Millions of People Worldwide Are ‘Left Behind in Pain’

By Pat Anson, PNN Editor

A new report by the World Health Organization (WHO) warns that limited access to morphine and other opioids is leaving millions of people in many parts of the world suffering in preventable pain.

The report, “Left Behind in Pain,” calls morphine a low cost, essential medicine for relieving moderate to severe pain. But access to morphine and other opioids is inadequate in many low and middle-income countries, with consumption patterns in wealthier nations that don’t correspond to medical need. Over 95% of the world’s supply of opioids is distributed in wealthy countries, with only 0.03% distributed in low-income ones.

“Leaving people in pain when effective medicines are available for pain management, especially in the context of end-of-life care, should be a cause of serious concern for policy-makers,” says Yukiko Nakatani, MD, WHO Assistant Director-General for Medicines and Health Products. “We must urgently advocate for safe and timely access to morphine for those in medical need through balanced policy, everywhere.”

The report calls for expanded access to morphine through local and regional distribution centers, changes in restrictive laws and guidelines, and reduced stigma surrounding opioid use.

“Some historical events, cultural beliefs, misinformation and disinformation about pain, and social stigma related to opioid use are known to have caused mistrust of opioids and contributed to fear of using them,” the report found.

Lawsuits and regulatory controls on the pharmaceutical industry are so strong in some countries that drug makers have stopped manufacturing morphine because the profit is low and risk of liability is high.

That may have played a role in Mundipharma’s recent decision to discontinue supplying Ordine, a liquid formulation of morphine, to Australia. Mundipharma is owned by the Sackler family, which has been enmeshed in opioid litigation over its role in the opioid crisis in the U.S. through its operation of Purdue Pharma.

A Mundipharma spokesperson told the Australia Broadcasting Corporation that the company’s third-party manufacturer decided to stop producing Ordine and that "sourcing another manufacturer would not be commercially viable."

Evolving Stance on Opioids

WHO’s position on opioids has evolved over the years. WHO’s guidelines for treating chronic pain, for example, used to say that opioids “are known to be safe and there is no need to fear accidental death or dependence.”

That changed in 2019, after two U.S. congressmen – without any real evidence -- accused WHO of being “corruptly influenced” by opioid manufactures. WHO withdrew the guidelines a month later, citing “new scientific evidence” – although critics said caved in to political pressure and threats to withdraw U.S. funding of WHO.

In 2021, WHO backpedaled further, recommending that morphine only be given to sick children when they are dying. Physical therapy and “biopsychosocial” treatments such as cognitive behavioral therapy were suggested as alternatives for children who are in pain, but expected to live.

WHO’s latest report recognizes the potential harms of opioids, couched in language about the world facing two opioid crises.

“The world is facing two crises related to the use of opioids. In the first, inappropriate use and over-prescription combined with the wide availability of illicit unregulated opioids, such as fentanyl, in some countries is causing significant harm and loss of life. In the second, a lack of access to opioids such as morphine in many parts of the world means that millions of people continue to suffer preventable pain,” said Nakatani.

About 80% of the world’s morphine supply was consumed in North America in 2021, primarily in the United States, although the rest of the developed world is catching up. Opioid consumption in the U.S. has fallen so sharply in recent years that Canada, Australia and several European countries have become the highest consumers of opioid analgesics, according to a 2022 study that ranked the U.S. as being 8th in per capita opioid sales.

FDA Urged to Regulate Poppy Seeds

By Pat Anson, PNN Editor

A consumer advocacy group is once again calling on the Food and Drug Administration to establish and enforce regulations that limit opiate contamination of poppy seeds.

Over a year ago, the Center for Science in the Public Interest (CPSI) petitioned the FDA to set a safe threshold for opiate alkaloids in imported poppy seeds, most of which come from Afghanistan. The tiny black seeds can become contaminated with trace amounts of codeine, morphine and other opiates when they are harvested from opium poppies.

Washed poppy seeds are often found in baked goods, but drug users have found they can use unwashed seeds to make a potent homemade tea. PNN has reported that some pain sufferers use the tea as an analgesic, although the bitter brew is mostly consumed by people who simply want to get high.     

In its petition, CSPI cited a study estimating that 19 people in the U.S. suffered fatal overdoses involving poppy seeds in recent years.

In a letter recently sent to the FDA Center for Food Safety and Applied Nutrition, CSPI renewed its call for the agency to take action to prevent more deaths.

“The time is overdue for the FDA to establish standards that will protect U.S. consumers from ingesting dangerous levels of opiates through the food supply,” wrote Peter Lurie, MD, President of CSPI wrote.  

The European Food Safety Authority established maximum levels of morphine and codeine in poppy seeds last year, which are scheduled to take effect in July.

In 2019, the U.S. Drug Enforcement Administration classified unwashed poppy seeds as a Schedule II controlled substance and closed a loophole that allowed them to be sold legally in the U.S.  

Enforcement actions since then have been scant. In October 2021, federal regulators filed a civil forfeiture action against an Oklahoma bakery to halt the sale of unwashed seeds. But within a few weeks the company was selling them again on its website, with a disclaimer saying the seeds “may contain trace amounts of opiate alkaloid residue” and should be thoroughly washed before consuming.

