Early Receipt of Opioids Reduces Hospitalization of Children with Sickle Cell Disease

By Pat Anson

Early administration of opioids for pain relief in emergency departments significantly reduces the chances of a child with sickle cell disease being hospitalized, according to a large new study published in JAMA Pediatrics. 

Sickle cell disease (SCD) is a genetic disorder that causes red blood cells to form in a crescent or sickle shape, which creates painful blockages in blood vessels. About 100,000 Americans live with sickle cell disease, primarily people of African or Hispanic descent.

It’s not uncommon for someone with SCD to visit an ER a few times each year due to pain or complications such as anemia, stroke, infection and organ failure. Many patients with SCD feel stigmatized when they visit an ER, where their pain is not taken seriously and they are seen as drug seekers. That delays their treatment, even though medical guidelines recommend early treatment with opioids and other pain relievers.    

“If we can stabilize and treat patients’ pain, they won’t need to be admitted to the hospital, where they would miss school, their families would miss work, and it’s disruptive to their lives,” said co-author Elizabeth Alpern, MD, Professor and Vice Chair in the Department of Pediatrics at Northwestern University Feinberg School of Medicine.

Alpern and her colleagues reviewed over 9,000 ER visits by 2,538 children with an uncomplicated SCD pain flare between 2019 and 2021. Their findings offer some of the first evidence that faster pain management with opioids can lead to better outcomes for pediatric SCD patients.

Children who received their first opioid dose within 60 minutes of arrival in the ER were 15% less likely to be hospitalized. The odds of hospitalization dropped even further when a second dose was administered within 30 minutes of the first. 

“We were able to statistically show that if patients receive a timely first dose of opioid medications and a timely second dose of opioid medications, we could drastically reduce the number of hospital admissions within this population,” said co-author Jacqueline Corboy, MD, Assistant Professor of Pediatrics in the Division of Emergency Medicine at the Feinberg School of Medicine. “This is the first study that shows concrete evidence, so this is really important.” 

The study was a collaborative effort among 12 pediatric hospitals. Two smaller. single-site studies showed no association between early receipt of opioids and lower odds of hospitalization.

SCD patients have few alternatives to opioids for pain relief. Last year Pfizer took the sickle cell medication Oxbryta off the market over concerns that it could be causing deaths and other complications. A 2022 study also found that SCD patients given corticosteroids are more likely to be hospitalized with severe pain.

Compared to other chronic illnesses, SCD has received little attention from researchers and pharmaceutical companies, resulting in a lag in the development of new treatments. Until 2018, only one drug was approved by the FDA to treat sickle cell patients. Bone marrow and stem cell transplants are currently the only curative therapies for SCD.

It’s Rare for Chronic Pain Patients to Overdose on Opioids

By Neen Monty

The Penington Institute is an Australian non-profit public health and drug policy research organization. Its core mission is to study drug use “in a safe, considerate and practical way. We seek solutions, not scapegoats. We strive for positive outcomes, not negative stereotypes.”

A most worthy cause.

Each year, Penington releases Australia’s Annual Overdose Report, the country’s most comprehensive study of overdose trends and impacts. I am not against the work of the Penington Institute. On the contrary, they serve a very necessary purpose and have a noble goal.

However, for several years running, they have demonized chronic pain patients and twisted the statistics to inflate the harms of prescription opioids. And this is generally what I write about. To correct the record.

Here’s the download page to Penington’s 2025 report. It documents how many overdoses and what substances were involved. The report relates to data from the 2023 calendar year. Paging through it, something jumped out at me immediately.

Naturally, I jumped straight to the ‘Opioids’ section. There is a table, with key facts. One of these key facts is:

“From 2019-2023, there were 163 unintentional drug-induced deaths involving pharmaceutical opioids as the sole drug type.”

That’s an average of nearly 33 people who died accidentally every year when pharmaceutical opioids were the sole drug type. 33 people. In a country with 27.4 million people.

Does that sound like an opioid crisis to you? Does that sound like a reason to deny tens of thousands of patients access to safe and effective pain relief?

Do you know what immediately occurred to me when I realised that less than 50 people per year die from prescription opioid overdose?

I remembered this 2023 report from the Therapeutic Goods Administration (Australia’s version of the U.S. Food and Drug Administration), justifying their changes to paracetamol scheduling. That’s acetaminophen for those of you in the U.S.

Paracetamol pack sizes were reduced to 16 tablets per packet and supermarkets could only sell two packs per person. Larger packs were only available at pharmacies, and some required a pharmacist’s approval.

Do you know why they made paracetamol harder to get?

Because 50 Australians were dying every year from paracetamol overdoses, with rates of intentional overdose highest among adolescents and young adults.

There was an outcry when the changes came into effect. Chronic pain patients were again being harmed by policy because a different patient group was overdosing.

Because 50 people die of paracetamol overdoses per year in Australia.

Do you get what I am saying?

Paracetamol is still available over-the-counter in Australia, albeit in smaller pack sizes. And yet opioids are almost impossible to access.

Fewer Australians die from prescription opioid overdoses than from paracetamol overdoses. This was true long before any changes were made in opioid scheduling in 2020, making opioids much harder to get.

Opioid prescribing was already declining in 2020, so there was no need to change opioid prescribing practices. Certainly no medical need. In fact, this policy change caused a great deal of harm to those who live with constant, severe pain, and has had no benefits. For anyone.

Please think about it. Reflect upon it. Make it make sense. How is this anything other than a witch hunt?

Paracetamol kills more people than prescription opioids, yet it’s still available over the counter. And doctors are torturing people who live with painful, progressive and incurable diseases, by denying us access to safe and effective pain relief.

Because 33 people die of prescription opioid overdoses every year. While 50 people die of paracetamol overdoses.

Does Australia have an opioid crisis? No.

Does Australia have a prescription opioid crisis? Also no!

We never had a prescription opioid crisis. And we were never heading for one. Prescription opioid overdoes have been falling in Australia since 2018. Check the statistics.

Unlearn what you have been told and learn the true statistics.

There was no need to make changes in 2020. Yet those changes caused interminable suffering to people who live with constant, severe pain from illness or injury.

Most chronic pain patients are still suffering. Many have died.

Does this seem fair to you? Does this seem right? Does it seem reasonable?

Does any of this seem like good policy?

To be clear, I am not saying that opioids should be available over-the-counter. Please do not twist my words to imply that.

Opioids for severe, daily pain should be managed as they were before 2020. By general practitioners who know their patients well.

There should be no dose ceilings because there is no evidence that dose ceilings reduce overdoses and death. GPs are more than capable of prescribing an appropriate dose and duration to manage severe chronic pain.

Instead, chronic pain patients in Australia are forced to go to a pain management specialist, who barely knows them and rarely understands their pain.

People who live with severe, daily pain from disease and injury have a right to pain relief. We need help.

And this year’s Penington report shows that we are not the ones who are overdosing.

It is time to restore access to safe and effective pain relief for those who desperately need it. Chronic pain kills far more often than the opioids prescribed for chronic pain do. Patients die from heart attacks, strokes, hypertension, and other stress-induced conditions when their pain is not treated.  

The true cause of most overdose deaths is polypharmacy: multiple drugs, both legal and illegal, that are often mixed with alcohol.

