Pain Can Make You Mean. Don’t Let It

By Crystal Lindell

As a child, I grew up hearing stories about just how viciously mean my late great-grandmother was. Her son, my late grandpa, was also described as “mean.”

Nobody wanted to be around them. Everybody wanted to be different from them. 

The moral of the tale – as I was so often told as a little girl – was to make sure I didn’t grow up to be “mean.”

As I got a little older though, I started to also hear the stories about their various medical ailments.  

My great grandma suffered from rheumatoid arthritis. She moved to Arizona in her later years hoping the dry desert air would bring her relief. And she started drinking a single beer every day to treat the pain, because her only other option was aspirin.  

Meanwhile, my grandpa regularly spent months in the hospital because of his scoliosis. He wore a back brace, and when he was home, he was either in bed or sitting at the kitchen table chain smoking cigarettes.

As an adult, with my own medical ailments, the picture has become much clearer. My great-grandmother and grandpa probably were very mean – but it’s only because they were both in a lot of pain.

They suffered every day. And they did what millions of others before them have done in that situation – they let the pain make them mean.

The healthy adults who told me these family fables never seemed to make the connections between the pain and temperament. They saw the mean personalities as something inherent in both my great grandma and my grandpa, as though it were some wholly separate thing from the health conditions that ravaged their bodies.

To my relatives, they were mean because they were bad people.

As an adult with chronic pain myself, I have come to understand things that were impossible for me to grasp as a child: They weren’t bad people, they just had bad bodies.

When you’re dealing with chronic pain, even the nicest, kindest person will develop an insatiable urge to lose their temper on those around them. After all, you can’t waste time with fake pleasantries and patience when your body feels like it’s been through a war zone.

I don’t want to be mean though.

Even on my worst pain days, I make a specific effort to ensure that I’m not taking out my physical pain on those around me.

But I struggle. There are so many times that I want to snap at my fiancé, yell at my mom, lose my temper on my friend. Can’t they see? I’m in pain! Why are they talking to me and annoying me when I’m in pain?

I stop myself though. Or, worst case, when I don’t have enough strength to stop myself, I apologize afterwards.

Beyond that though, when I know someone is struggling with physical pain, I don’t take their meanness personally. Instead, I offer sympathy.

All of us are just a few bad pain days away from becoming mean. Knowing that can help us offer understanding to others. But more than that, it can help us fight off the urge within ourselves.

So yes, pain can make someone “mean” - and those of us with chronic pain often are. But if we’re diligent, it doesn’t have to become our whole personality.

How Pain Became Profitable

By Neen Monty

Why have prescription opioids become virtually verboten?

Is it safety? Partly. Evidence? Allegedly. The evidence is pretty thin.

But let’s not overlook the less noble explanation: research dollars, commercial opportunity, institution building and careers.

There is now an enormous scientific and commercial industry devoted to solving “the opioid crisis.” And that industry depends, at least partly, on maintaining a particular story: Opioids are dangerously addictive, fundamentally unsuitable for chronic pain, and urgently need to be replaced.

The United States National Institutes of Health launched its HEAL Initiative in 2018, nearly doubling annual funding for opioid and pain research from approximately $600 million to $1.1 billion. 

By 2023, HEAL had invested $3.2 billion across more than 1,800 research projects. That is an awful lot of laboratories, salaries, grants, publications and careers attached to an “urgent public-health emergency.” 

This does not mean researchers are gathering in dark rooms, twirling their moustaches and plotting against pain patients.

They don’t need to. The incentives do the work perfectly well.

Declare an existing treatment unacceptable and you create an urgent scientific problem.

Urgent scientific problems attract grants, investment, patents, clinical trials, prestige and promotions. They also create a potentially enormous market for whichever company produces the replacement.

That is not a conspiracy theory. It is an incentive structure. It's capitalism.

The Awkward Truth Behind the Sales Pitch

A recent Science article asks: “Can a new, safer class of pain drugs ever rival opioids?”

It sounds like another story about escaping the horrors of opioid medicine. But the headline accidentally admits something important: Opioids are extremely difficult to rival. That is why scientists are still trying.

If opioids were useless painkillers, as some modern pain rhetoric would have us believe, there would be no need for new drugs to “rival” them. Researchers would merely need to produce something better than useless. Apparently, this has proved surprisingly difficult. 

In 2025, the U.S. Food and Drug Administration approved suzetrigine, marketed as Journavx, as the first drug in a new non-opioid class for moderate-to-severe acute pain. It blocks NaV1.8 sodium channels in peripheral nerves, interrupting pain signals before they reach the brain. 