To date, the only action the FDA has taken on the CSPI petition was to post a notice in the Federal Register asking for public comment on the need for poppy seed regulation. Over 3,000 people responded, most of them supporting the petition. Asked to comment on the CSPI’s new letter, an FDA spokesperson said the issue remains under review.

“As part of our review of CSPI’s petition, we are considering the points raised in the petition and the over 3,200 comments submitted to the docket. The FDA has been engaging with other federal partners in this effort to help protect the public’s health,” the spokesperson told PNN in an email. 

To be clear, consuming unwashed poppy seeds is risky. Home brewers usually have no way of knowing where the seeds came from or how heavily they are contaminated with opiates. The Internet is filled with cautionary stories from illicit drug users who nearly overdosed or became addicted to the tea and went into withdrawal when they tried to taper.

“I woke up yesterday with a migraine (that’s typical when I quit) and by the afternoon the withdrawals had started: sweating, anxious, can’t get comfortable, want to crawl out of my skin,” a person recently posted on Reddit. “I want to get off this merry go round. I feel like my brain is totally normal except that little piece that is constantly scheming where my next opiates are coming from. They don’t even make me high, they just make me feel ‘normal’, so what’s the point? I want to be free of this.”

For people in pain, there’s an added risk to poppy seeds. A recent study found that consuming just few seeds in a muffin or bagel could result in a positive drug test – a finding that could get a patient taken off opioids or dismissed by their doctor.

Study Finds Childhood Trauma Increases Risk of Opioid Addiction

By Pat Anson, PNN Editor

Several studies have found that if you experienced physical or emotional trauma as a child you are more likely to have migraines, fibromyalgia and other painful conditions as an adult.

Australian researchers have taken that theory a step further, with a small study that found adults with a history of childhood abuse or neglect are more likely to feel the pleasurable effects of opioids, putting them at greater risk of addiction.

That finding, recently published in the journal Addiction Biology, is based on a double-blind, placebo-controlled study that compared the effects of morphine on 52 healthy people – 27 with a history of severe childhood trauma and a control group of 25 who had no such experiences as children.

Participants in both groups were given an injection of morphine or a placebo dose, and then asked how it made them feel. People in the trauma group reported more euphoria or feeling high and more “liking” of morphine. They also felt less nauseous and dizzy after taking the drug compared to the non-trauma control group.

“Those with childhood trauma preferred the opioid drug morphine and they felt more euphoric and had a stronger desire for another dose,” lead author Molly Carlyle, PhD, a research fellow at The University of Queensland, said in a statement. “Those with no childhood trauma were more likely to dislike the effects and feel dizzy or nauseous.

“This is the first study to link childhood trauma with the effects of opioids in people without histories of addiction, suggesting that childhood trauma may lead to a greater sensitivity to the positive and pleasurable effects of opioids.”

Researchers say people in the trauma group were significantly more likely to have a history of anxiety or depression, and to use over-the-counter pain relievers regularly.  They were also more likely to report stress, loneliness and less social support and self-compassion than the control group.

“One possible explanation for the differing responses to morphine is that childhood trauma affects the development of the endogenous opioid system – a pain-relieving system that is sensitive to chemicals including endorphins, our natural opioids,” Carlyle explained. "It's possible that childhood trauma dampens that system.

“When a baby cries and is comforted, endorphins are released, so if loving interactions like this don't happen, this system may develop differently and could become more sensitive to the rewarding effects of opioid drugs."

Pain was also measured during the study, with participants immersing a hand in cold water both before and after receiving morphine. Researchers measured how long it took for them to find the cold water painful and how long it took before they pulled their hand out. Morphine was found to increase pain threshold and tolerance in both groups, regardless of whether they experienced childhood trauma.

“The findings of this study are a stepping stone in highlighting the role of childhood trauma in OUD (opioid use disorder), emphasising the need to address trauma symptoms in this vulnerable group, and targeting early interventions at traumatised young people,” researchers concluded. “These findings have many clinical and social implications including reducing the guilt and shame common amongst those with OUD about the reasons behind the development of this damaging addiction.”

How Poppy Seed Muffins Could Get You Flagged by a Drug Test

By Pat Anson, PNN Editor

If you’re a patient who is prescribed opioid pain medication, you may have been warned not to eat poppy seed muffins or bagels before a drug test.

The tiny black seeds may contain trace amounts of morphine and codeine, which can be detected in a drug screen and wreak havoc with your medical care. A positive test could result in your doctor taking you off opioid medication or even dropping you as a patient.

Is the poppy seed warning accurate or just an urban myth? A group of researchers wanted to find out, so they ran a series of tests to measure opiate levels in commercially available poppy seeds. They washed, steamed and heated the seeds to see how that changed concentrations of three opium alkaloids: morphine, codeine and thebaine.

Washing or soaking the poppy seeds in water significantly reduced the presence of all three opium alkaloids. So did heating the seeds at a temperature of 392 F for at least 40 minutes.

However, baking the seeds in a muffin for 16 minutes at 392 F didn't significantly change the opium alkaloids, possibly because the internal and external temperatures of the muffins reached only 211 F and 277 F, respectively.

