Hillary Clinton: Please Be Responsible for Opioids

By Lynn R. Webster, MD

While Presidential candidate Hillary Clinton only recently announced her bid for office in 2016, she has already declared a few important issues on her presidential agenda, including the ever-important opioid crisis in the United States.

Many are chiming in to offer their best solutions to curbing the opioid abuse epidemic; sadly, many of the proposed solutions fail to promote and fund safer alternative therapies for people suffering from chronic pain who rely on opioids to live a semblance of a normal life.

I applaud Clinton’s desire to work toward a safer, opioid-free world. It’s a goal we should all aspire to. In order to realize it, however, we must not forget those people who rely on opioids to get through the day in the absence of alternative treatments.

Here is what Hillary Clinton must consider as she seeks to curb opioid abuse:

Redefine the prescription opioid problem as the chronic pain problem

Prescription opioids have garnered a great deal of attention for the possible health risks involved in taking the drug. While it is easy to get caught up in the whirlwind of bad press, it is still important to remember why opioids are such a prominent treatment form in the first place.

More than 100 million people in the United States suffer from chronic pain, meaning a third of the entire country may rely on some form of medication to make their lives better. Pain ranges in severity, with many suffering from severe pain that makes it difficult to live a normal life.

While no medical professional advocates that opioids should be the first line of defense, in some cases, they happen to be the only thing that works for a patient. Trying to end opioid abuse without addressing the needs of those who rely on the drug may make the problem of chronic pain worse.

Understand why prescription opioids have risen in popularity

In 2007, Americans spent $34 billion in out of pocket expenses to cover the cost of alternative forms chronic pain treatment.  To be clear, opioids are not the only means of treating chronic pain. Alternative therapies exist, but are woefully underfunded by payers. As a result, many patients with severe chronic pain, those who struggle to get out of bed, who sometimes lose their jobs, must rely only on what their insurance covers – in most cases, that form of treatment is opioids.

The chronic pain community needs access to safer alternative therapies. We need to invest in research to bring even more alternative therapies to the market, and crucially, insurance companies must then cover those alternative forms of care.

In 2012 the National Institutes of Health (NIH) spent only about 400 million dollars on chronic pain conditions but more than 2.5 billion dollars was spent on drug and other substance research.  We certainly need to find safer and more effective therapies for addiction but some of the current cost associated with substance abuse it due to the limited options to treat the number one public health problem in America: pain.

Stop stigmatizing patients who currently rely on opioids

Alternative forms of medication that could potentially help chronic pain patients and decrease the demand for opioids remain underfunded and under-researched. Despite being one of the largest health researchers and sponsored by the U.S. Department of Health and Human Services (HHS), the NIH continues to operate on a shoestring budget.

Despite the lack of options for alternative therapies for chronic pain, the topic of opioid abuse has become a popular topic in the media, and sadly, caused an increase in stigmatization of patients who use opioids for pain management. Patients have reported reluctant doctors and pharmacists unwilling to prescribe necessary medications.

The DEA has rescheduled hydrocodone as a Schedule II drug, leading to a series of unintended consequences with which patients today are left to suffer. Many patients report feeling like drug addicts for simply trying to fill their legally obtained prescriptions.

Require all opioids to be abuse-deterrent

Abuse deterrent formulations (ADF) have been shown to curb some forms of opioid abuse, while maintaining the benefits for patients that need the drug.  Unfortunately payers have priced these safer formulations so that there is little incentive for market adoption.  HHS should lead the way and negotiate deals with manufactures to make ADFs no more expensive than generic alternatives to patients.

Remove methadone as a “preferred” drug

While the use of methadone as an analgesic for chronic pain has expanded in recent years, it shows up in mortality reports with a higher frequency than other opioids. Despite the evident risk associated with this drug, many states have listed it as a “preferred” analgesic in treating severe chronic pain, largely due to its low cost and savings for publicly funded health plans.

The American Academy of Pain Medicine holds that methadone should not be a preferred drug unless special education is provided, and that it should never be the first choice in treating chronic pain.

The opioid crisis is not a black and white issue. Until we stop treating it as such, we will not be able to tackle the problem at its root. Eliminating opioids does not alleviate the problem, end patient suffering or acknowledge what the true issue is. Millions of Americans suffer from chronic pain, but very few have access to multiple options to manage their pain.

Through an increase in funding and research of alternative therapies, implementation of ADF’s and greater coverage by payers, we can finally begin to treat the opioid epidemic in a safe and responsible way – a way that does not hurt the millions of Americans who rely on opioids to get out of bed, to play with their children, to get through the day.

Lynn R. Webster, MD, is Past President of the American Academy of Pain Medicine, and vice president of scientific affairs at PRA Health Sciences. He is a Pain Medicine News editorial board member and author of a forthcoming book, “The Painful Truth.” He lives in Salt Lake City. Follow him on Twitter @LynnRWebsterMD, Facebook and LinkedIn.

This column is republished with permission from Dr. Webster’s blog.

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.

UK Research Could Lead to Blood Test for Fibromyalgia

By Pat Anson, Editor

British researchers have launched a genetic study of fibromyalgia patients that they hope could lead to a new blood test to diagnose the disease.

Fibromyalgia is a poorly understood disorder characterized by deep tissue pain, fatigue, headaches, depression and insomnia. It is notoriously difficult to diagnose and treat, and some doctors refuse to recognize it as a disease.

Scientists at King’s College London will study tissue samples and measurements taken from volunteers enrolled in Twins UK, a comprehensive study on the effects of genes, aging, disease and the environment on over 12,000 identical and non-identical twins.

