Painful Choices About a Safe Space

By Cynthia Toussaint, PNN Columnist

It’s no secret. For me, there’s no better medicine than self-care.

To that point, I’m a proud member of my local YMCA. In fact, it’s been my ultimate safe-space for 15 years: around the block, accessible, a generous lap swimming pool, topped by a loving community of warm and caring people. A lot of perfect for someone who can’t walk a block due to Complex Regional Pain Syndrome, but can swim a mile.

To give back some, I’ve done quite a bit of fundraising to provide low-cost memberships for families in need, and landed one of the Y’s aquatic teachers a national ABC News print piece, the angle being the benefits of pool therapy for women in pain as I believe devotedly in the healing power of water.

All was going swimmingly, until COVID. When we returned in mid-2021, my heart sank when I spied a new member, Annie, who I sensed was going to be trouble with a capital T. What little lap swimming she did was overwhelmed by her excessive yelling and joke-telling mid-pool with the lifeguard.

Day after day, I became increasingly stressed while others rolled their eyes and donned ear plugs. To make matters worse, Annie soon blew past personal boundaries by jumping in on my conversations, often physically pulling friends away from me. My place of serenity was turning into a high-decibel scrum.      

CYNTHIA TOUSSAINT

It dawned on me that what was driving Annie’s aberrant behavior was a boatload of childhood trauma. She was deregulated and manic, showing earmarks of a deeply wounded woman. Annie flouted pool rules by wearing inappropriate, oversexualized swimwear (shorts and a braless t-shirt) with no cap for her long, black locks.

In one of the few encounters with Annie before things went south, she boasted about freezing her brother out, emphasizing all the legal folk he had to circumvent to get to her. Annie’s cackle as an exclamation point, her pure joy of hurting another person, was darkly disturbing.                     

One day, out of the blue, a deep freeze set in as Annie began avoiding me. This was terribly awkward, compounded by the Y pool and dressing room being an intimate place where everyone knows everyone’s business. I continued basic pleasantries until Annie yelled me down for doing so.

Next day, in an attempt to fix things, I asked Annie if I’d done something to offend her. Without looking my way, she briskly responded, “No, nothing’s wrong. We’re fine.” But I knew better.

Bad turned to worse when, at that point, Annie completely shut me out. It was as though I didn’t exist as she avoided eye contact altogether. This tactic was deeply uncomfortable and hurtful as she appeared to be in good standing, even sweet, with others. 

Due to Annie’s puzzling cruelty, I started dreading going to my “safe space.” My lower-body pain amp’d and my nervous system was in fight or flight mode before I’d head out to the Y. Even my anticipation the day prior was becoming unhealthy, and I often woke in the night with worry.

Because I couldn’t bear to lose my beloved pool and community, I went to a therapist whose assessment provided strong insight. She suspected Annie was “negatively transferring,” meaning that because I remind her of an abusive person in her childhood, she’s delusional about my power over her. My psychologist advised that this is a targeted psychotic process and, for safety sake, I swim elsewhere.  My close friends seconded that emotion. 

With heavy heart, I tried other Ys and fitness centers. In the end though, none of them worked because of my pain and limitations, e.g., I had to use my wheelchair to get to the pool, there were no exit stairs, and/or my partner and caregiver John couldn’t run necessary errands because we were far from home.

When I fearfully returned to my now toxic Y, John accompanied me in the pool to rehab an injury and offer support in the event of an encounter. Annie’s behavior immediately escalated when she spread a nasty rumor about me to a fellow swimmer who I adore. Zoe shared the gossip out of concern for my well-being, along with being disturbed by the grim energy now shrouding our community.

Before entering the pool the next day, Annie yelled at me twice and, for the first time, physically threatened me by raising her hand to my face. That was it. I went to member relations and made a thorough complaint. Luckily, Zoe, who’d witnessed the happenings, made one as well.

Fortunately, since the Y spoke to Annie, her behavior has simmered. While still avoiding conversation and eye contact, she’s not threatening me, though I’m aware her anger’s just below the surface. Better, but far from okay. What was once heavenly, now casts a pall.

If I was a fully functional person without high-impact pain, I’d have left this Y many moons ago and created a healthy community elsewhere. But because of limitations and specific needs, my only choice is to tolerate an unsafe, dysfunctional situation, to make the best of a bad.

Let’s face it. My choice was really no choice. And that’s the way it is with folk hammered by pain and disability. Pickings are slim and the best solutions are generally the ones that are physically do-able. This not only applies to our places of exercise and community, but also where we live, shop and work. Really, everything we do.   

But let’s not let a bully bury the lead. Come hell or high water, I’m continuing to swim, which is one of the best self-care cards I hold. And when it comes to wrangling with the pitfalls of pain and chronic illness, holding onto what health we can maintain and preserve, is always our best choice.               

Cynthia Toussaint is the founder and spokesperson at For Grace, a non-profit dedicated to bettering the lives of women in pain. She has lived with Complex Regional Pain Syndrome (CRPS) and multiple co-morbidities for four decades, and has been battling cancer since 2020. Cynthia is the author of “Battle for Grace: A Memoir of Pain, Redemption and Impossible Love.”

Living on False Hope

By Carol Levy, PNN Columnist

I live on false hope. I think hope is what keeps many of us afloat. And when the medical community tells you, “I have nothing left to offer you,” false hope is all there is.

And then I open my email, and there is a story in KevinMD, a medical site that I trust. It’s about using ultrasound as a treatment for pain. My heart soars with anticipation. Maybe, maybe this time, the answer has arrived.

The headline, “Ultrasound shows promise as new pain treatment, targeting a specific brain region,” sets off a specific area of my brain. I feel the false hope lifting and true hope taking its place.

And then I read the article.

Just like too many other studies I have read, this is not research that can be applicable to many people. The researchers only used a sample population of 23 people. That is just too small a number to extrapolate out to the larger pain community.

I have had many brain surgeries for my trigeminal neuralgia, so I'm not put off by a treatment that targets the brain. But the author of the article wonders if stimulating areas of the brain with ultrasound could be used for nefarious purposes, such as torture. 

I was going to do research to see what other new ideas and treatments are out there. Then I realized I didn’t really want to know, because most of the research doesn’t pan out or involves too few people to take it seriously.

I want to read about research involving enough participants that there is real hope in what they found. A study that uses a large number of people and with results so positive that it may be a realistic treatment option.

So far, I haven’t seen that. I know the pharmaceutical industry is working on non-opioid pain relievers, but I think the better way to go would be to find something that minimizes our pain. I'm afraid there may be no way to ever truly eradicate many painful conditions. 

Until I find a study involving hundreds or thousands of participants using a new pain treatment that actually works, is affordable, and has few side effects, I suppose false hope is better than none. 

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here. 

Does Netflix Trivialize Pain?

By Pat Anson, PNN Editor

Movies and TV shows have long been criticized for the way they depict women, minorities and religions -- either through sensationalism, stereotyped portrayals, or simply omission.

A new analysis of popular programs that aired on Netflix suggests that physical pain is also being ignored, trivialized, or presented in misleading ways.

Researchers in Canada and the UK looked at over a dozen movies and TV series that featured teenage characters. They found that the teens’ pain was almost always the result of violence or accidents – not common medical conditions such as migraine or menstruation. The characters often had minimal reactions to their own pain and observers had “an overwhelming lack of empathy” for them.   

