Adverse Drug Reactions Kill Over 100,000 In Hospitals Annually

This statistic is according to a recent article appearing in The Journal of American Medical Association. The author, Bruce Pomeranz, M.D., Ph.D., reviewed 39 different studies of adverse drug reactions in hospitals, and came up with some alarming conclusions. According to Pomeranz’s research, he estimates that 2,216,000 hospital patients experienced serious adverse drug reactions (side effects) and 106,000 died from these reactions in 1994 alone. This astounding number accounted for 4.6% of all recorded deaths in the U.S. in that year. This makes drug reaction deaths the fourth leading cause of death in the country.

Adverse drug reactions as defined in this study were not small problems. These reactions were only included in the study if they required hospitalization, prolonged hospitalization, caused permanent disability or resulted in death. Probably the most surprising finding of the study is that the rate of adverse drug reactions has not changed over the last 32 years. This suggests that despite an increase in cost and technology, the drug related care given in hospitals has not improved its safety level or its death rate in over three decades.

Prescription Drug Use On Rise

In a related story, it seems that the threat of serious adverse drug reactions has not decreased the usage. In an article in the January 7, 1999 New England Journal of Medicine, it was reported that, "Prescription drugs are the fastest-growing component of personal health expenditures amounting to $78.9 billion in 1997." This rate of consumption is growing at an ever-increasing rate. In 1995 spending for prescriptions grew by 10.6 percent, in 1996 it grew by 13.2 percent and in 1997 it continued the climb growing by 14.1 percent.

The Federal Office of Personnel Management blames the increase on several factors. They cite broader insurance coverage of prescription drugs, growth in the number of drugs dispensed, more approvals of more expensive drugs by the Food and Drug Administration, and direct advertising of pharmaceutical products to consumers.

It wasn’t too many years ago that they government forced the removal of cigarette advertising off television because of the health hazard. Considering the numbers, maybe its time to take a long hard look at the drug ads.

Over 106,000 Drug Related Deaths per Year

The USA Today, Wednesday, April 15, 1998, page 1 finds a report on a recent article in the Journal of the American Medical Association addressing the subject of unintended side-effects of properly prescribed, properly administered medications. The authors estimate deaths from such events to exceed 106,000 deaths per year. To offer some perspective on this number--57,000 US soldiers died in the Vietnam War! Keep in mind, this number represents a completely different data set than Lucian Leape's estimate of 180,000 hospital based iatrogenic deaths per year. Those deaths are associated with errors, not side effects of properly prescribed and administered medications. Over-the-counter ulcer medications linked to 16,500 deaths last year.

In a December 1, 1998 story in the USA Today comes a story whose first sentence reads, "About 16,500 Americans died last year from bleeding stomach ulcers brought on by common medications known as non-steroidal anti-inflammatory drugs, (NSAIDs)". For a comparison this was close to the number of deaths resulting from AIDS. Unfortunately for the victims bleeding stomach ulcers have no warning symptoms in 80% of the people who have them. Only 20% experience some symptoms such as abdominal pain or heartburn.

Some of the more common drugs that fit into this category are Motrin and Aleve as well as the prescription drug Relafen. While these drugs are some of the most common of their type on the market it seems the public does not recognize the danger. A recent national poll done by Roper Starch Worldwide showed that 75% of the people taking NSAIDs were either unaware, or unconcerned about the possible deadly effects.

Unfortunately, those most at risk are those most likely to use the drug, including people with severe arthritis and those over 65 years of age.

What this article doesn’t mention is that a growing number of these individuals are seeking non-drug solutions such as chiropractic. This approach eliminates the chance of serious complications and adverse effects from these drugs.

Drugs not answer for Health & Wellness

In a feature article in the November 16, 1998 issue of the U.S.News & World Report, it was noted that drug usage is actually going up in the US. Drug companies are certainly not crying the blues because of the trend toward health and wellness. In fact they have shifted their emphasis in sales. More and more drug companies are pushing drug usage not only for treatment but for usage before any problems arise as a preventative. This mass marketing shift has paid off as prescriptions for drugs went up 400 million from 1993 to 1997, up to an astounding 2.4 billion prescriptions being dispensed in 1997!

This new approach markets drugs with the promise to prevent such things as heart attacks, cancer, osteoporosis, diabetes and impotence. Unfortunately, many of the drugs being marketed for healthy people to take as a preventative, were only tested on sick people.

The article in U.S.News & World Report used the example of two drugs called Tambocor and Enkaid. These two drugs were routinely prescribed for years as a preventative of sudden heart attacks. Only after some time did a study of these drugs on healthy people reveal that the drug greatly increased the chance of sudden heart attacks when taken by healthy people. It is estimated that 50,000 people as a result of these drugs may have died before a halt was instituted.

