Pain studies enhance precision medicine

September 2, 2013 by Andrew Schwartz, University of California, San Francisco

In the 1980s, Christine Miaskowski, RN, PhD, was working as a clinical nurse specialist in a pain management center at the University Hospital of the Albert Einstein College of Medicine in New York.

"One day this woman walked in who couldn't move her shoulder," says Miaskowski. "She talked about the pain she'd experienced since her radical mastectomy, about how her surgeon kept telling her she was healed, and how she'd been hospitalized in a psychiatric institution as a crazy postmenopausal woman. She said if we didn't help her, she would kill herself. We were able to tell her she wasn't crazy – we knew the pain was real, a neuropathic, postsurgical pain syndrome – but as we began to explore these cases, nearly every surgeon I called told us this wasn't a real problem for their patients."

Her patients' ordeals and that of Miaskowski's own father – "who died in intractable pain from this same postsurgical syndrome" – have driven a career that has made Miaskowski an internationally respected pain researcher.

In December 2012 her work came full circle, when she and a diverse team of experts published the results of a major study in The Journal of Pain. The work established that after , about 25 percent of women experience persistent and 35 percent of women experience persistent arm and shoulder pain.

"It's rewarding to complete that work," says Miaskowski, now the associate dean for Academic Affairs at UC San Francisco's School of Nursing and co-director of the Research Center for Symptom Management, one of the only such centers housed at a school of nursing in the country.

The rewards may grow if the research team she has assembled with her primary collaborator, geneticist Bradley Aouizerat, PhD, can show that incorporating genomics into a much broader group of potential factors – including environmental and psychosocial components – can help clinicians better understand which patients are at greatest risk for persistent postsurgical pain and how to better prevent or treat it.

The result would be an important refinement and broadening of the precision medicine concept, which could in turn reduce a considerable amount of human suffering and billions of dollars in health care costs.

100 million people with persistent pain – and few effective therapies

According to a 2011 report from the Institute of Medicine, 100 million Americans live with , the treatment of which costs $635 billion every year in medical bills and lost productivity. The report was a culmination of how awareness of persistent pain as an important medical condition has grown over the last decade or so.

In the aftermath of the IOM report, Miaskowski was named one of six nonfederal scientists – and one of only three nurses – to a federal Interagency Pain Research Coordinating Committee, which is dedicated to improving pain research and patient care. In addition, UCSF recently became one of 12 National Institutes of Health Centers of Excellence in Pain Education, dedicated to making sure clinicians and those training to be clinicians are aware of best practices in pain management.

But treatment options remain limited. Despite a decade of scientific discoveries about the mechanisms, pathways and role of psychology in persistent or chronic pain – as well as advances in diagnostic tools and clinical breakthroughs in specific areas, like headache – for many types of chronic pain, effective therapies remain elusive. Highly publicized concerns about the addictive properties of opiates, one of the few known effective therapies for certain types of pain, have further constrained clinicians' options.

In the case of breast cancer, the theory is that postsurgical pain results from nerve injury. Thus the general wisdom is to try an anticonvulsant, but in Miaskowski's recent study, the most widely prescribed medications were antidepressants.

"Very few of these women were on analgesics, and we don't know why," she says.

"We've long appreciated the pain problems," says breast surgeon Charles Elboim of the Redwood Regional Medical Group, who was a co-investigator on the study. "I've always tried to listen to patients and anticipate … but doctors are different, and there may be surgeons who don't have the same appreciation of these patients' experience." For well over a decade, he has been involved in research to understand postsurgical symptoms, often working with nurse practitioner Kathleen Mott, a graduate of UCSF School of Nursing.

"I think a lot of practitioners still see the big problem – the cancer – and the symptoms are a lesser issue," says UCSF neurologist Gary Abrams, MD, a longtime research collaborator with Miaskowski and co-investigator on the breast cancer project. "But these symptoms have a significant impact on quality of life. As survival rates increase and cancer becomes more of a chronic disease, the associated symptoms will continue to rise in importance."

That's why the work of Miaskowski, Aouizerat and their team is so important. While it is still too early to generalize studies on persistent pain after surgery to other types of pain treatment, the group's broad, precision medicine approach can offer insights for other pain researchers.

"We're trying to understand all of the characteristics of the persistent pain – to not just find the associations between the and genes, but also do a detailed characterization of the phenotype," says Aouizerat.

Explore further: Many suffer chronic pain after breast cancer surgery, study finds

More information: www.jpain.org/article/S1526-59 … (12)00831-0/abstract

Related Stories

Many suffer chronic pain after breast cancer surgery, study finds

January 22, 2013
(HealthDay)—About one-quarter of women who've had breast cancer surgery have significant and persistent breast pain six months after the procedure, a new study finds.

Integrative medicine interventions found to significantly reduce pain, improve quality of life

July 22, 2013
An integrative approach to treating chronic pain significantly reduces pain severity while improving mood and quality of life, according to a new study from the Bravewell Practice-Based Research Network (BraveNet) published ...

Consultant to lead largest ever study into pain in Parkinson's

August 30, 2013
Salford Royal Consultant Neurologist and University of Manchester academic Dr Monty Silverdale is to launch the largest ever study of pain in Parkinson's Disease.

High pain sensitivity linked to dry eye disease symptoms

August 2, 2013
(HealthDay)—Pain sensitivity and pain tolerance are associated with symptoms of dry eye disease (DED), according to a study published online Aug. 1 in JAMA Ophthalmology.

Pre-op breast pain in about 28 percent of breast cancer patients

June 15, 2012
(HealthDay) -- More than a quarter of women about to undergo breast cancer surgery experience breast pain, with genetic polymorphisms in inflammatory cytokines correlating with pain, according to a study published in the ...

Baseline pain severity predicts worse long-term LBP outcomes

August 23, 2013
(HealthDay)—Patients' baseline pain and the perception that their pain will persist are significant predictors of poor outcomes for low back pain (LBP) over the short and long term, according to a study published in the ...

Recommended for you

Wine is good for you—to a point

January 18, 2018
The Mediterranean diet has become synonymous with healthy eating, but there's one thing in it that stands out: It's cool to drink wine.

Sleep better, lose weight?

January 17, 2018
(HealthDay)—Sleeplessness could cost you when it's time to stand on your bathroom scale, a new British study suggests.

Who uses phone apps to track sleep habits? Mostly the healthy and wealthy in US

January 16, 2018
The profile of most Americans who use popular mobile phone apps that track sleep habits is that they are relatively affluent, claim to eat well, and say they are in good health, even if some of them tend to smoke.

Improvements in mortality rates are slowed by rise in obesity in the United States

January 15, 2018
With countless medical advances and efforts to curb smoking, one might expect that life expectancy in the United States would improve. Yet according to recent studies, there's been a reduction in the rate of improvement in ...

Teens likely to crave junk food after watching TV ads

January 15, 2018
Teenagers who watch more than three hours of commercial TV a day are more likely to eat hundreds of extra junk food snacks, according to a report by Cancer Research UK.

Can muesli help against arthritis?

January 15, 2018
It is well known that healthy eating increases a general sense of wellbeing. Researchers at Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU) have now discovered that a fibre-rich diet can have a positive influence ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.