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Placebos, Words and Drugs: Sharing Common Mechanisms of Action

by Pamela Katz Ressler, MS, RN, HNB-BC, Adjunct Clinical Assistant Professor, PREP, Tufts University School of Medicine

Internationally recognized expert on pain and placebo, Dr. Fabrizio Benedetti will be exploring the topic “Placebos, words, drugs:  Sharing common mechanisms of action” on Wednesday, December 6 from 2:30-3:30 PM at Tosteson Medical Education Center (TMEC) 328, 260 Longwood Ave, Boston MA. Dr. Benedetti is a professor of neuroscience at the University of Turin Medical School in Turin, Italy. He was featured on the podcast RadioLab along with Tufts Pain Research, Education and Policy Program, founder and director, Dr. Dan Carr. To learn more about Dr Benedetti’s lecture, contact Program in Placebo Studies  

Fabrizio Benedetti, MD

“Placebos, words and drugs: sharing common mechanisms of action”

Professor, University of Turin Medical School, Neuroscience Dept, Turin, Italy
Center for Hypoxia, Plateau Rosà Labs, Plateau Rosà, Italy/Switzerland

Wednesday, December 6th
2:30 – 3:30pm

Tosteson Medical Education Center (TMEC) 328
260 Longwood Ave, Boston, MA 02115
For more information contact: placebostudies@bidmc.harvard.edu | 617-945-7827

Add comment November 29th, 2017

Virtual Reality in the Future of Pain Care

by Vivian Feng, MS-PREP Student

Virtual Reality (VR) is the computer-generated simulation of a three-dimensional environment which people can interact with using special electronic equipment. Through a portable headset with built-in screen and motion gloves, the audiences can discover an alternate universe. VR technology has piqued the interest of major companies like Google, Facebook, Microsoft, and Sony, as each of these companies has released its own VR products over the past years.

In an article published in Recode, author Jason Brush (2016) explains the success of VR and its impact in the digital-tech industry. Brush asserts that VR has the power to fully immerse its audiences into the virtual world. In addition, VR demands its audiences to be fully aware of their surroundings, and encourages them to mindfully engage in the experiences. No prior art or technology has make anyone feel so strongly present in another time and space.

Recently, VR has been suggested to be a potential tool for pain management. Based on the gate theory of pain processing, some researchers postulate that VR can reduce acute pain by triggering other senses to overwrite the original pain signal. Other researchers hypothesize that VR can reduce pain via cognitive attentional mechanisms, or it can lessen the anxiety related to pain with its psychotherapeutic property (Jones, Moore, & Choo, 2016). While the mechanism remains to be unclear, some studies have support the use of VR in acute pain management. For example, a study shows that VR has significantly reduced the amount of opioid medication administered during painful wound care procedures (McSherry et al., 2017). This suggests that VR may be the effective alternatives to opioid medication, and a suitable treatment regimen for the integrated pain management program. There are no valid evidences for the support of VR in managing chronic pain. Nevertheless, VR is generally viewed with great potential in helping pain management and supporting physical rehabilitation.

While acknowledging the potential of VR, we should be aware that the technology is still in its early stage of development. It is uncertain to what extent VR can impact its audiences after long-term use. Since VR can create the powerful illusion that leads people into accepting another reality, it may increase the risk of depersonalisation. To put it in another way, the physical body and actual surrounding may seem unreal to individuals after extended immersion in a virtual environment (Ananthaswamy, 2016). We do not know whether VR is safe for everyone. Without knowing the possible risks, it is inappropriate to introduce VR into pain treatment or any integrative pain management program.
There is also the ethical conundrum of deciding the rightful boundaries of human experiences with VR technology. Should all kinds of experience be available through VR? What happens when people can cross into unethical territory with VR’s strong manipulation of perception? Is it acceptable if the experience is for a good cause? As VR blurred the line between fantasy and reality, using the technology while abiding with ethical principals becomes a real challenge (West, 2016). This challenge may be even more complex when we consider the parallel nature between virtual and authentic reality. Based on the observations in neuroscience, we understand our physical surrounding through the processing of sensory information. Neural signals encoded by our various sense organs are transduced through neurons to the organizing network in our brains. The same biological mechanism is triggered when we perceived sensory information from both the virtual reality and the reality we exist in. Does this mean that we are merely comparing biological virtual reality that is generated by our brain with the artificial virtual reality that is generated by technology? Can we even consider one experience to hold more value than the other based on the provider of that experience?

