A Letter to My Younger Self on Living With Chronic Pain

By Crystal Lindell

This is a letter to myself. A letter I wish I had been able to write 13 years ago, when I first developed chronic pain at age 29. Hopefully, my fellow chronic pain survivors will find practical advice mixed with some hope in the words below.  

Dear Crystal,

I have some bad news. The pain you have in your ribs is not going to go away. 

It’s going to linger and spike, and sometimes it will make you want to slit your wrists in the bathtub. It’s going to completely change your entire life. 

In fact, the stabbing pain you’re now dealing with is going to alter your very soul.

Your entire life is going to change so dramatically, that 13 years later, it’ll be difficult for me to even put myself back in your shoes.

While I vividly remember the hopelessness, confusion and fear that’s crushing you right now, it’s difficult for me today, at age 42, to even remember your world view in 2013.

So much of what you think about the world around you, the people in it, and even of yourself is going to change. That change is going to be forced onto you by this new physical pain, which in 2026 will still have no cure. 

However, over time, and through lots of trial and error, you will eventually find a medication regime that mostly works for you. You will also finally find a doctor who believes you, and treats your pain as seriously as it demands.

There is so much other good stuff in store for you too. I promise. 

I know the concept of “good stuff” feels impossible right now, but I swear that good things will happen to you in the years to come. And so many of those good things will only happen because of the very pain that currently feels like it’s ruining your life.

For starters, the pain you’re feeling is eventually going to lead you to the love of your life.

Yes, I know you’re currently dating someone. But he is not the love of your life. Over the next few years, as your body betrays you, he will do the same. 

I know that since he is more than a decade older than you, you expect to help him through his health problems as he ages – but he is not expecting the same in return. He does not like that you now have a chronic illness, and he does not want to take care of you. He will even say this to you directly at one point. 

He is very selfish. But you’ll linger with him longer than you should because even selfish support feels like support with everything else that you’re going through. It’s ok. You’ll need time to process the loss of him in your life. And you need to play it all out – so that when you do finally meet your true love, you’ll understand what makes him so important.

The two of you will meet at a political event. You’ll both be there to advocate for pain patients to have better access to opioids. That’s right, the love of your life has chronic pain too. It’s the kind of double bad luck that almost cancels out, when you realize that it’s the very thing that brings the two of you into each other’s lives in the first place.

He’s handsome, he’s funny, and best of all, he doesn’t mind taking care of you for the rest of his life. 

You’re also going to move. And I don’t mean across town.  

Eventually you will realize that living with family is the only way you can endure all of this. But that is something you’ve already begun to realize. It will take you less than six months to decide to move in with your mom.

Yes, this means losing your part-time job as a youth leader that you love so much. It will be a heartbreaking loss. A loss you don’t deserve. There is not much good to say about this loss, other than the fact that you will survive it. And through that loss, your ability to empathize will expand. 

And while you will be able to maintain your career and even your current full-time job for the next nine years, eventually you will lose that too. That loss is only partly because of the chronic pain though. It’s more because of the burn out, which the chronic pain doesn’t exactly help with.

But it’s ok. You will still find other ways to write, and even ways to get paid a little to do it. And you will be happier without your former corporate overlords making you so miserable.

Plus, writing about all of your experiences will help countless people endure their own chronic pain. Many of them will even reach out to you to thank you for the many ways you helped them cope. Your pain will go out into the world and make it a slightly better place.

Also, in a few years, you’re going to get a cat. And that cat will lead to three more cats. I know, I know. It sounds impossible right now, but for some reason your cat allergies will fade, and those cats will eventually come to help you get through the especially bad pain flares.

For now, my most practical advice is to talk to your doctor about a prescription sleeping pill so that you can finally get some real rest. He will give it to you, I promise. 

Also, remember that doctors are not gods. They will get a lot of stuff wrong in the years to come, and you’re going to have to advocate for yourself if you want to survive. The confidence to do that will come to you first as a necessity, and then as something that’s part of your very being. You’ll wonder how you ever navigated the world without it.

One last thing – and this is especially important – I really need you to keep going. 

I need you to survive each long day – and each even longer night – so that we can make it to 2026. I need you to stay alive long enough to start to see that even a life with debilitating chronic pain is worth living. Because it very much is.

I wish that I was writing to tell you that your pain will be cured, and that everything will go back to how it was before your ribs started to feel like someone was stabbing them with a butcher knife every night.

But I really believe that your actual future is even better. Nothing goes back to the way it was before the pain started. And that’s the very best part.

CBD Enhances Oxycodone’s Pain Relieving Effects

By Pat Anson

Some pain sufferers firmly believe that cannabis can help boost the pain relieving effects of prescription opioids. The evidence behind that belief is mostly anecdotal, but some new research lends some credence to it.

In studies on laboratory rats, researchers at the University of Florida and Texas A&M University College of Dentistry found that cannabidiol (CBD) appeared to enhance the pain-relieving effects of oxycodone without increasing the risk of addiction. 

CBD is one of the many cannabinoids found in cannabis. It does not have the same psychoactive effects of tetrahydrocannabinol (THC), but is believed to have some therapeutic benefits.

The rats were treated with CBD, oxycodone or a combination of the two daily for two weeks, while acute pain was induced in the laboratory.

The study findings, published in The Journal of Pain, found that CBD enhanced oxycodone’s antinociceptive effect, meaning it blocked pain signals from reaching sensory neurons in the brain. CBD also did not affect the “rearing behavior” or “place preference” of rats, activities that may have suggested they were becoming dependent or addicted to oxycodone.

“Together, these findings suggest that cannabidiol potentiates the analgesic effects of oxycodone without affecting its reward-related properties. These results support the potential of cannabidiol as an adjunctive, opioid-sparing agent in pain management,” researchers wrote.

A recent study of 21 people with knee osteoarthritis reached a very different conclusion, finding that a low-dose of opioids taken with a cannabis-based medicine did not relieve acute pain. 

That study, however, was deeply flawed. The cannabis-based medicine was dronabinol (Marinol), a synthetic version of THC. Dronabil is FDA-approved to treat nausea and improve appetite, but is not intended to provide pain relief. The medication also has little in common with the various forms of cannabis (edibles, smoking, vaping) used in the real world.  

Granted, the use of dronabil and laboratory rats are major weaknesses in both studies, which highlights how cannabis research has long been stifled in the U.S. by marijuana’s status as an illegal Schedule I controlled substance.     

The DEA is now allowing more cannabis to be used for research purposes and recently reclassified medical marijuana as a Schedule III drug, which allows for medical uses. It could be years, however, before we see more high-quality studies about the risks and benefits of cannabis products.  

Electric Nerve Stimulation May Help Manage Osteoarthritis

By Louise Burgess

An estimated 595 million people globally are living with osteoarthritis. This makes it one of the leading causes of pain and disability.