Targeting people who live with painful, progressive and incurable diseases and injuries, denying us access to pain medication, is never going to reduce overdoses by illicit drug users. They are two different patient populations.

It is not chronic pain patients who are overdosing.

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 newsletter on Substack, “Arthritic Chick on Chronic Pain.”

5 Myths About Opioids That I Believed, Until I Needed Them

By Crystal Lindell

I had been enduring debilitating pain for months by the time I was given my first hydrocodone prescription for chronic pain in 2013.

At the time, I didn’t even know that hydrocodone was an opioid.

I had only heard of Vicodin being an opioid, and that was only because I lived near the Wisconsin border, where there are lots of Packer fans. The news that former Green Bay quarterback Brett Favre had to go to rehab for his Vicodin use was part of the local conversation.

But I had no idea that hydrocodone was the active ingredient in Vicodin.

It’s been over a decade now, and I have come to rely on opioids to manage the chronic pain I have in my right ribs, which is technically called “intercostal neuralgia.”

Before I needed opioids for pain relief, I used to buy into a lot of common cultural myths about them. Below is a look at what I used to believe, and how my views eventually shifted.

Myth #1: Only People Who ‘Misuse’ Opioids Have Physical Withdrawal

When I got my first hydrocodone prescription, I didn’t know it was a controlled substance with strict limits on how often you can get refills. And I definitely didn’t know that I would go through withdrawal if I stopped taking them abruptly.

My doctor prescribed 10mg pills and the label said: “Take 1-2 every 4-6 hours.”

So, that’s exactly what I did: Two pills every four to six hours.

My pain was (and still is) intense, but at the time I was still trying to keep pace with my pre-chronic pain lifestyle, which meant doing everything possible to push the pain away so that I could work and have a somewhat normal life.

But that meant that I ran out of my prescription early – something I was not aware was even a problem. When the doctor’s office said I would need to wait a couple days for a refill, I didn’t think it would be a big deal. Surely, I could easily ride out a couple of days without hydrocodone, no problem. After all, I had been taking them as prescribed.

Yeah. That’s not what happened. Turns out you actually cannot go from 40 to 80 mg of hydrocodone a day to zero.

I naively went to work that day, and still remember the trauma of spending the entire shift in the bathroom with diarrhea, nausea, horrible flu-like aches, and an odd feeling of anxiety.

Turns out, anyone can go through withdrawal from opioids. There is no magic spell that doctors can cast to give you immunity from it, just because you’re taking opioids exactly as prescribed. Your body doesn’t know the difference.

And that physical withdrawal is also not indicative that you have “a problem.”

In fact, it’s one of the reasons I think the entire conversation around addiction is often more nuanced than people want to admit. Taking a dose to combat withdrawal is often labeled as “misuse” – even though anyone can have withdrawal. 

And anyone who’s been through it knows that you’ll do almost anything to make it stop.

Myth #2: The Best Way to Stop Using Opioids Is Quitting Cold Turkey

There’s a common myth that the best way to stop using an addictive substance is to go cold turkey. That’s usually not true for things like nicotine and alcohol, and it’s also not true for opioids.

I used to believe in the common framing for this. That if you stopped using opioids cold turkey, made it through 72 hours of withdrawal, and then took just one dose, it would reset the whole process. You’d have to go through withdrawal all over again.

That’s not true. In fact, taking a dose after going longer than usual without one is often part of the tapering process that works best for getting off opioids. 

Ideally, you taper off slowly by lowering the amount you’re taking each day. So, if you’re on 40mg of hydrocodone a day, the best way to stop using it is to take 35mg daily for a week or so, then 30 mg, and so on until you get down to zero.

That’s the best way to reach success long-term and actually get off the medication, if that is your goal.

If you’re looking for more realistic tips on how to stop taking opioids, see “A Survival Guide for Opioid Withdrawal” that I wrote for PNN with my partner a few years ago. You can trust the advice because we learned it ourselves the hard way.

Myth #3: Opioid Doses Last as Long as Manufacturers Claim

I was eventually prescribed extended-release morphine pills for my chronic pain, and was told that each one should last a full eight hours. I was also told that hydrocodone should last four to six hours.

Unfortunately, neither of those things are true. So-called “extended release” morphine lasts about four hours, while the short-acting hydrocodone can stop working in just two or three hours.

So, it’s not wise to take another dose whenever your pain comes back. If you do that, you’ll end up running out of your prescription early every month.

Instead, you should expect to go through periods throughout the day when your pain starts to come back – and then you have to count down until your next dose.

Myth #4: Even One Dose of an Opioid Creates a High Risk of Addiction

Before I started taking opioids, I honestly believed the myth that just one 10mg dose of Vicodin could result in life-long addiction.

In reality, that’s nearly impossible. In fact, even among patients who take opioids long-term, the rate of addiction is still incredibly low. Estimates vary widely, but according to experts who have studied it, people who take opioids over long periods have addiction rates of 1 to 3 percent.   

Opioids are often framed as being so addictive that anyone can get hooked, so any exposure to them is dangerous and risky. In reality, low-dose opioids are incredibly safe, and most patients taking prescription opioids never develop an addiction to them

Myth #5: If Someone Is ‘Really’ in Pain, Doctors Will Prescribe Opioids

I am a little ashamed to admit this, but I used to think of a Vicodin prescription as an indicator of whether or not someone’s pain was actually severe.

If a doctor prescribed Vicodin to someone, that meant they were in “real” pain.

Boy, was I wrong.

While dealing with pain myself, I quickly learned that doctors will often ignore severe pain in patients because they don’t want to deal with the hassle of prescribing a controlled substance. That reluctance has only gotten worse since 2013. Much worse.

These days, doctors withhold opioid medication from post-op patients, cancer patients, palliative care patients, and even hospice patients. All of them are still in very real pain though.

Whether or not a doctor validates your pain with an opioid prescription has no bearing on how severe your pain actually is.

There’s a lot of misinformation about opioids and these are just some of the common myths perpetuated about them. While it’s understandable to believe them if you’ve actually never needed opioids, I encourage everyone to keep an open mind. After all, if you wait until you or a loved one needs opioids to see the truth, it may be too late.

VA Researchers Say Opioid Guidelines Should Include Cancer Patients

By Pat Anson

Most medical guidelines that limit the use of opioid pain medication are intended only for patients suffering from “non-cancer” pain. The CDC, for example, says that its guideline “does not apply to patients undergoing cancer-related pain treatment,” because the potential for addiction and overdose “might not be relevant” to patients at risk of dying.

That long-held policy is now being questioned. In a study published in CANCER, the medical journal of the American Cancer Society, VA researchers say cancer patients are living longer and may be at risk of “persistent opioid use.”

The study, led by researchers at the VA Medical Center in Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, followed over 9,000 veterans who had surgery for early-stage cancer, mostly prostate, colon, bladder or lung cancers. About a third of those patients also needed chemotherapy, immunotherapy or radiation therapy.  

Thirteen months after surgery, about one in ten patients (10.6%) were still prescribed opioids for pain relief. And about 4% of them were co-prescribed benzodiazepines for anxiety, a combination of medications that some consider risky.

Although none of the veterans overdosed from taking opioids, and less than one percent (0.78%) were diagnosed with opioid use disorder, researchers say stronger measures are needed to limit the use of opioids by cancer patients.

