States are making steady progress in adopting effective policies that help people with pain to alleviate their suffering, according to a newly released national report card. However, there are still states with policies that prevent healthcare professionals from effectively alleviating the suffering of their patients.

The report, Achieving Balance in State Pain Policy: A Progress Report Card (Second Edition), was prepared by the University of Wisconsin Pain & Policy Studies Group (PPSG) and jointly funded by the nation’s leading information and advocacy groups for people with cancer: the American Cancer Society, the Lance Armstrong Foundation (LAF) and the Susan G. Komen Breast Cancer Foundation.

PPSG researchers evaluated whether state pain policies and regulations enhance or impede pain management. In the report, each state is assigned a grade from ‘A’ to ‘F’ that reflects the effectiveness of its pain policy. PPSG also evaluated policies in place in 2000 and 2003 to determine what changes have been made over time. Results show continued momentum for positive policy change over the six-year evaluation period:

– Two states (Michigan and Virginia) received an ‘A’ grade, which no state received in 2003.

– 82 percent of states have a grade above ‘C,’ up from 49 percent that received a ‘C’ in 2000 and 67 percent in 2003.

– No state’s grade decreased between 2000 and 2006.

– 19 states saw their grades improve from 2003.

“We’re seeing positive results because healthcare regulators have adopted policies encouraging pain management, palliative care, and end-of-life care,” said Aaron Gilson, Ph.D., associate director of US policy research of the PPSG. “Additionally, many state legislatures have repealed restrictive or ambiguous policy language that has prevented healthcare professionals from aggressively treating pain.”

“Despite this progress, most states still face the challenge of removing their remaining policy barriers, communicating the new or revised policies to healthcare practitioners and ensuring that the spirit of these policies are put into practice.”

“The results of PPSG’s research show a very encouraging improvement in state pain policies, but more needs to be done to effectively address the national health crisis of undertreated pain,” said John R. Seffrin, Ph.D., CEO of the American Cancer Society. “States must effectively inform the medical community about improved pain policies so people with pain can benefit from them. Patients, health organizations, healthcare professionals, regulatory officials, licensing boards, and policymakers all have a role to play to promote a balanced approach to pain control policy and practice.”

“Cancer survivors deserve to have their pain managed effectively so that they can focus on living life on their own terms,” said Mitch Stoller, president and chief executive officer of the LAF. “We must ensure that policies are in place to help people obtain medical care to promote the highest quality of life possible. We know that many states still have work to do to remove barriers to effective pain management, and we are proud to join in that critical work.”

“Effective treatment of pain is a key element in ensuring a good quality of life for cancer patients and other people faced with life-threatening illness. We are committed to making sure remaining barriers to effective pain management are removed and that health care workers are adequately informed of recent policy changes that can positively impact the lives of their patients,” said Hala Moddelmog, president and CEO of the Susan G. Komen Breast Cancer Foundation.

Balanced Policies Necessary

For years, many states have had restrictive or ambiguous policies that could create barriers to the effective treatment of pain. An estimated 100 million Americans who are affected by chronic diseases and conditions suffer from pain. Untreated pain can devastate a person’s quality of life, affecting all aspects of daily functioning, including sleep, work, and relationships.

While there are several effective medications and non-drug therapies available for pain treatment, opioid pain medications are often the best treatment for managing serious, persistent pain. But health professionals can be reluctant to prescribe such medications because of the risk of violating laws aimed at preventing trafficking and abuse of controlled substances.

“Because state and federal policies can either enhance or interfere with pain management, it is important that such policies are balanced to ensure that prescription pain medications are available to patients who need them while at the same time preventing illegal trafficking and non-medical use of opioids,” Dr. Gilson said.

Additional details about the report findings and pain as a public health problem are attached. This project was made possible through joint funding provided by the American Cancer Society, the Lance Armstrong Foundation and the Susan G. Komen Breast Cancer Foundation.

Slipped disc is a common ailment that causes a great deal of back pain and nerve pain in the bone­-sciatica­-that leads to many sick days home from work. Sometimes the disorder rectifies itself, but sometimes a rather complicated operation is needed. But now it seems that a gentler alternative, ultrasound, is on its way. The new method has been developed at Lund University and the University Hospital at Lund in Sweden. The technique is described in a dissertation by the physicist Johan Persson.

