Listening to Lyrica: contested illnesses and pharmaceutical determinism

"Play!": Combatting Pathocentric Epistemic Injustice in Chronic Pain Care

Epistemic injustice is an analytical framework that is used to describe a wrong done to someone in their capacity as a knower. Epistemic injustice is well-documented across the healthcare spectrum, particularly in relation to the patient's capacity to understand, and thus derive meaning from, the experience of illness. This article contributes to the body of scholarship exploring how to achieve pathocentric epistemic justice by way of ethnographic case study. Findings draw on fieldwork conducted at a small, publicly funded chronic pain clinic. At MB clinic, pain care is delivered in a group setting. Patients and doctor exhibit a playful attitude: they lean into uncertainty, tell jokes, and eschew the concept of mastery. This produces an epistemic environment that departs from the kind critiqued in studies wherein epistemic injustice is present. By way of case study, this article provides support for the broad claim that there is a link between playfulness and epistemic well-being. Therefore, playfulness may be applied as a strategy to combat pathocentric epistemic injustice.

Gendered Worlds of Pain: Women, Marginalization, and Chronic Pain

The importance of gender is undertheorized in chronic pain research, meaning extant research cannot sufficiently shed light on how chronic pain experience and treatment are connected to institutions and societal structures. Much literature on gender and pain is not critical in orientation, making it difficult to translate data into recommendations for improved treatment and care. Our study takes a critical approach informed by social theory to understand chronic pain among women who experience socioeconomic marginalization. Drawing on a gender-based subanalysis of interview data collected in Canada as part of an institutional ethnography of chronic pain among people who are socioeconomically marginalized, from women's narratives, we identified 4 themes that speak to gender, chronic pain, and marginalization. These are 1) gendered minimization of women's health concerns, 2) managing intergenerational poverty, 3) living with violence and trauma, and 4) gendered organization of family care. Together, these themes highlight how women's experiences of chronic pain and marginalization amplify gendered vulnerabilities in health care, social services, and society in general. Our findings depict a deeply gendered experience of chronic pain that is inseparable from the daily struggle of managing one's life with pain with heavy responsibilities, the baggage of past trauma, and responsibility for others with few resources. We emphasize the importance of chronic pain care and health and social services that are both gender- and trauma-informed. PERSPECTIVE: This article draws on an institutional ethnography (a holistic qualitative methodology) of chronic pain and socioeconomic marginalization to demonstrate the importance of chronic pain care and health and social services that are both gender- and trauma-informed.

Experiencing birth trauma: Individualism and isolation in postpartum

Approximately 25-35% of individuals report experiencing a traumatic birth in the United States. Birth trauma has commonly been focused on the experience of labor and delivery itself, with definitions frequently pointing to specific clinical interventions, interactions with providers, and individual expectations during labor and delivery. These definitions however remain too limited, assuming that birth trauma has a discrete temporality-emerging in childbirth-and largely underestimate the social and structural factors that drive trauma. Drawing from interviews conducted between November 2021 and April 2023 with thirty cisgender women who have given birth at least once in the United States, I reveal how the postpartum period is a particularly vulnerable time for trauma emergence, even when absent of difficult delivery experiences. I reveal how social and structural factors in the postpartum period trigger trauma that remains largely invisible, leaving individuals isolated. I situate these women's experiences within the sociological scholarship on trauma, (bio)medicalization, neoliberalism, and risk, to reveal a critical need to expand definitions of, and approaches to, birth trauma.

Embedding artificial intelligence in healthcare: An ethnographic exploration of an AI-based mHealth app through the lens of legitimacy

Purpose

Skin cancer, a significant global health problem, imposes financial and workload burdens on the Dutch healthcare system. Artificial intelligence (AI) for diagnostic augmentation has gained momentum in dermatology, but despite significant research on adoption, acceptance, and implementation, we lack a holistic understanding of why technologies (do not) become embedded in the healthcare system. This study utilizes the concept of legitimacy, omnipresent but underexplored in health technology studies, to examine assumptions guiding the integration of an AI mHealth app for skin lesion cancer risk assessment in the Dutch healthcare system.

Methods

We conducted a 3-year ethnographic case study, using participant observation, interviews, focus groups, and document analysis to explore app integration within the Dutch healthcare system. Participants included doctors, policymakers, app users, developers, insurers, and researchers. Our analysis focused on moments of legitimacy breakdown, contrasting company narratives and healthcare-based assumptions with practices and affectively-charged experiences of professionals and app users.

Results

Three major kinds of legitimacy breakdowns impacted the embedding of this app: first, lack of institutional legitimacy led to informal workarounds by the company at the institutional level; second, quantification privilege impacted app influence in interactions with doctors; and third, interactive limits between users and the app contradicted expectations around ease of use and work burden alleviation.

Conclusions

Our results demonstrate that legitimacy is a useful lens for understanding the embedding of health technology while taking into account institutional complexity. A legitimacy lens is helpful for decision-makers and researchers because it can clarify and anticipate pain points for the integration of AI into healthcare systems.

Contesting misrecognition online: Experiences of epistemic in/justice by vloggers with contested illnesses

Contested illnesses, such as fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and chronic Lyme disease (CLD), are surrounded by polemic debates regarding their etiology, symptomology, treatment, and even their existence. People who suffer from these contested illnesses arguably also suffer from "epistemic injustice." This concept, coined by the philosopher Miranda Fricker, captures how people's knowledge may be discredited because of identity prejudices. In our paper, this concept is used to understand how seven Dutch women with contested illnesses experience the emancipatory potential of their vlogging practices. Our findings show how these women understood their vlogging as a means to break with epistemic smothering, understood as the propensity to cater ones testimony to one's audience (Dotson, 2011), and as a means to attain and enhance epistemic justice. However, our findings also show how vlogging about contested illnesses did not seem to allow these women to fully break with their epistemic smothering practices, and that the ableist design and gendered norms of YouTube were experienced as obstacles to attaining epistemic justice. We conclude that, even though social media do seem to hold emancipatory potential for these women, the experiences of individual users are diverse and ambiguous.

