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Self-care for the weary
"Try and be nice to people, avoid eating fat, read a good book every now and then get some walking in, and try and live together in peace and harmony with people of all creeds and nations."
–Monty Python, "The Meaning of Life"
1. Set boundaries. This is arguably the most important aspect of the physician-patient relationship. A relationship like this is inherently fertile ground for such Freudian defenses as transference and projection. It’s important to recognize, too, that the process is not necessarily a one-way street. Freud was, after all, flawed like his subjects.
2. Don’t sweat the small stuff. This is self-evident, yet surprisingly difficult to remember.
3. Keep a journal. You’ll want to remember the good times, and keeping track of the bad times just shows you how far you’ve come.
4. Nourish your spirit – church, yoga, meditation. Take your pick. The best life advice I’ve ever received is that the mind needs structured space for quiet because otherwise you are never alone; there is always that voice in your head, constantly narrating your life and probably judging you for it.
5. There is a whole world outside of medicine. How easy is it to let our lives be consumed by our profession? How much happier would it make us to be reminded that music and literature and art exist? For my birthday this year, I asked my sister to give me a book that she thinks I should own.
6. Related to #5: Learn something outside of medicine. There are brilliant podcasts on science, the economy, politics. There are audio courses on great books or philosophy. Pick up a new instrument or a new language.
7. Indulge in the experiences that make you happy, whether that’s going to the beach, or eating out, throwing parties, or traveling. In the arguably dubious field of happiness research, studies show that spending money on experiences leads to happiness much more so than spending money on objects. (Of course, there may be a selection bias problem, in that it is entirely possible that people who are likely to buy experiences are happier at baseline than people who are likely to buy objects. But you get my meaning.)
8. Exercise. Run, take bike rides, walk your dog. Go for hikes. Take rowing lessons.
9. Sleep is crucial. We are not teenagers any longer, and it is a losing proposition to think that you can still get away with barely sleeping. If I get 8 hours of sleep, I am almost guaranteed to not be as grumpy at work. I feel refreshed, my mind is clearer, and I feel better equipped to deal with the challenges of the workday.
10. Forgive yourself – for the grumpiness, for mistakes, for bad outcomes that you could not possibly have done anything about.
11. Bonus: Mental health therapy, if done right, is a fantastic investment in yourself.
Dr. Chan practices rheumatology in Pawtucket, R.I.
"Try and be nice to people, avoid eating fat, read a good book every now and then get some walking in, and try and live together in peace and harmony with people of all creeds and nations."
–Monty Python, "The Meaning of Life"
1. Set boundaries. This is arguably the most important aspect of the physician-patient relationship. A relationship like this is inherently fertile ground for such Freudian defenses as transference and projection. It’s important to recognize, too, that the process is not necessarily a one-way street. Freud was, after all, flawed like his subjects.
2. Don’t sweat the small stuff. This is self-evident, yet surprisingly difficult to remember.
3. Keep a journal. You’ll want to remember the good times, and keeping track of the bad times just shows you how far you’ve come.
4. Nourish your spirit – church, yoga, meditation. Take your pick. The best life advice I’ve ever received is that the mind needs structured space for quiet because otherwise you are never alone; there is always that voice in your head, constantly narrating your life and probably judging you for it.
5. There is a whole world outside of medicine. How easy is it to let our lives be consumed by our profession? How much happier would it make us to be reminded that music and literature and art exist? For my birthday this year, I asked my sister to give me a book that she thinks I should own.
6. Related to #5: Learn something outside of medicine. There are brilliant podcasts on science, the economy, politics. There are audio courses on great books or philosophy. Pick up a new instrument or a new language.
7. Indulge in the experiences that make you happy, whether that’s going to the beach, or eating out, throwing parties, or traveling. In the arguably dubious field of happiness research, studies show that spending money on experiences leads to happiness much more so than spending money on objects. (Of course, there may be a selection bias problem, in that it is entirely possible that people who are likely to buy experiences are happier at baseline than people who are likely to buy objects. But you get my meaning.)
8. Exercise. Run, take bike rides, walk your dog. Go for hikes. Take rowing lessons.
9. Sleep is crucial. We are not teenagers any longer, and it is a losing proposition to think that you can still get away with barely sleeping. If I get 8 hours of sleep, I am almost guaranteed to not be as grumpy at work. I feel refreshed, my mind is clearer, and I feel better equipped to deal with the challenges of the workday.
10. Forgive yourself – for the grumpiness, for mistakes, for bad outcomes that you could not possibly have done anything about.
11. Bonus: Mental health therapy, if done right, is a fantastic investment in yourself.
Dr. Chan practices rheumatology in Pawtucket, R.I.
"Try and be nice to people, avoid eating fat, read a good book every now and then get some walking in, and try and live together in peace and harmony with people of all creeds and nations."
–Monty Python, "The Meaning of Life"
1. Set boundaries. This is arguably the most important aspect of the physician-patient relationship. A relationship like this is inherently fertile ground for such Freudian defenses as transference and projection. It’s important to recognize, too, that the process is not necessarily a one-way street. Freud was, after all, flawed like his subjects.
2. Don’t sweat the small stuff. This is self-evident, yet surprisingly difficult to remember.
3. Keep a journal. You’ll want to remember the good times, and keeping track of the bad times just shows you how far you’ve come.
4. Nourish your spirit – church, yoga, meditation. Take your pick. The best life advice I’ve ever received is that the mind needs structured space for quiet because otherwise you are never alone; there is always that voice in your head, constantly narrating your life and probably judging you for it.
5. There is a whole world outside of medicine. How easy is it to let our lives be consumed by our profession? How much happier would it make us to be reminded that music and literature and art exist? For my birthday this year, I asked my sister to give me a book that she thinks I should own.
6. Related to #5: Learn something outside of medicine. There are brilliant podcasts on science, the economy, politics. There are audio courses on great books or philosophy. Pick up a new instrument or a new language.
7. Indulge in the experiences that make you happy, whether that’s going to the beach, or eating out, throwing parties, or traveling. In the arguably dubious field of happiness research, studies show that spending money on experiences leads to happiness much more so than spending money on objects. (Of course, there may be a selection bias problem, in that it is entirely possible that people who are likely to buy experiences are happier at baseline than people who are likely to buy objects. But you get my meaning.)
8. Exercise. Run, take bike rides, walk your dog. Go for hikes. Take rowing lessons.
9. Sleep is crucial. We are not teenagers any longer, and it is a losing proposition to think that you can still get away with barely sleeping. If I get 8 hours of sleep, I am almost guaranteed to not be as grumpy at work. I feel refreshed, my mind is clearer, and I feel better equipped to deal with the challenges of the workday.
10. Forgive yourself – for the grumpiness, for mistakes, for bad outcomes that you could not possibly have done anything about.
11. Bonus: Mental health therapy, if done right, is a fantastic investment in yourself.
Dr. Chan practices rheumatology in Pawtucket, R.I.
Face Time
In this time of evolving medical care, many factors are impinging on the physician-patient relationship. Unfortunately, one of the biggest barriers between our patients and us is a computer screen.
Before I started using an electronic health record (EHR) nearly 4 years ago, I was very anxious about the transition. How would I be able to maintain my patient volume while trying to create a comprehensive electronic document for each patient? Now I love my EHR. It creates a beautiful note quickly and effectively, and I can check all of my medical records from any location. I love e-prescribing, and, best of all, there is never a lost medical record. As I have become more connected to my EHR, however, I think my patients sometimes feel left out. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic record.
Recently, several studies have evaluated the effects of novel technologies on interactions between the patient and health care professionals (HCPs). Montague and Asan1 examined eye gaze patterns between patients and HCPs while EHRs were used to support patient care. Gaze was used because it provides a more objective and measurable indication of attention and communication. In their study, patient visits were recorded using 3 high-resolution video cameras placed at different angles to accurately capture gaze and avoid ambiguity of the gaze direction caused by a single camera angle. One hundred patients and 10 HCPs participated in the study.1
Results indicated that on average HCPs spent nearly one-third of the visit length gazing at the EHR.1 Paper medical records also were used during 79% of the visits with HCPs spending approximately 9% of the visit length gazing at the record. There were times when the patient gaze was undetermined and accounted for more than 28% of the visit length. This unknown gaze might have occurred when the HCP used the computer and the patient disengaged eye contact with the HCP. Another scenario recorded was when patients gazed at the HCP and the HCP gazed at the EHR, an event that accounted for more than 21% of the visit time. The investigators concluded that the patient-physician eye contact dynamic differed with EHRs compared to paper medical records. They also noted that when HCPs spent too much time looking at the computer screen in the examination room, nonverbal cues might have been overlooked. Also, the HCP’s ability to pay attention and communicate with patients was affected.1
Asan et al2 quantitatively examined and compared clinically experienced physician interactions with patients using paper medical records or EHRs in ambulatory primary care settings. Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits—40 with paper and 40 with EHRs—were recorded. The proportion of time physicians spent gazing at medical records was significantly more during EHR visits compared to paper chart visits (35.2% vs 22.1%; P=.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared to a paper medical record (52.6% vs 45.6%; P=.041).2
As our use of EHRs increases and evolves, it will be important to factor in these issues to maintain the centrality of the physician-patient rapport. We should attempt to place the computer screen and the patient in physical locations that facilitate the ability to maximally interact with the patient while entering the data. It will be important for those who design the next generation of EHRs to do so with this communication in mind. Until then, I will do my best to give the appropriate attention to both my patient and my EHR.
1. Montague E, Asan O. Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention. Int J Med Inf. 2014;83:225-234.
2. Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design [published online ahead of print May 19, 2014]. J Eval Clin Pract. doi:10.1111/jep.12182.
In this time of evolving medical care, many factors are impinging on the physician-patient relationship. Unfortunately, one of the biggest barriers between our patients and us is a computer screen.
Before I started using an electronic health record (EHR) nearly 4 years ago, I was very anxious about the transition. How would I be able to maintain my patient volume while trying to create a comprehensive electronic document for each patient? Now I love my EHR. It creates a beautiful note quickly and effectively, and I can check all of my medical records from any location. I love e-prescribing, and, best of all, there is never a lost medical record. As I have become more connected to my EHR, however, I think my patients sometimes feel left out. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic record.
Recently, several studies have evaluated the effects of novel technologies on interactions between the patient and health care professionals (HCPs). Montague and Asan1 examined eye gaze patterns between patients and HCPs while EHRs were used to support patient care. Gaze was used because it provides a more objective and measurable indication of attention and communication. In their study, patient visits were recorded using 3 high-resolution video cameras placed at different angles to accurately capture gaze and avoid ambiguity of the gaze direction caused by a single camera angle. One hundred patients and 10 HCPs participated in the study.1
Results indicated that on average HCPs spent nearly one-third of the visit length gazing at the EHR.1 Paper medical records also were used during 79% of the visits with HCPs spending approximately 9% of the visit length gazing at the record. There were times when the patient gaze was undetermined and accounted for more than 28% of the visit length. This unknown gaze might have occurred when the HCP used the computer and the patient disengaged eye contact with the HCP. Another scenario recorded was when patients gazed at the HCP and the HCP gazed at the EHR, an event that accounted for more than 21% of the visit time. The investigators concluded that the patient-physician eye contact dynamic differed with EHRs compared to paper medical records. They also noted that when HCPs spent too much time looking at the computer screen in the examination room, nonverbal cues might have been overlooked. Also, the HCP’s ability to pay attention and communicate with patients was affected.1
Asan et al2 quantitatively examined and compared clinically experienced physician interactions with patients using paper medical records or EHRs in ambulatory primary care settings. Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits—40 with paper and 40 with EHRs—were recorded. The proportion of time physicians spent gazing at medical records was significantly more during EHR visits compared to paper chart visits (35.2% vs 22.1%; P=.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared to a paper medical record (52.6% vs 45.6%; P=.041).2
As our use of EHRs increases and evolves, it will be important to factor in these issues to maintain the centrality of the physician-patient rapport. We should attempt to place the computer screen and the patient in physical locations that facilitate the ability to maximally interact with the patient while entering the data. It will be important for those who design the next generation of EHRs to do so with this communication in mind. Until then, I will do my best to give the appropriate attention to both my patient and my EHR.
In this time of evolving medical care, many factors are impinging on the physician-patient relationship. Unfortunately, one of the biggest barriers between our patients and us is a computer screen.
Before I started using an electronic health record (EHR) nearly 4 years ago, I was very anxious about the transition. How would I be able to maintain my patient volume while trying to create a comprehensive electronic document for each patient? Now I love my EHR. It creates a beautiful note quickly and effectively, and I can check all of my medical records from any location. I love e-prescribing, and, best of all, there is never a lost medical record. As I have become more connected to my EHR, however, I think my patients sometimes feel left out. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic record.
Recently, several studies have evaluated the effects of novel technologies on interactions between the patient and health care professionals (HCPs). Montague and Asan1 examined eye gaze patterns between patients and HCPs while EHRs were used to support patient care. Gaze was used because it provides a more objective and measurable indication of attention and communication. In their study, patient visits were recorded using 3 high-resolution video cameras placed at different angles to accurately capture gaze and avoid ambiguity of the gaze direction caused by a single camera angle. One hundred patients and 10 HCPs participated in the study.1
Results indicated that on average HCPs spent nearly one-third of the visit length gazing at the EHR.1 Paper medical records also were used during 79% of the visits with HCPs spending approximately 9% of the visit length gazing at the record. There were times when the patient gaze was undetermined and accounted for more than 28% of the visit length. This unknown gaze might have occurred when the HCP used the computer and the patient disengaged eye contact with the HCP. Another scenario recorded was when patients gazed at the HCP and the HCP gazed at the EHR, an event that accounted for more than 21% of the visit time. The investigators concluded that the patient-physician eye contact dynamic differed with EHRs compared to paper medical records. They also noted that when HCPs spent too much time looking at the computer screen in the examination room, nonverbal cues might have been overlooked. Also, the HCP’s ability to pay attention and communicate with patients was affected.1
Asan et al2 quantitatively examined and compared clinically experienced physician interactions with patients using paper medical records or EHRs in ambulatory primary care settings. Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits—40 with paper and 40 with EHRs—were recorded. The proportion of time physicians spent gazing at medical records was significantly more during EHR visits compared to paper chart visits (35.2% vs 22.1%; P=.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared to a paper medical record (52.6% vs 45.6%; P=.041).2
As our use of EHRs increases and evolves, it will be important to factor in these issues to maintain the centrality of the physician-patient rapport. We should attempt to place the computer screen and the patient in physical locations that facilitate the ability to maximally interact with the patient while entering the data. It will be important for those who design the next generation of EHRs to do so with this communication in mind. Until then, I will do my best to give the appropriate attention to both my patient and my EHR.
1. Montague E, Asan O. Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention. Int J Med Inf. 2014;83:225-234.
2. Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design [published online ahead of print May 19, 2014]. J Eval Clin Pract. doi:10.1111/jep.12182.
1. Montague E, Asan O. Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention. Int J Med Inf. 2014;83:225-234.
2. Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design [published online ahead of print May 19, 2014]. J Eval Clin Pract. doi:10.1111/jep.12182.
Can private practice survive?
I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.
"How’s the radiology business?" I asked him.
"Two more years," he said. "I should be able to hang on."
"That bad?"
"We were taken over by the academic department of a big teaching hospital," Peter said.
"What’s the problem? They want you to publish papers?" I asked.
"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."
"Measure what?"
"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."
You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.
"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."
"How about you?" I asked him. "Have they made you an offer you can’t refuse?"
"Not yet," he said.
Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.
"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."
Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.
The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.
Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.
"Yes," he said. "They just set that up recently."
"How did you find out?" I asked him.
"They sent out a memo," he said.
In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.
"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"
"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."
To say that hanging around colleagues who talk this way is dispiriting would be an understatement.
Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."
"I can see why," I said. "Whom do they take it out on?"
"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."
We agreed that seemed the best strategy.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.
"How’s the radiology business?" I asked him.
"Two more years," he said. "I should be able to hang on."
"That bad?"
"We were taken over by the academic department of a big teaching hospital," Peter said.
"What’s the problem? They want you to publish papers?" I asked.
"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."
"Measure what?"
"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."
You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.
"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."
"How about you?" I asked him. "Have they made you an offer you can’t refuse?"
"Not yet," he said.
Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.
"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."
Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.
The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.
Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.
"Yes," he said. "They just set that up recently."
"How did you find out?" I asked him.
"They sent out a memo," he said.
In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.
"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"
"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."
To say that hanging around colleagues who talk this way is dispiriting would be an understatement.
Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."
"I can see why," I said. "Whom do they take it out on?"
"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."
We agreed that seemed the best strategy.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.
"How’s the radiology business?" I asked him.
"Two more years," he said. "I should be able to hang on."
"That bad?"
"We were taken over by the academic department of a big teaching hospital," Peter said.
"What’s the problem? They want you to publish papers?" I asked.
"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."
"Measure what?"
"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."
You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.
"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."
"How about you?" I asked him. "Have they made you an offer you can’t refuse?"
"Not yet," he said.
Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.
"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."
Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.
The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.
Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.
"Yes," he said. "They just set that up recently."
"How did you find out?" I asked him.
"They sent out a memo," he said.
In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.
"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"
"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."
To say that hanging around colleagues who talk this way is dispiriting would be an understatement.
Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."
"I can see why," I said. "Whom do they take it out on?"
"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."
We agreed that seemed the best strategy.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Ebola, fear, and us
Recently, two American missionary workers in Liberia made headlines when they became infected with the Ebola virus, which causes a highly fatal hemorrhagic fever. They both received an experimental "secret serum" called ZMapp while in Africa and have since been flown back to the United States to be cared for at Emory University Hospital in Atlanta.
The response to their return has been mixed. While some hail their incredible selflessness and the mission they set out to accomplish, others are lukewarm, indifferent, or even very opposed to their return – so opposed that security was heightened in response to threats. I, of course, am among the former.
I once went on a 5-day missionary trip to Nicaragua. Optimistic about the potential to help the poor and hurting, my biggest challenges were the long plane ride and the hotel accommodations, which were not quite to my liking. The thought of contracting a potentially fatal disease and never returning home to my family never, ever crossed my mind.
Dr. Kent Brantly and Nancy Writebol, both missionary workers, were of a completely different mindset; they had different goals, they faced different challenges. They willingly boarded a plane to fly thousands of miles away from the comfort of their homes, the love of their families, the security of their close friends. They risked everything to care for complete strangers, strangers who posed a real threat to their lives. They never expected to receive any earthly thing in return. Interestingly, after contracting Ebola, Dr. Brantley did receive a unit of blood from a 14-year-old who had survived his fight with the Ebola virus while under his care.
Personally, I can only hope that one day I will have even half of the compassion and servant’s heart that these brave, incredibly selfless individuals possess.
I have to believe that those who object to their presence on American soil are afraid. They do not know what to expect and fear the epidemic spreading to the United States. I remember when I first started treating HIV/AIDS patients in the early ’90s. It was new and it was very, very scary. In those days, we donned protective garments above and beyond what we now know is necessary. Still, at times I, along with countless other health care workers, was overwhelmed by fear.
Like the human immunodeficiency virus, the Ebola virus is spread through direct contact with the blood or other body fluids of an infected person or through exposure to infected objects such as needles. It is not airborne, nor is it spread by contaminated food and water. Unlike with HIV, however, Ebola can be fatal within days. Another difference is that it is believed to be transmissible only if the individual is symptomatic, while countless cases of HIV were the result of exposure to seemingly healthy individuals.
While some in the American public still decry that Dr. Brantley and Mrs. Writebol were brought to a hospital in the United States, I have to believe that the great majority of Americans keep these two incredible individuals in their thoughts and prayers.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Recently, two American missionary workers in Liberia made headlines when they became infected with the Ebola virus, which causes a highly fatal hemorrhagic fever. They both received an experimental "secret serum" called ZMapp while in Africa and have since been flown back to the United States to be cared for at Emory University Hospital in Atlanta.
The response to their return has been mixed. While some hail their incredible selflessness and the mission they set out to accomplish, others are lukewarm, indifferent, or even very opposed to their return – so opposed that security was heightened in response to threats. I, of course, am among the former.
I once went on a 5-day missionary trip to Nicaragua. Optimistic about the potential to help the poor and hurting, my biggest challenges were the long plane ride and the hotel accommodations, which were not quite to my liking. The thought of contracting a potentially fatal disease and never returning home to my family never, ever crossed my mind.
Dr. Kent Brantly and Nancy Writebol, both missionary workers, were of a completely different mindset; they had different goals, they faced different challenges. They willingly boarded a plane to fly thousands of miles away from the comfort of their homes, the love of their families, the security of their close friends. They risked everything to care for complete strangers, strangers who posed a real threat to their lives. They never expected to receive any earthly thing in return. Interestingly, after contracting Ebola, Dr. Brantley did receive a unit of blood from a 14-year-old who had survived his fight with the Ebola virus while under his care.
Personally, I can only hope that one day I will have even half of the compassion and servant’s heart that these brave, incredibly selfless individuals possess.
I have to believe that those who object to their presence on American soil are afraid. They do not know what to expect and fear the epidemic spreading to the United States. I remember when I first started treating HIV/AIDS patients in the early ’90s. It was new and it was very, very scary. In those days, we donned protective garments above and beyond what we now know is necessary. Still, at times I, along with countless other health care workers, was overwhelmed by fear.
Like the human immunodeficiency virus, the Ebola virus is spread through direct contact with the blood or other body fluids of an infected person or through exposure to infected objects such as needles. It is not airborne, nor is it spread by contaminated food and water. Unlike with HIV, however, Ebola can be fatal within days. Another difference is that it is believed to be transmissible only if the individual is symptomatic, while countless cases of HIV were the result of exposure to seemingly healthy individuals.
While some in the American public still decry that Dr. Brantley and Mrs. Writebol were brought to a hospital in the United States, I have to believe that the great majority of Americans keep these two incredible individuals in their thoughts and prayers.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Recently, two American missionary workers in Liberia made headlines when they became infected with the Ebola virus, which causes a highly fatal hemorrhagic fever. They both received an experimental "secret serum" called ZMapp while in Africa and have since been flown back to the United States to be cared for at Emory University Hospital in Atlanta.
The response to their return has been mixed. While some hail their incredible selflessness and the mission they set out to accomplish, others are lukewarm, indifferent, or even very opposed to their return – so opposed that security was heightened in response to threats. I, of course, am among the former.
I once went on a 5-day missionary trip to Nicaragua. Optimistic about the potential to help the poor and hurting, my biggest challenges were the long plane ride and the hotel accommodations, which were not quite to my liking. The thought of contracting a potentially fatal disease and never returning home to my family never, ever crossed my mind.
Dr. Kent Brantly and Nancy Writebol, both missionary workers, were of a completely different mindset; they had different goals, they faced different challenges. They willingly boarded a plane to fly thousands of miles away from the comfort of their homes, the love of their families, the security of their close friends. They risked everything to care for complete strangers, strangers who posed a real threat to their lives. They never expected to receive any earthly thing in return. Interestingly, after contracting Ebola, Dr. Brantley did receive a unit of blood from a 14-year-old who had survived his fight with the Ebola virus while under his care.
Personally, I can only hope that one day I will have even half of the compassion and servant’s heart that these brave, incredibly selfless individuals possess.
I have to believe that those who object to their presence on American soil are afraid. They do not know what to expect and fear the epidemic spreading to the United States. I remember when I first started treating HIV/AIDS patients in the early ’90s. It was new and it was very, very scary. In those days, we donned protective garments above and beyond what we now know is necessary. Still, at times I, along with countless other health care workers, was overwhelmed by fear.
Like the human immunodeficiency virus, the Ebola virus is spread through direct contact with the blood or other body fluids of an infected person or through exposure to infected objects such as needles. It is not airborne, nor is it spread by contaminated food and water. Unlike with HIV, however, Ebola can be fatal within days. Another difference is that it is believed to be transmissible only if the individual is symptomatic, while countless cases of HIV were the result of exposure to seemingly healthy individuals.
While some in the American public still decry that Dr. Brantley and Mrs. Writebol were brought to a hospital in the United States, I have to believe that the great majority of Americans keep these two incredible individuals in their thoughts and prayers.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Odds Are
I’ve always wondered what kind of irresponsible, misguided parent brings children to Las Vegas. Now I have the answer, right in the mirror. Don’t judge: My sister lives there, so if the kids are ever going to see their cousins, they have to share the road with trucks that say, “Girls! Girls! Girls!” (We told the 9-year-old that these were advertisements for clothing, which the women pictured seemed to need.)
It’s true that Las Vegas has become more family friendly...for the Kardashians. We did, however, manage to make the trip educational. In psychology, the kids found that after 10:00 p.m., everyone’s tempers are shorter than a 9-year-old boy lost in a crowd. In chemistry, they discovered that no substance yet synthesized can mask the smell of cigarette smoke. And in meteorology, they learned never to step in a puddle on The Strip; whatever it is, it’s not rain.
Hope falls
Is there anything we wouldn’t do to prevent someone from dying of cancer? We will ride bikes 150 miles, run marathons, and wear endless seas of pink, even though honestly it’s not everyone’s color (you know who you are). So if there were, say, a safe and effective means of preventing up to 4,000 cancer deaths a year, certainly doctors would be first in line to make sure everyone is protected, right?
