UK Study Finds Weather Can Worsen Chronic Pain

By Pat Anson, PNN Editor

Do you feel “under the weather” when its rainy and cold outside? About 75% of chronic pain sufferers believe certain weather conditions can aggravate their pain. Some even think they can predict a storm coming because they “can feel it in their bones.”

A new analysis of weather patterns in the United Kingdom suggests there may be some truth to those old clichés.

For 15 months, researchers at the University Manchester collected data from over 10,500 UK residents, who recorded their daily pain levels on a smartphone app. The GPS location of their phones was then compared to local weather conditions.

The study found a modest association between weather and pain, with people more likely to feel pain on days with low barometric pressure – and the wet and windy weather that usually comes with it.

The key appears to be the upper level jet stream – a narrow band of air currents that circle the globe several miles above the earth. On days when the jet stream was aimed right at the UK, with above normal wind, humidity and precipitation, about 23% of people reported more pain.

But when the jet stream blew north of the UK, and pressure was above normal with less humidity and precipitation, only 10% of people reported higher pain levels.

“Although the weather may not be the primary cause of people’s pain, our results through multiple independent methodologies demonstrate that weather does modulate pain in at least some individuals,” lead author David Schultz reported in the Bulletin of the American Meteorological Society.

“The results of this project should give comfort and support to those who have claimed that the weather affects their pain, but have been dismissed by their friends, their coworkers, and even their doctors.“

The new analysis builds on earlier research from the Cloudy With a Chance of Pain study, which is the largest in both duration and number of participants to examine the link between weather and pain.  Previous studies have found little or no association between the two.

A 2014 Australian study, for example, found that acute low back pain was not associated with variations in temperature, humidity and rain.  And a 2013 Dutch study concluded that weather had no impact on fibromyalgia symptoms in women.

“Part of the reason for this lack of consensus is that previous researchers have treated the different measures of the weather such as pressure, temperature, humidity separately, which assumes that one could vary the temperature while holding all of the other weather measures fixed. Of course, the real atmosphere does not behave like this, as all the variables are changing simultaneously,” says Schultz.

Schultz and his colleagues plan to further study the data to see how environmental conditions modulate pain, insight that could be used to develop better treatments and individualized pain forecasts.

Experimental Treatment Targets Neuropathic Pain

By Pat Anson, PNN Editor

Researchers in Denmark have developed a promising new compound to treat neuropathy that targets the hyper-sensitized nerves that cause chronic pain. The experimental compound – a peptide called Tat-P4-(C5)2 -- has only been tested in mice, but researchers hope to begin clinical trials on humans soon.

"We have developed a new way to treat chronic pain. It is a targeted treatment. That is, it does not affect the general neuronal signaling, but only affects the nerve changes that are caused by the disease," says Kenneth Lindegaard Madsen, PhD, Associate Professor at the University of Copenhagen.

"We have been working on this for more than ten years. We have taken the process all the way from understanding the biology, inventing and designing the compound to describing how it works in animals, affects their behaviour and removes the pain.”

Madsen and his colleagues recently published their findings in the journal EMBO Molecular Medicine .

The image below shows the compound Tat-P4-(C5)2 after it is injected into the spinal cord. The compound (purple) penetrates the nerve cells of the spinal cord (yellow), but not the surrounding cells (the cell nuclei are blue). The compound blocks neuropathic pain signals – the kind associated with diabetic neuropathy, shingles, phantom limb pain and chemotherapy-induced pain — from being sent to the brain.

UNIVERSITY OF COPENHAGEN

In a previous study, the researchers showed in an animal model that use of the compound can also reduce tolerance and the risk of addiction. They believe the compound will be more effective and safer than the anti‐convulsants, antidepressants and opioid medications now used to treat neuropathy.

"The compound works very efficiently, and we do not see any side effects. We can administer this peptide and obtain complete pain relief in the mouse model we have used, without the lethargic effect that characterises existing pain-relieving drugs," said Madsen.

"Now, our next step is to work towards testing the treatment on people. The goal, for us, is to develop a drug, therefore the plan is to establish a biotech company as soon as possible so we can focus on this."

Is Your Pain Tolerable?

By Pat Anson, PNN Editor

There has long been controversy over the way pain is measured by healthcare providers. Critics say the two most widely used methods, the numeric 0 to 10 pain scale and the Wong Baker Pain Scale, are too subjective because they rely on patients to self-report their pain levels.

Some even claimed that asking patients about their pain encourages excess opioid prescribing. There was never any evidence to support that argument, but in 2017 the Centers for Medicare and Medicaid Services (CMS) caved into political pressure and dropped three survey questions that asked Medicare patients about the quality of pain care they received in hospitals.   

A new method of measuring pain is now being proposed, one that is designed to reduce opioid prescribing and other pain treatments. It hinges on a simple question:

“Is your pain tolerable?”

In a new study published in JAMA Network Open, researchers say asking patients that question could help doctors decide whether opioids and other treatments are really necessary.

"Because of concerns about overtreatment of pain with opioids there has been an enormous effort to rethink how we ask patients about pain," says lead author John Markman, MD, director of the Translational Pain Research Program at the University of Rochester Medical Center.

"Knowing that patients consider their pain to be tolerable, physicians wouldn't necessarily prescribe a medication with serious risks or expose them to surgery.”

Markman and his colleagues asked 537 primary care patients if their pain was tolerable, and then had them rate the intensity of their pain on the 0 to 10 scale.

Most patients who had mild pain (a score of 1 to 3) or moderate pain (4 to 6) said their pain was tolerable. Even with a severe pain score of 7, nearly 40% said their pain was tolerable. But after that, at level 8 or higher, severe pain becomes less and less tolerable.

JAMA NETWORK OPEN

“Our findings confirmed the intuitive assumption that most patients with low pain intensity find their pain tolerable,” Markman wrote. “In contrast, the tolerability of pain rated between 4 and 6 varies substantially among patients. In this middle range, if a patient describes pain as tolerable, this might decrease the clinician’s inclination to initiate higher-risk treatments.  A substantial subgroup of patients with severe pain reported their symptoms as tolerable.”