“Baking had no significant effect on concentrations of opium alkaloids. Overall, these results indicate that opium alkaloids may not be significantly affected by baking or steam application and that poppy seeds may require water washing or extended thermal treatment to promote reduction of these compounds,” said lead author Benjamin Redan, PhD, a research chemist who works in the FDA’s Institute for Food Safety and Health.

Redan says poppy seed muffins would have to be baked for at least two hours just to reduce morphine and codeine levels by 50 percent – which is not a recipe for passing a drug test or for baking tasty muffins.

The findings were recently published in the American Chemical Society’s Journal of Agricultural and Food Chemistry.

Poppy Seed Tea

Researchers and law enforcement agencies have been paying more attention to the lowly poppy seed because of anecdotal reports of people using the seeds to brew a potent tea that can be used for pain relief or to get high.

Late last year, Drug Enforcement Administration classified unwashed poppy seeds as a Schedule II controlled substance. While the poppy plant has long been classified as an illegal substance, the unwashed seeds were exempt because they were not perceived as a problem until recently.

“Individuals wishing to extract the opium alkaloid content from unwashed poppy seeds, use the seeds to create a tea, which contains sufficient amounts of alkaloids to produce psychoactive effects,” the DEA said. “Unwashed poppy seeds are a danger to the user and their abuse may result in unpredictable outcomes including death.”

The Internet is filled with stories about people experimenting with poppy seed tea. One alternative health website even has a recipe for making poppy seed tea that comes with a stark warning.

“Unfortunately, the abuse of or having insufficient knowledge about this tea has led to a few fatal incidences,” the recipe warns.

‘Opiophobia’ Leaves Millions Dying in Chronic Pain

By Pat Anson, Editor

More than 25 million people – most of them poor and living in developing countries – die each year in severe pain because they have little or no access to morphine and other painkillers, according to a new report.

A special commission created by The Lancet medical journal looked at pain care around the world and found major gaps in the availability of opioid pain medication. While opioid analgesics are relatively available in the United States and Canada, patients in many parts of the world have no access to them. In addition to the 25 million who die in pain, the commission estimated that another 35 million live with chronic pain that is untreated.

“The fact that access to such an inexpensive, essential, and effective intervention is denied to most patients in low-income and middle-income countries and in particular to poor people -- including many poor or otherwise vulnerable people in high-income countries -- is a medical, public health, and moral failing and a travesty of justice,” the Lancet commission found.

"Unlike many other essential health interventions already identified as priorities, the need for palliative care and pain relief has been largely ignored, even for the most vulnerable populations, including children with terminal illnesses and those living through humanitarian crises."

The voluminous report by 61 health experts from 25 countries took three years to prepare. It shared the story of a doctor in India who treated a patient named “Mr S” who suffered crippling pain from lung cancer. The doctor was able to provide him with morphine to relieve his pain, but when Mr S returned the next month, no morphine was available.

“Mr S told us with outward calm, ‘I shall come again next Wednesday. I will bring a piece of rope with me. If the tablets are still not here, I am going to hang myself from that tree.’ He pointed to the window. I believed he meant what he said,” the doctor said.

The commission said there were several barriers that stood in the way of effectively treating pain, including “opiophobia” – prejudice and misinformation about the medical value of opioids.

“A prevalent but unwarranted fear of non-medical use and addiction to opioids and opioid-induced side-effects, both among health-care providers and regulators and among patients and their families, has led to insufficient medical use. Unbalanced laws and excessive regulation perpetuate a negative feedback loop of poor access that mainly affects poor people,” the commission said.

“Efforts to prevent non-medical use of internationally controlled substances, such as morphine and other opioid analgesics, have overshadowed and crippled access to opioids for palliative care. These efforts have focused on preventing diversion and non-medical use rather than ensuring access by people with legitimate health needs.”

The commission also blamed the poor state of pain care on a tendency in the medical community to focus on curing and preventing disease, rather than preserving a patient’s quality of life and dignity.  

The report recommends that palliative care be included as part of universal health care coverage and that inexpensive morphine should be available “for any patient with medical need.”

How Chronic Pain Killed My Husband

By Meredith Lawrence, Guest Columnist

So much has been written about the opioid epidemic, but so little seems to be out there about what living with true chronic pain is like. My husband, Jay, lived and died in incredible pain at the age of 58.  As his wife, I lived that journey with him. 

Jay is no longer here to tell his story, but I want the world to see what I saw.  I want you to know how he went from working 60 hours a week doing hard physical labor, until his pain grew worse and he could not even get out of a chair on his own. 

I want you to know the deterioration Jay went through over the last ten years. I want you to know what a good day and a bad day is like when you live with chronic pain.  I want you to know exactly what happened when the doctor decreased his pain medication. And I want you to know how my husband finally made the decision to commit suicide. 

I want people to understand that when chronic pain runs your life, eventually you just want the pain to stop. 

First a bit of history.  I met Jay in 2005, when we both stopped drinking.  Two years later, Jay began to lose feeling in his legs and started having falls, as a result of compressed nerves in his spine. The pain was so bad Jay had to stop working and go on disability, which started his depressive episodes.