Sure...between half and two-thirds of the time, according to a new analysis from the Centers for Disease Control and Prevention. That’s how often providers recommend human papillomavirus (HPV) vaccine to their eligible female and male patients. Maybe cervical, anal, penile, and oropharyngeal cancers need to get together and claim a color that looks good on everyone: Is cerulean taken?
I know we all get frustrated with vaccine deniers, but why aren’t we at least recommending HPV vaccine to 100% of our patients? Is it because they won’t be our patients by the time they get cancer? Is it because the vaccine is more expensive and more painful than some (both true, but again, y’all, cancer)? Is it because it’s awkward to talk to parents about how their cherubic 11-year-old is one day going to grow up into an adult who is likely to have, you know, S-E-X?
Whatever the reason, I share Assistant Surgeon General Dr. Anne Schuchat’s disappointment that only 37.6% of eligible girls and 13.6% of eligible boys got vaccinated against HPV last year. When poor parental uptake is the problem, we need to work on education. But when we as providers are not even recommending the vaccine, you can color me embarrassed.
Yellow-bellied?
Parents look at me like I’m crazy all the time, which I resent, because I’m only crazy most of the time. For the first 3 months of their baby's life, I tell parents to call me at the first sign of a fever; then I tell them fever is a nothing to worry about. I say that sleeping face-down can be deadly until their baby learns to roll back-to-front; then I tell them not to worry. And for the first 7 days of life, I tell them that newborn jaundice can cause severe brain damage, until I start saying it’s normal, especially in breastfed infants. I flip-flop more than a candidate for Congress.
A new study may reassure some mothers of nursing infants who look a little orange (the infants, that is; orange mothers should still be concerned). We’ve always known that breastfed infants tend to keep high levels of indirect bilirubin in their bloodstreams long after the first week in life, but no one yet had bothered to establish the typical range and time course. Dr. M. Jeffrey Maisels and a team from Oakland University William Beaumont School of Medicine changed all that with the use of transcutaneous bilirubin (TCB) monitors and 1,044 predominately breastfeeding infants.
Not only did they determine that at age 3-4 weeks between 34% and 43% of these infants still had TCB measurements over 5 mg/dL, they also reaffirmed that we doctors are really bad at guessing bilirubin levels from looking at babies. They asked trained clinicians to guess the “jaundice zone scores” of the infants, which sound like a customer loyalty program at a sporting goods store but are really just an estimate of how far down the infant’s body it looks yellow. The scores were so far off that a baby with a score of 0 could have a bilirubin level as high as 12.8 mg/dL. I can only hope that with his expertise in ferreting out bad human judgment, Dr. Maisels’s next study will investigate candidates for Congress.
Inattention
A complex society cannot function without some degree of trust; there’s all sorts of scary stuff I’d like to know, and I’m happy to pay a few dollars in taxes to make sure someone more qualified than I am is checking. Does this bridge I’m crossing have severe erosion? Is there another plane in our airspace? What was my 14-year-old daughter texting to her “boyfriend” last night? (Thanks, National Security Agency!)
Drug safety is one of those things, especially when many of my patients and one of my own children are taking said drug. A new study from researchers at Boston Children’s Hospital suggests that perhaps when it comes to the long-term safety of attention-deficit/hyperactivity disorder (ADHD) medications, the U.S. Food and Drug Administration has not looked as hard as it might. Paging Dr. Edward Snowden!
One might assume that since up to 10% of U.S. children now carry a diagnosis of ADHD, and since those children start medications as young as age 4 and continue to use them for many years, the safety studies that got these drugs approved would have been especially rigorous. Yeah, no. Only 5 of 32 preapproval trials focused on safety, these trials enrolled an average of 75 patients (as opposed to the recommended 1,500), and few lasted as long as 12 months, with approval sometimes granted after only 8 weeks of study and some older drugs being “grandfathered” in with essentially no safety data whatsoever.
I see one bright spot in this desert of data. Whenever I prescribe a stimulant for ADHD, I’ll understand that I’m taking a gamble, and I’ll fondly remember our family trip to Las Vegas.
David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.
I’ve always wondered what kind of irresponsible, misguided parent brings children to Las Vegas. Now I have the answer, right in the mirror. Don’t judge: My sister lives there, so if the kids are ever going to see their cousins, they have to share the road with trucks that say, “Girls! Girls! Girls!” (We told the 9-year-old that these were advertisements for clothing, which the women pictured seemed to need.)
It’s true that Las Vegas has become more family friendly...for the Kardashians. We did, however, manage to make the trip educational. In psychology, the kids found that after 10:00 p.m., everyone’s tempers are shorter than a 9-year-old boy lost in a crowd. In chemistry, they discovered that no substance yet synthesized can mask the smell of cigarette smoke. And in meteorology, they learned never to step in a puddle on The Strip; whatever it is, it’s not rain.
Hope falls
Is there anything we wouldn’t do to prevent someone from dying of cancer? We will ride bikes 150 miles, run marathons, and wear endless seas of pink, even though honestly it’s not everyone’s color (you know who you are). So if there were, say, a safe and effective means of preventing up to 4,000 cancer deaths a year, certainly doctors would be first in line to make sure everyone is protected, right?
Sure...between half and two-thirds of the time, according to a new analysis from the Centers for Disease Control and Prevention. That’s how often providers recommend human papillomavirus (HPV) vaccine to their eligible female and male patients. Maybe cervical, anal, penile, and oropharyngeal cancers need to get together and claim a color that looks good on everyone: Is cerulean taken?
I know we all get frustrated with vaccine deniers, but why aren’t we at least recommending HPV vaccine to 100% of our patients? Is it because they won’t be our patients by the time they get cancer? Is it because the vaccine is more expensive and more painful than some (both true, but again, y’all, cancer)? Is it because it’s awkward to talk to parents about how their cherubic 11-year-old is one day going to grow up into an adult who is likely to have, you know, S-E-X?
Whatever the reason, I share Assistant Surgeon General Dr. Anne Schuchat’s disappointment that only 37.6% of eligible girls and 13.6% of eligible boys got vaccinated against HPV last year. When poor parental uptake is the problem, we need to work on education. But when we as providers are not even recommending the vaccine, you can color me embarrassed.
Yellow-bellied?
Parents look at me like I’m crazy all the time, which I resent, because I’m only crazy most of the time. For the first 3 months of their baby's life, I tell parents to call me at the first sign of a fever; then I tell them fever is a nothing to worry about. I say that sleeping face-down can be deadly until their baby learns to roll back-to-front; then I tell them not to worry. And for the first 7 days of life, I tell them that newborn jaundice can cause severe brain damage, until I start saying it’s normal, especially in breastfed infants. I flip-flop more than a candidate for Congress.
A new study may reassure some mothers of nursing infants who look a little orange (the infants, that is; orange mothers should still be concerned). We’ve always known that breastfed infants tend to keep high levels of indirect bilirubin in their bloodstreams long after the first week in life, but no one yet had bothered to establish the typical range and time course. Dr. M. Jeffrey Maisels and a team from Oakland University William Beaumont School of Medicine changed all that with the use of transcutaneous bilirubin (TCB) monitors and 1,044 predominately breastfeeding infants.
Not only did they determine that at age 3-4 weeks between 34% and 43% of these infants still had TCB measurements over 5 mg/dL, they also reaffirmed that we doctors are really bad at guessing bilirubin levels from looking at babies. They asked trained clinicians to guess the “jaundice zone scores” of the infants, which sound like a customer loyalty program at a sporting goods store but are really just an estimate of how far down the infant’s body it looks yellow. The scores were so far off that a baby with a score of 0 could have a bilirubin level as high as 12.8 mg/dL. I can only hope that with his expertise in ferreting out bad human judgment, Dr. Maisels’s next study will investigate candidates for Congress.
Inattention
A complex society cannot function without some degree of trust; there’s all sorts of scary stuff I’d like to know, and I’m happy to pay a few dollars in taxes to make sure someone more qualified than I am is checking. Does this bridge I’m crossing have severe erosion? Is there another plane in our airspace? What was my 14-year-old daughter texting to her “boyfriend” last night? (Thanks, National Security Agency!)
Drug safety is one of those things, especially when many of my patients and one of my own children are taking said drug. A new study from researchers at Boston Children’s Hospital suggests that perhaps when it comes to the long-term safety of attention-deficit/hyperactivity disorder (ADHD) medications, the U.S. Food and Drug Administration has not looked as hard as it might. Paging Dr. Edward Snowden!
One might assume that since up to 10% of U.S. children now carry a diagnosis of ADHD, and since those children start medications as young as age 4 and continue to use them for many years, the safety studies that got these drugs approved would have been especially rigorous. Yeah, no. Only 5 of 32 preapproval trials focused on safety, these trials enrolled an average of 75 patients (as opposed to the recommended 1,500), and few lasted as long as 12 months, with approval sometimes granted after only 8 weeks of study and some older drugs being “grandfathered” in with essentially no safety data whatsoever.
I see one bright spot in this desert of data. Whenever I prescribe a stimulant for ADHD, I’ll understand that I’m taking a gamble, and I’ll fondly remember our family trip to Las Vegas.
David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.
I’ve always wondered what kind of irresponsible, misguided parent brings children to Las Vegas. Now I have the answer, right in the mirror. Don’t judge: My sister lives there, so if the kids are ever going to see their cousins, they have to share the road with trucks that say, “Girls! Girls! Girls!” (We told the 9-year-old that these were advertisements for clothing, which the women pictured seemed to need.)
It’s true that Las Vegas has become more family friendly...for the Kardashians. We did, however, manage to make the trip educational. In psychology, the kids found that after 10:00 p.m., everyone’s tempers are shorter than a 9-year-old boy lost in a crowd. In chemistry, they discovered that no substance yet synthesized can mask the smell of cigarette smoke. And in meteorology, they learned never to step in a puddle on The Strip; whatever it is, it’s not rain.
Hope falls
Is there anything we wouldn’t do to prevent someone from dying of cancer? We will ride bikes 150 miles, run marathons, and wear endless seas of pink, even though honestly it’s not everyone’s color (you know who you are). So if there were, say, a safe and effective means of preventing up to 4,000 cancer deaths a year, certainly doctors would be first in line to make sure everyone is protected, right?
Sure...between half and two-thirds of the time, according to a new analysis from the Centers for Disease Control and Prevention. That’s how often providers recommend human papillomavirus (HPV) vaccine to their eligible female and male patients. Maybe cervical, anal, penile, and oropharyngeal cancers need to get together and claim a color that looks good on everyone: Is cerulean taken?
I know we all get frustrated with vaccine deniers, but why aren’t we at least recommending HPV vaccine to 100% of our patients? Is it because they won’t be our patients by the time they get cancer? Is it because the vaccine is more expensive and more painful than some (both true, but again, y’all, cancer)? Is it because it’s awkward to talk to parents about how their cherubic 11-year-old is one day going to grow up into an adult who is likely to have, you know, S-E-X?
Whatever the reason, I share Assistant Surgeon General Dr. Anne Schuchat’s disappointment that only 37.6% of eligible girls and 13.6% of eligible boys got vaccinated against HPV last year. When poor parental uptake is the problem, we need to work on education. But when we as providers are not even recommending the vaccine, you can color me embarrassed.
Yellow-bellied?
Parents look at me like I’m crazy all the time, which I resent, because I’m only crazy most of the time. For the first 3 months of their baby's life, I tell parents to call me at the first sign of a fever; then I tell them fever is a nothing to worry about. I say that sleeping face-down can be deadly until their baby learns to roll back-to-front; then I tell them not to worry. And for the first 7 days of life, I tell them that newborn jaundice can cause severe brain damage, until I start saying it’s normal, especially in breastfed infants. I flip-flop more than a candidate for Congress.
A new study may reassure some mothers of nursing infants who look a little orange (the infants, that is; orange mothers should still be concerned). We’ve always known that breastfed infants tend to keep high levels of indirect bilirubin in their bloodstreams long after the first week in life, but no one yet had bothered to establish the typical range and time course. Dr. M. Jeffrey Maisels and a team from Oakland University William Beaumont School of Medicine changed all that with the use of transcutaneous bilirubin (TCB) monitors and 1,044 predominately breastfeeding infants.
Not only did they determine that at age 3-4 weeks between 34% and 43% of these infants still had TCB measurements over 5 mg/dL, they also reaffirmed that we doctors are really bad at guessing bilirubin levels from looking at babies. They asked trained clinicians to guess the “jaundice zone scores” of the infants, which sound like a customer loyalty program at a sporting goods store but are really just an estimate of how far down the infant’s body it looks yellow. The scores were so far off that a baby with a score of 0 could have a bilirubin level as high as 12.8 mg/dL. I can only hope that with his expertise in ferreting out bad human judgment, Dr. Maisels’s next study will investigate candidates for Congress.
Inattention
A complex society cannot function without some degree of trust; there’s all sorts of scary stuff I’d like to know, and I’m happy to pay a few dollars in taxes to make sure someone more qualified than I am is checking. Does this bridge I’m crossing have severe erosion? Is there another plane in our airspace? What was my 14-year-old daughter texting to her “boyfriend” last night? (Thanks, National Security Agency!)
Drug safety is one of those things, especially when many of my patients and one of my own children are taking said drug. A new study from researchers at Boston Children’s Hospital suggests that perhaps when it comes to the long-term safety of attention-deficit/hyperactivity disorder (ADHD) medications, the U.S. Food and Drug Administration has not looked as hard as it might. Paging Dr. Edward Snowden!
One might assume that since up to 10% of U.S. children now carry a diagnosis of ADHD, and since those children start medications as young as age 4 and continue to use them for many years, the safety studies that got these drugs approved would have been especially rigorous. Yeah, no. Only 5 of 32 preapproval trials focused on safety, these trials enrolled an average of 75 patients (as opposed to the recommended 1,500), and few lasted as long as 12 months, with approval sometimes granted after only 8 weeks of study and some older drugs being “grandfathered” in with essentially no safety data whatsoever.
I see one bright spot in this desert of data. Whenever I prescribe a stimulant for ADHD, I’ll understand that I’m taking a gamble, and I’ll fondly remember our family trip to Las Vegas.
David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.
Is it time for telemedicine?
In the constantly advancing world of health information technology, the buzzwords are always changing. In the 90s, HIPAA dominated the literature. In the past few years, meaningful use took over. Most recently, a great deal of attention has been paid to telemedicine. For the uninitiated, telemedicine, a.k.a. telehealth, is not simply returning patient phone calls after hours. Telemedicine is the idea of substituting in-person patient encounters with virtual ones, typically using a secure video interface. In this column, we will explore a general overview of telemedicine and consider how this new medium fits into the ever-changing landscape of patient care.
The patient will ‘see’ you now
As evidenced by the feedback we have received on previous columns, many of our readers are still reeling from the arduous task of implementing an EHR and shudder at the thought of introducing even more technology into their office workflow. Others who enjoy being on the cutting edge of medicine are eager to embrace these virtual visits. We’ve spoken to several early adopters and have learned that it can be a rewarding way to handle certain patient interactions, but telemedicine obviously isn’t right for every patient or condition. Some feel that the lack of physical presence is not conducive to handling personal conversations or conveying sensitive information. Others have met with resistance from patients who just can’t get used to the idea of hands-free care. As with anything else, there will be patients who remain skeptical, but there will also be those who prefer it.
One patient we engaged saw his physician’s choice to offer virtual visits as a huge benefit, saying that "the idea of saving the 30 minutes of driving in each direction to visit the doctor, along with avoiding the hassle of taking time off work, makes [telehealth] a perfect way to handle my blood pressure control." In this case, as with others, patients use information from devices such as home blood pressure monitors or glucometers to supplement the visit and provide objective data. As home technology advances, connected devices are becoming more sophisticated and allowing more complicated diagnostics to be done remotely. Smartphone-connected otoscopes and ECG machines are just two examples of what’s to come, and we plan to highlight some of these in an upcoming column.
Getting started: Is it safe?
There are several things to consider when getting started in telemedicine in your practice. First is hardware. In general, this is fairly straightforward as most practices are now set up with broadband Internet and computers or tablets. Obviously, a good quality webcam is essential to ensure quality communication with patients. Beyond this, it’s critical to think about the security of the video interaction.
Standard consumer video-conferencing software such as Skype and Apple’s FaceTime are not HIPAA-compliant and can’t be used for patient communications. An encrypted video portal is essential to maintain patient privacy and make sure the patient interaction remains secure. The good news is that several easy-to-use software packages exist to allow this, if the functionality is not already built in to your EHR. A quick web search for "HIPAA-compliant video conferencing" returned several low-cost examples – some that are even free for a few interactions per month. This may be a good way to see if there is interest from patients prior to a large outlay of money. But what about the question of liability?
Unfortunately, physicians in the 21st century are wired to always be concerned about the threat of litigation, and there is no question that telemedicine offers a new opportunity for scrutiny of our clinical decisions. In addition, many rightfully fear the idea of diagnosis and treatment without the laying on of hands. As of now, there is little-to-no legal precedent for the malpractice implications of telehealth visits, but Teledoc, the country’s largest purveyor of telemedicine, advertises 7.5 million members and zero malpractice claims. Whether or not this is enough to convince the skeptics remains to be seen, but so far telemedicine has seemingly managed to fly below the radar of the courts. Following the pattern of all areas of medicine, this is likely to change, but it may be prevented if physicians limit the kinds of services offered through virtual visits. Many providers, such as Teledoc, for example, do not prescribe Drug Enforcement Administration–controlled or so-called nontherapeutic medications. (If you’re wondering, Viagra and Cialis are both on this list.) In this way, they are able to avoid becoming confused with illegitimate drug fulfillment warehouses and limit encounters that might raise questions of legality.
Can I get paid for this?
Although there are many conceivable benefits to telemedicine, such as access to patients who are homebound or live in isolated rural areas, it is hard to imagine setting off down the virtual path without the promise of reimbursement. According to the American Telemedicine Association, 21 states and Washington, D.C., require coverage of telemedicine services with reimbursement at a rate on par with in-person visits, while providers in the others are left wanting. Currently, 120 members of the U.S. Congress support various bills to expand the reach and acceptance of telemedicine, according to the telemedicine association, but it’s clear there is a long way to go before telemedicine receives the full support of insurers. In the meantime, its only financial benefit may be as a marketing advantage for practices. Those who leverage this may be able to draw new business from patients seeking more options in the delivery of their care.
Are you ready?
As with all burgeoning areas of health IT, telemedicine in its early stages appears at best like science fiction and at worst like just another headache. Unlike the other buzzwords of the past few years, adoption of telemedicine seems to be less of a requirement and more of an option. It may or may not work in your practice or for your patient population. Most importantly, though, it represents one point on the continuum of care that will take on an increasingly prominent role in the consumer-driven health care market, and it may represent a boon to both patients and providers alike.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
In the constantly advancing world of health information technology, the buzzwords are always changing. In the 90s, HIPAA dominated the literature. In the past few years, meaningful use took over. Most recently, a great deal of attention has been paid to telemedicine. For the uninitiated, telemedicine, a.k.a. telehealth, is not simply returning patient phone calls after hours. Telemedicine is the idea of substituting in-person patient encounters with virtual ones, typically using a secure video interface. In this column, we will explore a general overview of telemedicine and consider how this new medium fits into the ever-changing landscape of patient care.
The patient will ‘see’ you now
As evidenced by the feedback we have received on previous columns, many of our readers are still reeling from the arduous task of implementing an EHR and shudder at the thought of introducing even more technology into their office workflow. Others who enjoy being on the cutting edge of medicine are eager to embrace these virtual visits. We’ve spoken to several early adopters and have learned that it can be a rewarding way to handle certain patient interactions, but telemedicine obviously isn’t right for every patient or condition. Some feel that the lack of physical presence is not conducive to handling personal conversations or conveying sensitive information. Others have met with resistance from patients who just can’t get used to the idea of hands-free care. As with anything else, there will be patients who remain skeptical, but there will also be those who prefer it.
One patient we engaged saw his physician’s choice to offer virtual visits as a huge benefit, saying that "the idea of saving the 30 minutes of driving in each direction to visit the doctor, along with avoiding the hassle of taking time off work, makes [telehealth] a perfect way to handle my blood pressure control." In this case, as with others, patients use information from devices such as home blood pressure monitors or glucometers to supplement the visit and provide objective data. As home technology advances, connected devices are becoming more sophisticated and allowing more complicated diagnostics to be done remotely. Smartphone-connected otoscopes and ECG machines are just two examples of what’s to come, and we plan to highlight some of these in an upcoming column.
Getting started: Is it safe?
There are several things to consider when getting started in telemedicine in your practice. First is hardware. In general, this is fairly straightforward as most practices are now set up with broadband Internet and computers or tablets. Obviously, a good quality webcam is essential to ensure quality communication with patients. Beyond this, it’s critical to think about the security of the video interaction.
Standard consumer video-conferencing software such as Skype and Apple’s FaceTime are not HIPAA-compliant and can’t be used for patient communications. An encrypted video portal is essential to maintain patient privacy and make sure the patient interaction remains secure. The good news is that several easy-to-use software packages exist to allow this, if the functionality is not already built in to your EHR. A quick web search for "HIPAA-compliant video conferencing" returned several low-cost examples – some that are even free for a few interactions per month. This may be a good way to see if there is interest from patients prior to a large outlay of money. But what about the question of liability?
Unfortunately, physicians in the 21st century are wired to always be concerned about the threat of litigation, and there is no question that telemedicine offers a new opportunity for scrutiny of our clinical decisions. In addition, many rightfully fear the idea of diagnosis and treatment without the laying on of hands. As of now, there is little-to-no legal precedent for the malpractice implications of telehealth visits, but Teledoc, the country’s largest purveyor of telemedicine, advertises 7.5 million members and zero malpractice claims. Whether or not this is enough to convince the skeptics remains to be seen, but so far telemedicine has seemingly managed to fly below the radar of the courts. Following the pattern of all areas of medicine, this is likely to change, but it may be prevented if physicians limit the kinds of services offered through virtual visits. Many providers, such as Teledoc, for example, do not prescribe Drug Enforcement Administration–controlled or so-called nontherapeutic medications. (If you’re wondering, Viagra and Cialis are both on this list.) In this way, they are able to avoid becoming confused with illegitimate drug fulfillment warehouses and limit encounters that might raise questions of legality.
Can I get paid for this?
Although there are many conceivable benefits to telemedicine, such as access to patients who are homebound or live in isolated rural areas, it is hard to imagine setting off down the virtual path without the promise of reimbursement. According to the American Telemedicine Association, 21 states and Washington, D.C., require coverage of telemedicine services with reimbursement at a rate on par with in-person visits, while providers in the others are left wanting. Currently, 120 members of the U.S. Congress support various bills to expand the reach and acceptance of telemedicine, according to the telemedicine association, but it’s clear there is a long way to go before telemedicine receives the full support of insurers. In the meantime, its only financial benefit may be as a marketing advantage for practices. Those who leverage this may be able to draw new business from patients seeking more options in the delivery of their care.
Are you ready?
As with all burgeoning areas of health IT, telemedicine in its early stages appears at best like science fiction and at worst like just another headache. Unlike the other buzzwords of the past few years, adoption of telemedicine seems to be less of a requirement and more of an option. It may or may not work in your practice or for your patient population. Most importantly, though, it represents one point on the continuum of care that will take on an increasingly prominent role in the consumer-driven health care market, and it may represent a boon to both patients and providers alike.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
In the constantly advancing world of health information technology, the buzzwords are always changing. In the 90s, HIPAA dominated the literature. In the past few years, meaningful use took over. Most recently, a great deal of attention has been paid to telemedicine. For the uninitiated, telemedicine, a.k.a. telehealth, is not simply returning patient phone calls after hours. Telemedicine is the idea of substituting in-person patient encounters with virtual ones, typically using a secure video interface. In this column, we will explore a general overview of telemedicine and consider how this new medium fits into the ever-changing landscape of patient care.
The patient will ‘see’ you now
As evidenced by the feedback we have received on previous columns, many of our readers are still reeling from the arduous task of implementing an EHR and shudder at the thought of introducing even more technology into their office workflow. Others who enjoy being on the cutting edge of medicine are eager to embrace these virtual visits. We’ve spoken to several early adopters and have learned that it can be a rewarding way to handle certain patient interactions, but telemedicine obviously isn’t right for every patient or condition. Some feel that the lack of physical presence is not conducive to handling personal conversations or conveying sensitive information. Others have met with resistance from patients who just can’t get used to the idea of hands-free care. As with anything else, there will be patients who remain skeptical, but there will also be those who prefer it.
One patient we engaged saw his physician’s choice to offer virtual visits as a huge benefit, saying that "the idea of saving the 30 minutes of driving in each direction to visit the doctor, along with avoiding the hassle of taking time off work, makes [telehealth] a perfect way to handle my blood pressure control." In this case, as with others, patients use information from devices such as home blood pressure monitors or glucometers to supplement the visit and provide objective data. As home technology advances, connected devices are becoming more sophisticated and allowing more complicated diagnostics to be done remotely. Smartphone-connected otoscopes and ECG machines are just two examples of what’s to come, and we plan to highlight some of these in an upcoming column.
Getting started: Is it safe?
There are several things to consider when getting started in telemedicine in your practice. First is hardware. In general, this is fairly straightforward as most practices are now set up with broadband Internet and computers or tablets. Obviously, a good quality webcam is essential to ensure quality communication with patients. Beyond this, it’s critical to think about the security of the video interaction.
