Doctors Prescribing Opioids for Migraine Despite Risks

By Pat Anson, Editor

Physicians are still prescribing opioid painkillers or barbiturates to treat migraine, even though frequent use of the drugs can make headaches worse and raise the risk of addiction.

Over half the patients who visited a headache center in New York City said they had been prescribed opioids and/or barbiturates, according to a new study presented at the annual scientific meeting of the American Headache Society. About 20 percent of the 218 patients surveyed, most of whom had a migraine diagnosis, said they were still taking the drugs.

"Headache specialists are often in a difficult position when patients request opioids or increasing quantities of barbiturates," said lead author Mia Minen, MD, Director of Headache Services at NYU's Langone Medical Center. "Although many patients find these effective, they are known to contribute to headaches related to medication overuse."

Minen and her research team identified which physicians were prescribing the drugs and found the most frequent first prescribers of opioids were emergency room physicians, while general neurologists were the most frequent first prescribers of barbiturates. Primary care physicians were also identified as first prescribers.

"Taken as a whole, these data provide a useful snapshot of the wide variety of physician specialties that might benefit from additional education on the appropriate use of opioids and barbiturate-containing medications in patients with headaches," said Minen.

Opioids and barbiturates should only be used as a last resort to treat migraine, according to the American Board of Internal Medicine's "Choosing Wisely" campaign. The campaign recommends the first medications for migraine should be either over-the-counter pain relievers or a class of prescription drugs called triptans that are made specifically for migraine.

"This study underscores the fact that prescribers may not be aware of best practices in migraine care,” said Beth Darnall, PhD, a pain psychologist, clinical associate professor at Stanford University and author of Less Pain, Fewer Pills.

“Problems arise when ‘crisis solutions’ are applied as the de facto treatment for daily management of pain. Patients may believe that opioids are beneficial but they lead to worse migraine and headache pain, and are not considered appropriate first-line treatment for these conditions. If possible, patients should seek a specialized evaluation with a board certified specialist to ensure they receive medications that will help them in the long run.”

Darnall called opioids and benzodiazepines “a dangerous combination of medications,” and said they should be avoided or combined only under close medical supervision.

The problem extends far beyond the borders of the United States. According to the recently released Global Burden of Disease Study, the number of headaches caused by medication overuse has risen by 120% since 1990. Medication overuse headache is the 18th leading cause of disability worldwide.

New “Landmark” Class of Migraine Drugs Being Developed

Meanwhile, clinicians and researchers at the American Headache Society’s annual meeting are reportedly excited about a new class of drugs called Calcitonin Gene-Related Peptide (CGRP) monoclonal antibodies, which are showing promise in treating high-frequency episodic migraine and chronic migraine. Research studies on CGRP are being presented at the meeting, which draws more than 1,000 migraine specialists from around the world.

"This development is a transformative moment in migraine treatment," said Peter Goadsby, MD, who is chief of the UC San Francisco Headache Center and one of the world's leading headache treatment experts. "Up till now, migraine patients have had limited choices for preventive treatment. Now four pharmaceutical companies are showing positive results in human trials targeting CGRP mechanisms."

The new drugs appear to reduce elevated levels of the peptide known as calcitonin gene-related peptide, which is a key driver of migraine pain. Versions of anti-CGRP therapies are being tested by Alder Pharmaceuticals, Amgen, Eli Lilly and Teva Pharmaceuticals.

Teva reported that in a Phase II clinical study its CGRP therapy achieved a significant reduction in the number of headache hours after one week, with more than half of patients experiencing a 50% or greater reduction in headache frequency.

Amgen’s research showed showed that its anti-CGRP product also reduced the number of migraine days by 50% in about half the treated patients after 12 weeks.

"The potential of these new compounds is enormous and gives us real hope that effective specific treatments for migraine may be on the near horizon," said Goadsby. "The development of CGRP antibodies offers the simple, yet elegant and long awaited option for migraine patients to finally be treated with migraine preventives; it's a truly landmark development."

There has not been a new class of anti-migraine drugs since the development of triptans in the early 1990s.

Migraine is thought to affect a billion people and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

The month of June is Migraine Awareness Month.

Chronic Fatigue Patients ‘Disrespected and Rejected’

By Pat Anson, Editor

An independent panel convened by the National Institutes of Health is calling for major changes in the way the healthcare system treats people suffering from chronic fatigue – a complex and poorly understood disorder that affects an estimated one million Americans, most of them women.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is characterized by extreme fatigue, chronic pain, impaired memory, insomnia, and other symptoms that do not improve with rest.  Many of the symptoms overlap with other diseases and disorders -- including fibromyalgia, depression, and inflammation – making a correct diagnosis even more difficult.

There is also a stigma often associated with chronic fatigue.

“Both society and the medical profession have contributed to ME/CFS patients feeling disrespected and rejected. They are often treated with skepticism, uncertainty, and apprehension and labeled as deconditioned or having a primary psychological disorder,” the panel states in its final report.

“ME/CFS patients often make extraordinary efforts at extreme personal and physical costs to find a physician who will correctly diagnose and treat their symptoms while others are treated inappropriately causing additional harm.”

Although the economic burden of chronic fatigue is estimated at between $2 billion and $7 billion annually, the panel said there has been “minimal progress” in improving the state of science for ME/CFS over the last 20 years. There are no pathogens linked to chronic fatigue, no diagnostic tests and no known cures.

"We need to learn more about the cellular and molecular mechanisms of this disease and how immunologic, neurologic, and other factors contribute to ME/CFS," said Carmen Green, MD, the panel’s chair and professor of anesthesiology, obstetrics and gynecology, and health management and policy at the University of Michigan Schools of Medicine and Public Health.

"We need to fund more studies that can be easily reproduced, and we must gain a better understanding of how ME/CFS affects people and their families in terms that are clinically meaningful to them. In addition, we need to have a greater understanding of the impact of ME/CFS across the life span, especially in underserved and vulnerable populations."

What little research that has been done has focused on Caucasian, middle-aged women.  The panel said new studies need to include children, minorities, men, patients living in rural areas, and those who are homebound.

