Most Pain Patients Use Alternative Therapy (Video)

By Pat Anson, Editor

A large new study of chronic pain patients found that over half were using chiropractic care or acupuncture for pain relief, but many didn’t discuss their use of alternative therapy with their primary care providers.

Researchers surveyed over 6,000 patients in Oregon and Washington State who were Kaiser Permanente members and had three or more outpatient visits for chronic pain in 18 months.

The study, published in the American Journal of Managed Care, found that 58 percent of the patients had used chiropractic care, acupuncture, or both.

Over a third (35%) of the pain patients who had acupuncture never told their doctor, while 42% who had chiropractic care didn't talk to their providers about it. Almost all of the patients said they would be happy to share this information if their doctor had asked.

"Our study confirms that most of our patients with chronic pain are seeking complementary treatments to supplement the care we provide in the primary care setting," said Charles Elder, MD, lead author of the study and affiliate investigator at the Kaiser Permanente Center for Health Research. "The problem is that too often, doctors don't ask about this treatment, and patients don't volunteer the information.

"We want our patients to get better, so we need to ask them about the alternative and complementary approaches they are using. If we know what's working and what's not working, we can do a better job advising patients, and we may be able to recommend an approach they haven't tried,” said Elder, who is the lead physician for Kaiser Permanente's complementary and alternative medicine program.

The majority of the patients in the study (71 percent) were women, and the mean age was 61. Most suffered from back pain, joint pain, arthritis, neck and muscle pain, or headache.

The study was funded by a grant from the National Center for Complementary and Integrative Health.

A video report on the study that was produced by Kaiser Permanente can be seen here:

One-hundred million Americans suffer from chronic pain every year, and many of them turn to alternative therapies for relief. In fact, a new study shows that more than half of patients with chronic pain enrolled in a managed care setting use chiropractic care or acupuncture.

Study: Opioid Overdoses Occur Even at Low Doses

By Pat Anson, Editor

Overdoses from opioid painkillers occur frequently in people who are taking relatively small doses over a short period of time, according to a new study that has some experts calling for more restrictions on opioid prescribing.

Researchers at the University of Washington School of Public Health analyzed Medicaid data on over 2,200 opioid overdoses in Washington State between 2006 and 2010 – and found that many patients didn’t fit the usual profile of a long term opioid user taking high doses of pain medication.

The study, published in the journal Medical Care, found that less than half of the patients were “chronic users” who had been prescribed opioids for more than 90 days.

Only 17% percent of the overdoses involved patients taking a high morphine-equivalent dose of over 120 mg per day -- what is considered a "yellow flag" in Washington State for possible opioid abuse.

Surprisingly, nearly three out of ten (28%) patients who overdosed were taking a relatively low opioid dose of just 50 mg per day.

Sedatives were involved in nearly half of the overdoses and methadone in about a third of them.

In 2007, Washington State adopted some of the toughest regulations in the country on opioid prescribing -- guidelines that the researchers believe should be even more restrictive.

"It may be prudent to revise guidelines to also address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use, in addition to chronic, high-dose use," said lead author Deborah Fulton-Kehoe, PhD, a research scientist in the Department of Environmental and Occupational Health Sciences at the University of Washington School of Public Health in Seattle.

Based on the recommendations of this and other studies, Washington State’s Interagency Guideline on Prescribing Opioids for Pain was recently revised to caution doctors about prescribing opioids at any dose. The new guidelines extend to the treatment of acute pain, not just chronic pain. Physicians are also advised not to continue prescribing opioids to a patient if they don't show “clinically meaningful improvement” in physical function, in addition to pain relief.

While the overdose study focused on only one state, one expert says it has national and even global implications.

“The article notes that many overdoses occur when patients are prescribed medications at low doses. This has important implications for national policy and debate,” said  Dr. Jeroan Allison of University of Massachusetts Medical School, who is co-editor-in-chief of Medical Care. "The statistics are quite overwhelming and dramatic, and this problem affects every state in our nation."

According to the Centers for Disease Control, over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010.

More recent data suggest that the “epidemic” of painkiller abuse is abating.

Hydrocodone prescriptions fell by 8% last year and it is no longer the most widely prescribed medication in the U.S.

A recent report by a large national health insurer found that total opioid dispensing declined by 19% from 2010 to 2012 and the overdose rate dropped by 20 percent.

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.

Power of Pain: Facing Insurance Challenges

By Barby Ingle, Columnist 

You may have heard about singer Avril Levine’s battle with Lyme disease, a tick-borne illness that left her bedridden for months with debilitating pain and fatigue.

It took a long time for Avril to be diagnosed correctly by doctors. She had to keep researching and advocating for herself before she was finally given proper treatment – a problem faced too often by people with chronic pain and illness.

Sometimes doctors cause these delays, but often insurance companies are responsible.

Americans receive their health care coverage from a variety of sources; through their employers, self-purchased policies, and public programs such as Medicare or the Affordable Care Act.

As the cost of healthcare rises, consumers have seen a significant hike in premiums and out-of-pocket expenses such as deductibles, copayments, and other cost sharing.

Insurance companies are also working to keep their costs down, through policies such as prior authorization, “step therapy” requirements, and specialty tier pricing on medications.

It can be a battle that is time consuming, frustrating, and depressing when an insurance company denies payments for a medication, procedure or medical device. Sometimes the issue is due to a provider entering the wrong code, but most often it is a cost savings issue. Insurance companies can make blanket denials and question whether a certain treatment is appropriate for you. 

What can be done to change this?

Step Therapy and Fail First

We need to abolish the unethical “Step Therapy” or “Fail First” practices by insurance companies – which require a patient to use a different (and usually cheaper) medication than the one prescribed by their physician.

There are patients from all over the United States reporting how they are being forced to switch from one drug to another. This has personally happened to me twice. Both times, I fought the ruling using my medical records and providers support, and the insurance company reversed the decision. However, others are not so lucky. In my case, I had already tried all of the medications that the insurance company was willing to pay for, and I had documented records stating my reaction to each of the medications.  

Usually, a patient can tell immediately whether a medication is working or not, and they should not be forced to stay on drugs that don’t relieve their symptoms. Applying step therapy protocols rigidly to a chronic care patient is not in their best interest and simply creates more challenges.

This practice is especially hard on pain patients who are women, minorities, and economically disadvantaged. Studies have shown these groups are most affected and are either disproportionately undertreated or untreated for pain. We must urge insurers to reduce health disparities in our communities.  

If you are faced with a step therapy situation, what can you do? I would suggest you appeal immediately. If you have already tried that medication, get copies of your providers’ records, and your journal entries, and submit them with your appeal.

You can use a journal to help the provider document how step therapy drugs fail to help or make things worse.  Note when complications and bad side effects occur, and report them to your doctor.

You should also have your provider fill out and submit a Medform 3500 to the Food and Drug Administration when you have a bad reaction to a medication or medical device. Send a copy to your insurance company. That documentation can increase the chances of a successful appeal  favorable to you.

Prior Authorization

There are many insurance plans that require prior authorization for expensive drugs or treatments and they may not provide coverage if you do not get prior approval. Once again, this tactic is used as a cost containment measure. Prior authorization covers the correctness, suitability, and coverage of a service or medication. 

The process differs with each plan, but is supposed to ensure that a patient will receive the appropriate level of care in the appropriate setting. This is actually a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved. It can delay care months to years, and can be life threatening and health deteriorating to the patient in many ways. 

Services that may require prior authorization include hospital admissions, back surgery, hysterectomies, maternity stays longer than 48 hours, observational stays, cosmetic procedures, experimental and investigational procedures, and some outpatient procedures.  