Its manufacturer, Vertex, is investing heavily in its commercial launch and development across further pain indications. 

Good.

We desperately need more effective pain medications. We need different medicines for different pain mechanisms, different bodies and different medical circumstances. We need options for people who cannot tolerate opioids and better treatments for people whose pain does not respond to them.

Research and development is good. Obviously.

But developing new analgesics does not require pretending that existing ones do not work. Nor does it require sacrificing the patients who already use them successfully.

How Dangerous Is an Opioid Prescription, Really?

We are constantly told that prescribing an opioid exposes every patient to an intolerable risk of addiction and overdose.

The actual numbers are much less theatrical.

A 2023 systematic review and meta-analysis examined 28 observational studies involving almost 24 million patients prescribed opioids for chronic pain. It found a pooled prevalence of:

• 1.3 fatal overdoses per 1,000 patients

• 3.2 nonfatal overdoses per 1,000 patients

That is approximately 4.5 fatal or nonfatal overdose events per 1,000 patients prescribed opioids for chronic pain. Not zero. Not irrelevant. But a very long way from the impression that catastrophe inevitably follows the first prescription. 

More importantly, the risk was not distributed evenly.

Overdoses were strongly associated with identifiable risk factors, including a previous overdose, current substance-use disorder, multiple prescribers, multiple dispensing pharmacies, higher doses, certain mental-health diagnoses and particular medication combinations.

In other words, “a person prescribed an opioid” is not one uniform risk category.

That should be obvious. Apparently, it needed a meta-analysis involving 24 million people to elucidate.

A stable patient taking one medication, prescribed by one doctor and dispensed by one pharmacy is not medically interchangeable with a person obtaining drugs from multiple sources, combining them with sedatives or living with an active substance-use disorder.

Yet much public discussion places all of these people into one ominous bucket labelled “opioid users.”

Not very scientific. Can you say bias? Stigma? Stereotyping? Profiling?

For a well-selected and well-monitored patient on long term opioid therapy, the risk of overdose is very, very low. That’s what the evidence says.

Many pain management doctors are keen to advertise “evidence-based treatment for chronic pain” without ever reading the evidence.

A Swamp of Addiction Statistics 

The estimates of addiction following opioid treatment vary wildly.

That is not because addiction is a mysterious force capable of changing its prevalence depending on the phase of the moon. It is because researchers frequently measure different things and give them similar names. What constitutes “addiction” varies wildly. 

And overdose statistics often include non-fatal overdoses. Or even overdose deaths where an opioid was detected, but was not the main cause of death.

Some studies only measure diagnosed opioid-use disorder. Others measure abuse, misuse, physical dependence, administrative billing codes, unexpected urine results, requesting an early prescription, or a vaguely defined “aberrant behaviour.”

None of these are the same thing. They are thrown together to inflate the outcomes. To keep the panic alive.

One 2018 meta-analysis reported an incidence of opioid “dependence or abuse” in 4.7% among patients prescribed opioids for pain. But the included studies used different diagnostic systems and produced a “substantial heterogeneity” of 99.78%.

For non-statisticians, that is roughly the scientific equivalent of throwing apples, wombats and garden furniture into a blender and reporting the average fruit content. 

Physical dependence is an expected physiological adaptation to many medicines, including opioids. I don’t believe it’s avoidable. It means abrupt cessation may cause withdrawal. This is a normal response to suddenly stopping a medication. By choice or otherwise. It is not addiction.

Addiction - or opioid-use disorder - requires a pattern of use that involves impaired control, compulsive use or continued use despite evidence of harm.

A patient who takes a medicine consistently because it relieves severe pain and improves their ability to function is not demonstrating compulsive use despite harm. They are using a medicine for its intended purpose.

Needing insulin does not prove an unhealthy fixation on insulin.

Needing anti-hypertensive medication does not reveal a worrying psychological attachment to blood-pressure control.

Needing anti-depressants to live a functional life does not show a pattern of compulsive behaviour.

But needing ongoing pain relief? Suspicious. Apparently.

What Happened When Opioid Prescribing Fell?

If opioid prescribing were the principal driving force of the U.S. opioid epidemic, we should have seen precipitous reductions in prescribing to be followed by a substantial drop in opioid deaths.

But that is not what happened.

U.S. opioid prescribing has been declining since 2012. The percentage of adults filling an opioid prescription fell by 31% between 2008 and 2018, while the national dispensing rate continued falling to 35.4 prescriptions per 100 people by 2024.

