Smoking Linked to Longer Opioid Use

By Pat Anson, Editor

About one in five patients who are prescribed an opioid pain medication for the first time are still taking painkillers 90 days later, according to a small new study published in the Mayo Clinic Proceedings. Smokers and former smokers who were found to have the highest risk of using painkillers long-term.

Researchers at the Mayor Clinic studied a health database of residents in Olmsted County, Minnesota and identified 293 patients who were prescribed opioids in 2009. Nearly two-thirds were women who received their first opioid prescription after surgery, or some type of musculoskeletal pain or injury.

Most of the patients only needed one or two prescriptions and stopped taking pain medication. But 61 of them (21%) progressed to an “episodic” prescribing pattern in which they were still using opioids 90 days later. Nineteen patients (6%) were classified as “long term” users – which was defined as someone who had ten or more opioid prescriptions or at least 120 days of supply.

Women, Caucasians, people with a high school education or less, and patients with a history of depression or substance abuse had higher risks of long-term use.

But it was current or past smokers who stood out – nearly 74% of long-term opioid users had a history with tobacco. Nicotine is known to activate a group of nerve receptors in the brain, in a way very similar to how opioids and chronic pain activate them.

Researchers say the identification of potential risk factors like tobacco is an important tool for physicians, who should be careful about prescribing painkillers to patients with such histories.

“Before initiating a new opioid prescription, patients should be screened for past or current tobacco use and past or current substance abuse. This would allow the clinician to assess the risk of longer-term prescribing and would provide the opportunity to counsel the patient about these potential risk factors before actually receiving the initial prescription,” said lead author W. Michael Hooten, MD, a Mayo Clinic anesthesiologist.

"From a patient perspective, it is important to recognize the potential risks associated with these medications. I encourage use of alternative methods to manage pain, including non-opioid analgesics or other non-medication approaches. That reduces or even eliminates the risk of these medications transitioning to another problem that was never intended."

Not only does smoking raise the risk of longer opioid use, previous studies have shown it also increases your chances of having chronic pain.

A study of over 6,000 Kentucky women found that those who smoked had a greater chance of having fibromyalgia, sciatica, chronic neck pain, chronic back pain and joint pain than non-smokers. Women in the study who smoked daily more than doubled their odds of having chronic pain, while occasional smokers showed a 68% percent higher risk, and former smokers showed a 20% greater risk.

A large study in Norway found that smokers and former smokers were more sensitive to pain than non-smokers. Smokers had the lowest tolerance to pain, while men and women who had never smoked had the highest pain tolerance.

Is Your Doctor Getting Money from a Drug Company?

By Pat Anson, Editor

Have you ever wondered why your doctor recommended a particular drug or treatment, when cheaper and better alternatives were available?

A treasure trove of data released by the Centers for Medicare & Medicaid Services (CMS) may help you get some answers. It shows that pharmaceutical and medical device companies paid nearly $6.5 billion to doctors and research hospitals in 2014, the first full year the companies were required to disclose the payments under the Affordable Care Act (ACA).

You can see what your doctor was paid, if anything, by clicking here to search the CMS "Open Payments" database.

“Consumer access to information is a key component of delivery system reform and making the healthcare system perform better,” said acting CMS Administrator Andy Slavitt. “This is part of our larger effort to open up the health care system to consumers by providing more information to help in their decision making.”

About half of the $6.5 billion was for research, such as clinical trials to find new treatments for cancer, diabetes, Alzheimer’s and other debilitating diseases.

Over $400 million went to doctors to reimburse them for meals, beverages, lodging and travels costs.

The Wall Street Journal dug into the data further and found some questionable items, including a trip to a Cayman Islands resort, tickets to Alcatraz, and a $65 airport massage.

But it’s the sheer scale of the payouts – over 11 million payments to over 600,000 physicians – that has critics wondering if prescribing practices and treatment decisions are being unduly influenced by money and gifts. The average physician received about $3,644 last year.

“No pharma companies spend this kind of money in a disinterested way,” Jason Dana, a professor at Yale School of Management told Bloomberg Business. “We have to know where the money is going to really understand the problem, to develop policy.”

Dana says doctors can be influenced by free meals and perks, even if they’re not consciously aware of it.

“If we have a financial incentive to believe something or conclude something, we kind of trick ourselves into thinking it’s true. And we’re not always aware we’re doing it,” he said.

Purdue Pharma, the maker of OxyContin and several other painkillers, reported $5.8 million in research payments and $6.1 million in general payments to doctors -- modest amounts compared to what others companies paid.

Pfizer, the maker of Lyrica, reported at least $234 million in research payments and $53.3 million in general payments.

Eli Lilly, the maker of Cymbalta, paid over $137 million for research and $8.7 million in general payments.

The American Medical Association disputes a lot of this data, saying the “vast majority” was never vetted by physicians.

"The complicated and cumbersome process for physicians to register to review their data and seek correction of any inaccuracies continues to hinder their participation in the validation process," the AMA said in a statement.

Curious about your doctor? I was about our longtime family physician and searched his name in the CMS database.

I found nothing scandalous or suspicious, but there was a surprising amount of detail. I learned he received $707.59 in “food and beverage” and “informational meal” payments last year from AstraZeneca, Forest Pharmaceuticals, Eli Lilly, Pfizer and several other companies. What was on the menu is anyone’s guess, but what they talked about is duly noted.

For example, the arthritis drug Celebrex was discussed at a $12.60 meal that Pfizer paid for. And Eli Lilly bought a $11.74 meal for my doctor so he could learn more about the erectile dysfunction drug Cialis.

The most expensive item was a meal for $127.80 paid for by Shionogi, a Japanese drug company. The topic was Osphena, a post-menopausal drug for women to help them have pain free sex -- a discussion apparently reserved for only the finest of restaurants.

Which Marijuana Strain Works Best for Pain?

By Ellen Lenox Smith, Columnist

Unfortunately, “one size does not fit all” when it comes to using medical marijuana for pain relief. You and I could have exactly the same medical condition and use the same strain, but we will not necessarily react in similar fashion.

