The Fake Excuses Pharmacists Use to Avoid Filling Opioid Prescriptions

By Crystal Lindell

I still remember the first time a pharmacist lied to me about why they couldn’t fill my opioid prescription.

I went in to pick up my regularly scheduled morphine refill, and when I got to the counter, she told me that my insurance wouldn’t cover two prescription refills within the same calendar month. She claimed that the rule applied even if the refills were 30 days apart due to a month having 31 days. And, since the insurance wouldn’t cover it, they weren’t filling it.

At the time, it didn’t even occur to me that a pharmacist would blatantly lie to me about something like that. So I immediately walked away from the counter and pulled out my cell phone to call my insurance company.

I’m not going to lie, I had a whole rant ready to spew at them about this nonsensical rule.

As it turned out, my frustration was misplaced, because no such nonsensical rule existed. In fact, the representative told me no one from the pharmacy had attempted to even put the prescription through. If they had, the insurance company would have covered it.

When I went back to the pharmacy counter and relayed this information, the pharmacist shrugged and said it must have been a mistake. Then, she filled my prescription – which was indeed covered by insurance.  

It wouldn’t be the last time I would have to deal with a lying pharmacist.

Over the years I’ve realized that it’s common for pharmacists to throw up false hurdles when patients try to fill any type of controlled substance script. This includes opioids, but also stimulants like those prescribed for ADHD.

I’ve seen it happen many times to myself and loved ones. Their excuses seem to fall into three broad categories.

Claim #1: Insurance won’t cover the medication

This ties into my opening story here, but it’s also happened to me and my loved ones a number of other times.

For example, after my mom had a hip replacement surgery, the pharmacist tried to tell her that her insurance would only cover a specific number of pills, so they did not fill for the entire amount. My mom was too out of it to argue with them and just accepted the smaller amount – which is what the pharmacist was likely hoping would happen.

A related claim here is that the pharmacy can’t take cash payment for a controlled substance in cases where insurance is refusing to cover it. They never even offer the option in this circumstance, despite the fact that generic pain medications are relatively cheap, and many patients would be happy to pay cash if it meant getting their meds.

I can only speak to Illinois, but as someone who’s been living without health insurance since 2022, I can confirm that pharmacies here can definitely take cash for a controlled substance.

Claim #2: The pharmacy never received the prescription from your doctor

Just last week, one of my loved ones called his pharmacy when his pain medication was due to be refilled and the staff told him that they had not received the prescription. He asked them to check different computer files to see if they were missing it, because he was sure his doctor had sent it in.

The pharmacy staff insisted that they had not received it. It was a Saturday, so he was unable to get a hold of his doctor.

He called back on Sunday morning and they again claimed they had not received the prescription, but after he pushed them to look for it in different places they suddenly found it.

When he finally got the bottle, it said the prescription had been dated for that Saturday, meaning they had definitely lied about not receiving it the day before.  

Claim #3: The medication is completely out of stock

This is one that’s difficult to prove, but it happens so frequently that I have to assume that at least some of the time pharmacists are lying about being out of a medication. It’s an excuse they can give to avoid filling a prescription. 

Even if they aren’t lying about it, there’s nothing the patient can do to prove it. Opioids at many pharmacy chains are essentially being rationed due to opioid litigation settlements.

Beyond the direct lies, pharmacists use other tactics to make getting refills more uncomfortable and difficult. I assume that their hope is that it will deter patients from coming back.

For example, my current pharmacist will sometimes decide that he needs to discuss my opioid usage with me, and have a talk with me encouraging me to lower the dosage. It’s always an awkward and unwelcome conversation, and just the possibility of it happening makes me dread going in there every month.

My pharmacist has also tried to tell me that I needed a Narcan prescription to get another refill. The problem is I would have to pay cash for it, because I don’t currently have insurance. Thankfully, I convinced him that I already had Narcan at home – which was true. But I could see other patients giving up and leaving without their refill.  

The thought process among pharmacists seems to be that if they give pain patients enough hurdles to jump before they can get their opioid prescriptions, that some will just give up. That keeps more opioids out of patients’ hands.

I think pharmacists underestimate how much harm they cause when they straight up lie to patients. They see what they’re doing as protecting people from the supposed harms of opioids. But what they’re actually doing is eroding patient trust in them and medical professionals in general.

When pharmacists lie about being unable to fill prescriptions, it makes me wonder what else they are lying about. And it’s not a far leap to start questioning other medical information they provide.

I’m not sure what the solution is to all of this, other than to call out the behavior and to make more patients aware that it could be happening to them. People should know that they aren’t crazy, and that it’s okay to push back if you think the pharmacy is lying.

Maybe one day there will be more regulations in place to protect patients from being lied to by pharmacists. Or maybe pharmacists will be replaced by artificial intelligence programs – which may come with brand new problems that we haven’t even considered yet. 

Until then, my hope for you is that the next time you need to get a controlled substance prescription filled, the whole process goes so smoothly that it’s ready for pick up before you even get to the pharmacy.

Clinical Trials Were Used as Marketing Ploys for Gabapentin and Other Drugs

By Sukhun Kang

Some clinical trials aren’t designed to answer scientific questions. They’re designed to market drugs. 

In our recently published research, my team and I analyzed over 34,000 industry-funded trials and found that hundreds of studies across seven medical fields were likely designed to promote a drug to physicians rather than to generate scientific data. For some fields, nearly 1% of clinical trials were for marketing purposes.

Known as seeding trials, these studies prioritize marketing over science while disguising their commercial purpose as legitimate research. Pharmaceutical companies use them to familiarize physicians with new products under the guise of data collection. Participants sign consent forms, believing they are contributing to medical knowledge.

In reality, patients are absorbing risks that serve corporate interests rather than resolving genuine uncertainty about the therapeutic potential of a drug.

The term seeding trial first entered the medical literature in 1994, when then-commissioner of the Food and Drug Administration David Kessler and his colleagues described such studies as attempts to entice doctors to prescribe new drugs through trials that appear to serve little scientific purpose.

Three decades later, the problem of seeding trials persists.

How Seeding Trials Work

While the structure of a seeding trial looks similar to legitimate clinical trials on the surface, the objectives are different.

In a typical clinical trial, researchers recruit patients across clinics and hospitals to test whether a treatment is safe and effective.

In contrast, the pharmaceutical company behind a seeding trial enrolls large numbers of physicians at many sites, each seeing only a few patients. The goal is exposure: getting doctors to prescribe the drug, not generating robust data. Doctors may be selected based on their prescribing volume rather than their research credentials.

In a legitimate trial, the number of study sites reflects the number of patients needed to answer a scientific question. In a seeding trial, the number of sites reflects the number of doctors the company wants to reach.

Seeding trials often target drugs already on the market and operate as Phase 4, or postmarketing, studies. These types of studies are typically conducted after a drug has been approved to monitor its long-term safety or effectiveness. This trial stage receives less regulatory scrutiny than trials for initial drug approval, and the aims of the study may have limited relevance to actual patient care. 

For example, a seeding trial might measure whether patients prefer the taste of a new formulation or how quickly a drug dissolves in the stomach, rather than whether it actually improves health outcomes.

Legitimate trials also have independent oversight, with committees of scientists and ethicists who monitor the study’s progress and can halt it if patients are being harmed.

