We Need To Talk About Suicide Risk From Untreated Chronic Pain

By Neen Monty

Doctors, policymakers, journalists, and pain experts endlessly warn about the risk of overdose from long term opioid therapy.

But almost nobody talks about the risk of suicide from untreated pain.

Why is this being ignored? Swept under the rug?

Refusing to treat severe pain is not a neutral decision. It is not “playing it safe.” It is not “erring on the side of caution.”

It is a clinical decision that elevates one small risk, while pretending the other barely exists. 

Even when that risk is significantly larger, and not even remotely comparable.

Let’s look at the actual numbers. The annual overdose death rate for chronic pain patients prescribed long-term opioid therapy is estimated at:

• 0.017% to 0.256% per year

• Around 0.014% annually at lower doses

• Roughly 0.25% annually at high doses (>100 MME/day)

• Roughtly 0.75% annually at very high doses (>200 MME/day)

Look at those numbers. Take them in. Understand how small that risk is.

And those numbers are from recent, large scale, well designed studies. That is what the evidence says. Not the rhetoric.

Yet overdose risk is the only risk anyone talks about. The risk used to justify forced tapers. The risk used to deny prescriptions. The risk used to terrify doctors into abandoning pain patients.

Now let’s compare it to the suicide risk associated with chronic pain.

Studies suggest:

• 5–14% of chronic pain patients attempt suicide

• Chronic pain patients have a suicide risk 2–3 times higher than the general population

• Around 9% of all suicides in the United States involve chronic pain

Take a good look.

It’s not 0.014 percent. Or 0.25 percent.

It’s five to fourteen percent.

Unlike the overdose rhetoric, this is not a theoretical or hypothetical “what if.”

And the suicide numbers are going up, as more and more people are force tapered off their opioid pain medications.

The cruel irony is that the pain management providers often treat opioid overdose as the worst possible outcome, while treating suicide is an unfortunate but unrelated side issue.

But uncontrolled pain is devastating. It destroys lives.

This is not hard to understand. Think about the worst pain you’ve ever experienced. Now, imagine it did not go away. Imagine you have to live with it every single day for the rest of your life. How long could you handle that?

Uncontrolled pain causes:

• hopelessness

• isolation

• sleep deprivation

• loss of identity

• financial collapse

• disability

• relationship breakdown

• depression

• fear of the future

And if a person expresses any of these fears, they are often deemed as “catastrophising.” The psychological harm caused by uncontrolled pain is substituted as the cause of that pain.

And patients get psychological treatment, when what they really need is pain relief.

They are not the same thing. You cannot switch cause and effect and expect a good outcome. You cannot make physical pain go away with psychological therapies. 

The best you can hope for is improved coping skills. But no one can cope with 8+ pain on a daily basis.

No one.

Not for very long, anyway. Not when you know that pain is never going away. How long could you cope with that?

Eventually, for some people, it causes the desire to escape. And there is only one way to escape, when doctors refuse to treat the pain.

Not because people living with severe, untreated pain are weak. Not because they are “catastrophising.” Not because they need a mindfulness workshop or some grounding.

Because severe, relentless pain changes human psychology.

That should not be hard to understand. If you put your hand on a hot stove, your nervous system screams at you to escape. Take your hand off the stove!

What exactly do people think happens when that signal never stops?

For years? Or decades?

I know that many clinicians choose to believe this kind of pain does not exist. That no one has pain that is a constant and severe 8+. 

That is not true. That’s what we call denial. And it does a lot of patient harm.

My pain is an 8+ every day, for much of the day. My pain is not amplified by psychological issues. My pain is purely physical. I have been in pain for 20 years. If you think I haven’t learned about pain and coping skills, then you are doing me a grave disservice.

And here is the part nobody wants to say out loud:

When a clinician refuses to adequately treat severe pain, they are making a risk calculation.

They are deciding that preventing a comparatively rare overdose death is more important than preventing the far more common risk of suicide.

It makes no sense, not logically, not medically.

But it is true.

Every medical decision involves risk trade-offs. Medicine is all about risks vs benefits.

We accept bleeding risks to prevent stroke. We accept infection risks during surgery. We accept chemotherapy toxicity to treat cancer.

But somehow, in pain medicine, only one risk counts: Overdose.

Nothing else matters. Everything else disappears. The suffering disappears. The suicide risk disappears. And the patient disappears.