Standard consumer video-conferencing software such as Skype and Apple’s FaceTime are not HIPAA-compliant and can’t be used for patient communications. An encrypted video portal is essential to maintain patient privacy and make sure the patient interaction remains secure. The good news is that several easy-to-use software packages exist to allow this, if the functionality is not already built in to your EHR. A quick web search for "HIPAA-compliant video conferencing" returned several low-cost examples – some that are even free for a few interactions per month. This may be a good way to see if there is interest from patients prior to a large outlay of money. But what about the question of liability?
Unfortunately, physicians in the 21st century are wired to always be concerned about the threat of litigation, and there is no question that telemedicine offers a new opportunity for scrutiny of our clinical decisions. In addition, many rightfully fear the idea of diagnosis and treatment without the laying on of hands. As of now, there is little-to-no legal precedent for the malpractice implications of telehealth visits, but Teledoc, the country’s largest purveyor of telemedicine, advertises 7.5 million members and zero malpractice claims. Whether or not this is enough to convince the skeptics remains to be seen, but so far telemedicine has seemingly managed to fly below the radar of the courts. Following the pattern of all areas of medicine, this is likely to change, but it may be prevented if physicians limit the kinds of services offered through virtual visits. Many providers, such as Teledoc, for example, do not prescribe Drug Enforcement Administration–controlled or so-called nontherapeutic medications. (If you’re wondering, Viagra and Cialis are both on this list.) In this way, they are able to avoid becoming confused with illegitimate drug fulfillment warehouses and limit encounters that might raise questions of legality.
Can I get paid for this?
Although there are many conceivable benefits to telemedicine, such as access to patients who are homebound or live in isolated rural areas, it is hard to imagine setting off down the virtual path without the promise of reimbursement. According to the American Telemedicine Association, 21 states and Washington, D.C., require coverage of telemedicine services with reimbursement at a rate on par with in-person visits, while providers in the others are left wanting. Currently, 120 members of the U.S. Congress support various bills to expand the reach and acceptance of telemedicine, according to the telemedicine association, but it’s clear there is a long way to go before telemedicine receives the full support of insurers. In the meantime, its only financial benefit may be as a marketing advantage for practices. Those who leverage this may be able to draw new business from patients seeking more options in the delivery of their care.
Are you ready?
As with all burgeoning areas of health IT, telemedicine in its early stages appears at best like science fiction and at worst like just another headache. Unlike the other buzzwords of the past few years, adoption of telemedicine seems to be less of a requirement and more of an option. It may or may not work in your practice or for your patient population. Most importantly, though, it represents one point on the continuum of care that will take on an increasingly prominent role in the consumer-driven health care market, and it may represent a boon to both patients and providers alike.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
When ‘normal’ just isn’t normal
As pediatricians, we are constantly evaluating children of all ages. We make determinations of normal and abnormal all the time. But, sometimes determining normal can be a challenge because children come in all shapes, sizes, and complexions, so "normal" can appear in a variety of ways.
When it comes to the adolescent, this is an even greater challenge because the onset of puberty is so varied that children of the same age can look vastly different, and pubertal changes only widen the variety. Obesity also has impacted the appearance of normal because it makes children look older, pubertal changes more advanced, and a thorough exam more difficult. So when is it okay to say, "They will just grow out of it?" Well, the best answer is when all the serious illnesses have been considered and ruled out.
Gynecomastia is a common finding in the adolescent wellness exam; 50%-60% of adolescent males experience some degree of breast enlargement starting at the age of 10 years. This peaks at ages 13-14, then regresses over a period of 18 months (N. Engl. J. Med. 2007;357:1229-37). For approximately 25% of children, the breast tissue persists, which leads to significant anxiety and insecurities among adolescent males. Even when asked if they have concerns, few will admit to it because the thought of the evaluation is more than they can handle.
Gynecomastia is caused from the increased ratio of estrogen to androgen. Antiandrogens, drugs, and weight gain have all been implicated. But in the evaluation of increased breast tissue, normal as well as abnormal causes have to be considered.
Exogenous causes include herbal products, such as tea tree oil, or medications. The most common drugs are cimetidine, ranitidine, and omeprazole, as well spirolactone and ketoconazole. With the exception of spirolactone, these are all drugs that are used commonly for minor illness in children, but have been identified as a cause for gynecomastia. Discontinuation of these products usually resolves the issue within a few months (Pharmacotherapy 1993;13:37-45).
Obesity can cause a pseudogynecomastia as well as a true gynecomastia because aromatase enzyme increases with the increase in fat tissue, which converts testosterone to estradiol. Clinically, pseudogynecomastia can be distinguished from true gynecomastia by doing a breast exam. True gynecomastia is a concentric, rubbery firm mass greater than 0.5cm, and directly below the areola, where pseudogynecomastia has diffuse enlargement and no discernable glandular tissue.
Abnormal causes of gynecomastia are much less common, but do occur. A careful physical examination and a detailed review of systems can be very helpful in ruling in or out serious causes.
An imbalance of estrogen and testosterone can result from estrogen or testosterone going up or down. These changes can be caused by other hormonal stimulation. Human chorionic gonadotropin (HGC) is increased with germ cell tumors, which can be found in abdominal or testicular masses, resulting in secondary hypogonadism. Elevated estradiol is found with testicular tumors and adrenal tumors.
Hyperthyroidism can cause gynecomastia. Additional symptoms include palpitations, weight loss, and anxiety. Physical findings include a goiter, exophthalmoses, and tremors.
Klinefelter’s syndrome, a condition that occurs in men who have an extra X chromosome, includes gynecomastia and hypogonadism. There is a 20%-60% increased risk of breast cancer in these patients, who tend to have less facial and body hair, reduced muscle tone, and narrower shoulders and wider hips (N. Engl. J. Med. 2007;357:1229-37). Suspicion of breast cancer should increase if the mass is unilateral, nontender, and eccentric to the areola.
Although the vast majority of patients with gynecomastia will resolve spontaneously, careful evaluation and consideration of abnormal causes can lead to early diagnosis and treatment.
Experienced pediatricians know it’s never "nothing" unless all the possible "somethings" have been ruled out!
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
As pediatricians, we are constantly evaluating children of all ages. We make determinations of normal and abnormal all the time. But, sometimes determining normal can be a challenge because children come in all shapes, sizes, and complexions, so "normal" can appear in a variety of ways.
When it comes to the adolescent, this is an even greater challenge because the onset of puberty is so varied that children of the same age can look vastly different, and pubertal changes only widen the variety. Obesity also has impacted the appearance of normal because it makes children look older, pubertal changes more advanced, and a thorough exam more difficult. So when is it okay to say, "They will just grow out of it?" Well, the best answer is when all the serious illnesses have been considered and ruled out.
Gynecomastia is a common finding in the adolescent wellness exam; 50%-60% of adolescent males experience some degree of breast enlargement starting at the age of 10 years. This peaks at ages 13-14, then regresses over a period of 18 months (N. Engl. J. Med. 2007;357:1229-37). For approximately 25% of children, the breast tissue persists, which leads to significant anxiety and insecurities among adolescent males. Even when asked if they have concerns, few will admit to it because the thought of the evaluation is more than they can handle.
Gynecomastia is caused from the increased ratio of estrogen to androgen. Antiandrogens, drugs, and weight gain have all been implicated. But in the evaluation of increased breast tissue, normal as well as abnormal causes have to be considered.
Exogenous causes include herbal products, such as tea tree oil, or medications. The most common drugs are cimetidine, ranitidine, and omeprazole, as well spirolactone and ketoconazole. With the exception of spirolactone, these are all drugs that are used commonly for minor illness in children, but have been identified as a cause for gynecomastia. Discontinuation of these products usually resolves the issue within a few months (Pharmacotherapy 1993;13:37-45).
Obesity can cause a pseudogynecomastia as well as a true gynecomastia because aromatase enzyme increases with the increase in fat tissue, which converts testosterone to estradiol. Clinically, pseudogynecomastia can be distinguished from true gynecomastia by doing a breast exam. True gynecomastia is a concentric, rubbery firm mass greater than 0.5cm, and directly below the areola, where pseudogynecomastia has diffuse enlargement and no discernable glandular tissue.
Abnormal causes of gynecomastia are much less common, but do occur. A careful physical examination and a detailed review of systems can be very helpful in ruling in or out serious causes.
An imbalance of estrogen and testosterone can result from estrogen or testosterone going up or down. These changes can be caused by other hormonal stimulation. Human chorionic gonadotropin (HGC) is increased with germ cell tumors, which can be found in abdominal or testicular masses, resulting in secondary hypogonadism. Elevated estradiol is found with testicular tumors and adrenal tumors.
Hyperthyroidism can cause gynecomastia. Additional symptoms include palpitations, weight loss, and anxiety. Physical findings include a goiter, exophthalmoses, and tremors.
Klinefelter’s syndrome, a condition that occurs in men who have an extra X chromosome, includes gynecomastia and hypogonadism. There is a 20%-60% increased risk of breast cancer in these patients, who tend to have less facial and body hair, reduced muscle tone, and narrower shoulders and wider hips (N. Engl. J. Med. 2007;357:1229-37). Suspicion of breast cancer should increase if the mass is unilateral, nontender, and eccentric to the areola.
Although the vast majority of patients with gynecomastia will resolve spontaneously, careful evaluation and consideration of abnormal causes can lead to early diagnosis and treatment.
Experienced pediatricians know it’s never "nothing" unless all the possible "somethings" have been ruled out!
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
As pediatricians, we are constantly evaluating children of all ages. We make determinations of normal and abnormal all the time. But, sometimes determining normal can be a challenge because children come in all shapes, sizes, and complexions, so "normal" can appear in a variety of ways.
When it comes to the adolescent, this is an even greater challenge because the onset of puberty is so varied that children of the same age can look vastly different, and pubertal changes only widen the variety. Obesity also has impacted the appearance of normal because it makes children look older, pubertal changes more advanced, and a thorough exam more difficult. So when is it okay to say, "They will just grow out of it?" Well, the best answer is when all the serious illnesses have been considered and ruled out.
Gynecomastia is a common finding in the adolescent wellness exam; 50%-60% of adolescent males experience some degree of breast enlargement starting at the age of 10 years. This peaks at ages 13-14, then regresses over a period of 18 months (N. Engl. J. Med. 2007;357:1229-37). For approximately 25% of children, the breast tissue persists, which leads to significant anxiety and insecurities among adolescent males. Even when asked if they have concerns, few will admit to it because the thought of the evaluation is more than they can handle.
Gynecomastia is caused from the increased ratio of estrogen to androgen. Antiandrogens, drugs, and weight gain have all been implicated. But in the evaluation of increased breast tissue, normal as well as abnormal causes have to be considered.
Exogenous causes include herbal products, such as tea tree oil, or medications. The most common drugs are cimetidine, ranitidine, and omeprazole, as well spirolactone and ketoconazole. With the exception of spirolactone, these are all drugs that are used commonly for minor illness in children, but have been identified as a cause for gynecomastia. Discontinuation of these products usually resolves the issue within a few months (Pharmacotherapy 1993;13:37-45).
Obesity can cause a pseudogynecomastia as well as a true gynecomastia because aromatase enzyme increases with the increase in fat tissue, which converts testosterone to estradiol. Clinically, pseudogynecomastia can be distinguished from true gynecomastia by doing a breast exam. True gynecomastia is a concentric, rubbery firm mass greater than 0.5cm, and directly below the areola, where pseudogynecomastia has diffuse enlargement and no discernable glandular tissue.
Abnormal causes of gynecomastia are much less common, but do occur. A careful physical examination and a detailed review of systems can be very helpful in ruling in or out serious causes.
An imbalance of estrogen and testosterone can result from estrogen or testosterone going up or down. These changes can be caused by other hormonal stimulation. Human chorionic gonadotropin (HGC) is increased with germ cell tumors, which can be found in abdominal or testicular masses, resulting in secondary hypogonadism. Elevated estradiol is found with testicular tumors and adrenal tumors.
Hyperthyroidism can cause gynecomastia. Additional symptoms include palpitations, weight loss, and anxiety. Physical findings include a goiter, exophthalmoses, and tremors.
Klinefelter’s syndrome, a condition that occurs in men who have an extra X chromosome, includes gynecomastia and hypogonadism. There is a 20%-60% increased risk of breast cancer in these patients, who tend to have less facial and body hair, reduced muscle tone, and narrower shoulders and wider hips (N. Engl. J. Med. 2007;357:1229-37). Suspicion of breast cancer should increase if the mass is unilateral, nontender, and eccentric to the areola.
Although the vast majority of patients with gynecomastia will resolve spontaneously, careful evaluation and consideration of abnormal causes can lead to early diagnosis and treatment.
Experienced pediatricians know it’s never "nothing" unless all the possible "somethings" have been ruled out!
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
The Medical Roundtable: Pathophysiology of Headache Progression
DR. BURSTEIN: I am Rami Burstein. I am the academic director of the Headache Center at Beth Israel Deaconess Medical Center; Vice Chairman of Research in the Department of Anesthesia and Critical Care; and Professor of Anesthesia and Neuroscience at Harvard Medical School.
DR. CHARLES: I am Andrew Charles. I am a professor in the Department of Neurology at the UCLA School of Medicine and Director of the Headache Research and Treatment Program here.
DR. SCHOENEN: I’m Jean Schoenen. I’m a neurologist and professor at the University of Liege in Belgium and Director of the Headache Research Unit at the University hospital.
DR. GOADSBY: We are talking about the pathophysiology of headache progression, and in order to so, we should define at the start what we mean by “headache progression” so we’re all starting from the same point. Dr. Charles, when we talk about headache progression, what does it make you think about?
DR. CHARLES: It makes me think about a patient who has episodic migraine that occurs infrequently, let’s say once a month or once every other month, who at some point in the course of their life begins having headaches much more frequently, let’s say 2 or 3 or 4 times per week. Accompanying that, there may be a change in the quality of the headache, where it becomes somewhat less classic for episodic migraine and has fewer of the typical features that we consider associated with migraines.
DR. GOADSBY: That’s very helpful. What we’re really talking about and what we’re going to narrow ourselves down to is talking about the pathophysiology of migraine progression because we wouldn’t be able to cover all of the types of headaches. Dr. Schoenen, what is your comment on headache progression?
DR. SCHOENEN: I agree with what Dr. Charles said, although, clinically, I think that this disorder is quite heterogeneous between patients. Any migraineur has experienced, at some time in his life, progression of the disorder, where it becomes more frequent and then drops back again to its former frequency, but there seems to be a small population of patients in whom the disorder sometimes progress and then tips over into chronic migraine. That’s not the case for all migraineurs who progress, and many patients progress for some time and then do not progress up to what we call chronic migraines. So that may be something we have to consider from the pathophysiological point of view: What differs between those who progress to chronic migraine from those who do not?
DR. GOADSBY: Yes, you make a good point. Dr. Burstein?
DR. BURSTEIN: Maybe another aspect of the progression of headache is defined by treatment. When younger patients get a migraine, they go to sleep. When they wake up, their migraine is gone. They then progress to a point where they are unable to sleep off the migraine. They combine sleep with over-the-counter drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) in order to abort the migraine. As the disease progresses, they need something stronger than sleep and NSAIDs. As the disease continues to progress and they develop symptoms such as depression, anxiety, and fatigue, they benefit less from sleep and NSAIDs and seek alternative therapies, such as triptans.
Eventually, some aspects of the progression make them more and more resistant to conventional treatment and clearly define a pathophysiological or pathological change that makes it more difficult for them to become pain-free or respond to medication.
DR. GOADSBY: I think the other aspect of this, which is not often stated but may be incredibly informative if we understood it, is the basis for the regression of this progression. It seems that the population estimates for chronic migraine are stable, and that there’s clearly a group of people for whom the frequency of headaches can increase each year. There must be, clearly, a group of people in equal size who go from having more headache to less headache, and I wish I thought that was because we treated them properly, but I don’t think that’s the case on a population basis.
The resolution is almost as interesting as the induction. When we talk about progression, we’re talking about addition of burden, whether in terms of frequency, change in the type of headache, or, as Dr. Burstein just said, treatment. The other aspect of progression that’s discussed is whether there’s any progression of a consequent nature: Progression to acquisition of brain changes and, what have been, I think, erroneously been called brain lesions, progression in cognitive function. Dr. Schoenen, do you have a view about any of those things?
DR. SCHOENEN: I do not really believe that the majority of migraine patients accumulate brain lesions over their lifetime, even when they progress. Most patients who progress and experience chronic migraines have migraines without aura, very few or no white-matter lesions, and very little or no increased risk for stroke.1 Brain lesions on magnetic resonance imaging (MRI) were mainly reported in migraine-with-aura patients, and predominantly in females. The nature of these lesions is not known. In some studies, their prevalence was somewhat correlated with attack frequency, but the majority of subjects in the general population who suffer from migraine with aura experience low frequency of attacks. So, I do not believe that migraine without aura causes lesions in the brain, but I do believe that migraine without aura impairs, to some extent, cognitive performance, but that’s not related to the frequency of attacks, but likely due to the abnormal information processing that can be recorded in the brain of migraineurs between attacks.
DR. GOADSBY: Yes, exactly. Dr. Charles?
DR. CHARLES: The other imaging modalities that have shown changes are morphometric studies with MRI and functional MRI scans that show chronic changes in brain structure and function, particularly in areas related to pain processing, in patients with migraine. That is, I believe, something that may be occurring in patients who have progression of migraine, that there’s a plasticity of the brain that results in these structural and functional changes over time. I think that’s an area of great interest in terms of trying to understand how to reverse that process of progression.
DR. SCHOENEN: I agree completely with that. The problem is that many of these changes do not seem to be very specific to migraine. They are merely a consequence of the recurring head pain and also found in other pain disorders. Very few are specific to migraine. When patients develop chronic migraine, central sensitization occurs, and plastic changes appear in brain areas involved in pain processing and control. These areas are not specific to migraine. Taken together, I think brain changes seen in episodic migraine interictally are, for most cases, causally related to the disorder. In chronic migraine, these migraine-specific changes become overwhelmed by other brain modifications related to chronic pain, which have therapeutic implications.
DR. CHARLES: Yes, I agree.
DR. BURSTEIN: I think the biggest question that keeps coming up from all the imaging studies that show differences between migraine and non-migraine patients or migraine patients that progress and migraine patients that do not progress is what comes first: the changes that we see, which are responsible for the patient’s symptoms in the migraine, or the progression of the headache, which is causing the brain changes. For this, at least now, we don’t have a clear answer, although I think that most believe that progression of the migraine results in progressive changes and the beginning of brain malfunction. But the answer is not clear, and this belief somewhat conflicts with the concept of genetics, because if migraine patients do have genetic defects, you expect all changes to be there all along.
DR. GOADSBY: We currently have no clear data on what happens to migraineurs’ brains over time. Various changes in structure have been reported, but we do not know what happens, for example, if the migraine is controlled, do the brain changes revert? First, we must consider whether brain changes over time are linked with anything related to the headache. For example, if there’s high headache frequency or severity and then resolution, did changes occur? There don’t seem to be any long-term consequences of migraines. All the work done studying French people over the age of 70 on a population basis points to no untoward effect of a migraine on cognitive status,2 as do the data from the Women’s Health Study.3 Prospective examination of cognitive functions in that cohort identified absolutely no cognitive death attributable to migraine status. Whatever is happening in the brain can’t be all bad, since it doesn’t seem to have palpable consequences. I find that reassuring for patients.
DR. GOADSBY: I find the cognitive facts very reassuring for patients. I also find it reassuring to be able to tell them, even those with small changes, that as long as they live to even 75, they won’t have any particular problems.
I think we’ve probably come to the broad brush, that is, a group of migraineurs who have increased frequency and some change in quality. The treatment effects are perhaps most important for them. Before we go into the details of the pathophysiology, we should get some comments about the role of analgesic use, or the use of it in, as it is sometimes described, the evolution of migraines. Does analgesic use drive or follow the problem? I’ll start with Dr. Burstein.
DR. BURSTEIN: I belong to the group of people who believe that analgesics are overused, especially opiates and barbiturates, and contribute tremendously and significantly to the transition from acute to chronic pain, and from treatment that works to treatment that doesn’t work. They contribute on a molecular basis to sensitization; increase hyperexcitability; and add to the molecular aspects of the pathophysiology of increased excitability along the pain pathways in general, and in this case along the active trigeminovascular pain pathway.
DR. GOADSBY: We probably all agree that opioids are a problem, however, it’s how you look at it. Do you have in mind a particular site in the brain or particular pathways when you think about this process, or do you think “outside the brain” when you think about opioids and their role in this problem?
DR. BURSTEIN: I think that it will be in the first synapse between the peripheral and the central neuron. I think that the opioid’s ability to virtually bring to almost a complete stop the glutamate transporter and the inability of glutamate to clear itself out of the synapse contribute a lot to accessibility to susceptible pain neurons in the spinal cord, which is not where they eliminate pain. They eliminate pain in the brain stem, the rostral ventral inner medulla, the periaqueductal gray, and basal ganglia. When you eliminate the “off switch” by stopping medication, you’re left with a hyperexcitable spinal cord that has spinal glia that has a significantly reduced ability to clear glutamate from the synapse in the spinal cord.
DR. SCHOENEN: You’re right, but is that specific to migraine or not? Do you think that chronification due to medication overuse exists in other pain disorders?
DR. BURSTEIN: Yes, I think we have known that since 1988, when it first became clear in animal studies and then in human studies that opioids produced allodynia, hyperalgesia, and central sensitization.4
DR. SCHOENEN: I agree, but opioids are not a problem in Europe. Opioids are a problem in the United States. Analgesics containing opioids are very rarely overused in Europe right now because there are stricter limitations in their availability. The only one that still exists on the market is codeine combined with paracetamol. The most frequently overused preparations are non-opioid analgesics or NSAIDs combined with caffeine or triptans. The underlying process may be different between these molecules. Do you agree that it is possible that the daily intake of analgesics or NSAIDs by fibromyalgia patients, for instance, may play a role in chronifying their pain?
DR. BURSTEIN: Yes, I do. I think that whenever we prescribe opioids we make a big mistake, especially in the field of headache.
DR. GOADSBY: I will say one thing about Europe, when I was practicing there, the single biggest problem with overuse was codeine because codeine was available in the supermarkets. Medication overuse has regional and cultural dimensions, depending on what you have access to. Dr. Charles?
DR. CHARLES: I think with regard to the opioids, the other thing to keep in mind is that while they’re commonly viewed as having depressant or inhibitory actions, they in fact are excitatory in many areas of the brain, as well as the spinal cord. For example, most of the commonly used opioids can in fact cause seizures, and clearly have excitatory effects in the cortex. So it’s quite possible that in an episodic disorder of brain excitability, like migraine, they’re actually working not simply by changing pain, but also by changing some of the basic mechanisms until they reach a threshold that triggers migraine in the brain, even before the pain starts.
DR. GOADSBY: From that hypothesis, you might predict that patients with migraine with aura and opioid overuse would have more aura. You see where I’m headed with that?
DR. CHARLES: Sure. I wasn’t necessarily specifically referring to the visual cortex, but, in general, making the point that opioids have excitatory effects in the brain and using seizures as an example of a phenomenon, but not necessarily saying that it’s the cortex itself. Maybe it’s the hypothalamus or the thalamus or some other area of the brain in which they’re exerting excitatory effects.
DR. BURSTEIN: It can be the peripheral nervous system. Look, they produce itch, suggesting they are excitatory to certain classes of peripheral receptors.
DR. GOADSBY: Dr. Charles, do you agree that opioid-induced medication overuse problems precede as opposed to follow increased headache frequency, because there is this possibility that some medication overuse is simply because headache gets worse and patients just do what they need to do? I’m not sure lumping everyone together and saying everyone who overuses actually produces headache with the overuse so much as there’s more than one group.
DR. CHARLES: That’s right. Broadening the discussion to other medications, I think that it’s important to not lump all the acute medications for migraine into the same categories because they have such pharmacologically distinct properties that it isn’t plausible that they could all have the same effects. I think, as Dr. Schoenen mentioned, the combination analgesics, particularly those with caffeine, are particularly problematic. Recently in the United States, we’ve had a big uproar because of a shortage of one of the aspirin-and-caffeine-containing preparations. That, I think, is an example of how caffeine-containing preparations can be particularly problematic as a cause of medication-overuse headache.
DR. GOADSBY: Yes, I think the other component of this must be that there is some predisposition to it. The two studies that I’m aware of, the one that we were involved in in the rheumatology clinic and the one that Becker did in the gastro clinic, clearly show that there are people who overuse opioids by any standard definition who don’t have headache at all as a problem. So, there’s an important interaction, I think, between a genetic predisposition and these medicines. It’s something that would be wonderful to get at so we could be able to understand who are at risk and who aren’t at risk. One day I hope that we’ll be able to do that. Do you think that people who are at risk for one type of overuse are at risk for all? Let me ask Dr. Schoenen.