Specialty Tier

Insurance companies have divided medications and treatments into four main insurance tiers, based on type and price. The top and most expensive tier is known as the “specialty tier” or “tier 4 medications.”

Insurance companies classify the most innovative, expensive, and most essential to life medications as specialty tier.  These drugs can cost hundreds to thousands of dollars each month. Patients with chronic illnesses such as arthritis, Reflex Sympathetic Dystrophy, hemophilia, HIV/AIDS,  Crohn’s disease, Hepatitis C, multiple sclerosis, and many forms of cancer need these medications to help them function on a daily basis.  

According to the National Minority Quality Forum, 57 million Americans depend on specialty tier drugs that are often expensive and have no generic form yet available. 

With specialty tier pricing, a patient often pays a co-insurance instead of a co-pay, resulting in an out of pocket cost that can become astronomical. This often happens to patients who are  disabled, need catastrophic care, and have little or no income.

It is difficult to appeal specialty tier pricing decisions, as the medications are classified and a list is available to the insured at the time of coverage or when a medication is released to the market.

Many patients and providers give up when they get the first denial letter from an insurance company, but it’s important to keep fighting. An appeal can show a pattern that other patients with the same condition also need the same treatment. This can lead to an easier situation for other patients down the line, or if you need the procedure repeated.   

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.

How Does Your Surgeon Rate?

By Pat Anson, Editor

Before the Internet age, finding a good doctor usually depended on word-of-mouth referrals and recommendations -- or just sheer luck.

Now there are over a dozen online resources to help patients find physicians in all sorts of medical specialties, from oncology and neurology to podiatry and psychology.

The latest is Surgeon Scorecard, a searchable database put together by the non-profit ProPublica, that estimates complication rates for nearly 17,000 doctors who perform one of eight elective surgeries, including neck and lumbar spinal fusions, as well as hip and knee replacements.

The database – which uses government records collected from Medicare patients – can be searched by location, hospital or surgeon to learn how they performed during these “routine” procedures -- and whether they had complications such as infections, blood clots, internal bleeding or worse.

“It’s long overdue,” Dr. Charles Mick, a former president of the North American Spine Society told ProPublica. “Hopefully, it will be a step toward a culture where transparency and open discussion of mistakes, complications and errors will be the norm and not something that’s hidden.”

ProPublica found that even the best hospitals had surgeons with higher than average complication rates – and that selecting the right doctor could be a matter of life or death. Over 200,000 hospital patients die every year from preventable errors and complications.

Overall, complication rates are low for most surgeons – just 2 to 4 percent depending on the procedure – but a small share of doctors (11%) are responsible for about 25% of the complications. Hundreds of surgeons have complication rates double and triple the national average.

One such doctor is Constantine Toumbis, a surgeon at Citrus Memorial Hospital in Inverness, Florida. The “Surgeon Scorecard” shows that at least 27 of Toumbis’ patients have either died or suffered serious complications after surgery.

One patient died just days after a spinal fusion -- even though Toumbis had written in her records that the operation went well, according to ProPublica. An autopsy proved otherwise, when the medical examiner found bone fragments in the patient’s neck and signs of an extensive hemorrhage.

Toumbis and Citrus Memorial both declined to comment to ProPublica about the case.

Patient Resources

In addition to the "Surgeon Scorecard," several other searchable databases can be found in the “Patient Resources” section of this website that can help you find a good doctor, healthcare facility or the right treatment.

Vitals can help you locate a doctor with a specific specialty anywhere in the United States, along with patient reviews of that physician.

RateMDs has patient reviews of over a million doctors and healthcare facilities, including some outside the United States.

Healthgrades uses an extensive database and patient reviews to rate doctors based on their experience, complication rates and patient satisfaction.

The Centers for Medicare and Medicaid Services has a database that reveals if your doctor received money from a drug maker or medical device company for consulting, travel expenses, meals, research and promotional services.

Iodine has been called the "Yelp of Medicine." It uses patient reviews to rate the quality, efficacy and side-effects of prescription drugs, including opioid painkillers.

Healthcare Bluebook helps consumers save money on medical expenses -- everything from drugs to surgery to x-rays -- by giving them access to a nationwide database that estimates a "fair price" for whatever they're paying for.

Study: Drug Abusers Responsible for Painkiller Misuse

By Pat Anson, Editor

A new analysis of a federal health survey has confirmed what many pain patients have been saying all along – that drug abusers, not patients, are largely responsible for the so-called epidemic of prescription painkiller abuse.

Researchers at the University of Georgia analyzed data from the 2011-2012 National Survey on Drug Use and Health. Over 13,000 Americans aged 12 and older were asked about their use of prescription drugs, illegal drugs, tobacco, and alcohol.

Less than 5% of those surveyed reported they had used a pain medication not prescribed for them or that they took it only for the "high" feeling it caused.

A further analysis of those abusers found that marijuana, cocaine or heroin use within the past year was the “only consistent predictor” of pain reliever misuse among all age groups.

"Male or female, black or white, rich or poor, the singular thing we found was that if they were an illicit drug user, they also had many, many times higher odds of misusing prescription pain relievers," said lead author Orion Mowbray, an assistant professor in the School of Social Work and the University of Georgia.

The findings are published in the journal Addictive Behaviors.

Asked where they obtained painkillers, the vast majority of the abusers said they did not get the drugs through a legitimate prescription, but had stolen them, acquired them from friends or relatives, bought them from a drug dealer, or used a fake prescription.

"If we know how people come to possess the pain relievers they misuse, we can design better ways to lower that likelihood," said Mowbray. "This study gives us the knowledge we need to substantially reduce the opportunities for misuse."

Adults aged 50 and older were more likely to acquire pain relievers through more than one doctor, although the rate of misuse in that age group was the lowest (1.7%).

People between the ages of 18 and 25 were most likely to misuse painkillers (10.2%) and more likely to get them from a friend, relative or drug dealer.

The study calls for greater coordination between medical care providers to reduce the possibility of over-prescription of painkillers, and for improving the communication between doctors, patients and the public.

"Doctors may conduct higher quality conversations with older patients about the consequences of drug use before they make any prescription decisions, while families and friends should know about the substantial health risks before they supply a young person with a prescription pain reliever," said Mowbray.

According to the Centers for Disease Control, over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010.

More recent data suggest that the “epidemic” of painkiller abuse is abating.

Hydrocodone prescriptions fell by 8% last year and it is no longer the most widely prescribed medication in the U.S.

A recent report by a large national health insurer found that total opioid dispensing declined by 19% from 2010 to 2012 and the overdose rate dropped by 20 percent.

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.

A Pained Life: Speak Up, Speak Out

By Carol Levy, Columnist

I saw an advertisement on TV a few days ago. It was for some sort of a patch they were hawking for those with pain.

The testimonials were typical: "I use it and it's wonderful," said one man. "I recommend it highly," says a woman.

One testimonial really caught my attention: "I use it because I don't want to become addicted to pain medication."

So now the lie is even in TV commercials: Pain medication leads to addiction. And that should be your first thought and worry.

Never mind the reality that few people who use opioids for pain management become addicted. The lie has taken hold and is now part of the myth and stereotype; there is an epidemic of painkiller abuse and overdoses, and pain patients are on their way to addiction when they use these medications.

What bothers me about this, other than the spread of and belief in the lie, is the too many posts from members of chronic pain groups who have bought into the mythology and do not understand the difference between addiction and dependence.

They write they were on such and such a medication, often non-narcotic drugs like Lyrica, Cymbalta or anti-convulsants; drugs that do not have addictive properties.

"I have tried to get off it but I get sick when I do. Could I be addicted?"

No. Not from the poster's words. It may be physical dependence, which is nothing to be sneezed at. It is a bad problem and requires hard work to get off the medication. But that does not make it addiction.

