June 2017 – Scientists Talk Funny

Pain catastrophizing linked to opioid use, particularly for women, Stanford study shows

Our nation is struggling with an unprecedented opioid epidemic, which is pushing researchers to better understand how people experience pain and how this is impacts pain treatments.

A key factor may be something called pain catastrophizing — heightened negative thoughts and emotions in response to actual or anticipated pain. New research recently published in Anesthesiology shows that pain catastrophizing is a risk factor for prescription opioid misuse, and the role it plays is different for men and women. I connected with Beth Darnall, PhD, a Stanford clinical associate professor of anesthesiology, perioperative and pain medicine, to learn more about her new study, whose first author is Yasamin Sharifzadeh-Moghaddam, a medical student at Virginia Commonwealth University.

What is pain catastrophizing?

“Pain catastrophizing is the rumination and magnification of pain, and feelings of helplessness about it. People who catastrophize have a hard time thinking of anything but their pain. It’s common for people with chronic pain to catastrophize to some degree, but when it gets into the clinical ranges it indicates a need for treatment. Treatment involves learning targeted ways to redirect one’s attention, calm the nervous system in the face of pain and stress and cultivate awareness about what one can do to feel better. I think virtually everyone with chronic pain can benefit from learning skills that empower them to have better control over their pain and distress — even those who are not high catastrophizers.”

What inspired you to research pain?

“First, I was intensely curious about pain and why it varies between individuals; a lot of the “why” ends up involving psychological factors. I was fascinated with the connection between stress and pain and wanted to learn more about how they relate. … I also wanted to help people on a broader scale. I can only see a few individual patients in the clinic, but if I develop a treatment that others can use, the ripple effect potential is tremendous.”

How did you investigate the impact of pain catastrophizing on opioid use?

“Pain catastrophizing is associated with greater use of opioids after surgery and with opioid misuse. Across multiple studies, catastrophizing associates strongly with pain intensity, so we wanted to better understand how it might relate to pain medication.

In our study, we looked at patients receiving a new evaluation at the Stanford Pain Management Center. We examined the relationships between pain intensity, pain catastrophizing and existing opioid prescription. We used the Collaborative Health Outcomes Information Registry, a free open source health outcomes platform, to collect data on almost 1800 patients. We aimed to reveal whether sex differences existed for opioid prescription and our other variables of interest, using modeling to explore the associations. We found that almost 60 percent of patients referred to our center are taking prescription opioids, and people with greater pain were more likely to be taking opioids.

We also found that sex matters in the equation. For women, the relationship between pain catastrophizing and opioids occurred at much lower levels of pain catastrophizing than for men. Our data suggest that catastrophizing may be more impactful for women, and that these associations begin to appear at what we previously called ‘subthreshold’ levels. More research is needed to replicate our findings and to understand why we see these sex differences in catastrophizing and opioid prescription. I’m speculating, but women may be better communicators of pain-related distress — verbally and nonverbally — and this may translate into a prescription at the end of a medical visit.”

How can your results improve future clinical practice?

“If replicated, our findings signal that we should be treating our patients before frank problems arise. If we address psychosocial distress early on, we may prevent worsening of symptoms into clinical problems and the need for various treatments. We also need more research to develop a deeper understanding of the relationships between prescription opioids and psychological factors. … Our findings suggest that we need to further examine the prescribing doctor-patient interaction.”

What’s the next step?

“We are currently examining whether presurgical treatment for catastrophizing can reduce post-operative opioid use. Right now we are studying this in women only, but our planned studies include men and women so we can test sex differences in treatment response.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

East meets west: Stanford students can sample Tibetan medicine during clerkships

Stanford medical students must master genetics, biochemistry and immunology, among other disciplines. But school leaders don’t want these future doctors to be stumped when their patients describe their acupuncture sessions, or have questions about herbal supplements or other alternative therapies.

To help familiarize Stanford medical students with these practices, the students spend a day shadowing a practitioner at a participating integrative medicine clinic during their family medicine clerkship.

“We want to introduce students to the idea that the patients they see in clinic are using these other health-care systems,” said Art Johnson, coordinator for the family medicine clerkship. “They need to partner with patients in managing their health in the best way possible, and utilize all available resources.”

The Kunde Institute, a center for Tibetan wellness and healing located in Daly City, is one of these participating clinics. It offers a unique opportunity for students because most integrative medicine clinics in the Bay Area focus on Chinese medicine, Johnson said. About 10 Stanford students per year shadow practitioners at this center, said Tracy Rydel, MD, who directs the family medicine clerkship.