One weakness of the tolerable question is that it measures pain at a single point in time – and chronic pain patients often experience flares that can make their pain intolerable. It also assumes that every patient is alike and has the same level of tolerance.

Markman says numeric pain scales have "very little relevance" when patients who have lived with chronic pain for several years visit their doctors.

"If, instead, a patient could say 'my pain is tolerable when I'm doing this but intolerable when I'm doing that,' and it's in the context of that patient's life, I frankly think that's much more useful, and is what doctors really want to know," Markman said.

"In order to transform how we treat pain to make treatments safer and more effective, we need to start with a reformation in how we ask patients about pain."

PROP Linked to New Federal Opioid Study

By Pat Anson, PNN Editor

A small but influential group of anti-opioid activists continues to play an outsized role in guiding federal policy on the use of opioid pain medication.

The latest example is a new report by the Agency for Healthcare Research and Quality (AHRQ) on the effectiveness of opioids in treating chronic pain. In a lengthy review of over 150 clinical studies, AHRQ researchers concluded that opioids were no more effective in treating pain than nonopioid medication, and that long-term use of opioids increases the risk of abuse, addiction and overdose, especially at high doses.

The findings are essentially the same as those in a draft report released by the AHRQ last year. What’s different is that the agency finally disclosed the authors of the report and the outside advisors they consulted with. They include a cabal of academic researchers and physicians with biased views about opioids that federal agencies keep bringing in as consultants.   

The AHRQ’s report confirms what PNN reported in November. The study was led by Dr. Roger Chou, a primary care physician who heads the Pacific Northwest Evidence-based Practice Center at Oregon Health & Science University.

Most public health researchers keep a low profile to avoid accusations of bias, but Chou has been a vocal critic of opioid prescribing for years. In a 2019 podcast, for example, Chou said the benefits of opioids were “clinically insignificant” and the medications were often quite harmful.

“The impact of prescription opioids in terms of mortality and substance use disorder and all the other things that come along with it have really been quite staggering,” he said.

Chou also served on a state task force last year that supported a rigid opioid tapering policy. If adopted, the policy would have forced thousands of Oregon’s Medicaid patients off opioids.

DR. ROGER CHOU

“I don’t think there’s anything compassionate about leaving people on drugs that could potentially harm them,” Chou said.

Collaboration with PROP

Chou has collaborated on several occasions with members of Physicians for Responsible Opioid Prescribing (PROP), an advocacy group that seeks to reduce the use of opioid medication. PROP has never disclosed its donors or funding.

Last year Chou co-authored an op/ed with PROP President Dr. Jane Ballantyne and PROP board member Dr. Anna Lembke that encourages doctors to consider tapering “every patient receiving long term opioid therapy.”

In 2011, Chou co-authored another op/ed with PROP founder Dr. Andrew Kolodny and PROP vice-president Dr. Michael Von Korff. 

The article was prescient because it called for a major overhaul of opioid guidelines that were then primarily developed by pain management specialist organizations.

“Guidelines for long-term opioid therapy should not be developed by the field of pain medicine alone.”

— Kolodny, Chou, et al 2011

“Guidelines for long-term opioid therapy should not be developed by the field of pain medicine alone. Rather, experts from general medicine, addiction medicine, and pain medicine should jointly reconsider how to increase the margin of safety,” they said.

That major overhaul came in 2016, when the Centers for Disease Control and Prevention released its controversial opioid guideline, which soon displaced all of the other guidelines. Chou was one of the co-authors of the CDC guideline – so it’s not altogether surprising that the AHRQ study reaffirms many of the CDC’s conclusions.

“Findings support the recommendation in the 2016 CDC guideline that opioids are not first-line therapy and to preferentially use nonopioid alternatives,” Chou and his colleagues wrote.

In preparing the AHRQ study, researchers sought input from a dozen outside experts, who served as technical experts and peer reviewers. Three of the 12 are PROP board members: Drs. Mark Sullivan and David Tauben were technical experts, and PROP vice-president Dr. Gary Franklin was a peer reviewer. Sullivan, Tauben and Franklin are all professors at the University of Washington, and played prominent roles in the development of Washington state’s opioid prescribing regulations, which are some of the toughest in the nation.

Another peer reviewer was Dr. Erin Krebs, an associate professor at the University of Minnesota Medical School. Krebs was the lead author of a controversial 2018 study that found non-opioid pain relievers worked better than opioids in treating osteoarthritis pain. While some critics said the study was poorly designed and amounted to junk science, it drew praise from Chou.

"The fact that opioids did worse is really pretty astounding," Chou told the Chicago Tribune. "It calls into question our beliefs about the benefits of opioids." 

In addition to her work as a researcher, Krebs also appeared in a lecture series on opioid prescribing funded by the Steve Rummler Hope Foundation, which lobbies against the use of opioids. The non-profit foundation is the fiscal sponsor of PROP, and Kolodny and Ballantyne both serve on its medical advisory committee.

If these intertwining connections are making your head spin, there’s more.

Core Expert Group

Ballantyne, Franklin and Krebs served on the “Core Expert Group” that advised the CDC when it drafted its opioid guideline, and Tauben was on the CDC’s peer review panel. Kolodny and yet another PROP board member, Dr. David Juurlink, were part of a “Stakeholder Review Group” that provided input to the CDC.

When PNN filed a request under the Freedom of Information Act (FOIA) to see what kind of advice the Core Expert Group gave to the CDC, we were stiff-armed by the agency. The CDC sent us nearly 1,500 pages of documents, but most were so heavily redacted they were completely blank.    

Even financial conflict of interest statements were scrubbed of information, with the CDC citing “personal privacy” and “deliberative process privilege” as reasons not to provide them in full.

At least two unidentified members of the Core Expert Group worked for or consulted with organizations with an interest in opioids or other controlled substances. One of those individuals also provided “expert opinion or testimony,” which has become a lucrative sideline for some PROP members.

Critics wonder why federal health agencies keep bringing in consultants with obvious biases and conflicts of interest.

