Thursday, November 29, 2012

Mapping The Brain For Chronic Pain

Chronic pain is a disorder that affects thousands of Americans every year.  Chronic pain can result from surgical adhesions, a neurological condition, or as a result of an accident or injury.  Given the proliferation of Americans suffering from chronic pain, many researchers are now directly their studies to find the causes, treatments, and prevention methods associated with chronic pain.

Researchers at the University College of London who were examining chronic painrecently mapped the brain using MRI techniques to see how brains register, respond, and process pain signals.  This study was the first of its kind in the fact that the researchers individually mapped pain responses relating to individual fingers on a subject.  Such finely tuned mapping had never been widely available before this study.  When analyzing the results of this study, researchers discovered that the brain pathways associated with pain and touch are very similar.   This is interesting, as other studies have researched the link between touch and pain and how the brain sometimes confuses the two.

Chronic pain as a result of an accident due to the fault of another is frustrating, painful, and debilitating.  If you find yourself in this position, it might be time to consult with an attorney.  Attorney Doug Stoehr is a personal injury lawyer serving western and central Pennsylvania.  For more information on his Altoona, PA area firm, please visit his website at or call his office at 814-946-4100.

Wednesday, November 28, 2012

Medicare and Chronic Pain

The Providence Journal recently published an article on 10/30 about Medicare coverage as it relates to chronic pain treatment.  The original article, written by Janice Izlar, can be viewed by continuing to read below or byclicking this link.

Imagine that you're a 67-year-old farmer living in Wisconsin and suffering from chronic back pain. Seeing a physician who specializes in pain management entails a long, expensive trip. Fortunately, you don't have to make that trip because a local Certified Registered Nurse Anesthetist (CRNA) can administer the pain management that you need to lead a normal life.

But one day, your nurse anesthetist informs you that he or she can't administer your chronic pain treatments anymore because Medicare won't pay for them. With the nearest pain physician hundreds of miles away, you face the grim prospect of unnecessarily living in agony or regularly making the grueling journey to seek treatment.
That's precisely what's happening for countless seniors and other pain patients across America. Unless Medicare officials take action to guarantee patient access to chronic pain management administered by CRNAs, especially in rural and other medically underserved areas of the country, our hypothetical Wisconsinite's experience may become the norm nationwide.
The ins and outs of Medicare's reimbursement practices may seem arcane. But they have real effects on the lives of Medicare beneficiaries, particularly those in rural areas.
Seeing a doctor can pose a significant challenge for rural Americans. Roughly 20 percent of Americans live in rural areas, but only 9 percent of physicians practice there.
For pain patients, the access problem is even more acute. Today, with more than 100 million Americans suffering from chronic pain, our nation lacks sufficient healthcare providers to care for them, according to the Institute of Medicine. One nurse anesthetist in Kansas reports that her patients' lone alternative is a three-hour round trip to the nearest city.
CRNAs play a crucial role in filling the pain-care gap. There are more than 45,000 nurse anesthetists nationwide delivering 33 million anesthetics annually. They've been doing so for many years, and Medicare has long reimbursed them for their work.
That was the case until last year, when two Medicare administrative contractors operating in several western states suddenly cut off access to chronic pain care delivered by CRNAs.
Some nurse anesthetists have continued to provide such therapy without reimbursement, but others simply haven't been able to afford to do so in the wake of the Medicare contractors' decision.
Medicare officials are expected to soon settle the issue by issuing a uniform rule for the entire country. The proposal they're considering would guarantee reimbursement to CRNAs who are legally authorized by the laws of their state to administer chronic pain therapy.
The Institute of Medicine has made statements consistent with this policy, saying, "the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses" in order to solve the pain-care crisis.
And there's no question that CRNAs are qualified to provide chronic pain-management. They've graduated from accredited nurse anesthesia educational programs. In fact, the Council on Accreditation of Nurse Anesthesia Educational Programs requires nurse anesthetists to receive rigorous graduate education in such disciplines as pathophysiology, pharmacology, anatomy and pain management.
Many nurse anesthetists undergo further training in the form of fellowships, supervised practice, professional education, and weekend courses.
As Brian Bradley, a nurse anesthetist in Montana, recently put it, "If you're saying I can't treat chronic pain, you're telling me I'm a fireman but can only put out fires in the living room and bathroom."
Expanding access to pain care through CRNAs will also obviate patient need for prescription painkillers, which can be prone to abuse.
Medicare's very mission is to ensure that no senior goes without the health care that he or she needs. The agency's leaders must therefore ratify the rule they're considering, and guarantee patient access to Certified Registered Nurse Anesthetists.

Attorney Doug Stoehr is a personal injury lawyer serving western and central Pennsylvania who takes claims involving elder abuse and neglect, as well as motor vehicle accident cases. For more information on his central Pennsylvania practice, pleasevisit his website or call his office at 814-946-4100.

Monday, November 26, 2012

Chronic Pain New Public Health Epidemic?