“If we’re not showing the types of pain that adolescents might typically experience like back pain and menstrual pain, then we’re trivializing pain. We’re not doing a great job of enabling them to think about how to manage pain, how to talk about pain and how to show empathy when other people experience pain,” said lead author Abbie Jordan, PhD, a lecturer in the Department of Psychology and Centre for Pain Research at The University of Bath.

“This research matters because if every film and television series shows a boy being a ‘tough guy’ when they experience pain and a girl as a ‘damsel in distress’ in need of saving, they might think they have to be like that in real life. This depiction reinforces old-fashioned ideas about gender and is misleading."

Jordan and her colleagues watched programs such as Sex Education, Stranger Things and Enola Holmes, and found that viewers were exposed to an average of 10 incidents of pain every hour.

The two Netflix shows with the highest number of painful incidents were Outer Banks, a series about teens searching for a hidden treasure, and Spiderman: Homecoming, a movie about a young Peter Parker facing off against a new villain.

Violence (57%) was the most likely cause of pain on the Netflix shows, followed by everyday pain such as headaches (21%) and pain stemming from injuries (20%). Chronic pain or pain resulting from medical procedures were depicted less than one percent of the time.

“‘OUTER BANKS”

Researchers say the Netflix shows often reinforced sexist and patriarchal stereotypes. Boy characters were more likely to experience pain (77%) than girls (23%), and they were also more likely to be criticized or laughed at by other characters. Boys were often portrayed as heroic figures coming to the rescue, while girls were more emotional when reacting to pain.   

The plots and characters are all fictional, but researchers say adolescents watching at home are likely to mirror the behavior themselves.  

“Media is one of the most powerful engines of influence on children’s development and could be harnessed to address pain and suffering in the world. Stories matter. Fictional stories can matter more in some cases than real-life stories. So, let's create stories to reflect the world we want to see: A humane, diverse, inclusive, equitable, compassionate, and caring world,” says co-author Melanie Noel, PhD, an Associate Professor of Clinical Psychology at the University of Calgary.

“I want Netflix to take this seriously and get excited and inspired to directly influence millions of children around the world. They have a monumental opportunity to influence the compassion and humanity we see in our children and our future world.”

The study findings, published in the journal PAIN, echo a previous study that showed pain was trivialized for even younger children (aged 4-6 years). That study also showed that chronic pain in childhood and adolescence was rarely portrayed in popular media.

Keeping Hope Alive

By Mia Maysack, PNN Columnist

In 2022, I was fortunate enough to receive the International Pain Foundation's “Hero of Hope”' award for patient advocacy. I felt and still feel remarkably honored for the recognition, although I am not motivated by any accolade or prestige. I fight for those who can't. I use my voice so others can be heard.

As a patient advocate, I’ve learned the absolute most important thing that I can do is rescue myself – repeatedly. If I don't make it and I'm no longer here, what good can I do or offer to anybody else?

Recently, I've struggled immensely. There have been moments that haven't felt survivable. I sought support, reached out for help, attended therapy, and tried endless lifestyle approaches with little to no progress in how I feel.

It is important for me to express this publicly because I want to drive the point home: An optimistic perspective alone is not enough for survival. You can seek out the bright side, acknowledge how things could always be worse, recognize all your blessings, and be grateful for them -- yet still suffer immensely.

I reached out to someone to vent some of this, in what I'd hoped would be a receptive and safe space. But I was quickly reminded of the extent to which people simply don't know how to navigate others' hardships or struggles.

“I'm having a rough time,” I said.

“Maybe you need to go to counseling,” they replied.

“I tried that again recently. But my medical trauma is extensive. It did not help and actually worsened things for me."

[insert awkward silence here]

"Ordinarily,” I continued, “I’d pour myself into other causes, things, and people. That usually helps, but I am struggling with energy and motivation.”

“Sounds like depression,” they said.

“Depression isn’t new to me,” I explained. “Coping with daily ailments isn’t something that everyone can bear. Depression in these instances occurs by default. It’s an underlying current underneath the symptoms, constantly demanding my attention and effort to accommodate and manage it.”

"I think you need to pour into yourself,” was their reply.

"I have, extensively. But it is as though I'm a cracked cup and it all leaks out,” I said.

[insert another awkward silence]

At this point, I can sense they are uncomfortable, so I rush to ease their pain as mine intensifies. And I’m reminded how there’s just about nowhere for us to turn where we can be adequately received or understood.

“But I will figure it out, I always do,” I declared, tears running down my cheeks.

"Now that's the spirit!” they proclaimed.

I’ve always possessed “spirit” but sometimes it’s not enough. This is why I have such a profound empathy for those who idealize or even follow through on ending life. I see and understand how and to what extent we reach out for help, yet I'm repeatedly reminded that we're ultimately left on our own -- by each other, by our systems, and by society as a whole.

No one wants you to end your existence, yet almost nothing and no one is there to contribute meaningfully to your quality of life.

In observation of this and because I strongly believe in cultivating solutions -- as opposed to fixating on problems – I’m supporting efforts by the American Foundation for Suicide Prevention to raise awareness and talk about how we can prevent suicide and increase access to mental healthcare.

The darkness in me honors yours. It's not only okay, but profoundly necessary to allow that part of ourselves to exist out loud. It’s the only way through to the light. 

I imagine a future where we don't have to beg and plead for basic human needs, and we’re no longer alone in attempting to figure it all out.  This vision keeps me going and keeps the fire of hope alive.

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. She is a healthcare reform advocate and founder of Keepin’ Our Heads Up, a support network; Peace & Love, a life coaching practice; and Still We Rise, an organization that seeks to alleviate pain of all kinds.

For anyone thinking about suicide, please contact the 988 Suicide & Crisis Lifeline, available online, via chat, or by dialing “988.”  A comprehensive set of resources can also be found at this link.

Naltrexone Shortage Disrupts Addiction Treatment

By Pat Anson, PNN Editor

An inexpensive drug used to manage chronic pain and treat substance use disorders has joined the growing list of medications that are in short supply in the United States.

The Food and Drug Administration and the American Society of Health-System Pharmacists (ASHP) both recently added naltrexone tablets to their drug shortage lists. It’s not clear what caused the shortage, but the ASHP says “there is insufficient supply for usual ordering.”  

Naltrexone is FDA-approved to treat both alcohol and opioid use disorder, and is also used off-label in low doses to treat some chronic pain conditions.

In 50mg doses, naltrexone blocks opioid receptors in the brain and reduces cravings for opiates or alcohol. But in smaller doses of 5mg or less, patients have found low-dose naltrexone (LDN) to be an effective pain reliever for interstitial cystitis, Ehlers-Danlos syndrome, fibromyalgia, and other painful conditions.

LDN advocates believe the drug modulates the immune system, reduces inflammation and stimulates the production of endorphins, the body's natural painkiller. Because it is an opioid antagonist, naltrexone should not be taken with opioid medication.

So far, the shortage only affects 50mg naltrexone tablets. Pain patients usually obtain LDN by prescription from compounding pharmacies, which make the low dose versions in-house.