“The AHRQ review presents itself as an objective scientific analysis of the medical literature. In my opinion, the document is arguably contaminated with a political agenda,” says Dr. Dan Laird, a physician attorney in Las Vegas. “Some of those involved in the review could be perceived by the chronic pain community as having strong anti-opioid political views and biased ideas about the meaning and treatment of chronic pain.

“Most importantly, there is no input whatsoever from the chronic pain community in the review. There are certainly chronic pain patients with academic credentials that would qualify them to conduct a literature review. Several highly regarded academic physicians and scientists, known for opioid moderatism, are conspicuously absent as investigators, peer reviewers, or technical experts; these include pain medicine academicians such as Drs. Michael Schatman, Sean Mackey, Stefan Kertesz, and Vanila Singh.”

AHRQ Conflict Policy

If a peer reviewer or technical expert has a financial or professional conflict of interest, that does not automatically disqualify them in the eyes of the AHRQ, which will retain them “because of their unique clinical or content expertise.”  

It’s also been a long-standing AHRQ policy not to disclose the names of advisors or authors until its reports are finalized.

“This policy is aimed at helping the authors maintain their independence by not being subject to lobbying by industry reps or others with conflicts of interest, either financial or intellectual,” AHRQ spokesman Bruce Seeman explained in an email.

But others wonder if the policy damages the agency’s reputation and the credibility of its research, by not giving the public a chance to review and comment on possible biases before a final report is released. The American Medical Association urged the AHRQ to change its policy last year.

“We would suggest that AHRQ publish the list of all those involved in any aspect of the report during the comment period to help remove any perception of potential conflict,” Dr. James Madara, the AMA’s Executive Director and CEO, wrote in a letter to the agency last year.

CDC Guideline Update

It might be tempting to dismiss the work of an obscure federal agency that produces wonky reports that are mostly read by public health researchers and government bureaucrats. That would be a mistake. It was a 2014 AHRQ report on opioids – co-authored by Chou – that played a foundational role in the CDC guideline.

Although the CDC guideline is voluntary and only intended for primary care physicians treating chronic pain, it has become mandatory policy for doctors in all specialties, as well as other federal agencies, dozens of states, insurers, pharmacy chains and law enforcement agencies. In effect, the guideline has delivered on the goals sought by Kolodny, Von Korff and Chou in 2011. The standard of care in pain management is no longer determined by pain specialists.

Chou and his colleagues hope the new AHRQ report will have a similar impact, not just in government, but throughout the healthcare system.

“The information in this report is intended to help healthcare decision makers — patients and clinicians, health system leaders, and policymakers, among others — make well-informed decisions and thereby improve the quality of healthcare services,” they said.

In addition to its report on opioid treatments for chronic pain, AHRQ has also finalized studies on the effectiveness of Nonopioid Medications for Chronic Pain and Nonpharmacologic Treatments for Chronic Pain, such as acupuncture and meditation.

All three reports will be utilized by the CDC as it prepares an update and expansion of its opioid guideline, which is expected in late 2021.  That effort is being overseen by the Board of Scientific Counselors at the CDC’s Center for Injury Prevention & Control.  Roger Chou happens to be one of its members.  

How CDC Bungled Early Coronavirus Testing

By Rachana Pradhan, Kaiser Health News

As the novel coronavirus snaked its way across the globe, the Centers for Disease Control and Prevention in early February distributed 200 test kits it had produced to more than 100 public health labs run by states and counties nationwide.

Each kit contained material to test a mere 300 to 400 patients. And labs, whether serving the population of New York City or tiny towns in rural America, apparently received the same kits.

The kits were distributed roughly equally to locales in all 50 states. That decision presaged weeks of chaos, in which the availability of COVID-19 tests seemed oddly out of sync with where testing was needed.

A woman in South Dakota with mild symptoms and no fever readily got the test and the results. Meanwhile, political leaders and public officials in places like New York, Boston, Seattle and the San Francisco Bay Area — all in the throes of serious outbreaks ― couldn’t get enough tests to screen ill patients or, thereby, the information they needed to protect the general public and stem the outbreak of the virus, whose symptoms mimic those of common respiratory illnesses.

Rapid testing is crucial in the early stages of an outbreak. It allows health workers and families to identify and focus on treating those infected and isolate them.

Yet health officials in New York City and such states as New York, Washington, Pennsylvania and Georgia confirmed to Kaiser Health News that they each initially got one test kit, calling into question whether they would have even stood a chance to contain the outbreaks that would emerge. They would soon discover that the tests they did receive were flawed, lacking critical components and delivering faulty results.

During those early weeks, the virus took off, infecting thousands of people and leading to nationwide social distancing and sheltering in place. Public health officials are just beginning to grapple with the fallout from that early bungling of testing, which is likely to haunt the country in the months to come.

Too Little Too Late

The first shipment to Washington state arrived more than two weeks after officials there announced the first U.S. case of coronavirus, and at a moment when deadly outbreaks of the disease were already festering in places like the Life Care Center in Kirkland. Within weeks, three dozen people infected with COVID-19 would die at the nursing home in the suburbs of Seattle.

The spread of COVID19 would not take long to overwhelm the state, which has over 2,200 people infected.

The Trump administration in recent days has attempted to speed testing for the virus after early missteps hampered the government’s response to contain the contagion, and officials have had to respond to a barrage of criticism from public health experts, state officials and members of Congress.

Federal health officials have eased the process for university and commercial labs to perform their own tests, and they are ramping up their capacity. As of March 16, public and private labs in the U.S. had the ability to test more than 36,000 people a day, according to estimates compiled by the American Enterprise Institute, a conservative-leaning think tank in Washington, D.C., a figure expected to rapidly escalate in coming weeks. That figure, however, can vary considerably by state and does not indicate how many tests are actually given to patients.

“We are now beginning to see that they have spread out in a prioritized way. We asked them to prioritize the regions that were mostly affected,” Deborah Birx, the coronavirus response coordinator for the White House Coronavirus Task Force, said Wednesday of private labs’ testing, without elaboration.