The El Paso Times recently discussed the epidemic of chronic pain. The original 11/19 article, written by Dr. Ahmed Bahr, can be read by continuing below or going to their website:
Serious, chronic pain affects at least 116 million Americans each year, according to a recent report by the Institute of Medicine. The report referred to pain as the new "public health crisis."
People suffering chronic pain cost the country $560 billion to $635 billion each year in medical bills, lost productivity and missed work. The reasons for long-lasting pain are many - from cancer and multiple sclerosis to back pain and arthritis.
Chronic pain is any pain that lasts 30 to 60 days or more and takes a toll on someone's personal and professional life, which can lead to a downward cycle of sleeplessness, anxiety, depression and decreased mobility.
Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally incapacitating.
Further, as baby boomers age, the rate of chronic pain increases daily. The need has never been greater for therapies that provide long-term relief.
Specialty of pain medicine
The specialty of pain medicine is concerned with the prevention, diagnosis, treatment and rehabilitation of painful disorders. This specialty is practiced by physicians who are able to draw from a wide range of therapeutic modalities to design a treatment program tailored to a person's specific needs. Pain problems seen by pain management physicians include:

  • Low back pain.
  • Disc problems. 
  • Sciatica.
  • Failed back syndrome from a previous back surgery. 
  • Neck pain.
  • Arthritis.
  • Post-surgical pain syndromes. 
  • Complex regional pain syndromes.
  • Cancer pain.
  • Post-therapeutic neuralgia (shingles).

When it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. There are many different pain management options available. While medication can be effective, there are other treatment approaches used to bring relief to chronic pain sufferers. The following are just a few options:
  • Trigger point injections. Epidural steroid injections.
  • Discography.
  • Radiofrequency ablation.
  • Spinal cord stimulation.
  • Specialized nerve blocks.
  • Spinal medication delivery systems.
  • Minimally invasive lumbar decompression.
  • Rehabilitation.
  • Acupuncture.

Patients who suffer chronic pain that has not improved with conventional therapies such as pain medications can be referred by their primary care doctor to a pain management specialist. The specialist will discuss all options available before a treatment decision is made. 

Attorney Doug Stoehr is a personal injury lawyer serving the western and central Pennsylvania area. For more information on his practice, please visit his website at  

Tuesday, November 20, 2012

Distracted Driving In PA

Ben Simmoneau of CBS Local-Philadelphia took a look at distracted driving in his 11/20/2012 article.  To read, please click this link or continue below for the original article.
PHILADELPHIA (CBS) - Distracted drivers. You see them all the time. They’re on the road with a smartphone in one hand and the steering wheel in the other. It’s dangerous and there are laws against this. But not many people in Pennsylvania are getting in trouble for driving and texting. CBS 3′s I-Team reporter Ben Simmoneau hit the street to find out why.
“You know it’s illegal to text behind the wheel?”
That was the question the I-Team posed to driver after driver who was spotted using a cell phone and in some cases even using a tablet device.
“I’m stopping right now,” said one Philly cabdriver.
Another driver with an iPad in his lap denied that he was texting. He thought because he was stopped it was okay to use the device.
We even caught a Philadelphia Parking Authority supervisor cell in hand. She denied texting and said she was just reading.
But that’s still illegal. And it’s a law that can be confusing.
In New Jersey and Delaware, you must be hands-free all the time while driving.
But in Pennsylvania, a law passed last spring allows drivers to use their phones for anything except writing or reading texts and e-mails.
That makes it a very difficult law to enforce. How do police know what you’re doing while you’re holding that cell phone?
Records obtained by the I-Team show that Philadelphia police have written just 168 citations in the six months since the law passed.
That’s not even one citation a day.
Statewide, the count isn’t much better.
Records analyzed by the American Automobile Association found only 640 tickets written in Pennsylvania.
“It’s a meaningless law,” says Bill Green, a democratic councilman-at-large on Philadelphia’s City Council.
Green is angry that the new law tossed out a tougher city law.
Far more tickets were written under that one which banned the use of hand-held devices in the city.
“It’s absolutely clear what happened is when the cell phone industry couldn’t defeat the bill in Philadelphia, they went to Harrisburg,” said Green. “We have the best legislature that money can buy.”
In the Pennsylvania legislature, it was Republican State Senator Tommy Tomlinson who sponsored the no-texting law. He says he wanted a hands free law but the support wasn’t there.
“It’s all I felt we could get accomplished,” Tomlinson said. “If we put the cell phone ban in it, it would not have passed.
The law has the support of AAA.
“Overall we think it’s better to have a consistency throughout the state so you don’t have a patchwork of one law in one place and another law in one place,” said AAA spokesperson, Jenny Robinson.
But without punishment, how do you get people to take the crime seriously?
Another person who was caught texting by the I-team said, “It’s actually just something important.”
It’s always something important.

