlyne Johnson, 46, an obstetrician-gynecologist at South Shore Hospital in S. Weymouth, MA. is no stranger to pain – and not just the pain of other women having babies.

Over the years, Johnson has had surgery, and each time, wound up with such terrible nausea and vomiting from painkillers that she had to stay in the hospital overnight.

Not surprisingly, when she found out three years ago that she needed hernia surgery, she balked. “I knew what was going to happen – I’d get sick.” Then she heard about a device called ON-Q. It consists of a tiny tube, placed in the incision and connected to a small container of local anesthetic worn outside the body. Like water through a soaker hose, the medication, usually lidocaine, oozes into the wound for several days. The idea is that by blocking pain at the site of injury, patients should need smaller doses of opioid painkillers, which act on the whole body, often making people sick and spacey.

“Basically, I was pain-free,” says a delighted Johnson, who immediately began offering ON-Q to her patients undergoing C-sections.

And that is just the beginning of doctors’ increasingly successful efforts to manage pain.

Chronic pain, which can be caused by damage to nerves (as in shingles or diabetes), inflammation (as in arthritis) and diseases (such as cancer), is a fact of life for 50 million Americans, according to some estimates, and as many as 75 million Americans, according to the American Pain Foundation, a consumer group. Another 25 million more suffer every year from acute pain after surgery or injury.

At its essence, pain “is an unpleasant and emotional experience associated with tissue injury,” says anesthesiologist Dr. Daniel Carr, professor of pain research at Tufts-New England Medical Center in Boston. People can also feel pain when there is no obvious tissue damage, as in fibromyalgia, or after a limb has been amputated.

Pain, obviously, is an intensely subjective phenomenon. But there is growing objective evidence of how pain is registered in the brain, too.

In one recent report, Wake Forest University School of Medicine researchers subjected volunteers to pain (heat) on their skin and had them rate it on a scale of 0 to 10. They also scanned the subjects’ brains with fMRI (functional magnetic resonance imaging) and found that in those reporting the most intense pain, several regions of the outer layer of the brain (the cortex) were activated more often and more intensely.

Dr. Catherine Bushnell, a professor of anesthesiology at McGill University, also uses brain scans to study pain. When people are distracted from pain, she has found, the scans reflect a dampened experience of pain, suggesting that a person’s psychological state can  change the way pain is processed in the brain. 

On a more technical level, pain comes in several forms.

Nociceptive pain is triggered by tissue injury, including strong, noxious stimuli from the outside world such as a pin prick, heat or cold, as well as internal threats such as a kidney stone, obstructed bowe or infection. Neuropathic pain is caused by damaged nerves. Inflammatory pain is caused when joints or other tissues become swollen and release a cascade of natural, but harmful, chemicals.

During transmission of pain signals from, say, a cut finger, to the brain, a slew of chemical signals is produced by injured tissues and nerves, including substance P, bradykinin and glutamate, which Dr. Clifford Woolf, a professor of anesthesiology research at Massachusetts General Hospital, calls “the star of the show.”

At normal levels, glutamate is essential to the functioning of the nervous system; in excess, it can be devastating.

When excess glutamate over-stimulates certain receptors on spinal cord neurons (called NMDA receptors), acute pain can be transformed into chronic pain. Some drugs already on the market such as ketamine and dextromethorphan can block this process.

Researchers now know that not only do all cells, including nerve cells, have ion channels through which substances like sodium and calcium move in and out, but that particular subtypes of sodium channels govern the transmission of pain. “Some sodium channels are specific to pain fibers,” says Woolf. This means that drugs targeted at only these channels could block pain without affecting other cells.

The growing understanding of pain is the way pain is treated, says Dr. James Rathmell, chairman of the committee on pain medicine for the American Society of Anesthesiologists and a professor of anesthesiology at the University of Vermont Medical College in Burlington.

One example is sensitization, or “wind up” pain. When you injure nerves in your finger, nerves in the spinal cord “reorganize to amplify pain and remember it,” says Carr of Tufts. In other words, acute pain becomes transformed into chronic pain.

To prevent this in surgical patients, some doctors now give patients COX-2 inhibitors like Vioxx or Celebrex before surgery. These drugs block an enzyme called cyclooxygenase-2, a key player in pain transmission.

For women in labor, low doses of morphine injected into the intrathecal space around the spinal cord provides “tremendous pain relief,” Rathmell says.

For cancer pain, doctors also implant a permanent catheter (tiny tube) into the intrathecal space and attach the tube to a morphine pump placed in the abdomen. A major Johns Hopkins study showed that this technique not only provides dramatic pain relief, but increased longevity by a month or two.

For people with neuropathic pain, anti-epileptic drugs such as Neurontin (gabapentin) are showing promise. The rationale is that the body produces the same cascade of harmful chemicals during both the  “electrical storm” of partial seizures and in neuropathic pain.

Two 1998 studies showed that gabapentin can reduce nerve pain in both diabetes and shingles. Other gabapentin-type drugs are now in clinical trials for pain.

For people with back pain, microsurgery to remove damaged disks in the spine can improve pain control significantly, says Dr. Michael Ferrante, director of the UCLA Pain Management Center and co-director of the UCLA Spine Center. So can non-surgical techniques such as heated coils to destroy nerves in damaged disks.

Directly addressing the link between chronic pain and depression can also help, says Dr. Alan F. Schatzberg, chairman of the department of psychiatry and behavioral sciences at Stanford University Medical School. An epidemiological survey of 19,000 people in Europe shows that there is a huge overlap between pain and depression.

Anti-depressants that boost both serotonin and nor-epinephrine, neurotransmitters in the brain, seem to help with both pain and depression.

Non-drug approaches to pain control, most notably  acupuncture, can also be effective for some kinds of pain.

As for Dr. Darlyne Johnson and the ON-Q story?  One study by University of Vermont researchers on this method of post-surgical pain control following knee surgery found it had no effect. But the company that makes ON-Q, the I-Flow corporation, says studies of patients undergoing hysterectomies or colorectal surgery found that many patients using it needed less then the usual level of opioids after surgery.

At the Johns Hopkins Hospital, anesthesiologists Dr. Lee Fleisher and Dr. Christopher Wu are studying ON-Q in prostate surgery patients. “We are very interested in seeing if there is a benefit to blocking pain up front and never getting ‘wind up’ pain,” says Fleisher.

There’s no need to convince Dr. Darlyne Johnson of that. After her surgery, she went home quickly and needed only over-the-counter pain relievers: “It was a whole different experience.”

A Conversation with Kathleen Foley

Dr. Kathleen M. Foley, 59, spends most of her waking hours dealing with two subjects that make many people cringe: pain, and death.

As an attending neurologist at Memorial Sloan-Kettering Cancer Center, she treats the pain of cancer patients, including many who are dying.

As director for the last nine years of the Project on Death in America, an effort by George Soros’ Open Society Institute to change the culture of death in this country, she’s been a prominant voice for helping Americans get what polls show they want: a dignified death, in many cases at home, with good pain control and emotional support, for both patient and family.