Because of that, it may take time to find your effective strain. This process will require patience and holding onto hope that you will eventually succeed. I was lucky. The first time I tried some Indica oil, I literally slept the entire night. However, we have had patients who sampled numerous strains before they found what works for them.

a leaf of cannabis sativa

There are two strains of marijuana plants, both of which provide pain relief: Indica has a calming and soothing effect that can help you sleep, while Sativa helps stimulate the brain and body so you can have a more productive day.

The other thing you have to pay attention to is the THC (Tetrahydrocannabinol) and CBD (Cannabidiol) content of the strain you are selecting. THC is known to provide the “high” sensation that people refer to when marijuana is used recreationally.

Those of us who use marijuana for pain generally do not have that experience, unless we take too high of a dose or just react wrong to a strain. 

CBDs are believed to be responsible for the therapeutic and medical benefits of cannabis.  They don’t make people feel “stoned” and can actually counteract the psychoactive effects of THC.  The fact that CBD-rich cannabis doesn’t get you high makes it an appealing treatment option for patients seeking anti-inflammatory, anti-pain, anti-anxiety, anti-psychotic, and/or anti-spasm effects, without the troubling side effects of lethargy or depression.

However, we don’t all experience pain relief without a higher content of THC. In fact, we have seen some patients be more successful in reducing seizures with more of the THC included. So do not become discouraged if you don’t have success at first.

Please know that THC and CBD levels don’t mean that every plant ever produced of a specific strain will always have the same percentages and ratios. Due to different growing methods, those levels can vary. So, always make sure what you are buying has been tested by a reputable testing facility if cannabinoid levels are important to you.

One successful thing I would like to pass on to you is a trick we discovered making our sleep inducing pain relief oil and day tinctures. 

We now mix all of our five types of Indica strains or Sativa strains together to create the oil or tincture. We make it from the small clippings around the bud, instead of the whole bud. Patients seem to prefer it made this way. You are exposed to the benefits of each plant, along with it being very gentle and less expensive.

female flowers of cannabis indica

In conclusion, remember that you may have to test several strains of medical marijuana to find the right match for your personal needs. It is worth the time and effort, because the pain relief is gentle, non-invasive, and allows you to return to a more productive life without worrying about organ damage from pharmaceuticals.

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis.

Ellen 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. 

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.

Medical marijuana is legal in 23 U.S. states and the District of Columbia, but is still technically illegal under federal law. Even in states where it is legal, doctors may frown upon marijuana and drop patients from their practice for using it.

Opioid Implant Raises Safety Questions

(Editor’s Note: Our story about an opioid implant that could someday be used to treat chronic pain struck a nerve with a lot of readers. One of them was Mary Maston, a pain sufferer and  patient advocate, who wrote in expressing concern about the safety and risks associated with implants and other medical devices.)

By Mary Maston, Guest Columnist

Why is everything going to implants? Implants seem to have an initial success rate and I can't argue with the fact that they do work for some, but it seems that class action lawsuits for side effects and internal injuries invariably come about down the line.

Transvaginal mesh was touted as the "next big thing." I had a doctor try to convince me that it would solve all of my female problems. Luckily, I didn't bite. We all know how that ended up.

Bladder slings come to mind too. Some IUD’s have caused issues. People have had major problems with hip and knee replacements. Spinal cord stimulators are being pushed on patients in record numbers, and the bomb is eventually going to drop on those too.

While there are success stories, there are some pretty horrific stories floating around online about implanted devices in general. Some will argue collateral damage: "Just think of the ones they've helped. The many outweigh the few.”

But I can promise you that the ones that have been harmed by these implants see things much differently.

Here's the thing: anything implanted in the body is going to be seen as a foreign object. What does the body tend to do when there's a foreign object inside it? It attacks it, trying to force it out. That's why your eyes water when you get something in them, that's why you vomit when you ingest something that's harmful, and that's why you go to the bathroom -- so the body can rid itself of waste.

When it can’t force the implants out, the body rebels with side effects, infections and pain. The surgeries required to implant these things damage nerves and create scar tissue, which also contribute to pain.

courtesy titan pharmaceuticals

If they're planning on this new implant being simply injected into the arm instead of being surgically implanted, that's going to have to be one heck of a big needle! The size of a match stick? Ouch!!

Then there is the issue of tolerance. Pain medication is not a "one size fits all" fix like the makers of this implant are implying. It comes with a preloaded dose of buprenorphine. How can they guarantee that the dosage they put in it is going to work for the majority of the people it's implanted in? 

What if it stops working in a month or two, or doesn't work at all? Do they have that one taken out and another one put in, or is the old one left in and a new one with a stronger dose implanted?

Will the patient be able to go back to taking oral pain medication? What if it causes side effects in the patient after a few days or weeks that they can't handle, or they end up being allergic to the medicine? How long would they have to live with those issues before it is removed?

Some people metabolize medications faster than others, so saying that it's going to work for a full six months for the implant or an entire month for the injection in everyone isn't practical. What about breakthrough pain? If someone had the implant, but showed up in the ER in pain because of their condition, would they be treated respectfully and in a timely manner, or dismissed because they had the implant and "that should take care of all of your pain."

There needs to be a very specific and compassionate treatment protocol set up for patients before this scenario happens, and all doctors need to be required to follow it.

I can understand and appreciate some of the pros listed in the article. Not having to make trips to the pharmacy, not having to remember to take pills and waiting for them to kick in to feel better. Possibly and hopefully not having to go to the doctor every month and being subjected to random drug screens and pill counts.

Doctors would certainly benefit because they wouldn't be prescribing pain medications nearly as much or maybe not at all. That would definitely get them off the hook with the DEA and I can see how that would make them want to push it onto all of their patients.

I understand that addiction and chronic pain go hand in hand for some people. Not all, but some. But as a chronic pain patient, I don't want to be lumped into the same category as addicts, because I am not an addict, never have been and never will be.

This raises serious questions that I think should be considered before we shout to the heavens how wonderful this new implant is going to be for addicts and legitimate chronic pain patients alike.

I understand there is still a lot of work to be done, and that it's going to take time and testing to answer a lot of these questions. Oral medications certainly have their own set of problems and aren't without risks either. However, history tells us that jumping on a bandwagon isn't necessarily a good thing down the road in a lot of cases.

I'm not saying that the thought of being pain free for an extended amount of time isn't appealing. Honestly, I would probably be more apt to try this than a spinal cord stimulator. But I hope that the manufacturers and the FDA will address the questions I've posed. I guarantee you I'm not the only one that will ask them.