The scaling up of testing is set to take place after weeks of faltering and hundreds, if not thousands, of undiagnosed people spreading the virus. For example, New York’s state health department received a faulty CDC test kit on Feb. 8 for 800 patient specimens, an amount that’s consistent with other states, according to a spokesperson. It later began testing patients with a test that state officials developed based on the CDC protocol and has significantly increased testing.

In New York City, the first batch was obtained on Feb. 7.

“The other state and local public health laboratories got test kits as they became available,” said Eric Blank, chief program officer of the Association of Public Health Laboratories.

Places in the middle of the country with no outbreaks had the luxury of time to plan. For example, Missouri officials have had about 800 tests to work with, leading to only 395 performed so far in the region by public health labs ― 26 of which were positive. When private lab tests are accounted for, as of Friday there were 47 confirmed cases.

Health care providers and public health staff in the state, however, benefited from the fact that there is less international travel to the region, according to infectious disease expert Dr. Steven Lawrence of Washington University in St. Louis.

“This is very similar to 1918 with the influenza pandemic — St. Louis had more time to prepare and was able to put measures in place to flatten the curve than, say, Philadelphia,” Lawrence said. “Seattle didn’t have an opportunity to prepare as much in advance.”

While commercial labs are coming online, strict restrictions are limiting testing capabilities, Lawrence said.

“The state has had their hands tied,” he added.

Waiting and Wondering

Because of a widespread lag in testing, it is still a mystery for thousands of people to know whether they’ve come into contact with an infected person until well after it happens.

“CDC will distribute tests based on where they can do the most good. But without hospital-based testing and commercial testing, it will not be possible to meet the need,” said Tom Frieden, who led the CDC during the Obama administration and is a former commissioner of the New York City Health Department.

Since the CDC’s initial distribution, states have been reordering more tests through the office’s International Reagent Resource ― a long-standing tool that public health labs have relied on. They have also revised testing protocols to use only one sample per person, which boosts the number of people screened.

Yet problems still abound with tests or other materials needed to be able to detect the virus. California Gov. Gavin Newsom said on March 12 that county public health labs can’t use all of the 8,000 test kits the state has because they are missing key components.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Do Smartphones Cause More Headaches?

By Pat Anson, PNN Editor

People with headaches who use smartphones are more likely to use more pain medication, but get less relief from the drugs, according to a new study conducted in India.

Researchers surveyed 400 people who suffer from a primary headache condition, which includes migraine, tension headache and other types of headaches, asking them about their smartphone and medication use.

The smartphone users were more likely to take pain-relieving drugs for their headaches than non-users, with 96% of smartphone users taking the drugs compared to 81% of non-users. Smartphone users took an average of eight pills per month compared to five pills per month for non-users.

Smartphone users also reported less relief from pain medication, with 84% gaining moderate or complete relief of headache pain compared to 94% of non-users. The study findings were published in the journal Neurology Clinical Practice.

"While these results need to be confirmed with larger and more rigorous studies, the findings are concerning, as smartphone use is growing rapidly and has been linked to a number of symptoms, with headache being the most common," said lead author Deepti Vibha, DM, of All India Institute of Medical Sciences.

The study has limitations. It only examined people at one point in time and did not follow them over an extended period. It also relied on people to self-report their symptoms and use of pain medication.

While the study does not prove that smartphone use causes headaches or greater use of pain medication, it does show an association.

“There is a great deal of speculation among the lay population regarding the effect of computers and mobile phones on ailments such as headaches and neck pain. However, although there are anecdotal stories suggesting a link between technology use and pain, there is little evidence of either a definitive relationship or data absolving mobile phones or computers from a link to recurrent pain,” wrote Heidi Moawad, MD, of Case Western Reserve University, in an editorial accompanying the study.

“Smartphone users may rely on the devices for many hours per day -- while on the go, resting, or working -- which puts a strain on the eyes, neck, and back. As people are becoming more dependent on these devices, it would be worthwhile to know whether using smartphones could lead to health problems.”

A 2017 study speculated that high energy visible (HEV) light – also known as blue light – emitted by smartphones, laptops, desktop computers and other digital devices could contribute to headaches by causing eye strain. Blue light has a very short wavelength that penetrates deep into the eye.

A nationwide survey of nearly 10,000 adults by The Vision Council found that about a third had symptoms of digital eye strain, including neck and shoulder pain, headache, blurred vision and dry eyes.

More information about blue light can be found at BlueLightExposed.com.

U.S. Overdose Crisis Could Be Worse Than We Thought

By Pat Anson, PNN Editor

The number of deaths attributed to opioid overdoses in the U.S. could be 28 percent higher than reported due to incomplete death records, according to a new study appearing in the journal Addiction. Researchers at the University of Rochester say nearly 100,000 overdose deaths may not have been counted because the opioid involved was not identified.

The discrepancy is pronounced in several states, such as Pennsylvania, Alabama, Mississippi, Louisiana and Indiana, where the actual number of overdoses caused by legal and illicit opioids could be twice as high as current estimates.

"A substantial share of fatal drug overdoses is missing information on specific drug involvement, leading to underreporting of opioid-related death rates and a misrepresentation of the extent of the opioid crisis," said senior author Elaine Hill, PhD, an economist and assistant professor in the University of Rochester Medical Center. "The corrected estimates of opioid-related deaths in this study are not trivial and show that the human toll has been substantially higher than reported, by several thousand lives taken each year."

Hill and her colleagues found that almost 72 percent of unclassified drug overdoses that occurred between 1999 and 2016 involved prescription opioids, heroin or illicit fentanyl — translating into 99,160 additional opioid-related deaths.

Researchers discovered the discrepancy while studying the economic, environmental and health impact of coal mining and oil and gas drilling. Appalachia and other regions of the country hit hardest by the opioid crisis overlap with areas where there is coal mining and shale gas development.

As a part of her research, Hill was attempting to determine whether the shale boom improved or exacerbated the opioid crisis. She discovered that close to 22 percent of all drug-related overdoses were unclassified, meaning the drugs involved in the cause of death were not reported.

A 2018 study at the University of Pittsburgh reached a similar conclusion, estimating that as many as 70,000 opioid related-deaths were not reported. Coroners and medical examiners in many states often did not specify the drug that contributed to the cause of death.  

