Crowding in emergency rooms (ERs) has been an increasing problem in the developed world for the last few decades, especially in the United States. However, the political and medical arenas are not appropriately addressing this problem as from 1995 to 2009 annual ER visits in the U.S. increased by 41% (96.5 million to 136.1 million), but the number of hospital ERs have decreased by 27% (2,446 to 1,779)1-3 Among U.S. ERs in 2010 a mere 31% achieved their triage targets and only 48% were able to admit patients within 6 hours of registration.4 One of the immediate problems with this overcrowding problem is that it has become a normal occurrence. How could ERs effectively respond to outbreaks of highly contagious pathogens, industrial accidents, terrorist attacks, etc. if currently over half of the non-critical patients have to wait 6+ hours before receiving treatment? Apart from disasters ER crowding increases patient mortality, reduces quality of overall care, impaired transport access and increases financial losses and stresses. Also note that ER crowding is not a unique problem to market economics, but also affects countries with universal systems of medicine like Canada, Australia, New Zealand, etc., thus the passage of the Affordable Care Act will not systematically result in a reduction in crowding.
ER operations have numerous metrics to measure the effectiveness of operations, but typically the most commonly used ones are length of stay (LOS), % of patients who leave without being seen (LWBS), wait time (WT), and ambulance diversion (AD).5,6 However, while these metrics are commonly used, they should not be utilized in a vacuum because some ERs do not even have the ability to divert ambulances and patient wait metrics like LOS and WT are influenced by case complexity. Another concern about these metrics is that most of them are rarely made public nor are there set standards regarding quality, thus it is difficult to have common up-to-date information to determine whether or not a given community is receiving adequate medical care in both absolute and relative terms.
Opposite the fast-paced ambulatory delivery of a critical patient into an emergency room who is immediately admitted, the general operation of an emergency room from the perspective of an individual who enters outside an immediately apparent life threatening condition is as followed:
First, the attending nurse (rarely a physician) conducts a basic triage. Triage itself typically adheres to the Emergency Severity Index (ESI), which is a 3 or 5-tier categorization that combines urgency with an estimate of the resources required to treat the condition.7-9 In the original, now less common 3-tier system the three groups are: immediate treatment required (emergent); urgent, but not currently life or permanent health threatening; or minor condition that can be addressed in time (non-urgent); obviously these categorizations are required to ensure the best and most appropriate care for all potential patients.
In the 5-tier system an additional two groups are added: resuscitation and less urgent making the whole tier structure – 1) resuscitation; 2) emergent; 3) urgent; 4) less urgent; 5) non-urgent.8,9 Realistically the addition of these two new tiers seems rather unnecessary because resuscitation is an obvious choice for immediate treatment not requiring its own category and the difference between less urgent, urgent and non-urgent is marginal. However, it seems to work and does not appear to create significant complications with its seeming unnecessary redundancy.
Clearly individuals with urgent conditions should be seen by physicians before individuals with minor conditions even if the individual with a minor condition arrived first. Triage typically involves acquiring major vital signs (temperature, pulse, respiratory rate, blood pressure, etc.) and a short interview to assess what the patient is feeling and the major details regarding medical and medication history. Depending on the type of classification the new patient will be placed in a certain position on a waiting list.
The triage system typically functions under a scoring system to evaluate the condition of the individual. In addition to physical scoring, physiological scoring is also used to address urgency for treatment. Utilized scoring systems include APACHE II (which is also the most common ICU system to measure prospective mortality), SAPS II, MODS, PRM and GCS (becoming more popular due to its simplicity, sensitivity and specificity).10-14 Scoring systems have also demonstrated that ER care is significantly more important than follow-up care in the ICU showing significant drops in predicted mortality for proper ER care.15 In addition to the older tests, a newer test, the Mortality in Emergency Department Sepsis Score (MEDS), was recently been developed to predict the probability that ER patient contract an infection that could increase complications and/or mortality.16
While tests like APACHE II, SAPS II and MODS are important analysis elements, the development of new ER specific scoring systems like MEDS is important because the older systems were designed to measure illness severity and mortality risk probabilities in a less time dependent nature within the confines of an ICU whereas the ER environment is fast-paced and more time dependent creating a lead-time bias.10,15 Factors that are considered important for ER based scoring systems include: 1) variables that reflect pre-hospital illness severity; 2) illnesses that can be contracted from the ER; 3) ability to be incorporated into a multi-center database with sufficient size and power to validate the model’s accuracy; 4) analytical ability for the relationship between the predictive variables and actual patient outcome for calibration and reliability measurement; 5) secondary predictive effects beyond simple mortality to measure LOS, WT and return visits; 6) use of time-indexed variables to reflect treatment response during care.10,17,18
While a nurse typically governs triage, some studies have suggested that when a physician is in charge of triage instead of a nurse various performance metrics like LOS, LWBS and AD all decrease.19-21 Of course the trade-off for this potential improvement is an increase in cost due to hiring another physician. Otherwise in-room care for patients that have moved from the ER waiting room to an exam or operating room will suffer because of the lack of a physician or one being stretched between exams and triage.
Second, individuals who do not require immediate treatment enter the registration process where the patient officially registers as a patient, which involves filling out all of the relevant paperwork familiar to any first-time patient in a general practitioners office. This step is relevant to consolidate all relevant information including a more detailed medical history and payment information (insurance, etc.). These details are important to create a single medical record that can be referenced during the patient’s stay in the ER. It is important to note that a number of people incorrectly believe that an uninsured individual receives free medical care when going to an ER. This is not correct. The Emergency Medical Treatment and Active Labor Act of 1986 only obligates ERs to care for individuals regardless of ability to pay. Uninsured individuals that receive care from an ER still receive a bill for the services rendered. If they are unable to pay the bill then their credit score is negatively affected and if the hospital/physician so desires they can be sued for the amount. This billing is why uninsured individuals in the past did not go to the ER for every little thing that may be wrong with them.
Afterwards the ER visit proceeds similar to an standard physician visit where when it is an individual’s turn the individual enters an exam room where a nurse reassesses blood pressure and temperature, and if necessary draws blood and/or collects a urine sample for lab testing purposes. Next a physician visits the patient and after a brief discussion makes a differential diagnosis. After the diagnosis for conditions that are not immediately critical the patient is prescribed a treatment and sent home.
One of the major reasons critics cite for continued difficulty in transforming ERs to better manage their patient flow is their tradition/culture. As described above the standard operation of an ER is one person – one task with little intra-staff interaction, a methodology that in the era of computers and multi-tasking is viewed as inefficient and costly. A significant amount of this inefficiency comes from having different doctors and nurses repeat information gathering due to lost or “mistranslated” previous attempts. This problem is augmented by poor coordination among providers, which are typically highly fragmented encompassing multiple emergency medical service agencies with different standards and different practices to the point where agencies in different, but adjacent jurisdictions have difficulty communicating. This coordination is difficult due to turf wars and because transport options are limited.
To maximize the effectiveness of reform interventions dramatic improvement in intra and inter-hospital coordination will be required including standardization of procedures and practice. Incorporation of electronic health records would help in managing this concern, but applying electronic health records for an ER is significantly more difficult than a standard physician office due to the required pacing and lack of consistency in the repeat visitation of patients. Unfortunately in addition to the incorporation of electronic health records, the expanded coordination discussed above has always been the go-to solution and the general dream of individuals trying to address crowding problems, but this coordination is very slow to developed despite the desire to produce it.
One strategy to increase coordination is to increase multi-tasking. However, while some cite some limited studies about the improved efficiency born from multi-tasking there is concern about expanding this strategy for other studies suggest that demonstrated reduced cognitive efficiency in individuals who engage in multi-tasking versus focusing on a single task and then moving on to a secondary task.22 Reduced cognitive efficiency would increase the probability of medical errors and increase the probability of detrimental medical outcomes including death. In addition the demographic of ER patients and the seriousness and complexity of their conditions are changing with more older patients with chronic conditions and multiple co-morbidities with younger patients having fewer non-urgent and more semi-urgent and urgent visits.23 Increase the level of complexity in condition and diagnosis while decreasing the attentiveness and focus will further increase the probability of negative outcomes.
One of the past arguments rationalizing ER crowding was that too many uninsured individuals used the ER as a primary care physician because the lack of insurance dramatically reduced their ability to schedule appointments with general practitioners. Individuals who frequent the ER constantly are referred to as “frequent flyers” and typically make up 8-14% of ER patients and were thought to include large numbers of uninsured individuals.24 Therefore, one solution was increasing the probability that these individuals get insurance so instead of going to the ER they would go to a general practitioner to receive general medical care. Unfortunately this solution, while sound in theory, has not followed theory in reality. Both the expansion of insurance availability in Massachusetts in 2006 and various other states through the ACA have resulted in increases in ER patients with state based insurance (Medicare, Medicaid).25 So why is reality apparently trending contradictory to theory?
Two principle reasons jump to mind. First, most common analysis overestimated the number of individuals with no insurance who were using the ER for basic and principle medical care. While frequently flyers make up anywhere from 8-14% of the total patients during the day, most of these individuals have insurance. Recall that the ER is only bound to treat individuals regardless of ability to pay ensuring that they will receive treatment. However, that treatment is not free. Therefore, in the past individuals without insurance who received medical care from an ER would still have to pay for those services. It stands to reason that these individuals would not attend the ER constant because if they could not afford insurance, then they would not have consistent levels of disposable income to cover numerous ER visits for every nick and scrap.
This rationality hints at the second reason for why ER patients have increased. The primary assumption was that uninsured individuals would stop attending the ER when they received insurance. However, what appears to be happening is that previously uninsured individuals are actually attending the ER more often. The reason behind this behavior is probably derived from the fact that government sponsored insurance has significantly increased the number of individuals with insurance while the number of available general practitioners that are able to service these newly insured patients as well as past/current insured patients has increased at a much slower rate. Therefore, there are significant shortages between insured patients and available doctors to see them via appointment. With the lack of consistency in acquiring an appointment with a general practitioner, the consistency of an ER is appealing. The only real ways to resolve this behavior is train and certify more general practitioners, something that will not happen in the immediate future.
Interestingly enough this premise of ER crowding due to uninsured individuals using the ER for basic medical care in the past is not supported by research. Research suggests that while it was initially reported that this input factor was meaningful26,27 that initial interpretation was probably incorrect. ED crowding is more influenced by sickly and chronic patients who are admitted to the hospital than individuals who have minor injuries and are sent home after routine care/check-ups.28-32 Not surprisingly hospital occupancy (i.e. the number of available beds) versus the number of patients, which leads to boarding, is the strongest element correlated to length of stay in the ER and overall wait times.31,32 Other smaller factors leading to crowding are inappropriate ambulance diversion and direction33 and recently discharged inpatients looking for additional care under various motivations.34 However, as mentioned above boarding due to a lack of bed is the chief element responsible for ER crowding.
The most important consideration when identifying possible solutions to ER crowding is to create a standardized evaluation system to determine which solutions are effective, which are not effective and which are mediated by unique environmental conditions (i.e. effective for one particular hospital, but not for another). Developing this evaluation system would also make it much easier to assign accountability and measure overall and sector specific performance to create effective strategies to correct any problems. In addressing “quality” the Institute of Medicine (IOM) defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” and described six dimensions of quality care: a care that is safe, effective, patient centered, timely, efficient, and equitable.35
Not surprisingly various individuals have suggested that to measure the true value of a system an ER must be evaluated on the application of evidence-based medicine. While this solution should be effective it is sometimes difficult to coordinate the necessary information to ER doctors who typically have little downtime and do not want to spend it reading the latest meta-study. Ideally the practice of extensive evidence-based medicine is one of the dreams of incorporating technology into hospitals to the point where a physician can simply type a condition into a computer and the most effective treatments (as defined by existing evidence) with their corresponding caveats would appear. Unfortunately this reality has not arrived, but a less efficient substitution strategy involves conducting frequent physician meetings for brief reviews of the newest treatment strategies.
Some have suggested that patients define whether or not the quality metrics have been met through evaluations. However, patient evaluation is troublesome because patients may regard elements or instances of discomfort through their own personal lens without understanding or acknowledging the bigger picture. For example a patient may want a glass of water, but due to nurse/physician preoccupation in other more pressing tasks this individual waits a long time before getting the water and possibly develop a slight case of dehydration while waiting. For the patient such an event could easily be worth a quality demerit, but from the perspective of the hospital such an event is irrelevant. Similarly patients are not aware of a significant amount of “behind the scenes” actions relative to their treatment, thus have incomplete information regarding overall treatments and may mischaracterize certain outcomes as poor or negative. This is not to say that patients should not have the ability to make evaluations of their care, but it must be understood that there is high probability that those evaluation cannot be viewed as accurate inside the vacuum of the patient’s own opinion.