The bottom line is that "better living through chemistry" may exact a terrible price.

Annual Death Rate Due to Medications Continues to Rise

The following is reprinted from a recent article in the Boston Globe entitled, "Medication-Error Deaths Soar in U.S.," by Richard A. Knox,

"The incidence of death due to medication errors increased dramatically between 1983 and 1993 and shows no signs of abating, new research on the subject shows. Over the ten-year period in question, patient deaths due to medication leaped 260 percent overall, and 850 percent among persons receiving outpatient care. And these figures may represent "only the tip of the iceberg," according to David Phillips of U.C. at San Diego, who points out that many prescription error deaths aren't listed as such on death certificates. Death certificates from the ten-year period provided the raw data on which the findings are based.

Researchers involved in the study say that the increase in medication fatalities cannot be attributed simply to patients taking larger-than-prescribed doses of medication. Their comments are borne out by the fact that the sharpest increase in such deaths among outpatients occurred with the use of anesthetics. Anesthesia drugs are not self-administered, suggesting that the increase in outpatient care as part of overall cost-cutting measures among hospitals may be part of the problem. The study found that deaths due to anesthetics among outpatients increased 400 percent compared to anethesia deaths occurring in hospitals. Surprisingly, the steep rise in medication deaths is not due to an increase in prescriptions, which during the ten-year period rose 39 percent, compared to the 260 percent increase in medication error deaths.

Compounding the problem, according to research conducted by Harvard University, is the fact that medication errors commonly occur even in the nation's highest-ranking teaching hospitals. The findings clearly indicate the need for a close re-examination of modern medicine's over-reliance on drug use and symptom care as primary approaches for treating illness.

Drug Companies Marketing Aimed Directly At Consumers

A revolution in drug marketing and sales has occurred. In the early 1990’s a little known drug was introduced to doctors for blood pressure. The drugs name was Minoxidil. This drug, as all others before it, was only advertised in professional journals to medical doctors. Then, when someone noticed that this drug actually stimulated some hair growth, things changed. This little known drug was soon known as Rogaine. And the marketing was not aimed solely at doctors, but directly to the consumer. This changed the prescription drug game totally. Prior to that most consumers only saw over-the-counter drug advertisements. Now, the drug companies are advertising the prescription products right to the consumer.

The results are predictable. An article in the January 7, 1999, New England Journal of Medicine reports, "Prescription drugs are the fastest-growing component of personal health expenditures amounting to $78.9 billion in 1997". This rate of consumption is growing at an ever-increasing rate. In 1995, spending for prescriptions grew by 10.6 percent. In 1996, it grew by 13.2 percent, and in 1997, it continued the climb growing by 14.1 percent.

Based on the drug industries own figures, the top ten drug makers have spent 44% more money to advertise prescription drugs to consumers than to doctors. Claritin, a well advertised drug is one example where the makers spent over $70 million in 1998 advertising to doctors, while spending $183 million advertising to consumers.

The government, seeing the potential for abuse, has started to create guidelines for prescription drug advertisements. These guidelines are designed to inform consumers of major side effects of the advertised drugs, and give ways to get further information on their various reactions. Considering that children learn a lot about our world from television, we must consider if the drug companies message of "better living through drugs" is one we want our future generations to repeatedly see.

URL: http://www.mapinc.org/drugnews/v99/n642/a05.html
Newshawk: Dave Haans
Source: Toronto Star (Canada)
Copyright: 1999, The Toronto Star
Contact: [email protected]
Website: http://www.thestar.com/

PAIN KILLERS DEADLY Death Toll Said To Rival Aids

BOSTON ( Reuters ) -- ASA and related drugs kill almost as many people every year as AIDS and are responsible for a "silent epidemic," researchers say in an article published today.

Ulcers caused by such drugs kill about 16,500 people in the United States each year, they report in the New England Journal of Medicine. AIDS killed 16,685 Americans in 1997, according to the U.S. National Centre for Health Statistics.

Dr. M. Michael Wolfe of the Boston University School of Medicine said doctors have long known that nonsteroidal anti-inflammatory drugs, or NSAIDs, cause ulcers and other stomach problems in a small fraction of patients. But because they are used so widely -- about 26 billion tablets are consumed in the U.S. annually -- the number of deaths caused by the drugs is large, Wolfe said in a statement.

"We estimate that approximately 16,500 deaths occur annually in the U.S. from ulcer-related complications associated with their use," he said.

If those deaths were given their own category, the report states, the effects of NSAJD drugs "would constitute the 15th most common cause of death in the United States."

