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We identify which types of Social Security reforms are supported when people vote in their financial self-interest, under alternative economic and demographic projections and voting proclivity assumptions. While 40% of voters have negative lifetime net transfers, less than 10% have negative future transfers under the un- sustainable status quo. Framing the problem as a choice between reforms is necessary for any to receive majority support. Delayed reforms are often preferred, but immediate tax hikes or slower benefit growth win in some circumstances. Inter-generational AND intragenerational heterogeneity of economic interests combine to affect which reforms are blocked and which are feasible.

Treatment of back pain due to facet joint syndrome has been a challenge for physicians since its recognition ∼80 years ago. Intra-articular injections of steroids, local anesthetics, and phenol have been widely adopted despite their known shortcomings. Recently, intra-articular injection of amniotic membrane-umbilical cord (AMUC) has been utilized in various orthopedic indications, including those involving synovial joints, due to its reported anti-inflammatory properties. Herein, use of AMUC for facet joint syndrome was evaluated. A single-center case series was conducted on patients presenting with pain caused by facet joint syndrome, confirmed by single blocking anesthetic injection and treated using a single intra-articular injection of 50 mg particulate AMUC (CLARIX FLO) suspended in preservative-free saline. Patient reported back pain severity (numerical scale 0–10) and opioid use were compared between baseline and 6 months following treatment. A total of 9 patients (7 males, 2 females), average age 52.1 ± 15.9 years, were included. Five patients with cervical pain had a history of trauma, 1 patient had suffered lumbar facet injury and 3 had degenerative lumbar facet osteoarthritis. All patients had severe pain prior to injection (8.2 ± 0.8) and 4 (44%) were taking opioids (>100 morphine milligram equivalents). Six-month post-treatment, average pain had decreased to 0.4 ± 0.7 (P

Objective. Several prominent guidelines recommend that patients on long-term opioid therapy have periodic urine drug monitoring (UDM) for appropriate use; however, none address the specific questions of which patients to test, which substances to test for, how often to test, and how to act on the results. Design. In the absence of adequate scientific evidence in the literature, a panel of experts in the field of pain and addiction medicine was convened to develop consensus UDM recommendations. The panel met three times between March 2010 and April 2011, and reviewed several drafts of the recommendations document between meetings. Results. The group was able to achieve consensus on a set of UDM recommendations addressing test selection, test frequency, interpretation of results, and how to handle discrepancies based on specific results. Conclusion. While the participating panel members recognize that there currently is a limited evidence base to support the expert panel's recommendations, primary care providers and pain specialists are largely acting today based on anecdote, intuition, and individual experience. The recommendations are meant to begin to provide a framework for standardizing practices for UDM in the treatment of chronic pain, and to serve as a catalyst to advance research that quantifies the effects of UDM on opioid therapy management and patient outcomes.

Objective: Completely compliant drug-taking behavior is associated with opioid therapy that is usually highly beneficial to the pain patient, whereas frequent and severe aberrant behavior is generally associated with therapy that is potentially harmful to the patient and borders on addiction. There is a large group of patients in the middle between these two extremes: those who display aberrant behaviors periodically, who may additionally have a mixed response to opioid therapy, the overall results of which are less than satisfying (often in the domain of functionality) to the clinician. We have used the term chemical coping to describe this vast middle ground and seek to begin a line of research starting with the development of a clinically useful tool to identify this subset of patients.Methods: A background review is provided to highlight the need for better understanding of chemical coping. In addition, the first steps in creating a chemical coping tool are discussed, including the results of focus group interviews to determine the clarity, understandability of the items, and to assure that they are not objectionable or offensive. A total of 15 patients and 15 professionals completed this phase of the project.Results: Both the professionals and patients reported that the items were generally clear and understandable. In addition, although the items cover potentially sensitive topics and some were designed with a provocative edge, the respondents had few requested changes. The researchers are moving forward with the next phase of research.Significance of results: The middle ground between compliant medication use and addiction, which we call chemical coping, is poorly understood and woefully underresearched. Despite this gap in our knowledge base, it is an often observed phenomenon. Creating a tool to identify these characteristics can lead to better treatment outcomes and earlier interventions to help improve compliance with medication regimens.

Objective: We sought to assess the prevalence and characteristics of breakthrough pain (BTP) in patients with chronic back pain.Design; Researchers utilized a telephone survey using a pain assessment algorithm. This report represents a subset of patients from a larger survey of228patients with chronic pain unrelated to cancer.Participants: This study employed 117subjects taking opioids for a primary diagnosis of back pain and receiving care at geographically dispersed pain treatment centers. Subjects had pain lasting at least six months and had “controlled” baseline pain.Results: Eighty-seven subjects (74 percent) experienced 93 types of BTP. The median number of BTP episodes per day was two; median time to maximum intensity was 10 minutes, and median duration was 55 minutes. Onset could not be predicted for 46 percent of pains. Eighty-three percent of subjects used shorter-acting opioids for BTP. Other medications used for pain included NSAIDs, antidepressants, anticonvulsants, skeletal muscle relaxants, intrathecal local anesthetics, and transdermal local anesthetics.Conclusions: These patients with opioid-treated chronic back pain commonly experienced BTP, which often had a rapid onset and a relatively short duration and was difficult to predict. Opioids were the mainstay of pharmacologic therapy, but nonopioid analgesics and adjuvant analgesics were commonly used.