Distracted driving is a major cause of motor vehicle accidents on the highway.  If you have been injured as the result of a distracted driver, it might be time to consult an attorney.  Attorney Doug Stoehr is a personal injury lawyer serving western and central Pennsylvania.  Please visit his website at for more information.

Chronic Pain May Be Hereditary

HealthDay News recently covered an article discussing the hereditary aspect of chronic pain.  For more information on their 11/19/2012 article, please click this link or continue below for the original article.
MONDAY, Nov. 19 (HealthDay News) -- The teenage children of people who suffer chronic pain are at higher risk of suffering from such pain themselves, a new study finds.
The study tracked more than 5,300 teens (aged 13 to 18) in Norway and their parents and found that teens were more likely to have chronic nonspecific pain and chronic multisite pain if one or both of their parents had chronic pain.
The risk of chronic pain in teens was greater if both parents had chronic pain, according to the study published online Nov. 19 in the journal Archives of Pediatrics & Adolescent Medicine.
Adjusting for socioeconomic and psychosocial factors did not change the findings, but different types of family structure did have an effect, said Dr. Gry Hoftun, of the Norwegian University of Science and Technology, and colleagues. For example, among teens who lived primarily with their mothers, those whose mothers had chronic pain were at increased risk for chronic pain. No such association was found among teens who lived primarily with their fathers.
Shared environmental factors could play an important role in chronic pain that occurs among adults and their children, the researchers concluded.
One expert in the United States said the study raises some questions.
"The findings are not surprising, but causal factors -- what is the basis for this relationship -- remain unanswered," said Dr. Bradley Flansbaum, an internist at Lenox Hill Hospital in New York City. "We cannot account for every exposure, particularly social influences, and the impact genetics and environment play in the outcome are difficult to parse," he noted.
"This should not distract the take-home point -- mainly, cause aside, pain clusters in families," Flansbaum said. He believes that the finding could make it easier to spot those people who suffer from chronic pain and improve treatment.
Chronic pain can be caused by an accident, such as motor vehicle or slip and fall.  If you have chronic pain as a result of an accident due to the fault of another, it might be time to consult with an attorney.  Attorney Doug Stoehr is a personal injury lawyer serving western and central Pennsylvania.  For more information on his Altoona, PA practice, please visit his website at or call his office at814-946-4100.

Monday, November 19, 2012

Financial Fraud and the Elderly recently covered an article exploring banks protecting senior citizens against financial fraud.  To read more on the 11/17/2012 article written by Chris Mondics, please read below or click this link for the original article. 

Banks and other financial institutions are an important line of defense against scammers seeking to defraud the elderly, but too often tellers and branch managers are not trained to recognize the warning signs, says a Government Accountability Office report issued Thursday.
The study, which looked at programs aimed at fighting fraud that targets the elderly in California, Illinois, Pennsylvania, and New York, said that out of misguided concern they might breach federal privacy laws, banks and other financial institutions are sometimes reluctant to share information with agencies that work to protect older people from financial crimes.
"Banks are well-positioned to recognize, report, and provide evidence supporting investigations," said Kay E. Brown, director of Education, Workforce, and Income Security at the GAO. "However, many social-services and law enforcement officials we spoke with indicated banks do not always recognize and report exploitation or provide evidence needed to investigate it."
The report was released at the outset of a hearing Thursday before the Senate Special Committee on Aging in Washington on efforts nationally to combat elder financial abuse.
It comes one year after the indictment of Philadelphia lawyer Michael Kwasnik by a New Jersey state grand jury on charges of stealing $1.1 million from a Cherry Hill widow who had hired him for estate planning and to manage her money.
Along with filing criminal charges, authorities sued Kwasnik, alleging that he; his father, William; and others orchestrated a multimillion-dollar Ponzi scheme that victimized the elderly. A trial date on the criminal charges has not been set.
The GAO report said there was wide agreement that fraud schemes and other forms of theft aimed at the elderly are a burgeoning national problem. But efforts to fight the problem are hampered by poor data collection and the frequent failure of law enforcement and social-services agencies to work together.
The GAO cited a list of long-standing obstacles: poor data collection; scattershot enforcement; the belief by many prosecutors that such cases are too difficult; and too little awareness by the elderly that they might be exploited.
The GAO suggested that states adopt a uniform standard for power of attorney, a frequently abused legal instrument through which many elderly and others sign over authority to manage their financial affairs to another person. Recommended safeguards include a requirement for careful record-keeping by those who have been given such authority, and an option for financial institutions to decline to process financial transactions they deem suspicious.
Banks are uniquely positioned to fight such fraud, which authorities believe totals billions each year.
Scammers typically accompany elderly victims to a bank as they orchestrate fraudulent transactions. And though alert bank employees do report suspicious transactions to Adult Protective Services, local agencies that investigate allegations of abuse of the elderly told the GAO that the record has been spotty.
"Without information to correct banks' misconceptions about the impact of federal privacy laws on their ability to release bank records, APS and law enforcement agencies will continue to find it difficult to obtain the information they need," the GAO said.
In prepared testimony, Paul Smocer, a spokesman for the Financial Services Roundtable, which represents major banks in Washington, said the industry has worked to detect fraud schemes aimed at the elderly. But he acknowledged that financial institutions are at times concerned about being sued after reporting suspicious transactions. Statutes that seek to protect banks from liability in such situations differ from one state to the next, raising uncertainty, he said.
The problem of financial fraud involving the elderly is only going to intensify, he said, if for no other reason than that the population of people 65 and older is expected to double to 71 million by 2030.
Brown recommended that senior officials of federal agencies charged with combating elder abuse draft a national policy to better guide the many state and local efforts.