Mary Maston suffers from a rare congenital kidney disease called Medullary Sponge Kidney (MSK), along with Renal Tubular Acidosis (RTA) and chronic cystitis. She is an advocate for MSK and other chronic pain patients, and helps administer a Facebook support group for MSK patients.

Mary has contributed articles to various online media, including Kidney Stoners, and is an affiliate member of PROMPT (Professionals for Rational Opioid Monitoring & Pharmaco-Therapy).

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.

Implant Could Be ‘Game Changer’ in Pain Treatment

By Pat Anson, Editor

Imagine going to your doctor’s office and getting an implant put in your arm that delivers a steady flow of pain medication for six months.

No more pills. No more trips to the pharmacy. No more worries about your pain medication getting lost or stolen.

That’s the scenario a New Jersey drug maker envisions for its Probuphine implant – tiny rods about the size of a matchstick designed to be inserted subcutaneously under the skin of the upper arm.

Probuphine was developed by Braeburn Pharmaceuticals under a license agreement with Titan Pharmaceuticals (OTC: TTNP), which holds the rights to the implant technology. Both companies have applied to the Food and Drug Administration to have Probuphine approved to treat opioid addiction, but Braeburn’s long term goal is to also have the implant approved for chronic pain.

COURTESY TITAN PHARMACEUTICALS

“We are definitely interested in talking to the FDA about the use of Probuphine in pain,” said Behshad Sheldon, President and CEO of Braeburn.

The active ingredient in Probuphine is buprenorphine, a weaker opioid that’s long been used as an addiction treatment drug sold under the brand name Suboxone. Buprenorphine is also used to treat chronic pain and comes in various forms – pills, patches and film strips – but none as long-acting as an implant.

The advantages of an implant are many. The dosage is controlled and there’s hardly any risk of abuse, diversion, or accidental overdose. You also never have to remember to take a pill.

“We believe a buprenorphine implant could be a really great clinical tool to treat pain,” Sheldon told Pain News Network. “There’s just a peace of mind aspect for the patients. The medicine’s on board and they don’t have to worry about it.”

“I personally would want a Lipitor implant, because I can’t manage to take it three days in a row,” she joked.

Probuphine’s path to the marketplace hasn’t been a smooth one. Braeburn and Titan were stunned in 2013 when the FDA denied approval of the implant and asked for a new clinical study of Probuphine’s effectiveness in treating opioid addiction.

Braeburn recently reported the results of a six month, double-blind clinical trial of Probuphine on 177 patients, which found that the implant was more effective than buprenorphine tablets in treating addiction. The company said the implant insertion and removal were "generally well tolerated," although nearly one in four patients had a "mild" adverse event at the implant site.

“The data from this trial are encouraging and underscore the benefit of longer term medical treatments for patients with opioid addiction. I am confident that the implant, if approved by FDA, will be at least as effective as a sublingual formulation and have the added benefits of reducing problems related to compliance, misuse and abuse,"  said Richard Rosenthal, MD, Professor of Psychiatry and Medical Director of Addiction Psychiatry at the Icahn School of Medicine at Mount Sinai.

Braeburn and Titan plan to resubmit a New Drug Application (NDA) for Probuphine to the FDA in the second half of this year.

Long Term Injection for Pain

Braeburn has formed another partnership with Camurus, a Swedish drug company, to develop an injectable buprenorphine drug to treat addiction and chronic pain -- a single injection that lasts as long as a month. Camurus has already completed successful Phase I and II studies on the drug and both companies hope to start a Phase III trial later this year -- with the goal of seeking regulatory approval in 2016.

“There have been many conversations with expert clinicians and they’ve told us that they think buprenorphine in general, in a non or less abuse-able form of buprenorphine, in either an implant or an injection could really be game changing,” said Sheldon. “It is part of our plan to move into pain because pain and opioid addiction are so interconnected and we think there are ways, by treating patients with a less abuse-able formulation, you could actually help alleviate the addiction problem.”

Sheldon admits a lot more work needs to be done before a buprenorphine implant or injection is available to treat chronic pain.

“We haven’t studied it yet in pain and we haven’t had any conversations yet with the FDA. So there’s a lot more to do to get to that point,” she said.

Another formulation of buprenorphine to treat pain may be coming to the market relatively soon. Endo International (NASDAQ: ENDP) and BioDelivery Sciences (NASDAQ: BDSI) have submitted a new drug application for a buprenorphine film patch to the FDA. The companies are hoping for FDA approval by October of this year.

Although the patch contains much smaller doses than buprenorphine tablets or patches already on the market, the companies say the film is very effective in treating pain because the drug is absorbed through the inside lining of the cheek and enters the blood stream faster.

Why Choosing a Doctor Is Like a Job Interview

By Pat Akerberg, Columnist

There’s an online answer for just about everything.  If you use a search engine, you are soon inundated with links, marketing products and services to match your needs.  There are even dating services that connect you with possible romantic partners.

Choosing the right doctor isn’t quite as simple as shopping for a new pair of shoes or making a love connection. Shoes that don’t fit can be returned. First dates that don’t work out can be cut short.  But our medical needs carry significant costs, benefits and risks. The right -- or wrong -- doctor can be life changing.

Like any important decision, it’s best to begin with an approach in mind. Doctors carefully scrutinize us as would-be patients.  Isn’t it in our best interest to make the same effort? 

After all, we both have important needs to fill.  So what if we approach our decision just like a job interview, with us doing the hiring?

When I worked in business, the three key points of a solid job interview were focused on:

1. Does the person have the competence to be effective in this role?

2. Are they a “good fit” for the job requirements?

3. Does the person pose any risks or concerns?

If any of those questions turned up a negative answer, that candidate was eliminated. We can borrow from this formula as we search for the kind of doctor that we need.

Competence

This includes expertise, years of experience, a solid track record, and the transparency to share it.  Without transparency, there’s very little objective information available, like a surgeon’s complication rates, for instance.  

There are some ways to get a feel for this prior to your appointment.  The internet can be helpful with this part of your research.  You can conduct a search for support groups for your particular chronic pain condition. (Example: “support groups for trigeminal neuralgia”).