The practicality and safety of VR remains to be determined, and some ethical questions need to be addressed before fully introducing VR into the world of novel technologies. Nevertheless, we can see the future direction of pain treatment through the example of VR. Researchers have relied less on biochemical solution, and shifted their interest to cognitive and psychological intervention for pain relief. Researchers are also becoming more creative, as they attempt to integrate current technology into therapy and symptom management. There is no doubt that digital technology can be a positive driving force for future medicine. However, it is equally important to make sure that our good intention doesn’t hurt the interest of others. We should be cautious with novel technologies, but keep our faith in their potential to benefit future medical treatments.

Bibliography

Ananthaswamy, A. (2016, March 4). Virtual reality could be an ethical minefield – are we ready? Retrieved July 24, 2017, from https://doi.org/10.3389/frobt.2016.00003

Brush, J. (2016, July 19). Why virtual reality matters. Retrieved July 24, 2017, from https://www.recode.net/2016/6/28/12046730/virtual-reality-vr-creative-content-industry-investment

Jones, T., Moore, T., & Choo, J. (2016). The impact of virtual reality on chronic pain. PLoS ONE, 11(12), 1–10. https://doi.org/10.1371/journal.pone.0167523

McSherry, T., Atterbury, M., Gartner, S., Helmold, E., Searles, D. M., & Schulman, C. (2017). Randomized, Crossover Study of Immersive Virtual Reality to Decrease Opioid Use During Painful Wound Care Procedures in Adults. Journal of Burn Care & Research, Published Ahead of Print(). https://doi.org/10.1097/BCR.0000000000000589

West, D. (2017 July 20). The ethical dilemmas of virtual reality. Retrieved July 24, 2017, from https://www.brookings.edu/blog/techtank/2016/04/18/the-ethical-dilemmas-of-virtual-reality/

Add comment September 14th, 2017

Innovative Teaching in the Pain Research, Education and Policy Program

The Pain Research, Education and Policy Program (PREP) is innovative in its mission — “To champion an interprofessional educational program that addresses the multidimensional public health burden of pain by preparing diverse learners to contribute with expertise and compassion to pain research, education and policy”. To achieve this mission, our faculty must also be innovative and agile in continually assessing, implementing and evaluating exciting ways to build dialogue and community among students, faculty, alumni and community experts.

Two of our faculty members, Pamela Ressler and Maureen Strafford, created an innovative model using VoiceThread for their course, Mindfulness and its Application to the Experience of Pain. Read more about their success by clicking here

Add comment September 12th, 2017

Summer Course Offering: Interprofessional Team Management of Pain

Join other graduate learners this summer for a relevant, collaborative course at offered by Tufts’ Pain Research, Education and Policy Program. PREP 244, Interprofessional Team Management of Pain will be offered beginning June 4 as a blended learning course, with both onsite and online components. In today’s complex health care environment, interprofessional team practice is essential for optimal patient outcomes and satisfaction as well as preventing adverse events and decreasing provider burnout.

PREP 244 will be led by seasoned interprofessional clinical educators in the fields of medicine and psychology, along with guest lecturers in the fields of nursing, pharmacy and occupational therapy. Attendees will examine how teams function as small groups, identify how to shape cohesive functional groups, and develop skills to turn threats to team function from destructive forces to constructive/creative elements. In keeping with PREP’s approach of developing leaders in healthcare, attendees will be equipped to assume leadership roles in the assessment and treatment of pain within multiple organizational models, including the medical home.

Dates and Location of the Course:

Boston, MA (onsite): Sunday June 4 (3-6 pm) and Monday June 5 (9 am-5 pm) with dinner on Sunday and breakfast and lunch on Monday included.