Several drug makers are reporting short supplies of 50mg tablets, including Accord Healthcare, Major, Elite Laboratories, SpecGx, Sun Pharma, Tagi Pharma, and Avet Pharmaceuticals. The companies didn’t provide the ASHP with a reason for the shortage, but said the tablets are on back order and would be released when they become available.    

The naltrexone shortage comes at an inopportune time, as more people abused alcohol and other substances during the pandemic and sought treatment. The drug that helps them stay sober is now hard to get.

"People are coming in with more cravings," Dr. Aviva Zohar, an addiction medicine provider, told Philly Voice. "Even the feeling of, 'I don't know when my medicine is coming in,' is a huge struggle. It's horrific (and) causing a lot of stress.”

To make up for the shortage, some providers are giving patients Vivitrol, an injectable, extended-release formulation of naltrexone taken once a month. A single Vivitrol injection costs about $1,700, while a month’s supply of 50mg naltrexone tablets costs about $48.

The cheap price of naltrexone may be responsible for the shortage. Most drugs in short supply are low-cost generics with slim profit margins. Some manufacturers have reduced or stopped making generics because they’re not worth the cost of production or the risk of litigation.   

Three generic opioids commonly taken for pain — immediate-release oxycodone, oxycodone-acetaminophen, and hydrocodone-acetaminophen tablets — have been on the ASHP shortage list for nearly a year, with no end in sight.

Where is CDC’s Guidance About Its Opioid Guideline?

By Carol Levy, PNN Columnist

By happenstance, I recently came across the CDC's 2022 revised opioid prescribing guideline. Too many doctors and states saw the agency’s original 2016 guideline as being written in stone -- not the voluntary set of recommendations they were intended to be.

To their credit, the CDC tried to address that misconception in its updated guideline:

“Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient is paramount.”

The CDC also acknowledged the damage done by its 2016 guideline, when many pain patients were forcibly tapered or cutoff from opioids, regardless of their diagnosis or condition. 

Some patients were abandoned by doctors who no longer wanted to risk going to prison for prescribing opioids. Other physicians retired or closed their offices, sometimes without warning. And several states passed legislation limiting how many days initial opioid prescriptions could be written for.

It is always hard to put the genie back in the bottle. Two years after the revised guideline was released, about 90% of patients still have trouble getting their opioid prescriptions filled at pharmacies. Others have to fight with their insurance company to get opioid medication covered.

Patients are still being forced into withdrawal and disability, despite a history of taking opioids safely and responsibly. Some will have to leave jobs they could only perform with the help of opioids. Others can’t play with their kids, walk the dog or even get out of bed, because they are no longer able to get the medication that helped them lead relatively normal lives.

It should not have taken CDC six years to revise the opioid guideline, to make clear that they were only recommendations and never a mandate.

Is there a way to undo the damage? For the doctors who closed their practices or stopped treating pain, it is probably too late. For the patients who chose suicide because they could no longer get opioids, it is definitely too late

But maybe, just maybe, we can persuade doctors, pharmacists, lawmakers and insurers to take another look at the revised opioid guideline and convince them they are out of line.

It would be helpful if the CDC joined in an effort to fix the mess that it helped create.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here. 

How Does Kratom Relieve Pain?

By Dr. C. Michael White, University of Connecticut

Kratom doesn’t contain just one active ingredient; rather, it is made up of many substances that induce effects in the body. This is very common for natural products, since the cells of the plant make a variety of chemicals for different purposes.

When the body is experiencing pain, it releases hormones called endorphins that stimulate opioid receptors to mildly reduce the transmission of local pain sensations to the brain. This same process also causes the release of the neurotransmitter dopamine, inducing a feeling of pleasure to neutralize the pain.

Traditional opioids, like morphine and fentanyl, stimulate these same receptors to such a degree that they more potently numb pain, induce a euphoric feeling that can lead to addiction, and suppress the drive to breathe, which can result in death.

One of the key constituents of kratom is an organic compound called mitragynine. It interacts with the same opioid receptors as morphine and fentanyl, but does not recruit the beta-arrestin-2 (the reason for breathing suppression). As a result, kratom can provide pain relief with a lower risk of slowed or stopped breathing compared to traditional opioids.

Kratom also contains a small amount of 7-hydroxymitragynine, which is thought to more potently stimulate opioid receptors, leading to a greater risk of opioidlike adverse events.

One of the risks associated with kratom use is that products can differ dramatically in the doses of 7-hydroxymitragynine. In other words, one kratom product could be more dangerous than another. When kratom is used in high doses, it can lead to seizures and other issues. Since kratom products are not FDA-regulated, there is no uniformity to the products.

Is Kratom Legal?

Kratom’s current legal status is complicated. Kratom is not a prescription or over-the-counter drug, and while it is derived from a plant, it does not meet the FDA’s definition of a dietary supplement, food or food additive.

Natural products marketed in the U.S. before Oct. 15, 1994, were grandfathered in under the FDA’s list of dietary supplements. But since kratom came on the market later, the FDA would have to find, based on a history of use or other evidence, that when used under the conditions recommended or suggested in the labeling, the natural product can reasonably be expected to be safe – like the FDA does for all new dietary supplement ingredients.

In 2016, in response to increasing calls to poison control centers, the Drug Enforcement Administration sought to ban kratom by making it a Schedule I drug. This means the agency felt it had no currently accepted medical use and a high potential for abuse. But backlash from the public and support from congressional members made the agency postpone a final decision. So kratom is currently listed as a “drug of concern.”

Seven states and some counties have banned the sale of kratom. But in 2023, the U.S. House and Senate proposed legislation to prevent the FDA from regulating kratom more stringently than they do a dietary supplement or a food additive, in order to keep the product accessible to consumers.

Kratom Research Lacking

A 2024 literature review concluded that there are no clinical trials evaluating the effects of kratom on chronic pain management.

Research on acute pain tolerance in people is limited to a 2020 study that found participants who took a dose of kratom could endure immersion of their arms in an ice bath for significantly longer than those who did not take a dose of kratom. However, this study was conducted on chronic kratom users, and their pain tolerance before they took their dose for that study was much lower compared to that of non-kratom users in other studies. This suggests that chronic kratom use is lowering people’s background pain tolerance.

This is similar to another study showing that when people tried to stop taking kratom after chronic use, they experienced significant pain throughout their body. This increased sensitivity and reactivity to pain, called hyperalgesia, also occurs with traditional opioids and is one of the reasons why people who use them chronically find it so difficult to get off them.

Taken together, these studies suggest caution before starting kratom as a treatment for chronic pain, especially if safer methods such as acetaminophen, icing and heating, and physical therapy can suffice.

Some people also claim that kratom could be a natural treatment for withdrawal and other effects of opioid use disorder, the clinical term for opioid dependence.

A few methodologically weak studies reported that participants were able to reduce or stop their use of traditional opioids and that kratom reduced the severity of opioid withdrawal symptoms. These include diarrhea, runny nose and eyes, shaking, fast heartbeat and anxiety.

However, there are no clinical trials comparing kratom to methadone, buprenorphine or naltrexone, the FDA-approved treatment options for opioid use disorder. So if patients have access to traditional FDA-approved therapies, these are the safest and best place to start.

If traditional options are not effective or patients cannot access them due to financial or logistical barriers, kratom may be a potential alternative to illegal opioid products, but it is certainly not risk free. Speaking with a health care professional is critical before making treatment decisions.