DR. SCHOENEN: I don’t know. I can only say that I see patients in whom overuse recurs and with a different drug. There are patients with overuse of a combined analgesic who return to an episodic form of migraine after drug withdrawal, but come back to my office 6 months or 1 year later with daily headache and daily use of a simple NSAID or analgesic. There may be a genetic predisposition to chronification by overuse of any anti-migraine drug, despite the fact that in practice simple NSAIDs are less likely to chronify the disorder.
Just to pick up what Andrew said, there is clearly a difference between the drugs and their effect on the brain. For example, looking at sensitivity in the somatosensory cortex with evoked potentials, there’s clearly a difference between patients overusing triptans and those taking NSAIDs, although their clinical phenotype is the same.
DR. SCHOENEN: Oh, yes. Well that was a study where we looked at metabolic changes with fluorodeoxyglucose positron emission tomography in brain areas that belong to the so-called pain matrix, but also in areas that are known to be involved in substance abuse.5 What we found was that metabolism was clearly decreased in several areas that are thought to belong to the pain matrix, but these changes were reversible after withdrawal of the drug 3 weeks later. The only area where hypometabolism was not reversible after drug withdrawal was the orbitofrontal cortex. The orbitofrontal hypoactivity was even worse after withdrawal, and it was more pronounced in those patients who were overusing combined analgesics. The orbitofrontal cortex has been shown to play a crucial role in substance dependence. Its hypofunction could predispose patients to recurrence of medication-overuse headache. To prove this, we’re completing a long-term follow-up study.
DR. GOADSBY: That is interesting because I think that’s one of the important contributions to the pathophysiological understanding in humans.
DR. SCHOENEN: A Swiss group just published similar results measuring the amount of brain tissue with MRI.6 They found decreased tissue density in the orbitofrontal cortex, as well as in the dorsal pons, where abnormal activity is known to occur during migraine attacks.
DR. GOADSBY: You brought up nonsteroidals, a slightly more vexed issue. I’ll start with Dr. Charles. Do you think nonsteroidals, and you don’t have to lump them all together if you don’t want to, have a role in medication overuse in terms of inducing headache?
DR. CHARLES: My own view is no. It’s only the nonsteroidals in combination with caffeine that are the cause of medication overuse. I think that view is supported by the study by Bigal and Lipton,7 which basically suggests that, at a population level, frequent use of nonsteroidals is not associated with progression of headache. In fact, there’s a slight trend in the opposite direction, which has led them to suggest that it may possibly be protective. So, no, I do not put nonsteroidal anti-inflammatory drugs in the same category as a cause, but I see them more as a consequence, or frequent use as a consequence of frequent headache rather than as a cause.
DR. GOADSBY: How do you see the difference in a mechanistic sense? I’ll give everyone a chance to weigh in on this.
DR. CHARLES: This is something that may have to do with agonism versus antagonism of receptors and specific mechanisms of analgesia. I think the things that we think about that are the significant players in terms of causing medication overuse are ones that are working on neurotransmitter receptors, like γ-aminobutyric acid receptors and opioid receptors, and, in the case of caffeine, maybe adenosine receptors. I think the issue with the nonsteroidals is harder to understand, particularly how they might pharmacologically actually cause medication overuse. So, I think that mechanistically, those are the questions that are before us now.
DR. GOADSBY: Dr. Burstein, you published on nonsteroidals and triptans in the context of sensitization.8 What’s your view about this, particularly at a mechanistic level?
DR. BURSTEIN: Mechanistically, the data suggest that triptans disrupt communication between peripheral and central trigeminovascular neurons and that NSAIDs inhibit both the peripheral and the central neurons.
Accordingly, it is reasonable to suggest that triptans do not reverse central sensitization because they do not inhibit central trigeminovascular neurons directly, not at the level of the spinal cord at least, and that NSAIDs reverse central sensitization indirectly, through their anti-inflammatory action in the spinal cord (mostly unknown mechanism).
I think, again, that in the context of the opioid treatment, it became apparent both in the animal data and in patient data that opioid treatment makes patients resistant to successful NSAID treatment. NSAIDs work much better in patients who do not have a history of favoring opioids. Once patients begin to use opioids, however, they see a noticeable decline in the potential benefit of NSAIDs or triptan treatments. Again, I think that the key to that is the spinal cord inability to clear glutamate from the synapse, although I don’t think that the NSAIDs target glutamate release in any way.
DR. SCHOENEN: I do partially agree with what has been said. I think clinically, we clearly see patients who with overuse of simple analgesics, like paracetamol or a single NSAID like ibuprofen, enter the vicious circle of chronification and reverse to episodic migraine after reducing intake of these drugs.
The second point is that in the electrophysiological studies of patients overusing simple NSAIDs, there is clearly indication of sensitization in sensory cortices. Thirdly, Dr. Charles was alluding to the Bigal et al. study showing that NSAIDs protect against migraine chronification contrary to triptans.6 In this study, however, the protective effect of NSAIDs was only seen with patients who had low frequency of headaches. In patients with high frequency of headaches at baseline, NSAIDs also had a deleterious effect.
DR. GOADSBY: In the last few minutes that we have, I’d like to get some views about whether you think that more aggressive treatment with preventives would be helpful in terms of restricting headache progression. When medical practitioners see people who experience 6 or 8 headaches a month, and a couple months later they have 10 or maybe 12 or 14, they want to help them get better before they get worse. So if we intervened earlier, do we think that we could do a better job? Is that mechanistically plausible? I’ll start with you, Dr. Charles.
DR. CHARLES: I think it’s an appealing concept, but unfortunately I think that in practice we don’t see that concept being realized. Taking a cynical view, I think in many cases, even with preventative therapy, migraine finds its way around them, and even patients on preventative therapy end up having progression. So I think until we better understand the process, we can’t really say with confidence that early preventive therapy is something that is going to prevent the progression of the disorder.
DR. GOADSBY: Dr. Schoenen?
DR. SCHOENEN: I fundamentally agree with that. I think we are very lousy in the prevention of migraine. Most of the drugs don’t reach 50% efficacy. The patients who respond to these drugs may be those who have a peculiar pathophysiological, possibly genetic, profile, and do not progress. Those who do not respond are probably those who are most prone to chronification of migraine and at last fail on all available preventative drugs. So, in addition to much better preventative treatments, we also really need many more treatments.
DR. GOADSBY: Yes. Dr. Burstein?
DR. BURSTEIN: Well, I want to take it in a slightly different direction. I am aware of the fact that there is no evidence for it because nobody has done the study, but the question that I would like to answer is whether migraine progression would look completely different in a group of patients whose migraine attacks were treated early from the first migraine attack in their life (ie, they didn’t let their migraine last more than a few hours). Comparing this "early-treatment" group to a group of patients who treat late (ie, they let themselves have a migraine for 8, 10, or 12 hours before it goes away by itself or before they treat it).
DR. GOADSBY: Well, that would be an interesting study, very expensive as well. But as you say, one of the things we lack very much in longitudinal study is what’s really a dreadful problem, because whatever we think about the pathophysiology of headache progression, we’d all agree it’s bad to have more headache, it’s bad to have worse headache, and it’s bad to have headaches that don’t respond to therapy. It’s a subject which deserves study.
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DR. BURSTEIN: I am Rami Burstein. I am the academic director of the Headache Center at Beth Israel Deaconess Medical Center; Vice Chairman of Research in the Department of Anesthesia and Critical Care; and Professor of Anesthesia and Neuroscience at Harvard Medical School.
DR. CHARLES: I am Andrew Charles. I am a professor in the Department of Neurology at the UCLA School of Medicine and Director of the Headache Research and Treatment Program here.
DR. SCHOENEN: I’m Jean Schoenen. I’m a neurologist and professor at the University of Liege in Belgium and Director of the Headache Research Unit at the University hospital.
DR. GOADSBY: We are talking about the pathophysiology of headache progression, and in order to so, we should define at the start what we mean by “headache progression” so we’re all starting from the same point. Dr. Charles, when we talk about headache progression, what does it make you think about?
DR. CHARLES: It makes me think about a patient who has episodic migraine that occurs infrequently, let’s say once a month or once every other month, who at some point in the course of their life begins having headaches much more frequently, let’s say 2 or 3 or 4 times per week. Accompanying that, there may be a change in the quality of the headache, where it becomes somewhat less classic for episodic migraine and has fewer of the typical features that we consider associated with migraines.
DR. GOADSBY: That’s very helpful. What we’re really talking about and what we’re going to narrow ourselves down to is talking about the pathophysiology of migraine progression because we wouldn’t be able to cover all of the types of headaches. Dr. Schoenen, what is your comment on headache progression?
DR. SCHOENEN: I agree with what Dr. Charles said, although, clinically, I think that this disorder is quite heterogeneous between patients. Any migraineur has experienced, at some time in his life, progression of the disorder, where it becomes more frequent and then drops back again to its former frequency, but there seems to be a small population of patients in whom the disorder sometimes progress and then tips over into chronic migraine. That’s not the case for all migraineurs who progress, and many patients progress for some time and then do not progress up to what we call chronic migraines. So that may be something we have to consider from the pathophysiological point of view: What differs between those who progress to chronic migraine from those who do not?
DR. GOADSBY: Yes, you make a good point. Dr. Burstein?
DR. BURSTEIN: Maybe another aspect of the progression of headache is defined by treatment. When younger patients get a migraine, they go to sleep. When they wake up, their migraine is gone. They then progress to a point where they are unable to sleep off the migraine. They combine sleep with over-the-counter drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) in order to abort the migraine. As the disease progresses, they need something stronger than sleep and NSAIDs. As the disease continues to progress and they develop symptoms such as depression, anxiety, and fatigue, they benefit less from sleep and NSAIDs and seek alternative therapies, such as triptans.
Eventually, some aspects of the progression make them more and more resistant to conventional treatment and clearly define a pathophysiological or pathological change that makes it more difficult for them to become pain-free or respond to medication.
DR. GOADSBY: I think the other aspect of this, which is not often stated but may be incredibly informative if we understood it, is the basis for the regression of this progression. It seems that the population estimates for chronic migraine are stable, and that there’s clearly a group of people for whom the frequency of headaches can increase each year. There must be, clearly, a group of people in equal size who go from having more headache to less headache, and I wish I thought that was because we treated them properly, but I don’t think that’s the case on a population basis.
The resolution is almost as interesting as the induction. When we talk about progression, we’re talking about addition of burden, whether in terms of frequency, change in the type of headache, or, as Dr. Burstein just said, treatment. The other aspect of progression that’s discussed is whether there’s any progression of a consequent nature: Progression to acquisition of brain changes and, what have been, I think, erroneously been called brain lesions, progression in cognitive function. Dr. Schoenen, do you have a view about any of those things?
DR. SCHOENEN: I do not really believe that the majority of migraine patients accumulate brain lesions over their lifetime, even when they progress. Most patients who progress and experience chronic migraines have migraines without aura, very few or no white-matter lesions, and very little or no increased risk for stroke.1 Brain lesions on magnetic resonance imaging (MRI) were mainly reported in migraine-with-aura patients, and predominantly in females. The nature of these lesions is not known. In some studies, their prevalence was somewhat correlated with attack frequency, but the majority of subjects in the general population who suffer from migraine with aura experience low frequency of attacks. So, I do not believe that migraine without aura causes lesions in the brain, but I do believe that migraine without aura impairs, to some extent, cognitive performance, but that’s not related to the frequency of attacks, but likely due to the abnormal information processing that can be recorded in the brain of migraineurs between attacks.
DR. GOADSBY: Yes, exactly. Dr. Charles?
DR. CHARLES: The other imaging modalities that have shown changes are morphometric studies with MRI and functional MRI scans that show chronic changes in brain structure and function, particularly in areas related to pain processing, in patients with migraine. That is, I believe, something that may be occurring in patients who have progression of migraine, that there’s a plasticity of the brain that results in these structural and functional changes over time. I think that’s an area of great interest in terms of trying to understand how to reverse that process of progression.
DR. SCHOENEN: I agree completely with that. The problem is that many of these changes do not seem to be very specific to migraine. They are merely a consequence of the recurring head pain and also found in other pain disorders. Very few are specific to migraine. When patients develop chronic migraine, central sensitization occurs, and plastic changes appear in brain areas involved in pain processing and control. These areas are not specific to migraine. Taken together, I think brain changes seen in episodic migraine interictally are, for most cases, causally related to the disorder. In chronic migraine, these migraine-specific changes become overwhelmed by other brain modifications related to chronic pain, which have therapeutic implications.
DR. CHARLES: Yes, I agree.
DR. BURSTEIN: I think the biggest question that keeps coming up from all the imaging studies that show differences between migraine and non-migraine patients or migraine patients that progress and migraine patients that do not progress is what comes first: the changes that we see, which are responsible for the patient’s symptoms in the migraine, or the progression of the headache, which is causing the brain changes. For this, at least now, we don’t have a clear answer, although I think that most believe that progression of the migraine results in progressive changes and the beginning of brain malfunction. But the answer is not clear, and this belief somewhat conflicts with the concept of genetics, because if migraine patients do have genetic defects, you expect all changes to be there all along.
DR. GOADSBY: We currently have no clear data on what happens to migraineurs’ brains over time. Various changes in structure have been reported, but we do not know what happens, for example, if the migraine is controlled, do the brain changes revert? First, we must consider whether brain changes over time are linked with anything related to the headache. For example, if there’s high headache frequency or severity and then resolution, did changes occur? There don’t seem to be any long-term consequences of migraines. All the work done studying French people over the age of 70 on a population basis points to no untoward effect of a migraine on cognitive status,2 as do the data from the Women’s Health Study.3 Prospective examination of cognitive functions in that cohort identified absolutely no cognitive death attributable to migraine status. Whatever is happening in the brain can’t be all bad, since it doesn’t seem to have palpable consequences. I find that reassuring for patients.
DR. GOADSBY: I find the cognitive facts very reassuring for patients. I also find it reassuring to be able to tell them, even those with small changes, that as long as they live to even 75, they won’t have any particular problems.
I think we’ve probably come to the broad brush, that is, a group of migraineurs who have increased frequency and some change in quality. The treatment effects are perhaps most important for them. Before we go into the details of the pathophysiology, we should get some comments about the role of analgesic use, or the use of it in, as it is sometimes described, the evolution of migraines. Does analgesic use drive or follow the problem? I’ll start with Dr. Burstein.
DR. BURSTEIN: I belong to the group of people who believe that analgesics are overused, especially opiates and barbiturates, and contribute tremendously and significantly to the transition from acute to chronic pain, and from treatment that works to treatment that doesn’t work. They contribute on a molecular basis to sensitization; increase hyperexcitability; and add to the molecular aspects of the pathophysiology of increased excitability along the pain pathways in general, and in this case along the active trigeminovascular pain pathway.
DR. GOADSBY: We probably all agree that opioids are a problem, however, it’s how you look at it. Do you have in mind a particular site in the brain or particular pathways when you think about this process, or do you think “outside the brain” when you think about opioids and their role in this problem?
DR. BURSTEIN: I think that it will be in the first synapse between the peripheral and the central neuron. I think that the opioid’s ability to virtually bring to almost a complete stop the glutamate transporter and the inability of glutamate to clear itself out of the synapse contribute a lot to accessibility to susceptible pain neurons in the spinal cord, which is not where they eliminate pain. They eliminate pain in the brain stem, the rostral ventral inner medulla, the periaqueductal gray, and basal ganglia. When you eliminate the “off switch” by stopping medication, you’re left with a hyperexcitable spinal cord that has spinal glia that has a significantly reduced ability to clear glutamate from the synapse in the spinal cord.
DR. SCHOENEN: You’re right, but is that specific to migraine or not? Do you think that chronification due to medication overuse exists in other pain disorders?
DR. BURSTEIN: Yes, I think we have known that since 1988, when it first became clear in animal studies and then in human studies that opioids produced allodynia, hyperalgesia, and central sensitization.4
DR. SCHOENEN: I agree, but opioids are not a problem in Europe. Opioids are a problem in the United States. Analgesics containing opioids are very rarely overused in Europe right now because there are stricter limitations in their availability. The only one that still exists on the market is codeine combined with paracetamol. The most frequently overused preparations are non-opioid analgesics or NSAIDs combined with caffeine or triptans. The underlying process may be different between these molecules. Do you agree that it is possible that the daily intake of analgesics or NSAIDs by fibromyalgia patients, for instance, may play a role in chronifying their pain?
DR. BURSTEIN: Yes, I do. I think that whenever we prescribe opioids we make a big mistake, especially in the field of headache.
DR. GOADSBY: I will say one thing about Europe, when I was practicing there, the single biggest problem with overuse was codeine because codeine was available in the supermarkets. Medication overuse has regional and cultural dimensions, depending on what you have access to. Dr. Charles?
DR. CHARLES: I think with regard to the opioids, the other thing to keep in mind is that while they’re commonly viewed as having depressant or inhibitory actions, they in fact are excitatory in many areas of the brain, as well as the spinal cord. For example, most of the commonly used opioids can in fact cause seizures, and clearly have excitatory effects in the cortex. So it’s quite possible that in an episodic disorder of brain excitability, like migraine, they’re actually working not simply by changing pain, but also by changing some of the basic mechanisms until they reach a threshold that triggers migraine in the brain, even before the pain starts.
DR. GOADSBY: From that hypothesis, you might predict that patients with migraine with aura and opioid overuse would have more aura. You see where I’m headed with that?
DR. CHARLES: Sure. I wasn’t necessarily specifically referring to the visual cortex, but, in general, making the point that opioids have excitatory effects in the brain and using seizures as an example of a phenomenon, but not necessarily saying that it’s the cortex itself. Maybe it’s the hypothalamus or the thalamus or some other area of the brain in which they’re exerting excitatory effects.
DR. BURSTEIN: It can be the peripheral nervous system. Look, they produce itch, suggesting they are excitatory to certain classes of peripheral receptors.
DR. GOADSBY: Dr. Charles, do you agree that opioid-induced medication overuse problems precede as opposed to follow increased headache frequency, because there is this possibility that some medication overuse is simply because headache gets worse and patients just do what they need to do? I’m not sure lumping everyone together and saying everyone who overuses actually produces headache with the overuse so much as there’s more than one group.
DR. CHARLES: That’s right. Broadening the discussion to other medications, I think that it’s important to not lump all the acute medications for migraine into the same categories because they have such pharmacologically distinct properties that it isn’t plausible that they could all have the same effects. I think, as Dr. Schoenen mentioned, the combination analgesics, particularly those with caffeine, are particularly problematic. Recently in the United States, we’ve had a big uproar because of a shortage of one of the aspirin-and-caffeine-containing preparations. That, I think, is an example of how caffeine-containing preparations can be particularly problematic as a cause of medication-overuse headache.
DR. GOADSBY: Yes, I think the other component of this must be that there is some predisposition to it. The two studies that I’m aware of, the one that we were involved in in the rheumatology clinic and the one that Becker did in the gastro clinic, clearly show that there are people who overuse opioids by any standard definition who don’t have headache at all as a problem. So, there’s an important interaction, I think, between a genetic predisposition and these medicines. It’s something that would be wonderful to get at so we could be able to understand who are at risk and who aren’t at risk. One day I hope that we’ll be able to do that. Do you think that people who are at risk for one type of overuse are at risk for all? Let me ask Dr. Schoenen.
DR. SCHOENEN: I don’t know. I can only say that I see patients in whom overuse recurs and with a different drug. There are patients with overuse of a combined analgesic who return to an episodic form of migraine after drug withdrawal, but come back to my office 6 months or 1 year later with daily headache and daily use of a simple NSAID or analgesic. There may be a genetic predisposition to chronification by overuse of any anti-migraine drug, despite the fact that in practice simple NSAIDs are less likely to chronify the disorder.
Just to pick up what Andrew said, there is clearly a difference between the drugs and their effect on the brain. For example, looking at sensitivity in the somatosensory cortex with evoked potentials, there’s clearly a difference between patients overusing triptans and those taking NSAIDs, although their clinical phenotype is the same.
DR. SCHOENEN: Oh, yes. Well that was a study where we looked at metabolic changes with fluorodeoxyglucose positron emission tomography in brain areas that belong to the so-called pain matrix, but also in areas that are known to be involved in substance abuse.5 What we found was that metabolism was clearly decreased in several areas that are thought to belong to the pain matrix, but these changes were reversible after withdrawal of the drug 3 weeks later. The only area where hypometabolism was not reversible after drug withdrawal was the orbitofrontal cortex. The orbitofrontal hypoactivity was even worse after withdrawal, and it was more pronounced in those patients who were overusing combined analgesics. The orbitofrontal cortex has been shown to play a crucial role in substance dependence. Its hypofunction could predispose patients to recurrence of medication-overuse headache. To prove this, we’re completing a long-term follow-up study.
DR. GOADSBY: That is interesting because I think that’s one of the important contributions to the pathophysiological understanding in humans.
DR. SCHOENEN: A Swiss group just published similar results measuring the amount of brain tissue with MRI.6 They found decreased tissue density in the orbitofrontal cortex, as well as in the dorsal pons, where abnormal activity is known to occur during migraine attacks.
DR. GOADSBY: You brought up nonsteroidals, a slightly more vexed issue. I’ll start with Dr. Charles. Do you think nonsteroidals, and you don’t have to lump them all together if you don’t want to, have a role in medication overuse in terms of inducing headache?
DR. CHARLES: My own view is no. It’s only the nonsteroidals in combination with caffeine that are the cause of medication overuse. I think that view is supported by the study by Bigal and Lipton,7 which basically suggests that, at a population level, frequent use of nonsteroidals is not associated with progression of headache. In fact, there’s a slight trend in the opposite direction, which has led them to suggest that it may possibly be protective. So, no, I do not put nonsteroidal anti-inflammatory drugs in the same category as a cause, but I see them more as a consequence, or frequent use as a consequence of frequent headache rather than as a cause.
DR. GOADSBY: How do you see the difference in a mechanistic sense? I’ll give everyone a chance to weigh in on this.
DR. CHARLES: This is something that may have to do with agonism versus antagonism of receptors and specific mechanisms of analgesia. I think the things that we think about that are the significant players in terms of causing medication overuse are ones that are working on neurotransmitter receptors, like γ-aminobutyric acid receptors and opioid receptors, and, in the case of caffeine, maybe adenosine receptors. I think the issue with the nonsteroidals is harder to understand, particularly how they might pharmacologically actually cause medication overuse. So, I think that mechanistically, those are the questions that are before us now.
DR. GOADSBY: Dr. Burstein, you published on nonsteroidals and triptans in the context of sensitization.8 What’s your view about this, particularly at a mechanistic level?
DR. BURSTEIN: Mechanistically, the data suggest that triptans disrupt communication between peripheral and central trigeminovascular neurons and that NSAIDs inhibit both the peripheral and the central neurons.
Accordingly, it is reasonable to suggest that triptans do not reverse central sensitization because they do not inhibit central trigeminovascular neurons directly, not at the level of the spinal cord at least, and that NSAIDs reverse central sensitization indirectly, through their anti-inflammatory action in the spinal cord (mostly unknown mechanism).
I think, again, that in the context of the opioid treatment, it became apparent both in the animal data and in patient data that opioid treatment makes patients resistant to successful NSAID treatment. NSAIDs work much better in patients who do not have a history of favoring opioids. Once patients begin to use opioids, however, they see a noticeable decline in the potential benefit of NSAIDs or triptan treatments. Again, I think that the key to that is the spinal cord inability to clear glutamate from the synapse, although I don’t think that the NSAIDs target glutamate release in any way.
DR. SCHOENEN: I do partially agree with what has been said. I think clinically, we clearly see patients who with overuse of simple analgesics, like paracetamol or a single NSAID like ibuprofen, enter the vicious circle of chronification and reverse to episodic migraine after reducing intake of these drugs.
The second point is that in the electrophysiological studies of patients overusing simple NSAIDs, there is clearly indication of sensitization in sensory cortices. Thirdly, Dr. Charles was alluding to the Bigal et al. study showing that NSAIDs protect against migraine chronification contrary to triptans.6 In this study, however, the protective effect of NSAIDs was only seen with patients who had low frequency of headaches. In patients with high frequency of headaches at baseline, NSAIDs also had a deleterious effect.
DR. GOADSBY: In the last few minutes that we have, I’d like to get some views about whether you think that more aggressive treatment with preventives would be helpful in terms of restricting headache progression. When medical practitioners see people who experience 6 or 8 headaches a month, and a couple months later they have 10 or maybe 12 or 14, they want to help them get better before they get worse. So if we intervened earlier, do we think that we could do a better job? Is that mechanistically plausible? I’ll start with you, Dr. Charles.
DR. CHARLES: I think it’s an appealing concept, but unfortunately I think that in practice we don’t see that concept being realized. Taking a cynical view, I think in many cases, even with preventative therapy, migraine finds its way around them, and even patients on preventative therapy end up having progression. So I think until we better understand the process, we can’t really say with confidence that early preventive therapy is something that is going to prevent the progression of the disorder.
DR. GOADSBY: Dr. Schoenen?
DR. SCHOENEN: I fundamentally agree with that. I think we are very lousy in the prevention of migraine. Most of the drugs don’t reach 50% efficacy. The patients who respond to these drugs may be those who have a peculiar pathophysiological, possibly genetic, profile, and do not progress. Those who do not respond are probably those who are most prone to chronification of migraine and at last fail on all available preventative drugs. So, in addition to much better preventative treatments, we also really need many more treatments.
DR. GOADSBY: Yes. Dr. Burstein?