Meanwhile, illegally manufactured fentanyl spread through the illicit drug supply.

The CDC reports that approximately 70% of U.S. overdose deaths in 2023 involved illegally manufactured fentanyl. It states that illicit fentanyl entered the illegal drug supply around 2013 and subsequently replaced heroin as the dominant illegal opioid in the United States.

Even the FDA acknowledges that prescription opioids are no longer driving the opioid overdose epidemic. 

That sentence deserves to be printed in very large letters.

The truth that remains unsaid – and will never be admitted – is that prescription opioids were never the driving force behind the opioid crisis. Never. It was always about illicit drug use.

But prescription opioids are a much easier target than Mexican cartels and curbing illicit supply. Easy target, big wins, media headlines.

Who cares about the tens of thousands of patients who suffered and even died because their life saving pain medications were taken away? Very few.

Prescribed pain medication and illicit fentanyl are not completely separate worlds. There is some crossover. But most prescription opioid abuse is due to diversion. Yes, some people with opioid-use disorder were initially exposed to opioids through a medical prescription. But the vast majority of those already had a history of substance abuse.

And that crossover is very, very small. As can be seen from the major, large scale, systemic review already cited.

Stable therapeutic use, physical dependence, medication misuse, opioid-use disorder and exposure to an unpredictable illicit fentanyl supply are very different situations. Treating them as one big problem has not only failed to solve the illicit drug crisis; it has inflicted another crisis on people living with severe pain.

The Patients Who Spoil the Story

There is one group largely missing from the replacement narrative: patients for whom opioids work.

They are not getting “high.” They are not escalating their dose uncontrollably. They are not visiting six doctors or four pharmacies. They are not searching for euphoria.

They are searching for enough pain relief to shower, sleep, work, prepare food, and care for their children. To keep living a full and functional life despite moderate to severe pain due to disease or injury.

Some patients find opioids effective, but not remotely pleasurable. Many experience nausea, itching, sedation or mental fog. Others experience pain relief with few side effects. 

Individual responses vary, as they do with every other class of medicine. For every person, it’s a case of weighing up the risks and benefits.

Opioids have unpleasant side effects, but there are few things as unpleasant as living with constant, severe, pain. I’d prefer some itching and a bit of nausea than a knife twisting in every joint, and my arms and legs feeling like they are on fire. 

What would you choose?

In people with chronic low-back pain, research has shown that those with previous prescription opioid use got greater pain relief from morphine. But they were not more likely to feel “high.” In other words, stronger pain relief did not mean stronger euphoria.

But acknowledging those patients creates a problem.

If opioids are effective and acceptably safe for a properly selected and monitored group, then the scientific mission should not be to “replace opioids.”

It is “develop more choices while identifying who benefits from each one.”

Still very worthy. Still very important. Still very deserving of funding.

But we’re no longer talking about a “crisis.” Not quite as dramatic, and not as likely to receive that sweet, sweet funding for non-opioid alternatives.

Develop Better Drugs. But Stop Destroying Patients

To be clear, I am in no way saying that opioids are harmless. Opioids can have serious side effects. Patients need to be well screened and well monitored.

Opioids can cause adverse effects, physical dependence, respiratory depression, overdose and opioid-use disorder. Higher doses and dangerous medication combinations require particular care. Patients should receive honest information, individual risk assessment and proper monitoring.

Doctors are highly skilled and the very low overdose rate in chronic pain patients shows that doctors managed this risk very well. Right up until 2016 in the U.S and about 2020 in Australia.

But saying something “has risks” is not synonymous with “must never be used.”

I take many high-risk medications to treat my complex autoimmune diseases – medications that are much higher risk than any opioid could ever be. Yet taking that risk is allowed. Encouraged. Even insisted upon. 

Why are opioids singled out and denied when Xeljanz or Rituximab are much more dangerous?

It makes no sense. Scientific sense, medical sense or common sense.

Of course better pain medications should be funded. Safer analgesics is a lofty goal that should be celebrated. New treatments that are as good as, or even better than opioids, without opioid-related risks would be a genuine medical achievement.

But we should not be taking opioids away from those who need them, who have been stable and doing well for years, before those new non-opioid pain medications are available. That means leaving people to suffer needlessly, on the promise that something better is being researched.

Pain patients should not be treated like expendable research targets. They should not be forced to surrender their pain relief and functional lives to fortify the commercial and scientific case for tomorrow’s medication.

Develop the alternatives. Fund the research. Build the careers. Make the money, even. All good.

But stop denying people who need access to long term opioid therapy for any kind of quality-of-life. Put the risk/benefit equation where it belongs, where it is with all other medications – in the hands of the informed patient.

