Acetaminophen Ineffective for Back Pain

By Pat Anson, Editor

The world’s most widely used over-the-counter pain reliever is ineffective in treating low back pain and provides little benefit to people with osteoarthritis, according to a new study published in the British Medical Journal.

In a systematic review of a dozen research reports (a study of studies), Australian researchers also questioned many of the conventional treatments for back pain and other musculoskeletal conditions.

Acetaminophen -- also known as paracetamol – is the active ingredient in Tylenol, Excedrin, and hundreds of other pain medications. It is often recommended by doctors worldwide for back pain and osteoarthritis.

"Clinicians should carefully weigh benefits and harms when making treatment decisions. Paracetamol is not efficacious and potentially harmful. In this context we cannot justify its continued use for these prevalent diseases,” said Professor David Hunter of the University of Sydney.

The researchers found “high quality” evidence showing that patients taking acetaminophen are at greater risk of liver toxicity and nearly four times more likely to have abnormal results from liver function tests.

"World-wide, paracetamol is the most widely used over-the counter medicine for musculoskeletal conditions so it is important to reconsider treatment recommendations given this new evidence," said lead author, Gustavo Machado of The George Institute and the University of Sydney.

Low back pain is the leading cause of disability worldwide, and osteoarthritis of the hip or knee is the 11th highest contributor to global disability.

"This latest research, the most comprehensive systematic review of its kind, reaffirms this with an even larger, global patient base, and has for the first time also established that the effects of paracetamol for knee and hip osteoarthritis are too small to be of clinical importance." said senior author Manuela Ferreira of the George Institute for Global Health and the University of Sydney.

"We urgently need to take stock of the evidence for common musculoskeletal conditions, a largely under-recognized health priority, and make sure people are receiving appropriate care."

Treatments known to be effective for low back pain include counseling, physical therapy, exercise and psychological therapies such as cognitive behavioral therapy.

Aerobic exercise, strengthening exercise, weight management and anti-inflammatory medicines have been shown to provide benefit for patients with lower limb osteoarthritis.

A recent study published in The Lancet found that acetaminophen had no effect on pain, disability, function, sleep quality, or quality of life for people with low back pain.

Over 50 million people in the U.S. use acetaminophen each week to treat pain and fever. The pain reliever has long been associated with liver injury and allergic reactions such as skin rash. In the U.S. over 50,000 emergency room visits each year are caused by acetaminophen, including 25,000 hospitalizations and 450 deaths.

Study Claims 10% of Pain Patients Addicted to Opioids

By Pat Anson, Editor

Estimating rates of opioid abuse and addiction has never been easy. Dozens of different studies have come to startling different conclusions, and there is even disagreement over the definition of abuse and addiction.

Now a professor at the University of New Mexico is weighing in on the subject -- and his conclusions are likely to stir even more debate.

In a systematic review of 38 research reports (a study of studies) published in the journal PAIN, lead author Kevin Vowles and his colleagues estimate that up to 30 percent of the opioids prescribed for pain are misused and that about 10 percent of pain patients are addicted to them.

They also question whether opioids should be prescribed at all for chronic pain.

“It is not clear whether the risks of opioid use outweigh the potential for benefit. The efficacy of opioids and their suitability for the long-term management of chronic pain still remain very much in question and while this uncertainty in effectiveness is well established, it stands in somewhat stark contrast to the clinical reality of chronic pain treatment, where rates of prescriptions have skyrocketed such that opioids are now among the most frequently prescribed medications,” wrote Vowles.

“We are not certain whether the benefits derived from opioids, which are rather unclear based on the extant literature, compensate for this additional burden to patients and health care systems.”

The researchers noted there was extremely wide variation in the rates of opioid misuse and addiction in the studies they analyzed. Rates of “problematic use” ranged from less than 1% all the way up to 81%.

One study -- a review of 25 research reports – left the barn door wide open by broadly estimating the “prevalence of problematic opioid use behavior” at 0% to 50% of pain patients.

“The vagueness inherent in these definitions, areas of overlap among them, and their sometimes interchangeable use have made it difficult to determine exact rates and types of problematic opioid use,” conceded Vowles.

Exactly what constitutes opioid misuse is also debatable.

Vowles defined misuse as “opioid use contrary to the directed or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects.” Such a definition means a patient who has stopped using a prescribed opioid – even if they no longer have pain – is misusing the medication.

(Several years ago this writer was sent home from the hospital after surgery with a two week supply of Vicodin. Fortunately, the surgery was successful and the pain subsided after a few days. A half empty bottle of Vicodin sat unused in my medicine cabinet for years before I had sense enough to throw it out. Under Vowles’ definition, I had “misused” the Vicodin.)

Studies by some of the nation’s largest drug screening companies consistently show that many Americans don’t take the drugs that are prescribed for them. A large study by Quest Diagnostics found that 60% of Americans failed to take a medication as prescribed by their physicians and that 42% had no drugs in their system. Should they be included in estimates of misuse?

Rates of addiction in the studies analyzed by Vowles also varied greatly – from 0.7% of pain patients up to 34.1%.

An adjusted analysis by Vowles estimated the average rate of addiction at 8% to 12% -- a figure nearly double the estimate of the National Institutes of Health (NIH). According to the NIH, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.

“Misuse, abuse and addiction mean different things to different researchers,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine and vice president of scientific affairs at PRA Health Sciences.

“We must keep in mind that behaviors determine the diagnoses of misuse, abuse and addiction and these behaviors are subjective interpretations. Subjective interpretations are influenced by one's biases and perspective.  Misuse to one researcher can be addiction to another. Unfortunately there has not been a standard interpretation of behaviors and I doubt there ever will be due to personal beliefs about opioids and addiction.”  