The principle is to direct focused ultrasound directly at the disc that has started to bulge outward and press against the nerves. When the disc cartilage warms up, its collagen fibers shrink, so the cartilage no longer bulges so much. This means that it no longer presses against the nerves that cause the pain.

Johan Persson’s dissertation work involves the design of an ultrasound transmitter, temperature measurements in the laboratory, and simulation of the temperature distribution in the disc during ultrasound treatment­-some of the key steps in the development of this new technique. In traditional slipped disc operations, the damaged disc is opened up. The operation requires hospital care and a long period of sick leave, and it also involves a risk of complications. Ultrasound treatment, on the other hand, is done with a local anesthetic, takes only six minutes, and requires no hospital stay. If the method lives up to its promise, it will therefore be both more attractive to patients and cheaper for health care.

According to Björn Strömqvist, professor of orthopedics, the ultrasound method is intended for slipped discs that are not too large (so-called covered, non-perforated hernias). It is being tested now in a so-called multi-center study in Sweden, Germany, South Korea, Italy, and Turkey. The study is still in a very early phase, but preliminarily it seems that two thirds of the slipped disc patients treated have been helped by ultrasound.

Under the direction of Björn Strömqvist, the Section for Orthopedics at Lund will also study whether the method can be used for so-called disc degeneration. This is an age-related change in the cartilage discs of the vertebrae that is even more common than slipped discs.

nuLase announces an amazing new alternative to costly surgery, chemical peels and collagen injections; the first ever laser enhanced skin care treatment for use in the home. The nuLase Soft Touch Laser is part of a skin care system that works in tandem with our scientifically formulated moisturizer to penetrate the epidermis and stimulate production of cellular energy (ATP) within the skin cell. ATP (adenosine triphosphate) is the fuel our skin cells use for repair and rejuvenation. Unlike the typical ointments and creams that line the shelves of local pharmacies, this patent-pending laser technology gently stimulates the skin repair process from within the skin cell rather than from the surface of the skin.

The complete nuLase system is a daily three-step process that includes a foaming cleanser, microderm exfoliator, and a regenerating moisturizer. These exclusive formulations are augmented by the soft touch laser to deliver restorative nutrients deep within the skin’s cellular level for a clearer, more youthful looking complexion.

The Soft Touch Laser by nuLase works by emitting a safe and gentle laser light that oscillates in a uniform parallel wavelength targeting your skin cells. It helps clear up acne, reduce wrinkles, fade age marks, and diminish stretch marks.

Smoking might increase the risk of contracting HIV, according to a study published in the Aug. 21 online edition of the journal Sexually Transmitted Infections, the New York Times reports (Nagourney, New York Times, 9/26). Andrew Furber, a public health consultant at the South East Sheffield Primary Care Trust in the United Kingdom, and colleagues conducted a systematic review of studies examining tobacco smoking as a risk factor for either HIV infection or progression of the virus to AIDS. Of the six studies the researchers examined, five suggest that smoking tobacco is an independent risk factor for HIV seroconversion after adjusting for confounding factors (Furber et al., Sexually Transmitted Infections, 8/21). According to the study, smokers are between 60% and 300% more likely to contract HIV than nonsmokers (BBC News, 9/23). The researchers said they are not sure why the link exists, but they note the increasing evidence that smoking raises the risk of contracting all types of infections, possibly because it might alter the structure of the lungs or weaken the immune system. According to the researchers, tobacco use is often higher among groups at higher risk for HIV transmission, including commercial sex workers (New York Times, 9/26). Nine of 10 other studies the researchers looked at showed no evidence that tobacco smoking increased the progression of HIV to AIDS, according to the researchers (Reuters, 9/20).