Osteoarthritis is a degenerative joint disease, in which tissues in the joint break down over time. The condition can affect any joint, but most commonly the knees, hips, hands and spine.

However, the impact of osteoarthritis often goes beyond the affected joint. The condition can have profound effects on daily life.

Research shows that people with osteoarthritis are less likely to remain in work and more likely to develop additional health problems, such as diabetes, obesity and poor mental health, than those without the disease.

One of the key approaches recommended for managing osteoarthritis is exercise, including aerobic exercise and muscle strengthening. It’s shown to be extremely beneficial for managing the condition and its associated symptoms.

But not everyone who has osteoarthritis is able to exercise due to pain and limited mobility. This is why electrical muscle stimulation, a novel technology that uses small electrical impulses to help muscles contract, is being investigated for managing osteoarthritis.

Exercise for Osteoarthritis

Aerobic and muscle strengthening exercises are both proven to address key drivers of osteoarthritis symptoms.

Aerobic exercise can help manage body weight and improve pain by enhancing circulation and reducing inflammation.

Muscle strengthening exercise improves joint stability by supporting the surrounding musculature. This reduces stress on the joint and improves movement.

Together, these approaches can help to break the cycle of pain, inactivity, weight gain and physical decline that can happen in osteoarthritis.

But as beneficial as exercise is, many people with osteoarthritis are reluctant to try it or struggle to adhere to physical activity long term.

In fact, data suggests that people with musculoskeletal conditions (such as osteoarthritis) are around twice as likely to be physically inactive as their healthy counterparts.

Reported barriers to physical activity include pain, limited mobility, negative experiences of physical activity and a lack of motivation. But the less we move, the more muscle mass and strength we gradually lose.

A difficult cycle can then emerge, whereby pain, stiffness and fear of making symptoms worse all discourage movement. Then, without movement, stiffness and pain worsen.

An Alternative Approach

When exercise feels too painful or isn’t possible, electrical muscle stimulation (EMS) may offer an alternative method for maintaining and improving strength.

This works by placing electrodes on the skin to deliver small electrical impulses, causing muscles to contract without the joint needing to move. The electrical impulse is similar to the signal we normally send from our nervous system when we want to perform a movement.

When performed instead of exercise over several weeks and sessions, EMS has been shown to increase muscle size and strength and improve function in people with hip and knee osteoarthritis. For example, in people with knee osteoarthritis, EMS performed on the quadriceps muscles three days per week for 4-8 weeks has led to benefits.

The therapy can be used in isolation, or it can be applied during exercise to activate even more muscle fibres in what is called a superimposed muscle contraction.

Electrical muscle stimulation also shows promise for those with severe, end-stage osteoarthritis who are preparing for surgery.

For example, one study compared the effects of performing EMS or exercise before surgery for knee osteoarthritis on postoperative outcomes. The study found that participants who used EMS for 20 minutes a day, five days a week in the six weeks before surgery saw greater improvements in postoperative muscle mass, strength and function, compared with patients who performed physical exercise.

Muscle weakness is common both before and after surgery, partly due to pain and reduced movement. While exercise programmes before and after surgery are widely recommended, research suggests they often only have modest effects on functional recovery from joint replacement surgery.

One explanation may be that people with severe osteoarthritis cannot tolerate the level of intensity needed while exercising to build muscle effectively. In addition, joint trauma and swelling from surgery can cause disruption to the signalling pathways that are required to activate muscles.

Because EMS can bypass some of these signalling issues, it may help to maintain or rebuild muscle where conventional exercise is not feasible immediately after surgery. It’s often used in sports settings for this reason, such as when athletes require anterior cruciate ligament surgery.

That said, electrical muscle stimulation is not a magic solution and has its limitations. In many cases, it works best as a complement to, not a substitute for, active rehabilitation.

The body of evidence for its effectiveness in osteoarthritis is also still evolving. Some studies showed inconsistent results or were only conducted using a small sample.

Some people find the sensation of electrical stimulation uncomfortable. Some aren’t suitable for its use (for example, those with pacemakers) and devices can be expensive to buy.

Nonetheless, for those who cannot exercise due to pain, swelling or limited mobility, EMS offers a practical tool to maintain muscle strength. This can help them stay active and independent for longer, recover quicker from surgery, and maintain a better quality of life.

Louise Burgess, PhD, is a Lecturer in the School of Allied Health and Exercise Sciences at  Bournemouth University. She specialises in neuromuscular electrical stimulation (NMES), with a focus on its application in musculoskeletal rehabilitation and performance. Her research has also explored the use of NMES for healthy aging, osteoarthritis, joint replacement, intensive care patients with Covid-19, deep vein thrombosis prevention, and ankle sprains.

This article originally appeared in The Conversation and is republished with permission.  

Can Prayer Reduce Pain and Anxiety?

By Crystal Lindell

One of the strangest things about developing a chronic illness was realizing just how many people would suggest prayer to me as a medical treatment. They would say it as though they were suggesting surgery or a new medication.

New research seems to show that they may have been on to something. Not only that, the amount of relief is significant and could last two weeks or longer.

Having someone pray for you, which the study dubs “proximal intercessory prayer” – PIP for short – helped both pain and anxiety. Unfortunately, despite patients reporting lower pain scores, the researchers found that the pain relief did not result in reduced use of pain medication.

The study, which was published in The Annals of Family Medicine, was led by researchers at the University of Maryland and involved 180 patients with moderate-to-severe pain and/or anxiety.

Half the participants received 5 minutes of Christian prayer from a trained volunteer prayer practitioner, which included a “laying-on-of-hands.” The other half listened to Christian-themed piano music intended to promote meditation and relaxation.

At the start of the study, both groups had pain scores that averaged about 5.8 on the zero to ten pain scale.

Those who received prayer reported large reductions in pain immediately after, with pain scores falling to about 2.6 on average. Pain levels rose to 4.22 after two weeks and leveled off at 4.03 after six weeks.

Patients who listened to music also said their pain levels were reduced, although not as significantly.

Pain Levels Before and After Treatment

THE ANNALS OF INTERNAL MEDICINE

Participants reported similar reductions in anxiety immediately after PIP, but anxiety levels edged up again in the following weeks.

Interestingly, researchers found that the religious affiliation of patients and the intensity of their religious beliefs had no major effect on outcomes. Whether or not participants believed statements like “God heals through prayer” or “I expect to receive some healing through prayer” did not predict the amount of relief they felt.

“Our findings suggest that PIP may be effective for a wide range of patients, including non-Christians and those who do not expect the intervention to be effective,” researchers concluded.  “The results suggest that PIP may be a safe, quick, effective intervention that can be performed in medical settings as an adjunct to standard health care.”

Participants reported no adverse events, and most said they would want in-person prayer to be offered at future medical visits.

