Leaving Pain Untreated is Torture

By Janice Reynolds, Guest Columnist

One thing we need to keep in mind when discussing the so-called opioid epidemic is that people in acute pain are being persecuted and harmed, as well as those with persistent (chronic) pain. In fact, much of the witch hunt may have started with acute pain.

It has long been known that when acute pain is left untreated or undertreated it can lead to persistent pain, as well as a multitude of harmful side effects from pain.  I know my persistent post-craniotomy pain was at least partially caused by poor pain treatment after my surgery. Eight years later, I can still vividly recall the second night post-op, when the pain was horrendous. I cried and really wanted to die.

People in pain have always experienced prejudice and bias.  The current situation has allowed bigots to speak and act with impunity.  As with anything, you tell a lie often enough and it must be true.

Anyone who has worked in medicine has heard a physician, nurse, pharmacist, physical therapist, etc. make derogatory statements, refuse to prescribe appropriate medication, express opiophobia, and sometimes even hatred for people in pain.  Sometimes it can even be family members. 

I have two favorite stories that I’ll share. And believe me, after over 20 years as an advocate for people in pain, I have a lot of stories.

As a new nurse, I once had a patient admitted with severe abdominal pain and headaches. The doctor would only give her Tylenol.  He would go off duty, and I would call the covering physician and get morphine ordered.  The doctor would come in the next morning and discontinue the morphine, leaving her with nothing but Tylenol. 

The patient was diagnosed with cancer, and the doctor claimed her pain was just a reaction to her diagnosis (and some nurses bought into that!). 

I finally couldn’t take it anymore and told the family they could request another doctor (I could have lost my license for coming between a doctor and his patient). I suggested an oncologist, who was also a palliative care doctor, who I knew as compassionate and good at pain management.

The oncologist took over and got her comfortable. She died two weeks after the admission for acute pain.

The second story was in the midst of the AIDS epidemic. I had a patient who was dying (she had been a prostitute and IV drug user).  When I attempted to get more morphine for her because she was literally writhing in pain, the doctor refused, saying, “She should have considered her lifestyle choices before.”

In 2001, when the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) came out with the first standards for pain assessment, we were ecstatic.  We were going to make pain visible and more people would get better treatment. 

Unfortunately, that is not how it worked out.  The anti-opioid activists were vocal about how the standards would push doctors to prescribe opioids, enable drug seeking, and so on.  Some even blamed the pharmaceutical industry, even though it had absolutely nothing to do with the standards. They were written by a professor of pharmacology and a nurse practitioner experienced in pain.

Fifteen years later, so many of these myths were still circulating that the Joint Commission felt compelled to come out with a statement refuting them.

Many actions now being taken affect acute pain care the most, such as removing pain questions from patient satisfaction surveys and poor treatment in hospital emergency rooms.  A hospital in New Jersey won praise and international attention for sharply reducing the use of opioids, until it was found to be in the bottom 3% of hospitals nationwide for quality of care.

Now they want to prevent opioids from being ordered for so called “minor” procedures and to limit the amount of opioids or number of days they can be prescribed for acute pain. And although pain care for cancer patients and the terminally ill is still touted as sacred, it isn’t as good as it should be and is losing ground.

You would think because pain can affect anyone at anytime that there would be more compassion. Yet we have politicians saying, “Yes, children need their pain relieved, however with the opioid epidemic they shouldn’t be receiving these powerful drugs” or “We need to be able to objectively measure pain.”

Torture, for the most part, relies on pain.  I realize there is water boarding and psychological torture, however inflicting pain is the method used throughout history. Politicians and the media are against torture, yet they do not see the mistreatment of pain as torture. It is actually torture of the worst kind, perpetuated by those who profess to have your best interests at heart.

A quote I always used in my classes and presentations comes from The Culture of Pain by David B. Morris:

“Failure to relieve pain comes perilously close to inflicting it.”

Janice Reynolds is a retired nurse who specialized in pain management, oncology, and palliative care. She has lectured across the country on pain management and is co-author of several articles in peer reviewed medical journals. 

Janice has lived with persistent post craniotomy pain since 2009.  She is active with The Pain Community and writes several blogs for them.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Senate Bill Would Protect Marijuana Use in Legal States

By Ellen Lenox Smith, Columnist

A group of bipartisan U.S. senators has announced plans to reintroduce a bill that would allow state medical cannabis laws to supersede the current federal prohibition. The bill would also greatly expand opportunities for medical and scientific research of medical marijuana.

The Compassionate Access, Research Expansion and Respect States Act – also known as the CARERS Act – is being sponsored by Senators Kirsten Gillibrand (D-NY), Cory Booker (D-NJ), Al Franken (D-Minn.), Rand Paul (R-KY), Lisa Murkowski (R -Alaska), and Senator Mike Lee (R -Utah). The House version is sponsored by Reps. Steve Cohen (D-Tenn.) and Don Young (R-Alaska). 

"The fact is our marijuana laws in America are broken," Sen. Booker said at a press conference. "They are savagely broken, and the jagged pieces are hurting American people."