Uncertainty Management Strategies in Communication About Urinary Tract Infections

Urinary tract infections (UTIs) are the most common bacterial infection, and yet the etiology, treatment, and prevention of UTIs are often clouded by uncertainty. UTIs can cause severe pain and may lead to serious infection, but communication about UTIs can help individuals manage this condition and avoid recurring UTIs. Grounded in uncertainty management theory (UMT), this study explored how individuals with female anatomy manage uncertainty surrounding UTIs. Iterative analysis was employed using UMT to analyze 21 qualitative interviews. Participants used uncertainty management strategies of talking to health care providers, eliciting social support, and using the internet to gather information. Results indicated that talking to heath care providers was a dominant strategy intended to reduce uncertainty about the diagnosis and treatment of their symptoms. However, these interactions inadvertently increased uncertainty as well, as providers did not provide information about the causes and prevention of UTIs. Some participants also engaged in deception to reduce uncertainty about how their providers would respond to their pain and their illness. Finally, participants employed metaphors to interpret and neutralize uncertainty related to their experiences. Implications for these findings include guidelines and support for patient and provider communication, communication in social networks, as well as deeper nuances and development for UMT.

A long, winding trajectory of suffering with no definite start and uncertain future prospects - narratives of individuals recently diagnosed with fibromyalgia

Purpose

Fibromyalgia is a contested illness with unknown aetiology and poorly understood development. The present aim is to explore the pre-diagnostic illness trajectory narrated by individuals recently diagnosed with fibromyalgia (FM).

Methods

Individual interviews about the course of the illness were conducted with seven women and three men (age from early 20s to 50s) who had recently been diagnosed with FM. A narrative analysis of what the interviewees told and how the stories were narrated was conducted.

Results

The findings are expressed by three storylines. “Strenuous life and alerted body preluding illness” displays a difficult, unsupported life and bodily sensitivity to stimuli. “Recurrent pains unfolding to become a lasting and complex illness” describes individuals pushing themselves to meet social obligations until they come to a full stop. “Diagnosed but still uncertain presence and future” portrays satisfaction with finally being diagnosed with FM and being supported by others, but still there are no solutions as to do about it.

Conclusions

The three storylines portray a long, winding trajectory of suffering starting before the onset of illness, and unfolding illness gradually becoming persistent and overwhelming. Finally, a diagnosis of FM is arrived at, but how the situation will evolve is uncertain.

Lower odds of remission among women with rheumatoid arthritis: A cohort study in the Swiss Clinical Quality Management cohort

OBJECTIVE

To compare the likelihood of achieving remission between men and women with rheumatoid arthritis (RA) after starting their first biologic or targeted synthetic disease-modifying anti-rheumatic drug (b/tsDMARD).

METHODS

This cohort study in the Swiss Clinical Quality Management in Rheumatic Diseases (SCQM) registry included RA patients starting their first b/tsDMARD (1997-31/04/2018). The odds of achieving remission at ≤12-months, defined by disease activity score 28-joints (DAS28) <2.6, were compared between men and women. Secondary analyses were adjusted for age and seropositivity, and we investigated potential mediators or factors that could explain the main findings.

RESULTS

The study included 2839 (76.3%) women and 883 (23.7%) men with RA. Compared to women, men were older at diagnosis and b/tsDMARD start, but had shorter time from diagnosis to b/tsDMARD (3.4 versus 5.0 years, p<0.001), and they had lower DAS28 at b/tsDMARD start. Compared to women, men had 21% increased odds of achieving DAS28-remission, with odds ratio (OR) 1.21, 95% confidence interval (CI) 1.02-1.42. Adjusting for age and seropositivity yielded similar findings (adjusted OR 1.24, 95%CI 1.05-1.46). Analyses of potential mediators suggested that the observed effect may be explained by the shorter disease duration and lower DAS28 at treatment initiation in men versus women.

CONCLUSION

Men started b/tsDMARD earlier than women, particularly regarding disease duration and disease activity (DAS28), and had higher odds of reaching remission. This highlights the importance of early initiation of second line treatments, and suggests to target an earlier stage of disease in women to match the benefits observed in men.

Take the Day Off: Examining the Sick Role for Chronic Back Pain by Race and Gender

Research has largely overlooked the public’s willingness to validate entrance to the sick role for individuals experiencing chronic pain. To fill this gap, we conducted a survey experiment to assess how race, gender, and their intersection impact (1) the legitimation of missing work due to pain and (2) recommendations for help seeking, examining the role of both respondents and vignette characters. We find that respondent characteristics are associated with perceived acceptability of missing work due to pain, and both respondent and vignette characteristics are associated with help-seeking endorsements. White females are least likely to view pain as an acceptable excuse to miss work but are most likely to endorse help-seeking measures, while black women are recommended the most treatments for pain. We theorize how results provide evidence to counter assumptions of objectivity and linearity of the sick role and how gender and race influence the social response to pain.

Chronic Pain and Prescription Opioid Use Among Socially Marginalized Nigerian Women: Exploring Supply Channels and Pathways to Misuse

This study explores pathways to prescription opioid misuse and supply channels based on in-depth interviews with 16 socially marginalized Nigerian women suffering chronic pain. The pathways identified were medical pain treatment, prior substance use and opioid use for recreation and coping with psychological distress. Facing barriers to prescription opioids due to prescribing restrictions and provider stigma, many resorted to unlicensed chemist stores and street drug dealers for opioid analgesics, including fake and potentially harmful products. Patterns of prescription opioid misuse were woven into multiple and overlapping dynamics of marginalization shaping the lives of these women, including homelessness, sex work, substance use and intimate partner violence. Findings show a need to improve access to prescription opioids and other evidence-based approaches, framed within a trauma-informed approach to pain management. Further, integrating substance abuse treatment and pain management could make services responsive to the inter-related problems of chronic pain and prescription opioid misuse.

Carbon quantum dots as a sensitive fluorescent probe for quantitation of pregabalin; application to real samples and content uniformity test

A novel optical nano-sensor for the detection of pregabalin (PG) in its pharmaceutical (Lyrica®) capsules and biological samples was reported. For the fabrication of highly fluorescent carbon quantum dots (CQDts), a simple green hydrothermal approach was described, and ascorbic acid (AA) was used as a carbon source. The obtained CQDts were confirmed by spectroscopic characterization such as transmission electron microscopy (TEM) and Fourier-transform infrared (FTIR) spectra. The synthesized CQDts were capped by alcohol to form yellow emitters, showing strong fluorescent emission at 524 nm, and excitation at 356 nm. The method is based on fluorescence quenching of CQDts in the presence of PG. The proposed analytical method was validated according to ICH guidelines. PG was successively assayed in the concentration range of 4.0 to 100 μg/ml). The detection and quantitation limits were 1.12 and 3.39 μg/ml, respectively. The proposed method could be used in both quality control and pharmacokinetic research for the studied drug.