Objective: This report aims to describe the prevalence and characteristics of breakthrough pain in patients with neuropathic pain.Methods: The study represents data from a subset of patients from a larger survey of 228 patients with chronic noncancer pain. Patients were identified from nine pain programs and were administered a telephone questionnaire. The study population comprised 45 chronic noncancer pain patients with primary neuropathic pain diagnoses who were being treated with opioids.Results: Pain had been present for a median of six years. Medications used for pain in addition to opioids included nonsteroidal anti-inflammatory agents (29 percent), antidepressants (60 percent), and anticonvulsants (53 percent). Thirty-five of the patients (78 percent) described a total of 42 distinct types of breakthrough pain. The median number of episodes per day was two; the median time to maximum intensity was 10 minutes, and the median duration of pain was 60 minutes. Patients could identify a precipitant for 62 percent of the pains, and 88 percent of the precipitants were activity related. The onset of breakthrough pain could not be predicted for 48 percent of the pains and could only sometimes be predicted for 29 percent of the pains.Conclusion: Breakthrough pain is common in opioidtreated patients with chronic neuropathic pain. Such pain often has a rapid onset and a relatively short duration, and it is frequently difficult to predict, similar to breakthrough pain in cancer patients.

Many people suffering with interstitial cystitis (IC) and related pelvic pain syndromes do not benefit from the standard medical or surgical treatments. The pathophysiology of IC bears striking similarities to a wide variety of disorders driven by neurogenic inflammation, many of which may someday be controlled through neuromodulation. Because the bladder is accessible to repeated inspection, functional monitoring, biopsy, and collection of effluents, the study of neuromodulation in IC promises to yield important insights into the successful application of neuromodulatory approaches to diseases of the pelvis and other areas. Clinical experience suggests that neuromodulation in pelvic pain syndromes can successfully normalize the motor function of the bladder and pelvic muscles, as well as their sensoria. Useful neuromodulatory approaches that have potential for the treatment of intractable IC and related syndromes, such as certain cases of chronic prostatitis and pelvic floor dysfunction, include stimulation of afferent pathways using high-frequency stimulation of sacral roots and low-frequency stimulation of motor fibers innervating pelvic floor muscles via sacral roots or the posterior tibial nerve. While the lifetime incidence of chronic pelvic pain in American women is estimated to be as high as 33%, fewer than 1% of these patients are ever seen by pain specialists. Developing neuromodulatory strategies for IC and pelvic pain may also hold promise for the effective treatment of certain syndromes involving intractable urinary retention, lower bowel disorders, or sexual dysfunction.

Case Presentation: D.J. is a 58-year-old right-hand-dominant Caucasian woman who presented with a history of posterior interbody fusion (PLIF) L2-S1 in 2000 secondary to severe spinal stenosis L3-L5, severe degenerative disc disease of the lumbar spine L2-S1 with a Grade II dynamic anterolesthesis L3 on L4 and Grade I retrolesthesis L5 on S1. She awoke from the L2-S1 PLIF with severe burning dysesthesias across the lower aspects of the lumbar region and into the right buttock/posterior lateral right lower extremity; the lumbar dysesthesias lessened but did not completely cease (i.e., burning pain in the lumbosacral region continued, but sharp pain ceased); the right buttock and leg did not change (see Figure 1). Figure 1 Pain diagram. She trialed physical/manual therapy, aquatic therapy, epidural steroids (three series of three), gabapentin (3,600 mg/day), nortriptyline (100 mg qHS) without benefit. She presented taking the following medications: Fentanyl Transdermal 150 µg/h q2days Hydrocodone/acetaminophen 10/500 mg 2 tab q4h Tizanadine 8 mg qHS Metaxalone 800 mg QID Naproxen Sodium 250 mg BID 0.625 mg conjugated estrogens/2.5 mg medroxyprogesterone qday Gliburide 10 mg qAM She characterized the axial back pain as “constant,” “burning,” “searing,” “aching,” and “stabbing” with interposed “shooting” pain. She reported radiation of pain into the right buttocks and posterior/posterior lateral aspect of the right lower extremity utilizing similar descriptors. Over the 4–6 months preceding examination, she described a “popping” sensation in the low back with certain movements that worsens the right leg radicular symptoms. She reported pain 24 hours/day with only intensity fluctuations. She rated pain utilizing the Brief Battery for Health Improvement (version 2) (BBHI-2) (see Figure 2). Figure 2 BBHI. PTSD = post-traumatic stress disorder. Past Medical History: Adult-onset diabetes, hyperlipidemia. Past Surgical History: Anterior cervical discectomy and fusion (ACDF) C5-C72000; L2-S1 PLIF 2000. Allergies: Codeine/Morphine (rash). Social: Common law marriage with grown …