Four hundreds twins are enrolled in the fibromyalgia study. In each set of twins, one twin suffers from chronic widespread pain, while the other does not. Tissue samples from both twins will be compared to try to identify biomarkers in their DNA associated with chronic pain.

"Our research will help patients in two ways. First it'll contribute to our understanding of how fibromyalgia – and other chronic pain syndromes such as irritable bowel syndrome – develop, and point to pain pathways which we may not have suspected,” said lead researcher Dr. Frances Williams.

"Secondly, we hope it'll lead to identification of a biomarker which we could work into a blood test."

Fibromyalgia is believed to have genetic influences, but researchers say there are many complicated steps between the genes that may contribute to fibromyalgia and the condition itself.

The study will focus on identifying markers in DNA that are associated with the “switching” on or off certain genes. DNA switching is important to health, as it prevents inappropriate processes from occurring in the body when they should not. Identifying those markers could then lead to a blood test.

“As well as enabling the condition to be diagnosed more effectively, it could help to ‘stratify’ patients into groups depending on disease severity, which will help in clinical trials of potential new treatments. It might even help us predict how the condition will progress,” said Williams.

A bioresearch company based in Santa Monica, California is already marketing a blood test that it claims is 99% accurate in diagnosing fibromyalgia.

EpicGenetics introduced the blood test in 2013, calling it the first definitive test for fibromyalgia.

The FM test looks for protein molecules in the blood called chemokines and cytokines, which are produced by white blood cells. Fibromyalgia patients have fewer chemokines and cytokines in their blood, according to the company, and have weaker immune systems than normal patients.

The blood test costs several hundred dollars and results are available in about a week. Critics have said the test is unreliable and the same molecules can be found in people with other disorders, such as rheumatoid arthritis.

Study: Painkiller Abuse Costs Employers $25 Billion

By Pat Anson, Editor

Painkiller abuse is costing U.S. employers over $25 billion a year in lost productivity and missed work days, according to a new analysis by a healthcare consulting firm that also found that the vast majority of patients who are prescribed opioids do not have an abuse problem.

The “white paper” was produced by Healthentic, a Seattle-based company that helps employers identify health savings to reduce the cost of employee healthcare. You can download a copy of the report, called “Painkiller Abuse Is Costing Your Company” by clicking here.

"Opioid misuse costs employers in multiple ways including more medical costs and productivity loss," said Jeff O'Mara, CEO of Healthentic. "Employers have a unique opportunity to help people get more productivity for less money by identifying and engaging the people at risk."

Healthentic reviewed four years of health insurance claims data from 2011 to 2014 and found that only a small percentage of pain patients were misusing or abusing opioids.

"It was remarkably consistent that most people with an opioid prescription do not have a chronic or abuse problem. In fact, 87% of those prescribed an opioid in those four years didn’t show a cause for concern in the claims data,” the report states.

And what about the other 13 percent?

Healthentic identified three red flags in those patients that raised potential cause for concern:

1. Ten or more opioid prescriptions
2. A prescribed opioid supply for 120 days or more
3. A week or more of overlapping prescriptions for opioids and benzodiazepine, a sedative used to treat anxiety, depression and insomnia

“These people – just 13% -- are responsible for 92% of employer’s costs. And if you break it down even further, the 7% of the population with an opioid prescription that have two or more issues account for over 80% of the cost,” the report states.

Healthentic said opioid abusers used significantly more healthcare resources than non-opioid users, and cited a study that estimated the cost of their healthcare at $10,627 annually. In addition, opioid abusers cost employers $1,244 more in lost work days compared to non-abusers.

The company advised employers that opioids “should not be the first line of treatment” for back pain and other common workplace injuries, and said over-the-counter pain relievers like Tylenol and ibuprofen are “a more affordable and safer option.”

Healthentic recommended four actions to employers to address opioid abuse:

1. Understand and insist upon conservative prescribing guidelines for pain treatment for all participating providers.
2. Evaluate and know which employees are at risk by reviewing their insurance claims.
3. Educate employees about the risks of opioid drug use.
4. Increase and ensure access to treatment programs for employees with an abuse problem.

"Our hope is this analysis provides further insight into the societal and financial issue of prescription painkillers, and helps employers take strides in alleviating the problem to ensure the well-being of their people," said O'Mara.

Healthentic provides healthcare data and analytic services to nearly 11,000 corporate clients in 19 states.

My Life with Trigeminal Neuralgia

By Pat Akerberg

Most of us don’t focus on the idea of pain until we find ourselves in it for one reason or another.  We just know that we’re glad when it’s gone. 

But what if it doesn’t go away? 

Challenging conditions occur for some of us that catapult us into a life of chronic, intractable pain.  You know you are one of the unlucky ones when meetings with doctors end with statements like:

“There is nothing we can do.”

“You’ll just have to live with it.”

“It’s all in your head.”

That last statement is the one that literally began my life-altering journey with pain. An outgoing, upbeat owner of a thriving consulting practice, I was on a business trip enjoying dinner with a favorite client six years ago.  My meal started with a typical salad.  By the second bite, I was writhing through volleys of shocking pain shooting through the roots of my teeth on my left side.

PAT AKERBERG

I later learned that this neurological disorder of the 5th cranial nerve was trigeminal neuralgia -- also known as the “suicide disease” or “worst pain known to mankind.”  I had to cut my trip short and fly home to see my dentist, pronto.  Little did I know then that this event would mark the end my of work life, one of the growing list of ongoing losses for me to grieve.

I was both unfortunate and fortunate during my short search to find a proper diagnosis, one that often takes many months or years to receive.  Unfortunate in that trigeminal neuralgia (TN) is so rare, the cause is unknown, treatments do not offer a permanent cure, and sometimes create more pain issues.  Fortunate in that I escaped the needless root canals or extractions that most are subjected to prior to an accurate diagnosis.