Sociology of Chronic Pain

Chronic pain is a common, costly, and consequential health problem. However, despite some important analytic contributions, sociological research on pain has not yet coalesced into a unified subfield. We present three interrelated bodies of evidence and illustrative new empirical findings using 2010 to 2018 National Health Interview Survey data to argue that pain should have a central role in sociological investigations of health. Specifically, we contend that (1) pain is a sensitive barometer of population health and well-being, (2) pain is emblematic of many contested and/or chronic conditions, and (3) pain and pain treatment reflect and have wide-ranging implications for public policy. Overall, whether pain is analyzed quantitatively or qualitatively-focusing on its distribution in the population, its social causes and consequences, or its subjective meanings for individuals-pain reflects social conditions, sociopolitical context, and health-related beliefs of a society. Pain is thus an important frontier for future sociological research.

Medicalization Defined in Empirical Contexts - A Scoping Review

BACKGROUND

Medicalization has been a topic of discussion and research for over four decades. It is a known concept to researchers from a broad range of disciplines. Medicalization appears to be a concept that speaks to all, suggesting a shared understanding of what it constitutes. However, conceptually, the definition of medicalization has evolved over time. It is unknown how the concept is applied in empirical research, therefore following research question was answered: How is medicalization defined in empirical research and how do the definitions differ from each other?

METHODS

We performed a scoping review on the empirical research on medicalization. The 5 steps of a scoping review were followed: (1) Identifying the research question; (2) Identifying relevant studies; (3) Inclusion and exclusion criteria; (4) Charting the data; and (5) Collating, summarizing and reporting the results. The screening of 3027 papers resulted in the inclusion of 50 empirical studies in the review.

RESULTS

The application of the concept of medicalization within empirical studies proved quite diverse. The used conceptual definitions could be divided into 10 categories, which differed from each other subtly though importantly. The ten categories could be placed in a framework, containing two axes. The one axe represents a continuum from value neutral definitions to value laden definitions. The other axe represents a continuum from a micro to a macro perspective on medicalization.

CONCLUSION

This review shows that empirical research on medicalization is quite heterogeneous in its definition of the concept. This reveals the richness and complexity of medicalization, once more, but also hinders the comparability of studies. Future empirical research should pay more attention to the choice made with regard to the definition of medialization and its applicability to the context of the study.

Telling, Hearing, and Believing: A Critical Analysis of Narrative Bioethics

Narrative ethics taps into an inherent human need to tell our own stories centred on our own moral values and to have those stories heard and acknowledged. However, not everyone's words are afforded equal power. The use of narrative ethics in bioethical decision-making is problematized by a disparity in whose stories are told, whose stories are heard, and whose stories are believed. Here, I conduct an analysis of narrative ethics through a critical theory lens to show how entrenched patterns of narrative neglect in medicine are harming not only our capacity to make use of narrative ethics but also our capacity to deliver effective healthcare. To illustrate this point, I use three examples where the patient's gender affects how their stories unfold: autism, weight, and pain management. From these, I argue that the use of narrative ethics without the application of a critical theory lens risks the exacerbation of what Miranda Fricker refers to as "testimonial injustice," the prima facie harm experienced by individuals whose credibility is undermined by others' prejudices. Finally, I suggest that narrative ethics can be a powerful tool for mitigating oppressive practices in medicine if we couple it with critical analysis that enables us to understand the power dynamics at play in storytelling.

How do women suffering from multiple chemical sensitivity experience the medical encounter? a qualitative study in Spain

PURPOSE

Multiple Chemical Sensitivity is a condition principally suffered by women. As with fibromyalgia and chronic fatigue syndrome, Multiple Chemical Sensitivity is usually included among the so called "contested illnesses", defined as illnesses whose cause, diagnosis, prevalence and even existence are subject to controversy. This article seeks to explore how women with Multiple Chemical Sensitivity experience this contested illness, through their own descriptions of diagnostic processes, search for treatment and encounters with different health professionals. We aim to observe these experiences in detail and to identify aspects that could improve care for Multiple Chemical Sensitivity sufferers.

METHOD

Qualitative design. We performed personal in-depth interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7.

SUBJECTS/PATIENTS

22 women diagnosed with Multiple Chemical Sensitivity in Spain.

RESULTS

Two main categories were identified in the interviews: (1) unavoidable barriers: patients' exposure to chemicals and the absence of treatment, and (2) Skepticism on the part of care providers and lack of recognition in the process of diagnosis.

CONCLUSION

Training and above all awareness raising strategies are needed to address health professionals' prejudices regarding the existence of contested illnesses such as Multiple Chemical Sensitivity. These prejudices hinder diagnosis and medical follow-up, and add negative emotions to the physical limitations already suffered by patients.IMPLICATIONS FOR REHABILITATION Multiple Chemical SensitivityIt is important to promote a compassionate and empathetic attitude among health providers, in order to avoid rejection and delegitimization of the experiences of women with Multiple Chemical Sensitivity.Multiple Chemical Sensitivity protocols should be developed and implemented to give skills to health professionals to assist patients with Multiple Chemical Sensitivity.These protocols should include avoidance of exposure to chemicals present in healthcare facilities.Training programs for health providers should include not only knowledge, but awareness raising about the characteristics and severity of contested illnesses such as Multiple Chemical Sensitivity.Health providers should avoid stigmatizing patients by psychologizing their symptoms and be aware of the existence of stereotypes regarding women suffering from Multiple Chemical Sensitivity.

Invalidation of chronic pain: a thematic analysis of pain narratives

PURPOSE

Many people with chronic pain report feeling disbelieved or disparaged by others regarding their pain symptoms. Given the widely documented relationship between stress and pain, the importance of identifying psychosocial stressors such as pain-invalidation is apparent. This study was designed to identify and illustrate using first-person narratives, the effects of pain-invalidation by the self, family, friends, and healthcare professionals, toward individuals with chronic pain.

METHOD

A systematic search of five databases was performed using a search strategy consisting of terms related to pain-invalidation. A review of 431 peer-reviewed journal articles, containing narratives from a pool of over 7770 study participants with a wide range of pain conditions, was conducted, followed by a thematic analysis to establish themes of invalidation experienced by those with chronic pain.

FINDINGS

Five major pain-invalidation themes were revealed: Not being believed, lack of compassion, lack of pain awareness/understanding, feeling stigmatized, and critical self-judgement. Themes additional to pain-invalidation included: Threats to Self-Image, Loss of Identity, and Isolation.