Online synchronous sessions (via WebEx videoconferencing): Wednesdays (6-8 pm ET) June 7, 14, 21, and 28

Course can be taken for graduate credit or as a non-credit course. For more information, contact the course  co-director, Dr. Daniel Carr (Daniel.Carr@tufts.edu)

 

Add comment May 7th, 2017

PREP Faculty Recognized by the American Academy of Pain Medicine

L-R Dr Zahid Bajwa, Dr Dan Carr, Founder of PREP and President of AAPM, Dr Libby Bradshaw, Academic Director of PREP

On March 17, at its annual meeting held in Orlando, Florida, The American Academy of Pain Medicine (AAPM) formally recognized the faculty of the Tufts Pain Research, Education and Policy Program (PREP) for providing interprofessional pain education since 1999 to practicing health professionals as well as students seeking to transition to graduate or professional degree programs. The theme of this year’s AAPM meeting was Pain as a Public Health Issue. The PREP program is housed within Tufts University School of Medicine’s Department of Public Health making the recognition of its faculty especially appropriate.

Receiving Presidential Commendations were PREP faculty members:

Libby Bradshaw, DO, MS, Academic Director of the PREP program at Tufts University School of Medicine

Zahid Bajwa, MD

Ariana Desillier, MD

Carol Curtiss, RN, MS

Richard Glickman-Simon, MD

Lewis Hays, MD, MPH

Ronald Kulich, PhD

Ewan McNichol, RPh, MS

Srdjan Nedeljkovic, MD

Pamela Ressler, MS, RN, HNB-BC

Sharon Schwarzburg, EdD, OTR/L, FAOTA, CGP,FAGPA

Steven Scrivani, DDS, DmedSc

Marybeth Singer, MS, ANP-BC, AOCN, ACHPN

Maureen Strafford, MD

Additionally, Cindy Steinberg, longtime colleague of the PREP program received a Presidential Commendation for her ongoing leadership and advocacy for individuals living with chronic pain through the US Pain Foundation, and Michael Schatman, PhD, a a new member of the PREP faculty and Editor-in-Chief of the Journal of Pain Research, presented at the annual meeting.

Selection of the recipients of the AAPM recognition was on the basis of their individual and collective contributions to improve the lives of people living with chronic pain.

The PREP program is honored to be recognized  by the AAPM for the contributions it has made in leading the way with an interprofessional educational program that addresses the multidimensional public health burden of pain by preparing diverse learners to contribute with expertise and compassion to pain research, education and policy.

Add comment March 22nd, 2017

The Affordable Care Act with a Trump Presidency

Guest Post by Signe Peterson Flieger, Tufts Health Plan Professor of Health Care Policy Research,
Department of Public Health and Community Medicine, Tufts University School of Medicine

Many of you are likely wondering what do the election results mean for health care in the UniPhoto Signe Fliegerted States? Candidate Trump repeatedly stated he would repeal and replace the ACA on day one of his presidency. Since becoming President Elect Trump, he has declared that his three main priorities are: immigration, health care, and “big league jobs”. Just yesterday, he released his proposed health care plan on his transition website. While thin on details, it reiterates his plans for the elimination of the ACA:

A Trump Administration will work with Congress to repeal the ACA and replace it with a solution that includes Health Savings Accounts (HSAs), and returns the historic role in regulating health insurance to the States. The Administration’s goal will be to create a patient-centered healthcare system that promotes choice, quality and affordability with health insurance and healthcare, and take any needed action to alleviate the burdens imposed on American families and businesses by the law.   

Not surprisingly, health care, and more specifically the fate of the ACA, is squarely on the table. Repealing the ACA has been a repeated strategy among Republicans in Congress. Now, with interests more clearly aligned among the newly elected members of the executive and legislative branches, many health policy wonks are weighing in on what can actually happen. Despite many thoughtful opinions on the topic, major uncertainty remains.

With that said, there is pretty much agreement on the means by which the ACA could be dismantled. In order to do a full repeal, Republicans would need 60 votes in the Senate to prevent a filibuster by Democrats. Unless there is a Republican strategy for eliminating the opportunity to filibuster, as Austin Frakt has suggested or the ability of the Democrats to maintain a filibuster wains throughout the Trump presidency as Megan McArdle from BloombergView posits, a full repeal is likely off the table.