JAY LAWRENCE

Jay had a series of lower back and neck fusion surgeries.  This was when he was first prescribed painkillers, antidepressants and anti-anxiety medications.  From 2008 to 2011, Jay tried various treatments to control the pain that lingered even after a third back surgery.  These included steroid shots, nerve blocks and a spinal cord stimulator.  Ultimately he had a drug pump implanted that delivered morphine, in addition to the pain pills he was being prescribed.

In 2012, Jay was diagnosed with trauma induced dementia.  I believe that diagnosis was right, based on his symptoms, but not all of the doctors agreed.  Some believed the confusion was due to high doses of morphine and/or his sleep apnea.  

By 2016, Jay’s confusion and memory issues were increasing. He was on a steady dose of 120mg morphine daily, in addition to the medication he was receiving from his pain pump. 

Jay’s depression seemed to come and go, depending on the day and his pain levels.  He was weaned down on his Xanax to 2mg a day to help him sleep. He was aware of the risks of combining Xanax and morphine. 

JAY AND MEREDITH LAWRENCE

Let me tell you what a good day was like before they changed his medications. I worked a full time job from 2 pm to 10 pm five days a week. I would get home, and Jay would have my coffee ready for me at night.  We would stay up and watch TV until 2 or so.  When it was time for sleep, I went to bed and he slept in his recliner.

We started sleeping apart after his first surgery in 2007. He was more comfortable sitting up in the chair, but could never sleep more than three hours at a time.  He knew sleeping in bed would just keep me awake. 

A good day always meant it was not cold or raining.  On a good morning, he would be up first and get coffee started.  He would take our two miniature pinchers outside in the yard on their leash for potty time. 

We usually had at least one appointment a week, but if not we could have a nice quiet morning.  That meant coffee in front of the TV.  After a couple of hours of that, he might switch over to playing his computer games, but he was never far from his chair. 

A typical adventure for us would involve going to Walmart.  Jay was not able to walk through the store, but he hated using the handicapped carts. I could always see a look on his face when he had to do it.  After going to the store, we might have lunch or an early dinner at Steak n Shake or Cracker Barrel.  It always needed to be some place familiar and comfortable for him.  More than once we sat, ordered and then took our food home because he was in too much pain. 

In the summer we might walk the dogs after dinner.  Just a quick two block walk, but a lot of times he would have to stop halfway and go back home.  A couple of times I had to go get the car and pick him up because his legs just would not support him anymore. 

A bad day was awful for me to watch, and absolutely horrible for Jay to live. It meant no real sleep, just catnaps in the chair whenever he could.  He always made coffee for us, but on a bad day he would forget to add coffee to the coffee maker and we would just have hot water.  The pain was so much he was just distracted. 

On many bad days, I would look over and see tears just running down his face because he was in so much pain.  It also made Jay’s depression worse.  We spent many cold winter nights talking about how much pain would be too much and would make life not worth living.  It is the most horrible feeling in this whole world to hear the person you love most talk about ending their life. 

In January, 2017 Jay’s pain clinic decided they could no longer prescribe the high doses of morphine he was on.  In addition, they were not going to continue seeing him if he decided to stay on Xanax.  The Xanax was prescribed by another doctor, but they did not care.

I begged the pain doctor -- yes, literally begged -- for some other option. The doctor said that if Jay continued the Xanax he would no longer see him.  He would not give another option for medications, and at one point even said that most of his patients with pain were “making it up.”

The last thing the doctor said to us will stick with me forever.  He said, “My patient’s quality of life is not worth losing my practice over.”

When we left that day, we were barely in the car and I knew what Jay was going to say to me.  I will never forget how sad his voice was when he told me this was it for him. He was not going to continue to live like this.

Through the month of February, as Jay’s medication was decreased, we spent time doing things we did not normally do.  We went out on Valentine’s Day, he bought me the first jewelry he had bought since my engagement ring, and we went out to a fancy restaurant for dinner.  Jay tried to cram in as many good memories as he could into that last month, but I knew it was costing him.

Jay’s next doctor’s appointment was scheduled for March 2, and we knew they were going to decrease his medications again.  The night before, he woke me up to tell me it was time.  I knew what that meant, but I tried to be strong for his sake.  We talked all night long about what it meant, and how it should be.  It was the saddest, strangest, longest night of my life. 

Jay knew he did not have enough pills to kill himself.  He also knew that if he were to try and purchase a gun, they would not sell it to him.  It would have been almost obvious what he was going to use it for. 

In the end, I bought the gun that Jay used -- and yes, we talked about the ramifications of that action.  We went to the park where we had renewed our vows in 2015.  We talked in the car for a while, and then we sat in the same place we had cut our wedding cake.  I was holding his hand when he pulled the trigger. .

Through the shock and horror, my immediate feeling was one of relief for Jay. To know that he was finally out of pain was a weight lifted off both of us.

Because I purchased the gun that Jay used to end his life, I was charged under our state's assisted suicide law.  This charge was later reduced to reckless endangerment, and I am currently on probation. People close to me want me to be quiet about my role in Jay’s death, and I was at first. But I cannot continue that way. 

I know Jay wanted me to put his story out there.  I know he wanted people to know what it was like to live with the pain he lived with daily. When the doctor took away Jay’s medications, they took away his quality of life. That was what led to his decision. Jay fought hard to live with his pain for a long time, but in the end fighting just was not enough. 