CONCLUSION

Themes were largely interrelated and, together, build a picture of how levels of perceived social unacceptability of pain symptoms can impact on the emotional state and self-image of those with chronic pain. As such, pain-invalidation may potentially impede help-seeking or the effectiveness of therapeutic interventions.IMPLICATIONS FOR REHABILITATIONPain-invalidation can occur at the level of the self, social others, or healthcare professionals.Pain-invalidation can arise through a lack of understanding by others in the social network about having chronic pain.Pain-invalidation may be a barrier to seeking therapy for pain management and rehabilitation, and thus, efforts to identify and acknowledge invalidation experiences may be beneficial in the rehabilitation process.

Nothing and Everything: Fibromyalgia as a Diagnosis of Exclusion and Inclusion

The diagnostic process promises a label that validates patients' embodied experiences and a road map for living with and treating illness. Drawing on 31 qualitative interviews with women and men in Canada and the United Kingdom who have been diagnosed with fibromyalgia (FM), in this article, I examine the participants' experiences of the diagnostic process and how they feel about receiving this label. The interviews reflect that the FM label is plagued by uncertainty because the diagnosis is based on the absence of verifiable pathology. The respondents' narratives also reveal that FM is a vague diagnosis that includes a multitude of symptoms, overlaps with several other diagnoses, and results in feelings of doubt regarding whether it is the correct label. Thus, the participants' narratives reflect that the FM diagnosis is largely an empty promise because it fails to provide definitive answers or confer meaning and legitimacy to their illness experiences.

The Problematic Nature of Fibromyalgia Diagnosis in the Community

Background

Recently, some studies suggested that clinical diagnosis of fibromyalgia is inaccurate and does not reflect current definitions. However, this hypothesis has not been tested. We examined whether fibromyalgia was accurately diagnosed in the community.

Methods

We surveyed 3276 primary care patients to determine current fibromyalgia status by criteria (CritFM). We also determined whether the patients had a physician's diagnosis of fibromyalgia (MDFM) and the level of symptom severity as measured by the polysymptomatic distress scale (PSD).

Results

The prevalence of MDFM and CritFM was 6.1% (95% confidence interval [CI] 5.3%, 6.9%) and 5.5% (95% CI 4.8%, 6.3%), respectively. However, only 32.2% with MDFM met 2016 criteria (CritFM), and only 35.4% with CritFM also had MDFM. The kappa statistic for diagnostic agreement was 0.296 (minimal agreement). The mean PSD score was 12.4 and 18.4 in MDFM and CritFM, respectively. The odds ratio for being a woman compared with being a man was 3.2 for MDFM versus 1.9 for CritFM, P = 0.023. Of the patients with MDFM, 68.3% received specific fibromyalgia pharmacotherapy.

Conclusions

There is little agreement between MDFM and CritFM. Only one‐third of MDFM satisfy fibromyalgia criteria, and only one‐third of patients who meet the criteria have a clinical diagnosis of fibromyalgia. Physician diagnosis is biased and more likely in women. Fibromyalgia treatment is common in MDFM (70.7%). Overall, MDFM appears subjective and unrelated to fibromyalgia criteria. There appears to be no common definition of fibromyalgia in the community.

Diagnosis of Fibromyalgia: Disagreement Between Fibromyalgia Criteria and Clinician-Based Fibromyalgia Diagnosis in a University Clinic

OBJECTIVE

Recent studies have suggested that fibromyalgia is inaccurately diagnosed in the community, and that ~75% of persons reporting a physician diagnosis of fibromyalgia would not satisfy published criteria. To investigate possible diagnostic misclassification, we compared expert physician diagnosis with published criteria.

METHODS

In a university rheumatology clinic, 497 patients completed the Multidimensional Health Assessment Questionnaire (MD-HAQ) and the 2010 American College of Rheumatology preliminary diagnostic criteria modified for self-administration during their ordinary medical visits. Patients were evaluated and diagnosed by university rheumatology staff.

RESULTS

Of the 497 patients, 121 (24.3%) satisfied the fibromyalgia criteria, while 104 (20.9%) received a clinician International Classification of Diseases (ICD) diagnosis of fibromyalgia. The agreement between clinicians and criteria was 79.2%. However, agreement beyond chance was only fair (κ = 0.41). Physicians failed to identify 60 criteria-positive patients (49.6%) and incorrectly identified 43 criteria-negative patients (11.4%). In a subset of 88 patients with rheumatoid arthritis (RA), the kappa value was 0.32, indicating slight to fair agreement. Universally, higher polysymptomatic distress scores and criteria-based diagnosis were associated with more abnormal MD-HAQ clinical scores. Women and patients with more symptoms but fewer pain areas were more likely to receive a clinician's diagnosis than to satisfy fibromyalgia criteria.

CONCLUSION

There is considerable disagreement between ICD clinical diagnosis and criteria-based diagnosis of fibromyalgia, calling into question ICD-based studies. Fibromyalgia criteria were easy to use, but problems regarding clinician bias, meaning of a fibromyalgia diagnosis, and the validity of physician diagnosis were substantial.

Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias

Purpose

Multiple clinical and epidemiological studies have provided estimates of fibromyalgia prevalence and sex ratio, but different criteria sets and methodology, as well as bias, have led to widely varying (0.4%->11%) estimates of prevalence and female predominance (>90% to <61%). In general, studies have failed to distinguish Criteria based fibromyalgia (CritFM) from Clinical fibromyalgia (ClinFM). In the current study we compare CritFM with ClinFM to investigate gender and other biases in the diagnosis of fibromyalgia.

Methods

We used a rheumatic disease databank and 2016 fibromyalgia criteria to study prevalence and sex ratios in a selection biased sample of 1761 referred and diagnosed fibromyalgia patients and in an unbiased sample of 4342 patients with no diagnosis with respect to fibromyalgia. We compared diagnostic and clinical variables according to gender, and we reanalyzed a German population study (GPS) (n = 2435) using revised 2016 criteria for fibromyalgia.

Results

In the selection-biased sample of referred patients with fibromyalgia, more than 90% were women. However, when an unselected sample of rheumatoid arthritis (RA) patients was studied for the presence of fibromyalgia, women represented 58.7% of fibromyalgia cases. Women had slightly more symptoms than men, including generalized pain (36.8% vs. 32.4%), count of 37 symptoms (4.7 vs. 3.7) and mean polysymptomatic distress scores (10.2 vs. 8.2). We also found a linear relation between the probability of being females and fibromyalgia and fibromyalgia severity. Women in the GPS represented 59.2% of cases.