“Minimizing opioid exposure associated with cancer treatment while providing effective pain control will decrease long-term health risks among cancer survivors,” said lead author Marilyn Schapira, MD, Professor of Medicine at the University of Pennsylvania and Co-Director at the Center for Health Equity Research at the VA Medical Center.

“Prescription opioid practices associated with cancer treatment may lead to unsafe and long-term opioid treatment (LTOT) and the related adverse outcomes of opioid use disorder, opioid overdose, and nonoverdose adverse events, including suicide.”

Schapira and her colleagues say medical guidelines that exclude cancer patients from opioid prescribing limits, such as the CDC guideline and the Department of Defense/Veterans Affairs guideline, should be rewritten.

“There may be benefits to extending general guidelines regarding prescription opioids to those facing cancer treatment in consideration of health and well-being during the years of survivorship," researchers concluded. “Efforts should be taken to mitigate long-term opioid use and its potential adverse effects in this population. This is especially true because cancer is increasingly recognized as a chronic condition, and survivors of cancer are living longer.”

Cancer patients with a history of chronic pain, greater comorbidities, lower socioeconomic status, and those who received chemotherapy were said to be at “especially high risk of opioid use in the year after surgery.”

Regardless of what the guidelines say, many U.S. patients being treated for cancer already have trouble getting opioids for pain control. A recent study found a 24% decline in opioid prescribing to cancer patients on Medicare after the CDC’s 2016 guideline. Another study found the number of cancer patients seeking treatment for pain in hospital emergency rooms doubled. About a quarter of the patients had cancer pain so severe they were admitted.  

Other studies have found that cancer patients are getting smaller and fewer doses of opioids, while some can’t get them at all. A recent survey of palliative care doctors in New York City found that nine out of ten (88%) reported frequent obstacles in getting opioids for their patients due to tight supplies at pharmacies. Nearly a third said the shortages resulted in sub-optimal care for their patients.

One of the more egregious examples of a cancer patient being unable to get opioids was the case of April Doyle, a California woman with metastatic breast cancer who couldn’t get her Norco prescription filled at a Rite Aid pharmacy. April recorded a tearful video in the pharmacy parking lot and shared it online, where it went viral. Outrage over the incident led to an apology from Rite Aid and her prescription being filled. April died a year later at the age of 42, leaving behind a 9-year-old son.

How To Get More Pain Relief From Rx Opioids

By Drs. Forest Tennant, Martin Porcelli and Scott Guess

Due to a multitude of legal restrictions and biases, many persons living with pain who take opioid medication can’t get enough relief to function, be comfortable, and have quality of life.

Summarized below are some of the ways we have found to boost or enhance the pain-relieving effect of prescription opioids.

Take a Booster (Potentiator)

Opioids trigger the endorphin receptor to relieve pain. If you simultaneously take a medicine or supplement that triggers a different receptor or suppresses inflammation, pain relief is enhanced. This boosting effect is the reason opioids are combined with acetaminophen or aspirin in pain medications such as Vicodin or Percocet.

Here is a list of potential non-prescription boosters. You may have to experiment to find one or two that boost the potency of your opioid. You can swallow the booster with your oral opioid or take the booster within 15 minutes after taking the opioid.

• Taurine 1000 mg

• Glutamine 1000 mg

• Lion’s Mane mushrooms

• Quercetin

• Benadryl

• St. John’s wort

• White willow bark

• Cannabidiol (CBD)

• Kava

• Palmitoylethanolamide (PEA) 300 to 600 mg

Under the Tongue vs Swallowing

A medication dissolved under the tongue (sublingually) is always more potent than if you swallow it whole. That’s because digestion in the stomach and intestines may wipe out as much as 50% of an oral opioid’s pain relief capability.

Try dissolving an opioid tablet under your tongue. You may find it much more effective, as it will enter the bloodstream faster. We recommend starting with half your usual dose and increase it as needed, being careful not to exceed your usual dose. Discuss this practice with your medical practitioner.

Don’t Forget Aspirin

Aspirin has been disparaged to the point that people are afraid to take it. It is still one of the very best opioid boosters. Dissolve it under your tongue to avoid stomach upset or bleeding.

Receptor Health

The central nervous system has many receptors (“action points”) that relieve pain. They need to stay healthy and active to provide maximal pain relief. A good nutrition program that consists of daily protein, vitamin D, and magnesium helps keep nerve receptors healthy and maximizes opioid pain relief.

Bedtime Preparation

Some medicinals taken at bedtime have the effect of making the next day’s opioids more effective. Here are some suggestions:

• Metformin 500 mg + L-Theanine 200 mg

• Tryptophan 500 to 1000 mg

• Amitriptyline

• Pentoxifylline

Cannabis

Some persons find that cannabis provides significant pain relief, while others experience little or no relief.

Do not take cannabis products within four hours before or after an opioid dosage to avoid over-sedation, loss of coordination, and mental deficiency.

Kratom

Kratom is the only non-prescription herbal supplement that has opioid-like effects. It comes in a variety of forms, usually natural leaf powder that is sold in capsules, edibles or drinks.

Kratom can be simultaneously taken with opioids, but be wary of synthetic or concentrated kratom as its potency may be unknown or too high.

All persons who take opioids for pain relief should find a kratom form and dosage that relieves pain. Given today’s adverse attitudes and restrictions on opioids, a person relying on prescription opioids alone must face the fact that their medical practitioners may end or reduce their opioid therapy at any time. When this happens, you may have to rely on kratom.

Prescription Boosters

Many physicians prescribe non-opioid medications for pain relief, such as gabapentin (Neurontin), clonidine, tizanidine, baclofen, and pregabalin (Lyrica). These can also be used to boost the potency of opioids. Take these medications within four hours before or after your opioid dose.

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.

Martin J. Porcelli, DO, is a family medicine doctor in Pomona, CA and is affiliated with Casa Colina Hospital.

Scott Guess, PharmD, operates an independent pharmacy and clinic in Atascadero, CA that specializes in pain management and arachnoiditis.

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

Top Officials at CDC Resign After Director Fired in Dispute Over Vaccines

By Pat Anson

CDC Director Susan Monarez has been fired by President Trump, capping a week-long drama that began with Monarez refusing to make changes in vaccine policy ordered by Health and Human Services Secretary Robert F. Kennedy Jr.  At least four top CDC officials resigned in protest after Monarez was ousted, creating further chaos at the country’s top public health agency.   

“The agency is in trouble, and we need to fix it, and we are fixing it, and it may be that some people should not be working there anymore,” Kennedy told Fox News.

Kennedy, a longtime critic of vaccines, demanded that Monarez resign or be fired, and she refused. Monarez had been acting CDC director since President Trump took office and was confirmed by the US Senate only a month ago.

Attorneys for Monarez say she could only be fired by the president and accused Kennedy of “weaponizing public health for political gain” by dismissing CDC scientists and appointing vaccine skeptics to CDC advisory committees.

“When CDC Director Susan Monarez refused to rubber-stamp unscientific, reckless directives and fire dedicated health experts, she chose protecting the public over serving a political agenda. For that, she has been targeted,” attorneys Mark Zaid and Abbe Lowell said in a statement. “The attack on Dr. Monarez is a warning to every American: Our evidence-based systems are being undermined from within.”

