Akey component of the presiden-tial campaign this year is healthcare, a problem that has beendiscussed in just about every circle andcorner of society. No one will arguethat the need to improve health care is paramount. Children, the workingpoor, minorities, and women are at the top of the list when it comes toneeding better access and higher quality of health care. The goal must be to provide equal health care forevery man, woman, and child. In the United States there is an enormous gap between those withaccess to health care and those without. This gap increases each day,with no end in sight. The question is:where do we begin to create positivechange, ensuring that everyone hasaccess to high quality health care?Chronic pain is difficult enough tocope with without having to search desperately for high quality and timely care. Where you live, your ethnicity, or your race could affect the quality of care you receive. There are many reasons why there are such disparitiesin care and we will explore some ofthem in this issue. Ideas to Close the GapsWhile we dont have the answers to solve the health care crisis, there are many things that can be done to improve the medical management of pain and health care delivery in general. We need more information,communication, persistence, and understanding to help people withpain improve their relationships with their health care providers and possibly improve their ability to obtain quality care.Health care providers, support organizations, educators, legislators,payers, researchers, and health care consumers all play a role in this effort. These ideas would get thingsmoving in the right direction. Implement communication tools that are standard in all health care settings; create consistent ways to communicate symptoms and factors to promote greater understanding of the symptoms and concerns ofthe patient. Increase requirements in pain and pain management education for health care providers. Provide standards in care that must be strictly adhered to, ensuringthat each and every person seeking care is treated equallyby Penney Cowan, Executive Director, ACPA1SUMMER 2008C O N T I N U E D O N P A G E 1 3. . .I N S I D E2 G etting the H elpYou D eserve4 D isparities inPain Care AffectQuality of Life6 I s Pain CareBased on Race?8 An O verviewof Spinal CordStimulation10 Who We AreAffects H ow WeRespond to Pain11 ACPA U pdate11 N ew G roups &Members12 Book Reviews14 TributesConfronting Disparities in Health CareGet the Help You DeserveMembers Overcome Disparities in Pain TreatmentMany of us find it challengingto communicate with our doc-tors about our chronic painand get the help we need. But some ofusdue to other factors over which wehave no controlhave extra challenges.These factorswhere we live, our age,gender, economic or educational level, or even having a prior healthproblemcan interfere with gettingproper pain treatment.Take Louise VanDenHoogen, forinstance. An ACPA facilitator inOntario, Canada, Louise has overcomemuch since being diagnosed with juvenile arthritis at age 16. Now 48, she uses what she has learned to help others.She sees her ACPA group membersstruggling to get equal pain treatmentbecause they live in a rural area with-out benefit of advanced education orsocial status. She tries to help thesepeople with chronic pain identify their health problems and effectivelyreport their pains to their doctor.Louise said one of her members wastold by a doctor she should just stayhome and have babies and not worryabout her health. It took five years for this woman to be referred to a specialist and finally get a diagnosis of fibromyalgia.When Specialist Care is Far AwayLouise lives in Haliburton Highlands, a tourist area where most of the jobsare seasonal, earning it the distinctionof being the second poorest county inOntario. Like many rural areas, theresa shortage of doctors. Medical special-ists, surgeons, and high-tech tests likeCT scans are about 85 miles away, a three-and-a-half hour drive. Because of their limited education and economic circumstances, many residents have poor vocabularies andhave difficulty talking with medicalprofessionals, said Louise.Shell often meet with members justprior to doctor appointmentsor go with them to the appointmentsto make certain they are making themselves clear, so the doctors will listen and respond with appropriatetreatment. Shes good at it because she has learnedthe hard wayby experience. ForLouise, her age creates a large disparityin health care. They dont believe myphysical condition at my age unlessthey see test results, she said. Mybones are comparable to a 75-year-olds.Getting around is not easy.Louise is used to dealing with a number of challenges. She has had constant pain and limited range ofmotion on her right side from thoracicoutlet syndrome since a car accident in1988. She also has fibromyalgia, carpaltunnel syndrome, temporomandibularjoint disorder (TMJ), urinary stenosis, attention deficit hyperactivity disorder(ADHD), and dyslexia, in addition to a joint replacement necessitated by the arthritis.After repeatedly being misunderstoodby medical professionals, Louiselearned to explain everything she could at medical appointments. You cant just sit and demand proper treatment, she said. I try to be open with my doctors so they haveno excuse to treat me with disparity.Your Right to Fair TreatmentShe has become accustomed to havingto speak up for herself in doctorsoffices. Once she explained to a doctorwhy she needed to sit on her hands. It was due to her ADHD diagnosis. It helps me slow down. I find when I explain to them they treat me better.Disparities in health care can result in patients blaming themselves. Theystart to believe they