NSAIDs include acetylsalicylic acid ( ASA, sold generically and as Bayer's Aspirin ), ibuprofen, and the active ingredients in Aleve, Naprox, Voltaren and Indocin.

"This is, in many ways, a silent epidemic because gastrointestinal complications are not preceded by any warning signs in many individuals," Wolfe said.

NSAID-Induced GI Complications: What's New?

Identification and prevention of adverse drug reactions (ADRs) is a major focus in health care today. Based on the results of a recent meta-analysis (Lazarou, 1998), it was estimated that 2,216,000 hospitalized patients in the United States experienced a serious adverse drug reaction in 1994, and 106,000 had fatal ADRs. Based on this estimate, adverse drug reactions would be the fourth leading cause of death in the United States.

The single most frequent severe adverse drug reaction is gastrointestinal complications caused by nonsteroidal anti-inflammatory drugs (NSAIDs). The U. S. Food and Drug Administration has estimated that the incidence of symptomatic ulcers and potentially life-threatening ulcer complications in patients taking NSAIDs is 2-4% per year. More than 100 million prescriptions are filled for NSAIDs each year, and many more patients are taking nonprescription products, resulting in over 200,000 hospitalizations and 10,000 to 20,000 deaths due to NSAID-induced GI complications each year (Silverstein, 1998). Considering the frequent use of NSAIDs in arthritis, it is no wonder that NSAID gastropathy has been referred to as the second most deadly rheumatic disease.

Recent investigations into this problem include the Misoprostol Ulcer Complications Outcomes and Safety Assessment (MUCOSA) trial, evaluation of the use of high doses of famotidine or omeprazole for prophylaxis and evaluation of eradication of Helicobacter pylori in at-risk patients. Another promising development is COX-2 selective drugs that appear to have therapeutic efficacy in inflammatory conditions with possibly little or no risk for GI complications.

The MUCOSA trial (Silverstein, 1995) was the first randomized controlled study to determine the efficacy of misoprostol in reducing the incidence of serious GI complications (bleeding, perforation, obstruction) rather than just endoscopically identified ulcers. This is significant because there has been only a modest correlation between endoscopic findings and GI hospitalizations. Misoprostol has been shown to reduce endoscopic ulcers by almost 90% but the MUCOSA study showed a relative risk reduction in clinically significant complications of only 40%. Of the 4,406 patients randomized to receive misoprostol, 25 suffered a serious GI event in the six-month trial, compared to 42 events in the 4,433 patients in the placebo group. This difference represents an absolute risk reduction of 0.38% (p .05), meaning that 263 patients would be treated for six months in order to prevent one serious gastrointestinal event.

Misoprostol was not shown to reduce mortality in this study.

More informed decisions regarding the use of NSAIDs and prophylactic therapy with misoprostol require the identification of patients with additional risk factors such as age - 75 years, previous peptic ulcer, previous GI bleeding, major comorbid conditions, high doses of NSAIDs, concomitant steroids or anticoagulation therapy. The Arthritis Rheumatism and Aging Medical Information System (ARAMIS) is currently developing a more precise calculator based on these factors to estimate the risk of GI events so that the benefits and risks of therapy can be more accurately evaluated (Singh, 1998).

Two recent studies have evaluated high-dose famotidine for the prevention of NSAID-induced ulcer (Hudson, 1997; Taha, 1996). Famotidine 40 mg bid significantly reduced the incidence of gastric and duodenal ulcers. However, these studies were criticized for three important reasons: 1) the definition of ulcer, a mucosal break of 3 mm or more in diameter, could represent clinically insignificant events, 2) the correlation with significant GI events is not certain and 3) the incidence of ulcers in the famotidine treated patients was higher than most studies with misoprostol. Numerous previous trials with histamine-2 receptor antagonists (H2RA) have shown benefit in reducing duodenal but not gastric ulcers in patients taking chronic NSAIDs, and an observational trial (Singh, 1996) has implicated H2RA as a risk factor for increased NSAID-induced GI complications. In spite of the recent study results, famotidine should not be considered effective prophylaxis for NSAID-induced GI events.

Omeprazole has been compared to misoprostol (Hawkey, 1998) and to ranitidine (Yeomans, 1998) for treatment and prevention of NSAID-induced ulcers. Omeprazole was as effective as misoprostol in ulcer healing (71% to 76%) at eight weeks, and was more effective at maintaining remission during six months of continued NSAID therapy after ulcer healing, 61% vs 48% (p = 0.001). Compared to ranitidine, omeprazole was more effective in ulcer healing at eight weeks (80% vs 63%, p .001) and more effective at maintaining remission during six months of continued NSAID therapy (72% vs 59%). The primary criticism of these studies is that they were not designed to show that omeprazole is effective in reducing serious NSAID-associated GI complications or hospitalizations. Much larger studies would be needed to show this difference.