To address these knowledge gaps, the panel is calling for more research and opportunities for new investigators to study ME/CFS. It also called for the creation of a repository of biological samples from chronic fatigue patients (e.g., serum, whole blood, RNA, DNA) to support new studies.

In addition, the panel recommended new educational training courses to help health care providers diagnose and treat ME/CFS.

"ME/CFS exists, and despite the absence of a clear definition, an estimated one million Americans are affected by it," said Green. "In order to develop primary prevention strategies and effective drug treatments, there needs to be a clear understanding of its causes and the populations it affects."

Much of the information gathered by the panel came during a public workshop and public comment period in December of last year. The five member panel, which included Penney Cowan of the American Chronic Pain Association, operated as an independent commission. Its final report is not a policy statement of the NIH or the federal government, and there are no guarantees its recommendations will be funded or acted upon.

Value of Arthroscopic Knee Surgery ‘Inconsequential’

By Pat Anson, Editor

Arthroscopic knee surgery on older adults has become a routine procedure in North America and Europe – with over 850,000 arthroscopies performed every year to relieve knee pain in the UK and the United States alone.

But a new study published in the The BMJ questions the evidence behind the procedure and calls the benefit of knee surgery “inconsequential.” The article is part of The BMJ's “Too Much Medicine” campaign, which highlights the waste of resources and potential harm caused by unnecessary medical care.

“The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery,” the report says. “Taken together, these findings do not support the practice of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.”

Knee arthroscopies are a type of “keyhole” surgery in which the surgeon makes a small incision in the knee and inserts a tiny camera and instruments to diagnose and repair damaged ligaments or torn meniscus. Many specialists are convinced of the benefits of the surgery.

But when researchers in Denmark and Sweden reviewed 18 studies on arthroscopic knee surgery, they found that half were of poor quality or lacked a placebo control. The other nine studies found that the surgery provided pain relief for up to six months, but without any significant benefit in physical function.

Risks associated with arthroscopic knee surgery, although rare, include deep vein thrombosis (DVT), infection, pulmonary embolism, and death.

"It is difficult to support or justify a procedure with the potential for serious harm, even if it is rare, when that procedure offers patients no more benefit than placebo," argues Professor Andy Carr from Oxford University’s Institute of Musculoskeletal Sciences in an accompanying editorial.

With rates of knee surgery at their current level, Carr says thousands of lives could be saved and DVTs prevented each year if the procedure was discontinued or diminished.

“We may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests. When that point is reached, we should anticipate a swift reversal of established practice,” Carr wrote.

The BMJ study is not the first to question the value of arthroscopic knee surgery.  A 2014 report by a German health organization found the procedure provides no benefit to patients with osteoarthritis, and does not relieve pain any better than physical therapy or over-the-counter pain medications.

Another large study in Australia also questions the value of arthroscopic knee surgery, finding there was no significant benefit for osteoarthritis patients.

The American Medical Society for Sports Medicine (AMSSM) lists arthroscopic knee surgery as one of five procedures that are not always necessary in the Choosing Wisely campaign. The AMSSM advises physicians to avoid recommending knee arthroscopy as a treatment for patients with degenerative meniscal tears.

Depending on insurance, hospital charges and the surgeon, arthroscopic knee surgery costs about $4,000.

Nasal Spray Approved for Migraine in Children

By Pat Anson, Editor

The U.S. Food and Drug Administration has approved a nasal spray for the treatment of migraine in pediatric patients, the second migraine drug the agency has approved in the last month for patients 12 years of age and older.

About one in five teens suffer from migraine, but treatment options for them have been very limited compared to adults.

Zomig nasal spray was first approved by the FDA in 2003 for the treatment of migraine in adults. It provides pain relief in as little as 15 minutes, with most patients obtaining some relief in about two hours.

The FDA’s approval came after the agency reviewed safety and efficacy data from clinical trials demonstrating that Zomig was significantly more effective than placebo in relieving headache pain and other migraine symptoms in pediatric patients. It also had a safety profile similar to that in adults.

Zonig is the first prescription nasal spray approved for migraine in children. The most common adverse reaction to Zomig in pediatric patients during clinical trials was an unusual taste.

"Treatment options have been limited for pediatric patients and we are pleased with FDA's decision and look forward to bringing migraine relief to pediatric patients by making Zomig Nasal Spray available to this 'school age' patient population," said Fred Wilkinson, President and CEO of Impax Laboratories, which obtained the U.S. commercial rights to Zomig products from AstraZeneca in 2012. Impax has since lost exclusive rights to Zonig tablets and is focused on the nasal spray.

The recommended starting dose for Zomig in pediatric patients is 2.5 mg. The dosage can be adjusted on an individual basis, but should not exceed 5 mg in a single dose or a maximum daily dose of 10 mg in any 24 hour period.

Last month the FDA approved the migraine drug Treximet for pediatric patients 12 years of age and older.. Treximet is the first approved combination drug for migraine to contain sumatriptan and naproxen, a non-steroidal anti-inflammatory drug (NSAID). Sumatriptan is a triptan that works in the brain by reducing vascular inflammation. 

Like Zomig, Treximet had already been on the market for several years to treat migraine in adults.

Migraine is thought to affect a billion people worldwide and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound. About half of people living with migraine are undiagnosed.

The month of June is Migraine Awareness Month.

Do You Want More Pain Medication?

By Pat Anson, Editor

The question sounds so simple.

An emergency room doctor asks a patient in pain, “Do you want more pain medication?"

If the patient says “yes,” an intravenous injection of the opioid painkiller hydromorphone is given.

Thirty minutes later, the question is asked again. If the patient is still in pain, another injection is provided -- and another after that and another after that.

In all, up to four injections of hydromorphone are given within four hours if the patient asked for them.

That simple protocol – far different than what many chronic pain patients experience in a hospital emergency room -- resulted in satisfactory pain control in 99 percent of ER patients participating in a new study published in the Annals of Emergency Medicine.

