PSORIATIC ARTHRITIS MEDICAL NEWS

The Understanding and Treatment of Pain

Part 3

MEDICATIONS FOR PAIN
Medication can play a crucial role in controlling pain - whether acute or
chronic. For acute pain, medication is often the first treatment choice. For
chronic pain, it may serve as part of a broader treatment package. This could
include exercise, physical therapy and behavior change. Although they can be
helpful, medications aren't a cure-all and can cause side effects or be
ineffective and costly.

PAIN MEDICATIONS:
Acetaminophen
Antiseizure medications
COX-2 inhibitors
Injections
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Opioids (morphine and related drugs)
Topical agents (ointments)
Tramadol
Tricyclic antidepressants

COMPLEMENTARY AND ALTERNATIVE CARE
Alternative and complementary therapies aren't new - some have been practiced
for thousands of years. But their use has become more popular as Americans
seek greater control of their own health. Two of the most common reasons
people use alternative and complementary medicine is for treatment of anxiety
and pain.
General information:
Manipulation and touch
Chiropractic treatment
Osteopathic manipulation
Massage
Mind-body connection
Biofeedback
Hypnosis
Yoga
Restoring natural energy forces
Acupuncture
Tai chi

MAINTAIN CONTACT WITH YOUR PRIMARY DOCTOR
If you do seek specialized pain treatment, usually through a pain clinic or
pain center, stay in touch with your primary care doctor. Your pain physician
focuses on your chronic pain and generally won't monitor other health
concerns that you may have or make sure that you receive routine health
screenings, such as a mammogram or a prostate exam. Your primary care doctor
manages your overall health.

Make sure your primary care doctor and your pain physician communicate
openly. They both should know what pain medication you're taking, who's
prescribing it and if you're taking additional medications unrelated to your
pain. This decreases the chances of overdose or negative interactions between
medications.

Ask your pain physician to send a copy of your records back to your primary
care doctor. Often pain physicians will prescribe and adjust medications
while determining the correct combination and dosage. Once you're on a stable
regimen, your primary care doctor can provide ongoing prescriptions. This
allows your primary care doctor to ensure that your medications and therapies
are all compatible.

TAKE CONTROL
Most importantly, take responsibility for your pain. Don't become emotionally
dependent on your physician. He or she should be compassionate but not overly
sympathetic or enabling. Your doctor or pain physician can help you learn to
manage your pain, but ultimately you're the one in control.

ADDITIONAL RESOURCES:
American Chronic Pain Association
American Pain Foundation

This information was in part, provided by the Mayo Clinic - Pain Management
Center in Rochester, Minnesota. I suggest that you visit their website at
MayoClinic.com for further details.

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All
rights reserved. A single copy of these materials may be reprinted for
noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com,"
"Mayo Clinic Health Information," "Sharing our Tradition of Trusted Answers"
and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical
Education and Research.

This concludes the Mayo Clinic Pain Management Center website information.

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HEADACHES ASSOCIATED WITH ARTHRITIS
Headaches associated with arthritis (also called cervical headaches) are
caused by arthritis in the neck and spine. Pain is usually located in the
back of the head. In the case of a pinched nerve from arthritic bone or disk
degeneration, pain may be accompanied by weakness in the arms and/or tingling
or numbness in the neck, scalp or arms.

The pain of arthritis results from inflammation and subsequent damage of the
joints and connective tissues. There are several different forms of
arthritis, but the connection to headache is related more to the location of
arthritis than the type. If the cervical vertebrae are involved, headache is
likely to occur. Rheumatoid arthritis and degenerative joint disease are the
most common causes of cervical headache.

Arthritis is treated with nonsteroidal anti-inflammatory drugs including
aspirin, ibuprofen or naproxen, among others. Sometimes, additional pain
relievers are helpful, including acetaminophen (Tylenol and others). Heat,
massage and exercise -- under your doctor's supervision -- are also helpful
for some people. A neck collar, worn only intermittently, may reduce
symptoms. If there has been damage to the neck so that nerves or the spinal
cord are compressed, surgery may be necessary.