arent worthy ofbeing treated well. After walking awayfrom doctors who didnt treat her fair-ly, I learned to stand up for myselfand believethat I have the right toproper care, Louise said.2| TOP |by Sally Price| TOP || TOP |C O N T I N U E D O N P A G E 3 . . .She said most of her work with groupmembers who experience disparities in their health care is encouragingthem to believe in themselves. She alsoreminds them, When youre a patientand the doctor is not treating you verywell, sometimes (the doctor) is having a bad day. You cant blame yourself.Get a New DiagnosisSometimes disparity in pain treatmentoccurs when a prior medical conditioncomplicates getting a new diagnosis for a fresh problem. That happened to ACPA group facilitator Patrick Goertzof Wichita, Kansas. In January 2007, hefound himself in an emergency roomwith stroke-like symptoms of numbnessand tingling on one side of his body.But the ER team and the admittingneurologist focused on Patricks preex-isting bipolar disorder. He was told his symptoms were psychological andthat he was seeking drugs. Then he was sent home.After six months of trying to get someone to listen to me I fired thewhole crowd, said Patrick. Now Ihave doctors who understand that Ihave chronic pain. Weve developed arealistic treatment plan. Being involvedin ACPA as a facilitator is a part of myplan for living with chronic pain.It turned out that when Patrick reported to the emergency room he was experiencing a rare kind of stroke,one that doesnt show up on an MRIscan for months, he said. He currentlysuffers from post-stroke central nervoussystem chronic pain, which can resultfrom any type of injury to the brain,according to Patrick, a clinical nursespecialist. His symptoms today are aconstant tightness, severe burning, and a ripping kind of feeling on the right side of his body.In the emergency room with strokesymptoms, Patrick was also experienc-ing a daily bout of severe depression.He said, I was in such pain, I was cry-ing. Because I was acting emotionally,[the doctor may have thought] I wasjust seeking drugs.ACPA Provides Focus and ReliefIf I can focus on some activity I canforget about it for a while. Thats whythe ACPA has been so helpful, saidPatrick, who found the ACPA whenresearching pain management on theInternet. Now he is re-establishing anACPA support group in Wichita. Hesaid he uses ACPA relaxation tapes and the workbook in his daily life. I try to live it, he said.Like Louise, Patrick deals with his multiple diagnoses through acceptanceand courage. Since starting medication20 years ago, he deals with depressivesymptoms that come and go. Ive hadthe bipolar a long time and know itdoesnt last longer than a day, he said.He also knows how the two conditionsaffect each other. If I feel the depres-sive symptoms the pain becomes moreintense because Im just focused onmyself and I just kind of get lost inthat a little bit. On those days, he said, I give myself permission to bedown. I do cross-stitch and watch oldmovies. He is also writing a book for children.This author has also experienced disparities in pain treatment due to a prior diagnosis. After a spinal fusionto stop progressive scoliosis (spinal cur-vature) as a child, I had a difficult timegetting my doctors to look beyond mycurvature when I injured my back yearslater and experienced chronic pain. Finally, having no diagnosis other thanspinal arthritis, I had surgery (anotherfusion). Years later, I learned from adoctor trained in osteopathy that theinjury had knocked my sacroiliac jointout of alignment. The surgery and theyears of non-treatment precluded himfrom making any corrections. Lookingback, I see that I should have left thearea to find a doctor who would lookbeyond a prior diagnosis. Yes, disparities do happen. And its up to us to keep on trying and not give up.3If I focus on an activity, I forget about pain for awhile.| TOP |C O N T I N U E D F R O M P A G E 2 . . .Disparities in Pain Care Affect Quality of Lifeby Alison Conte4While many hospitals andphysicians follow set proce-dures for people with heartdisease, diabetes, and other wide-spreadhealth conditions, the course of treat-ment for chronic pain is not firmlyestablished.Further, researchers have found that the treatment you receive for your pain can vary because of who you are. Women, the elderly, and racial and ethnic minorities with pain maybe treated differently by health profes-sionals. These disparities in pain carecan lead to more pain as well as poor-er pain assessment and management,resulting in a lower quality of life. Carmen R. Green, MD of the Universityof Michigan Medical School, led a teamof researchers (including ACPA boardmembers Donna A. Kaloukalani, MD,MPH and Knox H. Todd, MD) inreviewing the literature, experience, and anecdotal evidence surroundingthe disparities in pain care. They pub-lished their results in Pain Medicinein 2003, under the title The UnequalBurden of Pain: Confronting Racial andEthnic Disparities in Pain.1They found differences existed in pain perception,assessment, and treatment in all set-tings (postoperative, emergency room,outpatient, and inpatient) and acrossall types of pain (acute, cancer, chronicnonmalignant, and experimental). The research shows minorities,women, and the elderly with pain are less likely to get attention, be prop-erly assessed, and optimally treated byclinicians, said Dr. Green. Dependingon where they live, they may be lesslikely to have their opioid analgesicprescriptions filled because their localpharmacies dont carry the medicationsthey need. Overall, minorities are atrisk for lesser quality care.Why? Disparities can be caused by: The way people with pain communicate their specific needs,track their pain