Over 200 patients in acute pain were involved in the study, which was designed to individualize pain treatment at Montefiore Medical Center in the Bronx, NY, one of the busiest emergency rooms in country.

Almost all of the patients were satisfied with their pain treatment: 67 percent reported being very satisfied and 29 percent said they were satisfied. About half asked for just one injection. Only two patients asked for all four injections.

"Our pain protocol is a departure from the more traditional ways of assessing pain relief, which typically use the visual analog scale or the numerical rating scale. Instead, our use of a non-numerical, simple yes/no question offers patients the ability to decide for themselves whether their pain is adequately controlled,” said lead author Andrew Chang, MD, of the Department of Emergency Medicine at Montefiore Medical Center.

“We initially had concerns that a protocol in which patients could receive as much as 4 mg hydromorphone simply by requesting it when asked might facilitate drug-seeking behavior. However, we found no evidence to support this concern.”

Patients in chronic pain or those who had used opioids in the past 7 days were excluded from the study because the research only focused on patients in acute, short-term pain.

Readers who posted comments to earlier stories we’ve done about emergency room pain care often express frustration with the treatment they received. Some were denied opioid analgesics. Even one doctor lamented the quality of ER pain care.

“I dread the day when I need to get ER help. Sadly, most of us physicians don't know it all. And, so far as pain care goes, it seems to have become medical care by committee. Caring for patients as individuals seems to have slipped their minds,” wrote Michael.

How have you been treated in emergency rooms?

Should chronic pain patients have been included in this study?

Power of Pain: Take Charge of Your Pain Care

By Barby Ingle, Columnist 

When it comes to living the best life you can, everyone has choices. There are even more choices for those who face a chronic illness. The patient can either let the disease run them or they can sort through the system and take control of their disease.

Coping with a chronic condition takes hope and self-awareness. You can make it through the toughest of situations. I know because if I can do it, anyone can.

Your first goal should be getting a correct diagnosis. If you need to go to multiple providers, take the time to do it to help prevent your health from deteriorating. Each provider has their specialty as well as treatment options with which they are comfortable. But that does not always mean they have the right plan for you or that another option won’t work. If you are not comfortable with the ones offered by your current provider, find a doctor who you trust to try different treatment options.

Getting organized is very important. It will take work in the beginning, but it gets easier as you go. You will save yourself from more pain by being organized in your approach to treating your chronic medical issue.

It can be very aggravating to deal with a kidney stone or torn ligament, but at least there is an end in sight. You can get back to a “normal life” once the stone passes or the bone break heals. Other conditions such as heart failure, diabetes, Lyme disease, multiple sclerosis, Reflex Sympathetic Dystrophy (RSD), arthritis, osteoporosis, and neuropathy can be more of a challenge and usually last a lifetime.

Take charge of your disease instead of letting it rule you. Some doctors, friends, and even family may say, “Just live with it” or “Get used to it.” But you are the one who lives with this chronic condition. You can learn to manage life around the symptoms and problems, without losing yourself.

For the person in pain there is usually a loss in quality of life. This can be due to financial burdens, loss of social support and  depression. Being depressed can result in isolation, loss of self-esteem, and self-worth.

It is important to recognize that we need support as patients. We need positive attitudes and must recognize there will be life changes. Some will be easier, such as changing your diet or beginning a physical therapy routine. Others will be more difficult, such as having to sever ties to a family member or friend who is hindering your recovery. We also need support from our healthcare providers.

Most of all, we need to recognize that we are responsible for ourselves and that successful treatment may result in necessary lifestyle changes that only we can provide to ourselves.

We all deserve to have our pain taken seriously. To have the pain managed instead of under-treated, untreated, or over-treated is an important aspect of successful outcomes. Pain must be managed effectively and in a timely manner. The underlying condition needs to be addressed while the pain is being managed.

Remember, every patient is different and doctors only know what they have been exposed to in their schooling and continuing education classes. For example, if they are a regular attendee at a pain education conference they may skip the class on multiple sclerosis or Lyme disease because they have a greater interest in migraines. As a patient it is up to you to become the chief of staff of your medical team.  Develop a strong team willing to help, learn, and treat you.

Chronic pain is a disease in itself. Our medical system needs to recognize this and change its practices to prevention, instead of just treating the person after they’ve become ill. For example, we should teach children about good posture and body alignment, and have them practice it. This can help them keep the habit throughout adulthood, cutting down on back issues and conditions that lead to the need for chronic care.

We must be mindful to get the proper healthcare professionals on our team. The goal is to receive effective relief, and be able to organize and manage all aspects of life. Finding good healthcare and support systems will lower the number of hospital visits, the amount of time spent in the hospital, unnecessary trips to the emergency room, repeated tests, and inadequate treatments. All of which contribute to the high costs of healthcare. 

Barby Ingle suffers from RSD and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the Power of Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at www.barbyingle.com and at www.powerofpain.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.

There is No 'Epidemic' of Painkiller Overdoses

By Ken McKim

There is no "epidemic" of opioid overdoses. If 16,000 deaths in a year is an epidemic, then we really need to focus on the pandemic that is the over 100 million people in the U.S. who suffer from chronic pain.

For example, car crash fatalities in 2013 claimed more lives than opioid overdoses (there were 30,057 fatal motor vehicle crashes in the United States in 2013 in which 32,719 deaths occurred according to IIHS). As this qualifies as an epidemic by some people's twisted logic, I suggest we handle reducing car crash fatalities in the same manner that we regulate the prescribing of painkillers.

Effective immediately, you will have to own your car for two months before you can get a license to drive it. To obtain a driver's license, you must first establish a history with the DMV by visiting them at least two times per month for two months, paying $40 per visit during the two-month period you are waiting to get approved for your license.

Once you have your driver's license, you will only be able to purchase gasoline at particular gas station with a signed fuel-certificate from the DMV, which will allow you to purchase what the DMV thinks is an adequate supply of gas for a 30-day period.

For each new 30-day supply of gasoline you must obtain a new fuel certificate from the DMV, which will require another $40/five-hour appointment at the DMV.