And stop pretending that scientific progress requires opioids to fail, along with the patients who benefit from them.

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.”

Why Hot Weather Makes Pain Worse

By Gulnaz Anjum and Mudassar Aziz

This summer’s amber heat warnings have brought with them many risks to health.

Many people have experienced these health effects first-hand: brain fog, physical fatigue, restless nights and reduced productivity. If that sounds familiar, you’re not imagining it. Science shows that high temperatures can affect both our bodies and our brains – even before they reach extreme levels.

But one consequence of hot weather that many people may not know about is that it can also affect physical pain.

Our research analysed data from a large, nationally representative survey from the global analytics firm Gallup, which recorded daily measures of pain from more than two million US residents. We found that as temperatures increased so did the likelihood of people reporting they were experiencing some type of generalised physical pain.

The largest increases occurred on very hot days – around 32°C (89.6°F) or above. Middle-aged adults and people from lower socioeconomic backgrounds were most likely to report experiencing pain on very hot days.

Scientists have identified several possible explanations for why you’re more likely to experience worse pain on hot days.

Some of these causes are direct triggers of pain – including dehydration caused by the heat, inflammation and other physiological processes, such as blood pressure changes which can make existing pain worse.

Other causes are indirect triggers. For instance, hot weather can increase stress, disrupt sleep, reduce wellbeing and limit our ability to perform our usual daily activities, such as exercise. All of these factors are known to amplify experiences of pain.

The relationship between pain and these potential triggers can go both ways as well. Sleep is a good example of this.

Poor sleep makes people more sensitive to pain, while pain itself makes it harder to sleep. During heatwaves, many people struggle to get a good night’s sleep, creating a vicious cycle in which poor sleep increases pain and pain further disrupts sleep. Over time, this cycle can take a toll on people’s wellbeing and quality of life.

The effects of pain extend beyond physical discomfort, as well. Pain competes for our brain’s attention. When the body hurts, attention is diverted towards coping with that pain, leaving fewer resources available for concentration, memory and decision-making. This can affect performance at work, learning in school and even everyday decision-making.

In some situations heat can be beneficial for pain – for example, applying a heating pad to help relieve lower back pain after a long day on your feet.

But there’s an important difference between using targeted heat to treat a specific area of the body and being exposed to sustained high temperatures that affect the entire body. The latter places stress on multiple physiological systems and can worsen, rather than relieve, physical pain.

The consequences of heat’s effects on pain are not only personal – they’re also economic.

In our study, we estimate that hotter temperatures already cost the United States’ economy around US$2 billion (£1.5bn) every year through higher levels of pain. If temperatures continue to rise and no action is taken to help people adapt to extreme heat, these costs could exceed US$9 billion annually by 2050.

The increasingly frequent and intense heatwaves experienced in recent UK summers suggest that comparable losses in healthcare costs, reduced productivity and diminished quality of life could become an important challenge if hot summers become the new normal.

Bodily pain should therefore be recognised as another hidden health consequence of extreme heat.

Heat affects us in more ways than we often realise. The good news is that there are practical steps we can take to reduce these effects. Staying well hydrated, avoiding strenuous activity during the hottest hours of the day, seeking cool indoor spaces and planning outdoor activities for the morning or evening can all help reduce heat-related pain and discomfort.

Gulnaz Anjum, PhD, is an Assistant Professor of Climate Psychology at the University of Limerick.

Mudassar Aziz, PhD, is an Associate Professor of Psychology at the University of Oslo.

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

A Brief History of Human Pain

By Lars Arendt-Nielsen 

Pain is one of the few things all of us experience, from stubbing a toe to waking up with an aching back; we can all relate to the feeling of being in pain.

Although pain is a universal experience, the way we understand it has changed dramatically over time.

Ancient societies might have blamed pain on demons entering the body through the nose or ears, but we now know pain to be more about nerve endings and biology.

Cures have also moved on a lot. While our ancestors may have tried to sneeze, vomit, or even urinate out their pain, these days we’re much more likely to take medications to ease our suffering.

Strange as these ancient “treatments” sound today, they do reveal something important about pain: that it’s never just a physical sensation. Because throughout history, culture, religion and social beliefs have shaped how people talk about and respond to suffering — and many of those ideas still influence us to this day.

Indeed, after more than 30 years studying pain, one thing has become clear to me: while pain is universal, our experience of it is anything but.

Ancient Pain

To understand the roots of how we think about pain today, it helps to go back and see how earlier cultures made sense of it.