Tensions have been rising at the CDC for months after steep cuts in its staff and budget, followed by the overhaul of advisory panels ordered by Kennedy.

Recently, a gunman angry about Covid vaccines fire hundreds of shots at CDC headquarters in Atlanta, killing a policeman and traumatizing employees. Both President Trump and Kennedy were notably silent after the attack, which only made morale worse.  

More than 750 HHS staffers signed a letter saying the Trump administration “failed to adequately respond” to the attack and that Kennedy was “endangering the nation’s health by repeatedly spreading inaccurate health information.”

‘This Is a Heartbreaking Decision’

The four high-ranking CDC officials who resigned are Dr. Debra Houry, the CDC’s deputy director and chief medical officer; Dr. Demetre Daskalakis, who headed the center that makes vaccine recommendations; Dr. Daniel Jernigan, who oversaw vaccine safety; and Dr. Jennifer Layden, who was in charge of the CDC’s public health data. Kennedy recently pressured the agency to share health data for a study to confirm his beliefs that vaccines cause autism.

“This is a heartbreaking decision that I make with a heavy heart,” Houry said in an email to colleagues.

When she started at CDC over a decade ago, Houry was director of the CDC’s National Center for Injury Prevention and Control, which oversaw the secretive drafting of the agency’s controversial 2016 opioid guideline. Critics say anti-opioid activists had too much influence on the guideline and accused then-CDC Director Thomas Frieden of “blatant violations” of federal advisory committee laws.

Although the guideline was voluntary, it was so widely implemented by doctors that it caused “serious harm” to pain patients who were tapered to lower doses or no longer able to get opioid medication. Many suffered through withdrawal, uncontrolled pain, psychological distress and, in some cases, suicide.

Things got so bad, the CDC revised its guideline in 2022 to give doctors more flexibility in prescribing opioids. By then, Houry had left the Injury Center and been promoted to chief medical officer.

“From a very narrow viewpoint, some might take comfort in the resignation of Debra Houry as chief medical officer of CDC. Prior to holding that position, she had been Tom Frieden's action arm for implementing the original opioid guidelines. However, like Frieden, she also had a history of positive accomplishments and her current resignation appears to be a laudable matter of principle,” said Dr. Charles LeBaron, a retired CDC epidemiologist.

LeBaron wrote a book critical of the agency’s guideline and its leadership: “Greed to Do Good: The Untold Story of CDC’s Disastrous War on Opioids.” He says the current turmoil at CDC and HHS is likely to disrupt other public health efforts besides vaccines.  

“This is a developing situation in which efforts to address both pain and addiction treatment matters are really suffering collateral damage in a war over vaccines and related matters of public health,“ LeBaron told PNN in an email. “Whatever happens, it's hard to imagine that RFK Jr, with his ‘healing farms’ approach to eliminating opioid use, is ever going to make matters better in this area. 

“Until we get a sane person in charge of HHS, it's hard to see how anything useful in any area, including pain treatment, is going to happen. If you want my opinion, the more that the pain treatment community (along with everybody else) can successfully urge for RFK Jr's replacement, the more likely we are to see some progress at some point, rather than the current headline-de-jour chaos.”

The most immediate impact of the turmoil at CDC is uncertainty and delay in the release of the updated 2025-2026 Covid vaccines. Earlier this week, the FDA approved the use of new vaccines made by Pfizer, Moderna and Novavax, but limited who can get them to older Americans or those with a high-risk health condition. Several states are reporting a surge in Covid infections caused by a new Omicron variant.

FDA approval will be enough for some states to begin offering the new Covid vaccines, but other states will wait for a recommendation from the CDC’s new advisory panel, which now includes doctors and researchers who have publicly questioned the safety of vaccines.

The Advisory Committee on Immunization Practices is scheduled to meet September 18-19. According to the agenda, the panel will discuss many common vaccines, including those for COVID-19, hepatitis, measles, mumps, and rubella. The panel will consider whether to “revise the list of vaccines for administration to vaccine-eligible children.”

Back Pain Will Cost Australia Billions, but Rx Opioids Dismissed as a Remedy

By Crystal Lindell

A new study is sounding the alarm about lost worker productivity in Australia caused by chronic back pain, but an inexpensive remedy is being dismissed as “low-value or harmful.” 

Published in JAMA and led by researchers at Monash University, the study projects massive losses in productivity in Australia caused by long-term back pain. In 2024, nearly 3 million Australians had chronic back problems. That’s projected to grow to nearly 3.3 million by 2033.

The researchers estimate that back problems will result in an estimated loss of 3.4 million productivity-adjusted life-years over a 10-year period. That equates to a loss of more than $638 billion in Australian dollars in the country’s gross domestic product. That’s about $414 billion in US dollars.

That’s a lot of lost productivity and money. Just a 10% reduction in the number of workers with long-term back problems would save over $41 billion Australian dollars 

“Substantial economic gains could be achieved from reducing the prevalence and impact of the condition,” wrote lead author Sean Docking, PhD, a health economist at Monash University. “Action is needed to reduce the prevalence and burden of long-term back problems, with a focus on better-quality care and supporting people of working age to remain in the workforce and working productively.”

Indeed, there is a need to reduce the “impact of the condition.” I completely agree. However, while the authors call for interventions, they ignore an obvious tool that used to be widely available in Australia until 2018: codeine. 

That’s when Australia made codeine available by prescription only. Until then, the opioid was sold over-the-counter, and no doubt was often used to help people with back pain get out of bed, go to work, and be more productive.

While pop culture has often crafted a view that opioid medications are sleep inducing and that people who take them are lazy, the reality is that millions of people take them so that they can work and be productive. That’s especially true for mild, low-risk opioids like codeine.

The Monash researchers also point out that calling in sick and working less creates “considerable financial stress and may disproportionally impact already disadvantaged communities.”

Again, I agree. Not being able to work because of chronic pain can definitely result in a huge financial burden. And effectively treating that pain can literally make it possible for people to continue working and not rely on public assistance programs.

Unfortunately, rather than addressing this or offering practical solutions, the researchers dismiss all opioids as a “low-value” care option. Instead, they recommend “high-value” care, which basically consists of vague advice to “stay active” and get back to work as soon as possible. 

“A major way of addressing the burden of long-term back problems is to reduce the proportion of individuals who receive low-value or harmful care,” researchers said. “However, contrary to evidence-based guidelines, low-value care is prevalent. Examples of low-value care have been associated with longer absences from work. By contrast, high-value care could prevent chronicity, improve patient health outcomes, and result in productivity gains that benefit society.”

Perhaps the use of opioids is associated with “longer absences” because the pain medications are only given out when patients have severe back pain and really should stay at home.

It’s frustrating that, like many pain studies these days, the Monash researchers found a way to work in a negative view of opioids and suggest that they don’t “benefit society” or improve patient health.  

The fact that they left out how the crackdown on opioid prescribing contributes to lost productivity is also disheartening, especially when opioids are an inexpensive remedy.

When people have adequate pain relief, they can be productive. When they don’t, they can’t. Chronic pain patients understand this. Now we just need medical professionals to understand it too.

The Strange Denial of Complications Caused by Poorly Treated Pain

By Drs. Forest Tennant and Scott Guess

There has been no shortage of controversy, scandal and fraud regarding the opioid and pain crises of the past decade. One standout in the debate over opioids and pain treatment has been a lack of an honest, objective discussion of the benefits of pain care.