The American Society of Addiction Medicine defines addiction behavior as an “inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.”

PainEDU.org defines dependence as a “state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.”

I cannot recall every reading or talking with people in chronic pain who said liked the narcotics they were prescribed. No one has ever said to me, "Wow. I love the way this drug makes me feel."

They may write or say the opioid has helped reduce their pain and that makes them happy, but invariably this lament usually follows: "But I hate the way it make me feel. Foggy, dry mouthed, and slow."

I hate writing and saying this because we have so much on our plates already, just getting through a day with pain, but we have to be the advocates. We have to get out the word that we do not take these drugs for fun. For some of us they are truly life savers. And yet it is our voice that seems to be absent in the midst of all the media hoopla and sensationalism.  

It is past time for us to take up our pens and raise our voices. We are the ones who get hurt by the misinformation. It is up to us to change the conversation.

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.

‘Amazing’ New Stem Cell Treatment for Neuropathy

By Pat Anson, Editor

Researchers at Duke University say an experimental stem cell therapy being tested on animals shows great potential to provide long-lasting pain relief for people suffering from diabetic neuropathy or other types of nerve damage.

In a study published in the Journal of Clinical Investigation, researchers said mice injected with a type of stem cell known as bone marrow stromal cells (BMSCs) were much less sensitive to nerve pain.

"This analgesic effect was amazing," said Ru-Rong Ji, PhD, a professor of anesthesiology and neurobiology in the Duke School of Medicine. "Normally, if you give an analgesic, you see pain relief for a few hours, at most a few days. But with bone marrow stem cells, after a single injection we saw pain relief over four to five weeks."

BMSCs are known to produce an array of healing factors and can be coaxed into forming other types of cells in the body. They are already being used to treat people with serious burns, inflammatory bowel disease, heart damage and stroke.  

"Based on these new results, we have the know-how and we can further engineer and improve the cells to maximize their beneficial effects," said Ji.

Researchers injected the mice with stem cells through a lumbar puncture, infusing them into the fluid that bathes the spinal cord.

The picture on the right shows how the injected stem cells (in red) migrated to the site of the nerve injury and were still present four weeks after treatment.

A molecule emitted from the injured nerve cells -- which has previously been linked to neuropathic pain – is believed to act as a “homing signal” and attract the stem cells.

Researchers measured levels of anti-inflammatory molecules in the mice and found that one in particular, TGF-β1, was present in higher amounts in the spinal fluid of the stem cell-treated animals.

TGF-β1 is a protein that is secreted by immune cells and is common throughout the body. Research has shown that people with chronic pain have too little TGF-β1.

courtesy duke university

Injecting TGF-β1 directly into spinal cord fluid provides pain relief, but only for a few hours, according to Ji. By contrast, bone marrow stromal cells stay on site for as much as three months after the infusion.

Ji’s research team is working to identify stem cells that produce more TGF-β1, as well as other types of pain relieving molecules. In addition to diabetic neuropathy, researchers believe stem cell therapy could also be used to treat pain from chemotherapy, surgical amputation, lower back pain and spinal cord injuries.

Nearly 26 million people in the United States have diabetes and about half have some form of neuropathy, according to the American Diabetes Association.  Diabetic peripheral neuropathy causes nerves to send out abnormal signals. Patients feel pain or loss of feeling in their toes, feet, legs, hands and arms. It may also include a persistent burning, tingling or prickling sensation. The condition can lead to injuries, chronic foot ulcers and even amputations.

Another recent animal study by researchers in the U.S. and South Korea found that diabetic rats given intramuscular injections of bone marrow stromal cells experienced both angiogenesis (blood vessel growth) and a restoration of the myelin sheath -- a protective covering over nerve cells damaged by neuropathy.

"Currently, the only treatment options available for DN (diabetic neuropathy) are palliative in nature, or are directed at slowing the progression of the disease by tightly controlling blood sugar levels," said Dr. John Sladek, Jr., Professor of Neurology, Pediatrics, and Neuroscience, Department of Neurology at the University of Colorado School of Medicine.

"This study offers new insight into the benefits of cell therapy as a possible treatment option for a disease that significantly diminishes quality of life for diabetic patients.”

The study is being published in the journal Cell Transplantation.

Is Cinnamon a Safer Pain Reliever?

By Pat Anson, Editor

A new warning from the U.S. Food and Drug Administration about the risk of serious side effects from non-steroidal anti-inflammatory drugs (NSAIDs) may have you thinking about finding safer, more natural pain relievers.

The idea isn’t new by any means – about 2,400 years ago the Greek physician Hippocrates was writing about the use of willow bark to ease aches and pains. Other natural remedies used for centuries to relieve pain and reduce inflammation include St. John’s Wort, ginger, ginseng, turmeric, and cinnamon.

Cinnamon, in fact, was recently found to be nearly as effective as the NSAID ibuprofen in relieving pain from menstrual cramps (dysmenorrhea).

The results of a small double-blind clinical trial, published in the Journal of Clinical and Diagnostic Research, evaluated the effects of cinnamon, ibuprofen and a placebo in 114 Iranian female college students. The women were broken up into groups of three; and given either 420 mg of Cinnamon Zeylanicum, 400 mg of ibuprofen or a starch placebo during the first 72 hours of their menstrual cycle.

Eight hours after treatment, researchers found that pain severity in the cinnamon group was significantly less than those who took a placebo, while pain severity in the ibuprofen group was less than those who took cinnamon.

Although ibuprofen was found to be the more effective pain reliever, the researchers believe cinnamon may be a better treatment for menstrual cramps because it doesn’t have the side effects of ibuprofen.

“The research results suggest that, Cinnamon as compared significantly reduces the severity and duration of pain during menstruation, but this effect is less compared to that of Ibuprofen. Due to the lack of adverse events in this study, Cinnamon can be used as a safe and non-pharmacological treatment for primary dysmenorrheal pain in young girls,” the researchers reported.

Iranian researchers have also found that thyme oil and lavender oil were effective in treating menstruation cramps, according to GreenMedInfo.

Last week, the FDA warned that "everyone may be at risk" from using NSAIDs – and ordered drug makers to strengthen warning labels about the risk of a fatal heart attack or stroke.

The warning applies to Advil, Tylenol, Motrin and other popular pain relievers sold over-the-counter, as well as all prescriptions drugs containing ibuprofen and acetaminophen. Many multi-symptom cold and flu products, such as NyQuil and DayQuil, also contain NSAIDs.

The agency said studies have shown the risk of serious side effects can occur in the first few weeks of using NSAIDs and could increase the longer people use the drugs. The revised warning does not apply to aspirin.

Changing Our Country One Addict at a Time

By Mary Maston, Guest Columnist

It’s obvious that our current ways of dealing with addiction aren’t working. They have never worked. The entire process of making drugs illegal and incarcerating those who use, possess, and sell them has been an epic fail in every way imaginable.

The “War on Drugs” – a phrase coined by President Nixon -- has been raging for almost 45 years, longer than I have been alive. How many trillions of our tax dollars have been spent in that time and where has it gotten us?

According to the officials, the problem of addiction is worse now than it’s ever been, despite throwing people in jail left and right. Making things even worse, legitimate chronic pain patients are being lumped together with addicts and drug abusers -- making opioid pain medication harder and harder to get.

We haven’t solved anything, and we never will if this is the path we continue to take.

"Insanity: doing the same thing over and over again and expecting different results.” -- Albert Einstein

It’s time that we start thinking outside the box. We need a different approach and the police chief of Gloucester, Massachusetts may have found one.