C. Michael White, PharmD, is a Distinguished Professor and Chair of the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy. He has been studying the science behind kratom to help consumers better understand its potential benefits and adverse effects.

White’s research work has been funded by the Agency for Healthcare Research and Quality (AHRQ), Donaghue Foundation, Pfeiffer Foundation, and American College of Clinical Pharmacy.

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

There’s an App for That

By Barby Ingle, PNN Columnist

Have you noticed that many healthcare companies, medical providers and support groups now have apps for patients?

A recent survey found that about 40% of U.S. adults use healthcare apps and 35% use wearable devices to track their fitness, sleep, diet and other health-related activities. The market for healthcare apps was estimated to be worth $10 billion in 2022 and is expected to grow to $41 billion by 2030.

There are some great “patient-centric” apps. Patient-centric or "person-centered care" means the technology approaches healthcare in a manner that directly involves patients. I have used apps to track my eating, hydration, movement, medications, sleep time and more. Some apps can also help you organize your medical care and recognize issues or changes needed in your medical records.

Patient Portal Apps

The patient portal apps I suggest below are typically set up by the provider, and then the patient can log in and check their records, set up appointments, and access other resources. There are many choices for medical providers to use for patient portals, but these seem to be the ones used the most:  

• HealthTap: This telehealth app connect patients with primary care doctors for online care. Patients can use HealthTap for checkups, prescriptions, lab tests, treatment plans, and specialist referrals. They take patients with and without insurance. Costs start as low as $15 a month, making this affordable for even those without insurance.

• MyChart: This one is my personal favorites and I use it often, as do most of my providers in Arizona. I used MyChart this morning to check on my appointments and to pay an outstanding balance. This app can also give friends and family access to your medical records if you choose. It is excellent for parents to take care of their children and other family members from one account. It will store your medical and lab records, and even some images from MRIs, x-rays, etc. There is transparency in who has accessed your medical records, so you will know which providers have this information.

• FollowMyHealth: This app allows patients to access their medical records, request prescriptions, schedule appointments, and send messages to medical providers and staff. FollowMyHealth can also connect with medical devices such as glucose, heart and blood pressure monitors, and digital scales.

Apps for General Health 

There are many apps for overall general health, with the most popular ones being Headspace, Talkspace, Doctor on Demand, Sleep Cycle, My Fitness Pal, Fooducate, Teladoc, Fitbit, Noom, mySugr, and WebMD.  I have used many of them, but I will focus on my top three:  

• Fitbit: I never considered using a Fitbit watch until I won one from the WEGO Health Awards (now Health Union). I quickly got more involved in tracking my life by using the device. I loved how it could track my movement, sleep and stress levels, and allowed me to put in notes on things such as hydration, migraines and gastrointestinal challenges. I also like Fitbit’s PurePulse, which tracks blood flow and heart rate. FitBit devices range from $80 to $300 each.

• Noom: This is a subscription-based app that helps users track their food intake and exercise. Noom uses psychology to help users develop healthy eating and physical activity habits to lose weight. It takes a lot of dedication and focus to use Noom successfully. I lost over 20 pounds using it. I am not very active physically, and they considered that in developing an individualized program for me as a chronic pain and rare disease patient. The app encourages you to think about food differently and change your eating habits so your body works better for you. The average subscription is $60 monthly.  

• Sleep Cycle: This app tracks and analyzes your sleeping patterns. It was helpful for me to take sleep data from the app to my primary care provider so he could better understand why I have trouble sleeping. I do not sleep consistently through the night, especially on high-pain days. It’s a good tool to figure out why you are struggling to sleep and how pain is affecting your internal clock or waking you up. The Sleep Cycle app is free to download, but a premium subscription costs $40 per year. I used the free accessible portions of the app at no cost.

Chronic Pain Apps

There are many apps that can help a patient track their pain levels, types of pain, whether treatment options are helping or hurting, and more. I used to do this the old-fashioned way with a journal, but having digital data to break it down scientifically for my providers was helpful once I started using pain-tracking apps. I have tried a few and heard others find them helpful as well.  

• PainChek: This app uses artificial intelligence (AI) and facial expressions to assess pain in people who cannot reliably communicate their pain levels, such as those with dementia or young children. PainChek uses a smartphone camera to analyze a person's face. The AI system then automatically recognizes and documents facial movements that indicate pain. It’s more of an objective tool for me, since I can speak about my pain, but for those who are voiceless, it could help their daily life and individualize their care. 

• Vivify:  This is a 28-day program for people with chronic back or neck pain that includes pain education, meditation, exercises, and guided walks through an app or website connection. Vivify also monitors patients remotely, allowing providers to create and manage wellness programs for their patients. Although the goal is to “overcome or remove chronic pain entirely,” I see this app as more of a tool for people to assist in their daily activities and motivate them to move.

• My Pain Diary:  This pain-tracking app reminds me of when I used to manually keep track of my pain before apps were available. It gives patients a way to document and track their pain triggers and symptoms. You can also use the data to print detailed reports that are easy to share with your providers. I like the color-coded calendar, graphs and searchable history. The app looks at the data and sees trends you may not notice yourself. The Gold Edition of My Pain Diary costs just $5.

• PainScale: This app was recommended to me by a friend. PainScale is made by Boston Scientific and helps users track their pain, suggests treatment options, and generate reports to providers. It can also provide information from the Mayo Clinic, WebMD and other trusted pain resources to help patients manage chronic pain triggers. This app is free to download.  

The apps mentioned above are some of the most used and trusted apps by patients and providers. Patient-centric apps have become an essential part of the healthcare industry. As technology and AI continue to advance, we can expect to see more of these innovative patient apps in the future.

Barby Ingle is a reality TV personality living with multiple rare and chronic diseases. She is a chronic pain educator, patient advocate, motivational speaker, and the founder and former President of the International Pain Foundation. You can follow Barby at www.barbyingle.com. 

Researchers Find No Clear Link Between Weather and Pain

By Pat Anson, PNN Editor

The Greek philosopher Hippocrates in 400 B.C was one of the first to suggest that changes in the weather can worsen pain conditions. Since then, a large body of folklore and personal anecdotes have reinforced that belief – although the science behind it is mixed, at best.

A large new systematic review – a study of studies – is once again throwing cold water on the common belief that chilly, rainy weather can trigger muscle and joint pain.

“There is a common perception that there is an increase of musculoskeletal symptoms such as back pain, hip pain or arthritic symptoms during certain types of weather,” said lead author Manuela Ferreira, PhD, Principal Research Fellow at the Institute of Bone and Joint Research, the University of Sydney. “Our research challenges that thinking by showing that come rain or shine, weather has no direct link with most of our aches and pains.”

Ferreira and her colleagues started out by reviewing over 1,100 studies involving weather and pain, rejecting most because they were small or poor quality. Only eleven studies met their criteria for inclusion. An analysis of those studies found no sign that humidity, air pressure, temperature or precipitation significantly raise the risk of a pain flare from rheumatoid arthritis or low back and knee pain.

But they did find evidence that a combination of warm temperatures and low humidity is associated with a higher risk of a pain flare in people with gout, a form of arthritis that causes severe pain and swelling in the joints of the feet and lower legs.