Filibuster issue aside, remember how Obamacare was passed by Democrats once Republican Scott Brown won the Massachusetts Senate seat? Yes, that’s right – budget reconciliation. This process cannot be stopped by a filibuster, so a simple majority is sufficient. There are some limitations on what can be included in a budget reconciliation process. Tim Jost’s recent blog post on Health Affairs explains this well:

Budget reconciliation legislation is subject to strict procedural and substantive limits. Reconciliation in the Senate can only contain provisions that affect the revenues and outlays of the United States and cannot contain “extraneous provisions” that only incidentally affect revenue and expenditures. Budget reconciliation is a two-step process—first Congress adopts a budget resolution with instructions to committees to meet reconciliation targets and then it adopts the reconciliation itself. This cannot happen on “day one.”

This strategy was attempted earlier this year when the Restoring Americans’ Healthcare Freedom Reconciliation Act was sent to President Obama’s desk. President Obama vetoed it, but we cannot expect the same response from President Trump.

In addition to reiterating the likelihood of the process, the budget reconciliation bill sent to President Obama earlier this year gives us some insight into which components of the ACA might be on the chopping block. The Congressional Budget Office (CBO) scored the bill, and a House summary highlights many of the ACA provisions at risk, detailing the elimination of: the optional Medicaid expansion, tax credits (i.e., subsidies) for health insurance premiums in the exchanges, the individual mandate and penalties, employer requirements and associated penalties, the Prevention and Public Health fund, and the higher Medicare tax rate for individuals above $200,000 and couples making more than $250,000, among other things. Importantly, this bill reinstated additional payments for providers with a disproportionate share of Medicaid and uninsured recipients, since those providers would no longer being receiving reimbursement through insurance for this population and included some funding for state substance use and mental health programs.

Regardless of the means of repealing provisions of the ACA, there remains uncertainty about what a replacement plan would look like. We don’t know when the replacement will come. Will replacement be ready to go alongside the dismantling of other aspects of the ACA? Or will the ACA be taken down first? And perhaps even more importantly, what will a replacement include? As detailed in President Elect Trump’s recently released proposal, health savings accounts and enabling individuals to buy insurance across state lines appear to be central to his plan for replacement. We could also look to Speaker of the House Paul Ryan’s proposal for replacement, which has slightly more details. Here, we see some support for keeping private insurance reforms that are part of the ACA (e.g., keeping young adults on their parents’ plan until age 26 and protection for people with pre-existing conditions). This is consistent with President Elect Trump’s recent change in rhetoric, although not in substance, from his interview with the Wall Street Journal on Friday after the election where he suggested he was open to keeping these two components of the ACA in place. Perhaps he now knows that a full repeal is not possible.

On Medicare, all we know from Trump’s written plan is a call to “modernize Medicare” to preserve it for baby boomers and beyond, while Ryan’s plan explicitly calls for enabling beneficiaries to choose private plans as alternatives to traditional Medicare starting in 2024, eliminating the Independent Payment Advisory Board, with continued investment in alternate payment models.

Both plans propose block granting Medicaid to the states, in other words, eliminating the entitlement part of the Medicaid program. Again, the details matter here. With the elimination of the Medicaid expansion, certainly fewer people would be covered by the program, and the relative robustness of the program for those traditional eligible for Medicaid pre-ACA would depend on how well these proposed block grants keep up with expected costs for this population.

There is also debate about what will happen to the Innovation Center at CMS, the hub of payment and delivery system reform innovation created through the ACA. While the recent bipartisan MACRA law has embedded value-based payment into the Medicare program outside of the ACA, there has been reported opposition to the Innovation center by Republicans in the past.