The CARERS Act was originally introduced in 2015, but did not move forward. Back then, the bill only had three sponsors: Sen. Booker, Sen. Gillibrand and Sen Paul.

A big change from 2015 is that a new administration now occupies the White House and there are fears the Justice Department could once again start enforcing federal marijuana laws in states where it is legal.

Some in Congress do not want the feds messing around again with legal cannabis.

“The people have been pretty clear that this is something they don’t want the federal government to interfere with,” said Rep. Earl Blumenauer (D-Oregon).

If passed, the CARERS Act would leave in place laws legalizing medical marijuana in 30 states, the District of Columbia, Puerto Rico and Guam, and protect their citizens from federal prosecution. The bill would also allow veterans to access legal cannabis in those states. Currently, there are federal regulations that bar doctors in Veterans Affairs hospitals from prescribing cannabis to their patients. Veterans caught with marijuana in the system are also being denied access to opioid pain medication.

While running for president, President Trump said marijuana laws should be decided at the state level, but then he tapped Jeff Sessions to be his Attorney General. It is clearly known through his words and actions that Sessions does not believe marijuana should be considered a legitimate medicine, despite the beneficial impact noted by medical professionals across the globe.

In fact, Sessions sent a letter to Congressional leaders back in May, asking them to undo a provision in federal law that bars the Justice Department from going after legal marijuana businesses.

"I believe it would be unwise for Congress to restrict the discretion of the Department to fund particular prosecutions, particularly in the midst of an historic drug epidemic and potentially long-term uptick in violent crime," Sessions wrote. "The Department must be in a position to use all laws available to combat the transnational drug organizations and dangerous drug traffickers who threaten American lives."

But supporters of the CARERS Act feel Sessions' thinking is very wrong, especially when it comes to people gripped with chronic pain or conditions such as epilepsy.

Clinical studies have found that cannabidiol, or CBD as it's commonly known, can reduce epileptic seizures in children and young adults as much as 45 percent. The CARERS Act would take CBD off the list of controlled substances, thus allowing children in states where medical cannabis isn't legal to access the life changing oil.

"I dare him (Sessions) to sit down with families and listen to their stories and then pursue a policy like he's advocating for now," says Sen. Booker.

An uphill battle is expected, but the effort is picking up steam. Many red states have now passed some form of legal cannabis.

"I believe things are changing and they're changing fast," Sen. Gillibrand told Rolling Stone. "I think we will get the support we need."

Let’s write and/or call our Senators and ask them to not only support, but also co-sponsor the CARERS Act. To reach their D.C. offices, you can contact the Capitol switchboard at 202-224-3121. To send an email, check this website for their email addresses.

You can also go to this link set up by Americans for Safe Access to contact your Senator.

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis. Ellen and her husband Stuart live in Rhode Island. They are co-directors for medical marijuana advocacy for the U.S. Pain Foundation and serve as board members for the Rhode Island Patient Advocacy Coalition.

For more information about medical marijuana, visit their website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Acetaminophen May Harm Male Fetuses

By Pat Anson, Editor

The pain reliever acetaminophen may inhibit the sexual development of male babies whose mothers take the over-the-counter drug while pregnant, according to a new study by Danish researchers. The study only involved laboratory rodents, but one researcher called the findings “very worrying” and said pregnant women should think carefully before using the painkiller.

Acetaminophen – which is more commonly known as paracetamol outside the U.S. -- is used by over half the pregnant women in the United States and European Union. It is the active ingredient in Tylenol, Excedrin, and hundreds of pain medications.

Previous research has already indicated that acetaminophen can suppress the development testosterone in male fetuses. It has also been linked to autism and attention deficit problems in young children.

The new study, published in the journal Reproduction, involved mouse fetuses that were exposed to acetaminophen at a dose equivalent to that which pregnant women are usually recommended. Researchers evaluated the male rodents' behavior after their birth, studying their aggressiveness toward other male mice, their ability to mark their territory, and their ability to mate. They were found wanting in all three areas.

The abnormal behavior was apparently caused by lower levels of testosterone, the male sex hormone that fuels the development and programming of the male body and brain. Testosterone also controls sex drive and the production of sperm.

"We have demonstrated that a reduced level of testosterone means that male characteristics do not develop as they should. This also affects sex drive," said Dr. David Møbjerg Kristensen of the Department of Biomedical Sciences at the University of Copenhagen. "Mice exposed to paracetamol at the fetal stage were simply unable to copulate in the same way as our control animals. Male programming had not been properly established during their fetal development, and this could be seen long afterwards in their adult life. It is very worrying."

When the brains of the mice exposed to acetaminophen were analyzed, researchers found significantly fewer neurons in the brain region that controls sex drive.

“These findings add to the growing body of evidence suggesting the need to limit the widespread exposure and use of APAP (acetaminophen) by pregnant women,” said Kristensen.

A study published last year in JAMA Pediatrics  linked prenatal use of acetaminophen to a higher risk of behavior problems, hyperactivity and emotional problems in children. The pain reliever has also long been associated with liver injury and allergic reactions such as skin rash.