Research became my middle name as I sought to learn everything that I could to get my problem “fixed.” I was driven to get back to my career and serve my clients.  Research collectively pointed to an invasive brain surgery done by a neurosurgeon.  It seemed to have the best odds for a cure, with the least chance of further damage to the nerve. 

Unfortunately, permanent nerve damage is exactly what occurred.  Imagine my concern when I awoke from surgery with my face immovable; frozen like a block of concrete, numb with pulling sensations, and the stabbing pain in my teeth now constant. 

The neurosurgeon who held out a sure cure quickly distanced himself -- perceiving me as “too anxious” about the devastating impairments and pain frequency.  With dispatch and without explanation, my case was closed.    

Left on my own to seek out answers and help, I pursued consultations with several other leading TN experts.  With honesty and compassion, each one delivered the same bad news: medicine and science have not caught up with how to effectively treat a damaged trigeminal nerve.  Advising against further procedures, my lifetime membership into the intractable pain club was validated. 

“Invisible” Pain

Being a co-habitant with an intrusive bully like intractable pain has been all consuming.  Any illusions I had of control have been shattered. 

There’s also an invisible aspect to my pain that can create issues with believability.

Most people are unaware of orphan diseases like trigeminal neuralgia, and have little understanding and compassion towards those who have them. 

Family members, who are turned into caregivers overnight, scramble to figure out how to relate to a frightening pain condition.  Many close friends eventually drift away when you don’t get better, are unable to keep up, or cancel plans too often. And busy medical professionals can skeptically question what they cannot see or touch.  

That’s partly because we are so often judged by how we look versus what we say. If we don’t look sick or in pain, then the erroneous assumption follows that we can’t be that bad.  But we can be! 

When I report that I am unable to chew solid food (eat out), talk, smile, laugh (socialize), move my face or have anything touch it (brush teeth, take walks, exercise) without triggering unbearable facial pain; most people can’t square such an unthinkable loss of natural life functions with how I appear to them.

I agree. It is hard to fathom, yet with neuropathic pain disorders like TN, simple things that normally don’t cause pain now do. Combine those quality of life diminishments and misconceptions with disabling pain and the ingredients for a lonely, isolated existence can’t be denied. 

Often I feel as if I am living in an inescapable bubble, missing out while the rest of the world goes by without me. It takes tremendous fortitude daily for me to counter those negative effects in my life with meaningful ones.  Some days are more successful than others. 

Like most who suffer with chronic pain, the search for any kind of relief becomes a way to keep hope alive.  In the meantime, I do find it helpful to post, blog, and reach out to connect with people like myself whenever I can.  It reminds me that I am not alone in this often debilitating journey.

Pat Akerberg lives in Florida. Pat is a member of the TNA Facial Pain Association and serves as a moderator for their online support forum.

Pat is also a supporter of the Trigeminal Neuralgia Research Foundation.

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.

Researchers Develop New Painkiller from Lidocaine

By Pat Anson, Editor

A fast acting pain reliever widely used to treat everything from itching to dental pain could be developed into a new medication that offers longer lasting pain relief.

"Because of its versatility and effectiveness at quickly numbing pain in targeted areas, lidocaine has been the gold standard in local anesthetics for more than 50 years," said George Kracke, PhD, an associate professor of anesthesiology and perioperative medicine at the University of Missouri (MU) School of Medicine.

"While lidocaine is effective as a short-term painkiller, its effects wear off quickly. We developed a new compound that can quickly provide longer lasting relief. This type of painkiller could be beneficial in treating sports injuries or in joint replacement procedures."

Lidocaine is used as an injectable pain reliever for minor surgical or dental procedures, and as an over-the-counter ointment or spray to relieve itching, burning and pain from shingles, sunburns, and insect bites.

The new compound -- called boronicaine -- could potentially serve many of those same functions as an injectable or topical painkiller.  

MU researchers synthesized boronicaine as a derivative of lidocaine by changing its chemical structure. They found that boronicaine provided pain relief that lasted five times longer than lidocaine. In pre-clinical, early stage studies, boronicaine provided about 25 minutes of relief, compared to about five minutes of pain relief with lidocaine.

"Although some conditions may warrant the use of a short-lasting painkiller, in many cases a longer lasting anesthetic is a better option," said Kracke, who is lead author of a study published in the chemistry journal ChemMedChem . "Having a longer lasting anesthetic reduces the dosage or number of doses needed, limiting the potential for adverse side effects."

Other types of short term analgesics provide longer pain relief than lidocaine, but they also have side effects they can cause heart toxicity and gastrointestinal problems. Preliminary findings show no toxicity in single-dose studies of boronicaine, though more studies are needed.

"Boronicaine could have distinct advantages over existing painkilling medications," said M. Frederick Hawthorne, PhD, director of MU's International Institute of Nano and Molecular Medicine and a pioneer in the field of boron chemistry. "We're conducting more research into the side effects of the compound, but in time it could very well become a useful material to use as an anesthetic."

Rheumatoid Arthritis Raises Risk of Heart Attack

By Pat Anson, Editor

Rheumatoid arthritis is a painful, disabling and incurable disease of the joints. But what many RA patients don’t know is that it also significantly raises their risk of a heart attack.

A new study by researchers in Mexico found that one quarter of patients with rheumatoid arthritis and no prior symptoms of heart disease could have a surprise heart attack. Their risk was higher even without cardiovascular risk factors such as smoking and diabetes.

“The condition nearly doubles the risk of a heart attack but most patients never knew they had heart disease and were never alerted about their cardiovascular risk," said  Adriana Puente, MD, a cardiologist at the National Medical Center in Mexico City.