Critics have long complained that overdose data reported by the CDC and other federal agencies is flawed or cherry-picked. CDC researchers admitted in 2018 that deaths attributed to opioid medications were “significantly inflated” because overdoses involving illicit fentanyl were erroneously counted as prescription opioid deaths. Toxicology tests cannot distinguish between pharmaceutical fentanyl and illicit fentanyl.

The overdose data is further muddied because multiple drugs are involved in almost half of all drug overdoses.

Poor Overdose Data Concentrated in Several States

In their study, Hill and her colleagues obtained overdose death records from the CDC’s National Center for Health Statistics. Using statistical analysis, they correlated information on unclassified overdose deaths with potential contributing causes, such as previous opioid use and chronic pain conditions.

While the overall percentage of unclassified deaths declined over time – apparently due to efforts to improve overdose data -- the number remained high in several states. In Pennsylvania, for example, the official number of opioid-related deaths was 12,374. Researchers estimate that the actual number of deaths was 26,586.

"The underreporting of opioid-related deaths is very dependent upon location and this new data alters our perception of the intensity of the problem," said Hill. "Understanding the true extent and geography of the opioid crisis is a critical factor in the national response to the epidemic and the allocation of federal and state resources."

The CDC recently reported that drug overdose deaths dropped 4.1% in 2018 – the first decline in nearly three decades -- led by a significant drop in overdoses involving hydrocodone, oxycodone and other painkillers. But deaths linked to illicit fentanyl, methamphetamines and psychostimulants are surging, threatening to reverse the overall trend.

“One thing that we’re seeing is that the decline doesn’t appear to be continuing in 2019. It appears rather flat, maybe actually increasing a little bit,” said Robert Anderson, PhD, Chief of the Mortality Statistics Branch, National Center for Health Statistics.

Drugs Kill in Other Ways

All of these studies miss the mark, according to research published in PLOS ONE, because they don’t include deaths caused by infectious disease, drunk driving, suicide, and cardiovascular disease — all of which are affected by drug use.

"The basic records being kept are annual reports on the number of deaths from drug overdose. But that's only part of the picture,” said Samuel Preston, a professor of sociology at the University of Pennsylavnia. "Drugs can kill in other ways."

In 2016, 63,000 deaths were attributed to drug overdoses, but Preston and his colleagues estimate that the actual number of drug-associated deaths was around 142,000. Drug use shaved off nearly a year-and-a-half of life for men and three-quarters of a year for women.

"It's not just about the supply of drugs, but that there's something else behind all of it that causes people to either use drugs or alcohol or commit suicide because they've lost interest in their life," said co-author Dana Glei, a Georgetown University demographer.

Patients with Arachnoiditis and Ehlers-Danlos Need Adrenaline for Pain Control

By Dr. Forest Tennant, PNN Columnist

In this era of opioid controversy and tragedy due to forced opioid reduction, the scientific information on adrenaline-type agents can help control constant, intractable pain and help reduce opioid use.

Overlooked in the opioid controversy is the key point that an adequate supply of adrenaline-related neurotransmitters – such as dopamine and norepinephrine – are necessary in the brain and spinal cord for pain relief. Unfortunately, constant intractable pain depletes the natural supply of endorphin, dopamine, adrenaline and noradrenalin, and their levels must be replaced to adequately control pain.  

Persons with a severe, intractable pain condition like Adhesive Arachnoiditis (AA) and/or a genetic connective tissue disorder like Ehlers-Danlos syndrome (EDS) will need an adrenaline agent, also called a stimulant, for pain control, maximal function, keeping opioid dosages stable, and preventing sedation and overdose. 

Adrenaline agents have long been known to boost or potentiate opioids, enhance pain relief, and allow less opioid to be used. A study by this author found that the simultaneous use of a stimulant and clonidine lowered opioid dosage by 30 to 50 percent. 

The use of a stimulant in this manner is not new. In the 1920’s, physicians at the Royal Brompton Hospital in London found that a stimulant was a necessary ingredient in the famous “Brompton Cocktail” for relief of severe pain. Today, modern pain relief agents often add caffeine as a stimulant to make the codeine and oxycodone more potent.

Most observers believe that an adrenaline agent given to an intractable pain patient will automatically raise blood pressure and pulse rate. This is generally a myth, because the person with intractable pain often depletes their reserve of dopamine, noradrenalin and adrenaline.  

The use of an adrenaline agent will serve to replace these depleted neurotransmitters and will not generally cause blood pressure and pulse rate to rise. Periodic monitoring is, however, recommended to be continued.  

Multiple Benefits  

A person with intractable pain due to AA, EDS, Reflex Sympathetic Dystrophy (RSD), or another severe and tragic condition will usually have the following conditions – all of which will benefit by an adrenaline agent:

• Weight Gain

• Attention Deficit Disorder (ADHD)

• Depression

• Sedation

• Fatigue

• Memory Loss

Descending Pain

Recent research has learned that constant, intractable pain establishes a “biologic battery” in the brain and spinal cord. This “battery” sends electric currents down the autonomic (non-spinal cord nerves) nervous system. Symptoms of this descending pain include excess heat, muscle spasms, jerking, tremors, sweating and “all-over” pain.  

In contrast to other forms of pain, descending pain isn’t well controlled by opioids and anti-inflammatory agents. The drugs clonidine and tizanidine are less effective. Only adrenaline agents stop it. Some adrenaline agents for persons with AA and EDS include:

• Phentermine

• Adderall

• Phendimetrazine

• Methylphenidate

• Dexedrine

• Modafinil  

Every person with intractable pain due to AA, EDS, RSD, cancer or other painful disease, should educate themselves on adrenaline agents and discuss them with their medical practitioners in order to either lower their opioid dosage or keep it from escalating.   

Simply stated, a person with intractable pain needs at least a small dose of an adrenaline agent for pain relief and optimal function. 