It’s great that many of the patients experienced significant pain relief, and it’s even better than it lasted multiple weeks. However, as with all studies involving unconventional pain treatments, such as mindfulness and cognitive behavioral therapy, my concern is that in-person prayer will be forced onto patients who aren’t interested.

Anyone who has ever been in true pain will tell you that they are willing to try just about anything to find relief. That includes atheists being offered prayer. So if it works, that’s great.

We just need to make sure that prayer is not used as a substitute for opioids and other conventional treatments. In the grand scheme of things, who’s to say that pain medication isn’t just God’s way of answering prayers for relief in the first place?

21 Million Americans in Severe Pain Don’t Have a Diagnosis

By Pat Anson 

A new study has found what many chronic pain patients have already learned the hard way: It’s difficult to get a diagnosis.

Researchers at The University of Texas at Arlington (UTA) estimate that 21 million Americans living with severe pain have never received a medical diagnosis for what’s causing it.

Their findings, recently published in the journal PAIN, are based on four years of federal health data, which found a significant gap between the painful symptoms that patients report and what actually appears in their medical records.

“What this study shows is that a significant number of people experience pain that interferes with their work and daily activities, yet the healthcare system does not capture a reason for that pain,” said lead author Feinuo Sun, PhD, an Assistant Professor of Kinesiology at UTA. “That mismatch represents a real problem.”

Pain is one of the most difficult conditions to diagnose because of its subjective nature. What may be “severe” pain to one patient may be “minor” to someone else.

Given the well-known disparities in healthcare access in the United States, it’s not surprising that undiagnosed pain is more common in some groups than others.

Compared to white and native born Americans, people who are Black, Asian or foreign born are more likely to have undiagnosed pain, due to barriers in getting treatment and more limited healthcare resources. People without health insurance and those with poor mental health face similar obstacles in getting a diagnosis.

Undiagnosed pain is also more common among men and young or middle-aged adults. Researchers think that may be due to the fact that women and older adults are more likely to see a doctor and describe their symptoms in a more detailed way – making them more likely to get a diagnosis.

Geography also plays a role. Americans living in the West are more likely to have pain, and more likely to be without a medical diagnosis. A previous study by Sun found that people have less access to healthcare in rural areas, and have greater distances to travel for treatment.

Two findings were unexpected: People with higher incomes and those who are employed are more likely to have undiagnosed pain. That’s because wealthier people are more likely to self-manage minor pain with over-the-counter painkillers and alternative treatments. And people who have jobs may be reluctant to take time off to see a doctor or to use up their sick days.

Overall, about 30% of Americans who have some degree of pain do not have a corresponding medical diagnosis. The percentage of undiagnosed pain drops to 17.8% for those with moderate-to-severe pain. 

It’s worth noting that the UTA study analyzed health data from 2016–2019, a period when pain was still classified as a symptom rather than a disease. That changed in 2022, when the World Health Organization updated the International Classification of Disease (ICD) coding system to recognize chronic pain as a disease for the first time.

The implementation of a new ICD-11 code may help narrow the diagnosis gap by bringing greater clinical attention to chronic pain, leading to quicker diagnosis and treatment. 

“Because pain was not classified as a disease during the years we studied, many people likely had their pain overlooked or inadequately documented, even when it significantly affected their quality of life,” Sun said. “When pain goes undiagnosed, it is very likely to be undertreated or poorly managed.” 

A recent study found that rates of chronic pain and disabling pain surged in the U.S. after the Covid pandemic, reaching the highest levels ever recorded. Today, about 60 million Americans have chronic pain, and 21 million have “high impact” pain severe enough to interfere with work and everyday life.

Inflation Is Especially Hard on Chronic Pain Patients

By Crystal Lindell

These days it feels like just walking into a grocery store costs $100. And topping off your gas tank is the kind of thing you have to start a savings plan to achieve.

It’s not your imagination. Everything has gotten outrageously more expensive, and it’s only getting worse.

According to a recent PBS article, overall food prices are up 3.2% in the last year, with foods like beef (+15%), coffee (+18.5%), and fresh tomatoes (+40%) rising even more.

Gas prices have soared to a nationwide average of $4.49 a gallon – up from $2.98 just before the Iran war began at the end of February.

Rent and utilities are also going up, and consumer confidence is so gloomy that two-thirds of Americans are cutting back on spending.

There seems to be no aspect of life where people can catch a break financially these days, but it’s especially difficult for chronic pain patients.

Many of us live on fixed incomes, and rely on aid programs like food stamps and Medicaid.

Unfortunately, the government is not increasing the amount of money recipients get from those programs to account for inflation. So as prices go up, the only choice is to live on less.

Of course, it’s not really a choice, because many patients are already living on a bare bones budget to begin with. You can’t shift down by going to a food pantry if you’ve already been going to a food pantry for the last three years.  

So what actually happens is that we end up cutting back on essentials. We’re eating less, moving in with relatives to save money, and never turn on the A/C to keep the electric bill down. 

There’s also the fact that patients have ongoing medical expenses to contend with, like prescriptions, insurance premiums, and co-pays. Those have all increased as well.

Those of us who are able to work can’t physically endure working more hours or taking a second job to help with the constant price increases.

It also means that we have less money for the types of services that are considered a “convenience” by healthy people, but are necessities when you have a chronic illness and can’t get around well. Things like grocery and restaurant delivery services become extravagances.

On the other side of that, jobs with DoorDash and Uber used to be good side gigs, because you can choose your own hours, and take a day off when you’re having a pain flare.

I personally spent the last year earning extra cash that way, but had to give it up when gas prices spiked because DoorDash refused to increase driver pay to cover the higher cost. It was costing me more to make deliveries than I was earning. 

With all the constant financial pressure, it just feels important to lay everything out in one place, and to validate what many patients are struggling with these days. 

When you’re already dealing with chronic pain that makes it painful to live, it’s easy for the whole situation to make you feel depressed, despondent, and lose hope. 

Making it worse is that there doesn’t seem to be any sort of path or plan to make any of this better. Sure, maybe gas prices will inch down a few cents, and maybe you’ll be able to find a good two-for-one deal on beans at the grocery store. 

But in the grand scheme of things, when your health is bad and your financial health is worse, it’s difficult to keep going.

But keep going is exactly what you need to do. Because if you’re still here, then the world still needs you in it. And you have no idea how much you may be helping others to endure all this as well.

Maybe one day, the government will finally start working for the people again, and we can start to dig our way out of this. Crazier things have happened.

A Simple Chart Destroys a Myth About the Opioid Crisis

By Neen Monty

There’s a simple reason the narrative around the “opioid crisis” falls apart when you actually look at the overdose data.

Because the data doesn’t show what they claim it shows. 

And that false narrative has been retrofitted to cover the deception and lies wrought by bad actors in the U.S. healthcare system.

The chart below tracking overdose deaths by opioid type tells two stories:

1. Prescription opioid deaths rose, stabilized, and then fell.

2. Fentanyl arrived… and everything exploded.

Those are not the same curve. Those are not the same problem.

