Medical Update (2002)

Volume1/2002_SpringMEDICAL PDATE Spring 2002 Facing Down Pain UNIVERSITY OF UTAH HOSPITALS & CLINICS U Pain Center Tackles Undertreated Medical Problem An estimated 20 million Americans suffer from chronic, non- cancer pain- and 11,000 of those people are treated every year at the University of Utah Hospital and School of Medicine Pain Management Center. The center, located in Research Park south of the U campus, assists people from Utah and surrounding states with problems ranging from headaches to arthritis to backaches- and everything in between, according to Michael A. Ashburn, M. D., M. P. H., professor of anesthesiology and center director. The center's services are in such high demand that 400 people are on a waiting list of several months to get in, says Ashburn, a former health-policy adviser to U. S. Sen. Orrin G. Hatch, R- Utah. The need for relief doesn't surprise Ashburn, who believes the U. S. health- care system has done a woeful job of helping people with chronic pain. " It's a huge societal issue," he says. A staff of about 40 anesthesiologists, psychiatrists, psychologists, nurse practitioners, nurses, physical and occupational therapists and support staff work at the Pain Management Center's chronic and acute pain clinics. The center also conducts " front- edge" research, such as a promising project using controlled heat to deliver pain- relieving drugs through the skin, according to Ashburn. Salt Lake City obstetrician John C. Nelson, M. D., agrees that physicians can do more to help patients with pain. Nelson, a member of the Ameri-can Medical Association board of trustees, has a unique view of the issue- that of both patient and physician. Nelson ruptured a disk in his back after he sneezed a couple of years ago. He immediately was struck with pain so sharp that he hardly could stand or walk. Surgery wasn't an option because he has a congenital problem with his spine. He was getting desperate for relief. " Nothing had worked," Nelson says. He called Ashburn, whom he knew, and made an appointment at the pain clinic. He recalled walking On the cover. . . Brad Smith, who holds a black belt in Tae Kwon Do, says the U's Pain Management Center helped him get on with his life after suffering back pain for 31 years. into Ashburn's office that day, his wife and son having to help him climb the stairs to get there. Ashburn gave him an epidural block that relieved the pain, and Nelson walked out on his own. After that, he took steroids to reduce the inflammation in his spine and today is pain free. That solution sounds deceptively simple. But the number of people suffering from chronic and acute pain belies the truth- physicians don't always recognize their patients' pain or know how to treat it. The answer to that, Nelson says, is better training. His own experience, Nelson says, made him more cognizant of his patients' pain, and because of it he's more likely now to prescribe medication to help them. " I hope it has improved the way I treat patients," he says. Farmington, Utah, resident Brad Smith has suffered chronic back pain for 31 years. Smith, 49, broke his back when he was 18, and then had successful surgery. But 11 years after that, he refractured the same vertebra. The first operation had been so difficult to recover from that he would not undergo a second operation. After seeing " everybody on the planet" to get help, Smith was referred to the Pain Management Center last fall. The center's holistic approach to alleviating pain is the best program he's found. Many physicians depend solely on medication to relieve pain, something Smith doesn't like. Although he takes a " relatively conservative" dose of medication, Smith also meditates, practices yoga and does other PupamAcwemToi SCAM Michael A. Ashburn, M. D., M. P. H., says the education system that trains U. S. physicians needs to do a better job of teaching pain management. A bout with incapacitating back pain helped obstetrician John C. Nelson, M. D., better understand his patients' needs for pain care. stretching exercises to help his back. His injury never stopped Smith from doing things he likes. He kept skiing and even earned black belts in Tae Kwon Do and Tang Soo Do after breaking his back. Everything he has done the past 31 years has included a level of pain- and that will never change. But, because of the Pain Management Center, Smith is controlling his pain better than ever. " They have helped me get on with my life," he says. Pain management is only beginning to get the attention many patients and physicians, including Ashburn, believe is overdue. He cites three obstacles that have kept pain care from being part of main-stream U. S. medicine: policies of the federal govern-ment and private insurance companies to deny pain-care payment; lack of physician training; and, the result of inadequate training, a shortage of physicians qualified in pain management. Federal and state governments deny millions of people access to pain care by disallowing Medicare and Medicaid payments, or by requiring large co- payments for pain treatment, according to Ashburn. Denying payment, in his view, not only fosters poor medical care, but also is not cost- effective. People denied payment for pain care from their primary physician, or a specialist, often go to a hospital emergency room, where doctors are obligated to provide treatment. In the long run, that costs the government