As chair of three World Health Organization expert panels over the last 27 years, she helped create  guidelines for doctors on managing cancer pain, setting up palliative care services and controlling pain in children.

A New Yorker through and through, Dr. Foley was born and raised, with her four sisters and two brothers, in Queens by her homemaker mother and banker father. Though her mother died when Dr. Foley was 13, she chugged straight through a Catholic girls’ school, St. John’s University for a B.S. in biology, Cornell University Medical College (now Weill Medical College of Cornell University) for her M.D., and New York Hospital for her internship and neurology residency. She has been at Sloan-Kettering ever since.

Q. How did you get interested in the subject of death and dying?

A. I was dragged into it. I was being interviewed for a position at Sloan-Kettering to focus on pain in cancer. I told the interviewer I knew nothing about pain. He said, ‘That’s okay. Nobody else does, either.’ This was 1974. Researchers had just discovered that there were receptors in the brain for painkillers, or opiates.

We knew how to give morphine for acute pain, but we didn’t know how to use it for chronic pain. It’s quite shocking to remember. Six years after I got to Sloan-Kettering, we set up the first pain service in the country for cancer patients.

Q. In the last five years, three major reports from the Institute of Medicine (part of the National Academy of Sciences) have shown that pain control is woefully inadequate. A 1995 study by the Robert Wood Johnson Foundation showed that 50 percent of adults die in pain. If we know so much about pain these days, why aren’t we more aggressive about controlling it?

A.  A big part of the problem is that our efforts to treat pain aggressively have run into the war on drugs, as the furor over opioids (or narcotics) like oxycodone [OxyContin] shows. Opioids are safe and effective medications and patients can function very well on them. But the increase in abuse of prescription opioids is impacting the use of these drugs for legitimate medical problems. Some drug stores won’t stock opioids. In some states, Medicaid makes doctors get prior authorization before prescribing them. Some doctors in New York – 30 percent in one survey – report they are reluctant to prescribe them because of strict regulations.

Q. So, what’s the solution?

A. We need to balance our concerns about the risk of prescription drug abuse with the needs of pain patients. There are certain pain syndromes like neuropathic pain –  pain resulting from injury to a nerve – for which current therapies work for less than half of the patients less than half of the time. We need to make pain research a national priority.

Q. Why don’t medical schools do a better job on all this? According to a 2000-2001 survey of 125 medical schools compiled by the Association of American Medical Colleges, only three percent had a separate, required course on pain management and only four percent had one in end-of-life care. The 2003 survey, which asked questions differently, still shows only a few schools teaching pain and palliative care as a separate course, though most do include these issues to some extent in the curriculum. 

A. The three Institute of Medicine reports identified lack of professional education in pain and palliative care as the major barrier to advancing these areas of expertise.

Q. Hospice care, usually in the patient’s home but also in nursing homes, assisted living facilities and hospitals, is growing. According to the National Hospice and Palliative Care Organization, 11 percent of all deaths in 1993 took place in hospice; by 2002, it was 28 percent. Yet polls show about 75 percent of Americans want to die at home. Why hasn’t the hospice movement grown more?

A. It’s complicated. To qualify for hospice benefits, a patient has to have about six months to live. But doctors have trouble prognosticating like that, especially for diseases other than cancer, such as Alzheimer’s disease and congestive heart failure. So people get to hospice late – when they have only a week or two to live. But the biggest issue is that in our culture, we don’t want to address death until it happens.

Q. If more people were in hospice or palliative care, wouldn’t that save money? It must be cheaper to take care of someone at home than in a hospital.

A. It’s probably at least cost-neutral. If we expand hospice to non-cancer populations, we may shift costs from acute, inappropriate care to appropriate, quality care.

Q. In many ways, palliative care seems like an ideal form of medicine. Why do you have to be dying to get that kind of pain control and emotional support?

A. Actually, we argue that palliative care should be an integrating principle for both those at risk of imminent death and those with chronic diseases.  The World Health Organization has it right – palliative care is an approach to care for patients with life-threatening illnesses that focuses on their quality of life.

Q. If we really had that, would we need physician-assisted suicide?

A. Probably not. Since Oregon passed its law in 1997, there have been 129 cases of physician-assisted suicide, although requests for a doctor’s aid in dying have increased. The real issue is providing palliative care for all Americans. At the present time, we have not provided the education to health care professionals and to the public about their real choices.

Q. A Canadian study three years ago showed that terminally ill cancer patients who denied that they were dying were three times more likely to be depressed than those who exhibited understanding of their imminent deaths. Do you think talking about death helps?

A. There is a distinction between people knowing they are going to die soon and their being willing to talk about it. Many people know, but don’t wish to articulate it. Some don’t need to talk about it. But you don’t have to force someone to talk about it to be helpful. I am most humbled by all of this. What you can ask is ‘What do you know about your situation? What are you worried about? And how can we help.’

Q. So what is your definition of a “good death?”

A . It’s a good death is if the patient has what he or she wanted – having the family there, if that’s what they wanted, or not, if it’s not. It’s not suffering in the last days or hours or minutes. It’s having an opportunity to say goodbye, if that was something they valued. And it’s being recognized as the person they have been.

The Politics of Pain (This is the first of a two part column on pain)

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America is seriously schizophrenic about controlling chronic pain, which afflicts more than 50 million people and costs the country $100 billion a year.

So, on the one hand, we grossly under-treat it: Management of chronic pain and the pain of dying patients is arguably the most egregiously neglected field of medicine.

On the other hand, as a society, we have become obsessed with the war on drugs — and the fear of addiction to opioids (narcotics).

Pain patients who were functioning well on morphine-like drugs such as oxycodone (OxyContin) are now fearful of them — or just plain can’t get them.

Some drug stores, wary of robberies of OxyContin, are afraid to stock it. Some unscrupulous doctors have written excessive prescriptions for it. Some patients, like talk show host Rush Limbaugh, abuse it as well. And in some states, Medicaid regulations require doctors to get prior authorization before prescribing the drug.

The basic problem is obvious: Some of the drugs that most effectively treat pain are the same ones that are commonly abused. In one survey of New York doctors, 30 percent said they were prescribing fewer opioids or were switching patients to less-effective pain medications for fear that the Drug Enforcement Agency (DEA) might investigate them.

At the root of our national ambivalence is what June L. Dahl, professor of pharmacology at the University of Wisconsin-Madison Medical School, calls “opiophobia” — the fear of addiction to opioids. That phobia has led to serious undertreatment of pain — particularlychronic pain.

“Every bit of evidence suggests that we have been under-treating pain,” said Dr. Kathleen Foley, an attending neurologist at the Memorial Sloan-Kettering Cancer Center and director of the Project on Death in America of the Open Society Institute, an operating foundation supported by George Soros.

In the last five years alone, three major reports from the Institute of Medicine, an arm of the National Academy of Sciences, have concluded that pain control in this country is woefully inadequate. These pronouncements follow a 1995 study by the Robert Wood Johnson Foundation that found that 50 percent of people had moderate to severe pain in the last three days of life.