In many ancient cultures, for example, people believed pain was caused by external forces. Treatments relied on occult rituals, amulets, or trying to drain “bewitched” fluids from the body to expel such forces.

The ancient Egyptians believed that if you hadn’t obviously hurt yourself (so no broken bones, no visible wound), then clearly something more sinister was at play. This could be the gods or perhaps a wandering spirit of death, which had decided to pay your body an unwelcome visit.

Others tried to explain pain in more bodily, rather than spiritual, terms. The ancient Greeks, including physicians like Hippocrates, believed pain and disease arose when the body’s “four humours” — blood, phlegm, yellow bile and black bile — fell out of balance. Healers would use plant and animal remedies to try to restore harmony.

Moral Judgement

By the middle ages, pain had taken on a moral and religious meaning.

Across Europe, convents and monasteries often served as early hospitals and had access to powerful pain-relieving substances such as opium. Yet pain was not always treated.

This is because many Christians believed suffering to be a test of faith, while others saw it as a path to spiritual purification.

As a result, enduring pain was viewed as virtuous. So rather than seeking relief, sufferers were often encouraged to bear their discomfort with patience and devotion.

Echoes of these beliefs can still be seen today. For example, some women choose to go without pain relief during childbirth because of the idea that labour pain is a meaningful or a necessary part of the experience.

Toughing It Out

Indeed, the idea that suffering should be endured hasn’t disappeared as religion’s influence has waned. In many societies, it has simply found a new home in philosophy.

If you’ve ever felt pressure to “tough it out” when you’re ill or injured, you may recognise the influence of stoicism. At its core is the idea that we cannot always control pain, but we can control how we respond to it.

In many parts of the world, to this day, enduring pain quietly can be seen as a sign of resilience and self-control, with people often encouraged to minimise their discomfort and avoid making a fuss. This is despite the fact that vocalisations of pain are a common way for humans to bond, with research showing that human exclamations of pain are similar across the world.

So whether you like to express your pain or keep it on the down low, one thing is certain: the way we think about and even feel our pain has been directly influenced by human history.

And although most of us no longer blame demons or divine punishment for our aches and illnesses, we are still, in many ways, just trying to make sense of our suffering — much in the same way as our ancestors did.

Lars Arendt-Nielsen, PhD, is a Professor and Head of Pain Research at Aalborg University in Denmark.

He served as the President of the International Association for the Study of Pain (IASP) from 2018 to 2020, and is an active member of the IASP council. 

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

People Who Live Without Pain Rarely Think or Care About Those Who Do

By Ann Marie Gaudon

As I crawl into bed early at night, so grateful for the bed I have, I strategically place two separate heating pads for pain relief. Simultaneously, I strategically place two ice packs for pain relief. 

What’s one to do? “A” and “B” require heat for relief, and “C” and “D” require ice for relief. 

Such is my life.

What is it like to not have pain? To just go to bed at a regular adult time, slip into your sheets, and drift off? I have no idea, and so I can only imagine this. I would have to go back at least four decades in time and I just cannot remember that far back.

It’s ironic that I am so high maintenance, but not as you might think. I couldn’t be less of a diva. The days of hair, make-up, and stylish clothes are long gone. I care nothing for those things because they don’t do anything to make me feel better. 

I putter along with regular haircuts, minimal make-up on days I can manage it, and that’s about it.

I have no fear of what any pain may or may not mean. I do not have a cascade of stress hormones flooding my system daily out of fear. That is not in my life, and is what I have achieved from a healthy dose of self-care and chronic pain management. 

What it cannot do, however, is stop a body from deteriorating, stop pain from increasing, or stop the course of disease.  

As a young person, I can assure you I never saw this coming. There are other illnesses in my family of origin, but not chronic pain as I have experienced for 40+ years.

Unfortunately, there is not a lot of help out there. Health Canada, which is the Canadian agency responsible for “helping Canadians maintain and improve their health,” claims to ensure that everyone has access to high-quality health services. 

But from all that I have read and meetings I have attended, Health Canada remains essentially clueless to the plight of a person in pain. They have always drunk the Kool-Aid of anti-opioid zealots, and believe the endless published rubbish about those medications. 

As sickening as that is (no pun intended), I was never able to find anyone with any type of power that actually was a person in pain. That’s a big problem. 

Just to be clear, this is not a column about opioids or any other type of medication. It’s about the sheer ugliness of chronic pain. For some of us, the diagnoses just keep rollin’ along. I have officially lost count. 