DR. BURSTEIN: Well, I want to take it in a slightly different direction. I am aware of the fact that there is no evidence for it because nobody has done the study, but the question that I would like to answer is whether migraine progression would look completely different in a group of patients whose migraine attacks were treated early from the first migraine attack in their life (ie, they didn’t let their migraine last more than a few hours). Comparing this "early-treatment" group to a group of patients who treat late (ie, they let themselves have a migraine for 8, 10, or 12 hours before it goes away by itself or before they treat it).
DR. GOADSBY: Well, that would be an interesting study, very expensive as well. But as you say, one of the things we lack very much in longitudinal study is what’s really a dreadful problem, because whatever we think about the pathophysiology of headache progression, we’d all agree it’s bad to have more headache, it’s bad to have worse headache, and it’s bad to have headaches that don’t respond to therapy. It’s a subject which deserves study.
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DR. BURSTEIN: I am Rami Burstein. I am the academic director of the Headache Center at Beth Israel Deaconess Medical Center; Vice Chairman of Research in the Department of Anesthesia and Critical Care; and Professor of Anesthesia and Neuroscience at Harvard Medical School.
DR. CHARLES: I am Andrew Charles. I am a professor in the Department of Neurology at the UCLA School of Medicine and Director of the Headache Research and Treatment Program here.
DR. SCHOENEN: I’m Jean Schoenen. I’m a neurologist and professor at the University of Liege in Belgium and Director of the Headache Research Unit at the University hospital.
DR. GOADSBY: We are talking about the pathophysiology of headache progression, and in order to so, we should define at the start what we mean by “headache progression” so we’re all starting from the same point. Dr. Charles, when we talk about headache progression, what does it make you think about?
DR. CHARLES: It makes me think about a patient who has episodic migraine that occurs infrequently, let’s say once a month or once every other month, who at some point in the course of their life begins having headaches much more frequently, let’s say 2 or 3 or 4 times per week. Accompanying that, there may be a change in the quality of the headache, where it becomes somewhat less classic for episodic migraine and has fewer of the typical features that we consider associated with migraines.
DR. GOADSBY: That’s very helpful. What we’re really talking about and what we’re going to narrow ourselves down to is talking about the pathophysiology of migraine progression because we wouldn’t be able to cover all of the types of headaches. Dr. Schoenen, what is your comment on headache progression?
DR. SCHOENEN: I agree with what Dr. Charles said, although, clinically, I think that this disorder is quite heterogeneous between patients. Any migraineur has experienced, at some time in his life, progression of the disorder, where it becomes more frequent and then drops back again to its former frequency, but there seems to be a small population of patients in whom the disorder sometimes progress and then tips over into chronic migraine. That’s not the case for all migraineurs who progress, and many patients progress for some time and then do not progress up to what we call chronic migraines. So that may be something we have to consider from the pathophysiological point of view: What differs between those who progress to chronic migraine from those who do not?
DR. GOADSBY: Yes, you make a good point. Dr. Burstein?
DR. BURSTEIN: Maybe another aspect of the progression of headache is defined by treatment. When younger patients get a migraine, they go to sleep. When they wake up, their migraine is gone. They then progress to a point where they are unable to sleep off the migraine. They combine sleep with over-the-counter drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) in order to abort the migraine. As the disease progresses, they need something stronger than sleep and NSAIDs. As the disease continues to progress and they develop symptoms such as depression, anxiety, and fatigue, they benefit less from sleep and NSAIDs and seek alternative therapies, such as triptans.
Eventually, some aspects of the progression make them more and more resistant to conventional treatment and clearly define a pathophysiological or pathological change that makes it more difficult for them to become pain-free or respond to medication.
DR. GOADSBY: I think the other aspect of this, which is not often stated but may be incredibly informative if we understood it, is the basis for the regression of this progression. It seems that the population estimates for chronic migraine are stable, and that there’s clearly a group of people for whom the frequency of headaches can increase each year. There must be, clearly, a group of people in equal size who go from having more headache to less headache, and I wish I thought that was because we treated them properly, but I don’t think that’s the case on a population basis.
The resolution is almost as interesting as the induction. When we talk about progression, we’re talking about addition of burden, whether in terms of frequency, change in the type of headache, or, as Dr. Burstein just said, treatment. The other aspect of progression that’s discussed is whether there’s any progression of a consequent nature: Progression to acquisition of brain changes and, what have been, I think, erroneously been called brain lesions, progression in cognitive function. Dr. Schoenen, do you have a view about any of those things?
DR. SCHOENEN: I do not really believe that the majority of migraine patients accumulate brain lesions over their lifetime, even when they progress. Most patients who progress and experience chronic migraines have migraines without aura, very few or no white-matter lesions, and very little or no increased risk for stroke.1 Brain lesions on magnetic resonance imaging (MRI) were mainly reported in migraine-with-aura patients, and predominantly in females. The nature of these lesions is not known. In some studies, their prevalence was somewhat correlated with attack frequency, but the majority of subjects in the general population who suffer from migraine with aura experience low frequency of attacks. So, I do not believe that migraine without aura causes lesions in the brain, but I do believe that migraine without aura impairs, to some extent, cognitive performance, but that’s not related to the frequency of attacks, but likely due to the abnormal information processing that can be recorded in the brain of migraineurs between attacks.
DR. GOADSBY: Yes, exactly. Dr. Charles?
DR. CHARLES: The other imaging modalities that have shown changes are morphometric studies with MRI and functional MRI scans that show chronic changes in brain structure and function, particularly in areas related to pain processing, in patients with migraine. That is, I believe, something that may be occurring in patients who have progression of migraine, that there’s a plasticity of the brain that results in these structural and functional changes over time. I think that’s an area of great interest in terms of trying to understand how to reverse that process of progression.
DR. SCHOENEN: I agree completely with that. The problem is that many of these changes do not seem to be very specific to migraine. They are merely a consequence of the recurring head pain and also found in other pain disorders. Very few are specific to migraine. When patients develop chronic migraine, central sensitization occurs, and plastic changes appear in brain areas involved in pain processing and control. These areas are not specific to migraine. Taken together, I think brain changes seen in episodic migraine interictally are, for most cases, causally related to the disorder. In chronic migraine, these migraine-specific changes become overwhelmed by other brain modifications related to chronic pain, which have therapeutic implications.
DR. CHARLES: Yes, I agree.
DR. BURSTEIN: I think the biggest question that keeps coming up from all the imaging studies that show differences between migraine and non-migraine patients or migraine patients that progress and migraine patients that do not progress is what comes first: the changes that we see, which are responsible for the patient’s symptoms in the migraine, or the progression of the headache, which is causing the brain changes. For this, at least now, we don’t have a clear answer, although I think that most believe that progression of the migraine results in progressive changes and the beginning of brain malfunction. But the answer is not clear, and this belief somewhat conflicts with the concept of genetics, because if migraine patients do have genetic defects, you expect all changes to be there all along.
DR. GOADSBY: We currently have no clear data on what happens to migraineurs’ brains over time. Various changes in structure have been reported, but we do not know what happens, for example, if the migraine is controlled, do the brain changes revert? First, we must consider whether brain changes over time are linked with anything related to the headache. For example, if there’s high headache frequency or severity and then resolution, did changes occur? There don’t seem to be any long-term consequences of migraines. All the work done studying French people over the age of 70 on a population basis points to no untoward effect of a migraine on cognitive status,2 as do the data from the Women’s Health Study.3 Prospective examination of cognitive functions in that cohort identified absolutely no cognitive death attributable to migraine status. Whatever is happening in the brain can’t be all bad, since it doesn’t seem to have palpable consequences. I find that reassuring for patients.
DR. GOADSBY: I find the cognitive facts very reassuring for patients. I also find it reassuring to be able to tell them, even those with small changes, that as long as they live to even 75, they won’t have any particular problems.
I think we’ve probably come to the broad brush, that is, a group of migraineurs who have increased frequency and some change in quality. The treatment effects are perhaps most important for them. Before we go into the details of the pathophysiology, we should get some comments about the role of analgesic use, or the use of it in, as it is sometimes described, the evolution of migraines. Does analgesic use drive or follow the problem? I’ll start with Dr. Burstein.
DR. BURSTEIN: I belong to the group of people who believe that analgesics are overused, especially opiates and barbiturates, and contribute tremendously and significantly to the transition from acute to chronic pain, and from treatment that works to treatment that doesn’t work. They contribute on a molecular basis to sensitization; increase hyperexcitability; and add to the molecular aspects of the pathophysiology of increased excitability along the pain pathways in general, and in this case along the active trigeminovascular pain pathway.
DR. GOADSBY: We probably all agree that opioids are a problem, however, it’s how you look at it. Do you have in mind a particular site in the brain or particular pathways when you think about this process, or do you think “outside the brain” when you think about opioids and their role in this problem?
DR. BURSTEIN: I think that it will be in the first synapse between the peripheral and the central neuron. I think that the opioid’s ability to virtually bring to almost a complete stop the glutamate transporter and the inability of glutamate to clear itself out of the synapse contribute a lot to accessibility to susceptible pain neurons in the spinal cord, which is not where they eliminate pain. They eliminate pain in the brain stem, the rostral ventral inner medulla, the periaqueductal gray, and basal ganglia. When you eliminate the “off switch” by stopping medication, you’re left with a hyperexcitable spinal cord that has spinal glia that has a significantly reduced ability to clear glutamate from the synapse in the spinal cord.
DR. SCHOENEN: You’re right, but is that specific to migraine or not? Do you think that chronification due to medication overuse exists in other pain disorders?
DR. BURSTEIN: Yes, I think we have known that since 1988, when it first became clear in animal studies and then in human studies that opioids produced allodynia, hyperalgesia, and central sensitization.4
DR. SCHOENEN: I agree, but opioids are not a problem in Europe. Opioids are a problem in the United States. Analgesics containing opioids are very rarely overused in Europe right now because there are stricter limitations in their availability. The only one that still exists on the market is codeine combined with paracetamol. The most frequently overused preparations are non-opioid analgesics or NSAIDs combined with caffeine or triptans. The underlying process may be different between these molecules. Do you agree that it is possible that the daily intake of analgesics or NSAIDs by fibromyalgia patients, for instance, may play a role in chronifying their pain?
DR. BURSTEIN: Yes, I do. I think that whenever we prescribe opioids we make a big mistake, especially in the field of headache.
DR. GOADSBY: I will say one thing about Europe, when I was practicing there, the single biggest problem with overuse was codeine because codeine was available in the supermarkets. Medication overuse has regional and cultural dimensions, depending on what you have access to. Dr. Charles?
DR. CHARLES: I think with regard to the opioids, the other thing to keep in mind is that while they’re commonly viewed as having depressant or inhibitory actions, they in fact are excitatory in many areas of the brain, as well as the spinal cord. For example, most of the commonly used opioids can in fact cause seizures, and clearly have excitatory effects in the cortex. So it’s quite possible that in an episodic disorder of brain excitability, like migraine, they’re actually working not simply by changing pain, but also by changing some of the basic mechanisms until they reach a threshold that triggers migraine in the brain, even before the pain starts.
DR. GOADSBY: From that hypothesis, you might predict that patients with migraine with aura and opioid overuse would have more aura. You see where I’m headed with that?
DR. CHARLES: Sure. I wasn’t necessarily specifically referring to the visual cortex, but, in general, making the point that opioids have excitatory effects in the brain and using seizures as an example of a phenomenon, but not necessarily saying that it’s the cortex itself. Maybe it’s the hypothalamus or the thalamus or some other area of the brain in which they’re exerting excitatory effects.
DR. BURSTEIN: It can be the peripheral nervous system. Look, they produce itch, suggesting they are excitatory to certain classes of peripheral receptors.
DR. GOADSBY: Dr. Charles, do you agree that opioid-induced medication overuse problems precede as opposed to follow increased headache frequency, because there is this possibility that some medication overuse is simply because headache gets worse and patients just do what they need to do? I’m not sure lumping everyone together and saying everyone who overuses actually produces headache with the overuse so much as there’s more than one group.
DR. CHARLES: That’s right. Broadening the discussion to other medications, I think that it’s important to not lump all the acute medications for migraine into the same categories because they have such pharmacologically distinct properties that it isn’t plausible that they could all have the same effects. I think, as Dr. Schoenen mentioned, the combination analgesics, particularly those with caffeine, are particularly problematic. Recently in the United States, we’ve had a big uproar because of a shortage of one of the aspirin-and-caffeine-containing preparations. That, I think, is an example of how caffeine-containing preparations can be particularly problematic as a cause of medication-overuse headache.
DR. GOADSBY: Yes, I think the other component of this must be that there is some predisposition to it. The two studies that I’m aware of, the one that we were involved in in the rheumatology clinic and the one that Becker did in the gastro clinic, clearly show that there are people who overuse opioids by any standard definition who don’t have headache at all as a problem. So, there’s an important interaction, I think, between a genetic predisposition and these medicines. It’s something that would be wonderful to get at so we could be able to understand who are at risk and who aren’t at risk. One day I hope that we’ll be able to do that. Do you think that people who are at risk for one type of overuse are at risk for all? Let me ask Dr. Schoenen.
DR. SCHOENEN: I don’t know. I can only say that I see patients in whom overuse recurs and with a different drug. There are patients with overuse of a combined analgesic who return to an episodic form of migraine after drug withdrawal, but come back to my office 6 months or 1 year later with daily headache and daily use of a simple NSAID or analgesic. There may be a genetic predisposition to chronification by overuse of any anti-migraine drug, despite the fact that in practice simple NSAIDs are less likely to chronify the disorder.
Just to pick up what Andrew said, there is clearly a difference between the drugs and their effect on the brain. For example, looking at sensitivity in the somatosensory cortex with evoked potentials, there’s clearly a difference between patients overusing triptans and those taking NSAIDs, although their clinical phenotype is the same.
DR. SCHOENEN: Oh, yes. Well that was a study where we looked at metabolic changes with fluorodeoxyglucose positron emission tomography in brain areas that belong to the so-called pain matrix, but also in areas that are known to be involved in substance abuse.5 What we found was that metabolism was clearly decreased in several areas that are thought to belong to the pain matrix, but these changes were reversible after withdrawal of the drug 3 weeks later. The only area where hypometabolism was not reversible after drug withdrawal was the orbitofrontal cortex. The orbitofrontal hypoactivity was even worse after withdrawal, and it was more pronounced in those patients who were overusing combined analgesics. The orbitofrontal cortex has been shown to play a crucial role in substance dependence. Its hypofunction could predispose patients to recurrence of medication-overuse headache. To prove this, we’re completing a long-term follow-up study.
DR. GOADSBY: That is interesting because I think that’s one of the important contributions to the pathophysiological understanding in humans.
DR. SCHOENEN: A Swiss group just published similar results measuring the amount of brain tissue with MRI.6 They found decreased tissue density in the orbitofrontal cortex, as well as in the dorsal pons, where abnormal activity is known to occur during migraine attacks.
DR. GOADSBY: You brought up nonsteroidals, a slightly more vexed issue. I’ll start with Dr. Charles. Do you think nonsteroidals, and you don’t have to lump them all together if you don’t want to, have a role in medication overuse in terms of inducing headache?
DR. CHARLES: My own view is no. It’s only the nonsteroidals in combination with caffeine that are the cause of medication overuse. I think that view is supported by the study by Bigal and Lipton,7 which basically suggests that, at a population level, frequent use of nonsteroidals is not associated with progression of headache. In fact, there’s a slight trend in the opposite direction, which has led them to suggest that it may possibly be protective. So, no, I do not put nonsteroidal anti-inflammatory drugs in the same category as a cause, but I see them more as a consequence, or frequent use as a consequence of frequent headache rather than as a cause.
DR. GOADSBY: How do you see the difference in a mechanistic sense? I’ll give everyone a chance to weigh in on this.
DR. CHARLES: This is something that may have to do with agonism versus antagonism of receptors and specific mechanisms of analgesia. I think the things that we think about that are the significant players in terms of causing medication overuse are ones that are working on neurotransmitter receptors, like γ-aminobutyric acid receptors and opioid receptors, and, in the case of caffeine, maybe adenosine receptors. I think the issue with the nonsteroidals is harder to understand, particularly how they might pharmacologically actually cause medication overuse. So, I think that mechanistically, those are the questions that are before us now.
DR. GOADSBY: Dr. Burstein, you published on nonsteroidals and triptans in the context of sensitization.8 What’s your view about this, particularly at a mechanistic level?
DR. BURSTEIN: Mechanistically, the data suggest that triptans disrupt communication between peripheral and central trigeminovascular neurons and that NSAIDs inhibit both the peripheral and the central neurons.
Accordingly, it is reasonable to suggest that triptans do not reverse central sensitization because they do not inhibit central trigeminovascular neurons directly, not at the level of the spinal cord at least, and that NSAIDs reverse central sensitization indirectly, through their anti-inflammatory action in the spinal cord (mostly unknown mechanism).
I think, again, that in the context of the opioid treatment, it became apparent both in the animal data and in patient data that opioid treatment makes patients resistant to successful NSAID treatment. NSAIDs work much better in patients who do not have a history of favoring opioids. Once patients begin to use opioids, however, they see a noticeable decline in the potential benefit of NSAIDs or triptan treatments. Again, I think that the key to that is the spinal cord inability to clear glutamate from the synapse, although I don’t think that the NSAIDs target glutamate release in any way.
DR. SCHOENEN: I do partially agree with what has been said. I think clinically, we clearly see patients who with overuse of simple analgesics, like paracetamol or a single NSAID like ibuprofen, enter the vicious circle of chronification and reverse to episodic migraine after reducing intake of these drugs.
The second point is that in the electrophysiological studies of patients overusing simple NSAIDs, there is clearly indication of sensitization in sensory cortices. Thirdly, Dr. Charles was alluding to the Bigal et al. study showing that NSAIDs protect against migraine chronification contrary to triptans.6 In this study, however, the protective effect of NSAIDs was only seen with patients who had low frequency of headaches. In patients with high frequency of headaches at baseline, NSAIDs also had a deleterious effect.
DR. GOADSBY: In the last few minutes that we have, I’d like to get some views about whether you think that more aggressive treatment with preventives would be helpful in terms of restricting headache progression. When medical practitioners see people who experience 6 or 8 headaches a month, and a couple months later they have 10 or maybe 12 or 14, they want to help them get better before they get worse. So if we intervened earlier, do we think that we could do a better job? Is that mechanistically plausible? I’ll start with you, Dr. Charles.
DR. CHARLES: I think it’s an appealing concept, but unfortunately I think that in practice we don’t see that concept being realized. Taking a cynical view, I think in many cases, even with preventative therapy, migraine finds its way around them, and even patients on preventative therapy end up having progression. So I think until we better understand the process, we can’t really say with confidence that early preventive therapy is something that is going to prevent the progression of the disorder.
DR. GOADSBY: Dr. Schoenen?
DR. SCHOENEN: I fundamentally agree with that. I think we are very lousy in the prevention of migraine. Most of the drugs don’t reach 50% efficacy. The patients who respond to these drugs may be those who have a peculiar pathophysiological, possibly genetic, profile, and do not progress. Those who do not respond are probably those who are most prone to chronification of migraine and at last fail on all available preventative drugs. So, in addition to much better preventative treatments, we also really need many more treatments.
DR. GOADSBY: Yes. Dr. Burstein?
DR. BURSTEIN: Well, I want to take it in a slightly different direction. I am aware of the fact that there is no evidence for it because nobody has done the study, but the question that I would like to answer is whether migraine progression would look completely different in a group of patients whose migraine attacks were treated early from the first migraine attack in their life (ie, they didn’t let their migraine last more than a few hours). Comparing this "early-treatment" group to a group of patients who treat late (ie, they let themselves have a migraine for 8, 10, or 12 hours before it goes away by itself or before they treat it).
DR. GOADSBY: Well, that would be an interesting study, very expensive as well. But as you say, one of the things we lack very much in longitudinal study is what’s really a dreadful problem, because whatever we think about the pathophysiology of headache progression, we’d all agree it’s bad to have more headache, it’s bad to have worse headache, and it’s bad to have headaches that don’t respond to therapy. It’s a subject which deserves study.
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The Medical Roundtable: Current Indications of Acupuncture
Acupuncture (a traditional Chinese medical practice systematically used for over 2000 years) involves insertion of thin stainless steel needles into specific points on the body to facilitate recovery and good health. This practice was first brought to Europe in the 17th Century,1 and the first journal article on acupuncture appeared in the 1820s.2 Not until recently has acupuncture been widely accepted because of the clash of east versus west paradigms.
Scientific advances in acupuncture research, coupled with the side effects of treating pain by conventional drugs, have dramatically promoted the use of acupuncture in the last 20 years. It is estimated that over 1 million practitioners (outside China) administer acupuncture treatments for chronic pain. Of these practitioners, over 300000 are physicians.3 An estimated 3 million American adults receive acupuncture treatments each year, and chronic pain is the most common presentation.4
One of the most significant events in the 1990s for acupuncture was the decision taken by the US Food and Drug Administration in March 1996 to reclassify the legal status of acupuncture as safe and effective medical devices.
Further, in November 1997, there was a consensus conference on acupuncture by the National Institutes of Health.5 This was a 2.5-day conference conducted to evaluate the scientific and medical data on the uses, risks, and benefits of acupuncture for a variety of conditions. The findings after reviewing approximately 2300 studies stated that “Promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and postoperative dental pain.”
“There are other conditions such as stroke rehabilitation, headache, tennis elbow, osteoarthritis, lower back pain, carpal tunnel syndrome, and asthma, for which acupuncture may be useful as an adjunct treatment or could be included in a comprehensive management program. Although many issues remain to be clarified, there is sufficient evidence to prove the value of acupuncture in order to expand its use in conventional medicine and encourage further studies of its physiology and clinical value.”
Since the consensus conference in 1997, there has been a huge increase in the number of scientific studies conducted on acupuncture. The Cochrane Collaboration’s database includes now 6035 clinical trials and 53 systematic reviews on acupuncture in their database.6 This roundtable today will focus on the current indications for acupuncture, and we will discuss how it is used in clinical settings, its safety issues and clinical evidence, and how it works.
The other participants are Dr. Joseph Helms, Dr. Gary Kaplan, and Dr. Lixing Lao. Dr. Helms is the founding president of the American Academy of Medical Acupuncture. In 1980, Dr. Helms developed the Medical Acupuncture Physicians program as a continuing medical education course for the University of California, Los Angeles (UCLA), School of Medicine; has chaired the program since then through the Helms Medical Institute (HMI); and has trained over 6000 physicians during this period. Dr. Helms is professor of medical acupuncture on the adjunct clinical faculty of the Stanford Medical School and the author of Acupuncture Energetics: A Clinical Approach for Physicians.
Dr. Kaplan is the medical director of the Kaplan Center for Integrative Medicine in McLean, Virginia, and is an associate professor in the Department of Community and Family Medicine at Georgetown University, School of Medicine. He served on the board of the American Academy of Medical Acupuncture and was president of the Medical Acupuncture Research Foundation.
Our final participant, Dr. Lao, is a professor of Family Medicine and the director of Traditional Chinese Medicine Research program at the Center for Integrative Medicine, University of Maryland School of Medicine. Dr. Lao graduated from the Shanghai University in the Traditional Chinese Medicine Program, holds a PhD in physiology from the University of Maryland in Baltimore, and has practiced acupuncture for 30 years and conducted research for 20 years.
To begin this discussion, Dr. Helms, can you describe for us the different types of acupuncture, training, and how acupuncture is used in a clinical setting?
DR. HELMS: Thank you, Dr. Berman. Acupuncture is relatively new in the collection of American medical disciplines. It has been in constant evolution since President Nixon’s visit to China in 1972. This evolution is driven by public interest and demand as well as scientific evidence of its mechanism and clinical value. This started with linking the impact of acupuncture on pain to the endogenous opioid peptide cascade, which is currently being reinforced through functional magnetic resonance imaging studies that confirm an intracranial response to peripheral needling.
The 1997 Consensus Development Conference report5 that endorsed a handful of acupuncture applications was based on the quality of research design to evaluate acupuncture’s impact on different problems, rather than on the actual practice of acupuncture. Since that paper, over 400 randomized control trials have been published in peer review journals internationally. These studies demonstrate the favorable impact of acupuncture on a wide spectrum of medical problems, including, but not limited to, pain.
There are many different styles of acupuncture. This discipline has evolved through multiple cultures over the last 2000 years. Each culture and era of its blossoming has contributed its enduring quality and approach. Many of these styles of acupuncture were retained only in family traditions, while others were propagated nationally. It is only in the late 20th century and beginning of the 21st century that we have had the privilege to access many of the family and most of the national traditions of acupuncture training and practice.
The tradition, with which I’m most familiar with, is known as medical acupuncture. Medical acupuncture would best be described as a hybrid approach combining our understanding of acupuncture neuroanatomy and physiology with traditional precepts from the classics of acupuncture. Medical acupuncture is generally practiced by licensed practitioners of conventional biomedical medicine and is considered an additional qualification to their scope of practice. These would include doctors of medicine, doctors of osteopathy, doctors of dental surgery, and doctors of podiatric medicine.