Conclusions, Reaction
The researchers concluded that smoking tobacco might be an “independent risk factor for HIV infection although residual confounding is another possible explanation.” They also write that smoking does not “appear to be related to progression to AIDS, although this finding may not be true in developing countries or with the longer life expectancies seen with highly active antiretroviral therapy” (Sexually Transmitted Infections, 8/21). “More research clearly needs to be done in this area,” Furber said. He added, “As the tobacco market is squeezed in the developed world, the tobacco industry increasingly looks to Asia, Eastern Europe and Africa.” Keith Alcorn, a senior editor at National AIDS Map, said, “The weakness of this analysis, as the authors themselves acknowledge, is that most of the studies reviewed were carried out before the widespread use of antiretroviral therapy in developed countries.” According to Alcorn, a large study in 2006 of HIV-positive women in the U.S. receiving antiretroviral therapy finds that smokers had a 36% greater risk of developing an AIDS-related illness over five years of follow-up care. “Anyone living with HIV would be strongly advised by their doctor to stop smoking because of the increased risk of cardiovascular disease and the much greater risk of various smoking-related cancers for HIV-positive people, whether on treatment or not,” Alcorn said (BBC News, 9/23).

After years of research, scientists at The University of Texas M. D. Anderson Cancer Center are now able to explain, in exquisite molecular detail, how the estrogen hormone can help keep breast cancer cells alive.

In the Sept. 24 issue of the journal, Nature Cell Biology, they assign roles to a number of genes and proteins thought to play a part in breast cancer cell survival, and in the process, have identified potential molecular drug targets.

“It’s a very complex story, but we have been able to bring together a number of basic discoveries from different fields of research to work out the basic mechanism by which estrogen can exert a pro-life effect on cancer cells,” said the study’s lead author, Edward T. H. Yeh, M.D., professor and chair of The University of Texas M. D. Anderson’s Department of Cardiology.

Along the way, the researchers have provided some novel insights. One is that they have provided a role for breast cancer-associated protein 3 (BCA3), which had been recently found to be over-expressed in both breast and prostate cancers. Yeh and his team show that this protein, by itself, doesn’t have any relationship to the cancer, but when modified by the protein NEDD8, can act like a tumor suppressor.

The researchers also found that SIRT1, a key protein involved in this molecular pathway, is a member of a family of proteins responsible for prolonging life span in both yeast and worms. “The fact that these molecules, which maintain life span in other species, has been found to be involved in suppressing cancer development seems important to us,” Yeh said. “The reason people live longer is that they don’t develop cancer as readily.”

Players in this newly defined pathway are:

* BCA3, which had no known function.

* NEDD8, a protein that can bind to other proteins and alter their function.

* SENP8, a protease (enzyme) that can break bonds between other molecules.

* SIRT1

* NFkB (Nuclear Factor kappa B), a family of proteins that turn on genes involved in cell death (apoptosis) and cell proliferation. When over-expressed, NFkB can protect cells from undergoing apoptosis, and in general, the more NFkB is expressed, the more resistant the cell is to apoptosis.

* Estrogen, a hormone that acts as growth fuel for about 70 percent of breast cancers.

Researchers are interested in ways that cells can efficiently turn genes on or off, and one of the newest mechanisms is dubbed “NEDDylation,” which Yeh helped to find 10 years ago. This process requires multiple enzymes to attach NEDD8 to other proteins.

To find proteins that can be altered by NEDD8, the four-member research team used yeast as their experimental platform, and SENP8 as a tool. This enzyme is known to be able to separate NEDD8 from the proteins it binds to. In this way, they could use SNEP8 “as bait” to fish for protein complexes held together by NEDD8.

They first found that BCA3 binds to SENP8 and was modified byNEDD8, and then discovered that this complex affects NFkB signaling. It does this by binding on to p65, one of the two proteins that make up NFkB proteins, the researchers say. “NEDD8 modified BCA3 regulates the activity of NFkB, but BCA3 alone does not have any impact on NFkB,” says Yeh.

Then they looked at how this NEDDylation further works to suppress the ability of NFkB to transcribe (activate) other genes. Here the investigators found SITR1, the molecule known to prolong life span in several other species. SITR1 is a histone deacetylase, a protein that blocks transcription factors from regulating genes. “When NEDD8 modified BCA3, it binds to p65 and recruits SITR1 to suppress NFkB-mediated transcription,” Yeh said.