In a seeding trial, this oversight is often minimal. The sponsor of the study – typically the pharmaceutical company funding the research – maintains heavy control over the trial’s design and conduct.

Vioxx and Gabapentin Seeding Trials

Seeding trials had attracted little public attention until litigation in the 1990s forced open the internal files of two major pharmaceutical companies, revealing that studies presented as science had been designed as marketing campaigns.

The most notorious example is Merck’s ADVANTAGE trial for the painkiller Vioxx (rofecoxib), which was first approved in 1999. The company presented the study, which ran from 1999 to 2001, as scientific research, but internal documents revealed that its primary purpose was to encourage physicians to prescribe Vioxx to their patients.

Meanwhile, Merck was accused of downplaying the significant cardiovascular risks associated with the drug. The consequences were severe: Approximately 30,000 lawsuits and nearly $5 billion in compensation followed Vioxx’s withdrawal from the market.

Parke-Davis’ STEPS trial for the painkiller Neurontin (gabapentin) – first approved in 1993 for epilepsy – followed a similar pattern of disguising marketing as research. Internal documents showed that the trial, which ran from 1996 to 1998, aimed to disseminate marketing messages through the medical literature and encourage clinicians to prescribe the drug off-label for conditions it was not approved for, such as neuropathic pain and bipolar disorder.

Unlike Vioxx, gabapentin was never withdrawn. The trial’s commercial legacy outlasted its scientific one.

These cases came to light only because litigation forced the release of internal company documents. Without that exposure, they would have remained indistinguishable from ordinary research.

How Common Are Seeding Trials?

My team and I study how pharmaceutical firms innovate and respond to regulations. To estimate the prevalence of seeding trials, we analyzed nearly 34,400 industry-funded Phase 3 and Phase 4 studies that posted results on ClinicalTrials.gov between 1998 and 2024. 

The trials covered seven therapeutic areas where researchers had previously documented seeding trials, including major depressive disorder, epilepsy, Type 2 diabetes and rheumatoid arthritis.

We screened these trials for criteria that prior research has identified as hallmarks of a seeded trial, such as low patient-to-site ratios and limited independent oversight.

Ultimately, we identified 204 trials – 0.59% – that had characteristics consistent with marketing-driven study design. The prevalence of these probable seeding trials in different disciplines ranged from 0.15% in osteoarthritis to 0.98% in rheumatoid arthritis.

These figures might understate the true scope of marketing-driven research. The criteria we used capture only the most identifiable cases of studies driven by marketing purposes. Definitively identifying seeding trials requires access to internal sponsor documents revealing the intent of the study, and those documents surface only through litigation or whistleblowers.

Many trials occupy an ambiguous middle ground, generating useful data while simultaneously serving promotional objectives. Without systematic surveillance, the full extent of marketing-driven studies remains unknown.

The criteria to identify seeding trials also require careful interpretation. A low patient-to-site ratio, for instance, can reflect the practical difficulties of enrolling patients in studies of drugs already on the market, such as trials testing new drug combinations or new uses for an existing treatment. These markers are best understood as signals of possible marketing intent warranting closer scrutiny, not proof of marketing intent.

Whether the prevalence of seeding trials has shifted with the expansion of transparency requirements over the past decade cannot be determined from existing registry data.

What Can Be Done

Seeding trials may be uncommon, but they are not accidental. They reflect structural incentives in a system where the companies that fund research also stand to gain from its results. Strengthening transparency in clinical trial registration, funding disclosure and oversight would help ensure that clinical research serves patients first.

Along with other researchers, we’ve proposed reforms that cluster around two areas. The first is standardized reporting that discloses trial funding, investigator payments, enrollment criteria and the rationale for site selection. 

The second is independent oversight, such as committees funded through pooled industry levies, which are fees collected from pharmaceutical companies to finance independent monitoring. Random audits with publicly available results are one form of such oversight.

Some infrastructure for tracking financial relationships between industry and physicians is already in place. In the U.S., the Open Payments database allows public tracking of industry payments to physicians. But regulatory variability across countries creates openings for companies to conduct marketing-driven trials in jurisdictions with weaker oversight, particularly in low- and middle-income countries.

Clinicians can protect themselves and their patients by screening for a set of red flags before agreeing to participate in or cite a trial in their research. These include unusually low patient-to-site ratios, selecting investigators based on prescribing volume, sponsor-dominated oversight and study endpoints of limited clinical relevance. Consent forms are among the few documents patients see before enrolling, and clearer disclosure of the commercial and scientific purpose of a study is among the reforms we have called for.

For patients, clinicians and regulators alike, the question to ask of any trial is the same: Whom does it really serve?

Sukhun Kang, PhD, is an Assistant Professor of Technology Management at University of California, Santa Barbara.

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

The Downside to Powering Through Pain

By Crystal Lindell

I spent the last few days being incredibly active physically, and using 7-OH to help me power through my pain.

And I’m going to be honest with you: It was FANTASTIC… in the moment.

I got so much stuff done! I felt amazing. And other than the fact that I had to take a bite of a 7-OH tablet every few hours, I got to pretend I was completely healthy!

If you’re unfamiliar with it, 7-OH is an alkaloid that occurs naturally in kratom. When concentrated, it has opioid-like effects that relieve pain and boost energy levels. 

I was swimming in wins after I took it.

But, today? Today does not feel fantastic. Today feels like hell.

When I woke up, I realized that all that activity was done with a predatory loan, and now the bill is due.

Every joint hurts, my eyes are extremely dried out, and the bottom of my right foot is swollen because I have been ignoring my bone spur for the last week. I struggled to even stand up out of the bed and walk to the bathroom.

I am also completely exhausted.

Over the years, anti-opioid advocates have started to spread the idea that pain medication is bad because it covers up pain that your body is trying to communicate. For example, if you don’t feel like you can walk on a sprained ankle, it probably means you should not be walking on your sprained ankle.

This has always annoyed me because my most prominent pain – intercostal neuralgia in my ribs – is both unexplained and incurable. It’s not trying to communicate anything at all. It just IS. And the only thing I can do is treat it with pain relievers.

But that makes it easy for me to forget about all the other ways that having Ehlers-Danlos Syndrome impacts my body. My joints are not as strong as other people’s, I seem to get injured more frequently, and just existing causes exhaustion.

The good news is that I can take pain medication to power through all that if I need to. And I have recently found 7-OH to be especially great at helping me do that. 

The bad news is that powering through pain and fatigue will eventually catch up with me – an effect that I’m clearly dealing with today.

I definitely do not want anyone to think that I am siding with the anti-opioid crowd about how pain medication is bad because it covers up symptoms. Pain medication is a godsend. And many chronic pain patients – myself included – desperately need to power through because we have no other choice. 

When the pain lasts for years, or even decades, you can’t just stay in bed all day “listening to your pain.” The world doesn’t work that way. 

But perhaps it is best to admit that there is a limit to just how much we should be using pain relievers to power through. And maybe it is wise to make sure that we don’t go too far past that limit – if only because the bill will eventually come due. 

As for me, I will be spending the rest of the day paying for my excesses over the last week with lots of naps and recovery time. Hopefully, I’ll be relatively functional again soon.

I will definitely be using 7-OH again. But next time, I’ll also be taking breaks and listening to my body. 

From CRPS Patient to Triathlete

By Madora Pennington

“It’s called the ‘suicide disease’ because the pain is so bad people cannot live with it,” Susie Ruvalcaba tells me about Complex Regional Pain Syndrome (CRPS), a severe pain condition she’s had for about eight years.