While Webster doesn’t take issue with the design of the study – he does dispute the overall conclusion that the risks of opioid abuse outweigh the benefits.  

“It is undoubtedly true that some people should not be prescribed opioids.  But even using their reported averages for abuse and addiction, a majority of people do not abuse or become addicted and therefore shouldn't necessarily be denied treatment particularly if there is no other option,” Webster wrote in an email to Pain News Network. 

Ironically, only one study analyzed by Vowles even looked at the recreational abuse of opioids – perhaps the biggest contributor to the so-called “epidemic” of prescription drug abuse in the U.S.  That study estimated the rate of abuse by pain patients at just 8% -- far below their estimated rates of misuse.

Vowles admits there are several limitations to his study.

“The most obvious is the degree of variability within this literature. In spite of our attempts to minimize the impact of this variability, the range of misuse and addiction was incredibly broad,” he wrote.

“These sources of variability will likely continue to cloud our ability to make precise estimates. There is clearly room here for a series of carefully controlled studies where sources of variability are held constant, or as constant as possible, to more clearly illuminate prevalence rates of problematic opioid use in individuals with chronic pain.”

Knee Osteoarthritis Raises Risk of Early Death

By Pat Anson, Editor

Osteoarthritis is painful no matter where it occurs – in the hip, fingers, elbow or other joints. But osteoarthritis of the knee seems to be particularly troublesome for middle-aged women. 

British researchers say knee osteoarthritis significantly raises the risk of cardiovascular disease and can even lead to early death.

In a study of early mortality in middle-aged women with osteoarthritis, researchers looked at data collected by the Chingford Study, which followed the health over 1,000 British middle-aged women for over two decades.

They found that osteoarthritis of the knee was strongly associated with early overall death and cardiovascular mortality. Women with knee pain and radiographic osteoarthritis had almost two times greater risk of early death and over three-times increased risk of dying from a cardiovascular event, when compared with women without knee pain or osteoarthritis. 

No link was found between hand osteoarthritis and a higher risk of mortality. 

“These findings suggest that any self-reported knee pain in osteoarthritis, as opposed to hand pain, seems to be a crucial factor leading to early cardiovascular mortality and is likely to be linked with decreased mobility. Radiographic osteoarthritis without pain is not affecting long-term mortality. More research is needed to understand how people adapt to knee pain, and how this leads to cardiovascular impairment,” said lead author Stefan Kluzek, PhD, of the Arthritis Research UK Centre of Excellence for Sport, Exercise and Osteoarthritis at the University of Oxford.

Researchers did not examine the reasons for the higher death rate, but an earlier look at data from the Chingford study found that women with knee OA were more likely to have hypertension, raised blood glucose, and moderately raised serum cholesterol.

Osteoarthritis is a joint disorder that leads to thinning of cartilage and progressive joint damage. Knee osteoarthritis is quite common and affects over 250 million people worldwide. Nearly 40 percent of Americans over the age of 45 have some degree of knee OA, and those numbers are expected to grow as the population ages.

A Pained Life: Depression is Allowed

By Carol Levy, Columnist

"You're depressed."

Friends say it. Family may say it. Sometimes doctors say it.

Well, duh. We live with pain for much of the day or all day long. It is hard not to be depressed!

Our lives have been changed in ways we never could have imagined. Pain is the boundary by which we live. Can I do this, go there, be with people, or work?

Pain is often the arbiter. I want to do something, but the pain tells me I can't.

How depressing. How sad.

Does that then mean we are psychiatrically ill? Does it mean that the pain is, as many of us have been told, "All in your head?"

I won't deny that for some patients the pain is psychosomatic or has a large psychological and emotional component. But for most of us the diagnosis is firm, the pain real and physical.

Interestingly and sadly however, MedicineNet.com and many other sources include this in their definition and description of what causes depression: “Chronic pain that does not respond to treatment.”

And yet when you click the link for "chronic pain" they do not refer to it being psychosomatic or having psychosomatic causes.

How many of us continue with treatments, procedures, and surgeries despite a lack of benefit? Does that automatically translate into psychogenic origin?

The questions arise. Did depression cause my pain? Would my illness not have appeared if I wasn’t depressed? Is that answerable? Would an answer matter?

What I do know is that depression carries with it not only a feeling of persistent sadness, but feelings of hopelessness and helplessness.

And how can we not feel hopeless, and helpless, when at one time or another most of us hear these kinds of statements from our doctors:

"There is no cure. You’ll have to learn to live with it.”

“I don't have an answer for why you have the pain you do.”

“There is nothing left to try.”

I remember being upset the first time I was prescribed an antidepressant. My doctor had to reassure me, "No, Carol. These drugs can work on the pain. I am not giving it to you because I doubt your pain is real."

Whether we have depression arising from pain or depression causing our pain to appear, it is worth trying to deal with it, through counseling and maybe medication too.

I often hear people with chronic pain ask if their shortness of breath, weakness, insomnia, etc. could be related to the fibromyalgia, back pain, neuropathy or whatever condition they suffer from.  It is easy to think that all our physical changes and complaints come from our diagnosed illnesses. It is harder to see past what we know we have.

I think the same is true for depression. Even if we get relief from pain, the depression may still be there.

It is incumbent on doctors -- and us -- to accept that a psychological issue and diagnosis may exist separate and distinct from our chronic pain.

