DEA Missed Deadline for Opioid Production Quotas. Will It Worsen Shortages?

By Pat Anson

In recent years, hundreds of physicians have been prosecuted by the U.S. Justice Department for violations of the Controlled Substances Act (CSA).

In many cases, the doctors were accused of prescribing opioid pain medication without “a legitimate medical purpose” – a vague term in the CSA that was meant to prevent drug abuse, but in practice put the DOJ in charge of deciding whether healthcare decisions involving controlled substances are legal. 

The CSA is rigidly enforced when federal prosecutors believe opioids are prescribed excessively. But when it comes to enforcing another provision in the CSA, the DOJ and Drug Enforcement Administration have routinely ignored deadlines for setting aggregate production quotas (APQs) for opioids and other Schedule I and II controlled substances:

“On or before December 1 of each year, upon application therefor by a registered manufacturer, the Attorney General shall fix a manufacturing quota for the basic classes of controlled substances in schedules I and II.”

The December 1 deadline is important because it gives the pharmaceutical industry a small window to prepare for the coming year by acquiring raw materials for drugs, setting manufacturing schedules, and distributing medications to hospitals and pharmacies – a process that can take as long as six months. . 

But Attorney General Pam Bondi and acting DEA Administrator Terry Cole didn't publish their proposed quotas for 2026 in the Federal Register until November 28, which call for a 6% cut in the supply of oxycodone.

Allowing for a shortened public comment period that ends December 15, and time to review thousands of comments and make changes in the quota allotments, that means the final APQs for next year will likely not be ready until after January 1.

The last time production quotas were that late was in 2024, when the final APQs were not published until January 3. Drug shortages spiked to record levels in the first few months of that year, including many medications that are covered under the quota system. 

Missing the deadline again this year threatens to worsen chronic shortages of oxycodone, hydrocodone, fentanyl, hydromorphone, morphine and amphetamine-based stimulants that are vital to millions of patients who live with pain or attention deficit disorder (ADHD).

The DOJ and DEA did not respond to multiple requests from PNN to explain why the CSA deadline was missed again.

This is not a new problem. Late quotas and drug shortages have persisted for years, as the DOJ and DEA have focused on going after doctors – at times using “flimsy evidence” – rather than ensuring that essential medications are available on time. 

That mindset of being a law enforcement agency first – with maintaining the drug supply an afterthought – may have cost some patients their lives. 

“We talk a lot about opioid misuse, but almost never about the quiet suffering caused when essential pain medicines simply aren't available,” says Lynn Webster, MD, a pain management expert and former president of the American Academy of Pain Medicine. “Chronic delay and rigidity in quota decisions make patients with serious illness feel like collateral damage in a war on drugs that has lost sight of its humanitarian obligations.

“Quotas were meant to curb diversion, not to create a permanent state of scarcity for people in pain. By keeping quotas tight and decisions late, the DEA has turned an already fragile supply chain into a game of musical chairs where patients lose their seats.”

Late Quotas Worsened Drug Shortages

As far back as 2015, the General Accountability Office (GAO) warned in an audit report that the DEA “has not effectively administered the quota process.” Although a decade old, many of the problems cited by the GAO still exist today.

“Each year, manufacturers apply to DEA for quota needed to make their drugs. DEA, however, has not responded to them within the time frames required by its regulations for any year from 2001 through 2014,” the GAO said.

“Manufacturers who reported quota-related shortages cited late quota decisions as causing or exacerbating shortages of their drugs.”

The report found that drugs containing Schedule II controlled substances accounted for over half the shortages between 2001 and 2013. Several manufacturers complained to the FDA the shortages were caused by the DEA’s mishandling of the quota system.

But the DEA denied any responsibility for the shortages, while blaming the missed deadlines on  “inadequate staffing” and an “increasing workload” in its Quota Unit.

“DEA is confident that its administration of the quota process did not affect a shortage during the period of review because drug product shortages are not limited to products that contain Schedule II controlled. substances,” Joseph Rannazzisi, then-DEA Deputy Assistant Administrator, wrote in the agency’s response to the GAO report.

Rannazzisi would later emerge as a “whistleblower” on 60 Minutes, who blamed the opioid crisis on lax policies at the FDA that favored that drug industry.

The relationship between DEA and FDA, at least in 2015, was not one of trust. The FDA advised the DEA about medical demand for Schedule II drugs and any shortages that may exist, but the DEA didn’t always listen.

“DEA and FDA are not able to effectively collaborate due to fundamental disagreement over whether any given shortage exists. DEA has made it clear it does not trust FDA’s information, as it does not consider many of the shortages that FDA verifies to be legitimate,” the GAO said. “They do not believe FDA appropriately validates or investigates the shortages.” 

The GAO concluded that problems in DEA’s Quota Unit run deeper than any petty rivalries with the FDA. 

“Our work shows that DEA’s lack of internal controls, such as controls to ensure data reliability, performance measures, and monitoring of performance, may hinder the agency’s ability to ensure an adequate and uninterrupted supply of controlled substances,” the 2015 report found. “This approach to the management of an important process is untenable and poses a risk to public health.”

New Deadline

The GAO’s critique came at a time when the DEA’s deadline for final APQs was October 1 – a deadline the agency consistently failed to meet. 

To buy itself more time to work on quotas, the DEA lobbied Congress to change the annual deadline to December 1 in the 2018 Support Act, a bill intended to reduce opioid diversion. The DEA also reduced the amount of inventory drug manufacturers are allowed to keep of controlled substances, and agreed to base its quotas on dosages, not the raw supply of drugs.

How has that worked out? Poorly.

The DEA has not only been unable to meet the December 1 deadline, but the smaller inventories have worsened the ability of drug manufacturers to respond to late quotas and emerging drug shortages. 

The pharmaceutical industry warned the DEA that reducing inventories would only worsen shortages and do little to prevent diversion.

“We believe that risks associated with this proposal, including the increased likelihood for drug shortages and market outages, greatly outweigh the negligible benefit this provision will provide,” Larry Cote, an attorney representing a drug manufacturer, wrote to the agency in 2019.

“Given the timing of procurement quota issuance, it will become more imperative to carry increased levels of inventory at year end in order to ensure continued drug supply, as opposed to decreased levels.”

The DEA ignored those warnings and reduced inventories anyway. As a result, analgesic medications needed for surgery and post-op care, such as injectable fentanyl and hydromorphone, have been on the FDA shortage list for years, in part due to low inventories. The two drugs are rarely diverted.

‘Vulnerable to Supply Shocks’

Two pharmacists recently criticized the DEA for its “outdated system” for APQs.

“The current one-size-fits-all system for setting APQs is ineffective and Congress recognized this back in 2018, passing the SUPPORT Act to modernize the APQ setting process and require quota allocations based on dosage form. Yet seven years later, the DEA has failed to implement this law, leaving manufacturers constrained, patients underserved, and the nation vulnerable to supply shocks,” Soumi Saha, PharmD, and Justin Schneider, PharmD, wrote in a recent op/ed published in the Pharmacy Times.   

Saha and Schneider believe many of the quota problems could be addressed if the DEA were to hire a Chief Pharmacy Officer who is familiar with the drug supply system and is put in charge of the quota system.

“It is time to elevate the agency’s clinical responsibility by establishing a Chief Pharmacy Officer (CPO) within the DEA - a role dedicated to ensuring that patient access is not an afterthought, but a core priority,” they said. “A strong CPO would not only modernize quota systems but also bring agility, accountability and patient advocacy to the heart of DEA decision-making.”

To be clear, the DEA is not solely at fault for persistent shortages of opioids and other controlled substances. A 2021 opioid litigation settlement with three drug distributors essentially rationed the supply of opioids at many pharmacies and made pharmacists even more wary of filling new prescriptions. 

In a 2023 PNN survey of over 2,800 patients, 90% said they experienced delays or problems getting their opioid prescriptions filled, mostly because their pharmacy was out of stock. Nearly one in five were unable to get their pain medication, even after contacting multiple pharmacies.

Some generic drug manufacturers have stopped making opioids because of low profit margins and because of concerns they could be targeted by plaintiff law firms in opioid lawsuits that could cost them billions of dollars. 

Bad weather and a heavy reliance on foreign drug manufacturers have also made the supply chain less reliable and contributed to shortages.  

But the DEA’s chronic failure to meet quota deadlines – a problem dating back decades – and its slow-walking of efforts at reforming the quota system, have made a fragile drug supply chain even more vulnerable to disruptions. And it is patients who pay the ultimate price for the DEA’s negligence.

“When DEA repeatedly misses its own deadlines for setting opioid production quotas, that uncertainty reverberates all the way to the bedside,” says Dr. Webster. “Manufacturers pull back, pharmacies ration, and it's the patients – people with cancer, sickle cell disease, or severe chronic pain – who are left wondering if their next prescription will even be filled.” 