There are two epidemics. And one deliberately blurred narrative.

In the United States, prescription opioid deaths peaked around 2012, at about 5 deaths per 100,000 Americans. 

Meanwhile, fentanyl-related deaths – almost non-existent before 2012 – began rising exponentially as illicit fentanyl entered the black market.

In 2023, they peaked at 22.2 deaths per 100,000 people. By then, overdoses linked to prescription opioids had fallen to 3.8 deaths per 100,000.

That means there are almost 6 times the number of overdose deaths caused by illicit fentanyl than prescription opioids.

Yet prescription opioids remain the target.

That “opioid crisis” curve?

That’s illicit fentanyl. Not pain patients. Not prescription opioids. Not doctors treating disease.

The Uncomfortable Truth

When overdose deaths skyrocketed, prescription opioid deaths were already flattening out and falling. That should have changed the narrative right there.

But the narrative stayed the same.

The explosion in deaths aligns with one thing: iIlicit fentanyl and its analogues flooded the U.S. drug supply with counterfeit pills of unknown, often lethal, potency.

That is why deaths surged, not because someone with intractable rheumatoid arthritis got oxycodone prescribed for their pain.

The numbers don’t lie. If the opioid crisis were really about prescriptions, the lines on the chart would look very different.

So why didn’t the narrative charge?

Because blaming illicit fentanyl means:

• Confronting illicit drug supply chains

• Admitting policy failure

• Acknowledging complexity

Blaming prescriptions is easier. It creates easy villains to target:

• Doctors

• Patients

• Pain medication

And it opens the door to:

• Restrictions

• Guidelines

• “Education programs”

• Entire industries built on fear

Who paid the price?

Pain patients. People with cancer, autoimmune disease, neurological damage, and severe structural pathology.

People who were stable. Functioning. Living.

Until they were cut off.

This was never about prescriptions. The chart makes one thing brutally clear: The U.S. overdose crisis is a fentanyl crisis.

Everything else is a false narrative. A fairy story. One designed to vilify people who are already among the most vulnerable people in our communities – the ill, the disabled, people living with severe pain.

It’s important to note that by the time Physicians for Responsible Opioid Prescribing (PROP) was created in 2012, prescription opioid deaths had already stabilised and were falling.

PROP was instrumental in creating the CDC’s infamous 2016 opioid prescribing guidelines. But there was no need to restrict opioid prescribing. There was no need for forced tapers that lead to suicides and overdose deaths. There was no need for dose ceilings that meant people’s pain was no longer treated adequately.

There was also no need for the fabrication of “evidence” that does not stand up to even a little scrutiny. Just read the studies that the CDC guidelines are based on. They do not show what you have been told they show.

But no one actually reads the studies. No one examines the data. No one questions. Doctors just blindly follow the guidelines. It’s hard to blame them when they face prison time if they don’t.

It has been ten years since the forced tapers started in the U.S. Six years since Australia blindly copied this failed policy. No one in Australia bothered to read the research. Australia just copied the U.S. guideline and allowed politicians to decide who gets pain relief and who does not.

Australia could see the policy going horribly wrong in the U.S. Yet it implemented those same policies and tortured Australian chronic pain patients the same way. The same is true for Canada and the UK as well.

This should never have happened.

Patients on three continents have been abandoned, left to suffer in agony day after day. Given psychological therapies for physical disease and injury. And no one says a word. 

I have contacted many politicians, journalists, and senior public servants in Australia.  No one will take this on. No one will right this wrong.

And the media continues to push a false narrative about an opioid crisis that does not exist. But it gets clicks.

It may be futile, but my life and those of many others depend on access to safe and effective opioid therapy.

And so, I will continue to fight.

Neen Monty is a patient advocate in Australia who lives with rheumatoid arthritis and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), a progressive neurological disease that attacks the nerves.

Neen is dedicated to challenging misinformation and promoting access to safe, effective pain relief. For more information on chronic pain, the science, the politics and the lived experience, go to Pain Patient Advocacy Australia. You can also subscribe to Neen’s free newsletter on Substack: “Arthritic Chick on Chronic Pain.”

What If Medical Marijuana Was Free?

By Pat Anson

Chronic pain patients in the U.S. who are curious about trying medical marijuana are often turned off by the cost. Depending on where they live and how much legal marijuana is taxed, an ounce of medium-quality cannabis costs about $250; a one-ounce tincture bottle can cost up to $80; and a package of edibles might range from $20 to as high as $60.

Consulting with a doctor and getting a prescription for medical marijuana costs $40 to $150, and getting a medical marijuana card from your state could be another $100.  

All of these are out-of-pocket expenses, since health insurers don’t cover cannabis, although that could be changing now that the DEA has reclassified medical marijuana as a Schedule 3 controlled substance, which allows for some medical use. That opens the door to insurance coverage, but private insurers, Medicare and Medicaid have yet to take that step. 

In short, medical marijuana is currently out of reach financially for many patients.

But imagine if it was free. Would pain sufferers benefit if the cost of cannabis was no longer an issue?

The short answer is yes, according to a small new study in the Cureus Journal of Medical Science.

Researchers at the University of Pennsylvania’s Perelman School of Medicine found 29 patients with long-term chronic pain who wanted to reduce their opioid use and try medical marijuana, but considered cost a “major barrier.” With advice from a medical cannabis pharmacist, patients selected from a variety of no-cost cannabis products and started on a personalized opioid tapering plan.

“To our knowledge, this is the first prospective study evaluating whether medical cannabis can be used as an alternative to opioids in patients with chronic pain for whom cost has been a primary barrier to access,” wrote lead author Franklin Caldera, DO, who specializes in Physical Medicine and Rehabilitation at Hospital of the University of Pennsylvania.

At the start of the study, the average daily dose of opioids for participants was 46.8 morphine milligram equivalents (MMEs). Most had been taking opioids for over a decade to treat chronic back pain caused by degenerative disc disease or lumbar radiculopathy.

After five weeks of daily medical marijuana use, the average pain score for patients fell from 7 (on the zero to 10 pain scale), to a little less than 6 – a 16% reduction. Participants also reported improvements in their physical functioning, fatigue, general health, social functioning, and emotional well-being.

Even more impressively, patients reduced their average daily opioid dose to 16.2 MME – a 65% reduction. Seven participants were able to completely discontinue opioid therapy. Researchers say the reductions were sustained after a five month follow-up period.

“The findings of this study add to the growing body of literature supporting the safety profile and potential therapeutic role of cannabis. These data may help inform future considerations regarding reclassification, which could reduce financial barriers to access and help destigmatize its use for pain management and other medical indications,” said Caldera. 

“When used under appropriate medical supervision, medical cannabis may represent an effective adjunctive strategy for reducing opioid use among patients receiving long-term opioid therapy.” 