levels, question their doctors, and assert their rights An individuals image, attitudes, and cultural beliefs The way a healthcare provider makes decisions How geography and economic status influence access to pain medication, therapies, and healthprofessionals.Inequality in Health Care DeliveryThe National Institute of Health andthe Institute of Medicine define healthdisparities as differences in the incidence, prevalence, mortality, andburden of disease and other adversehealth conditions existing among specific population groups in the U.S.2In 1999, the Institute of Medicine (IOM)of the National Academy of Sciences(NAS) described health care inequitiesin the delivery of health care servicesamong racial and ethnic minorities,including pain therapies. IOM foundthat the legal and regulatory environ-ment for healthcare systems, along withdiscrimination, biases, and stereotypesamong providers, were some of thereasons that African Americans andHispanics were more likely to be poorly assessed and treated for painthan Caucasians. However, when considering the significant burden and socio-economic costs associatedwith pain, the IOM directed minimalattention to disparities in pain care,especially for chronic pain.In Ethnicity as a Risk Factor forInadequate Emergency DepartmentAnalgesia (JAMA 1993)3, Dr. Todd andother researchers found that in theemergency department (ED), Hispanicswith isolated bone fractures were twiceas likely as non-Hispanic Whites withsimilar fractures to receive no painmedication during their stay. Theresults suggest that ethnicity mightinfluence ED pain management by having an impact on: How patients perceive pain, How comfortable they are admittingtheir level of pain, How their pain intensity is assessed, and A lack of action in ordering the analgesics.Dr. Green explained more research is needed because clinicians are stillnot well educated about how to assessand treat pain. They also dont alwaysunderstand how they, as well as peopleexperiencing pain, may differ in theirattitudes about their pain. Communication Makes a DifferenceBreakdowns in patient-doctor commu-nications may be partially responsiblefor disparities in pain treatment, particularly in the way people preparefor a doctors visit. People in pain and their families can get better care if they prepare for their visit by record-ing pain intensity and any associatedsymptoms, Dr. Green added. People should track their pain overtime, listing variations in intensity andreaction to medications or other treat-ment, thereby providing their doctorswith the necessary information neededto assist them in assessing the pain.| TOP |C O N T I N U E D O N P A G E 5 . . .5This allows doctors to make bettertreatment decisions. On the other hand, researchers found that some cancer patients may not report paincomplaints due to fear their cancer is progressing. They also dont want to belabeled as complainers or distract theirphysicians focus on treating the cancer.According to the article in PainMedicine, Many Hispanics andAfrican Americans report stoicism andthe belief that pain is an inevitablepart of having cancer and must beaccepted [157159]. Hispanic and AfricanAmerican patients are often concernedabout taking opioid analgesics becausethey fear that they will become addict-ed, develop tolerance, or experienceintolerable side effects.We know how important it is for people in pain to be active participantsin their treatment decisions. Thereforeit is interesting to note that peopleparticipated more actively in treatmentdecisions when their physicians were of the same ethnic background [164].Thus, ethnicity-related differences inwillingness to communicate about painmay influence and impact pain care,according to the article.But pain scales and communicationonly work for those who can speak the language or communicate throughother mechanisms. Thus, children, thosewith developmental delays, or thosewho are cognitively impaired, such aspeople with Alzheimers disease, are atrisk for poor assessment and treatment.Dr. Green said, Physicians arent tryingto under treat. They may lack necessarytools. We need more research so we can develop better models of care forall people.Understanding is the First StepSome health professionals are begin-ning to view chronic pain as a diseaseof its own and not just a symptom ofsomething else. Pain should be treatedin an interdisciplinary and multidisci-plinary fashion to manage the physical,emotional, and social impact, Dr. Greenexplained. She added that the ACPA and other pain groups need to encouragefederal and state agencies to fund more research and develop policies to improve care and to ensure equalityin pain treatment. More specifically,pain research receives less than 1% ofNIH-granted research dollars, yet it is afrequent cause of healthcare utilizationand disability, she said.Research leads to new knowledge that can lead to greater awareness and education. Increased awarenessand new attitudes are the first steps to changes in policy and practices. Im a positive person, Dr. Greenadded. It is my belief that raisingawareness is the cornerstone. We need to get the right people involved in supporting the right research and talking about the best policy fixes. The increasing burden of pain is a socio-economic issue, while the unequal burden of pain is a socialinjustice and human rights issue.1 Carmen R. G reen,MD,et al. ; The U nequalBurden of Pai n: Confronti ng Raci al andEthni c D i spari ti es i n Pai n.Pain Medicine,Volume 4,N umber 3,20 0 32 Anderson G F,H ussey PS. Populati on agi ng:A compari son among i ndustri ali zed countri es. H ealth Aff Mi llwood)20 0 0 ; 19: 19120 3.3 Todd K H ,Samaroo N ,H offman JR; Ethni ci ty as a ri sk factor for i nadequateEmergency D epartment Analgesi a.JAMA 1993;269: 15379.4 G reen CR,Baker,TA,N dao-Brumblay; Pati ent atti tude regardi ng healthcare uti li zati on and referral:A descri pti ve compari son i n Afri can- and Caucasi anAmeri cans wi th chroni c pai n.Journal of the National Medical Association 20 04;96 1) : 31-42.5 G reen CR,N dao-Brumblay SK ,West B,Washi ngton T; D i fferences i n prescri pti onopi oi d analgesi c avai labi li ty:Compari ngmi nori ty and whi te pharmaci es acrossMi chi gan.Journal of Pain 20 0 5;6 10 ) : 689-699. People participated more actively in treatment decisionswhen their physicians were of the same ethnic background.