Something has to be done to wake up the doctors, insurers and regulators to make them see pain patients as real people. People with husbands, wives and children that love them.  People that are suffering and just barely holding on. 

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

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

FDA Approves New Long Acting Painkiller

By Pat Anson, Editor

The U.S. Food and Drug Administration has approved a new extended release opioid pain medication with abuse deterrent properties.

Egalet Corporation announced Monday that the FDA has approved Arymo ER – a long-acting version of morphine -- for the management of pain severe enough to require daily, around-the-clock opioid treatment. It comes in the form of a pill that is very difficult to crush or liquefy, methods used by abusers to speed the release of an opioid into the bloodstream.

"With the majority of ER opioids in easy to abuse forms, it is important that healthcare professionals have additional treatment options like Arymo ER that are resistant to different methods of manipulation using a variety of tools," Bob Radie, president and CEO of Egalet said in a news release.

“Arymo ER has physical and chemical properties expected to make abuse by injection difficult which is important given it is the most common non-oral route of morphine abuse and the most dangerous.”

An FDA advisory panel recommended in a 18-1 vote last August that Arymo be approved. It is is the 7th opioid with abuse deterrent properties approved by the FDA. The other medications are OxyContin, Targiniq, Embeda, Hysingla, Morphabond, and Xtampza.

Arymo has been approved in three dosage strengths: 15 mg, 30 mg and 60 mg. Egalet plans to make the drug available in the first quarter of 2017.

Arymo is the first commercial product developed with Egalet’s Guardian technology, which incorporates the medication into a polymer matrix tablet to make it difficult to misuse or abuse.

“Guardian Technology results in tablets that are extremely hard, very difficult to chew, resistant to particle size reduction, and inhibit/block attempts at chemical extraction of the active pharmaceutical ingredient,” the company says in a statement on its website.

“In addition, the technology results in a viscous hydrogel on contact with liquid, making syringe-ability very difficult. These features are important to address the risk of accidental misuse (e.g., chewing) in patients with chronic pain, as well as intentional abuse using more rigorous methods of manipulation. “

The approval of abuse-deterrent medications is still somewhat controversial. Some medical professionals and anti-opioid activists say the technology does not completely prevent abuse and the drugs are still being misused by addicts.

How Two Toddlers Saved My Life

By Crystal Lindell, Columnist

I wish I could say it’s been a rough couple months for me, but that’s not exactly true. It’s actually been more like a rough couple years.

I spent three years battling debilitating rib pain that nobody seemed to be able to cure. And then, when I discovered that my obscenely low vitamin D levels were likely to blame and I started to feel better, I faced an entirely new version of hell — opioid withdrawal.

I had been on morphine for three years, 24 hours a day, 7 days a week, and I honestly thought that when the rib pain subsided I could just endure 72 hours of physical hell and move on with my life.

But morphine is like an abusive boyfriend, it lingers. It hurts you and then offers you the cure, and then it hurts you again. And you always pay for the highs with desperate lows.

Studies have shown that it can take two years for your brain to adjust after withdrawing from opioids. And it turns out it doesn’t much matter if you were buying them off the street or getting them via a legitimate prescription from a legitimate doctor. Your brain doesn’t care.

And yes, I know, there are people out there who have an easy breezy time with it. They just decide to stop and then they stop.

I am not one of those people. I hate those people.

I have spent the last few months suffering from a potent mix of suicidal thoughts and anxiety attacks. And navigating the whole mess is especially hard because for some reason people think that if you are just a strong enough person, you’ll be fine. Let me tell you the truth, opioids don’t care if you are Wonder Woman herself, they will ravage you.

In the midst of all this, my best friend since childhood was pregnant with her third child. She and I are like sisters, having both endured crazy families, growing up poor and our 20’s together.

And so when she was put on strict bed rest about 27 weeks in, I said I would come stay with her during weekdays to help with her other two kids, who are both just toddlers themselves at 1 and 3 years old.

I work from home, so I have the luxury of volunteering for such things. And I confess I was pretty pleased with myself at the thought of playing a small role in making sure the newest member of their family was born healthy.

But if we’re being honest, she could have said no. She could have said that she didn’t want an opioid addict around her kids. She could have easily pointed to my debilitating anxiety attacks and said I was unfit to supervise toddlers.

Maybe she was too desperate to say anything like that to me. But I honestly don’t think she ever even thought it.

So, in late May, I basically moved in with her, her husband and two toddlers. I went from the cool chick who comes over and plays bubbles to the cool chick who has to give the kids baths, feed them, change diapers, clean up spit up, watch Sesame Street on repeat for 16 hours a day, AND play bubbles.

And somewhere along the way, I forgot that I was having a really rough couple of years.

Kids have a way of forcing you to be in the present. There’s no time to anxiously contemplate the meaning of life and whether or not you’ll ever find true love, when the meaning of life and true love are staring up at you calling you “Bistol” because the C sound is hard, and asking for another pack of gummy bears.

And I don’t care who you are, watching a child literally learn to do the most fundamental of human movements, walking, over a period of about three weeks is breathtaking and jaw dropping and mid-afternoon Taylor Swift dance party worthy.