An obvious weakness of the study is its small size. Participants also wanted to reduce or stop their opioid use, which may have influenced the results.

We know nothing about the dose or type of medical marijuana they consumed, since patients selected their own cannabis products, the dose, and frequency of use. Without a standardized dose and method of delivery, we don’t know whether vaping or smoking were more effective, or if tinctures provided better pain relief than edibles. That’s unfortunate.

Previous studies have found that medical cannabis can help reduce the use of opioids and other medications. A recent survey of over 3,500 cannabis users in Germany found that most were able to reduce their use of painkillers, sleep medications, anti-depressants and other prescription drugs once they started using medical cannabis.

A similar survey of medical cannabis users in Florida found that many who have chronic pain were able to reduce or stop their use of opioids. Patients also reported less pain, and better physical and social functioning.  

Managing Expectations Is Often Key to Chronic Pain Treatment

By Chris Seenan

In a 2026 study I conducted with colleagues on people with peripheral arterial disease, one participant described how leg pain had disrupted his golf for years. It forced him to stop mid-round, shake his leg and apologise to his playing partners while he waited for the pain to pass. He found it mortifying. 

Then he tried a small electrical device that delivered gentle pulses through pads stuck to his skin. He still had pain. But he could get round the course.

When we measured his walking on a treadmill, we found no improvement. He had not noticed. That was not the outcome that mattered to him. Before the study ended, he had already gone out and ordered his own device.

A different participant reached the opposite conclusion. The pain was still there when he used the device, he said. It had not done him any good. And he was right, in a narrow sense. The device had not eliminated his pain. 

What it had done was reduce its intensity and delay its onset, allowing him to walk measurably further. His expectation of complete relief meant that genuine, partial relief felt like failure. He concluded the treatment did not work.

The study did not tell a simple story of success or failure. For some participants, standard treadmill measures did not capture what had changed in daily life. For others, measurable improvements still failed to feel meaningful because they fell short of what the person had hoped for. 

The difference was not only the treatment, or the severity of their condition. It was what each person had been led to expect.

Recognising Relief

Both men were living with peripheral arterial disease, a condition caused by a build-up of fatty deposits inside the arteries that supply the legs. It affects an estimated 236 million people worldwide. 

Its hallmark symptom is a cramping pain in the calf during walking that eases with rest. Over time, it can shrink a person’s world, limiting independence and increasing the risk of serious cardiovascular problems.

The recommended first-line treatment is supervised exercise therapy: structured exercise sessions led by trained professionals. But in many countries, access to supervised exercise therapy remains patchy and under-resourced. That gap is fertile territory for the wellness market.

Transcutaneous electrical nerve stimulation (TENS) delivers small electrical impulses through electrode pads on the skin to interfere with pain signals travelling to the brain. There is evidence that it can help with some kinds of pain, and it is used in hospital pain management settings. It is not a wellness product. 

In our study, we explored what happened when people with peripheral arterial disease used TENS independently at home, outside the controlled conditions of a clinical trial.

The findings point to something standard clinical tests rarely capture. Expectation can shape whether useful relief is recognised as useful.

That finding matters well beyond this particular device or condition. The global wellness industry is worth over a trillion dollars and operates with minimal regulatory oversight. People living with painful long-term conditions are among its most heavily targeted consumers. 

Companies sell electrical stimulation devices, supplements and wearable gadgets to people in chronic pain, using influencer testimonials in place of evidence and social media algorithms to reach people who are frightened, frustrated or in pain.

When a product fails to deliver the transformation it promised, patients rarely conclude they were misled. They conclude that nothing can help them. In conditions where reduced physical activity carries real health consequences, that conclusion is not merely disappointing. It is dangerous.

Poor Communication Hinders Treatment 

This is where the study speaks to a much wider problem. Whether a person is using a clinical device, a wearable gadget or a supplement sold online, they are often asked to judge it against expectations they did not set for themselves. Even legitimate, clinically tested treatments can be undermined by poor communication about what to expect.

The golfer’s experience illustrates this clearly. He valued an outcome that no clinical trial had thought to measure: the ability to play a round of golf without humiliation. Once he understood the device could offer that, it worked for him. His fellow participant was never given the chance to find his equivalent.

A market built around selling hope is poorly equipped for that kind of honesty. But the same danger can appear even when the person giving advice has medical credentials.

Research shows that even medically qualified doctors who become prominent wellness influencers on social media are subject to many of the same pressures as their unqualified counterparts: to build a personal brand, produce content constantly, stand out from competitors and make advice sound more certain than it really is. 

Having a medical degree does not make someone’s Instagram post better at managing a patient’s expectations. It just makes it more convincing.

What actually helps requires something platforms cannot provide: time, a genuine clinical relationship and communication that is not contingent on making a sale. 

It requires asking a patient not just whether their pain has reduced, but what they were hoping to do that pain had been stopping them from doing. It requires explaining that partial relief is still relief and that the outcome worth measuring might not be the one on the form.

That kind of honesty does not feature in any influencer’s discount code, medical degree or otherwise. But for the person who just wants to get round the golf course, it might be the most important part of the treatment.

Chris Seenan, PhD, Senior Lecturer in Physiotherapy at the University of Stirling 

His research focuses on the lived experiences of people with long-term conditions, particularly Peripheral Arterial Disease (PAD), Diabetes, and Chronic Pain. 

This article originally appeared in The Conversation and is republished with permission.  

Lawsuit Claims ChatGPT’s ‘Unlicensed Practice of Medicine’ Led to Teen’s Death

By Crystal Lindell

The parents of a 19-year-old college student who died of an accidental overdose are blaming ChatGPT for giving their son deadly advice about his drug use. 

Leila Turner-Scott and Angus Scott are suing OpenAI – which makesChatGPT -- and founder/CEO Sam Altman over the death of their son, Sam Nelson.

They allege Nelson was seeking advice on combining different drugs, and ChatGPT encouraged him to take the prescription drug Xanax to treat nausea caused by kratom.

“Sam was a smart, happy, normal kid. I talked to him often about internet safety, but never in my worst nightmare could I have imagined that ChatGPT would cause his death. If ChatGPT had been a person, it would be behind bars today,” Leila Turner-Scott told Tech Justice Law, which helped file the lawsuit.

“Sam trusted ChatGPT, but it not only gave him false information, it ignored the increasing risk he faced and did not actively encourage him to seek help.”

According to the lawsuit, ChatGPT “engaged in the unlicensed practice of medicine” when it advised Nelson to take Xanax to counteract the nausea caused by a high dose of kratom. He died in 2025 from a fatal combination of Xanax, kratom, and alcohol.

SAM NELSON

Nelson’s parents are seeking monetary damages, but they also want the court to pause OpenAI’s rollout of ChatGPT Health, a platform that allows users to upload medical records and receive personalized health advice.