| TOP |C O N T I N U E D F R O M P A G E 4 . . .6Is Pain Care Based on Race?Research into Ethnic Disparities in the Emergency DepartmentTreatment of PainEthnic disparities in health care have been described for a number of illnesses andinjuries. There is also a growing bodyof research literature that addressesinequalities in the treatment of pain.The first documentation of ethnic disparities in analgesic prescribingcame from an emergency department(ED) almost 15 years ago. ED clinicalinteractions are often characterized bya lack of patient-physician continuity,diagnostic uncertainty, and significantdemands on time. These featuresincrease the probability that uncon-scious bias may influence a physicianstreatment decisions. A new study, funded by the Agency for HealthcareResearch and Quality, suggests that thequality of pain treatment you receivein the emergency department continuesto depend on the color of your skin.In 1993, our research team publishedthe first report of ethnic disparities inanalgesic treatment, among patientswith extremity fractures seen in theUCLA emergency department. In thatstudy, Hispanics with fractures weretwice as likely as other Whites to receive no analgesic during their ED visit. While only 26 percent of non-Hispanic Whites failed to receiveanalgesics, fully 55 percent of Hispanicswent without pain medication. Wecould not explain these findings basedon any characteristics other than eth-nicity. We thought that language diffi-culties might explain some part of thedisparity in analgesic treatment, buteven after controlling statistically forour patients primary language, thesedifferences could not be explained.Assessments Accurate AcrossEthnic GroupsIn a second study at UCLA publishedin 1994, we tried to determine if therewere differences in the ability of physicians to accurately assess pain inWhites and Hispanics. Our hope wasthat improved pain assessment mightcause disparities in pain managementpractices to lessen or even disappear. In this study, we asked patients with a wide range of extremity injuries(sprains, strains, and fractures) to reportthe intensity of their pain. We askedphysicians to ask the same questions.To our surprise, there was no differencein the ability of physicians to assesspain in Whites and Hispanics.A third study by our group, at EmoryUniversity in Atlanta, found ethnic disparities in pain treatment betweenAfrican-Americans and Whites withextremity fractures that were very simi-lar to those observed in Los Angeles. By this time, a number of organiza-tions, including the American PainSociety and The Joint Commission, had advocated for routine standardizedpain assessments in many clinical settings including the ED. Importantly,in the Emory study, the ED medicalrecords of White and African-Americanpatients contained similar assessmentsof pain intensity. This finding suggestedthat initiatives solely designed toimprove and standardize pain assess-ments were unlikely to help reduceracial and ethnic disparities in anal-gesic practice.A number of other investigators haveassessed the role of patient ethnicity in pain treatment. Ethnic disparitieshave been found in a wide range ofclinical settings, including nursinghomes, cancer treatment centers, and post-operative hospital wards.Although there are exceptions, moststudies have found evidence for disparities in pain treatment andnational healthcare databases havetended to support their presence.Opioid Prescriptions Show BiasIn a recently published study fromUCSF, Dr. Mark Pletcher examined data from the National HospitalAmbulatory Medical Care Survey(NHAMCS), a national survey administered by the U.S. Census Bureau to assess the provision of ambulatory care at U.S. hospitals. In this study, Dr. Pletcher and his colleagues examined ED data collectedfrom 1993 to 2005. They determined that by Knox H. Todd, MD, MPH| TOP |C O N T I N U E D O N P A G E 7 . . .7pain monitoring and treatment in theED had improved markedly over this 13-year period. The use of opioids forED patients with pain increased from23 percent in 1993 to 37 percent in 2005.However, even though emergency physi-cians were prescribing analgesics moreaggressively, the gap between White andnon-White patients pain treatment hadnot changed. While 23 percent of Blacksand 24 percent of Hispanics presentingto the ED with pain received an opioidmedication, fully 31 percent of Whiteswere treated with opioids. Differentialprescribing by ethnicity was observedfor all types of pain visits and wasmore pronounced with increasing painseverity. In commenting on his study, Dr. Pletcher suggested that although emergency physicians unconscious ethnic bias might explain these results,many other factors could contribute to disparities in health care. His studydid not attempt to determine a causeof the observed disparity.Eliminating Ethnic DisparitiesA number of measures may help usmove forward toward eliminating ethnic disparities in pain treatment.Evidence-based guidelines and performance measures are promisinginterventions that should promote con-sistency