It is important that our psychological state be seen as equally important, worthy, and possibly separate from our chronic pain. And we need to allow ourselves the acceptance of a dual diagnosis, even if it is a psychological one.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” 

Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

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

Racial Disparities Found in Joint Replacement Surgery

By Pat Anson, Editor

Black, Hispanic and Medicaid patients are significantly more likely to be readmitted to the hospital after total joint replacement (TJR) surgery, while women are less likely to suffer complications, according to new studies presented at the annual meeting of the American Academy of Orthopaedic Surgeons in Las Vegas.

In one study, researchers analyzed race and ethnic data on nearly 53,000 patients admitted to Connecticut hospitals for TJR from 2008 to 2012. The average patient was 67 years of age, white, female and covered by Medicare.

Patients who were African-American were 62% more likely to be readmitted to the hospital within 30 days of TJR. Hispanic patients were 50% more likely and Medicaid patients were 40% more likely to be readmitted than patients with private insurance.

"Our study shows that black patients who undergo total knee replacement may have poorer outcomes," said lead study author and orthopedic surgeon Courtland Lewis, MD. "After controlling for two key variables implicated in race and ethnic disparities in hospital readmission -- preoperative comorbidities and type of insurance coverage -- black patients still have a 35 percent higher likelihood of all-cause, 30-day readmission compared to white patients.”

Lewis said the disparity with white patients may be due to black patients having less access to primary care and less communication with health care providers.

Racial disparities in health care have long been documented, including that black patients utilize hip and total knee replacement at rates nearly 40 percent less than white patients, despite having higher rates of osteoarthritis—a leading cause of joint deterioration. Total hip and knee replacements are common surgical treatments for late-stage arthritis.

The overall 30-day readmission rate for patients in the study was about 5 percent. The most common reasons for readmission were postoperative infection, inflammatory reaction due to a joint prosthesis, hematoma complications, and dislocation of a prosthetic joint.

A second study looked at nearly 60,000 knee and hip replacements at a hospital in Ontario, Canada. Researchers found that men were 15% likely than women to return to the emergency department within 30 days of TJR surgery – even though women who had the surgery were older and more likely to be frail. Over half the patients in the study were women.

The findings contradict the theory that TJR is underutilized in female patients because they have worse outcomes then men.

"Despite the fact that women have a higher prevalence of advanced hip and knee arthritis, prior research indicates that North American women with arthritis are less likely to receive joint replacement than men," said lead study author Bheeshma Ravi, MD, an orthopaedic surgery resident at the University of Toronto. "One possible explanation is that women are less often offered or accept surgery because their risk of serious complications following surgery is greater than that of men.

"In this study, we found that while overall rates of serious complications were low for both groups, they were lower for women than for men for both hip and knee replacement, particularly the latter" said Dr. Ravi. "Thus, the previously documented sex difference utilization of TJR cannot be explained by differential risks of complications following surgery." 

Men in the study were found to be up 70 percent more likely to have a heart attack within three months of TJR surgery and 70 percent more likely to have an infection or require revision surgery within two years of a total knee replacement.

Depression and Obesity Raise Risk of Low Back Pain

By Pat Anson, Editor

Depression, obesity, smoking, and alcohol use significantly raise the risk of having low back pain, according to a large new study presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

“The results were pretty surprising to us. We kind of expected to find a significant difference but not to that extent,” said lead study author and orthopedic surgeon Scott Shemory, MD.

Shemory and his colleagues at Summa Health and the Crystal Clinic Orthopedic Center in Akron, Ohio reviewed the health records of over 26 million patients from 13 health care systems in the U.S. Of those 26 million patients, 1.2 million were diagnosed with lower back pain.

Researchers then analyzed the records to see if the patients with low back pain had any of the four modifiable risk factors: obesity, depressive disorders, alcohol and tobacco use.

• 19.3% of low back pain patients were depressed
• 16.75% were obese with a body mass index (BMI) over 30
• 16.53% were nicotine dependent.
• 14.66% abused alcohol

The study did not address the “chicken and egg question” of which came first. Do depression and obesity cause low back pain, or does low back pain lead to depression, obesity and other risk factors?

“With our study there was no way to determine the cause and the effect or which came first because there was so much overlap,” Shemory told Pain News Network.

“Especially with alcohol abuse and depressive disorders. Anybody who’s got low back pain for years and years, I don’t think it would be surprising that they would have a higher chance of depression or alcohol abuse.”

Regardless of which came first, Shemory says patients should take steps to improve their health by eliminating risk factors that they can control.

“If a patient has any of these risk factors and has low back pain that doesn’t have a neurogenic cause, like a pinched nerve or something like that, I would be counseling them on trying to control these risk factors, not just for their general health but their back pain and livelihood as well,” he said.

According to the National Instituteof Neurological Disorders and Stroke, about 80 percent of adults experience low back pain at some point in their lives. It is the most common cause of job-related disability and a leading contributor to missed work days. One large survey found that over a quarter of adults reported having low back pain during the past 3 months.

Accepting Chronic Pain: Is it Necessary?

By Jennifer Martin, Columnist

A patient of mine told me the other day, “I don’t think I will ever be able to accept my chronic pain. It has completely changed my life.” 

I think this is something that most people with chronic pain contend with at some point in time; wanting to hold onto hope that their diagnosis isn’t chronic or not wanting to come to the realization that they will have to live with the pain forever.

When most people hear the word “acceptance” they equate it with the notion that they should feel that it’s okay or it’s alright to have a chronic condition.  Many people don’t ever feel okay about having to live with pain or an illness for the rest of their lives. It is not something that is easy to get used to and it’s not fair.

• Accepting chronic pain does not mean giving into it and it doesn’t mean that you stop looking for treatment.
• Accepting chronic pain does not mean accepting a lifetime of suffering.
• Accepting chronic pain does not mean you are never allowed to feel angry or sad.
• Accepting chronic pain does not mean that you have to give up hope for the future.