Unfortunately, this whole situation is the logical outcome of patients not having candid conversations with their doctors about their use of drugs, including kratom. Even if they get up the courage to do so, most doctors will dismiss kratom as dangerous and ineffective, and then end the conversation.

Personally, years ago I brought up natural leaf kratom with my psychiatrist, who I thought was very progressive and open when it comes to substance use. He immediately told me kratom was way too dangerous to use and shut down the discussion. I was shocked because I had already been using kratom for months and knew first-hand how mild it actually was.

Aside from how interactions like that erode trust between patients and doctors, poor access to healthcare also sends patients to seek answers from less reliable sources. In the past, that would mean talking to friends and family, or to look for answers online in places like Reddit.

Today, however, many turn to artificial intelligence and chatbots like ChatGPT. A ​recent report from OpenAI estimated that 40 million users ask ChatGPT healthcare-related questions daily.

But ChatGPT does not have a medical degree. It’s essentially an advanced “auto complete” AI system, which means it may give bad medical advice.

I can’t imagine why ChatGPT would advise anyone to take an anti-anxiety medication like Xanax for nausea, much less nausea induced by another substance. It’s the kind of bad medical advice that would probably be immediately down voted on Reddit.  

According to the lawsuit, Nelson used ChatGPT repeatedly over the course of 18 months, asking for advice on how to get high by combining prescription and recreational drugs. ChatGPT initially advised Nelson to seek medical help, but over time “became a validator of harmful behaviors.”

Drew Pusateri, a spokesperson for OpenAI, told Reuters that the situation was ​heartbreaking, and that Nelson used an earlier version of ChatGPT that is no longer available. 

“ChatGPT is not a substitute for medical or mental health care, and we have continued to strengthen how it responds in sensitive and acute situations with input from mental health ​experts,” Pusateri said. “The safeguards in ChatGPT today are designed to identify distress, safely handle harmful requests, and guide users to real-world help.” 

At the end of the day, ChatGPT is still learning and is not always a reliable source of information. That’s why the best solution is to make medical professionals more accessible and more open to the types of discussion that patients might be seeking help on.

What Is the Worst Pain Imaginable?

By Dr. Forest Tennant

In the 1970’s, when I first started treating intractable pain, my first cases were the bone pain of metastatic cancer, usually melanoma, breast, or prostate cancer. In those days, chemotherapy and radiation were just hopeful treatments, so pain management with opioids was essential. 

Interestingly, a second group of patients that I treated had post-polio neuropathies – not unlike today’s neuropathies of HIV and Covid.

A third group had adhesive arachnoiditis (AA), which can be caused by the toxic dyes used in myelograms during epidural injections.

Clinically, the patients with AA had pain as severe as the bone cancer patients. This was a revolutionary finding since, in those days, metastatic bone cancer pain was believed to be the “worst” pain imaginable. Left untreated, persons afflicted with AA suffered the severest of pain, debilitation, wasting, a bed-bound state, and premature death.

Other pain conditions thought to be the “worst” include small fiber neuropathy, late-stage degenerative arthritis, Complex Regional Pain Syndrome (CRPS), trigeminal neuralgia, and Ehlers-Danlos Syndrome (EDS).

Today, most pain patients are dumped into a waste basket with only the diagnosis of “chronic pain” and given some assembly line symptomatic treatment.

Few pain clinics even attempt to determine the underlying cause of pain. Fibromyalgia is treated the same as AA or pudendal neuropathy. Dosages of opioids and other pain relievers are based on a pain scale, rather than a determination as to the underlying disease. 

This sorry state has led some doctors to believe they will be prosecuted if they prescribe even low potency Norco for AA or CRPS. Another unfortunate consequence is that many parties now automatically view a “pain patient” as an addict with opioid use disorder.

Why AA Is So Painful 

AA pain will occur when a spinal nerve is damaged and prohibits the normal flow of bioelectricity. Consequently, bioelectricity will accumulate around the nerve damage.

The cauda equina nerve roots are major carriers of bioelectricity. When they are damaged, clumped or scarred, there is substantial accumulation of bioelectricity and the pain is profound. 

To keep bioelectricity and pain under control in AA, one needs a combination of medical and physical measures to prevent bioelectricity from accumulating.

My latest book, “Building a Life With Adhesive Arachnoiditis and Stories of Hope,”  describes these new clinical protocols and measures for the treatment of AA. 

Patients, family members, and medical practitioners can all benefit from the book’s information on this rare disease. Included are chapters on medical management, pain control, restorative measures, physical therapies, and electromedical administration. 

Stories from patients are also included in the book, not only to recognize the survivorship of the patients, but to share the measures they took to “build a life” with adhesive arachnoiditis. 

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to his research bulletins here.   

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section. 

Study Shows Antibiotics Don’t Relieve Chronic Lower Back Pain

By Crystal Lindell

Antibiotics are not an effective treatment for chronic lower back pain caused by bulging herniated discs, according to a small new study by researchers in Australia.

That may sound like a “Well, duhhh” finding, but some patients with back pain are actually being treated with antibiotics.

“Antibiotics are currently being recommended for chronic low back pain, particularly when treatments have failed, even though the evidence for their use is conflicting,” writes lead author Flavia Cicuttini, PhD, School of Public Health and Preventive Medicine at Monash University. 

Low levels of bacteria have been found in the spines of people suffering lower back pain from bulging discs, and some previous studies have found that antibiotics have a “substantial effect” in relieving their pain.

One such study in 2013 estimated that up to 40% of patients with chronic back pain could benefit from antibiotic treatment. That research created a bit of a frenzy in the media, with a prominent UK surgeon saying the discovery was “the stuff of Nobel Prizes” and predicting “this is going to require us to rewrite the textbooks.”    

Now, more than a decade later, the new study seems to disprove that theory.

Monash researchers set up a clinical trial with 170 adults, all of whom had chronic low back pain (LBP) caused by disc herniation that was confirmed with an MRI. Half the participants were randomly assigned to receive the antibiotic amoxicillin twice per day for 90 days, while the other half received a placebo.

Their findings, published in JAMA Network Open, show that amoxicillin did not result in greater pain reduction than treatment with a placebo.

“Our results do not support the findings of previous studies,” wrote Cicuttini. “These findings suggest that antibiotics should not be used in the management of chronic low back pain and provide important data to prevent their inappropriate and harmful use.

“Although the potential for antibiotics to be an effective treatment has been an appealing prospect, the results of this trial do not support this hypothesis. These findings are important in informing updates of clinical practice guidelines for LBP, which to date have been unable to make recommendations for or against the use of antibiotics.”

Not only was the antibiotic ineffective, it caused more side effects. Over 16% of people who received amoxicillin stopped taking it due to adverse events, compared to about 2% in the placebo group.  