Another idea would be to create a small group of government based auditors who would periodically visit ERs and after observation and various informal interviews these individuals would evaluate ER performance and quality based on a series of standardized evaluation metrics. Under this system the bias of patients can be neutralized by an individual who has an understanding of a bigger picture and the bias of the ER authority will be eliminated by a neutral un-invested individual as well as dramatically reduce the time requirements that would be required for mandatory employee based evaluations. The one major drawback to this method would involve producing additional money to fund these government-sponsored auditors.
As mentioned above creating an effective evaluation system will increase the ability to produce quality solutions. Currently one of the most obvious solutions to addressing ER crowding is to reduce boarding. Boarding is the official term to describe when a patient who cannot be moved into an inpatient unit due to a lack of beds remains in the general ER area and receives periodic treatment within. During normal operating hours boarding represents anywhere from 20-40% of the total ER patient population.36 Boarding levels are also significantly influenced by financial decisions in effort to maximize hospital revenues. Not surprisingly average revenue per patient is higher for non-ER admissions than for ER admissions,37 thus hospitals favor giving beds and rooms to those higher value patients leaving ER patients waiting for a bed. The easiest method to reduce boarding is to increase the number of beds available in a hospital. However, this method costs significant amounts of money not only for the beds, but also for hospital expansion to place the beds. Hospitals have already attempted to increase bed number by placing more beds in single rooms, but this strategy can reduce patient welfare being counterproductive.
Some argue that how the bed is utilized also needs to be considered. There are two major types of beds: observation and inpatient. Observation beds are less costly to construct and staff due to building code requirements and upkeep relative to the patients that utilize them.38 In addition in Certificate of Need states constructing additional observation beds do not require the approval of a state agency unlike constructing additional inpatient beds.38 However, when constructing beds in general it must be understood that there are diminishing returns based on changes in patient inflow and medical requirements. Roemer’s Law is frequently cited when considering bed expansions because if one expands bed capacity one is expected to need it and use it. In some context similar to the psychology behind the Jevons paradox if beds are constantly used then the perception for more beds typically results. Basically there appears to be a positive feedback between bed capacity and number of beds used, which may create an inverse relationship where increased capacity increases demand rather than addresses it.39 Thus characteristics behind bed addition must be carefully analyzed before it occurs.
While the metric behind the need to increase bed occupancy is not standard, some research has suggested that a consistent level of 85% during measurements taken at midnight is the minimum level required before beds should be added.40 Note that the average “midnight census” typically calculates the minimum level of occupancy in a given day. The principle reason for this characteristic is the process of the “23-hour patient”. These types of patients are admitted in the morning and discharged in the late evening as a means to allow for evaluation of patients, yet avoiding unnecessary hospitalization. While estimating the difference between the midnight census and the actual occupancy is not universally deterministic most estimate a 5-15 absolute percentage point increase from the midnight census percentage value.40 However, it must be noted that the “23-hour patient” was a popular strategy in managed care, with the ebb and flow in the popularity of managed care it is difficult to estimate how significant this strategy will have in the future.
85% occupancy is the target more cited by professionals and in research, but this figure is typically applied universally not considering the size of the hospital and the number of people that seek medical services. Due to a lack of economies of scale and usage flows, smaller hospitals should have smaller target levels because they will typically have a smaller number of beds creating a greater sense of urgencies when facing greater than average patient visitation. For example if hospital A has 100 beds, an 85% occupancy utilizes 85 beds leaving 15 free; however, hospital B may only have 35 beds, an 85% occupancy utilizes 30 beds leaving only 5 free placing them in more danger for exceeding capacity on an above average admittance day.
Also there are some elements that must be considered including the difference between certified beds and staffed beds. Certified beds are those that are approved by authorities for use on a permanent basis and have been deemed to have sufficient staff to support its use where staffed beds are those that designated only for inpatient or day case care. One commonly suggested improvement to manage bed use is to establish a management program run by a “bed team” who would operate discharge, facilitate rapid turnaround of newly vacated beds, initiate ambulance diversion, and assign waiting patients to an inpatient bed.35 Unfortunately for most hospitals increasing the number of beds is not a viable option without a significant increase in funding, a result that is not forthcoming from state or Federal legislatures.
Another popular method that has been explored to improve ER crowding is the “fast track”. Broadly stated “fast track” is a system designed to process lower acuity patient quicker in order to increase bed turnover and reduce boarding.41 Individuals with injuries like superficial wounds, minor allergic reactions, small bone fractures and minor burns are typical fast track candidates. Interestingly enough fast tracking patient with minor injuries is not new and has been utilized by a number of ERs since the late 1980s.41 Due to this significant penetration fast tracking has been studied the most of any ER reform strategy and has demonstrated reductions in LOS and WT,42-44 yet almost all of this study has focused on LOS and WT and not whether or not patient safety outcomes are improved. One of the concerns with evaluating the efficacy of fast track is that there really is no standard evaluation protocol instead many hospitals have their own rules and criteria. While fast track proponents sing its praises, the overall ability to expand fast tracking is limited because most studies estimate fast tracking only encompasses 10-30% of the total patients seen in an ER and any gains seen when applying a fast track strategy only occur during peak hours.43,45,46
Unfortunately benefits from fast track only emerge when patients are discharged, not streamed through hospital admission.46 Also fast track benefits may be negatively impacted in the future because it largely depends on eliminating technological diagnostic procedures (blood tests, x-rays, CT scans, etc.) versus physical cues that can be evaluated by physicians. The need for diagnostic procedures will more than likely increase in the future as the number of elderly patients with more extensive health histories continue to increase in the future. This demographic change in ER population will not eliminate the advantages of fast track, but should reduce its rate of use limiting its usefulness. This additional testing will add to the already 60-70% of individuals who require laboratory tests when visiting an ER.47
While some strategies have been introduced to reduce testing time like pre-defined test panels for specific symptoms, faster laboratory transportation and early ordering,48 realistically testing takes time and little can be done about it. Some believe that the most useful strategy may be point-of-care testing (POCT) which involves moving laboratory analysis and tests to the ER. As expected undertaking a POCT strategy reduces WT and LOS through a reduction in turn-around time in the laboratory.48 However, a POCT strategy typically involves either large capital expenditure for hospital expansion or giving up space in other areas of the ER which may increase inefficiency and/or boarding for patients with more severe conditions due to a reduction in beds. The potential loss of some beds will be detrimental, but with reasonable expectation in the future for the expansion of primary care from general practitioners (when they eventually start to expand) and the increased need for laboratory services for elderly patients, currently preparation for and utilization of a POCT strategy seems beneficial overall.
A consideration for the increasing elderly population must be made in the scope of ER reform for all signs point to this increase continuing and accelerating. It is projected that demographically elderly patients will increase from approximately 15% to 25-35% of ER visits over the next 30 years.19 As previously mentioned elderly individuals typically require more time and resources for their medical care both on a logistics level (greater medical history) and a biological level (higher probability something can go wrong). Unfortunately there is also a side concern with the elderly. Typically seniors have fewer travel options than younger individuals and may have difficulty attending routine physical examinations (from general practitioners or the ER) even if appointments can be made. Therefore, this lack of option for travel can increase the probability that these elderly individuals put off medical care until it becomes critical creating a problem from nothing.
Another issue with the elderly is that nearly 25% of nursing home residents visit the ER at least once per year.49 Unfortunately a number of nursing homes tend not to promote good health, but instead attempt to simply keep their residence alive, thus those who are suffering from deteriorating health continue to have failing health. This “strategy” produces ER patients that are typically in poorer health than those elderly individuals who live on their own, about 67% of nursing home ER patients have cognitive impairment50 that complicate medical history collection and the nursing home records are rarely helpful. In fact 10% of nursing home ER patients arrive without any written medical documentation and 90% have significant gaps in their histories.51-53 Thus there is little coordination between ERs and nursing homes, largely because it appears that nursing homes do not care enough to apply the effort. However, ERs do need to be more diligent in ensuring that elderly patients across the board receive more clearly written instructions regarding their outpatient care.
Addressing current and future crowding in the ER will first require the development of a standard definition for quality and measurable components that encompass that definition because it is difficult to identify and classify problems when those problems cannot be identified. Independent government sponsored auditors, to ensure effective care and root out any problems quickly, should periodically evaluate these quality metrics. ERs should develop strategies to better manage beds through understanding real average occupancy values, not those taken from overnight values, to determine where there are excess beds and where/when bed demand is greatest. Finally it should be useful to study strategies that will increase the ability to manage elderly patients due to the logical expectation that their ER demographic will increase in the future. It stands to reason that areas with large elderly populations and quality ER service should have some effective strategies that can be applied to other ERs. Overall there are solutions that can be applied to the problem of ER crowding, but it is important that individuals ask the right questions and appreciate the change in future trends rather than declare simplistic panaceas like the incorporation of electronic health records.
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Citations –
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Showing posts with label healthcare. Show all posts
Showing posts with label healthcare. Show all posts
Friday, June 27, 2014
Wednesday, March 26, 2014
Transparency in Medical Care
There is a concern that one of the principle reasons for why healthcare costs are so expensive and why the Affordable Care Act (ACA) will have a limited influence on healthcare costs is that there is little direct information pertaining to prices for given services. This “blind” pricing creates an environment of uninformed consumption where individuals hope that they receive a competitive/fair price rather than know they got a competitive price. Therefore, some individuals believe that if hospitals and other medical institutions list their prices for given services consumers will be able to comparison shop using market forces and competition to lower prices. To this end a number of proponents for this form of transparency hope for the establishment of a procedure marketplace similar in design to existing online booking agents like Expedia, Travelocity, etc.
Note that a number of transparency sites already exist operated by various insurance companies. Some of these insurance companies, like Cigna and United Healthcare, have sites that are fairly effective at demonstrating to consumers differences in price between various hospitals for various procedures whereas others like Healthnet and Kaiser Permenente have sites that fair badly at accomplishing this goal.1 Unfortunately most people do not realize that these sites exist because few people actually use them. It stands to reason that the existence of these individual sites provides support for the creation of a centralized procedure marketplace. However, there are some important issues that must be addressed before this new procedure marketplace (PrMa) could be developed.
First, it is not accurate to compare medical services to consumer goods like pears or toilet paper. The principle distinction between these two categories is that there is a limited supply market for medical services, which involve inherent price modifiers. Basically there are only a limited number of physicians and surgeons that can perform a given examination or procedure. Therefore, even if hospital A offers a lower price on an angioplasty versus hospital B there are only so many angioplasties hospital A can perform, thus the influence of the lower price on business gained for hospital A and business lost for hospital B is conditional and limited; depending on the market size this limit may allow hospital B to avoid lowering their prices even in a transparent and competitive environment and yet retain the same number of patients/customers.
Another problem is that supporters of a PrMa appear to view it in the most simplistic manner possible where all parties pay for medical services out of their own pocket rather than utilize health insurance as a cost modifier. Clearly this presumption is inaccurate, especially after the passage of the ACA placing a mandate on health insurance coverage for all citizens of the United States. Therefore, any transparency in prices will need to include the reduced negotiated rates by given insurance providers as well as co-payments and deductibles for given plans in addition to clear information regarding hospitals that are in a given network. Even if transparency is created for these elements there still exists significant price inelasticity based on the factors tied to the insurance companies.
Extending on this above point is a major reason Expedia and similar sites work is because consumers can select any flight from any participating airline and the price shown is the price paid, there are no second party negotiations creating changes in that price. Airlines participate because there is typically a glut of supply (available seats) and selling a seat at a 20% discount is superior to not selling a seat at all and this sale is more efficient on Expedia and other similar sites. A PrMa site could not produce similar results because there is more complexity. Due to a limited number of surgeons and operating venues there is a supply-based limiting factor that heavily influences the ability to profit due to volume for healthcare providers. Therefore, hospitals are going to charge as much as they can in order to maximize profits. This limiting factor makes it difficult for insurance companies to undercut a competitor to increase customer number; this fact also ignores the ease of switching insurance companies.