The study was published in the journal Seminars in Arthritis and Rheumatism.

“Although changes in weather conditions are frequently described by patients as triggers for pain and other symptom exacerbation, they do not appear to be significant risks for knee, hip, low back pain, or headache exacerbation, and have a small influence in symptom exacerbation of gout disease,” researchers concluded.

A 2017 study in Australia had similar findings, showing no association between back pain and changes in temperature, humidity, air pressure, wind direction or precipitation. Damp weather appeared to make people more aware of their pain, but the symptoms disappeared as soon as the sun came out – suggesting there’s a psychological cause.

Another recent study in the UK found only a modest association between weather and pain. The Cloudy with a Chance of Pain study collected data from 10,500 people who recorded their daily pain levels on a smartphone app for over a year. The GPS location of their phones was then compared to local weather conditions. Participants reported feeling more pain on days with low barometric pressure – and the wet and windy weather that usually comes with it.

Hippocrates may or may not have a point, but researchers say people in pain would be better off paying less attention to the weather and more on getting treatment.

“When seeking pain prevention and relief, both patients and clinicians should focus on how to best manage the condition, including weight management and exercises, and not focus on the weather and let it influence treatment,” says Ferreira.

My Story: Kratom Helps Treat Fibromyalgia

By Jim Hunter

The following narrative is not meant as medical advice. I am not a medical professional. I am simply relating my own experience.

Most of my adult life I have suffered from a variety of symptoms that were never diagnosed by any of the doctors I saw. Eventually, I became aware that these symptoms seemed to be consistent with the list of symptoms that appear under the heading of fibromyalgia. The most conspicuous symptom was painful muscles all over my body. The one symptom often associated with fibromyalgia that I did not have was insomnia.

Do I actually have fibromyalgia? I don’t know. What I have is an assortment of symptoms that, when compared to a checklist for fibromyalgia, make it look pretty close to that mysterious affliction.  Since there seemed to be no reliable objective signs of fibromyalgia, and I seemed to have almost all the subjective ones, it seemed reasonable to diagnose myself as having it.

I treated it for a long time (years) by taking more ibuprofen than is recommended for pain relief. The ibuprofen did help some, so I took more than I should have. I am not recommending anyone else do this, but I didn’t see an alternative at the time.

Then I discovered kratom. I don’t recall how I happened to run into it. But I discovered that when I took small doses of kratom regularly throughout the day, the fibromyalgia symptoms simply went away. Above all else, I didn’t hurt anymore.

Kratom even cleared up the stomach and intestinal problems. That was a surprise. I figured that anything that tasted as harsh as kratom wouldn’t help my stomach, but it did.

As long as I didn’t take too much kratom, I didn’t have any loopy feelings. I didn’t mind the slightly euphoric sensations it sometimes generated, but I learned to fine tune it so I didn’t experience that. It simply took away all the muscle aches and pains, fatigue and stomach problems. I felt normal again and was productive.

A Complication

That happy state facilitated by kratom lasted for years. But then I ran into a glitch. I got an inguinal hernia that strangulated. The surgeon was able to push it back in, but that was clearly just a temporary solution. Clearly, I needed surgery. One can die a nasty death from a strangulated hernia.

There was a complication about whether the local hospital could do the operation or whether my condition would require a bigger hospital with an intensive care unit. They eventually agreed on the local hospital (which is what I wanted), but the only glitch was that I had barely mentioned my use of kratom and sort of played it down. I was pretty sure most of the professionals in the medical field would be suspicious of it. Kratom is, after all, reported to have a mild opioid-like effect.

I’m 83 years old. I was perfectly willing to take any reasonable risk in surgery. I am not going to live forever, and I suspect that the end will not be decades off.

But I did feel obligated to the hospital that agreed to do the operation. I had to either level with them about the kratom I was taking or get off it. I knew that if I explained everything in detail, it would raise questions again about who should do the operation and when. I imagined there might be an issue with a possible interaction of kratom with anesthesia.

I decided to get off the kratom, at least long enough for the operation. There might be some withdrawal symptoms, but they were described in the literature as mild to moderate and short lived.

So, I began phasing out my kratom, for which I calculated I needed about two weeks. Two weeks stretched into three and then four. I was feeling horrible – considerably worse than what was described as kratom withdrawal. This was neither short, nor mild or moderate.

Then my wife put her finger on the problem. The symptoms for withdrawal and fibromyalgia, though similar, were not exactly the same. I was experiencing less nausea, but more pain. The fibromyalgia was back in full force. At that point, as I saw it, I had no choice. I took a little bit of kratom once again and felt fine, except for the hernia.

It was while on the minimal dose of kratom needed for the fibromyalgia that I went in for surgery. After the operation, the anesthesiologist reported that her part of the operation went well. I was relieved. However, another problem emerged. An expected two or three-hour operation with laparoscopic surgery turned into a seven-hour ordeal.

I still cannot visualize the exact nature of the unexpected problem the surgeon encountered. Apparently, my bladder was drawn into and tangled up with the hernia. The surgeon, who had done this operation thousands of times, had never seen it before and nobody else had heard of it.

The surgeon was able to unravel the problem and repair the hernia. This led to yet another problem. I had expected to be in the hospital most of one day, but they kept me in the hospital overnight and, as far as I knew, might keep me hospitalized even longer.

By three in the morning, I was beginning to experience moderate to severe pain. The medication given to me by the night nurse didn’t touch the pain. I realized I had no choice. I had to confess my sin -- the incomplete and unsatisfactory way I told them about the kratom -- and plead for mercy.

I called in the night nurse and explained the whole thing. She was very nice about it, let the head nurse know right away, and notified the surgeon as soon as he arrived in the morning.

To make a long story short, arrangements were made for me to be released from the hospital so I could resume my regime of small doses of kratom.

I had lots of minor aches and pains from being worked on so hard and so long during the operation, while in an awkward position. They had raised my legs a considerable angle to the ground, expanded the inner cavities of my body with CO2, and done God knows what to separate my scrotum, testicles and whatever else from the hernia. But with some Aleve, these were now manageable pains. 

Do I have any advice? Not really. The nearest thing I can offer is to say that, should the situation rise again, I would simply tell the medical people about my dependence on kratom. And if they insisted that I get off it before they would do the surgery, I would not have the surgery done.

Jim Hunter lives in Maine. He is a retired social worker.

Do you have a “My Story” to share?

Pain News Network invites other readers to share their experiences about living with pain and treating it.

Send your stories to editor@painnewsnetwork.org.

A Guardian Angel Stronger Than Pain

By Cynthia Toussaint, PNN Columnist

What I’m going to write about I can’t fully explain. There was a time when I would have been skeptical of my own forthcoming words. 

But here goes…

I’m certain that I’m in touch with another plain of existence due to my pain. To be precise, it’s a person I deeply love, a person I was never blessed to meet.

My aunt Grace has always been bigger than life to me, an angel who I named my work for. Like me, she was in the vortex of monumental generational trauma, the bread and butter of our family.

Despite my grandmother disowning Grace, her oldest daughter, then having her only other child, my mother, kidnapped, and then her ex-husband, my grandfather, committed, Grace managed to keep her feet planted on the ground.

