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
The Pain Research, Education and Policy program prides itself in addressing the complex nature of pain in the individual and in society through multidisciplinary learning and collaboration. The 2015 capstone projects exemplified the depth and breadth of the program by the varied nature of the graduating students’ innovative selection of topics and research. Congratulations to these members of the MS-PREP Class of 2015, the next generation of leaders in the field of pain.
Emily Rowe, MS-PREP, PharmD
- Low-Dose Ketamine Infusion for Vaso-Oclusive Crises in Pediatric Patients with Sickle Cell Disease
- Preceptor: Cathy Rosenfield, MD, Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, MA
Lindsay St. Louis, MS-PREP
- Social Support for Chronic Pain Patients: Are There Unmet Needs?
- Preceptor: Pamela Katz Ressler, MS, RN, HN-BC, Stress Resources LLC
Dora Kaluma, MS-PREP
- Opioid Risk Management: Quality Improvement Evaluation
- Preceptor: Ronald J. Kulich, PhD, Craniofacial Center, Tufts University School of Dental Medicine
Lyndsey A. Walsh, MS-PREP, MAc
- Cancer Patients and Their Experience Receiving Acupuncture: How Treatment Impacts Quality of Life
- Preceptors: Marybeth Singer, MS, ANP-BC, AOCN, ACHPN and Barbara Parton, LicAc, MAc, Tufts Cancer Center, Tufts Medical Center, Boston, MA
May 19th, 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
New Tufts PREP Course Offering for Summer 2014
Interprofessional Team Management of Pain (PREP 244; 0.5 credit)
Health care is increasingly delivered by groups of providers with diverse professional training, roles and identities. Lack of coordination and communication between health professionals may lead to adverse patient outcomes and lower patient satisfaction, risk management challenges, and provider dissatisfaction and burnout. This course provides tools to construct effective interprofessional (“IP”) teams to treat pain within models of care such as the medical home, to assess how well these teams are functioning, and to analyze and repair their dysfunction. Attendees will acquire knowledge and skills for achieving outcomes crucial to patient-centered care, focusing on pain and its treatment.
Led by seasoned IP clinician educators from occupational therapy and medicine, joined by fellow educators from the nursing and pharmacy professions, this innovative course will present methods to analyze and optimize team function. Attendees will examine how teams function as small groups, and identify how to shape cohesive functional groups. Participants will also develop skills to turn typical threats to team function from destructive forces to constructive and/or creative elements.
Pain is the most common reason for patients to seek medical care. By the conclusion of this course, participants will be able to analyze, optimize, and if circumstances require create de novo the team-based processes and policies that shape effective and efficient care of patients with pain. Applying these principles to optimize IP team management of pain will impact upon patient satisfaction, quality measures and potentially, and quality-based payment. In keeping with the PREP’s approach of training the trainers, attendees will be equipped to assume leadership roles in the assessment and treatment of pain within multiple organizational models including the medical home.
Dates & Location
· The 2014 course will take place from Thursday May 29 through July 2.
· Onsite class sessions will take place on Thursday evening, May 29 from 4-7 PM and Friday May 30 from 9AM- 5PM. [Dinner Thursday and lunch Friday plus snacks are included.]
· Online synchronous videoconferencing for case discussions and team problem-solving continue at 5:30-7:30 PM Wednesdays on June 11, June 18, June 25 and July 2.
To learn more about our Summer 2014 courses visit: publichealth.tufts.edu/Academics/MS-Pain-Research-Education-and-Policy/Programs-of-Study/Blended-Learning. To register for non-credit enrollment click “Register now for a course” at the end of the first paragraph on that web page. Non-credit enrollment is meant for those who want the experience of this course without receiving a grade, nor submitting homework or other assignments. Course cost for non-credit enrollees is $1,130 ($905 if paid before April 29, 2014).
Current Tufts graduate students may enroll in the course through the Integrated Student Information System (iSIS) and will be responsible for pre-course readings and 2 papers. The standard fee per graduate credit will apply. Prospective applicants wishing to earn credit graduate credit towards a future Tufts degree should follow this link: publichealth.tufts.edu/Admissions/Apply-to-PHPD-Programs/MS-in-Pain-Research-Education-and-Policy .