If you try to take your DMV fuel-certificate to a different gas station than you normally use, your fuel-certificate may be refused and your name entered into a national database as someone guilty of "fuel seeking behavior."

Additionally, you will not be able to refill your gas supply after 3PM on Fridays, weekends or holidays. Your gas allotment must last for the full 30-day time-frame specified by the DMV. If you run out of gas before that 30-day period is up, you will not be able to get another fuel-certificate until the 30-day calendar period has ended. So remember, you should not be driving anywhere except to and from work, with possibly a once a week trip to the grocery store.

NOTE: Asking for more than your allotted fuel allowance will also constitute "fuel seeking behavior" and the DMV may choose to no longer see you.

The DMV also reserves the right to randomly smog check your vehicle at any time. If your vehicle fails the smog inspection, your driver's license will immediately be revoked.

NOTE: You must pay the cost of the smog inspection yourself.

I'm sure this will result in an immediate drop in automobile deaths. You're welcome.

This column is republished with permission from Ken McKim’s website, “Don’t Punish Pain.”

Ken began advocating for pain patients when his wife was diagnosed with Crohn’s disease – and he came to realize that the chronically ill were often stigmatized by society. That realization led him to make a 32-minute video called "The Slow Death of Compassion for the Chronically Ill"

Ken has a series of other informative videos on You Tube.

All Forms of Medical Marijuana Now Legal in Canada

By Pat Anson, Editor

Medical marijuana advocates are cheering – and some health officials are jeering – a landmark ruling by the Supreme Court of Canada allowing patients to use cannabis in any form they choose.

The unanimous decision greatly expands the use of medical marijuana in Canada beyond the traditional means of smoking it – to include everything from cookies and teas to ointments and tinctures that are laced with THC and cannabinoids, marijuana’s active ingredients.

Many users believe smoking marijuana is harmful to their health. But under Canada’s Controlled Drug and Substances Act, use of marijuana outside of its “dried” form could result in possession and drug trafficking charges.

That’s what happened to Owen Smith, a baker for the Victoria Cannabis Buyers Club, who was arrested in 2009 for making over 200 cookies containing marijuana, as well as various oils and lotions.

The Supreme Court upheld two lower court decisions that acquitted Smith, saying the government’s marijuana law violated his right to liberty and security "in a manner that is arbitrary and hence is not in accord with the principles of fundamental justice." 

The court declared the marijuana section of the law “null and void” immediately, rather than give Parliament a chance to rewrite it. To do otherwise, the court said, would "leave patients without lawful medical treatment.”

"I'm proud and really happy today for all those people who are going to benefit from this ruling," Smith said at a press conference in Victoria, British Columbia. “Across the country there will be a lot more smiles and a lot less pain.”

“How exciting is this! I am thrilled with this decision,” said Ellen Lenox Smith, a medical marijuana advocate and columnist for Pain New Network. 

Smith, who is not able to smoke marijuana because of a medical condition, wrote a column earlier this month about ways to consume marijuana for pain relief without smoking it.  She prefers a nightly dose of a marijuana oil that she makes herself.

“It all depends on the patient, condition, type of medicine used and how your body reacts. This is a wonderful alternative. We all have to find the magical way to administer,” she said. “I applaud them for having the courage to understand the reality of this medication. One size does not fit all and allowing for the variety is wonderful and something I hope we will always be allowed to turn to for help.”

Canadian health officials are angry about the court’s decision.

"Frankly, I'm outraged by the Supreme Court," said Health Minister Rona Ambrose, according to CBC News.

"Let's remember, there's only one authority in Canada that has the authority and the expertise to make a drug into a medicine and that's Health Canada," she said. "Marijuana has never gone through the regulatory approval process at Health Canada, which of course, requires a rigorous safety review and clinical trials with scientific evidence."

Ambrose said the government would fight against the court's "normalization" of marijuana with a public relations campaign outside the courtroom.

"We will continue to combat it. We will continue our anti-drug strategy, we will target youth with the message that marijuana pot is bad for them," the minister said. "We'll continue to work with medical authorities across the country to make sure they're involved in the message."

British Columbia’s chief medical health officer says edible marijuana products should come with labels listing the strains used and their potency, to help ensure that users don’t accidentally overdose and get sick.

“Quality control, certainly for medical use, should be labelled and analyzed,” Dr. Perry Kendall told the Vancouver Sun. “It would be better for people, if they’re taking an illegal product by mouth, to know how much and what, is in it.

“It can take a half an hour to an hour to absorb through the stomach.  If you’re a naive young user you might go on eating and eating because you don’t feel anything and then you take more than you want to.”

Medical marijuana – in all its various forms -- is legal in 23 U.S. states and the District of Columbia. However, there are no regulations governing its quality, dosage or labeling.  

“Evidence in the U.S. is that wider availability of these products is causing increased poisonings in children, and we want to prevent this from occurring here in Vancouver,” the city of Vancouver warned in a news release after the Supreme Court’s ruling. “Unregulated edible products also pose a greater risk to adults than other forms of marijuana.”

Aleve & Other Pain Relievers Reduce Fertility in Women

By Pat Anson, Editor

Health experts have warned for years about the side effects of over-the-counter pain relievers – everything from liver failure to heart disease to hearing loss.

Now researchers are saying that Aleve and some other non-steroidal anti-inflammatory drugs (NSAIDs) reduce the fertility of women so significantly they could potentially be used as an emergency form of contraception.

The results of a small study presented at the European League Against Rheumatism Annual Congress show that three NSAIDs --  naproxen, diclofenac, and etoricoxib -- inhibited ovulation in women after just a few days of treatment.

Naproxen, diclofenac, and etoricoxib are the active ingredients in several brand name drugs sold around the world, including Aleve, Voltaren, and Arcoxia, respectively. Etoricoxib is not approved for use in the United States.

Thirty nine Iraqi women of childbearing age who suffered from back pain took part in the study; receiving diclofenac (100mg once daily), naproxen (500mg twice daily), etoricoxib (90mg once daily), or a placebo.

