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Friday 21 March 2014

On Science and Salesmanship

Today I had to sit through three seminar talks given by candidates for a post at my institution.  The audience reaction is quite important to the hiring process here and so it is a duty not a pleasure, which is what seminars normally are for me.


The thing with seminars is that they have changed over time, and not in a good way.  Originally seminars were a discussion- the talk kicked off the questions and the questions kicked off the debate.  In some places this has degraded so that the only questions asked tend to be toadying ones, or occasionally, horror of horrors, there are no questions at all.  Frankly if I ever presented work where it roused no questions I would retire.  But luckily, where I work the spirit of the original seminar is alive and well.  There is often a debate.

I am well known for asking questions.  I once took my wife to a conference, partly to prove to her that it was indeed work not fun.  She was waiting outside a lecture hall with a friend of mine when a group of pale sweating students wandered past clearly shaken up.  when she asked what the matter was she was informed that they had had questions from me and needed to recover.  So today i was expected to ask questions.

I struggled.  It wasn't the 3 hrs pain racked sleep.  It wasn't that I didn't understand the subject.  It was simply that the only question I could think of was "What the hell was that crap?".  Because what I saw was bullshit layered thick and hard.

The problem is the insidious presence of advertising in science.  Of people selling themselves.  And not in an honest, up front prostitution type way.  Each talk started off with a gush about the areas of application.  Each one was about environmental/green/natural fallacy stuff.  And each gush was TOTALLY UNRELATED TO THE RESEARCH.  I mean for the love of god I bullshit for a living.  If you are going to sell me a line at least make it plausible.

In one of the films where he plays God George Burns has some advice for an evangelist, and I would like to paraphrase it for scientists.  If you want to sell something sell shoes.  Don't try to sell a line of bollocks in science.  It degrades the subject and it degrades you.

Sunday 16 March 2014

Pimping my other place

Just to let you know that the more sickness related and personal stuff will be being posted at my other blog.
Please visit and look around the site.  The guys at Chronically Skeptical need some traffic

Wednesday 5 March 2014

On pain, brains and drugs. And Vultures

Your standard GP struggles to treat pain.  I think it would be hard to find a GP who did not agree with that statement to some extent.  That's because pain isn't a thing.  It is lots of things.

For a start pain can be chronic or acute.  Or in some cases chronic acute.  The treatments for these are different, for complex reasons.

For another thing, pain is not what people think.  Or rather thinking plays a big part.  Because pain is not nociception.

Nociception is the nerve stimulus, the signal that tells the nervous system that Bad Thing Happen.  This is then processed into pain, which is the feeling.  Feeling is a good word for it because there is a strong emotional component there.  Now you may think that this is the same stuff, because the feeling arises from a signal.

Well no.  the same stimulus will give you different amounts of pain depending on mental state.  How you feel mentally affects how much pain you feel.  Bigtime.

Painkillers work in many different ways but they focus , for the most part, on the nociception end of pain.  Reducing the signal.  This is particularly true of the NSAIDS which don't do very much else.  It is also true of the opiates to a degree.  However some of the opiates have other effects which cross over into emotionsville, particularly Tramadol and Buprenorphine.  Tramadol has a lot of cross activity which makes it act very much like an SNRI antidepressant such as venlafaxine.  Buprenorphine plays with the kappa opioid receptor, which has effects on the emotional processing of pain.

Any drug based therapy for pain will have limitations because it is trying to fix a moving problem.  the same amount of stimulus feels different on different days, so the same amount of drug may not cope.  It may be fair to say that breakthrough pain is emotional in origin. So for long term use its best to have an emotional therapy as well as a pharmaceutical one. However despite limitations drug based therapies are probably the best we have, showing the strongest results.

Drugs do have limitations.  In the context here addiction is not one of them.  Dependence yes, addiction no.  Study after study has shown that when you are using the drugs for actual pain then addictive behaviour is unlikely.  Dependence and habituation are likely, and are difficulties with drug treatment.  Pain management programs can help a lot, but it depends who runs them and how they are run.  The intent should be to give the patient their life back by any means.  Anecdote alert but I have several friends whose experience of these programs is that all they are interested in is getting you off drugs.  never mind if you suffer, never mind if the result of this is that you have to spend all day every day thinking about your pain to manage it, drugs are bad mmkay.  This is what happens when ideology enters medicine.

