A Proposal to Recognize a Legal Obligation on Physicians to Provide Adequate Medication to Alleviate Pain

This note seeks to show how the current practice among medical practitioners in the United States, by treating pain retroactively after it begins, is inadequate. Administering narcotics to patients on an as needed basis unnecessarily prolongs pain and suffering. A more effective approach, which is advocated by the Agency for Health Care Policy & Research (AHCPR), is to treat pain preventatively rather than retroactively. The myth that pain medication is addictive, and that physicians should therefore prescribe as little pain medication as possible, is just that, a myth. Patients are suffering pain in today\u27s hospitals and at home unnecessarily. Given today\u27s advanced medical technology and expertise, physicians should be responsible for administering adequate pain relief. If physician-assisted suicide remains unavailable to a majority of patients to relieve them from excruciating pain, then physicians should be held legally bound to provide adequate pain relief. This note also seeks to reveal that American health care systems are lacking in critical pain management techniques. Part II explores the basic principles of pain, including the pain experience, the differences between subjective and objective pain, and the differences between chronic and acute pain. This section also discusses the fear of addiction to pain medication as well as the inadequacies in today\u27s management of pain. Part III analyzes various alternatives to the current pain management philosophy, including the AHCPR\u27s guideline recommendations for the treatment of pain, hospice care, and physician-assisted suicide. Finally, Part IV analyzes the recognition of legal liability on medical personnel for the failure to adequately medicate for pain, beginning with a discussion of the factors to take into consideration in recognizing a legal obligation to render adequate pain relief medication

A Proposal to Recognize a Legal Obligation on Physicians to Provide Adequate Medication to Alleviate Pain

This note seeks to show how the current practice among medical practitioners in the United States, by treating pain retroactively after it begins, is inadequate. Administering narcotics to patients on an as needed basis unnecessarily prolongs pain and suffering. A more effective approach, which is advocated by the Agency for Health Care Policy & Research (AHCPR), is to treat pain preventatively rather than retroactively. The myth that pain medication is addictive, and that physicians should therefore prescribe as little pain medication as possible, is just that, a myth. Patients are suffering pain in today\u27s hospitals and at home unnecessarily. Given today\u27s advanced medical technology and expertise, physicians should be responsible for administering adequate pain relief. If physician-assisted suicide remains unavailable to a majority of patients to relieve them from excruciating pain, then physicians should be held legally bound to provide adequate pain relief. This note also seeks to reveal that American health care systems are lacking in critical pain management techniques. Part II explores the basic principles of pain, including the pain experience, the differences between subjective and objective pain, and the differences between chronic and acute pain. This section also discusses the fear of addiction to pain medication as well as the inadequacies in today\u27s management of pain. Part III analyzes various alternatives to the current pain management philosophy, including the AHCPR\u27s guideline recommendations for the treatment of pain, hospice care, and physician-assisted suicide. Finally, Part IV analyzes the recognition of legal liability on medical personnel for the failure to adequately medicate for pain, beginning with a discussion of the factors to take into consideration in recognizing a legal obligation to render adequate pain relief medication

A brief cognitive-behavioural intervention for pain reduces secondary hyperalgesia

Repeated exposure to pain can result in sensitization of the central nervous system, enhancing subsequent pain and potentially leading to chronicity. The ability to reverse this sensitization in a top-down manner would be of tremendous clinical benefit, but the degree that this can be accomplished volitionally remains unknown. Here we investigated whether a brief (~5 min) cognitive-behavioural intervention could modify pain perception and reduce central sensitization (as reflected by secondary hyperalgesia). In each of 8 sessions, 2 groups of healthy human subjects received a series of painful thermal stimuli that resulted in secondary hyperalgesia. One group (regulate) was given brief pain-focused cognitive training at each session, while the other group (control) received a non-pain-focused intervention. The intervention selectively reduced pain unpleasantness but not pain intensity in the regulate group. Furthermore, secondary hyperalgesia was significantly reduced in the regulate group compared with the control group. Reduction in secondary hyperalgesia was associated with reduced pain catastrophizing, suggesting that changes in central sensitization are related to changes in pain-related cognitions. Thus, we demonstrate that central sensitization can be modified volitionally by altering pain-related thoughts

The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer.