When I use the word “acceptance,” I mean accepting the reality of your situation and recognizing that this new reality could be permanent. Those of us with chronic conditions may never like this reality and it may never be okay, but eventually it is necessary to accept it and learn to live life with it. It is the new norm with which we must learn to live.

Acceptance also involves making adaptations and alterations to our lives.  We must find new things that bring us joy and we must have hope for the future.

• Accepting chronic pain means learning to live again.
• Accepting chronic pain means advocating for ourselves and our health so that we can be as healthy as possible.
• Accepting chronic pain means learning our limits and learning to cope with feelings of guilt when we have to say “no.”
• Accepting chronic pain means being able to look at your diagnosis as something you have, not who you are.  Your condition does not define you.
• Accepting chronic pain means re-evaluating your role as a husband/wife, mother/father, etc. as well as your life’s goals -- and figuring out how you can maintain these roles and attain your goals with your chronic condition.

For many of us, learning to accept our chronic condition isn’t easy.  It is a learning process with a lot of ups and downs.  It is something we may resist and something we may think impossible.  It is difficult to accept something that has completely changed our lives and possibly the direction we thought our life was going to take.

Why is it necessary to accept your chronic condition?

Once you are diagnosed with a chronic condition, it will be always be with you.  The sooner you are able to begin the process of acceptance, the sooner you will be able to learn exactly how to live with it.  It is also how you will learn to cope.

Accepting chronic pain means learning to live life in a different way than before your diagnosis.  It means learning to pace your activities, educating yourself, taking your medications, advocating for yourself, and surrounding yourself with support.  It also means accepting that some aspects of your condition are out of your control. 

Chronic pain can be unpredictable.  There may be days when you feel in control of your pain and you are able to accomplish everything you would like to.  There may also be days when your pain is unbearable, you feel angry about your situation, and all you can do is rest.  Accepting your chronic pain means adjusting and adapting to the ways in which your life is different now that you may be living with this kind of unpredictability.

Your life may never go back to what it was prior to your chronic pain.  But that doesn’t mean you can’t live a happy, successful, hopeful life with pain.  Learning to accept your chronic pain can help you get there.

Jennifer Martin, PsyD, is a licensed psychologist in Newport Beach, California who suffers from rheumatoid arthritis and ulcerative colitis. In her blog “Your Color Looks Good” Jennifer writes about the psychological aspects of dealing with chronic pain and illness. 

Jennifer is a professional member of the Crohn’s and Colitis Foundation of America and has a Facebook page dedicated to providing support and information to people with Crohn’s, Colitis and Digestive Diseases, as well as other types of chronic pain.

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.

DEA Issues Fentanyl Alert

By Pat Anson, Editor

The U.S. Drug Enforcement Administration has issued a nationwide alert about the abuse and diversion of fentanyl – a potent opioid analgesic that recreational drug users are increasingly combining with heroin.

“Drug incidents and overdoses related to fentanyl are occurring at an alarming rate throughout the United States and represent a significant threat to public health and safety,” said DEA Administrator Michele M. Leonhart. “Often laced in heroin, fentanyl and fentanyl analogues produced in illicit clandestine labs are up to 100 times more powerful than morphine and 30-50 times more powerful than heroin.”

In the last two years, the DEA has seen a significant increase in fentanyl-related drug seizures, particularly in the northeast and California. While most of the seized fentanyl appears to be coming from illegal drug labs run by Mexican drug cartels, some of it is being diverted.

Over 6.5 million legal prescriptions for fentanyl were written in the U.S. in 2014, often in the form of transdermal patches used to treat chronic pain.

“Fentanyl patches are abused by removing the gel contents from the patches and then injecting or ingesting these contents. Patches have also been frozen, cut into pieces and placed under the tongue or in the cheek cavity for drug absorption through the oral mucosa. Used patches are attractive to abusers as a large percentage of fentanyl remains in these patches even after a 3-day use,” the DEA said in a statement. 

The DEA warning comes on the heels of another government report warning about a surge in heroin related deaths. This month the Centers for Disease Control and Prevention reported the death rate from heroin overdoses in the U.S. nearly tripled between 2010 and 2013. Over 8,200 Americans died of heroin overdoses in 2013.

The sharp increase in heroin deaths coincided with a crackdown on prescription drug abuse and pill mills dispensing painkillers. Some health officials have called opioids a “gateway drug” to heroin, and claimed pain patients are switching to heroin because it is now cheaper and easier to get – even though there is scant evidence to support that claim.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem. And in a 2014 study of urine drug screens collected from over 171,000 chronic pain patients, Ameritox says it detected heroin in just 1.3% of the samples.

“The initial entry of heroin was no doubt in response to the over-use of prescription opioids. Now it is occurring because of the influx of cheap heroin,” said Percy Menzies, president of Assisted Recovery Centers of America, which operates four addiction treatment clinics in the St. Louis, Missouri area.

“The two strongest factors contributing to addiction are price and access. Mexican farmers have lost their marijuana market in the U.S. and have switched to growing the poppies and these poppies are being converted into heroin by the drug cartels. This is immensely profitable and we are going to see a steep increase in heroin addiction as more and more heroin is smuggled into the U.S.

“The U.S. has to curb its appetite for prescription opioids and we have to find better treatments for chronic pain,” Menzies wrote in an email to Pain News Network. “To add insult to injury, the new avenue for using heroin is coming from the medications used to treatment opioid addiction - methadone and buprenorphine. The sale of buprenorphine formulations is around $2 billion and patients are using these medications to sustain their heroin addiction.