A separate study found similar rates of untreated pain in dying children. Even the US Supreme Court, in deciding in 1997 against a constitutional right to physician-assisted suicide, highlighted the need for better pain control and palliative care. Though the fear of addiction is great, in reality, the risk is small, when patients take drugs in the doses prescribed by physicians.

“Addiction,” to be sure, is a loaded word. Researchers prefer to speak of physical dependence, which does occur in patients taking opioids, and psychological dependence, which typically does not. It is psychological dependence — a compulsion to seek more and more of the drug, despite the harm it causes — that lay people usually mean by “addiction.” One 1982 study on patients in 93 burn facilities found no evidence that any patients became addicted to opioids. More recent data from pain clinics suggest the addiction rate might be around 10 percent, but people who attend pain clinics are not typical of all pain patients. 

Moreover, though opioids can cloud the mind, they don’t damage vital organs such as the liver, stomach and kidneys, notes Foley of Sloan-Kettering. And once doses are adjusted correctly and monitored by a doctor, patients on opioids for chronic pain often function “at high levels,” including taking care of families and even driving, she said.

Dr. James Rathmell, chairman of the committee on pain medicine for the American Society of Anesthesiologists and professor of anesthesia at the University of Vermont College of Medicine in Burlington, puts it even more forcefully.

Fears of addiction? “Forget it,” he said. “If you have intractable cancer pain, addiction should be the farthest worry from your mind. Addiction is very unlikely. There are wonderful medications that provide continuous relief over time.” That is true for non-cancer pain as well, although aggressive control of pain for non-lethal diseases is even more controversial. 

Arthritis, both rheumatoid and osteoarthritis, affect an estimated 70 million Americans, said Dr. John Klippel, medical director of the Arthritis Foundation. Yet many suffer daily because their pain is inadequately controlled.

With rheumatoid arthritis, one way of controlling the pain is by treating the underlying inflammatory disease itself, with drugs called DMARDS, disease-modifying anti-rheumatic drugs such as methotrexate. In addition,non-steroidal anti-inflammatory drugs such as ibuprofin (Motrin) and COX -2 inhibitors (like Vioxx and Celebrex) can help.

And despite America’s conflicted views, there are signs that we’re overcoming our collective phobia. Last month, the American Academy of Pain Medicine and leading doctors announced a new initiative called Top Med which will provide a web-based “virtual textbook” available free to all medical students across the country.It is sorely needed.

At the moment, only 3 percent of medical schools have a separate, required course on pain management and only 4 percent require a course in end-of-life care, according to a 2000-2001 survey of 125 medical schools by the Association of American Medical Colleges. A new survey (2003) shows that most medical schools now cover these topics as part of existing required courses.

There’s other good news, too. In 2001, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the group that accredits the vast majority of the nation’s hospitals, mandated that hospitals must assess and manage pain for all patients, something that, astonishingly enough, had not been done routinely until then.

On a more grass roots level, almost all states (including Massachusetts, California and Maryland) have launched pain initiatives to reduce legislative barriers to effective pain control.

Many states are also establishing electronic systems to monitor prescribing and dispensing of controlled substances — a tricky business because the idea is to protect against abuse while not restricting access for people who need opioids. Nationally, there is a controversial bill pending in Congress dubbed NASPER (National All Schedules Prescription Electronic Reporting Act) that would do much the same thing. Klippel of the Arthritis Foundation said what pain control — for arthritis sufferers and others in chronic pain — should ultimately come  down to is quality of life.

Patients should realize, he said, that, when taken properly, “the potential for addiction is really minimal.”

Chronic pain often goes untreated because some doctors don’t believe their patients

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James Murphy is only 26, but some days, he can hardly get out of bed.

Three years ago, Murphy, a North Easton man who used to fix power tools for a living, damaged a disc in his back lifting a steel workbench. The injury allowed the jelly-like material that cushions vertebrae to ooze out and press on a nerve. Pain raged through his lower back and shot down his right leg.

Despite surgery, cortisone injections, pills and numerous visits to a major Boston pain clinic, where, he says, he was told it was all in his head, Murphy’s pain is worse.

Murphy became so disgusted at what he feels is the medical establishment’s disregard of chronic pain that a year ago he started a web site (http://come.to/painsupport). It now gets 400 hits a week from people, some suicidal, whose lives are ruined by pain.

Chronic pain, defined as pain lasting more than three months, affects 35 to 40 million Americans, says Dr. Russell Portenoy, head of the American Pain Society and of pain medicine and palliative care at Beth Israel Medical Center in New York.

And researchers now know that, far from being all in one’s head, it is an all-too-real physiological phenomenon, though the specifics vary depending on whether it’s caused by damage to nerves, as in shingles or diabetes; by inflammation, as in arthritis; or by other things, like spreading cancer.

With a nerve injury, for instance, chronic pain may be the body’s way of learning to avoid future injuries. When you injure nerves in your finger, nerves in the spinal cord “reorganize to amplify pain and remember it,” says Dr. Daniel Carr, a professor of anesthesia at New England Medical Center. This reaction is so ancient — it’s been in the genetic structure of animals for 600 million years — it must be crucial to survival.

But despite this new understanding and an explosion of treatments — including non-drug remedies — millions suffer “because doctors don’t believe patients’ reports,” says Dr. Kathleen Foley, a cancer pain specialist at Memorial Sloan-Kettering Cancer Center in New York.

Chronic pain is also undertreated because of the fear that patients — even those who are dying — might become addicted to high doses of powerful painkillers like morphine. And doctors fear running afoul of drug enforcement officials.

In reality, such abuse is rare. One study of 12,000 patients showed only four became addicted. Another found that not one of 10,000 burn patients became addicted. In yet another study of 2,000 patients, only three became addicted.

What does happen is that people don’t get enough medication. A major 1995 by the Robert Wood Johnson Foundation showed that 50 percent of dying patients had pain in the last three days of life.

Another found that only 12 percent of cancer patients in nursing homes got basic pain care recommended by the World Health Organization. And a New England Journal of Medicine study of 1,000 cancer doctors showed half their patients had bad pain — and the doctors didn’t know what to do about it.

And it’s not just dying patients whose pain is inadequately addressed, it’s people without terminal illnesses as well.

In a recent Roper survey of 805 people without cancer and with moderate to severe chronic pain, 40 percent said their pain was out of control. The survey, which was sponsored by a drug company that develops pain relief medication, found that half of the respondents had switched doctors at least once, and half had been in pain for more than five years.

Much of that suffering can be avoided, and the first step is to get an evaluation to see exactly what type of pain you have.

If it’s arthritis pain, for instance, traditional NSAIDS (nonsteroidal anti-inflammatory drugs) and newer ones called COX-2 inhibitors may help. If your pain is from spreading cancer, opioids such as morphine, hydromorphone, oxycodone, codeine, methadone or fentanyl often help. These drugs all work through a special type of opioid receptor in the brain called mu.

On the other hand, if you have nerve pain, opioids may not be the answer. But other drugs that work through a different receptor, called NMDA, may be, including dextromethorphan and ketamine. Another drug, d-methadone, also shows promise.