There have been conflicting results regarding the benefits of eradication of H. pylori in reducing the incidence of NSAID-induced peptic ulcers. One randomized trial (Chan, 1997) of eradication of H. pylori prior to initiation of eight weeks of naproxen therapy demonstrated a reduction in the incidence of ulcer: 26% in H. pylori-infected patients vs 3% with successful eradication (p = 0.002). Cross-sectional studies on the risk of H. pylori and NSAID-induced ulcers have shown conflicting results (Wilcox, 1997), and previous prospective trials have not shown an effect of H. pylori on the incidence of NSAID-induced ulcers (Bianchi Porro, 1996). In addition, examination of the results from two trials (Yeomans, 1998; Hawkey, 1998) designed to evaluate the effects of acid inhibition or misoprostol on NSAID-induced ulcers, suggested that H. pylori may offer protection from ulcer in this setting. The physiologic argument for this result is that H. pylori infection increases prostaglandin production. It is possible that there are multiple interactions of various risk factors of age, previous ulcer, use of prophylactic therapy, etc., that will eventually be identified as important for decision making for treatment of patients. Certainly the issue of H. pylori infection and the risk for developing NSAID-induced ulcer is not resolved; however, it is difficult to justify not treating H. pylori infection in a patient who has developed an ulcer.

In spite of many years of research into the incidence, risk factors, mechanisms of injury, pathophysiology and other issues, many unanswered questions remain regarding the most effective and cost-effective clinical management strategies for prevention of NSAID-induced GI complications.

For patients at low risk of NSAID-induced ulcers, no prophylaxis would be indicated considering the low level of potential benefits and the significant associated adverse reactions and costs. Patients infected with H. pylori may benefit from eradication therapy. Patients at high risk of serious gastrointestinal complications from NSAIDs should avoid use of these drugs if at all possible. If NSAIDs must be used, the lowest effective dose, for the shortest duration, and in combination with misoprostol should be considered. For at-risk patients unable to tolerate at least 200 mcg bid of misoprostol, a proton pump inhibitor may be considered for prophylaxis.

We need new studies to assess the relationship of NSAID-induced ulcer complications and the H. pylori status of the patient (infected, uninfected, cured). The relative and absolute benefits and risk of preventive and curative therapies may be significantly different based on this status, and current evidence does not allow this difference to be analyzed. Standard doses of H2RA, sucralfate and antacids are not effective in reducing the incidence of NSAID-associated gastric ulcers and should not be used as prophylaxis for GI events. Further data are needed to confirm the clinical safety and efficacy of the COX-2 selective drugs.

Genes Explain Why Pain Hurts More for Some

Reuters Health
By Alison McCook
Thursday, February 20, 2003

NEW YORK (Reuters Health) - People who are especially sensitive to pain are not necessarily wimps: in fact, many healthy people carry normal genetic variations that may cause them to be more sensitive to pain than others, researchers said Thursday.

The investigators discovered that people who carry certain genetic instructions for a protein that plays a role in pain perception were more sensitive to pain, and had more trouble conjuring up brain activity that helps cope with painful experiences.

In contrast, people with different genetic instructions for the same protein were both less vulnerable to pain and showed more brain activity in regions that lessen the impact of pain, the authors report in the February 21st issue of the journal Science.

"There are genetic reasons why some people are more responsive to pain," study author Dr. Jon-Kar Zubieta of the University of Michigan in Ann Arbor told Reuters Health.

The next step, he said, is to investigate further what happens in the body to render pain worse for some than others, and to try to use that information to help people stricken with chronic pain.

The gene in question is known as COMT, and it encodes for a protein that plays a role in how we respond to pain. Different people have different configurations of amino acids within this gene. Among the general population, people may have a gene that carries two copies of the amino acid valine, two copies of the amino acid methionine or one copy of each.

People who carry two valines show the highest activity of the protein produced by COMT, while those with two methionines have much lower COMT protein activity.

During the current study, Zubieta and his colleagues injected the jaw muscles of 29 healthy people with either a pain-causing fluid or one that produced no sensation. Study participants reported how much pain they felt every few seconds, and the investigators observed brain scans while people were in pain.

Zubieta and his team discovered that people with two copies of methionine were more sensitive to pain, needing a smaller injection of the pain-causing substance to feel the same amount of pain as those given larger injections. Moreover, participants with two methionines also showed the least amount of activity in the brain regions that help people respond to pain, and reported more negative emotions while in pain.