The overuse of antibiotics is actually an emerging problem in medicine, due to some strains of bacteria developing resistance to antibiotics. The World Health Organization considers antibiotic resistance to be a global health threat, with about 5 million deaths per year associated with drug-resistant bacteria. 

Cannabis Extract Gets Breakthrough Therapy Status From FDA

By Pat Anson

A German biopharmaceutical company says its cannabis extract has received a Breakthrough Therapy designation from the FDA, which will speed up its development and review as a potential treatment for chronic low back pain. 

If approved by the agency, the investigational extract – called VER-01 – would be the first cannabis-based medicine in the U.S. designated for the treatment of chronic pain. The full spectrum extract is derived from THC, CBD and terpenes found in cannabis sativa, a strain of cannabis known for its pain relieving properties.

"The FDA's Breakthrough Therapy Designation for VER-01 is a major recognition of its potential to address the significant unmet need in chronic pain," Dr. Clemens Fischer, Founder of Vertanical, said in a press release.

"Patients have waited far too long for meaningful progress. We believe VER-01 has the potential to change how chronic pain is treated and offer physicians a much-needed non-opioid solution."

If approved, VER-01 would be sold under the brand name Exilby and be taken orally in drops. The company is also studying VER-01 as a pain treatment for patients with osteoarthritis and peripheral neuropathy. 

The FDA’s Breakthrough Therapy designation was granted after two Phase 3 clinical trials found that VER-01 provided better pain relief to patients with chronic low back pain than low doses of opioids.

Patients taking VER-01 also reported improvements in nerve pain, sleep quality and physical function, and were less likely to be constipated than those on opioids.

Vertanical plans to launch a third Phase 3 placebo-controlled study in the U.S. to confirm the efficacy and safety of VER-01 in patients with chronic low back pain. The company anticipates the first data from that study in 2027 and, if they are positive, plans to submit a New Drug Application to the FDA in 2028.

VERTANICAL IMAGE

Vertanical hopes to get marketing authorization for VER-01 from European regulators in the next few weeks.

Research into the pain-relieving properties of cannabis has long been slowed in the U.S. by marijuana’s status as an illegal Schedule 1 controlled substance. The DEA is now allowing more cannabis to be used for research purposes and recently reclassified medical marijuana as a Schedule 3 drug, which allows for medical uses.

We Need To Talk About Suicide Risk From Untreated Chronic Pain

By Neen Monty

Doctors, policymakers, journalists, and pain experts endlessly warn about the risk of overdose from long term opioid therapy.

But almost nobody talks about the risk of suicide from untreated pain.

Why is this being ignored? Swept under the rug?

Refusing to treat severe pain is not a neutral decision. It is not “playing it safe.” It is not “erring on the side of caution.”

It is a clinical decision that elevates one small risk, while pretending the other barely exists. 

Even when that risk is significantly larger, and not even remotely comparable.

Let’s look at the actual numbers. The annual overdose death rate for chronic pain patients prescribed long-term opioid therapy is estimated at:

• 0.017% to 0.256% per year

• Around 0.014% annually at lower doses

• Roughly 0.25% annually at high doses (>100 MME/day)

• Roughtly 0.75% annually at very high doses (>200 MME/day)

Look at those numbers. Take them in. Understand how small that risk is.

And those numbers are from recent, large scale, well designed studies. That is what the evidence says. Not the rhetoric.

Yet overdose risk is the only risk anyone talks about. The risk used to justify forced tapers. The risk used to deny prescriptions. The risk used to terrify doctors into abandoning pain patients.

Now let’s compare it to the suicide risk associated with chronic pain.

Studies suggest:

• 5–14% of chronic pain patients attempt suicide

• Chronic pain patients have a suicide risk 2–3 times higher than the general population

• Around 9% of all suicides in the United States involve chronic pain

Take a good look.

It’s not 0.014 percent. Or 0.25 percent.

It’s five to fourteen percent.

Unlike the overdose rhetoric, this is not a theoretical or hypothetical “what if.”

And the suicide numbers are going up, as more and more people are force tapered off their opioid pain medications.

The cruel irony is that the pain management providers often treat opioid overdose as the worst possible outcome, while treating suicide is an unfortunate but unrelated side issue.

But uncontrolled pain is devastating. It destroys lives.

This is not hard to understand. Think about the worst pain you’ve ever experienced. Now, imagine it did not go away. Imagine you have to live with it every single day for the rest of your life. How long could you handle that?

Uncontrolled pain causes:

• hopelessness

• isolation

• sleep deprivation

• loss of identity

• financial collapse

• disability

• relationship breakdown

• depression

• fear of the future

And if a person expresses any of these fears, they are often deemed as “catastrophising.” The psychological harm caused by uncontrolled pain is substituted as the cause of that pain.

And patients get psychological treatment, when what they really need is pain relief.

They are not the same thing. You cannot switch cause and effect and expect a good outcome. You cannot make physical pain go away with psychological therapies. 

The best you can hope for is improved coping skills. But no one can cope with 8+ pain on a daily basis.

No one.

Not for very long, anyway. Not when you know that pain is never going away. How long could you cope with that?

Eventually, for some people, it causes the desire to escape. And there is only one way to escape, when doctors refuse to treat the pain.

Not because people living with severe, untreated pain are weak. Not because they are “catastrophising.” Not because they need a mindfulness workshop or some grounding.

Because severe, relentless pain changes human psychology.

That should not be hard to understand. If you put your hand on a hot stove, your nervous system screams at you to escape. Take your hand off the stove!

What exactly do people think happens when that signal never stops?

For years? Or decades?

I know that many clinicians choose to believe this kind of pain does not exist. That no one has pain that is a constant and severe 8+. 

That is not true. That’s what we call denial. And it does a lot of patient harm.

My pain is an 8+ every day, for much of the day. My pain is not amplified by psychological issues. My pain is purely physical. I have been in pain for 20 years. If you think I haven’t learned about pain and coping skills, then you are doing me a grave disservice.

And here is the part nobody wants to say out loud:

When a clinician refuses to adequately treat severe pain, they are making a risk calculation.

They are deciding that preventing a comparatively rare overdose death is more important than preventing the far more common risk of suicide.

It makes no sense, not logically, not medically.

But it is true.

Every medical decision involves risk trade-offs. Medicine is all about risks vs benefits.

We accept bleeding risks to prevent stroke. We accept infection risks during surgery. We accept chemotherapy toxicity to treat cancer.

But somehow, in pain medicine, only one risk counts: Overdose.

Nothing else matters. Everything else disappears. The suffering disappears. The suicide risk disappears. And the patient disappears.

But the pain does not disappear.

Even worse, pain patients are often blamed for the emotional consequences of living in agony.

If they become distressed, hopeless, fearful, withdrawn, anxious or depressed, that is now framed as a psychological problem, a mental illness that requires psychotherapy, rather than an understandable and normal response to relieve their physical suffering.

Imagine applying that logic anywhere else in medicine.