“Our addiction to opioids comes from three sources - prescription opioids, heroin and prescription opioids to treat opioid addiction. Until we drastically curtail these three sources, the addiction is going to be alive, well and thriving.”

Blood Test Could Detect Early Osteoarthritis

By Pat Anson, Editor

British researchers are close to developing a blood test that would detect osteoarthritis in its early stages, a development that could lead to diagnosis and treatment of the disease years before joint damage occurs.

Osteoarthritis is a progressive joint disorder caused by painful inflammation of soft tissue, which leads to thinning of cartilage and joint damage in the knees, hips, fingers and spine. The World Health Organization estimates that about 10% of men and 18% of women over age 60 have osteoarthritis.

Researchers at the University of Warwick’s Medical School have identified a biomarker linked to both rheumatoid and osteoarthritis. Diagnostic blood tests already exist for rheumatoid arthritis (RA), but the newly identified biomarker could lead to one which can diagnose both RA and osteoarthritis (OA).

“This is a remarkable and unexpected finding. It could help bring early-stage and appropriate treatment for arthritis which gives the best chance of effective treatment,” said lead researcher  Naila Rabbani, PhD.

“This discovery raises the potential of a blood test that can help diagnose both RA and OA several years before the onset of physical symptoms."

Rheumatoid arthritis is a chronic autoimmune disease in which the body’s own defenses attack joint tissues, causing swelling, inflammation and bone erosion. About 1% of adults worldwide suffer from RA.

Rabbani’s research focused on citrullinated proteins (CPs), a biomarker suspected to be present in the blood of people with early stage rheumatoid arthritis. It had previously been established that patients with RA have antibodies to CPs, but it was not thought that this was the same for those with OA.

However, the Warwick researchers found for the first time increased CPs levels in both early-stage OA and RA.

They then produced an algorithm of three biomarkers; CPs, anti-CP antibodies, and a bone-derived substance called hydroxyproline.

Using the algorithm the researchers found that with a single test they could potentially detect and discriminate between the two types of arthritis in their early stages, before joint damage has occurred. The test correctly identified 73% of the people with eary OA and 57% of the people with early RA.

“It has been long established that the autoimmunity of early-stage RA leads to antibodies to CPs, but the autoimmunity, and hence antibodies, are absent in early-stage OA. Using this knowledge and applying the algorithm of biomarkers we developed provides the basis to discriminate between these two major types of arthritis at an early stage,” said Rabbani.

“Detection of early stage-OA made the study very promising and we would have been satisfied with this only – but beyond this we also found we could detect and discriminate early-stage RA and other inflammatory joint diseases at the same.

The research is published online in Nature Scientific Reports.

My Life with Arachnoiditis

By Tom Bresnahan, Guest Columnist

Let me tell you briefly about my past before I describe the hell I live with every day.

Before moving to Florida in 2000, I owned and operated a 6 store Domino's Pizza franchise in Tacoma, Washington. I served as an elected fire commissioner, belonged to two search and rescue groups, and was trained and certified as a swift water rescue technician. As you can see, I'm no couch potato.

tom bresnahan

After selling my business and moving to Florida I decided to pursue a career in healthcare, something I had wanted to do for many years. I went back to school and received a degree in Radiological Technology.

While attending school I fell off of a roof, damaged my back, and required surgery. In 2003, I had a triple fusion of my lumbar region performed by a local orthopedic surgeon. Everything went well and I went on to work as cardiac catheter technician, a fast paced, adrenaline junkie’s dream job! I took a lot of calls and enjoyed the challenge of working with a team trying to save the life of someone having a heart attack. 

In 2009, I started to have sciatica pain in my right leg. It was interfering with my work, so I went back to the doctor who had performed my surgery. He suggested a series of epidural steroid injections. He said they were extremely safe and could eliminate my pain.

When I arrived for my first injection, I reminded the nurse to tell the doctor of the “outpouching” I had on my spinal cord. This is known as a pseudomeningoceale. It was caused when the doctor doing my first back surgery performed a laminectomy and didn't take the right steps to keep the pouch from forming. When I discovered this on an MRI and asked him about it, I was told that it was completely normal and that I shouldn't be concerned. 

The image on the right shows the pouch as a white mass on my spine.

The first steroid injection had no effect, so a few months later I went in for a second. Again I reminded the nurse about the outpouching. This message was never shared with the doctor, although he should have looked at my chart prior to the procedure.  The injection was given and within hours my pain became elevated. I called the doctor and was told this is normal and not to be concerned.

Over the next several days my pain increased, and it was difficult to concentrate and perform my job. I was seen again by the doctor and he scheduled a discogram, a test is to see if a disk is ruptured or torn. It is a very painful test. The results came back stating I had a torn disk above the level of my first surgery. The doctor said I would need another fusion. 

I went in for surgery on September 8, 2009. By then the pain was quite bad and I was looking for anything to give me some relief. After I was partially sedated the doctor came in and told my wife that this surgery would most likely not help with my pain. I was nearly out and she didn't know what to do, so in I went for what would be a totally unnecessary procedure. 

As the pain medication from surgery wore off, the pain was so bad it made me scream out loud. This went on for months! My wife took me to the ER and back to the doctor’s office, where I was told, “We don't know what’s wrong." 

I couldn't work and after being out for 90 days I was terminated. I was devastated that I was losing a job I loved and spending every moment in horrific pain.  I finally went to see a neurosurgeon who ordered a myelogram, an image of my spine that was performed at the hospital where I had worked.

The neurosuregon, who I had worked with on several occasions, did the test. Afterward he came into the recovery room and said, "Tom, you're screwed!" 

I laughed thinking he was joking. 