Treatment was given for 10 days from day 10 of the onset of their menstrual cycle, with their progesterone levels and follicle diameter analyzed via blood sample and sonography.

“After just ten days of treatment we saw a significant decrease in progesterone, a hormone essential for ovulation, across all treatment groups, as well as functional cysts in one third of patients,” said study investigator Professor Sami Salman, Department of Rheumatology, University of Baghdad.

“These findings show that even short-term use of these popular, over-the-counter drugs could have a significant impact on a woman's ability to have children. This needs to be better communicated to patients with rheumatic diseases, who may take these drugs on a regular basis with little awareness of the impact.”

Of the women receiving NSAIDs, only 6.3% taking diclofenac, 25% taking naproxen, and 27.3% taking etoricoxib ovulated, compared with 100% of the control group that was not taking a pain reliever.

The dominant follicle remained unruptured in 75% of the women taking diclofenac, 25% taking naproxen and 33% of the patients receiving etoricoxib. Rupturing of the dominant follicle and the subsequent release of an oocyte (unfertilized egg), is essential for ovulation to occur.

“These findings highlight the harmful effects NSAIDs may have on fertility, and could open the door for research into a new emergency contraception with a more favorable safety profile than those currently in use,” said Salman.

NSAIDs are among the most common pain relief medicines in the world. Every day more than 30 million Americans use them to relieve pain, lower fever and reduce inflammation.

How Chronic Pain Changes Mood and Motivation

By Pat Anson, Editor

Researchers in California have found the first biological evidence that chronic pain alters regions in the brain that regulate mood and motivation -- raising the risk of depression, anxiety and substance abuse.

In animal studies at UCLA and UC Irvine, researchers found that brain inflammation in rodents that was caused by chronic nerve pain led to accelerated growth and activation of immune cells called microglia. Those cells trigger chemical signals within the brain that restrict the release of dopamine, a neurotransmitter that helps control the brain's reward and pleasure centers.

"For over 20 years, scientists have been trying to unlock the mechanisms at work that connect opioid use, pain relief, depression and addiction," said Catherine Cahill, associate professor of anesthesiology & perioperative care at UCI, Christopher Evans of UCLA's Brain Research Institute. "Our findings represent a paradigm shift which has broad implications that are not restricted to the problem of pain and may translate to other disorders."

The study also revealed why opioid drugs such as morphine and cocaine may lose their effectiveness as animals transition from acute pain to chronic pain. Cahill and her colleagues learned that opioids fail to stimulate a dopamine response in mice and rats, resulting in impaired reward-motivated behavior.

Treating the rodents with a long-acting antibiotic called minocycline inhibited microglial activation, and restored dopamine release and reward-motivated behavior. That finding suggests that a similar approach could be used in treating chronic pain in humans.

"Our findings demonstrate that a peripheral nerve injury causes activated microglia within reward circuitry that result in disruption of dopaminergic signaling and reward behavior. These results have broad implications that are not restricted to the problem of pain, but are also relevant to affective disorders associated with disruption of reward circuitry," the study found.

The results of the five-year study appear online in the Journal of Neuroscience.

Cahill and her research team are now trying to establish that pain-derived changes in human brain circuitry can account for mood disorders.

"We have a drug compound that has the potential to normalize reward-like behavior," she said, "and subsequent clinical research could then employ imaging studies to identify how the same disruption in reward circuitry found in rodents occurs in chronic pain patients."

Back Pain World's Leading Cause of Disability

By Pat Anson, Editor

Lower back pain remains the world's leading cause of disability, according to an extensive new study of health data that also warns that the number of people living in poor health is set to rise rapidly over coming decades.

Using a statistical analysis known as "years lived with disability" (YLD),  the Global Burden of Disease Study ranks lower back pain as the leading cause of disability worldwide, followed by major depression.  

Low back pain was the leading cause of YLDs in 86 countries and the second or third leading cause in 67 countries. It also caused more health loss than diabetes, chronic obstructive pulmonary disease, and asthma combined.

Several other painful conditions also ranked high, including neck pain (#4), migraine (#7),  musculoskeletal disorders (#10), osteoarthritis (#13) and medication overuse headache (#18).

The study, which is published online in The Lancet, is the first to examine the extent, pattern, and trends in disabilities worldwide. An international consortium of researchers led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington studied 301 diseases and injuries in 188 countries.

They found that while people around the world are living longer, they are spending more time in ill health as rates of diseases and injuries decline more slowly than death rates.

Just one in 20 people worldwide had no health problems in 2013, with a third of the world’s population -- 2.3 billion people -- experiencing more than five ailments. Of those, 81% were younger than 65 years old.

The disease burdens for low back pain and depression both increased more than 50% since 1990. There was also a startling increase in disability caused by diabetes (up 136%), Alzheimer’s disease (up 92%), medication overuse headache (up 120%), and osteoarthritis (up 75%).

"What ails you isn't necessarily what kills you," said IHME Director Dr. Christopher Murray. "As nonfatal illnesses and related ailments affect more people of all ages, countries must look closely at health policies and spending to target these conditions."

Between 1990 and 2013, YLDs increased from 537.6 million to 764.8 million for both sexes. The leading causes of YLD remained largely stable during this period, but they took an increased toll on health due to population growth and aging.

Musculoskeletal disorders, combined with fractures and soft tissue injuries, accounted for one-fifth of YLDs globally in 2013, ranging from a low of 11% for Mali's population to a high of 30% in South Korea.

"Many countries around the world have made great progress in addressing fatal diseases, but nonfatal illnesses pose the next major threat in terms of disease burden," said Professor Theo Vos of IHME, the study's lead author. "This need to meet the challenge of nonfatal diseases and injuries only becomes more urgent as the population increases and people live longer."

Leading Causes of YLDs in 2013:

1.  Low back pain
2.  Major depressive disorder
3.  Iron-deficiency anemia
4.  Neck pain
5.  Hearing loss
6.  Diabetes
7.  Migraine
8.  Chronic obstructive pulmonary disease
9.  Anxiety disorders
10.  Other musculoskeletal disorders

“Large, preventable causes of health loss, particularly serious musculoskeletal disorders and mental and behavioral disorders, have not received the attention that they deserve. Addressing these issues will require a shift in health priorities around the world, not just to keep people alive into old age, but also to keep them healthy,” said Vos.