This limiting factor creates an environment where health insurance companies do not have ultimate bargaining power with healthcare providers. There is a limit to how much of a “discount” health insurance companies can negotiate based on competing profit potential for both insurance companies and hospitals. Finally based on market segregation of health insurance there is little reason for health insurance companies to participate in such a website. Due to the limiting supply factor it stands to reason that they would be as likely to lose money as make money, thus there is no real reason for any to actually participate in such service unless required by law.
The problem is further complicated in that customers purchasing plane tickets have a greater level of flexibility increasing the value of the transparency. For example suppose a person wants to travel to Miami and one week later wants to travel to Stockholm. The lack of contract between different airlines allows this individual to purchase a ticket from carrier A for price x to travel to Miami and then purchase a ticket from carrier B for price y to travel to Stockholm. In a PrMa the consumer is tied to their insurance company. Person A cannot easily switch insurance companies even if another insurance company has negotiated a lower price on a particular surgery at hospital A. Basically this restriction limits most consumers to only comparing prices between different hospitals not different insurance companies. Even for those shopping for new health insurance policies have difficulties because of a lack of knowledge regarding what procedures they would need in the future.
Worse still there are significant legal questions associated with transparency laws that conflict with gag clauses, most favored nation/provider arguments and possible trade secrets. Gag clauses are the most concerning challenge disallowing the publication of provider-insurer contracts. Arguments on the grounds of trade secrets and most favored providers are usually fairly soft and are cited more for their ability to act as a litigation threat versus their legal viability; however, courts have become more corporation friendly in the past decade and could buy an argument regarding the way a price is negotiated between insurance company and healthcare provider as a form of trade secret as strange as it sound intuitively for revealing a final price would not reveal any negotiation strategy.
Other concerns are that such a pricing tool would only be applicable for preventative or chronic care versus acute/emergency conditions for individuals suffering from a stroke could hardly compare prices on the Internet or telephone on which hospital to be rushed to for lifesaving surgery. Also unlike airlines, prices for medical services are influenced by geographical cost of living because they are not as volume flexible. Therefore, it must be guaranteed that new competitive transparency does not lead to such a great price reduction that it hurts healthcare workers. Clearly due to their earned skill set physicians will have salary security, but nurses, medical technicians and other “more disposable” hospital personnel could be fired or receive a cut in salary in order to maintain hospital profits if prices drop significantly due to increased competition. This salary cut could damage the overall care in the hospital because cost of living for a given region would create an inherent price and salary floor creating staffing shortages.
One concern that may not be imperative to address is the alteration of hospital and insurance billing practices. Some individuals believe that hospital and insurance billing need to be changed to more specific invoice-like documents with less medical and/or technical jargon so consumers can easily identify what goods and services are charged at what prices. However, an itemized breakdown of price may not be necessary because consumers don’t care about what each individual item involved in a medical procedure costs, they only care about the total cost of the procedure. For example patients staying overnight for observation do not need to know how much hospital food, catheters and pain medication cost individually, just the total cost of spending the night.
However, there is an important consideration for multiple pricing in a transparent real-time marketplace. By necessity hospitals outsource certain responsibilities to other medical service providers (radiologists, anesthesiologists, etc.) where some of the large price tag procedures require multiple bills from these multiple service providers. Therefore, diligent maintenance of transparency will be required to track each time a specific provider changes the price for his/her/its services to ensure accuracy in the overall price.
Fortunately one of more easily solvable concerns is that prices need to be intertwined with quality of the service. There is a natural psychology for consumers to equate a lower price with lower quality, especially if the difference in price is hundreds to thousands of dollars. Therefore, safety records for hospitals will need to be referenced in addition to the price for their services otherwise individuals may be reluctant to select lower priced service options defeating the entire point of price transparency.
Another significant concern that is seemingly never considered by PrMa proponents is that these direct price comparison tools may actually increase costs instead of reducing them. The idea of transparency functions on a general principle of capitalism that businesses with a common product will compete against each other because it is generally thought that consumers should migrate to the lower priced good, quality being similar; however, what individuals typically forget about this principle is that a goal of modern capitalism is to maximize profits.
Current gag clauses between hospitals and insurance providers limit the information that insurance providers and hospitals have to maximize profits. For example suppose hospital A charges $1,000 for a service and hospital B charges $2,500 for a service. In the current environment this difference is not readily known even between hospitals. In most versions of the transparent environment desired by proponents this information would be available to all parties. What stops hospital A from raising their price on the particular service from $1,000 to $2,000 instead of hospital B lowering their price from $2,500 to $1,250? This possibility should be a serious concern for transparency proponents.
Currently it appears that a dream of creating an Expedia-like website for comparison of prices and quality of care for various medical procedures will be very difficult, if not impossible to achieve. A better option would be focusing on expanding the transparency procedure comparison websites that some health insurance companies have already set up. Creating state and federal statutes to expand the details, features and accuracy of these websites on an individual basis should effectively deal with large disparities in price between hospitals and other medical providers. The reason this strategy will work is that individuals cannot jump between insurance companies and their respective coverage easily and the ACA demands all individuals have health insurance or face a fine; after a few years this fine will be of sufficient size that almost all individuals will have health insurance. Therefore, if all insurance companies have effective price transparency websites, those run by Cigna and United Healthcare are a suitable start, then consumers who are already “locked-in” to company will have a website that will help them plan for more cost effective medical treatment. Overall transparency procedure proponents should focus on the creation and optimization of these individual websites and phone information tied to specific insurance companies due to their ease of establishment and greater effectiveness versus a broad all-encompassing system.
--
Citations –
1. http://www.pbgh.org/component/content/article/10/199-health-plan-shopping-services-evaluation
Note that a number of transparency sites already exist operated by various insurance companies. Some of these insurance companies, like Cigna and United Healthcare, have sites that are fairly effective at demonstrating to consumers differences in price between various hospitals for various procedures whereas others like Healthnet and Kaiser Permenente have sites that fair badly at accomplishing this goal.1 Unfortunately most people do not realize that these sites exist because few people actually use them. It stands to reason that the existence of these individual sites provides support for the creation of a centralized procedure marketplace. However, there are some important issues that must be addressed before this new procedure marketplace (PrMa) could be developed.
First, it is not accurate to compare medical services to consumer goods like pears or toilet paper. The principle distinction between these two categories is that there is a limited supply market for medical services, which involve inherent price modifiers. Basically there are only a limited number of physicians and surgeons that can perform a given examination or procedure. Therefore, even if hospital A offers a lower price on an angioplasty versus hospital B there are only so many angioplasties hospital A can perform, thus the influence of the lower price on business gained for hospital A and business lost for hospital B is conditional and limited; depending on the market size this limit may allow hospital B to avoid lowering their prices even in a transparent and competitive environment and yet retain the same number of patients/customers.
Another problem is that supporters of a PrMa appear to view it in the most simplistic manner possible where all parties pay for medical services out of their own pocket rather than utilize health insurance as a cost modifier. Clearly this presumption is inaccurate, especially after the passage of the ACA placing a mandate on health insurance coverage for all citizens of the United States. Therefore, any transparency in prices will need to include the reduced negotiated rates by given insurance providers as well as co-payments and deductibles for given plans in addition to clear information regarding hospitals that are in a given network. Even if transparency is created for these elements there still exists significant price inelasticity based on the factors tied to the insurance companies.
Extending on this above point is a major reason Expedia and similar sites work is because consumers can select any flight from any participating airline and the price shown is the price paid, there are no second party negotiations creating changes in that price. Airlines participate because there is typically a glut of supply (available seats) and selling a seat at a 20% discount is superior to not selling a seat at all and this sale is more efficient on Expedia and other similar sites. A PrMa site could not produce similar results because there is more complexity. Due to a limited number of surgeons and operating venues there is a supply-based limiting factor that heavily influences the ability to profit due to volume for healthcare providers. Therefore, hospitals are going to charge as much as they can in order to maximize profits. This limiting factor makes it difficult for insurance companies to undercut a competitor to increase customer number; this fact also ignores the ease of switching insurance companies.
This limiting factor creates an environment where health insurance companies do not have ultimate bargaining power with healthcare providers. There is a limit to how much of a “discount” health insurance companies can negotiate based on competing profit potential for both insurance companies and hospitals. Finally based on market segregation of health insurance there is little reason for health insurance companies to participate in such a website. Due to the limiting supply factor it stands to reason that they would be as likely to lose money as make money, thus there is no real reason for any to actually participate in such service unless required by law.
The problem is further complicated in that customers purchasing plane tickets have a greater level of flexibility increasing the value of the transparency. For example suppose a person wants to travel to Miami and one week later wants to travel to Stockholm. The lack of contract between different airlines allows this individual to purchase a ticket from carrier A for price x to travel to Miami and then purchase a ticket from carrier B for price y to travel to Stockholm. In a PrMa the consumer is tied to their insurance company. Person A cannot easily switch insurance companies even if another insurance company has negotiated a lower price on a particular surgery at hospital A. Basically this restriction limits most consumers to only comparing prices between different hospitals not different insurance companies. Even for those shopping for new health insurance policies have difficulties because of a lack of knowledge regarding what procedures they would need in the future.
Worse still there are significant legal questions associated with transparency laws that conflict with gag clauses, most favored nation/provider arguments and possible trade secrets. Gag clauses are the most concerning challenge disallowing the publication of provider-insurer contracts. Arguments on the grounds of trade secrets and most favored providers are usually fairly soft and are cited more for their ability to act as a litigation threat versus their legal viability; however, courts have become more corporation friendly in the past decade and could buy an argument regarding the way a price is negotiated between insurance company and healthcare provider as a form of trade secret as strange as it sound intuitively for revealing a final price would not reveal any negotiation strategy.
Other concerns are that such a pricing tool would only be applicable for preventative or chronic care versus acute/emergency conditions for individuals suffering from a stroke could hardly compare prices on the Internet or telephone on which hospital to be rushed to for lifesaving surgery. Also unlike airlines, prices for medical services are influenced by geographical cost of living because they are not as volume flexible. Therefore, it must be guaranteed that new competitive transparency does not lead to such a great price reduction that it hurts healthcare workers. Clearly due to their earned skill set physicians will have salary security, but nurses, medical technicians and other “more disposable” hospital personnel could be fired or receive a cut in salary in order to maintain hospital profits if prices drop significantly due to increased competition. This salary cut could damage the overall care in the hospital because cost of living for a given region would create an inherent price and salary floor creating staffing shortages.
One concern that may not be imperative to address is the alteration of hospital and insurance billing practices. Some individuals believe that hospital and insurance billing need to be changed to more specific invoice-like documents with less medical and/or technical jargon so consumers can easily identify what goods and services are charged at what prices. However, an itemized breakdown of price may not be necessary because consumers don’t care about what each individual item involved in a medical procedure costs, they only care about the total cost of the procedure. For example patients staying overnight for observation do not need to know how much hospital food, catheters and pain medication cost individually, just the total cost of spending the night.
However, there is an important consideration for multiple pricing in a transparent real-time marketplace. By necessity hospitals outsource certain responsibilities to other medical service providers (radiologists, anesthesiologists, etc.) where some of the large price tag procedures require multiple bills from these multiple service providers. Therefore, diligent maintenance of transparency will be required to track each time a specific provider changes the price for his/her/its services to ensure accuracy in the overall price.
Fortunately one of more easily solvable concerns is that prices need to be intertwined with quality of the service. There is a natural psychology for consumers to equate a lower price with lower quality, especially if the difference in price is hundreds to thousands of dollars. Therefore, safety records for hospitals will need to be referenced in addition to the price for their services otherwise individuals may be reluctant to select lower priced service options defeating the entire point of price transparency.
Another significant concern that is seemingly never considered by PrMa proponents is that these direct price comparison tools may actually increase costs instead of reducing them. The idea of transparency functions on a general principle of capitalism that businesses with a common product will compete against each other because it is generally thought that consumers should migrate to the lower priced good, quality being similar; however, what individuals typically forget about this principle is that a goal of modern capitalism is to maximize profits.
Current gag clauses between hospitals and insurance providers limit the information that insurance providers and hospitals have to maximize profits. For example suppose hospital A charges $1,000 for a service and hospital B charges $2,500 for a service. In the current environment this difference is not readily known even between hospitals. In most versions of the transparent environment desired by proponents this information would be available to all parties. What stops hospital A from raising their price on the particular service from $1,000 to $2,000 instead of hospital B lowering their price from $2,500 to $1,250? This possibility should be a serious concern for transparency proponents.