Should the DEA hire a Chief Pharmacy Officer? Should deciding what is or isn’t “a legitimate medical purpose” be left to the DEA and DOJ? Only a few days are left to comment on the DEA’s proposed APQs for 2026. You can leave a public comment by clicking here.

A War on Drugs That Bombs Boats, Pardons ‘Narco-State’ President, and Prosecutes Doctors

By Dr. Lynn Webster

On September 1, 2025, a U.S. warplane blew apart a small speedboat in the Caribbean, killing all eleven people on board. President Trump released the video like a trailer for a new season of a drug war TV series, boasting that the vessel was loaded with narcotics and crewed by Venezuelan “narco-terrorists.”

The strike was the opening salvo in a new campaign of air attacks on suspected drug boats in the Caribbean and eastern Pacific — Operation Southern Spear — that has killed at least 87, all on the strength of the administration’s unproven claims about who was on board and what cargo they were carrying.

On December 1, the same administration quietly did something very different. It issued a “full and complete pardon” to former Honduran president Juan Orlando Hernández, who was convicted in a U.S. federal court of helping move more than 400 tons of cocaine into the United States and running Honduras as what prosecutors called a “narco-state.”

Hernández was serving a 45-year sentence when the pardon came through. The White House justified the move by claiming the trial was “politicized” under the prior administration and that Hernández was the victim of overzealous prosecutors relying on compromised witnesses.

So, in the space of a few months, we have a government that claims the authority to kill alleged drug traffickers on the high seas without a trial, while freeing a former head of state that U.S. courts found to be deeply enmeshed in the cocaine trade.

At the same time, ordinary physicians inside the United States continue to be charged as “drug dealers in white coats” for prescribing opioid analgesics to patients in pain—often amid clinical uncertainty and shifting standards of care.

Drug Control by Spectacle

Together, the boat killings, the Hernández pardon, and the prosecution of well-intended physicians reveal something fundamental about the modern American war on drugs: It is less a coherent public-health strategy than a flexible political script.

Consider Hernández. For years, he was treated as a reliable U.S. ally, an eager partner in migration control and anti-drug cooperation. Only after he left office did the Justice Department present evidence that his government functioned as a protection racket for traffickers, with bribes flowing in and cocaine flowing north.

A New York jury convicted him; a federal judge imposed a 45-year sentence; and families ravaged by the cocaine trade were told this was a landmark in the fight against high-level corruption.

Yet, with the stroke of a pen, that message has been reversed. The pardon has been widely read in Honduras as an intervention on behalf of Hernández’s political allies, and it signals that even the most spectacular narcotics conviction is negotiable if the defendant is useful to Washington.

Now, set that alongside the first boat killing and the broader air campaign that followed. Under Operation Southern Spear, U.S. forces have been authorized to strike suspected drug-running vessels in international waters, killing dozens of people so far in the Caribbean and Eastern Pacific.

Human-rights experts call this an extrajudicial killing regime. They cite the fact that there has been little transparency and no meaningful process to distinguish a trafficker from, say, an unlucky fisherman who happened to be in the wrong place at the wrong time.

This is drug control by spectacle. It projects toughness and reassures a domestic audience that someone is paying the price for drug trafficking. But it does little to reduce supply, and it risks deepening resentment in countries that already bear the brunt of the U.S.’s drug policy.

Physicians Targeted

Meanwhile, inside the United States, the same punitive mindset has migrated into medicine. Under the Controlled Substances Act, doctors commit a crime if they “knowingly or intentionally” distribute or dispense controlled substances in an unauthorized way.

In our amicus brief in Ruan v. United States, my co-authors and I explained how prosecutors have increasingly treated alleged deviations from the “standard of care” as proof that a prescription lacked a “legitimate medical purpose in the usual course of professional practice.” This effectively turned malpractice or medical guideline disputes into drug-trafficking charges, and eroded the requirement that the government prove a guilty mind.

In the Ruan ruling, the Supreme Court unanimously held that the government must show that a prescriber knew their conduct was improper and illegal.

Yet for many clinicians, the message from years of aggressive prosecutions is that prescribing opioids to patients with complex pain conditions can be a fast track to a felony indictment. Physicians have watched colleagues led from their offices in handcuffs, their careers and reputations destroyed, sometimes on the basis of retrospective judgments about “red flags” rather than evidence of deliberate criminality.

Put crudely, our system has developed three very different responses to people labeled “drug traffickers.”

If you are a poor person on a boat in the Caribbean, you may be killed without a trial.

If you are a former president whose government helped move hundreds of tons of cocaine, you may be pardoned.

If you are a physician treating complex pain patients in a fragmented, under-resourced health system, you may be prosecuted as a drug dealer if your prescribing patterns later look suspicious on a spreadsheet.

That is not a rational drug policy. It is a hierarchy of whose lives are expendable, whose conduct is negotiable, and whose mistakes are treated as crimes.

None of this is to deny that real traffickers wield violence and that some clinicians have abused their prescribing privileges. But when we glorify lethal force at sea, quietly forgive a leader of what U.S. prosecutors themselves called a narco-state, and simultaneously treat legitimate clinical judgment as suspect, we are no longer talking about a war on drugs.

We are talking about a war on certain kinds of people: the poor, the foreign, the sick, and medical professionals all serve as convenient scapegoats.

If we are serious about reducing overdose deaths and drug-related harm, we need to abandon the theatrics. That means three things.

First, we must subject military operations to rigorous legal and human-rights scrutiny.

Second, we must acknowledge that pardoning a convicted narco-president while bombing alleged couriers does not “send a message” of resolve. It sends a message of incoherence — and of a system more invested in performance than in justice or saving lives.

Third, once and for all, we must end the use of criminal law to second-guess good-faith medical practice.

Lynn Webster is a physician specializing in pain and addiction medicine, a former president of the American Academy of Pain Medicine, Senior Fellow at the Center for U.S. Policy, and author of “The Painful Truth” and the forthcoming book “Deconstructing Toxic Narratives – Data, Disparities, and a New Path Forward in the Opioid Crisis.” He has written extensively on drug policy, the opioid crisis, and the criminalization of medicine.  

Feline Good: A Sense of Purpose Helps Me Manage Chronic Illness

By Crystal Lindell

Every morning, at around 5 a.m., my very fat orange cat Goose starts his daily routine: Screaming at the top of his lungs in an effort to wake up me and my partner.

He’s hungry and he doesn’t care if we’re asleep – it’s time for cat breakfast.

Trust me when I tell you that we have tried a number of workarounds to help avoid this daily cat alarm clock.

We have attempted to ignore his screams. We have tried feeding him a bigger meal later at night before bed. And we have left dry food out overnight.

We even gave him a late-night catnip snack in hopes that it would help him sleep later into the morning.

Goose doesn’t give a shit about any of that. He still gets up at 5 a.m. every single morning so that we can feed him.

Turns out, though, this daily ordeal may actually be helping me manage my chronic pain from Ehler-Danlos syndrome.

GOOSE AND CRYSTAL

New research from Cigna shows that having a strong sense of purpose can help offset the effects of chronic disease. And every single morning, Goose makes sure that I know that my purpose is to take care of him.

Cigna researchers found that while adults with chronic conditions usually have much lower vitality scores than those who are not sick, the same does not hold true when they also have a strong sense of purpose. 

Adults with chronic conditions and a strong sense of purpose actually have a significantly higher vitality score — nearly matching the scores of people without health issues. Cigna defines vitality as the ability to pursue life with health, strength and energy. 

People with a strong sense of purpose are significantly more likely to have vitality than those who do not (89% vs. 61%). They are also five times more likely to say they feel energized (63% vs. 13%) and nearly three times as likely to look forward to each new day (86% vs. 31%).

Notably, having a strong sense of purpose is linked to greater ownership of physical health — 84% of adults with strong purpose say they feel in control of their health vs. 55% of those without strong purpose. People with a strong purpose are also more likely to get regular exercise, sleep better, and to see their doctors for regular checkups. They also have less anxiety and depression.

“Having a sense of purpose gives people energy and helps them feel happier and healthier,” says Stuart Lustig, MD, National Medical Executive for Behavioral Health at Cigna. “When you know what matters to you, you’re more likely to bounce back from tough times, build strong friendships, and take care of yourself, which impacts your overall physical health.”

It can be easy to shrink into yourself when you’re dealing with chronic health problems, especially when it comes to chronic pain. And truth be told, one of the reasons I resisted my fiancé’s pleas to get a cat in the first place is that I was worried I wouldn’t be able to take care of the cat on bad pain days. 

But as fate would have it, having Goose actually helps me get through the bad pain days —  especially when he is waking me from a deep sleep by screaming for breakfast. In fact, Goose and his cat sisters give my life meaning and make me feel needed every morning, even on the days when I don’t feel like I have much to give.