Discussion

The perception of fibromyalgia as almost exclusively (≥90%) a women’s disorder is not supported by data in unbiased studies. Using validated self-report criteria and unbiased selection, the female proportion of fibromyalgia cases was ≤60% in the unbiased studies, and the observed CritFM prevalence of fibromyalgia in the GPS was ~2%. ClinFM is the public face of fibromyalgia, but is severely affected by selection and confirmation bias in the clinic and publications, underestimating men with fibromyalgia and overestimating women. We recommend the use of 2016 fibromyalgia criteria for clinical diagnosis and epidemiology because of its updated scoring and generalized pain requirement. Fibromyalgia and generalized pain positivity, widespread pain (WPI), symptom severity scale (SSS) and polysymptomatic distress (PSD) scale should always be reported.

Challenges in fibromyalgia diagnosis: from meaning of symptoms to fibromyalgia labeling

Fibromyalgia (FM) is a contested illness with ill-defined boundaries. There is no clearly defined cut-point that separates FM from non-FM. Diagnosis of FM has been faced with several challenges that occur, including patients' health care-seeking behavior, symptoms recognition, and FM labeling by physicians. This review focuses on important but less visible factors that have a profound influence on under- or over-diagnosis of FM. FM shows different phenotypes and disease expression in patients and even in one patient over time. Psychosocial and cultural factors seem to be a contemporary ferment in FM which play a major role in physician diagnosis even more than having severe symptom levels in FM patients. Although the FM criteria are the only current methods which can be used for classification of FM patients in surveys, research, and clinical settings, there are several key pieces missing in the fibromyalgia diagnostic puzzle, such as invalidation, psychosocial factors, and heterogeneous disease expression. Regarding the complex nature of FM, as well as the arbitrary and illusory constructs of the existing FM criteria, FM diagnosis frequently fails to provide a clinical diagnosis fit to reality. A physicians' judgment, obtained in real communicative environments with patients, beyond the existing constructional scores, seems the only reliable way for more valid diagnoses. It plays a pivotal role in the meaning and conceptualization of symptoms and psychosocial factors, making diagnoses and labeling of FM. It is better to see FM as a whole, not as a medical specialty or constructional scores.

Gabapentin and Pregabalin Use and Association with Adverse Outcomes among Hemodialysis Patients

Background Gabapentin and pregabalin are used to manage neuropathic pain, pruritus, and restless legs syndrome in patients on hemodialysis. These patients may be especially predisposed to complications related to these agents, which are renally cleared, but data regarding the risk thereof are lacking.Methods From the US Renal Data System, we identified 140,899 Medicare-covered adults receiving hemodialysis with Part D coverage in 2011. Using Cox regression models in which we adjusted for demographics, comorbidities, duration of exposure, number of medications, and use of potentially confounding concomitant medications, we investigated the association between gabapentin and pregabalin, modeled as separate time-varying exposures, and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture. We evaluated risk according to daily dose categories: gabapentin (>0-100, >100-200, >200-300, and >300 mg) and pregabalin (>0-100 and >100 mg).Results In 2011, 19% and 4% of patients received gabapentin and pregabalin, respectively. Sixty-eight percent of gabapentin or pregabalin users had a diagnosis of neuropathic pain, pruritus, or restless legs syndrome. Gabapentin was associated with 50%, 55%, and 38% higher hazards of altered mental status, fall, and fracture, respectively, in the highest dose category, but even lower dosing was associated with a higher hazard of altered mental status (31%-41%) and fall (26%-30%). Pregabalin was associated with up to 51% and 68% higher hazards of altered mental status and fall, respectively.Conclusions Gabapentin and pregabalin should be used judiciously in patients on hemodialysis, and research to identify the most optimal dosing is warranted.

"Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain

Background

Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.

Methods

A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.

Results

The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.

Conclusions

Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

The role of 'social support' in the experience of fibromyalgia - narratives from South Africa

This paper focuses on the role of 'social support' in the experience of fibromyalgia (a musculoskeletal pain disorder) in South Africa. In-depth semi-structured interviews were used to collect narratives from 15 participants. Sources of social support constitute important mechanisms for coping with the illness experience of fibromyalgia. In providing a space for consultation and validation of the diagnosis of fibromyalgia, and the person living with the condition, people giving support fulfil a critical role in shaping the experience. The findings show how support from family, partners, and peers plays an integral role in the process of accepting fibromyalgia diagnosis, adapting to the demands of the condition, and seeking help from healthcare providers. The findings also show the ways in which people with fibromyalgia provide support for others with the condition, and the importance of this peer network in shaping the paths and outcomes of this illness experience. The findings of this study corroborate existing evidence that show fibromyalgia to be a complex condition to manage, due to the multiplicity, uncertainty and contestation that feature in the experience of the illness. Additionally, this study presents the challenges related to the limitations of access to healthcare in the South African context, and the utility of narrative approaches in garnering insight into the ways in which social support is harnessed in this environment.

Struggles for medical legitimacy among women experiencing sexual pain: A qualitative study

Given the prominent role of medical institutions in defining what is "healthy" and "normal," many women turn to medicine when experiencing pain during intercourse (dyspareunia). The medical encounter can become a contest between patients and providers when physicians do not grant legitimacy to patients' claims of illness. Drawing on interviews conducted from 2007 to 2008 and 2011 to 2012 with 32 women experiencing dyspareunia (ages 18-60 years) and living in New York City and its surrounding areas, this study examined women's and their physicians' claims regarding bodily expertise, particularly women's perceptions of physician invalidation, their understanding of this invalidation as gendered, and the consequences for women's pursuit of medicalization. Women overwhelmingly sought a medical diagnosis for their dyspareunia, in which they believed that providers would relieve uncertainty about its origin, give treatment alternatives, and permit them to avoid sexual activity. When providers did not give diagnoses, women reported feeling that their bodily self-knowledge was dismissed and their symptoms were attributed to psychosomatic causes. Furthermore, some women linked their perceptions of invalidation to both historical and contemporary forms of gender bias. Exploration of women's struggles for medical legitimacy may lead to a better understanding of the processes by which medicalization of female sexuality takes place.

Living With a Contested, Stigmatized Illness: Experiences of Managing Relationships Among Women With Fibromyalgia

This study focuses on the negotiation of relationships among women living with the chronic illness fibromyalgia. Twenty in-depth, semistructured interviews were conducted with women diagnosed with fibromyalgia. Drawing from interactional and constructionist perspectives, the analysis focuses on participants' approaches to communicating with others about their illness, the reactions of others to their experiences, and participants' strategies to manage stigma. Participants attempted to describe their illness experience to others through direct and educational approaches. Often, in the management of their relationships with close family and friends, there was an unspoken awareness of illness effects, and social support was offered. However, disbelief and a lack of understanding often led participants to avoid social interactions in the attempt to hide from the stigma associated with an invisible and contested illness.