Currently it appears that a dream of creating an Expedia-like website for comparison of prices and quality of care for various medical procedures will be very difficult, if not impossible to achieve. A better option would be focusing on expanding the transparency procedure comparison websites that some health insurance companies have already set up. Creating state and federal statutes to expand the details, features and accuracy of these websites on an individual basis should effectively deal with large disparities in price between hospitals and other medical providers. The reason this strategy will work is that individuals cannot jump between insurance companies and their respective coverage easily and the ACA demands all individuals have health insurance or face a fine; after a few years this fine will be of sufficient size that almost all individuals will have health insurance. Therefore, if all insurance companies have effective price transparency websites, those run by Cigna and United Healthcare are a suitable start, then consumers who are already “locked-in” to company will have a website that will help them plan for more cost effective medical treatment. Overall transparency procedure proponents should focus on the creation and optimization of these individual websites and phone information tied to specific insurance companies due to their ease of establishment and greater effectiveness versus a broad all-encompassing system.
--
Citations –
1. http://www.pbgh.org/component/content/article/10/199-health-plan-shopping-services-evaluation
Monday, December 10, 2012
Addressing Pain before it becomes chronic
It is estimated that 50-60% of patients do not receive adequate pain control after surgical or other invasive medical procedures.1,2 Not surprisingly when this pain is not addressed properly there are significant increases in morbidity as well as increases in short-term and long-term medical costs.1,3-9 Some estimate that approximately 116 million individuals suffer from either acute or chronic pain that is not managed properly.10 While there are various, somewhat arbitrary, time periods assigned to the development of chronic pain the general definition is pain that persists beyond the expected period of healing for a given injury. There are two major types of chronic pain: nociceptive, which results due to nocieptor activation (pain receptors) and neuropathic, which results due to damage to the spinal cord or periphery sensory neurons.
One of the initial problems with addressing pain management is the method that is used to evaluate the intensity of pain. While numerous criticisms have been levied against the standard pain numerical reporting system because of its subjective non-uniform nature (a 5 out of 10 for pain for person A may be much different than a 5 out of 10 for person B), little attention is paid to tracking changes in pain progression. Typically post-operative pain is characterized by one or two visits by a nurse with assignment of some pain medication. Basically the pain is viewed as a somewhat static condition that will persist at the recorded level for the duration of the day if not treated by medication. Therefore, one way of better managing pain requires more attentive inquiry regarding how pain is progressing in a patient over the course of a day. Instead of once or twice, inquiries should be made every hour during a normal diurnal time frame for tracking changes. This method will also assist in improving pain management by creating a more reliable evaluation metric for specific treatments. Some seek to measure pain by looking at how certain metabolites change in the bloodstream with time, but with currently limited knowledge of threshold concentrations it is difficult to judge how effective such a strategy would be.
Another problem with pain management is addressing the development of chronic pain. The first question is whether the development of chronic pain stems from improper pain management shortly after surgery or a traumatic event created by improper/inefficient surgery? Based on existing statistics outlining how much long-term pain the population appears to be suffering from it is unlikely that improper/inefficient surgery is the cause of a majority of the chronic pain development. Therefore, this increase in experienced longer-term pain in the population is more than likely due to improper pain management. Unfortunately the current treatment methodology must be flawed in some way because it draws concern that these inconsistencies in effectively dealing with pain arise despite an increase in the overall use of opioids to manage pain.11-14.
While the use of multi-modal analgesia strategies has created sufficient levels of hope in better managing pain, most notably reducing side effects, this hope has not created significantly better long-term outcomes for a majority of people. The inability to attain the potential of multi-modal analgesia is largely due to the large number of variables involved in researching the effectiveness of various technique combinations (dose levels, surgery type, specific genetic factors, analgesic agents, etc.). Basically the individuality demanded by the development and application process reduces a large potential for streamlining and standardizing multi-modal analgesia strategies.
One of the hallmark symptoms of pain is hyperalgesia, which is an increase in pain sensitivity/perception in response to pain inducing stimuli. The typical cause of hyperalgesia is amplification and prolonged nociceptive excitation. Pursuant to this development there is evidence to suggest that current pain management techniques are short-term gain and long-term loss when it comes to addressing pain. One of the most popular choices to managing pain are opioids, especially for acute and chronic cancer pain, but opioids have also started to expand to chronic non-malignant pain. Opioids operate by binding to one of their seventeen different receptors, but three (Mu, Kappa and Delta) are largely responsible for the pain reduction ability of most opioids. Interaction with mu opioid receptors (MOR) either directly or as agonists is the most common pain management pathway. While MORs are expressed on numerous types of neurons the most important with regards to the propagation of pain appear to be the primary sensory neurons called small-sized (C-fiber) and medium sized (A-fiber, specifically Adelta) in the dorsal root ganglia (DRGs).14-17
When molecules interact with MORs they induce presynaptic inhibition that prevents N-type calcium channels from opening, which release neurotransmitters contacting with superficial dorsal horn neurons.18-20 Additional inhibition occurs through activation of G protein-coupled inwardly rectifying potassium channels on dorsal horn neurons resulting in hyperpolarization.20,21 Basically these opioid agonists are effective at addressing pain because of this dual neutralization methodology. Note that there is also some belief of indirect neutralization methods like immune cell activation of opioid receptors.22,23
Unfortunately improper activation of MORs can result in counteracting excitatory activity through the up-regulation of pronociceptive pathways,24,25 which leads to hyperalgesic effects. This specific outcome has been labeled opioid-induced hyperalgesia (OIH). OIH is characterized by increased probabilities for pain in general leading to increased probabilities for the development of chronic pain and tolerance to opioids, which decreases the ability to treat that chronic pain. There is concern that OIH routinely develops into chronic pain due to abrupt inappropriate withdrawals of opioids leading to long-term potentiation (LTP) in the spinal cord. This LTP response is thought to derive from massive activation of NMDA receptor glutamate responses with potential dependency on spinal cord-based TRPV1-expressing afferents along with substance P and chemokines.26-29 OIH can either be acute or chronic.30,31
Focus is applied to spinal cord and DRG LTP because it can develop due to electrical stimulation of appropriate afferents or noxious stimulation (nerve injury or inflammation).27,31-33 One common place for LTP augmentation is at synapses between nociceptive afferents and neurokinin 1 (NK1) receptor expressing projection neurons in lamina I.27 These projection neurons are principally responsible for sending pain signals to the brain.31,34-35 In addition there is similar pharmacology between LTP generation and long-term hyperalgesia.27 Finally LTP development at synapses between C-fibers and superficial dorsal horn neuron is induced by abrupt withdrawal of opioids.26 This is an important distinction because medication in general is typically only administered until symptoms subside. Unfortunately in most situations, including opioid treatment, suddenly stopping medication can result in negative biological consequences.
OIH can ‘leak’ over into the spinal cord by promoting the activation and translocation of protein kinase C, nitric oxide and cholecystokinin and in worst-case scenarios this development can lead to neuronal apoptosis further increasing pain reception problems.36-39 In some respects OIH could be viewed as initially nociceptive and eventually progresses into a neuropathic element.
However, all of this information is still indirect because LTP in the spinal cord with a relation to pain has not been studied directly.27 The lack of direct testing leaves an open question regarding spinal LTP length and how it fully influences the development of chronic pain. LTP for a given group of neurons can last for hours, days, months or a lifetime, but indirect evidence suggests LTP in the spinal cord lasts for several days.27 In this light chronic pain is thought to develop from inhibition of endogenous anti-nociceptive systems or intermittent low-level nociceptive input from periphery neurons. For example pain threshold reduction LTP is also perpetuated to a chronic level through the decreased activity of endogenous anti-nociceptive systems, thus reducing the ‘natural’ abatement adding chronic pain development.
One of tricky elements with addressing OIH is differentiating it from opioid tolerance. When increasing the opioid dosage for treatment of chronic pain the reason for the increase must be identified between opioid tolerance or OIH. In situations of tolerance it may be appropriate to increase opioid concentration depending on the severity of the pain, but in OIH more opioids would result in greater probability of pain. The most common strategy for treating OIH is to cease opioid treatment and substitute a non-opioid analgesic. Unfortunately non-opioid analgesics are typically not as effective as opioids and have their own side effects thus reducing the ability to manage pain.
Differences in analgesic treatment ability has lead to some rotational methodologies where opioids are used for a time and then replaced by non-opioids before a return again to opioids in an attempt to manage pain, but avoid compounding side effects from either treatment. Obviously the success of weaning a patient off of opioids as a means to treat OIH is based on the rate of OIH progression. Unfortunately it is difficult to assess the rate of advancement of OIH in a given patient. However, interestingly enough the future of managing chronic pain may not be developing a new pill or new multi-modal analgesia strategy, but instead developing a strategy where chronic pain does not develop in the first place.
A critical element in the pathway development for OIH is matrix metalloprotease (MMP) concentration. MMPs are a multigene family of tightly regulated zinc-dependent enzymes that maintain homeostasis through their role in tissue degradation and repair.40,41 The two MMPs that appear to play the most prominent roles in pain development are MMP-2 and MMP-9. MMP-9 is frequently released after nerve injury and directs the cleavage of IL-1b.14 Continued cleavage of IL-1b is then governed through a positive feedback mechanism with MMP-2.14,40 There is also suggestion that MMP-9 can interact with NMDA receptors NR1 and NR2B through integrin-beta1 and NO pathways.41 However, MMP-9 influence only seems to occur over a very short time frame (< 24 hrs) for after OIH acquisition to role played by MMP-9 seems to lessen significantly.14
Morphine is one of the most commonly utilized drugs for pain management and is frequently regarded as the standard for comparing the effectiveness of other pain management drugs. Due to its interaction with the μ-opioid receptor morphine chiefly influences in the posterior amygdala, hypothalamus, thalamus, nucleus caudatus and putamen with some associated action in the laminae I and II of the spinal cord. The effects of morphine interaction with its receptor are analgesia and sedation, but can also result in physical dependence.
While morphine is a commonly used pain management drug, its action may have a more detrimental long-term effect in that its interaction with opioid receptors leads to induction of rapid MMP-9 up-regulation. The initial up-regulation occurs in the DRG neurons, not in the spinal cord, and activates pro-nociceptive pathways from the DRG, most notable the cleavage of IL-1b.14 The increased concentration of MMP-9 is not derived from mRNA increases, but translational regulation instead.14 MMP-9 up-regulation does occur in the spinal cord after sustained morphine exposure and could play a role in opioid-induced withdrawal symptoms.41 In some context this biological response could be the body attempting to neutralize the synthetic (non-natural) neutralization of pain possibly in effort to ensure that the mind recognizes that the pain is occurring in effort to cease the pain creating activity, ward off its future application or begin/speed the healing process because pain usually involves some form of injury.
One of the chief aspects of hyperalgesia is the augmentation of Adelta fibers from mechanically insensitive (silent) to mechanically sensitive. This process occurs at high probability in two separate areas: first, during the surgery itself due to cutting an incision and second from MMP-9 up-regulation.42,43 Incision derived hyperalgesia does not rely on NMDA receptor activation, but instead its ‘sister’ receptor a-amino-3-hydroxy-5-methyl-4-isoxazole-propionate (AMPA).30,42 This sensitivity increase applies not simply to pain invoking stimuli, but also non-pain inducing mechanical stimuli due to a reduced mechanical response threshold in Adelta fibers.43 Reduced mechanical response also translates into a much larger spontaneous activity (up from 0% to 38% in Adelta afferents and from 0% to 40% in C-fibers).43 This spontaneous activity may play a role in the facilitation of chronic pain through LTP or mechanical sensitization of nociceptors. Inflammation also is though to reduce this spontaneous firing threshold.44,45 In both scenarios the reduced mechanical response threshold decreases gradually to a new equilibrium instead of all at once. This gradual reduction may play a role in the capriciousness of chronic pain development (different people may have different new equilibriums that are obtained at different rates).