Of course, you don’t have to get a cat to have a sense of purpose. You don’t even need to have a constant level of activity. Small, gentle acts of generosity can go a long way. 

There are many things in my own life beyond my cats that help me see the world outside of myself and my chronic pain. I also care for my elderly grandma, babysit my niece, volunteer at a local animal shelter, and cook for my family on a regular basis. I also write these columns, which gives me a very direct connection between my pain and my purpose. 

Finding purpose can happen in a million small ways, throughout the days and years. As the old saying goes, it’s better to give than to receive.  And ultimately, when you give, you do, in fact, receive.  

Study Shows Anger Makes Chronic Pain Worse

By Crystal Lindell

A new study claims that the angrier someone is about their chronic pain, the worse their pain will be. But to be honest, the whole thing kind of pisses me off.

All kidding aside, the research published in The Journal of Pain, looked at four distinct “multidimensional anger profiles” in pain sufferers.

Researchers followed 735 adult patients with different types of chronic pain, assessing how they experience, express and control anger, and how strongly they feel about being wronged by their situation. About a third of the participants completed follow-up assessments 5 months later.

They found that people with medium to high levels of anger and feelings of “perceived injustice” had some of the most severe pain. They reported greater pain intensity, more widespread pain, and higher levels of disability and emotional distress. 

In contrast, people who seemed to manage their anger more effectively and viewed their condition with less resentment tended to have less pain..

However, the researchers did not clarify which treatments the patients had access to or how being denied treatment impacted their pain. Instead, they encouraged doctors to make an “early assessment” of patients that emphasizes “the need for tailored, anger-focused, patient-specific interventions.”

One of the biggest issues I have with this study is that it sets up doctors to blame the patient’s demeanor and mood for their physical pain – something they are often already prone to do. 

I can hear the in-office conversations now.

“Have you tried being less angry?” the doctor asks, as though he’s offering an actual treatment option to the patient sitting on a cold exam table.

The question would rightly be infuriating, which would then just lead the doctor to type in their notes that the patient’s pain is partly caused by their inherent anger and sense of injustice.

Leaving the insulted patient in a state of untreated limbo. 

Yes, people whose pain is left untreated or poorly treated are more likely to be justifiably angry overall. And they are especially more likely to feel like their pain is unjust.

In fact, anger is a very appropriate response to such suffering. It inspires you to push those around you to help you find relief. And unfortunately, it’s often required to get real help from medical doctors. 

In the study's conclusion, the authors admit as much.

"Anger is not inherently harmful - when adaptive, it can be a strong motivator, helping individuals set boundaries and navigate challenges," wrote lead author Gadi Gilam, PhD, a psychologist and neuroscientist at the Hebrew University of Jerusalem. "Rather than eliminating anger, interventions should harness this adaptive potential while mitigating its harmfulness."

Perhaps they could also focus on interventions that actually treat physical pain? Especially since the most effective treatment for many types of pain – opioids – has been severely restricted over the last decade.

Anyone who tells you they’d be calm and accepting while dealing with chronic pain, while at the same time knowing there was an effective treatment they weren’t allowed to have, is lying to you.

It’s actually very normal to be angry in that situation and to feel a strong sense of injustice. The situation itself is not just. 

I have long said that lack of sleep will make you crazy so much faster than you expect, and a version of that applies to pain as well. Unrelenting pain will make you angry so much faster than you expect.

Rather than trying to treat the anger, doctors should focus on the source, and treat the pain itself. 

Feds Target Large 7-OH Vendor

By Pat Anson

Federal agents have seized about 73-thousand tablets, gummies, shots and other products containing 7-hydroxymitragynine (7-OH) from a Missouri company that sells 7-OH products nationwide. The seized items have an estimated value of about $1 million.

The seizure is part of a growing effort by federal and state regulators to crackdown on sales of 7-OH, an alkaloid that occurs naturally in kratom. When concentrated, 7-OH has opioid-like effects that can relieve pain and boost energy levels. Health officials say 7-OH can be abused and is addictive, although they have offered little evidence to support those claims.

“This enforcement action is a strong step to protect Americans from the dangers of concentrated 7-OH products, which are potent opioids,” FDA Commissioner Marty Makary, MD, said in a press release.  “We must be proactive and vigilant to address emerging threats to our communities and our kids.”

To be clear, 7-OH and kratom are not opioids. But they act on nerve receptors in the brain that control pain and mood, as do many other non-opioid substances, such as coffee and chocolate. Kratom and its alkaloids also don’t cause respiratory depression, the leading cause of an overdose.

The FDA worked with the Missouri Department of Health in targeting Kansas City-based CBD American Shaman, a company that was the subject of a recent investigative series by the Kansas City Star. American Shaman sells its kratom, CBD and hemp-based Delta-8 products online and in hundreds of smoke shops, gas stations and retail stores around the country.

Missouri’s Health Department released a health advisory in October claiming 7-OH was 13 times more potent than morphine, and could cause poisoning and overdose. The advisory noted the Missouri Poison Center was aware of three cases involving 7-OH, including one person who was “evaluated in a health care facility.”

The FDA’s Adverse Events Reporting System lists 52 “serious cases” associated with 7-OH so far this year, including 6 deaths. Most of the adverse effects were for dependence or withdrawal symptoms.

Warning Letters 

The FDA sent a warning letter to Shaman Botanicals, a subsidiary of American Shaman, last summer accusing it of illegally selling 7-OH in adulterated dietary supplements. Warning letters were also sent to six other companies selling 7-OH products. In response, some removed the 7-OH products from their websites, while others kept right on selling them.   

American Shaman currently still offers 7-OH tablets on its website, saying the tablets provide “relief, relaxation, and focus.” Asked if the tablets are safe, a chat bot gave us this answer:

“Great question! Our Advanced Alkoloids tablets feature precise, lab-tested 7-hydroxymitragynine (7-OH) or mitragynine pseudoindoxyl, depending on the variety. Many customers appreciate their reliable effects and controlled dosing compared to traditional kratom products.

As with any supplement, it’s a good idea to consult with your doctor before starting – especially if you have health concerns or take other medications.”

A disclaimer on the website also warns consumers not to use the tablets if they are taking pain relievers, opioids or other medications, and not to take them daily or for prolonged periods.

CBD AMERICAN SHAMAN

The FDA has recommended to the DEA that it classify 7-OH as a Schedule I controlled substance, which would make it illegal to sell or possess. The FDA says it is not focused on banning natural kratom leaf products, although some state and local governments have already banned kratom sales. 

The DEA has yet to act on the FDA’s request, a process that could take several months once a proposed scheduling is posted in the Federal Register. Kratom and 7-OH are not even mentioned in the DEA’s 2025 National Drug Threat Assessment, an annual report on the production and distribution of illicit drugs in the United States.

Gabapentin’s Side Effects May Lead to ‘Prescribing Cascade’

By Pat Anson

Over the years, we’ve published many warnings about gabapentin (Neurontin), a nerve medication that is widely prescribed off-label for pain conditions it was never intended to treat. 

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

According to a new study, those side effects may lead to a “prescribing cascade” in which physicians mistakenly prescribe unnecessary medications to a patient that cause even more side effects. 

The problem is not limited to gabapentin, but includes other gabapentinoids such as pregabalin (Lyrica). Both medications may cause edema – fluid retention and swelling in the legs and feet –  leading doctors to suspect congestive heart failure and prescribe diuretics that can cause kidney injury, light headedness, and falls. 

Researchers with the VA Health Care System and the University of California, San Francisco (UCSF) analyzed the medical records of 120 older veterans, most of whom were male and long-term users of five or more medications. All had taken gabapentinoids and diuretics, which are often prescribed for edema.  

Although none of the veterans had fluid buildup in the year before they started taking gabapentinoids, only 4 doctors suspected the drugs were the culprit and just one discontinued the medication.

The vast majority of physicians – 69 in all – never suspected or downplayed the possibility that gabapentinoids may be causing the edema. Since fluid retention is a symptom of congestive heart failure and poor blood circulation, the veterans were put on loop diuretics such as Lasix.

Within two months, 28 veterans had side effects from the new drugs, including poor kidney function, dizziness, and blurred vision, along with low levels of sodium or potassium, which can disrupt critical body functions. Six patients had symptoms so severe they were hospitalized or taken to an emergency department. 

“Gabapentinoids may be prescribed at unnecessarily high doses or for conditions that they may not help,” said Matthew Growdon, MD, an Assistant Professor of Medicine at UCSF and first author of the study in JAMA Network Open. “In these cases, doctors should consider not prescribing these drugs — or giving lower doses to lessen the risk of prescribing cascades and other side effects.” 