A basic tenet in medical practice and therapeutics is what is called the “risk-benefit” ratio. This is a simple analysis of whether a specific drug or therapeutic measure has more benefit than risk.

For example, the risk-benefit of drugs taken during pregnancy is well-known and established. But strangely, the debate over whether opioids have more benefit than risk in the treatment of pain has never been broached.

None of the parties involved, especially the anti-opioid zealots, will discuss any benefit that opioids may bring. In fact, essentially their only discussion is that opioids are a risk for overdose and addiction, so they have no benefit and shouldn’t be used.  

This risk is overrated and overstated in relation to opioids prescribed and monitored by a physician. According to the CDC, total opioid overdose deaths in the US (including deaths from illicit opioids) were 24 deaths per 100,000 population in 2023.

That compares to the overdose death rate for prescribed opioids, which was 4 per 100,000 population. That is a raw number for prescribed opioids.  Some data reports opioid deaths among physician monitored chronic pain patients to be as low at 0.1 per 100,000 population. 

In other words, the overdose risk of evidence with prescription opioid is minuscule.

Pain has a number of pathological complications that benefit from opioid therapy. In addition to physical relief, there are humanitarian benefits, such as a reduction in suffering, and the ability to mentally and physically function as a productive person.

When poorly treated or left untreated, chronic pain has profound negative and deleterious effects on the cardiovascular and endocrine (hormonal) systems. Pain puts the cardiovascular system into overdrive, which raises blood pressure and pulse rates. Coronary artery spasm may also result from severe chronic pain.

We can personally attest to prescribing blood pressure medication and nitroglycerin to many pain patients at risk of cardiac arrest or heart failure.

Hormonal suppression and deficiency of cortisol, testosterone, estradiol and other hormones are also common in undertreated chronic pain patients. Cortisol levels can drop below levels that sustain life. We have administered emergency cortisone to pain patients who were severely ill, debilitated, and near collapse because they had inadequate cortisol levels.

Among Dr. Thomas Addison’s eleven reported original cases of Addison’s Disease in 1855, about half had serious intractable pain conditions such as adhesive arachnoiditis.

Chronic pain has also been found to alter blood glucose and lipids (cholesterol). Sleep deprivation is another major problem in pain patients.  And anorexia with malnutrition is common.

Given the medical complications induced by pain, one would logically think that there would always be a discussion of risk-benefit when discussing opioid therapy. But we’ve never heard or seen such a discussion in medical literature or in political circles.

As if denial of benefits over risks weren’t bad enough, an even stranger denial has occurred. We have searched the major medical textbooks used in medical schools today, and couldn’t find a single word that chronic pain is a risk for hypertension and cardiac disease, much less hormonal deficiencies.

Isn’t it time we quit denying that chronic pain has medical complications that can be easily treated with opioids and other medicinals? The risks of opioid therapy simply don’t outweigh the benefits. 

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.   

Scott Guess, PharmD, operates an independent pharmacy and clinic in Atascadero, CA that specializes in pain management and arachnoiditis.

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

Hydromorphone Injections Can Quickly Relieve Intractable Pain

By Dr. Forest Tennant

I recall the time over a decade ago when Anazao Laboratory in Tampa, Florida informed me they had developed ultra-high potency (50 mg/ml) hydromorphone for palliative pain care. Anazao Labs was well aware of my patients’ needs, since they formulated my endocrine medicinals. 

In contrast to the other injectable opioids, Anazao’s hydromorphone formulation could be injected subcutaneously under the skin rather than intramuscularly.  The injection required a very small amount of fluid (.1 to .2 ml) that was administered with an allergy or insulin syringe.

My patients’ pain was called “intractable” to meet California’s Medical Board guideline and legal definitions.  The criteria for patients to enter my clinic was a determination that there was a high risk of death within one year unless opioid treatment could be administered. The top causes of intractable pain were adhesive arachnoiditis, traumatic brain injury, severe neuropathies (CRPS), autoimmune disease, and post-cancer care.

I recall the first patient to whom I prescribed ultra-high potency hydromorphone.  She was not receiving adequate pain relief with long-acting and breakthrough opioids, so she was referred for an intrathecal implanted device (pain pump) for opioid administration.  Due primarily to its cost and insurance reasons, she could not obtain this expensive treatment, so I chose to experiment with the new ultra-high potency hydromorphone. 

It worked remarkably well.  In fact, she soon found she didn’t require a long-acting or breakthrough opioid. Using the new hydromorphone formulation, she dropped her daily morphine milligram equivalent (MME) dosage from over 500 to less than 100 MME per day.

After success with this patient, I prescribed the hydromorphone formulation to other patients on high dose oral opioids, who could not obtain intrathecal opioids or an implanted electrical stimulator.  All the patients tolerated and adjusted well to it.  Ultra-high dose hydromorphone became an alternative to intrathecal opioids at my pain clinic.

When I later prescribed the hydromorphone formulation to other patients with intractable pain, I found that I could eliminate or reduce their use of high dose opioids through oral, patch or sublingual administration, and obtain equal or superior pain relief.

I have since retired from clinical practice, but still believe this is a major reason for using ultra-high potency hydromorphone for patients in severe pain.  My initial experience told me that the hydromorphone formulation could be an alternative to standard intractable pain care, which is the combined use of a long-acting opioid with a short-acting opioid for breakthrough pain. That therapy has shortcomings, because long-acting opioids suppress endocrine levels, which can lead to a wide range of health problems.

My procedure in prescribing hydromorphone was to instruct both the patient and a live-in family member on proper injection technique, secure storage, and maintaining sterility.  At the time I closed my clinic, I probably had about 2 dozen patients who successfully used this innovative formulation.

I have come to some conclusions that go against common beliefs about opioid therapy.  First and foremost, high potency hydromorphone can usually substitute in most cases for long-acting opioids such as OxyContin, transdermal fentanyl, and methadone.  Effective pain relief occurs within minutes after the injection, so the patient doesn’t have a proclivity to follow the opioid dose with a sedative or neuropathic drug such as a benzodiazepine. 

Seldom did my patients use over 3 to 4 injections a day.  To date, I know of no overdoses occurring.  I attribute this to hydromorphone’s rapid, potent, short-acting activity, which doesn’t invite the use of other drugs (including alcohol), to help the patient achieve pain relief.  Blood levels of the hydromorphone don’t stay elevated longer than about two hours, which protects against overdose. Pain relief remains much longer, however, likely because it is hydrophilic in neurologic tissues.

In summary, I have found ultra-high potency hydromorphone to be a significant advance in palliative pain care for intractable pain patients.  It has proven to be a bonafide alternative to intrathecal opioid delivery and to high opioid dosages necessary when combining the use of long and short acting opioids.  Its unique properties seem to reduce the risk of overdose. 

Families and patients can be trained to safely and effectively use this medicinal to relieve suffering from the most severe forms of intractable pain.  Unfortunately, it is an under-recognized and underused treatment for the palliative care of intractable pain patients.

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. 

Limits on Rx Opioids Led to Unintended Consequences in Australia

By Pat Anson

An Australian study highlights some of the benefits and unintended consequences of efforts to limit the prescribing of opioid pain medication.