Attorney Doug Stoehr is a personal injury lawyer who takes claims for elderly clients who have been abused financially, physically, emotionally, or sexually.  For more information on his Altoona, PA area practice, please visit his website at or call his firm at814-946-4100.

Wednesday, November 14, 2012

Distracted Driving by the Numbers

Mallory Lane of the news website We Are Central PA recently highlighted the growing problem of the dangers of texting and driving in her 11/5/2012 article.  To read, please continue below or click this link.

So far this year in the United States, there have been an estimated 1.1 billion crashes as a result of distracted driving.

According to PenDot, in Pennsylvania in 2011, there were 848 crashes that were cell phone related. Six of them were fatal. In our viewing area, there were 71 crashes. One of them was fatal.

As part of the Driver's Education course at Bellefonte High School, students are required to spend at least six hours behind the wheel with an instructor.

But the Driver's Ed teacher wants to take things a step further and make sure his students really understand what it means to drive distracted.

Driving to distraction is something Mike Wilson says he sees all the time.

"We've had a number of accidents over my career here at the high school," Wilson said. "We've seen the switch from the DUI accidents to the texting and driving."

But since March of 2012, it's against the law in Pennsylvania to text and drive.

"It is one of the more difficult laws to enforce, especially because it varies by age," School Resource Officer for Bellefonte High, Jason Brower said.

Officer Brower says its new drivers that typically have trouble remembering the law.

"It's not just there to try to stop them from doing something because we want them to, it's because it can cause accidents and cause a problem," he said.

So what's the solution? Mr. Wilson's Driver's Education class is practicing their driving skills behind the wheel of a golf cart, but there's one twist.

They start off with a piece of paper, telling them what to text and then, they're off.

"It's very difficult, especially how they have the cones set up," Lindsey Beran said. "They're very narrow, which makes it even harder to try and drive and text at the same time."

Lindsey Beran is a sophomore at Bellefonte High School. She says this simulation is teaching her, "not to text and drive or drive drunk because it could hurt somebody," she said.

But for Lindsey, this lesson is about more than just practicing her driving skills.

"My one best friend was killed by a drunk driver," Beran said.

It happened back in 2010 and it's a day Lindsey says she'll never forget.

"It was really hard taking that and you can't help but not like the person, but in the end, it was something that was able to be prevented, but it wasn't," she said. "Knowing that he could have not been behind the wheel of that boat, it could have saved her life. It just kind of irritates you."

She says it's through that experience that she has learned just how dangerous distracted driving can be.

"I guess it seems like it's fun, but honestly, in the end, I don't think it's ever worth it," Beran said. "I don't think the risk of losing a life or getting severely hurt is worth one text or one drink."

If you're pulled over for texting and driving in Pennsylvania, you'll receive a $50 traffic violation ticket.

Attorney Doug Stoehr is a personal injury lawyer who takes claims for many clients who have been injured in car accidents due to the fault of another.  For more information on his central Pennsylvania practice, please call his office at 814-946-4100 or by visiting his website at

Six Car Distracted Driving Accident

Distracted driving caused a serious 6 car accident in Dauphin County, PA.  Fox43 News covered the story, which may be viewed below or by clicking this link.

A chain reaction crash involving a tractor trailer and five other vehicles during rush hour in Dauphin County.  It happened just before 6 o'clock on Interstate 83 at mile marker 45, the Paxton Street Exit in Swatara Township.  Pennsylvania State Police say the driver of the big rig, Nicholae Lucaciu, of Drums, rear ended the five vehicles which had stopped in heavy slow moving traffic.
Lucaciu admitted that he was distracted and could not bring his truck to a stop. All six vehicles had to be towed. One driver was treated at Hershey Medical Center and another was treated at Harrisburg Hospital for minor injuries. 

Attorney Doug Stoehr is a personal injury lawyer who takes claims for many clients who have been injured in car accidents due to the fault of another.  For more information on his central Pennsylvania practice, please call his office at 814-946-4100 or by visiting his website at

Tuesday, November 13, 2012

Pain Injections and Meningitis

ABC online recently ran a story about chronic pain patients' fears surrounding the recent outbreak of meningitis due to steroid injections.  To read the full story, written on 10/16/2012 by Erika Edwards, can be viewed by reading below or clicking this link.