Chief Leonard Campanello has worked in law enforcement for 25 years. In that time, I’m sure he’s seen just about every scenario imaginable and then some. Perhaps he’s grown tired of seeing the same people in and out of his jail repeatedly. Or perhaps he just has a bigger heart than most, and the desire to contribute to a real solution. That’s what I choose to believe.

After dealing with addicts repeatedly over the years, Campanello has decided to change the way he does things and tackle the issue from a totally different angle.

Campanello recently announced that anyone who walks into his police station and asks for help with addiction, and surrenders any drugs and paraphernalia they have, will not be arrested. Instead he/she will be put into a detox and rehab program, funded by the money the police department has collected from drug raids.

You read that correctly: Anyone who asks for help will receive it without judgement, persecution, fines, or jail time. It’s called the Gloucester Initiative.

It’s a bold move. It’s never been attempted before. Many may say it’s crazy, that it will never work. It goes against everything we’ve heard about addiction.

Get this though: it is working.

It’s an absolutely brilliant concept and it’s already changing lives in the short time since it’s been started. It’s also gaining national attention. There are many organizations that are starting to come on board, and because of that, the Police Assisted Addiction and Recovery Initiative  was born.

police chief leonard campanello

So far over two dozen people have entered the program. While that doesn’t seem like many in the grand scheme of things, it’s a start. The drugs those people had are off the streets, and they are getting help when they would otherwise be using and selling. What if 28 drug addicts were no longer on YOUR streets and in YOUR community? Would you feel a little bit safer, maybe a little less cynical? Everyone has to start somewhere.

This proves that there are people who are addicted and who truly want help, but haven’t been able to get it for any number of reasons. Maybe they can’t afford it – rehab facilities aren’t cheap. Maybe they don’t have insurance or if they do, it doesn’t cover extended treatment.

If they are using illegal drugs but haven’t been caught yet, maybe they are afraid of going to jail for the first time. Maybe they enjoyed being an addict for a long time, but don’t want to be one anymore and don’t know how to stop.

Think about it for a moment. This could be a huge game changer for chronic pain patients, especially if this initiative takes off nationally like I’m hoping it will.

Right now, everyone is so quick to label anyone that uses pain medication for any reason as an addict. What if addicts weren’t abusing anymore? Perhaps that would equate to better treatment for us, without the stigma of being judged so harshly because we actually need medications to function; not because we want to get high, but because we want to live somewhat productive lives and medication is the only thing that helps us.

Think about how much better your life would be if medical professionals got back to actually treating patients with debilitating diseases and conditions – respectfully – instead of focusing on policing everyone that walks through their doors and denying medical care.

I’m not naïve enough to think that this is going to completely solve everything. Not everyone wants help and there are some genuinely bad people in this world, but I’m holding onto hope that this can potentially make a positive difference in the lives of millions – the ones that do want help.

Putting people in jail doesn’t accomplish that, and there are people out there that would stop using drugs if given the opportunity to do it in the right environment.

Just ask those that have come forward. Out of all of the things I’ve read over the years on the subject of the war on drugs, this is the only thing I’ve come across that has the potential to actually change things for the better and make an impact.

That’s why I fully support this cause. I would be insane not to.
 

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.

FDA: 'Everyone May Be at Risk' from NSAIDs

By Pat Anson, Editor

Warning that "everyone may be at risk," the U.S. Food and Drug Administration has ordered warning labels for non-steroidal anti-inflammatory drugs(NSAIDs) to be strengthened to indicate they increase the risk of a fatal heart attack or stroke.

The warning applies to ibuprofen, Advil, Motrin and other popular pain relievers sold over-the-counter, as well as prescriptions drugs containing NSAIDs. Many multi-symptom cold and flu products also contain NSAIDs.

The agency said studies have shown the risk of serious side effects can occur in the first few weeks of using NSAIDs and could increase the longer people use the drugs. The revised warning does not apply to aspirin.

“There is no period of use shown to be without risk,” says Judy Racoosin, MD, deputy director of FDA’s Division of Anesthesia, Analgesia, and Addiction Products.

The FDA said people who have a history of heart disease, particularly those who recently had a heart attack or cardiac bypass surgery, are at the greatest risk for a serious cardiovascular event associated with NSAIDs. But the risk is also present for people who don't have heart problems.

“Everyone may be at risk – even people without an underlying risk for cardiovascular disease,” Racoosin said.

NSAIDs are widely used to treat everything from fever and headache to low back pain and arthritis. They are in so many different pain relieving products that health officials believe many consumers may not be aware how often they use NSAIDs. 

“Be careful not to take more than one product that contains an NSAID at a time,” said Karen Mahoney, MD, deputy director of FDA’s Division of Nonprescription Drug Products.

The labels for both prescription and over-the-counter NSAIDs already have information warning of heart attack and stroke risk. In the coming months, FDA will require drug manufacturers to update their labels with more specific information warning that the risk is heightened even in the first few weeks of use.

“Consumers must carefully read the Drug Facts label for all nonprescription drugs. Consumers should carefully consider whether the drug is right for them, and use the medicine only as directed. Take the lowest effective dose for the shortest amount of time possible," Mahoney said.

Several recent studies have found that NSAIDs increase the risk or heart attack and other health problems. The exact cause is unclear, but researchers believe NSAIDs may raise blood pressure and fluid retention, which can affect how the heart functions.  

A 2013 study published in The Lancet warned that high doses of NSAIDs may increase the risk of heart problems by about a third. In a review of over 600 clinical trials involving more than 353,000 patients, researchers found that NSAIDs doubled the risk for heart failure. People on high doses of the drugs also had up to four times greater risk for bleeding ulcers or gastrointestinal problems.

Another large study at the University of Florida in 2014 found that the over-the counter pain reliever naproxen raises the risk of a heart attack, stroke and death in postmenopausal women. Naproxen is a NSAID and the active ingredient in Aleve and other pain relievers commonly used to treat arthritis.

Studying data from over 160,000 postmenopausal women participating in a study funded by the National Institutes of Health, researchers estimated that using naproxen just twice a week raises the risk of cardiovascular problems by about 10 percent. The same study did not find a higher risk of a heart attack, stroke and death associated with ibuprofen, another type of NSAID.

Opioids Less Effective for Back Pain When Depressed

By Pat Anson, Editor

Patients who have low back pain are significantly less likely to get relief from opioid pain medication if they suffer from depression or anxiety, according to a new study published in the journal Anesthesiology.

Lower back pain is the leading cause of disability worldwide, with about 80 percent of adults experiencing back pain at some point in their lives. According to one recent study, about one in five low back pain patients also suffer from depression.

"High levels of depression and anxiety are common in patients with chronic lower back pain," said Ajay Wasan, MD, study author and professor of anesthesiology and psychiatry at the University of Pittsburgh School of Medicine.

"Learning that we are able to better predict treatment success or failure by identifying patients with these conditions is significant. This is particularly important for controlled substances such as opioids, where if not prescribed judiciously, patients are exposed to unnecessary risks and a real chance of harm, including addiction or serious side effects."

Wasan and his colleagues examined 55 chronic lower back pain patients with low- to-high levels of depression or anxiety. The patients were given morphine, oxycodone or a placebo to take orally for pain as needed over a six-month period.  

Patients with high levels of depression or anxiety experienced 50 percent less improvement in back pain (21% vs. 39% pain improvement) when compared to patients with low levels of depression or anxiety. They were also significantly more likely to abuse their medication.

Wasan says doctors should be cautious in prescribing opioids for depressed patients with back pain.

"It's important for physicians to identify psychiatric disorders prior to deciding whether to prescribe opioids for chronic back pain as well as treat these conditions as part of a multimodal treatment plan," he said

"Rather than refusing to prescribe opioids, we suggest that these conditions be treated early and preferably before lower back pain becomes chronic. For those prescribed opioids, successful treatment of underlying psychiatric disorders may improve pain relief and reduce the chance of opioid abuse in these patients."