One veteran in his 60’s was put on a heavy dose of gabapentin for neuropathy that was induced by chemotherapy for lung cancer. He developed edema and was switched to pregabalin. When the fluid retention didn’t stop, he was put on a diuretic. Within two days he developed light headedness and felt off-balance, and the diuretic was stopped.

Another patient in his 60’s was prescribed gabapentin twice a day for back pain, an off-label use. After two months he had edema and was put on a diuretic. Soon after, he experienced a fall, went to the ER, and was given IV pain medication. The diuretic and polypharmacy are believed to have contributed to the man falling.

The cases highlight how a prescribing cascade with multiple drugs can have serious health consequences. Patients on gabapentinoids may be prescribed sleep aids, anti-depressants and other medications to counteract the drugs’ many side effects.

Gabapentin is often prescribed off-label for migraine, fibromyalgia, cancer pain, postoperative pain, and many other pain conditions for which it is not FDA-approved. Off-label prescribing is legal and sometimes appropriate, but has reached extreme levels for gabapentin. Studies estimate the drug is prescribed off-label up to 95% of the time. 

“Gabapentinoids are non-opioids, and prescribers associate them with a relatively favorable safety profile,” says senior author Michael Steinman, MD, a Professor of Medicine at UCSF.  “Patients taking them should regularly check in with their doctor to assess whether this is the best treatment for them and consider other options, including non-drug alternatives that might be more appropriate.” 

In 2024, gabapentin was the fifth most prescribed drug in the U.S., with prescriptions nearly tripling since 2010. The number of patients prescribed gabapentin reached 15.5 million in 2024, up from 5.8 million in 2010.

Lupus May Be Caused by Common Virus

By Graham Taylor and Heather Long

Around 5 million people worldwide live with the autoimmune condition lupus. This condition can cause a range of symptoms, including tiredness, fever, joint pain and a characteristic butterfly-shaped rash across the cheeks and nose.

For some people, these symptoms are mild and only flare-up occassionally. But for others, the disease is more severe – with constant symptoms

Although researchers know that lupus is caused by the immune system mistakenly attacking the body’s own tissues and organs, it isn’t entirely clear what triggers this response. But a new study suggests a common virus may play a key role in lupus.

There are two main forms of lupus. Discoid lupus primarily affects the skin, while systemic lupus erythematosus – the most common form of lupus – is more severe and affects the organs.

The immune system’s B cells play a key role in systemic lupus. B cells normally produce proteins called antibodies to target pathogens such as viruses and bacteria. But in people with systemic lupus, some B cells produce antibodies, called autoantibodies, that instead bind to and damage their own organs.

What causes B cells to produce autoantibodies in people with systemic lupus is poorly understood. But this recent study suggests that the trigger may be a common virus.

EBV Infection

Epstein-Barr virus (EBV) infects most people worldwide. Infection with EBV most commonly occurs in childhood, when it usually goes unnoticed. But if a person becomes infected by EBV in adolescence, it can cause infectious mononucleosis (better known as glandular fever).

EBV is a type of herpes virus. These are complex viruses that are able to escape the body’s immune response by hiding inside certain cells.

In these cells, herpes viruses switch off their genes and go silent – like submarines diving beneath the waves to hide from the enemy. This allows herpes viruses to persist throughout a person’s lifetime – occasionally reawakening to spread to new people.

Interestingly, EBV has evolved to hide within the immune system itself, infecting and persisting in a very small number of B cells.

This strategy has proven highly successful for EBV. Over 90% of adults around the world are infected with EBV – meaning the virus is hiding in their immune system’s B cells.

EPSTEIN-BARR (ebv) VIRUS

While most people experience no adverse consequences from their infection, EBV has been linked to certain diseases.

For instance, EBV was the first virus shown to cause cancer. Subsequent research has linked EBV to several different types of cancer – including certain lymphomas and 10% of stomach cancers. Each year, about 200,000 people develop an EBV-associated cancer.

More recently, large epidemiological studies have linked EBV with multiple sclerosis, which is an autoimmune condition. Studies have shown that people with multiple sclerosis are almost always infected with EBV.

Previous research has also suggested that EBV may be involved in systemic lupus. But this new study provides insight into the specific mechanism involved.

To conduct their study, the researchers developed a sensitive test to analyse the genetic material in thousands of B cells isolated from the blood of people with systemic lupus and healthy donors as a control.

They found that EBV was present in around 25 times more B cells in systemic lupus patients compared to participants who didn’t have the condition. In systemic lupus patients, EBV was present in around one in 400 B cells – while in healthy controls it was only present in around one in 10,000 B cells.

This is an interesting finding – though the researchers acknowledge it could potentially be caused by the medicines patients with systemic lupus take to control their illness. These decrease the activity of the immune system which reduces the symptoms of systemic lupus. But these medicines also reduce the immune system’s ability to control EBV infection.

How EBV Causes Autoimmunity

The most important finding from the research was that many of the EBV-infected B cells from systemic lupus patients made autoantibodies that bound to specific proteins. These same proteins are often targeted by autoantibodies in people with systemic lupus. In contrast, EBV-infected B cells from healthy donors did not make these autoantibodies.

To understand the mechanisms involved, the researchers then studied the expression of EBV genes in the infected B cells. Although EBV was generally shown to be in its silent state, some EBV-infected B cells from systemic lupus patients produced the viral protein EBNA2, which reprogrammed the B cells to become more inflammatory. These activated B cells were better able to stimulate responses from other immune cells, including non-EBV infected B cells and T cells.

Together, these observations suggest that EBV may initiate systemic lupus by infecting and reprogramming dormant B cells to become activated. These cells produce autoantibodies that could potentially contribute to the development of systemic lupus. They also appear to recruit additional immune cells able to produce stronger autoimmune responses that are more likely to play a role in systemic lupus development.

These new findings raise the possibility that targeting EBV could form the basis of a new therapy to treat people with systemic lupus. But given these infected B cells also recruit additional immune cells, a broader therapeutic strategy may be needed.

Additional research will also be needed to confirm whether EBV is indeed an essential trigger for the development of systemic lupus. If this is confirmed, preventing EBV infections through vaccination could prevent systemic lupus developing.

Currently there are a number of potential EBV vaccines in development – and two candidates are being tested in large clinical trials. A key requirement for any effective EBV vaccine will be its ability to generate long-term protection against infection. This is because EBV is already widespread in the population. If vaccination only delays infection until later in life, then this could lead to many cases of glandular fever.

The results of these trials are eagerly anticipated, given the potential impact an effective vaccine could have to reduce the numbers of people worldwide that develop lupus, other autoimmune conditions, or cancers caused by EBV.

Graham Taylor, PhD, is an Associate Professor in Viral and Tumour Immunology at the University of Birmingham. The main focus of Graham’s work is to increase our knowledge of the immune system in health and disease and how best to harness the immune system to treat cancer. His research helped lead to a therapeutic cancer vaccine that has undergone testing in several clinical trials. 

Heather Long, PhD, is an Associate Professor in the Department of Immunology and Immunotherapy, at the University of Birmingham. She leads a research team in the fields of viral and cancer immunology, with a long-term focus on understanding T cell control of viruses and virus-associated cancers.

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

DEA Plans Further Cuts in Oxycodone Supply

By Pat Anson

The Drug Enforcement Administration is planning to cut the supply of oxycodone by over 6% in 2026, along with marginal reductions in the supply of hydrocodone, morphine and other Schedule II opioids. 

If the DEA’s plans are finalized after a short public comment period, it would be the 10th consecutive year the opioid supply has been reduced in the United States.

The DEA announced its plans Friday in the Federal Register. Under the Controlled Substances Act (CSA), the agency has broad legal authority to set annual aggregate production quotas (APQs) for drug makers – in effect telling them the amount of Schedule I and Schedule II chemicals and medications they can produce. 

The DEA is planning another round of cuts in the Schedule II opioid supply because it continues to see declines in the “medical usage” of opioids – an average decrease of 10.5% in 2024 alone. 

It’s important to note that medical usage is different from “medical need.” Doctors simply aren’t prescribing as many opioids as they used to, so while the need for pain relief hasn’t changed and may have even increased due a spike in rates of chronic pain, the number of prescriptions written for opioids has declined. 

DEA expects that trend to continue, based in part on data from IQVIA, a private company that tracks prescription drug use. The agency is also seeing fewer requests from drug manufacturers to make oxycodone.

“DEA projects that the medical usage of these controlled substances will continue to decline in 2026 based on a review of domestic usage data from IQVIA,” DEA said in its Federal Register notice. “Additionally, DEA has observed a significant decline in requests for product development quotas to support manufacturing towards FDA approval of drug products containing oxycodone.” 