An exploratory study of the experience of fibromyalgia diagnosis in South Africa

Within the conceptual framework of 'medically-ill-defined' conditions, this article focuses on the experiences of 'diagnosis' through a narrative analysis of fibromyalgia (a chronic musculoskeletal pain disorder) in South Africa. In-depth interviews were used to collect narratives from 15 participants. The findings show how the contested and confusing experience of fibromyalgia diagnosis can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The currency of fibromyalgia as a diagnosis and the inequalities present in the South African health care system characterise the experiences of symptom recognition, diagnosis and treatment. The analysis reveals how those living with fibromyalgia search for diagnosis, and struggle to maintain legitimacy for their experience in the complex constellation of porous symptoms that appear infrequently. The findings of this study confirm the existing evidence that shows fibromyalgia to be a challenging illness experience, which is attributed to the lack of clarity and legitimacy, and high contestation that surrounds the condition. Additionally, this study presents the ways that limited access to diagnosis and treatment for fibromyalgia in the South African context shapes this specific illness experience, and the value of using narrative approaches to gain insight into how people live with hidden and poorly understood conditions in this environment.

Electronic Support Groups: An Open Line of Communication in Contested Illness

BACKGROUND

Patients with functional somatic syndromes are often difficult to treat. The relationship between doctors and patients can be strained, which limits communication. Instead, patients often communicate with each other over the Internet in electronic support groups.

OBJECTIVE

This perspective summarizes studies of patient-to-patient communication over the Internet and uses the concept of contested illness to provide insights into the experiences of patients with functional somatic disorders.

DISCUSSION

Conflict between a patient and their physician is a key feature of functional somatic syndromes. Physicians and patients do not have a shared understanding or appreciation of the patient's experiences. Patients with functional somatic syndromes often value their own embodied experience over medical knowledge. At the same time, they remain deeply invested in finding a "good doctor" who believes that the patient is suffering, agrees with their conception of the cause, and assents to the treatment as directed by the patient. Electronic support groups reinforce these beliefs.

CONCLUSION

Patients may benefit from a compromising, collaborative approach that is realistic about the limitations of medical knowledge. However, physicians should not engage in unsafe treatment practices. Electronic support groups exist for a wide range of illnesses and the issues that rise to the surface in functional somatic syndromes likely occur to some extent with almost every patient.

Understanding Users in the 'Field' of Medications

The numbers of medicinal drugs available for human consumption have increased rapidly in the past several decades, and physician prescribing practices reflect the growing reliance on medicines in health care. However, the nature of medicines-as-technology makes problematic taken-for-granted relationships among actors involved in the delivery, or who are the recipients of medicines-reliant health care. In this article, I situate the medicine user in the 'field' of medications-where interests, actions and outcomes are continually negotiated among and between the various players-physicians, pharmacists, government regulatory bodies, the pharmaceutical industry and users of medicines. The objective of the paper is to illuminate the complex context in which the medicine-user-the target of the pharmacy profession's service to the public-accesses and uses medicines.

Pharmaceutical direct-to-consumer advertising and US Hispanic patient-consumers

Hispanic Americans use prescription medications at markedly lower rates than do non-Hispanic whites. At the same time, Hispanics are the largest racial-ethnic minority in the USA. In a recent effort to reach this underdeveloped market, the pharmaceutical industry has begun to create Spanish-language direct-to-consumer advertising (DTCA) campaigns. The substantive content of these campaigns is being tailored to appeal to the purported cultural values, beliefs and identities of Latino consumers. We compare English-language and Spanish-language television commercials for two prescription medications. We highlight the importance of selling medicine to a medically under-served population as a key marketing element of Latino-targeted DTCA. We define selling medicine as the pharmaceutical industry's explicit promotion of medicine's cultural authority as a means of expanding its markets and profits. We reflect on the prospects of this development in terms of promoting medicalisation in a US subgroup that has heretofore eluded the pharmaceutical industry's marketing influence. Our analysis draws on Nikolas Rose's insights concerning variations in the degree to which certain groups of people are more medically made up than others, by reflecting on the racial and ethnic character of medicalisation in the USA and the role DTCA plays in shaping medicalisation trends. A video abstract of this article can be found at: https://www.youtube.com/watch?v=ZabCle9-jHw&feature=youtu.be.

The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey

BACKGROUND

Most knowledge of fibromyalgia comes from the clinical setting, where healthcare-seeking behavior and selection issues influence study results. The characteristics of fibromyalgia in the general population have not been studied in detail.

METHODS

We developed and tested surrogate study specific criteria for fibromyalgia in rheumatology practices using variables from the US National Health Interview Survey (NHIS) and the modification (for surveys) of the 2010 American College of Rheumatology (ACR) preliminary fibromyalgia criteria. The surrogate criteria were applied to the 2012 NHIS and identified persons who satisfied criteria from symptom data. The NHIS weighted sample of 8446 persons represents 225.7 million US adults.

RESULTS

Fibromyalgia was identified in 1.75% (95% CI 1.42, 2.07), or 3.94 million persons. However, 73% of identified cases self-reported a physician's diagnosis other than fibromyalgia. Identified cases had high levels of self-reported pain, non-pain symptoms, comorbidity, psychological distress, medical costs, Social Security and work disability. Caseness was associated with gender, education, ethnicity, citizenship and unhealthy behaviors. Demographics, behaviors, and comorbidity were predictive of case status. Examination of the surrogate polysymptomatic distress scale (PSD) of the 2010 ACR criteria found fibromyalgia symptoms extending through the full length of the scale.

CONCLUSIONS

Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. The association of fibromyalgia-like symptoms over the full length of the PSD scale with physiological as well as mental stressors suggests PSD may be a universal response variable rather than one restricted to fibromyalgia.

Variations of the social: some reflections on public health, social research and the health-society relation

The idea of a social dimension of health is widely accepted as unavoidable and relevant for public health. This article proposes a reflection around the notion of the social examining some of the manifold ways in which it might be inherited by researchers, professionals, administrative staff and material settings involved in the practices of public health care. It will be argued that this inheritance has deep consequences for efforts of care inasmuch these different versions of the social characterise, circumscribe and reframe the health-society relation, modifying the scope under which public health issues are tackled or dismissed. To ground this seemingly abstract discussion I will work considering a specific public health problem: the case of frequent attenders in public health. Drawing on two approaches from the Sociology of Health (i.e. illness-behaviour and the user-professional relation) and the field of Science and Technology Studies, I will show how these ways of framing the study of frequent attenders assume and simultaneously promote three different versions of the social. The article aims to explore how social research in these traditions participate in the achievement and promotion of specific health-society relations, in which certain notions of the social operate helping or limiting research and care efforts by creating richer or poorer possibilities for posing, examining and facing the problems of public health.

