Study Discusses Overlap of Opioid Therapy for Physical and Social Pain Relief Interview with:
Mark Sullivan, MD, PhD
Professor, Psychiatry and Behavioral Sciences
Adjunct Professor, Anesthesiology and Pain Medicine, Bioethics and Humanities
Medical Co-Director, UW Telepain

Dr. Sullivan

University of Washington
Seattle, WA 98195  What is the background for this study?  What are the main findings?

Response: This is a review paper than synthesizes neuroscience, pharmacological and epidemiological research on the opioid epidemic. It has been known since at least the 1970s that opioids treat not only pain due to physical damage, but also separation distress.

Functional neuroimaging (fMRI) studies have shown that physical pain (tissue injury) and social pain (social rejection) activate the same limbic brain centers (insula, cingulate cortex). Both chronic pain and depression are associated with dysfunction of the endogenous opioid system in the human brain. Studies of opioid prescribing have shown that patients with chronic pain, who also have anxiety and depressive disorders are more likely to be prescribed long-term opioid therapy at high doses and with concurrent sedatives.

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Challenges in Providing Osteoarthritis Pain Relief Interview with:
Rebecca L Robinson
Patient Outcomes and Real-World Evidence
Eli Lilly and Company, Indianapolis, IN  What is the background for this study?

Response: Osteoarthritis (OA) pain is unfortunately common and greatly affects patients’ quality of life. Treatment varies from patient to patient and can include nonpharmacologic therapies, over-the-counter (OTC) and prescription pain medications, as well as surgery. The combination of these treatment modalities and especially the use of acetaminophen, NSAIDs or opioids in OA patients has not been examined thoroughly. This study helps to address this gap while also demonstrating variations in treatment received by patients with different levels of pain severity. We analyzed data from the United States OA Adelphi Disease Specific Programme (DSP), which links patient and physician perspectives on the management of OA via cross-sectional surveys.

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Mindfulness-Based Stress Reduction for Chronic Pain in Breast Cancer Patients Interview with:
Andra Smith, Ph.D.
Full Professor, School of Psychology
University of Ottawa, Ottawa, ON

Andra Smith, Ph.D. Full Professor, School of Psychology University of Ottawa, Ottawa, ON
Dr. Smith  What is the background for this study?
Response: The process of going through breast cancer treatment is challenging enough on its own and can continue to impact cancer survivors long after treatment ends. One of the common side effects of breast cancer treatment is the development of chronic neuropathic pain (CNP), which for many women is debilitating and difficult to manage. Medications are not always effective and quality of life, cognitive abilities, and overall well-being can be reduced due to this pain. Knowing personally and from previous research how effective mindfulness can be for well-being, it made sense to introduce a mindfulness-based stress reduction program (MBSR) to these women going through chronic neuropathic pain due to breast cancer treatment. Mindfulness has occasionally been dismissed as a ‘fad’ so it was important to investigate the impact of an MBSR program with objective measures that could provide empirical evidence of its effects within this population. Dr. Poulin had the clinical resources and participants for the study while Dr. Smith had the imaging expertise. Together we performed a brain imaging (MRI/fMRI) study with women more than a year following treatment for breast cancer, suffering from chronic neuropathic pain. We scanned them all before and after either an MBSR program or usual care, assessing brain health, resting-state brain activity, and neurophysiological responses to emotional/pain-related words (Emotional Stroop task).    

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Withdrawal Symptoms Common in People Using Cannabis for Pain Relief Interview with:
Lara Coughlin, Ph.D.
Assistant Professor | Addiction Center
Department of Psychiatry
University of Michigan  What is the background for this study?  What are the main findings?

Response: In this study we followed people that were seeking certification for medical cannabis use for chronic pain over the course of two years. We assessed the prevalence and progression of cannabis withdrawal.

We found that most people experienced multiple withdrawal symptoms, such as craving cannabis, anxiety, and irritability, when they went without cannabis. People that used cannabis more frequently, used larger amounts, and reported smoking cannabis had more withdrawal symptoms. Over time, people that were younger were more likely to experience increasing withdrawal symptoms and people that vaped cannabis tended not to experience improvement in their withdrawal symptoms.  