In my case, I rely upon one that I consider to be my most valuable resource for facial pain – it’s the TNA Facial Pain Association.  Once I joined, through discussion groups I could get candid feedback from other members about their experiences with different doctors or treatments -- and learn who the leading experts are in the field. Support and friendship with people who truly understand what you’re going through are extra benefits

An informative website from the Agency for Health Care Resources and Quality can also help with several quality of care topics, including pertinent questions to ask your doctor.

The leading experts may not be in your geographic area.  Will you allow that to keep you from consulting with them?  Some doctors offer Skype consultations if you ask.  Local may not always equal the best chances for success.

A Good Fit

From a doctor’s perspective, a good fit requires you to share factual information about yourself so that they can effectively treat you. 

A good fit from a patient’s perspective begins with a list of the traits and characteristics that meet your unique needs.  These are your “must have’s.”  Here are a few of mine for doctors:

• Listens and makes eye contact with me
• Seeks to understand, invites my input
• Seems engaged and interested in addressing my situation
• Takes time to explain things to me
• Comfortable with questions (isn’t defensive or dismissive)
• Flexible, operates well in a partnership
• Transparent about treatment outcomes
• Offers a clear plan

There is no substitute for the experience gained from tuning up your radar and conducting your own interview.  It can be helpful to have a spouse or family member accompany you to appointments to compare notes. 

You may want to make a “nice to have” list too. People in pain often want some empathy from healthcare providers, yet may not always get it.  Is empathy a “nice to have” or “must have” for you? 

Risks and Concerns

Caution is also a part of doing your due diligence to find the best possible doctor.

Unless there’s an extreme need for aggressive treatment, a good rule of thumb to minimize risk is to start with the least invasive, lowest risk treatments. These are often done by practitioners who offer complementary, alternative approaches (acupuncture, physical therapy, chiropractic, homeopathic, etc.)

There is no substitute for doing your homework and becoming knowledgeable about several important things:

• The costs involved for services and treatments, and how they relate to your insurance coverage and out of pocket expenses. Healthcare Bluebook uses a nationwide database to estimate a “fair price” for everything from drugs to surgery to x-rays.
• Patient reviews and experiences with a physician.  There are a number of websites where you can read what people are saying about a particular doctor, including RateMDs, Vitals and Healthgrades.
• Red flags like sanctions, malpractice claims, or medical board actions against a physician can usually be found through your state medical board or licensing agency.  
• The latest research studies related to your condition.  It will serve you well to be aware of the most effective treatments, the odds for success and potential risks. You can see published research studies at PubMed and the National Institutes of Health.

In terms of knowing the risks upfront about treatments, later is too late if the unthinkable should happen.  You don’t want to be left on your own to scramble for help. 

In the end, it never hurts to have more than one choice available or more than one opinion before you decide. 

Becoming informed will empower you to be your own best advocate when entrusting your medical care to someone. Just like any good hiring decision, choosing the best doctor can prove to be an investment well worth your active involvement.

Pat Akerberg suffers from trigeminal neuralgia. 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.

Cymbalta and Lyrica in Legal Battles

By Pat Anson, Editor

The makers of Cymbalta and Lyrica – two blockbuster drugs widely used to treat fibromyalgia and other chronic pain conditions – face legal battles this summer that could potentially cost the companies billions of dollars.

In London, a court case begins next week on Pfizer’s efforts to keep doctors in the U.K. from prescribing pregabalin – a cheaper generic version of Lyrica.

And in Los Angeles, a federal judge this week ordered Eli Lilly to face claims in lawsuits alleging that the company misled consumers about the side effects of withdrawal from Cymbalta.

Over 5,000 patients have filed suit against Lilly claiming that Cymbalta caused “brain zaps” – electric shocking sensations – as well as nausea, vomiting and insomnia when they stopped taking the drug.  The first two cases will be heard in August.

“The withdrawal symptoms from Cymbalta were hell,” wrote Crystal Lindell, a Pain News Network columnist in a recent article.

“Less than a week after my last pill, I was getting so dizzy that I seriously thought I had a new disease. Then, there was this thing called the brain zaps that I didn’t understand until they happened to me. In short, it literally felt like my brain was being, well, zapped by electricity. There was also nausea and vertigo and just an overall feeling of falling off a skyscraper.” 

Several readers shared their own experiences with Cymbalta.

“My neurologist put me on Cymbalta, I took 2 pills, I thought my head was going to explode,” wrote Judy Dunn.

“I suffered from 6 weeks of vertigo, nausea, dizziness, and MASSIVE headaches,” said Andy, who was prescribed Cymbalta to treat depression. “I will never take Cymbalta again. EVER.”

“While on the drug I did get a better mood and it helped a lot, but it raised my blood pressure and I was shaky and jittery. I also went through the brain ZAPS!!” wrote Candra Clark.

“We believe in our defenses to these claims and we will continue to defend Lilly vigorously,” Scott MacGregor, a Lilly spokesman told Bloomberg Business.

Cymbalta generated annual sales of $5 billion for Lilly until its patent expired in 2013 and cheaper generic versions of Doluxetine became available.

Lyrica Legal Battle

Like Cymbalta, Lyrica wasn’t originally developed to treat pain. It was used as a treatment for anxiety and epilepsy until drug maker Pfizer realized it could also be effective for fibromyalgia and neuropathic pain.

Pfizer’s patent on Lyrica for epilepsy and anxiety expired last year, but its secondary patent for pain is good until July of 2017 – and that is the essence of its legal fight in the U.K.

Rival drug makers started making pregabalin – the generic version of Lyrica – when its original patent expired. But it didn’t take long for doctors to also start prescribing pregabalin for pain.

According to Pharmalot, about 80% of all U.K. patients on pregabalin are using it to treat pain and Pfizer has launched an aggressive campaign to stop that. Last year the company wrote an unusual letter to physician groups in the U.K. warning them that prescribing pregabalin for pain was a violation of its patent.

“Pfizer believes the supply of generic pregabalin for use in the treatment of pain whilst the pain patent remains in force in the U.K. would infringe Pfizer’s patent rights,” the company said in the letter.

The Royal College of Physicians, which represents 29,000 U.K. doctors, responded with a statement of its own.