Arthritis is the focus of considerable research effort, but currently there
is no known way to reliably prevent neck arthritis and the headaches it
causes. Treatment today typically involves relieving symptomatic pain and
reducing the burden of this illness. It is encouraging that medical research
is discovering ways to slow down the destructive process in rheumatoid
arthritis, one of the more severe forms.

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RESEARCHERS FIND GENE INVOLVED IN PAIN RELIEF
Discovery points to new approach to pain treatment: by Megan Easton

Researchers at the University of Toronto, The Hospital for Sick Children and
the Amgen Institute have discovered a genetic mechanism involved in pain
modulation that could lead to an entirely new approach to pain control. The
results of their research are published in the Jan. 11 issue of the journal
Cell.

In the study, genetically engineered mice lacking a gene called DREAM
(downstream regulatory element antagonistic modulator) showed a dramatic loss
of pain sensitivity compared to mice who had the DREAM gene. "This is an
exciting development," says study co-author Professor Michael Salter,
director of the University of Toronto Centre for the Study of Pain and a
senior scientist at The Hospital for Sick Children. "There's a great interest
in this finding because it's so different from the traditional approaches
researchers have been taking to pain management." The work was done in the
laboratory of principal investigator Professor Josef Penninger at Amgen by
graduate students Mary Cheng and Graham Pitcher, lead authors of the study.
The Amgen Institute is affiliated with the Ontario Cancer Institute at
Princess Margaret Hospital.

The DREAM gene's role in reducing production of the chemical dynorphin had
been previously identified. DREAM produces a protein that suppresses the
genetic machinery that reads the DNA code for dynorphin, which decreases
dynorphin production. Dynorphin is a peptide normally produced in the body.
Known as an endorphin, it is produced in response to pain or stress. "We knew
about DREAM and its role in dynorphin expression, but the purpose of this
study was to determine DREAM's actual physiological function," says Salter, a
professor of physiology in U of T's Faculty of Medicine.

When the DREAM gene was absent in mice, the researchers discovered increased
production of dynorphin in the region of the spinal cord involved in
transmitting and controlling pain messages. The mice, they discovered, had
decreased sensitivity to acute, inflammatory and neuropathic pain. "The
attenuated pain response was evident for all types of pain in all types of
tissue tested," says Salter. "The fact that even mice with neuropathic
pain-the kind of sharp, chronic pain resulting from nerve injury-experienced
this effect is exciting because the medical community currently doesn't have
any widely effective treatments for this debilitating type of pain."

Current approaches to pain management focus on drugs such as morphine that
stimulate cell receptors for the endorphin family of proteins, also called
the endogenous opioid system, or drugs such as aspirin that block the enzyme
cyclo-oxygenase. The DREAM gene, however, works in an entirely different way
by binding directly to DNA and regulating the expression of a protein in the
endogenous opioid system. "These findings point to a novel pharmacological
approach to pain management where researchers will be looking for drugs that
could block the ability of DREAM to bind to DNA or simply prevent the
production of DREAM," says Salter.

The mice in the study who lacked the DREAM gene were otherwise completely
normal and showed no reduction in their motor function, learning or memory.
They also did not become addicted to the pain control chemicals their bodies
produced, which may prove to be an advantage over the potentially addictive
drugs such as morphine that act on opioid receptors.

"Pain is a huge, silent public health crisis that is only beginning to be
addressed by researchers," Salter says. "Evidence of the severity of this
crisis can be found in the fact that the U.S. government has declared
2001-2010 the Decade of Pain Research and Management. This declaration
highlights a growing awareness of the vast problem of untreated or
under-treated pain, and we hope this research will contribute in a
significant way to current efforts by scientists to confront this challenge."
The study was funded by CANVAC, the National Cancer Institute of Canada, the
Canadian Institutes of Health Research and Amgen Inc.
Megan Easton is a news services officer with the Department of Public
Affairs.

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STUDY: PAIN DRUGS CUT ALZHEIMER RISK
(The Associated Press)- Dutch researchers have found the strongest evidence
yet that pain relievers like Advil, Aleve and Motrin may ward off Alzheimer's
disease.

A large study of people 55 or older concluded that those who took certain
nonsteroidal anti-inflammatory medicines every day for at least two years
were 80 percent less likely to develop Alzheimer's.