A large study presented in March at the annual meeting of the American Academy of Orthopedic Surgeons found that depression, as well as obesity, smoking and alcohol use significantly raise the risk of having low back pain.

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

“With our study there was no way to determine the cause and the effect or which came first because there was so much overlap,” said lead author and orthopedic surgeon Scott Shemory, MD. “Especially with alcohol abuse and depressive disorders. Anybody who’s got low back pain for years and years, I don’t think it would be surprising that they would have a higher chance of depression or alcohol abuse.”

A leading U.S. medical organization recently urged its members not to prescribe opioids for back pain – whether patients are depressed or not. The American Academy of Neurology released a position paper last year saying the risk of serious side effects from opioids outweigh the benefits of pain relief. The Academy represents 28,000 neurologists and other healthcare providers.

“Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction,” wrote Gary M. Franklin in the journal  Neurology.

Searching for Medical Marijuana’s ‘Therapeutic Window’

Dr. Mark Ware is one of the world’s leading experts on medical marijuana. Ware is an associate professor in Family Medicine and Anesthesia at McGill University in Montreal and director of clinical research at the Alan Edwards Pain Management Unit at McGill University Health Centre. He practices pain medicine at Montreal General Hospital.

Although medical marijuana is legal throughout Canada, and in 23 U.S. states and the District of Columbia, mainstream medicine still frowns upon its use. Research into the therapeutic benefits of cannabis -- particularly for pain management -- has also been limited.

Pain News Network editor Pat Anson recently spoke with Ware at the annual meeting of the American Pain Society. The interview has been edited for content and clarity.

DR. MARK WARE.

Anson: You’ve called medical marijuana an “incredible social experiment.” What do you mean by that? 

Ware: I think what we’re seeing is the lid coming off something that’s been going on for a long time. I think people have been self-experimenting with marijuana for years and years. People have been growing it in their basements and backyards. So there’s been a social experiment with cannabis since the 1960’s in the Western world.

I think the medical aspect of it has kind of followed through with that, because as you get thousands of people using cannabis, eventually somebody with an illness is going to stumble upon it. Lester Grinspoon (a marijuana researcher) reported on this in 1971. So that’s how long we’ve known or suspected the potential medical properties. The fact that the drug has been illegal has suppressed the possibility of there being much in the way of good quality research. So the experiment has been going on underground, out of sight and out of the public eye.

What we’re seeing now is that suddenly we’re able to talk about it. We’re able to look at this seriously. And we’re beginning to realize how much was already going on. So I think it’s an experiment that’s been going on for a long time and we’re beginning to put some parameters around it now, which allow us to track it more carefully. And hopefully it can yield some important results that can help inform the patient and the physician about what to do with this.

Anson: Some doctors have told me they don’t think marijuana will ever go mainstream until big companies like Pfizer and Purdue Pharma start backing marijuana research and doing clinical studies. Would you agree with that?

Ware: I don’t know if I would agree with that. That’s true for new pharmaceutical drugs. If you’re developing a molecule from the lab up, you need Big Pharma to come along and take that and move it to the point where they can do the big clinical trials.

With an herbal medicine, I think you almost don’t want to look at the pharmaceutical model for drug development. It’s more like how we regulate natural health products in Canada. We want good quality cultivation techniques, we want good quality processing, and we want to know what it is that we’re giving to patients.

I think fundamentally what we have to figure out is what we want to know about this drug. What is it that we need to know and how do we go about getting that information?

I think if we wait for Big Pharma to come along it’s going to be a long wait.  They would have been on this long ago if they thought this was important.

It’s a plant based medicine that’s already in our society at some level and we need to recognize the reality that mainstream doesn’t mean mainstream prescription availability. It’s going to mean mainstream figuring out how to put cannabis in a safe place in our society.

Anson: Medical marijuana is so widely available today, it’s like we’re already past the clinical trial phase.

Ware:  Exactly.  And to go back and do the Phase III study now, it’s expensive and would take hundreds of millions of dollars. And that requires knowing whether you’re going to get your money back. Companies invest that money when they know they’ve got a patent and they can make money back on the drug in the ten years after it’s launched. It’s much harder to see that happening with an herbal material like cannabis.

Why invest the money? It’s already available. You can already buy it at the dispensary. So now the question is how do we improve that process? How do we improve the quality of the product? How do we label them so people know what’s in them? How do we provide information to the patients that are buying them? What they should be looking for and what they should be careful about?

And how do we inform the physicians and health professionals who should be managing that whole process or at least informing it? What kinds of patients should be avoiding this? This isn’t for young kids. This isn’t for women who are pregnant. Some of this is obvious, but some of it needs to be specified and mandated.

I don’t think there’s strong enough evidence to start using cannabis in younger people. I think that the risks of cannabis on the developing brain in teenagers is significant enough that, unless there is a very real reason like a younger person with a severe intractable illness, this is a drug that should be held for the 25 and older crowd.

I would caution people who have unstable heart problems against using cannabis. It does increase your heart rate, can open up your blood vessels, and that could precipitate some heart problems.

Anson: What are the pain conditions that you think medical marijuana can be beneficial for?

Ware: I think for sure it’s more likely effective for chronic pain than acute pain. It’s never been reported for acute pain syndromes, but it has been reported for chronic pain.  There are clinical trials now that bear out that chronic neuropathic pain is one of the relieved conditions that it seems to respond to. We’ve seen reports for spinal cord injury, fibromyalgia, and PTSD (post-traumatic stress disorder). Cannabinoids appear to have some signals in some of these conditions.

And then you go beyond that to abdominal pain with Crohn’s disease, diabetic neuropathy, and so on. The list of conditions where it looks like it may work is as long as your arm.  There are individual case reports of cannabis being used on a huge range of conditions.

Anson: What is the most effective delivery system? Everyone thinks of smoking, but there are plenty of other ways to ingest marijuana.

Ware: There are. And I think the key thing is the difference between inhaling and taking it by mouth. The inhaled route is a very quick onset, has a very rapid effect on the patient, and then a fairly quick half-life; whereas the oral route takes much longer to absorb and takes a longer time for the patient to feel the effects. But then it lasts a lot longer. 

courtesy drug policy alliance

So it’s almost like a short acting versus a long acting medication. I don’t think there’s any way of saying one is more effective than the other. I think they’re effective in different ways.

If I was vomiting because of chemotherapy, I’d want something I could inhale to control the vomiting quickly. But if I’m not able to sleep because of my chronic pain, I want something that would be longer lasting so I could sleep through the night.  I don’t want to wake up three hours later and have to do it again. So I think we just have to figure out how to use the different administrative techniques for different clinical conditions.

Anson: Most of our readers are pain patients and when this subject comes up many of them say, “I’ve never tried marijuana. I’m curious about it and I’d like to try it, but I’m worried about getting high.” Can they get pain relief without getting high?

Ware: We’ve done studies where we kept the doses very, very small -- to the point where people have read the protocols and said you’re not giving these patients enough to feel the effect. And in fact, what happens is patients are still able to find analgesic benefit and avoid that euphoric or psychoactive effect.

That’s important for most patients. They want to be able to use a drug or any kind or a therapy that doesn’t impair them from doing the things that they need to do. They need to drive. They need to work. They need to hang out with their families. They need to do their sports and their activities. And this is part of pain management generally. We want people to be living as full and as active a life as possible. We don’t want them collapsing on the couch all day long.