Under most circumstances the application of a NMDA antagonist like ketamine can prevent OIH, but such action also reduces the pain neutralization ability of the administered opioid and studies looking at the benefit of combining opioids and NMDA antagonists have resulted in mixed results.46 Include that result with the significant psychotomimetic side effects (sedation, confusion, and lack of coordination) associated with NMDA antagonists and these types of opioid antagonists are typically only used to address opioid overdoses. Part of the problem with using NMDA antagonists to treat pain directly outside of combination with an opioid is that different molecular organizations of the NMDA receptors due to the three different subtypes, each having multiple isoforms, which results in different binding affinities.47
New strategies for short-circuiting the development of the OIH or other chronic pain pathways could be addressed through two different means. First, prevention of IL-1b cleavage, which is a downstream agent in the pain development pathway, will reduce hyperexcitability of sensory neurons by inhibiting potassium channel opening and increasing sodium channel opening.48-50 A similar alternative would be to prevent IL-1b binding by use of a IL-1 receptor antagonist. Second, the elimination of MMP-2 or MMP-9 could treat chronic pain for MMP-2 appears to be a maintenance pain molecule of some sorts whereas MMP-9 seems to be a trigger.
Some believe one strategy to prevent the development of neuropathic pain is to utilize loco-regional anaesthesia techniques over general anaesthesia.30 Some of the loco-regional agents that are hypothesized to be useful are μ-opioid receptor agonists and clonidine along with antagonists at T-type VGCCs and GABAA receptors.27 At least for major morbidities, the data looks promising for the results of several meta-analyses suggest that use of loco-regional analgesia or continuous paravertebral blockade is associated with decreased risk of postoperative pulmonary complications in patients undergoing upper abdominal and thoracic surgical procedures.51,52
The preoperative use of loco-regional analgesia is also associated with a reduction in respiratory complications after major abdominal surgery, although the effect of loco-regional analgesia might not be as prominent as it was previously, partly because the incidence of respiratory complication has progressively decreased during past years.53 Meta-analyses in patients undergoing high-risk cardiothoracic and vascular procedures suggest that use of preoperative thoracic loco-regional analgesia might decrease pulmonary complications, cardiac dysrhythmias, and overall cardiac complications.54,55 So even if current loco-regional analgesia techniques do not have any significant pain reduction characteristics they have some positive benefits.
However, there may be an even better means to amplify loco-regional anaesthesia through the use of MMP-2 and/or 9 inhibitors in the anaesthesia prior to surgery. By preventing MMP-2/9 activity during the pain inducing surgery itself, it may prevent the pain cascade from initiating at any significant level, thus eliminating the need to large amounts of pain control and the potential for the development of OIH. For example NOV manipulation can inhibit MMP-2 expression in the DHSC and MMP-9 expression in DRG and the spinal cord.56 Under normal pain conditions NOV is down-regulated in DRG and DHSC. One means to increase NOV expression is treat individuals with dexamethasone. However, caution must be taken before utilizing the increase of NOV or a similar agent as a treatment possibility because its influence has different effects on different cells. There is little information regarding what negative side effects may stem from applying MMP2/9 inhibitors immediately prior to surgery, so studies must be done to determine their nature and severity. One important consideration is to create the proper balance of inhibition because of the positive role MMP-9 has in wound healing.57
Overall pain management continues to be problematic in society. With the continued increases in OIH development it is more difficult because unless strict controls are established a common means to treat pain can become a catalyst for its further development. Unfortunately patients have a tendency not to be logical and practical when it comes to pain management for when a person is in pain they tend to do stupid things. It could be a great boon to pain management to develop a strategy to neutralize chronic pain before it even fully develops allowing other analgesia elements to be moved to a secondary strategy to treat more extreme conditions. The pre-surgical inhibition of MMP2/9 could have the potential to be such a strategy.
Citations:
1. Chapman, R, et Al. “Postoperative pain trajectories in cardiac surgery patients.” Pain Research and Treatment. 2012. Article ID 608359. doi:10.1155/2012/608359
2. Wheeler, M, et Al. “Adverse events associated with postoperative opioid analgesia: a systematic review.” Journal of Pain. 2002. 3(3):159–180.
3. Oderda, G, et Al. “Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay.” Ann Pharmacother. 2007. 41:400–06.
4. Ballantyne, J, et Al. “The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials.” Anesthesia and Analgesia. 1998. 86(3): 598–612.
5. Rodgers, A, et Al. “Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.” The British Medical Journal. 2000. 321(7275):1493–1497.
6. Beattie, W, Badner, N, and Choi, P. “Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.” Anesthesia and Analgesia. 2001. 93(4):853–858.
7. Holte, K and Kehlet, H. “Effect of postoperative epidural analgesia on surgical outcome.” Minerva Anestesiologica. 2002. 68(4):157–161.
8. Marret, E, Remy, C and Bonnet, F. “Postoperative Pain Forum Group. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery.” Br J Surg. 2007. 94:665–73.
9. Fischer, H, et Al. “A procedure-specifi c systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty.” Anaesthesia. 2008. 63:1105–23.
10. Institute of Medicine of the National Academies Report (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care Education, and Research. Washington DC: The National Academies Press.
11. Frasco, P, Sprung, J and Trentman, T. “The impact of the joint commission for accreditation of healthcare organizations pain initiative on perioperative opiate consumption and recovery room length of stay.” Anesth Analg. 2005. 100:162–68.
12. Zaslansky, R, et Al. “Tracking the effects of policy changes in prescribing analgesics in one emergency department: a 10-year analysis.” Eur J Emerg Med. 2010. 17:56–58.
13. Manchikanti, L, et Al. “Therapeutic use, abuse, and non-medical use of opioids: a ten-year perspective.” Pain Physician. 2010. 13:401–35.
14. Liu, Y, et Al. “Acute morphine induces matrix metalloproteinase-9 up-regulation in primary sensory neurons to mask opioid-induced analgesia in mice.” Molecular Pain. 2012. 8:19-36.
15. Ji, R, et Al. “Expression of mu-, delta-, and kappa-opioid receptor-like immunoreactivities in rat dorsal root ganglia after carrageenan-induced inflammation.” J. Neurosci. 1995. 15:8156-8166.
16. Wang, H, et Al. “Coexpression of delta- and mu-opioid receptors in nociceptive sensory neurons.” PNAS. 2010. 107:13117-13122.
17. Lee, C, et Al. “Dynamic temporal and spatial regulation of mu opioid receptor expression in primary afferent neurons following spinal nerve injury.” Eur J. Pain. 2011. 15:669-675.
18. Heinke, B, Gingl, E, and Sandkühler, J. “Multiple Targets of mu-Opioid Receptor-Mediated Presynaptic Inhibition at Primary Afferent A{delta}- and C-Fibers.” J. Neurosci. 2011. 31:1313-1322.
19. Kohno, T, et Al. “Actions of opioids on excitatory and inhibitory transmission in substantia gelatinosa of adult rat spinal cord.” J. Physiol. 1999. 518(3):803-813.
20. Kohno, T, et Al. “Peripheral axonal injury results in reduced mu opioid receptor pre- and post-synaptic action in the spinal cord.” Pain. 2005. 117:77-87.
21. Yoshimura, M, North, R. “Substantia gelatinosa neurones hyperpolarized in vitro by enkephalin.” Nature. 1983. 305:529-530.
22. Mousa, S, et Al. “Beta-Endorphin-containing memory-cells and mu-opioid receptors undergo transport to peripheral inflamed tissue.” J. Neuroimmunol. 2001. 115:71-78.
23. Stein, C, et Al. “Peripheral mechanisms of pain and analgesia.” Brain Res Rev. 2009. 60:90-113.
24. Angst, M, Clark, J. “Opioid-induced hyperalgesia: a qualitative systematic review.” Anesthesiology. 2006. 104:570-587.
25. Mao, J, Price, D, and Mayer, D. “Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions.” Pain. 1995. 62:259-274.
26. Drdla, R, et Al. “Induction of synaptic long-term potentiation after opioid withdrawal.” Science. 2009. 325:207-210.
27. Ruscheweyh, R et Al. “Long-term potentiation in spinal nociceptive pathways as a novel target for pain therapy.” Molecular Pain. 2011. 7:20-57.
28. Chen, Y, Geis, C, and Sommer, C. “Activation of TRPV1 contributes to morphine tolerance: involvement of the mitogen-activated protein kinase signaling pathway.” J. Neurosci. 2008. 28:5836-5845.
29. Ma, W, et Al. “Morphine treatment induced calcitonin gene-related peptide and substance P increases in cultured dorsal root ganglion neurons.” Neuroscience. 2000. 99:529-539.
30. Wu, C and Raja, S. “Treatment of acute postoperative pain.” The Lancet. 2011. 377:2215–25.
31. Ikeda, H, et Al. “Synaptic amplifier of inflammatory pain in the spinal dorsal horn.” Science. 2006. 312:1659-1662.
32. Zhang, H, et Al. “Acute nerve injury induces long-term potentiation of C-fiber evoked field potentials in spinal dorsal horn of intact rat.” Sheng Li Xue Bao. 2004. 56:591-596.
33. Sandkühler, J and Liu, X. “Induction of long-term potentiation at spinal synapses by noxious stimulation or nerve injury.” Eur J Neurosci. 1998. 10:2476-2480.
34. Nichols, M, et Al. “Transmission of chronic nociception by spinal neurons expressing the substance P receptor.” Science. 1999. 286:1558-1561.
35. Mantyh, P, et Al. “Inhibition of hyperalgesia by ablation of lamina I spinal neurons expressing the substance P receptor.” Science. 1997. 278:275-279.
36. Mayer, D, et Al. “Cellular mechanisms of neuropathic pain, morphine tolerance, and their interactions.” PNAS. 1999. 96:7731– 6.
37. Chen, L and Huang, L. “Sustained potentiation of NMDA receptormediated
glutamate responses through activation of protein kinase C by u-opioids.” Neuron. 1991. 7:319 –26.
38. Chen, L, and Huang, L. “Protein kinase C reduces Mg2+ block of NMDA-receptor channels as a mechanism of modulation.” Nature. 1992. 356:521–3.
39. Mao, J, Price, D and Mayer, D. “Thermal hyperalgesia in association with the development of morphine tolerance in rats: roles of excitatory amino acid receptors and protein kinase C.” J. Neurosci. 1994. 14:2301–12.
40. Ribeiro, A, et Al. “Expression of matrix metalloproteinases, type IV collagen, and interleukin-10 in rabbits treated with morphine after lamellar keratectomy.” Veterinary Ophthalmology. 2012. 15(3):153-163.
41. Liu, W, et Al. “Spinal matrix metalloproteinase-9 contributes to physical dependence on morphine in mice.” J. Neurosci. 2010. 30:7613-7623.
42. Zahn, P, Umali, E and Brennan, T. “Intrathecal non-NMDA excitatory amino acid receptor antagonists inhibit pain behaviors in a rat model of postoperative pain.” Pain. 1998. 74:213–23.
43. Pogatzki, E, Gabhart, G and Brennan, T. “Characterization of Adelta- and C-Fibers Innervating the Plantar Rat Hindpaw One Day After an Incision.” J. Neurophysiol. 2002. 87:721-731.
44. Ahlgren, S, White, D and Levine, J. “Increased responsiveness of sensory neurons in the saphenous nerve of the streptozotocin-diabetic rat.” J Neurophysiol. 1992. 68:2077–2085.
45. Kocher, L, et Al. “The effect of carrageenan-induced inflammation on the sensitivity of unmyelinated skin nociceptors in the rat.” Pain. 1987. 29:363–373.
46. Van Elstraete, A, et Al. “A Single Dose of Intrathecal Morphine in Rats Induces Long-Lasting Hyperalgesia: The Protective Effect of Prior Administration of Ketamine.” Anesth Analg. 2005. 101:1750 –6.
47. Paoletti, P and Neyton, J. “NMDA receptor subunits: function and pharmacology.” Curr Opin Pharmacol. 2007. 7(1):39–47.
48. Takeda, M, et Al. “Enhanced excitability of nociceptive trigeminal ganglion neurons by satellite glial cytokine following peripheral inflammation.” Pain. 2007. 129:155-166.
49. Binshtok, A, et Al. “Nociceptors are interleukin-1beta sensors.” J. Neurosci. 2008.
28:14062-14073.
50. Takeda, M, et Al. “Activation of interleukin-1beta receptor suppresses the voltage-gated potassium currents in the small-diameter trigeminal ganglion neurons following peripheral inflammation.” Pain. 2008. 139:594-602.
51. Marret, E, et Al. “Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery.” Br J Surg. 2008. 95:1331–38.
52. Hudcova, J, et Al. “Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain.” Cochrane Database Syst Rev. 2006. 4:CD003348.