Forest Tennant, MD, MPH, DrPH, has retired from clinical practice but continues his groundbreaking research on the treatment of intractable pain and arachnoiditis. This column is adapted from a bulletin recently issued by the Arachnoiditis Research and Education Project of the Tennant Foundation, and is republished with permission. Correspondence should be sent to veractinc@msn.com.  

Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

Does Discrimination Cause Blacks to Feel More Pain?

By Pat Anson, PNN Editor

Racial and ethnic bias is a fact of life that impacts almost every aspect of our society – and healthcare is no exception. Research has shown that African-Americans are more likely to be undertreated for pain compared to white Americans, and that blacks are less likely to be prescribed opioid pain medication than whites.

Part of that stems from a false belief that there are biological differences between blacks and whites that cause African-Americans to feel less pain.

New research published in the journal Nature Human Behaviour disputes that stereotype, suggesting that African-Americans experience more pain due to the lasting effects of discrimination and other stressful life experiences.

In a small study led by researchers at the University of Miami, 28 African-Americans, 30 Latinos and 30 whites were subjected to a series of painful heat tests on their forearms while undergoing MRI brain scans.

The African-Americans not only rated their pain more intense and unpleasant than the other two groups, but the MRI’s found that the parts of their brains that process pain signals became more active than their counterparts’ as the temperature of the heat probes increased.

“There's evidence that both the general public and clinicians believe that African Americans are less sensitive to pain than non-Hispanic whites; yet research, including our own, shows exactly the opposite." said lead author Elizabeth Losin, PhD, an assistant professor of psychology at the University of Miami.  "Minorities, particularly African Americans, actually report more pain."

Losin began her research eight years ago while at the University of Colorado, recruiting volunteers in the Denver area. In addition to the heat tests and MRI scans, all participants completed questionnaires about various aspects of their lives, including unfair social treatment, discrimination and their trust in doctors.

Using the MRI brain scans, Losin and her colleagues identified two areas of the brain, the ventral striatum and ventromedial prefrontal cortex, which responded to pain more strongly in African Americans than the other two groups. Prior research has found that these two brain regions also respond more to pain signals in chronic pain patients.

“Our findings suggest that the link between chronic pain and ethnic differences in pain sensitivity may lie in the chronic stress associated with discrimination. Discrimination has been consistently associated with chronic stress and other adverse health outcomes in AA (African Americans) and other minority groups,” Losin wrote.

“It is also plausible that the higher pain sensitivity we and others have observed in AA compared to WA (White Americans) participants may be related to previous negative experiences with medical care in particular, which are more common in AA compared to non-Hispanic WA populations.”

Previous studies have found that childhood trauma, domestic violence and other stressful life situations can also increase the likelihood of chronic pain – so this new research does not prove that discrimination alone contributes to the increased risk of pain. Nevertheless, it lays the groundwork for future studies on the relationship between pain and discrimination.

"These findings exemplify how neuroimaging is teaching us that there are multiple contributions to pain," said co-author Tor Wager, PhD, a professor of neuroscience at Dartmouth College. "We need to consider the broader psychological and cultural setting when we think about what is underlying pain and how to address it."

Losin is continuing her research by studying the relationship between patients' trust in their doctors and their experience with pain.

"It's a common misconception that any difference you see between groups of people must be an intrinsic difference, rooted in our biology. But the differences we found in this study were related to people's life experiences," she said. "It reaffirms our similarities and provides hope that racial and ethnic disparities in pain can be reduced."

Current and Former Smokers Have More Pain

By Pat Anson, PNN Editor

There are many good reasons to stop smoking. Within hours, your heart rate and blood pressure will drop, you’ll cough less and feel more energy. Within a few months your lung function will start to improve. And after 20 years, your risk of dying from lung disease or cancer will be about the same as someone who never touched a cigarette.

Unfortunately, one thing that may not improve is your pain. According to a large new study in the UK, former smokers report higher levels of pain than people who never smoked, and their pain levels are similar to people who still continue to smoke.

Researchers at University College London (UCL) analyzed health data from over 220,000 people in the UK who were asked to report how much pain they experienced during the previous 4 weeks and whether it interfered with their work.  

After adjusting for other health factors such as anxiety and depression, current and former daily smokers were more likely to report bodily pain compared to people who never smoked. The difference was small, but considered significant. Surprisingly, the association between smoking and pain was highest in the youngest group of smokers (aged 16 to 34).

The study was observational and did not establish a cause-and-effect relationship between smoking and pain. But researchers say their findings, published in the journal Addictive Behaviors, suggest that regular smoking at any age results in more pain.

“We cannot rule out that there is some other difference between former smokers and never smokers that is causing these surprising results, but we have to consider at least the possibility that a period of daily smoking at any time results in increased pain levels even after people have stopped smoking,” said lead author Olga Perski, PhD, a research associate in UCL’s Department of Behavioural Science & Health.

“This may be due to negative effects of smoking on the body’s hormonal feedback loops or undiagnosed damage to body tissues. This is certainly an issue that needs looking into.” 

Another possibility is differences in personality. People who take up smoking may handle the psychological stress of illness differently than non-smokers or have a lower level of pain tolerance, which makes them feel pain more acutely. A large study in Norway, for example, found that smokers and former smokers were more sensitive to pain than non-smokers, who had a higher pain tolerance.

Regardless of the reason, smoking is linked with many negative health consequences.

“The possibility that smoking may increase lifelong pain is another important reason not to take up smoking in the first place,” said Perski.

Studies have also found that smoking increases your chances of having several types of chronic pain conditions, such as degenerative disc disease.

A 2011 study of over 6,000 Kentucky women found that those who smoked had a greater chance of having fibromyalgia, sciatica, chronic neck pain, chronic back pain and joint pain than non-smokers. Women in the study who smoked daily more than doubled their odds of having chronic pain.

Research Links Auto Plant Closures to Opioid Overdoses

By Pat Anson, PNN Editor

A new study is adding to the growing body of evidence linking the opioid crisis to unemployment, depression, suicide and declining economic opportunities – the so-called epidemic of despair.

Researchers at the Perelman School of Medicine at the University of Pennsylvania and Massachusetts General Hospital looked at the closure of automotive assembly plants in the U.S from 1999 to 2016, primarily in the Midwest and Southeast. They found that opioid overdoses rose significantly in 29 counties where an auto plant shutdown.