millions of dollars. Similar policies exist with private health insurance companies as well, according to Ashburn. The education system that trains physicians has, until recently, largely ignored pain care. A national survey two years ago found that, despite years of schooling, U. S. physicians receive, on average, two hours of pain- care training, most of which is learned bedside. Nurses receive far more training in that area, Ashburn says. University Hospital has been well ahead of the curve on pain management, according to Ashburn, and has long recognized the importance of pain care. Nationally, there are signs of change, in both government and the private arena. The Centers for Medicare and Medicaid Services- the federal agency that oversees those programs ( for-merly called the Health Care Finance Administra-tion)- recently recognized pain management as a medical specialty, according to Ashburn. That may lead to more Medicare and Medicaid payments for pain care. The state of California also now requires physi-cians to receive pain- management training. In the private sector, the Joint Commission on Accreditation of Healthcare Organizations ( JCAHO)- which gives national accreditation to hospitals- now mandates that hospitals have a pain-management program to receive national accreditation. " As a result, great strides are being made in pain management," Ashburn says. To help ensure those strides continue, Ashburn, when he isn't seeing patients, keeps a packed schedule of promoting pain management to health- care associa-tions, physicians and government officials. In March, for example, he spoke before the American Society of Pain Management Nurses. He also just ended a term as president of the American Pain Society, and also belongs to the American Academy of Pain Medicine and the Pain Care Coalition. Ultimately, he's counting on education to effect change. " I try to inform federal policy makers so they can develop good health- care policy," Ashburn said. For information call the Pain Management Center at WI- 585- 7690. University of Utah Hospitals & Clinics toll- free referral and consultation numbers in Utah 1- 800- 662- 0052 outside Utah 1- 800- 453- 0122 uuhsc. utah. edu Chemoradiotherapy for Advanced Cervical Cancer U Clinical Trial Studies Effect of COX- 2 Inhibitor Treatment for advanced cancer of the cervix took a leap forward when, in February 1999, an alert from the National Institutes of Health advised that chemo-therapy and radiation were superior to radiation alone for treatment of this condi-tion. Now, University of Utah medical school scientists are investigating what effect the addition of the drug Celebrex, a COX- 2 inhibitor, combined with radiation and chemotherapy, will have on improving the chance of a cure. David K. Gaffney, M. D., Ph. D., assis-tant professor of radiation oncology, is principal investigator for the study, in which 83 women will participate nationwide. Researchers believe the combination of Celebrex, an arthritis medication with applications for anti- cancer use, and cisplatin- based chemotherapy with radio-therapy has the potential to improve tumor control and reduce complications in women with advanced carcinoma of the cervix, according to Gaffney. Preliminary evidence suggests that inhibition of COX- 2 can slow angiogenesis and works with radiation therapy without enhancing normal tissue toxicity. Angiogenesis, the process by which new blood vessels are formed, is prerequisite for tumor growth. The idea for the trial came about at a profes-sional meeting about the involvement of the enzyme cyclooxygenase- 2, or COX- 2, in cancer of the cervix. Gaffney and Mark K. Dodson, M. D., assistant professor and chief of the Division of Gynecologic Oncology, were aware of research at the University's Huntsman Cancer Institute regarding COX- 2 in cancer treatment. Gaffney, Dodson and others at the University performed a study that showed that patients with cells that heavily expressed COX- 2 were more likely to die of their cancer. The protocol, using Celebrex, the chemotherapy drugs 5- FU and cisplatin, and radiation, is now a study sponsored by the National Cancer Institute David K. Gaffney, M. D., Ph. D., is principal investigator for a clinical trial seeking better treatment for advanced cervical cancer, and Karen Zempolich, M. D., is conducting microarray testing for gene expression. and is open to members of the Radiation Therapy Oncology Group ( RTOG), a national cooperative research organization, under the auspices of the American College of Radiology. Lilia Hernandez, Orem, who is enrolled in the U's clinical trial, came from Colombia in 1982 to join her mother and siblings in New York City. A regis-tered nurse in Bogota for 20 years, she worked at White Plains Hospital in New York before coming to Utah in 2001. The first symptom she noticed was leg swelling, but physicians could not find the cause at that time. When she had unusual vaginal bleeding, she didn't pay attention because she had been working hard housecleaning, and attributed the problem to that. In September, intense pain and a swollen abdomen sent her to an emergency room. Karen Zempolich, M. D., assistant professor of obstetrics and gynecology, diagnosed the problem as cervical cancer, which had spread beyond the cervix. Hernandez had had Pap smears in the past, although 4 Lilia Hernandez, Orem, is hopeful that results from the clinical trial in which