"So they had the worst experience," Zubieta said.

In contrast, people with two copies of the valine amino acid needed more of the painful injection to experience the same level of pain as the other participants, and were better able than others to activate the brain regions that protect during painful experiences.

And for people with one copy of each amino acid, the response was somewhere in the middle, Zubieta said in an interview.

In another study, published in the same issue of Science, researchers led by Hiroshi Ikeda of Heidelberg University in Germany and Vienna University Medical School in Austria uncovered information on how certain spinal cord cells can become oversensitized to pain after injury.

These findings may also help researchers develop new means of treating people with chronic pain conditions, they write.

SOURCE: Science

Scientists Find 'Ouch' Gene

It determines who reacts to the slightest discomfort
By Jennifer Thomas
HealthScoutNews Reporter
THURSDAY, Feb. 20 (HealthScoutNews) -- If you find yourself whining over a paper cut or moaning over a stubbed toe, blame your genes.

The difference between a wimp and a tough guy (or girl) is due in part to a tiny variation of a single gene, a new study says.

In a second report, researchers have identified how neurons form "memories" of past pain. The research could help to explain why some people experience chronic pain even after the injury or inflammation that sparked the pain has subsided.

The discoveries, which appear in the Feb. 21 issue of Science, add to a growing body of research finding that an individual's perception of pain is largely dependent on his genes and brain chemistry.

"We know as clinicians that that there are certain individuals who, given the same exposure to pain, experience it chronically and forever, while there are those who get over the pain quickly," says Dr. Charles Argoff, director of the Cohn Pain Management Center and an assistant professor of neurology at New York University School of Medicine.

"This work is fantastic in that it starts to show that there could be underlying genetic differences that may explain why some people, given the same experience, never get rid of the pain or experience it longer while some barely experience it at all," he adds.

In the study on "pain memories," researchers from Germany and Austria knew from previous research that when a certain group of neurons in the spinal cord are stimulated by pain-related matter called "substance P," abnormally enhanced sensitivity to pain can result.

The researchers determined that the activation of a key set of receptors creates conditions that promote the strengthening of the connections among the neurons, leading to a permanent enhancement of the pain-processing pathways, and, therefore, increasing sensitivity to even the most minor pain.

In the second study, which focused on the genetic differences of pain perception, researchers injected 15 men and 14 women ages 20 to 30 with salt water. The injection simulated the pain someone would feel if he had a chronic condition called temporomandibular joint pain disorder.

During the experiment, the study participants were asked to rate their pain every 15 seconds while researchers monitored their brain activity using positron-emission tomography, or PET scans. The participants were also asked to fill out a detailed questionnaire about their perception of pain and their level of emotional distress after the study. Researchers found study participants who had a single variation on the COMT (catechol-O-methyl transferase) gene experienced more severe pain and were more troubled by the experience.

Researchers focused on the COMT gene because it contains enzymes that control the metabolism of the neurotransmitters dopamine and noradrenaline. The enzymes act as a sort of brain janitor, breaking down and metabolizing dopamine and noradrenaline, says Dr. Jon-Kar Zubieta, lead author of the study and an associate professor in the departments of radiology and psychiatry at the University of Michigan.

Each person has two copies of the COMT gene, inherited from each parent. The COMT gene carries one of two amino acids: valine ("val"), or methionine ("met"). Therefore, you can have one of three combinations: val-val, met-met or met-val.

People with the val-val combination make powerful COMT that mops up dopamine rapidly, Zubieta says. People with the met-met combination make poor COMT that can't clean up the dopamine in their brains very well. Those with one copy of each gene variety, the met-val combination, fall somewhere in the middle. The met-val combination is the most common, Zubieta says.

Animal studies have shown that when the dopamine system is highly active, the brain reduces its production of chemicals called enkephalins, Zubieta says. Enkephalins, which are part of the body's pain-control system, regulate and suppress painful or stress-related signals in the brain.

Zubieta and his colleagues found that people with the val-val combination were able to activate the brain's painkilling system better than those with the met-met combination.

Therefore, people with the val-val combination were able to tolerate the most pain, while those with the met-met had the most pronounced response to pain. As researchers suspected, people with the met-val combination fell in between. "A single gene can impose how your body responds to pain and controls pain," Zubieta says.

The discoveries open the door to identifying other pathways that impact or pain perception and emotions, Argoof says.

For help coping with chronic pain, check out the American Pain Foundation or the American Chronic Pain Association.