Finally, the researchers discovered that estrogen blocks NEDD8 from modifying BCA3, a finding which goes some way to “explaining estrogen’s pro-life effect in breast cancer cells,” Yeh says. “Estrogen could enhance the survival of breast cancer cells by silencing BCA3, through eliminating its hold on NFkB transcription.”

Now that this cancer-promoting molecular pathway has been described, Yeh says it might be possible to interfere with a number of the players to inhibit cancer growth. “NEDD8 is key,” he said. “It may be possible to design drugs that block the removal of NEDD8 from BCA3.” By increasing the amount of NEDD8-modified BCA3, there will be a corresponding decrease in the level of NFkB and the cancer cells will be more sensitive to chemotherapy, Yeh says.

“There is a lot we need to sort out, of course, but this is a model of how estrogen may function to promote growth in breast cancer that we can all now work from,” Yeh says.

CDC’s revised recommendations on HIV testing in the U.S. — that say HIV tests should become a routine part of medical care for residents ages 13 to 64 and that requirements for written consent and pretest counseling should be dropped — could harm the health and civil rights of people who receive the tests, the American Civil Liberties Union said in a release on Thursday, CQ HealthBeat reports (Reichard, CQ HealthBeat, 9/22). The recommendations, published in the Sept. 22 edition of CDC’s Morbidity and Mortality Weekly Report, say health care providers should continue routine HIV testing unless they establish that less than one of every 1,000 patients tested is HIV-positive, “at which point such screening is no longer warranted.” Providers do not have to require patients to sign written consent forms or undergo counseling before receiving an HIV test, but physicians must allow patients to opt out of the test, according to the guidelines. The recommendations — which states can choose to adopt and modify — also say that all pregnant women should be tested for the virus unless they opt out and that women who inject illicit drugs, are commercial sex workers or who live in a higher prevalence region should be tested again in the third trimester of pregnancy (Kaiser Daily HIV/AIDS Report, 9/22). “CDC should be commended for trying to increase the number of people tested for HIV, but eliminating the only safeguards that guarantee that testing is voluntary and informed does little to ensure that people will receive the care they need,” Rose Saxe, a staff attorney with the ACLU AIDS Project, said, adding, “Without pre- and post-test counseling requirements, we risk losing a critical opportunity to educate people about HIV and how to prevent the spread of it” (ACLU release, 9/21). Saxe said privacy could be compromised under the guidelines because most states collect the names of HIV-positive people and “[m]any states also require doctors to report private information, such as drug use and sexual history about those who test positive.” Kevin Fenton, director of CDC’s National Center for HIV, STD and TB Prevention, said the recommendations will make “routine HIV screening feasible in busy medical settings where it previously was impractical,” adding, “Making the HIV test a normal part of care for all Americans is also an important step toward removing the stigma still associated with testing” (CQ HealthBeat, 9/22).

Related Editorial
CDC “took the right step” in revising its HIV testing guidelines to recommend routine testing, which offers “the best hope to reduce the stubborn persistence of HIV infections in the American population,” a New York Times editorial says. “[T]imes have changed” since the “early days of the AIDS epidemic,” the editorial says, adding that new treatments have made early HIV diagnoses more “valuable,” that the stigma surrounding the disease seems to have lessened and that health officials have proven they can keep test results private. In addition, written consent requirements “for HIV testing beyond the general consent forms signed by patients all too often scares patients away from a test that would help them,” the editorial says. Analogous policies to CDC’s revised recommendations for routinely testing pregnant women for HIV have “greatly reduced” HIV prevalence among infants, the editorial says, adding, “Surely it would be better for every [HIV-positive] individual to learn of his status as early as possible … [a]nd surely it would be better for community health if hidden chains of transmission could be detected and interrupted to slow the spread of infection” (New York Times, 9/25).

An over-the-counter medication used to treat heartburn and acid reflux also appears to help decrease the debilitating effects of chronic heart failure, preliminary research shows. But more testing must be done before the drug is recommended for use by heart failure patients, doctors say.