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.

Dr. Puente’s study, which was presented this week at the International Conference of Nuclear Cardiology in Madrid, involved 91 RA patients with no prior symptoms of heart disease. Ninety percent of the patients were women, their average age was 59, and they had similar cardiovascular risk factors as the general population.

Nearly one quarter of the patients (24%) had abnormal Gated SPECT, indicating the presence of ischaemia or infarction – decreased blood flow to the heart which can lead to the death of heart tissue.

"The ischaemia and infarction may be explained by the persistence of the systemic inflammation in rheumatoid arthritis which may cause an accelerated atherosclerosis process,” said Puente.

"The results highlight the importance of conducting diagnostic tests in patients with rheumatoid arthritis to see if they have cardiovascular disease, specifically atherosclerotic coronary artery disease (ischaemia or myocardial infarction) even if they have no symptoms and regardless of whether they have cardiovascular risk factors.”

Puente says patients should be warned that some RA medications, such as corticosteroids and methotrexate, can elevate plasma lipid levels and raise their risk of cardiovascular disease.

"Patients with rheumatoid arthritis should be told that they have an elevated predisposition to heart disease and need pharmacological treatment to diminish the inflammatory process and atherosclerotic complications. They also need advice on how best to control their rheumatoid arthritis and decrease their cardiovascular risk factors,” she said

Many health experts believe the inflammation triggered by RA in the joints may raise inflammation throughout the whole body, including the heart’s coronary arteries.

According to the Arthritis Foundation, more than 50 percent of premature deaths in people with rheumatoid arthritis result from cardiovascular disease.

But the heightened risk of heart disease applies to all forms of arthritis, including osteoarthritis, gout, lupus and psoriatic arthritis.

“Inflammation, regardless of where it comes from, is a risk factor for heart disease,” says rheumatologist Jon T. Giles, MD, assistant professor of medicine at Columbia University School of Medicine. “So it’s not surprising that people with inflammatory arthritis like RA, lupus and psoriatic arthritis have more cardiac events.”

Survey: Most Pain Patients Don't Abuse Painkillers

By Pat Anson, Editor

Only a small percentage of chronic pain patients misuse or abuse their opioid painkillers, according to a wide ranging survey by the Partnership for Drug-Free Kids that also found a “disconnect” between patients and their doctors about opioid prescribing.

About one in ten pain patients (7% of chronic pain patients and 13% of acute pain patients) admitted misusing their opioid medications. Nearly half took longer to finish their prescriptions than directed – which was usually an effort to save the pain medication for another time.

More than one in ten (13% of chronic pain patients and 15% of acute pain patients) admitted using someone else's opiate prescription.

The online survey of 705 pain patients and 360 prescribing physicians was conducted by the research firm Whitman Insight Strategies (WINS) earlier this year.

About two-thirds of the opioid prescribers said they “always” warned their patients about the risk of addiction and dependency.

But when patients were asked who, if anyone, explained to them the potential for becoming dependent or addicted to painkillers, 19% of chronic pain patients and 40% of acute pain patients said "no one."

The survey also found that most patients pay little attention to the proper storage and disposal of pain medication. Only 11% of chronic pain patients and 13% of acute pain patients said they were concerned that someone else in their household might use their medications.

Less than half of chronic pain patients (42%) who have children said they store their medication somewhere their kids can’t reach. Most patients said their doctors never discussed the proper storage and disposal of painkillers.

"This research highlights key opportunities for prescribers of Rx opiates and their patients to have better communication around proper use and disposal of prescribed painkillers," said Marcia Lee Taylor, Interim President and CEO of the Partnership for Drug-Free Kids.

"The Centers for Disease Control has deemed abuse of prescription painkillers an 'epidemic,' and we can all do our part to help turn the tide on this critical health issue. Prescribers and patients can become more aware of the repercussions surrounding the improper storage and disposal of Rx pain medications and talk more at length in order to improve doctor-patient communication and help curb abuse."

The survey also found that many physicians are concerned about patients misusing their pain medication – by either taking too little or taking too much.

The majority of prescribers (77% of primary care physicians and 75% of pain management specialists) believe their patients do not always use their prescribed opiates in accordance with instructions. Twenty percent of the primary care physicians said they don’t feel comfortable prescribing opiates at all.

"This research suggests to us that prescribers need to feel more confident in assessing the potential risk of misuse or abuse of the Rx medicines, but unfortunately many of them feel they have not received proper training to assess those risks. There is a lot more we can do to help prescribers feel they have the proper tools they need to feel comfortable prescribing these medicines and taking action if a patient is abusing them," Taylor said.

The survey also found that most pain patients would prefer alternatives to opioids. About 9 in 10 chronic pain patients have tried an alternative treatment such as physical therapy and massage. Many were hindered in their use of alternative therapies by restrictions on insurance coverage.

My Life with Spinal Stenosis

By Brandis Standridge

I was a young, 16-year old track athlete the first time I experienced my back “going out.” The spasms, the pain and the sciatica were horrible. 

My family physician did everything right and I learned how to manage my symptoms for the next twenty years, although each time by back went out it was a little worse than the last.

At 37, my back went out again. I found out that I had severe spinal stenosis on multiple levels due to facet and ligament hypertrophy. Basically, osteoarthritis had overgrown the ligaments and joints in my spine so badly that it was crushing my spinal cord on 10 levels.

I was referred to several pain management specialists.  All of them were horrible.  I had to fill out lengthy questionnaires and they refused to give me pain medication unless I consented to their procedures.

They pushed for spinal injections and for fusion surgery, even while admitting the surgery had only a 50/50 success rate. I refused.