“Pregabalin is a useful drug for many patients and, given the current financial pressures the NHS (Britain’s National Health Service) is under, it is disappointing that a pharmaceutical company has made a move that will, potentially, prevent some patients from getting access to it,” a spokesman said.

The NHS has since issued guidance to doctors telling them to use the brand name Lyrica when prescribing pregabalin for pain “so far as reasonably possible.” Pfizer is seeking a stronger statement from the British High Court.

Ironically, Pfizer paid $2.3 billion dollars in 2009 to settle criminal and civil charges in the U.S. for the “off-label” marketing of Lyrica and other medications – the very sort of off-label use it is trying to stop in the U.K.

Lyrica remains one of Pfizer’s top selling drugs, generating $5.1 billion in revenue in 2014.  

Power of Pain: The Benefits of a Positive Attitude

By Barby Ingle, Columnist

Mental health can be disrupted when living with a chronic illness -- even more so when it involves chronic pain. Anxiety, depression, isolation, and feelings of hopelessness and helplessness can increase to dangerous levels -- particularly for people who have been suffering with a pain condition for a long period of time.

There are going to be good and bad days, and if this is a bad day for you, remember to focus on the good times, good feelings, and positive past and future experiences. It is very important for you and your family to recognize the symptoms of diminished emotional well-being and take action.

Depression and thoughts of suicide are common among chronic pain patients – so it is helpful to create a strategy to get through the rough times. Chronic pain patients learn over time that they can better cope and adjust to both physical and psychological problems with the help and support of spiritual guidance, family and therapists. Creating an arsenal of tools, such as spirituality, physical modalities and meditation, are all ways to better your situation. 

Chronic pain is not understood very well, and there are physicians and psychiatrists who believe that it is all in our heads or that people just complain for the sake of workmen’s compensation or personal injury cases. If we are seen as malingering patients who just won’t go away, doctors who don’t understand chronic pain may find it difficult to look for any other diagnosis other than psychological.

With the loss of independence and function, it is hard for many patients to accept their changing life. Be sure to surround yourself with a team who is on your side, or you will be in a fight with long-term health consequences that you will have trouble winning.

It is important to maintain a healthy lifestyle, including getting enough sleep, exercise, and eating healthy foods.

Patients with chronic pain typically lead a more sedentary lifestyle, making them at greater risk for developing other medical problems, such as cardiovascular disease, diabetes and osteoporosis. The risk for these conditions is heightened with inactivity. 

Creating a positive attitude starts with being inspired. Begin by finding an interest or hobby you can become involved with and will enjoy. A few suggestions are joining a non-profit cause, solving puzzles, writing a journal, joining or starting a support group, or even starting a blog.

Creating a purpose can assist with your self-esteem and confidence. Just because you are disabled does not mean you are not worth anything. I have learned that every person has value. Believing in yourself and your abilities, choosing happiness and thinking creatively is good motivation when it comes to accomplishing your goals.

Learn to expect success when you are going through your daily activities. It might take you longer or you may need to use more constructive thinking to achieve success, but it is possible.

Negative situations are bound to appear, but when you are looking for solutions and displaying self-esteem and confidence, you will also attract other people to participate in helping you accomplish your needs and goals. Try looking at failure and problems as blessings in disguise. Doing so will help solutions find you. Seize the opportunities in everyday life. Using your outings to inform others about your condition and finding pleasure in minor accomplishments are ways to increase your power of positive thinking.

There are great benefits to having a positive attitude. Staying optimistic will give you more energy, happiness and lower your pain levels. Achieving goals is a great motivator for positive thinking. Success is achieved faster and more easily through positive thinking, and it will inspire and motivate you and others. I have found that when I am letting the pain get the better of me, it comes across to others as disrespect and brings those around me down. 

Staying calm and positive creates an atmosphere for greater inner strength and power. You can also create better communication with a calm positive attitude, which will assist you in working with your doctors and caretakers. When you take life one task at a time and approach each challenge with optimism, it leads to fewer difficulties encountered along the way and increases your ability to overcome problems.  As my father always says when I am having a bad day, “Tomorrow will be a better day.”

No matter the challenges of today, they will pass, and in retrospect they will not seem as bad as time moves on. The challenges may just turn out to be a bump that looked like a mountain at the time. Try displaying a positive attitude, and the moods of others and the challenges of life will become easier to deal with.

Choosing to be happy starts with you. No person or thing can make you happy and positive. It is a skill you have to practice and develop when living with chronic pain. When you are able to live in a happy, positive and optimistic light, your life will become a life worth the ups and downs that come with it.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (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 her website.

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.

Childhood Trauma Linked to Adult Migraine

By Pat Anson, Editor

Children who witness domestic violence between their parents are significantly more likely to experience migraine headaches as adults, according to a large new study published in the journal Headache.

Researchers at the University of Toronto examined a nationally representative sample of over 12,000 women and 10,000 men who participated in the 2012 Canadian Community Health Survey-Mental Health. About 6.5% of the men and 14.2% of the women experienced migraine, which is consistent with prior research.

Participants were asked if they had experienced three types of childhood trauma: physical abuse, sexual abuse or if they witnessed parental domestic violence.

"We found the more types of violence the individual had been exposed to during their childhood, the greater the odds of migraine. For those who reported all three types of adversities -- parental domestic violence, childhood physical and sexual abuse -- the odds of migraine were a little over three times higher for men and just under three times higher for women" said Sarah Brennenstuhl, PhD, first author of the study.

Researchers said the most surprising finding was the link between migraines and parental domestic violence. Even after accounting for variables such as age, race, and socioeconomic status, men and women who had witnessed parental domestic violence had 52% and 64% higher odds of migraine compared to those who did not see their parents fighting.

"The cross-sectional design of our study does not allow us to determine if the association between early adversities and migraines is causative, but our findings do underline the importance of future prospective studies investigating the long-term physical health of children exposed to parental domestic violence,” said co-author Esme Fuller-Thomson, professor and Sandra Rotman Endowed Chair at University of Toronto's Factor-Inwentash Faculty of Social Work.

Previous research by Fuller-Thomson has found that depression and thoughts of suicide are more likely among individuals with migraine.

The risk of depression and suicide ideation is about twice as high for those who experience migraine. Individuals with migraine who are under the age of 30 had six times the odds of depression compared to migraineurs aged 65 and over.

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.