NBC NATIONAL NEWS — Fifteen people have died and 233 others have fallen ill in an outbreak of fungal meningitis tied to tainted steroid shots.
The problem has thousands of patients concerned they, too, will get sick.
Patients are inundating doctors' offices with phone calls, concerned their own steroid injections prescribed to treat their chronic pain might result in meningitis.
Dr. Reuben Gobezie of UH Case Medical Center in Cleveland says the meningitis outbreak linked to contaminated steroids has translated into high anxiety among some of his patients.
Experts say all of the potentially contaminated lots of steroid injections have been recalled, and should be no danger to patients currently undergoing injections.
"This is such a rare occurrence that it would be like trying to avoid a tsunami. It can happen, but it's extremely difficult to predict," Dr. Gobezie says.
But that's just what federal health investigators are trying to do.
In the "war room" at the Centers For Disease Control and Prevention scientists are on the front lines, trying to stop the rare fungal meningitis from killing again.
They're tracking cases, talking to doctors and contacting the thousands of patients who may have been exposed.
"We're still in the middle of this problem. We're nowhere near the end yet, I'm afraid," says Vanderbilt University's Dr. William Schaffner.
On Monday the Food and Drug Administration warned other drugs from the New England Compounding Center may have been tainted.
"We don't know where they went - those medications - and where they were distributed have not yet been identified," Dr. Schaffner warns.
There are unconfirmed reports of fungal infections in two heart patients and a person who received a different steroid, an ominous sign cases may continue to rise.
Signs of meningitis can include severe headache, nausea, stiff neck and difficulty walking or speaking.
Those symptoms may not show up until weeks after exposure.

Attorney Doug Stoehr is a personal injury lawyer serving the western and central Pennsylvania region.  Please visit his website at or call his office at 814-946-4100 to learn more.

Monday, November 12, 2012

Chronic Pain and the Elderly

The Star Online recently published an article about chronic pain and elderly citizens by Chin Ken Lee on 11/11/2012.  To read more,please click here or continue below for the original article.