Never in my entire life have I felt as segregated, helpless, victimized, and scared as I have dealing with these specialized "professionals.” After the last one, I returned to my family physician in tears and told her I would rather live in agony than be forced into procedures and treated as if I were some local street addict before they even knew me.

BRANDIS STANDRIDGE

Two years ago I had to move.  My doctor gave me a letter of reference, medical and MRI records, and a report from my state pharmacy board. All of this was to help the new doctor with the vetting process to help get me treatment. But, it started all over again; the assumptions, ultimatums, and power plays: "If you don't do this, you won't get medication.”

Once again I refused to be without choices or a voice of my own.

I am a former social worker.  I know how to advocate and refuse to be pushed into procedures that will more than likely hurt me more in the long and short term.  I refuse to let doctors push me into places where I have no voice, where I am not able to be a member of my medical treatment team.

I did eventually find a doctor. Our relationship is a bit tense at times but I am receiving the care that I choose.

We have a right to choose our medical procedures without fear of punishment. We have a right to be active in our treatment and to live as pain free as possible.

Never lose faith in yourself. Never stop having hope.  We are chronic pain warriors, not victims!

Brandis Standridge lives in Idaho.

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.

Injectable Gel Could Help Knee Cartilage Heal

By Pat Anson, Editor

With the number of knee replacement surgeries soaring in the United States, researchers at the University of Iowa are working on an injectable gel that could repair damaged cartilage and make many knee surgeries unnecessary.

"We are creating an [injectable, bioactive] hydrogel that can repair cartilage damage, regenerate stronger cartilage, and hopefully delay or eliminate the development of osteoarthritis and eliminate the need for total knee replacement," says Yin Yu, a graduate student at the University of Iowa (UI) whose study is featured in the journal Arthritis and Rheumatology.

Osteoarthritis (OA) is a joint disorder that leads to thinning of cartilage and progressive joint damage. 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.

About 600,000 knee replacement surgeries are performed annually in the U.S. – about twice the number performed 20 years ago. Recent studies have questioned whether many of the surgeries are appropriate.

UI researchers have previously identified precursor cells in healthy cartilage that can mature into new cartilage tissue – a surprising development given the long-held assumption that cartilage is one of the few tissues in the body that cannot repair itself.

The researchers also identified molecular signals that encourage precursor cells to migrate out of healthy tissue and into damaged areas – stimulating the development of new cartilage. One of the signals, called stromal cell-derived factor 1 (SDF1), acts like a “homing beacon” for the precursor cells.

In an experimental model of cartilage injury, Yu loaded the hydrogel with SDF1 and injected it into holes punched into the model cartilage. The precursor cells migrated toward the SDF1 infused gel and filled in the injury site. Subsequent application of a growth factor caused the cells to mature into normal cartilage that repaired the injury.

The new tissue is not as strong as normal cartilage, but researchers think it could be strengthened through physical therapy and exercise.

"There's really no cure for osteoarthritis except for total joint replacement, which is not particularly suitable for younger patients because the artificial joints wear out and need to be replaced multiple times," said James Martin, PhD, a UI assistant professor of orthopedics and rehabilitation who leads the research team.

"Our approach aims to leverage the body's own capacity for repair, and what we've shown is that cartilage does have regenerative potential; you just have to manipulate it just right."

UI Researchers are now looking at different ways to include the growth factor in the hydrogel – possibly by using nano-size plasmids that carry genetic instructions for the growth factor or microspheres loaded with the substance.

Yu and Martin plan to start animal trials within a year and, if the results are promising, begin human trials in about five years.

Injections of platelet rich plasma (PRP) into the knee also show promise in the treatment of osteoarthritis, according to a recent study published in The Journal of the American Osteopathic Association (JAOA).

Only a few small clinical trials have been conducted on the effectiveness of PRP therapy. Researchers at the University of Miami Miller School of Medicine analyzed those trials and found that patients with knee osteoarthritis and other musculoskeletal injuries showed significant improvements as long as two years after PRP injections.

The procedure involves withdrawing blood from the patient and then spinning it to produce a high concentration of platelet cells. The plasma is then injected back into the patient at the injury site, speeding up the healing process. Several top athletes, including Kobe Bryant and Peyton Manning, have used a form of PRP therapy to help them recover from injuries.

A Pained Life: The Balancing Act

By Carol Levy, Columnist

It is time for a renewal for my pain meds but I have a number of pills left.  I was excited for a few seconds. Maybe the pain has been better so I need fewer pills!

And then I thought about it a little bit more.

It is not because the pain has lessened.  

I realized I have stopped doing a lot of what I used to do.  It was not the pain that had backed off. It was a reduction in my willingness to do things that trigger pain.

I had been working on a line of greeting cards that I both wrote and illustrated. I had also created a doll and made pins of the character that had her jogging, playing the trumpet, skating and more. I had hoped to learn to sew and bring the doll to market.

Looking back, I realized I stopped working on all of it a few months after my brain implant stopped working.  I had not realized it had been helping reduce the pain. 

I still had the eye usage and movement pain that caused me to be unable to do any consistent eye work for more then 15 - 20 minutes -- before the severe and often unrelenting pain started.

Apparently, the stimulator had reduced the anesthesia dolorosa (phantom pain) in the left side of my face. And now that it had failed, the weight of small plastic glasses or the use of facial muscles (tight as a result of facial paralysis) set off pain again.

I had moved from my house to a small apartment.  Well heck, that‘s why I’m not doing things. No room to do my crafts and art.

That made sense, except I had stopped before I sold the house, when I had an entire room devoted solely to my art and crafts work.

So what stops me?

The pain, of course.  But it is also the fear of pain.

The thought occurs: I need to work on the doll, the cards, even this column, and immediately the next thought comes: But then it will set off the pain, or make it worse if it is already in play.