The FDA label for products containing acetaminophen warns about the risk of liver damage and other side effects, but does not specifically warn pregnant women about using the pain reliever. The agency said in 2015 that the evidence was “too limited” to justify such a warning.  

In its 2016 opioid prescribing guidelines, the CDC recommends acetaminophen as an alternative to opioid pain medication. The guideline only briefly mentions that acetaminophen was involved in nearly 900 overdose deaths in 2010 and can cause liver problems. The guideline does warn pregnant women -- at length -- that opioids can cause birth defects, poor fetal growth, still births and neonatal opioid withdrawal syndrome.

Can Human Touch Relieve Pain?

By Pat Anson, Editor

Holding hands with a loved one is a simple and effective way to relieve some of their pain, according to the results of a novel study.

The key is to take advantage of an evolutionary trait that helped humans become social beings.

“Skin to skin touch is important for pain reduction, which may explain people’s preference for social touch. Moreover, touch activates reward circuits in the brain. Indeed, skin-to-skin touch has been shown to activate the reward system, which results in pain reduction both in animals and in humans,” wrote lead author Pavel Goldstein, a pain researcher in the Cognitive and Affective Neuroscience Lab at CU Boulder.

“It seems that this phenomenon has evolutionary roots. For example, non-human primates devote much more time to grooming than they actually need for hygiene reasons, resulting in endogenous opioid release, as well as pain and stress reduction.”

The new study, published in the journal Scientific Reports, is the first to explore interpersonal synchronization in the context of pain and touch.

Scientists have long known that people subconsciously sync their footsteps with the person they're walking with or adjust their posture to mirror a friend's during conversation. Studies have also shown that when romantic couples are simply in each other's presence, their cardiorespiratory and brainwave patterns sync up.

Goldstein came up with the idea of testing how synchronization affects pain after witnessing the birth of his daughter.

"My wife was in pain, and all I could think was, 'What can I do to help her?' I reached for her hand and it seemed to help," he recalls. "I wanted to test it out in the lab: Can one really decrease pain with touch, and if so, how?"

Goldstein recruited 22 healthy heterosexual couples, age 23 to 32, and put them through a series of tests aimed at mimicking that delivery-room scenario.

Men were assigned the role of observer, while the women were subjected to mild heat pain in the forearm for two minutes. As instruments measured their heart and breathing rates, the couples were put in three different scenarios: together but not touching; together holding hands; or sitting in separate rooms.

The couples’ heart and breathing rates synced physiologically while just sitting together. But when a woman was subjected to pain and her partner couldn't touch her, that synchronization ended. When he was allowed to hold her hand, their rates fell into sync again and her pain decreased.

"It appears that pain totally interrupts this interpersonal synchronization between couples," Goldstein said. "Touch brings it back.

“It is possible that the target of pain communicates back the analgesic effect of touch to the observer. Thus, the use of touch may improve the quality of non-verbal physiological communication between partners, especially when one of them feels pain, enabling the toucher to better project his empathy to the female partner and consequently have an analgesic effect.”

Goldstein's previous research found that the more empathy a man showed for a woman, the more her pain subsided during touch. The more physiologically synchronized they were, the less pain she felt. It's not clear yet whether the decrease in pain increased the synchronicity, or vice versa.

"It could be that touch is a tool for communicating empathy, resulting in an analgesic, or pain-killing, effect," said Goldstein.

Further research is needed to figure out how a partner's touch eases pain. Goldstein suspects interpersonal synchronization may play a role, by affecting a region of the brain that is associated with pain perception, empathy, and heart and respiratory function.

The study did not explore whether the same effect would occur with same-sex couples, or what happens when the man is the subject of pain. Goldstein hopes the research will help lend scientific credence to the notion that touch can ease pain.

The Link Between Chronic Pain and Depression

By Lana Barhum, Columnist

There are nearly 40 million American adults living with severe or significant chronic pain, according to the National Institutes of Health. Chronic pain affects more people than cancer, diabetes and heart disease combined.   

Chronic pain is devastating and can be a challenge to treat. Pain also causes depression and depression leads to decreased function, poor treatment outcomes and further healthcare costs. About half of people with chronic pain are also depressed, according to a recent study in the Journal of Affective Disorders.

"The dual burden of chronic physical conditions and mood and anxiety disorders is a significant and growing problem," wrote senior author Silvia Martins, MD, associate professor of Epidemiology at the Mailman School of Public Health.

Pain experiences are different for each person and your response to chronic pain depends on how you feel pain, and thoughts and behaviors related to your underlying pain conditions.  

When pain invades every aspect of your life and leaves you uncertain of the future, anxiety, sadness, anger and grief are imminent. For many, the burden is so difficult, it leads to major depressive disorder, also known as clinical depression.

Research shows the highest rates of clinical depression are in people with fibromyalgia. According to a study in Pain Research and Treatment, people with fibromyalgia have a 90% chance for depressed symptoms and up to 86% risk for major depressive disorder. 