“You have a condition known as Adhesive Arachnoiditis,” the doctor told me. “You're going to be in pain the rest of your life!" 

I was shocked and couldn't believe this was happening. He told me the nerves within my spine were all clumped together. He said over time scar tissue would form and probably make the pain worse and cause things like bladder and bowel dysfunction. And there was no cure.

The test was done and I learned my fate on Dec 31, 2009. Happy New Year!   

Over the next few months I went through many medications, trying to get the pain under control. The drugs did very little to help. I also ordered copies of the dictations from all of the procedures I had done by my surgeon. On the dictation done for my last injection the surgeon stated, "I did get withdrawal so I repositioned the needle and did 4 injections.” 

The "withdrawal" was spinal fluid. He had punctured my spinal cord, yet continued to inject the steroid Depo-Medrol into my spine. When I confronted him at what was to be my last appointment, he told me, "You would have a hard time proving it!" 

Since that time I've been through the 5 stages of grief, with anger being the hardest to overcome.  I was determined to find a fix, but eventually realized there was none. 

I came close to ending my life on two occasions. My wife of 3 years told me, "I didn't sign up for this!" We divorced shortly after that. 

I have spent the last 2 years trying to effect a change and educating people on the dangers of epidural steroid injections. I have tried to help others with Arachnoiditis find medications, support and the faith to continue on each day.

I have a phrase that I tell those who feel the desire to end their pain and their life, "As long as we are breathing there is hope!" 

The pain has gotten worse over the last 2 years. I have had episodes of not being able to move my legs when I wake up in the morning. This alone will scare a person terribly! My legs go numb if I sit for more than 15 minutes.  The pain now extends into my arms and hands. 

Because this condition affects the nervous system I have developed an internal thermostat problem. I will feel cold and actually shiver in a room that is 76 degrees. At other times I will break into a sweat that's so bad I'm drenched within a few minutes, to the point that I have to change shirts. I can't tell you how many times I've lain in bed screaming because the pain is so bad. 

I have never in my life been one to take it easy, yet I've had people actually tell me, "It couldn't be that bad!" 

This is demoralizing, frustrating and depressing. Steroid injections are a band aid at best and the destroyer of life at worst. Please help us put a stop to these injections that are causing so many to suffer so much!

I want to thank you for taking the time to read my story. I pray every night that if we can stop anyone else from ending up with this hellish pain then I will feel that I have made a difference. 

Tom Bresnahan lives in Florida. He is a patient advocate and activist with the Arachnoiditis Society for Awareness and Prevention.

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.

Survey: Two-Thirds of Patients Unable to Get Hydrocodone

By Pat Anson, Editor

About two-thirds of pain patients say they were no longer able to obtain hydrocodone after the opioid painkiller was reclassified by the U.S. government from a Schedule III medication to a more restrictive Schedule II drug, according to the results of a new survey.

Many patients who had been taking hydrocodone at the same dose for years said their doctor would no longer prescribe the painkiller. Over a quarter (27%) said they had suicidal thoughts after being denied a prescription for hydrocodone.

The survey of over 3,000 patients was conducted online by the National Fibromyalgia & Chronic Pain Association (NFMCPA) and the findings presented this week at the annual meeting of the American Academy of Pain Medicine. An abstract of “Hydrocodone Rescheduling: The First 100 Days” can be found here.

Hydrocodone was rescheduled by the Drug Enforcement Administration in October of last year to combat an “epidemic” of prescription drug abuse. The rescheduling limits patients to an initial 90-day supply and requires them to see a doctor for a new prescription each time they need a refill. Prescriptions for Schedule II drugs also cannot be phoned or faxed in by physicians.

The reclassification quickly made a drug that was once the most widely prescribed pain medication in the country – at nearly 130 million prescriptions each year – to one of the hardest to get.

Other key findings of the survey:

• 88% of respondents believe the change to Schedule II denies pain patients the right to adequate pain care.
• 75% believe the change will not prevent prescription drug abuse.
• 72% believe the change is harmful to pain patients.
• 18% said it led to a "worsened relationship" with their doctor.
• 30% reported "issues" with their pharmacy filling prescriptions.

Patients also reported higher expenses due to increased doctor’s visits, higher co-pays, greater transportation costs to visit the doctor and multiple pharmacies, and lost income due to inability to work because of pain.

The survey is believed to be the first to report on the experiences of pain patients treated with hydrocodone since the rescheduling took effect. The respondents were overwhelmingly female, which reflects the demographics of fibromyalgia and many other chronic pain conditions.

Hydrocodone isn’t the first pain medication to be in short supply. A report released last month by the Government Accountability Office (GAO) faults the DEA for poor management and “weak internal controls” of the quota system under which controlled substances are produced and distributed.

Between 2001 and 2013, the GAO said there were 87 “critical” shortages of drugs containing controlled substances, over half of them pain relievers. The vast majority of drug shortages lasted over a month and some dragged on for years. An oral solution of oxycodone was difficult to obtain for eight and a half years.

“The shortcomings we have identified prevent DEA from having reasonable assurance that it is prepared to help ensure an adequate and uninterrupted supply of these drugs for legitimate medical need, and to avert or address future shortages. This approach to the management of an important process is untenable and poses a risk to public health,” the report states.

Patients Deserve to Know the Truth about Cymbalta

By Crystal Lindell, Columnist

Look, yes, Cymbalta probably saved my life. But it also sucks. So, I’m not surprised people are suing Eli Lilly, the makers of the drug. 

I can still remember talking to a nurse over the phone at the Mayo Clinic’s pain rehab program when she mentioned Cymbalta. It was the same pain program my insurance company would eventually deny, prompting the Mayo Clinic to ask for $35,000 up-front, and prompting me to laugh in their faces and instead buy a $7 Yoga DVD at Best Buy and hope for the best. 