Survey Finds Doctors Need More Addiction Education

By Pat Anson, Editor

Many primary care physicians -- the top prescribers of opioid pain medication in the United States – lack a basic understanding of how the drugs can lead to abuse and addiction, according to a new survey by the Johns Hopkins Bloomberg School of Public Health. The survey was conducted by several longtime critics of opioid prescribing practices who advocate tighter restrictions on painkillers.

The survey of over 500 practicing internists, family physicians, and general practitioners was conducted by mail in early 2014. Primary care physicians treat over half of the chronic pain patients in the U.S. and prescribe most of the pain medication.

The survey results, reported in the Clinical Journal of Pain, found that nearly half the physicians incorrectly believe that abuse-deterrent pills – which are harder to crush or liquefy for snorting or injecting – are less addictive than their standard counterparts. .

"Physicians and patients may mistakenly view these medicines as safe in one form and dangerous in another, but these products are addictive no matter how you take them," says study leader G. Caleb Alexander, MD, an associate professor in the Bloomberg School's Department of Epidemiology and co-director of the school's Center for Drug Safety and Effectiveness.

“Opioids serve an important role in the treatment of some patients. However, our findings highlight the importance of patient and provider education regarding what abuse-deterrent products can and cannot do. When it comes to the opioid epidemic, we must be cautious about overreliance on technological fixes for what is first and foremost a problem of overprescribing."

Every primary care physician who was surveyed thought that prescription drug abuse was a problem in their communities. Large majorities also supported efforts to reduce abuse, including patient contracts, urine drug testing, databases that monitor opioid prescribing, and greater restrictions on the marketing and promotion of opioids.

About a third of the doctors incorrectly reported that the most common route of prescription drug abuse is by means other than swallowing pills. Numerous studies have shown that most drug abuse is through oral ingestion, followed by snorting and injection.

Interestingly, one third of the physicians (33%) believed that efforts to reduce opioid abuse have had a chilling effect on pain management practices, and were preventing legitimate pain patients from gaining access to appropriate treatment.

Despite that finding, Alexander said further efforts are needed to combat opioid abuse, saying “doctors continue to overestimate the effectiveness of prescription pain medications and underestimate their risks.”

"For the sake of making a dent in an epidemic of injuries and deaths, we have to find ways to make changes. Too many lives are at stake to stick with the status quo," he said.

Two of the co-authors of the study are Andrew Kolodny, MD, and Stefan Kruszewski, MD. Kolodny is president of Physicians for Responsible Opioid Prescribing, a group that has lobbied Congress and petitioned the Food and Drug Administration to limit access to opioids. Kruszewski has served as an expert witness in multiple lawsuits against pharmaceutical companies.

Their research was supported by the Robert Wood Johnson Public Health Law Research Program and the Lipitz Public Health Policy Award at Johns Hopkins Bloomberg School of Public Health.

The Centers for Disease Control says over 16,000 Americans die annually from painkiller overdoses, an estimate that dates back to 2010. Most of those deaths also involved alcohol or other drugs.

Several recent studies suggest the tide of opioid abuse has turned in the U.S.

Dispensing of opioid pain medication and painkiller overdoses have declined substantially since 2010, according to a recent study published in JAMA Internal Medicine.

The number of prescriptions filled in the U.S. for hydrocodone has also declined, the first concrete evidence that restrictions on hydrocodone prescribing that were adopted in 2014 are starting to have an impact. Hydrocodone is no longer the most widely filled prescription in the U.S.

The National Institutes of Health estimates that only about 5 percent of pain patients become addicted to opioids after using them as directed for a year.

Study Finds ‘Moderate' Evidence Marijuana Treats Pain

By Pat Anson, Editor

The American Medical Association, the nation’s largest medical group, still officially considers medical marijuana “a dangerous drug and as such is a public health concern."

But studies being published this week in JAMA, the AMA’s official journal, highlight the slim but growing body of evidence that cannabis can be used to treat pain – as well as the lack of standards regulating medical marijuana in states where it is legal.

In a review of nearly 80 clinical trials involving over 6,400 patients, researchers found “moderate-quality evidence” that cannabinoids –  chemically active compounds in marijuana – are effective in treating chronic neuropathic pain and cancer pain, as well as muscle spasms and stiffness caused by multiple sclerosis.

There was “low-quality evidence” suggesting that cannabinoids are effective in treating sleep disorders, weight loss, Tourette syndrome, and symptoms of nausea and vomiting caused by chemotherapy; and “very low-quality evidence” for treating anxiety.

Some of the side-effects associated with medical marijuana were dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination.

"Further large, robust, randomized clinical trials are needed to confirm the effects of cannabinoids, particularly on weight gain in patients with HIV/AIDS, depression, sleep disorders, anxiety disorders, psychosis, glaucoma, and Tourette syndrome are required. Further studies evaluating cannabis itself are also required because there is very little evidence on the effects and AEs (adverse events) of cannabis," the authors write.

An accompanying editorial in JAMA also called for more research and lamented the lack of evidence supporting the legalization of medical marijuana in 23 U.S. states and the District of Columbia.

"If the states' initiative to legalize medical marijuana is merely a veiled step toward allowing access to recreational marijuana, then the medical community should be left out of the process, and instead marijuana should be decriminalized," wrote Deepak Cyril D'Souza, MD, and Mohini Ranganathan, MD, of the Yale University School of Medicine.

"Conversely, if the goal is to make marijuana available for medical purposes, then it is unclear why the approval process should be different from that used for other medications… Since medical marijuana is not a life-saving intervention, it may be prudent to wait before widely adopting its use until high-quality evidence is available to guide the development of a rational approval process."

The Trouble with Edibles

A second study published in JAMA looked at marijuana edibles – cookies, brownies, candies and other foods containing cannabis – that are being sold at dispensaries in Los Angeles, San Francisco and Seattle.

An estimated 16% to 26% of cannabis patients consume edibles. Many are essentially homemade products that vary from dispensary to dispensary.

Researchers found that many of the edibles had lower amounts of THC (tetrahydrocannabinol) – the active ingredient in marijuana that makes people “high” – than their labels indicated. Over half had significantly higher amounts of THC, putting patients at risk of unintended side-effects.