But the pain does not disappear.

Even worse, pain patients are often blamed for the emotional consequences of living in agony.

If they become distressed, hopeless, fearful, withdrawn, anxious or depressed, that is now framed as a psychological problem, a mental illness that requires psychotherapy, rather than an understandable and normal response to relieve their physical suffering.

Imagine applying that logic anywhere else in medicine.

An amputee becomes depressed and hopeless because they can no longer walk.

Would we respond by saying: “Have you tried reframing your thoughts?”

Or would we offer them treatment? Prosthetics? A wheelchair? The ability to regain some of what they have lost?

A person loses their hearing, and becomes depressed and hopeless because they can no longer communicate.

Would we respond by saying: “Have you tried learning about how hearing works?”

Or would we teach them lip reading and sign language, and introduce them to the deaf community?

I could list a million examples. The point is, we should treat the problem. In no other forum do we withhold treatment and offer psychological therapies that are inappropriate and ineffective, rather than treat the actual pain.

None of this means that opioids are risk-free. They are not.

Opioids can absolutely cause harm, especially when combined with sedatives, are used recklessly, or prescribed without appropriate monitoring.

But pretending that untreated pain is safer than treating with opioids is not evidence-based medicine.

It is ideology.

And the people paying the price are patients trapped in severe pain with fewer and fewer options.

Medicine loves the phrase: “First, do no harm.”

But untreated and undertreated pain is doing harm.

Patient abandonment is harmful. Forcing people to suffer while congratulating yourself for reducing opioid prescribing is harmful.

Sometimes, it is simply choosing a different kind of death for your patient. 

An earlier death.

One that happens quieter.

One that is easier to ignore.

One that can be separated from lack of treatment.

One that can be attributed to poor mental health, instead of pain.

One that leaves no scandalous headline.

One that policymakers do not have to feel responsible for.

Perhaps that is the real issue. Overdose deaths are visible, while pain patients are invisible.

So only one becomes politically inconvenient.

Neen Monty is a patient advocate in Australia who lives with rheumatoid arthritis and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), a progressive neurological disease that attacks the nerves.

Neen is dedicated to challenging misinformation and promoting access to safe, effective pain relief. For more information on chronic pain, the science, the politics and the lived experience, got to Pain Patient Advocacy Australia. You can also subscribe to Neen’s free newsletter on Substack, “Arthritic Chick on Chronic Pain.”

CYP2D6: The Enzyme That Determines How Effective an Opioid Is

By Dipa Kamdar

For a medicine so commonly found in bathroom cabinets and high street pharmacies, codeine has a surprisingly complicated story. It sits at the intersection of pain relief, genetics, public health and regulation. 

As the UK and other countries continue to tighten rules around opioid use, codeine offers a useful case study in how a drug can be both helpful and potentially harmful, depending on who takes it and how it is used.

Codeine is an opioid used to treat mild to moderate pain. In some formulations, it is also used to suppress coughing. Over-the-counter products typically combine it with paracetamol, as in co-codamol, or ibuprofen, while stronger doses are available only on prescription.

Codeine itself is a weak opioid. Its analgesic effect is about one tenth that of morphine. Once swallowed, it is metabolised by enzymes in the liver, with some of it converted into morphine. That morphine then produces pain relief by acting on opioid receptors in the brain. 

For most people, the body makes enough morphine to ease symptoms. For others, the same dose can be ineffective or unexpectedly strong.

Fast vs Poor Metabolisers

One of the most striking features of codeine is how differently people process it. The enzyme mainly responsible for converting codeine into morphine, CYP2D6, varies significantly between people. Most metabolise codeine at an expected rate, but some carry genetic variants that alter the process.

A small proportion of the population are ultra-rapid metabolisers, thought to make up around 1% to 2% of people. They convert codeine into morphine much faster than average. 

This trait is more common among people of North African and Middle Eastern backgrounds, for whom even standard doses can produce unexpectedly high morphine levels, increasing the risk of severe drowsiness, breathing difficulties and other serious side effects.

Around 2% to 11% of people are intermediate metabolisers. Their CYP2D6 enzyme works more slowly or less effectively, so codeine may provide only limited benefit.

At the other end of the spectrum are poor metabolisers, estimated to make up 5% to 10% of the population. They convert very little codeine into morphine, so the drug may offer little or no pain relief. 