The complex regional pain syndromes (CRPS I and CRPS II), also known as reflex sympathetic dystrophy and causalgia, have been recognized for the past 2,500 years and believed in for the past 150, but they have yet to be understood. These syndromes can be characterized by discrete sensory, motor, and autonomic findings, but many patients with CRPS continue to suffer for years without a diagnosis. The role of the sympathetic nervous system in maintaining these syndromes and its appropriateness as a target for treatment continue to be subjects of enduring controversy. As might be expected in a group of disorders that we still have trouble naming, much less diagnosing, it has been very difficult to reach a consensus on how to treat people afflicted with the CRPS. Recent insights into how the nervous system responds to injury are beginning to explain some of the “impossible” neurological findings that are characteristic of CRPS. These research findings may soon be translated into specific therapies targeted at the processes of neural inflammation that appear to play an important role in these syndromes. Using currently available techniques of quantitative sensory testing should allow us to improve our approach to diagnosing our patients and monitoring their responses to treatment. Incorporating these diagnostic techniques into clinical studies now promises to improve the utility of clinical research in this field. Case-series studies suggest that spinal cord stimulation is a safe and effective treatment for many people with advanced CRPS who have not obtained adequate relief with other treatments.

An international panel of pain specialists including physicians and health policy scholars met to discuss the impact of fear of opioids on the clinical use of these strong analgesics. Recognizing potential risk from opioids, the panel members concluded that irrational fear of the drugs often impedes their appropriate use. The need for education among clinicians was recognized and the panel concluded that while progress has been made, much remains to be done to correct unfounded fears and misconceptions that impede provision of opioid analgesia when it is indicated.

Objective. To evaluate effectiveness of spinal cord stimulation (SCS) applied to complex regional pain syndrome I (CRPS I). To analyze trends to focus the design of a multicenter prospective study. Design. Retrospective multicenter series, 3 years. Outcome measures. We collected visual analog scales for pain and patient satisfaction data on n= 101 patients. Patients were divided into two groups: Group I had single-lead quadrapolar systems, Group II had dual-lead octapolar systems. Results. Mean pain scores decreased in both groups with a significantly greater decrease in Group II (p0.0001). 74.6% of Group II patients preferred multiple programming arrays with 15.5% requiring frequencies250Hz.; overall satisfaction scores were 70% in Group I and 91% in Group II (p0.05). Conclusions. SCS is an effective treatment of pain in CRPS I. Frequencies250Hz were necessary in some patients to maintain or re-establish pain control. Bilateral multielectrode leads appear superior with application of multiple arrays, permitting paresthesia steering without need for surgical revision. A multicenter, prospective design is needed applying dual-lead multichannel systems with high frequency capabilities in the treatment of CRPS I.

Breakthrough pain is well-characterized in cancer patients but not in patients with chronic noncancer pain. We recruited 228 patients with diverse types of chronic noncancer pain from 9 pain programs and administered a telephone questionnaire with a breakthrough pain assessment algorithm originally designed for cancer patients. All patients had controlled baseline pain, and 168 (74%) experienced severe to excruciating breakthrough pain. Among those with breakthrough pain, the most common syndrome was low back pain (52%), and the underlying pathophysiology was variably characterized as somatic (38%), neuropathic (18%), visceral (4%), or mixed (40%). A total of 189 different types of breakthrough pain were reported. The median number of episodes per day was 2 (range,1 to 12). Median time to maximum intensity was 10 minutes (range, 0 to 180 minutes). Median duration of the breakthrough pain was 60 minutes (range, 1 to 720 minutes). Patients identified a precipitant for 69% of pains, and 92% of these were activity-related. Onset could never be predicted for 45% of pains and only sometimes predicted for 31% of pains. Breakthrough pain is highly prevalent and varied in this population. Further studies are warranted to clarify whether the clinical impact and therapeutic challenges posed by this phenomenon are comparable to the cancer population.This article presents results from a survey that demonstrates that breakthrough pain is highly prevalent and varied in opioid-treated patients with chronic noncancer pain. These findings will assist clinicians in assessing and managing this type of pain.

An international panel of pain specialists including physicians and health policy scholars met to discuss the impact of fear of opioids on the clinical use of these strong analgesics. Recognizing potential risk from opioids, the panel members concluded that irrational fear of the drugs often impedes their appropriate use. The need for education among clinicians was recognized and the panel concluded that while progress has been made, much remains to be done to correct unfounded fears and misconceptions that impede provision of opioid analgesia when it is indicated.