Chronic pain also makes many people depressed and anti-depressants often help. But these medications actually do more than simply elevate mood — they fight pain directly.

Older anti-depressants like Elavil work through brain chemicals such as norepinephrine both to reduce transmission of pain signals up the spinal cord and to rev up transmission of pain-killing signals down it. Newer antidepressants like Paxil work by boosting another neurotransmitter, serotonin, which helps control pain just as it elevates mood.

Other drugs besides anti-depressants have this dual use. Anti-convulsants such as Neurontin are now known to block the firing of nerves that have grown new sprouts in response to injury. Anti-anxiety medications such as Valium, Ativan and Klonopin also block transmission of signals along pain nerves.

Researchers are also finding better ways to deliver painkillers in patients who can’t swallow or don’t want injections. Fentanyl, for instance, comes in patches that deliver a steady dose over several days. Some patches now come with buttons that a patient pushes when relief is needed. There’s even a lozenge of fentanyl on a stick, so the drug can be absorbed directly through mucus membranes in the mouth.

If pain is intractable, doctors can implant pumps in the spinal cord to supply morphine or even “snail slime” (a substance called SNX-111 that mimics a chemical put out by ocean snails).

At a few clinics, including the Advanced Pain Management Center in Stoneham, doctors are trying to shrink damaged spinal discs with heat. A wire is inserted into the disc through a tube and then heated to 194 degrees Fahrenheit. This seems to shrink collagen in the disc and reduce pain, says Dr. Anil Kumar, who has performed the procedure on a dozen patients so far.

In other patients with back pain, steroids injected near the spinal cord sometimes work, as can injections of local anesthetics into nerve ganglia in the neck or lower back.

In some cases, doctors put electrical devices in the brain or spinal cord to activate the descending pain pathways that block pain. They can also destroy pain nerves surgically or chemically. For tic douloureux, for instance, the trigeminal nerve in the face can be cut by radiofrequency waves; a similar technique is used in the neck in cancer patients.

But nerve destruction is usually done only if patients have a short life expectancy because new pain nerves can sprout, notes Dr. Douglas Merrill, chairman of the committee on pain management for the American Society of Anesthesiologists.

The bottom line is that there is help available. But, as James Murphy have discovered, you may have to fight to get your doctor to take you seriously or to get your insurer to pay.

You may also have to fight your own tendency to let pain become “a way of life,” says Merrill. You may not want to hear that you should get off the couch and onto the treadmill. But the ultimate solution may be to “find something to do with your life other than watch TV and wait for six hours to go around to take your pills again.”

SIDEBAR

Other treatments for chronic pain

Whether you treat chronic pain with mainstream medications, nondrug therapies, or alternative remedies like acupuncture, it pays to match the type of pain to the remedy.

Cognitive behavioral therapy, for instance, in which you learn ways to control your response to pain is effective for many people, For others, the answer may be biofeedback, relaxation, meditation or plain, old distraction.

For many people, exercise helps with the deconditioning that accompanies chronic pain. Acupuncture, the ancient Chinese technique of inserting needles through specific sites on the skin, may help, too, says the National Institutes of Health.

Some researchers, among them Dr. Paul White, an anesthesiologist at the University of Texas Southwest Medical Center at Dallas, use acupuncture needles plus electrical stimulation (a technique called PENS, for percutaneous electrical nerve stimulation) to treat back pain. A similar technique called TENS sends electrical signals through skin without needles.

Some also swear by magnet therapy. In one small study at Baylor College of Medicine in Houston, researchers found that attaching a magnet to muscles or joints provided relief to some post-polio patients. Other data suggest magnet therapy may help people with nerve damage from diabetes.

Overall, however, there’s “little scientific evidence that magnet therapy works,” says Jim Livingston, an MIT physicist who studies magnets.

Whatever your particular type of chronic pain, the real key, pain specialists say, is to be assertive: Don’t allow your primary physician to focus solely on the underlying disease. Insist on addressing the pain, too.

If your regular physician can’t help, see a pain specialist, which is often an anesthesiologist, neurologist or psychologist. Or go to a special pain clinic, which many hospitals now have.

And don’t avoid psychological treatments. If something like cognitive-behavioral therapy helps, it doesn’t mean your pain was all in your head — it means you’ve learn how to cope with the pain better.

For more information on chronic pain on the Web:

American Pain Society (www.ampainsoc.org)

American Academy of Pain Medicine (www.painmed.org)

American Academy of Pain Management (aapainmanage.org)

American Society of Anesthesiologists (www.asahq.org)

International Association for the Study of Pain www.halcyon.com/iasp)

Chronic Pain Forum (come.to/painsupport).

American Chronic Pain Association (theacpa.org)

National Foundation for the Treatment of Pain (www.paincare.org)

After April 1, you may also try: American Pain Foundation (www.painfoundation.org)

Women do have more pain, but they cope

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Jean Cummings, a 38-year-old urban policy analyst from Cambridge, lives in almost constant pain.

Diagnosed with rheumatoid arthritis 10 years ago, she’s had two hip replacements and will have both knees replaced in June, right after her wedding.

She’s tried every medication in the book — and some in the pipeline. “There’s almost nothing left for me to take,” she says. She can barely stand or walk without crutches. There are times her body hurts so much she can’t roll over in bed.

Yet she copes, “with humor, mostly,” and sheer grit. “There’s a temptation to stop everything and stay in bed. But that doesn’t work for me. It makes the pain more apparent and makes you stiffer. And it’s so boring.”

Both her problems with pain and her fortitude in dealing with it are impressive. And both may be enhanced, a growing body of research suggests, by one basic fact: Cummings is female.

Not only are there some painful afflictions — migraines, arthritis, lupus, problems with jaw joints — that are more common in females, there may be gender differences in the perception of and response to other types of pain as well.

Furthermore, many differences show up not just in human beings — who are clearly subject to cultural teachings about how men and women should deal with pain — but in lab animals, too.

Not long ago, the question of gender differences in pain might have been hooted off the research agenda. But tomorrow, researchers from around the country will gather at the National Institutes of Health in Bethesda, Md., for a first-of-its-kind conference to discuss just that.

“Women do report more pain. . .and that’s likely related to varied mechanisms, physiological and cultural,” says M.A. Ruda, a neuroscientist at the National Institute of Dental Research and the conference organizer.

There will, of course, be a few skeptics, among them psychologist Dennis Turk from the University of Washington. He studied about 400 men and women at a pain clinic and found few differences, except the women were more depressed.

But since other data show women in general are more depressed than men, this doesn’t prove much, he says. And when he studied cancer patients, men and women had equally severe pain and were equally depressed, probably because a life-threatening illness is upsetting for anyone, male or female.

But other researchers have uncovered provocative evidence that there are gender-specific responses to pain. For instance:

– Men get more upset about pain, at least when it lingers. In a study of 48 men and women having surgery for dental implants, McGill University dentist Jocelyne S. Feine found that in the 10 days afterwards, they rated pain equally. But as pain ebbed, men got more impatient.