With grit and dogged determination, she ran Grandpa’s dairy farm, regularly brought food to my mother, who was being starved by my grandmother, and eventually got her father out of the asylum. That’s a lot on one pair of shoulders.

Grace paid the ultimate price for her goodness in the jaws of trauma when she died from leukemia at age 20 in 1947. I’ve always been compared to my sweet aunt, and even repeated the familial illness pattern when I got Complex Regional Pain Syndrome at the same age, ending my life in a different way.

When I was diagnosed with aggressive breast cancer in 2019 and told by my doctors that the toll of fixing my dysfunctional family was the cause of my cancer and decades of pain, I brought Grace into my daily rituals and meditations for comfort. I was in treatment hell, and her essence was safe and loving and healing. With time, I discovered that Grace was my guardian angel.

When I brought this seemingly illogical ritual up with a respected integrative medicine colleague, he advised that “Ancestral Healing” is a real thing, something Native American people have done for millennia. He went on to share, “You instinctively knew to go there, Cynthia, because healing their trauma will heal your own.”

Over the last year, my daily conversations with Grace became so intense, I began asking her to visit me at my condo. The love I felt for her was profound and reciprocated so strongly, I just had to have her near.

You see, 2023 was the worst year of my life. After fighting a cancer recurrence, complications left me in the hospital near death. Then I had ever-piling pain problems seemingly signed, sealed and delivered from a dark realm. This led to crushing isolation compounded by COVID protocols, as I feared its long version would end me. I desperately needed my angel. 

This is when things got inexplicable, straining the boundaries of human logic and reason.

It started dead of night Christmas morning. My partner, John, and I have a tradition of keeping a small, faux tree in our bedroom, and this year we added a ballerina snow-globe to our light show.

Somehow, though one ran on battery and the other via cord, they both turned off while we slept. After checking them, we turned them back on, only to witness them go off a second time simultaneously later that morning. Separate power sources, no timers, no condo power outage.

The first time was beyond baffling, the second time I just knew. Grace had accepted my invitation. Both light show objects went off as many times as I could turn them back on during the season, and it felt loving and magical to know Grace was with me.

During this time, John recalled an incident shortly before Christmas. He was in our condo plaza giving our kitty some outdoor time, when he distinctly heard a friendly young woman say, “Hello, John.” The weird part was that no one was there. He only later connected the dots.

When the dreaded day came to take Christmas decor down, I sobbed and John’s eyes welled. It felt like we were saying goodbye to Grace until next year. But the “miracles” kept rolling.

That night, to curb our loss, I put up a large butterfly nightlight (run by batteries) given to me by a close girlfriend for my New Year’s Eve birthday. You guessed it. The next morning it was off.  Then the next, and the next. No timer, even changed the batteries. As of this writing, my butterfly goes off up to five times a night.

Other mystical things have happened, too numerous to mention, though they include a tree-top vintage angel, another vocal communication from a young woman and the number 1111, which I’ve learned signifies the nearness of a guardian angel. I still speak intimately to Grace every day during my Ancestral Healing work and have no doubt she salved me through the worst year of my life. You see, Grace is stronger than pain.

What do I make of all of this? I asked Grace to come, and she did. Every day I ask her to come again, and she does. I think she’s made herself known because I was in the right place and space to receive her love. I needed her like no other time.

And having her here, watching over me, comforting me, guiding me, eases my body and soul. I feel blessed, like I’m absorbed in a healing light of well-being. I’ve gone from a life of illness and desperation to one of wellness and gratitude. I’m even pursuing passions I’d let go of for far too long. 

I’ve come to believe that the universe bestows other-worldly gifts upon those who experience great loss. I also believe we women in pain are more sensitive than others, which is, in part, why we have pain. But that sensitivity, that portal if you will, can bring us blessings more powerful than pain - if we are prepared to receive and believe.

He, she, it, they are ready to help, to guide, to ease. Seek the sacred and be open to its grace.

Cynthia Toussaint is the founder and spokesperson at For Grace, a non-profit dedicated to bettering the lives of women in pain. She has lived with Complex Regional Pain Syndrome (CRPS) and multiple co-morbidities for four decades, and has been battling cancer since 2020. Cynthia is the author of “Battle for Grace: A Memoir of Pain, Redemption and Impossible Love.”

A Pained Life: Setting the Record Straight

By Carol Levy, PNN Columnist

Decades ago, my pain management doctor suggested that my family doctor write my codeine prescriptions. “Dr. Feld” had no problem doing so.

The last time that I saw Dr. Feld and asked for the prescription, he had me sign the opioid consent form and provide a urine sample. Then he called in the prescription to my pharmacy. No muss, no fuss.

Dr. Feld just retired, so I saw one of the new doctors in the practice. I was there for another reason but asked, “As long as I'm here, can you call in the codeine prescription?”

To my surprise, the new doctor said, “Yes, but I will only give you 30 milligrams, not the 60.”

“Dr. Feld has been giving me 60 milligrams for years.”

“Well, I won't. I'll only give you half the dosage.”

This was the first time the new doctor had seen me, so he knew little about me or my diagnosis. There were no questions about my level of pain, when I took the codeine, or why had I been taking it less often. Nothing. He decided I was going to get less and reality didn't matter. 

This jumping to conclusions seems to be pervasive. I had neuropsychological testing a few weeks ago. I was having some issues with recalling words and wanted to be assured all was well with my cognitive abilities.

When I received a copy of the report, I was upset. The doctor had couched many of the results in his preconceived notions about me, rather than reality. Some of it could have easily been rectified in the follow-up appointment, if he had bothered to ask. He could have asked why I seemed anxious throughout the testing or if I was depressed. Instead, he drew his own conclusions.

Missing from the report was the fact that I had to stop at one point during the test due to the pain. When I told the tester that I needed to take a pain pill, she told me they didn't want me to do that.

So yes, I was anxious for the rest of the test, not because I had anxiety but because I had pain and knew that each additional part of the test could well make the pain worse.

The depression he thought he found was in response to questions about my life circumstances. I checked yes to “Do you feel isolated?” and “I do not go out much.” That is my life circumstance, because of the pain. 

Understandably, many doctors are afraid to give us the opioids we have been on for years or to give us the same dosages. They’re afraid of the FDA. But I am also finding, in my singular experience, that it may be because they just don't care about our circumstances, our pain or the benefits that opioids provide, allowing many of us to have fuller lives.

It is not acceptable when our medical records contain falsehoods that are based on preconceived notions or the laziness of those who examine us.

When I went to the online portal to see my medical records, I noticed the doctor wrote about tests and exams he didn't do. The results for them were patently false, indicating I could do things like move my neck fully, which I am incapable of doing. I contacted him through the portal, telling him what he wrote was wrong. To his credit, he changed it.

At first, I didn't like the idea of a portal and too much personal information being online, even if it was behind a firewall. But now I find it is an excellent instrument for seeing if the doctor, nurse, or tester posted accurate results and if my records contain falsehoods.

We don't have a lot of power when it comes to what is put in our medical records, what is ignored, or flat out wrong. I used to think getting my records when they were on paper was not worth the effort, because there was no way to set the record straight. But now that I can read the reports online, I fell like I have been empowered to correct them.

We must take back as much power as we can. Take a moment and check your medical records. And, if necessary, tell them what they got wrong. 