“It was really bad, but I am much better now,” Ruvalcaba adds. 

Tanned and amazingly fit, she is training for a double triathlon: an ultra-endurance multi-day race that includes a 4.8 mile swim, 224 mile bike ride, and 52.4-mile run. She is 48 years old.

Her recovery from CRPS is astounding. For many, it is a lifelong disability. 

CRPS usually starts with an injury that triggers — for reasons not well-understood — inflammatory and immune dysfunction, resulting in extreme, difficult-to-treat nerve pain and musculoskeletal problems. About 26 out of 100,000 people get this mysterious condition every year.

For Ruvalcaba, it started with a chiropractic adjustment to her neck. Past chiropractic visits always made her feel relaxed. But this time, things just didn’t feel right. She was in pain immediately. That pain turned into more pain as weeks went by. 

The pain was also weirdly different. It ran down one arm, skipped her torso, then continued down her leg. It was maddening in how it made no sense.

“Did you just stick your hand in hot water?” a doctor asked because one of her hands was sweaty and red, a telltale sign of CRPS. Ruvalcaba was referred to a neurologist.

“I don’t remember how many doctors I saw, but I think they were afraid to tell me this might be CRPS,” she recalls. 

Susie Ruvalcaba

Early intensive treatment for CRPS with physical therapy, pain medication, and modalities such as nerve blocks has a better chance of stopping CRPS and reversing it. But Ruvalcaba was not lucky enough to get diagnosed quickly.

A year and a half later, a doctor finally leveled with her that she had CRPS. He advised her to quit her job and go on disability. Ruvalcaba was horrified. She was young and had kids to raise. She refused his disability paperwork, but eventually lost her job as coping with CRPS interfered with work. 

Ruvalcaba’s “crazy pain that would not stop” would fluctuate but wouldn’t go away. Often, it was triggered by touch. During bad flares, she had to lie in bed unclothed, her body feeling like it was on fire.    

The sensation of clothing made the pain sensations worse. She had to keep her hair tied up and off her neck for the same reason -- the slight touch of her own hair was too much to bear. 

“Doctors gave me pain meds. They didn’t do enough. I became physically dependent on them. Then I had to take them just to prevent withdrawal symptoms,” she says. 

Some CRPS patients are helped by opioids, but for others, opioids can increase pain sensitivity and suppress hormones and the immune system, making CPRS worse.  

‘Doctors Didn’t Believe Me’

 Ruvalcaba kept trying to find better treatment. 

“Some doctors didn’t believe me. I often left appointments in tears. Pharmacists looked at me like I was a drug addict. I didn’t look like someone who was sick,” she recalls. 

A CRPS specialist gave Ruvalcaba high-dose ketamine infusions, which lessened her pain. She also tried a nerve block, which seemed to irritate her nervous system and make her pain worse. She was too afraid to try an implanted stimulator.

Throughout her illness, Ruvalcaba was advised to limit exercise to gentle walking. She was spending most of her days in bed. It was a good day if she could do some chores. 

“It was a dark time. I felt like I was withering away.”

Depressed and hopeless about her circumstances, she got the idea to try the CrossFit gym nearby because she had enjoyed being an athlete as a teenager.

“I loved it. I got to feel alive for one hour per day," she says. "Doctors, friends, and family begged me to stop, telling me I would hurt myself. I didn’t care. I would come home after, take a pain pill and lie down.” 

She kept at it, and her body became stronger and able to tolerate more. 

Ruvalcaba's instinct to exercise was spot on. High intensity exercise can boost immunity, lower stress hormones, reduce inflammation and re-set pain sensitivity.

A recent, large European study showed that intense exercise is more protective from immune-mediated inflammatory diseases than more gentle exercise done with more frequency. 

The isolation of Covid gave Ruvalcaba extra time and space to take care of herself. She switched from opioids to cannabis edibles, which provided better pain relief with fewer side-effects.

The THC in cannabis is known to be more effective than opioids for the nerve pain common to CRPS. In 2025, a survey of CRPS patients using THC found that THC improved pain, sleep quality, and overall health while reducing anxiety. 

"Covid was the perfect storm, but in a good way. I avoided stress and took care of myself like this for eight months. This gave my nervous system a break,” Ruvalcaba says. 

She did CrossFit everyday, meditated, and pursued healthy diets. She also went to psychotherapy. This focused regimen seemed to give her body the opportunity and support to heal. 

"Before I knew it, I was signing up for a triathlon, wondering where all my pain and gone.” 

Ruvalcaba is working on a documentary about her recovery from CRPS called “Double the Distance, Beyond the Pain.” You can follow her journey on Instagram @susythesoulreader 

Methylene Blue: A New Pain Relief Option

By Dr. Forest Tennant

Over the past 1-2 years, the fatty acid palmitoylethanolamide (PEA) was found to reduce pain and inflammation. PEA occurs naturally in our bodies and in some foods, and is sold in over-the-counter supplements.  

PEA has been urgently needed because of the poor accessibility of opioid pain medication. The menu of non-opioid pain relievers is small: ketamine, oxytocin, CBD, marijuana, and kratom.  

I am pleased to add methylene blue (MB) to the list. Every adhesive arachnoiditis (AA) patient needs to try PEA and MB. One can no longer be confident that their doctors and insurance plans will cover opioids. 

Methylene blue is a salt first used in the 1870’s as a textile dye. It was then used medically as an anti-malaria drug and to treat a rare blood disorder called methemoglobinemia. 

MB has also been used off-label for a variety of medical conditions. Its best-known value has been for the treatment of severe pain associated with head and neck cancer.

About a year ago, Arachnoiditis Hope began receiving reports that MB was being used by persons with AA. Some had stopped taking opioids or were no longer able to obtain them.

There are multiple ways to purchase MB online as a supplement. MB is typically sold as a liquid taken orally, or in capsules and gummies. It is inexpensive and the recommended dosage is on the label. 

AA patients can take MB to boost the effect of opioids or PEA. It is important to note that MB is a monoamine oxidase inhibitor, so patients who are taking an anti-depressant should not take it.

The medical world is well aware of the CDC opioid guidelines and the prosecution of physicians who prescribed high dose opioids. For the most part, there was not a governmental assault on the use of short-acting low potency opioids, such as tramadol and codeine. 

I cannot identify a single case in which a physician was disciplined for prescribing a short-acting, low potency opioid to an MRI-documented case of AA.

The movement to force all patients to stop taking potent long-acting opioids doesn’t seem to be calming down. Their goal is to stop patients from taking high dose opioids and to use electric stimulators, intrathecal pumps, or buprenorphine/methadone. 

Every AA patient needs to be aware of PEA and MB as alternatives. 

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 its research bulletins here.   

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

How To Tell if Your Dog Is in Pain

By Jacqueline Boyd

If you live with a pet, you might feel like you can almost read each other’s minds.

You might even have experienced your pet responding to your emotional state. Animals seem to have impressive skills at detecting our state of health too.

However, new research suggests that many dog owners are not skilled in recognising pain in their pets as they might like to think. This could have significant consequences for the behaviour, health and welfare of our pets.

As a migraineur, I am amazed at how my dogs cope with me when a migraine hits. They seem to recognise the pain, distress and incapcacity that comes along with a migraine and respond with more gentle interactions than usual. I hope that when the situation is reversed and they are unwell or in pain, that I too can recognise it.