53. Wijeysundera, D, et Al. “Epidural anaesthesia and survival after intermediate-to-high risk non-cardiac surgery: a population-based cohort study.” Lancet. 2008. 372:562–69.
54. Wu, C, et Al. “Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients.” Reg Anesth Pain Med. 2004. 29:525–33.
55. Liu, S and Wu, C. “Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence.” Anesth Analg. 2007. 104:689–702.
56. Kular, L, et Al. “NOV/CCN3 attenuates inflammatory pain through regulation of matrix metalloproteinases-2 and –9.” Journal of Neuroinflammation. 2012. 9:36-55.
57. Broadbent, E, et Al. “Psychological stress impairs early wound repair following surgery.” Psychosomatic Medicine. 2003. 65:865-869.
One of the initial problems with addressing pain management is the method that is used to evaluate the intensity of pain. While numerous criticisms have been levied against the standard pain numerical reporting system because of its subjective non-uniform nature (a 5 out of 10 for pain for person A may be much different than a 5 out of 10 for person B), little attention is paid to tracking changes in pain progression. Typically post-operative pain is characterized by one or two visits by a nurse with assignment of some pain medication. Basically the pain is viewed as a somewhat static condition that will persist at the recorded level for the duration of the day if not treated by medication. Therefore, one way of better managing pain requires more attentive inquiry regarding how pain is progressing in a patient over the course of a day. Instead of once or twice, inquiries should be made every hour during a normal diurnal time frame for tracking changes. This method will also assist in improving pain management by creating a more reliable evaluation metric for specific treatments. Some seek to measure pain by looking at how certain metabolites change in the bloodstream with time, but with currently limited knowledge of threshold concentrations it is difficult to judge how effective such a strategy would be.
Another problem with pain management is addressing the development of chronic pain. The first question is whether the development of chronic pain stems from improper pain management shortly after surgery or a traumatic event created by improper/inefficient surgery? Based on existing statistics outlining how much long-term pain the population appears to be suffering from it is unlikely that improper/inefficient surgery is the cause of a majority of the chronic pain development. Therefore, this increase in experienced longer-term pain in the population is more than likely due to improper pain management. Unfortunately the current treatment methodology must be flawed in some way because it draws concern that these inconsistencies in effectively dealing with pain arise despite an increase in the overall use of opioids to manage pain.11-14.
While the use of multi-modal analgesia strategies has created sufficient levels of hope in better managing pain, most notably reducing side effects, this hope has not created significantly better long-term outcomes for a majority of people. The inability to attain the potential of multi-modal analgesia is largely due to the large number of variables involved in researching the effectiveness of various technique combinations (dose levels, surgery type, specific genetic factors, analgesic agents, etc.). Basically the individuality demanded by the development and application process reduces a large potential for streamlining and standardizing multi-modal analgesia strategies.
One of the hallmark symptoms of pain is hyperalgesia, which is an increase in pain sensitivity/perception in response to pain inducing stimuli. The typical cause of hyperalgesia is amplification and prolonged nociceptive excitation. Pursuant to this development there is evidence to suggest that current pain management techniques are short-term gain and long-term loss when it comes to addressing pain. One of the most popular choices to managing pain are opioids, especially for acute and chronic cancer pain, but opioids have also started to expand to chronic non-malignant pain. Opioids operate by binding to one of their seventeen different receptors, but three (Mu, Kappa and Delta) are largely responsible for the pain reduction ability of most opioids. Interaction with mu opioid receptors (MOR) either directly or as agonists is the most common pain management pathway. While MORs are expressed on numerous types of neurons the most important with regards to the propagation of pain appear to be the primary sensory neurons called small-sized (C-fiber) and medium sized (A-fiber, specifically Adelta) in the dorsal root ganglia (DRGs).14-17
When molecules interact with MORs they induce presynaptic inhibition that prevents N-type calcium channels from opening, which release neurotransmitters contacting with superficial dorsal horn neurons.18-20 Additional inhibition occurs through activation of G protein-coupled inwardly rectifying potassium channels on dorsal horn neurons resulting in hyperpolarization.20,21 Basically these opioid agonists are effective at addressing pain because of this dual neutralization methodology. Note that there is also some belief of indirect neutralization methods like immune cell activation of opioid receptors.22,23
Unfortunately improper activation of MORs can result in counteracting excitatory activity through the up-regulation of pronociceptive pathways,24,25 which leads to hyperalgesic effects. This specific outcome has been labeled opioid-induced hyperalgesia (OIH). OIH is characterized by increased probabilities for pain in general leading to increased probabilities for the development of chronic pain and tolerance to opioids, which decreases the ability to treat that chronic pain. There is concern that OIH routinely develops into chronic pain due to abrupt inappropriate withdrawals of opioids leading to long-term potentiation (LTP) in the spinal cord. This LTP response is thought to derive from massive activation of NMDA receptor glutamate responses with potential dependency on spinal cord-based TRPV1-expressing afferents along with substance P and chemokines.26-29 OIH can either be acute or chronic.30,31
Focus is applied to spinal cord and DRG LTP because it can develop due to electrical stimulation of appropriate afferents or noxious stimulation (nerve injury or inflammation).27,31-33 One common place for LTP augmentation is at synapses between nociceptive afferents and neurokinin 1 (NK1) receptor expressing projection neurons in lamina I.27 These projection neurons are principally responsible for sending pain signals to the brain.31,34-35 In addition there is similar pharmacology between LTP generation and long-term hyperalgesia.27 Finally LTP development at synapses between C-fibers and superficial dorsal horn neuron is induced by abrupt withdrawal of opioids.26 This is an important distinction because medication in general is typically only administered until symptoms subside. Unfortunately in most situations, including opioid treatment, suddenly stopping medication can result in negative biological consequences.
OIH can ‘leak’ over into the spinal cord by promoting the activation and translocation of protein kinase C, nitric oxide and cholecystokinin and in worst-case scenarios this development can lead to neuronal apoptosis further increasing pain reception problems.36-39 In some respects OIH could be viewed as initially nociceptive and eventually progresses into a neuropathic element.
However, all of this information is still indirect because LTP in the spinal cord with a relation to pain has not been studied directly.27 The lack of direct testing leaves an open question regarding spinal LTP length and how it fully influences the development of chronic pain. LTP for a given group of neurons can last for hours, days, months or a lifetime, but indirect evidence suggests LTP in the spinal cord lasts for several days.27 In this light chronic pain is thought to develop from inhibition of endogenous anti-nociceptive systems or intermittent low-level nociceptive input from periphery neurons. For example pain threshold reduction LTP is also perpetuated to a chronic level through the decreased activity of endogenous anti-nociceptive systems, thus reducing the ‘natural’ abatement adding chronic pain development.
One of tricky elements with addressing OIH is differentiating it from opioid tolerance. When increasing the opioid dosage for treatment of chronic pain the reason for the increase must be identified between opioid tolerance or OIH. In situations of tolerance it may be appropriate to increase opioid concentration depending on the severity of the pain, but in OIH more opioids would result in greater probability of pain. The most common strategy for treating OIH is to cease opioid treatment and substitute a non-opioid analgesic. Unfortunately non-opioid analgesics are typically not as effective as opioids and have their own side effects thus reducing the ability to manage pain.
Differences in analgesic treatment ability has lead to some rotational methodologies where opioids are used for a time and then replaced by non-opioids before a return again to opioids in an attempt to manage pain, but avoid compounding side effects from either treatment. Obviously the success of weaning a patient off of opioids as a means to treat OIH is based on the rate of OIH progression. Unfortunately it is difficult to assess the rate of advancement of OIH in a given patient. However, interestingly enough the future of managing chronic pain may not be developing a new pill or new multi-modal analgesia strategy, but instead developing a strategy where chronic pain does not develop in the first place.
A critical element in the pathway development for OIH is matrix metalloprotease (MMP) concentration. MMPs are a multigene family of tightly regulated zinc-dependent enzymes that maintain homeostasis through their role in tissue degradation and repair.40,41 The two MMPs that appear to play the most prominent roles in pain development are MMP-2 and MMP-9. MMP-9 is frequently released after nerve injury and directs the cleavage of IL-1b.14 Continued cleavage of IL-1b is then governed through a positive feedback mechanism with MMP-2.14,40 There is also suggestion that MMP-9 can interact with NMDA receptors NR1 and NR2B through integrin-beta1 and NO pathways.41 However, MMP-9 influence only seems to occur over a very short time frame (< 24 hrs) for after OIH acquisition to role played by MMP-9 seems to lessen significantly.14
Morphine is one of the most commonly utilized drugs for pain management and is frequently regarded as the standard for comparing the effectiveness of other pain management drugs. Due to its interaction with the μ-opioid receptor morphine chiefly influences in the posterior amygdala, hypothalamus, thalamus, nucleus caudatus and putamen with some associated action in the laminae I and II of the spinal cord. The effects of morphine interaction with its receptor are analgesia and sedation, but can also result in physical dependence.
While morphine is a commonly used pain management drug, its action may have a more detrimental long-term effect in that its interaction with opioid receptors leads to induction of rapid MMP-9 up-regulation. The initial up-regulation occurs in the DRG neurons, not in the spinal cord, and activates pro-nociceptive pathways from the DRG, most notable the cleavage of IL-1b.14 The increased concentration of MMP-9 is not derived from mRNA increases, but translational regulation instead.14 MMP-9 up-regulation does occur in the spinal cord after sustained morphine exposure and could play a role in opioid-induced withdrawal symptoms.41 In some context this biological response could be the body attempting to neutralize the synthetic (non-natural) neutralization of pain possibly in effort to ensure that the mind recognizes that the pain is occurring in effort to cease the pain creating activity, ward off its future application or begin/speed the healing process because pain usually involves some form of injury.
One of the chief aspects of hyperalgesia is the augmentation of Adelta fibers from mechanically insensitive (silent) to mechanically sensitive. This process occurs at high probability in two separate areas: first, during the surgery itself due to cutting an incision and second from MMP-9 up-regulation.42,43 Incision derived hyperalgesia does not rely on NMDA receptor activation, but instead its ‘sister’ receptor a-amino-3-hydroxy-5-methyl-4-isoxazole-propionate (AMPA).30,42 This sensitivity increase applies not simply to pain invoking stimuli, but also non-pain inducing mechanical stimuli due to a reduced mechanical response threshold in Adelta fibers.43 Reduced mechanical response also translates into a much larger spontaneous activity (up from 0% to 38% in Adelta afferents and from 0% to 40% in C-fibers).43 This spontaneous activity may play a role in the facilitation of chronic pain through LTP or mechanical sensitization of nociceptors. Inflammation also is though to reduce this spontaneous firing threshold.44,45 In both scenarios the reduced mechanical response threshold decreases gradually to a new equilibrium instead of all at once. This gradual reduction may play a role in the capriciousness of chronic pain development (different people may have different new equilibriums that are obtained at different rates).
Under most circumstances the application of a NMDA antagonist like ketamine can prevent OIH, but such action also reduces the pain neutralization ability of the administered opioid and studies looking at the benefit of combining opioids and NMDA antagonists have resulted in mixed results.46 Include that result with the significant psychotomimetic side effects (sedation, confusion, and lack of coordination) associated with NMDA antagonists and these types of opioid antagonists are typically only used to address opioid overdoses. Part of the problem with using NMDA antagonists to treat pain directly outside of combination with an opioid is that different molecular organizations of the NMDA receptors due to the three different subtypes, each having multiple isoforms, which results in different binding affinities.47
New strategies for short-circuiting the development of the OIH or other chronic pain pathways could be addressed through two different means. First, prevention of IL-1b cleavage, which is a downstream agent in the pain development pathway, will reduce hyperexcitability of sensory neurons by inhibiting potassium channel opening and increasing sodium channel opening.48-50 A similar alternative would be to prevent IL-1b binding by use of a IL-1 receptor antagonist. Second, the elimination of MMP-2 or MMP-9 could treat chronic pain for MMP-2 appears to be a maintenance pain molecule of some sorts whereas MMP-9 seems to be a trigger.