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

Most Americans and Canadians Use OTC Drugs and Self-Care for Pain Relief

By Pat Anson, PNN Editor

Most Americans and Canadians who experience pain prefer over-the-counter drugs, exercise and bed rest over prescription pain medication, according to a large new survey. A surprising number of respondents said they do nothing or simply accept their pain.  

The online survey, led by a research team at Ontario’s Western University, asked over 4,100 adults in 2020 what types of treatment, medication or self-care methods they use to deal with or prevent pain. Respondents were given ten different pain management techniques to choose from.

The survey findings, published in the journal Innovation in Aging, show that most people use a combination of methods for pain relief, along with a healthy dose of stoicism. Over half said they use OTC pain relievers, often in combination with self-care techniques such as exercise, bed rest or physical therapy.

Over 41% selected “just live with pain” and 10% chose “do nothing” – which essentially amounts to pain acceptance.

Only one in four (24%) said they use prescription pain medication. Not surprisingly, respondents who said they had high pain levels were over four times as likely to use a prescription drug  

SOURCE: INNOVATION IN AGING

The responses from Americans and Canadians were similar, with one notable exception. Americans were twice as likely than Canadians to turn to alcohol to dull their pain, with just under 4% of Canadians using alcohol as a pain management strategy, compared to almost 8% in the U.S. Alcohol use jumped to 21% for those with the highest levels of pain in both countries.

"Our research shows that using alcohol to treat pain is somewhat common, unfortunately. Previous research has shown that is not only ineffective at treating pain, but it can actually be counterproductive," said lead author Anna Zajacova, PhD, a demographer and sociology professor at Western University. "Our study also indicates that there is likely a lot of unmet need for better treatment options for people to manage their pain."

Zajacova and her colleagues noted that high alcohol use in the U.S. may be a reflection of more limited access to healthcare than in Canada, which has a national health system.

"What we learned from this survey is that people aren't necessarily just visiting their doctor to manage their pain, and it's important to understand the non-medical and non-pharmacological strategies that people are using, for better or for worse," said Zajacova.

A major weakness of the study, which the authors acknowledge, is that they did not differentiate between acute, short-term pain and chronic pain. They also didn’t ask if the prescription pain medication used was an opioid or non-opioid.

Why We Need to Study Suicides After Opioid Tapering

By Stefan G. Kertesz, MD

How can we understand and prevent the suicides of patients in the wake of nationwide reductions in opioid prescribing?

Answering that question is the passion and commitment of our research team at the University of Alabama at Birmingham School of Medicine. Our study’s name, “CSI: OPIOIDs,” stands for “Clinical Context of Suicide Following Opioid Transitions.” Let me tell you why we are doing this work, what we do, and how you can help.

Opioid prescribing in the US started falling in 2012, after a decade of steady increases. The original run-up in prescribing was far from careful and a judicious correction was needed. A judicious correction, however, is not what happened. Instead, opioid prescriptions fell, rapidly, to levels lower than those seen in 2000. It may require a book to understand how prescribers swung so easily from one extreme to another.

For the 5 to 9 million patients who were taking prescription opioids long-term, reductions and stoppages were often rapid, according studies in the US and Canada. In one Medicare study, 81% of long-term opioid discontinuations were abrupt, often leaving patients in withdrawal and uncontrolled pain.

Prescription opioid reductions are not always good, and not always bad. For some patients, modest reductions are achievable without evident harm, especially if a reduction is what the patient wants to achieve. For others, the outcomes appear to be harmful. Several who serve on our research team have witnessed friends, family, or patients deteriorate physically or emotionally following a reduction. Some attempted suicide and, tragically, others died by suicide.

Large database analyses tell a similar (and nuanced) story. In research derived from Kaiser Permanente, Veterans Health Administration, Oregon’s Medicaid program, and Canadian databases, patient outcomes were diverse. Some researchers found no safety problems after opioid reductions, but others describe suicides, mental health crises, medical deteriorations, and overdoses at frequencies that are too common to ignore. These are not acceptable outcomes. 

The shocking nature of patient suicides led some experts to jump to conclusions, arguing that acute withdrawal from opioids explains all the bad outcomes, and that slow reductions or tapers prevent harm. But that’s not true. In two studies, mental health crises or overdoses occurred at elevated rates a full year after modest dose reductions, such as a 39% reduction in one national study.

Jumping to conclusions about why something bad happens is another way of saying, “We don’t want to investigate.”

After a suicide, we think the right step – the respectful step – is to ask questions: What happened here? Why did it happen? What were all the factors in a person’s life that might have played a role in their death? And where does an opioid reduction fit, or not fit, into explaining what happened?

Asking those questions is crucial. The decision to end one’s life through suicide is rarely simple, but understanding the person’s history and reasoning will spur better approaches to care. Approaching these questions through in-depth rigorous research, rather than pretending we already know why suicides happen, could also induce leaders to take them more seriously than they have to date.

Just like investigators examining a plane crash, we intend to collect the full story of what happened, carrying out detailed interviews and, where possible, reviewing medical records. Studying just one case can tell us a great deal. But our goal is to study over 100 patient suicides.

This approach is called a “psychological autopsy interview.” That phrase can sound a bit daunting. In reality, it’s an interview where we ask about the person’s life, their health, their care, and what happened before they died.

How You Can Help

We seek people who have lost somebody, such as a close family member or good friend, to suicide after a prescription opioid reduction. We are studying deaths in the US among veterans and civilians, and hope to interview more than one person for each suicide.  

Interview topics range from health and social functioning, to care changes prior to death, to whether the person who died felt a sense of connection to others or perceived themselves to be a burden. To our knowledge, no other team is attempting to do this work.  

We face a singular challenge: recruitment. That’s why we need your help. For the last 60 years, studies of suicides involved collaboration with medical examiners in a state or county. That option is not available to us, because medical examiners usually don’t know about health care changes that took place prior to a person’s death.  

There is no master list of suicides that occurred following a reduction or stoppage in opioids. Yet those deaths are precisely the ones we need to learn about. The only way we can document those cases is to reach out to the public and ask if survivors are willing to come to us, either online or by phone (1-866-283-7223, select option #1). 

If enough survivors are willing to participate in this initiative, then we can begin to describe, understand, and prevent future devastating tragedies.  

For the people who are considering participation in the study and wondering what risks are involved, let me offer some reassurance. First, there is an online questionnaire housed on a very secure server. A person can start it and stop at any point if they choose, no questions asked.  

Also, this study is protected by two federal “Certificates of Confidentiality.” These federal orders prohibit release of identifiable data under any circumstances, even a court order.  We are aware that some families are pursuing legal action, and this was a major factor in our decision to take this extra step to protect participants. 

When a person completes the survey, we will evaluate their answers to see how confident they were that the death was likely a suicide, and whether the death occurred after a prescription opioid dose reduction. If they meet these criteria, then we will reach out to discuss further participation in the research study.  

What follows is a more detailed informed consent process. There is a modest incentive ($100) for being interviewed, and a smaller one if the person can work with our medical record team. It is not necessary for a survivor to have access to a loved one’s medical records.  

So far, the interviews we’ve conducted have been serious, warm and thought-provoking. At the outset, we were concerned that these interviews could be upsetting. We learned from reading the literature on this type of interview, that the individuals who agree to participate usually have a desire to share their feelings about their loved one’s death and tend to perceive the interview as a positive experience.  