So, how can you recognise if your pet is in pain and what should you do if you think they are?

Signs of Pain

It is easy to assume that an animal in pain will make some noise about it and show obvious physical signs. This might be the case if they are in acute pain as the result of severe injury for example. However, animals often disguise pain as a survival mechanism, and many signs of pain show only as subtle changes in behaviour.

Humans do seem to be able to recognise basic animal emotional states such as anger, fear or joy, through facial and body expressions. But we are less good at linking these cues to more complex emotional states including pain, anxiety and frustration.

The recently published study assessed how good people are at recognising signs of pain in dogs. This was carried out via an online questionnaire completed by 530 dog-owners and 117 non-owners. 

Participants were given a list of 17 types of dog behaviour. They were asked to rank how likely  the behaviour types indicated their dog was in pain, based on their prior knowledge and experience. In reality, all 17 types of behaviour listed suggest a dog is in pain.

The signs of pain provided included obvious behavioural changes such as hesitant paw lifting, reduced play behaviour and changes in personality. Participants were good at recognising these prominent behaviour changes were linked with pain. 

However, they didn’t realise more subtle indicators such as yawning, lip and nose licking and changes in facial expressions including looking away and increased blinking. These are all warnings that a dog may be suffering.

Notably, participants without dogs were actually more likely to recognise that freezing or turning the head or body away are associated with pain than dog owners. This suggests that dog owners may become complacent in their observations of their dog’s behaviour.

The Link Between Pain and Behaviour

The study participants were also asked to assess the potential relevance of pain in three written canine behaviour cases. The participants were not told this, but two were suffering from painful conditions, one outwardly obvious, and one more subtle. The third case was not linked to a painful condition.

Dog owners noted that pain was likely in the case with obvious signs of movement problems – hopping and lifting of legs. This was higher for dog owners than non-owners. In the case where pain signs were more subtle (night restlessness and “shadowing” family members), there was no difference in the ability of dog-owners and non-owners to identify the behaviour as signs of pain.

However, the dog owners with previous experience of pets with a painful condition seemed to be better at recognising signs of suffering. This applied to overt changes in movement as well as body language. This suggests that prior experience can be valuable in developing skills when its comes to pet behaviour.

What is interesting from this study is that there were some discrete differences between dog-owners and non-owners in recognising signs of pain. However, owning a dog was no guarantee that someone would be better able to identify subtle pain indicators.

Previous studies have shown animal species may show pain in different ways. For example rabbits often freeze, which might be considered a fearful response. Facial grimace scales are also increasingly being used to assess pain for a range of species including cats and horses. These assessment tools track minute muscular movements in the face such as tightening eyes.

What To Do If Your Pet Is in Pain

Recognising signs of pain in your pet is critical so you can respond quickly. This may also help reduce the risk of dog bites, which are often linked to the dog struggling with chronic pain.

Pain can lead to increased noise reactivity too, where dogs flinch or bark loudly in response to sudden, unusual or loud noises.

If you suspect your pet might be in pain because of a sudden change in their behaviour or movement, seek veterinary advice. Soreness can manifest outwardly such as lameness, lethargy or a lack of desire to exercise or play, but it can be easy to miss more subtle signs such as altered blinking, momentary pauses or freezing.

Research indicates that dog owners should be alert to altered sleep patterns, restlessness, clinginess and unusual licking or chewing their body. Even changes in a dog’s ear position, coat quality, texture, or how their coat lies on their skin can indicate underlying discomfort. Reluctance to being touched in specific areas of a dog’s body might also be a sign of discomfort that needs veterinary investigation.

So if you think your dog needs training or a session with a behaviourist because of a gradual or sudden alternation in their behaviour, it’s worth ruling out whether your pooch is acting strangely because they’re in pain first.

Jacqueline Boyd, PhD, is a Canine Consultant and Senior Lecturer in Animal Science at Nottingham Trent University.

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

Can AI Outperform Human Doctors?

By Crystal Lindell

It may not be long before a trip to the emergency room means telling your symptoms to an AI robot, potentially before you even talk to a human doctor. 

New research published in Science seems to highlight the potential for artificial intelligence to create such a future in healthcare.

The study -- which was conducted by both Harvard and Stanford researchers – tested OpenAI’s experimental “o1 preview” models against human physicians. OpenAI makes ChatGPT.

They asked the o1 models to do a patient diagnosis and create a diagnostic testing plan, then compared its skill in clinical reasoning to experts and generalist physicians.

They also assessed AI on 76 real-life emergency room patients at a Boston hospital in three stages: the initial triage at first arrival; first contact with a physician; and upon admission to the hospital. 

The results showed that the new AI model outperformed human physicians and showed improvement from earlier generations of AI. 

“Our findings suggest the urgent need for prospective trials to evaluate these technologies in real-world patient care settings and for health care systems to prepare for investments for computing infrastructure and design for clinician-AI interaction that can facilitate the safe integration of AI tools into patient-care workflows,” wrote lead authors Arjun Manrai, PhD, Assistant Professor of Biomedical Informatics at Harvard University and Adam Rodman, MD, Director of AI Programs at Beth Israel Deaconess Medical Center. 

In the emergency department cases, the o1 model was diagnostically correct 67.1% of the time during the initial triage, outperforming two expert attending physicians (55.3% and 50.0%).

Physicians who reviewed the diagnostic results – without knowing if they were made by AI or human doctors – were unable to distinguish between the two. 

“AI models are evolving from static question-and-answer tools into agents that can, for example, analyze patient records, monitor clinical encounters through ambient listening, and interact in real time with predictive models built on patient data," Ashley Hopkins, PhD, and Erik Cornelisse, PhD candidate, at the College of Medicine and Public Health at Flinders University in Australia, wrote in an op/ed on the study.

“This advance sets a new evaluation benchmark — testing AI against physician performance, and ideally alongside physicians, on authentic clinical tasks.”

Interestingly, Hopkins and Cornelisse pushed back on the idea that the ideal method for evaluating patients is physicians collaborating with AI. They think AI may perform better on its own. 

“That collaborative configuration itself must be tested,” they write. “It has been argued that for certain well-defined tasks across health care, AI may operate more effectively independently.”

They also wrote that since many doctors are already using AI in their practices, sometimes without institutional oversight, further studies are urgently needed to determine when AI improves patient care and when it does not.

In an article about the AI study published in Harvard Magazine, Arjun Manrai, the senior co-author of the study, said the results do not show that “AI replaces doctors, despite what some (AI) companies are likely to say.”

“I think it does mean that we’re witnessing a really profound change in technology that will reshape medicine,” Manrai said. “We need to evaluate this technology now and rigorously conduct prospective clinical trials.”

Manrai also makes an important point. The AI study was based entirely on text-based inputs, while practicing physicians evaluate many other forms of information and communication, such as listening to a patient, observing how a patient behaves, examining images and x-rays, and evaluating other test results. 

AI can’t do all those things – at least not yet.

Manrai’s co-author, Adam Rodman, also thinks it’s premature for AI to replace doctors in clinical settings. AI might prove useful in providing second opinions and finding diagnostic mistakes, but Rodman doesn’t want to see “AI doctor companies” replacing human physicians.

“I do not think that these results support that,” Rodman said. “What these results support is a robust and ambitious research agenda to try to figure out how we can use these technologies to make patients’ lives better.”

