by Pamela Ressler, MS, RN, HNC-BC, Adjunct Assistant Clinical Professor, Pain Research , Education and Policy Program, Tufts University School of Medicine
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.
Governors Panel with moderator Dr. Dan Carr 2016 International Conference on Opioids
June 15th, 2016
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
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)
April 25th, 2016
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.
March 24th, 2016
by Libby Bradshaw, DO, MS, Academic Director, Pain Research, Education and Policy Program and Daniel Carr, MD, Director, Pain Research, Education and Policy Program, Tufts University School of Medicine
We were delighted and extremely proud to learn that PREP graduate and faculty member Pamela Ressler, MS, RN, HNB-BC was just named to the Medicine X Program Executive Board as a Senior Leader for this renowned, cutting edge program. Six years ago while a student in the PREP program, Pam began to explore the use of social media by patients with chronic pain and other disabilities, as a mean to overcome their social isolation. Pam started and maintains this same PREP-Aired blog. Pam’s award-winning PREP Capstone project characterized this emerging social trend in detail, and led to subsequent publications in the professional and lay press, and numerous speaking engagements. She has collaborated with other faculty members in Public Health at Tufts, including Libby Bradshaw, Lisa Gualtieri and Ken Chui, in the PREP and Health Communication programs.
As a faculty member in the PREP program, Pam has taken on the role of Course Director for established courses such as those on the social and ethical dimensions of pain, and end-of-life and palliative care issues (another section of the latter course is taught by Lewis Hays). Recently with the assistance of PREP faculty Maureen Strafford, Pam inaugurated a well-received PREP course in mindfulness and pain. Outside of the PREP program, Pam is the founder of Stress Resources in Concord, Massachusetts, a firm specializing in building resiliency for individuals and organizations through tools of connection, communication and compassion.
Pam first began to present at Medicine X in 2014. As described on its website, Medicine X is an initiative “designed to explore the potential of social media and information technology to advance the practice of medicine, improve health, and empower patients to be active participants in their own care. The ‘X’ is meant to evoke a move beyond numbers and trends—it represents the infinite possibilities for current and future information technologies to improve health. Under the direction of Dr. Larry Chu, Associate Professor of Anesthesia, Medicine X is a project of the Stanford AIM Lab.”
Further details on this important appointment may be found at http://medicinex.stanford.edu/2016/01/05/program-board/
January 26th, 2016
Guest blogger: Felice Indindoli, MS-PREP 2015, MAc 2015, Tufts University School of Medicine, Pain Research, Education and Policy Program
Raring to go! That’s me. Upon entering the MS-PREP program I made quick work of getting a grant and press pass to fly out to the PainWeek Conference, 2013, in Las Vegas. It comes with my territory; jump with both feet or don’t jump (it hurts more when you leave a limb behind) and it was time to immerse myself in the goings-on in the world of pain research.
My prior ventures into pain research and theories about pain were mainly on the literary side. Great writers have said great things about the human experience of pain with full realization that cosmic irony applies; language fails us in the face of pain. From the point of view of narrative, this is a massive conundrum. A lot can be said about that, or nothing.
Off I went to PainWeek with an editor’s sense of story development. I was eager to report on the conference. And, as someone not new to the learning process, I wanted to discover just what I’d gotten myself into pursuing both research and clinical degrees in pain management.
Kid in a candy store. That was me at the conference. But, in wrangling with the mountain of new material I had to absorb, fascinating though it was, I found myself in an odd place: speechless. Looking back, it was an apt response (or lack thereof and still appropriate) in the face of so much new information. Odd how it seemed to parallel what I knew from literature about the language of pain, the metaphors and analogies all refer to the evaporation of meaning in language. Words mean nothing. Or, given a state of pain, one has no words at all.
I left the conference with my memory and laptop stuffed with information about pain research. The second year of my acupuncture program was already in session and I’d just missed a cool week of class and lab to attend the conference. As I started to unpack what I’d learned, the writing process turned swiftly from thinking about what I had learned to, “what was I thinking?” in taking on a full week of pain research. Ouch…no pun intended.