In the long-run, we hope that after looking at 110 suicides, we can formulate recommendations and programs for care, without leaping to any conclusions. We want to help save lives.  

A study like this is clearly not the only answer to an ongoing tragedy. Research is almost never a “quick answer” to anything. That’s why many members of our team have already engaged in direct advocacy with federal agencies. It was 4 years ago that several of us urged the CDC to issue a clarification regarding its 2016 Guideline on Prescribing Opioids for Pain. A revised CDC guideline was released last year, but we’ve noticed that the health care situation faced by countless patients with pain remains traumatic and unsettled.

These events are hidden and need exploration. We need to take this next step and learn more to prevent further tragedies and lost lives.

If you would like to enter the screening survey for this research, please click here.

If you would like to learn more general information about our study, click here.

If you know a group of patients or clinicians who would like a flyer, presentation, or a link to our study, please let us know by email at csiopioids@uabmc.edu or stefan.kertesz@va.gov

Stefan G. Kertesz, MD, a Professor of Medicine and Public Health at the University of Alabama at Birmingham School of Medicine, and a physician-investigator at the Birmingham Alabama Veterans Healthcare System.  Stefan is Principal Investigator for the CSI: OPIOIDs study.

Views expressed in this column are those of Dr. Kertesz and do not represent official views of the United States Department of Veterans Affairs or any state agency.

For anyone thinking about suicide, please contact the 988 Suicide & Crisis Lifeline, available online, via chat, or by dialing “988.”  A comprehensive set of resources can also be found at this link.

Back Pain? Bum Knee? Be Prepared to Wait for Physical Therapy

By Mark Kreidler, KFF Health News

At no point along his three-year path to earning a degree in physical therapy has Matthew Lee worried about getting a job.

Being able to make a living off that degree? That’s a different question — and the answer is affecting the supply of physical therapists across the nation: The cost of getting trained is out of proportion to the pay.

“There’s definitely a shortage of PTs. The jobs are there,” said Lee, a student at California State University-Sacramento who is on track to receive his degree in May. “But you may be starting out at $80,000 while carrying up to $200,000 in student debt. It’s a lot to consider.”

As many patients seeking an appointment can attest, the nationwide shortage of PTs is real. According to survey data collected by the American Physical Therapy Association, the job vacancy rate for therapists in outpatient settings last year was 17%.

Wait times are generally long across the nation, as patients tell of waiting weeks or even months for appointments while dealing with ongoing pain or post-surgical rehab. But the crunch is particularly acute in rural areas and places with a high cost of living, like California, which has a lower ratio of therapists to residents — just 57 per 100,000, compared with the national ratio of 72 per 100,000, according to the association.

The reasons are multifold. The industry hasn’t recovered from the mass defection of physical therapists who fled as practices closed during the pandemic. In 2021 alone, more than 22,000 PTs — almost a tenth of the workforce — left their jobs, according to a report by the health data analytics firm Definitive Healthcare.

Growing Demand for PT

And just as baby boomers age into a period of heavy use of physical therapy, and covid-delayed procedures like knee and hip replacements are finally scheduled, the economics of physical therapy are shifting. Medicare, whose members make up a significant percentage of many PT practices’ clients, has cut reimbursement rates for four years straight, and the encroachment of private equity firms — with their bottom-line orientation — means many practices aren’t staffing adequately.

According to APTA, 10 companies, including publicly held and private equity-backed firms, now control 20% of the physical therapy market.

“What used to be small practices are often being bought up by larger corporate entities, and those corporate entities push productivity and become less satisfying places to work,” said James Gordon, chair of the Division of Biokinesiology and Physical Therapy at the University of Southern California.

There’s a shortage of physical therapists in all settings, including hospitals, clinics, and nursing homes, and it’s likely to continue for the foreseeable future, said Justin Moore, chief executive of the physical therapy association. “Not only do we have to catch up on those shortages, but there are great indicators of increasing demand for physical therapy,” he said.

The association is trying to reduce turnover among therapists, and is lobbying Congress to stop cutting Medicare reimbursement rates. The Centers for Medicare & Medicaid Services plans a 3.4% reduction for 2024 to a key metric that governs pay for physical therapy and other health care services. According to the association, that would bring the cuts to a total of 9% over four years.

Several universities, meanwhile, have ramped up their programs — some by offering virtual classes, a new approach for such a hands-on field — to boost the number of graduates in the coming years.

“But programs can’t just grow overnight,” said Sharon Gorman, interim chair of the physical therapy program at Oakland-based Samuel Merritt University, which focuses on training health care professionals. “Our doctoral accreditation process is very thorough. I have to prove I have the space, the equipment, the clinical sites, the faculty to show that I’m not just trying to take in more tuition dollars.”

Rising Cost of PT Education

All of this also comes at a time when the cost of obtaining a physical therapy doctorate, which typically takes three years of graduate work and is required to practice, is skyrocketing. Student debt has become a major issue, and salaries often aren’t enough to keep therapists in the field.

According to the APTA’s most recent published data, median annual wages range from $88,000 to $101,500. The association said wages either met or fell behind the rate of inflation between 2016 and 2021 in most regions.

A project underway at the University of Iowa aims to give PT students more transparency about tuition and other costs across programs. According to an association report from 2020, at least 80% of recent physical therapy graduates carried educational debt averaging roughly $142,000.

Gordon said USC, in Los Angeles’ urban core, has three PT clinics and 66 therapists on campus, several of whom graduated from the school’s program. “But even with that, it’s a challenge,” he said. “It’s not just hard to find people, but people don’t stay, and the most obvious reason is that they don’t get paid enough relative to the cost of living in this area.”

Fewer therapists plus growing demand equals long waits. When Susan Jones, a Davis, California, resident, experienced pain in her back and neck after slipping on a wet floor in early 2020, she went to her doctor and was referred for physical therapy. About two months later, she said, she finally got an appointment at an outpatient clinic.

“It was almost like the referral got lost. I was going back and forth, asking, ‘What’s going on?’” said Jones, 57. Once scheduled, her first appointment felt rushed, she said, with the therapist saying he could not identify an issue despite her ongoing pain. After one more session, Jones paid out-of-pocket to see a chiropractor. She said she’d be hesitant to try for a physical therapy referral in the future, in part because of the wait.

Universities and PT programs graduate about 12,000 therapists a year, Moore said, and representatives of several schools told KFF Health News they’re studying whether and how to expand. In 2018, USC added a hybrid model in which students learn mostly online, then travel to campus twice a semester for about a week at a time for hands-on instruction and practice.

That bumped USC’s capacity from 100 students a year to 150, and Gordon said many of the hybrid students’ professional skills are indistinguishable from those of students on campus full time.

Natalia Barajas received her PT doctorate from USC last year and was recently hired at a clinic in nearby Norwalk, with a salary of $95,000, a signing bonus, and the opportunity to earn more in incentives.

She’s also managing a lot of debt. Three years of tuition for the USC physical therapy program comes to more than $211,000, and Barajas said she owes $170,000 in student loans.

“If it were about money alone, I probably would have shifted to something else a while ago,” Barajas said. “I’m OK with my salary. I chose to do this. But it might not be the perfect situation for everybody.”

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