in pain care. Quality assuranceand improvement activities conductedat the institutional level should usepatient ethnic identifiers to identifyethnic disparities when they exist.Simply supplying this feedback toheath care providers may be an effective intervention. At the regional and national levels,health plans should incorporate ethnicidentifiers to determine whether painmanagement disparities exist. The definition of quality ED care shouldinclude the absence of such disparities.If these conditions are not met,providers should receive notice fromthird-party purchasers. Ultimately,third-party payers (i.e., all of us) shoulddemand that our costly premiums buyus top quality medical care that is freefrom disparities and offer to pay less if we receive unequal care.I believe that emergency medicine is an inherently egalitarian specialty, in which we strive to treat all peopleequally. Our profession should be guided by principles of distributive justice, and provide high quality servic-es to all. One of our specialtys mostimportant roles within the U.S. healthcare system is to promote fairness andequal access to quality medical care.The provision of superior ED analgesia,as well as the elimination of analgesia-related health disparities in our depart-ments, should be a fundamental goal of emergency medicine practice.Knox H. Todd, MD, MPH is director of thePain and Emergency Medicine Institute atBeth Israel Medical Center in New York. He serves on the Board of Directors of the ACPA.References:1 Todd K H ,Lee A,H offman JR. The effect ofethni ci ty on assessment of pai n severi ty i npati ents wi th i solated extremi ty trauma.JAMA 1994; 271 12) : 925-928.2 Todd K H ,Samaroo N ,H offman JR. Ethni ci ty as a ri sk factor for i nadequateemergency department analgesi a. JAMA1993; 269 12) : 1537-1539.3 Todd K H ,D eaton C,D Adamo AP,G oe L. Ethni ci ty and analgesi c practi ce. Annals ofEmergency Medicine 20 0 0 ;35: 11-16.4 Pletcher MJ,K ertesz SG ,K ohn MA,G onzales R. Trends i n opi oi d prescri bi ng byrace/ethni ci ty for pati ents seeki ng care i nU . S. emergency departments. JAMA 20 0 8;299 1) : 70 -78.The elimination of analgesia-related health disparitiesshould be a fundamental goal of emergency medicine practice.| TOP |C O N T I N U E D F R O M P A G E 6 . . .8An Overview of Spinal Cord Stimulationby David Provenzano, MDSpinal cord stimulation (SCS)involves the delivery of pulsedelectric signals near the spinalcord to reduce and control pain forcertain medical conditions. It was originally described by Shealy* in 1967. Since its introduction, majorimprovements and discoveries havehelped us understand how SCS works,for which conditions it is beneficial,and the optimal equipment design. Technique and Mechanism of ActionUnfortunately, the effective treatment of chronic pain cannot always beachieved with conventional and non-invasive pain treatments. SCS may be considered when medical management, surgical intervention, and physical therapy have not beeneffective in relieving pain. Two stages are involved in SCS. In botha physician, guided by an x-ray, placesa lead into the epidural space locatedwithin the bony spinal canal. The firststage is the trial phase which providesinformation to predict the success ofpermanent implantation.During the trial phase, one or twoleads are placed via an epidural needle in the appropriate position. This is an outpatient procedure under light sedation. Once the lead is in position, it is tested to see if the patient's painful area is coveredwith a tingling sensation (paresthesia).It is important that the patient is alert during the insertion and testing of the lead so they can inform thehealth care provider if the lead is in the appropriate position.The lead is programmed with a com-puter. The patient then goes home forthree to five days. He or she has an external power source and remote control that allows him or her to control the amount of stimulationbeing received. During the trial thepatient determines if the treatment ishelpful in relieving pain and improv-ing function. At the end of the trial, the patient returns to the physicians office to discuss the results and havethe lead removed.Together, the health care provider andthe patient decide whether or not toadvance to permanent implantation. In this stage the lead is again placedand implanted underneath the skinwith a power source the size of a pace-maker battery. Rechargeable batteriescan extend the life of the battery, givingthe patient up to nine years before areplacement battery must be surgicallyplaced. The SCS recipient goes homewith a remote-control and batterycharger, limiting activity for about 12 weeks to allow for healing.Medical researchers are still investigating how SCS controls painand are considering multiple theories.One is the gate control theory, whichwas the originally proposed mechanismof action of SCS. This theory states that by providing a pleasant vibratory andtouch sensation via the SCS system,pain signals that reach the brain are decreased. Recently, we have discovered that spinal cord stimulationmodifies the chemical makeup of thespinal cord.Its Not for EveryoneSome people respond better to SCSthan others, which is why selecting the right individuals is so important.Prior to SCS treatment, patients shouldhave tried more conservative therapiesand have undergone psychologicalscreening to make sure that underlyingpsychological conditions have beenaddressed and effectively treated.Furthermore, it is important for thepatient and health care provider tohave realistic expectations regardingtreatment, with the goal being painreduction and control rather than complete elimination.Currently, conditions that can respondfavorably to SCS treatment include: Failed back surgery syndrome Complex regional pain syndrome (previously known as RSD andcausalgia) It is important for people with SCS toinvolve themselves in a multidisciplinarytreatment plan if they are to get the best results.... SCS treatment can be animportant tool in a treatment plan andsignificantly reduce pain and associatedlimitations.