Traditional Chinese Medicine is the approach most widely practiced in this country. It is an approach exported from post-Maoist China, having been developed to provide basic healthcare to the Chinese population as the country was transitioning from its revolutionary period in the 1950s and 1960s into a more stable political and social period. The Traditional Chinese Medicine model doesn’t contain the totality of the classics, but rather is an extraction that can be taught and absorbed by the western community. The Traditional Chinese Medicine approach covers internal medicine problems as well as pain problems.
Two additional, commonly used subdivisions of acupuncture are auricular acupuncture and Chinese scalp acupuncture. Auricular acupuncture was developed in France in the 1950s and 1960s and uses points exclusively on the ear to influence pain and organ function. Chinese scalp acupuncture is a recent development in Chinese medicine. It involves placing needles in the scalp overlying the cortical surfaces that relay pain signals.
DR. BERMAN: Could you elaborate on auricular acupuncture a little more and on what it is used for?
DR. HELMS: Auricular acupuncture is the least complex and most easily learned approach to acupuncture. It can be effective either as a standalone treatment or as an adjunct to body acupuncture. The scientific foundation of auricular acupuncture involves the ear’s complex innervation that links it to all 3 embryologic germ levels. Thus, with neurological representation of endoderm, mesoderm, and ectoderm, the ear manifests a homunculus of all body parts. Ear points that correspond to painful or disturbed structures demonstrate increased electrical conductivity, and thereby allow the ear to serve as a diagnostic tool and a therapeutic signal.
DR. BERMAN: I think in the past, auricular acupuncture was also used for problems of addiction but I don’t know if it’s still being used for this purpose.
DR. HELMS: There are several widely used acupuncture point combinations that have been shown to be useful in assisting a multidisciplinary approach to substance abuse problems, referred to as the “NADA protocol” that was developed by Michael Smith, MD. There is also a 5-point formula called battlefield acupuncture that is useful in dealing with acute traumatic pain.7
DR. BERMAN: Thank you, Dr. Helms. Dr. Kaplan and then Dr. Lao, could you comment about what’s being done in clinical settings and how acupuncture is used to treat certain diseases beyond what Dr. Helms has just explained?
DR. KAPLAN: We do a great deal of work for the treatment of pain and find acupuncture to be extremely effective for conditions such as headaches, back pain, and neck pain. We also find it useful for the treatment of peripheral neuropathies. In addition, because we deal with many chronic pain patients, we also see a lot of psychoemotional issues comorbid with the chronic pain. Acupuncture has proven to be very helpful as an adjunctive therapy dealing with the psychoemotional components that we see associated with chronic pain.
In my practice, approximately 20% of our pain population has posttraumatic stress syndrome, while approximately 60% has comorbid anxiety disorders or major depressive disorders. Acupuncture has been particularly unique as a therapeutic modality because it addresses both the pain and the psychological component of an individual’s illness at the same time. We’re able to talk about the totality of the individual as opposed to segmenting them into psychiatric versus pain versus sleep issues. From an acupuncture perspective, these conditions are not separate issues but different manifestations of a pattern of disharmony in the individual.
DR. LAO: I agree with Drs. Kaplan and Helms. In my practice, I see patients with a variety of complaints. In addition to pain, they also experience menstruation disorders, depression, and attention deficit disorder (ADD) (in children). A wide variety of diseases can be treated by acupuncture. Evidence of the effectiveness of acupuncture for the treatment of pain has recently been published by Vickers.4
Individual raw data show the full area of musculoskeletal pain, which includes neck pain, low back pain, headaches (migraine and tension headaches), osteoarthritis in the knees, and shoulder pain. There is a significant difference between acupuncture and conventional treatment in terms of their therapeutic effectiveness. There was also a significant difference between acupuncture and sham acupuncture, ie, placing of needles at points on the body that are not thought to be acupuncture points (off site points). Although the benefits were modest, they were highly significant.4
Dr. Berman, do you also want me to cover a little bit about the side effects or shall we save that for later?
DR. BERMAN: Let’s stick to the clinical use first, and then we’ll go to the side effects.
DR. KAPLAN: I’d like to chime in here. I’m boarded in family medicine and pain medicine and started my clinical practice in a general medical setting. As my practice evolved, I began seeing a greater number of individuals suffering with chronic pain and illness issues.
Over the last 30 years, acupuncture has heavily influenced my approach to patient care. Acupuncture is not simply a tool but a philosophy of care that has greatly enriched my western medical training. At times, when treating a patient, I believe the prism of a western approach will be more effective; there are also times when I rely exclusively on an acupuncture approach, but more commonly, I integrate the two in designing and implementing a care program.
Pain can be very effectively managed with acupuncture alone or as an adjunct. Many so-called functional or psychosomatic problems can be more effectively addressed using acupuncture in place of pharmaceutical agents. Likewise, the conventional approaches to organic problems can be reinforced and facilitated with acupuncture treatment.
Acupuncture covers a much broader range of clinical applications than simple neuromusculoskeletal pain or psychoemotional issues. It really covers the full spectrum of medicine.
DR. KAPLAN: We have used acupuncture successfully in women with hyperemesis gravidarum. Most of the medications are contraindicated because of the potential harm to the fetus. Acupuncture has been successful in at least providing these women with some level of relief in treating this condition.
I don’t have experience with acupuncture therapy for postoperative nausea/vomiting. We have used it a little bit in nausea/vomiting associated with chemotherapy, and again, we’ve been able to reduce the amount of medications that the patients require in order to control it; in some cases, we’ve actually been able to eliminate the need for medications.
Further, I want to go over what Dr. Helms was talking about—the importance of integrating acupuncture into a comprehensive treatment program. It is sometimes the main therapeutic modality that we use, but on many occasions, it is integrated into our medication regimes. In a comprehensive approach, we may use it in conjunction with physical therapy, and we will also be probing trigger points. We may also do prolotherapy with the patients.
Acupuncture gives us the ability to treat a wider range of conditions with fewer medications. We are frequently able to address irritable bowel syndrome (IBS), sleep disorders associated with the medical conditions, as well as the psychiatric conditions I was talking about earlier. Acupuncture is a beautiful adjunctive therapy and sometimes can be used as the sole therapeutic approach.
DR. BERMAN: In general, we’re now talking about acupuncture being part of a comprehensive approach to a number of chronic disorders.
DR. KAPLAN: That’s absolutely correct. You want to use all of the tools you have available, and acupuncture is a very powerful therapeutic modality in the treatment of these conditions.
DR. LAO: One of the nonpain areas that I think people should consider using acupuncture as a therapy is infertility. Many women now come to the clinic, particularly after the publication of the enhanced success rate of in vitro fertilization (IVF) in women receiving acupuncture treatment.8 Even those patients who elect to not go through IVF come for acupuncture treatment to enhance their chances of getting pregnant.
DR. BERMAN: Dr. Lao, is there evidence to support acupuncture for infertility?
DR. LAO: There’s a paper that was published a couple years ago through our center.8 The authors show a higher success rate of conventional IVF procedure when combined with acupuncture than with sham control. Current studies give clear evidence of the benefits of acupuncture to IVF patients.
DR. BERMAN: With the breathlessness COPD I was referring to, there was a study in the Archives of Internal Medicine just this past June 2012,9 which was a very well-done clinical trial aimed at studying COPD and using acupuncture in addition to conventional care, that showed clear outcomes of the benefits of acupuncture in this particular condition.
Dr. Helms, you have experienced acupuncture in the military setting. Can you talk a little bit about that?
DR. HELMS: In the last 5 years, 3 branches of the US Military have shown interest in pursuing acupuncture training for physicians to provide these services to their population. This interest reflects what’s happening in the civilian population and is more intensively motivated by the report of the Army’s pain management task force that identified some severe shortcomings in managing acute and chronic pain.
The feedback we’ve received from the military physicians we’ve trained has been very rewarding. The bulk of their treatments are for pain, ranging from headache to cervical, lumbar, and peripheral pain. Much of this pain is caused by the weight of their 75-pound protective gear, which they wear no matter where they are in the world, and of course, the physical trauma of battle. Interestingly, an almost equal percentage of treatments for active duty service members are for psychoemotional problems (anxiety, insomnia, depression, acute stress, and chronic stress) as for pain and physical trauma.
DR. BERMAN: Let me move on to the next subtopic. Dr. Lao, can you talk to us about how safe acupuncture is?
DR. LAO: There are few reported cases of complications in the English literature from 1965 to 1999, a 35-year span. There were a total of 202 case reports, which is about 5–6 cases per year.10 I have completed 2 reviews of case reports on adverse events associated with acupuncture. One was published in 200310 and the other one is accepted for publication.11 Events are divided into complications and adverse reactions. Complications such as injured organs or infections occur if acupuncture is not carefully performed. Adverse reactions include syncope and allergic reaction.
Infections constituted 50% of all complications. Needle infections may cause hepatitis. However, since the late 1980s, acupuncturists started using disposable needles, resulting in lower incidence of hepatitis and other infections.10 In recent years, another infection emerged that involves many different invasive procedures in medical settings such as methicillin-resistant Staphylococcus aureus (MRSA). This is likely due to the unsanitary conditions of these clinical settings, such as the use of contaminated disinfectant. It’s not the acupuncture needle itself that caused infection.
A larger survey12 showed that approximately 7% to 8% of the adverse events were classified as mild. These events include local site bleeding, pain in local needling site, nausea, or light-headedness. The occurrence of these mild adverse events is very low especially in the context of the large numbers of patients attended to acupuncture clinic every year.
In the last 10 years, 308 cases of side effects were noted from 26 countries.11 In the United States, only 17 cases have been reported, which is a very small percentage. I believe that this is due to extensive professional licensing requirement that is called Clean Needle Techniques (CNT) training. This requirement has dramatically decreased the risk of unnecessary side effects.
Other types of adverse events such as organ and tissue injuries are associated with knowledge of anatomy. Therefore, proper training of the acupuncturist could help reduce the occurrence of side effects due to acupuncture.
DR. BERMAN: From these prospective studies,10–12 we can conclude that serious adverse events are very rare with acupuncture and that there is, depending on the surveys, a 2% to 7% probability of occurrence of a mild side effect such as local site bleeding or occasional dizziness or localized pain to the area. Is there anything else on safety that either, Dr. Kaplan or Dr. Helms would like to add?
DR. HELMS: In addition to reinforcing that acupuncture is a very safe and forgiving therapeutic approach, I’d like to discourage readers from concluding that useful indications for acupuncture in medical practice are limited to what is published in the evidence-based literature. Acupuncture has been used for simple and complex problems by responsible practitioners in oriental and occidental cultures for much longer period than we have been documenting its efficacy. Acupuncture comes from a long tradition of the practice of medicine, albeit in cultures and eras quite distant from ours. Our hybrid medical acupuncture allows remarkable creativity in the hands of well-trained practitioners, to treat many problems that are not included among those already studied in the pharmaceutical model.
DR. BERMAN: I think that’s a very important point, but let’s talk a little bit about the research first, and then go back to this when we’re putting the research into the context of clinical practice. How should we take this into account?
DR. KAPLAN: Let’s briefly look at the clinical research, and then talk about some of the problems that we run into with research and what the research shows us in terms of how to better study procedures such as acupuncture, because studying procedures is different from studying drugs. The clinical studies roughly fall into 2 categories: effectiveness studies and efficacy studies, and many studies overlap and attempt to do both.
An effectiveness study looks at the extent to which a drug or procedure achieves its intended effect in the usual clinical setting. In these circumstances, you’re randomizing acupuncture against something such as a wait list control or usual care such as physical therapy or medications.
In 2009, a Cochrane database review studying acupuncture for prophylaxes of migraine showed that acupuncture was at least as effective, and possibly more effective, than prophylactic drugs with fewer adverse effects.13
In 2012, Andrew Vickers and his colleagues4 performed individualized patient data meta-analysis of 17,922 patients with a variety of back, neck, shoulder, osteoarthritic-related and headache pains and concluded that acupuncture was, in fact, effective for the treatment of chronic pain. Some effectiveness trials have shown acupuncture to be useful for some specific conditions, pain being the number one condition.
Efficacy is the extent to which a drug or procedure has the ability to bring about its intended effect under ideal circumstances, that is, acupuncture compared to a placebo. In the Vickers study,4 Vickers looked at the efficacy of acupuncture in the treatment of chronic pain and again concluded that true acupuncture was statistically slightly more efficacious than sham. Although this was not a big effect, it was nonetheless statistically significant.
From the 2012 Cochrane database review of IBS14 it was concluded that acupuncture was not efficacious as compared to a creditable sham, but there were several effectiveness trials where acupuncture tested better against 2 antispasmodic medications, which have some effect on both the severity and quality of life in patients with IBS.
While the Vickers study reported the efficacy as well as effectiveness of acupuncture, the IBS trial did not find any efficacy, when compared to the placebo, but did find evidence of the effectiveness of acupuncture.
What is particularly interesting about this study is that the natural history of carpal tunnel suggests that you will notice a 20% to 40% improvement over time. However, this study showed an 88% statistically significant improvement in both the true and sham acupuncture groups, which was maintained over 3 months of follow-up after the treatments ended.
The question that arises now is how you reconcile all of this, because it seems that the first piece of information that you come up with is that the sham may actually be a different form of active treatment. There’s an interesting study by Richard Harris and others in neuroimaging that was published in 2009.16 Harris’ team looked at the effects of true and sham acupuncture on the mu-opioid receptors in the central nervous system (CNS) using positron emission tomographic scanning in patients with fibromyalgia. Prior studies in patients with fibromyalgia have demonstrated increased levels of endogenous opioids in the cervical spinal fluid with decreased sensitivity in the mu-opioid receptors in the CNS regions known to be associated with the modulation of pain.
In the Harris study, the authors found that true acupuncture therapy evoked both short- and long-term increases in mu-opioid-binding potential receptors in the multiple pain areas and sensory processing areas associated with pain regulation. This was associated with clinical reports of pain reduction on the part of the subjects.
In the sham group, they also reported reduction in pain, though less than that in the true acupuncture group, and the positron emission tomographic scan showed no effect on the sensitivity of the mu-opioid receptors. The binding potential of these receptors did not improve as they did with the acupuncture treatments.
We know from prior studies that both true and sham acupuncture seem to increase the release of endogenous opioids, and we see that effect occurring in the ascending pathways and a segmental effect occurring in the spinal cord as well as in the descending modulating pathways mediated via dynorphins serotonin and norepinephrine. However, the effects of true acupuncture on the mu-opioid binding sensitivities are different from that of sham acupuncture.
In addition to this, we have imaging studies that have been conducted since the 1990s, and a recently published meta-analysis by Huang et al,17 which showed that while there is a problem with heterogeneity of these studies, they were able to conclude that the brain response to acupuncture encompasses a broad network of regions consistent with somatosensory affective and cognitive processing.
Overall, the neurophysiological evidence shows that acupuncture treatments affect the CNS in ways that are beneficial, long lasting, and unique to true acupuncture treatments. The neurophysiological evidence is also beginning to explain why we see different degrees of clinical effectiveness of acupuncture in conditions as diverse as gastrointestinal disorders, pain, and psychiatric conditions.
We have a lot more to learn and, far from being discouraged by this conflicting evidence in the literature, we should be excited by how much acupuncture has challenged and taught us about our understanding of human physiology. Does acupuncture work? Yes, according to the literature. Does acupuncture have unique and beneficial mechanisms of action on our neurophysiology? Again, I believe that the accumulative answer to that is yes.
The abovementioned discussion was about what’s going on in the CNS with acupuncture. There are a couple of other theories about how acupuncture may be effective. The one most commonly cited is work is that of Helen Langevin,18 where she writes about the network of acupuncture points and meridians viewed as representations of a network formed by interstitial connective tissue and that there has been an 80% correlation of the acupuncture points where the intramuscular connective tissue planes.
The needle grasp is a result of a winding of connective tissue and causes a tight mechanical coupling between the needle and the tissue, and there’s mounting evidence that this mechanical transduction can be translated into a variety of cellular and extracellular events. The 2 major models are the neurologic model, which is by far the most accepted and studied, and the connective tissue model.
Again, this is an evolving area. We have a lot more to learn, and I completely agree with Dr. Helms that we don’t want to be locked into the evidence-based approach that we fail to understand the true clinical benefits that acupuncture has shown repeatedly over thousand years of practice and that we see ourselves in day-to-day practice in our offices.
DR. BERMAN: Apart from summarizing the mechanisms, Dr. Kaplan, I think you mean that when we’re talking about evidence-based medicine, it’s not just about the efficacy shown by randomized control trials. There’s a wider range of methodologies and diseases to consider, depending on the question being asked. This is true of all medicine, including acupuncture, and if we narrow it down too much, we may fail to reap the benefits of using a very valuable tool as part of medicine.
DR. KAPLAN: I think you’re absolutely correct. The other thing that we need to keep in mind is that the evidence-based research itself is a very limiting concept because we keep finding new mechanisms and understanding new subtleties about how the nervous system is working, how our physiology works, and then we’re able to go back and say, “Ah, that’s the mechanism via which this is happening.” This whole topic about mu-opioid receptors is actually a breakthrough in terms of understanding how acupuncture may affect the CNS, which is unique and different from the way that sham does.
DR. BERMAN: What do you think are the cutting-edge research questions that still need to be answered as we go forward, questions that could not only inform us of how acupuncture works but could also affect clinical practice?
DR. KAPLAN: One of the areas that I’ve been particularly focused on is the microglial cells and their impact as the ultimate transducers between psychological stress, which gets translated into neurologic damage; and physical stress such as traumatic brain injury; as well as infectious stress, which also creates problems with neuroinflammation and neurodegeneration in conditions such as chronic pain and chronic illness.
We have seen evidence that acupuncture is actually neuroregenerative in some circumstances, certainly from some of the carpal tunnel studies that have been performed. We know that the microglia are involved in neuroregeneration; therefore, studying the effects of acupuncture on microglia may give us much more insight into how acupuncture works. This would be one area that I think should be focused on.
DR. BERMAN: Dr. Helms or Dr. Lao, any questions you think still need to be answered that can really make a difference?
DR. LAO: I agree with everything you have already said, but I think I’ll add one point: we need more translational studies on how to apply the scientific information to our daily practices in order to enhance the effectiveness of acupuncture treatment. We did some studies in which the effectiveness of a combination of conventional medication and acupuncture was evaluated. We found that the effectiveness of the combined therapy was much higher than that of acupuncture or the medication alone. Maybe, in the future, the research should be designed to answer the question of whether acupuncture reduces the side effects of a medication, resulting in enhanced effectiveness of both medicine and acupuncture.
DR. BERMAN: I would add one point that goes along with that: we need to get a better idea of the responders and nonresponders to acupuncture. We could begin to address this by setting up some pragmatic clinical trials with the idea of comparative effectiveness research in actual settings of clinical practice as well as cost effectiveness. Further, we could determine who responds, and we can include imaging and genomics assessments as part of the biomarkers that we’re analyzing.
Dr. Kaplan, do you have any final comments you want to add?
DR. KAPLAN: In terms of additional research, our thinking has been very much from a Bohr atom perspective [Bohr was a physicist who originally described the atom like a small solar system with electrons neatly orbiting the nucleus of the atom is a fixed orbit. This is a cartoon approximation of reality.] in terms of how the nervous system works, and we need to move toward a more quantum understanding. The whole field of neuroimaging is moving toward the concept of neuro-networking and trying to understand how the different regions of the brain interact with each other. I think that’s going to show a lot of promise even in terms of how acupuncture is affecting the system.
I also think that, as you mentioned briefly, the cost effectiveness research is extremely important. Integrating acupuncture into conventional medical practice has the potential, at least to significantly reduce cost to the patient and side effects of medications. I think studies need to be conducted on this issue. I’m optimistic these studies will confirm what we have witnessed in clinical practice.
DR. HELMS: Just a comment on that, Dr. Kaplan. You first need a model environment where acupuncture is fully integrated into a broad-based clinical setting, not individual practices. That’s the first hurdle to overcome before one looks at the impact of reducing reliance on pharmaceutical products or cutting back on the frequency of office visits and referrals to specialists.
DR. KAPLAN: I completely agree with you. I think that’s a challenge that we need to potentially take on in the future, but it’s something to be looking towards as we’re going to have to be more cost effective and more cost conscious in our treatment of a variety of diseases. I think acupuncture has a significant role to play here but we are not ready to perform those studies yet. We need to start to think about them and how they can be accomplished.
DR. HELMS: In the past, we have thought of acupuncture as a treatment for chronic conditions, but one of the biggest problems we face in the military today is trauma. It could be possible to compare management outcomes at military facilities that have integrated acupuncture into their trauma treatment with those that have not.
DR. BERMAN: Here is where the military comes into play. They have proposed a move towards expanding availability of acupuncture immediately following trauma and then follow that through with intermediate and long-term care facilities. If this approach succeeds, it would create an environment in which those issues of acute, sub-acute, and chronic consequences of trauma could be evaluated.
DR. LAO: In ancient literature, early acupuncture was largely used for emergency medicine, particularly in the ancient times when patients were unconscious or in conditions such as fainting or convulsions where they could not be treated with oral medicines. There is a large body of ancient literature that has documented this use.
DR. BERMAN: I want to thank all of you for participating in this discussion; it’s been a real pleasure.
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Acupuncture (a traditional Chinese medical practice systematically used for over 2000 years) involves insertion of thin stainless steel needles into specific points on the body to facilitate recovery and good health. This practice was first brought to Europe in the 17th Century,1 and the first journal article on acupuncture appeared in the 1820s.2 Not until recently has acupuncture been widely accepted because of the clash of east versus west paradigms.
Scientific advances in acupuncture research, coupled with the side effects of treating pain by conventional drugs, have dramatically promoted the use of acupuncture in the last 20 years. It is estimated that over 1 million practitioners (outside China) administer acupuncture treatments for chronic pain. Of these practitioners, over 300000 are physicians.3 An estimated 3 million American adults receive acupuncture treatments each year, and chronic pain is the most common presentation.4
One of the most significant events in the 1990s for acupuncture was the decision taken by the US Food and Drug Administration in March 1996 to reclassify the legal status of acupuncture as safe and effective medical devices.
Further, in November 1997, there was a consensus conference on acupuncture by the National Institutes of Health.5 This was a 2.5-day conference conducted to evaluate the scientific and medical data on the uses, risks, and benefits of acupuncture for a variety of conditions. The findings after reviewing approximately 2300 studies stated that “Promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and postoperative dental pain.”
“There are other conditions such as stroke rehabilitation, headache, tennis elbow, osteoarthritis, lower back pain, carpal tunnel syndrome, and asthma, for which acupuncture may be useful as an adjunct treatment or could be included in a comprehensive management program. Although many issues remain to be clarified, there is sufficient evidence to prove the value of acupuncture in order to expand its use in conventional medicine and encourage further studies of its physiology and clinical value.”
Since the consensus conference in 1997, there has been a huge increase in the number of scientific studies conducted on acupuncture. The Cochrane Collaboration’s database includes now 6035 clinical trials and 53 systematic reviews on acupuncture in their database.6 This roundtable today will focus on the current indications for acupuncture, and we will discuss how it is used in clinical settings, its safety issues and clinical evidence, and how it works.
The other participants are Dr. Joseph Helms, Dr. Gary Kaplan, and Dr. Lixing Lao. Dr. Helms is the founding president of the American Academy of Medical Acupuncture. In 1980, Dr. Helms developed the Medical Acupuncture Physicians program as a continuing medical education course for the University of California, Los Angeles (UCLA), School of Medicine; has chaired the program since then through the Helms Medical Institute (HMI); and has trained over 6000 physicians during this period. Dr. Helms is professor of medical acupuncture on the adjunct clinical faculty of the Stanford Medical School and the author of Acupuncture Energetics: A Clinical Approach for Physicians.
Dr. Kaplan is the medical director of the Kaplan Center for Integrative Medicine in McLean, Virginia, and is an associate professor in the Department of Community and Family Medicine at Georgetown University, School of Medicine. He served on the board of the American Academy of Medical Acupuncture and was president of the Medical Acupuncture Research Foundation.
Our final participant, Dr. Lao, is a professor of Family Medicine and the director of Traditional Chinese Medicine Research program at the Center for Integrative Medicine, University of Maryland School of Medicine. Dr. Lao graduated from the Shanghai University in the Traditional Chinese Medicine Program, holds a PhD in physiology from the University of Maryland in Baltimore, and has practiced acupuncture for 30 years and conducted research for 20 years.
To begin this discussion, Dr. Helms, can you describe for us the different types of acupuncture, training, and how acupuncture is used in a clinical setting?
DR. HELMS: Thank you, Dr. Berman. Acupuncture is relatively new in the collection of American medical disciplines. It has been in constant evolution since President Nixon’s visit to China in 1972. This evolution is driven by public interest and demand as well as scientific evidence of its mechanism and clinical value. This started with linking the impact of acupuncture on pain to the endogenous opioid peptide cascade, which is currently being reinforced through functional magnetic resonance imaging studies that confirm an intracranial response to peripheral needling.
The 1997 Consensus Development Conference report5 that endorsed a handful of acupuncture applications was based on the quality of research design to evaluate acupuncture’s impact on different problems, rather than on the actual practice of acupuncture. Since that paper, over 400 randomized control trials have been published in peer review journals internationally. These studies demonstrate the favorable impact of acupuncture on a wide spectrum of medical problems, including, but not limited to, pain.