What is Clinical Depression?

Clinical depression is more complicated than dealing with sadness and grief. This type of depression leaves you unable to focus on work, get good quality sleep, eat well, or enjoy time with friends and loved ones.  Some people experience clinical depression once, but many have experienced it several times during their life.

Some symptoms of clinical depression are:

  • Fatigue and loss of energy
  • Feelings of guilt and worthlessness
  • Struggles with concentration and decision making
  • Sleep problems, including insomnia or excessive sleeping
  • Disinterest in almost all activities
  • Constant thoughts of dying and suicide
  • Significant weight loss or gain

My Experience with Clinical Depression

Depression has been a frequent visitor to my chronically painful life, but the first time I was formally diagnosed with clinical depression was 2011.  It had been 3 years since I was diagnosed with rheumatoid arthritis and fibromyalgia, two painful and life-altering conditions.  Not only was pain dominating my life, there was so much more happening because of pain, that I couldn’t handle it all. 

I knew I was struggling, but I didn’t know the extent.  I was crying for no reason, not sleeping, and my mind was constantly racing.  And I thought about death – not contemplating suicide but that death had to be better than living with real physical and emotional pain.

It was my rheumatologist who recognized the extent of my depression, prescribed an anti-depressant and referred me to a therapist. Talk therapy helped me better handle my feelings about living with pain and other obstacles, and the medication managed the chemical part of depression. Eventually and with time, I found some clarity.

There have been other times in more than nine years of living with illness and pain that depression has gotten its clutches on me. But it was not until last summer that I had another episode of clinical depression.  I unexpectedly lost my mother in late August and that loss shook me to my very core and brought back my old friend depression with it.

Preventing Recurrent Depression

Anyone who has suffered from at least one episode of depression is at risk for another, and the risk is higher in people who have been diagnosed with clinical depression. According to a 2104 report from the University Medical Center Groningen in The Netherlands, recurrent depression is more common in people who live with pain.

The best way to treat and prevent recurrent depression, according to a discussion in the Primary Care Companion to The Journal of Clinical Psychiatry, is through maintenance therapy that includes talk therapy and medication, and where medication is decreased as the depression lessens.

Depression does not have to last forever and it doesn’t have to consume your life. But when you are dealing with the sadness, anger, grief and pain, relief seems unimaginable.  My experience with clinical recurrent depression and pain has taught me that there is always hope.  It won’t be easy, but it’s not impossible.

If you want to manage your depression and prevent it from coming back, it is important to take a proactive approach.  Here’s how:

Early Recognition. If you have been clinically depressed before, you know that depression comes and goes.  If you find you are feeling exhausted, hopeless, distressed and struggling to be productive daily, reach out to your doctor or therapist to find ways to keep symptoms from worsening.  

Learn Your Triggers. For most of us, pain is a stressor and increases the chance being depressed.  But depressed feelings and anxiety also worsen pain. Therefore, it’s important to focus on minimizing things that exacerbate pain.

Communication.  Many people with chronic pain do not reach out to their doctors because they don’t think there is anything that can be done or they feel that if their pain levels are managed, then their depression will go away. But depression doesn’t just go away and it only worsens your pain levels.  Getting treatment is the only way to a full recovery and to prevent depression from returning.

Please know you are not alone.  There are millions of people with chronic pain and clinical recurrent depression. Reach out and seek support, whether it is online, in a local community support group or from others – a pastor, a mental health professional, a friend or loved one.   Your mental health is just as important as your physical and it is important to treat it as such.

Lana Barhum lives in northeast Ohio. She is a freelance medical writer, patient advocate, legal assistant, and mother. Having lived with rheumatoid arthritis and fibromyalgia since 2008, Lana uses her experiences to share expert advice on living successfully with chronic illness. She has written for several online health communities, including Alliance Health, Upwell, Mango Health, and The Mighty.

To learn more about Lana, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Do Depression and Back Pain Lead to More Opioids?

By Pat Anson, Editor

Depressed patients with low back pain were twice as likely to be prescribed an opioid medication and to receive higher doses, according to the results of a new study that looked at data from a decade ago.

Lower back pain is the world’s leading cause of disability and the most common condition for which opioids are prescribed. Nearly a quarter of the opioid prescriptions written in the U.S. are for low back pain.

"Our findings show that these drugs are more often prescribed to low back pain patients who also have symptoms of depression and there is strong evidence that depressed patients are at greater risk for misuse and overdose of opioids," said John Markman, MD, director of the Department of Neurosurgery's Translational Pain Research Program at the University of Rochester Medical Center and senior author of the study published in the journal PAIN Reports.

The researchers found that patients who screened positive for depression were more than twice as likely to be prescribed an opioid, and they received twice the cumulative dose of opioids per year.

This not only suggests that doctors were more likely to prescribe opioids to a patient suffering both physically and psychologically, but it also implies that analgesics are less effective in pain patients who are depressed.