| TOP |C O N T I N U E D O N P A G E 9 . . .9 Peripheral neuropathic pain Peripheral vascular disease** Ischemic heart disease** SCS has been proven to be effective formany of these conditions with lastingresults in terms of pain relief, painmedication reduction, and improve-ment in quality-of-life indices and satisfaction scores. For example, approximately 10 to 40percent of people in United States thathave had previous surgery for backpain continue to have significant pain.Compared to another operation for persisting back and extremity pain, SCS is often more clinically effectiveand more cost effective. Although there are significant upfrontcosts for SCS, the treatment oftenreduces costs in the long run secondaryto its efficacy and reduction in healthcare services used by patients with SCS. A significant advantage of a SCSsystem is that it is a reversible andnondestructive treatment option.It can also be effective for inoperableperipheral vascular disease (PVD).In the United States more than eightmillion people are affected by PVD. In some of these individuals, SCS mayimprove microcirculation (i.e. bloodflow), reduce pain, increase walking distance, and promote ulcer healing.However, one must remember that PVD is often a progressive disease.Associated Risks andComplicationsAs with other implantable devices, SCShas associated risks and complications.With improvement in technology andimplanting techniques, the risks haveoften been reduced. Some of the com-plications associated with SCS includesubcutaneous hematoma (collection of blood and fluids), headache, nerveinjury, infection (typically requiringremoval of the system), lead migrationwith loss of coverage, and hardwarefailure. People with SCS implants cannot have MRI studies, althoughcomputed tomography and x-rays can be performed. The Beginning of a Long-TermRelationshipEffectively treating pain by implantingan SCS system requires a responsive,long-term relationship between the person with pain and his or her health care provider. Occasional re-programming will be needed to optimize coverage of the painful area.As with most treatments for chronicpain, it is important for people withSCS to involve themselves in a multi-disciplinary treatment plan if they areto get the best results. In appropriatelyselected individuals, SCS treatment canbe an important tool in a treatmentplan and significantly reduce pain and associated limitations.David Provenzano, MD, is Medical Directorof the Pain Treatment Center, at Ohio Valley General Hospital in Pittsburgh, Pa.He is on the ACPA board of directors.*Shealy CN ,Morti mer JT,Reswi ck,JB 1967) .Electri cal I nhi bi ti on of pai n by sti mulati on of the dorsal columns:Preli mi nary Cli ni cal Report.AnesthAnalg 46: 489-91. * *N ot FD A-approved i ndi cati ons| TOP |C O N T I N U E D F R O M P A G E 8 . . .10Who We Are Affects How We Respond to Pain In this issue of The Chronicleweve reported on researchers who are exploring how race, gender,and other traits influence how paintreatment is delivered. We know thatindividuals vary in the way they perceive, track, and report their pain to a physician. These studies show that physicians in various settings alsorespond differently to people, based on their ethnicity and other factors.Here are some of the many factors thatmight influence how people managetheir pain and communicate with thehealth care providers. Language: How do people in pain describe pain in their native tongue?How well can their healthcareproviders understand them? How do we account for words that meandifferent things to different cultures? Education: Can they research new treatments and carefully documenttheir pain? Literacy: Can they read directions and medication instructions? Culture: What does an ethnic group believe about illness and pain? Gender: Are a mans complaints treated differently than a womans? Ethnicity/Race: Do people relate better to a medical professional of the same race? Religion/Spirituality: Who do people believe has the power to heal them? Geography: Do they live close to pain centers, pharmacies, and physicians? Economic Status: Are they insured? Can they afford care givers to help at home? Status: Are they unemployed, in jail, under psychiatric care, in a nursinghome? Age: How well is the pain of children or the elderly understood? Disability: Are there mental or physical challenges or sensory disabilities that make it hard toassess pain? Illness: Do pre-existing conditions mask new causes of pain?Disparities in pain care exist, but whois responsible, the health care providersor the person with pain? In fact,responsibility is shared by both. Providers must be aware of their ownbias when treating people with pain.But disparities also can happen if aperson with pain is not literate in thelanguage of health care, able to readand act on medical instructions, andother health information. Unfortunately, more than half of theU.S. population lack these very skills,skills that often lead to longer andimproved quality of life. Disparities Found in Treating Cancer Pain The Intercultural Cancer Council sharesinformation about how disparities inhealth care affect those with cancerpain in their brochure, Pain andCancer. It discusses disparities in clinical assessment and patient/provider communications, includingthese findings about how different ethnic