DEA Opioid Production Cuts Planned for 2026

• Oxycodone          6.24% decrease

• Morphine             0.559% decrease

• Hydrocodone       0.529% decrease

• Hydromorphone  0.109% decrease

• Fentanyl              0.014% decrease

• Codeine               0.002% decrease

From year-to-year, the cuts may not appear significant. But over the past decade, there has been an historic decline in the nation’s opioid supply. If its current plan is adopted, DEA will have cut the supply of hydrocodone by 72.9% and oxycodone by 70.6% since 2014.

Some of the decline in “medical usage” is driven by scarcity. For example, Endo Pharmaceuticals recently informed the FDA it discontinued production of 2.5, 5, 7.5 and 10 mg Percocet (oxycodone/acetaminophen) tablets. Major Pharmaceuticals stopped making oxycodone/acetaminophen tablets a few months ago. And Teva Pharmaceuticals, a large generic drug maker, stopped making immediate-release oxycodone in 2023.  

The FDA does not currently list oxycodone products on its drug shortage database, but the American Society of Health-System Pharmacists (ASHP) has since 2023. Limited supplies of oxycodone are available from some manufacturers, according to ASHP, while others have the medications on back order.

Hydrocodone/acetaminophen tablets have also been on the ASHP’s shortage list (but not on the FDA’s) since 2023. Major and Camber Pharmaceuticals have both stopped making them.

Health Canada reported a nationwide shortage of oxycodone/acetaminophen combinations over the summer, a shortage that persists today but is expected to resolve soon.

Why would the DEA be reducing production quotas for opioids that are already in short supply?

DEA sets its APQs after consulting with states willing to share their prescription drug data, as well as federal agencies like Health and Human Services and the Food and Drug Administration. 

DEA also asked for input from the Centers for Disease Control and Prevention, an agency in turmoil after several months of layoffs, budget cuts and leadership changes. A response to that request “was inadvertently delayed” at CDC, but DEA says it will take it under consideration when or if it ever arrives. 

“DEA remains committed to monitoring drug shortages, limiting their impact, and resolving them as quickly as possible. DEA continues to seek additional information that will assist in accurately forecasting domestic medical usage and export requirements of schedule I or II substances,” DEA said.

Unlike previous years, when there was a 30-day period for public comments on the DEA’s quota proposal, the agency is only allowing about two weeks. You can leave a comment here, but it must be posted no later than December 15. DEA did not explain why it was reducing the amount of time the public can comment. 

7 Gift Ideas for People with Chronic Illness

By Crystal Lindell

Black Friday marks the unofficial start of the holiday shopping season, and that means hunting for the perfect gifts for those we love.

Below are some gift ideas for loved ones with chronic pain and illness. It’s a gift list you can trust because it’s all based on my own experiences of living with daily pain myself for over a decade.

All of these items also make a great addition to your own holiday wish lists, if you have chronic condition yourself. 

1. Comfy Clothes

The #1 must-have fashion item for people with chronic pain is any clothes that are super comfortable. 

When you have chronic pain, clothing comfort just takes precedent over the latest trends. 

I personally have re-purchased these comfy pants more than 7 times over the last few years. I love how soft they are, and I love that they have pockets! 

But any comfy clothes, from sweat shirts to pajama pants, make a great gift for those with chronic pain. 

Find Women’s Jogger Pants on Amazon 

2. Heated Blanket

There’s nothing better than getting under a cozy heated blanket when you’re dealing with chronic pain. Even if someone already owns one, there’s always a need for one more! 

This heated blanket is my favorite and not only do I own two myself, I’ve also purchased it as a gift for loved ones over the years. And all of them always come back to tell me how much they love it! 

Find this Heated Blanket on Amazon

3. Reminders of Your Love

Little trinkets like a keychain can be a great way to give a constant reminder of your love for someone. Every time they see it, they can think of how much you care about them. 

This keychain features the phrase, “May you always have one more spoon.” It’s a reference to the Spoon Theory, which uses spoons to illustrate the limited energy that people with chronic pain and illness often have. 

It doesn’t have to be a key chain though. A special coffee mug or a bracelet can also make great gifts! 

Find the Spoon Theory keychain on Amazon 

4. Lego

Of course, it doesn’t have to be Lego specifically, but any sort of home-based hobby activities are great for people with chronic pain. 

I personally love this Lego Cat because I’m a huge cat person as well as a huge Lego fan. 

But you can also get your loved ones art supplies, crafting tools, or any other projects they can work on at home.

And bonus points if they can do it from the couch on bad pain days. 

Find the Lego Tuxedo Cat on Amazon 

5. A Good Book

Some days, a pain flare means I don’t have the energy to do anything other than read a book. So having good ones around that I know a loved one recommends is always welcome! 

I recently read The Frozen River by Arial Lawhon, and I really enjoyed the cozy winter setting and completely immersive 1700s plot. 

But you can really buy any book that you’d recommend to share as a gift with your loved ones. 

Also be sure to check out PNN’s holiday reading guide, which has books to help you better understand and treat many chronic pain conditions.  

Find The Frozen River on Amazon 

6. Bread Machine

While a bread machine may not seem like a gift typically associated with chronic pain, it’s actually perfect.

A good bread machine makes it super easy to whip up homemade bread, even when you’re also dealing with a pain flare. You just toss the ingredients in, hit start and presto! A perfect loaf of homemade bread!

It’s also great for anyone on a restrictive diet, since you can easily customize the ingredients. There’s even a setting for a gluten-free loaf! 

Find the Bread Machine on Amazon 

7. Gift Cards

Of course, when in doubt, it’s always a good idea to go with a gift card, especially if you’re shopping at the last minute — because the cards can be instantly delivered via text. 

That way your loved one is guaranteed to get the perfect holiday gift, because they pick it out themselves!

Happy shopping this holiday season!

Find Gift Cards on Amazon

We hope you have happy holidays, and many low pain days in the year ahead! 

PNN makes a small commission, at not additional cost to you, on items purchased through Amazon. 

A Holiday Reading Guide for People Living with Chronic Pain

By Pat Anson

Is kratom really as dangerous as public health officials say it is? What foods can help reduce pain and inflammation? Why do some people get Long Haul Covid and others don’t? How can I manage pain flares from Ehlers-Danlos syndrome? What is percutaneous hydrotomy and why is it growing in popularity with injured athletes?

The answers to these and other questions can be found in PNN’s annual holiday reading guide. If you live with chronic pain and illness or have a friend or family member who does, here are 12 books that would make great gifts over the holidays. Or you can “gift” one to yourself. Click on the book cover or title to see price and ordering information.

The Essentials of Ehlers-Danlos Syndrome

This book is intended to help people understand and manage Ehlers-Danlos syndrome (EDS), a genetic and painful disorder that presents as a confusing set of symptoms that are often misdiagnosed. Topics covered include the 7 sub-types of EDS, what specialists to see, and how to create a personalized care plan to manage pain flares and fatigue.

Kratom: Facts, Myths, and Cultural Insights

This is one in a series of books by Adrian Colewood that seeks to present a balanced and neutral view on kratom, a controversial supplement used by millions to relieve pain, anxiety, depression and withdrawal. With kratom facing new regulations and outright bans due to its opioid-like effects, the book explores the myths and misinformation about a medicinal plant that’s been used for centuries in southeast Asia.

Handbook for Newly Diagnosed Cases of Adhesive Arachnoiditis

This second edition of Dr. Forest Tennant’s book for new cases of Adhesive Arachnoiditis (AA) explores the treatments that can reduce the symptoms of this debilitating spinal nerve disease. Left untreated, AA can result in intractable pain, a bed-bound state, and premature death. This handbook summarizes Dr. Tennant’s 3-step protocol to suppress inflammation and autoimmunity, regenerate damaged tissue, and control pain caused by AA.

Eat to Heal: Unlock the Healing Power of Food

After years of suffering from chronic migraine, fatigue and cancer pain, Dr. Joseph Jacobs turned to nutrition, developing the Advanced Soft Tissue Release (ASTR) diet to reduce inflammation, relieve pain and restore energy. In this book, he shares how eating the right foods helped him beat chronic pain from the inside out, while debunking the myths of so-called “healthy diets” that have left millions of people chronically sick and fatigued.

The Comprehensive Guide to Ibuprofen

Aldrin Gomes, PhD, and his team of researchers at UC Davis look at the benefits and risks of ibuprofen, one of the world’s most widely used pain relievers. Like many NSAIDs, ibuprofen increases the risk of heart attack, stroke and stomach ulcers — even at regular doses — and may interact with hundreds of medications. Studies suggest ibuprofen may also have some surprising health benefits, such as lowering the risk of dementia.

It Doesn’t Have to Hurt: Your Smart Guide to a Pain-Free Life

CNN medical correspondent Dr. Sanjay Gupta is a neurosurgeon by trade who believes all pain starts in the brain, and chronic pain “comes with baggage attached.” Gupta is not a fan of opioid medication, and thinks the body’s own pain relief system can be primed through meditation, sleep, nutrition, acupuncture and physical therapy such as foam rolling. He calls pain “the most mysterious of all human sensations.”