It is a game of balance and juggling.

Do I give up on the things that make me happy, give me a sense of accomplishment and purpose, because the pain will be bad, even unrelentingly bad?

Or do I give up? 

Lately my choice has been the latter, maybe not consciously, but a choice nevertheless.

At what point and how do we make the choices balance out? 

I wish I knew.

I only know that right now, for me, the pain is doing the choosing for me.

It is a decision most of have to make at some point.  Can we master the pain or does pain become the master of us?

Maybe, as long as we do not make it a permanent decision, it is okay now and then to give in to the pain and the fear.  Maybe it is a healthy way of taking care of ourselves.  Not a capitulation, but a short term concession.

And that is not always such a terrible thing.

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.

Better Sleep Means Less Pain

By Pat Anson, Editor

Getting a good night’s sleep plays a key role in determining how bad your pain levels are doing the day, according to a large new study by researchers in Norway.

The study included more than 10,400 adults from an ongoing Norwegian health study. Each participant underwent a standard test of pain sensitivity -- the cold pressor test -- in which they were asked to keep their hand submerged in a cold water bath for 106 seconds.

Only 32% of participants were able to keep their hand in cold water throughout the experiment. Those who suffered from insomnia were more likely to take their hand out early: 42% did so, compared with 31% of those without insomnia.

Pain sensitivity also increased depending on the frequency of insomnia. Those who had trouble sleeping at least once a week had a 52% lower pain tolerance, while those who reported insomnia once a month had a 24% lower tolerance for pain.

"While there is clearly a strong relationship between pain and sleep, such that insomnia increases both the likelihood and severity of clinical pain. It is not clear exactly why this is the case," wrote lead author Børge Sivertsen, PhD, of the Norwegian Institute of Public Health.

The study, which is published in the journal PAIN,  is the first to link insomnia and impaired sleep to reduced pain tolerance in a large, general population sample. The results suggest that psychological factors may contribute to the relationship between sleep problems and pain, but they do not fully explain it.

“We conclude that impaired sleep significantly increases the risk for reduced pain tolerance. As comorbid sleep problems and pain have been linked to elevated disability, the need to improve sleep among chronic pain patients, and vice versa, should be an important agenda for future research,” the study said.

A previous study in Norway found that women who have trouble sleeping are at greater risk of developing fibromyalgia – although it’s not clear if there’s a cause and effect relationship between the two symptoms.

Another study, recently published in PLoS One, found that insomnia – not surprisingly – made chronic pain patients less likely to exercise. Researchers followed 119 chronic pain patients, most of whom suffered low back pain, and found that quality of sleep was the best predictor of physical activity the next day – not mood or pain intensity.

Why You Should Consider Medical Marijuana

(Editor’s note: Pain News Network is pleased to welcome Ellen Lenox Smith as our newest columnist. Ellen has suffered from chronic pain all of her life, but it wasn’t until a few years ago that she discovered the pain relieving benefits of medical marijuana. In future columns, Ellen will focus on marijuana and how it can be used as pain medication. Medical marijuana is legal in 23 U.S. states and the District of Columbia. But even in states where it is legal, doctors may frown upon marijuana and drop patients from their practice for using it.)

By Ellen Lenox Smith, Columnist

Why -- at the age of 57 -- would one ever consider turning to medical marijuana? 

I wondered the same thing after being sent to a pain doctor just before another surgery in 2006. After reviewing my records and seeing that I was unresponsive to pain medication, the doctor clearly had no idea what to suggest, except trying medical marijuana. 

I was born with Ehlers Danlos syndrome and later also added sarcoidosis to my life. I was living with chronic pain that was preventing me from sleeping, thinking straight, and functioning.

From birth, I had one issue after another reacting to medications. And after 22 surgeries, you can imagine the horror of all I had to endure and the added pain of never knowing the proper relief my body could have from pain medication. Eventually, a DNA drug sensitivity test was ordered and it confirmed I could not metabolize most drugs. This meant no aspirin, Tylenol, or any opiates. 

I took the advice to try medical marijuana with tremendous trepidation. At that time in Rhode Island, you either had to grow your own or buy it on the black market.  Since growing takes about three months, I decided the only way to find out what marijuana would do for me was to find a source and give it a try. 

ELLEN LENOX SMITH

When I was able to find some marijuana, I ground it up, heated up some olive oil and let it release the medicine into the oil. I had no choice, since I was told by a pulmonologist that smoking marijuana with sarcoidosis in the chest would be fatal. I wanted to try a different way to administer it.

That night, I measured out one teaspoon of the infused oil. I mixed it with some applesauce and one hour before bedtime, I swallowed it down. I remember being scared -- for I am not one that likes to be out of control of my body. Having smoked marijuana once in college, I hated that sensation. 

As soon as I took the dose, I went to my husband and warned him that I had taken marijuana and to keep an eye out for me. I was convinced this was a stupid thing to be doing and I would be stoned all night.

One hour later, we got in bed, I closed my eyes and before I knew it, it was morning. I had slept the whole night, never waking up once!

I woke up refreshed, not groggy, and ready to take on life again. I had no “high” or stoned sensation like you would guess would happen. 

I learned quickly that someone in pain does not react the same way to cannabis as someone who uses it for recreational reasons. The brain receptors connect with the THC and cannabinoids (the active ingredients in marijuana), and provide safe and gentle pain relief.

I was shocked and thrilled with the result. My husband and I quickly got to work setting up a legal way to grow marijuana. I realized that life was directing us to new topic we just had to advocate for. 