Some believe one strategy to prevent the development of neuropathic pain is to utilize loco-regional anaesthesia techniques over general anaesthesia.30 Some of the loco-regional agents that are hypothesized to be useful are μ-opioid receptor agonists and clonidine along with antagonists at T-type VGCCs and GABAA receptors.27 At least for major morbidities, the data looks promising for the results of several meta-analyses suggest that use of loco-regional analgesia or continuous paravertebral blockade is associated with decreased risk of postoperative pulmonary complications in patients undergoing upper abdominal and thoracic surgical procedures.51,52
The preoperative use of loco-regional analgesia is also associated with a reduction in respiratory complications after major abdominal surgery, although the effect of loco-regional analgesia might not be as prominent as it was previously, partly because the incidence of respiratory complication has progressively decreased during past years.53 Meta-analyses in patients undergoing high-risk cardiothoracic and vascular procedures suggest that use of preoperative thoracic loco-regional analgesia might decrease pulmonary complications, cardiac dysrhythmias, and overall cardiac complications.54,55 So even if current loco-regional analgesia techniques do not have any significant pain reduction characteristics they have some positive benefits.
However, there may be an even better means to amplify loco-regional anaesthesia through the use of MMP-2 and/or 9 inhibitors in the anaesthesia prior to surgery. By preventing MMP-2/9 activity during the pain inducing surgery itself, it may prevent the pain cascade from initiating at any significant level, thus eliminating the need to large amounts of pain control and the potential for the development of OIH. For example NOV manipulation can inhibit MMP-2 expression in the DHSC and MMP-9 expression in DRG and the spinal cord.56 Under normal pain conditions NOV is down-regulated in DRG and DHSC. One means to increase NOV expression is treat individuals with dexamethasone. However, caution must be taken before utilizing the increase of NOV or a similar agent as a treatment possibility because its influence has different effects on different cells. There is little information regarding what negative side effects may stem from applying MMP2/9 inhibitors immediately prior to surgery, so studies must be done to determine their nature and severity. One important consideration is to create the proper balance of inhibition because of the positive role MMP-9 has in wound healing.57
Overall pain management continues to be problematic in society. With the continued increases in OIH development it is more difficult because unless strict controls are established a common means to treat pain can become a catalyst for its further development. Unfortunately patients have a tendency not to be logical and practical when it comes to pain management for when a person is in pain they tend to do stupid things. It could be a great boon to pain management to develop a strategy to neutralize chronic pain before it even fully develops allowing other analgesia elements to be moved to a secondary strategy to treat more extreme conditions. The pre-surgical inhibition of MMP2/9 could have the potential to be such a strategy.
Citations:
1. Chapman, R, et Al. “Postoperative pain trajectories in cardiac surgery patients.” Pain Research and Treatment. 2012. Article ID 608359. doi:10.1155/2012/608359
2. Wheeler, M, et Al. “Adverse events associated with postoperative opioid analgesia: a systematic review.” Journal of Pain. 2002. 3(3):159–180.
3. Oderda, G, et Al. “Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay.” Ann Pharmacother. 2007. 41:400–06.
4. Ballantyne, J, et Al. “The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials.” Anesthesia and Analgesia. 1998. 86(3): 598–612.
5. Rodgers, A, et Al. “Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.” The British Medical Journal. 2000. 321(7275):1493–1497.
6. Beattie, W, Badner, N, and Choi, P. “Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.” Anesthesia and Analgesia. 2001. 93(4):853–858.
7. Holte, K and Kehlet, H. “Effect of postoperative epidural analgesia on surgical outcome.” Minerva Anestesiologica. 2002. 68(4):157–161.
8. Marret, E, Remy, C and Bonnet, F. “Postoperative Pain Forum Group. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery.” Br J Surg. 2007. 94:665–73.
9. Fischer, H, et Al. “A procedure-specifi c systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty.” Anaesthesia. 2008. 63:1105–23.
10. Institute of Medicine of the National Academies Report (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care Education, and Research. Washington DC: The National Academies Press.
11. Frasco, P, Sprung, J and Trentman, T. “The impact of the joint commission for accreditation of healthcare organizations pain initiative on perioperative opiate consumption and recovery room length of stay.” Anesth Analg. 2005. 100:162–68.
12. Zaslansky, R, et Al. “Tracking the effects of policy changes in prescribing analgesics in one emergency department: a 10-year analysis.” Eur J Emerg Med. 2010. 17:56–58.
13. Manchikanti, L, et Al. “Therapeutic use, abuse, and non-medical use of opioids: a ten-year perspective.” Pain Physician. 2010. 13:401–35.
14. Liu, Y, et Al. “Acute morphine induces matrix metalloproteinase-9 up-regulation in primary sensory neurons to mask opioid-induced analgesia in mice.” Molecular Pain. 2012. 8:19-36.
15. Ji, R, et Al. “Expression of mu-, delta-, and kappa-opioid receptor-like immunoreactivities in rat dorsal root ganglia after carrageenan-induced inflammation.” J. Neurosci. 1995. 15:8156-8166.
16. Wang, H, et Al. “Coexpression of delta- and mu-opioid receptors in nociceptive sensory neurons.” PNAS. 2010. 107:13117-13122.
17. Lee, C, et Al. “Dynamic temporal and spatial regulation of mu opioid receptor expression in primary afferent neurons following spinal nerve injury.” Eur J. Pain. 2011. 15:669-675.
18. Heinke, B, Gingl, E, and Sandkühler, J. “Multiple Targets of mu-Opioid Receptor-Mediated Presynaptic Inhibition at Primary Afferent A{delta}- and C-Fibers.” J. Neurosci. 2011. 31:1313-1322.
19. Kohno, T, et Al. “Actions of opioids on excitatory and inhibitory transmission in substantia gelatinosa of adult rat spinal cord.” J. Physiol. 1999. 518(3):803-813.
20. Kohno, T, et Al. “Peripheral axonal injury results in reduced mu opioid receptor pre- and post-synaptic action in the spinal cord.” Pain. 2005. 117:77-87.
21. Yoshimura, M, North, R. “Substantia gelatinosa neurones hyperpolarized in vitro by enkephalin.” Nature. 1983. 305:529-530.
22. Mousa, S, et Al. “Beta-Endorphin-containing memory-cells and mu-opioid receptors undergo transport to peripheral inflamed tissue.” J. Neuroimmunol. 2001. 115:71-78.
23. Stein, C, et Al. “Peripheral mechanisms of pain and analgesia.” Brain Res Rev. 2009. 60:90-113.
24. Angst, M, Clark, J. “Opioid-induced hyperalgesia: a qualitative systematic review.” Anesthesiology. 2006. 104:570-587.
25. Mao, J, Price, D, and Mayer, D. “Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions.” Pain. 1995. 62:259-274.
26. Drdla, R, et Al. “Induction of synaptic long-term potentiation after opioid withdrawal.” Science. 2009. 325:207-210.
27. Ruscheweyh, R et Al. “Long-term potentiation in spinal nociceptive pathways as a novel target for pain therapy.” Molecular Pain. 2011. 7:20-57.
28. Chen, Y, Geis, C, and Sommer, C. “Activation of TRPV1 contributes to morphine tolerance: involvement of the mitogen-activated protein kinase signaling pathway.” J. Neurosci. 2008. 28:5836-5845.
29. Ma, W, et Al. “Morphine treatment induced calcitonin gene-related peptide and substance P increases in cultured dorsal root ganglion neurons.” Neuroscience. 2000. 99:529-539.
30. Wu, C and Raja, S. “Treatment of acute postoperative pain.” The Lancet. 2011. 377:2215–25.
31. Ikeda, H, et Al. “Synaptic amplifier of inflammatory pain in the spinal dorsal horn.” Science. 2006. 312:1659-1662.
32. Zhang, H, et Al. “Acute nerve injury induces long-term potentiation of C-fiber evoked field potentials in spinal dorsal horn of intact rat.” Sheng Li Xue Bao. 2004. 56:591-596.
33. Sandkühler, J and Liu, X. “Induction of long-term potentiation at spinal synapses by noxious stimulation or nerve injury.” Eur J Neurosci. 1998. 10:2476-2480.
34. Nichols, M, et Al. “Transmission of chronic nociception by spinal neurons expressing the substance P receptor.” Science. 1999. 286:1558-1561.
35. Mantyh, P, et Al. “Inhibition of hyperalgesia by ablation of lamina I spinal neurons expressing the substance P receptor.” Science. 1997. 278:275-279.
36. Mayer, D, et Al. “Cellular mechanisms of neuropathic pain, morphine tolerance, and their interactions.” PNAS. 1999. 96:7731– 6.
37. Chen, L and Huang, L. “Sustained potentiation of NMDA receptormediated
glutamate responses through activation of protein kinase C by u-opioids.” Neuron. 1991. 7:319 –26.
38. Chen, L, and Huang, L. “Protein kinase C reduces Mg2+ block of NMDA-receptor channels as a mechanism of modulation.” Nature. 1992. 356:521–3.
39. Mao, J, Price, D and Mayer, D. “Thermal hyperalgesia in association with the development of morphine tolerance in rats: roles of excitatory amino acid receptors and protein kinase C.” J. Neurosci. 1994. 14:2301–12.
40. Ribeiro, A, et Al. “Expression of matrix metalloproteinases, type IV collagen, and interleukin-10 in rabbits treated with morphine after lamellar keratectomy.” Veterinary Ophthalmology. 2012. 15(3):153-163.
41. Liu, W, et Al. “Spinal matrix metalloproteinase-9 contributes to physical dependence on morphine in mice.” J. Neurosci. 2010. 30:7613-7623.
42. Zahn, P, Umali, E and Brennan, T. “Intrathecal non-NMDA excitatory amino acid receptor antagonists inhibit pain behaviors in a rat model of postoperative pain.” Pain. 1998. 74:213–23.
43. Pogatzki, E, Gabhart, G and Brennan, T. “Characterization of Adelta- and C-Fibers Innervating the Plantar Rat Hindpaw One Day After an Incision.” J. Neurophysiol. 2002. 87:721-731.
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Monday, February 1, 2010
Solving the Question of Abortion
This coming Super Bowl Sunday marks another instance where the issue of abortion takes center stage when former University of Florida quarterback Tim Tebow will reminisce with his mother about her decision to forgo the abortion of Mr. Tebow despite an increased threat to her life. Clearly many individuals believe that this advertisement, sponsored by the Christian group Focus on the Family, is inappropriate for its Super Bowl venue on a wide variety of grounds ranging from those that do not want to mix politics and sports to those that believe outlawing abortion is legally and/or morally wrong. Unfortunately once again another discussion about abortion however tangential, in this instance the venue, fails to identify the genuine reality behind the issue of abortion because of emotional fervor and stubborn selfishness.
The principle element upholding the argument of outlawing abortion in the anti-abortion crowd (why such a designation is appropriate over pro-life will be explained later) is that the fetus is a human being and therefore, it is morally wrong, and should be legally wrong, to end the existence of the fetus. Unfortunately in the realm of science a fetus cannot be viewed as an independent life form until it is outside of the mother’s womb. Instead one can only argue from the position of ‘potential human life’ which from a legal standpoint is not enough. No ‘potential’ anything has the expectation of any form of legal protection. Any attack or attempt to forcibly ‘birth’ the fetus, under the mindset of ‘the fetus would live if the potential mother would give it a chance’ is a violation of the women’s rights and cannot be tolerated in a civil society. Therefore, until the fetus is born, it cannot be afforded any rights akin to that of a currently independent living human being. The only categorical position that can be taken against abortion is one of a religious nature with the perspective that life begins at conception not at birth. Overall for anti-abortionists their argument for outlawing abortion is not only disallowed by logic, but is also disallowed by the 1st Amendment which separates church and state and prevents the passing of laws based on specific religious beliefs or scriptures.
Suppose for a second that somehow logic and respect for the Constitution of the United States ceased to exist and Roe v. Wade was overturned allowing states to determine the legality of abortion within their boarders. Then suppose that for some reason all 50 states banned abortions. Would such action prevent abortions from occurring? Looking at the track record for anti-laws it is unlikely as speed limits hardly stop individuals from speeding nor does the illegality of possession and/or distribution of certain drugs stop those activities and the list could go on and on. Therefore, outlawing abortions would not stop abortions, but instead probably result in fewer abortions (which anti-abortion individuals would cheer), but also make an abortion for those that still insist upon on (there will still be a number of individuals that fit this mold) much more dangerous, which no one should cheer.