Tibetan Medicine, which originated more than 4,000 years ago, attributes the roots of all disease to an imbalance of the three Nyepas (rlung, tripa and peken) that emanate from the three mental poisons of desire-attachment, hatred-anger and closed-mindedness. Treatments at the Kunde Institute include herbal medicines, hot oil therapy, acupuncture, copper cupping, and individualized counseling on diet, nutrition and lifestyle behaviors.

At the Kunde Institute, the participating students learn from Menpa Yangdron Kalzang, LAc, who has a Tibetan medicine degree from the Tibetan Medical University in Lhasa, Tibet and a master’s in traditional Chinese medicine from Five Branches University in Santa Cruz. They learn about the connection between the physical, emotional and mental health of patients, one student told me.

Stanford medical student Victoria Boggiano first learned about Tibetan medicine when she attended a symposium at Stanford, she said. When she shadowed Kalzang, she told me she became very interested in how Tibetan medicine can complement the biomedicine traditionally taught in medical school. Boggiano described her experience via email:

“I spent an afternoon with Menpa Kalzang shadowing her as she saw patients with a variety of ailments. I remember really distinctly that two separate patients we saw that day had very bad plantar fasciitis, an inflammation of thick tissue in the foot that leads to pain in the heel and bottom of the foot. Before coming to the institute, neither patient had been able to walk without feeling terrible pain that had been resistant to any of the medications or physical therapy that their primary care physicians had provided them. Both patients started seeing Menpa Kalzang to receive acupuncture and herbal remedies, after which they both saw dramatic reductions in their symptoms. It was incredible to see how much Menpa Kalzang had helped them!”

Since 2008, about 100 Stanford students have visited Kunde, Kalzang said. She said she plans to continue with the program.

“I do this to build bridges between the Western and Eastern medical systems,” Kalzang said. “We need to establish integrative medical systems that allow providers from different disciplines to share information and put in referrals for both types of treatments. This is particularly important for patients with complex cases when Western or Eastern medical systems alone can’t answer or solve the problem.”

Boggiano hopes to be part of this vision of integrative care. After medical school, she plans to specialize in family medicine and work in a primary care clinic. She explained:

“I am eager to learn more about alternative medicine, and particularly Tibetan medicine, both by continuing to work with Menpa Kalzang and by gaining additional clinical experience. It would be incredible to work at a clinic where both biomedicine and alternative medicine are practiced side by side. Tibetan medicine encourages us to view patients in a holistic way and reminds us that mental health and physical health are incredibly intertwined. Patients deserve to receive both types of health care.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

CTs predict survival by measuring frailty following hip fractures, study shows

When elderly people fall, a hip fracture is a common and serious result. It is typically treated with surgery, but physicians need a better way to determine how frail a patient is in order to select the best surgical method. The need is great: Each year over 300,000 older people are hospitalized in the United States for hip fractures. These disabling injuries are associated with significant mortality, loss of independence and financial burden.

Now, a new research study led by radiologists from the University of California, Davis and Wake Forest Baptist medical centers may help guide these critical treatment decisions.

The research team performed a retrospective 10-year study of 274 patients who were 65 years or older and treated for hip fractures at the UC Davis Medical Center. Using CT images previously taken to diagnose the hip fracture, the researchers measured the size and density of the patients’ core muscles that stabilize the spine. They then compared the health of these core muscles with survival rates. The reported 1-year mortality rate after fracturing a hip is between 14 and 58 percent.

They found that hip-fracture patients with better thoracic (mid-upper back) core muscles had significantly better survival rates, whereas no significant trend was seen for patients with better lumbar (low back) muscles, as recently reported in the American Journal of Roentgenology.

Robert Boutin, MD, a radiologist at UC Davis and the lead author, summarized the importance of their results in a recent news release:

As patients age, it becomes increasingly important to identify the safest and most beneficial orthopaedic treatments, but there currently is no objective way to do this. Using CT scans to evaluate the muscles is addition to hip bones can help predict longevity and personalize treatment to a patient’s needs. We’re excited because information on muscles is included on every routine CT scan of the chest, abdomen and pelvis, so the additional evaluations can be done without the costs of additional tests, equipment or software.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Opioid receptors in brain affect reaction to another person’s pain

Watching someone else suffering from pain is distressing. What mechanisms cause that distress? And why do some of us experience it more strongly than others?