This study was funded by the Bill & Melinda Gates Foundation.

Five Ways TIME Gets Pain Pills So Wrong

By Crystal Lindell, Columnist

Access to pain pills is not a cause I chose. I didn’t wake up one day and think, “Gee, more people need opioids.”

No, access to pain pills is a cause that chose me. Because I really did wake up one day two and half years ago, and say, “What is wrong with me? Why do I suddenly have insane pain in my ribs?”

It’s a pain that never went away. And for months, the doctors didn’t take me seriously. They gave me prescription-strength Advil, Lidoderm patches, and told me to wear looser bras.

None of that worked.

So, for weeks on end, the pain got worse and worse, while I tried multiple doctors, trying to find someone who could help.

I was in so much pain that I would often lay down on the ground mid-sentence because I didn’t have it in me to keep standing. The pain was just that overwhelming.

And at night, after trying to survive the day, I would lay in bed and plan ways to commit suicide. I wish I was exaggerating.

Finally, I found a pain specialist who put me on hydrocodone. At the time I had no idea that opioids were controversial. I was just happy to finally have found something that gave me relief.

The problem with hydrocodone though is that it comes with these crazy spikes. So you take a pill, it relieves the pain and then it completely wears off within a couple hours — and you to wait six hours for your next dose. It’s a horrible way to live.

I’m also on a time-released morphine that lasts about 8 hours. I take it three times a day — so I am always on an opioid, 24 hours a day. And then, on top of that, I also take hydrocodone as needed.

I pretty much always need it.

The pain still gets bad. But now, because of the pain pills, I have times when I am nearly pain free. Times when I can catch my breath and remember that life is worth living.

Opioids have literally saved my life.

Which is why I’m so upset about TIME magazine’s cover story about the “worst addiction crisis America has ever seen.” 

I realized when I read the article that I am spoiled by my Facebook news feed. I tend to follow chronic pain groups, so most of the information I see is about how chronic pain patients need access to these drugs. As a result, I’ve been lulled into thinking that the chronic pain community is actually making progress on this issue.

Apparently, we aren’t.

And it is articles like this that make it that much harder for pain patients like me to get the relief they need.

Let’s break down what it gets so wrong, with some quotes from the report:

1.    It implies time-released morphine is basically heroin.

“The longer patients stay on the drugs, which are chemically related to heroin and trigger a similar biological response, including euphoria, the higher the chances users will become addicted.”

Aside from the excessive number of commas, there are so many infuriating things about this sentence. 

While the drugs can give you a “high” feeling when you first start taking them, I can promise you — after being on morphine all day, every day for over a year — that the “high” is only a short-term side effect.

Also, comparing the drugs I take to heroin is like saying that both TIME and US Weekly are similar because they both require reading. Yes, that’s true. But that’s about all they have in common.

2. The article focuses on how much the drug companies are supposedly making on these meds.

“The total annual sales for opioids in the U.S. has grown over 20 years to more than $8 billion.”

While there have been some new meds on the market, like Zohydro, the pills that I take and the pills most of the people I know take, are generic. Morphine isn’t exactly a brand name.

Giving people relief from horrific, daily pain is not part of some drug company conspiracy. It’s called compassion.

3. It devalues how horrible pain can be.

“The standard-setting Joint Commission on Accreditation of Health Care Organizations in 1999 required doctors to measure pain as part of their basic assessment of a patient’s health, which had the effect of elevating pain the same level of importance as objective measurements like temperature and heart rate.”

The author writes that like it’s a bad thing. I’m here to tell you, it’s not. Pain is such a huge part of your health. And managing it is just as important as managing your blood pressure or your insulin level.

Having too much pain will ruin your life and your body just like any other health issue.

Living with chronic pain is like living every day of your life with the same amount of pain you would wake up with after an extensive surgery, or a horrific car accident, or a stabbing.

Anyone in those situations would be given adequate pain relief. And, just because people with chronic pain have that same pain every day, all day, doesn’t mean they don’t deserve the same relief.

4. It implies that anyone on long-term pain medications is an “addict.”

“With America awash in opioids for the foreseeable future, health care providers and public officials are searching for ways to help addicts get clean.”

I don’t need to “get clean.” I need a cure, but there isn’t one for what I have. The next best thing is daily pain relief. Going off all my meds would be catastrophic for me, not because I’m addicted, but because I would end up stuck on the couch for the rest of my life in too much pain to shower.

Also, we need to take a second to talk about the word “addicted.” It is very different from what’s actually happening for most people, which is “dependence.”

Dependence is what happens when you take lots of different types of drugs long-term. Your body becomes dependent, so going off them cold turkey would be hell. However, if you taper off it, you’re good. Just like anti-depressants. And nobody ever says people are “addicted to anti-depressants.”

Addiction is when you start to crave that high feeling you get the first few times you take the drug, so you start taking higher and higher doses seeking it out. Sort of like how all of us are dependent on food, while a select few are addicted.

5. The authors don’t mention any alternatives.

For those enduring chronic pain, the real-life alternative to not having adequate pain pills is suicide.

Articles like this just make it that much harder for people with chronic pain to get the medications they need. If you want to see the suicide rate jump, just take away the medications that so many people rely on to do even simple things, like make dinner or do a load of laundry.

Look, I’m not saying everyone with a cold should get a prescription for morphine. I’m just saying that there are millions of people out there who need these drugs. And more regulation just gets in the way of decisions that doctors and patients should make together to help those who are suffering cope with their pain. The government should never be in anyone’s doctor’s appointment.

At the end of the day, I guess I just wish that TIME had talked to even one chronic pain patient for the article. There are millions of us out here, responsibly using opioids long-term, and we would have loved to chat with TIME.

If only they had asked.

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.