she is enrolled will help her and others. her most recent one was two years before her symp-toms appeared. " There is usually a longer period of time between a previous Pap smear and detection of cervical cancer. Two- thirds of American women diagnosed with cervical cancer haven't had a Pap smear within the past five years. When done regularly, Pap smears do a very good job of detecting pre- cancerous changes and early cancers that are easier to treat," Zempolich said. Symptoms of cervical cancer include post-menopausal bleeding or a change in menstrual cycles- heavier bleeding or other discharge- in pre-menopausal women. Ultimately there may be pelvic pain or leg swelling. Women often tend to downplay their symptoms, according to Zempolich. " They are caregivers and concentrate on the wellbeing of others more than their own, " she believes. Hernandez hopes the research will help not only her but also other women in the future. She had five weeks of external beam radiotherapy and four brachytherapy implants, done at weekly intervals starting about the third week. In addition, she received three cycles of chemotherapy at three- week intervals. She began taking Celebrex when radiation started and will take it for a year. Brachytherapy is a method of delivering radiation directly to a tumor. A device which has hollow tubes in it is inserted into the uterus and the tubes are loaded with radioactive implants to deliver a local dose to the cervical cancer. Hernandez has completed the radiation/ chemotherapy phase of the protocol and now will be followed at regular intervals. Microarray testing for gene expression is being done by Zempolich. Biopsies of the cervix prior to treatment and at the time of the first implant are required of patients in the study. Zempolich hopes to find which genes may be turned on or off to try to find out why the tumor developed. " Microarray analysis is an amazing technology. The tissue sample is smeared over a slide on which there are 10,000 genes and a laser scanner reads the results," said Zempolich. " We want to know if there is a pattern in the genes affected. Do all the patients who do well, or do all those who do not do well, have the same affected genes? If a pattern shows up repeatedly, can it predict the response to a treatment? " The goal is to have sufficient scientific evidence to recommend a therapy and to develop new therapy approaches," she said. Of the 500,000 cases of cervical cancer diagnosed worldwide, 14,000 are in the United States. Around 4,400 women will die from the disease every year. Before 1940 and the discovery of the Pap smear, cervical cancer was the number one cancer in women; now it's 111^ . " If cancer of the cervix is detected early, it is easily cured with surgery or radiation," Gaffney said. " Radiation can cure cervical tumors up to 8 cm, but the success is stage- specific." Stage I has an 80- 98 percent cure rate; Stage II, 50- 70 percent; and stage III, 30- 50 percent, the U physicians said. Pap smears have drastically reduced death from cervical cancer in the United States, but, in Mexico and other developing countries, cervix cancer is the leading cause of cancer death, said Gaffney. " It is an enormous public health prob-lem elsewhere in the world." Screening is effective and simple, but, in other parts of the world, there's a shortage of trained people to test the samples, Zempolich said, adding that the means to treat pre- cancerous situations are not plentiful. © For more information, call DavidKGaffney, M. D., Ph. D., 801- 581- 2396or Karen Zempolich, M. D., 801- 585- 2477 5 Neurobehavior Clinic Team Treats Developmentally Disabled Children Scott R. Stiefel, M. D., director of the neurobehavior program, works with a child during an office visit. The program treats whole families, not just children, according to Stiefel. The University of Utah's Neurobehavior Clinical Research Program is redefining the treatment of developmentally disabled children, adolescents and young adults. The program, based at Univer-sity Hospitals & Clinics' Red Butte Health Center in Research Park, brings together a whole cadre of pediatric caregivers to work as a team to treat the patient's total needs. " We give these children some-thing they have never had before- a medical home," said program director Scott R. Stiefel, M. D. Children with developmental disabilities often struggle with devastating medical, neurological, emotional and behavioral issues that accompany their primary problems. The specialists who treat them- from neurologists to physical therapists- typically work indepen-dently of each other without ever understanding all of the child's issues. The result, according to Stiefel, can be expensive, inefficient care. When Stiefel, also assistant professor of pediatrics and child and adult psychiatry at the U School of Medicine, became director of the clinic in the mid- 1990s, he sought a better way to treat these children. He reorganized the program with the goals of achieving better, more cost- efficient care. The center's staff of 14- including physicians, mental health workers, nurses, social workers and others- treat the clinic's 350 patients. The children range in age from infancy to 22 years old, but most are 18 and under. The program, founded in the 1980s by a couple of U medical school faculty members, gets funding from the school's pediatrics department, as well as philanthro-pies. It also brings in