groups react to pain. Religion and faith are important ways in which Hispanic patientscope with cancer and pain. African-Americans with chronic illness use more pain coping techniques that employ distraction, praying, or hoping, while Whites use more pain techniques thatinvolve ignoring pain. Attitudes and cultural beliefs about coping with pain may explain whyAsian patients are less likely torequest an opioid or cease its useprematurely even when there is some pain relief. Patients who are less educated or who have lower incomes are significantly more likely to holdbeliefs that may be barriers to effective pain management.Understanding these issues is the firststep to education and advocacy, so thatagencies and government can developpositions to curtail disparities andencourage equal treatment.Use these online resources to learn more:National Institute of Health, Clear Communicationshttp://www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htm Healthy People 2010http://www.healthypeople.govHealth Exchangehttp://www.health-exchange.net(for health care providers)Intercultural Cancer Council, 713-798-4617, info@iccnetwork.org orhttp://iccnetwork.org. | TOP |11Partners Against PainWebsitePurdue Pharma L.P. has redesigned its Partners Against Painwebsite atwww.partnersagainstpain.com.Information for people with pain, caregivers, and healthcare providers on pain assessment, documentation, advocacy,pain education, integrative medicine, and other resources are noweasier to find. PartnersAgainst Painworks toalleviate unnecessarysuffering by leadingefforts to advancestandards of paincare though educa-tion and advocacy.Board Member Named to Professorship Steven D. Feinberg, MD, medical editor of The Chronicle, has been named anAdjunct Clinical Professor, StanfordUniversity School of Medicine. Stanford,California. Dr. Feinberg serves on the Board of Directors of the ACPA and is our Medical Advisor.AgrAbility Helps Agricultural WorkersGrowing Well with Pain is a program thatencourages people in rural communities to actively manage their pain. It will be presented by the American Chronic PainAssociation and the AgrAbility project in 12 states.We received funding for eight presenta-tions but we are doing 12 because the need is so great, said Penney Cowan,Executive Director, ACPA. The focus of this educational campaign will be unique. It will build awareness of chronic painamong agricultural workersmost of whomdo not have any health care insurance.Working within rural communities, ACPAhopes to provide these workers with thecoping skills they need to allow them tobegin to take an active role in managingtheir pain, improve the quality of theirlives, and reduce their sense of suffering.The events will be held in conjunction with the state AgrAbility projects in Utah,Wyoming, Kansas, Maryland, West Virginia,Pennsylvania, Colorado, Mississippi,Missouri, Virginia, Idaho, and Michigan.We will work to empower people withchronic pain and their caregivers and families, giving them information,resources, and tools to help them managetheir pain, said Cowan. The campaign isalso designed to foster productive dialoguebetween people with chronic pain and their health care providers to facilitate better diagnosis and treatment.For more information on AgrAbility go to:http://www.agrabilityproject.org/.ACPA UpdateNew ACPA GroupsWelcome to our newgroups and facilitators.Robin ArenaWest Palm Beach, FLJannie WhiteWest Detroit, MI Rosalind BallardSterling Heights, MIFelisha StarkeySaint Louis, MO Edwin W. KitzesLas Cruces, NM Jan McNamaraCleveland, OhioCarolyn RainsYakima, WA| TOP |12Book ReviewsYouve Gotta Fight Back! Winning with Serious Illness,Injury, or Disability by Dirk Chase Eldredge Reviewed by Samantha Nagy, ACPA Michigan Regional Director This book was based on the life-threatening illnesses that have struckcertain people and the people whotook care of them. The author sharesmany stories of people with cancer,spinal cord injuries, and ALS, etc. Someof these people survive and some dont,which I found very depressing. It doesnot discuss the problems of peoplewith Fibromyalgia, back problems, or migraines.I feel that this book would be moreuseful for a person with cancer oranother life-threatening illness andtheir family members, than someonewith, say Fibromyalgia or lower backpain (something that is not life threatening). In the last chapter, the author writesabout his sons battle with alcoholismand speaks a lot about AA meetingsnot what I consider to be appropriatein a book about chronic pain. However,the author shared a few interestingwebsites and sprinkled a very few tipshere and there about how to deal withchronic pain. The book does not provide any copingskills or exercises, so I walked awayfrom it none the wiser, only depressedby the stories of peoples deaths (whichI felt was very inappropriate in a bookabout fighting back.)Youve Gotta Fight Back! Winning withSerious Illness, Injury, or Disability, by Dirk Chase Eldredge, $16.46, LovingHealing Press; paperback: 288 pages,ISBN-10: 1932690344http://booksbydirk.com/Live Well with Chronic Pain: A Journey of DiscoveryBy Liza H. Leal, M.D. Reviewed by Evelyn Cooper This book followed my line of thinkingas it promotes a way of living withpain that does not rely primarily ondrugs. The way it is written, mostly as a conversation, made it easy for me to read and understand. I would recommend this book to someone with chronic pain. Here are a few quotes that illustrate the authorspoint of view: The only real disabilitypeople have is a negative attitude.Show me a person, young, old, or in-between, who is inactive and without goals, and I will show yousomeone who is unhappy.I learned new and useful things fromthis