Social security work disability and its predictors in patients with fibromyalgia

OBJECTIVE

To determine prevalence and incidence of US Social Security Disability and Supplemental Security Income (SSD) in patients with fibromyalgia and to investigate prediction of SSD.

METHODS

Over a mean of 4 years (range 1-13 years), we studied 2,321 patients with physician-diagnosed fibromyalgia (prevalent cases) and applied modified American College of Rheumatology (ACR) 2010 research criteria to identify criteria-positive patients.

RESULTS

During the study, 34.8% (95% confidence interval [95% CI] 32.9-36.8%) of fibromyalgia patients received SSD. The annual incidence of SSD among patients not receiving SSD at study enrollment was 3.4% (95% CI 3.0-3.9%), and 25% were estimated to be work disabled at 9.0 years of followup. By comparison, the prevalence of SSD in rheumatoid arthritis (RA) patients with concomitant fibromyalgia was 55.6% (95% CI 54.3-57.0%) and was 42.4% in osteoarthritis (OA). By study conclusion, 31.4% of SSD awardees were no longer receiving SSD. In univariate models, incident SSD in patients with fibromyalgia was predicted by sociodemographic measures and by symptom burden; but the strongest predictor was functional status (Health Assessment Questionnaire disability index [HAQ DI]). In multivariable models, the HAQ DI and the Short Form 36-item health survey physical and mental component summary scores, but no other variables, predicted SSD. Fibromyalgia criteria-positive patients had more SSD, but the continuous scale, polysymptomatic distress index derived from the ACR criteria was a substantially better predictor of SSD than a criteria-positive diagnosis.

CONCLUSION

The prevalence of SSD is high in fibromyalgia, but not higher than in RA and OA patients who satisfy fibromyalgia criteria. The best predictors of work disability are functional status variables.

Peering into the pharmaceutical "pipeline": investigational drugs, clinical trials, and industry priorities

In spite of a growing literature on pharmaceuticalization, little is known about the pharmaceutical industry's investments in research and development (R&D). Information about the drugs being developed can provide important context for existing case studies detailing the expanding--and often problematic--role of pharmaceuticals in society. To access the pharmaceutical industry's pipeline, we constructed a database of drugs for which pharmaceutical companies reported initiating clinical trials over a five-year period (July 2006-June 2011), capturing 2477 different drugs in 4182 clinical trials. Comparing drugs in the pipeline that target diseases in high-income and low-income countries, we found that the number of drugs for diseases prevalent in high-income countries was 3.46 times higher than drugs for diseases prevalent in low-income countries. We also found that the plurality of drugs in the pipeline was being developed to treat cancers (26.2%). Interpreting our findings through the lens of pharmaceuticalization, we illustrate how investigating the entire drug development pipeline provides important information about patterns of pharmaceuticalization that are invisible when only marketed drugs are considered.

Medication and the patient-doctor relationship: a qualitative study with patients suffering from fibromyalgia

BACKGROUND

Fibromyalgia is characterized by a diffuse and predominantly axial and chronic pain, for which there is no explicit rationale for treatment options.

OBJECTIVE

This qualitative study aims to understand the medication experience of patients with fibromyalgia and their relationship with the doctors derived from treatment negotiation.

DESIGN

A qualitative approach was used, based on interviews with patients.

SETTING AND PARTICIPANTS

Semi-structured interviews were held in a public hospital, with 35 patients diagnosed with fibromyalgia. Qualitative content analysis was performed.

RESULTS

The first axis is centred on the unsuccessful quest for an effective treatment for pain and the feeling of dismissal of patients, who are in search of validation and recognition. The second part of the accounts explains the medication adjustments and the search for collaboration. Developing a model of partnership with the doctor enables the patients to shape their own illness, through the medication.

DISCUSSION

It is by mediating their relationship with medication that patients gain access to this state of co-expertise and that they put sense into the collaboration they develop with their doctors. Through this collaboration, useful drugs are identified and adjusted to treat the pain.

Symptoms, the nature of fibromyalgia, and diagnostic and statistical manual 5 (DSM-5) defined mental illness in patients with rheumatoid arthritis and fibromyalgia

Purpose

To describe and evaluate somatic symptoms in patients with rheumatoid arthritis (RA) and fibromyalgia, determine the relation between somatization syndromes and fibromyalgia, and evaluate symptom data in light of the Diagnostic and Statistical Manual-5 (DSM-5) criteria for somatic symptom disorder.

Methods

We administered the Patient Health Questionnaire-15 (PHQ-15), a measure of somatic symptom severity to 6,233 persons with fibromyalgia, RA, and osteoarthritis. PHQ-15 scores of 5, 10, and 15 represent low, medium, and high somatic symptom severity cut-points. A likely somatization syndrome was diagnosed when PHQ-15 score was ≥10. The intensity of fibromyalgia diagnostic symptoms was measured by the polysymptomatic distress (PSD) scale.

Results

26.4% of RA patients and 88.9% with fibromyalgia had PHQ-15 scores ≥10 compared with 9.3% in the general population. With each step-wise increase in PHQ-15 category, more abnormal mental and physical health status scores were observed. RA patients satisfying fibromyalgia criteria increased from 1.2% in the PHQ-15 low category to 88.9% in the high category. The sensitivity and specificity of PHQ-15≥10 for fibromyalgia diagnosis was 80.9% and 80.0% (correctly classified = 80.3%) compared with 84.3% and 93.7% (correctly classified = 91.7%) for the PSD scale. 51.4% of fibromyalgia patients and 14.8% with RA had fatigue, sleep or cognitive problems that were severe, continuous, and life-disturbing; and almost all fibromyalgia patients had severe impairments of function and quality of life.

Conclusions

All patients with fibromyalgia will satisfy the DSM-5 “A” criterion for distressing somatic symptoms, and most would seem to satisfy DSM-5 “B” criterion because symptom impact is life-disturbing or associated with substantial impairment of function and quality of life. But the “B” designation requires special knowledge that symptoms are “disproportionate” or “excessive,” something that is uncertain and controversial. The reliability and validity of DSM-5 criteria in this population is likely to be low.

Media, messages, and medication: strategies to reconcile what patients hear, what they want, and what they need from medications

Background

Over the past 30 years, patients’ options for accessing information about prescription drugs have expanded dramatically. In this narrative review, we address four questions: (1) What information sources are patients exposed to, and are they paying attention? (2) Is the information they hear credible and accurate? (3) When patients ask for a prescription, what do they really want and need? Finally, (4) How can physicians reconcile what patients hear, want, and need?