One obvious weakness of the study is that it relied on prescription data from 2004 to 2009 that was compiled by the Medical Expenditure Panel Survey, a federal survey of patients, their families, healthcare providers and employers. That time frame coincides with a steep rise in opioidprescribing, but does not represent the current environment in which opioid medication is harder to obtain.

The researchers believe, however, that understanding prescribing patterns from a decade ago may help improve the effectiveness of clinical trials. Low back pain is the condition most often studied to approve new pain medications, and depressed patients are often excluded from trials because of incentives to get positive findings about a new analgesic.

“Because several pivotal clinical trials for opioid treatment of LBP (low back pain) have systematically excluded the most depressed patients, it is probable that clinicians and patients alike are drawing conclusions from a study group that may differ in important ways from likely opioid recipients. These clinical trial populations may underrepresent the patients most likely to receive opioids, especially those who are mostly likely to receive higher dosages for longer durations,” Markman said.

Lower back pain may be the world’s leading cause of disability, but there is surprisingly little evidence about the best ways to treat it.

A recent review of 20 clinical studies involving nearly 7,300 patients found that opioids provide only “modest” short-term relief from lower back pain. Opioids were also no more effective than non-steroidal anti-inflammatory drugs (NSAIDs). About half of the patients involved in the studies dropped out because they didn’t like the side-effects of opioids or because they found them to be ineffective.

The Consequences of Untreated Pain

By Roger Chriss, Columnist

Pain is an alarm signal requiring attention. Whether the pain lasts minutes or months, it demands a response. To ignore pain is to invite serious consequences, from burned skin or an infected wound to a damaged joint or dysfunctional nerve. It is for this reason that healthcare professionals ask patients where it hurts.

Recent research found the consequences of untreated pain go farther and deeper than are generally recognized:

  • JAMA Internal Medicine reported that older people with chronic pain experience faster declines in memory and are more likely to develop dementia.
  • Pain Medicine reported that osteoarthritis and related joint pain were strongly associated with memory loss.
  • Arthritis Care & Research reported that pain severe enough to interfere with daily life was associated with an increased risk of mortality.

In the latter study, people who were “often troubled with pain” had a 29% increased risk of dying, and those who reported “quite a bit” or “extreme’ pain” had 38% and 88% increased risk of mortality, according to Medical Dialogues.

These results are new, but they are far from unique. For years researchers have been finding that chronic pain conditions have major long-term medical consequences.

In 2011, Pain Medicine reported that chronic pain “negatively impacts multiple aspects of patient health, including sleep, cognitive processes and brain function, mood/mental health, cardiovascular health, sexual function, and overall quality of life.”

In 2016, a study in the Journal of Pain Research reviewed the research literature and found that chronic pain “has significant consequences for patients, as well as for their families, and their social and professional environment, causing deterioration in the quality of life of patients and those close to them.”

However, awareness of the consequences of persistent pain conditions does not necessarily translate to effective care. As I wrote in a recent column, under treatment of pain is common, and the CDC opioid prescribing guidelines and groups like Physicians for Responsible Opioid Prescribing (PROP) are making things worse by demonizing opioids.

“The role of opioid analgesics has been distorted to the point where the word ‘oxycodone’ uttered in front of a patient in my palliative medicine clinic is met with raised eyebrows,” wrote Susan Glod, MD, in a recent op/ed on “The Other Victims of the Opioid Epidemic” published in The New England Journal of Medicine

Fear of a drug makes for bad medicine. Although opioid therapy includes possible cognitive side effects, so do anticholinergic muscle relaxants, which have been shown to increase the risk of dementia. Similar risks exist for many other treatment modalities.

Thus, effective management of chronic pain conditions requires expert care. The best results are often obtained in pain management programs that combine drug therapy with physical therapy or other modalities tailored to the individual patient’s needs.

Persistent pain is a danger sign that a major and potentially life-threatening toll is being exacted on the human body and mind. We do not have the luxury of ignoring or undertreating chronic pain conditions. Good pain management is one of the best ways to improve long-term outcomes and quality of life.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Women ‘Catastrophize’ About Pain More Than Men

By Pat Anson, Editor

Women who complain or focus negatively on their pain – a psychological condition known as catastrophizing -- not only feel chronic pain more intensely, they are more likely than men to be prescribed opioids for the same condition, according to a new study.

"Our research underscores how psychological factors such as negative thoughts or emotions have the capacity to influence how we experience pain and the likelihood that someone will be taking prescribed opioids," said Beth Darnall, PhD, a clinical associate professor at Stanford University School of Medicine and senior author of the study published in the journal Anesthesiology.

"The findings suggest that pain intensity and catastrophizing contribute to different patterns of opioid prescribing for male and female patients, highlighting a potential need for examination and intervention in future studies."

Previous studies have found that pain catastrophizing can have a powerful influence on a patient’s sensory perception, and may magnify the intensity of chronic pain by as much as 20 percent.

In their retrospective study, Darnall and her colleagues analyzed clinical data from nearly 1,800 adult chronic pain patients at a large outpatient pain treatment center. Most of the patients said they were prescribed at least one opioid medication.