SOURCES: Jon-Kar Zubieta, M.D., associate professor of radiology and psychiatry, University of Michigan, Ann Arbor; Charles Argoff, M.D., director, Cohn Pain Management Center, Syosset, N.Y., and assistant professor of neurology, New York University School of Medicine; Feb. 21, 2003, Science

Estrogen Helps Fight Pain

A woman's tolerance of it linked to levels of the hormone, study says
By Colette Bouchez
HealthScoutNews Reporter

WEDNESDAY, Feb. 19 (HealthScoutNews) -- A woman's tolerance of pain may have more to do with the power of her reproductive hormones than the strength of her muscles.

That's the theory a group of Michigan researchers presented Feb. 18 at the annual meeting of the American Association for the Advancement of Science in Denver.

"Our studies have shown that although pain is influenced by both genetics and brain chemistry, it is clear that gender and hormones also play a role in our individual response to pain," says Dr. Jon-Kar Zubieta, lead researcher and a University of Michigan neuroscientist.

The key to pain response in women, Zubieta says, may be the hormone estrogen.

"When estrogen levels are high, the brain's natural pain chemicals -- endorphins or enkephalins -- are much more potent. The response is much greater than when estrogen levels are low," Zubieta says.

Pregnancy, he adds, is a good example of this brain chemistry in motion: One of the reasons women can tolerate the pain of childbirth is that just before they deliver, estrogen levels are soaring.

According to his new research, this hormone activity increases the number of receptor sites in the brain where such natural pain-relieving chemicals as endorphins can "dock."

The more "ports" available to receive the endorphins, the greater the ability of the brain to control the pain response, and ultimately, the less pain a woman feels, Zubieta says.

For pain management expert Allen Lebovits, the research makes good sense and it may help open the door for better and more efficient use of anesthesia, particularly in women.

"We don't routinely question women about where they are in their menstrual cycle when we are prescribing pain medications or even anesthesia. But if these studies prove right, then perhaps that should be something that doctors should consider when prescribing certain medications for women," says Lebovits, co-director of the pain management program at New York University Medical Center.

Zubieta and his colleagues spent several years using positron-emission topography (PET) scans to document brain changes linked to hormone activity. Rather than rely on just the images of brain chemistry in motion, they used the scans to document actual changes in the levels of brain chemicals under varying conditions.

In their first study, published in the July 2001 issue of Science, researchers injected the jaws of volunteers with a harmless solution designed to initiate a painful muscle spasm. Using the PET scan they documented how, within 20 minutes, the pain response activated endorphins, the brain's natural pain-mediating chemicals. Not surprisingly, Zubieta says, the rise in endorphin activity correlated with a reduction in the volunteers' perception of pain.

In the latest study, they used the same techniques to document how a woman responds to pain during high and low phases of estrogen production.

In the first part of the study, jaw pain was induced during the early follicular phase of the menstrual cycle -- a time when estrogen levels are low. In the second part, the women were given an estrogen patch to wear for one week, and the jaw pain experiment was repeated. In both instances, researchers recorded the women's reactions to the pain, while the PET documented brain activity.

The result: Under high estrogen conditions, the number of brain receptors available to receive endorphins increased dramatically, compared to the low estrogen conditions. During high estrogen times, the women also showed what researchers called a "remarkable" ability to release endorphins and activate the receptor sites.

The women reported less pain when estrogen levels were high, even though the level of pain inflicted was the same as it was during their low estrogen cycle, Zubieta says.

The data, now being confirmed in larger studies, hints at the powerful effects of female hormones on the pain and stress response, he adds.

Chronic Pain Often Untreated in Nursing Homes

Reuters Health
By Stephanie Riesenman
Monday, February 17, 2003

NEW YORK (Reuters Health) - Nursing home residents may not get adequate pain relief, due to their own fears of drug abuse or dependence, or because staff may be too over-worked to recognize a patient's pain, according to a new study.

"There is no reason for folks to be suffering with pain on a daily basis, we have the tools to take care of it, we have the knowledge to take care of it, we just need to do it," said Dr. Michael Gloth, associate professor of medicine at Johns Hopkins University in Baltimore, Maryland.

A fellow of the American Geriatrics Society, Gloth was not involved in the research.

In the study, which was funded by the National Institutes of Health, Dr. Debra K. Weiner of the University of Pittsburgh and her colleague Dr. Thomas E. Rudy surveyed nursing home staff and residents. They consulted 75 nurses, 75 certified nursing assistants (CNAs) and 75 residents who said they had pain or discomfort on a daily basis. The results are published in a recent issue of the Journal of the American Geriatrics Society.

The study found that nursing home residents don't speak up about their discomfort because they believe it can't be treated, or fear they might become addicted to medications prescribed to treat their pain. Many elderly said that nurses did not acknowledge their complaints--possibly because the symptoms weren't physically obvious.

