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Pain Press

Pain Matters supplement
June 2020

 
Hello and welcome to Pain Press, the monthly e-newsletter from Pain Concern, the charity working to support and inform people living with pain and those who care for them, whether family, friends or healthcare professionals.

Feature

Chronic Pain Following Cancer Treatment
This is an edited version of an interview first published on painresearchforum.org on 6 August 2019

Brenda Dyal, PhD, DNP, is a postdoctoral associate at the University of Florida. She met Lesley Colvin MBChB, PhD, during the 7th International Congress on Neuropathic Pain. Lesley Colvin is Chair of Pain Medicine in the Division of Population Health and Genomics at the University of Dundee, Scotland, UK. She gave a talk at the conference on problem of chemotherapy induced peripheral neuropathy, the nerve damage that sometimes follows chemotherapy for cancer.

Brenda: What led you to spend your career on the study of pain?

Lesley: I’m an anaesthetist by training, and during my training I became very interested in pain and how we managed it because it is such a major clinical challenge. I took time out of anaesthetics school and worked in a lab with Professor Arthur Duggan, who was my supervisor, and I spent three years trying to understand the spinal mechanisms of neuropathic pain. I then went back and finished my training in anaesthetics, and during that time specialized in pain medicine, which is what I do all the time now.

Brenda: How did you become interested in chemotherapy-induced peripheral neuropathy (CIPN)?

Lesley: That’s a good question. My PhD was in neuropathic pain, and I’ve always had a particular interest in neuropathic pain. In my clinical practice, I did for many years a combined clinic with palliative care in the Edinburgh Cancer Centre, where we saw many patients with cancer pain, but also, more and more over time, with cancer treatment-related pain. CIPN in particular has become an increasingly significant problem over the years that I’ve worked in clinic. It struck me week after week that the patients we saw there were hugely disabled, in terms of their quality of life, from the treatment that often cured them of their cancer, but we really didn’t have any effective therapies to offer them. That’s how I became interested in CIPN.

Brenda: You recently published in PAIN an article titled “Chemotherapy-induced peripheral neuropathy: where are we now?” There you discuss the role of genetic factors in CIPN. What do we know about this area?
 
Lesley: It’s part of the effort to understand the genetic and physical make up of individual patients in order to link their signs and symptoms to underlying mechanisms, so we can tailor our treatments ideally to each individual. As I mentioned in my lecture this morning, one of the issues is that everyone gets a standard dose of chemotherapy, and it’s only altered if there is a problem, as in the case, for instance, of CIPN.

What I think cancer specialists need to be doing and would like to do is better understand the side effects of treatments. In cancer medicine we are now using the patient’s genetic make-up to choose which treatment to use, but we’re not there yet in terms of understanding chemotherapy-induced peripheral neuropathy and perhaps managing it. So that’s one direction that will be interesting to explore further.

Also, there are healthcare databases and research databases, such as the UK Biobank, which contain a lot of patient information. Patients can sign up to participate in these databases. So we are beginning to have the opportunity to have large enough patient populations so that we can start to look at the genetics in a bit more detail and get something meaningful out of it.

Within Scotland we also have some interesting opportunities with an initiative called SHARE, which is the Scottish Health Research Register. People can sign up online, and doing so gives consent so that if you’re a patient in any National Health Service (NHS) system within Scotland, your data can be used, and if you have any stored blood, that can be used, and you can be contacted for potentially relevant research studies. That’s a huge database for the genotyping that is beginning to go on within SHARE. The SHARE database has about 250,000 to 260,000 individuals signed up to it, so it’s a hugely powerful resource.

What we can also do in Scotland, if an individual who has contact with the healthcare system has a unique identifier, called the CHI number, is link the data from SHARE with national prescribing data, for instance. So potentially you could look at individuals with cancer, the chemotherapy they’ve had, and then look at other conditions they have and also the genetics.
 