According to the research, the same type of chemical reaction that allows stomach acid to cause heartburn and create ulcers also appears to damage and weaken diseased hearts. Blocking this process with the drug famotidine (Pepcid) may help to slow the progression of chronic heart failure (CHF).

The research, conducted by the National Cardiovascular Center in Suitra, Japan, appears in the Oct. 3, 2006 edition of the Journal of the American College of Cardiology. Lead researcher Masafumi Kitakaze, MD, PhD, said although the initial results look promising, more research is needed.

“We performed the present prospective study with only 50 CHF patients,” said Dr. Kitakaze, director of the Cardiovascular Division and vice president of the Research and Clinical Center at the National Cardiovascular Center. “Now we need to conduct a large-scale trial to confirm the present findings. The large-scale trial based on the results our present research may not help current heart failure patients because it takes time, but we hope it helps our children and grandchildren and others in the future.”

Gary Francis, MD, did not participate in the research, but is a cardiologist and heart failure expert at Ohio’s Cleveland Clinic. He, too, cautions that the benefits of famotidine for CHF patients remain unclear.

“At this point, we don’t know whether it would help,” said Dr. Francis, head of the Section of Clinical Cardiology at Cleveland Clinic. “In addition, there is an expense involved, and we’re not certain what the dose should be or what the safety would be of larger doses if they were necessary.

“I certainly would not recommend that patients go out and start taking Pepcid three times a day or anything like that,” he said.

Still, the research is important because it opens a new avenue of study in the ongoing effort to treat chronic heart failure, said Dr. Francis, who co-wrote an editorial that will be published in conjunction with Dr. Kitakaze’s research. Heart failure, which affects an estimated 23 million people worldwide, occurs when the heart is unable to pump as effectively as it should, resulting in shortness of breath, swelling in the legs and ankles, and other health issues.

For the current study, Dr. Kitakaze and his colleagues at Japan’s National Cardiovascular Center began with a unique hypothesis. Based on previous research, they speculated that blocking the effects of a specific chemical released by damaged heart cells would slow the development of heart failure. This chemical, one of several types of histamines produced by the body, also contributes to chronic heartburn and stomach ulcers. Famotidine is a histamine blocker, which prevents the chemical from binding to its receptor and causing problems.

To prove their theory, the researchers began by searching existing medical data for patients being treated for both chronic heart failure and gastroesophageal reflux disease (GERD). As suspected, the patients taking famotidine for their stomach problems seemed to have less-severe heart failure symptoms than patients using other types of stomach remedies. But could heart health really be linked to a stomach medication?

To find out, the researchers designed a prospective study in which 25 patients with both medical conditions were given famotidine and 25 patients were given an alternate heartburn medication called teprenone. (Instead of blocking histamine, this second medication works by causing the stomach to secret more mucous to coat and protect itself against excess acid.)

After 24 weeks, Dr. Kitakaze and his colleagues discovered that - as hypothesized - those patients receiving 30 mg doses of famotidine each day were displaying less-severe symptoms of chronic heart failure. All patients were examined by three independent cardiologists who were unaware of the treatment protocols to ensure unbiased results.

Dr. Kitakaze reports no disclosures with this research. Funding comes from the Japan Cardiovascular Research Foundation.

The European Commission on Friday approved Merck’s human papillomavirus vaccine Gardasil for sale and marketing in the European Union, London’s Guardian reports (Batty, Guardian, 9/22). FDA in July approved Gardasil for sale and marketing to girls and women ages nine to 26. According to Merck, the vaccine — which is given in three injections over six months and costs $360 — in clinical trials has been shown to be 100% effective in preventing HPV infection with strains 16 and 18, which together cause about 70% of cervical cancer cases, in women who do not already have the virus, and about 99% effective in preventing HPV strains 6 and 11, which together with strains 16 and 18 cause about 90% of genital wart cases. Gardasil also protects against vaginal and vulvar cancers, two other gynecological cancers that are linked to HPV, according to a study presented in June at a meeting of the American Society of Clinical Oncology in Atlanta (Kaiser Daily Women’s Health Policy Report, 9/22). Gardasil will be sold in the E.U. by Sanofi Pasteur, a joint company of Merck and Sanofi-Aventis. Sanofi Pasteur President Didier Hoch said the company will begin selling the drug in a European country by the end of next month (Reuters, 9/22). In the United Kingdom, the Joint Committee on Vaccination and Immunisation, an independent advisory committee for the U.K. Department of Health, will decide if the vaccine will be covered by the National Health System (Daily Mail, 9/22). A U.K. heath department spokesperson said the JCVI later this year will have meetings to review the vaccine’s safety, efficacy and benefits, adding, “No decisions will be taken until the main JVCI present their recommendations to ministers for consideration” (BBC News, 9/22).