Of the 75 edible products that were analyzed in a laboratory, only 17% were accurately labeled with THC, 23% were “overlabeled” and 60% were “underlabeled.” The greatest likelihood of obtaining an underlabeled edible was in Seattle.

A little over half (59%) of the edibles tested had detectable levels of cannabinoids.

"Edible cannabis products from 3 major metropolitan areas, though unregulated, failed to meet basic label accuracy standards for pharmaceuticals," the authors write. "Because medical cannabis is recommended for specific health conditions, regulation and quality assurance are needed."

The lack of regulation was highlighted last year in Colorado – where both medical and recreational use of marijuana is legal. A brand of brownie mix, Rice Krispy treats and candy made with cannabis was recalled after inspectors found the edibles contained marijuana that had been “cleaned” in a washing machine.

How Chronic Pain Ruins You Financially

By Crystal Lindell, Columnist

I was already living paycheck to paycheck before I got sick. I mean, rent in the Chicago suburbs doesn’t pay itself and journalism isn’t the lucrative job I think it used to be back when Clark Kent got into the business.

But then, I woke up one day with horrible pain in my ribs and my bank account somehow got even worse. Is there a number below zero? Because that’s about where I like to keep my balance.

I’m not telling you this in an attempt to solicit any type of personal donations. I just want the world to know what those dealing with chronic pain are actually dealing with financially. I want to give a voice to all of those people out there who are too sick to take a shower and, as a result, are too broke to upgrade their tacos to supreme.

I can still remember the first time I went to pick up a name-brand prescription at the local Walgreens, and being completely horrified by the fact that they wanted a freaking $50 co-pay. That’s a tank of gas. Or a cell phone bill. Or like three dresses at Kohl’s during a good sale.

Now, I’d kill to get all my drugs for $50.

I’m an American. I have insurance. I have a job. You wouldn’t think getting some random pain in my ribs would completely ruin me financially.

It has.

There are the co-pays for the doctor visits and the drugs; the money I owe before my deductible each year for the MRIs and the ER visits; and the vain attempt to find cures from snake oil salesmen offering alternative medicine that’s never covered by medical insurance.

I have so many medical bills that I can’t even keep track of how much I owe which doctor anymore.  Let’s just say, it’s “a lot.”

But it’s not just the medical bills that have to me too broke to buy fresh fruit on the regular.

It’s kind of hard to keep a job, when you literally don’t know from day to day if you’re going to be able to get out bed.

I’ve been very lucky in that my full-time job has been extremely accommodating, allowing me to mostly work from home and even take breaks during the day as needed. I know that if I had any other job, I would have had to file for disability a while ago.

That doesn’t mean I haven’t lost anything though. Back when I was healthy, I was able to maintain a side job as a part-time youth leader. I had to walk away from that when it became obvious that I couldn’t be sure I’d be able to get out of bed and make it to church most Sunday mornings. And when I resigned, I also gave up $10,000 a year.

Now, I’m barely making enough to make ends meet.

I spent the entire second week of June with $0.00 in my bank account.

And I can’t exactly go looking for a new job to make up for that $10,000 pay cut. I mean, where else am I going to work that allows me to make my own hours and write feature stories in my pajamas on the couch?

So, I’m stuck. I’m stuck in job I can barely hold onto that only pays me barely enough to eat on a daily basis.

When you’re well, it seems like you’re constantly hearing about fundraisers for sick people. Someone, somewhere always seems to be walking for cancer, or hosting a fancy ball for MS, or doing an ice bucket challenge for ALS.

But there are no fundraisers for people like me. Nobody does a 5K for chronic pain — maybe because most people with chronic pain are too sick to walk 3.1 miles.

I think there’s also still a lot of stigma associated with chronic pain. A sort of, “Well if you would just give up gluten and go to a chiropractor, you’d get better, so it’s kind of your fault.”

I get it, I mean watching someone lay on the couch all day with an illness nobody can see doesn’t exactly scream, “I’m super sick.” It’s easy for people to assume you’re just too lazy to get better. After all, if it’s just a matter of will power, then they don’t have to worry about the same fate becoming them.

And, I’ve noticed that people never like to use the word “sick” to describe chronic pain. They much prefer, “I’m in pain,” to “I’m sick.” It’s a way of separating those suffering with daily pain from the “truly sick.”

The thing is, having chronic pain does make you sick. It’s an all-encompassing chronic illness just like any other all-encompassing chronic illness. And it steals little pieces of your life in exactly the same way.

Sometimes, when I’m in really bad pain, when I’m literally so sick that I can’t even get to the bathroom, I think about a world where I would be forced to apply for disability. But then, I’d be even more broke than I am now.

I’m not sure what you’ve heard, but Social Security isn’t exactly paying people with bags of gold. Everyone I know who’s living on disability payments is barely living. It’s not exactly the kind of life I thought I’d end up with back when I got my freaking master’s in journalism.

But I guess that’s the thing about chronic pain. It completely destroys everything about your life that you thought you’d end up with. It wipes out all your hopes and dreams, and makes you start all over with nothing. And then, it sends you a hurricane just to make sure you got the message.

Being broke all the time only makes it that much worse.

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.

Opioid Abuse Takes Back Seat to Cost at Medicare

By Pat Anson, Editor

The U.S. Food and Drug Administration calls the development of abuse deterrent opioids a “priority” in combatting the so-called epidemic of prescription painkiller overdoses.

But when it comes to Medicare coverage of opioids, new research shows that lowering the cost of painkillers is a bigger priority for the federal government than discouraging abuse.

The study by Avalere, a health analytics research firm, found that Medicare Part D coverage of abuse deterrent OxyContin is falling rapidly. From 2012 to 2015, OxyContin coverage fell from 61% to 33% of Medicare Part D plans. In addition, one quarter of Part D plans now require prior authorization for OxyContin. 

In contrast, a generic version of OxyContin (oxycodone hydrochloride) that has no abuse-deterrent properties is covered by all Medicare Part D plans – and prior approval for it is only needed in 0.3% of Part D plans.

“While prescription opioid abuse continues to be a priority for public health experts and lawmakers, coverage for these products by Part D plans is limited and plans are increasingly favoring lower-cost generic products on their formularies,” said Caroline Pearson, senior vice president at Avalere.