– Some medications work differently in men and women. Christine A. Miaskowski, a nurse and physiologist at the University of California in San Francisco, has studied people having wisdom teeth extracted. Morphine, a painkiller that works through one type of receptor (called mu) in the brain and spinal cord, works equally well in men and women. But other morphine-like drugs that work through a different receptor (called kappa) work better in women, suggesting the biology of pain control is gender-specific.

– In mice, too, pain control differs by gender, at least for stress-induced analgesia — the phenomenon that occurs when overwhelming stress, like childbirth or running from a predator, temporarily blocks awareness of pain. In mice, says neuroscientist Jeffrey S. Mogil of the University of Illinois/Urbana-Champaign, a drug called MK-801 reverses stress-induced analgesia, but only in males. He believes females have a separate system for some types of pain control, and he’s found a region on chromosome 8 that may carry the gene for it.

– Though studies are somewhat mixed, women seem to be more sensitive to experimentally-induced pain than men, and some research suggests female sensitivity to pain may fluctuate with the menstrual cycle, indicating hormones may play a role.

In fact, researchers recently identified receptors for the hormone estrogen “in the portion of the spinal cord through which pain signals pass,” says Dr. Daniel Carr, medical director of pain management at New England Medical Center.

Another clue that hormones may affect pain sensitivity is that pregnant women who have surgery need less anesthesia than nonpregnant women, probably because progesterone, secreted during pregnancy, blocks some pain.

The data on gender differences have important implications for treatment, especially the growing evidence that doctors tend to ignore or undertreat pain in women.

In a study of 550 AIDS patients, for instance, Dr. William Breitbart, chief of psychiatry at Memorial Sloan-Kettering Cancer Center in New York, found women’s pain was twice as likely to be undertreated.

It’s not that women are more reluctant to tell doctors about pain, he says. It’s how doctors respond. “I didn’t want to believe it, but it all boils down to the stereotypes about women being hypochondriacal. . .exaggerating symptoms.”

But ignoring any patient’s report of pain can be costly, because it can be the first signal of serious disease.

Several studies, for instance, show that doctors take chest pain more seriously in men, says Dr. C. Noel Bairey Merz, director of the prevention and rehabilitation medicine center at Cedars-Sinai Medical Center in Los Angeles.

One shows doctors are less likely to refer for further evaluation patients who talk about chest pain in “histrionic” terms, versus those who are “more businesslike.” Another shows doctors are simply less likely to refer women with chest pains.

And two studies presented last week at a meeting of the American College of Cardiology showed that women are 13 percent more likely than men to die of their heart attacks. One reason is that women take longer to get to the hospital because instead of the crushing chest pain that men often have, women often have more ambiguous symptoms such as shortness of breath, an ache in the neck or jaw or something that feels like gas pains.

Merz and others are now studying whether chest pain in women correlates to estrogen levels, on the hunch that higher estrogen levels — as in younger women — lead to more awareness of pain.

Even among children, pain can manifest itself differently in boys and girls. At Children’s Hospital, Drs. Charles Berde and Christine Greco are studying a disorder called reflex sympathetic dystrophy, in which one arm or leg becomes painful and gets cold, turns blue, or becomes sweaty while the other doesn’t, suggesting a neurological abnormality.

For mysterious reasons, the condition is six times more common in girls than in boys, says Berde.

Despite inequities in the incidence of pain, research suggests that women and men believe that women cope better, perhaps because nature has somehow endowed them to withstand the pain of childbirth.

Part of women’s skill is an ability to control their emotions during intense pain, says Francis Keefe, an Ohio University psychologist. Even though arthritis caused more intense pain in women than in men in his study, women were better able to maintain a positive mood.

Cummings can buy that, especially when guys approaching 40 complain to her about minor injuries cramping their athletic style. “It’s stunning to me,” she says. Stacked against the pain she copes with every day, “there is no comparison.”

Migraine – New drugs offer the best hope yet

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It was June, 1996 and Dr. Michael Cutrer, head of the headache unit at Massachusetts General Hospital, was hard at work as usual in his sixth floor lab in Charlestown.

Suddenly, he’d look at somebody “and part of the face wouldn’t be there, just a shimmering blind spot” that grew “until half of the vision in both eyes was sparkling and shimmering,” he recalls.It was, as Cutrer knew all too well from both personal and professional experience, a classic “aura,” often the first sign of a crippling migraine headache.

But this time, Cutrer, 41, dashed down to a special MRI (magnetic resonance imaging) scanner on the first floor and jumped into position – as the patient.

For the next 45 minutes, as he lay watching the blind spot creep to the periphery of his vision, technicians tracked sharp changes in blood flow to the visual cortex of his brain. It was one of the first times scientists had been able to catch a spontaneous aura in progress, and it yielded an important clue to the underlying dynamics of migraines, which plague 16 to 18 million Americans.

In the nick of time, just as the aura turned into a throbbing headache, Cutrer gave himself a shot of a drug called Imitrex, or sumatriptan. Within minutes, the pain and vomiting he had come to expect with migraines since age 14 were gone.

In the not-so-old days – before Imitrex reached the market in 1993 – the main remedies for migraine were addictive painkilling drugs or ergotamine, either in a pill form that could make you “sicker than when you started,” as Cutrer puts it, or a less nauseating injectable form called DHE-45.

But today, migraine sufferers can often abort attacks in an hour or less with injectable Imitrex, and since last year, with a slower-acting pill form as well. And next month, a just-approved, fast-acting Imitrex nasal spray will become available.

That’s just the beginning. A nasal spray form of DHE-45 is also expected to be approved soon. A number of other remedies – an herb called feverfew, biofeedback, new Imitrex-like drugs – are showing some promise in preventing or aborting migraines.

And scientists, among them the MGH brain scanners who have recorded seven auras and 15 migraines in progress, are beginning to understand what goes wrong in a migraine headache, including identifying alterations in genes on chromosomes 1 and 19 that seem to put some people at risk.

Chronic headaches plague 45 million Americans. Most are “tension headaches,” with vise-like pain that can be severe – and frequent – but that often responds to antidepressants or over-the-counter remedies like ibuprofen and caffeine.

A tiny share of headaches – about 2 percent – are caused by brain tumors, aneurysms (weakened blood vessels in the brain) or infections in or near the brain.

Most of the rest are vascular headaches – migraines, which affect 18 percent of women and 6 percent of men, and cluster headaches, which are more rare and occur mainly in men.

While migraines cause a horrible, throbbing pain, cluster headaches cause a severe “cutting” type of pain, says Dr. Seymour Diamond, head of the Diamond Headache Clinic in Chicago and executive chairman of the National Headache Foundation.

In both types, some scientists believe, the pain, usually on just one side, comes from activation of nerve fibers in blood vessels in and around the brain.

While migraines, which often run in families, are often accompanied by nausea, vomiting and severe sensitivity to light and sound, cluster headaches are not. Migraines typically last from several hours to three days; cluster headaches last several hours but can strike two or three times a day for months.

At the onset of a migraine, some believe, the level of serotonin, a natural chemical in the brain, drops suddenly, allowing blood vessels in the brain and the meninges (the fibrous tissue surrounding the brain) to dilate, which can cause surrounding tissues to swell painfully.