How Emotional Distress Makes Chronic Pain Worse

By Pat Anson

Many chronic pain sufferers bristle at the notion that pain is “all in their head” or that it has psychological origins.

They’re not going to like some recent headlines in the news:

“Chronic pain is not just in your head, but it is in your brain”

“Mental defeat can worsen chronic pain, researchers say”

“This Common Mental Disorder Has a Strange Link to Severe Chronic Pain”

“New Study Finds Link Between Difficulty Identifying Emotions and High Chronic Pain Levels”

Yikes. It’s almost like the headline writers wanted to insult pain patients, as much as they want to inform them.

I found the last headline intriguing though, if only because it introduced me to a new word: alexithymia.

Alexithymia is a personality trait characterized by difficulty in identifying or describing emotions. If someone is always “at a loss for words” and can’t express their feelings to others, it could mean they have alexithymia. 

About 10% of the population has alexithymia, which is more common in men (no surprise there), and people who have autism, post-traumatic stress, or depression.

Researchers at Johns Hopkins Medicine wondered if there was a connection between alexithymia and chronic pain. They enrolled over 1,450 people with various chronic pain conditions in a two-year study to answer a chicken-and-egg question: Does chronic pain cause alexithymia or does alexithymia make chronic pain worse? 

“Prior studies have shown that alexithymia tends to be higher in people who have chronic pain. However, we did not know whether alexithymia leads to worse pain, or whether worse pain leads to alexithymia. We also have not had a good understanding of why these two distinct processes were related,” said senior author Rachel Aaron, PhD, Associate Professor of Physical Medicine and Rehabilitation at the Johns Hopkins University School of Medicine.

Aaron and her colleagues had patients fill out questionnaires to see how well they identified their feelings and described their emotions. They also asked participants about their pain, anxiety and depression levels.

The research team then used statistical modeling methods to see if emotional difficulties could predict pain outcomes.

The study’s findings, recently published in the journal American Psychological Association, show that patients with higher levels of alexithymia at the start of the study developed greater psychological distress one year later. That emotional stress had a profound impact. After two years, those same patients had greater pain interference – meaning their daily functioning and quality of life were worse. 

Alternatively, researchers found that chronic pain did not predict or cause alexithymia. That supports evidence that emotional processing difficulties are a risk factor, but not a consequence of chronic pain.

“Greater difficulties identifying one’s own feelings can lead to greater symptoms of psychological distress, including symptoms of depression and anxiety,” says Aaron. “This in turn can lead to greater difficulties managing chronic pain. These findings highlight the role of considering alexithymia in psychological treatment for chronic pain, and how it might lead to psychological distress.”

Aaron led a previous study, which found that 40% of adults with chronic pain have clinical symptoms of depression or anxiety.

How do you treat alexithymia? Various types of psychotherapy can be used, such as Cognitive Behavioral Therapy (CBT) or Emotion-Focused Therapy (EFT), to help patients recognize and express their emotions in healthier ways. Creative therapies can also be used to help people express their feelings through journaling, art, music and dancing. 

There are no drugs that specifically treat alexithymia, although antidepressants and anti-anxiety medications can treat co-occurring conditions like depression or PTSD, which may help improve emotional processing. 

How to Dress When You Go to the Doctor

By Crystal Lindell

I always wear mascara when I go to the doctor. 

In fact, every time I have a doctor’s appointment, I leave myself plenty of time beforehand to shower, curl my hair, put on a nice outfit, and do my makeup.

It may sound unrelated to medical care, but it’s worth it.

You see, there’s actually a dress code for doctor’s appointments that nobody at their office ever tells you about. Rather, you just have to figure it out on your own.  

The common misconception is that you should look as sick as possible when you show up for a visit. A lot of patients assume that looking disheveled while wearing pajamas is the best way to convey just how crappy you feel. Not to mention the fact that being sick means you probably have less energy to dress nicely anyway.  

But doctors are just as ableist as the rest of society, and the truth is they don’t actually like people who look too sick. In my experience, doctors will actually treat you better if you get a little bit dressed up.

Not too dressed up, obviously. You don’t want to show up in a suit and tie, or a dress. But you do want to look at least as nice as you’d look for a casual date. Showered, business casual clothes, and light makeup if you present as female.

Dressing nice conveys that you are trying to take care of yourself, and doctors like that. In essence, they want to invest their time and energy into patients who are also invested, which dressing nicely conveys.  

In 2010, Consumer Reports surveyed 660 primary care physicians and found that being “respectful and courteous” was the second most important thing doctors said patients could do to get better care. 61 percent of physicians said it would help very much.

Note the word "respectful." And how doctors admitted that showing them respect leads to better care. Make no mistake, doctors very much see how you present yourself in appointments as a sign of how much you respect them. 

It all makes sense, when you consider how many doctors love their own dress codes, e.g. their famous white coats, which they use to convey authority.

I know it is tempting to show up to appointments in the comfiest clothes available. I also know that it’s not always ideal to use precious time and energy to shower and pull yourself together. But it’s one of the few ways you can control how good your medical care is. 

So it really is worth it to grab a nice shirt and a little mascara before you head to the doctor’s office.

Bitter Rivals: Kratom’s Three-Ring Circus

By Pat Anson

In recent years, you’ve probably come across stories about kratom, an herbal supplement used by millions of Americans for pain relief and to help manage conditions such as anxiety and depression. 

While the vast majority of consumers use kratom safely, there is growing concern about outlier cases where kratom is abused or has even been associated with overdoses. 

That has led to several states and dozens of cities and counties banning natural leaf kratom or a potent, concentrated kratom alkaloid called 7-hydroxymitragynine (7-OH). In some cases, they’re banning both.

Less well known is that the growing controversy over kratom is being fueled, in part, by an ongoing turf war between three rival industry-funded advocacy groups. Or, to use another cliche, a three-ring circus.

In one ring is the American Kratom Association (AKA), an organization of kratom manufacturers and vendors that sell natural leaf kratom products. 

In another ring is the Holistic Alternative Recovery Trust (HART), which represents 7-OH manufacturers like American Shaman. 

In the third ring is the Global Kratom Coalition (GKC), which was founded by JW Ross, who made a fortune selling a popular kratom-kava shot called “Feel Free.” 

Like the AKA, the GKC favors natural leaf kratom, and takes a pugnacious approach to critics and competitors. The GKC likens rival 7-OH products to “powerful prescription opioids” that should be banned or heavily regulated. 

You would think the AKA and GKC would be on the same team, since they both want to keep natural leaf kratom legal and accessible. But they are bitter rivals.

In an open letter, AKA chairman Matt Salmon said that GKC founder Ross is actually Jerry Cash, a convicted embezzler, who is trying to “make the AKA look bad” by misstating its position on kratom product formulations.

Salmon, a former congressman, also accused the GKC of launching a smear campaign against Mac Haddow, an AKA lobbyist who had his own run-ins with the law. Salmon’s letter is nearly three years old, but helps explain what is happening today.

“The most recent attacks against AKA and the personal attacks on Mac Haddow came after several ambush interviews orchestrated by Mr. Ross and his PR team providing incomplete, mischaracterized, and demonstrably false information to reporters,” said Salmon.