Scientists first noticed in the mid-1990s that regular use of these drugs for
aches and pains may protect against Alzheimer's. Studies in the late 1990s
found no such effect, but had flaws such as asking people with Alzheimer's to
recall their past medication use.

The Dutch study appears to solve that problem because it drew information on
the patients' drug use from a national database in Holland.

Still, the lead author, Bruno Stricker, said researchers must confirm the
results with controlled experiments in which patients are randomly assigned
to take either anti-inflammatory drugs or dummy pills.

Stricker and other experts warned people not to start taking NSAIDs on their
own. Anti-inflammatory drugs such as ibuprofen and naproxen can cause
serious, sometimes fatal side effects such as gastrointestinal bleeding and
kidney damage.

"Whatever you do, go to your doctor first," said Stricker, a professor of
clinical epidemiology at Erasmus University Medical Center in Rotterdam.

The research was reported in Thursday's New England Journal of Medicine.

Doctors studied 6,989 people, many of whom had been prescribed
anti-inflammatory medications for joint problems. The patients were evaluated
in the early 1990s to be sure they did not have Alzheimer's.

They were followed on average for seven years to see which ones developed the
incurable mind-robbing disease. Checking Holland's national pharmacy
database, the researchers determined which patients took NSAIDs and for how
long.

Altogether, 293 patients were diagnosed with Alzheimer's and 101 others
developed other types of dementia.

For people who already have Alzheimer's, Stricker said, "There's no reason to
believe that treatment with these drugs would improve symptoms."

The Dutch researchers believe NSAIDS work against Alzheimer's by relieving
minor brain inflammation. However, other researchers reported last week that
NSAIDS appear to work by inhibiting production of a protein found in the
buildups that clog brain cells.

In the Dutch study, one of the most commonly used NSAIDs, aspirin, did not
reduce Alzheimer's risk at all. Likewise, none of the 17 anti-inflammatory
drugs used by patients in the study cut the risk of vascular dementia, in
which repeated, undetected minor strokes damage the brain.

Alzheimer's causes about two-thirds of all dementia cases; other causes
include heavy drinking. Roughly 4 million Americans have the disease.

Because the Dutch government provides medicines free with a prescription, the
extensive pharmacy records provided much better data than was available in
prior studies, said Neil Buckholtz, chief of the Dimensions of Aging Branch
at the U.S. National Institute on Aging.

The institute is enrolling 2,500 patients in a new study comparing the
potential protective effects of two widely used drugs - naproxen, also known
as Aleve, and the newer Celebrex - with dummy pills. Results are expected
around 2008.

Dr. John C.S. Breitner and Peter P. Zandi of Johns Hopkins University in
Baltimore wrote in an accompanying editorial that the Dutch study appears to
resolve puzzling conflicts among previous studies on the topic.

Copyright 2001 The Associated Press. All rights reserved.

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MISUNDERSTOOD OPIOIDS AND NEEDLESS PAIN
(The New York Times News Service)- Chronic pain suffered by 30 million
Americans robs people of their dignity, personality, productivity and ability
to enjoy life. It is the single most common reason people go to doctors,
contributing to an overall cost to the economy of billions of dollars a year.

Yet chronic pain, whether caused by cancer or a host of nonmalignant
conditions, is seriously undertreated, largely because doctors are reluctant
to prescribe - and patients are reluctant to take - the drugs that are best
able to relieve persistent, debilitating, disabling pain that fails to
respond to the usual treatments.

These drugs are called opioids - narcotics, as they are generally known - and
many studies have indicated that ignorance and misunderstanding seriously
impede their appropriate use.

Opioids are natural and synthetic compounds related to morphine. Studies
suggest that about half of patients with cancer-related pain and 80 percent
of those with chronic noncancer pain are undertreated as a result. These
patients suffer needlessly, as do their loved ones.

"Some patients who experience sustained unrelieved pain suffer because pain
changes who they are," say Dr. C. Richard Chapman of the University of Utah
School of Medicine and Dr. Jonathan Gavrin of the University of Washington
School of Medicine.