Five years after the plants closed, opioid overdose rates among adults were 85 percent higher in counties where closures occurred compared to 83 counties where plants remained open.

"Major economic events, such as plant closures, can affect a person's view of how their life might be in the future. These changes can have a profound effect on a person's mental well-being, and could consequently influence the risk of substance use," said lead author Atheendar Venkataramani, MD, an assistant professor of Medical Ethics and Health Policy.

"Our findings confirm the general intuition that declining economic opportunity may have played a significant role in driving the opioid crisis."

The findings are published in JAMA Internal Medicine.

JAMA INTERNAL MEDICINE

The demographic group with the biggest increase in opioid overdose deaths after an auto plant closure was non-Hispanic white men between 18-34 years old, followed by non-Hispanic white men ages 35-65 years old. Opioid overdose rates also increased among young non-Hispanic white women.

Death rates involving heroin and other illicit opioids were higher for young white men and women than for prescription opioids, while older white men were more likely to die from prescription opioids.

"While we as clinicians recognize and take very seriously the issue of overprescribing, our study reinforces that addressing the opioid overdose crisis in a meaningful way requires concurrent and complimentary approaches to diagnosing and treating substance use disorders in regions of the countries hardest hit by structural economic change," Venkataramani said.

“Our findings should not be interpreted in such a way as to diminish the role of opioid supply, either from physician prescriptions or from illicitly made and supplied synthetic substances, in the US opioid overdose crisis.”

Princeton researchers Anne Case and Angus Deaton were the first to suggest in 2015 that the declining life expectancy of Americans was not caused by drug abuse alone, but linked to unemployment, poor finances, lack of education, divorce, depression and loss of social connections. They estimate that nearly half a million white Americans died due to a quiet epidemic of pain, suicide, alcohol abuse and opioid overdoses.

The epidemic of despair has also been cited as one of the reasons for the election of Donald Trump and for a “syndemic” of overdoses occurring in counties where the opioid crisis first erupted, particularly in mid-sized cities in Kentucky, Ohio and West Virginia. 

Humidity and Wind Affect Pain Levels, But Rain Doesn’t

By Pat Anson, PNN Editor

Many people with chronic pain strongly believe that rainy or cold weather aggravates their pain. Some even believe they can predict the weather based on their pain levels. 

But the results of a long-term study in the UK – recently published in the journal Digital Medicine -- show that weather conditions have only a modest effect on pain.

Researchers at the University of Manchester led a 15-month study of over 2,600 UK residents who recorded their daily pain levels with a smartphone app. The results were then compared with local weather conditions, based on the GPS locations of the participants’ phones.

Contrary to popular belief, rainfall was not associated with more pain. Results from the Cloudy with a Chance of Pain study showed that humid days were most likely to be painful, followed by days with low atmospheric pressure and strong winds. But the overall effect was modest, even when all three conditions were present.

“The analysis showed that on a damp and windy days with low pressure the chances of experiencing more pain, compared to an average day, was around 20%. This would mean that, if your chances of a painful day on an average weather day were 5 in 100, they would increase to 6 in 100 on a damp and windy day,” said lead author Will Dixon, PhD, Professor of Digital Epidemiology at the University of Manchester.

Dixon and his colleagues believe the study could be used to develop a “pain forecast” for people with chronic pain.

“This would allow people who suffer from chronic pain to plan their activities, completing harder tasks on days predicted to have lower levels of pain. The dataset will also provide information to scientists interested in understanding the mechanisms of pain, which could ultimately open the door to new treatments,” Dixon said.  

A 2017 study by Australian researchers at The George Institute for Global Health also found that damp weather increases pain. But because the symptoms disappeared as soon as the sun came out, researchers believe they could be influenced by psychological factors, not the weather itself. Previous studies on back pain, osteoarthritis and weather at The George Institute had similar findings.

The Greek philosopher Hippocrates in 400 B.C was one of the first to note that changes in the weather can affect pain levels. Although a large body of folklore has reinforced the belief that there is a link between weather and pain, the science behind it is mixed.

Do Selfless People Feel Less Pain?

By Pat Anson, PNN Editor

Are you selfless? Do you show concern for other people and take an interest in their well-being?

If the answer is yes, then your brain may be hardwired to feel less pain than people who tend to act more selfishly.

That’s the conclusion of a novel study conducted at China’s Peking University, where researchers performed MRI brain scans on nearly 300 people to learn about the biological reasons for altruistic behavior. They wanted to know why “performers” act selflessly in a crisis – such as food shortages or a natural disaster – even when there may not be a direct or indirect benefit from helping others.  

Their findings, published in the journal Proceedings of the National Academy of Sciences, showed that selfless behavior reduced activity in regions of the brain that process pain signals.  

“Our research has revealed that in adverse situations, such as those that are physically threatening, acting altruistically can relieve unpleasant feelings, such as physical pain, in human performers of altruistic acts from both the behavioral and neural perspectives,” wrote lead author Yilu Wang. “Acting altruistically relieved not only acutely induced physical pain among healthy adults but also chronic pain among cancer patients.”

Altruistic behavior has long been cherished in human society because it enables group members to collectively survive earthquakes, famines, floods and other crises. However, behaving selflessly also puts people at risk because it means giving away food, shelter and other resources.  

The MRI findings shed light on this paradox – and the psychological and biological mechanisms behind selfless behavior. 

“Engaging in altruistic behaviors is costly, but it contributes to the health and well-being of the performer of such behaviors,” Wang said. “Our findings suggest that incurring personal costs to help others may buffer the performers from unpleasant conditions.

“Whereas most of the previous theories and research have emphasized the long-term and indirect benefits for altruistic individuals, the present research demonstrated that participants under conditions of pain benefited from altruistic acts instantly.”

Heroic behavior isn’t necessary to reduce pain. Sometimes all it takes is a little empathy. 

According to a small 2017 study, just holding hands can reduce pain levels. Researchers found that when a woman was exposed to mild heat pain, her pain levels dropped when she held hands with a male partner. The more empathy the man showed, the more her pain subsided.     

