How An Overdose Can Be Wrongly Reported

By Rochelle Odell, Guest Columnist

I started researching government statistics on overdose deaths a few weeks ago and learned the data is compiled by the Healthcare Cost and Utilization Project (HCUP), which is part of the Department of Health and Human Services.

HCUP keeps databases of ICD codes (International Classification of Diseases), which are built from hospital billing records. Basically, the codes identify what someone was being treated for at the hospital at the time of their death.

I realized that the ICD coding often begins when a person first enters the healthcare system (i.e. a trip to the emergency room or admission to a hospital). I also noticed that ICD codes for opioid overdoses do not separate the legal use of opiates from illegal drug use.

Then I learned that if a person dies, it could be months before the final coroner's report comes out. Does the government go back and change the ICD codes once the actual cause of death is determined?

Unfortunately, they do not.

So it all boils down to whether a person has opiates – any kind of opiate -- in their system at the time of death. If they are a chronic pain patient, there’s a good chance they will have opioid pain medication in their system. But rather than focusing on the true cause of death, everyone seems to immediately assume it was the medication.

I brought the point up with HCUP and told them their numbers were flawed and why. I was surprised to receive a nice email in response, validating my concerns and stating they would be passed along to the correct agency, the National Center for Health Statistics (NCHS).

“We will forward your email to NCHS to see if anything can be done to make the separation between illicit and licit use clearer in the coding,” HCUP replied.

If a citizen can find these flaws in a short time why can't anyone else? And how do I know if my concerns were truly shared and who received them?

As pain patients, we need to ensure that our families are aware that if we die from something unrelated to opiates, they’ll need to advocate for us even in death. Just finding opiates in our system does not mean we died of an overdose.

A good example of what could go wrong – and misreported -- happened earlier this month. A neighbor told me she had been walking her little dachshund when she stopped by a friend's house. The door was ajar, but there was no response. She sends her dog in and gets him to bark. At that point, her friend finally woke up. She had apparently suffered a stroke!

They called 911 and my neighbor waved down the ambulance as it approached. Her friend is in her 60's and right away the EMT verbally stated "it must be an overdose."

My neighbor immediately corrected the EMT and said her friend was not on pain medication and that this was not an overdose.

If my neighbor had not been there to set them straight, her friend may have been taken to the hospital and given the ICD code for a suspected overdose. The code could have followed her throughout her stay at the hospital, and if she had died, her death may have been wrongly reported as an overdose.

We need to stop this nonsense at step one.

Rochelle Odell lives in California. She suffers from Complex Regional Pain Syndrome (CRPS).

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 represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Health Insurer to Adopt 5 Day Limit on Opioids

By Pat Anson, Editor

The largest health insurer in the Philadelphia area, Independence Blue Cross, has announced plans to limit the prescribing of opioids in its network to just five days for acute pain.

New Jersey and several others states have implemented or are considering laws to limit the number of days opioids can be prescribed for acute, short-term pain, but Independence is one of the first insurance companies to adopt such as policy. Independence provides health coverage to more than 2.5 million people in southeast Pennsylvania, and through its affiliates to another 8.5 million people in 25 states and Washington, DC.

Independence already limits the quantity of opioids that physicians can prescribe. The company claims that policy has reduced "inappropriate" opioid use by its members by nearly 30 percent since 2014.

"Beginning in July 2017, we will further restrict prescriptions to no more than five days for initial low dose opioids. We will continue to cover longer lengths of opioid prescription use for members suffering from cancer related pain and hospice patients," the company said in a statement.

"This safeguard prevents multiple opioid prescriptions from being filled at different pharmacies and reduces the risk for addiction while addressing legitimate pain treatment. It also reduces the risk of unused medication being diverted into the hands of unintended users."

The company said it regularly promotes the Centers for Disease Control and Prevention's opioid prescribing guidelines, however those guidelines are voluntary and only intended for primary care physicians who are treating chronic pain. They do not recommend limiting opioids for acute pain.