A new Finnish research study has now demonstrated that seeing others in pain activates the same brain regions involved in firsthand pain, which suggests that a shared neuromolecular pathway processes both types of pain. Specifically, the researchers showed that the endogenous opioid system, but not the dopamine system, contribute to vicarious pain.

The endogenous opioid system is a set of neurons in the brain that naturally produces opioids to help modulate emotions and pain. Similarly, the dopamine system consists of neurons that synthesize and release dopamine, which helps manage motor control, pain, reward and addictive behaviors. So both of these systems are known to play an important role in processing firsthand pain, but their role in vicarious pain was unexplored.

The research team conducted the study by imaging 35 healthy women ranging in age from 19 to 58 years old. First, they performed two positron emission tomography (PET) studies on different days using radiopharmaceuticals that quantified the availability of opioid and dopamine receptors in each woman’s brain to better understand the individual opioid and dopamine systems. Next, they investigated how each woman responded to vicarious pain by performing a functional MRI scan while she watched videos of humans experiencing painful and painless situations.

The researchers found a negative correlation between opioid receptor availability and response to vicarious pain — women with less opioid receptors reacted more strongly to seeing someone else’s distress, as recently reported in Cerebral Cortex. In contrast, they found no correlation with the dopamine receptor availability.

The authors concluded in the paper, “These results suggest that the opioid system contributes to neural processing of vicarious pain, and that interindividual differences in opioidergic system could explain why some individuals react more strongly than others to seeing pain.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

4 H’s and 4 T’s Walk Into a Bar…”: A joke? No, an episode from a medical education podcast

Medical school is jam packed with information to memorize as well as with high-stakes exams and expectations, creating a cauldron of stress and tension. Enter the mnemonic-filled Humerus Hacks podcast, part of a growing movement to make medical education more entertaining and accessible.

I recently learned about Humerus Hacks from its Australian founders and hosts Karen Freilich, MBBS, education coordinator at The Nookie Project, and Sarah Bush, MBBS, medical intern at Western Health. They started the bimonthly podcast to liven up their studies, but have continued it after graduating from medical school despite hectic intern schedules. Each 10- to 40-minute episode is filled with humor and casual conversation, which should be no surprise given episode titles like, “4 H’s and 4 T’s Walk Into a Bar…” (Which, for non-cardiologists, is a reference to potential causes of cardiac arrest.)

What inspired you to create a podcast?

Freilich: “Sarah and I have been mates since we were ten years old, and study buddies since day one of med school. We were both constantly overwhelmed by the sheer quantity of information we had to learn, especially when it came to learning the tongue-twisting names of medications. We began breaking down our curriculum into funny snippets to make it easier to learn, but also more enjoyable to study.

The tables turned in our penultimate year of medicine, when I was commuting over two hours daily to placement and Sarah hurt her back and couldn’t properly sit down at a desk to study. We raked through the medical podcast world to find something aimed at our level that wouldn’t put us to sleep, and there wasn’t too much out there. And so, Humerus Hacks was born. We picked the name because it was dorky, fun and medical — just like us.”

How did you learn to make podcasts?

Bush: “As an avid podcast devourer, going through at least four hours of content a day during my commutes about town, I became interested in the sound engineering — and turn’s out its super simple! We opted for high quality microphones, although we didn’t figure out how to use them properly until episode 3 or 4. And I learnt how to edit using Audacity. And then I just give it to a podcast hosting company, and voila!”

Why do you format the episodes as conversations?

Freilich: “We wanted to create content that was funny and enjoyable to listen to. We always aim to include banter and tangents, because that’s what keeps learning interesting. Before an episode, we often write down the three most important things we want the listeners to learn that episode. If our listeners can learn those things, and be entertained at the same time, then we’ve done our job.”

You mentioned that you’ve had feedback from patients. Isn’t your podcast for medical students?

Freilich: “Doctors, nurses and other health practitioners often have jargon so deeply ingrained that it makes it hard for them to explain a health topic simply. We didn’t initially intend to incorporate patients in our listenership, and we are still surprised and quite honored that people have used our podcast as a way to further understand their condition. It’s great that Humerus Hacks can help improve access to medical education.”

What is your favorite Humerus Hacks episode?

Bush: “My favorite is definitely the murmurs rap (at time 9:20) about ejection and pansystolic murmurs, because it has helped me out in real life diagnosis. And it has the added benefit of teaching people how to beat box: start by saying boots and cats, and we’ll go from there. Also I get to rap, which is always fun and embarrassing.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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