However, the issue of outlawing abortion does not end with the overturning of Roe v. Wade, despite almost every anti-abortion group thinking it does. What these groups fail to address is what happens to fetuses, which would have been aborted, when they are born? Remember these new infants are being born into an immediate environment where their parents, especially the mother, do not want to or are not willing to care for them. Do anti-abortion groups believe that once the fetus is born that everything will magically work out and the parents will instantly want to care for the child? If that is their plan then these groups are truly living in a delusional dream world because child abuse and domestic violence certainly never happens in the real world. That is why these groups should be regarded as anti-abortion not pro-life because a vast majority of them, if not all of them, care nothing for the fetus once it becomes an infant. No, they just pat themselves on the back because the fetus was born, say ‘job well done’ and then move on to the next case. Out of sight, out of mind, not actually solving the problem, what a nice philosophy to have.
There in lies the real solution to the abortion ‘problem’. Making abortion illegal does not solve the problem; in fact depending on the course of life those newly surviving take it may create even more problems in society in general, a reality that is more probable due to the type of home life these individuals will experience. Ending abortions cannot truly come from stripping them of their legality. Unfortunately this fact seems lost on the anti-abortion movement. Instead the strategy should be to limit abortions through strengthening the alternatives and reducing its overall probability of necessity.
First things first, the process of going through an abortion is both physically and mentally taxing on a women; there are many other avenues which cost less both financially and emotionally that reduce the probability of pregnancy when having sexual intercourse. Thus it is unreasonable to conclude that abortion is used as a consistent measure of birth control. Therefore, anyone that argues against abortion using that particular point is a fool who should be dismissed.
Two key elements must be addressed when looking to reduce abortions without focusing on the status of their legality. The first issue is expanding sexual education to limit the amount of error present when two young individuals engage in sexual behavior, thus lowing the probability of creating a situation where abortion is even an option. Being realistic abstinence only programs are a complete joke and have failed in every major instance in which they have been applied. Through legitimate and frank discussion of sex both by educators and by parents, teenagers and young adults can be better prepared to responsibly engage in sexual behavior which in turn lowers the probability of abortions.
In addition to proper discussion about sex through sex education, the discussed tools must also be made available to those that do not have effective access to those items. Unfortunately some ideas to ensure this access have been criticized, most notably free condom programs in schools. Opponents of these programs harbor unjustifiable fears that if individuals are given access to free condoms it will substantially increase the probability of those individuals having sex. The primary reason that these fears are irrational is that a condom is not a necessary element to the process of sexual intercourse, thus having better access to one is not going to effectively change the probability that sexual intercourse takes place. Secondary is that a condom is not perishable; there is no set short-term time period in which it has to be used, so there is no increased incentive to use it before it ‘goes bad’. Overall there is no reason to believe that increasing available access to things like condoms in an education environment will increase the probability of individuals engaging in sexual intercourse. However, it must be said that it is important that this increased access be accompanied by proper education in their application and use otherwise there is a chance that their application will be incorrect thus creating unnecessary waste.
The second issue is increasing the efficiency and effectiveness of adoption. As previously discussed even if abortion is eliminated there are a number of fetuses that will enter environments in which they are not welcome. Therefore, there must be a better means to extract them from that environment and place them in a more beneficial environment. Unfortunately very little attention is paid to the adoption and foster-care programs throughout the country and as a result they are under-funded and frequently unpleasant. In fact since Dave Thomas’s death, one really does not see anything concerning adoption in the mainstream anymore. Such a reality is sad because streamlining and improving adoption proceedings is an essential element to reducing the number of abortions.
Overall if the goal in the issue of abortion is to minimize the total number of abortions performed in a given year, at least if it is not then it should be, then the most popular strategy employed by anti-abortion groups is not plausible. Trying to deduce convoluted rationalities on how a fetus is a human deserving of rights or stacking courts with dishonorable justices that care more about their personal beliefs than the law will not accomplish the goal.
Coming full circle, this is what is wrong with the forthcoming Tim Tebow-Focus on the Family abortion commercial. This commercial will focus on a sentimental message/argument with little value beyond the immediate players involved and entirely dependent on the result of the childbirth. What would have happened if both Tim Tebow and his mother had died during childbirth instead of both surviving? Either way a commercial with such a message convinces no one of consequence. What weak-minded individual is going to change his/her personal viewpoint on abortion after viewing it? In essence the entire idea is just a waste of time and a waste of money. A donation equal to the cost of the Super Bowl advertisement to a group like the Dave Thomas Foundation would be much more beneficial in the fight against abortion.
The strategy anti-abortion groups should utilize is a focus on reducing the probability that abortion can even be entertained as an option by reducing unwanted pregnancies through sex education and then ensure that viable options exist beyond an abortion for when education fails as an option largely by reforming and expanding the adoption and foster-care. An alliance with Planed Parenthood, as ironic as that seems, would also be useful in this regard allowing pregnant women the ability to understand their options some of which may originally be unknown.
In fact the entire issue over 3rd trimester abortions acts as a microcosm for this entire issue. Many anti-abortion groups and politicians work hard to ban 3rd trimester abortions. However, such action is rather silly because unless the health of the mother is at stake no prospective parent is logically going to abort a fetus carried for so long. Any thought of an abortion is simply the result of fear or apprehension, which in the proper education and nurturing environment can be alleviated eliminating the prospect of an abortion. In the end the real issue is whether anti-abortion groups genuinely want to limit the number of abortions in the world or whether they want to try to limit the number of abortions their way using their methodology even if their way is not the most effective or practical way.
The principle element upholding the argument of outlawing abortion in the anti-abortion crowd (why such a designation is appropriate over pro-life will be explained later) is that the fetus is a human being and therefore, it is morally wrong, and should be legally wrong, to end the existence of the fetus. Unfortunately in the realm of science a fetus cannot be viewed as an independent life form until it is outside of the mother’s womb. Instead one can only argue from the position of ‘potential human life’ which from a legal standpoint is not enough. No ‘potential’ anything has the expectation of any form of legal protection. Any attack or attempt to forcibly ‘birth’ the fetus, under the mindset of ‘the fetus would live if the potential mother would give it a chance’ is a violation of the women’s rights and cannot be tolerated in a civil society. Therefore, until the fetus is born, it cannot be afforded any rights akin to that of a currently independent living human being. The only categorical position that can be taken against abortion is one of a religious nature with the perspective that life begins at conception not at birth. Overall for anti-abortionists their argument for outlawing abortion is not only disallowed by logic, but is also disallowed by the 1st Amendment which separates church and state and prevents the passing of laws based on specific religious beliefs or scriptures.
Suppose for a second that somehow logic and respect for the Constitution of the United States ceased to exist and Roe v. Wade was overturned allowing states to determine the legality of abortion within their boarders. Then suppose that for some reason all 50 states banned abortions. Would such action prevent abortions from occurring? Looking at the track record for anti-laws it is unlikely as speed limits hardly stop individuals from speeding nor does the illegality of possession and/or distribution of certain drugs stop those activities and the list could go on and on. Therefore, outlawing abortions would not stop abortions, but instead probably result in fewer abortions (which anti-abortion individuals would cheer), but also make an abortion for those that still insist upon on (there will still be a number of individuals that fit this mold) much more dangerous, which no one should cheer.
However, the issue of outlawing abortion does not end with the overturning of Roe v. Wade, despite almost every anti-abortion group thinking it does. What these groups fail to address is what happens to fetuses, which would have been aborted, when they are born? Remember these new infants are being born into an immediate environment where their parents, especially the mother, do not want to or are not willing to care for them. Do anti-abortion groups believe that once the fetus is born that everything will magically work out and the parents will instantly want to care for the child? If that is their plan then these groups are truly living in a delusional dream world because child abuse and domestic violence certainly never happens in the real world. That is why these groups should be regarded as anti-abortion not pro-life because a vast majority of them, if not all of them, care nothing for the fetus once it becomes an infant. No, they just pat themselves on the back because the fetus was born, say ‘job well done’ and then move on to the next case. Out of sight, out of mind, not actually solving the problem, what a nice philosophy to have.
There in lies the real solution to the abortion ‘problem’. Making abortion illegal does not solve the problem; in fact depending on the course of life those newly surviving take it may create even more problems in society in general, a reality that is more probable due to the type of home life these individuals will experience. Ending abortions cannot truly come from stripping them of their legality. Unfortunately this fact seems lost on the anti-abortion movement. Instead the strategy should be to limit abortions through strengthening the alternatives and reducing its overall probability of necessity.
First things first, the process of going through an abortion is both physically and mentally taxing on a women; there are many other avenues which cost less both financially and emotionally that reduce the probability of pregnancy when having sexual intercourse. Thus it is unreasonable to conclude that abortion is used as a consistent measure of birth control. Therefore, anyone that argues against abortion using that particular point is a fool who should be dismissed.
Two key elements must be addressed when looking to reduce abortions without focusing on the status of their legality. The first issue is expanding sexual education to limit the amount of error present when two young individuals engage in sexual behavior, thus lowing the probability of creating a situation where abortion is even an option. Being realistic abstinence only programs are a complete joke and have failed in every major instance in which they have been applied. Through legitimate and frank discussion of sex both by educators and by parents, teenagers and young adults can be better prepared to responsibly engage in sexual behavior which in turn lowers the probability of abortions.
In addition to proper discussion about sex through sex education, the discussed tools must also be made available to those that do not have effective access to those items. Unfortunately some ideas to ensure this access have been criticized, most notably free condom programs in schools. Opponents of these programs harbor unjustifiable fears that if individuals are given access to free condoms it will substantially increase the probability of those individuals having sex. The primary reason that these fears are irrational is that a condom is not a necessary element to the process of sexual intercourse, thus having better access to one is not going to effectively change the probability that sexual intercourse takes place. Secondary is that a condom is not perishable; there is no set short-term time period in which it has to be used, so there is no increased incentive to use it before it ‘goes bad’. Overall there is no reason to believe that increasing available access to things like condoms in an education environment will increase the probability of individuals engaging in sexual intercourse. However, it must be said that it is important that this increased access be accompanied by proper education in their application and use otherwise there is a chance that their application will be incorrect thus creating unnecessary waste.
The second issue is increasing the efficiency and effectiveness of adoption. As previously discussed even if abortion is eliminated there are a number of fetuses that will enter environments in which they are not welcome. Therefore, there must be a better means to extract them from that environment and place them in a more beneficial environment. Unfortunately very little attention is paid to the adoption and foster-care programs throughout the country and as a result they are under-funded and frequently unpleasant. In fact since Dave Thomas’s death, one really does not see anything concerning adoption in the mainstream anymore. Such a reality is sad because streamlining and improving adoption proceedings is an essential element to reducing the number of abortions.
Overall if the goal in the issue of abortion is to minimize the total number of abortions performed in a given year, at least if it is not then it should be, then the most popular strategy employed by anti-abortion groups is not plausible. Trying to deduce convoluted rationalities on how a fetus is a human deserving of rights or stacking courts with dishonorable justices that care more about their personal beliefs than the law will not accomplish the goal.
Coming full circle, this is what is wrong with the forthcoming Tim Tebow-Focus on the Family abortion commercial. This commercial will focus on a sentimental message/argument with little value beyond the immediate players involved and entirely dependent on the result of the childbirth. What would have happened if both Tim Tebow and his mother had died during childbirth instead of both surviving? Either way a commercial with such a message convinces no one of consequence. What weak-minded individual is going to change his/her personal viewpoint on abortion after viewing it? In essence the entire idea is just a waste of time and a waste of money. A donation equal to the cost of the Super Bowl advertisement to a group like the Dave Thomas Foundation would be much more beneficial in the fight against abortion.
The strategy anti-abortion groups should utilize is a focus on reducing the probability that abortion can even be entertained as an option by reducing unwanted pregnancies through sex education and then ensure that viable options exist beyond an abortion for when education fails as an option largely by reforming and expanding the adoption and foster-care. An alliance with Planed Parenthood, as ironic as that seems, would also be useful in this regard allowing pregnant women the ability to understand their options some of which may originally be unknown.
In fact the entire issue over 3rd trimester abortions acts as a microcosm for this entire issue. Many anti-abortion groups and politicians work hard to ban 3rd trimester abortions. However, such action is rather silly because unless the health of the mother is at stake no prospective parent is logically going to abort a fetus carried for so long. Any thought of an abortion is simply the result of fear or apprehension, which in the proper education and nurturing environment can be alleviated eliminating the prospect of an abortion. In the end the real issue is whether anti-abortion groups genuinely want to limit the number of abortions in the world or whether they want to try to limit the number of abortions their way using their methodology even if their way is not the most effective or practical way.
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