And so, that is how one of the worst times in my life was transformed by two toddlers. Two boys who had no idea they were helping me navigate opioid withdrawal when they were screaming for teddy bears at 1 a.m., and spitting up all over the carpet, and eating rocks, and begging for ketchup, and laughing and crying and cuddling and loving.

Because that’s actually how it works, isn’t it? You think you’re saving someone, but then you realize that this whole time they were saving you.

Crystal Lindell is a journalist who lives in Illinois. She loves Taco Bell, watching "Burn Notice" episodes on Netflix and Snicker's Bites. She has had intercostal neuralgia since February 2013.

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

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.

How Opioid Prescribing Guidelines Use Pseudoscience

By Michael Schatman and Jeffrey Fudin, Guest Columnists

Recently, we (along with our colleague, Dr. Jacqueline Pratt Cleary) published an open access article in the Journal of Pain Research, entitled “The MEDD Myth: The Impact of Pseudoscience on Pain Research and Prescribing Guideline Development.”

In this work, we address the issue of how governmental and managed care opioid guideline prescribing committees use the flawed concept of morphine-equivalent daily dose (MEDD or MME) to arbitrarily place limits on the amount of opioids that a clinician “should” prescribe to any patient with chronic pain -- as if all patients were identical. 

The article cites excellent research that exposes the invalid concept of MEDD – and while guideline authors are fully aware of that lack of evidence, they are hypocritically fine with using MEDD as a device to thwart chronic opioid use. In the case of opioids for chronic non-cancer pain, there is at least some evidence.  But for MEDD, there is no evidence.   

One reason the MEDD concept is not legitimate is pharmacogenomic differences – that is, due to each of our unique genetic compositions, various individuals and geographical groups metabolize some opioid analgesics differently.  These differences are often enormous. 

For example, it may require Person “A” 20 milligrams of hydrocodone to achieve adequate pain relief, while Person “B” (of the same gender and weight) may require 60 milligrams of the same drug for the same type of chronic pain condition.  Does this make Person “B” an addict?  Of course not.

We believe that by arbitrarily limiting the “appropriate” amount of an opioid that a physician should prescribe to a patient (which all recent guidelines – including the CDC’s guideline – call for), physicians feel compelled to limit the amount of opioid analgesic therapy that they prescribe – irrespective of the amount of relief that a patient with chronic pain receives. 

Is this good pain medicine practice?  Hardly.  However, in the eyes of the anti-opioid zealots who have dominated recent opioid prescribing guideline committees, their agenda of taking opioids out of the picture altogether for patients with chronic pain is evidently more important than is patient well-being.

Aside from the pharmacogentic issues, we also have conversion issues because of simple mathematics.  We cite data that clearly shows there are no universally accepted opioid equivalents.  Even if there were no issues with genetic variability, there is still no consensus on how to mathematically convert one opioid to another. For example, the state of Washington may decide on a different MEDD equivalent than the one New York state chooses.

Will the anti-opioid zealots admit that they have a non-scientifically-based agenda to take opioids out of the American chronic pain management discussion?  No – because if they were to do so, they would be seen as cruel or uncaring.  Rather, they emphasize that their concerns are for the well-being of patients and society.  Their logic suggests that if clinicians stop prescribing opioid analgesics altogether, then the unfortunate number of opioid-related overdoses and deaths will decrease dramatically. 

Not surprisingly, they lack the data that supports this assertion, yet the data are clear that when this happens, heroin use increases proportionally. 

As scientists and practitioners who work with patients with chronic pain every day, we see the damage in which these guidelines result.  For example, while the guidelines are described as “voluntary” by the committees that write them, that is clearly not the case.  Although the zealots deny the existence of a chilling effect on prescribing, there are data that suggest that progressively fewer physicians are willing to prescribe opioids since these non-evidence-based guidelines have surfaced.  Despite being touted as voluntary, physicians fear regulatory sanction should they disobey them, and accordingly are taking opioids out of their treatment armamentaria. 

Are we suggesting that opioid therapy be considered the first-line treatment for chronic pain?  Certainly not.  Chronic opioid therapy should be considered only when other available treatments have proven ineffective. However, given the for-profit health insurance industry’s business ethic of cost-containment and profitability, insurance access to many treatments that may be superior to opioid therapy are out of reach for the vast majority of Americans. We also have to remember that 20% of Americans live in underserved areas in which more sophisticated and safer treatment options are completely inaccessible.

We are concerned about this ethical imbroglio, as it is extremely damaging to our patients who suffer from the disease of chronic pain.  To quote from our article, opioid prescribing guideline committees’ continued utilization of the antiquated and invalid concept of MEDD is “scientifically, ethically, and morally inexplicable.”

As a result of this highly unethical practice, “impressionist lawmakers and anti-opioid zealots are basing clinical policy decisions on flawed concepts that ultimately could adversely affect positive outcomes for legitimate pain patients.”

It’s difficult enough to suffer from chronic pain under the best circumstances.  What patients with pain and society in general certainly don’t need is a group of smug inexperienced pain policymakers, politicians, and managed care administrators impacting public policy by evoking pseudoscience. There is sufficient good science being published that demonstrates that their reliance upon the MEDD myth is highly disingenuous.