Hip Pain Relief For Seniors

This book is designed for older adults who want to overcome hip pain and limited mobility without surgery or medication. Simple and gentle exercises can be done at home to regain flexibility, strength and movement. These “senior-friendly routines” will help you stay active and independent, including older adults recovering from hip replacement or arthritis.

Secrets to Long Haul Viral Recovery

Author Michael Alcock is a “long-hauler” from Covid-19 and the Epstein-Barr virus, who spent a decade researching why some people are more prone to long-haul viral infections, while others recover easily. This book explains how to recover holistically from viral infections like long Covid by strengthening the immune system through better nutrition, vitamins and supplements.

The Complex PTSD Workbook for Self-Healing

Has chronic pain or a chronic illness left you exhausted — physically and emotionally? Do you live in dread of another pain flare or sleepless night? Alex Carter wrote this self-help handbook to guide you on a 6-week action plan to overcome Post Traumatic Stress Disorder (PTSD) with practical ways to help quiet your mind and nervous system.

The Headache: The Science of a Most Confounding Affliction

Over 3 billion people worldwide suffer from a headache disorder, including author Tom Zeller Jr., who suffers from cluster headaches. Zeller wrote this book to better understand what causes migraines and headaches, and why there are few effective treatments for such a common condition. Zeller looks at the inner workings of the human nervous system and provides a vivid account of the disabling pain that headache sufferers endure.  

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS) is a debilitating chronic nerve disease that is usually caused by trauma and can strike any part of the body. This book, edited by Drs. Lynn Webster and Jijun Xu, is part of the "What Do I Do Now? Pain Medicine" series. It looks at 11 clinical cases of CRPS and how they were treated with conventional analgesics and novel therapies, including neuromodulation and ketamine infusions.

Stopping Pain: A Simple, Revolutionary Way to Stop Chronic Pain

Chances are you’ve never heard of percutaneous hydrotomy, a minimally invasive regenerative treatment in which a sterile saline solution is injected into the body to relieve musculoskeletal pain and “flush out” inflammatory substances. Percutaneous hydrotomy has been used in Europe for 30 years and is gaining popularity with amateur and professional athletes who want to stop pain, heal nagging injuries, and boost performance.

These and other books about living with chronic pain and illness can be found in PNN’s Suggested Reading page.  PNN receives a small amount of the proceeds -- at no additional cost to you -- for orders placed through Amazon.

A Beginner’s Guide to Using Kratom for Pain Relief

By Crystal Lindell

Whenever I meet someone who’s having trouble managing their chronic pain, I always suggest that they look into kratom. However, many soon realize that there’s not much trustworthy information out there about what kratom is and how to use it. 

I’ve been taking kratom for my own chronic pain since 2018, and I have found that it’s the only thing sold over the counter that actually helps me. 

Below is a look at my experiences with it, and some tips to help if you’re new to the idea of taking kratom for chronic pain. 

Also, I want to make clear that this column is not sponsored, and you’ll notice that there are no links to any specific kratom products or companies. There is a lot of spammy content in articles about kratom, but this isn’t one of them.

What Is Kratom?

The formal name for kratom is “Mitragyna speciosa.” It’s a tropical tree that’s native to southeast Asia, and belongs to the same botanical family as coffee. 

Kratom has been used for centuries in Asia as a natural stimulant and pain reliever, but only in the past decade has it become widely available in the United States

To create the powder that’s usually sold in smoke shops, gas stations and online, kratom leaves are dried and ground up into a fine powder. 

There are three basic strains of kratom, and each one has different effects. 

There is a white strain, which I have found acts as a stimulant or energy booster. The red strain seems more like a mood booster that helps with pain. And then there’s a green strain, which is seen as more of the middle point between the two. 

You’ll also find products labeled as “gold” and “black” and those claim to be stronger versions of kratom, although I haven’t always found that to be the case. 

I personally use a mix of the strains, which is commonly referred to as a "trainwreck" mix. 

Is Kratom Legal?

Laws vary by state, county, and even cities in the United States. So it’s best to check your local laws before purchasing kratom. 

In June, the FDA sent warning letters to 7 kratom vendors about illegally marketing their products as dietary supplements. The letters were specifically in regards to an alkaloid in kratom called 7-hydroxymitragynine -- known as 7-OH -- which relieves pain and increases energy.

The FDA said it would try to get 7-OH classified as an illegal controlled substance, falsely claiming it was an opioid. While 7-OH occurs naturally in kratom, it is present only trace amounts.

To boost its potency, some vendors are selling gummies, tablets and extracts with concentrated levels of 7-OH, which the FDA says “may be dangerous.” For more information about 7-OH, check out this recent column I wrote about that product.

Although some states and cities have already banned 7-OH, the natural leaf powder is widely available (and still legal) in most U.S. states, as long as no medical claims are made about it. 

Is Kratom Dangerous?

It’s rare for someone to have an adverse reaction to natural kratom leaf, which is the form I take. However, people who consumed the concentrated extracts have been hospitalized or experienced overdoses. In most cases, they also consumed alcohol and other substances.

Recently, former CDC Commissioner Robert Redfield, MD, talked about a 2024 FDA-funded study, the final results of which have never been published. He said they found that kratom has low abuse potential.

“In 2024, the FDA completed a single ascending-dose clinical trial examining ground kratom leaf in experienced users. The results were illuminating: participants experienced no serious adverse events at doses up to 12 grams, with side effects limited to mild nausea and pupil constriction. Crucially, subjective ‘drug liking’ scores never reached statistical significance compared to placebo, indicating low abuse potential for natural leaf.”

According to the American Kratom Association, FDA researchers were "profoundly disappointed” at the lack of adverse events associated with kratom, as its contradicts the agency’s long-standing opposition to it. That’s supposedly why the study’s findings have not been formally released.

Does Kratom Relieve Pain?

I think kratom really works, at least it does for my chronic pain. I can tell there’s a difference in my pain level shortly after I take a dose. My partner also swears by kratom as an effective treatment for chronic pain.

A 2016 PNN survey of over 6,000 kratom users found that 97% thought it was very or somewhat effective in treating their pain, depression, anxiety and other medical conditions. Over 98% said that kratom wasn’t harmful or dangerous.  

I always say that the best way to know that kratom actually works is when people try to regulate or ban it.

How Do You Take Kratom?

I mostly use the powder form of kratom. It comes in a bag, and it’s usually sold by weight.

I take half a spoonful of the powder, put it under my tongue, and then wash it down with a non-carbonated flavored beverage like juice or Gatorade. The powder is gritty and tastes bad, so you’ll probably need something to wash it down quickly with. To improve the taste, the powder can be mixed into a beverage directly.

You can also buy the powder in capsules, which are easier to consume. I personally find that capsules give me heartburn, so I tend to avoid them. 

There are also edible versions of kratom on the market, such as gummies, chocolates and even seltzers. I find those take longer to kick in, but they tend to offer a more even effect. However, they are more expensive than the raw powder, so I don’t buy them very often. 

If you do try kratom, I recommend using an extremely small dose to start with and, if possible, purchasing it from a smoke shop where employees can help you navigate your options. 

Overall, kratom has the potential to help a lot of people. But everyone is different, so your experience with the substance may vary. My hope is that people who could benefit from using kratom will feel more confident about trying it after learning more about it. 

A Pained Life: Should Doctors Be More Curious?

By Carol Levy

In my last column, I wrote about doctors needing more empathy. I feel it’s important for them to understand and relate to whatever their patients are experiencing.

I have been sick for a few months, a jaw infection that keeps coming back. The left side of my face, the side with the trigeminal neuralgia, is where the swelling is located. 

The doctors all seem afraid to try and figure it out: “Well, it's probably related to the issues you already have there.”

If that were true, the swelling wouldn't be new. But it is, and that doesn't seem to faze them.

My family doctor referred me to a bunch of different specialists. Some actually touched the area of swelling, but other than a cursory heart and lung check, they did nothing but order blood tests, an MRI and CAT scan. All were negative. 

Then they threw antibiotics at it. That too didn’t help. Maybe that means they should look into it further, maybe by examining me? It doesn't happen. I merely get, in one form or another, “I haven't a clue. Sorry I can't be of more help.”

All of them were nice to me. Some even showed empathy. That made me feel heard. And yet, I wasn't heard. Had I been, they would have done more than the basic exam and tests. 

I thought a connection, through empathy, would enable more trust in doctors, more acceptance of a diagnosis or lack of one. 

It turns out, it’s not a question of empathy, but a lack of curiosity that makes me doubt their medical ability. Is a lack of curiosity the same as indifference? Do they just not care?