There will be attention to women’s issues as well. The reconciliation bill from earlier this year eliminated federal funds for Planned Parenthood, a position reinforced by Vice President Elect Mike Pence’s longstanding and vehement anti-planned parenthood stance. Trump’s plan reinforces existing law that “protect individual conscience in healthcare,” likely a call to the  Weldon Amendment, reiterated in Ryan’s plan which currently prohibits the federal government from discriminating against any health care entity or provider who does not pay for, provide, or refer for abortion services. NARAL has their own perspective on the Weldon Amendment. Remember, how one of the ACA provisions is the requirement for contraceptives to be covered by health insurance without a copay? There are already reports of women rushing to get long-acting birth control (i.e., IUDs) in the few days since the election.

On the other hand, there is a real question of whether the Trump Administration and the Republicans in Congress will actually go through with the dismantling as proposed. For example, McArdle suggests Republicans might not really want to eliminate some of the ACA provisions. She rightly explains that there are parts of the ACA that are particularly popular with Americans, especially the private health insurance reforms that make it possible for people who are sick to get health insurance without having to pay more.

While, yes, Republicans have repeatedly voted for repeal, so far they have always known it could not result in victory. Now, the stakes have changed. Will they really be willing to take health insurance away from the more than 20 million people estimated by to lose health insurance under a full repeal, likely with similar implications under a severe dismantling? While public polling suggests that people do not actually know the significant impact the ACA has had on the rate of the uninsured, bringing it to an all-time low of 8.6 percent counting seniors, polling also suggests support for the private insurance reforms.

One thing is certain. The Republicans now dictate the health care reform agenda and there are serious concerns about what a dismantling of the ACA would mean for many Americans struggling to pay their health care bills and access to high quality health care, not to mention the potential impact on the federal deficit. Despite the rhetoric that suggests the Trump Administration will eliminate the ACA right away, the reality of the policy making process, implementation challenges, and the desire not to throw people off of health insurance overnight suggest that most of the significant changes to the ACA will take some time.

Add comment November 14th, 2016

Dr Dan Carr Moderates Governors Panel on Opioids

by Pamela Ressler, MS, RN, HNC-BC, Adjunct Assistant Clinical Professor, Pain Research , Education and Policy Program, Tufts University School of Medicine

Governor Charlie Baker and Dr. Dan Carr

Massachusetts Governor Charlie Baker and Dr. Dan Carr, Director of the Tufts Pain Research, Education and Policy Program

Dr. Daniel Carr, Director of the Pain Research, Education and Policy Program at Tufts University School of Medicine recently moderated an esteemed panel at the International Conference on Opioids held at Harvard University. Panelists included all six governors of the New England states: Gov. Charlie Baker, MA; Gov. Maggie Hassan, NH; Gov. Paul LePage, ME, Gov. Dannel Malloy, CT; Gov. Gina Raimondo, RI; and Gov. Peter Shumlin, VT.  The discussion of state by state initatives was framed around the topic of the conference: Opioids the New Normal — The future of opioid prescription. The balance between opioid overuse and addiction and effective treatment for those suffering with chronic pain is a difficult one. The bipartisan panel agreed that a multimodal approach will be necessary for systemic societal change. To watch the entire panel discussion moderated by Dr. Carr,  click here  This unprecedented forum was featured in a wide variety of media, including a front cover editorial (“Self-medicating in the opioid crisis”) in the June 18 issue of The Lancet.

 

Governor's Panel w NE Governors and Dr Dan Carr

Governors Panel with moderator Dr. Dan Carr 2016 International Conference on Opioids

Add comment June 15th, 2016

PREP Program Represented at AAPM Scientific Meeting

PREP AAPM 2016 speakers

L-R Marta Illueca, Heather Tick, Elvira Lange, Beth Murinson Hogans

by Pamela Katz Ressler, MS, RN, HNB-BC, faculty Pain Research, Education and Policy Program, Tufts University School of Medicine, and PREP-Aired blog moderator

The American Academy of Pain Medicine recently held a scientific meeting with several PREP-affiliated presenters. The topic “Non-pharmacological/Integrative Therapies: Pearls” was moderated by former PREP student,  Heather Tick, MD, of the University Washington, Seattle.