ACROSS the globe, persistent (chronic) pain is one of the most common reasons for the elderly to seek consultation with healthcare professionals.
Persistent pain, by definition, continues to affect the person for prolonged periods of time, and may or may not be associated with a well-defined disease. Different bodies have different defined persistent pain of various durations, ranging from three months to over a year.
Persistent pain manifests in various forms. Among the elderly, persistent pain is frequently associated with musculoskeletal disorders, such as a degenerative spine condition and osteoarthritis. Nighttime leg pain, pain from claudication, cancer pain, neuralgia secondary to diabetes mellitus, amputation, peripheral vascular disease, herpes zoster, and pain due to trauma, are common as well.
In the US, it has been estimated that 21% to 70% of community-dwelling older adults (more than 65 years of age) suffer from persistent pain. Other studies have demonstrated that 35% to 48% of older adults in the community are affected by pain on a daily basis, while up to 85% of elderly people residing in nursing homes experience pain.
Notably, persistent pain also affects Malaysian senior citizens. According to the Community Oriented Programme for the Control of Rheumatic Diseases (COPCORD) Study in Malaysia, pain rates increase with age, with up to 53.4% in the age group of more than 65 years experiencing pain.
Low back pain, knee pain and joint pain are the most common complaints among those studied.
The most common disability in the Malaysian survey is inability to squat (3.1%), largely due to knee joint symptoms.
In fact, it is not surprising to observe such a trend, as the average life expectancy of Malaysians has increased. In 2010, approximately 5.1% of the Malaysian population consisted of people aged more than 65 years.
The increasing prevalence of weight problems (overweight and obesity), diabetes mellitus and cancer worldwide, adds to the pain problem.
The National Health and Morbidity Survey III (NHMS III) indicated that 43.3% of Malaysians were either overweight or obese. One in six Malaysian adults above 30 years old had diabetes, making an estimated 1.4 million in total.
Persistent pain is a multifaceted problem. It is associated with many secondary problems, such as disturbed sleep, depression, impaired physical function and disability, decreased participation in social activities, and higher healthcare costs.
Hence, it is not surprising that persistent pain leads to reduced quality of life, often resulting in substantial strain on the relationship between the patient and their caregivers.
Behaviour, attitudes and beliefs
A major challenge in persistent pain management is the under-reporting of pain. There is growing evidence that help-seeking behaviour is closely associated with individual characteristics, attitudes and causal beliefs.
Increasing age, pain severity, female gender, lower education levels and disability have been associated as salient factors for people to seek help for their pain problem.
Stoic attitudes, ie putting up a brave front in the face of pain, has been identified as another factor that leads to under-reporting among older adults.
It is common to hear statements such as “if you have a pain, put up with it” or “what can’t be cured must be endured” among this cohort who suffer from pain.
Furthermore, the belief that pain is a normal part of ageing forms barriers in elderly people to seek help.
Drug selection in pain management depends heavily on an individual’s physiological factors. Medications may linger longer in the bodies of older adults due to age-related changes in physiological function. These changes include decline in metabolism capacity and excretion rate in the liver, as well as the kidney.
Changes in fat-to-water ratio also affect the volume of distribution of some medications. Slowing the gastrointestinal tract transit time may prolong the effect of continuous release enteral drugs. The elderly tend to experience anticholinergic effects more easily, which is manifested as incontinence, dry mouth, constipation, increased confusion and movement disorders.
Medication safety issues in older adults
Pain management should be evidence-based, where established guidelines and clinical practice guidelines on pain management are referred to when dealing with elderly patients.
Similarly, older people should not self-medicate without referring to a healthcare provider trained in pain management.
The mere fact that many older adults have polypharmacy issues further complicates the matter. Older adults who are exposed to inappropriate drug choices face higher risk of experiencing adverse drug reactions and drug interactions, compared to younger people.
Many drugs that work well in the younger population may not be appropriate in older adults. For instance, long term use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) with long half lives in full dosages, such as naproxen, piroxicam and indomethacin, are not recommended in older adults due to relatively higher risk of gastrointestinal bleeding, renal failure and heart failure.
The use of tricyclic antidepressants (TCAs) in pain management in older adults who have seizures, cardiovascular diseases, and risk of falling should be managed very cautiously. TCAs are contraindicated in patients who are taking monoamine oxidase inhibitors (MAOIs) or selective serotonin reuptake inhibitors (SSRIs), and for patients who have uncontrolled narrow angle glaucoma, hepatic diseases or heart block.
Treatment in persistent pain
Perhaps the biggest misconception about treatment in persistent pain is that many believe that drugs are a panacea or substitute to non-pharmacological therapies.
Another myth is the belief that NSAIDs are effective for all kinds of pain.
Lastly, many are reluctant to use opiods in pain management, largely due to the concern about addiction issues.
In reality, paracetamol (acetaminophen) remains the first-line recommendation among non-opiod drugs in older adults. NSAIDs and COX-2 inhibitors are useful in nociceptive pain, but not neuropathic pain.
On the other hand, antidepressants and anticonvulsants are indicated for neuropathic pain.
The selection of analgesics must be tailored according to the pathology of pain, as well as the mechanism of action of the drug, apart from considering the efficacy and safety factors in older adults.
Research has shown that generally, older adults have lower risk of developing opiod addiction. Nevertheless, opiod users may develop tolerance to the drug and may need higher doses eventually.
Appropriate selection of analgesics at correct doses and frequency is crucial in the older adult. However, despite having a wide choice of pharmacological agents to choose from, persistent pain is best managed together with non-pharmacological modalities.
There is a growing body of literature that shows the combination of pharmacological therapies with non-pharmacological treatments further improves a patient’s functional activities, emotional functioning, as well as quality of life.
Achieving 365 pain-free days and a good quality of life is possible, if appropriate multimodal therapies are discussed and planned together by healthcare providers and the patient.
Multidisciplinary frameworks, involving physicians, pharmacists, nurses, physiotherapists and other related healthcare providers, is crucial to ensure pain-free days in older adults.

Attorney Doug Stoehr is a personal injury lawyer who serves the western and central Pennsylvania areas.  For more information on his Altoona, PA practice, please click here or call his office at 814-946-4100.

Thursday, November 8, 2012

PROP vs. PROMPT: Chronic Pain Medication Management

Pain Medicine News highlighted the opposing views of regulating opioid pain reliever use for non-cancer chronic pain patients. To read the commentary from the November 2012 issue, please read below orclick this link

Should the reins be tightened on the use of long-term opioid therapy for patients with chronic noncancer pain (CNCP)?
That question is at the heart of a controversy that has boiled over since July when 37 physicians in pain management, public health, psychiatry and other specialties issued a citizen petition calling on the FDA to require opioid label changes that would strike the word “moderate” from CNCP opioid treatment indications and limit the drug’s use solely to severe pain—and then only for a maximum of 90 days at no more than the equivalent of 100 mg of morphine daily.
The petition from Physicians for Responsible Opioid Prescribing (PROP) cited growing U.S. rates of opioid addiction and overdose deaths along with what it said was a lack of evidence for the safety and effectiveness of long-term opioid use for CNCP as the main reasons for the group’s action.
“Unfortunately,” the petition stated, “many clinicians are under the false impression that chronic opioid therapy (COT) is an evidence-based treatment for chronic noncancer pain and that dose-related toxicities can be avoided by slow upward titration. These misperceptions lead to overprescribing and high dose prescribing.”
Pharmacists and physicians opposed to PROP’s proposed label restrictions were quick to respond. Professionals for Rational Opioid Monitoring and Pharmacotherapy (PROMPT), a group of 26 physicians, sent a letter to the FDA expressing its own concerns about the safety of chronic opioid use, but suggesting an alternative approach emphasizing “clinician education, proactive risk stratification and appropriate therapeutic monitoring.”