Some of the most thought provoking talks at the conference were subjects I would soon tackle in PREP classes, under the tutelage of highly experienced teachers and mentors, which proved essential to my gradual understanding of the landslide of pain information I had subjected myself to…willingly, I might add. The following topics were of particular interest:
• Learning to Unlearn: How Coaching is Changing the Pain Management Landscape
• When Does Acute Pain Become Chronic?
• The Complexity Model: A Novel Approach towards Improving the Treatment of Chronic Pain
• Glia and Chronic Pain
• Teaching the Five Pain Coping Skills
• The Mad Woman in the Attic: Pain and Personality Disorders
• Chronic Pain in Children: Are they a Population at Risk?
• Drug Diversion VS Pain Management: Finding a Balance
• Opioid-Induced Hyperalgesia: Clinical Implications for Pain Practitioners
• Rational Polypharmacy
• Interview with an anesthesiologist and researcher working on a new drug NKTR-181 (now in phase 3 trials): taking the likeability out of pain medication via slow rate of entry
• Living on the Edge: Depression, Pain, and Suicide
The above lists only a handful of the talks I attended during the week-long conference. But, hopping from bullet to bullet, this list traces my learning curve in the PREP program. Pain topics in 2013 have not fallen off the table in 2015; they remain relevant.
What did I know before I started the PREP program? As I mentioned, reading about the human experience of pain from the literary side only goes so far in the understanding of that experience from the clinical side, the pragmatics of what it means to diagnose, treat, and manage pain. What I did not know before the PREP program is that each time one approaches a patient with a pain dilemma, one immediately steps into a minefield of several other issues. The ripple effect was new to me. Pain isn’t separate from anything—it’s a cause and an effect. I began to understand this concept during the PainWeek conference and it was hugely motivating. I was also starting to see patients as an assistant and then intern in my acupuncture training—the “ah-ha!” light bulbs were going off everywhere. Almost too many to manage. For a newbie, the deep-dive into pain research, education and policy brought me to a place of near blindness. Education shines a very bright light on the unknown…you do the math.
The 12 bullets listed above weren’t just talks I attended at the conference; they represent opening lectures in my education on pain. Concepts in ethics and culture that I knew from literary references were turned, virtually overnight, into case studies on the impact society and our ability to listen to medical narrative have on the pain patient. Haruki Murakami, in his book 1Q84, says, “I can bear any pain as long as it has meaning.” For a healthcare practitioner, this is the hallmark of bearing witness: enter Social and Ethical Aspects of Pain, PREP 232, with Pam Ressler and Dr. Libby Bradshaw. This was the class in which I discovered my capstone topic (though I didn’t know it at the time). I remember admitting to Pam that my topic was messy, disorganized, big holes in the research, more questions than answers and that perhaps I shouldn’t “go there.” Her answer was, “perhaps you should.”
Topics on pharmacy and medicine that had been the subject of my pre-med studies, an interest in the history of medicine, and web content on parenting, were addressed in detail in Neuroanatomy and Neurochemistry of Pain, PREP 230, and Introduction to Clinical Pain Problems, PREP 234, with Dr. Dan Carr, Ewan McNichol, and Dr. Steve Scrivani. We examine the physical, the empirical while understanding that the experience and expression of pain do not survive our granular look at the specifics; in fact, they seem to evaporate. More neurons, less person. More person, less neurons. Either way, we may try to get our hands on the shadow of pain left by a scar and chase it into a corner so we might label it, manage it, or at the very least identify it with nothing to use as a benchmark or basis of comparison. We understand that Palahniuk’s words in his nightmarish Diary, “We have no scar to show for happiness,” underscore the horror inherent in grappling with pain; happiness will not be found hiding under the scar or by following the pain once its neurological pathway is established–it’s somewhere else. Where, you ask? Cue the psyche.
On matters existential and psychiatric, I would point to Shakespeare for a juicy literary explanation that undoubtedly summed up a world of hurt in verse. This resonates with other literary critics, such as Elaine Scarry in her book, The Body in Pain. She suggests, “Whatever pain achieves, it achieves in part through its unsharability, and it ensures this unsharability through its resistance to language. [She continues] “English,” writes Virginia Woolf, “which can express the thoughts of Hamlet and the tragedy of Lear has no words for the shiver or the headache.” … Physical pain does not simply resist language but actively destroys it.” For all her insight into Virginia Woolf and the human body as a political map, Scarry didn’t make patients more real to me than evaluating them in Dr. Kulich’s class, Psychological Approaches to Pain Management, PREP 238. That mangled language left in the wake of pain can be even more difficult to interpret in those patients who struggle with disorder, in and of itself, applied not only to their expression of pain but also to their thought processes and mental health. I remember the talk given at PainWeek, The Madwoman in the Attic: Pain and Personality Disorders, which borrowed its title from the landmark text written by Gilbert and Gubar, with the intention of infusing a ruthlessly unfunny topic with some sense of humor.