Chronic pain, they wrote in The Lancet medical journal, results in "an
extended and destructive stress response" characterized by brain hormone
abnormalities, fatigue, mood disorders, muscle pain and impaired mental and
physical performance.

Neurochemical changes caused by persistent pain perpetuate the pain cycle by
increasing a person's sensitivity to pain and by causing pain in areas of the
body that would not ordinarily hurt.

"This constellation of discomforts and functional limitations can foster
negative thinking and create a vicious cycle of stress and disability," the
researchers wrote. "The idea that one's pain is uncontrollable in itself
leads to stress. Patients suffer when this cycle renders them incapable of
sustaining productive work, a normal family life and supportive social
interactions."

Dr. Jennifer P. Schneider, a specialist in addiction medicine and pain
management in Tucson, Ariz., agrees. "When patients feel hopeless and think
they will never get relief, it makes chronic pain and its effects that much
worse," she said in an interview. Abundance of Misinformation

Far too little has been done to correct the misunderstandings of both
patients and doctors that stand in the way of using opioids to control
chronic pain. Nowadays, doctors are more inclined to use narcotics for pain
relief in patients with advanced cancer, assuming erroneously that "since
they're dying anyway, it won't matter if they become addicts." But the
reluctance to use opioids for noncancer-pain patients persists, and patients
are equally likely to resist taking them should they be prescribed.

"Like most doctors, most patients are relatively uninformed about the safety
of using narcotics for pain, thinking they're dangerous drugs that will do
bad things to them," Dr. Schneider explained. "They don't understand the
difference between physical dependence and addiction, and as a result they're
afraid they'll become addicts."

As Dr. Henry McQuay, a pain specialist at the University of Oxford in
England, put it: "Opioids are our most powerful analgesics, but politics,
prejudice and our continuing ignorance still impede optimum prescribing. What
happens when opioids are given to someone in pain is different from what
happens when they are given to someone not in pain. The medical use of
opioids does not create drug addicts, and restrictions on this medical use
hurt patients."

In three studies involving nearly 25,000 patients treated with opioids who
had no history of drug abuse, only seven cases of addiction resulted from the
treatment.

Schneider was distressed last month by a segment of "48 Hours" on CBS
depicting a woman who had been taking the sustained-release opioid Oxycontin.
The woman said that although the drug had relieved her chronic pain, she
stopped taking it because she feared becoming an addict. But instead of
tapering off gradually, she quit cold turkey. As any pain expert would
predict, she suffered withdrawal symptoms typical of physical dependence on a
narcotic: aches all over, tearing eyes, runny nose, abdominal cramps and
diarrhea.

Physical dependence, whether to an opioid or to an immune-suppressing drug
like prednisone, involves reversible changes in body tissues. To avert
withdrawal symptoms, the medication must be stopped gradually. Addiction is
mainly a psychological and behavioral disorder. Schneider described the
hallmarks of addiction, whether to alcohol or narcotics, as loss of control
over use, continuing use despite adverse consequences and obsession or
preoccupation with obtaining and using the substance.

Unlike an addict, whose life becomes increasingly constricted by an obsession
with drug use, a patient using the drug for pain experiences an expansion of
life when relief comes from this life-inhibiting disorder, Schneider said. An
addict gets high by taking the drug in a way that rapidly increases the dose
reaching the brain. But opioids properly used for pain do not result in a
"rush" or euphoria. When given for chronic pain, opioids are typically given
in a form that provides a steady amount throughout the day.

Nor do pain patients require ever-increasing amounts of opioids to achieve
pain control, because patients in pain do not become "tolerant" to properly
prescribed opioids. Higher doses are needed only if an inadequate amount of
the drug is given in the first place or if the pain itself worsens with time.

Tolerance does develop to some of the common side effects of opioids,
including sedation, respiratory depression and nausea, although constipation
tends to persist for as long as the drug is taken. But an opioid taken to
relieve chronic pain does not block acute pain sensations that might result,
for example, from surgery or an injury. A broken arm or gallbladder surgery
will hurt just as if no opioid were being taken and will require additional
treatment with some other analgesic, Schneider said.