But blood vessel dilation is only part of the story, says neurologist Cutrer. Whatever the initial trigger of a migraine – a particular food, alcohol, missing meals, changes in sleep patterns, menstruation, bright lights, loud noises – nerve cells in the meninges and in the meningeal blood vessels release chemicals called pain peptides.

Signals from the meninges are then transmitted deeper into the brain, causing exquisite pain – as millions can attest.

Ellen Blau, for instance, a 47-year-old Michigan woman who now coordinates support groups for the National Headache Foundation, has had migraines since she was 17.

“I was in bed half the week for many years,” she says. Her son often “came home to notes saying, ‘Quiet, I’m sick.’ ” At one point, she was so sick – and so sick of being sick – that she was “ready to commit suicide, to not live anymore.”

What finally brought Blau’s migraines under control was a course of Nardil (a type of antidepressant).

Now, to prevent attacks, she takes the antidepressant Prozac (although Prozac’s effectiveness for migraine prevention is controversial), another drug that combines a muscle relaxant with the antidepressant Elavil, and an anti-inflammatory drug. (Antidepressants often help people with migraine because they not only elevate mood but combat pain.)

Like Blau, Valerie Socha, a 38-year-old Revere computer programmer, has also suffered migraines since she was 17 – in her case, every time she got her period.

Now, she says, her attacks have been reduced, thanks in part to an herbal remedy, feverfew, which she takes daily – three 380 milligram capsules morning and night.

For many people with migraine, however, among them Patricia Poisson, 56, a self-employed Wayland businesswoman, finding relief means trekking from doctor to doctor.

Many women find their migraines get better after menopause, but Poisson says hers got worse: “I had seven headaches a week – I either woke up with one or got one as the day went on.”

She now swears by atenolol, a beta-blocker drug used to treat high blood pressure. She still gets two migraines a week, but says, “This is nothing compared to what I have had to live with for the last eight years.”

The options may keep expanding for Poisson and others.

Encouraged by data suggesting that Imitrex aborts migraines by constricting blood vessels and blocking release of pain peptides, researchers are now working on a number of Imitrex “clones.”

About six months ago, researchers also reported that Lidocaine nose drops can help abort a migraine attack. This summer, at an international conference in Amsterdam, Belgian researchers reported that 400 milligrams a day of riboflavin (vitamin B-2) seemed to cut migraines by more than 50 percent.

And at the New York Headache Center, researchers have found that half of people with migraines and cluster headaches may have low levels of the mineral magnesium, and that intravenous injections of magnesium may help.

But Dr. Dhirendra Bana, director of the headache and pain center at Faulkner Hospital, cautions that in practice some remedies fall short.

“We haven’t had much luck with magnesium,” he says, or with melatonin, the sleeping aid sold as a dietary supplement. While some data suggest high (10 mg) doses of melatonin may prevent cluster headaches, Bana says it hasn’t worked well in his patients.

Another drug, Stadol, a nasal spray used for pain, has also come under attack – after numerous reports of adverse reactions.

Still, there is a powerful sense among both migraine specialists and patients that “all of a sudden, because of the success of sumatriptan Imitrex, there has been created an awareness of migraine and that treatments are available,” says Diamond of Chicago.

Cutrer agrees, noting that many patients now prevent attacks with beta-blockers, calcium channel blockers, nonsteroidal anti-inflammatory drugs like Naprosyn, the antidepresssant Elavil, or Depakote, an anti-epileptic drug that also fights pain.

Increasingly, nondrug therapies are also an option, especially biofeedback, which can teach patients to increase blood flow to their hands, perhaps causing blood vessels in the head to become less swollen and painful.

Once you find something that works, says Patricia Poisson, life can be utterly transformed: “It’s like having that faucet shut off from Chinese torture. . . I don’t know how I stood it all those years.”

To learn more

For more information on migraines, call:

  • 1-800-843-2256 begin_of_the_skype_highlighting              1-800-843-2256      end_of_the_skype_highlighting, the National Headache Foundation.

  • 1-800-372-7742 begin_of_the_skype_highlighting              1-800-372-7742      end_of_the_skype_highlighting, to find or start a headache support group in your area.

If you have migraines with auras that occur after you eat a certain food or another “trigger” and would like to participate in the brain scan study at Massachusetts General Hospital, call 617-726-6939 begin_of_the_skype_highlighting              617-726-6939      end_of_the_skype_highlighting.

Follow the ‘rule of 3’s’ on back pain

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Annie Baehr, who works at the Berklee College of Music, figures she has struggled with back pain for nearly 40 of her 55 years.

For a while, the Winchester woman says, she trudged to orthopedic specialists, but “nobody gave me any relief.” Last year, when the back pain evolved into daily headaches, she turned to prescription painkillers, but they didn’t help either. The pills “covered up the pain,” she says, but made things worse when she stopped.Cherie Hoffman, 35, a Wellesley mother and publisher of a travel guide for students, has trod a similar path, searching fruitlessly – until recently – for any method or magician who might ease her pain.

“I was living on Advil,” she says, from the pain of lifting her kids in and out of car seats. “My back was killing me.”

Back pain, especially in the lower back, which bears the brunt of the human penchant for walking upright, is endemic – and probably has been since our species got off all fours.

In fact, it’s so common that some specialists say “it’s normal if you have it and abnormal if you don’t,” jokes Dr. Edward Hanley, chairman of orthopedic surgery at Carolinas Medical Center in Charlotte, N.C.

Over a lifetime, 80 percent of us will have at least one episode of incapacitating back pain, the data show, making bad backs second only to colds as a reason to see a doctor, and the leading reason for missed days of work among under 45. The good news is that even when back pain is acute, the best remedy is almost always common sense and tincture of time.

Usually, relief comes in a few days if you pop a few over-the-counter anti-inflammatory drugs (judiciously, so you don’t get an upset stomach or ulcer), apply ice packs or heating pads (it doesn’t seem to matter which, though heat may feel better on muscle aches and cold on acute injuries) and lie down for a few hours or, at most, a few days.

Then get up and get on with life, including regular walking, biking or swimming with a few sit-ups or back-strengthening exercises thrown in for good measure. Staying in bed more than two days, research shows, can do more harm than good – it weakens bones and muscles and creates a “sickness” mentality.

In fact, for most bad backs, you don’t even need to call a doctor unless pain is severe or doesn’t begin to go away within a few days. Just follow what Dr. Howard Martin, an orthopedic surgeon at New England Baptist Hospital and at SportsMedicine Brookline, a clinic for athletes, calls “the rule of threes.”

“If your pain starts to get better by three days and is all gone by three weeks, it’s perfectly safe to ignore it,” he says. Even pain in the buttocks or back of the thigh doesn’t need medical attention, he adds, unless it shoots below the knee, a sign of possible nerve irritation from more serious injury.

Your bad back does need an immediate professional evaluation, however, if you can’t control your bowel or bladder or if you feel numbness in a leg, the groin or rectal area – all signs of possible damage to the spinal nerves in your back.