So many of us have experienced this when we present to a doctor with chronic pain. First of all, pain is wholly subjective. They have to choose to believe us (or not) when we say we are in pain. Then they have to make an effort to find the cause. That almost requires them to do a full exam, to show curiosity about our bodies, and therefore our pain.

It seems to me, if someone decides to go to medical school, curiosity has to be a motivator. Curiosity about how our bodies work, what happens when they don't, and what causes them not to work as they should.

What happens to that curiosity? Do doctors become jaded? Does the thought process go something like this: “I don't need to do an exam. Blood work and x-rays will tell me, and if they don't, that's the way it goes.”

I find I have to ask my doctor if it could be this or that. I have to suggest that he order an x-ray. It seems to be my job to come up with ideas. Since there is an infection, maybe there is an underlying disorder? 

Sometimes he merely shrugs.  Other times, he goes with my suggestions.

Maybe that makes it a partnership, but it’s one based on my work and thoughts, not his. And it’s all based on my curiosity about what is making me sick. 

Somehow, that feels wrong. Because, after all, isn’t being curious enough to figure out what is wrong the doctor's job?

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 40 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.  

Does Mindfulness Really Help with Chronic Pain?

By Neen Monty

“Mindfulness” is one of those words that’s been stretched so far it’s almost lost its meaning. We’re told it will calm our nerves, ease our pain, and maybe even transform our lives. 

But what is mindfulness, really? And what can it actually do for people living with chronic pain?

The popular definition goes something like this: Mindfulness is the practice of focusing your awareness on the present moment, without judgment.

Does that make sense to you? It didn’t make sense to me the first time I heard it. It sounds so simple… but it’s not so simple to do.

Most people think mindfulness is meditation. It’s not. Mindfulness is a state of awareness, a way of relating to your thoughts and sensations, while meditation is a tool that helps you develop that state. Meditation is how we practice mindfulness, the training ground for the skill of self-awareness.

Clear? As mud…

Okay, let me try again. At its core, mindfulness rests on two ideas:

1. Paying attention to the present moment.

2. Doing so without judgment.

That second part is the hardest. It can take a lot of practice. But in practical terms, living mindfully is living in the present moment. It’s not wasting time worrying about a future that may never happen, or dwelling on a past that can’t be changed.

The Difference Between Pain and Suffering

Let’s use pain as an example. Being mindful doesn’t mean ignoring pain or pretending it’s not there. It means noticing it: “I feel pain right now” and stopping there.

What we usually do next is the problem: “Oh no, it’s back. The pain is so bad! It’s going to get worse. I can’t take this anymore.”

Those thoughts are the suffering part. They layer emotion, fear, and meaning on top of the physical sensation of pain.

Mindfulness helps peel that layer away. Pain still hurts, but without the extra story, the extra worry, the panic, the hopelessness and the emotional response. It’s just pain.

Pain then becomes something we can observe, without emotion, rather than something that swallows us whole. This distinction isn’t just philosophical. Brain imaging studies show that mindfulness changes the way we process both thoughts and sensations.

Meditation strengthens brain regions that regulate attention and emotion, such as the prefrontal cortex and anterior cingulate cortex, while reducing reactivity in the amygdala, the brain’s alarm system. Other reviews confirm that meditation produces measurable neurobiological changes that are associated with greater emotional stability and self-regulation.

Over time, meditation helps the mind become less reactive. We learn to notice sensations, thoughts, and emotions without immediately trying to fight or fix them. 

Instead of launching into fight or flight, we remain calm and in control. Meditation, in that sense, is kind of the laboratory in which mindfulness is trained.

The Limits of Mindfulness

Does mindfulness cure pain? No. It does not.

Systematic reviews and meta-analyses find that mindfulness training has only small effects on pain intensity. What it does reduce is distress — the anxiety, fear, and emotional turmoil that often surrounds chronic pain.

That distinction matters. Mindfulness was originally designed as a treatment for stress and anxiety. And therefore, its benefits for pain are more indirect. It helps people who are fearful of pain or overwhelmed by it, to regulate their emotions and cope better.

But, if you’re already calm and accepted your pain without fear, mindfulness won’t make the pain go away. It won’t have much effect at all on your pain.

Most importantly, mindfulness is not a treatment for severe pain. You cannot be mindful and you cannot meditate, when you’re in severe pain. Mindfulness is not an intervention for 8 or 9/10 pain. That’s pure cruelty. I would even call that medical negligence.

Mindfulness is a treatment for fear and anxiety in the setting of chronic pain. In that sense, mindfulness may be helpful for someone in mild to moderate pain, where there is a lot of negative emotion surrounding that pain – such as fear, anxiety and catastrophising.

Mindfulness is a psychological tool, a treatment for fear and anxiety that’s been repurposed for pain. 

And often oversold as something it’s not.

Why Mindfulness Is Still Worth Trying

Even within those limits, I still believe mindful living is the best way for me to live. It doesn’t make my pain stop. My pain is caused by disease, pathology and biology, not by anxiety or fear.

Mindfulness does make my days quieter. It keeps me from being dragged into fear or frustration. I don’t worry about the future and don’t dwell on the past. Mindful living keeps me grounded. In the present moment. Because that’s where life is happening – the here and now.

That’s what mindfulness is, living in the present moment.

Mindfulness won’t fix what’s broken in the body. Mindfulness cannot fix pathology. But it can help restore what pain often breaks in the mind: calmness, control, and your sense of peace in the middle of chaos.

And sometimes, that’s enough.

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. She has created a website for Pain Patient Advocacy Australia to show that prescription opioids can be safe and effective, even when taken long term. You can subscribe to Neen’s free newsletter on Substack, “Arthritic Chick on Chronic Pain.”

5 Tips for Surviving the Holiday Season with Chronic Pain

By Crystal Lindell

The holiday season kicks off this week, but for people with chronic pain, this time of year can be difficult to navigate. 

Below are some tips for surviving the season while also dealing with chronic pain and illness. You can trust that they actually work, because all of them are gleaned from my own experiences of surviving the holidays while dealing with chronic pain myself.  

1. Check Your Pharmacy Schedule

A lot of pharmacies are closed on holidays or they close early, so if you have refills scheduled on those days, it’s best to plan ahead. Make sure you know when they are open so you can get your medications.

If you have a refill scheduled for a day when your pharmacy is closed, you may want to ask your doctor if they can send in any refill prescriptions the day before the holiday.

In my experience, a lot of doctors are surprisingly accommodating about this. Of course, if they refuse, you can ration out your medication a little so that you have enough to cover the holiday.  

2. Embrace Pre-Made Food

One of the most draining tasks over the holiday season is cooking. So, I highly recommend embracing pre-made food options.

Whether that means grabbing pre-made sides from the grocery store or ordering a fully prepared holiday feast from a local restaurant, outsourcing the labor of cooking can be a huge help if you have chronic pain.

Obviously though, buying pre-made food does usually cost more than cooking from scratch, but if you’re really in a pinch, I do have one more suggestion: Order takeout.

Fast food is usually inexpensive and quick, which means you’ll have more time and energy to actually enjoy the holiday season with loved ones.

Later, when you look back on those memories, it won’t matter if dinner was tacos or chicken wings, as long as you were all together. 

3. Include Rest Days in Your Holiday Plans

If you have multiple family functions to attend, try your best to plan days of rest into your schedule. 

Put “Rest” on your calendar as though it were any other required activity. And if it conflicts with other events, don’t be afraid to say that you just can’t make it. 

I know that saying “no” is easier to suggest than actually accomplish, especially when it comes to family. So if you do get pressured into doing multiple events in a row, just do your best to schedule an equal number of guilt-free rest days afterward. Emphasis on the “guilt-free.”

For example, if you have plans on Christmas Eve and Christmas Day, try to use Dec. 26 and Dec. 27 to recover. And I don’t mean, spend those days cleaning up, I mean actual rest.

When you’re dealing with chronic illness, providing your body with rest is just as important as providing food. 

4. Wear Compression Socks on Long Trips

Swollen feet and ankles are a common side effect of both chronic illness and many prescription medications.

So, if you’re traveling this holiday season — whether it’s a three-hour flight or a one-hour drive — I highly recommend wearing compression socks during your trip. Aside from preventing swelling, they can also help prevent dangerous blood clots.

5. Use Gift Bags

Wrapping gifts is a lot more time consuming than people usually like to admit, so do yourself a favor and just use gift bags instead. And save the ones you get, so you can reuse them next year.

Gift bags don’t have to be expensive either. If you head over to Dollar Tree, you can find a wide assortment of gift bags for just $1.25 each. 

The holiday season can easily turn into a series of stressors and pain triggers, but if you plan ahead and allow yourself some grace, you still can enjoy it — even with chronic pain. 