For women, pain catastrophizing was strongly associated with having an opioid prescription, even when there were relatively low levels of pain. Pain intensity was a stronger predictor of opioid prescriptions in men.

"Our findings show that even relatively low levels of negative cognitive and emotional responses to pain may have a great impact on opioid prescribing in women," said lead author Yasamin Sharifzadeh, a medical student at Virginia Commonwealth University.

It was Sharifzadeh who first sought to study the relationship between pain catastrophizing and opioid prescriptions as a third-year undergraduate student at Stanford, where the research was conducted. She says more research is needed to understand sex differences in pain so clinicians can develop better treatments for both men and women.

“If physicians are aware of these gender-specific differences, they can tailor their treatment,” she said. “When treating chronic pain patients — especially women — they should analyze pain in its psychological aspect as well as its physical aspect.”

Previous studies have found that women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and to use them for longer periods. Women may also become dependent on medication more quickly than men, according to the CDC.

Opioid Addiction Linked to Range of Health Problems

By Pat Anson, Editor

An extensive new analysis of insurance claims has found that patients being treated for opioid addiction are much more likely to suffer from a wide range of other health problems, including hepatitis C, HIV, bronchitis, fibromyalgia and chronic pain.

The large study by Amino – a healthcare information company – looked at 205 million private health insurance claims involving patients with “opioid use disorder,” a loosely defined diagnosis that includes both mild and severe forms of “problematic” opioid use. The diagnosis does not distinguish between prescription opioids used therapeutically and illegal opioids such as heroin that are used recreationally.

In just four years, Amino found a 6-fold increase in the number of Americans diagnosed with opioid use disorder, from 241,000 in 2012 to 1.4 million 2016.  

Amino also found that patients with opioid use disorder were significantly more likely to be diagnosed with diseases linked to substance abuse and intravenous drug use, including hepatitis C, HIV, alcoholism and mental health issues.

“Behavioral health issues like alcoholism and binge drinking were 8.4x and 5x more frequently diagnosed among patients who were also diagnosed with opioid use disorder, while mental health issues like suicidal ideation and post traumatic stress disorder were 6.9x and 4.2x more frequently diagnosed,” wrote Amino researcher Sohan Murthy.

Murthy and his colleagues also found many diagnoses related to pain, including chronic regional pain syndrome (CRPS), herniated disc, failed back syndrome, stenosis and fibromyalgia.

Stanford psychiatrist Anna Lembke, MD, a board member of Physicians for Responsible Opioid Prescribing (PROP), told Amino there is a high risk for addiction even when opioids are prescribed for a “bonafide” medical use.

“What I thought was really interesting was the correlation with failed back syndrome. Perhaps failed back syndrome is a risk factor for developing an opioid use disorder—and that could be part of the reason why this community experiences such chronicity and lack of improvement. This is a subgroup that’s especially vulnerable to opioid misuse,” Lembke said.

"Failed back syndrome" is a diagnosis used to describe patients who do not respond or whose pain grows worse after spinal surgery, injections or other "interventional" procedures. Ironically, these same procedures are often promoted as "non-opioid" treatments for chronic back pain.

Amino notes in the study that the data does not make a "causal" link between different diagnoses, meaning the study doesn't conclude that opioid use disorder causes hepatitis C or HIV. However, the FDA recently asked that Opana ER be removed from the market  because the painkiller was associated with outbreaks of hepatitis C, HIV and other diseases spread by intravenous drug use; indicating that health problems other than abuse and addiction are now being used by the agency as a rationale to limit the sale of opioids.

Amino found that geography is often a major factor in the diagnosis of opioid use disorder. The study found a disproportionate number of patients with opioid use disorder in Appalachia and Florida, suggesting that doctors in regions with a history of opioid abuse may simply be more likely to make the diagnosis.  Kentucky alone had 9 of the top 10 counties for doctors treating a high volume of patients with opioid use disorder.

CDC Guidelines Making Opioid Problem Worse

By Gary Nations, Guest Columnist

I’m a medically retired police officer with over 22 years of service. I have been in chronic pain management for many years now and my condition will never get better.

Throughout my time dealing with workers compensation and the public employee retirement system in Mississippi, I have been examined by no less than five medical doctors. Unfortunately for me, the conclusion is my condition is progressive and will only get worse.

I’ve had four neck surgeries and one lower back surgery due to on-the-job injuries. For the past few years I have found a pain management regimen that allows me to have somewhat of a normal life, although I still experience pain 24/7. I would love to see a substance that relieved pain without the problems caused by opioid medication.

The recent upswing in deaths from opioid abuse is tragic. However, the guidelines developed by the CDC for doctors to reduce opioid dosages for pain patients like me will cause more problems than it solves.

I believe some of the actions taken so far have created a vacuum and worsened the epidemic, which I believe is about to get much bigger.  Some people are going to abuse some type of substance no matter what. That’s an unfortunate fact that cannot be stopped.

Cutting the dose of medication for people in my position who need it will force them to violate the law to maintain their level of pain management and quality of life.