Contact the co-course director, Dan Carr at firstname.lastname@example.org with any questions.
April 15th, 2014
by Pamela Katz Ressler, MS, RN, HN-BC, Faculty, Pain Research, Education and Policy Program (PREP), Tufts University School of Medicine
The Pain Research Education and Policy Program (PREP) invites you to attend an informative talk by Edward Bilsky, PhD on Tuesday, February 25 from 4-5 PM at the Tufts Dental School, 14th floor, 1 Kneeland St, Boston (room 1414, Rachel’s Amphitheater). Dr. Bilsky is the 2014 Recipient of the Patient Advocacy Award from the American Academy of Pain Medicine, and his talk: “Lighting the Song with Sense and Color: an Interprofessional Humanistic Approach to Relieving Pain in America” will provide a springboard to discussion of interdisciplinary pain care. Dr. Bilsky is the Vice President for Research and Scholarship, and a Professor of pharmacology at the University of New England. Additionally, his is the founder and co-director of the Center for Excellence in Neurosciences.
Please join us in welcoming Dr. Bilsky to the Tufts University Health Sciences campus — all are welcome to attend this free event.
Tufts University School of Medicine
Public Health & Professional Degree Programs
Pain Research, Education and Policy Program (PREP) presents:
“Lighting the Song with Sense and Color: an Interprofessional Humanistic Approach to Relieving Pain in America”
Edward Bilsky, PhD
VP for Research & Scholarship, University of New England; Professor, Pharmacology; Founder & Co-Director, Center for Excellence in Neurosciences; 2014 Recipient of Patient Advocacy Award, American Academy of Pain Medicine
When: 4-5 PM, Tuesday, February 25, 2014
Where: Tufts Dental School, 14th Floor
1 Kneeland Street, Boston (corner of Washington St)
Rachel’s Amphitheater (Room 1414)
February 14th, 2014
by Pamela Katz Ressler, MS, RN, HN-BC, faculty, Pain Research Education and Policy Program (PREP), Tufts University School of Medicine
PREP graduates go on to become leaders in the field of pain management, as evidenced by PREP/NESA alumnus, Ian Koebner, in his role as co-director of the Integrative Health for Pain Relief Conference to be held from April 3-6, 2014 in Maui, Hawaii.
The Integrative Health and Pain Relief Conference is being sponsored by University of California-Davis Division of Pain Medicine and Integrative Medicine Program and will provide an opportunity for a diverse group of professionals to come together in both didactic and experiential inquiry to explore the best practices in integrative pain management. Ian states, “The conference is very aligned with the Tufts Pain Research, Education and Policy program’s focus on exploration of pain from the molecule to macro.” Leading academic and clinical experts in multiple disciplines relating to the integrative management of pain have been selected to present at the conference. The overall objective of the conference will be to provide current, scientific evidence on complementary and alternative medicine approaches used in relieving pain and suffering such as acupuncture, mindfulness based stress reduction, yoga, and nutritional interventions, with the ultimate goal of translating these approaches into improved patient outcomes. The conference planning committee hopes that the interactive nature of the conference will attract a wide variety of professionals, including physicians, nurses, acupuncturists, massage therapists and other allied health care professionals interested in integrative models of pain management. For more information on registration for the Integrative Health for Pain Relief Conference,click here
December 30th, 2013
by Pamela Katz Ressler, MS, RN, HN-BC, faculty, Pain Research, Education and Policy Program (PREP), Tufts University School of Medicine
In 1964, the Declaration of Helsinki ushered in a new paradigm of thinking about medical ethics and research worldwide. Since that time there have been seven revisions of the original Declaration of Helsinki, the most recent one being released this week by the World Medical Association. In the past 50 years healthcare has undergone a myriad of changes, including additional checks and balances for patient protection, such as informed consent and hospital ethics committees: the Declaration of Helsinki has been instrumental in helping to increase awareness of the importance of ethic principles in relation to patients and human research participants. As a living document, there will undoubtedly be continued revisions of the Declaration of Helsinki in years to come. It is important to realize that as far as we have come in the past 50 years, building awareness of ethics in patient care and human subject research, there is still much work to be done locally, nationally and globally.
Click here to read the newly released 2013 Declaration of Helsinki. Are there additional areas that you would amend or revise ?
October 20th, 2013