Kratom vs 7-OH

All three kratom groups accuse each other of jeopardizing what has become a lucrative business opportunity: selling a popular herbal supplement that is still largely unregulated by the federal government. Currently estimated to be worth over $2 billion, the global kratom industry is projected to grow to nearly $8 billion by 2032.

The latest example in this turf war is a self-styled “consumer alert” by the AKA warning about the “growing proliferation of dangerous products” containing 7-OH and other kratom extracts.   

“Consumers deserve to know the truth,” said Haddow, Senior Fellow on Public Policy for the AKA, in a press release. “These 7-OH products are not traditional kratom. They are being engineered, concentrated, and marketed in ways that create risks that are not associated with natural kratom leaf.” 

As evidence, the AKA cites lab results commissioned by the Texas Attorney General, which found that several 7-OH products contain alkaloid concentrations that exceed safety limits under state laws modeled after the Kratom Consumer Protection Act (KCPA) – legislation that the AKA has lobbied Texas and 20 other states to enact.    

One such product, Opia 7-OH tablets, contain over 16mg of 7-OH – which is 96% of their total alkaloid content – well above the 2% limit under the KCPA.  

AKA IMAGE

Critics of the KCPA say the law is misleading, doesn’t protect consumers, and is designed primarily to protect the financial interests of the AKA and other vendors who sell natural leaf kratom.    

Not surprisingly, the AKA disagrees. It wants 7-OH scheduled as a controlled substance and a ban on 7-OH being marketed as “kratom” –  moves that would preserve the legal status of natural leaf kratom.

“This is not a debate about kratom,” says Haddow. “This is about stopping a new class of unregulated, opioid-like substances from being disguised as something they are not.” 

The Holistic Alternative Recovery Trust takes issue with the portrayal of 7-OH as a dangerous opioid.

“7-OH is not a synthetic substance or a novel additive, it is a naturally occurring alkaloid found in the kratom leaf itself. Calling it anything else misrepresents the science,” a HART spokesperson said in a statement to PNN.

“This is part of a broader pattern we’ve seen from the American Kratom Association and the Global Kratom Coalition, misrepresenting the science in ways that benefit certain segments of the market, particularly whole-leaf producers, while dismissing or sidelining millions of consumers who rely on 7-OH products.”

‘Kratom Is an Opioid’

The AKA’s latest attack on 7-OH comes on the heels of the GKC’s endorsement of a bill in Congress that would target “lab-made opioids” by amending the Controlled Substance Act to include 7-OH as a Schedule One substance, in the same category as heroin.

The association with opioids is a bit of a canard, but it makes for a good headline. Kratom comes from the leaves of the Mitragyna speciosa tree, which has more in common with coffee trees than it does with poppy plants, from which opioids such as heroin are produced. 

Like kratom, coffee and other comfort foods such as chocolate stimulate endorphin nerve receptors and have “feel good” effects. You might even say they have mild “opioid-like” effects. But that doesn’t make Hershey’s Kisses opioids or Mrs. Olson a drug dealer for peddling Folgers coffee.  

Squabbling over the safety of each other’s products has not benefited kratom consumers and has contributed to sensational reporting about kratom and 7-OH causing addiction and overdoses. 

The latest example appears in The Conversation, which commissioned Dr. Andrew Kolodny to write an op/ed about kratom. Kolodny is the founder and president of Physicians for Responsible Opioid Prescribing (PROP), an influential anti-opioid activist group. 

Kolodny used a misleading CDC study about calls to poison control centers to paint a misleading portrait of kratom as just another opioid.

“For now, the evidence shows that kratom is an opioid with real risks – not a harmless supplement,” wrote Kolodny, while shamelessly ignoring his own role in restrictions on the use of opioid medication, which ironically led to greater use of kratom.

“Kratom’s rising use over the past decade coincided with the opioid crisis, as people searched for alternatives to prescription opioids,” he wrote. “Some in the kratom industry argue that only newer products with boosted levels of 7OH are dangerous. But the evidence does not support that claim. Deaths linked to kratom were already rising before the newer 7OH products appeared on the market in late 2023.”  

The three kratom advocacy groups – who all favor limited regulation – would be wise to consider that demonizing each other’s products only blurs the lines between kratom and 7-OH, which contributes to state after state and city after city enacting bans on both.

“There are legitimate concerns in the marketplace, particularly around inconsistent products, unclear labeling, and lack of transparency. Those issues deserve attention. Consumers should know exactly what they are purchasing through clear labeling, verified third-party testing, and honest disclosure of potency and contents,” says HART.

“But the solution is not to single out or ban one compound based on flawed narratives. Policymakers should instead focus on enforceable manufacturing standards and practical safeguards, such as milligram-per-serving limits, standardized labeling, and quality controls, rather than arbitrary caps that risk eliminating products people currently rely on.”

Last summer, the FDA said it would ask the DEA to have 7-OH – but not whole leaf kratom – classified as an illegal Schedule One controlled substance.

The DEA, which doesn’t even mention kratom or 7-OH in its most recent National Drug Threat Assessment, has yet to move forward on the FDA’s request. Perhaps federal agencies are just as divided about kratom as kratom advocates are.

EDS Means a Life Filled With Ankle Sprains

By Crystal Lindell

I sprained my ankle again last week. If you have ever sprained your ankle, you know that swearing is more than warranted. 

After stepping on a crack in our driveway, my stupid goddamn left foot just immediately rolled right under me. Within seconds, it was the size of a baseball. 

I have spent the last few days doing RICE: Rest, Ice, Compression, Elevation. The bruises that developed have spread, making it look like I stepped in navy paint. 

I wish I could say it was the first time I sprained my ankle, but I have hypermobile Ehlers Danlos Syndrome (EDS). As such, I’ve been spraining my ankle on a regular basis since high school. I even have my own personal stash of crutches and ankle wraps always at the ready. 

The first time it happened, I was practicing a dance routine in socks on a wooden floor at my high school and – WHACK! — I hit the ground.

Another time, I tripped off the edge of a sidewalk.

I have also fallen down a flight of stairs; landed wrong during a jump sequence in my Jazzercise class; and face-planted while running into a Target store to shop.  

Just because it happens a lot though, doesn’t mean it hurts any less. The day after it happened this time, I could barely get myself to the bathroom, as the pain radiated through my body into my chest. And that was with pain meds! It was hell. 

Until recently, I always blamed myself for these falls. I thought I was just careless when I walked. I thought, somehow, I got distracted when I was going down steps. I figured that I should have worn better shoes. That I shouldn’t have been practicing a dance routine in socks.

I genuinely thought that I was an idiot.

I’ve also lost count of how many times someone accused me of spraining my ankle for attention. I don’t know how that would even work, but logistics don’t stop people from being cruel.

Anytime I needed crutches or a day off school or work to recover, I was also accused of being lazy, overdramatic or a wimp. 

But then on March 15, 2018, I was diagnosed with hypermobile EDS by a doctor at the University of Wisconsin-Madison.

While he was evaluating me he said, “I bet you sprain your ankles a lot, huh?”

“Ummm. Yes!  How did you know?”

“Well,” he said. “Your ankles bend way past the point where they should, so if they go just a little bit further, BAM! They just roll right under. And then you sprain them.”

It’s difficult to explain the emotions that come with such a revelation. I couldn’t believe there was finally a reason beyond “I’m bad at walking.”

It turns out, my ligaments just don’t work the way they are supposed to.