Brenda: What is the role of patient education in understanding risk factors for CIPN as well as other treatment approaches, whether medicinal or non-medicinal?

Lesley: Patient education throughout the cancer journey is really important, because if you get a diagnosis of cancer, it turns your life upside down. Many people say that they receive a diagnosis and a whole load of information about potential treatment options, but it’s such a difficult time to actually take in that information and make the right decisions about treatment.

We need to deliver education at the right time and in the right way to allow patients to make an informed decision about the cancer treatment they might choose. If you’re going for chemotherapy, having an understanding of risks and benefits is important. If you’re in one of the high-risk groups that might develop CIPN to the extent where you’re so miserable that life is not worth living, then your choice as an individual is quite different from someone who’s at very low risk of developing these very unpleasant side effects. So we are beginning to understand who is vulnerable, what the risk factors are, and how to use this for patient education and informed choice.

In terms of managing pain, patient education and understanding of pain is important. In addition to using drug therapies, psychological techniques are valuable; we know the evidence that they are effective in the management of chronic pain.

Brenda: What are your thoughts about the use of opioids in the treatment of neuropathic pain?

We’ve looked at this issue within Scotland, and from 2003 to 2013 there was a doubling of opioid prescribing. In 2012, which was the year that we focused on in particular to find a bit more detail about why that might be, 18% of the Scottish population were prescribed some form of opioid, which is a huge number of individuals.

So, should we be using opioids for neuropathic pain? If you look at the neuropathic pain guidelines, opioids are there but they are quite far down the list; they’re known as third-line therapy. There was one trial published last year that looked at opioid or non-opioid pain relief for osteoarthritis and for back pain and followed individuals for a year. Patients who were on strong opioids had worse pain, so there was actually a downside to being on a strong opioid.

We do know from our understanding of the mechanisms of neuropathic pain that, potentially, opioids may not be that good for neuropathic pain. You need a really careful analysis and discussion, on a case-by-case basis. If you have patients who are really struggling, and opioids work for them, that’s fine. But my feeling from having worked with opioids over many years is that sometimes patients with neuropathic pain who run into problems get partial benefit, and then they develop a bit of tolerance and the benefit wears off, and they end up with an ever-increasing dose, resulting in physical dependence, withdrawal, and sometimes addiction.

Brenda: What are the most challenging aspects of your research, and why?

Lesley: Where to start? I enjoy the challenges of research; otherwise, I wouldn’t be doing it. You have to be very optimistic to do research, and for me it’s a balance between having a busy clinical practice and finding time to do all the research there is to do. One of the challenges for me is that there are so many research questions that are all very interesting, and so it’s about focusing on the ones that you can realistically work on in the number of days in a week that you have.

Brenda: What are the key research questions in neuropathic pain that need to be addressed?
 
Lesley: In terms of CIPN, one of the key things is, how do we assess it? We have very good guidelines for assessing neuropathic pain in general, and these are currently being updated, but CIPN is unique because you’re not only looking at the disease process of neuropathic pain, but also the coexisting, underlying diagnosis of cancer, and in addition to that there is the toxic insult of chemotherapy. There’s no international consensus as to exactly how you make the diagnosis of CIPN, so we need to develop a proper way of assessing it.

Another key challenge with CIPN is how to prevent it. So it’s about understanding the mechanisms of CIPN and targeting those so that in the future we can prevent it, rather than struggle to manage patients with really debilitating neuropathic pain who are referred to the pain clinic several years after they’re finished with chemotherapy.

Brenda: What advice do you have for early-career investigators?
 
Lesley: As a researcher you have to love what you’re doing, so go for a research position in an area that you’re passionate about. You have to do that because it takes up so much of your life, and then you’ll have a job that’s hugely enjoyable and rewarding.

Brenda: What do you do for fun when you are not doing science—any hobbies?