Anyway, yeah, the nurse. She was all, “Oh! Cymbalta is a WONDERFUL drug! So many people love it! And it works so well! That’s a great drug to go on when you go off opioids!”  

But all I could think was, “Obviously you have never been on Cymbalta or opioids or had chronic pain, because Cymbalta sucks.”

I always tell people I was tricked into starting the drug. 

My doctor, whom I really do love, put me on it about a year and a half ago. He brought it up at my first appointment with him -- the same appointment I also decided to confess that I was having suicidal thoughts daily. He told me he was putting me on Cymbalta because it had been shown to help with pain. I’d later find out that was only half the reason. 

When I went to a follow-up appointment, the doctor asked if  Cymbalta had helped with my pain at all. And because my pain is stronger than the U.S. military, it hadn’t. But, then came the reveal. 

“Well, how’s your mood?” he asked, slowly.  

“Actually, better,” I replied, realizing that had been his secret plan all along. 

But you know what? I can sincerely tell you that I didn’t want to kill myself anymore. I mean, I still thought about it, but the drug had sort of diluted the thoughts, and made them less of a legitimate option and more of a fleeting idea I had in passing. 

And I totally get why my doctor did what he did. Because when someone is suicidal, it just makes sense that staying alive is the one and only goal. So, in the beginning I was fine with whatever worked — and it just so happened that Cymbalta is what worked for me. 

Until it didn’t. 

Cymbalta was able to keep the suicidal thoughts away, but it also kept a lot of other thoughts away too. Like my creative thoughts, my writing thoughts and, honestly, my sex thoughts. The drug straight up slaughtered my sex drive.  

It also made me so tired. Like, sleep-for-16-hours-a-day tired. Yes, it had help from all the other drugs I’m on, but I can clearly tell you that the fatigue is worse than it was before I started taking Cymbalta.

So, a couple months ago I tried to go off it. I chose the only method I knew and cut it out cold turkey. Within just two days, my writing voice came back like the great flood. And I was getting turned on by my boyfriend again. I even got to see and understand 8 a.m. again for the first time in like a year. 

All was well with the world. Except when suddenly it wasn’t. Because Oh. My. God. The withdrawal symptoms from Cymbalta were hell. 

Less than a week after my last pill, I was getting so dizzy that I seriously thought I had a new disease. Then, there was this thing called the brain zaps, that I didn’t understand until they happened to me. In short, it literally felt like my brain was being, well, zapped by electricity. 

There was also nausea and vertigo and just an overall feeling of falling off a skyscraper. 

I can honestly tell you that going off Cymbalta was worse than going off any opioid I’ve ever been on. At least with opioids it only takes like 18 hours to get out of your system, and when it’s over, it’s over. Cymbalta lingered. It took it’s time with me. It gradually poured on the withdrawal symptoms in a tortuous piling on. 

So, a week after I went off it, I went back on it.

Apparently though, I’m not the only one staring down at a lifetime of daily Cymbalta doses. According to the Internet, (always a reliable source) there’s a possible class action lawsuit being brought against Eli Lilly.

“Studies show that between 50% and 78% of Cymbalta users experience antidepressant withdrawal symptoms after discontinuing the drug. Yet the drug label misleadingly states that Cymbalta withdrawal symptoms occur in only 1% to 2% of cases,” claims attorney Steven D. Gacovino.

You can read more about it here.

Now, I literally have no idea how legit this whole thing is. Can you really fill out a form on a random website and be part of  a class action lawsuit? I have no idea. But I can tell you that I totally submitted the form. 

If nothing else, doctors should be telling their patients about this. They should have a conversation that goes something along the lines of, “Hey, this drug might quell your suicidal thoughts, but you’re never going to be able to go off of it. I mean, you will, but it will be hell. You’ll probably get vertigo and brain zaps and you may not be able to stand up without falling over. Also, there’s no telling how long those withdrawal symptoms are going to last.”

If nothing else, patients deserve to know the truth. I deserved to know the truth.

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.

Can Viagra Treat Diabetic Neuropathy?

By Pat Anson, Editor

An experimental animal study suggest that sildenafil, an erectile dysfunction drug commonly known by the brand name Viagra, may be effective in relieving symptoms of peripheral neuropathy in men with long-term diabetes. The study is published online in PLOS ONE.

Diabetic peripheral neuropathy causes nerves to send out abnormal signals. Patients feel pain, tingling or burning sensation in their toes, feet, legs, hands or arms. Nearly 26 million people in the U.S. have diabetes and about half have some form of neuropathy, according to the American Diabetes Association. 

In previous animal studies, researchers at Henry Ford Hospital in Detroit found that sildenafil improved blood supply to the sciatic nerve and relieved symptoms of neuropathy. However, it was not known if this therapeutic effect held true for long-term peripheral neuropathy, because the diabetic mice used in the previous experiments were relatively young - 16 weeks old.

"Generally, young diabetic animals with an early stage of peripheral neuropathy are used to investigate various drug treatments," said Lei Wang, MD, the Henry Ford neuroscientist who led the research. "But patients with diabetes who are enrolled in clinical trials often are older and have advanced peripheral neuropathy.

To mimic clinical trials in which diabetes patients have advanced peripheral neuropathy, Wang and his colleagues chose male mice with type II diabetes that were 36 weeks old, roughly equivalent to middle age in humans.

In one group, 15 diabetic mice were treated with an oral dose of sildenafil/Viagra every day for eight weeks. A control group of 15 age-matched diabetic mice were treated daily with the same amount of saline.