It wasn’t just ankle sprains that my EDS diagnosis shed light on. Another symptom of EDS is that I bruise much easier than other people. 

It doesn’t bother me much, but it did really bother the doctor I saw at the women’s health clinic in grad school, years before my diagnosis. She was certain that my body being covered in bruises meant that I was being abused by my then-boyfriend. She tried multiple times to get me to open up to her and call the abuse hotline. 

I most certainly was NOT being abused though. Not a single bruise had come from him. Thankfully, that doctor never involved the authorities without my consent.  

Unfortunately, that’s not the case for many parents who are wrongly accused of abusing their undiagnosed EDS children for the same reason though, i.e. lots of bruises. It’s just one reason that refusing to diagnose kids with EDS or their genetically connected parents can have very dangerous consequences. 

There’s a lot of discussion these days about whether or not it’s worth it to be diagnosed with EDS. A lot of doctors think it’s being over-diagnosed, claiming patients just want the label for attention or some other vague reason.

I’m in a different camp though. I think EDS is still exponentially under-diagnosed. There is value in understranding our bodies, and that’s what a diagnosis like EDS brings. After all, we can’t cope or treat things that we refuse to even name. 

I suspect that many of my family members also have EDS. While most haven’t had the resources to get their own diagnosis, mine was enough for them to start understanding. It helped shed light on the things that their own bodies have always done. Many of them have come to realize that their injuries and pain were also not their fault.  

Hypermobile EDS is a very real condition, with very real physical markers, and very real symptoms. It causes very real pain. 

Patients have a right to know when they have it – just like they have a right to know that they have any other medical condition. Any doctor who believes otherwise shouldn’t be working in medicine. 

As for my ankle, it’s slowly getting better. The swelling has gone down significantly, and I’m hoping that within the next couple days I’ll be able to fully walk on it. Now my goal is to just make it through the rest of 2026 without another sprain.

Ohio Nursing Homes Dump Patients at Homeless Shelters

By Crystal Lindell

A woman at a Columbus, Ohio nursing home who was suffering from a painful leg fracture, diabetes, and other health problems was dumped by the staff at a homeless shelter because she drank a beer in her room.

That’s according to a 2023 inspector’s report by the Centers for Medicare and Medicaid Services (CMS), which found other disturbing incidents of Ohio nursing homes discharging older and medically fragile residents to homeless shelters.  

The Columbus nursing home, Eastland Rehabilitation and Nursing Center, told CMS it tried to get the woman into a rehabilitation program for substance use but they couldn’t find a bed. 

At the time of her discharge, she was using a walker, incontinent, and carrying a large bag of medications, according to a news report from Ohio-based Signal. 

And the story only gets worse.

The nursing home staff didn’t even bother to call the homeless shelter ahead of time to let them know that they were dropping her off. So when they left her at the homeless shelter, staff there initially refused to take her in “leaving her outside in the late-summer heat." They said they had their own 100-person-long waiting list.

According to the CMS inspector, “The [homeless shelter] staff member revealed Resident #83 was unclear of what was going on, scared, and not sure who dropped her off there.”

Eventually the homeless shelter let her into the lobby, gave her a glass of cold water and allowed her to come inside, while they called the fire department and a social worker. 

But after that, her story just… ends. None of the people involved have since been able to track her down. Administrators at Eastland did not return phone calls about the incident, according to the Signal. 

It’s a truly disgusting tale. And anyone who deals with chronic pain or other health issues should sympathize with the woman.

Medicare gives Eastland just two out of five stars in its nursing home ratings system, which is considered below average. The facility, which gets only one star for “health inspections” and “staffing,” has been fined four times over the last few years for over $300,000. 

It’s not a one-off situation either. CMS has faulted Eastland and six other Ohio nursing homes in the last few years for discharging residents to homeless shelters.

“We are starting to deal with it more and more. The facilities are so closely monitored on discharges, but yet they still try and send them to hospitals and not take them back. Or drop them off at homeless shelters,” Chip Wilkins, who heads Dayton’s Long Term Care Ombudsman program, told the Signal. 

It’s inhumane and upsetting that the only consequences the nursing homes seem to face for such a cruel act was a fine. It’s not nearly enough to deter them from doing it again. 

It’s tempting to believe that people like Resident #83 are in some outlier group. As though such a situation could never happen to you or me or someone we love. 

But the scenario is indicative of how some nursing homes treat their patients. It can happen when a resident behaves aggressively, has a substance use problem, or even if they lose their Medicare or Medicaid coverage. If you can’t pay your bills or cause too much trouble, you’re out.

Personally, I’m lucky enough to have family who I can live with now, and I’m also lucky enough that my health issues have not yet required skilled nursing care. But I’m well aware of my deteriorating body and how easily I too could end up in such a situation.

We are supposed to be human beings. We are supposed to care for each other. It shouldn’t matter if Resident #83 was drinking three 24-packs of beer a day. She still deserved medical care. All of us do.

Unless we start truly regulating medical providers to force them to actually care for their patients, situations like this will only get more common. And one day, it could happen to us or someone we love.

I have thought about Resident #83 many times since first reading the Signal article last week. I hope that she found somewhere to go. That some distant relative took her in, or that she was able to get a bed in a hospital or a different nursing home. But I know that the most likely outcome is that she died, alone and scared. 

It’s horrifying and it should never be allowed to happen.

DOJ Legalizes Medical Marijuana But Stops Short of Rescheduling Cannabis

By Pat Anson

In a major shift in U.S. drug policy, the Department of Justice is legalizing medical marijuana at the federal level by moving it from an illegal Schedule I controlled substance to a less restrictive Schedule III status, which allows for some medical use. Medical marijuana is most commonly used to treat pain, anxiety, insomnia and other health conditions. 

The move by Acting Attorney General Todd Blanche affects medical marijuana sold under qualifying state issued licenses and a handful of FDA-approved drugs containing synthetic marijuana. It also makes it much easier for researchers to study cannabis and for cannabis companies to develop new products for medical use.

“The Department of Justice is delivering on President Trump’s promise to expand Americans’ access to medical treatment options,” Blanche said in a statement. “This rescheduling action allows for research on the safety and efficacy of this substance, ultimately providing patients with better care and doctors with more reliable information.”

Medical marijuana is already legal in 40 states and the District of Columbia, and 24 of these states and DC have also legalized recreational cannabis for adult use.

Blanche’s order stops short of legalizing recreational cannabis, which remains in the Schedule I category – for the time being. Hearings will begin this summer to consider rescheduling all cannabis from Schedule I to Schedule III. Until then, federal criminal laws still apply and interstate trafficking of cannabis remains illegal. 

"While today's move is a historic step forward, it still falls well short of the comprehensive changes necessary to bring federal marijuana policy into the 21st century. Specifically, rescheduling fails to fully harmonize federal marijuana policy with the cannabis laws of many states, particularly the 24 states that have legalized its use and sale to adults," said Paul Armentano , Deputy Director of NORML, a marijuana advocacy group. 

"In order to rectify this state/federal conflict, and in order to provide state governments with the explicit authority to establish their own cannabis regulatory policies — like they already possess with respect to alcohol — cannabis must be removed from the Controlled Substances Act altogether." 

Blanche’s order also removes federal tax penalties from state-licensed marijuana dispensaries and operators, which inflated prices and restricted how businesses could operate financially. Many dispensaries are unable to get loans and can only accept cash payments because banks are reluctant to do business with them. 