Critics Question Oxygen Therapy for Fibromyalgia

By Pat Anson, Editor

Some experts are challenging the findings of a new clinical study that found that hyperbaric oxygen therapy (HBOT) could be used to treat -- and possibly even cure -- fibromyalgia.

Israeli researchers gave HBOT therapy to dozens of women suffering from fibromyalgia and found there was a significant improvement in their pain and other symptoms. The women were put in pressurized air chambers and breathed pure oxygen for 90 minutes, five times a week for two months.

Researchers say brain scans of the women before and after HBOT proved their theory that additional oxygen alters brain pathology and "repairs" parts of the brain overly sensitized by chronic pain. 

"Brain pathology? This is speculation being presented as established knowledge," said John Quintner, MD, an Australian rheumatologist who maintains that fibromyalgia is not a disease, but a "symptom cluster" that could have many different causes.

tHE INTERIOR OF A HYPERBARIC CHAMBER. COURTESY OF Sagol Center for Hyperbaric Medicine and Research

Fibromyalgia is a poorly understood disorder that is characterized by deep tissue pain, headaches, fatigue, depression and insomnia. The cause is unknown.

"This clinical trial is using a methodology that is predicated upon fibromyalgia being a distinct medical condition," said Quintner, telling Pain News Network that the study proved little, but was "good news for those who manufacture portable HBOT units." 

Researchers at the Sagol Center for Hyperbaric Medicine and Research at the Assaf Harofeh Medical Center and Tel Aviv University were studying the use of HBOT on stroke and concussion patients when they realized that oxygen therapy might also change the neural activity of patients with fibromyalgia.

"Patients who had fibromyalgia in addition to their post-concussion symptoms had complete resolution of the symptoms," said Shai Efrati, MD,  lead author of the study that is published online in PLoS ONE. 

Efrati said some patients will require follow-up sessions of HBOT and some won't need to.

"We have learned, for example, that when fibromyalgia is triggered by traumatic brain injury, we can expect complete resolution without any need for further treatment. However, when the trigger is attributed to other causes, such as fever-related diseases, patients will probably need periodic maintenance therapy."

HBOT puts more oxygen into the bloodstream, which delivers it to the brain. Efrati's earlier studies found that HBOT induces neuroplasticity, which leads to repair of chronically impaired brain functions. Most of the women who participated in the new study had fibromyalgia that the researchers believe was triggered by brain trauma.

DR. SHAI EFRATI

"Symptoms in about 70 percent of the women who took part have to do with the interpretation of pain in their brains," said Eshel Ben-Jacob, a study co-author who is an adjunct professor of biosciences at Rice University. "They're the ones who showed the most improvement with hyperbaric oxygen treatment. We found significant changes in their brain activity.

"Most people have never heard of fibromyalgia. And many who have, including some medical doctors, don't admit that this is a real disorder. I learned from my MD friends that this is not the only case in which disorders that target mainly women raise skepticism in the medical community as to whether they're real or not."

HBOT Claims Called "Crazy" 

One of those skeptics is Fred Wolfe, MD, a prominent fibromyalgia researcher who says the Israeli study lacks proper controls used in most clinical studies -- such as patients being "blinded" to whether they are receiving treatment or a placebo.  

"The fibromyalgia study world is filed with positive studies based on unacceptable controls," said Wolfe. "While I don't know enough about this treatment to be sure, I would tend to think the symptomatic improvement could be based on control and blinding problems. It is possible that the demonstrated effect on the brain of oxygen is separate from the effect of symptoms." 

Wolfe is particularly troubled by a recommendation at the end of the study that fibromyalgia patients should undergo HBOT therapy now, "rather than wait until future studies are completed.”  

"I could only characterize (that) as crazy. Crazy because of the money it would cost and crazy because it posits fibromyalgia as brain disease. FM is not a disease and there is a difference between mechanism and causes. One needs some replication before jumping in," said Wolfe in an email to Pain News Network. 

Many fibromyalgia patients are ready to jump in, based on the comments from readers to our first report about the Israeli study.

"Where do you find studies like this to volunteer? I would so do this," wrote one fibromyalgia sufferer.

"I would so try this. I often feel like I'm not getting enough oxygen," said another.

"Sign me up, please," a woman wrote.

"Is this available in Tucson or Phoenix, Arizona?" asked another woman.

Many fibromyalgia sufferers are desperate for any kind of treatment that would provide relief, much less a cure. In the Israeli study, several patients either drastically reduced or eliminated their use of pain medications.

"The results are of significant importance since, unlike the current treatments offered for fibromyalgia patients, HBOT is not aiming for just symptomatic improvement," said Efrati. "HBOT is aiming for the actual cause -- the brain pathology responsible for the syndrome. It means that brain repair, including even neuronal regeneration, is possible even for chronic, long-lasting pain syndromes, and we can and should aim for that in any future treatment development."

John Quintner is not convinced.

"I have thought long and hard about this issue and have come to the conclusion that we have been dealing with a 'symptom cluster' rather than with a syndrome," he said. "According to my understanding, fibromyalgia is best explained as an  'idiom of human distress' and, as such, is outside the purview of the biomedical model." 

Invisible Illness: A Blessing or Burden?

(Editor’s note: Pain News Network is pleased to welcome Pat Akerberg as a columnist. Pat is an executive coach and business consultant who suffers from trigeminal neuralgia, a rare facial pain disorder. She shared her story recently in a column.)

By Pat Akerberg, Columnist

Even though we can’t see some things, they still exist nonetheless.  Take imperceptible things like belief, faith, hope, or even the air that we breathe.  Our indirect experience of those things comes from a hidden world.  I suppose we could view their invisibility as either a blessing or a burden.

Sometimes invisibility is a deliberate strategy intended to hide or protect.  I readily count make-up as a blessing designed to hide or conceal.  Military clothing is a tactic borrowed from nature that camouflages for protection. 

The question that I ask is posed in the context of living with invisible chronic illness and/or pain, certainly not felt indirectly or deliberately designed. 

So ask yourself: Is the invisible illness and pain that you live with a blessing or a burden?