Poor metabolism is more common in people of white European descent. In these cases, it may make more sense to prescribe a different painkiller rather than rely on a drug the body cannot use efficiently. This wide variation makes codeine far less predictable than many people assume.

The Trouble With Codeine

That unpredictability matters because low-dose codeine does not always offer much in return. Research suggests that many over-the-counter codeine products provide little proven benefit for pain relief, particularly at doses below 10mg, while still carrying the risk of side effects. 

A review found that low-dose codeine combinations gave only modest relief for short-term pain, such as dental pain, episiotomy pain or pain after minor surgery, and many of the underlying trials were small.

By contrast, combinations such as ibuprofen 400mg with higher-dose codeine, between 25mg and 60mg, appear to provide more reliable relief. Even so, studies suggest that simple combinations such as paracetamol plus ibuprofen can match or outperform low-dose codeine products without the risks associated with opioids.

Common side effects include constipation, nausea, dizziness and drowsiness. At higher doses, codeine can slow breathing and impair coordination. It can also interact with other medicines that cause sedation, including some antiepileptic drugs. Certain antidepressants can block the enzyme that converts codeine into morphine, making it less effective.

Like other opioids, codeine can also become less effective with repeated use. This process, known as tolerance, happens when the brain’s opioid receptors adapt to the drug. People may then need higher doses to achieve the same effect. Even when taken as directed, tolerance can develop within days, and as doses rise, so does the risk of physical dependence.

Stopping suddenly after regular use can trigger withdrawal symptoms such as restlessness, sweating, anxiety and poor sleep. This is why health professionals advise using codeine for the shortest possible time and tapering the dose if it has been taken for longer periods.

Concerns about misuse, addiction and accidental harm have prompted tighter regulation in the UK. The Medicines and Healthcare products Regulatory Agency has introduced clearer warnings on packaging about addiction risk and limited over-the-counter pack sizes to a maximum of 32 tablets or capsules. Non-prescription codeine-containing products are now intended for use for no more than three days. Stronger codeine tablets, including 30mg formulations, have long been prescription-only.

Some products have faced even stricter controls. Codeine linctus, once widely used as a cough suppressant, was reclassified as prescription-only in 2023 because of growing concerns about misuse and diversion. 

It has been used in “purple drank”, a recreational mixture of codeine cough syrup with soft drinks and sometimes alcohol. Its opioid effects can lead to dependence, breathing difficulties and overdose, especially when combined with other sedatives.

Codeine remains a useful option for short-term pain when other medicines are unsuitable or insufficient. But its effectiveness, safety and potential for dependence vary far more than many people realise.

In a landscape where medicines are often judged by how familiar they feel, codeine is a reminder that common does not always mean simple. Used carefully, it can help. Used carelessly, it can cause problems that last long after the pain itself has passed.

Dipa Kamdar is a Senior Lecturer in Pharmacy Practice at Kingston University.

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

Does Depression Screening Work for Chronic Pain Patients?

By Crystal Lindell

For many patients with a chronic illness, every time they go to the doctor they have to fill out the infamous depression questionnaire – even if the reason for their visit has absolutely nothing to do with their mental health.

Formally known as “Patient Health Questionnaire-8 (PHQ-8),” it starts with this question:

"Over the last 2 weeks, how often have you been bothered by any of the following problems?"

It then lists things like "Little interest or pleasure in doing things" or if you are feeling tired, have trouble sleeping, or have a poor appetite.

Patients are then asked to rank their responses on a scale that goes from "Not at all" to "Nearly every day."

Over the years, I have often scored poorly on this questionnaire, which means I ranked very high for clinical depression during those times in my life. 

Looking back, I’m pretty sure what it really measured was whether I was so depressed that I just didn’t care about trying to hide anything. But regardless, I do think that when I scored high, I actually was very depressed.

However, there has long been a belief that the questions don’t work well for chronic pain patients, who often have sound physical reasons for their poor sleep, appetite, and other symptoms. This would inflate their depression scores. 

For example, "Feeling tired or having little energy" as well as "Trouble falling or staying asleep, or sleeping too much" and "Trouble concentrating on things" are all symptoms that can be greatly impacted by physical pain, regardless of your mental health.

Now, a new study claims to prove the questions are an accurate way to measure clinical depression – even in patients with chronic pain. Published in the Journal of Affective Disorders, the research analyzed how reliable the questions are for people with and without chronic pain.