Minorities in Oregon Less Likely to Get Emergency Pain Care

By Pat Anson, PNN Editor

Oregon’s treatment of chronic pain patients came under fire this year when state health officials drafted a controversial plan to forcibly taper thousands of Medicaid patients on long-term opioid therapy. The proposal was scaled back after nationwide criticism from patient advocates and pain management experts, who said it would “exacerbate suffering for thousands of patients.”

Minorities in Oregon needing emergency treatment for pain may also be suffering unnecessarily, according to a new study by Portland State University researchers.

"We found evidence that the odds of receiving a lower quality of care from EMS providers are higher among racial minorities in Oregon, when compared to white patients in Oregon, after experiencing traumatic and painful injuries," said Jamie Kennel, a PhD student and lead author of the study published in the journal Medical Care.

PSU researchers analyzed nearly 26,000 health records of patients who received emergency care for traumatic injuries in Oregon between 2015 and 2017.

Only about one in five white patients received opioids or other types of pain medication from EMS responders in Oregon. But the odds were 32% lower for black patients, 24% lower for Asian patients and 21% lower for Latino patients. This was despite the fact that black and Latino patients reported higher average pain scores than white patients.

ODDS OF GETTING EMS PAIN MEDICATION

• White Patients 20.1%

• Latino Patients 17.2%

• Asian Patients 14.2%

• Black Patients 13.9%

"This is very large, concerning and should be motivating for change," said Kennel. "Like most healthcare providers, EMS providers don't desire to provide inequitable healthcare but often have never been exposed to evidence suggesting these disparities are taking place."  

The researchers also found that Asian and Latino patients were less likely to have their pain assessed – a simple procedure in which patients are asked to rate their pain on a scale of zero to 10.

While previous studies have found racial and ethnic disparities in medical care, this was the first to look at both pain assessment and pain medication during emergency care in a large statewide database. Researchers did not look at what caused the inequities in pain treatment, but speculated that racial stereotypes and difficulty in communicating with patients with limited English played a role.

“Although it has been shown conclusively that there are no medically significant biological differences between individuals of different races/ethnicities, there is evidence that medical providers nevertheless believe race/ethnicity to be a medically relevant factor and may be adjusting their clinical actions accordingly,” researchers concluded.  

"We hope that, when exposed to this new evidence, individual EMS providers will work with their agencies to better understand, and take steps to mitigate, this phenomenon in their community." 

A large 2016 study found that black patients who visit hospital emergency rooms are significantly less likely to receive opioid prescriptions than white patients. Opioids were prescribed for blacks at about half the rate for whites with back and abdominal pain.

Another large study of VA patients found that African-Americans on long-term opioid therapy were more likely to be drug tested and significantly more likely to have their opioid prescriptions stopped if an illicit drug was detected.

How to Avoid the Holiday Blues

By Pat Anson, PNN Editor

For many of us, the holiday season wouldn’t be complete without Christmas cookies, jelly donuts, plum pudding, chocolate babka, or even the much-maligned fruit cake.

But if you're prone to depression or have an inflammatory condition, you might want to avoid those sweet treats. Or at least enjoy them in moderation.

New research by clinical psychologists at the University of Kansas suggests that dietary sugars found in many holiday foods can trigger metabolic, inflammatory and neurobiological processes that can lead to insomnia, digestive problems and depression – which all enhance physical pain.

"A large subset of people with depression have high levels of systemic inflammation,” said lead author Stephen Ilardi, PhD, an associate professor of clinical psychology at KU. "When we think about inflammatory disease we think about things like diabetes and rheumatoid arthritis - diseases with a high level of systemic inflammation. We don't normally think about depression being in that category, but it turns out that it really is.

“We also know that inflammatory hormones can directly push the brain into a state of severe depression. So, an inflamed brain is typically a depressed brain. And added sugars have a pro-inflammatory effect on the body and brain."

Depression Causes Sugar Cravings

Dwindling daylight in winter can worsen depression and prompt people to consume more sweets, which provide a temporary emotional lift.

"One common characteristic of winter-onset depression is craving sugar," Ilardi said. "So, we've got up to 30% of the population suffering from at least some symptoms of winter-onset depression, causing them to crave carbs - and now they're constantly confronted with holiday sweets.

"When we consume sweets, they act like a drug. They have an immediate mood-elevating effect, but in high doses they can also have a paradoxical, pernicious longer-term consequence of making mood worse, reducing well-being, elevating inflammation and causing weight gain."

The KU research team analyzed a wide range of studies on the physiological and psychological effects of sugar, including the Women's Health Initiative study, the NIH-AARP Diet and Health Study, and studies of Australian and Chinese soda-drinkers. Their research is published in the journal of Medical Hypotheses.

Ilardi says consuming high amounts of sugar could be as physically and psychologically harmful as drinking too much liquor.

"We have pretty good evidence that one alcoholic drink a day is safe, and it might have beneficial effect for some people," Ilardi said. "Alcohol is basically pure calories, pure energy, non-nutritive and super toxic at high doses. Sugars are very similar."

The average American gets about 14% of their calories from added sugars – the equivalent of 18 teaspoons of sugar each day. Most people know a high-sugar diet can lead to diabetes, obesity and cardiovascular problems.

Another way to look at sugar is to think of it as fuel for bacteria.  

"Our bodies host over 10 trillion microbes and many of them know how to hack into the brain," Ilardi said. "The symbiotic microbial species, the beneficial microbes, basically hack the brain to enhance our well-being. They want us to thrive so they can thrive.

“But there are also some opportunistic species that can be thought of as more purely parasitic - they don't have our best interest in mind at all. Many of those parasitic microbes thrive on added sugars, and they can produce chemicals that push the brain in a state of anxiety and stress and depression. They're also highly inflammatory."

Ilardi recommends eating a minimally processed diet rich in fruits, vegetables, fish and whole grains, while avoiding red meats, refined grains, fructose and other unhealthy foods. As for sugar, the KU researcher urges moderation -- not just during the holidays, but year-round.