There are two new ones that I can tell you about. One is Baxter’s nerve entrapment, which feels like a razor sliding up into your heel with every step. For a long time, I thought it was a very stubborn case of plantar fasciitis in both feet. However, I have since learned there’s a different diagnosis entirely in my right heel. 

The second newer diagnosis is something called costochondritis. No, I hadn’t heard of it either. I thought I was having a massive heart attack when I awoke in the middle of the night in severe chest pain. I resigned myself and just felt ready to go unconscious. However, that didn’t happen. 

I was advised over the next three days to go to the emergency department, but having care-avoidant health anxiety, I refused to go. 

I was in tremendous pain and could hardly move at all, but on the third day, someone said to me that I might have pneumonia. That word is what got me to the emergency department, because I could not forgive myself if I ever infected someone else. 

It wasn’t pneumonia, it wasn’t a heart attack, and it wasn’t a pulmonary embolism. It was costochondritis, which the Mayo Clinic advises can feel much like a heart attack. Now the chest pain comes and goes.

At times I feel angry and sad for myself, but where my heart really lies is for younger people. What’s to become of the young at the beginning of their chronic pain or not quite there yet? I shudder at the thought of it. 

I recently had a young client with painful rheumatoid arthritis who was especially suffering with pain in one hip that was causing mobility issues. Practically begging her neurologist for pain relief, the response was: “No one with rheumatoid arthritis should expect to live a pain-free life.” 

They were gutted by those words. 

Is this what to expect? “Don’t expect to live a pain-free life” when there are scores of medications out there developed for just that? What is wrong with people? 

I can tell you my unscientific theory about this. People who do not live in pain rarely think or care about others that do.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for over 40 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.     

A Fentanyl Vaccine Is a Horrible Idea

By Crystal Lindell

A few years ago, I saved a loved one’s life when he was overdosing on fentanyl.

His lips and fingertips were blue when I found him, and as I administered NARCAN (naloxone), all I could think at that moment was that if he was dead, I never got the chance to say good-bye.

It was one of the most traumatizing experiences of my life, and I’m forever grateful that my efforts to save him were successful.

Even with that experience, I’m here to tell you that a fentanyl vaccine is an absolutely horrible idea. And I pray that nobody I love ever takes it – even the man who’s life I saved.

This week, JAMA published an article about the current status of the fentanyl vaccine, which is in development.

In the article, Associate Managing Editor Kate Schweitzer interviews Collin Gage, a cofounder and chief executive officer of ARMR Sciences, which has begun early-phase human trials of a fentanyl vaccine in the Netherlands.

Schweitzer seems to think such a vaccine would be a net positive for the world.

"If proven safe and effective, it could become the first proactive pharmaceutical approach designed to prevent fentanyl overdose and, potentially, treat addiction," she writes.

However, as both a chronic pain sufferer and someone whose loved one struggled with fentanyl addiction, I’m here to tell you that this entire research project should be ended right now.  

First and foremost, my biggest concern is that such a vaccine would be pushed onto people who do not want or need it, including pain patients.

I can already see doctors having a policy where they won’t prescribe opioids unless the patient agrees to receive the fentanyl vaccine. They’ll claim the policy is meant to protect patients, when in reality, it would only cause them more harm.

The article even points out what those harms could look like. Schweitzer quotes Kathryn Frietze, PhD, associate professor of molecular genetics and microbiology at the University of New Mexico, who is one of many researchers working to develop vaccines against drugs of abuse.

Doctors, according to Frietze, have expressed concern about how a vaccine could complicate medical care, given that prescription fentanyl is a widely used medication for acute pain control and anesthesia.

“Can they increase the fentanyl dose medically if needed, or is it going to completely eliminate fentanyl as an option?” Fritze asked. 

Read that again. Do we really want to eliminate fentanyl as an option for pain control and anesthesia? This is a medication used in hospitals, usually on patients in severe trauma or undergoing surgery.

Do we really want a vaccine to make fentanyl ineffective for them? 

Do we really want a vaccine that requires more fentanyl to be administered?

In practice, either scenario could be disastrous, especially in an emergency situation where an unconscious patient would be unable to explain to doctors that they had the fentanyl vaccine.

The thing about fentanyl is that you have no idea that you might need it someday. We don’t usually know when we’ll need anesthesia or acute pain control.

That is particularly relevant in this situation, because the article quotes multiple experts who seem excited about pushing a fentanyl vaccine onto high-risk groups, such as college students and young adults, who are experimenting with drugs. They may not be aware that the counterfeit pill they bought or got from a friend has a lethal dose of fentanyl. 