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Chiropractic Manual Therapy for Chronic Low Back Pain Relief Interview with:
Kylie Isenburg
Athinoula A. Martinos Center for Biomedical Imaging
Massachusetts General Hospital, Boston, MA  What is the background for this study?  What are the main findings?

Response: Chronic low back pain (cLBP) is the leading cause for disability worldwide, with a lack of efficacious non-pharmacological treatments. Back pain doesn’t just effect the back. Recent investigations using brain imaging have shown changes in brain structure and function in cLBP patients. Therefore, there is a growing interest in how different non-pharmacological therapies might impact cLBP by studying alterations in brain function that follow such therapies.

For our project, we assessed resting brain connectivity for a specific set of regions known as the Salience Network, a network involved in detection of salient information that arises from continuous sensory input. We assessed Salience network connectivity pre- and post- a single session of Manual Therapy (MT), a chiropractic manipulation technique used to treat a range of musculoskeletal disorders. We found that manual therapy reduced clinical low back pain intensity after a single-session. Additionally, assessment of two different grades of MT; Spinal Manipulation and Spinal Mobilization, suggested that Manipulation increases connectivity of the Salience Network to the Primary Motor Cortex and the Thalamus. Furthermore, the reduction in low back pain post-MT was associated with increased Salience connectivity to the lateral Prefrontal Cortex. These findings suggest modulation of sensorimotor, affective, and cognitive regions of the brain via Manual Therapy may play an important role in reducing Chronic low back pain. What should readers take away from your report?

Response: Our report suggests that non-pharmacological therapies, specifically Manual Therapy, can be successful in reducing chronic low back pain intensity. It also suggests that brain changes following Manual Therapy are important, and specifically that changes in Salience network connectivity to brain regions important for processing sensory, affective, and cognitive information might underly this reduction in low back pain.

Altogether this work promotes increased investigation into brain-based mechanisms by which Manual Therapy can reduce chronic low back pain. What recommendations do you have for future research as a result of this work?

Response: Following this study, we have a better idea of what a single manual therapy session can accomplish, but assessment of the long-term effects of a series of MT sessions will be useful in allowing for a better understanding of its efficacy in treating low back pain. Additionally, clinical trials assessing manual therapy against other treatment modalities can allow for direct comparisons against the current standard of care approaches. 


Kylie Isenburg, Ishtiaq Mawla, Marco L. Loggia, Dan-Mikael Ellingsen, Ekaterina Protsenko, Matthew H. Kowalski, David Swensen, Deanna O’Dwyer-Swensen, Robert R. Edwards, Vitaly Napadow, Norman Kettner,

Increased salience network connectivity following manual therapy is associated with reduced pain in chronic low back pain patients,
The Journal of Pain, 202

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Why is Exercise Prescribed for Low Back Pain Relief? Interview with:
Matthew Jones PhD, AEP

Department of Exercise Physiology, Faculty of Medicine

Dr. Jones  What is the background for this review?

Response: Bck pain is the leading cause of disability worldwide and is associated with significant individual and societal costs. Low back pain can significantly impact an individual’s ability to carry out day to day tasks. Clinical guidelines consistently recommend that people with low back pain take exercise, and there does not appear to be a type of exercise (e.g., walking, Pilates, lifting weights) that is better than another for reducing pain and improving function. Despite hundreds of studies of exercise in people with low back pain, researchers do not have a good idea of how it works. This is important, because if we know how something works, we can design more effective interventions to reduce the burden of low back pain. The aim of this review was to summarise why researchers think exercise helps people with chronic low back pain (i.e., pain persisting for longer than 3 months).

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Understanding Back Pain During Neuroendovascular Procedures Interview with:

Adnan Qureshi, MD
Zeenat Qureshi Stroke Institute
Department of Neurology
University of Missouri
Columbia, MO

Dr. Qureshi What is the background for this study? What are the main findings?