"Most people may not require more than 5 days of an opioid for minor operations like skin biopsies or dental procedures.  However, there are many people who will require more than 7 days due to the type of operation and the person's response to pain," said Lynn Webster, MD, past president of the American Academy of Pain Medicine. "This shows how uninformed the (insurance) payers are with limiting days of treatment.

"A 5-day limit of opioids will increase the insurance company’s profits by paying for fewer pills, but there will be people who will needlessly suffer." 

Independence's parent company reported record revenue of $16.7 billion in 2016, an increase of 21 percent from the previous year. The company ended 2016 with a surplus of $2.4 billion.

Last year, 907 people died of drug overdoses in Philadelphia. Heroin and illicit fentanyl were involved in about half of the opioid overdoses. The city is currently on track to reach 1,200 fatal overdoses in 2017.

Deaths from prescription opioids like oxycodone and hydrocodone have been declining in Philadelphia since 2013, according to the city's Department of Public Health, a year before Independence started limiting access to painkillers.

Doctor Makes California Pain Clinic a Special Place

By Kristen Ogden, Guest Columnist

Rarely have I spent five days engaged in doing work that left me feeling as fulfilled as my recent stint helping as a volunteer in Dr. Forest Tennant’s pain clinic in West Covina, California.

For the past 3 years, I have been privileged to volunteer whenever I have traveled with my husband, Louis, for his appointments with Dr. Tennant. However, this was the first time I have given much thought to exactly what makes a visit to Dr. Tennant’s clinic such a special experience for his patients and their families.

COURTESY CORIN CATES-CARNEY/MONTANA PUBLIC RADIO

COURTESY CORIN CATES-CARNEY/MONTANA PUBLIC RADIO

Dr. Tennant and his wife and office manager, Miriam Tennant, sometimes refer to the clinic as a “mom and pop” operation.  If “mom and pop” makes you think of behind-the-times or unsophisticated, think again. 

Hidden in plain view, among the simple furnishings and interesting artifacts of a long career, is a true frontier in medicine, where discoveries are made, causes of rare diseases are pursued with vigor and, most importantly, a place where people suffering from constant pain are helped like nowhere else. 

One thing that stands out about Dr. Tennant’s clinic is the focus on family participation.  He requires prospective patients to be accompanied by a family member on their initial visits and encourages family members to attend.  The active engagement and participation of family is critical to a successful partnership with Dr. Tennant.  Patients and family members are required to sign documents to show their understanding of the off-label use of medications, willingness to participate in research, and acceptance of potential risks involved. 

The role of the family in supporting the patient is critical.  And why wouldn’t it be?  Intractable pain exacts its toll on the entire family.  A person suffering from undertreated severe pain becomes unable to function normally or participate fully in life.  Many face  loss of income, depletion of savings, routine tasks that don’t get done, loss of quality time with family, loss of contact with friends, and the loss of the ability to enjoy life.  Families with excellent relationships and coping skills are greatly affected. The impact on families less tightly bound can be enormous.  

I know many of Dr. Tennant’s patients and their family members.  They are just regular folks, nice people from all kinds of backgrounds, with one thing in common.  Somewhere along the way, their lives were hijacked by a rare illness or disease that bombarded them with unimaginable pain. 

Dr. Tennant’s embrace of patients extends beyond the walls of the clinic and the usual office hours.  During clinic week, you can expect to find him with Miriam enjoying dinner at a favorite restaurant with patients and family members, including many who traveled across the country and are staying in local hotels. It’s common to hear Dr. Tennant say, “We’ll be at Marie’s tonight around 7. Come join us for dinner.” 

Who has ever gone to see a doctor and gotten invited to dinner?  But that’s what he and Miriam do.  It’s another way they engage with families, and demonstrate their interest and care for patients.  They like to get to know their patients as people, not just names on a medical chart.

The informal group dinners bring other benefits.  For some, it is the first time they will meet others who share the agony of intractable pain or share the same illness. You may go to dinner wondering if you will enjoy an evening with strangers, and leave feeling like you have found a new extended family. 