book. It helped me see the need to do more to manage my pain.Live Well With Chronic Pain: A Journey of Discovery (Paperback) by Liza H. Leal M.D. Available for $12.95 through http://www.amazon.com/.Mayo Clinic Guide to Pain ReliefEditors: B. Bruce and W. M. Hooten Review by Patrick Goertz RN, MSN,CNS, Facilitator, Wichita Chapter This book is the best primary resource I have seen for explaining the manyaspects of living with chronic pain. Itpresents complex concepts in easy-to-understand language. It explains thephysical, financial, and social effectsthat chronic pain has on individualsand their families. More importantly, it offers hope.It provides useful techniques that people can use to lessen and begin to control their pain. The Mayo Clinicsmulti-disciplinary pain treatment teamoffers this book as a tool that peoplewith chronic pain can use to regaintheir lives. I am a clinical nurse specialist and Ilive with chronic post-stroke centralnerve pain. I highly recommend thisbook from both these perspectives. As a nurse I could use this book as a primary resource to teach peopleabout the medical aspects of the causes, diagnostic procedures, and treatments for chronic pain.I wish this book had been availablewhen I began dealing with my ownsymptoms. It would have helped medeal with the overwhelming fears and frustrations that come with thediagnosis of chronic pain.This book would make an excellent primary text for use in any pain treatment program. It would take the person with pain and family members step-by-step from diagnosis to learning to live with chronic pain. | TOP |C O N T I N U E D O N P A G E 1 3 . . .13| TOP |In addition physicians and healthcareproviders in other disciplines could useit to help explain pain related conceptsto their patients.I also appreciated the list of organiza-tions that provide more informationabout chronic pain and associated conditions.Mayo Clinic Guide to Pain Relief, How to Manage, Reduce and Control ChronicPain, B. Bruce and W. M. Hooten, $29.95 from the Mayo Clinic bookstore. http://bookstore.mayoclinic.comThe Chronicle is published quarterly by the AmericanChronic Pain Association.We welcome essays, poetry, articles, and book reviews written by people with chronicpain or their families.Please send inquiries to:The ACPAP. O. Box 850Rocklin,CA 95677Executi veDi rector:Penney Cowa nPresi dent,BoardofDi rectors:Nicole KellyMedicalEditor:Steven Feinberg, M.D.CopyEditor:Alison ConteSpecialFeatures:Sally Price Use an evidence-based medicine model that would integrate clinicalexpertise, patient values, and thebest evidence into the decision-making process of patient care. Push for clinical trials that include a cross section of people from allages, races, genders, and health status. This would establish a greater understanding of the waymedications work on all peoplerather than a select few. Work to improve the health literacy of every consumer/patient so he or she can share in health care decisions. Involve consumers in developing culturally appropriate training mate-rials, media, and educational toolsfor a range of diverse audiences. Practice preventive medicine: treat acute pain and diagnose its symp-toms before it becomes chronic. Consider multiple health issues, treatment goals, and preferenceswhen deciding which treatment is appropriate.Confronting Disparities C O N T I N U E D F R O M P A G E 1 . . . Provide consumers information that clearly explainsin terms they canunderstandthe choices and costs ofall treatments. The chance to makean informed decision about healthcare can have a positive impact on apersons attitude about the possibleoutcome of an illness or disease.Perhaps addressing the issues of disparities in care is like living withpain: you must start out by taking thefirst step and remain focused on yourgoal. We need to start somewhere if weare to improve health care for everyoneand provide the right medicine at theright time for the right person.One of our basic rights is to be treatedwith dignity and respect. Lets hopethose who practice medicine will keepthis in mind. Ensure that every person seekingcare is treated equallyTake A BreakWe know tension increases pain. When you need a time out from the stress of your day, visitwww.theacpa.org and try our new five-minute relaxation exercise. Like the longer relaxation CDs, thisquick de-stresser takes you through a progressive relaxation process aimed at helping you let go of the tension that can build in muscles in the course of the day. Just follow the link on the home page and enjoy!C O N T I N U E D F R O M P A G E 1 2 . . .14Thank You!Special thanks to these corporate sponsors:K I N G PH ARMACEU TI CALS as an Ambassador level corporate sponsorALPH ARMA I N C. as an Educator level corporate sponsorTH E MED TRO N I C FO U N D ATI O Nfor a Patient Link Leadership Development Award that was awarded to support a retreat for ACPA Regional DirectorsABBO TT LABO RATO RI ESin support of the ACPA Medication Supplement DVD/Web Project EN D OPH ARMACEU TI CALSin support of the ACPA Medication Supplement DVD/Web ProjectPFI ZERin support of the ACPA Medication Supplement DVD/Web ProjectRO CH E PH ARMACEU TI CALSin support of the ACPA Medication Supplement DVD/Web ProjectPFI ZER for the Fibromyalgia campaign TH E MED TRO N I C FO U N D ATI O N in support of the AgrAbility project| TOP |The ACPA appreciates the support of the corporate donors who share our valuesand make our work possible by underwriting key outreach projects. The ACPA is a peer support organization: we help each other learn to live fully in spite of chronic pain.Your membership, donations, and purchase of materials keep the ACPA alive and reaching out to even more people with pain.