There are many different styles of acupuncture. This discipline has evolved through multiple cultures over the last 2000 years. Each culture and era of its blossoming has contributed its enduring quality and approach. Many of these styles of acupuncture were retained only in family traditions, while others were propagated nationally. It is only in the late 20th century and beginning of the 21st century that we have had the privilege to access many of the family and most of the national traditions of acupuncture training and practice.
The tradition, with which I’m most familiar with, is known as medical acupuncture. Medical acupuncture would best be described as a hybrid approach combining our understanding of acupuncture neuroanatomy and physiology with traditional precepts from the classics of acupuncture. Medical acupuncture is generally practiced by licensed practitioners of conventional biomedical medicine and is considered an additional qualification to their scope of practice. These would include doctors of medicine, doctors of osteopathy, doctors of dental surgery, and doctors of podiatric medicine.
Traditional Chinese Medicine is the approach most widely practiced in this country. It is an approach exported from post-Maoist China, having been developed to provide basic healthcare to the Chinese population as the country was transitioning from its revolutionary period in the 1950s and 1960s into a more stable political and social period. The Traditional Chinese Medicine model doesn’t contain the totality of the classics, but rather is an extraction that can be taught and absorbed by the western community. The Traditional Chinese Medicine approach covers internal medicine problems as well as pain problems.
Two additional, commonly used subdivisions of acupuncture are auricular acupuncture and Chinese scalp acupuncture. Auricular acupuncture was developed in France in the 1950s and 1960s and uses points exclusively on the ear to influence pain and organ function. Chinese scalp acupuncture is a recent development in Chinese medicine. It involves placing needles in the scalp overlying the cortical surfaces that relay pain signals.
DR. BERMAN: Could you elaborate on auricular acupuncture a little more and on what it is used for?
DR. HELMS: Auricular acupuncture is the least complex and most easily learned approach to acupuncture. It can be effective either as a standalone treatment or as an adjunct to body acupuncture. The scientific foundation of auricular acupuncture involves the ear’s complex innervation that links it to all 3 embryologic germ levels. Thus, with neurological representation of endoderm, mesoderm, and ectoderm, the ear manifests a homunculus of all body parts. Ear points that correspond to painful or disturbed structures demonstrate increased electrical conductivity, and thereby allow the ear to serve as a diagnostic tool and a therapeutic signal.
DR. BERMAN: I think in the past, auricular acupuncture was also used for problems of addiction but I don’t know if it’s still being used for this purpose.
DR. HELMS: There are several widely used acupuncture point combinations that have been shown to be useful in assisting a multidisciplinary approach to substance abuse problems, referred to as the “NADA protocol” that was developed by Michael Smith, MD. There is also a 5-point formula called battlefield acupuncture that is useful in dealing with acute traumatic pain.7
DR. BERMAN: Thank you, Dr. Helms. Dr. Kaplan and then Dr. Lao, could you comment about what’s being done in clinical settings and how acupuncture is used to treat certain diseases beyond what Dr. Helms has just explained?
DR. KAPLAN: We do a great deal of work for the treatment of pain and find acupuncture to be extremely effective for conditions such as headaches, back pain, and neck pain. We also find it useful for the treatment of peripheral neuropathies. In addition, because we deal with many chronic pain patients, we also see a lot of psychoemotional issues comorbid with the chronic pain. Acupuncture has proven to be very helpful as an adjunctive therapy dealing with the psychoemotional components that we see associated with chronic pain.
In my practice, approximately 20% of our pain population has posttraumatic stress syndrome, while approximately 60% has comorbid anxiety disorders or major depressive disorders. Acupuncture has been particularly unique as a therapeutic modality because it addresses both the pain and the psychological component of an individual’s illness at the same time. We’re able to talk about the totality of the individual as opposed to segmenting them into psychiatric versus pain versus sleep issues. From an acupuncture perspective, these conditions are not separate issues but different manifestations of a pattern of disharmony in the individual.
DR. LAO: I agree with Drs. Kaplan and Helms. In my practice, I see patients with a variety of complaints. In addition to pain, they also experience menstruation disorders, depression, and attention deficit disorder (ADD) (in children). A wide variety of diseases can be treated by acupuncture. Evidence of the effectiveness of acupuncture for the treatment of pain has recently been published by Vickers.4
Individual raw data show the full area of musculoskeletal pain, which includes neck pain, low back pain, headaches (migraine and tension headaches), osteoarthritis in the knees, and shoulder pain. There is a significant difference between acupuncture and conventional treatment in terms of their therapeutic effectiveness. There was also a significant difference between acupuncture and sham acupuncture, ie, placing of needles at points on the body that are not thought to be acupuncture points (off site points). Although the benefits were modest, they were highly significant.4
Dr. Berman, do you also want me to cover a little bit about the side effects or shall we save that for later?
DR. BERMAN: Let’s stick to the clinical use first, and then we’ll go to the side effects.
DR. KAPLAN: I’d like to chime in here. I’m boarded in family medicine and pain medicine and started my clinical practice in a general medical setting. As my practice evolved, I began seeing a greater number of individuals suffering with chronic pain and illness issues.
Over the last 30 years, acupuncture has heavily influenced my approach to patient care. Acupuncture is not simply a tool but a philosophy of care that has greatly enriched my western medical training. At times, when treating a patient, I believe the prism of a western approach will be more effective; there are also times when I rely exclusively on an acupuncture approach, but more commonly, I integrate the two in designing and implementing a care program.
Pain can be very effectively managed with acupuncture alone or as an adjunct. Many so-called functional or psychosomatic problems can be more effectively addressed using acupuncture in place of pharmaceutical agents. Likewise, the conventional approaches to organic problems can be reinforced and facilitated with acupuncture treatment.
Acupuncture covers a much broader range of clinical applications than simple neuromusculoskeletal pain or psychoemotional issues. It really covers the full spectrum of medicine.
DR. KAPLAN: We have used acupuncture successfully in women with hyperemesis gravidarum. Most of the medications are contraindicated because of the potential harm to the fetus. Acupuncture has been successful in at least providing these women with some level of relief in treating this condition.
I don’t have experience with acupuncture therapy for postoperative nausea/vomiting. We have used it a little bit in nausea/vomiting associated with chemotherapy, and again, we’ve been able to reduce the amount of medications that the patients require in order to control it; in some cases, we’ve actually been able to eliminate the need for medications.
Further, I want to go over what Dr. Helms was talking about—the importance of integrating acupuncture into a comprehensive treatment program. It is sometimes the main therapeutic modality that we use, but on many occasions, it is integrated into our medication regimes. In a comprehensive approach, we may use it in conjunction with physical therapy, and we will also be probing trigger points. We may also do prolotherapy with the patients.
Acupuncture gives us the ability to treat a wider range of conditions with fewer medications. We are frequently able to address irritable bowel syndrome (IBS), sleep disorders associated with the medical conditions, as well as the psychiatric conditions I was talking about earlier. Acupuncture is a beautiful adjunctive therapy and sometimes can be used as the sole therapeutic approach.
DR. BERMAN: In general, we’re now talking about acupuncture being part of a comprehensive approach to a number of chronic disorders.
DR. KAPLAN: That’s absolutely correct. You want to use all of the tools you have available, and acupuncture is a very powerful therapeutic modality in the treatment of these conditions.
DR. LAO: One of the nonpain areas that I think people should consider using acupuncture as a therapy is infertility. Many women now come to the clinic, particularly after the publication of the enhanced success rate of in vitro fertilization (IVF) in women receiving acupuncture treatment.8 Even those patients who elect to not go through IVF come for acupuncture treatment to enhance their chances of getting pregnant.
DR. BERMAN: Dr. Lao, is there evidence to support acupuncture for infertility?
DR. LAO: There’s a paper that was published a couple years ago through our center.8 The authors show a higher success rate of conventional IVF procedure when combined with acupuncture than with sham control. Current studies give clear evidence of the benefits of acupuncture to IVF patients.
DR. BERMAN: With the breathlessness COPD I was referring to, there was a study in the Archives of Internal Medicine just this past June 2012,9 which was a very well-done clinical trial aimed at studying COPD and using acupuncture in addition to conventional care, that showed clear outcomes of the benefits of acupuncture in this particular condition.
Dr. Helms, you have experienced acupuncture in the military setting. Can you talk a little bit about that?
DR. HELMS: In the last 5 years, 3 branches of the US Military have shown interest in pursuing acupuncture training for physicians to provide these services to their population. This interest reflects what’s happening in the civilian population and is more intensively motivated by the report of the Army’s pain management task force that identified some severe shortcomings in managing acute and chronic pain.
The feedback we’ve received from the military physicians we’ve trained has been very rewarding. The bulk of their treatments are for pain, ranging from headache to cervical, lumbar, and peripheral pain. Much of this pain is caused by the weight of their 75-pound protective gear, which they wear no matter where they are in the world, and of course, the physical trauma of battle. Interestingly, an almost equal percentage of treatments for active duty service members are for psychoemotional problems (anxiety, insomnia, depression, acute stress, and chronic stress) as for pain and physical trauma.
DR. BERMAN: Let me move on to the next subtopic. Dr. Lao, can you talk to us about how safe acupuncture is?
DR. LAO: There are few reported cases of complications in the English literature from 1965 to 1999, a 35-year span. There were a total of 202 case reports, which is about 5–6 cases per year.10 I have completed 2 reviews of case reports on adverse events associated with acupuncture. One was published in 200310 and the other one is accepted for publication.11 Events are divided into complications and adverse reactions. Complications such as injured organs or infections occur if acupuncture is not carefully performed. Adverse reactions include syncope and allergic reaction.
Infections constituted 50% of all complications. Needle infections may cause hepatitis. However, since the late 1980s, acupuncturists started using disposable needles, resulting in lower incidence of hepatitis and other infections.10 In recent years, another infection emerged that involves many different invasive procedures in medical settings such as methicillin-resistant Staphylococcus aureus (MRSA). This is likely due to the unsanitary conditions of these clinical settings, such as the use of contaminated disinfectant. It’s not the acupuncture needle itself that caused infection.
A larger survey12 showed that approximately 7% to 8% of the adverse events were classified as mild. These events include local site bleeding, pain in local needling site, nausea, or light-headedness. The occurrence of these mild adverse events is very low especially in the context of the large numbers of patients attended to acupuncture clinic every year.
In the last 10 years, 308 cases of side effects were noted from 26 countries.11 In the United States, only 17 cases have been reported, which is a very small percentage. I believe that this is due to extensive professional licensing requirement that is called Clean Needle Techniques (CNT) training. This requirement has dramatically decreased the risk of unnecessary side effects.
Other types of adverse events such as organ and tissue injuries are associated with knowledge of anatomy. Therefore, proper training of the acupuncturist could help reduce the occurrence of side effects due to acupuncture.
DR. BERMAN: From these prospective studies,10–12 we can conclude that serious adverse events are very rare with acupuncture and that there is, depending on the surveys, a 2% to 7% probability of occurrence of a mild side effect such as local site bleeding or occasional dizziness or localized pain to the area. Is there anything else on safety that either, Dr. Kaplan or Dr. Helms would like to add?
DR. HELMS: In addition to reinforcing that acupuncture is a very safe and forgiving therapeutic approach, I’d like to discourage readers from concluding that useful indications for acupuncture in medical practice are limited to what is published in the evidence-based literature. Acupuncture has been used for simple and complex problems by responsible practitioners in oriental and occidental cultures for much longer period than we have been documenting its efficacy. Acupuncture comes from a long tradition of the practice of medicine, albeit in cultures and eras quite distant from ours. Our hybrid medical acupuncture allows remarkable creativity in the hands of well-trained practitioners, to treat many problems that are not included among those already studied in the pharmaceutical model.
DR. BERMAN: I think that’s a very important point, but let’s talk a little bit about the research first, and then go back to this when we’re putting the research into the context of clinical practice. How should we take this into account?
DR. KAPLAN: Let’s briefly look at the clinical research, and then talk about some of the problems that we run into with research and what the research shows us in terms of how to better study procedures such as acupuncture, because studying procedures is different from studying drugs. The clinical studies roughly fall into 2 categories: effectiveness studies and efficacy studies, and many studies overlap and attempt to do both.
An effectiveness study looks at the extent to which a drug or procedure achieves its intended effect in the usual clinical setting. In these circumstances, you’re randomizing acupuncture against something such as a wait list control or usual care such as physical therapy or medications.
In 2009, a Cochrane database review studying acupuncture for prophylaxes of migraine showed that acupuncture was at least as effective, and possibly more effective, than prophylactic drugs with fewer adverse effects.13
In 2012, Andrew Vickers and his colleagues4 performed individualized patient data meta-analysis of 17,922 patients with a variety of back, neck, shoulder, osteoarthritic-related and headache pains and concluded that acupuncture was, in fact, effective for the treatment of chronic pain. Some effectiveness trials have shown acupuncture to be useful for some specific conditions, pain being the number one condition.
Efficacy is the extent to which a drug or procedure has the ability to bring about its intended effect under ideal circumstances, that is, acupuncture compared to a placebo. In the Vickers study,4 Vickers looked at the efficacy of acupuncture in the treatment of chronic pain and again concluded that true acupuncture was statistically slightly more efficacious than sham. Although this was not a big effect, it was nonetheless statistically significant.
From the 2012 Cochrane database review of IBS14 it was concluded that acupuncture was not efficacious as compared to a creditable sham, but there were several effectiveness trials where acupuncture tested better against 2 antispasmodic medications, which have some effect on both the severity and quality of life in patients with IBS.
While the Vickers study reported the efficacy as well as effectiveness of acupuncture, the IBS trial did not find any efficacy, when compared to the placebo, but did find evidence of the effectiveness of acupuncture.
What is particularly interesting about this study is that the natural history of carpal tunnel suggests that you will notice a 20% to 40% improvement over time. However, this study showed an 88% statistically significant improvement in both the true and sham acupuncture groups, which was maintained over 3 months of follow-up after the treatments ended.
The question that arises now is how you reconcile all of this, because it seems that the first piece of information that you come up with is that the sham may actually be a different form of active treatment. There’s an interesting study by Richard Harris and others in neuroimaging that was published in 2009.16 Harris’ team looked at the effects of true and sham acupuncture on the mu-opioid receptors in the central nervous system (CNS) using positron emission tomographic scanning in patients with fibromyalgia. Prior studies in patients with fibromyalgia have demonstrated increased levels of endogenous opioids in the cervical spinal fluid with decreased sensitivity in the mu-opioid receptors in the CNS regions known to be associated with the modulation of pain.
In the Harris study, the authors found that true acupuncture therapy evoked both short- and long-term increases in mu-opioid-binding potential receptors in the multiple pain areas and sensory processing areas associated with pain regulation. This was associated with clinical reports of pain reduction on the part of the subjects.
In the sham group, they also reported reduction in pain, though less than that in the true acupuncture group, and the positron emission tomographic scan showed no effect on the sensitivity of the mu-opioid receptors. The binding potential of these receptors did not improve as they did with the acupuncture treatments.
We know from prior studies that both true and sham acupuncture seem to increase the release of endogenous opioids, and we see that effect occurring in the ascending pathways and a segmental effect occurring in the spinal cord as well as in the descending modulating pathways mediated via dynorphins serotonin and norepinephrine. However, the effects of true acupuncture on the mu-opioid binding sensitivities are different from that of sham acupuncture.
In addition to this, we have imaging studies that have been conducted since the 1990s, and a recently published meta-analysis by Huang et al,17 which showed that while there is a problem with heterogeneity of these studies, they were able to conclude that the brain response to acupuncture encompasses a broad network of regions consistent with somatosensory affective and cognitive processing.
Overall, the neurophysiological evidence shows that acupuncture treatments affect the CNS in ways that are beneficial, long lasting, and unique to true acupuncture treatments. The neurophysiological evidence is also beginning to explain why we see different degrees of clinical effectiveness of acupuncture in conditions as diverse as gastrointestinal disorders, pain, and psychiatric conditions.
We have a lot more to learn and, far from being discouraged by this conflicting evidence in the literature, we should be excited by how much acupuncture has challenged and taught us about our understanding of human physiology. Does acupuncture work? Yes, according to the literature. Does acupuncture have unique and beneficial mechanisms of action on our neurophysiology? Again, I believe that the accumulative answer to that is yes.
The abovementioned discussion was about what’s going on in the CNS with acupuncture. There are a couple of other theories about how acupuncture may be effective. The one most commonly cited is work is that of Helen Langevin,18 where she writes about the network of acupuncture points and meridians viewed as representations of a network formed by interstitial connective tissue and that there has been an 80% correlation of the acupuncture points where the intramuscular connective tissue planes.
The needle grasp is a result of a winding of connective tissue and causes a tight mechanical coupling between the needle and the tissue, and there’s mounting evidence that this mechanical transduction can be translated into a variety of cellular and extracellular events. The 2 major models are the neurologic model, which is by far the most accepted and studied, and the connective tissue model.
Again, this is an evolving area. We have a lot more to learn, and I completely agree with Dr. Helms that we don’t want to be locked into the evidence-based approach that we fail to understand the true clinical benefits that acupuncture has shown repeatedly over thousand years of practice and that we see ourselves in day-to-day practice in our offices.
DR. BERMAN: Apart from summarizing the mechanisms, Dr. Kaplan, I think you mean that when we’re talking about evidence-based medicine, it’s not just about the efficacy shown by randomized control trials. There’s a wider range of methodologies and diseases to consider, depending on the question being asked. This is true of all medicine, including acupuncture, and if we narrow it down too much, we may fail to reap the benefits of using a very valuable tool as part of medicine.
DR. KAPLAN: I think you’re absolutely correct. The other thing that we need to keep in mind is that the evidence-based research itself is a very limiting concept because we keep finding new mechanisms and understanding new subtleties about how the nervous system is working, how our physiology works, and then we’re able to go back and say, “Ah, that’s the mechanism via which this is happening.” This whole topic about mu-opioid receptors is actually a breakthrough in terms of understanding how acupuncture may affect the CNS, which is unique and different from the way that sham does.
DR. BERMAN: What do you think are the cutting-edge research questions that still need to be answered as we go forward, questions that could not only inform us of how acupuncture works but could also affect clinical practice?
DR. KAPLAN: One of the areas that I’ve been particularly focused on is the microglial cells and their impact as the ultimate transducers between psychological stress, which gets translated into neurologic damage; and physical stress such as traumatic brain injury; as well as infectious stress, which also creates problems with neuroinflammation and neurodegeneration in conditions such as chronic pain and chronic illness.
We have seen evidence that acupuncture is actually neuroregenerative in some circumstances, certainly from some of the carpal tunnel studies that have been performed. We know that the microglia are involved in neuroregeneration; therefore, studying the effects of acupuncture on microglia may give us much more insight into how acupuncture works. This would be one area that I think should be focused on.
DR. BERMAN: Dr. Helms or Dr. Lao, any questions you think still need to be answered that can really make a difference?
DR. LAO: I agree with everything you have already said, but I think I’ll add one point: we need more translational studies on how to apply the scientific information to our daily practices in order to enhance the effectiveness of acupuncture treatment. We did some studies in which the effectiveness of a combination of conventional medication and acupuncture was evaluated. We found that the effectiveness of the combined therapy was much higher than that of acupuncture or the medication alone. Maybe, in the future, the research should be designed to answer the question of whether acupuncture reduces the side effects of a medication, resulting in enhanced effectiveness of both medicine and acupuncture.
DR. BERMAN: I would add one point that goes along with that: we need to get a better idea of the responders and nonresponders to acupuncture. We could begin to address this by setting up some pragmatic clinical trials with the idea of comparative effectiveness research in actual settings of clinical practice as well as cost effectiveness. Further, we could determine who responds, and we can include imaging and genomics assessments as part of the biomarkers that we’re analyzing.
Dr. Kaplan, do you have any final comments you want to add?
DR. KAPLAN: In terms of additional research, our thinking has been very much from a Bohr atom perspective [Bohr was a physicist who originally described the atom like a small solar system with electrons neatly orbiting the nucleus of the atom is a fixed orbit. This is a cartoon approximation of reality.] in terms of how the nervous system works, and we need to move toward a more quantum understanding. The whole field of neuroimaging is moving toward the concept of neuro-networking and trying to understand how the different regions of the brain interact with each other. I think that’s going to show a lot of promise even in terms of how acupuncture is affecting the system.
I also think that, as you mentioned briefly, the cost effectiveness research is extremely important. Integrating acupuncture into conventional medical practice has the potential, at least to significantly reduce cost to the patient and side effects of medications. I think studies need to be conducted on this issue. I’m optimistic these studies will confirm what we have witnessed in clinical practice.
DR. HELMS: Just a comment on that, Dr. Kaplan. You first need a model environment where acupuncture is fully integrated into a broad-based clinical setting, not individual practices. That’s the first hurdle to overcome before one looks at the impact of reducing reliance on pharmaceutical products or cutting back on the frequency of office visits and referrals to specialists.
DR. KAPLAN: I completely agree with you. I think that’s a challenge that we need to potentially take on in the future, but it’s something to be looking towards as we’re going to have to be more cost effective and more cost conscious in our treatment of a variety of diseases. I think acupuncture has a significant role to play here but we are not ready to perform those studies yet. We need to start to think about them and how they can be accomplished.
DR. HELMS: In the past, we have thought of acupuncture as a treatment for chronic conditions, but one of the biggest problems we face in the military today is trauma. It could be possible to compare management outcomes at military facilities that have integrated acupuncture into their trauma treatment with those that have not.
DR. BERMAN: Here is where the military comes into play. They have proposed a move towards expanding availability of acupuncture immediately following trauma and then follow that through with intermediate and long-term care facilities. If this approach succeeds, it would create an environment in which those issues of acute, sub-acute, and chronic consequences of trauma could be evaluated.
DR. LAO: In ancient literature, early acupuncture was largely used for emergency medicine, particularly in the ancient times when patients were unconscious or in conditions such as fainting or convulsions where they could not be treated with oral medicines. There is a large body of ancient literature that has documented this use.
DR. BERMAN: I want to thank all of you for participating in this discussion; it’s been a real pleasure.
FoxP2 Media LLC is the publisher of The Medical Roundtable.
Acupuncture (a traditional Chinese medical practice systematically used for over 2000 years) involves insertion of thin stainless steel needles into specific points on the body to facilitate recovery and good health. This practice was first brought to Europe in the 17th Century,1 and the first journal article on acupuncture appeared in the 1820s.2 Not until recently has acupuncture been widely accepted because of the clash of east versus west paradigms.
Scientific advances in acupuncture research, coupled with the side effects of treating pain by conventional drugs, have dramatically promoted the use of acupuncture in the last 20 years. It is estimated that over 1 million practitioners (outside China) administer acupuncture treatments for chronic pain. Of these practitioners, over 300000 are physicians.3 An estimated 3 million American adults receive acupuncture treatments each year, and chronic pain is the most common presentation.4
One of the most significant events in the 1990s for acupuncture was the decision taken by the US Food and Drug Administration in March 1996 to reclassify the legal status of acupuncture as safe and effective medical devices.
Further, in November 1997, there was a consensus conference on acupuncture by the National Institutes of Health.5 This was a 2.5-day conference conducted to evaluate the scientific and medical data on the uses, risks, and benefits of acupuncture for a variety of conditions. The findings after reviewing approximately 2300 studies stated that “Promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and postoperative dental pain.”
“There are other conditions such as stroke rehabilitation, headache, tennis elbow, osteoarthritis, lower back pain, carpal tunnel syndrome, and asthma, for which acupuncture may be useful as an adjunct treatment or could be included in a comprehensive management program. Although many issues remain to be clarified, there is sufficient evidence to prove the value of acupuncture in order to expand its use in conventional medicine and encourage further studies of its physiology and clinical value.”
Since the consensus conference in 1997, there has been a huge increase in the number of scientific studies conducted on acupuncture. The Cochrane Collaboration’s database includes now 6035 clinical trials and 53 systematic reviews on acupuncture in their database.6 This roundtable today will focus on the current indications for acupuncture, and we will discuss how it is used in clinical settings, its safety issues and clinical evidence, and how it works.
The other participants are Dr. Joseph Helms, Dr. Gary Kaplan, and Dr. Lixing Lao. Dr. Helms is the founding president of the American Academy of Medical Acupuncture. In 1980, Dr. Helms developed the Medical Acupuncture Physicians program as a continuing medical education course for the University of California, Los Angeles (UCLA), School of Medicine; has chaired the program since then through the Helms Medical Institute (HMI); and has trained over 6000 physicians during this period. Dr. Helms is professor of medical acupuncture on the adjunct clinical faculty of the Stanford Medical School and the author of Acupuncture Energetics: A Clinical Approach for Physicians.
Dr. Kaplan is the medical director of the Kaplan Center for Integrative Medicine in McLean, Virginia, and is an associate professor in the Department of Community and Family Medicine at Georgetown University, School of Medicine. He served on the board of the American Academy of Medical Acupuncture and was president of the Medical Acupuncture Research Foundation.
Our final participant, Dr. Lao, is a professor of Family Medicine and the director of Traditional Chinese Medicine Research program at the Center for Integrative Medicine, University of Maryland School of Medicine. Dr. Lao graduated from the Shanghai University in the Traditional Chinese Medicine Program, holds a PhD in physiology from the University of Maryland in Baltimore, and has practiced acupuncture for 30 years and conducted research for 20 years.