Michael E. Schatman, PhD, is a clinical psychologist who has spent the past 30 years working in multidisciplinary chronic pain management. Until recently, he served as the Executive Director of the Foundation for Ethics in Pain Care in Bellevue, WA.

Dr. Schatman is Editor-in-Chief of the Journal of Pain Research and Director of Research for the U.S. Pain Foundation.

Jeffrey Fudin, PharmD, is a Clinical Pharmacy Specialist and Director at the Pharmacy Pain Residency Programs at the Stratton Veterans Administration Medical Center in Albany, NY.  

Dr. Fudin is Diplomate to the American Academy of Pain Management and a Fellow of both the American College of Clinical Pharmacy and the American Society of Health-system Pharmacists. 

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.

E-coli Bacteria Used to Produce Morphine

By Pat Anson, Editor

While politicians and regulators in the U.S. try to decrease access to opioid pain medications, scientists are developing new techniques to mass produce them.

The latest development is at Kyoto University in Japan, where researchers have learned how to tweak E coli bacteria so that they pump out thebaine, a morphine precursor that can be modified to make opioid pain relievers.

The genetically modified Escherichia coli – a common gut microbe -- produces 300 times more thebaine than a recently developed method involving yeast.

"Morphine has a complex molecular structure; because of this, the production of morphine and similar painkillers is expensive and time-consuming. But with our E coli, we were able to yield 2.1 miligrams of thebaine in a matter of days from roughly 20 grams of sugar,” said lead author Fumihiko Sato of Kyoto University.

"Improvements in opiate production in this E. coli system represent a major step towards the development of alternative opiate production systems."

Sato’s study is published in the journal Nature Communications.

 Escherichia coli

Morphine is extracted from opium poppy sap in a process that typically takes up to a year. Morphine can then be converted to opiates such as codeine, hydrocodone or even heroin.

Scientists at Stanford University last year engineered the yeast genome so that it produces opiate alkaloids from sugar. The genetically altered yeast cells grow so rapidly they convert sugar into hydrocodone in just three to five days. That raised fears that opioids could be produced cheaply and easily, provided that one has access to the necessary yeast strain.

With E coli, Sato says that such a production risk is unlikely.

"Four strains of genetically modified E coli are necessary to turn sugar into thebaine," explains Sato. "E coli are more difficult to manage and require expertise in handling. This should serve as a deterrent to unregulated production."

In 2011, Sato and colleagues engineered E coli to synthesize reticuline, another morphine precursor. In the new system, the team added genes from other bacteria and enzyme genes from two strains of opium poppies, Coptis japonica, and Arabidopsis.

"By adding another two genes, our E coli were able to produce hydrocodone, which would certainly boost the practicality of this technique," Sato said. "With a few more improvements to the technique and clearance of pharmaceutical regulations, manufacturing morphine-like painkillers from microbes could soon be a reality."

Opioid pain medications are widely available in the United States, where the focus is often on their potential misuse. But the World Health Organization estimates that 5.5 billion people worldwide have little or no access to opioids because of their limited supply and high cost.

Going Off Morphine is Hell

By Crystal Lindell, Columnist

This past weekend, as I tried to get off morphine once and for all, one thought kept going through my mind — if the devil is any good at his job, hell will just be eternal opioid withdrawal.

It’s like, have you ever had the flu, and also food poisoning, and also been hit by a train, and also had the fight or flight anxiety that comes from being chased by a bear for a week straight — all the same time? Well it’s worse than that.

It’s effing hell.

And it’s all made even worse by the fact that I had the cure the whole time. Every single minute that went by, I knew that I all had to do to make it all go away was pop one of those little blue pills in my purse.

I made it to the 72 hour mark last night at midnight. That’s 72 hours without morphine or a hydrocodone. I haven’t gone a full 72 hours without an opioid in almost two and a half years.

I spent all of November tapering down my dose. Going so effing slow. Like three pills, then two pills, then three pills, then two pills. Then after a week, I’d do one pill then two pills, then one pill.

I was down to one pill every other day, of the lowest dose, and I knew the next step was going through withdrawal. I thought maybe it wouldn’t be that bad since I had been going so slowly with the tapering. I was wrong.

Honestly, the first 24 hours weren’t so bad. My body was just chilling, expecting another dose in a day or so. But then, at midnight, exactly 24 hours in, the involuntary leg movements started. I was lying in bed, in the middle of the night, and my right leg would just move. Also, my anxiety started skyrocketing so high you’d have thought I was in a war zone.

By the morning, about 31 hours in, the muscle aches had set in, and everything I had ever eaten over the last two years had started to come out. Diarrhea doesn’t sound like the worst thing in the world, until you literally spend so much time on the toilet that your legs go numb. And then when you do get up, you are so dehydrated that you can’t even walk without holding on to the wall.

There’s other stuff too, the kind of stuff that maybe sounds minor until it happens to you. Like, my nose was randomly running, and I was sneezing like there was a secret cat hidden in the bathtub. And I could not sleep. At all. And if somehow I did get a couple minutes of shut eye, I would wake up drenched in sweat. Also, everything made cry. Seeing the sun? Tears. Facebook posts about makeup? I’d start weeping. Basically the fact that I was alive was enough of a reason.