In a news release about the study published by the University of Arizona, lead author Jennifer De La Rosa, PhD, discussed the motivation for her research.

"Could pain symptoms artificially inflate depression screening scores among those with chronic pain? It's a reasonable question, but it had not yet been definitively answered," said De La Rosa, who also serves as Director of Strategy at the school’s Comprehensive Center for Pain and Addiction.

"Using nationally representative population data, we rigorously evaluated this question and found no evidence to support this long-standing concern."

De La Rosa and her team analyzed data from nearly 32,000 U.S. adults who participated in the 2019 National Health Interview Survey. They found that the questionnaire achieved an excellent level of consistency for people with chronic pain and those without. They concluded that the consistency equaled reliability.

"Clinicians need to know that a positive depression screening is just as reliable in their patients with chronic pain as patients without chronic pain, and they should not hesitate to offer mental health supports to any patient with unmet mental health needs," De La Rosa said. "These conversations require sensitivity to ensure patients feel supported by these conversations rather than stigmatized.”

She also lamented that many clinical trials for depression exclude chronic pain patients. De La Rosa hopes that will change.

"This study provides robust evidence that there would be no scientific problem with including folks living with chronic pain in depression research to help develop treatments capable of meeting the needs of this uniquely underserved population," she said.

The study reinforces De La Rosa's previous research, which found that while 1 in 5 people with chronic pain have depression, more than half of those with clinically significant depression also have chronic pain.

Another recent study estimated that about 40% of chronic pain patients have clinical symptoms of depression or anxiety. The depression rate is even higher for those who have fibromyalgia or chronic pelvic pain.

Why Chronic Pain Patients Often Pretend to Be Healthy

By Crystal Lindell

Whenever I meet new people, I like to spend a little time in that magical in-between land where they don’t yet know I have chronic pain.

It’s a place that only exists in fantasy, but it lets me play pretend. 

I get to pretend that I’m just a regular person whose entire life does not revolve around my pain.  

How long I get to stay in that fantasy land with new people depends on a few factors. Namely, how often I have to see them, how effectively my medication is currently working, and how often my pain is flaring. 

Of course, because I write about my health issues online, it’s also greatly dependent on them not Googling my name.

But it’s fun while it lasts.

Look at me! I’m just a regular person! I don’t need 15 hours of recovery time after activities! Rainy days don’t render me incapable of getting out of bed! I can definitely skip sleep to get more work done!

I’m TOTALLY HEALTHY!

In essence, I’m socially masking. But instead of trying to mask my true personality to fit in, I’m trying to mask my physical pain.   

Eventually, my body always betrays my charade though, and I have to reveal at least some of my health issues. It usually happens because I have to cancel plans due to a pain flare, or because I get an injury.

Even then, I still only like to reveal small bits of information. I don’t give an entire back story and list of diagnoses right away. I only share what I need to.

I don’t have Ehlers-Danlos Syndrome, I have “a genetic condition.” I don’t have intercostal neuralgia, I have “some pain in my ribs sometimes.”

There’s a common trope that people with chronic health issues like to let it define their entire identity. Doctors often point to this as a reason why people might be claiming to be sicker than they actually are. Like it’s a fun fad.

But that’s not my experience at all. Yes, my chronic health issues do define my entire identity – but I do not like it. In fact, I hate it. 

I want to be a regular person so badly – even if it’s just in the minds of casual acquaintances. I want to be who I remember I was before I started having chronic pain. I want to be reliable, bubbly, and sober.

Of course, there’s one major downside to always trying to hide my chronic pain and my health issues from new people: It makes it that much harder for others to ask me for help.

That’s why I chose to write online about my chronic pain so openly. I want people to know that they are not alone, and I want to share things with them that have helped me survive in this broken body.

I just don’t always want that experience in real life, with real people, in real situations.

That said, over the years, I have found that when my health issues do eventually come up in-person, many people are often quick to confide that they are also hiding their own ailments, and their own need for help.

When I share my health-related secrets, theirs usually come flooding out as well. And if not theirs, then the struggles of loved ones and those they care for.

Then, once that bridge is crossed, we can commiserate. More importantly, we can share the secret ways in which we cope.

As the fantasy of being healthy dies, true friendship blooms. But that doesn’t mean the fantasy wasn’t magical while it lasted.

In the end, the truth is most people aren’t going around pretending to be sicker than they actually are. Rather, a lot of people are trying to pretend that they are healthier than they ever could be – myself included.