I’d have to answer “yes” to both blessing and burden.  It’s not either one or the other for me; it’s  both -- a burden that also offers some blessings.

In the burden category, explaining my neurological disorder to raise awareness and educate others can require energy that I don’t always have.  This is especially true if you have a rare illness like mine that triggers unseen pain when you speak. 

A SCENE FROM THE 1933 MOVIE "THE INVISIBLE MAN"

It’s a real Catch-22, because emotionally I desire the understanding. However, there’s a high price physically in trying to get some level of it.

Then there are the not always successful attempts to find an effective way of answering the oft dreaded questions, like:

 How are you?

 Are you feeling better now (or yet)?

 You don’t seem to be getting better. Have you thought of trying (fill in the blank)? 

Six years later and my continual test drives of better ways to answer those questions -- that don’t shut down a conversation or open it up to redundant, ill-fitting advice -- still take lots of practice, just like a workout routine. 

High on my burden list would be all the small, insidious ways in which I extend myself to fit in or help others be more comfortable around someone who doesn’t look sick or in pain -- yet won’t get “back to normal” again. 

Sometimes I say yes to invites so as not to disappoint someone close.  I minimize the level or graphic description of pain that I’m in; contort my facial expression into a smile or semi-laugh to keep rapport; or attempt to eat something someone brought, even though it physically pains me to do those things.

Longing for Connections

You’re probably asking, “Why, Pat, do you do them if they can be a burden? “

It’s a fair question. 

The short answer is because they relate to the blessing part of my burden.  Living with invisible chronic pain is a great social isolator; one that prescriptions don’t treat. 

To the contrary, human connection for me serves as a much needed lubricant that primes my psychological and emotional gears to work better.  So I’m motivated to interact in spite of the price.  And, realistically, when I can, I do. And when I can’t, I don’t.   

In talking with my trigeminal neuralgia (TN) friends, we have remarked how it would be easier if our plight and handicaps were visible.  Maybe then, we fantasize, the understanding and compassion that we seek and need would be more forthcoming. 

We have also wondered if our experience of being misunderstood would be different if we had an illness or disease that had a medical label more widely recognized, publicized, or even scary. 

We witness that even the terrifying descriptions used for TN, like “the worst pain known to medical practice” or “the suicide disease” seem to diminish in stature in comparison to those. 

It’s maddening and confounding how something so torturous going on inside of us rarely registers to that extent in our external world. 

Yet, at the same time, these longings of ours do contain the special favor of not attracting the kind of unfavorable attention that we don’t want.  Those who don’t know us aren’t as likely to stare at us, give us those judgmental looks, or jump to conclusions about our health or wellness based solely on what they see. 

So in that sense, I have come to view the invisibility of TN as a mixed blessing that protects me from those hurtful, unwarranted glances.

Having the luxury of being able to control how much information that I want to share about my particular affliction is another blessing I receive from the invisibility of it.  That includes my personal struggles with the burden of it all. 

That’s a freedom of choice that many with visible illnesses, handicaps, and disabilities have to a much lesser degree. 

Thankfully, I am learning to accept the trade-offs involved with this odd paradoxical mix and view them as blessings in disguise.  They are unseen and sincerely felt.

I offer a few of my answers, but in no way profess to have yours.  Sometimes asking a question can serve as a catalyst to search beneath the surface of our particular medical labels. 

One of my favorite professors always challenged his students to “mine for the gold.”    Maybe this question will uncover some important nuggets for you. 

We are still offered the potential to learn from each other and grow in different ways, despite our incapacities and similar challenges.  That’s another blessing in my book. 

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

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.

Experimental RA Vaccine Shows Promise

By Pat Anson, Editor

Australian researchers have developed an experimental vaccine for rheumatoid arthritis (RA)  that could prevent the disease from developing in high-risk patients who have a genetic predisposition for RA.

In a small Phase I clinical study, researchers say the "Rheumavax" vaccine was safe and effective in suppressing the immune system response that triggers RA -- 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.

"Current therapies only treat the symptoms and slow the progression of the disease,” said Professor Ranjeny Thomas of the University of Queensland Diamantina Institute. “We have designed a vaccine-style treatment or ‘immunotherapy’ specifically for individuals carrying high-risk rheumatoid arthritis genes and specific rheumatoid arthritis antibodies, called anti-CCP."

CCP antibodies are present in about 60% to 70% of people with RA and can be detected years before symptoms appear.

The personalized Rheumavax vaccine is made by taking a sample of each patient's blood and extracting an immune system cell called dendritic cells. Those cells are then challenged with a foreign peptide and an immune system modulator to create a vaccine that is then injected back into the patient.

Researchers say Rheumavax "teaches" the patient’s immune system to ignore a naturally occurring peptide that triggers the production of CCP antibodies that cause inflammation. In the study, 18 patients received a single injection of Rheumavax and one month later showed no signs of inflammation or RA disease flares.

“At this stage, the technique would not be ideal for widespread treatment or prevention of rheumatoid arthritis because it’s costly and time-consuming," said Thomas. “However, the promising results of this trial lay the foundations for the development of a more cost-effective, clinically-practical vaccine technology that could deliver similar outcomes for patients." 

"This research is such an exciting advancement for arthritis sufferers.  To know that someday in the future, hopefully the near future, there may be a treatment that actually treats the cause, not just the symptoms of rheumatoid arthritis, makes me very hopeful," said  Jennifer Martin, a rheumatoid arthritis sufferer and columnist for Pain News Network.  

"I often worry that my son could have inherited this awful illness from me and that one day he will begin to show symptoms.  To think that there may be a treatment that is effective very early on, or even before symptoms arise if they are able to detect the gene is very reassuring."

Professor Thomas says if Rheumavax proves successful treating RA, it could also be applied to other autoimmune diseases, such as Type 1 diabetes.  The study is published in the journal Science Translational Medicine. 

Until the late 1990s, one in three RA patients were permanently disabled within five years of disease onset. Although there are no cures for RA, in recent years there has been significant improvement in treatment, with disease control now possible for many patients who receive biologic drugs.