Dr. Tennant always has some new diagnostic test or research study up his sleeve.  Recently, he asked patients to participate in a new DNA study of genetic indicators not previously studied in rare diseases that involve chronic pain.   Every new test and diagnostic tool reveals important information – hormone panels, nerve conduction studies, blood tests for inflammatory biomarkers, and MRI images that may reveal the presence of adhesive arachnoiditis.  

All of these diagnostic research efforts produce new insights.  For example, in a study of over 100 intractable pain patients who require relatively high opioid doses, Dr. Tennant found that 91% of them had genetic defects that impacted their ability to metabolize medications, suggesting why they need higher doses for effective pain relief. 

Another example is the growing understanding of the impact of pain on hormone levels.  Severe chronic pain initially elevates hormones, but if uncontrolled for too long, hormone levels become depleted.  Hormone levels that are too high or too low are biomarkers of uncontrolled pain, and indicate that higher doses of pain medications or hormone replacement may be necessary.  Ongoing clinical research is a key element of Dr. Tennant’s approach to pain care. 

In my visits with Louis to numerous pain doctors prior to finding Dr. Tennant, almost all of them said, “The goal is to get you off those pain medications.” 

I was shocked when I first heard Dr. Tennant say, “The goal is to relieve your pain.” 

Dr. Tennant has the expertise to “see” a patient’s pain and to ask the right questions. His discerning eye can distinguish between intractable pain patients and the few who come to the clinic seeking drugs for the wrong reasons. 

Dr. Tennant understands that most patients have already tried and failed at many different pain treatments.  When that is the case, he tries to determine what will work. The goal is to relieve pain so that the patient has a chance at meaningful improvement of function and quality of life.  There is no demeaning treatment, there are no words said that convey doubt or suspicion, there are no looks that say, “You must be a drug seeker.”  Dr. Tennant’s clinic is one of very few medical facilities I have visited where there was no evidence of stigma toward pain patients. 

An important piece of Dr. Tennant’s philosophy is that if you effectively treat the pain, improvements in function and quality of life will follow.  Dr. Tennant prescribes medication as needed to enable patients to effectively manage their pain, which in turn helps to stabilize their overall condition, while the underlying causes are identified and treatments are attempted.  If a patient’s pain remains undertreated, the likelihood of successfully treating the underlying causes is greatly reduced.

Transforming Pain Care

The Institute of Medicine’s 2011 report, Relieving Pain in America, called for “a cultural transformation in the way pain is understood, assessed, and treated.”  The characteristics I would seek in such a transformation of pain care are visible every day in Dr. Tennant’s clinic.  I wish that other doctors who treat chronic pain could get outside the bounds of their particular specialties and professional societies to view their patients differently. 

As Dr. Tennant’s research has moved forward, he has found that the majority of chronic pain patients who go to his clinic have 4 or 5 rare disease conditions:  adhesive arachnoiditis, post-viral autoimmune disease, Reflex Sympathetic Dystrophy (also called Complex Regional Pain Syndrome), and connective tissue disorders such as Ehlers-Danlos Syndrome.  All of these conditions are often accompanied by very severe, constant pain. 

In the last few years, Dr. Tennant has made great advances in identifying and treating the underlying causes of intractable pain.  He credits two recent scientific advances for enabling him to treat the causes rather than just the symptoms of pain. First, we now know that microglial cells within the central nervous system, once activated by a painful injury, disease or trauma, cause inflammation inside the brain and spinal cord.  This neuro-inflammation causes chronic pain to centralize in the spinal cord and brain, resulting in severe pain that is constant. 

Second, we now know that nerve cells may regrow, a process called neurogenesis.  Certain neuro-hormones in the brain and spinal cord can promote neurogenesis when neuro-inflammation is reduced.  Dr. Tennant’s approach is to reduce neuro-inflammation while simultaneously promoting neurogenesis.  His protocols for treatment of neuro-inflammation are in their early stage, but they are already providing disease regression, enhanced pain relief, less suffering, and, for some patients, reduction in the use of opioids. 