If I was scared to try marijuana, there is no question that others felt the same way -- and we had to let them know how amazing it really is. Society brought us up to be negative about marijuana, yet it was used in our country many years ago and even sold in pharmacies. The success of this medication was squashed, and we were all led to believe that it was bad and dangerous.

What we learned is that no one dies from using marijuana, no one develops organ damage, and with a body in chronic pain -- you can regain your life back. 

Are my conditions cured? No, they are both incurable. But I have been able to advocate, think, feel and live again thanks to using medical marijuana. 

Don’t be scared. Consider how much safer this medication is than all the other pain relief choices out there. Turn your body and your life with pain around. You won’t regret it.

Ellen Lenox Smith and her husband Stuart live in Rhode Island. They are co-directors for medical marijuana advocacy for the U.S. Pain Foundation and serve as board members for the Rhode Island Patient Advocacy Coalition. For more information about medical marijuana, visit their website. 

If you have a question for Ellen about medical marijuana, leave a comment below or send it to editor@PainNewsNetwork.org.

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

When Nobody Believes You

By Jennifer Martin, Columnist

“It’s all in your head.”

“Your doctors are wrong.”

“You don’t really feel as bad as you say you do.”

“You must not really be in that much pain because you look fine.”

These words are far too common in the ears of chronic pain patients.  They can make one feel isolated, alone, and as if nobody cares.

One of my patients told me the other day, “My husband doesn’t believe I’m in as much pain as I say I am.  He thinks it’s all psychological.” 

A week earlier, a friend told me, “No matter how many doctors and specialists I have been to, my family still does not believe my diagnosis.  They think it is wrong.  I feel like I have to hide my pain around them.”

I listen to story after story from patients and friends with chronic pain stating the same thing: that family members, friends, doctors, co-workers, teachers, etc. do not believe they are in as much pain as they say they are. Often it’s because they look fine on the outside. 

They have told me they feel like they are whining about their pain, that people just brush them off or that they feel guilty for even talking about their pain.

They ask me, “What’s the point? I feel like nobody believes me anyway.”

No matter how many times I hear these stories, it still angers me.  Chronic pain is not something that anyone should feel like they have to convince another person of.  It is not something to feel guilty about and it is not something anyone should feel like they have to hide -- especially from those closest to them.

Unlike having diabetes, cancer or a broken arm, most people do not understand chronic pain and the effects it has. And many who think they understand are misinformed.

What they often don't understand is that chronic pain sufferers don’t always look sick.  Because their pain is chronic, they have learned to go on and live their daily lives to the best of their ability.  Just because you can’t physically see someone’s pain, that doesn’t mean it is all in their head and it doesn’t mean they are fine.  

And being told that their doctor must be wrong or that they should hide their pain only makes things worse. 

When someone is diagnosed with chronic pain, they want more than anything for that diagnosis to be wrong.  However, more times than not, the diagnosis they receive, especially if they have been to multiple doctors, is correct.  After the shock and denial has worn off, that patient, more than anything, is going to need support and acceptance, not criticism and disbelief.

Being diagnosed with a chronic condition is life changing, even for the strongest individuals.  It means finding a new normal, contending with things that are unimaginable and going through life feeling like those closest to you will never understand.  

It means trying to make sense of this new person they have been forced to become and the new reality they are now living.  All of these things could be managed just a little easier by hearing the simple words, “I believe you.”

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.

National Pain Strategy: A Rough Beast?

(Editor’s Note: Earlier this month, The National Institutes of Health (NIH) released a draft copy of its National Pain Strategy, a long awaited report designed to advance pain research and healthcare in the U.S. The report identifies several areas where the healthcare system is failing pain sufferers and how it can be improved

A coalition of 17 chronic pain organizations called the Consumer Pain Advocacy Task Force was quick to endorse the National Pain Strategy, and is now lobbying the NIH to create an oversight body to implement the plan and provide funding for it

David Becker is a social worker, patient advocate and political activist who believes the needs and concerns of pain sufferers are not adequately addressed by the National Pain Strategy.)

By David Becker

The Consumer Pain Advocacy Task Force started promoting the National Pain Strategy (NPS) less than a week after it was made public. Obviously they didn't wait to hear from their members or people in pain -- as they are intent on seeing that rough beast of a plan be born no matter what people in pain think or want. The NPS is not "urgently needed" as they claim.

The NPS did not put a price tag on any of its plans or estimate how much their plan might save in costs; or how much the prevalence of painful conditions might be lowered or how much incidents of healthcare disparities might be reduced.

It is clear the government didn't want to include clear performance measures in the NPS. They do not wish to be held accountable to Americans or people in pain if the plan doesn’t work.

I do not support this thinly veiled occupational strategy that serves special interest groups without regard to the public good. Like a box of chocolates -- you don't know what you’re getting with this plan. 

DAVID BECKER

It is a big lie to say that the biopsychosocial model or interdisciplinary care meets the evidence based pyramid standards. Not enough research on their paradigm has ever been done and what little there is does not provide strong evidence for their paradigm over treatment as usual.

This plan has failed to learn from the mistakes of the past. A decade of pain control and research was a failure. It based its efforts on the “experts” -- as does the NPS. The more things change in pain care the more they remain the same. And people in pain remain condemned to the failed strategies of the past. The NPS, essentially, is nothing new.

It is clear that the 80 people who created the NPS don't have "the right stuff.” They have left too much to the imagination with their plan and leave out any plan for multi-morbidity or for treatment burden, and don't allow for an ongoing dialogue with people in pain.

To paraphrase Immanuel Kant, “We can think what we want, as long as we obey.”

The NPS was not a conversation with people in pain. It is a top down reductionist strategy by special interest groups to maintain their power and prestige. It will do very little for people in pain or address the ever rising economic burden of poor pain care.