"This change levels the playing field and lowers these entities’ costs of doing business," Armentano said. "This change also likely benefits patients by resulting in lower overall prices for state-licensed retail medical products."

Rescheduling Slow Walked

Some marijuana advocates say the DOJ order doesn’t go far enough, and that federal agencies continue to slow walk meaningful reform. 

“We should be clear-eyed about what this is and what it is not,” said Betty Aldworth, Chair of The Marijuana Policy Project. “Rescheduling is a step in the right direction, not a solution. It does not resolve the fundamental contradictions between federal and state law.

“It does not protect people from the legal consequences of cannabis use embedded in housing, immigration, employment, or family law. And it does not create a pathway for patients to access cannabis through insurance coverage, even when it may be safer or more effective than legal options.”

It was President Biden who initiated the rescheduling process four years ago, when he told the Department of Health and Human Services (HHS) to review the scientific evidence on cannabis and make a recommendation for rescheduling. 

It took HHS nearly a year to complete its review, but further action was delayed by DOJ and DEA decisions to postpone public hearings until after the 2024 presidential election. 

Last week, four months after signing an executive order instructing his administration to reschedule cannabis, President Trump was still complaining about how slow the process was.

“Will you get the rescheduling done, please?” Trump asked a federal health official. “They’re slow-walking me on rescheduling. OK, you’re going to get it done, right?”   

The FDA has already approved four synthetic marijuana drug products: Epidiolex (cannabidiol), Marinol (dronabinol), Syndros (dronabinol), and Cesamet (nabilone). They require a prescription and are used to treat seizures, nausea, vomiting, and loss of appetite in select patients.

Combining Opioids With a Cannabis-Based Medicine Doesn’t Add to Pain Relief

By Pat Anson

Combining a low dose of opioids with a cannabis-based medicine did not improve acute pain for people with arthritis, according to results of a small clinical study published in the journal Anesthesiology.

Animal studies have suggested that the two drugs might have a synergistic effect and provide better pain relief, but the study of 21 people with knee osteoarthritis found no added benefit. 

“Some patients believe combining cannabis with opioids can help with pain, and clinicians may recommend or prescribe it in states where cannabis is legal,” said lead author Katrina Hamilton, PhD, a Psychiatry Professor at Johns Hopkins School of Medicine. “Our study suggests that isn’t the case and patients may experience more side effects when the drugs are combined.”

There are some important caveats to the study that diminish its findings.

One is the design of the study and its small size – just 21 patients – who received placebo pills, hydromorphone alone, dronabinol alone, and a combination of hydromorphone and dronabinol. 

Participants received all four combinations prior to having pain induced by sticking their hands in cold water or having their skin rubbed with a “hot” capsaicin cream. That means the researchers were evaluating acute pain induced in a laboratory, not the chronic pain caused by arthritis.

Second, dronabinol (Marinol) is not cannabis. Dronabinol is a synthetic version of THC, the active ingredient in cannabis. It is FDA-approved to treat nausea and vomiting in chemotherapy patients, and to improve appetite in AIDS patients. Dronabinol was never intended to provide pain relief and has little in common with the various forms of cannabis (edibles, smoking, vaping) used in the real world. 

Third, while hydromorphone is a potent opioid, the oral dose (2 mg) that was used is relatively low – about 10 morphine milligram equivalents (MME). The research team had previously conducted a similar study using 4mg of hydromorphone. That also produced little pain relief for participants, so it’s not surprising that 2mg didn’t help either, although researchers say the lower dose has a “better safety profile.” 

The researchers found that taking hydromorphone and dronabinol, either alone or in combination, did not provide significant relief from acute pain. The opioid alone reduced pain sensitivity, while dronabinol did not, but neither meaningfully reduced participants’ self-reported pain.

When the two drugs were combined, side effects such as drowsiness, dizziness and impaired thinking were stronger and more noticeable, but without added pain relief.

“Opioid and cannabinoid medications failed to produce robust analgesia in experimentally induced pain among patients with knee osteoarthritis. In contrast to preclinical studies, there was no evidence of synergistic analgesic effects by combining hydromorphone and dronabinol,” researchers concluded.

While the dose of hydromorphone was low, the 10mg dose of dronabinol that was used in the study is a hefty amount. Interestingly, participants reported more of a “high” sensation from the dronabinol than from hydromorphone. But again, dronabinol is a synthetic version of cannabis and has little in common with what most cannabis consumers use.    

“In the real world, people often use cannabis differently, including lower starting doses, using gradually stronger doses, which may affect both benefits and side effects,” said Hamilton, acknowledging the limits of her study. “More research is needed to better understand how cannabis affects pain when used in real-world settings.”

Physical Therapy Provides Only Modest Relief For Chronic Lower Back Pain

By Pat Anson

Physical therapy, cognitive behavioral therapy (CBT), and mindfulness are often recommended as non-pharmacological treatments for chronic lower back pain. The World Health Organization even calls them first-line treatments in a 2023 guideline for low back pain that discourages the use of most pain medications. 

But which therapy works better?

A new study, published in the Annals of Internal Medicine, found that physical therapy provides minor improvement in physical function for patients with chronic low back pain, but no change in pain intensity compared to CBT and mindfulness.

A research team led by the University of Utah enrolled 749 adults with chronic low back pain (cLBP) to compare the effectiveness of physical therapy with other non-pharmacological treatments.

Participants were randomly assigned to 8 weeks of either physical therapy or CBT. Those who did not improve were reassigned to a second treatment, either switching therapies or trying mindfulness-based care for another 8 weeks.

The physical therapy was provided by licensed therapists, while mental health care professionals provided CBT and mindfulness training. CBT is a form of psychotherapy, in which a therapist works with a patient to reduce unhelpful thinking and behavior; while mindfulness focuses on increasing awareness and acceptance of physical discomfort to minimize its impact on daily life.

After 10 weeks, participants who started with physical therapy showed a small improvement in function, while pain levels were similar between groups. After one year, no meaningful differences were seen among the second-stage treatments. 

The findings suggest physical therapy (PT) may be a reasonable first option for chronic low back pain, but switching or adding other psychological therapies may not change long-term outcomes.

“We found some benefits to PT as the first treatment offered to patients, but we could not detect subgroup differences and effect sizes were small. Our results support PT as a first-line option for cLBP and no differences in potential benefits of second-line care with mindfulness or switching for nonresponders,” researchers concluded.

The study does not mean that CBT and/or mindfulness are ineffective, just that their impact is minor. That finding is similar to another recent study of patients with chronic low back pain, which found that CBT and mindfulness reduced pain levels by about 10% after a year. 

That’s nice, but not the kind of pain relief most people are looking for. 

Chronic low back pain is the leading cause of disability worldwide. It usually begins with acute pain caused by muscle strain or musculoskeletal injuries, and becomes chronic over time when it fails to resolve. Chronic low back pain mostly affects adults of working age in lower socioeconomic groups, who often have physically demanding jobs.  

For such a common disorder, affecting about 500 million people at any given time, there is little consensus on how to treat it. 

A 2018 review in The Lancet by an international team of researchers found that cLBP is often treated with bad advice, inappropriate tests, risky surgeries and painkillers. The authors said there was limited evidence to support the use of opioids for chronic low back pain, and epidural steroid injections and acetaminophen (paracetamol) were not recommended at all.