The advent of neuroimaging methodologies, such as functional magnetic resonance imaging (fMRI), has significantly advanced our understanding of the neurophysiological processes supporting a wide spectrum of mind-body approaches to treat pain. A promising self-regulatory practice, mindfulness meditation, reliably alleviates experimentally induced and clinical pain. Yet, the neural mechanisms supporting mindfulness-based pain relief remain poorly characterized. The present review delineates evidence from a spectrum of fMRI studies showing that the neural mechanisms supporting mindfulness-induced pain attenuation differ across varying levels of meditative experience. After brief mindfulness-based mental training (ie, less than 10 hours of practice), mindfulness-based pain relief is associated with higher order (orbitofrontal cortex and rostral anterior cingulate cortex) regulation of low-level nociceptive neural targets (thalamus and primary somatosensory cortex), suggesting an engagement of unique, reappraisal mechanisms. By contrast, mindfulness-based pain relief after extensive training (greater than 1000 hours of practice) is associated with deactivation of prefrontal and greater activation of somatosensory cortical regions, demonstrating an ability to reduce appraisals of arising sensory events. We also describe recent findings showing that higher levels of dispositional mindfulness, in meditation-naïve individuals, are associated with lower pain and greater deactivation of the posterior cingulate cortex, a neural mechanism implicated in self-referential processes. A brief fMRI primer is presented describing appropriate steps and considerations to conduct studies combining mindfulness, pain, and fMRI. We postulate that the identification of the active analgesic neural substrates involved in mindfulness can be used to inform the development and optimization of behavioral therapies to specifically target pain, an important consideration for the ongoing opioid and chronic pain epidemic

Thinking like a trader selectively reduces individuals' loss aversion

Research on emotion regulation has focused upon observers' ability to regulate their emotional reaction to stimuli such as affective pictures, but many other aspects of our affective experience are also potentially amenable to intentional cognitive regulation. In the domain of decision-making, recent work has demonstrated a role for emotions in choice, although such work has generally remained agnostic about the specific role of emotion. Combining psychologically-derived cognitive strategies, physiological measurements of arousal, and an economic model of behavior, this study examined changes in choices (specifically, loss aversion) and physiological correlates of behavior as the result of an intentional cognitive regulation strategy. Participants were on average more aroused per dollar to losses relative to gains, as measured with skin conductance response, and the difference in arousal to losses versus gains correlated with behavioral loss aversion across subjects. These results suggest a specific role for arousal responses in loss aversion. Most importantly, the intentional cognitive regulation strategy, which emphasized “perspective-taking,” uniquely reduced both behavioral loss aversion and arousal to losses relative to gains, largely by influencing arousal to losses. Our results confirm previous research demonstrating loss aversion while providing new evidence characterizing individual differences and arousal correlates and illustrating the effectiveness of intentional regulation strategies in reducing loss aversion both behaviorally and physiologically

Cortical response variability is driven by local excitability changes with somatotopic organization