“Overdose from fentanyl doesn’t just happen to people who are purposely taking fentanyl,” Frietze said. “People may be exposed without their knowledge.” 

So they want to go to college campuses and give students a vaccine against a very valid pain medication, when they have no idea if they will ever need it?

Schweitzer says a vaccine that specifically targets fentanyl could still allow for the use of other analgesics, such as morphine and propofol. 

As a pain patient, I’m skeptical about that. If a vaccine blocks the effects of one opioid, it may also dampen the effects of other ones.  

The other major issue with a potential fentanyl vaccine is a phrase coined by Richard Cowan in 1986: “The Iron Law of Prohibition.” That essentially means that when law enforcement targets a specific drug, the potency of other prohibited substances increases.

Or, as Cowan said, "The harder the enforcement, the harder the drugs."

If you give everyone fentanyl vaccines, people will just find even stronger drugs to take. And those drugs will likely be more deadly. It’s no coincidence that illicit fentanyl arrived on the black market just as opioid pain medication became harder to get. 

As such, a fentanyl vaccine could result in more overdose deaths, not less, as people seek substitute drugs that bypass the vaccine.

Gage’s response to that possibility is to call the fentanyl vaccine “a platform technology—one that we plan to adapt."

In other words, they will just make new vaccines for new drugs. But in practice, how long would it take to actually develop new ones? And how long would it take to get them to drug users, who are often difficult for the medical community to reach?

Trust me when I tell you that drug users and their dealers will move exponentially faster than any research and development team ever could.

In practice, the reason street fentanyl is so deadly is because it’s unregulated. Users don’t know how much they are taking or what is mixed in with it – and those two things make it more likely that the drug will cause an overdose.

The solution then is to offer drug users a regulated supply, which is what methadone treatment is. In a perfect world, if they really wanted to help fentanyl users, these researchers would be working to make methadone treatment more accessible.

Instead, they’d rather make it so patients can’t use one of the most effective pain and anesthesia medications on the market, while pushing them onto harder or less effective drugs.

It’s a bad idea, and I hope these researchers see the error of their ways before it’s too late.

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.

Sleep, Pain and Mental Health Are Motivating Older Americans To Try Cannabis

By Pat Anson

Older Americans increasingly identify as cannabis consumers, with about 6% saying they’ve used cannabis products in the past year. That percentage is likely to increase due to the long-awaited federal legalization of medical marijuana. 

A new study helps explain why older adults are turning to cannabis. Researchers at the University of Utah Health and University of Colorado Boulder interviewed 169 adults over age 60 who were about to purchase cannabis for the first time. 

When asked what symptoms or health issues led to their decision to try cannabis, nearly 57% said better sleep was the driving factor, followed by pain relief (49.7%) and mental health (24.9%).

The study findings, recently published in JAMA Network Open, found that most older adults turn to cannabis because they are seeking more effective non-pharmaceutical options. Many base their decisions on word of mouth and positive anecdotes from others, rather than discussions with healthcare providers.

“Because I’ve read about it and I have friends who are on medical cannabis who are getting relief, getting help with sleep and some relief from pain,” one participant told researchers. 

“They brought a lot of feedback from other people to inform their opinions,” says first author Rebecca Delaney, PhD, Assistant Professor of Population Health Sciences at the University of Utah. “Overall, they really wanted better quality of life, reducing their pain, getting better sleep, and being able to enjoy time with family and friends a little bit more.”

Many of those interviewed had grown tired of side effects from pharmaceutical drugs or found them ineffective.

“I worry about the side effects of the NSAID meds, the Aleve, Excedrin, aspirin, ibuprofen. They all really do help my arthritis when I take it, but I’ve also had friends that have gotten bleeding ulcers from taking those meds too much. So that’s made me very worried about taking them too often,” said one study participant.. 

“I’m a little concerned about alcohol as a sleep aid because it’s toxic and affects your kidneys and liver and all kinds of other things. And I found that melatonin isn’t that effective. I don’t really want to do prescription, over-the-counter drugs. I’ve done those in the past and they just make you groggy the next day,” said another.

“As I am aging I have some joint pains that I would like to get rid of. I’m very active. I’d rather not have those. They are kind of adding up. I’ve had lower back problems for many, many years,” another participant told researchers.  

Given a choice of what cannabis product to use, over half the older adults (57.5%) selected a product that combined THC and CBD. Many thought CBD was more beneficial for physical health, while THC was best for improving mood. Most people chose combination products to give them the best of both worlds.