The panel featured current PREP student, Marta Illueca, MD, sharing insights on spirituality and religion-based therapies across the continuum of pain and suffering; as well as PREP guest lecturer, Beth Murinson Hogans, MD discussing evidence-based recommendations for acupressure versus trigger-point massage.

Current PREP student Marta Illueca presenting at AAPM Scientific Meeting

Current PREP student Marta Illueca presenting at AAPM Scientific Meeting

Additionally, Elvira Lange, MD  introduced evidence-based hypnotic techniques in acute care settings to the audience.

The Pain Research, Education and Policy Program (PREP) is exceptionally proud that program’s  director and co-founder, Dan Carr, MD  is currently serving as the president of the American Academy of Pain Medicine, furthering the mission of the PREP program: “To champion an interprofessional educational program that addresses the multidimensional public health burden of pain by preparing diverse learners to contribute with expertise and compassion to pain research, education and policy.”

L-R Beth Murinson Hogans, Libby Bradshaw (Academic Director, PREP), Marta Illueca, Elvira Lange, Heather Tick, Dan Carr (Director and co-Founder PREP)

L-R Beth Murinson Hogans, Libby Bradshaw (Academic Director, PREP), Marta Illueca, Elvira Lange, Heather Tick, Dan Carr (Director and co-Founder PREP)

 

Add comment April 25th, 2016

National Pain Strategy Announced by U.S. Department of Health and Human Services

by Pamela Katz Ressler, MS, RN, HNB-BC, faculty Pain Research, Education and Policy Program, Tufts University School of Medicine, and PREP-Aired blog moderator

The U.S. Department of Health and Human Services has announced the federal government’s first coordinated plan for addressing the immense burden of pain that affects millions of adults and children in the United States. The National Pain Strategy (NPS) is a direct result of recommendations put forth in the 2011 Institute of Medicine’s report, Blueprint for Transforming Pain, Prevention, Care, Education and Research, calling for a cultural transformation in pain prevention, care and education as well as recommending a comprehensive population health-level strategy.

Dr. Daniel Carr

Patients, patient advocates, researchers, and pain-related professional groups such as the American Academy of Pain Medicine (AAPM) played an instrumental role in the development of the National Pain Strategy (NPS). Participants included Dr. Daniel Carr, the director of the Pain Research, Education and Policy Program (PREP) at Tufts University School of Medicine and the current president of the American Academy of Pain Medicine. In discussing the importance of the National Pain Strategy and its relevance to the public health crisis surrounding opioid abuse, Dr. Carr stated “The NPS is comprehensive and far-reaching in scope. The other influential pain report released within days of the NPS — CDC’s Guideline on Opioid Prescribing — extends current efforts focused upon reducing opioid abuse. I believe the opioid epidemic will be brought under control, in large part through public and professional education about the broad spectrum of options for treating pain, as advocated in the NPS. As the opioid epidemic recedes, patients, health care professionals, and policy makers will look to the NPS for guidance on enduring, systems-level solutions to improving the assessment, treatment and prevention of pain–and reducing disparities in access to quality pain care.”

The Pain Research, Education and Policy program at Tufts will continue to lead the way in training leaders in the comprehensive field of pain, working to reduce the burden of pain and suffering for individuals, families and society.

 

Add comment March 24th, 2016

Unintended Consequences

by Pamela Katz Ressler, MS, RN, HNB-BC, Faculty, Pain Research, Education and Policy Program, Tufts University School of Medicine, moderator of PREP-Aired Blog

The PREP program congratulates faculty member Carol Curtiss, MSN, RN-BC on the publication of her article, I’m Worried About People in Pain, in the American Journal of Nursing ( AJN, Jan 2016, Vol 1Carol Curtiss, MSN, RN16, No. 1).  Carol skillfully argues that while both chronic pain and prescription drug abuse are public health crises in the U.S., efforts to address opioid abuse may lead to unintended consequences for people who suffer with persistent pain and benefit from responsible use of opioids as part of a comprehensive treatment plan.  As we tackle the complex public health crisis of prescription abuse through regulation and policy, we must also remain cognizant of the needs of those who suffer from chronic pain by including pain clinicians and patients at the health policy table.

Add comment March 22nd, 2016

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