Of drug diversion, complexity models, and clinical trials, I can’t say I have a good literary reference. I was enlightened, however (and not without some degree of pain) by two epidemiology and biostatistics classes, Professor Mark Woodin’s Principles of Epidemiology, PH 201, and Professor Janet Forrester’s Epi-Bio: Reading Medical Literature, HCOMM 502. I can return to the PainWeek slide presentation on NKTR-181 and make sense of the visual display of the quantitative analysis. This feels like a different type of accomplishment to me, like looking under the hood of a car and knowing what to do. At the same time, one needs to be able to reverse-engineer the information; take the information, understand it scientifically, express it and then turn it back into information accessible to a lay audience, perhaps a patient. Alia Bucciarelli was instrumental in helping me further hone my writing and editorial skills by using them to address scientific and medical information in a semester-long directed study in Advanced Writing for Medicine, PREP 400. We took the research from my capstone project and turned it around for parents of adolescent girls with chronic abdominal pain. It’s not a short journey from a systematic search in PubMed, to articles on pediatric abdominal pain, to interpreting the stats and overarching epidemiological issues, to analysis and back again but writing this time 5 truly cogent bullet points for parents in need of reliable information.
For the PainWeek talks that focused on educational issues and touched on healthcare policy, I was able to lean into some literary insights on pain. The discussions about children and chronic pain research as well as the pitfalls of trying to teach adult chronic pain patients coping skills, I would later learn in Dr. Srdjan’s Nedeljkovic’s class on Public Policy, Legislative, and Forensic Issues in Pain, PREP 235, were both examples of those minefields I mentioned earlier. Children and pain research, adults and coping skills to manage reliance on medication—instant ethics dilemmas served up with a side of forensics. For literary references, there are two that I like. One is from C.S. Lewis in his book, The Problem of Pain. He says, “Pain insists upon being attended to. God whispers to us in our pleasures, speaks in our consciences, but shouts in our pains. It is his megaphone to rouse a deaf world.” What can we do, what are we supposed to do when roused in this way for the sake of children who are sick and in pain? More concerning is what happens when we do nothing. Of all of the PREP classes I took, it was in this class that I found myself dumbfounded more often than not in the face of policies that both help and hurt, the clever maneuvering of legal language that sometimes, always, or never (you chose) lives up to the actions it purports to protect or expose. But, one must understand these things in order to navigate the minefield of pain issues in a given case—it’s never just one patient, with one problem, somehow in a vacuum. For discussions about pain and education in general, I will end with my favorite literary author on pain, Alphonse Daudet. His book, In the Land of Pain, written in the late 19th Century while suffering the final stages of tertiary syphilis, is a simple yet brilliant collection of the writer’s thoughts and feelings. It brings us back to the significance of language in the study of pain. Daudet asks, “Are words actually any use to describe what pain really feels like? Words only come when everything is over, then things have calmed down. They refer only to memory, and are either powerless or untruthful.”
This is the essence of what I learned both at the PainWeek Conference and in the PREP program: the value of listening. It’s the golden rule of pain management. Learn how to do it and why. Policy or poetry? You tell me. Actually, I’ll let my patients do the talking.
October 25th, 2015
By Pamela Katz Ressler, MS, RN, HN-BC, Faculty, Pain Research, Education and Policy Program, Tufts University School of Medicine, PREP-Aired blog moderator
When Pope Francis recently visited the United States, CNN asked its viewers to share, in three words, what the Pope meant to them. What a brilliant idea! As September is Pain Awareness Month, we in the PREP program put forth a similar challenge to our alumni, faculty and current students. We asked “what three words express what you want the world to know about pain”. Here are the results of our query in the form of a word cloud and some three word phrases:
- “Don’t give up”
- “Try acupuncture first”
- “The invisible captivity”
- “Share with us”
- “Don’t be afraid”
- “There is hope”
What three words express what you want the world to know about pain? We welcome your comments.