“Policymakers seeking to limit opioid abuse will have to balance the desire for greater access to abuse-deterrent opioids with the increased costs of such medications to public programs and private payers.”

OxyConin was reformulated by Purdue Pharma in 2010 to make it harder for addicts to crush or liquefy for snorting and injecting. In 2014, the FDA approved three other opioids with abuse deterrent properties and in April of this year issued guidance to drug makers strongly encouraging them to develop more.  

“The science of abuse-deterrent medication is rapidly evolving, and the FDA is eager to engage with manufacturers to help make these medications available to patients who need them,” said FDA Commissioner Margaret Hamburg, MD. “We feel this is a key part of combating opioid abuse.”

But combating opioid abuse apparently takes a back seat to price, not only for Medicare but private insurers and the drug makers that developed abuse deterrent formulations.

According to the Healthcare Bluebook, a website that estimates the market price of medications, the “fair price” for a 60-day supply of OxyContin 20mg is $316.

A 60-day generic version of oxycodone -- without abuse deterrence -- retails for just $78.

“It will be important for policymakers to monitor and consider the implications of these trends,” the Avalere study says, warning that abuse-deterrence formulations may be pricing themselves out of the market.

“The potential increase in costs due to new innovations may be a barrier to policies that increase the coverage of abuse-deterrent opioids, especially in public programs, despite potential long-term public health savings associated with lower levels of opioid abuse. While the greater number and quality of abuse-deterrent options—both brand and generic—can support competition, reduce cost, and increase plan coverage, the potential of abuse-deterrent technologies may not be fully realized as long as non–abuse deterrent alternatives have less restrictive insurance coverage.”

Funding for the Avalere study came from Pfizer. Avalere says it maintained “full editorial control” over its content.

Over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010, according to the CDC. The government estimates that over 400,000 seniors are  “misusing” pain medication.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.

New Drugs Could Relieve Neuropathy Pain

By Pat Anson, Editor

After more than a decade of study, researchers at Boston Children’s Hospital are close to developing a new class of non-narcotic drugs that relieve chronic nerve pain by targeting a protein that enhances pain and inflammation.

Their findings, reported in the journal Neuron, could lead to new treatments for diabetic peripheral neuropathy, post-herpetic neuralgia, and inflammatory diseases like rheumatoid arthritis. Current treatments provide meaningful pain relief in only about 15 percent of patients.

"Most pain medications that have been tested in the past decade have failed in Phase II human trials despite performing well in animal models," notes Clifford Woolf, MD, PhD, director of Boston Children's F.M. Kirby Neurobiology Center and a co-senior investigator on the study. "Here, we used human genetic findings to guide our search from the beginning."

Previous research by Woolf and his colleagues found that people with variants of the gene for GTP cyclohydrolase (GCH1) -- about 2 percent of the population -- are at markedly lower risk for chronic pain. GCH1 is needed to synthesize the protein tetrahydrobiopterin (BH4), and people with GCH1 variants produced less BH4 after a nerve injury. This suggested that BH4 regulates pain sensitivity.

To test their theory, researchers took a "reverse engineering" approach in genetic experiments on mice.  First they showed that mice with severed sensory nerves produce excess BH4, created by the injured nerve cells and by macrophages-- immune cells that infiltrate damaged nerves and inflamed tissue.

Mice that were genetically engineered to make excess BH4 had heightened pain sensitivity even when they were uninjured. Conversely, mice that were genetically unable to produce BH4 had lower pain hypersensitivity after a peripheral nerve injury.

"We then asked, if we could reduce production of BH4 using a drug, could we bring about reduction of pain?" said Alban Latremoliere, PhD, also of Boston Children's Kirby Center, who led the current study.

The answer was yes. The researchers blocked BH4 production using a specifically designed drug that targets sepiapterin reductase (SPR), a key enzyme that makes BH4. The drug reduced the pain hypersensitivity induced by nerve injury and without any detectable side effects.

Because BH4 plays an important role in the brain and blood vessels, the goal of any treatment would be to dial down excessive BH4 production, but not eliminate it entirely. Latremoliere showed that blocking SPR still allowed minimal BH4 production through a separate pathway and reduced pain without causing neural or cardiovascular side effects.

"Our findings suggest that SPR inhibition is a viable approach to reducing clinical pain hypersensitivity," says Woolf. "They also show that human genetics can lead us to novel disease pathways that we can probe mechanistically in animal models, leading us to the most suitable targets for human drug development."

A Pained Life: When Habits Hurt

By Carol Levy, Columnist

I am a creature of habits, some of them bad. Not the “I can't stop eating chocolate”  kind of bad,  but bad in that I don’t always follow my own advice.

For example, I have a bad neck and as a result lifting something heavy often leaves me with worse neck pain. Every time I lift something heavy, I hesitate and think, “You need to put on the neck brace first. You really need to do that.”

Then I get annoyed and tell myself putting on the neck brace would be too much trouble.

The fact that I leave the brace out on the dresser and it is easily accessible makes no difference. My neck is held together with clamps and screws. How can a neck held together with a bunch of metal not be able to pick up anything, no matter what it is?

The fallacy of that thought is proven each time I move something heavy. But I don't heed myself and I pick it up anyway. Bad habit #1.

Then comes bad habit #2. The neck brace is supposed to help hold up my neck. But even when I wear it, I fight it. A good example is what happens when I take out the trash

The containers are a little ways away from my apartment. I do not want to have to make a number of trips (there is always a minimum of 2 large bags and more often 3). At least one is filled with cat box litter and is always heavy. The extra weight turns me into a turtle. I automatically scrunch up my shoulders and lower my neck as I lift the bags, feeling that somehow makes me stronger.

It doesn't, of course. And once I am finished my neck hurts horribly and the pain exhausts me.

So why don't I learn my lesson? Why do I fight doing a really simple thing that will help me?

One reason is denial and the other is looking at the short term rather than the long. I have to make the decision to accept what I can and cannot do -- sometimes just out of sheer stubbornness -- if I want help myself and reduce the pain when and where I can.

It is a lesson so hard to learn because it comes out of an acceptance of our limitations. At the end of the day, it is not the physical things that I do or refuse to do that cause the pain. It is my refusal to accept. Then I’m not a turtle but an ostrich, keeping my head in the sand.

I wish they had a neck brace for that.

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.