In the old days, back specialists assumed that most lower back troubles stemmed from problems with the squishy discs that act as shock absorbers between the vertebrae.

Today, these slipped, herniated or ruptured discs – all terms for the same problem, in which the gristle-like disc gets pushed out of position and pinches a nerve – are believed to be a serious problem for only about 2 percent of the population.

And even for disc patients, specialists say, surgery is no longer as common as it once was because 75 percent of disc problems get better on their own over time.

In fact, surgery helps in only about one in 100 cases, according to a 1994 report from a panel of low back pain specialists convened by the government’s Agency for Health Care Policy and Research. It is generally reserved for patients with sciatica – pain that shoots down the leg past the knee.

Most back pain, in other words, is caused not by structural damage to the spine, nor by even rarer tumors or infections, but by run-of-the-mill soft tissue problems like muscle strains and ligament sprains.

But run-of-the-mill pain is definitely no joke, especially when it’s your back. So what really works and what doesn’t?

That depends on whom you talk to, and there is an embarrassment of specialists in the booming $ 50 billion-a-year back pain industry, all eager for your health care dollars.

You might, for instance, take your bad back to an orthopedic surgeon, an M.D. who, historically, may have been inclined to steer you toward surgery but today may well be open to other options. Or you can try a physiatrist (also called a medical orthopedist), an M.D. who is not a surgeon but has orthopedic training.

Or you can look for an osteopathic physician – a challenge in Boston, but easier elsewhere. Osteopaths (D.O.s) are not M.D.s, but they get almost identical training and the same license and have extra training in spinal manipulation.

If you’d rather see a non-physician, you can try a chiropractor, who has more than four years of post-college training and specializes in spinal adjustments; a physical therapist, who can suggest exercises for weak muscles and gentle mobilization of spinal joints; or a massage therapist, who can massage away some aches and pains, at least temporarily.

With so many pros to choose from, does it matter whom you pick? For truly serious problems, yes, which means you should probably see a physician of some type, including an internist, at some point. But for less serious troubles, it probably doesn’t matter much, since you’re destined to get better anyway.

There is consensus, according to the 1994 government panel, that spinal manipulation by a chiropractor or osteopath does help, though if it hasn’t worked for an acute episode of back pain after four weeks, you should stop and reevaluate.

You can also use friends’ testimonials to guide you through the maze, but this can be as confusing as listening to the pros.

Cherie Hoffman, for instance, raves about the hands-on help she’s gotten from her osteopath in Rhode Island, which makes sense to Dr. Charles Radbill, an osteopath in Wellesley Hills.

Radbill believes that the root of much back pain is joint dysfunction – particularly in the sacroiliac joint in the pelvis. Gentle osteopathic manipulation, he says, including of fascial tissue that wraps around muscles, can help considerably.

Osteopathy “has been a miracle cure for me,” says Hoffman, who stayed away from chiropractors because she disliked “the thought of having somebody crack my back into submission.”

But her sister-in-law, Penney Hoffman, 37, a Marblehead human resources manager, wouldn’t take her aching back to anyone but a chiropractor. She’s so enthusiastic, she calls her chiropractor her “primary doctor” and even has him treat her kids, though her insurance doesn’t cover it and the family pays $ 1,500 a year.

That kind of passion is familiar to Barry Freedman, a Quincy chiropractor, who is convinced the basic problem in many bad backs is subluxation, or misalignment of the spine, which puts pressure on nerves and triggers muscle spasms.

Muscle relaxants or physical therapy are “not going to get rid of subluxation,” Freedman argues, but chiropractic can.

And what of other things like traction, TENS (transcutaneous electrical nerve stimulation), massage, biofeedback, acupuncture, injections, corsets and ultrasound?

If you believe the government panel, none of these speeds recovery from acute back pain or wards off recurrences, though they may offer short-term relief. But practitioners – and patients – tell a different story.

Massage therapist Linda Whitcomb of Concord Avenue Physical Therapy Associates in Cambridge, for instance, says massage can loosen tight muscles “so that when you lift something awkwardly, you won’t put as much strain on the muscle.”

Her partner, physical therapist Nicholas R. Giurleo adds that physical therapists can also teach you to prevent back problems by sitting right so as not to overstretch ligaments, and lifting things correctly, with a slight arch in your back.

They can also prescribe individualized abdominal and back exercises to help keep muscles strong in the “body core,” says Michael Wood, a research associate at Tufts University.

If you already have a bad back, though, take care before embarking on any exercise program, warns Daniel Dyrek, a physical therapist at the Institute for Health Professions at Massachusetts General Hospital. Generic exercises that are not tailored to your specific problem may do more harm than good.

But the most important message, he says, is that if you’re not getting better with whatever specialist you’re seeing, try another one, either in the same discipline or another.

Annie Baehr seconds that notion.

Thanks to osteopathy, she says, “I am getting better.” But like many others who struggle with bad backs, she has found that true healing is “a long, long process.”

To learn more

For more information on low back problems, call the Agency for Health Care Policy and Research, 1-800-358-9295 begin_of_the_skype_highlighting              1-800-358-9295      end_of_the_skype_highlighting.

You can also get information from this agency on the Internet by clicking on: http://www.ahcpr.gov/ and then clicking on “guidelines” and following the directions from there.

1. Back pain is almost normal, jokes Dr. Edward Hanley. 

2. Barry Freedman thinks spinal misalignment is a factor in back pain.

Painkillers often take toll on stomach

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Gabriel Belt, 66, a retired Brookline accountant, figured he was doing the smart thing by taking an aspirin every other day.

Both his father and brother had died of cardiovascular problems in their sixties and he knew aspirin could reduce his own risk. He also figured that if he took the aspirin only every other day and took a type that was enteric-coated to protect his stomach, he should have no problems.Wrong.

Last October, Belt was rushed to Beth Israel Hospital with internal bleeding from an ulcer probably caused by the aspirin.

Len Levin,34, tells a similar story. A health science librarian at New England Baptist Hospital, he had been the picture of health, his only complaint an occasional bad back. One day two years ago, Levin helped move heavy furniture and the next day, felt what seemed like the old, familiar back pain.

After checking with his health practitioners, who also assumed the problem was a sore muscle or ligament, he started on ibuprofen, a popular pain-killing, anti-inflammatory drug. But by Thanksgiving, the pain was no better and he was so anemic he “felt like I would pass out if I stood up,” he says.

In retrospect, Levin believes he had a tiny stomach ulcer all along. But the NSAIDs – that’s shorthand for non-steroidal anti-inflammatory drugs – made it far worse, causing it to bleed so much that Levin needed emergency surgery to save his life.

In recent years, Americans have taken to popping aspirin, ibuprofen and other drugs in the NSAID (pronounced EN-SAID) class like candy – and often for good reason.

These pills – with names like Anacin, Bayer and Bufferin for aspirin-type drugs; Advil, Motrin IB and Nuprin for ibuprofen-based drugs, and Aleve for naproxen sodium-based drugs – help.