So can we find that window, what we call that therapeutic window, that dose where you get the benefit but you don’t get the sedative or psychoactive effect? And I think we can. I think for patients who are considering this approach, they really have to learn to be very patient and use very, very small doses. Try very small amounts first and allow your body to feel what the drug is doing to you. And if nothing happens, that’s okay. You’ve started with a low enough dose that you felt nothing. You gradually work your way up.

The interesting thing about cannabis is that there are two ways of thinking about dose. One is the amount of the drug itself, the number of grams, joints or pipes, if you will. The other is the THC level of the cannabis itself.

courtesy drug policy alliance

If patients have access to material where the THC level has been standardized or has been measured, they should be trying to use THC cannabis that is as low as possible, because the likelihood of having a psychoactive reaction to a high THC cannabis is much higher.

If it’s high in THC, it doesn’t take much to get that effect, where if they use very low THC levels, less than 10 percent THC, and they use a small quantity of the material, then potentially they can find that therapeutic window that can be effective.

Anson: What about taking marijuana with opioids? Can you do that?

Ware: You can. There’s no medical reason why you shouldn’t. I think the key thing for patients who are doing that, and again I emphasize with the knowledge and support of their physician, is that they can reduce the doses of other medications which may not be helping as much.

Cannabis use can be seen in terms of improving patients in two ways. One is in reducing the medications that they’re already taking, which may have side effects. And the other is in improving their functioning state so that they’re doing more. This is where I think the responsibility lies with the patient to prove to the doctor that this drug is helping. And you do that by reducing your other medications with the doctor’s support, by increasing your functioning and by showing that you’re doing things that you weren’t doing before. That is what doctors want to see.

There appears to be evidence, at least in animal studies, that opioids and cannabinoid drugs work synergistically. So if you take the two separately and you take the two combined, you get a greater effect with the combination than if you took either of the others by themselves.

This synergism, we’ve seen it in patients who started using cannabis successfully and they were able to reduce their other medications. In some cases they find that the dose of opioids they were taking, they can lower it and get a similar effect with much lower doses. With others, they don’t need the opioids any longer and they can taper off it and stop completely. 

Anson: One fear of using medical marijuana is that it could make you more prone to abusing other substances.

Ware: I think patient selection is very important when you’re considering as a physician whether to authorize or prescribe cannabis, because cannabis is a drug with a known risk of abuse and dependence by itself. There are people who struggle with their marijuana use and withdrawal when they try to get off it. Physicians need to be sure they’re not making things worse for a patient that has a dependency disorder by authorizing cannabis.

Screening for dependence means looking for abuse of other substances, such as alcohol. If you’ve done that carefully, prescribing cannabis to a patient who doesn’t have that addiction risk appears to be fairly safe.

Medical cannabis should be used as an option only when all the conventional therapies have failed; when all of the other approaches to pain management, and I’m not just talking about pharmacology, but when all of the non-pharmacological approaches have all been considered and tried. Cannabis is not at the point where it can be thrown in as a first line agent for a patient struggling with pain management.

Anson: Thank you, Dr. Ware.

How Pain Clinics Fail Patients

By Jennifer Kain Kilgore, Guest Columnist

“You have exhausted all of your options.”

That is what I was told when I was denied as a new patient at Massachusetts General Hospital. Western medicine has officially given me the heave-ho.

Because I have a “long-standing relationship with another pain management clinic,” unless I am being referred for a specific procedure that my current doctors do not have, I am not allowed to become a patient elsewhere.

It’s so strange to reach the end of the road. It’s one thing to be told that the doctors are running out of ideas; it’s another thing entirely to have someone tell you that there is literally no other procedure in existence. All the treatments they are willing to try have been attempted. Science and research have not caught up yet. This is as good as it’s going to get.

What they’re willing to try. That’s the operative phrase here. Despite my decade of experience in the medical system, despite never exhibiting pill-seeking behavior, my pain management doctors refused to prescribe any kind of opioid safety net. If the pain gets really bad? “Go to the ER.”

Really? That’s the best you can offer? “Go to the ER”?

“I don’t think you understand,” I told my doctor. “I’ll have to quit my job. I can’t function like this.”

Shrug.

That’s the thing about pain management clinics. They do not cure. Most of the time they do not even have the power to manage. They try to dull the pain, to numb it, just long enough to get you out of their office. The problem is that pain is subjective. A finger slammed in a door can hurt worse than a fracture, and everyone thinks their pain is intolerable.

So if you keep coming back and complaining, then the problem must be in your head. Even though I told my pain doctor that I am already seeing a pain psychologist, she insisted that I meet with one in-house in order to come to terms with the “new” me. Like I’m not letting some kid sit at the lunch table with me. Play nice, you two!

I actually told her that when she said “you have to learn how to live with the ‘new you,'” not only did she make me want to murder everyone in my immediate vicinity, but she was also entirely patronizing. I’m sure I got some black mark in my medical file for that comment (“aggressive,” “argumentative,” “abusive,” etc.), but don’t tell me how to react to my issues when you have no experience dealing with them. I hope to God she never says those words to another patient.

Pain management doctors do not work well with patients who need more than the usual series of steroid injections. I’ve had the steroid injections, the ablations, the Botox in my muscles, the pills, the trigger point injections, the surgery, the infusion. There are no other procedures.

“We’ve done everything. So why are you still hurting? It must be in your head.”

Of course it’s in my head. That’s where pain is processed: IN YOUR BRAIN. My brain has learned these pain pathways, and my nervous system is constantly hyper-stimulated. It doesn’t take a Philadelphia lawyer to figure that one out.

 “Give her antidepressants. Give her nerve meds. Just don’t give her opioids.” That’s the reasoning my pain doctor kept parroting: “It’s been clinically proven that opioid medication doesn’t help chronic pain.”

I know that it doesn’t — not in the long run. Not if you take it every day, multiple times a day. All I need is a safety net for the really bad days. I was prescribed 14 Vicodin in March. Guess what? Still one left. Whole bottle of Tramadol? Untouched. I take them when I need them.

Doctors are more interested in protecting their own medical licenses than handing out medication to those who need it — which I can understand. If it were between my law license and some person I only see once a month, I’d go for the law license. For years, however, doctors over-prescribed until the government cracked down; now they under-prescribe and hope that none of their patients will notice. The pendulum has swung so far in the other direction that it’s only a matter of time before something breaks.

Pain management doctors must be frustrated with patients like me. It’s not like they’re huddled in a conference room, rubbing their hands together and muttering under their collective breath the names of patients they’re going to disappoint. I hate when I fail at my job. I’m sure they feel the same. But they are the gatekeepers, and they are in my way.

Everything that has helped recently has been found by my father, by my husband, and by me. I exercise as much as I can when the pain allows. I use a BodyBlade in order to strengthen my core muscles. I practice mindfulness and meditation. I stretch and do yoga on a daily basis. I walk at lunch. I get pain relief massages. I go to the chiropractor. I found the Quell pain relief device, which I adore and wrote about on my blog.

These are alternative forms of care, and they have been all found — wait for it — by people other than my pain management team.

We chronic pain patients truly have to be our own advocates. It is our responsibility to find the interventions that will help us. These treatments might seem strange or like some sort of hippie nonsense, but I am done being told by doctors that the pain is all in my head and that they can do nothing to help me. I will help myself. This is not the best it is going to be.

J. W. Kain is an attorney in the Greater Boston area who also works as a writer and editor in her spare time.  She has chronic back and neck pain after two car accidents.

This column is republished with permission from her blog, Wear, Tear, & Care.  

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.

Power of Pain: Avoiding Summer Travel Pain Storms

By Barby Ingle, Columnist

If you’re flying somewhere this summer, chances are you’ll have to contend with overcrowded terminals, flight delays, and security checkpoints. There are ways to make traveling easier and less stressful for chronic pain patients.