Only a small number of participants wanted to use cannabis to get high or to relax during social gatherings. Others want to try cannabis as a substitute for alcohol or other recreational substances that are potentially harmful. 

“For the most part, we found that these folks aren’t really interested in getting high. They just want to feel better,” said senior author Angela Bryan, PhD, Professor of Psychology and Neuroscience at CU Boulder.

An important caveat is that the study was conducted in Colorado, where medical and recreational cannabis have been legal for several years. For older adults in other states where cannabis is illegal or where only medical use is permitted, attitudes about cannabis may be different. 

Researchers say healthcare providers need to be better educated and more involved in helping their patients make thoughtful decisions about cannabis use. Whether they approve or not, more people are going to try cannabis as barriers against its use are taken down.

“The ultimate goal is to develop resources to help people make decisions and find products that meet their needs, and to figure out how we can distill information to patients and physicians,” Delaney says. “We would really love to see more of these conversations happening between physicians and patients to make sure that people feel supported and informed when seeking alternative ways to address their pain.”

Previous studies have found that medical cannabis can be beneficial for older adults, improving cognitive function, lowering blood pressure, and reducing the need for painkillers.

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 

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.

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.

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.”

Co-Prescribing of Opioids and Gabapentinoids Grows Despite Warnings

By Pat Anson

In 2019, the FDA warned that serious breathing problems can occur in patients who take gabapentinoids with opioids or other medications that suppress the central nervous system. The agency said elderly patients and those with pre-existing lung problems were at highest risk of respiratory depression, which can lead to a fatal overdose.

Those warnings went unheeded by many doctors, according to a new study that found the co-prescribing of gabapentinoids to patients on long-term opioid therapy increased over the past decade, rising from 47% in 2015 to 58.7% in 2023.

Gabapentinoids are a class of nerve medication originally developed to prevent seizures, but are widely prescribed off-label to treat pain. They include gabapentin (Neurontin) and pregabalin (Lyrica), as well as generic versions of the drugs.

Not only did co-prescribing with gabapentinoids increase, but the age of patients on long-term opioids also rose, from 52.5 years in 2015 to 60.5 in 2023. Nearly half of those patients (48.7%) are on Medicare. 

“Because older adults are at higher risk of adverse events from polypharmacy, the increased rates of coprescribing, particularly with gabapentinoids, raises additional safety concerns,”  said Thuy Nguyen, PhD, Assistant Professor of Health Management and Policy at the University of Michigan’s School of Public Health.

Nguyen and her colleagues' findings, published in a JAMA research letter, also document a steady decline in long-term opioid use, which coincides with federal and state guidelines that were imposed to limit opioid prescriptions.  

Between 2015 and 2023, the number of U.S. patients on long-term opioid therapy for at least 90 days fell from 5.6 million to about 4.2 million — a 24.3% decrease. 

At the same time, the average daily dose of opioids also declined, from 47.9 morphine milligram equivalents (MME) in 2015 to 38.6 MME in 2023 – which is in line with CDC guidelines that recommend caution when doses exceed 50 MME.

Researchers think more work is needed to reduce opioid use and to find alternative ways to relieve pain.

“With almost 5 million Americans on long-term prescription opioids for chronic pain, and likely millions more who are taking shorter courses of prescription opioids for acute pain, most clinicians are likely to care for someone using prescription opioids for pain, highlighting the pressing importance for investing in better treatment models for pain,” said senior author Pooja Lagisetty, MD, Associate Professor of Internal Medicine at the University of Michigan Medical School.

In addition to gabapentinoids, researchers tracked overlapping prescriptions for other controlled substances. They found that co-prescribing of long-term opioids with benzodiazepines declined from 43.8% in 2015 to 33.5% in 2023; while co-prescribing for stimulants rose from 5.9% to 6.7%.

In short, polypharmacy is relatively common with patients on long-term opioids, despite the known risks of combining certain drugs. 

Common side effects from gabapentin include brain fog, dizziness, weight gain, headache, fatigue, and anxiety. The drug has also been linked to a higher risk of dementia.

Those side effects may lead to a “prescribing cascade,” in which doctors mistakenly prescribe unnecessary medications to patients that cause even more side effects – never suspecting that gabapentin was the cause and they should consider discontinuing the drug.

In 2024, gabapentin was the fifth most prescribed drug in the U.S., with prescriptions nearly tripling since 2010. The number of patients prescribed gabapentin reached 15.5 million in 2024.

The off-label prescribing of gabapentin is legal and, in some cases, appropriate. But it has reached extreme levels, with studies estimating gabapentin is prescribed off-label up to 95% of the time.