Lesley: My main hobby, and that of my children, is horse riding. My girls like eventing, which includes dressage, show jumping, and cross-country riding; watching that as a parent can be slightly stressful at times. So I don’t have a lot of time to sit around at home because we have four horses, and we’re in the process of buying another one. I’ve had to learn how to drive a large truck; I’ve got my heavy goods vehicle license and I’m licensed to drive a truck up to 38 tons. Most of my weekends are spent driving around the countryside going to various competitions.

Airing Pain 123: Opioids

The new episode of Airing Pain will be released on Tuesday 7 July 2020.

Tune in as producer Paul Evans talks to Dr Cathy Stannard, leading pain specialist and expert on opioids, about the opioid crisis in both the US and the UK; patient advocate Louise Trewern tells her story of reducing her opioid use; and GP Dr Jim Huddy talks about the rate of prescribing in his surgery.

Watch the trailer below

Airing Pain #123: Opioids. Listen or Download 7 July 2020
 

Subscribe to Airing Pain via Apple Podcasts, Spotify or wherever you get your podcasts

Latest News

Could Electrical Impulses Relieve Chronic Pain by Stimulating the Vagus Nerve?
Technology Networks - 27 May 2020

The vagus nerve plays an important role in our body. It consists of various fibres, some of which connect to the internal organs, but the vagus nerve can also be found in the ear. It is of great importance for various body functions, including the perception of pain. Therefore, a lot of research has been focusing on how the vagus nerve can be stimulated effectively and gently with special electrodes.

Until now, medical doctors had to rely on experience when positioning the electrodes in the ear. Now, for the first time, a microanatomical study has been carried out by Prof. Eugenijus Kaniusas (Institute for Microwave and Circuit Engineering, TU Wien) and his team to investigate spatial arrangements of the nerve fibres and blood vessels in the ear. This helps to find the correct spot for placing the stimulation electrodes. A computer model can also be used to calculate which electrical signals should be used. Not only the strength of the signal is important, but also its shape.

This type of stimulation was tested on people suffering from chronic pain – and the experiments showed that the triphasic stimulation pattern is particularly effective.

According to Prof. Kaniusas, "Vagus nerve stimulation is often a lifesaving option, especially for people with chronic pain who have already been treated with other methods and do not respond to medication anymore.”

For more information, click here
Could Electrical Impulses Relieve Chronic Pain by Stimulating the Vagus Nerve?
Technology Networks - 27 May 2020

The vagus nerve plays an important role in our body. It consists of various fibres, some of which connect to the internal organs, but the vagus nerve can also be found in the ear. It is of great importance for various body functions, including the perception of pain. Therefore, a lot of research has been focusing on how the vagus nerve can be stimulated effectively and gently with special electrodes.

Until now, medical doctors had to rely on experience when positioning the electrodes in the ear. Now, for the first time, a microanatomical study has been carried out by Prof. Eugenijus Kaniusas (Institute for Microwave and Circuit Engineering, TU Wien) and his team to investigate spatial arrangements of the nerve fibres and blood vessels in the ear. This helps to find the correct spot for placing the stimulation electrodes. A computer model can also be used to calculate which electrical signals should be used. Not only the strength of the signal is important, but also its shape.

This type of stimulation was tested on people suffering from chronic pain – and the experiments showed that the triphasic stimulation pattern is particularly effective.

According to Prof. Kaniusas, "Vagus nerve stimulation is often a lifesaving option, especially for people with chronic pain who have already been treated with other methods and do not respond to medication anymore.”

For more information, click here
Movement Is Key to Recovery, says Chronic Pain Educator
By Sophie Trigger, Stuff.co.nz/Health - 25 May 2020

Ameli Anton, a Pain Neuroscience Educator from Marlborough, New Zealand, works with chronic pain patients one-on-one after they are referred by a GP, many of which go on to begin an eight-week pain management programme (PMP). 