Again, all these things don’t sound so horrible, but when they are all happening at once, it is literally hell on earth. 

I spent most of the 72 hours watching Breaking Bad — which is either the worst show to watch during withdrawal because it’s all about drugs, or the best because it’s all about the horrible things drugs lead to.

I also spent most of the 72 hours trying to process how I got to this point. Morphine has been so good to me over the last two years. And I stand by the fact that it literally saved my life. If it wasn’t for the pain relief I got from the drug, I don’t know if I would have been able to endure. And I am thankful to morphine for that.

But I wouldn’t wish the morphine withdrawal on Hitler.

And I thought about everyone who has ever had to endure this for whatever reason. And my heart filled with compassion and love for them. Some people like to say that drug addicts are just weak, or lack self-control. Those people are a**holes.

I also thought a lot about how much I wanted to just pop a morphine and make everything better. I thought about it so hard. Vividly picturing the little blue pill in my head and fantasizing about how good it would feel to take just one.

And I thought about how going through withdrawal was a good thing because I wouldn’t even be going off morphine if I wasn’t feeling better. (See Crystal's last column: "Is Vitamin D Making Me Feel Better?")

I felt like this was a final step. A last stand by my pain to suck me in. I had to get off this drug to move on with my life. But it was so incredibly hard.

And I kept thinking about how, I am a good person. I am a strong person. I should be able to get through this. Why am I struggling so much?

My best friend was extremely supportive during the whole thing, constantly checking on me, praying for me, and sending me encouragement. And at one point she sent me a text that said, “I think the last two years were the toughest times of each of our lives (in different ways). Glad I get to see you on the other end.”

The other end. Wow. I honestly never thought I would ever get to see the other end. For a long time, I didn’t even think there was an “other end” to get to.

The idea that I could get to this proverbial “other end” though, it was enough to keep me going.

Honestly, I still feel like I was jumped, and then tossed in front of a train. But I’m doing a lot better than I was doing on day two. From what I can tell, the withdrawal symptoms can last anywhere from a week to months, but it’s those first 72 hours that are the most horrible. And I have made it through those.

I also discovered that there’s a cocktail of over-the-counter drugs that help. Specifically, I have been popping handfuls of Advil, Imodium and Benadryl.

I saw my brother this morning. And as I walked toward him, I felt like I was just regaining my footing after being in a plane crash. Still shaken up, disoriented and feeling like hell, I said, “Well, I’m finally feeling a little better. I made it to 72 hours.”

“Great. Now you have to make it a week,” he said.

Crap, I thought. He’s right.

Crystal Lindell is a journalist who lives in Illinois. She loves Taco Bell, watching "Burn Notice" episodes on Netflix and Snicker's Bites. She has had intercostal neuralgia since February 2013.

Crystal writes about it on her blog, “The Only Certainty is Bad Grammar.”

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.

Two Drug Combo Relieves Neuropathy Pain

By Pat Anson, Editor

British researchers say a combination of two widely used drugs – an antidepressant and an opioid – can significantly relieve pain and other symptoms caused by neuropathy.

In a study published in the journal PAIN, researchers at Queens University say combining the painkiller morphine with the antidepressant nortriptyline relieved chronic neuropathic pain in nearly 90 percent of patients – significantly better than when either drug is used alone.

"Morphine and nortriptyline are excellent candidates for pain management because of the extensive research conducted on them, their low cost, and widespread availability all over the world," said Ian Gilron, MD, a professor in Queen's School of Medicine and anesthesiologist at Kingston General Hospital.

"Current neuropathic pain treatments are ineffective or intolerable for many sufferers so this new evidence supporting the morphine-nortriptyline combination is important news for patients."

Nortriptyline, an antidepressant sold under the brand names Aventyl and Pamelor, is already being used to treat pain in the arms and legs caused by multiple sclerosis. Morphine has long been used to treat both acute and chronic pain.

Neuropathic pain is characterized by tingling or burning sensations that develop as result of nerve damage caused by conditions such as shingles, diabetes, amputation, inflammation, and cancer. About 8% of adults worldwide suffer from neuropathy. Many drugs used to treat neuropathic pain, such as Neurontin and Lyrica, often don’t work or have unpleasant side effects.

In the double-blind, randomized study, 52 neuropathy patients were given a choice of trying every one of three treatments: morphine alone, nortriptyline alone, and a combination of the two drugs over six-week treatment periods. Patients were asked to record their pain levels and side effects during each treatment.

The average daily pain before treatment was 5.6, measured using a rating scale from 0-10. Average daily pain dropped to 2.6 when patients received the two drug combination. Patients taking nortriptyline and morphine alone rated their pain at 3.1 and 3.4, respectively.

Researchers said that common side effects for both drugs, which include constipation and dry mouth, did not worsen with the combined treatment.

"It's important to remember that we don't want to completely eliminate patients' ability to sense pain as it's a warning system for us, but we do want to find the right balance of pain relief and drug side effects," said Gilron

Nortriptyline and morphine are currently not available in a combined formulation. According to the Mayo Clinic, using the two drugs together is usually not recommended because they both cause sedation.