Like the United States, there’s been a fair amount of controversy in Australia about opioid medication and the role it played in the so-called opioid crisis. In response, Australian regulator took two steps in 2020 to limit prescribing: creating prescription drug monitoring programs (PDMPs), and limiting the amount of opioids and repeat prescriptions subsidized by the government.

To see how well the changes worked, researchers analyzed emergency department (ED) visits by patients prescribed opioids by primary care doctors in Victoria, the second most-populated state in Australia with over seven million people. Victoria was the first state to adopt a mandatory PDMP, which doesn’t stop a doctor from prescribing opioids but alerts them to possible misuse by a patient.

The research findings, published in the Medical Journal of Australia, show that ED visits by patients on prescription opioids fell by 11.8 visits per 100,000 people after opioids restrictions were implemented. At the same time, however, researchers identified a short-term but statistically significant increase of 7.3 ED visits per 100,000 people that were linked to non‐opioid substances.

The study didn’t identify what those non-opioid substances were, but researchers suspect that some were uncontrolled medications, such as pregabalin and antidepressants, which are often prescribed as alternatives to opioids for pain relief.

“As we expected, the new policies were associated with reduced opioid‐related harm; the reduced availability of prescription opioids presumably explains this change. We also expected that the changes would have unintended effects, and found an immediate increase in the non‐opioid substance‐related ED presentation rate that was greater among people prescribed opioids than in the control group,” researchers reported.

“One possible mechanism underlying the increase in non‐opioid substance‐related harms could be related to increased prescribing of unmonitored pain medicines, such as pregabalin and tricyclic antidepressants, following the introduction of the prescription drug monitoring program.”

PDMPs have also had unintended consequences in the United States. In a 2021 study, the Reason Foundation found that opioid prescribing declined in states that adopted PDMPs, but that overdoses involving heroin, illicit fentanyl and cocaine significantly increased – suggesting that some patients were substituting illicit drugs for prescription opioids.

The focus on prescription opioids may have been misplaced in Victoria. According to a 2023 report by the state’s coroner, the anti-anxiety medication diazepam was the lead drug involved in fatal overdoses (213 deaths) in Victoria, followed by heroin (204 deaths), methamphetamine (164 deaths), alcohol (153 deaths) and pregabalin (78 deaths). In contrast, oxycodone was involved in 41 deaths and codeine in 24 deaths.

Bad News Continues for Non-Opioid Analgesics

By Pat Anson

The bad news keeps piling up for non-opioid analgesics, which are often touted as safer and more effective alternatives to opioid pain medication.

A large new study found that pregabalin (Lyrica) raises the risk of heart failure in older patients, while Vertex Pharmaceuticals said it was stopping development of an experimental drug for post-operative pain because it was less effective than a low dose of hydrocodone.   

The pregabalin study, recently published in JAMA Network Open, compared the drug to gabapentin (Neurontin) among Medicare patients with chronic non-cancer pain. Both pregabalin and gabapentin are gabapentinoids, a class of nerve medication that was originally developed to prevent seizures in epileptic patients.

Because they are not opioids and perceived as safer, both drugs are now widely being prescribed for a variety of pain conditions, usually off-label.  

In a subset of patients with cardiovascular disease, researchers found that hospitalizations and emergency department visits for heart failure were more common in pregabalin users compared to patients on gabapentin. The difference wasn’t significant (18.2 visits vs 12.5 per 1,000 person-years), but it was enough for researchers to recommend caution when prescribing pregabalin.

“Practicing clinicians should undertake a careful assessment of ongoing cardiovascular risk factors and perform adequate risk-benefit counseling for older patients before prescribing pregabalin for chronic pain,” wrote lead author Elizabeth Park, MD, Columbia University Irving Medical Center.

Pregabalin is believe to be riskier because it binds to calcium channels associated with heart failure and arrhythmias. Both the American Heart Association and European Medicines Agency already list pregabalin as a drug that increases the risk of heart failure.

"The study serves as an important reminder that not all gabapentinoids are created equal and that in the pursuit of safer pain control, vigilance for unintended harms remains paramount," said Robert Zhang, MD, and Edo Birati, MD, in an accompanying editorial.

"For older adults with chronic pain, particularly those with cardiovascular disease, clinicians should weigh the potential cardiovascular risks associated with pregabalin against its analgesic benefits. This is particularly relevant given the growing use of gabapentinoids in older populations and ongoing polypharmacy issues in this age group."

The research doesn’t give gabapentin a clean bill of health, since it also raises the risk of heart failure in older patients – just not as much as pregabalin. Last month another study found that gabapentin increases the risk of dementia and cognitive impairment.

Researchers have long been concerned about the effects of gabapentinoids on the brain, while many patients have complained the drugs cause brain fog, dizziness, weight gain and mood changes. Despite warnings that they are overprescribed for conditions they were never intended to treat, the use of gabapentinoids continues to grow in the United States. 

New Analgesic No Better Than Vicodin

The new analgesic being developed by Vertex Pharmaceuticals – called VX-993 -- will apparently never reach patients, after the company announced disappointing results from a Phase Two clinical trial.  VX-993 is a non-opioid that blocks pain signals in peripheral nerves before they reach the brain, which means it doesn’t have the same “liking” effects of opioids, which can lead to addiction.  

When given to patients recovering from bunionectomy surgery, VX-993 was slightly more effective than a placebo in reducing post-operative pain, but provided less pain relief than a low dose of a hydrocodone/acetaminophen combination (Vicodin).  

“Based on these results, as well as the totality of preclinical data and results from our previous bunionectomy clinical studies, VX-993 is not expected to be superior to our existing NaV1.8 inhibitors and therefore we will not be advancing it as monotherapy in acute pain,” Carmen Bozic, MD, Executive Vice President and Chief Medical Officer at Vertex, said in a statement.

VX-993 acts similarly to Journavx (suzetrigine), a non-opioid developed by Vertex that acts on peripheral nerves. Journavx was recently approved by the FDA to treat moderate to severe acute pain, despite lackluster results in clinical trials that also showed it was no more effective than Vicodin.

The FDA’s approval of Journavx coincides with implementation of the NOPAIN Act, which makes non-opioid analgesics in outpatient surgical settings eligible for higher Medicare reimbursement rates. Journavx costs about three times as much as Vicodin.

Canada Facing Nationwide Shortages of Opioid Pain Medication

By Pat Anson

Pain patients in the United States have been dealing with persistent shortages of opioid pain medication for years. Now their counterparts in Canada face a similar issue.

Health Canada has issued a warning about nationwide shortages of oxycodone and acetaminophen combinations, along with medications that combine codeine with acetaminophen. Acetaminophen and oxycodone are sold under the brand names Percocet and Endocet, while acetaminophen-codeine combinations are often sold as Tylenol #3.

While the opioid shortages in the U.S. appear to be largely driven by a national opioid settlement that rations pain medication at the pharmacy level, the Canadian shortages are being blamed on manufacturing disruptions and increased demand.

“We recognize the importance of having acetaminophen with codeine or oxycodone products available for patients. Addressing this shortage is a top priority,” Health Canada said in a statement.

“We're communicating with health care providers, provincial and territorial governments, and distributors to coordinate the sharing of information about this shortage. We're also working with manufacturers and stakeholders to monitor the supply of acetaminophen with codeine or oxycodone and looking at options for increasing access to these products.”

The Canadian Pharmacists Association (CPA) expects the shortages to last a few more weeks, when a “significant resupply” is expected.

“The shortage is the result of manufacturing issues affecting one major supplier, which has increased pressure on other manufacturers. While the supply situation is expected to improve by mid-August, supply constraints are expected to continue until the end of September,” the CPA said in a statement.

A patient advocate says the opioid shortages don’t appear to be causing many problems for patients, at least not yet.

“As far as the shortages go, at least for those I was able to speak with, they are coping with it,” Barry Ulmer of the Chronic Pain Association of Canada told PNN.

“The real problem is the lack of actual doctors who will prescribe (opioids) and in doses needed. Even though Health Canada and the provincial regulators say opioids are O.K. to use, they still warn doctors about overprescribing and tapering is still a very real reality. Almost every doctor that I have known over the years have now retired or just plain quit because of this ongoing problem.”

Smaller Doses and Tapering Recommended

Until the shortages ease, the CPA is advising pharmacists to suggest non-opioid pain relievers for patients suffering from acute short-term pain, such as headaches and muscle strains.

For long-term pain patients already using oxycodone and codeine combinations, the CPA recommends limiting doses to 90 morphine milligram equivalents (MME) a day. Switching to another opioid and/or tapering is another alternative.

“If the current dose is high, give 50% or less of the new opioid converted to morphine equivalents. Otherwise, start with 60–75% of the previous dose converted to morphine equivalents,” the CPA said.

In the United States, either scenario would be considered a rapid taper, which can raise the risk of an overdose or mental health crisis. The CDC recommends more cautious tapering of patients, with a dose reduction of just 10% a month.

The American Society of Health-System Pharmacists (ASHP) first reported U.S. shortages of oxycodone-acetaminophen combinations in the summer of 2023. Not much has changed in the last two years.

In its June report, the ASHP said several drug manufacturers have oxycodone-acetaminophen combinations on back order, with no estimated resupply date. Only one drug maker, Major Pharmaceuticals, anticipates having new supplies in early August.

Some companies are phasing out the production of opioid medication. Endo Pharmaceutical stopped making Percocet in 2024, while Teva Pharmaceuticals discontinued production of immediate release oxycodone in 2023 and Transmucosal Immediate-Release Fentanyl Medicine (TIRF) in 2024. Opioid litigation has been very costly to Teva and other drug makers. In 2022, Teva paid $4.25 billion to settle thousands of opioid liability lawsuits.

Continued Blaming of Purdue Pharma Won’t Solve the Opioid Crisis

By Lynn R. Webster, MD

On July 15, The Washington Post published an editorial urging states to use opioid settlement funds to expand naloxone access and addiction treatment programs.

These are sound public health goals. But the editorial’s framing — tying these investments to reparations for damage attributed to Purdue Pharma — rests on an oversimplified and misleading narrative that has shaped policy and public opinion for over a decade.

Purdue Pharma aggressively market OxyContin and contributed to early overprescribing. However, it was never the dominant supplier of prescription opioids. Analyses of pill counts, morphine milligram equivalents, and regional variation show that Purdue’s market share was often far less than one-third. While its actions were consequential, the disproportionate focus on Purdue distracts from the broader, ongoing drivers of the crisis.

Addiction is not caused by the availability of opioids alone, but also by the conditions that make people vulnerable: poverty, trauma, housing instability, and untreated mental illness. By fixating on corporate actors, we risk mistaking the spark for the fire — and neglecting the deeper issues that sustain the epidemic.

The editorial also perpetuates confusion between physical dependence and addiction. The former is a predictable response to long-term opioid use; the latter involves compulsive behavior and impairment. Blurring the two has led to harmful policies, including forced opioid tapers and abandonment of stable pain patients.

These policies have not reduced deaths. As prescription opioids became harder to obtain — often due to regulatory pressure — some patients turned to illicit alternatives; not to get high, but to avoid withdrawal or manage pain. This shift laid the groundwork for the explosion of heroin and illicit fentanyl use. Today, illicit synthetic opioids are involved in more than 70% of overdose deaths.

Framing settlement spending as payback reinforces a punitive narrative rather than advancing evidence-based solutions. Naloxone, youth prevention, and addiction treatment should be pursued because they work — not because they symbolize restitution.

The real challenge lies in addressing the conditions that lead to substance use in the first place. Reforming housing policy, expanding mental health care, and ensuring access to meaningful employment are more difficult— but are far more essential — than litigating against a defunct company.

We should also be asking why the healthcare system permitted aggressive opioid marketing, why insurers incentivized pill volume over outcomes, and why evidence-based addiction care and harm reduction remain chronically underfunded.

Managing the crisis requires more than blame. It requires accurate explanations, structural change, and sustained investment in public health — rather than narratives that feel satisfying but obscure the truth.

Lynn R. Webster, MD, is a pain and addiction medicine specialist, and serves as Executive Vice President of scientific affairs at Dr. Vince Clinical Research, where he consults with pharmaceutical companies.

Dr. Webster is the author of the forthcoming book, “Deconstructing Toxic Narratives – Data, Disparities, and a New Path Forward in the Opioid Crisis,” to be published by Springer Nature.

‘This Is Blood Money’: Who Is Policing How Opioid Settlement Funds Are Spent?

By Aneri Pattani, KFF Health News

After years of legal battles, state attorneys general won billions of dollars in opioid settlements from drug companies accused of fueling the addiction crisis. They declared victory at press conferences, and some touted the deals during their gubernatorial campaigns.

But now that the windfall is being spent, are attorneys general doing enough to ensure it’s used for the intended purposes?

No, say many families affected by the overdose crisis, recovery and harm reduction advocates, policy experts, and researchers following the cash.

“This is blood money,” said Toni Torsch, a Maryland resident whose son Dan died of an overdose at age 24. It can’t make up for the lives lost, but “we do want to make sure that it’s going to count.”

Torsch and others affected by the crisis are increasingly worried that no one seems to be guarding the opioid settlement cash while elected officials eye it hungrily. With the Trump administration slashing federal funding for addiction and Congress approving massive reductions to Medicaid — the largest payer for addiction care nationwide — people fear state legislators will use the settlements as a grab bag to fill budget shortfalls.

In the face of these concerns, two research and advocacy organizations are proposing a solution: a crowdsourced database to identify potential examples of misuse and prompt attorneys general to investigate.

The Opioid Policy Institute and Popular Democracy launched a website that allows members of the public to submit alleged cases of waste, fraud, abuse, and mismanagement of opioid settlement funds. Submissions are reviewed by Jonathan Stoltman, director of the Opioid Policy Institute, and then posted with details such as how much money was spent, what was purchased, who made the decision, and links to relevant news articles or budget documents.

The database, shared first with KFF Health News, includes about 150 examples to start, including $2,362 awarded by a Missouri county to its roads and bridge department and $375,600 spent on a body scanner for a Michigan county jail. The initial examples were sourced from people in recovery, advocates, and others Stoltman and his team asked to test the project. Stoltman acknowledged he’ll face criticism as the primary arbiter of what qualifies as misuse for the database, but said he’ll use research studies to defend his decisions.

The website also shows people how to file complaints with their state attorney general and ask the office to develop a formal process for receiving and investigating such complaints.

“I hope this is a wake-up call for state AGs that their work on this project is not done,” said Frank Kearl, who co-led the effort with Stoltman and is working as an attorney at Popular Democracy until July 14. “We still have time” to make changes to ensure we “spend this money in a way that actually responds to the harm that was caused.”

The website’s launch comes just over a week after New Jersey lawmakers passed a budget that gave health systems $45 million in settlement funds despite the state attorney general’s opposition. Legislators said it would shield hospitals from the blow of federal Medicaid cuts, but harm-reduction advocates said it gives short shrift to people with substance use disorders, whom the money was meant to serve.

Lawmakers in North Carolina and Washington, D.C., are also considering using settlement funds to plug gaps, and Connecticut and Nevada have discussed it too.

“That’s not what it’s there for,” said Torsch, who runs a nonprofit dedicated to addiction recovery in her son’s honor. “We want to make sure that money is being spent in the most responsible and effective way to help people that are still struggling.”

Last year, when Torsch heard that a western Maryland county spent some of its settlement money on guns, she reached out to her state attorney general to complain. The office said it wasn’t its responsibility, Torsch said, and told her to contact the health department.

She was confused.

The attorney general’s office is supposed to represent “the top cops,” Torsch told KFF Health News.

The Maryland attorney general’s office declined to answer KFF Health News’ questions about how it handles opioid settlement complaints.

Few States Monitor Spending

About a dozen companies are expected to pay state and local governments more than $50 billion in opioid settlements over nearly two decades. Purdue Pharma’s case, the most well known, is still wending its way through court. But other companies, including Johnson & Johnson, CVS Health, and Walgreens, have begun paying.

Although the specifics of each settlement deal vary, most require states to use at least 85% of the money on efforts related to the opioid crisis. But enforcement is left to the companies that paid out the money. And legal experts are skeptical that the companies are monitoring state spending.

Attorneys general should be enforcing that standard too, said Stoltman, of the Opioid Policy Institute. “If you’re going to bang your chest about how much money you got for your state for opioids,” he said, “what are you doing to make sure that it’s actually being spent well?”

Stoltman’s and Kearl’s teams surveyed attorneys general offices in 56 states and territories to see if each office had a complaint form specific to this pot of money, explained the details needed to report misuse, and allowed submitters to track their complaints. They also searched websites of state auditors, comptrollers, and similar entities for complaint forms or procedures.

Their findings? Only three states mentioned specific processes for reporting misuse of opioid settlement money.

South Carolina and New Jersey had links on settlement-related websites that directed people to general complaint forms. Oklahoma was the only state to have an opioid settlement-specific form.

Jill Nichols, opioid response and grant coordinator in the Oklahoma Office of Attorney General, said it was created in April in response to the researchers’ inquiry. As of late June, she’d received one complaint, which was found to be without merit.

Stoltman and Kearl said they hope the crowdsourced database will encourage more attorneys general to take an active oversight role by illustrating how much potential misuse is occurring.

The Michigan attorney general’s office said it plans to publish a settlement-specific complaint form this year.

But some attorneys general told KFF Health News it wasn’t their job to track how the money is spent.

Brett Hambright, a spokesperson for Pennsylvania Attorney General David Sunday, said the state created an opioid settlement council to take on that responsibility.

In North Carolina, Attorney General Jeff Jackson’s office said, settlement funds are controlled by the state legislature and local governments. “Our office does not administer the funds nor do we have the power to withhold them,” spokesperson Ben Conroy said.

Even when attorneys general watch the money closely, their power may be limited. For example, Arizona Attorney General Kris Mayes went to court last year to stop the state legislature from giving $115 million in settlement funds to the Department of Corrections. But a judge ruled against her.

Maryland Attorney General Anthony Brown’s office directed KFF Health News’ questions to other state agencies.

Michael Coury, a spokesperson for Maryland’s Office of Overdose Response, said members of the public can email the office with complaints. If the office agrees misuse has occurred, it will bring the complaint to the attorney general, who — per the state’s agreement with local governments — “may” take action.

As of this year, the attorney general’s office will receive $1.5 million of Maryland’s opioid settlement funds annually to cover personnel and administration costs related to opioid-related lawsuits. This may involve suing more companies for future settlement deals.

Torsch, the Maryland mom, said she wishes the focus wasn’t just on winning more money but also ensuring that existing settlement dollars are spent well.

“We owe it to all the families that have been destroyed and suffered great losses,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling, and journalism. Learn more about KFF.

Study Links Gabapentin to Increased Dementia Risk

By Crystal Lindell

Gabapentin (Neurontin) may significantly increase the risk of dementia and cognitive impairment, even for middle-aged patients who only took the nerve medication for six months.

That’s according to a new study, published in the Regional Anesthesia & Pain Medicine journal, which looked at health records for over 26,000 U.S. patients with chronic low back pain.

Researchers found that patients with six months or more of gabapentin use had a 29% higher risk of developing dementia and an 85% higher risk of developing mild cognitive impairment (MCI). 

Gabapentin was originally developed to prevent epileptic seizures, but is now commonly prescribed off-label as an alternative to opioids for pain management.

Researchers have long been concerned about gabapentin’s effects on neurotransmitters in the brain, while patients have complained the drug causes brain fog, dizziness, weight gain and worsens mood. 

Perhaps the most startling aspect of the study is that gabapentin increases the risk of dementia and cognitive decline in middle aged adults.

Dementia risk more than doubled and MCI risk tripled among 35–49 year olds. A similar pattern was observed among 50–64 year olds.

Risks also rose the more often patients use gabapentin. Those with 12 or more prescriptions were 40% more likely to develop dementia and 65% more likely to develop MCI than those with fewer prescriptions.. 

“Our findings indicate an association between gabapentin prescription and dementia or cognitive impairment within 10 years. Moreover, increased gabapentin prescription frequency correlated with dementia incidence,” wrote lead author Nafis Eghrari, a medical student at Case Western Reserve University School of Medicine.

“Our results support the need for close monitoring of adult patients prescribed gabapentin to assess for potential cognitive decline.”

As a patient who has taken gabapentin for chronic pain, these results are alarming to say the least. And I wonder if the findings would also apply to pregabalin (Lyrica) and other gabapentinoids in the same class of medications. I have also been prescribed Lyrica. 

I don’t believe I was ever warned that gabapentin could increase my risk of cognitive decline, despite the fact that was a known concern. I don’t know if such a warning would have deterred me from taking it, but that’s still a choice that should have been given to me. 

I am also concerned that the information about these very real risks associated with even relatively short-term gabapentin use will reach patients and prescribers. Sales of gabapentin and pregabalin have tripled from a decade ago, when they were first touted as safer alternatives to opioids. 

Gabapentin is FDA-approved for epilepsy and neuropathic pain caused by shingles, but is also prescribed off-label for depression, ADHD, migraine, fibromyalgia, bipolar disorder and postoperative pain.  

Anyone prescribed gabapentin for pain should be told that using the medication for just six months greatly increases their risk of developing dementia. However, I doubt that will happen. In my experience, while medical professionals are quick to point out the supposed risk of opioids like hydrocodone, they often push alternatives like gabapentin onto patients without much discussion. 

The assumption is always that anything must be safer than opioids. Unfortunately, that doesn’t always seem to be the case.