Trump’s Endorsement of ‘Natural 7-OH’ Stirs Debate in Kratom Industry

By Pat Anson

The Trump administration has given another sign that it plans to keep some “natural” forms of kratom legal under federal law. Left unclear, however, is what the administration means by “natural.” 

In wide-ranging remarks on healthcare Monday in the Oval Office, President Trump said his administration would seek to have “natural 7-OH” approved. That is a reference to 7-hydroxymitragynine (7-OH), an alkaloid in kratom that has pain relieving and mood enhancing qualities.   

“We’re looking very seriously at natural 7-OH and getting that approved, natural 7-OH. And we’ll take a look at that very strongly. I think Oz and everybody, we’re looking to see if we can do something there. A lot of people are asking for it. And thank you very much for the work on that,” Trump said, while gesturing towards Dr. Mehmet Oz, Administrator of the Centers for Medicare & Medicaid Services.

Trump’s remark about “natural 7-OH” soon became a Rorschach test for rival advocacy groups in the kratom industry. Supporters of natural leaf kratom said the president was referring to the trace amount of 7-OH – usually no more than 2% – found in unadulterated kratom.

MNG Brands, a kratom vendor, said it was “encouraged by the support shown for natural leaf kratom Trump was clearly endorsing” – not the concentrated and more potent forms of 7-OH that have entered the market in recent years.

Several states and dozens of cities and counties have banned those "synthetic" forms of 7-OH, saying they are potentially harmful and addictive. 

"MNG Brands has long supported regulatory frameworks that protect consumers, prevent youth access, and create accountability within the industry," Dafna Revah, Chief Strategy Officer of MNG Brands, said in a statement.

"We believe there is a meaningful difference between traditional natural leaf kratom products and highly concentrated or synthetic derivatives being introduced into the market without consistent standards or oversight."    

But the Holistic Alternative Recovery Trust (HART), which represents 7-OH manufacturers like American Shaman, has a different take on what Trump said. A HART news release said the president was endorsing all forms of 7-OH, even the concentrated products that contain as much as 96% 7-OH. 

7-OH vendors maintain that their products are “natural” since they contain an alkaloid that occurs naturally in kratom and is produced by the human body itself. That happens when the liver processes and converts mitragynine, another kratom alkaloid, into even more 7-OH.

“President Trump said his administration is trying to keep 'natural 7-OH' available. That distinction matters, and it is the same distinction lawmakers and regulators should be moving forward. Policymakers should focus on stopping bad actors, mislabeled products, unsafe marketing practices, and inconsistent manufacturing standards, not criminalizing naturally derived products that millions of Americans already use,” said Jeff Smith, HART Executive Director. 

“A blanket ban on natural 7-OH is now directly at odds with the President’s stated goal. The FDA should support the direction set by the President and work toward a regulatory framework that protects consumers without eliminating lawful access to natural products.”

Mac Haddow, Senior Fellow on Public Policy for the American Kratom Association, a group of natural leaf kratom vendors, said that was a misleading take on what the president said.

“As I understand it, from people who are familiar with the President's view on this, that he was speaking about natural kratom, as opposed to synthetic or chemically manipulated 7-OH,” Haddow told PNN.

“These people are deliberately misleading legislators and public health officials in order to try to make their products sound like, ‘Oh, they're okay, they're just like natural kratom.’ They are not, and it's a big con job.”

Like other dietary supplements, kratom and 7-OH currently are lightly regulated under federal law. As long as manufacturers and vendors don’t make medical claims about them, kratom and 7-OH can be sold legally as far as the federal government is concerned. They are not controlled substances — at least not yet.

But that hasn’t stopped states and local governments from banning 7-OH or natural leaf kratom for their opioid-like qualities, as many have in recent months.

It’s been nearly a year since the FDA asked the DEA to have 7-OH – but not whole leaf kratom – classified as an illegal Schedule One controlled substance. The DEA has yet to act on the FDA’s request, leaving 7-OH in a legal limbo.

President Trump’s remark this week doesn’t change 7-OH’s status, but it does signal that the administration is willing to have some forms of 7-OH remain on the market. Whether that’s the “natural” 2% or concentrated 96% versions remains unclear.

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

By Pat Anson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Many Rx Opioids – Not Just Suboxone – Raise Risk of Dental Disease

By Pat Anson

Suboxone isn’t the only opioid medication linked with dental decay and disease.