New Autism Guidance on CDC Website Angers Health Experts

By Arthur Allen, KFF Health News

The rewriting of a page on the CDC’s website to assert the false claim that vaccines may cause autism sparked a torrent of anger and anguish from doctors, scientists, and parents who say Health and Human Services Secretary Robert F. Kennedy Jr. is wrecking the credibility of an agency they’ve long relied on for unbiased scientific evidence.

Many scientists and public health officials fear that the Centers for Disease Control and Prevention’s website, which now baselessly claims that health authorities previously ignored evidence of a vaccine-autism link, foreshadows a larger, dangerous attack on childhood vaccination.

“This isn’t over,” said Helen Tager-Flusberg, a professor emerita of psychology and brain science at Boston University. She noted that Kennedy hired several longtime anti-vaccine activists and researchers to review vaccine safety at the CDC. Their study is due soon, she said.

“They’re massaging the data, and the outcome is going to be, ‘We will show you that vaccines do cause autism,’” said Tager-Flusberg, who leads an advocacy group of more than 320 autism scientists concerned about Kennedy’s actions.

Kennedy’s handpicked vaccine advisory committee is set to meet next month to discuss whether to abandon recommendations that babies receive a dose of the hepatitis B vaccine within hours of birth and make other changes to the CDC-approved vaccination schedule. 

Kennedy has claimed — falsely, scientists say — that vaccine ingredients cause conditions like asthma and peanut allergies, in addition to autism.

The revised CDC webpage will be used to support efforts to ditch most childhood vaccines, predicts Angela Rasmussen, a virologist at the University of Saskatchewan and co-editor-in-chief of the journal Vaccine. 

“It will be cited as evidence, even though it’s completely invented,” she said.

The website was altered by HHS, according to one CDC official who spoke on condition of anonymity. The CDC’s developmental disability group was not asked for input on the website changes, said Abigail Tighe, executive director of the National Public Health Coalition, a group that includes current and former staffers at the CDC and HHS.

FROM CDC WEBSITE

Scientists ridiculed the site’s declaration that studies “have not ruled out the possibility that infant vaccines cause autism.” While upward of 25 large studies have shown no link between vaccines and autism, it is scientifically impossible to prove a negative, said David Mandell, director of the Center for Autism Research at Children’s Hospital of Philadelphia.

The webpage’s new statement that “studies supporting a link have been ignored by health authorities” apparently refers to work by vaccine opponent David Geier and his father, Mark, who died in March, Mandell said. 

Their research has been widely repudiated and even ridiculed. David Geier is one of the outside experts Kennedy hired to review safety data at the CDC.

Asked for evidence that scientists had suppressed studies showing a link, HHS spokesperson Andrew Nixon pointed to older reports, some of which called for more study of a possible link. Asked for a specific study showing a link, Nixon did not respond.

‘Using CDC to Spread Lies’

Infectious disease experts, pediatricians, and public health officials condemned the alteration of the CDC website. Although Kennedy has made no secret of his disdain for established science, the change came as a gut punch because the CDC has always dealt in unbiased scientific information, they said.

Kennedy and his “nihilistic Dark Age compatriots have transformed the CDC into an organ of anti-vaccine propaganda,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.

“On the one hand, it’s not surprising,” said Sean O’Leary, a professor of pediatrics and infectious disease at the University of Colorado. “On the other hand, it’s an inflection point, where they are clearly using the CDC as an apparatus to spread lies.”

“The CDC website has been lobotomized,” Atul Gawande, an author and a surgeon at Brigham and Women’s Hospital, told KFF Health News.

CDC “is now a zombie organization,” said Demetre Daskalakis, former director of the National Center for Immunization and Respiratory Diseases at the CDC. The agency has lost about a third of its staff this year. Entire divisions have been gutted and its leadership fired or forced to resign.

Kennedy has been “going from evidence-based decision-making to decision-based evidence making,” Daniel Jernigan, former director of the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, said at a news briefing Nov. 19. With Kennedy and his team, terminology including “radical transparency” and “gold-standard science” has been “turned on its head,” he said.

Sen. Cassidy Goes Quiet

The new webpage seemed to openly taunt Sen. Bill Cassidy (R-La.), a physician who chairs the Senate Health, Education, Labor, and Pensions Committee. Cassidy cast the tie-breaking vote in committee for Kennedy’s confirmation after saying he had secured an agreement that the longtime anti-vaccine activist wouldn’t make significant changes to the CDC’s vaccine policy once in office.

The agreement included a promise, he said, that the CDC would not remove statements on its website stating that vaccines do not cause autism.

The new autism page is still headed with the statement “Vaccines do not cause Autism,” but with an asterisk linked to a notice that the phrase was retained on the site only “due to an agreement” with Cassidy. The rest of the page contradicts the header.

“What Kennedy has done to the CDC’s website and to the American people makes Sen. Cassidy into a total and absolute fool,” said Mark Rosenberg, a former CDC official and assistant surgeon general.

On Nov. 19 at the Capitol, before the edits were made to the CDC website, Cassidy answered several unrelated questions from reporters but ended the conversation when he was asked about the possibility Kennedy’s Advisory Committee on Immunization Practices might recommend against a newborn dose of the hepatitis B vaccine.

“I got to go in,” he said, before walking into a hearing room without responding.

Cassidy has expressed dismay about the vaccine advisory committee’s actions but has avoided criticizing Kennedy directly or acknowledging that the secretary has breached commitments he made before his confirmation vote. Cassidy has said Kennedy also promised to maintain the childhood immunization schedule before being confirmed.

The senator criticized the CDC website edits in a Nov. 20 post on X, although he did not mention Kennedy.

“What parents need to hear right now is vaccines for measles, polio, hepatitis B and other childhood diseases are safe and effective and will not cause autism,” he said in the post. “Any statement to the contrary is wrong, irresponsible, and actively makes Americans sicker.”

Leading autism research and support groups, including the Autism Science Foundation, the Autism Society of America, and the Autism Self Advocacy Network, issued statements condemning the website.

“The CDC’s web page used to be about how vaccines do not cause autism. Yesterday, they changed it,” ASAN said in a statement. “It says that there is some proof that vaccines might cause autism. It says that people in charge of public health have been ignoring this proof. These are lies.”

What the Research Shows

Parents often notice symptoms of autism in a child’s second year, which happens to follow multiple vaccinations. “That is the natural history of autism symptoms,” said Tager-Flusberg. “But in their minds, they had the perfect child who suddenly has been taken from them, and they are looking for an external reason.”

When speculation about a link between autism and the measles, mumps, and rubella vaccine or vaccines containing the mercury-based preservative thimerosal surfaced around 2000, “scientists didn’t dismiss them out of hand,” said Tager-Flusberg, who has researched autism since the 1970s. “We were shocked, and we felt the important thing to do was to figure out how to quickly investigate.”

Since then, studies have clearly established that autism occurs as a result of genetics or fetal development. Although knowledge gaps persist, studies have shown that premature birth, older parents, viral infections, and the use of certain drugs during pregnancy — though not Tylenol, evidence so far indicates — are linked to increased autism risk.

But other than the reams of data showing the health risks of smoking, there are few examples of science more definitive than the many worldwide studies that “have failed to demonstrate that vaccines cause autism,” said Bruce Gellin, former director of the National Vaccine Program Office.

The edits to the CDC website and other actions by Kennedy’s HHS will shake confidence in vaccines and lead to more disease, said Jesse Goodman, a former FDA chief scientist and now a professor at Georgetown University.

This opinion was echoed by Alison Singer, the mother of an autistic adult and a co-founder of the Autism Science Foundation. “If you’re a new mom and not aware of the last 30 years of research, you might say, ‘The government says we need to study whether vaccines cause autism. Maybe I’ll wait and not vaccinate until we know,’” she said.

The CDC website misleads parents, puts children at risk, and draws resources away from promising leads, said Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. “Kennedy thinks he’s helping children with autism, but he’s doing the opposite.”

Many critics say their only hope is that cracks in President Donald Trump’s governing coalition could lead to a turn away from Kennedy, whose team has reportedly tangled with some White House officials as well as Republican senators.

Polling has also shown that much of the American public distrusts Kennedy and does not consider him a health authority, and Trump’s own approval rating has sunk dramatically since he returned to the White House.

But anti-vaccine activists applauded the revised CDC webpage. 

“Finally, the CDC is beginning to acknowledge the truth about this condition that affects millions,” Mary Holland, CEO of Children’s Health Defense, the advocacy group Kennedy founded and led before entering politics, told Fox News Digital.

“The truth is there is no evidence, no science behind the claim vaccines do not cause autism.”

Céline Gounder, Amanda Seitz, and Amy Maxmen contributed to this report. KFF Health News is a national newsroom that produces in-depth journalism about health issues.