My first suggestion is to pack your medications in a carry-on bag. If your luggage gets lost, you won’t have to worry about where or how to get your medications.

Airport terminals are hectic and people are at a frantic pace, so by arriving early you can go at a slower, more relaxed pace and make the hassles of dealing with disabilities more manageable. Your goal is to make it to your destination on time, in a low pain level, and in a good mood.

When you decide to make a trip, it is best to plan ahead. I use the Internet to get destination information. I check out the floor plans of the airports I am coming and going from, and what types of foods are available in the terminals. I also request handicapped services from the airline, bus depot, car rental company, and hotel ahead of time.

If you are on oxygen, let the airline know 30 days prior to travel or as soon as you know that you will be flying. In-flight oxygen needs to be prearranged, and there is typically a charge. Then call 24 to 48 hours before your flight to confirm the oxygen arrangements.

At the airport, if traveling alone, bring tip money. I try to bring one-dollar bills and tip a dollar for each bag that I am assisted with, both when I am departing and at my destination. I also pay the person pushing my wheelchair one to two dollars for their assistance. I also have a scooter, so I do not always have to pay for the wheelchair assistance.

It is not mandatory to pay for help; however, the person pushing you often works for tips only or tips with a low wage.

Be sure to let them know if you want to make any stops to use the restroom or purchase food while they are assisting you. When they bring you to your gate, ask to be “parked” at the door or the start of the line. Make sure that the airline person sees you. If you sit off to the side, they may miss you, and you will not be able to take advantage of pre-boarding.

If you need extra time and assistance, you may have a problem. Typically, the flight attendant or ground crew comes over to me and moves me up in the plane if I have a seat towards the back, and they ask me if I need any assistance walking, or if I need an aisle chair to get to my seat.

Sometimes I board with the first group, when they call for people who need assistance. I do not tip the attendant who brings me down the jet way.

When I pre-board, once on the plane, if I need to take medication or I am nauseated, I ask for a small glass of water. If they do give you a glass of water, they must take it back before the plane takes off, so make sure you drink what you need when they give it to you.

Let them know while in flight if you need assistance in using the restroom or need blankets and pillows for comfort.

When you arrive at your destination, stay in your seat until your wheelchair assistance has arrived. They typically ask you to wait until the other passengers unload so that you do not hold them up or so that they do not bump against you and cause you further injury.

At baggage claim, if you are alone, ask the assistant to get your luggage and to bring you outside to meet your party. Once you are in a place you do not need assistance, give them their tip and thank them, so they may go help other travelers needing assistance.

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.

198 Thoughts I Had While Watching ‘Cake’

By Crystal Lindell, Columnist

I finally got around to watching Cake, the movie about chronic pain starring Jennifer Aniston.

Aniston plays Claire Bennett, who suffers from chronic pain and has visions of Nina Collins, played by Anna Kendrick. Nina also had chronic pain, but in the opening scene we are told she killed herself by jumping off a highway overpass.

I would definitely recommend you see this movie. It’s currently playing on Netflix, and if I know anything about people with chronic pain, it’s that they all have Netflix. So get on that, and then read this.

Basically everyone in my life has recommended this movie to me.

Lots of spoilers ahead, obviously.

1. Well, I guess, since it’s on Netflix, I’ll give it a go. It’s basically free.

2. I swear if they show Jennifer Aniston “getting better” in any way I’m going to scream.

3. And I really hope she doesn’t magically “get off opioids” because that crap is not realistic at all.

4. Of course it opens on a support group.

5. Seriously, where is this support group? Because I have yet to find one for people with chronic pain anywhere near me.

6. Hey, that’s Lynette Scavo from Desperate Housewives!

7. I’m glad she’s found some work since that show ended.

8. Yay! It’s Anna Kendrick!!! I hope she sings something from Pitch Perfect in this movie.

9. Oh. Anna Kendrick killed herself.

10. That’s sad.

11. Why is this group so mad at Anna Kendrick?.

12.  If you have chronic pain, and you can’t at least understand why someone would kill themselves in that situation, then you don’t actually have chronic pain.

13. #SorryNotSorry

14. Look! It’s Rachel from Friends.

15.  I wonder if Ross is going to be in this too.

16. Nevermind, he’s probably on a break.

17. Ha! I crack myself up. 

18. Someone should tell Claire about dry shampoo.

19.  I get it, showers suck when you have chronic pain. But that’s why God invented Batiste.

20. The fact that Anna Kendrick ended up in Mexico after her suicide is actually kind of hilarious. In a dark humor kind of way.

21. Man, everything gets stuck in customs. Even Nina.

22. So Claire’s laying down in the back of the cab?

23. I’m assuming because sitting up hurts?

24. Whenever I try that I get super car sick because of all my meds.

25  I wish I had a really nice Hispanic woman to take care of me and make me quesadillas.

26. That would probably make it a lot easier to cope with my chronic pain.

27.  What? The freaking support group kicked Claire out? Is that a thing? That support group sucks.

28.  Lynette, I’m so disappointed in you.

29. Ug. Claire and her husband are separated. Chronic pain man. It effs up your love life.

30.  I always wonder how/why people try to keep a secret stash of meds. I never have anything extra to put in a bottle behind a painting. I use all of my meds, every month.

31. Yep, trying to sleep with chronic pain is a bitch.

32  And I cry throughout the night a lot too.

33. This movie got that part right.

34. I wish I had a pool like Claire.

35. Maybe if I had a personal pool in my backyard, I could go in it and feel better.

36. Why is the pool green though. Just the evening light? It makes it look like a scummy lake.

37. And the opossum isn’t helping the vibe.

38. Seriously, I need to move to California though, where you can apparently take a dip in the middle of the night, and it’s so nice outside that you can fall asleep in a lawn chair like it’s nbd.

39. I feel like this movie is trying to make Claire seem like a bitch, but honestly, when you’re in pain and you’re riding in a car, every bump really does make you want to die.

40. I try to be nice and witty with my doctors too, just to make sure that they don’t think I’m just a drug seeker.

41. Ahh. Wine and meds. The best meal ever.

42. Also, true story, the doctor I saw at the Mayo Clinic once told me that drinking alcohol could help with my pain. So it’s not as crazy as it sounds.

43. Even chronic pain, greasy hair and a massive scars isn’t enough to repel men when it’s Jennifer freaking Aniston.

44. Congrats Claire! You get it girl!

45. Yep, having sex with chronic pain sucks.

46. How can you be physically intimate when it hurts every time someone touches you?

47. So based on Claire’s housekeeper’s reaction here, I’m going to guess that Claire’s kid died and those toys belonged to that kid.

48. Yep, this movie really is trying to make Claire look like a bitch.

49. I mean, what is up with this scene between the housekeeper and her daughter?

50. Claire’s not a bitch though. She’s just in pain.

51. And apparently, her freaking kid died.

52.Those two things would drive anyone to crazy town.

53. Yay! Anna Kendrick is back!!! I hope she sings Cups.

54. So Claire is kind of trying to kill herself with help from Anna Kendrick?

55. I can see that.

56. I think drowning would be a particularly awful way to die though.

57. Oh look! It’s that chick from the Good Wife!

58. Who was she on that show? Like an incompetent lawyer or something? 

59. I wish I could get aqua therapy. There’s nothing like that where I live.

60. Yeah. I’m on Claire’s side here. I don’t think the super healthy chick in the water really understands how much it hurts.