As Helen Keller wrote, it is a terrible thing to see with no vision. The NPS fails to see much of the problems in pain care, failed to listen to the dried voices of people in pain, and offers no inspiring vision to address the many problems in pain care. The NPS is one rough beast that slouches toward Bethlehem and should never be born.

It is tragic that America can’t get it right when it comes to pain care. The politicos are anti-democratic and too ignorant of the real problems to create a sophisticated model or plan for dealing with pain.

My official comments to the NPS will excoriate their claims to expertise and their claims that they care about pain in America. But no article or comments will stop this rough beast from being born – too many organizations have been working hard to make it a reality.

What do you think? You can read the National Pain Strategy for yourself, by clicking here.

The NIH is accepting comments on the NPS until May 20, 2015.

Written comments can be emailed to NPSPublicComments@NIH.gov. They can also be addressed by snail mail to Linda Porter, NINDS/NIH, 31 Center Drive, Room 8A31, Bethesda, MD 20892.

Doctor Defends Use of Urine Drug Tests

By Pat Anson, Editor

A prominent pain doctor is disputing reports that a widely used urine drug test often gives faulty results.

“They are reasonably reliable and highly cost effective for use in a pain management practice. I would strongly recommend the practitioners use this,” said Laxmaiah Manchikanti, MD, chairman and CEO of the American Society of Interventional Pain Physicians.

Dr. LAXMAIAH MANCHIKANTI

Dr. Manchikanti, who is medical director of a pain clinic in Paducah, Kentucky, was the lead author of a study published in the journal Pain Physician in 2011, which looked at the reliability of immunoassay “point-of-care” (POC) tests. The urine tests are inexpensive and give immediate results, and doctors often use them to monitor their patients for opioid or illicit drug use.

“The UDT (urine drug test) with immunoassay in an office setting is appropriate, convenient and cost effective. Compared with laboratory testing for opioids and illicit drugs, immunoassay office testing had high specificity and agreement,” Manchikanti's study found.

Pain News Network recently reported on the results of a second study conducted by Millennium Health, a San Diego-based drug testing laboratory, which found that POC tests were wrong about half the time – frequently giving false positive and false negatives results for drugs like marijuana and oxycodone. The Millennium study advocates the use of chromatography-mass-spectrometry – a more complex laboratory test that costs thousands of dollars – to confirm POC test results.

“Following the advice from companies in reference to numerous expensive tests and also income generating avenues will only lead to time in the slammer and will not improve patient care at all,” said Manchikanti.

“(The) Millennium study is performed by the company which makes a living by testing. The more samples that are sent to them, the better off they are. Further, they are not even a practical setting. From our practice we send approximately only 2% of the samples for confirmation testing. Even then, the patients can’t pay their bills.”

Manchikanti’s study found false negative and false positive rates for POC tests that were far below the rates reported by Millennium.

For example, Millennium’s false positive rate for oxycodone was 41.3 percent. For Manchikanti, it was only 7.7 percent.

Millennium’s false positive rate for marijuana was 21.3 percent. For Manchikanti, it was just 2 percent.

There were discrepancies between the two studies for several other drugs, including methadone, cocaine and methamphetamine.

Millennium Sponsored Both Studies

How could two studies come to such different conclusions?

There were some differences in their design. Urine samples in the Millennium study came from nearly 4,300 patients in addiction treatment clinics, while the urine samples in Manchikanti’s study came from 1,000 patients in pain management programs. Millennium maintains the patients in its study were younger and more likely to be drug users.

Ironically, the laboratory tests for both studies were conducted by Millennium – which collected samples and provided chromatography-mass-spectrometry testing at no cost to Manchikanti. Millennium is identified as the “sponsor” of Manchikanti’s study, but he says the company had “no influence or interference” in his and his three co-authors’ findings.

“We had our agreement in the beginning itself that they will not be involved in any way in writing the manuscript or publishing the results. Consequently, they really did not have much input into the publication. The publication was as it is and without any bias from the industry,” Manchikanti wrote in an email to Pain News Network.

Millennium’s study, which was published last year in the Journal of Opioid Management, had six co-authors. All but one were employees of the company. The lone exception is a pain management doctor who frequently testifies as a legal expert for Millennium in court cases.

A source with broad experience in the drug testing industry told Pain News Network the data in Millennium’s study was “skewed toward exaggeration.”

“It does not surprise me that Millennium would show a high rate of inconsistencies with the POC test. Remember, their business is to sell confirmation testing, so they will skew the way they present data to try to influence the market to do more confirmation testing.  In most cases, that’s how it works in any study conducted or funded by a device or pharmaceutical company,” the source said.

Millennium bristles at the notion that its study was biased.

“Millennium Health strongly disagrees with the characterization… that the study was skewed or biased in any way,” the company said in a statement to Pain News Network.

“The study was accepted and published by a well-respected, peer-reviewed publication. Millennium Research Institute is committed to the highest ethical and research science standards, and we stand by the results of our study. The study was based on random samples from addiction treatment clients. The data clearly indicated that immunoassay, or point-of-care, tests have a high rate of false positives and false negatives when used to screen patients for illicit drug use.

“Millennium is committed to providing data that helps clinicians evaluate the best course of treatment for patients with pain and addiction issues. Millennium Health performs only the tests ordered by clinicians.”

In recent years a growing number of doctors who treat addicts and pain patients have required them to submit to drug tests. The competition between Millennium and other laboratories for this business is intense. According to one estimate, drug testing has grown into a lucrative $4 billion dollar a year industry.

But Manchikanti maintains that a single inexpensive urine test that costs about $20 is often the only one that’s needed.

“If a proper (patient) history is provided which matches with the test, there is no need for further testing,” he said.