She understands that fear of pain can cause people with chronic pain to isolate themselves and stop moving, which can only make the problem worse. Indeed, prolonged inactivity can make the nervous system become hyper sensitised and any type of stimuli can trigger the pain response. One of Anton's key messages to her patients is "motion is lotion".

Anton is a firm believer that movement also has social, emotional and financial benefits, keeping people working and reducing their social isolation. 

For more information, click here
Is Chronic Pain Affected by the Weather?
By David Hambling, The Guardian – 15 May 2020

Many people feel that the weather affects their chronic joint pain.

A new meta-study in Pain, the journal of the International Association for the Study of Pain, explores the science behind such anecdotes. 

They found that 63% of studies reported a correlation between weather and chronic pain. This sounds quite definite, but the actual findings varied wildly.

The only definite and consistent result was that wind direction does not influence pain; no other positive finding emerged from the mass of data.

The authors say better-quality studies are needed, with large sample sizes, consistent ways of reporting pain and rigorous statistical analysis. If there is any connection between joint pain and weather, it remains as elusive as ever.

For more information, click here
Scientists Find Brain Center that 'Profoundly' Shuts Down Pain
ScienceDaily – 18 May 2020

A research team has found a small area of the brain in mice that can profoundly control the animals' sense of pain. Somewhat unexpectedly, this brain centre turns pain off, not on. It is located in an area where few people would have thought to look for an anti-pain centre, the amygdala, which is often considered the home of negative emotions and responses, like the fight or flight response and general anxiety.

For more information, click here
 

Pain Matters 75

Our new issue, Pain Matters 75, marks the twenty-fifth anniversary of the very first Pain Concern (UK) Lothian Group newsletter, later to become the Pain Matters we know today, we have gone back to where it all started.

The Lothian Group was a patient support group set up by members of the Astley Ainslie Hospital pain management programme, so it seems appropriate that this issue is being guest-edited by the Chronic Pain Management Service from NHS Lothian, based at the same hospital.
 
The team have themed this issue around the topic of compassion-focused therapy, showing different ways in which compassion can be a key concept as part of a holistic pain management approach. A lot has changed in the world since our last issue, and here at Pain Concern we think that compassion is something which we could all use more of at the moment.
 
To buy or subscribe, click here
For a digital version, click here
 

Missed an issue of Pain Matters? Fear not. You can now buy a selection of back issues via our website or our Pocketmags page for inspirational information about a range of chronic pain-related issues.

Please note: physical magazines are only available to people in the UK and while stocks last.

PAIN MATTERS
25TH ANNIVERSARY SPECIAL: PAIN MATTERS #1  


Happy 25th Birthday to Pain Matters!

As a little treat to celebrate the 25th birthday of Pain Matters, we have made the very first Pain Concern (UK) Lothian Group newsletter, later to become Pain Matters magazine, available free through our digital magazine service, Pocketmags. Click here to read it.

Published in the spring of 1995, this newsletter was distributed amongst members of the patient support group of the pain management programme at Astley Ainslie Hospital in Edinburgh, a group which would end up as the charity Pain Concern. Coincidentally, the pain management team at Astley Ainslie are also the guest editors for the upcoming 25th anniversary edition. It's almost like it was meant to be!

Times, and production values, have definitely changed over the years, so please enjoy this little blast from the past on behalf of all the staff, volunteers and supporters who have made the past 25 years possible.

Pain Matters Evaluation

We are continuing the evaluation of Pain Matters over the course of the next few months. Evaluation is a key factor in securing funds, not just for future issues of Pain Matters, but to fund all the work we do here at Pain Concern.
 
We have included a short questionnaire with this issue of Pain Matters and we would be extremely grateful if you could complete and return it to us. This is not just for people with chronic pain, we are looking for responses from all our readers. Alternatively, you can visit survey.painconcern.org.uk and complete the online version. It should only take about five minutes and your responses will help us to continue producing the wide variety of resources for people living with pain.
 

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