61. Oh? Really? Someone with chronic pain hasn’t magically gotten better in six months?

62. SHOCKING!

63. Like I said, the healthy chick in the pool doesn’t get it.

64. Another drowning attempt.

65. See, drowning isn’t a fun way to go Claire.

66.  I knew she would quit mid-way through.

67. And by “quit” I mean, “decide to live.”

68. Again with the laying down while they drive stuff.

69. Seriously, I would be throwing up all over the place if I tried that.

70. Maybe I should try that.

71. I mean, long car rides are one of my biggest issues. Would lying down in full recline position maybe help?

72. Oh, Claire’s going to go see where Anna Kendrick tried to kill herself. Interesting.

73.  I really don’t think Claire is going to jump, seeing as how we’re only 23 minutes into this movie.

74.  It was dream.

75. Maybe.

76. Either way, Claire lives!

77. Go Claire! You totally should sue the support group!

78. Oooo! Anna Kendrick’s husband is Australian!

79. I LOVE Australian accents!!!

80. This movie has suddenly become an episode of House Hunters. “Look what we’ve done with the kitchen!” Fun.

81. The Australian guy looks strikingly like Chris Pratt.

82. Is Chris Pratt from Australia?

83. Man, I wish I was Jennifer Aniston with chronic pain. Even Australian Chris Pratt look-a-like is into her.

84. Claire and her housekeeper are going to Tijuana!

85.  I want to go Tijuana! 

86.  Is this real? Can you really get opioids without a prescription in Mexico?

87.  Now I REALLY want to go to Tijuana.

88.  I wonder how much opioids cost in Mexico.

89. The pharmacist in Tijuana just called Claire a rich, white woman. But that’s where this movie get chronic pain wrong. If all you do is sit around all day, drink wine, and pop pills, there is no way you are rich.

90. Oh, maybe Claire got some kind of insurance money when her kid died. I guess that makes sense.

91. Now I want Mexican food.

92. I really wish the only Mexican restaurant in my town hadn’t give me and my family food poisoning.

93. Crap. They got stuck in customs.

94. Just like Nina.

95. Oh. Hello there, Danny from the Mindy Project!

96. So Claire’s ex-husband was able to get them out of customs?

97.  I need to find an ex-husband who can get me out of customs.

98. “Tell me a story where everything works out in the end for the evil witch.” Ok Claire.

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99.  Now Claire’s back at the Australian guy’s house.

100. Apparently Australian guy is cool with her randomly showing up in the middle of the night?

101.  He seems weird.

102. Anna Kendrick was 31 when she died in this movie?

103.  Crap. I’m 31.

104.  And she already had a 5-year-old?

105.   I’m so behind in life.

106.  Wow, Australian guy is really mad at Anna Kendrick.

107.   I feel like if Anna Kendrick was in so much physical pain that she jumped off an overpass, then you know, maybe she was in a lot of physical pain. Something her husband doesn’t seem to be taking into account.

108.  But, also I get it: Grief, it sucks.

109. Billy Joel. Interesting choice Claire.

110. Ahh. More wine. Better choice Claire.

111.  Now Claire is back at the Australian guy’s house AGAIN?

112. Do you think they’re ever going to have sex?

113. Or no?

114. Really? Anna Kendrick had a bunch of pain meds in the house, and they’re still just sitting there in the medicine cabinet?

115. I call B.S.

116. Oh. Hey. Anna Kendrick is back again.

117. She’s sassy in this movie.

118. Are we ever going to get Anna Kendrick’s back story?

119. Like, did she have a bad back? Or MS? Or intercostal neuralgia? Or what? Why was she in so much pain that she killed herself?

120. Hello Australian guy’s son.

121. “I like any animal that bites.” Ok again Claire.

122. And we’re back at the cemetery.

123. Now we’re in a diner. With Anna Kendrick. Seriously? If we don’t get to hear Cups in about five seconds, I’m gonna be so mad.

124.  I’m so mad.

125. Claire, I hate to tell you this, but you’re officially losing your shit.

126. You’re yelling at a ghost in a diner? This does not look good for you.

127. And don’t try to blame the meds, because I take tons of meds, and I don’t see Anna Kendrick anywhere.

128. Amazing Hispanic housekeeper invited Australian guy and his son to lunch.

129. AND she’s going to make mango tamales.

130. Now I want Mexican food again.

131. And we’re back with the healthy lady in the pool who has no clue.

132. “Sometimes I suspect you think I’m just this uncooperative, old bitch who’s making all of this up.” Preach Claire. 

133. Did she just ask Claire if she wants to get better?

134. Pretty sure everyone, everywhere with chronic pain WANTS to get better.

135. It’s Lynette again.

136. Really? Claire made you look unprofessional Lynette? Pretty sure you kicking her out of group was what made you look unprofessional.

137. Vodka from Costco solves everything.

138. What the heck was the point of that scene?

139. Are they just advertising Costco?

140. Woah! Claire curled her hair!!

141. You look nice Claire.

142. Oh no. Claire is going to try to lend her dead kid’s swimsuit to Australian guy’s kid.

143. This is not going to go well.

144. Nope. Didn’t go well.

145. Thank God for the nice Hispanic housekeeper.

146. She fixes everything.

147. Even Claire.

148. Australian guy, “How can you still live here?”

149. Umm, well, it’s a gorgeous house in California, with a freaking pool, that’s how.

150. This lunch is going so well.

151. Nevermind.

152. Hey, that’s Lynette’s real-life husband at the door.

153. Yep, that’s pretty much how I would react in that situation if I was Claire.

154. TBH, that guy was dumb for even showing up at Claire’s house.

155. Jerk.

156. So wait, did Claire try to kill herself with the pills?

157. Or was she just trying to take a lot of pills so she would feel better?

158. And there’s the nice Hispanic Housekeeper again.

159. Seriously, I wish she was my housekeeper.

160. Hello again, Anna Kendrick.

161. I would totally want to have sex with the entire Madrid soccer team too.

162. Soccer players are hot.

163. Baking a cake is cool too, I guess.

164. Oh. A cake. I get it now.

165. “Saints don’t jump off bridges.” Don’t they?

166. Ok. Sure, Claire. You’re just going to go off your meds cold turkey. Uh huh.

167. Why would they put up a drive-in theater right next to train tracks?

168. Wouldn’t that make it hard to hear the movie?

169. Claire is totally going to try to kill herself on those tracks.

170.  Anna Kendrick, “What would Saint Jude do?”

171. Claire, “I bet that son of a bitch would lay down on those tracks and just let Union Pacific put him out of his misery.”

172.  Agreed.

173. Mmmmm. McDonald’s French Fries.

174. Those things are so delicious.

175. You WERE a good mother Claire.

176. Maybe.

177.  We actually don’t really know.

178. And, once again the Hispanic Housekeeper to the rescue.

179. I can totally understand the housekeeper’s Spanish.

180. Well some of it.

181. I could totally get by in Argentina.

182.  Really? Someone stole their car? Because their lives don’t suck enough.

183. Why does every single movie and TV show ever set in California feature a runaway?

184. Everyone must run away to LA.

185. I should run away to LA.

186. Runaway: “Gross. I won’t do porn.” Famous last words.

187. “A homemade, yellow cake with fudge frosting.” That does sound good.

188.  Why can’t the housekeeper make the cake for Claire though? Because it’s American food?

189. I feel like the housekeeper could handle it. She makes mango tamales for goodness sake.

190. That is a gorgeous picture of Claire’s son.

191. Seriously, if I had a kid die AND I had chronic pain, I’d be a way worse shape than Claire.

192. Aww. Look. She got Anna Kendrick’s kid the cake that Anna Kendrick wished she could make him AND a huge shark kite.

193. Claire sat up. In the car

194. And that’s it. That’s the end.

195. Effing independent movies. They always just stop in like the middle of scene.

196. But also, chronic pain. It never ends either.

197. So maybe the best you can hope for if you have chronic pain is learning to sit upright in the car?

198. And cake.

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.