Officials at the World Health Organization’s Asia-Pacific conference in Auckland, New Zealand, on Friday said a resolution calling for universal HIV/AIDS treatment access was withdrawn after U.S. delegates proposed amendments, including removing wording that supported the use of needle-exchange programs to curb the pandemic among injection drug users, the AP/International Herald Tribune reports. Health officials from across the region on Thursday called for universal access to treatment for all HIV-positive people who need it by 2010. U.S. officials, in addition to a dispute over the needle-exchange provision in the resolution, had differences with the resolution’s wording on high-risk groups — including IDUs, commercial sex workers and men who have sex with men — Richard Nesbit, WHO acting regional director, said. New Zealand Health Minister Pete Hodgson, chair of the meeting, said “[H]aving ascertained that no resolution would do no damage … I put it to the meeting that we would be better off to have no resolution than one that was perceived to be weakened.” Hodgson said the U.S. “position is that if they have needle exchanges, then people will use needles more and use intravenous drugs more,” adding, “I think it is demonstrably wrong. New Zealand has had needle swaps for 20 years. It has been an amazing success.” According to the AP/Herald Tribune, U.S. officials declined to comment (Mason, AP/International Herald Tribune, 9/21). U.S. foreign aid cannot be used to provide funding or services to programs that include needle exchanges. The U.N. Office on Drugs and Crime in 2005 at the 48th session of the Commission on Narcotic Drugs in Vienna, Austria, adopted the U.S. position opposing needle exchanges (Kaiser Daily HIV/AIDS Report, 6/29/05).

Staff members for House Republican leaders on Thursday submitted proposed changes to the fiscal year Homeland Security spending bill that would “weaken prescription drug reimportation provisions” lawmakers agreed to earlier in the day, CongressDaily reports (Cohn, CongressDaily, 9/22). On Thursday, House and Senate negotiators on a $33.7 billion FY 2007 Homeland Security appropriations bill reached a tentative agreement on prescription drug reimportation provisions that have delayed passage of the legislation for several days. Under the agreement, the final Homeland Security appropriations bill would include a provision under which U.S. residents could personally transport as much as a 90-day supply of prescription drugs from Canadian pharmacies. The provision would not allow U.S. residents to purchase prescription drugs from other nations through the Internet or by mail. The Senate in July voted 68-32 to approve an amendment to the Homeland Security appropriations bill sponsored by Sen. David Vitter (R-La.) that would prohibit seizures by U.S. Customs and Border Protection of prescription drugs purchased from Canadian pharmacies by U.S. residents. The House has approved two appropriations bills — Homeland Security and Agriculture — with provisions that would allow the purchase of prescription drugs from other nations. The provision included in the House Homeland Security appropriations bill would allow the purchase of prescription drugs from any nation (Kaiser Daily Health Policy Report, 9/22). The changes proposed Thursday would permit people in the U.S. to purchase drugs for personal use from other countries only with “documentation of intended use from a U.S.-licensed physician responsible for the individual’s treatment.” The proposed prohibitions also would apply to biological products, including infused drugs, such as dialysis solution; injected drugs; drugs that are inhaled during surgery; and drugs that are intended for topical use or in the eyes. Rep. Jo Anne Emerson (R-Mo.), who wrote the original proposed amendment allowing the overseas purchase of medications by mail or through the Internet, said the proposal is a “deal-breaker” that would serve to “basically gut the entire intent” of the previous compromise. A spokesperson for the House Appropriations Committee said, “We are working with the conferees to develop an acceptable compromise” (CongressDaily, 9/22).