revenue from health insurance and private payments of patients and their parents. Children in the program undergo an initial interview, psychological testing and psychiat-ric examinations, according to Katrina Rayls, Ph. D., a neuropsy-chologist and clinical research director. Once a child has been evaluated, which takes up to a couple of months, a team of caregivers meets to review the patient's situation. They examine everything from medication and medical treatment to psychological counseling and school and social functioning, said Rayls, assistant professor of pediatrics. Parents are heavily involved in the evaluation. " From there, we determine which services and treatment are appropriate," she said. Developmental disabilities often are treated more effectively when children are younger, so the earlier a child gets into the neurobehavior program, the better, according to Stiefel. When a patient turns 22, he Neurobehavior Clinical Research Team Scott R Steifel, M. D., Katrina Rayls, Ph. D., Richard Ferre, M. D., William McMahon, M. D., Janna Hartle, FNP- C, Barbara Faust, PNP- C, Roger Christensen, LCSW, Stephanie Topolovec, B. S., Phyllis O'Brien, R. N., Alison J. Donnell, M. A., Heather Parkin- Sokoloff. Katrina Rayls, Ph. D., clinical research director of the neurobehavior program, says a key long- term goal is to better understand the needs of developmentally disabled children. or she can be placed in a program for developmentally disabled adults, also run by the neurobehavior program. Although the neurobehavior clinic focuses on children, whole families often need help. The rates of divorce, depression and abuse are higher in families with a develop-mentally disabled child, according to Stiefel. Parents and siblings often need counseling and treatment. " There is no greater stress that I can think of than caring for a developmentally disabled child," he said. " We treat families." A Salt Lake City woman whose son is in the program knows the stress of raising a developmentally disabled child. Her son, Josh ( not his real name), suffers from anxiety, depression, and motor- skill prob-lems that started when he was 5. Now 11, Josh has seen doctors, therapists, social workers and others and has been hospitalized and placed in special programs and schools. He has had trouble devel-oping social relationships and friendships with other children. His anxiety manifests itself in psoriasis and some days his skin is so sensi-tive he can't wear clothes, Josh's mother said. Before he started in the neurobehavior program in late 2000, his treatment was scattered and piecemeal. But having his physicians, therapists and other caregivers in one place gives Josh's parents a greater sense of control. " In this office, I feel like every-thing is together," his mother said. " I don't feel like things are frag-mented." That doesn't mean they've found all the answers for Josh. They're still searching for the best medication for his anxiety and depression, something that has proved elusive so far. But since starting at the Neurobehavior Clinical Research Program, Josh's problems have stabilized, and his mother is hopeful he can return to a normal life. Along with changing the way children are cared for, Steifel also refocused the program on research. For example, the relationship between genetics and behavioral problems in developmentally disabled children is not fully understood. Many of these children suffer from mental illness, and researchers are learning to separate these problems, such as depression, from genetic- based neurological behavior problems. Their research, Rayls said, has two goals: to better understand the needs of children with developmen-tal and neurological disorders through long- term tracking; and to determine the most effective treatments for them. The care of developmentally disabled children does not end in a year or two, or even a decade. It lasts a lifetime. Through a better understanding of their needs and a team approach to treating these patients and their families, the neurobehavior program staff works toward a larger goal: to improve their quality of life. " This is what we do," Rayls said. " We adore these kids." For information call the Neurobehavior Clinical Research Program, 801- 581- 5515. Visit uuhsc. utah. edu The new Health Sciences Center Web site has comprehensive medical resources, and a list of all the University of Utah Health Sciences Center experts. 7 University of Utah School of Medicine Continuing Medical Education May 8- 12: The Cutting Edge of Clinical Science Audience: Specialists in sports medicine, fitness training, health Monaco Hotel, Salt Lake City ARUP, Research Park Chair: Juliana G. Szakacs, M. D. 19.5 AMA Category 1 hours Contact: Juliana G. Szakacs, 801- 581- 2507 szakacs@ path. utah. edu June 16- 21: University of Utah School on Alcoholism and Other Drug Dependencies/ Physicians' Section Audience: M. D. & D. O. physicians, physician assistants, nurse practitioners, medical students who have completed at least second year Parlor A, Olpin Union Bldg., U of U campus Chair: John Speed, M. D. 27 AMA Category 1 hours July 31- August 3: Regional Roundup 2002- Return to Sun Valley Audience: Ophthalmologists Sun Valley Resort, Sun Valley, Idaho 12 AMA Category 1 hours Chair: Paul L. Zimmerman, M. D. Contact: Paula F. Morris, CRA, 801- 581- 6219 paula. morris@ hsc. utah. edu August 11- 13: Pain and Negative Emotion: Towards an