A well run pain program should focus on reducing drugs where that can be doen without impacting quality of life.  Its main focus should be reduction of pain.

So we have an imperfect world, with no real answer to pain, just some strategies to make it a bit better.  Enter the vultures.

Its hard to talk about pain without someone bringing up some of the tired old bollocks beloved of the worried well.  You know, homeopathy, chiropractic, acupuncture, reiki, having your underpants chanted over, that sort of thing.  The people offering this are, in my honest opinion, either idiots or vultures.  Idiots in that in the face of all reliable evidence they believe this witchcraft works or vultures in that they know it doesn't but still prey on the desperate.  In the case of Ehlers Danlos even the support organisations have this stuff.  The HMSA in the UK has form here  where they say magnet plasters help some people.  Well yes, if your pain is being caused by iron filings, or by having geographically puzzled pigeons migrating into you.  But if its real this is just a distraction.  The Ehlers Danlos National Foundation in the US suggests in this tome that acupuncture or acupressure may help despite increasing evidence that its simply being in the room with someone who appears to care that reduces pain as acupuncture , sham acupuncture and placebo acupuncture ( synonyms) have the same effect.

Essentially selling hope to the hopeless makes you rich.  It also makes you pond slime.

Monday 3 March 2014

To start with I am rather new to this so the blogging thing may take a while to get going.  Possibly it will fizzle.  But unless you try you never know.

So I am going to imagine I have an audience out there.  Hello *waves*

Why am I blogging?  because I like ranting about things.  And other bloggers don't rant correctly.

So for my first rant...pain.

EDS comes with pain as a standard feature.  EDS-HT has more pain than other types, even though it is generally the least serious variety.  I spend my life in pain, sometimes severe, often just a background ache.  One of the better ways I have heard this described is think of the day you get flu.  You don't have the fever yet or the cough but your joints ache all over and you are so-darned-tired.

That's EDS-HT on a good day.

Now this rant is not a cry for sympathy.  I wouldn't know what to do with that if i got it and it certainly wouldn't change anything.  This rant is about attitudes to pain and pain medication.  There may be a supplemental rant about Pain Vultures.

If you mention to anyone that you are on pain medication the first thing you will be asked is when you are coming off it.  That's my experience anyway.  If you take pain medication in front of people they become uncomfortable.  I have had people change seats on flights to get away from me because I have used my in-flight coke to wash down some tramadol.  Pain medication is seen as a short term thing, and it is also seen as a vice.

When pain medication is mentioned in the media it is frequently in a context such as this call to tackle addiction or this warning about secret addiction in fact addiction is often the stand-out word.  After all who wants an addict as a husband, teacher, lawyer?  But what do we mean by addict?  Most people will develope a physical dependency on opiates and opioids through long term legitimate usage.  Are they addicts?  Well many people would say yes.

Pain medication is only fine if you are dying.  It is almost synonymous with palliative care.  If you are living it is something that should be short term, rationed and shunned.  But what does this mean for people living with chronic pain?  Generally a choice between being shunned and being in pain.

Drugs can change you, and change your behavior.  But nowhere near as much as constant pain does.  Chronic pain is undertreated, ignored and even seen as something that refines ones spirit.  Of course it makes you four times more likely to commit suicide, and that, mark you is amongst the ones who get specialised pain treatment at a dedicated clinic.  Pain clinics in the UK are not widely available, and often have pressures put on them by ideologues so that their goals are redefined toward reduction of drug use rather than control of symptoms.

Pain is something we treat poorly, understand poorly and tolerate poorly.  In this background the pain vultures thrive.  You know who i mean, the osteopaths, acupuncturists, Hopi ear candle merchants etc.  Offering hope to the hopeless.  There is a special circle of hell reserved for these people.

But that's another rant.