PROMPT also endorsed the lengthier and more heated response from the American Academy of Pain Medicine, which called the PROP proposals “seriously flawed, potentially harmful to patients with debilitating pain conditions for whom opioid therapy is indicated, and without substantive scientific foundation.”
Pain Medicine News talked with the principals of both PROP and PROMPT and found a depth of conviction on the issue from both sides.
PROP’s Kolodny: More Opioid Oversight Needed
Andrew Kolodny, MD, president of PROP and chairman of the Department of Psychiatry at Maimonides Medical Center in New York City, spoke about a decade of rising addiction and overdose death rates “fueled by overprescribing of opioids” mostly for “people with a diagnosis of chronic noncancer pain.”
“What caused this increase,” he said, “was a very effective marketing and education campaign to convince doctors that we were underutilizing opioids.” Physicians were “incorrectly” told, he said, that “we didn’t have to worry about getting patients addicted and that opioids were effective.
“This increase in prescribing,” he added, “has led to this public health crisis. We think it’s now time for the FDA to communicate clearly to the medical community that long-term use of opioids for chronic noncancer pain has not been proven safe and effective.”
According to Dr. Kolodny, “the best available evidence does not suggest that they’re safe and effective. In the United States, where we’re consuming a large portion of the world’s opioid supply, there’s absolutely no evidence that we’re doing any better a job of treating chronic pain than in countries where opioids are prescribed more cautiously.
“In fact,” he added, “the best available epidemiologic data that’s looked at this question comes from Denmark. What they found in a very large study [Pain2006;125:172-179] was that people who are on opioids long-term for chronic pain were doing very poorly compared with people who were having their pain treated with nonopioid analgesics. There are other studies from the United States that have replicated that.”
He added: “So I don’t believe a reduction in prescribing of opioids for chronic pain will worsen the problem of untreated chronic pain. In fact, because I don’t believe that opioids are effective for most people with chronic pain, I think it exacerbates the problem of untreated chronic pain and to some extent we’re undertreating pain by overprescribing opioids.”
PROMPT’s Dr. Fudin: A More Rational Solution Needed
Jeffrey Fudin, PharmD, FCCP Diplomate, American Academy of Pain Management, chairman of PROMPT and adjunct associate professor of pharmacy practice and pain management at Albany College of Pharmacy and Health Sciences, in New York, offered a number of objections to PROP’s proposals. First, he said, it was “absurd” of PROP to ignore the multiplicity of therapeutic options required to treat all of the “unique disorders” that cause CNCP. Moreover, he said, “a lot of patients [with chronic pain] can’t take [other] analgesics for one reason or other.”
Also, limiting opioid dosages to the equivalent of 100 mg of morphine per day disregards the variability in conversion calculations that can occur among different opioid products. He pointed to one study of accepted conversion charts that showed variations in calculations ranging “all the way from –50% to +245%.”
As for adverse events associated with chronic analgesic treatment, Dr. Fudin said many more are linked to nonsteroidal anti-inflammatory drugs than to opioids, including bleeding disorders, kidney dysfunction and death. He also said that most opioid deaths occur in patients on multiple sedating medications including alcohol and in those abusing multiple medications, not in patients being treated by knowledgeable pain management clinicians and who takes the medication as prescribed.
Moreover, he noted that the largest contributor to rising opioid mortality rates was methadone. A recent report by the Centers for Disease Control and Prevention, he said, found that although 2% of all opioid prescriptions are written for methadone, 33% of opioid-related deaths involve the synthetic opioid. “That’s huge,” Dr. Fudin said. “Methadone pharmacokinetics are very complex and a lot of prescribers don’t have experience and should not be prescribing it.”
A clear example of this, he noted, was seen in the state of Washington, where “the state’s decision to list methadone as a preferred painkiller to cut costs contributed to increasing numbers of overdoses among patients covered by Medicaid” (JAMA2012;8:749-750).
So what is the answer to the problems that PROP is addressing?
Dr. Fudin believes the FDA’s risk evaluation and mitigation strategy (REMS) program for extended-release opioids “is a step in the right direction,” but regulations “should go further and make education mandatory for all people who prescribe opioids.
“It doesn’t matter if [the opioids] are extended-release or not,” he continued. “[Prescribers] need to learn about risk stratification, and they need to be trained in how to do urine drug screens and how to interpret them. They also need to know that if the urine screen shows something unusual, they have to take the next step to order a qualitative confirmation or perhaps follow up with a [serum analysis], and they need to know how to evaluate those serums.”
If prescribers had that knowledge, he said, “outcomes would be much better.”
The PROP proposal is on the FDA docket, and the agency has until January 2013 to respond. Dr. Kolodny noted that even if the agency decided to require label changes, individual physicians would not be restricted from prescribing off-label for longer-term opioid therapy at higher doses for patients with CNCP. “The FDA doesn’t regulate the practice of medicine. It regulates drug companies,” he said.
Dr. Fudin said that although physicians would be able to prescribe off-label, the presence of label restrictions could dissuade many from doing so because of liability concerns, thus denying relief to patients needing more potent analgesics. Additionally, he said, many health insurers including Medicare and Medicaid likely would withhold payments for opioid prescriptions not adhering to label indications, a potential financial hardship for people unable to work because of painful disabilities.
He cited Florida’s experience with the so-called “Pill Mill” legislation. The new law, he said, is causing many doctors to fear prescribing opioids and pharmacies unwilling to fill prescriptions, leaving many elderly patients with chronic pain syndromes not only in pain but also going through withdrawal. “If Florida represents even a small percentage of what we can expect countrywide from the PROP petition, it will be a disaster.”
Dr. Kolodny said the assertion that medical insurers would withhold payments from physicians prescribing opioid therapy off-label was “just plain wrong,” adding that psychiatrists like himself “do a lot of prescribing for off-label indications” and encounter no payment problems with Medicare and Medicaid or other insurers. He also maintained that the reluctance of many legitimate retail pharmacies in Florida and other states to fill prescriptions for opioids like oxycodone was due not to state laws seeking to curb illicit “pill mills,” but to their fear of robberies and because “they just don’t want to be caught in the middle of all this.”