Of course, round-the-clock narcotics are only one aspect of proper treatment
for chronic pain that fails to respond adequately to lesser drugs. As
Schneider explained, chronic pain is "a primary disorder" that can itself
cause disabling complications, including difficulty sleeping, muscle spasms
and depression.

Thus, pain specialists commonly prescribe a low-dose antidepressant like
Elavil to promote sounder sleep, muscle relaxants and anticonvulsants to
relieve spasms, anti-inflammatory drugs, full-dose antidepressants to counter
depression and an increase in physical activity to improve mood and reduce
feelings of incapacity.

Patients may also be referred to psychologists for cognitive-behavioral
therapy, physiatrists (for exercises and pain-relieving injections), physical
therapists, hypnotists, biofeedback specialists, and even acupuncturists,
Schneider said.

To help reduce the risk of drug abuse, Schneider and many other pain
specialists insist that before receiving opioids for chronic pain, patients
sign a "contract" that, among other things, insists that only one doctor and
one pharmacy be used to provide opioids and that no change in dose be made
without prior consultation with the prescribing physician.

The contract also states that there will be "no early refills," no matter
what the excuse, and that patients must agree to undergo random urine drug
tests if the doctor suspects the drug is being abused.
Copyright 2002 The New York Times News Service.

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0XYCONTIN RECOMMENDED FOR ARTHRITIS
March 15, 2002 - CHICAGO (AP) - New treatment guidelines for osteoarthritis
recommend using a wide range of drugs, from Tylenol to the controversial
painkiller OxyContin, depending on the severity of the pain.

The American Pain Society's endorsement of opiates and heavily promoted newer
drugs like Vioxx and Celebrex is among the strongest yet from medical groups
that deal with arthritis patients, said Ada Jacox, a nurse who chaired the
guidelines committee.

According to the guidelines, acetaminophen, or Tylenol, is the first choice
for mild pain. Drugs like Vioxx and Celebrex -- known as cox-2 inhibitors --
are best for patients with joint inflammation or moderate to severe pain. And
opiates including morphine and oxycodone, the active ingredient in OxyContin,
should be used for severe pain that does not respond to other drugs or
treatments.

The society said the guidelines -- its first for arthritis -- are based on
studies showing that cox-2 drugs work as well as other nonsteroidal
anti-inflammatory drugs, including ibuprofen, but with less risk of stomach
irritation.

OxyContin has been blamed in highly publicized overdose deaths linked to
recreational use, but Jacox said the doses often needed to reduce severe
arthritis pain are small and unlikely to be addictive.

While opiates are usually associated with cancer treatment, pain can be just
as severe for the 20 million U.S. patients with osteoarthritis, Jacox said.

Last year, the Drug Enforcement Administration and several medical groups
said they favored potent painkillers such as OxyContin for patients with a
legitimate need.

The guidelines were slated for release Friday in Baltimore at the society's
annual meeting.

Arthritis treatment guidelines from the American College of Rheumatology do
not favor cox-2 drugs over less expensive over-the-counter medications such
as acetaminophen.
Dr. Thomas Schnitzer, a Northwestern University rheumatologist who helped
write the American College of Rheumatology guidelines, said opiates "are fine
if people don't respond adequately" to other drugs, but that applies to very
few arthritis patients.

Dr. Gary Kaplan, medical adviser to the Arthritis Foundation, said the
foundation has guidelines similar to the pain society's, but he said
first-choice treatment for moderate pain shouldn't be limited to cox-2 drugs.

Based in suburban Chicago, the American Pain Society represents 3,500 pain
specialists, including doctors, nurses and pharmacists.
Copyright 2002 The Associated Press. All rights reserved.

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PURDUE PHARMA, MAKER OF PAINKILLER OXYCONTIN STARTS AD CAMAIGN- February 21,
2002 - STAMFORD, Connecticut (AP) -
The maker of the painkiller OxyContin is starting an advertising campaign in
U.S. newspapers to highlight its efforts to combat abuse of the powerful
prescription drug.

Purdue Pharma's six-month campaign was to begin Thursday, with ads in papers
from Maine to Florida. Company officials declined to say how much the
campaign would cost.

"There's been too little recognition in the media for what we have been
doing," company spokeswoman Robin Hogen said.