ResponseOptimizing of patient experience is a very important goal for any procedure. Neuro Endovascular procedures are unique because most of them are performed awake to perform repeated neurological examinations during the procedure. The angiographic tables have to be made of unique stiff material to ensure X rays can pass through and any movement during procedure can distort images. We believe understanding the factors that can be improved upon given the unique settings remains an important goal of the specialty. 

Our research broadens our understanding of complications of the procedures. Previous studies have look at the risk of stroke or bleeding but not complications like back pain which are far more common.

Motion Control Shoes May Reduce Painful Injuries in Some Pronation-Prone Runners Interview with:
Laurent Malisoux, PhD
Group Leader, Public Health Research
Department of Population Health
Luxembourg Institute of Health  What is the background for this study?

Response: Pronation refers to the way the foot rolls inward during the gait cycle. Foot pronation during running is normal, but over-pronation (increased amount or poor timing) has previously been related to the risk of running-related injury. Indeed, alterations in the movements at the foot-ankle complex results in abnormal repetitive load, and may subsequently lead to an injury at the foot-ankle complex or more proximally in the kinetic chain. A previous trial demonstrated that motion control shoes reduced the risk of injury in recreational runners.1

Importantly, in the previous trial, the effect of motion control shoe was investigated on all injury types concurrently. However, risk factors as well as mechanisms underlying the development of injury might differ across injury types. Thus, motion control shoes may only be effective in preventing some injury types, and the effect might be partially masked if it is assessed on different injury types concurrently.

The present study is a secondary analysis of the abovementioned trial. Based on previous literature, we assumed that some injury types, namely Achilles tendinopathy, plantar fasciopathy, exercise-related lower leg pain and anterior knee pain, were related to over-pronation and were defined as pronation-related running injuries, while other running-related injuries are not. We hypothesised that motion control shoes aiming at reducing excessive pronation would reduce the risk of pronation-related running injuries in recreational runners compared to shoes with no motion control technology.

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Recorded Music plus Text During Anesthesia Reduced Need for Pain Medication Interview with:
Prof. Dr. Ernil Hansen
Department of Anesthesiology
University Hospital Regensburg
Regensburg, Germany

Prof. Dr. Hansen What is the background for this study? What are the main findings?

Response: It is becoming more and more clear that besides drugs and surgery it is communication that makes therapy effective. A meta-analysis we had conducted recently, suggested some beneficial effects of taped words played during surgery in older studies.

Our current study on 385 patients showed evidence that a text based on hypnotherapeutic principles an reduce postoperative pain and use of opioids. Pain within the first 24h after surgery decreased by 25%, opioid requirement by 34%. Six patients needed to be treated to save one patient from opioid exposure at all. High demand for analgesics was reduced by 41%. 

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5-Year Follow-Up of Open-Label Placebo Trial for Chronic Low Back Pain Relief Interview with:
Claudia Carvalho, PhD
Instituto Universitário de Ciências Psicológicas
Social e da Vida
Lisbon, Portugal What is the background for this study? What are the main findings?

Response:  Some clinical trials on chronic pain have shown placebo responses that rival those of commonly prescribed first-line therapies for low back pain (LBP).  However, prescribing placebos would pose ethical problems in clinical practice.  One solution to this problem is the use of open label placebos (OLP), which are presented to patients openly as pills without active ingredients, along with a rationale indicating that because of classical conditioning of relief with active medications, the pills themselves might reduce pain. OLP has been shown effective compared to treatment-as-usual for a number of clinical conditions, including chronic LBP.  Having conducted the first clinical trial on OLP on back pain, my colleagues and I wondered whether the effects were long-lasting. To answer that question, we conducted a five-year follow-up on the patients who had received OLP for their back pain.

In our original study, patients who took OLP pills for three weeks experienced greater reduction in back pain intensity and in back pain related disability than patients that simply continued their usual treatment. Additionally, after this phase of the trial, we offered OLP to participants  in the treatment as usual group) and they also reported a significant reductions in pain and disability, together with a spontaneous decrease in the use of pain medication by participants.

In our current follow-up, we found that patients who had taken OLP for three weeks had maintained their reductions in pain and disability 5 years later. In addition, pain medication usage was reduced by 49%. This follow-up study is currently in press (