Attorney Doug Stoehr is a personal injury lawyer who takes claims for clients who have chronic pain as a result of an accident or injury caused by another.  For more information on his Altoona, PA practice, please visit his website at 

Wednesday, November 7, 2012

Nursing Home Rating System

EIN News ran a press release recently about new ways families can track nursing homes to see histories of abuse and neglect among its patients.  The original story, written on 11/1/2012 by Baker Ballick, can be viewed by reading below or clicking this link.

November 01, 2012 /24-7PressRelease/ -- Elder abuse is an increasingly common occurrence in the United States. Between 500,000 and one million reports of the criminal behavior filed each year. Now, two online tools allow users to identify nursing homes treat their residents well and those that tend to neglect or mistreat the elderly in their care.
Nursing Home Compare and Nursing Home Inspect
The Centers for Medicare and Medicaid have made good on a promise to upload the full texts of 15,000 nursing home inspection reports. Prior to this change, users could use Medicare's online ranking tool Nursing Home Compare to view rankings and general inspection results, but not to obtain any details crucial to making a housing decision for loved ones.
Now, users can go to Nursing Home Compare, click "Inspections and Complaints" and click "View Full Report" to download the full text of any nursing home's most recent inspection. Nursing Home Compare allows families to look up national and state average deficiencies, star rankings of various nursing homes and nursing home staff information, all of which put the full text data into context.
Families may use another online tool to assess nursing homes. The investigative website ProPublica has developed Nursing Home Inspect, originally developed as a tool for journalists reporting on nursing home abuses. However, the data is accessible to anyone, so families can use the tool to look for trends in nursing home abuse and safety hazards and to learn about specific incidents at a particular facility.
Elder Abuse Possible at Nursing Homes
Unfortunately, the safety risks at nursing homes are not contained to food safety violations or understaffing. Sometimes, the elderly themselves are targets of neglect and abuse. Though every year in the United States 500,000 to one million instances of elder abuse are reported, experts believe this type of abuse is grossly underestimated.
Elder abuse can take many forms. It can be physical abuse, like kicking, slapping or striking, or sexual abuse, such as unwanted touching. Elder abuse may also be emotional, for example, isolating a resident, not allowing a resident to receive family or other visitors or giving a resident the silent treatment.
Abuse can also take a financial form. Some seniors may experience the theft of their money or other valuables or be duped into participating in a scam. Lastly, elder abuse can result from neglect, including neglect in medical care, nutrition and maintenance of facilities.
Many professionals are required to reportelder abuse when they witness it, including medical professionals, social workers, staff members of nursing homes and assisted living facilities, counselors and law enforcement. Nursing homes also must post information on how to report abuse to an elder abuse hotline and make phones available to residents so they can report abuse.
Who May Be Held Liable for Elder Abuse Offenses?
In all states, elder abuse crimes are punishable under various criminal codes for assault, sexual assault and fraud, among others. However, victims of elder abuse and neglect may also be able to collect punitive and other damages in a civil lawsuit. For example, an individual injured by negligent personal care could sue for damages resulting from that injury. Similarly, damages for injuries caused by negligent maintenance of the facility and its equipment may also be pursued in civil court.
Elder abuse is a serious problem and seniors deserve to be compensated for injuries sustained from abuse or neglect. To find out how to hold the responsible party accountable for your or a loved one's injuries, please contact an experienced personal injury attorney.
Attorney Doug Stoehr is a personal injury lawyer serving western and central Pennsylvania.  He takes nursing home and hospital claims for elderly victims of abuse and neglect.  For more information on his Altoona, PA practice, please visit his website at or call his office at 814-946-4100.