OxyContin is the nation's top-selling narcotic painkiller and generates more
than
$1 billion in annual sales. It's widely prescribed for victims of moderate to
severe chronic pain resulting from arthritis, back trouble or cancer. One
OxyContin pill is designed to last 12 hours.

Those who abuse the drug crush it, then snort or inject it, producing a
quick, heroin-like high. Federal officials blame OxyContin and similar drugs
for hundreds of deaths nationwide over the past two years.

Many doctors, patients and even some of its critics say OxyContin is highly
effective in relieving chronic pain.

The company faces lawsuits, growing scrutiny from regulators and even calls
for banning the drug.

The new ads never mention OxyContin. Instead, they say 4 million Americans
each month abuse a variety of prescription drugs, including pain medications,
weight-loss pills and antidepressants.

"And Purdue Pharma is doing something about it," the ad says.

The ads highlight Purdue's effort to develop new abuse-resistant medicines,
distribute free tamper-resistant prescription pads and educate teens on the
dangers of prescription drug abuse.

Dr. James Graves became the first doctor in the country convicted of
manslaughter in the OxyContin death of a patient. The Florida doctor was
convicted of prescribing OxyContin to four patients who died from overdoses.
Copyright 2002 The Associated Press. All rights reserved.

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LILLY OFFERS $12 PRESCRIPTION CARD by Janelle Carter
.c The Associated Press - WASHINGTON (AP) - Low-income seniors with no drug
insurance will be able to get a month's supply of prescriptions like the
depression-treating Prozac and the osteoporosis-fighting Evista for $12 each.

The new drug assistance plan from Eli Lilly and Co. is the pharmaceutical
industry's latest effort to help needy older Americans while the federal
government debates broader coverage. In January, Pfizer Inc. announced a
similar program offering a month's supply of one of its prescriptions for
$15.

Lilly's program, called Lilly Answers, began Tuesday. It is open to seniors
with no prescription drug coverage and annual incomes below $18,000, or under
$24,000 for couples - same as for Pfizer's plan.

Seniors can apply for a card by calling 1-877-RX-LILLY. The application
process takes two to four weeks, and eligibility will be verified through
copies of the applicant's most recent tax return and Medicare card.
Participating pharmacies will begin accepting the card April 1.

Once a Medicare beneficiary receives the card, it is valid for one year.
After a year, participants must reapply.

``Families, caregivers, communities and companies such as ours all recognize
many seniors need extra assistance at this time,'' said Sidney Taurel,
president and chief executive officer of the Indianapolis-based Lilly. ``We
hope and expect that Congress will enact federal legislation that provides
broad prescription drug coverage to all seniors. In the meantime, we decided
to act now in order to provide this assistance to individuals in need.''

Eligible participants can save an average of nearly $52 on a 30-day
prescription or $600 in a year for one medication, the company said.

For instance, Evista, a drug for osteoporosis, has a retail price of about
$782.74 a year, according to company figures. Participants in the program
will pay only $144 in a year. Similarly, a year's worth of Prozac would
retail about $1,000.29. At $144 a year, program participants would save
$856.29.

``Lilly has taken an important step in helping the neediest of seniors gain
access to critical prescription drugs,'' Health and Human Services Secretary
Tommy Thompson said. ``This innovative approach demonstrates the private
sector's willingness to address this important issue between now and the time
we implement Medicare reform.''

Congress is weighing how best to provide a prescription drug benefit to
seniors. Democrats have said they want to make the benefit universal for all
40 million Medicare recipients. President Bush and other Republicans have
called for first providing benefits to the most needy.

On Monday, Rep. Bill Thomas, R-Calif., the House Ways and Means Committee
chairman charged with crafting such a plan, said House Republicans will
propose a plan close to 60 percent more than the amount being sought by the
president.

Bush included $190 billion, to be spent over 10 years, for a prescription
drug benefit in his budget proposal. But Congress in its last budget
earmarked $300 billion. This year's number will be slightly higher than last
year's, Thomas said.
Copyright 2002 The Associated Press.

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This concludes our 3 part series on pain and pain management.

Good Health to all

Jack Nicholas
Newsletter Editor
Issue 2002 3/23/02 - 8