Analysis

A critical synthesis of the literature is reported. Observations indicate that the public is generally aware of and attends to a growing body of health information resources, including traditional news media, advertising, and social networking. However, lay audiences often have no reliable way to assess the accuracy of health information found in the media, on the Internet, or in direct-to-consumer advertising. This inability to assess the information can lead to decision paralysis, with patients questioning what is known, what is knowable, and what their physicians know. Many patients have specific expectations for the care they wish to receive and have little difficulty making those expectations known. However, there are hazards in assuming that patients’ expressed desires are direct reflections of their underlying wants or needs. In trying to reconcile patients’ wants and needs for information about prescription medicines, a combination of policy and clinical initiatives may offer greater promise than either approach alone.

Conclusions

Patients are bombarded by information about medicines. The problem is not a lack of information; rather, it is knowing what information to trust. Making sure patients get the medications they need and are prepared to take them safely requires a combination of policy and clinical interventions.

Creating the 'dis-ease' of high cholesterol: a sociology of diagnosis reception analysis

Using a sociology of diagnosis approach, this paper discusses the implication of high cholesterol being promoted as a disease rather than a risk factor for cardiovascular diseases. Drawing on data collected during the spring/summer of 2012 from 49 in-depth interviews with women over the age of forty concerned with high cholesterol in Ontario, Canada, I explore participants' understanding of the issue of high cholesterol as a disease. More specifically, I examine where blame and responsibility for high cholesterol are placed and if they vary by women's class background. My findings reveal that all the participants believed in and internalized the diagnosis of high cholesterol. However, the disease is blamed on 'lifestyle choices', and individual responsibilities, while women's awareness of the social determinants of health varies by class. I argue the sense of urgency surrounding high cholesterol is worrisome and the sole focus on lifestyle choice as both the cause and solution to high cholesterol is problematic for three reasons: it assumes that individual responsibility is adequate; it minimizes the socioeconomic constraints women face on a daily basis; and it reinforces the idea that individuals can be blamed for their health problems.

Patients' and professionals' views on managing fibromyalgia

BACKGROUND

Managing fibromyalgia is a challenge for both health care systems and the professionals caring for these patients, due, in part, to the fact that the etiology of this disease is unknown, its symptoms are not specific and there is no standardized treatment.

OBJECTIVE

The present study examines three aspects of fibromyalgia management, namely diagnostic approach, therapeutic management and the health professional-patient relationship, to explore specific areas of the health care process that professionals and patients may consider unsatisfactory.

METHODS

A qualitative study involving semistructured interviews with 12 fibromyalgia patients and nine health professionals was performed.

RESULTS

The most commonly recurring theme was the dissatisfaction of both patients and professionals with the management process as a whole. Both groups expressed dissatisfaction with the delay in reaching a diagnosis and obtaining effective treatment. Patients reported the need for greater moral support from professionals, whereas the latter often felt frustrated and of little help to patients. Patients and professionals agreed on one point: the uncertainty surrounding the management of fibromyalgia and, especially, its etiology.

CONCLUSION

The present study contributes to a better understanding regarding why current management of fibromyalgia is neither effective nor satisfactory. It also provides insight into how health professionals can support fibromyalgia patients to achieve beneficial results. Health care services should offer greater support for these patients in the form of specific resources such as fibromyalgia clinics and health professionals with increased awareness of the disease.

Longitudinal patterns of analgesic and central acting drug use and associated effectiveness in fibromyalgia

BACKGROUND

We describe the changing pattern of analgesic and new central acting drug (NCAD) use (pregabalin, duloxetine, milnacipran) in fibromyalgia and measure NCAD effectiveness in clinical practice.

METHODS

About 3123 US adult patients with fibromyalgia participated in an 11-year longitudinal study of fibromyalgia outcomes. We assessed severity-adjusted treatment prevalence and measured the effect of any use of NCAD on pain and fatigue, and functional status using the Health Assessment Questionnaire (HAQ) disability index.

RESULTS

In 2010, 46.7% of patients used opioids, including 12.5% who used strong opioids. During the 11 years, severity-adjusted strong opioid use increased from 6.3% to 11.7% and any opioid use from 40.0% to 46.6%. Nonsteroidal anti-inflammatory drug (NSAID) use decreased from 74% to 44%. Tricyclic use dropped in half, from 27% to 15%, while NCAD use increased from less than 10% to 39%. The estimated 25th and 50th percentiles for NCAD discontinuation time were 1 and 2.5 years. Overall pain, fatigue and HAQ scores were unchanged over the 11 years. For patients treated with NCAD, pain scores were reduced significantly by 0.17 (0.03, 0.30) units following the start of NCAD, an improvement of 2.8%. Some sensitivity analyses showed improvements of up to 4.3%. There was no significant improvement in fatigue or functional status.

CONCLUSIONS

There is a changing pattern of drug treatment in fibromyalgia, consisting mostly of decreased NSAID and amitriptyline use and an increase in NCAD. Drug costs are substantially higher because of NCAD use, but we found no evidence of clinical benefit for NCAD compared with prior therapy.

"Not all my fault": genetics, stigma, and personal responsibility for women with eating disorders

Medical researchers and clinicians increasingly understand and present eating disorders (anorexia and bulimia nervosa) as biologically-based psychiatric disorders, with genetic risk factors established by high heritability estimates in twin studies. But there has been no research on interpretation of genetic involvement by people with eating disorders, who may hold other views. Their interpretations are particularly important given the frequent presumption that biogenetic framing will reduce stigma, and recent findings that it exacerbates stigma for other mental illnesses. To identify implications of genetic framing in eating disorders, I conducted semi-structured interviews with 50 US women with a history of eating disorders (half recovered, half in treatment; interviewed 2008-9 in the USA). Interviews introduced the topic of genetics, but not stigma per se. Analysis followed the general principles of grounded theory to identify perceived implications of genetic involvement; those relevant to stigma are reported here. Most anticipated that genetic reframing would help reduce stigma from personal responsibility (i.e., blame and guilt for eating disorder as ongoing choice). A third articulated ways it could add stigma, including novel forms of stigma related to genetic-essentialist effacing of social factors. Despite welcoming reductions in blame and guilt, half also worried genetic framing could hamper recovery, by encouraging fatalistic self-fulfilling prophecies and genetic excuses. This study is the first to elicit perceptions of genetic involvement by those with eating disorders, and contributes to an emerging literature on perceptions of psychiatric genetics by people with mental illness.