GARY NATIONS

GARY NATIONS

This could prove a disaster, as we know many street drugs contain powerful opioids such as fentanyl, which the DEA has been very unsuccessful in stopping. Some of these street drugs are counterfeit. They appear to be a medication that a doctor would prescribe, yet they contain other drugs that cause people to overdose and die. From what I read and understand, this is what happened to the entertainer Prince. Some patients may also tire of the constant pain and commit suicide with street drugs.

The Declaration of Independence endows each citizen the right to life, liberty and the pursuit of happiness. I believe the CDC’s attempt to curb the opioid overdose and death rate is very noble. However, I also believe in the long run it will violate citizens’ rights, do much more harm than good and end up in the civil courts. As I’m sure you are aware, in some cases large sums of money are paid out each year in legal cases for “pain and suffering.”

There is no way the CDC can tell what medication and how much medication I or anyone else needs to attempt to maintain their current level of activity, quality of life and pursuit of happiness.  Only a qualified physician with medical training, medical records and medical images can understand what a patient may or may not need. The CDC needs to remember there are many people with very legitimate needs for these controlled substances. 

Last year was the first time in over ten years I could enjoy hunting and fishing again. I became active enough that I went from 255 pounds down to 215 pounds. I started feeling better and asked my doctor to drop my “breakthrough” pain meds from 120 to 90 per month. I’ve since realized I really need about 100 per month, but I get by.

The key here is I volunteered to stop taking 30 pills per month. Yes, my doctor was surprised.  However, because of rule changes, I can’t get my pain meds from that doctor anymore. I have to drive one hour each way to a pain management doctor to get my meds now. The long drive is very painful and the cost is higher.

Cutting my current pain management regimen will result in me being in more pain than I am now. It will cause me to be unable to exercise my right to hunt and fish. It will cause me to be unable to do yard work, such as mowing the lawn. Not being able to mow the lawn will result in an additional expense of $80 to $100 per month during the warm weather months.

It will cause me to once again be unable to travel and engage in some aspects of the only hobby I can currently enjoy, amateur radio. In other words, much of my liberty will be taken and my quality of life heavily impacted. My only income is Mississippi Public Employees Retirement System disability payments. Some citizens that are currently able to work with proper pain management may also have to seek disability if their doses are cut.

As I stated, I believe the effort to stop drug abuse and addiction is very noble. However, the route to solving this opioid problem should not include violating the rights of our disabled citizens or cause some patients to become criminals while trying to maintain what little normalcy and quality of life they have now.

I’m seeking your help to stop the CDC from punishing citizens that need to be on long term pain management and to get the CDC to reevaluate how it is handling a very important problem. I believe it’s time for someone to help us by filing for an injunction or a class action lawsuit to stop this craziness.

Gary Nations lives in Mississippi.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Pain Mismanagement

By Jillian Drexler, Guest Columnist

I’ve been going to the same pain management doctor for over 8 months. While at these appointments, I see the physician assistant (PA) far more often than I see the doctor.

The PA is a very unpleasant person and lacks basic compassion and bedside manner. At an appointment last year, I was crying because of my pain and lack of sleep, and she couldn’t even be bothered to hand me a tissue. She was just more of her typical overbearing, sarcastic self.

Since I’ve been going there, I’ve been prescribed tramadol (which I’m allergic to), Lyrica (causes my wrists and ankles to swell and my pain to worsen), compound cream, lidocaine patches, Flector patches and a TENS unit. I’ve also had a few injections, with the most recent ones causing severe adverse effects.

They would have a better idea of what medications work and don’t work for me had they bothered to read the medication genetic testing report my primary care physician ordered. But, the pain management doctor turned down making copies on two occasions. They finally made a copy when I asked a medical assistant instead of the doctor or PA to make copies.

They’ve asked me more than once what opioids have worked for me in the past. I tell them and also explain that these medications have only been prescribed in the ER and after surgeries. Either way, I’m still denied the opioids I know can help alleviate some of my pain and improve my quality of life.

I’ve passed their drug tests and jumped through their hoops, only to get nothing in return but treatments that don’t work. On one occasion, the PA told me she didn’t know what I expected her to do about my fibromyalgia because that wasn’t her “baby.”

JILLIAN DREXLER

JILLIAN DREXLER

Often, they fail to realize I’m not just a patient, but a paying customer. And a very unhappy one, too. They don’t care though.

Patients are told they should play an active role in their treatment, but when we do, it doesn’t seem to matter. Nothing changes. We're perceived as drug seekers or told we’re exhibiting drug seeking behavior. It could never be that we’re in legitimate pain and hoping for relief.

I don’t ask for much from my medical team other than respect, answers and help with an improved quality of life. I’m 33 years old and this life wracked with pain isn’t living. I’m simply existing and missing out on so much in life. I’ve lost my ability to work, provide for my family and spend quality time with them.

I recently was denied for disability again. I wonder if the government ever considered just how many of us are forced to stop working because our pain medications were reduced or stopped entirely.