The most common response by nursing assistants in the survey was a lack of time to attend to all the needs of residents. Both nurses and CNAs believe that pain complaints by the elderly often go unheard.

Residents requiring the most assistance with daily activities had the strongest opinions about management of persistent pain. The researchers concluded that residents who are more mentally and functionally disabled believe nursing staff label them as unworthy of pain treatment.

Gloth said studies estimate 45% to 80% of nursing home residents experience some type of chronic pain, yet pain management has historically been overlooked in medical school training.

"We have seen more and more medical schools incorporate issues like pain management and end of life care into the medical school curriculum, but less than one third have anything like that in their curriculum right now," said Gloth. The researchers conclude that "effective pain management in the nursing home requires that all members of the primary caregiving team (CNAs, nurses and physicians) have the necessary knowledge, attitudes, and skills to implement this important agenda."

However, facilities must learn to do this with a limited staff and a finite budget.

There have been several studies and reports indicating that nursing homes nationwide are understaffed. Gloth says nursing facilities are desperate to hire more personnel, but they simply don't have the funding.

It's important to recognize that health care and education in the nursing facility is a "team approach," said Gloth. He recommends that medical directors put protocols in place to educate all staff members on how to recognize and adequately manage chronic pain.

Families of residents in nursing homes can help, he said.

"I am convinced that family members need to play an important role in terms of selecting a facility and as serving as advocates for pain control for loved ones who may not be able to perform that role adequately themselves," said Gloth.

SOURCE: Journal of the American Geriatrics Society 2002;50:2035-2040.

The Pitfalls of Over-the-Counter Painkillers

Campaign alerts consumers to dangers of widely used drugs

THURSDAY, Nov. 7 (HealthScoutNews) -- Your over-the-counter anti-inflammatory pain medications may not just kill pain -- they may kill you.

More than 16,500 people die each year and 103,000 are hospitalized for serious complications caused by pain relievers known as non-steroidal anti-inflammatory drugs (NSAIDs), says the National Consumers League (NCL). "People mistakenly assume that if a prescription is not required for a medication that is sold in a drugstore or a supermarket, then it must be safe," NCL president Linda Golodner says in a news release.

"As a result, consumers who too often self-diagnose and self-treat without seeking a doctor's advice unwittingly put themselves at risk for potentially deadly consequences," Golodner says.

The NCL has started a campaign to educate the estimated 30 million Americans who use NSAIDs about the possible dangers of the products. As part of the campaign launch, the NCL released results of national survey of people who use NSAIDs.

The survey found that 64 percent of the survey respondents are unconcerned about possible serious side effects caused by NSAIDs, including stomach bleeding or ulcers.

Only 5 percent of the respondents talked with their doctor about potential risks for serious side effects caused by NSAIDs (stomach bleeding, ulcers, kidney and liver problems), and two of five respondents said they'd never talked with a doctor, pharmacist or health professional about such medicines.

Nearly 30 percent of the respondents said they don't usually read instructions on the labels because they think they already know what to take.

The NCL campaign to educate people about the dangers of over-the-counter painkillers will include public service announcements and consumer education. A new brochure about the painkillers is available at the NCL.

The U.S. Food and Drug Administration has more information about over-the-counter drugs.
SOURCE: National Consumers League, news release, October 2002

Monroe Wyatt Pattillo, Jr. - On NSAIDs and Acetaminophen

Oh, for the ability to publicly respond in real time to statements in commercials so that the general populous would be able to hear another side of the story. Kind of an MST3K for commercials. The one example that disturbs me the most is the reoccurring commercial battle between NSAIDs (like aspirin) and Acetaminophen (like Tylenol), usually with the acetaminophen suppliers firing the most outrageous vollies.

First some medical terms for those not into this sort of stuff. Aspirin is an NSAID (pronounced IN- said). It is a member of the Salicylates (pronounced SA-li-sill-ates) family of drugs. They come from the bark of the willow tree. A chemical synonym for aspirin is acetophenetidine.

A chemical synonym for acetaminophen (pronounced a-seat-a-MIN-oh-fen) is 4-hydroxyacetanilide.

Both of these are CNS (Central Nervous System) agents since they both provide an anesthetic action. A pain reducer is an anesthetic. An inflammation reducer is an analgesic. A fever reducer is an antipyretic.