September 29th, 2015
by Pamela Katz Ressler, MS, RN, HN-BC, Faculty, Pain Research, Education and Policy Program and PREP-Aired moderator, Tufts University School of Medicine
Five graduating PREP students took to the lectern on August 10, presenting their capstone projects to an audience of faculty, students, alumni, family and friends. After rigorous study and investigation, each student highlighted their chosen area of interest. While the capstones mark the culmination of matriculation in the PREP program, each of the graduates plan on continuing to expand their capstone projects in the areas of education, policy, and research as they move into their careers.
Congratulations to our newest graduates of the PREP program:
• Susan Neary, DVM
Integrating the Ancient Wisdom of Acupuncture into Modern Medicine: Using Case Studies in Developing CME for the Health Care Team
o Preceptor: Steven Scrivani, DMD
• Felice Indindoli
Gut Instinct: The Need for Guidelines in the Evaluation and Management of Chronic Abdominal Pain in Adolescent Girls
o Preceptor: Lisa Conboy, MA, MS, ScD
• Alexandra vander Baan
Mind Over Matter: The Development of a Pilot Study Combining Acupuncture and Mindfulness
o Preceptor: Maureen Strafford, MD
• Byron Cheng-Han Lu, MAOM
Wear Your Pain on Your Sleeve: Exploration of Fitness Wearables and Pain Tracking
o Preceptor: Pamela Ressler, MS, RN, HN-BC
• Abdulaziz Alfadhel, MD
Strategies that Transform: Toward Development of Electronic Self-Management Care in Chronic Pain Conditions
o Preceptor: Daniel B. Carr, MD
August 11th, 2015
By Pamela Katz Ressler, MS, RN, HN-BC, Faculty, Pain Research, Education and Policy (PREP) Tufts University School of Medicine
The Pain Research, Education and Policy Program is looking forward to welcoming guest lecturer, Dr. Beth Murinson, Director of Pain Education at Johns Hopkins School of Medicine and Co-Chief of the Chronic Pain Program at the Veterans Administration Medical Center, Washington, DC on Wednesday, April 8, from 4-5 PM (DuBlois Auditorium, Sackler Building, 145 Harrison Ave, Boston, MA). Dr. Murinson, a distinguished thought leader in the area of pain education, will be speaking on the topic of “Expertise, Skillfulness and Professional Comportmant: Preparing Trainees for Clinical Effectiveness in Pain Care”.
I recently had the pleasure of interviewing Dr. Murinson about her thoughts on the need for creation of robust interdisciplinary models of pain education.
Pamela Ressler (PR): “What are we doing well and what might be improved in educating new clinicians in treating pain?”
Dr. Beth Murinson (BM): “Educating new clinicians in treating pain starts with the fundamentals of clinical assessment but needs to be augmented with several important concepts, including the multi-dimensional impact of pain, e.g. social, functional, sleep quality, etc.; the importance of assessing and re-assessing for efficacy; developing capacity as a clinician to deliver care that is attuned to the natural history of specific pain-associated conditions, e.g. recognizing and anticipating the difference between ligamentous strain and nerve injury; as well as consistently providing care that is compassionate and patient-centered, e.g. responding to patient’s report of pain with the utmost seriousness and empathy while not being incapacitated or hardened by high levels of self-reported pain; and finally demanding of ourselves and others the development of comprehensive, multi-modal treatment plans for those devastated by treatment-resistant chronic pain.”
PR: “How can the interdisciplinary nature of pain management be brought into medical education?”
BM: “The interdisciplinary and interprofessional nature of pain management brings several opportunities for advances in step with recent developments in medical education: development of teaching teams that are interprofessional, the creation of curricular innovations that bring together students from different health professions programs, and the exposure of trainees to clinical settings where physicians of different disciplines as well as different types of health professionals are working together collaboratively. Although the current mantra is ‘assessment drives learning’, the reality is that the most enduring lessons that most of us absorb are those of the enlightening example: both positive and negative role models, as well as especially insightful teachers give us the most important and durable guidance in our careers.”
PR: “How can we be change agents in pain education?”