The CDC should have come up with something for us before putting their guidelines in place. It’s wrong and unfair that we are being punished for the actions of the guilty few. Because of this, the issue becomes an “us vs. them” situation. Addicts need love and treatment, just like any other patient, but while lifesaving measures are in place for them, we’re left feeling slighted and wondering if anyone cares about us. Already, far too many chronic pain patients have lost hope and feel there is no other option but to end their lives.

My governor recently announced plans to limit opioid prescriptions for acute pain to 7 days. Gov. John Kasich said it won’t effect chronic pain patients, but I tend to doubt that. I mean, how could it not? Ohio is considered one of the hardest hit states in the heroin and opioid epidemic.

Last September, a new state law was approved that allows doctors to prescribe medical marijuana to patients with qualifying medical conditions. The program won’t be in operation until September 2018.

If we’re going through such a difficult time getting opioids, I can just imagine how difficult it will be getting a medical marijuana card and then the marijuana itself. If a pain patient is still working, many would risk losing their jobs because some employers have publicly said they will have no tolerance for marijuana use for any reason.

Ultimately, there’s no win here for chronic pain patients, not as this time. We must stick together and fight for our right to a life of reduced pain. Respect, improved quality of life, and effective treatment aren’t too much to ask for. They wouldn’t take blood pressure medication away from someone who has hypertension or insulin from a diabetic, so why deny or take medications away from pain patients?

Jillian Drexler is from Cincinnati, Ohio. She lives with fibromyalgia, bulging and herniated discs in her neck and back, migraines, sciatica, and post tubal ligation syndrome (PTLS).

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Addiction Treatment Initial Focus of Opioid Commission

By Pat Anson, Editor

President Trump’s commission on drug addiction and the opioid crisis held its first public meeting today, a two-hour session focused largely on expanding access to addiction treatment.

Chaired by New Jersey Governor Chris Christie, the commission is expected to make interim recommendations to the president in the next few weeks on how to combat drug abuse, addiction and the overdose epidemic, which is blamed for the deaths of nearly 60,000 Americans last year. A final report from the commission is due by October 1.

It is not clear yet how much of a role opioid prescribing and pain medication will play in the commission’s work. Most of its five members have publicly blamed overprescribing for causing the opioid epidemic.

“No offense, but that is where this came from,” said Massachusetts Gov. Charlie Baker, a commission member.

“The opioid crisis is ruining lots of people’s lives and lots of families across America," David Shulkin, Secretary of Veterans Affairs told the commission. "At the VA, my top priority is to reduce veteran suicides. And when we look at the overlap between substance abuse and opioid abuse, it’s really clear.

“We’ve been working on this for seven years and we’ve seen a 33 percent reduction in use of opioids among veterans, but we have a lot more to do.”

Shulkin did not mention that veteran suicides have soared during that period, and are now estimated at 20 veterans each day.

“We also need to look at pharmaceutical companies making generic drugs more tamper resistant and looking at making drugs that do not cause addiction,” said North Carolina Gov. Roy Cooper, a commission member.

Commission member Patrick Kennedy, a former congressman who has battled substance abuse himself, said there has been a “historic discrimination” against mental health and addiction treatment.

“I’m excited by the chance to kind of push for ways that we can hold insurance companies more accountable, so that the public sector doesn’t have to pick up the tab. Because its taxpayers that are picking up the tab when insurance companies continue to push folks with these illnesses off into the public system,” Kennedy said. “This is a cost shift that is a windfall for insurance companies if they can get rid of people who have mental health or addiction issues.”

Limits on Opioid Medication Not Working

“Let me be blunt. Today there is not nearly enough drug treatment capacity in America to help most of the victims of the epidemic,” said Mitchell Rosenthal, MD, who founded Phoenix House, a nationwide chain of addiction treatment centers.

“Most terrifying is the reality that nothing we are doing today has been able to halt the spread of opioid addiction. Controlling prescription opioid medication has not done so. Prescription monitoring programs, strict limits on the number of pills physicians can prescribe, and the CDC pain management guidelines seem to have capped usage of prescribed opioid medications. But overdose deaths from heroin and highly potent synthetics like fentanyl have gone through the roof.”

One activist called for wider adoption of the CDC opioid guidelines and rigid enforcement if doctors don’t follow them. Gary Mendell, the CEO and founder of Shatterproof, a non-profit focused on preventing addiction, said each state should be held accountable and federal funding reduced to states if their prescribing exceeds a certain level.

“If every primary care doctor in this country followed the CDC guideline, you would cut by more than half, instantly, the number of new people becoming addicted,” said Mendell, whose son committed suicide after years of struggle with addiction. “We need a goal for the country. Divide it up by 50 states, a proper goal developed by the CDC, and then we need to publicize it and hold people accountable. Just like you would do in any business.”

Patrick Kennedy is a member of Shatterproof's board of advisors, and Andrew Kolodny, MD, founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP) is a member of its "opioid overdose advisory board."

No pain patients or pain management experts testified before the commission or were appointed to the panel.

Watch below for a replay of today's meeting: