Lessons from ‘The United States of Opioids’

By Roger Chriss, PNN Columnist

Harry Nelson’s new book “The United States of Opioids: A Prescription for Liberating a Nation in Pain” looks closely and productively at the opioid overdose crisis. It comments on origins and causal factors, and offers pragmatic policy ideas for addressing it. The book is succinct and well-organized, designed for easy reading and reference.

Nelson starts with a dire description of addiction and overdose, calling the U.S. opioid crisis “American healthcare’s self-inflicted wound.” He then gives a brief history of opioids, explaining the three waves of the crisis, culminating in illicit fentanyl and “an increasing crackdown on physician overprescribing.”

Nelson touches on the history and science of opioids, then looks at causes of the crisis. These include not only Purdue Pharma and the Sacklers, but also drug distributors, retailers and health insurers. Institutional and regulatory failures on opioids are not ignored.

“The overarching problem when it comes to physician overprescribing has been insufficient training and education on how to prescribe opioids,” he writes. “The FDA approved these drugs and oversaw the data concerning the risks of their misuse, abuse, addiction, and overdose.”

But Nelson digs deeper, looking at the underlying social and cultural determinants that play into the longer term. He cites a 2018 University of Pittsburgh study that underscores that opioids are part of a broader trend in which abuse of multiple drugs and a rising drug overdose rate “that shows no signs of slowing, with sub-epidemics of different drugs over time.”

Unlike other books, Nelson writes in depth about how to address the crisis: “I believe that our attention should first be focused on a host of intersecting trends that point to suffering in America — parallel crises that include suicidality, anxiety, depression, and pain.”

He explores other options for pain management, from NSAIDs and nerve blocks to non-pharmacological techniques: “It is critical to push insurers and government programs to cover non-opioid treatment, even if it means spending more to achieve this priority.”

Nelson includes a whole chapter on cannabis and other alternative therapies for opioid addiction, in particular kratom and psychedelics. He is optimistic but tentative about cannabis: “Despite the potential to address health issues, consumers need to be cautious about both the claims and contents of cannabis products.”

He also looks at addiction treatment, including AA-type abstinence programs and medication-assisted therapy, and notes that “the biggest challenge in addiction treatment is the complexity of addiction itself.”

Nelson is highly critical of much of the response to the crisis to date: “When I think about the government and health system’s approach for taking on the opioid crisis, the thing that strikes me most is how much it feels tactical rather than strategic.”

Nelson condemns the rampant fraud and patient brokering in the recovery industry. But he also points out that addiction treatment itself needs improvement.

“We will know that addiction treatment has ‘arrived’ in terms of its integration into healthcare when we have relatively uniform professional and program licensure requirements from state to state — something seemingly decades away,” he wrote.

Nelson lists seven general recommendations for the crisis in his OPIOIDS acronym:

• Outreach for prevention and early intervention

• Physician improvements

• Innovation in pain and addiction care

• Overdose interventions

• Interdiction off illicit opioids

• Data analytics to better track the crisis

• Strengthening access to addiction care

He emphasizes the value of harm reduction, improving social capital, and organizing prevention in schools and the workplace — instead of “stop gap” measures that do little beyond preventing fatal overdoses.

“The key to solving the opioid crisis lies in not being satisfied with tackling the overdose death issue, but in addressing two of the fundamental problems that got us here: the inadequate management of ongoing issues for people living with chronic pain, which overlaps with the second problem of people living with an opioid use disorder (OUD),” he writes.

Finally, Nelson gives a warning: “If we think about the opioid crisis as the ‘canary in the coal mine,’ it’s warning us that we need to address a much bigger, toxic set of problems.”

For all the book offers, it also has problems. Nelson overstates the number of people with opioid use disorder, misrepresents the complex nature of opioid initiation, and misconstrues the varied trajectory of heroin addiction. Most importantly, Nelson gives little attention to rising rates of cocaine and methamphetamine overdose deaths, and ignores that most overdoses involve multiple drugs.

“The United States of Opioids” offers a suite of tools and ideas for moving forward, a refreshing change from the many righteous rants or poignant laments about the crisis.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

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

Chronic Pain Patients in Alberta Revolt

By Marvin Ross, Guest Columnist

Last week the Chronic Pain Association of Canada issued a press release calling upon the Alberta health minister to investigate the College of Physicians and Surgeons of Alberta (CPSA) for “its unwarranted and secret cautioning and sanctioning” of doctors who prescribe opioid medication.

The press release came after a public meeting of pain patients in Edmonton organized by the group Help Alberta's Pain. Numerous patients showed up to complain about the poor quality of pain care in Alberta.

The meeting was so successful that the organizer, Tracy Fosum, told me that more meetings are being arranged in Edmonton, Calgary, Sherwood Park, Lethbridge and one in Northern Alberta.

An estimated 1.25 million Albertans suffer from chronic pain and 125,000 have long used opiate analgesics in order to function. In March, an Edmonton pain practice shutdown, throwing nearly 1,000 of these patients out of care.  

“Thousands of Albertans with pain have lost specialist and primary care because the College of Physicians and Surgeons of Alberta has forced doctors to stop prescribing opiates. The province's pain specialists are retiring in large numbers, citing College intimidation,” Barry Ulmer, Executive Director of the Chronic Pain Association of Canada said in a statement.

In response, the CPSA issued a statement from Registrar Dr. Scott McLeod calling such claims “misinformation” and denying there was an exodus of pain physicians from the profession.   

“Many Albertans suffer with severe daily pain and need medical assistance to allow them to live productive lives with their family, friends and in the workplace. We understand the challenges these Albertans face and encourage physicians to work with their patients to find a sustainable solution,” McLeod said. “Responsible prescribing does not include abrupt discontinuation or tapering of opioids or abandoning patients who use opioids.”

McLeod said the CPSA has been successful in reducing overdoses and opioid prescriptions. Accidental overdose deaths in Alberta from prescription opioids have been cut in half, there has been a 20% decline in opioid prescribing since 2016, and 13% fewer patients received an opioid in 2018 compared to 2016.

Patients Denied Treatment

Tracy Fosum recently appeared on the Roy Green syndicated radio show to talk about her personal experiences as a long time chronic pain patient in Alberta. Suffering from what even I recognized as the classic signs of a heart attack, she went to a local Edmonton hospital. Staff were suspicious of Tracy because of her high opioid use and, after a cursory exam, suggested she go home and take some NSAIDs for what they decided were chest muscle spasms.

Later, Tracy went to another hospital emergency room, where she was forced to wait for six hours as, she contends, they mistook her for a drug seeking addict. While trying to convince them to do an EKG, she went into cardiac arrest and collapsed. Fortunately, Tracy survived but ended up with heart damage because she had to wait too long.

Meanwhile, the Ontario College of Physicians and Surgeons is in the process of revising their opioid prescribing guidelines. A new draft policy states: “Physicians must not taper patients inappropriately or arbitrarily. Physicians are reminded that it is not always possible or appropriate to taper below a specific dose, nor is it usually appropriate to suddenly or rapidly taper prescriptions.”

The proposed guideline also states that “arbitrarily refusing to prescribe these drugs in all cases and without consideration for the circumstances of the patient may lead to inadequate patient care.”

While this is a step in the right direction, the problem is that patients have little recourse other than filing a formal complaint if a doctor provides poor treatment. A formal complaint can take months to years to resolve and ruins a doctor/patient relationship.

I am personally familiar with one case where a chronic pain patient was refused care by a doctor unless she agreed not to take any opioid medication. That doctor was sanctioned for refusing a patient on narcotics and refusing to prescribe narcotics, but the sanction was simply “Don't do that. You cannot refuse.” That patient now has no doctor because no one will take her on.

The Colleges can revise their rules and recommendations all they want, but they also need to ensure that doctors adhere to them.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He is a regular contributor to the Huffington Post.

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

Kratom Saved My Life

By Kim DeMott, Guest Columnist

I was diagnosed with lupus in 2013 after spending several years with unexplained chronic pain, debilitating fatigue and other awful symptoms. Lupus was the first of many chronic conditions that I would be diagnosed with in coming years, including fibromyalgia, Sjogren’s syndrome, osteoarthritis, osteoporosis, carpal tunnel syndrome, migraines, endometriosis, interstitial cystitis, chronic fatigue, chronic pain, anxiety and depression.

To treat these conditions, I was prescribed 28 different medications a day, including massive amounts of powerful opiates like oxycodone, hydrocodone and morphine, along with high doses of benzodiazepines such as Ativan, Xanax and Klonopin.

Even though I was taking all these medications, I was still in pain, had bad anxiety and no quality of life. I was housebound and practically bedridden (or at least couch-ridden) most days.  I had to use a cane, walker and even the walls in my house to walk on the really bad days, which is no way for a young woman and mother of two to live.

My health became so bad that in the fall of 2014 my doctors labeled me permanently disabled and told me to get in-home support services and file for SSI. I was only 29 years old.

I would have to tell my kids that mommy was in too much pain and too tired to take them to the park, play with them, pick them up, take them to school or be involved in any of their activities. This caused me and them to miss out on precious time and memories we can’t ever get back.

I couldn’t cook, clean, drive, go to the store or even go for a quick walk. They would see and hear me hiding in the bathroom or bedroom crying from the pain and the feeling of failure I felt as their mom.

I couldn’t take a shower, brush my teeth and get dressed in the same hour because I would have to rest after every task I did. Getting dressed consisted of putting on clean pajamas, because that’s the only thing that wouldn’t hurt to wear. I became isolated and depressed. I stopped answering my phone, texts, messages and emails.

KIM DEMOTT

The medications that the doctors put me on made me gain a ton of weight and made me feel incredibly dizzy, sleepy, forgetful, sick to my stomach and like I was in a fog. These side effects led to even more medications being prescribed, which meant more pills to add to the already huge amount I took daily. I was so depressed and hopeless that I actually attempted suicide a few times.

For over two years now I have enjoyed drinking my kratom tea a couple of times a day. It helps promote my mood and energy like a cup of coffee would. The tea also relieves my aching joints and muscles, making my chronic fatigue and pain much more bearable.  

I am in no way cured and my pain is not completely gone, it never is and never will be. But the discomfort is down to a level that I can deal with, live with and function at. I still have bad days, but they are nowhere near as frequent or as bad as they used to be.  

Kratom has greatly improved my quality of life and dramatically changed it for the better. I’m not spending every day on the couch or in bed anymore and my kids have their mom back. We are doing so much more together.

Not only are my kids happy, but so are my fiancé, family and friends. Everyone tells me they have seen a huge change in me and that I am much more like the old me, which is something I have longed for since everything started. For the first time in years I don't feel like a prisoner in my own body and like my chronic illnesses and pain control me.

I am healthier, happier, take better care of myself and eat better. I’ve also been able to lose weight since I can cook and exercise again because I have better mobility. I even feel confident that I will be able return to work again someday soon and plan on returning to school this year.  

I look forward to each day and excited for what the future will bring. Most importantly, I am setting a better example for my kids. All thanks to this plant. Kratom has truly not only saved my life but also given me renewed hope. Without this plant I do not believe I would still be alive today.  

Kim DeMott lives in California with her two children.

Do you have a story you want to share on PNN? Send it to: editor@painnewsnetwork.org.

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

WHO Recognizes Chronic Pain as Disease With New Coding System

By Pat Anson, PNN Editor

The World Health Organization has adopted a new classification system for chronic pain, assigning it the code ICD-11 in a revision of the International Classification of Diseases (ICD). It’s the first time the ICD will include a specific diagnostic code for chronic pain, along with sub-codes for several common chronic pain conditions. 

The new classification system is important because it treats chronic pain as a distinct health condition and as a symptom to an underlying disease. It also takes into account the intensity of pain, pain-related disability, and psychosocial factors that contribute to pain.

“The inclusion of the new classification system for chronic pain in ICD-11 is an important milestone for the pain field,” says Lars Arendt-Nielsen, MD, President of the International Association for the Study of Pain (IASP), which headed a task force that developed ICD-11.

The new coding system will make it easier for physicians to diagnose, classify and get treatment for chronic pain patients. Insurers will use the new codes to authorize payments and researchers can use them to more easily track and measure the effectiveness of therapies. That’s the good news. 

The bad news is that the ICD changes won’t formally take effect until January 1, 2022. 

Under the current system, chronic pain conditions are poorly categorized under the code ICD-10, which makes it difficult for complex conditions such as fibromyalgia and Complex Regional Pain Syndrome (CRPS) to be classified. That led some physicians to diagnose patients with unexplained pain as having a somatic symptom disorder. 

“A diagnosis of somatic symptom disorder implies that the pain is caused by a behavioral, that is, mental condition. However, it is not appropriate to diagnose individuals with a mental disorder solely because an alternative medical cause cannot be established,” Jaochim Scholtz, MD, an IASP task force member, explained in Practical Pain Management.  

Under the new coding system, patients with fibromyalgia or CRPS could be classified as having a “primary pain” disorder, one of seven new sub-codes for chronic pain conditions:

1. Chronic primary pain

2. Chronic cancer-related pain

3. Chronic post-surgical or post-traumatic pain

4. Chronic neuropathic pain

5. Chronic secondary headache or orofacial pain

6. Chronic secondary visceral pain

7. Chronic secondary musculoskeletal pain.

There is some overlap between the different diagnostic codes. For example, neuropathic pain can be a symptom of cancer or chemotherapy, while trigeminal neuralgia could fall under neuropathic or orofacial pain. The idea is to give physicians a range of codes to choose from instead of the limited choices they have today.

“The integration of chronic pain in ICD-11 sends a strong signal that pain will achieve appropriate representation in this international standard for reporting diseases and health conditions,” said Scholtz. “The coding system also provides fundamental information for the identification of health trends and healthcare planning. It is widely hoped that the new systematic classification of chronic pain in the ICD-11 will support epidemiological, and other research that is essential for the development of future health policies.”

The classification system was outlined in a free online article published in the January 2019 issue of PAIN.

Emmy Winning Video Perpetuates Myths About Addiction

By Dr. Lynn Webster, PNN Columnist

"Rebekkah's Story" recently won an Emmy for Short Format Daytime Program at the 46th Annual Daytime Emmy Awards. The six-and-a-half minute video was produced by Truth Initiative, a non-profit created to campaign against tobacco use that recently launched an opioid misuse and education campaign called The Truth About Opioids.

Rebekkah is a young woman addicted to opioid medication and heroin who spent five days in a “treatment box” publicly detoxing on a New York City street.  The documentary has also been broadcast on television and can be seen online:  

Though billed as educational, the producers of “Rebekkah’s Story” failed to accurately convey the facts. This is not the first time we've seen movies about drug use and addiction that misinform.  

I wrote a blog not long ago about the problems with two mainstream movies -- "Ben Is Black" and "Beautiful Boy"— both of which reinforced unhelpful narratives about addiction. In both films, good people from good families found themselves caught in the web of addiction, seemingly with no personal responsibility for it. 

"Rebekkah's Story" continues in the same tradition. It exploits Rebekkah and her experience while perpetuating three myths about addiction that do us no favors as our nation struggles with this terrible illness.

At the same time, millions of Americans with chronic pain are being forced off opioid medication — left to suffer in part because of these three myths:

Myth #1: Heroin Use Starts With Prescription Drugs

The movie begins with a misleading statistic: “Eighty percent of heroin users started with a prescription painkiller.” That implies taking painkillers as prescribed for medical use leads to using heroin 80% of the time, and that is not accurate. 

The 80% statistic comes from a 2013 study of heroin users who reported nonmedical use of opioid pain relievers before initiating heroin. Most of them had not been prescribed those opioids for pain; they obtained the drugs from family or friends for nonmedical use.  

In fact, the vast majority of people who use heroin have abused other substances prior to abusing prescription opioids. Usually, their long history of substance abuse begins in adolescence with tobacco, alcohol and other substances besides opioids. Moreover, by 2015, one in three heroin users initiated their opioid use with heroin.

Rebekkah's situation -- progressing from oxycodone to heroin -- was unusual. The video presents her story as a cautionary tale of what can happen if you use prescription opioids, but her story is atypical. Almost always, there are other factors that contribute to the transition from appropriate use to abuse and addiction. This is a truth not addressed in the film. 

The film begs the question: Why did Rebekkah start to use heroin? What did heroin provide that she could not resist? 

Myth #2: Withdrawal Is Synonymous to Addiction

"She had been an accomplished dancer and athlete, and that was lost when her addiction took over her life and self-image," explains the video's website. "Now Rebekkah is regaining control of both — courageously making her detox public in order to help other people while she works towards a new start."

The producers of “Rebekkah’s Story” present a poignant story, but they propose that withdrawal is synonymous with addiction. That is incorrect.

Withdrawal may be associated with addiction, but it does not necessarily follow from addiction. Not everyone who goes through withdrawal has the disease of addiction, and not everyone with addiction must go through the agonizing withdrawal that Rebekkah did.

A major problem that most people with addiction face is the stigma associated with their disease and their inability or unwillingness to obtain help. Fear of facing a legal penalty (such as incarceration) or a social consequence (estrangement from family members, job loss, etc.) often prevent those who use heroin from seeking treatment.  

People experience opioid withdrawal largely because the healthcare and criminal justice systems make access to appropriate and safe treatment illegal, unavailable or unaffordable.  

Myth #3: Detoxification Ends Addiction 

The ending of "Rebekkah's Story" differs from reality, too. Addiction is usually a life-long disease and patients who recover frequently relapse. The video's tidy and triumphant resolution does not accurately reflect what occurs in real life.  

It's troubling how the producers went about creating the video in ways that subtly strengthen and exploit the three myths about addiction.

Their set was a makeshift hospital room projected in a cubicle visible to pedestrians walking near Times Square. The setting was essentially a stage for performance art at Rebekkah's expense.

Rebekkah takes on the role of a gladiator engaging in combat against a metaphorical beast: the agony of opioid addiction.

She is the heroine with whom we should empathize. We are supposed to share her anger toward the wicked doctors who prescribed her pain medication. 

People watch as Rebekkah suffers from withdrawal without receiving the medical treatment that should be available to anyone in withdrawal. It was surprising that, in the documentary, an addiction physician was complicit in exploiting a person undergoing withdrawal.   

No one should be forced to experience what Rebekkah went through. She should have been given appropriate medical care as she recovered from heroin abuse. 

"Rebekkah's Story" claims to tell the truth about opioids. It does not. All it shows is Rebekkah’s decision to voluntarily and publicly experience a horrible withdrawal that was both unnecessary and avoidable.

Unfortunately, compliant and non-addicted pain patients who are currently being forced off opioid medication don’t have the same stage to tell their stories. Their voices often go unheard, and their agonies are invisible.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is a former president of the American Academy of Pain Medicine and is author of the award-winning book “The Painful Truth” and co-producer of the documentary “It Hurts Until You Die.”

You can find him on Twitter: @LynnRWebsterMD.

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

Pain Clinic Sign ‘Unauthorized and Untrue’

By Pat Anson, PNN Editor

A Florida-based chain of surgery centers and pain clinics says a sign that briefly appeared at one of its clinics implying that the company would no longer prescribe opioid medication is unauthorized and untrue.

The sign appeared in a window at Physician Partners of America’s Jacksonville clinic on May 14.  Someone took a picture of the sign and posted it online, where it was widely shared on Twitter and Facebook among pain patients, advocates and doctors.

“ATTENTION ALL PATIENTS,” the sign said in bold red letters. “Per our chief (medical) officer, Dr. Rivera, we will be starting to focus on interventional medicine only and we will not be managing medication. This will be fully effective within the next 30 days or less.”

For someone taking opioid medication for chronic pain, the threat of being cutoff is very real. The potential number of patients that would be impacted would also be significant. Physician Partners of America (PPOA) treats around 20,000 patients in Florida and Texas.

The problem with the sign is that it isn’t true, according to the company.

“This sign was brought to our attention through social media. It was in no way authorized or approved by management, and its message is untrue. It resulted from an employee’s misinterpretation of our goal to reduce opioid dependence,” Maria Hickman, PPOA’s social media and content specialist, said in a statement on the company’s website.

“We recognize the opioid crisis backlash. As an organization, we sympathize with the plight of people who rely on, but who do not intentionally abuse, prescription opioid medications to manage their chronic pain. We aim to show them what we consider a better, safer way to reduce or eliminate pain.”

That “safer way” is interventional pain management, a more aggressive form of treatment that includes epidural steroid injections, nerve blocks, “minimally invasive” spinal procedures, Botox injections, spinal cord stimulators and stem cell therapy. Interventional methods are more expensive than pain medication, are not always covered by insurance, and many patients believe they are neither safer or effective.

PPOA said it would continue prescribing opioids to patients when it is appropriate, adding that they would be tapered to lower doses. “Patients are and will continue to be titrated down according to CDC guidelines; however, there is no cut-off date,” Hickman said.

That part of the company’s statement reflects a common misconception about the CDC’s controversial guideline, which is voluntary and does not mandate tapers. The 2016 guideline only recommends tapering “if benefits do not outweigh harms of continued opioid therapy” and explicitly says tapering should be voluntary, with the patient’s consent.

“Clinicians should emphatically review benefits and risks of continued high-dosage opioid therapy and should offer to work with patients to taper opioids to safer dosages. For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan,” the guideline says.

That part of the guideline has been so widely ignored that CDC Director Robert Redfield, MD, released a letter last month warning doctors not to taper patients without their consent.

“The Guideline does not endorse mandated or abrupt dose reduction or discontinuation, as these actions can result in patient harm,” Redfield said. “The Guideline includes recommendations for clinicians to work with patients to taper or reduce dosage only when patient harm outweighs patient benefit of opioid therapy.”

The marketing of Physician Partners of America clearly states a preference for interventional therapy over opioid medication, so patients who go to a PPOA clinic shouldn’t be surprised if tapering or discontinuation is recommended.

“At its foundation, PPOA uses interventional pain management modalities to treat pain at its source instead of masking it with medication,” the company says. “We have championed remedies to the opioid crisis in public forums, in the media, in televised town halls and at medical conventions. PPOA physicians strictly follow the prescribing laws of the states in which they operate.”

A new law recently went into effect in Florida limiting the initial supply of opioids to 3 days, with a 7-day supply allowed if it is medically necessary. However, the law only applies to acute, short-term pain.  Most of PPOA’s patients suffer from chronic back pain and other long-term chronic conditions.

Honoring Our Veterans on Memorial Day

By Dr. Lynn Webster, PNN Columnist

On Memorial Day, we honor those who lost their lives while serving in the United States military. It is a time when we should also acknowledge the sacrifices all veterans have made, and continue to make, for our country.

Physical and mental trauma are some of the most devastating consequences veterans suffer as a result of their sacrifices. Opioid drug use in military populations is nearly triple that of civilian populations.

A 2014 JAMA study reported that more than 44 percent of active-duty U.S. infantry soldiers suffered from chronic pain. Other reports state that combat injuries cause most of the chronic pain.  

That doesn't surprise me. I've received many emails from veterans who describe their struggles to find treatment for the pain they acquired during their military service.

Here are three typical stories from veterans:

A Persian Gulf veteran, John, is being forced to slowly taper from a combination of opioids that he claims worked for him. His dose of medication is being tapered because his physician feels pressured to comply with recommendations of the CDC Opioid Prescribing Guideline.  

John is afraid that the new limit will be inadequate to treat his pain.  

"I am VERY upset with my government, as their draconian 'solutions' to the perceived 'drug problem' will only exacerbate pain issues with legitimate chronic pain patients. I don't think their efforts will have ANY effect on the illegal drug problems that plague the U.S.," John wrote me.  

He may be more fortunate than others. At the time John contacted me, he had a pain specialist who was still able and willing to support his need for treatment. 

Others have not been as lucky. Mark is a 100% disabled veteran with post-traumatic stress disorder (PTSD), severe lower back pain and severe knee problems. After surgery, Mark was only able to get a two week supply of pain medicine. For two and a half months, he suffered without any medication until he was able to go outside the VA system to obtain oxycodone.  

Then there is Jason. He is a young American hero who used opioids to self-medicate his PTSD and chronic pain. His story may help people understand why there are approximately 20 suicides each day by America's veterans.  

Although firearms are a common method of suicide with veterans, the use of prescription medication has also been implicated. Having access to opioids gives veterans a less violent way to end their lives. 

Unfortunately, the number of veteran suicides may even be underreported. As many as 45 percent of drug overdoses -- including those of military members -- might be related to suicide, according to a former past president of the American Psychiatric Association. 

Veterans' suicides make up 18% of all suicides in the U.S. The suicide rate among members of the military is nearly 3 times that of civilians.  In 2012, for the first time in a generation, the number of active duty soldiers who killed themselves exceeded the number of soldiers who were killed in battles.

Approximately 20% of recent war veterans suffer from PTSD, in addition to chronic pain. PTSD was the most common mental health condition for almost 1 million soldiers who served between 2001 and 2014. Nearly one in four of those who served during those years developed PTSD within a year of coming back home. 

Much of the general public and many mental health professionals have doubted that PTSD was a true disorder until recently. Even now, soldiers with symptoms of PTSD face rejection by their military peers and are often feared by society as potentially dangerous. Movies ranging from "American Sniper" to "Thank You for Your Service" frequently depict characters with PTSD struggling to fit into society.  

In real life, those with PTSD symptoms are often labeled as “weak” and removed from combat zones, and sometimes they are involuntarily discharged from military service. 

These disturbing trends are difficult to read anytime, but they seem especially troubling as we commemorate Memorial Day. This is the time for us to acknowledge that those who have served our country deserve the best medical care available.  

Five years ago, retired Gens. Wayne Jonas, MD, and Eric Schoomaker, MD, wrote a commentary in JAMA titled “Pain and Opioids in the Military: We Must Do Better.” Recognizing that veterans often misuse opioids to self-medicate mental health disorders, they proposed teaching members of the military a greater degree of self-management skills such as problem-solving and goal setting.   

Of course, self-management would be preferable to using opioids if it were sufficient to afford veterans a quality of life they deserve. However, teaching self-management skills is often insufficient. That is clear in the cases of John, Mark and Jason. 

On Memorial Day, I hope we can take a moment to think about the men and women who have fought -- and sometimes died -- for a country they believed in.  

I also hope we honor the living by showing them that they deserve treatment for their chronic pain, PTSD, addiction and any other health care issues they may have. We owe it to them. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is a former president of the American Academy of Pain Medicine and is author of the award-winning book “The Painful Truth” and co-producer of the documentary “It Hurts Until You Die.”

You can find him on Twitter: @LynnRWebsterMD.

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

Chronic Pain Causes Brains to Age More Rapidly

By Pat Anson, PNN Editor

Poorly treated or untreated chronic pain can lead to a number of other health problems, from high blood pressure and insomnia to depression and anxiety.

Now there is evidence that chronic pain also causes brains to age more rapidly, raising the risk of developing Alzheimer’s disease and other neurological problems associated with aging.

“Our findings highlight the need to address chronic pain, not just in older individuals but in potentially everyone, as pain may have unintended consequences in the brain that we don’t yet fully understand,” said lead author Yenisel Cruz-Almeida, PhD, a researcher at the University of Florida Institute on Aging.

Over a three-year period, Cruz-Almeida and her colleagues used magnetic resonance imaging (MRI) to measure the volume of gray and white matter in the brains of 47 older adults, ages 60 to 83.  The volunteers were free of neurological disorders and in generally good health, although 33 of them had some type of chronic pain.

Volunteers who did not have chronic pain had brains that appeared four years younger than their actual age.

Chronic pain sufferers had brains that appeared an average of two years older. They were also more likely to have greater pain intensity, have a “less agreeable personality” and be less emotionally stable, according to researchers.

The University of Florida produced this video on the study, which was recently published online in the journal Pain.

“Not everybody ages the same way,” said Cruz-Almeida. “I don’t want people to think, ‘Oh, I have chronic pain. I’m doomed.’ This is not the case. That is not the message we want to get out. There is more nuance than that.”

Interestingly, the volunteers who reported getting pain treatment in the last three months had younger-appearing brains compared to those that did not, suggesting that pain relief slows brain aging. Pain sufferers who had a happier outlook on life and were generally more upbeat also had younger-appearing brains.

“The pain experience is not just in your brain,” said Cruz-Almeida. “There appear to be avenues or things that could be done to change brain age.

“Our findings also suggest that both pain treatments and psychological traits may significantly mitigate the effect of pain on the aging brain and could further decrease the risk of age-related deterioration and death.”

Cruz-Almeida is planning additional research with a larger sample of older adults that will look at ways to alleviate accelerated brain aging.

A Pained Life: Fearful Fortunes

By Carol Levy, PNN Columnist

I love fortune cookies, but have no faith in the fortunes themselves. I opened a cookie recently and out came this message: “Listen to what you know instead of what you fear.”

I am going through a bad time recently. For 19 years I have had a spontaneous remission of the worst of my trigeminal neuralgia pain.

The trigeminal nerve now seems to be regenerating and it worries me. I get sporadic tingling sensations in the numbed areas of my face, the result of a procedure done in 1979. Within the last few months, the spontaneous pain has also started coming back, not in the same way, and only one or two flares were horrific.

I am very fearful all the pain will return.

My new neurologist specializes in headaches. My situation is an unknown to him. He is very nice but is essentially throwing drugs at me, a new one each time the one he just prescribed doesn't help or gives me terrible side effects. He is throwing things at the wall and hoping something will stick. I fear nothing will.

I finally found someone who specializes in trigeminal neuralgia and facial neuropathy, my disorders. She asked for a copy of my medical records so she can decide if she will accept me as a patient.  I fear she will refuse. Or if she agrees to see me will be unable to help — like almost all the others.

A woman I know has fibromyalgia and Complex Regional Pain Syndrome (CRPS). For years she has been on high dosages of Dilaudid and another strong opioid. Her doctor decided he would halve her dosages of both. She was appropriately fearful of being tapered. But to her astonishment she found she could tolerate the reductions. She is happily doing just as well on the lower dosages as she had been on the higher amounts.

A lot of what we go through is often based on fear. It is legitimate. We know what the pain is like, we know what the medications do, we know what we can and cannot do. A lot of our choices are fear based: It hurts when I do this, so therefore I will never do it again.

I am able to do so much more, feel so much better when I am on this particular medication and this particular dosage, so I will refuse any changes. I am used to this doctor/physical therapist/specialist being involved in my treatment, even though I am not always happy with them, so I will stay anyway.

It is hard to give up the fear. Pain is not like painting a room a new color and then deciding you don’t like it. You can always just repaint. But change what I am used to doing to deal with the pain? That is not so simple. My pain may increase and be even more unbearable, more daunting.

But what if I take the chance and find I am okay?

Our minds and bodies have been programmed to do all we can to avoid pain. Fear is one of the ways we deal with it. As a kid you touch a hot stove and feel the excruciating pain of a burn. You very quickly learn to fear a hot stove, the fear keeping you from hurting yourself in the same way again.

It is almost counter intuitive to heed the fortune: “Listen to what you know instead of what you fear.”

What we know is why we fear. Maybe, at least for us, the fortune should read: “'Listen to what you know, but take the chance of fear anyway.”

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 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.

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

What It’s Like to Be Forcibly Tapered Off Fentanyl

By Emily Ullrich, Guest Columnist

Although I have been on this chronic intractable pain, illness and medical refugee train for nearly a decade, I’ve been lucky to have the love and support my husband, family and wonderful people around the world that I've met through this shared anguish. They lift me up and allow me to lift them, when I can.

Right now, I'm holding onto them in utter panic, because they’re all that I have left.

About four years ago, I met a palliative care doctor, who had taken the time to read my 3-page health history. I take that paperwork with me to every visit to the ER or new doctor, so they can fully understand the things that I have tried, what worked, and what made things worse. No doctor had ever looked at it, until she did.

She approached me with zero judgment, and 100% sympathy and empathy. She actually cared about what I'd been through. I broke down sobbing, because I could finally let my guard down. I told her how my husband had to take a day off from work every month to drive me five hours and three states away, to see the only doctor I could find who was willing to treat my complicated needs. She told me I could see her instead. That was a tremendous gift.

Last year I began to sense that there was growing pressure on her about prescribing high doses of opioids, so I asked if I should worry about her cutting my meds or passing me off to another doctor. She reassured me that she would do no such thing.

Then came my visit one month later. I knew something was awry, because there was a case worker present for my appointment. My suspicions were confirmed when I was told the dose of my fentanyl patch would be tapered significantly lower. I was thrown into a tailspin.

With my doctor’s help and willingness to prescribe the meds and dosages that I needed, I had been able to achieve about a 4/10 on the pain scale, daily. I was able to participate in life again and do things that I love, like cooking, getting dressed up to go on a date with my husband, and other things that healthy people take for granted.

I was furious and traumatized that I was going to have to give up living my life. I still am.

On my next visit to see my doctor, she dropped another bomb. She told me that I had to choose between anti-anxiety meds and pain meds. Ironically, she was the one who put me on a higher dose of Xanax to help me cope with anxiety and insomnia. I felt betrayed.

I would not wish the hell of abruptly and simultaneously tapering off fentanyl and Xanax on anyone.  Even when I had a higher dosage, I still had pain flares that were not properly controlled. But since the taper began, I now have them daily.

I want this to be very clear: Fentanyl is a necessary medicine for many people with high pain levels. I have tried every other extended release medication known and none even touched my pain.

Fentanyl has gotten a bad reputation and patients who take it live with heavy stigma because the media usually report on fentanyl overdoses without distinguishing between illicit fentanyl and properly prescribed legal fentanyl.  

I would like to make a plea to the media: Stop the ignorant reporting and do your due diligence. By not distinguishing between legal and illicit fentanyl, you are causing even more strife for those of us who need the relief that only fentanyl medication brings.

I have still not gotten a clear reason for my doctor's decision to force a taper on me. I fear if I prod too much, she will totally cut me off or advise me to see someone else. This is making the struggle even worse, because even though we still have a pleasant relationship, I'm hurt and confused about this. I suspect it is being forced upon her.

As I wrote this, I had to take breaks for hours, sometimes days, because my pain is escalating to such a level that anxiety and insomnia are ravaging my mind and body. I have been in withdrawal (which, by the way, does not mean I am addicted to my medication, it means I'm physically dependent on it) for about four months.

As my medicine has been tapered, my life has crumbled. I get about two hours of sleep every five days. At times I get uncontrollable head shaking, leg kicking, arm flailing and vocal ticks. My pain gets so bad that I develop a full-body rash and migraines that last for days.

I don't know what is real and what my brain has concocted. I hold nonsensical conversations, like my grandparents did when they developed dementia. It is embarrassing and terrifying.

One night, while counting down the minutes until I could take my next dose of meds, I passed out from pain and anxiety, which scared my husband so bad that he called 911.

I hope that insurers, pharmacies and especially government officials who are infringing on doctors' ability to treat their patients, might read this and see that forcing tapers on patients is dangerous. There have already been many suicides because of them.

A gap is growing between many doctors and their patients. We know this is not “What's best for us.” It is actually a twisted way to make more money off the sick and vulnerable, forcing us to replace a medicine that is effective and safe when used responsibly with drugs that are ineffective, expensive and dangerous.

Emily Ullrich lives with Complex Regional Pain Syndrome (CRPS), chronic pancreatitis, endometriosis,  interstitial cystitis, migraines, fibromyalgia, osteoarthritis, anxiety, insomnia, depression, and other chronic illnesses. She is also a writer, filmmaker, activist, advocate, philanthropist and comic. As she is able, Emily devotes her time and energy fighting for pain patients’ rights.

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