Is NSAID a bad word or does it just sound bad? In reality it just sound bad. NSAID is an acronym for Non-Steroidal Anti-Inflammatory Drug. In other words, its a medicine which is not a steroid and it reduces inflammation. No harm in that, actually sounds kind of innocent and helpful. But by using the acronym NSAID in commercials to people who are not told what the acronym stands for, it makes the word and the competition's NSAID products sound really harmful. Now that doesn't mean that acetaminophen is a steroid, however since it is not an NSAID, it does put in a category of drugs which do nothing to alleviate inflammation.

The next time you are having any form of muscle or joint pain, ask yourself whether or not the area in question is red, puffy, or swollen. If it is any of these, then it is inflammed, which is associated with a fluid build up in the affected area.

To alleviate your symptoms, you need to reduce the pain and reduce the inflammation. What you need is a medicine which has an anesthetic action (pain killer) as well as an analgesic action (reduces inflammation). NSAIDs, like aspirin, are included in that category. They kill pain and reduce inflammation. Acetaminophen, while it does kill pain, it does not reduce inflammation.

If you have arthritis, you be the judge. The latest acetaminophen commercial says that arthritis pain is not caused by inflammation. I guess if the acetaminophen commercial were not telling the truth about arthritis pain, then the good folks at the Arthritis Foundation would step in with the truth, but they haven't, so the commecial must be telling the truth, right. Oh, by the way, did you know that the makers of Tylenol (acetaminophen) have given heafty amounts of funding (about one million dollars in one year) to the Arthritis Foundation for research. What was that one about not biting the hand that feeds you.

Ignore the commercial spokesperson and the brand names, look for the types of medicines you need to alleviate your symptoms. Anethestic for pain. Analgesic for inflammation. Antipyretic for fever.

Now lets compare side effects to see which is worse, NSAIDs or acetaminophen. NSAIDs can cause stomach upset is some individuals and therefore should not be taken by those who have stomach ulcers or who have hyperacidic stomachs. It should also not be taken by those who have an allergic reaction to aspirin. Aspirin, in particular, should not be used for fever reduction with children as this can lead to a complication known as Rye's syndrome which can lead to hearing loss or other more threatening complications. End result is that a certain set of individuals and a certain range of ages of children should not use aspirin. For the rest of us, NSAIDs are the best thing going. In fact, it has been proven that low dosage aspirin therapy is helpful in the prevention of secondary heart attacks. What this comes down to is that NSAIDs are helpful when used wisely. This can be said for just about any medicine.

Now to our other friend, acetaminophen. Turns out that about 95% of acetaminophen is passed through the body and out the urine, which is very good, but what, you might ask, about that other 5%? Turns out that for most people that other 5% attaches itself to features in your liver and reduces the liver's ability to function properly. Most people have no difficulty recovering from this effect. Five percent you might say is no big deal, but consider the following, are there classes of individuals for which this could be a bad thing? Yes indeed. Those individuals whose liver is not up to normal performance levels, such as those who like to consume alcohol at more than a couple of drinks per week, or those who already have a liver problem, such as those with hepatitus or other liver disease. For these individuals, acetaminophen can cause a temporary or a permanent shutdown of liver function. This can lead to hepatitus or even death. The next time you read the label on a bottle of acetaminophen and the dosage is two every four hours, you might think twice before popping four or more in less than four hours. Complete and permanent liver shutdown can occur in some individuals who overdose on acetaminophen and do not receive prompt specific treatment.

Seems as though there is another issue with acetaminophen which doesn't get a level of press coverage equal to its seriousness. Since we shouldn't be giving aspirin to a young child with a fever we have been giving them a liquid formulation of acetaminophen. All well and good, but did you know that this liquid formulation is concentrated and is usually about three time stronger than your acetaminophen pills or capsules, and it is sold over the counter. When the dosage says drops, it means drops, not droppers full. Children have suffered serious liver damage and death from liver failure due to their parent's overdosing them on acetaminophen. Just because its for infants and its in liquid form doesn't mean that it should not be taken seriously when giving it to children.

The conclusion is that all medicines should be taken seriously. They should be accepted for their shortcomings as well as their benefits. There is no perfect pill. NSAIDs aren't as bad as they would have you believe and acetaminophen isn't as innocent as they would have you believe. Unfortunately, you have to do your homework, get some knowledge, and be your own judge. Don't leave the fate of your health up to the medicine company executives who tell the commercial spokesperson what to say to convince you to buy their product instead of the other guy's.

The following are a few of the links I used to uncover the above information, just to let you know that I am not completely unfounded in my statements.

You can go to the home pages of these organizations and use their search engines to look for key words like, acetaminophen, liver, aspirin, etc.

USP (US Pharmacopeia)
Official American Medical Association (AMA) Home Page
National Institutes of Health (NIH)
American College of Rheumatology Home Page
Arthritis Foundation

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