It is a true privilege to work as a volunteer in Dr. Tennant’s clinic.  When I asked him in 2014 if I could be a volunteer, I had two specific reasons:  to learn more so I could fight back against our insurance provider (who had suddenly decided to reduce the reimbursement for my husband’s pain medications), and to educate myself so that I could become an effective advocate for chronic pain patients.  We lost the battle with the insurance company, but I have certainly received an education that very few people have a chance to experience. 

Dr. Tennant’s methods and approaches are not proprietary -- he's eager to share them. There are many good doctors out there who could learn to do what he does, instead of focusing solely on the treatment of pain as a symptom. It doesn’t require a fancy clinic, lots of money, and corporate or university infrastructures.  What it takes is a doctor who is truly committed to relieving pain and practicing the art of healing. 

It is possible to manage pain with medicine instead of injecting the spine, inserting stimulators and pumps, or using other invasive procedures.  Instead of treating pain with these modalities, treat and relieve the pain with medication, stabilize the patient, and search for the underlying causes so that they can be addressed. 

At age 76, Dr. Tennant could have retired and given up his practice many years ago. Why does he put up with the many challenges of operating a pain clinic?  Because he truly cares about helping people who are suffering.

Kristen Ogden has advocated for her husband, a long-term intractable pain patient, for over 20 years.  She is the co-founder of Families for Intractable Pain Relief, an advocacy group for pain patients and their loved ones.

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 represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

VA Study Could Lead to More Cuts in Opioid Prescribing

By Pat Anson, Editor

A new study by a prominent think tank could give further ammunition to the Department of Veterans Affairs to reduce access to opioid pain medication in its healthcare system.

Researchers at the RAND Corporation studied data from nearly 32,500 patients who were treated at VA facilities in 2007 and were identified as having an opioid use disorder. The goal was to identify “quality measures” that could help reduce the death rate of addicted patients.

The researchers found that deaths were much lower among patients who were not prescribed opioids or anxiety medications, those who received counseling, and patients who had regular visits with a VA physician. They estimate the number of deaths could be reduced by a third if all three quality measures were adopted. 

"This is a very large drop in mortality and we need to conduct more research to see if these findings hold up in other patient care settings," said Dr. Katherine Watkins, a physician scientist at RAND and lead author of the study published in the journal Drug and Alcohol Dependence.

"But our initial findings suggest that these quality measures could go a long way toward improving patient outcomes among those who suffer from opioid addiction."

The findings suggest that a key to reducing mortality is to minimize the prescribing of opioid medication and benzodiazepines to veterans with opioid addiction. Benzodiazepines are a class of psychiatric medication used to treat anxiety disorders.

Because lower death rates were also associated with counseling and quarterly visits with a VA physician, researchers concluded that addicted patients benefit from making a connection with a caregiver, who can identify changes in their behavior and potential for relapse.

Surprisingly, patients in the study who were prescribed addiction treatment drugs such as Suboxone (buprenorphine) did not have lower death rates.

"We know from other research that medication-assisted therapy can help people stay off drugs, get jobs and lead more-productive lives," Watkins said. "But in this study, the treatment strategy was not associated with lower mortality."

The VA has already taken a number of measures to reduce opioid prescribing, including a new guideline that strongly recommends against prescribing opioids for chronic pain. VA physicians are also being urged not to prescribe opioids long-term to anyone under the age of 30. The guideline recommends exercise and psychological therapies such as cognitive behavioral therapy as treatments for chronic pain, along with non-opioid drugs such as gabapentin.

“We’ve been working on this now 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. We have a lot we can learn,” Secretary of Veterans Affairs David Shulkin told a White House opioid commission earlier this month. "At the VA, my top priority is to reduce veteran suicides. And when we look at the overlap with substance abuse and opioid abuse, it’s really clear.”

According to a recent VA study, an average of 20 veterans die each day from suicide, a rate that is 21 percent higher than the civilian population.  Veterans also suffer from high rates of chronic pain, depression and post-traumatic stress disorder.

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.