They kill pain. They lower fever. And perhaps most important for millions of older people with arthritis, they often work like a charm to combat the inflammation that makes joints ache.

In fact, 80 million of us take over-the-counter NSAIDs whenever we feel like it, with 200 brands to choose from. We also gobble 75 million prescriptions for stronger NSAIDS, to the tune of $ 1.8 billion a year, according to IMS America, an outfit that tracks such things for the pharmaceutical industry.

But the more popular NSAIDS become, the more doctors are becoming aware of a serious downside: sneaky, often totally painless ulcers that can bleed, with potentially fatal consequences, as well as other types of internal bleeding that can leave people so anemic they pass out or bleed to death.

An estimated 40 to 60 percent of people who chronically use NSAIDS, either in prescription or over-the-counter form, develop “erosions” in the lining of the stomach or upper intestine, says Dr. Helen Shields,a Beth Israel gastroenterologist. And 10 to 30 percent get deeper lesions – ulcers.

Prescription NSAIDS alone trigger bleeding in 1 to 3 percent of people who take them, says Dr. Linda Katz, a rheumatologist at the US Food and Drug Administration.

Indeed, NSAIDS now cause 41,000 hospitalizations and 3,300 deaths a year from ulcer complications such as bleeding and perforation, a condition in which stomach contents spill into the abdomen, according to testimony presented to the FDA last fall by Dr. Sidney M. Wolfe, president of Public Citizen Health Research Group in Washington, a consumer activist group.

The risk is particularly serious for older people, says Dr. David Cave, chief of gastroenterology at St. Elizabeth’s Medical Center. Shocked relatives may “find grandma on the floor in a pool of blood,” he says.

When an ulcer bleeds, Cave says, “the blood comes out under pressure. This is arterial bleeding. . . With a big, bad ulcer, you can bleed out – die – in an hour,” though this does not always happen. If bleeding is severe, cauterization of the ulcer through a tube called an endoscope or emergency surgery can staunch the flow, provided the procedures are done in time.

Despite such problems, however, many doctors say that NSAIDS overall “are very safe,” as Dr. David Puera, associate chief of gastroenterology at the University of Virginia Health Sciences Center, puts it.

“Problems don’t occur often, but when they do, they can be life-threatening,” says Puera, who co-authored a recent study that found the risk of stomach or intestinal bleeding was three times higher in people taking NSAIDS, a figure consistent with other research.

To be sure, about 80 percent of stomach ulcers are caused by a bacterium called Helicobacter pylori. But half the rest are caused by NSAIDS, according to data presented recently at a meeting of the American Gastroenterological Assocation. And even when ulcers are caused by bacteria, doctors say, NSAIDS make things worse by causing ulcers to bleed.

Biochemically, the reason that NSAIDS are both good painkillers and dangerous triggers of bleeding is one and the same. NSAIDS work by blocking chemicals called prostaglandins, which are made all over the body. Prostaglandins are often seen as “bad” because they cause pain.

But some prostaglandins are “good” because they help regenerate the mucus lining of the stomach and duodenum (the upper part of the small intestine) and maintain a healthy blood supply to these tissues.

When prostaglandins are blocked with NSAIDS, the lining of the GI tract becomes more vulnerable to normal digestive fluids – acids and pepsin – that are always present.

In addition, NSAIDS may trigger ulcers by interfering with production of bicarbonate, a natural antacid. They may also trigger bleeding by reducing the clotting of platelets in the blood, a special problem for people taking blood-thinning drugs.

But not all NSAIDS are created equal.

Consumer advocate Wolfe, for instance, has tried repeatedly to get the FDA to ban Feldene, made by Pfizer. He is convinced it “is by far the worst of all the NSAIDS” and says it “should not be on the market in the US. . . Do not use Feldene.”

Wolfe cites data obtained from the FDA linking Feldene to 299 deaths between 1982 and 1994, including 144 in which deaths were related to gastrointestinal problems like ulcers and bleeding.

Others disagree.

“Certainly drugs that stay in the body longer, like Feldene, have the theoretical potential to do more harm and if they cause a problem, it’s likely to be more serious,” says Dr. David Trentham,head of rheumatology at Beth Israel. “However, usage of Feldene over several decades has not indicated that Feldene has a greater risk than other commonly used NSAIDS.”

A recent FDA advisory committee agreed with that assessment, finding there was not enough evidence to consider Feldene different from other NSAIDS, a position with which Pfizer, not surprisingly, concurs.

So what should you do if, as the ads of yesteryear used to put it, you don’t want to trade your headache or aching knees for an upset or bleeding stomach?

One option is Tylenol (acetaminophen), a drug that reduces fever and pain. It is not an NSAID because it has little anti-inflammatory action, but this may also make it less useful against arthritis. Some people also that feel Tylenol doesn’t attack pain as well as NSAIDS, and it has other problems, too.

Regular alcohol consumption – about three drinks a day – can change liver metabolism so that when the liver breaks down Tylenol, a toxic compound may be produced. The result can be serious liver damage, on rare occasions with as few as five 500 milligrams of Tylenol a day.

But alcohol may increase the ulcer risk with NSAIDS, too, says Shields of Beth Israel.

Another option is to stick to the weakest NSAIDS, notably aspirin – especially the enteric-coated kind that is absorbed in the intestines, not the stomach, though this coating can make absorption erratic. Buffered preparations, which neutralize stomach acids, may also help, and some doctors advocate ibuprofen-based drugs. But as Belt and Levin discovered, even these relatively benign medications can cause trouble.

If you need stronger prescription NSAIDS, ask your doctor about newer types like Relafen or Disalcid, which may be less toxic to your stomach.

Another approach, which some gastroenterologists recommend, is to take other stomach-protecting drugs with your NSAIDS.

One such drug is Cytotec, a synthetic prostaglandin that can replace the prostaglandins in the stomach destroyed by NSAIDS.

Increasingly potent acid-blocking drugs are also pouring onto the market, including Prilosec and Prevacid, available by prescription, and the so-called H-2 blockers such as Zantac, Pepcid or Tagamet. These three are available over-the-counter, though these doses may be too low to help much, and by prescription for higher doses.

But the most important advice is this: Tell your doctor about all NSAIDS you’re taking – including over-the-counter – and the doses.

“Your doctor may be able to suggest an alternative that can control your pain or inflammation yet be less dangerous to your stomach,” says Shields of Beth Israel. “And there are more and more such alternatives available.”

Signs of problems from painkillers

If you take non-steroidal anti-inflammatory drugs – NSAIDS – and have any of a number of symptoms, you may have an ulcer or internal bleeding from some other cause. You should call your doctor promptly.

It is a medical emergency if you have black stools, which may indicate bleeding in the upper gastrointestinal tract, or if you vomit blood.

It is a potential problem if you have other signs of ongoing bleeding and possible anemia, such as dizziness, weakness, fainting, sudden confusion or shortness of breath.

And it may be a sign of an ulcer if you suffer nausea, loss of appetite or indigestion or a gnawing pain in the upper abdomen, especially if it is relieved by food or antacids but returns several hours later. Pain that wakens you from sleep can also be a sign of an ulcer.