A large study led by VA Connecticut researchers found that patients on long-term opioid therapy with pain medications such as morphine and oxycodone have a significantly higher risk of infection-related dental disease.

The observational study included data from over 2 million U.S. veterans, 36% of whom were on long-term opioid therapy (LTOT). Those taking opioid pain medication for at least 90 days had a 24% higher chance of tooth decay, infections or tooth loss. 

Suboxone, which contains the partial opioid agonist buprenorphine, was excluded from the study, along with the opioid methadone. Both medications are used to treat opioid use disorder (OUD). 

The FDA warned in 2002 that buprenorphine tablets and film, when dissolved in the mouth, were linked to serious dental problems, including tooth decay, cavities, oral infections, and loss of teeth. Methadone has also been associated with dental problems because it induces dry mouth (xerostomia), which reduces saliva needed to wash away bacteria and plaque.  

The new study is believed to be the first linking dental disease to opioids taken long-term for pain relief.

“To our knowledge, this is the first study to demonstrate the association between LTOT exposure and dental disease. This finding is important in light of recent warnings of buprenorphine risks that may influence decision-making in the context of chronic pain and/or OUD,” researchers reported in the journal PLOS One.

In their analysis, VA researchers compared veterans who took 12 opioids (hydrocodone, oxycodone, morphine, fentanyl, hydromorphone, dihydrocodeine, meperidine, pentazocine, propoxyphene, levorphanol, tramadol, or tapentadol) to veterans who had no exposure to LTOT in the prior year.

Researchers think the higher rate of dental disease for those on LTOT stems from immune suppression and reduced saliva flow, which raises the risk of bacterial infections that lead to dental disease and cavities. 

The findings suggest that all patients on LTOT – whether for pain relief or OUD treatment – should be cautioned about the risks of dental problems.

“Concern over these risks may present a barrier to buprenorphine initiation in patients prescribed LTOT for whom such treatment is indicated. However, full opioid agonists themselves may pose oral health risks due to immunosuppression and well-documented effects on saliva flow causing xerostomia; both create opportunity for oral disease development,” researchers concluded.

Doctors who have patients on LTOT are advised to monitor their oral health and to have discussions with patients about dental risks before starting them on opioids.

There are simple steps patients on long-term opioids can take to reduce their risk of dental disease. Patients on buprenorphine or methadone are often advised to drink more water to combat dry mouth, and to brush and floss regularly to help prevent dental infections. 

The Fake Excuses Pharmacists Use to Avoid Filling Opioid Prescriptions

By Crystal Lindell

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

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

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

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

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

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

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

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

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

Claim #1: Insurance won’t cover the medication

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

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

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

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

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

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

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

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

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

Claim #3: The medication is completely out of stock

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

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

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

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

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

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

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

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

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

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

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

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

By Sukhun Kang

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

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

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

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

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

Three decades later, the problem of seeding trials persists.

How Seeding Trials Work

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

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

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

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

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

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

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

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

Vioxx and Gabapentin Seeding Trials

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

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

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

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

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

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

How Common Are Seeding Trials?

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

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

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

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

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

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

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

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

What Can Be Done

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

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

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

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

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

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

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

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

The Downside to Powering Through Pain

By Crystal Lindell

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

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

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

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

I was swimming in wins after I took it.

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

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

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

I am also completely exhausted.

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

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

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

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

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

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

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

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

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

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

From CRPS Patient to Triathlete

By Madora Pennington

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

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

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

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

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

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

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

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

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

Susie Ruvalcaba

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

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

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

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

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

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

‘Doctors Didn’t Believe Me’

 Ruvalcaba kept trying to find better treatment. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Methylene Blue: A New Pain Relief Option

By Dr. Forest Tennant

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

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

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

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

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

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

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

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

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

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

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

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

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its research bulletins here.   

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

How To Tell if Your Dog Is in Pain

By Jacqueline Boyd

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

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

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

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

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

Signs of Pain

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

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

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

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

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

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

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

The Link Between Pain and Behaviour

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

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

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

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

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

What To Do If Your Pet Is in Pain

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

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

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

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

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

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

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

Can AI Outperform Human Doctors?

By Crystal Lindell

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How Emotional Distress Makes Chronic Pain Worse

By Pat Anson

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

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

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

“Mental defeat can worsen chronic pain, researchers say”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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