BM: “The study of change is a field in itself and merits study by those of us wishing to foment a positive revolution. Perhaps Gandhi said it best: “We must be the change we wish to see in the world.” But change is most often the result of sustained, positive effort. Few people realize that Charles Darwin’s grandfather Erasmus actually had a well-developed theory of neuroembryologic phylogeny. In recent years he has been acknowledged as the founder of evolutionary biology popularly credited to his grandson Charles. In short, we must demand of ourselves a long-range vision, but maintain nimble readiness to innovate and insert curricula at a moments notice. Consistently reflective, eloquent advocacy with policy makers, institutional and national leadership is also essential. Know what you need to say and be ready to say it: ‘Why do you need time in the curriculum?’ ‘How will this improve care?’ and ‘Are you updated on trends in general medical education and prepared to deliver curriculum that is timely and effective?'”
The conversation is happening in this field, will you be a part of it? Please join us on Wednesday, April 8, 4-5 PM at the DuBlois Auditorium to continue the dialogue with Dr. Murinson and the PREP program students, alumni and faculty.
April 7th, 2015
by Pamela Ressler, MS, RN, HN-BC, PREP faculty and blog moderator, Pain Research, Education and Policy Program, Tufts University School of Medicine
The Pain Research, Education and Policy Program welcomes Rosemary C. Polomano, PhD, RN, FAAN, Professor of Pain Practice, Professor of Anesthesiology and Critical Care (Secondary) at the University of Pennsylvania School of Nursing and
Perelman School of Medicine to Tufts on Tuesday October 14 (4-5 PM, DeBlois Auditorium, Sackler Building 1st floor,145 Harrison Avenue, Tufts Medical School, Boston). She will be discussing her experiences in improving pain control and treating pain with members of the armed services, as well as addressing the intersection of practice, research and policy in times of war and peace.
Dr. Polomano, an accomplished researcher and clinician, has co-authored more than 25 peer reviewed data-based publications. Her research focuses on instrument development and testing of patient-reported outcome measures with emphasis on improving pain management and pain control with military service members and veterans experiencing pain from combat-related injuries.
Please join the students, alumni, faculty and friends of the Tufts’ Pain Research, Education and Policy Program for this important and informative lecture on Tuesday, October 14. Read more on the PREP Website
September 30th, 2014
Lynn Teo, ’12 MS-PREP, is a contributing author to a recent special issue of the peer-reviewed journal, Pain Medicine, “Are Active Self-Care Complementary and Integrative Therapies Effective for Management of Chronic Pain?: A Rapid Evidence Assessment of the Literature and Recommendations for the Field“.
In 2010, the Army Surgeon General’s Pain Management Task Force and the Institute of Medicine recommended active self-care complementary and integrative therapies that require minimal training for the management of chronic pain. This systematic review put out by the Samueli Institute sought to rigorously assess the quality and effectiveness of these self-care strategies. Yoga, tai chi and music therapies yielded the most compelling studies in the treatment of chronic pain, with music therapy showing the best results. The report also sought to identify gaps in the literature, and to make recommendations for further research as well as steps for implementing programs to increase the practice of these complementary and integrative therapies.
Lynn Teo, MAOM, MSc, graduated from the New England School of Acupuncture in 2011 and from the Tufts University School of Medicine’s Pain Research, Education and Policy Program in 2012. She is a review manager for the Systematic Review Initiative at the Samueli Institute, a non-profit research organization committed to exploring the science of healing, including complementary modalities such as acupuncture, meditation and yoga. Alongside her work as a researcher, Lynn is owner of Three Rivers Wellness in Bethesda, MD where she teaches yoga and practices Japanese-style acupuncture, Chinese herbs and shiatsu. She enjoys bringing her clinical expertise to her research work and applying the knowledge she acquires as a researcher to her practice.
Office of the Army Surgeon General. Pain Management Task Force Final Report: Providing a standardized DoD and VHA vision and approach to pain management to optimize the care for warriors and their families. Falls Church, VA: 2010
Lee C, Crawford C, Teo L, Spevak S. Active Self-Care Therapies for Pain (PACT) Working Group. An analysis of the various chronic pain conditions captured in a systematic review of active self-care complementary and integrative medicine therapies for the management of chronic pain symptoms. Pain Med 2014;15
July 2nd, 2014