An amputee becomes depressed and hopeless because they can no longer walk.

Would we respond by saying: “Have you tried reframing your thoughts?”

Or would we offer them treatment? Prosthetics? A wheelchair? The ability to regain some of what they have lost?

A person loses their hearing, and becomes depressed and hopeless because they can no longer communicate.

Would we respond by saying: “Have you tried learning about how hearing works?”

Or would we teach them lip reading and sign language, and introduce them to the deaf community?

I could list a million examples. The point is, we should treat the problem. In no other forum do we withhold treatment and offer psychological therapies that are inappropriate and ineffective, rather than treat the actual pain.

None of this means that opioids are risk-free. They are not.

Opioids can absolutely cause harm, especially when combined with sedatives, are used recklessly, or prescribed without appropriate monitoring.

But pretending that untreated pain is safer than treating with opioids is not evidence-based medicine.

It is ideology.

And the people paying the price are patients trapped in severe pain with fewer and fewer options.

Medicine loves the phrase: “First, do no harm.”

But untreated and undertreated pain is doing harm.

Patient abandonment is harmful. Forcing people to suffer while congratulating yourself for reducing opioid prescribing is harmful.

Sometimes, it is simply choosing a different kind of death for your patient. 

An earlier death.

One that happens quieter.

One that is easier to ignore.

One that can be separated from lack of treatment.

One that can be attributed to poor mental health, instead of pain.

One that leaves no scandalous headline.

One that policymakers do not have to feel responsible for.

Perhaps that is the real issue. Overdose deaths are visible, while pain patients are invisible.

So only one becomes politically inconvenient.

Neen Monty is a patient advocate in Australia who lives with rheumatoid arthritis and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), a progressive neurological disease that attacks the nerves.

Neen is dedicated to challenging misinformation and promoting access to safe, effective pain relief. For more information on chronic pain, the science, the politics and the lived experience, got to Pain Patient Advocacy Australia. You can also subscribe to Neen’s free newsletter on Substack, “Arthritic Chick on Chronic Pain.”

CYP2D6: The Enzyme That Determines How Effective an Opioid Is

By Dipa Kamdar

For a medicine so commonly found in bathroom cabinets and high street pharmacies, codeine has a surprisingly complicated story. It sits at the intersection of pain relief, genetics, public health and regulation. 

As the UK and other countries continue to tighten rules around opioid use, codeine offers a useful case study in how a drug can be both helpful and potentially harmful, depending on who takes it and how it is used.

Codeine is an opioid used to treat mild to moderate pain. In some formulations, it is also used to suppress coughing. Over-the-counter products typically combine it with paracetamol, as in co-codamol, or ibuprofen, while stronger doses are available only on prescription.

Codeine itself is a weak opioid. Its analgesic effect is about one tenth that of morphine. Once swallowed, it is metabolised by enzymes in the liver, with some of it converted into morphine. That morphine then produces pain relief by acting on opioid receptors in the brain. 

For most people, the body makes enough morphine to ease symptoms. For others, the same dose can be ineffective or unexpectedly strong.

Fast vs Poor Metabolisers

One of the most striking features of codeine is how differently people process it. The enzyme mainly responsible for converting codeine into morphine, CYP2D6, varies significantly between people. Most metabolise codeine at an expected rate, but some carry genetic variants that alter the process.

A small proportion of the population are ultra-rapid metabolisers, thought to make up around 1% to 2% of people. They convert codeine into morphine much faster than average. 

This trait is more common among people of North African and Middle Eastern backgrounds, for whom even standard doses can produce unexpectedly high morphine levels, increasing the risk of severe drowsiness, breathing difficulties and other serious side effects.

Around 2% to 11% of people are intermediate metabolisers. Their CYP2D6 enzyme works more slowly or less effectively, so codeine may provide only limited benefit.

At the other end of the spectrum are poor metabolisers, estimated to make up 5% to 10% of the population. They convert very little codeine into morphine, so the drug may offer little or no pain relief. 

Poor metabolism is more common in people of white European descent. In these cases, it may make more sense to prescribe a different painkiller rather than rely on a drug the body cannot use efficiently. This wide variation makes codeine far less predictable than many people assume.

The Trouble With Codeine

That unpredictability matters because low-dose codeine does not always offer much in return. Research suggests that many over-the-counter codeine products provide little proven benefit for pain relief, particularly at doses below 10mg, while still carrying the risk of side effects. 

A review found that low-dose codeine combinations gave only modest relief for short-term pain, such as dental pain, episiotomy pain or pain after minor surgery, and many of the underlying trials were small.

By contrast, combinations such as ibuprofen 400mg with higher-dose codeine, between 25mg and 60mg, appear to provide more reliable relief. Even so, studies suggest that simple combinations such as paracetamol plus ibuprofen can match or outperform low-dose codeine products without the risks associated with opioids.

Common side effects include constipation, nausea, dizziness and drowsiness. At higher doses, codeine can slow breathing and impair coordination. It can also interact with other medicines that cause sedation, including some antiepileptic drugs. Certain antidepressants can block the enzyme that converts codeine into morphine, making it less effective.

Like other opioids, codeine can also become less effective with repeated use. This process, known as tolerance, happens when the brain’s opioid receptors adapt to the drug. People may then need higher doses to achieve the same effect. Even when taken as directed, tolerance can develop within days, and as doses rise, so does the risk of physical dependence.

Stopping suddenly after regular use can trigger withdrawal symptoms such as restlessness, sweating, anxiety and poor sleep. This is why health professionals advise using codeine for the shortest possible time and tapering the dose if it has been taken for longer periods.

Concerns about misuse, addiction and accidental harm have prompted tighter regulation in the UK. The Medicines and Healthcare products Regulatory Agency has introduced clearer warnings on packaging about addiction risk and limited over-the-counter pack sizes to a maximum of 32 tablets or capsules. Non-prescription codeine-containing products are now intended for use for no more than three days. Stronger codeine tablets, including 30mg formulations, have long been prescription-only.

Some products have faced even stricter controls. Codeine linctus, once widely used as a cough suppressant, was reclassified as prescription-only in 2023 because of growing concerns about misuse and diversion. 

It has been used in “purple drank”, a recreational mixture of codeine cough syrup with soft drinks and sometimes alcohol. Its opioid effects can lead to dependence, breathing difficulties and overdose, especially when combined with other sedatives.

Codeine remains a useful option for short-term pain when other medicines are unsuitable or insufficient. But its effectiveness, safety and potential for dependence vary far more than many people realise.

In a landscape where medicines are often judged by how familiar they feel, codeine is a reminder that common does not always mean simple. Used carefully, it can help. Used carelessly, it can cause problems that last long after the pain itself has passed.

Dipa Kamdar is a Senior Lecturer in Pharmacy Practice at Kingston University.

This article originally appeared in The Conversation and is republished with permission.