To begin this discussion, Dr. Helms, can you describe for us the different types of acupuncture, training, and how acupuncture is used in a clinical setting?
DR. HELMS: Thank you, Dr. Berman. Acupuncture is relatively new in the collection of American medical disciplines. It has been in constant evolution since President Nixon’s visit to China in 1972. This evolution is driven by public interest and demand as well as scientific evidence of its mechanism and clinical value. This started with linking the impact of acupuncture on pain to the endogenous opioid peptide cascade, which is currently being reinforced through functional magnetic resonance imaging studies that confirm an intracranial response to peripheral needling.
The 1997 Consensus Development Conference report5 that endorsed a handful of acupuncture applications was based on the quality of research design to evaluate acupuncture’s impact on different problems, rather than on the actual practice of acupuncture. Since that paper, over 400 randomized control trials have been published in peer review journals internationally. These studies demonstrate the favorable impact of acupuncture on a wide spectrum of medical problems, including, but not limited to, pain.
There are many different styles of acupuncture. This discipline has evolved through multiple cultures over the last 2000 years. Each culture and era of its blossoming has contributed its enduring quality and approach. Many of these styles of acupuncture were retained only in family traditions, while others were propagated nationally. It is only in the late 20th century and beginning of the 21st century that we have had the privilege to access many of the family and most of the national traditions of acupuncture training and practice.
The tradition, with which I’m most familiar with, is known as medical acupuncture. Medical acupuncture would best be described as a hybrid approach combining our understanding of acupuncture neuroanatomy and physiology with traditional precepts from the classics of acupuncture. Medical acupuncture is generally practiced by licensed practitioners of conventional biomedical medicine and is considered an additional qualification to their scope of practice. These would include doctors of medicine, doctors of osteopathy, doctors of dental surgery, and doctors of podiatric medicine.
Traditional Chinese Medicine is the approach most widely practiced in this country. It is an approach exported from post-Maoist China, having been developed to provide basic healthcare to the Chinese population as the country was transitioning from its revolutionary period in the 1950s and 1960s into a more stable political and social period. The Traditional Chinese Medicine model doesn’t contain the totality of the classics, but rather is an extraction that can be taught and absorbed by the western community. The Traditional Chinese Medicine approach covers internal medicine problems as well as pain problems.
Two additional, commonly used subdivisions of acupuncture are auricular acupuncture and Chinese scalp acupuncture. Auricular acupuncture was developed in France in the 1950s and 1960s and uses points exclusively on the ear to influence pain and organ function. Chinese scalp acupuncture is a recent development in Chinese medicine. It involves placing needles in the scalp overlying the cortical surfaces that relay pain signals.
DR. BERMAN: Could you elaborate on auricular acupuncture a little more and on what it is used for?
DR. HELMS: Auricular acupuncture is the least complex and most easily learned approach to acupuncture. It can be effective either as a standalone treatment or as an adjunct to body acupuncture. The scientific foundation of auricular acupuncture involves the ear’s complex innervation that links it to all 3 embryologic germ levels. Thus, with neurological representation of endoderm, mesoderm, and ectoderm, the ear manifests a homunculus of all body parts. Ear points that correspond to painful or disturbed structures demonstrate increased electrical conductivity, and thereby allow the ear to serve as a diagnostic tool and a therapeutic signal.
DR. BERMAN: I think in the past, auricular acupuncture was also used for problems of addiction but I don’t know if it’s still being used for this purpose.
DR. HELMS: There are several widely used acupuncture point combinations that have been shown to be useful in assisting a multidisciplinary approach to substance abuse problems, referred to as the “NADA protocol” that was developed by Michael Smith, MD. There is also a 5-point formula called battlefield acupuncture that is useful in dealing with acute traumatic pain.7
DR. BERMAN: Thank you, Dr. Helms. Dr. Kaplan and then Dr. Lao, could you comment about what’s being done in clinical settings and how acupuncture is used to treat certain diseases beyond what Dr. Helms has just explained?
DR. KAPLAN: We do a great deal of work for the treatment of pain and find acupuncture to be extremely effective for conditions such as headaches, back pain, and neck pain. We also find it useful for the treatment of peripheral neuropathies. In addition, because we deal with many chronic pain patients, we also see a lot of psychoemotional issues comorbid with the chronic pain. Acupuncture has proven to be very helpful as an adjunctive therapy dealing with the psychoemotional components that we see associated with chronic pain.
In my practice, approximately 20% of our pain population has posttraumatic stress syndrome, while approximately 60% has comorbid anxiety disorders or major depressive disorders. Acupuncture has been particularly unique as a therapeutic modality because it addresses both the pain and the psychological component of an individual’s illness at the same time. We’re able to talk about the totality of the individual as opposed to segmenting them into psychiatric versus pain versus sleep issues. From an acupuncture perspective, these conditions are not separate issues but different manifestations of a pattern of disharmony in the individual.
DR. LAO: I agree with Drs. Kaplan and Helms. In my practice, I see patients with a variety of complaints. In addition to pain, they also experience menstruation disorders, depression, and attention deficit disorder (ADD) (in children). A wide variety of diseases can be treated by acupuncture. Evidence of the effectiveness of acupuncture for the treatment of pain has recently been published by Vickers.4
Individual raw data show the full area of musculoskeletal pain, which includes neck pain, low back pain, headaches (migraine and tension headaches), osteoarthritis in the knees, and shoulder pain. There is a significant difference between acupuncture and conventional treatment in terms of their therapeutic effectiveness. There was also a significant difference between acupuncture and sham acupuncture, ie, placing of needles at points on the body that are not thought to be acupuncture points (off site points). Although the benefits were modest, they were highly significant.4
Dr. Berman, do you also want me to cover a little bit about the side effects or shall we save that for later?
DR. BERMAN: Let’s stick to the clinical use first, and then we’ll go to the side effects.
DR. KAPLAN: I’d like to chime in here. I’m boarded in family medicine and pain medicine and started my clinical practice in a general medical setting. As my practice evolved, I began seeing a greater number of individuals suffering with chronic pain and illness issues.
Over the last 30 years, acupuncture has heavily influenced my approach to patient care. Acupuncture is not simply a tool but a philosophy of care that has greatly enriched my western medical training. At times, when treating a patient, I believe the prism of a western approach will be more effective; there are also times when I rely exclusively on an acupuncture approach, but more commonly, I integrate the two in designing and implementing a care program.
Pain can be very effectively managed with acupuncture alone or as an adjunct. Many so-called functional or psychosomatic problems can be more effectively addressed using acupuncture in place of pharmaceutical agents. Likewise, the conventional approaches to organic problems can be reinforced and facilitated with acupuncture treatment.
Acupuncture covers a much broader range of clinical applications than simple neuromusculoskeletal pain or psychoemotional issues. It really covers the full spectrum of medicine.
DR. KAPLAN: We have used acupuncture successfully in women with hyperemesis gravidarum. Most of the medications are contraindicated because of the potential harm to the fetus. Acupuncture has been successful in at least providing these women with some level of relief in treating this condition.
I don’t have experience with acupuncture therapy for postoperative nausea/vomiting. We have used it a little bit in nausea/vomiting associated with chemotherapy, and again, we’ve been able to reduce the amount of medications that the patients require in order to control it; in some cases, we’ve actually been able to eliminate the need for medications.
Further, I want to go over what Dr. Helms was talking about—the importance of integrating acupuncture into a comprehensive treatment program. It is sometimes the main therapeutic modality that we use, but on many occasions, it is integrated into our medication regimes. In a comprehensive approach, we may use it in conjunction with physical therapy, and we will also be probing trigger points. We may also do prolotherapy with the patients.
Acupuncture gives us the ability to treat a wider range of conditions with fewer medications. We are frequently able to address irritable bowel syndrome (IBS), sleep disorders associated with the medical conditions, as well as the psychiatric conditions I was talking about earlier. Acupuncture is a beautiful adjunctive therapy and sometimes can be used as the sole therapeutic approach.
DR. BERMAN: In general, we’re now talking about acupuncture being part of a comprehensive approach to a number of chronic disorders.
DR. KAPLAN: That’s absolutely correct. You want to use all of the tools you have available, and acupuncture is a very powerful therapeutic modality in the treatment of these conditions.
DR. LAO: One of the nonpain areas that I think people should consider using acupuncture as a therapy is infertility. Many women now come to the clinic, particularly after the publication of the enhanced success rate of in vitro fertilization (IVF) in women receiving acupuncture treatment.8 Even those patients who elect to not go through IVF come for acupuncture treatment to enhance their chances of getting pregnant.
DR. BERMAN: Dr. Lao, is there evidence to support acupuncture for infertility?
DR. LAO: There’s a paper that was published a couple years ago through our center.8 The authors show a higher success rate of conventional IVF procedure when combined with acupuncture than with sham control. Current studies give clear evidence of the benefits of acupuncture to IVF patients.
DR. BERMAN: With the breathlessness COPD I was referring to, there was a study in the Archives of Internal Medicine just this past June 2012,9 which was a very well-done clinical trial aimed at studying COPD and using acupuncture in addition to conventional care, that showed clear outcomes of the benefits of acupuncture in this particular condition.
Dr. Helms, you have experienced acupuncture in the military setting. Can you talk a little bit about that?
DR. HELMS: In the last 5 years, 3 branches of the US Military have shown interest in pursuing acupuncture training for physicians to provide these services to their population. This interest reflects what’s happening in the civilian population and is more intensively motivated by the report of the Army’s pain management task force that identified some severe shortcomings in managing acute and chronic pain.
The feedback we’ve received from the military physicians we’ve trained has been very rewarding. The bulk of their treatments are for pain, ranging from headache to cervical, lumbar, and peripheral pain. Much of this pain is caused by the weight of their 75-pound protective gear, which they wear no matter where they are in the world, and of course, the physical trauma of battle. Interestingly, an almost equal percentage of treatments for active duty service members are for psychoemotional problems (anxiety, insomnia, depression, acute stress, and chronic stress) as for pain and physical trauma.
DR. BERMAN: Let me move on to the next subtopic. Dr. Lao, can you talk to us about how safe acupuncture is?
DR. LAO: There are few reported cases of complications in the English literature from 1965 to 1999, a 35-year span. There were a total of 202 case reports, which is about 5–6 cases per year.10 I have completed 2 reviews of case reports on adverse events associated with acupuncture. One was published in 200310 and the other one is accepted for publication.11 Events are divided into complications and adverse reactions. Complications such as injured organs or infections occur if acupuncture is not carefully performed. Adverse reactions include syncope and allergic reaction.
Infections constituted 50% of all complications. Needle infections may cause hepatitis. However, since the late 1980s, acupuncturists started using disposable needles, resulting in lower incidence of hepatitis and other infections.10 In recent years, another infection emerged that involves many different invasive procedures in medical settings such as methicillin-resistant Staphylococcus aureus (MRSA). This is likely due to the unsanitary conditions of these clinical settings, such as the use of contaminated disinfectant. It’s not the acupuncture needle itself that caused infection.
A larger survey12 showed that approximately 7% to 8% of the adverse events were classified as mild. These events include local site bleeding, pain in local needling site, nausea, or light-headedness. The occurrence of these mild adverse events is very low especially in the context of the large numbers of patients attended to acupuncture clinic every year.
In the last 10 years, 308 cases of side effects were noted from 26 countries.11 In the United States, only 17 cases have been reported, which is a very small percentage. I believe that this is due to extensive professional licensing requirement that is called Clean Needle Techniques (CNT) training. This requirement has dramatically decreased the risk of unnecessary side effects.
Other types of adverse events such as organ and tissue injuries are associated with knowledge of anatomy. Therefore, proper training of the acupuncturist could help reduce the occurrence of side effects due to acupuncture.
DR. BERMAN: From these prospective studies,10–12 we can conclude that serious adverse events are very rare with acupuncture and that there is, depending on the surveys, a 2% to 7% probability of occurrence of a mild side effect such as local site bleeding or occasional dizziness or localized pain to the area. Is there anything else on safety that either, Dr. Kaplan or Dr. Helms would like to add?
DR. HELMS: In addition to reinforcing that acupuncture is a very safe and forgiving therapeutic approach, I’d like to discourage readers from concluding that useful indications for acupuncture in medical practice are limited to what is published in the evidence-based literature. Acupuncture has been used for simple and complex problems by responsible practitioners in oriental and occidental cultures for much longer period than we have been documenting its efficacy. Acupuncture comes from a long tradition of the practice of medicine, albeit in cultures and eras quite distant from ours. Our hybrid medical acupuncture allows remarkable creativity in the hands of well-trained practitioners, to treat many problems that are not included among those already studied in the pharmaceutical model.
DR. BERMAN: I think that’s a very important point, but let’s talk a little bit about the research first, and then go back to this when we’re putting the research into the context of clinical practice. How should we take this into account?
DR. KAPLAN: Let’s briefly look at the clinical research, and then talk about some of the problems that we run into with research and what the research shows us in terms of how to better study procedures such as acupuncture, because studying procedures is different from studying drugs. The clinical studies roughly fall into 2 categories: effectiveness studies and efficacy studies, and many studies overlap and attempt to do both.
An effectiveness study looks at the extent to which a drug or procedure achieves its intended effect in the usual clinical setting. In these circumstances, you’re randomizing acupuncture against something such as a wait list control or usual care such as physical therapy or medications.
In 2009, a Cochrane database review studying acupuncture for prophylaxes of migraine showed that acupuncture was at least as effective, and possibly more effective, than prophylactic drugs with fewer adverse effects.13
In 2012, Andrew Vickers and his colleagues4 performed individualized patient data meta-analysis of 17,922 patients with a variety of back, neck, shoulder, osteoarthritic-related and headache pains and concluded that acupuncture was, in fact, effective for the treatment of chronic pain. Some effectiveness trials have shown acupuncture to be useful for some specific conditions, pain being the number one condition.
Efficacy is the extent to which a drug or procedure has the ability to bring about its intended effect under ideal circumstances, that is, acupuncture compared to a placebo. In the Vickers study,4 Vickers looked at the efficacy of acupuncture in the treatment of chronic pain and again concluded that true acupuncture was statistically slightly more efficacious than sham. Although this was not a big effect, it was nonetheless statistically significant.
From the 2012 Cochrane database review of IBS14 it was concluded that acupuncture was not efficacious as compared to a creditable sham, but there were several effectiveness trials where acupuncture tested better against 2 antispasmodic medications, which have some effect on both the severity and quality of life in patients with IBS.
While the Vickers study reported the efficacy as well as effectiveness of acupuncture, the IBS trial did not find any efficacy, when compared to the placebo, but did find evidence of the effectiveness of acupuncture.
What is particularly interesting about this study is that the natural history of carpal tunnel suggests that you will notice a 20% to 40% improvement over time. However, this study showed an 88% statistically significant improvement in both the true and sham acupuncture groups, which was maintained over 3 months of follow-up after the treatments ended.
The question that arises now is how you reconcile all of this, because it seems that the first piece of information that you come up with is that the sham may actually be a different form of active treatment. There’s an interesting study by Richard Harris and others in neuroimaging that was published in 2009.16 Harris’ team looked at the effects of true and sham acupuncture on the mu-opioid receptors in the central nervous system (CNS) using positron emission tomographic scanning in patients with fibromyalgia. Prior studies in patients with fibromyalgia have demonstrated increased levels of endogenous opioids in the cervical spinal fluid with decreased sensitivity in the mu-opioid receptors in the CNS regions known to be associated with the modulation of pain.
In the Harris study, the authors found that true acupuncture therapy evoked both short- and long-term increases in mu-opioid-binding potential receptors in the multiple pain areas and sensory processing areas associated with pain regulation. This was associated with clinical reports of pain reduction on the part of the subjects.
In the sham group, they also reported reduction in pain, though less than that in the true acupuncture group, and the positron emission tomographic scan showed no effect on the sensitivity of the mu-opioid receptors. The binding potential of these receptors did not improve as they did with the acupuncture treatments.
We know from prior studies that both true and sham acupuncture seem to increase the release of endogenous opioids, and we see that effect occurring in the ascending pathways and a segmental effect occurring in the spinal cord as well as in the descending modulating pathways mediated via dynorphins serotonin and norepinephrine. However, the effects of true acupuncture on the mu-opioid binding sensitivities are different from that of sham acupuncture.
In addition to this, we have imaging studies that have been conducted since the 1990s, and a recently published meta-analysis by Huang et al,17 which showed that while there is a problem with heterogeneity of these studies, they were able to conclude that the brain response to acupuncture encompasses a broad network of regions consistent with somatosensory affective and cognitive processing.
Overall, the neurophysiological evidence shows that acupuncture treatments affect the CNS in ways that are beneficial, long lasting, and unique to true acupuncture treatments. The neurophysiological evidence is also beginning to explain why we see different degrees of clinical effectiveness of acupuncture in conditions as diverse as gastrointestinal disorders, pain, and psychiatric conditions.
We have a lot more to learn and, far from being discouraged by this conflicting evidence in the literature, we should be excited by how much acupuncture has challenged and taught us about our understanding of human physiology. Does acupuncture work? Yes, according to the literature. Does acupuncture have unique and beneficial mechanisms of action on our neurophysiology? Again, I believe that the accumulative answer to that is yes.
The abovementioned discussion was about what’s going on in the CNS with acupuncture. There are a couple of other theories about how acupuncture may be effective. The one most commonly cited is work is that of Helen Langevin,18 where she writes about the network of acupuncture points and meridians viewed as representations of a network formed by interstitial connective tissue and that there has been an 80% correlation of the acupuncture points where the intramuscular connective tissue planes.
The needle grasp is a result of a winding of connective tissue and causes a tight mechanical coupling between the needle and the tissue, and there’s mounting evidence that this mechanical transduction can be translated into a variety of cellular and extracellular events. The 2 major models are the neurologic model, which is by far the most accepted and studied, and the connective tissue model.
Again, this is an evolving area. We have a lot more to learn, and I completely agree with Dr. Helms that we don’t want to be locked into the evidence-based approach that we fail to understand the true clinical benefits that acupuncture has shown repeatedly over thousand years of practice and that we see ourselves in day-to-day practice in our offices.
DR. BERMAN: Apart from summarizing the mechanisms, Dr. Kaplan, I think you mean that when we’re talking about evidence-based medicine, it’s not just about the efficacy shown by randomized control trials. There’s a wider range of methodologies and diseases to consider, depending on the question being asked. This is true of all medicine, including acupuncture, and if we narrow it down too much, we may fail to reap the benefits of using a very valuable tool as part of medicine.
DR. KAPLAN: I think you’re absolutely correct. The other thing that we need to keep in mind is that the evidence-based research itself is a very limiting concept because we keep finding new mechanisms and understanding new subtleties about how the nervous system is working, how our physiology works, and then we’re able to go back and say, “Ah, that’s the mechanism via which this is happening.” This whole topic about mu-opioid receptors is actually a breakthrough in terms of understanding how acupuncture may affect the CNS, which is unique and different from the way that sham does.
DR. BERMAN: What do you think are the cutting-edge research questions that still need to be answered as we go forward, questions that could not only inform us of how acupuncture works but could also affect clinical practice?
DR. KAPLAN: One of the areas that I’ve been particularly focused on is the microglial cells and their impact as the ultimate transducers between psychological stress, which gets translated into neurologic damage; and physical stress such as traumatic brain injury; as well as infectious stress, which also creates problems with neuroinflammation and neurodegeneration in conditions such as chronic pain and chronic illness.
We have seen evidence that acupuncture is actually neuroregenerative in some circumstances, certainly from some of the carpal tunnel studies that have been performed. We know that the microglia are involved in neuroregeneration; therefore, studying the effects of acupuncture on microglia may give us much more insight into how acupuncture works. This would be one area that I think should be focused on.
DR. BERMAN: Dr. Helms or Dr. Lao, any questions you think still need to be answered that can really make a difference?
DR. LAO: I agree with everything you have already said, but I think I’ll add one point: we need more translational studies on how to apply the scientific information to our daily practices in order to enhance the effectiveness of acupuncture treatment. We did some studies in which the effectiveness of a combination of conventional medication and acupuncture was evaluated. We found that the effectiveness of the combined therapy was much higher than that of acupuncture or the medication alone. Maybe, in the future, the research should be designed to answer the question of whether acupuncture reduces the side effects of a medication, resulting in enhanced effectiveness of both medicine and acupuncture.
DR. BERMAN: I would add one point that goes along with that: we need to get a better idea of the responders and nonresponders to acupuncture. We could begin to address this by setting up some pragmatic clinical trials with the idea of comparative effectiveness research in actual settings of clinical practice as well as cost effectiveness. Further, we could determine who responds, and we can include imaging and genomics assessments as part of the biomarkers that we’re analyzing.
Dr. Kaplan, do you have any final comments you want to add?
DR. KAPLAN: In terms of additional research, our thinking has been very much from a Bohr atom perspective [Bohr was a physicist who originally described the atom like a small solar system with electrons neatly orbiting the nucleus of the atom is a fixed orbit. This is a cartoon approximation of reality.] in terms of how the nervous system works, and we need to move toward a more quantum understanding. The whole field of neuroimaging is moving toward the concept of neuro-networking and trying to understand how the different regions of the brain interact with each other. I think that’s going to show a lot of promise even in terms of how acupuncture is affecting the system.
I also think that, as you mentioned briefly, the cost effectiveness research is extremely important. Integrating acupuncture into conventional medical practice has the potential, at least to significantly reduce cost to the patient and side effects of medications. I think studies need to be conducted on this issue. I’m optimistic these studies will confirm what we have witnessed in clinical practice.
DR. HELMS: Just a comment on that, Dr. Kaplan. You first need a model environment where acupuncture is fully integrated into a broad-based clinical setting, not individual practices. That’s the first hurdle to overcome before one looks at the impact of reducing reliance on pharmaceutical products or cutting back on the frequency of office visits and referrals to specialists.
DR. KAPLAN: I completely agree with you. I think that’s a challenge that we need to potentially take on in the future, but it’s something to be looking towards as we’re going to have to be more cost effective and more cost conscious in our treatment of a variety of diseases. I think acupuncture has a significant role to play here but we are not ready to perform those studies yet. We need to start to think about them and how they can be accomplished.
DR. HELMS: In the past, we have thought of acupuncture as a treatment for chronic conditions, but one of the biggest problems we face in the military today is trauma. It could be possible to compare management outcomes at military facilities that have integrated acupuncture into their trauma treatment with those that have not.
DR. BERMAN: Here is where the military comes into play. They have proposed a move towards expanding availability of acupuncture immediately following trauma and then follow that through with intermediate and long-term care facilities. If this approach succeeds, it would create an environment in which those issues of acute, sub-acute, and chronic consequences of trauma could be evaluated.
DR. LAO: In ancient literature, early acupuncture was largely used for emergency medicine, particularly in the ancient times when patients were unconscious or in conditions such as fainting or convulsions where they could not be treated with oral medicines. There is a large body of ancient literature that has documented this use.
DR. BERMAN: I want to thank all of you for participating in this discussion; it’s been a real pleasure.
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Meet Dr. Leslie Baumann at the Summer AAD meeting
You love Dr. Baumann’s Cosmeceutical Critique column in Skin & Allergy News, and soon that content will be expanded in a new book entitled "Cosmeceuticals and Cosmetic Ingredients," available this November via Amazon.com. Meet Dr. Baumann at the Skin Disease Education Foundation (SDEF)/Skin & Allergy News Booth #1500 from 12:00-12:30 p.m. on Saturday, Aug. 9 at the 2014 Summer Academy Meeting in Chicago. And be sure to pick up a copy of her latest column from Skin & Allergy News, the leading news publication for aesthetic, medical, and surgical dermatology.
In addition, you can visit Dr. Baumann at her booth (#1716) during the meeting.
Read Dr. Baumann’s columns online at edermatologynews.com.
You love Dr. Baumann’s Cosmeceutical Critique column in Skin & Allergy News, and soon that content will be expanded in a new book entitled "Cosmeceuticals and Cosmetic Ingredients," available this November via Amazon.com. Meet Dr. Baumann at the Skin Disease Education Foundation (SDEF)/Skin & Allergy News Booth #1500 from 12:00-12:30 p.m. on Saturday, Aug. 9 at the 2014 Summer Academy Meeting in Chicago. And be sure to pick up a copy of her latest column from Skin & Allergy News, the leading news publication for aesthetic, medical, and surgical dermatology.
In addition, you can visit Dr. Baumann at her booth (#1716) during the meeting.
Read Dr. Baumann’s columns online at edermatologynews.com.
You love Dr. Baumann’s Cosmeceutical Critique column in Skin & Allergy News, and soon that content will be expanded in a new book entitled "Cosmeceuticals and Cosmetic Ingredients," available this November via Amazon.com. Meet Dr. Baumann at the Skin Disease Education Foundation (SDEF)/Skin & Allergy News Booth #1500 from 12:00-12:30 p.m. on Saturday, Aug. 9 at the 2014 Summer Academy Meeting in Chicago. And be sure to pick up a copy of her latest column from Skin & Allergy News, the leading news publication for aesthetic, medical, and surgical dermatology.
In addition, you can visit Dr. Baumann at her booth (#1716) during the meeting.
Read Dr. Baumann’s columns online at edermatologynews.com.