Identical sensory stimuli can lead to different neural responses depending on the instantaneous brain state. Specifically, neural excitability in sensory areas may shape the brain´s response already from earliest cortical processing onwards. However, whether these dynamics affect a given sensory domain as a whole or occur on a spatially local level is largely unknown. We studied this in the somatosensory domain of 38 human participants with EEG, presenting stimuli to the median and tibial nerves alternatingly, and testing the co-variation of initial cortical responses in hand and foot areas, as well as their relation to pre-stimulus oscillatory states. We found that amplitude fluctuations of initial cortical responses to hand and foot stimulation - the N20 and P40 components of the somatosensory evoked potential (SEP), respectively - were not related, indicating local excitability changes in primary sensory regions. In addition, effects of pre-stimulus alpha (8-13 Hz) and beta (18-23 Hz) band amplitude on hand-related responses showed a robust somatotopic organization, thus further strengthening the notion of local excitability fluctuations. However, for foot-related responses, the spatial specificity of pre-stimulus effects was less consistent across frequency bands, with beta appearing to be more foot-specific than alpha. Connectivity analyses in source space suggested this to be due to a somatosensory alpha rhythm that is primarily driven by activity in hand regions while beta frequencies may operate in a more hand-region-independent manner. Altogether, our findings suggest spatially distinct excitability dynamics within the primary somatosensory cortex, yet with the caveat that frequency-specific processes in one sub-region may not readily generalize to other sub-regions

The presentation, clinical features, complications, and treatment of congenital dacryocystocele

Purpose To determine the incidence and presenting features of congenital dacryocystocele in the United Kingdom. To report on those cases complicated by dacryocystitis, respiratory compromise, and the treatment undertaken. Methods A prospective observational study of cases of congenital dacryocystocele presenting in the United Kingdom between September 2014 and October 2015. Infants <3 months of age presenting with a cystic swelling in the medial canthal area were included. Cases were identified via the British Ophthalmology Surveillance Unit (BOSU) reporting system. Results A total of 49 cases were reported during the study period. This gives an incidence of 1 in 18 597 live births. There was a 71% response rate to the questionnaire. The average age at presentation was 16.94 days. Dacryocystoceles were unilateral in 91% of cases. Dacryocystitis was a complicating factor in 49% of patients and 17% had respiratory distress. Uncomplicated dacryocystocele responded well to conservative measures in 86%. Surgical intervention was required in 23% of patients. Those cases complicated by dacryocystitis (29%) and nasal obstruction (17%) were more likely to require surgical intervention compared to those with dacryocystocele alone (14%). Digital massage appears to reduce the likelihood of requiring surgical intervention. The mean time to resolution was 19 days. Conclusions Congenital dacryocystocele is a rare presentation in the United Kingdom. Dacryocystitis and respiratory compromise commonly complicate a dacryocystocele. The use of digital massage as an early intervention is advocated and conservative measures may be sufficient in cases of uncomplicated dacryocystocele

Expectation effects on repetition suppression in nociception

Repetition suppression, the reduced neural response upon repeated presentation of a stimulus, can be explained by models focussing on bottom-up (i.e. adaptation) or top-down (i.e. expectation) mechanisms. Predictive coding models fall into the latter category and propose that repetitions are expected and therefore elicit smaller prediction error responses. While studies in the visual and auditory domain provide some support for such models, in nociception evidence remains inconclusive, despite the substantial influence expectations exert on pain perception. To assess expectation effects on repetition suppression in nociception, we developed a paradigm in which healthy volunteers received brief CO2 laser stimuli, while we acquired electroencephalographic (EEG) and peripheral physiological data. Importantly, laser stimuli could be either repeated after one second or not be repeated, with the probability of repetitions manipulated in a block-wise fashion, such that repetitions were either expected or unexpected. We observed repetition suppression in laser-evoked potentials as well as laser-induced gamma band oscillations, but not in laser-induced desynchronisations in the alpha and beta band. Critically, neither these EEG responses, nor the peripheral physiological data showed significant differences between the expectation conditions, with Bayesian analyses mostly providing evidence for an absence of effects. This indicates that repetition suppression to brief nociceptive laser stimuli is not driven by top-down factors, but rather mediated by other adaptation processes. While this does not preclude an influence of predictive coding models in nociception, it suggests that when the nervous system receives highly precise input, its responses are less susceptible to influence from expectations

The spinal cord is never at rest

Even when we are at rest, our spinal cords show spontaneous, yet well organised, fluctuations of activity that might reflect sensory and motor networks.</jats:p