Researchers found after a battery of nerve and function tests on both groups of mice that sildenafil markedly improved sensory function after six weeks of treatment.

“Treatment of diabetic mice at age 36 weeks with sildenafil significantly increased functional blood vessels and regional blood flow in the sciatic nerve,” said Wang. “Functional analysis showed that the sildenafil treatment considerably improved motor and sensory conduction velocities in the sciatic nerve and peripheral thermal stimulus sensitivity compared with the saline treatment.

“These findings provide new insights into mechanisms underlying the neurological dysfunction of long term diabetic peripheral neuropathy and may lead to the development of a sildenafil therapy for long term diabetic peripheral neuropathy.”

Since becoming available in 1998, Viagra has been found to relieve several other conditions beside erectile dysfunction, such as jet lag and altitude sickness. Some professional athletes also believe that Viagra enhances their performance by opening their blood vessels and increasing oxygen supply to their muscles.

Imaging for Back Pain Often Doesn't Help Older Adults

By Pat Anson, Editor

Spending thousands of dollars on CT scans or MRI’s is often a waste of time and money for older adults with low back pain, according to a large new study published in JAMA.

Researchers at the University of Washington in Seattle say older adults with lower back pain who had spine imaging within six weeks of visiting a primary care doctor had pain and disability over the following year that was no different than other patients who did not have advanced imaging.

“Among older adults with a new primary care visit for back pain, early imaging was not associated with better one-year outcomes. The value of early diagnostic imaging in older adults for back pain without radiculopathy is uncertain,” said Jeffrey G. Jarvik, MD, a professor of radiology in the UW School of Public Health, who studies the cost effectiveness of treatments for patients with low back pain.

Jarvik and his colleagues studied over 5,200 adults aged 65 or older who had a new primary care visit for back pain at three U.S. health care systems. They followed up with the patients 12 months later, comparing pain and disability for those who received early imaging with those who did not. The imaging included radiographs (X-rays), computed tomography (CT scans) and magnetic resonance imaging (MRI) of the lumbar or thoracic spine.

Among the patients studied, 1,174 had early radiographs and 349 had early MRI/CT. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on measures of back or leg pain-related disability.

When to image older adults with back pain remains controversial. Some guidelines recommend that older adults undergo early imaging because they are more likely to have serious underlying medical conditions, such as cancer or infections.

The American College of Radiology recommends early imaging with MRI for patients older than 70 with back pain, as well as patients older than 50 with osteoporosis. European guidelines say patients older than 55 with back pain should have imaging.

However, Jarvik says there is no strong evidence to support those guidelines.

“Despite the lack of evidence supporting routine imaging for older adults with back pain, guidelines commonly recommend that older patients with back pain undergo imaging,” he wrote. "Our study results support an alternative position that regardless of age, early imaging should not be performed routinely.”

Jarvik says adverse consequences from early imaging are more likely in older adults because they can lead to unnecessary treatments, including steroids injections and surgery.

Early imaging for lower back pain is not recommended for people at any age, according to the Choosing Wisely campaign, an initiative of the ABIM Foundation to encourage physicians and patients to make better choices about their healthcare treatment.

“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” Choosing Wisely states on its website.

“A study that looked at 1,800 people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an OTC pain reliever. Another study found that back-pain sufferers who had an MRI in the first month were eight times more likely to have surgery, and had a five-fold increase in medical expenses.”

According to HealthCareBlueBook.com, an MRI of the lower back can range from $880 to $1,230, and a CT scan from $1,080 to $1,520.

A Pained Life: Is Chronic Pain One Disease or Many?

By Carol Levy, Columnist

When someone asks to join the online chronic pain support group I administer, they are asked what brings them to the group. Most often the reply is along the lines of, "I have fibro, CRPS, neuropathies, migraines, spinal issues, etc." 

The naming is usually long, and sad to read. 

Even after doing this for many years it still surprises me when the reply is a laundry list of diagnoses.

It is silly for me to continue to be taken aback. It is the very rare person who names only one illness. 

There has been a lot of discussion surrounding the issue of childhood trauma and abuse as being a progenitor for chronic pain. I have my arguments with that theory. I also wonder if we lose sight of other possible originators of chronic pain disorders in our, and the research community's, willingness to hop on the “abuse as cause” train. 　

I googled, "Chronic pain patients have multiple chronic pain disorders. Why?" The search came up with a number of websites for treatment, but nothing about research that addresses the question. Is there a biological reason, a chemical cause, or maybe genetic issues that cause a body to develop these combinations of diseases?

Often people with cancer in one part of the body see it metastasize to other areas.  My simplistic understanding is that a cancer cell gets loose and travels, spreading the disease.

Diabetics have the risk of eye and skin complications, kidney disease, neuropathy and other problems as a direct result of the diabetes, even when they have been managing the illness very well. The diabetes itself is the trigger for the body processes that cause the side effects. 

Is there a similar mechanism in chronic pain disorders? Does the presence of one condition set off a process that allows other pain disorders to take root? Does the body lose some of its defenses or ability to fight off other pain disorders? 

I am not a medical person. I have no idea if this is nothing more than the personal woolgathering thoughts of someone who thinks we, as a group, are in desperate need of answers.

We already clamor for more research into treatments for our pain. We need to also send out a clarion call for more research into what causes these disorders. This call needs to include looking outside of the box, maybe seeing chronic pain illnesses as a cluster of ailments rather than individual disorders that are distinct and separate from one another. 

We need researchers who can see past a name, who can look at chronic pain and ask the opposite of the Sesame Street song “One of These Things (Is Not Like The Others).”

All of these things are like the others, but what about these things are all the same?

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

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