Using Meditation for Chronic Pain Relief

By Pat Anson, Editor

“Imagine standing by a fountain in a beautiful garden on a warm summer day.”

The female voice is both soothing and alluring, as she invites you into a garden and guides you toward a hammock.

"It is peaceful and safe. And no one expects anything from you here,” she says. “Here you can escape from the troubles of daily life.”

The birds are chirping. The fountain is gurgling. You close your eyes and relax.

And your pain disappears.

That’s the goal of a meditation program created by Wellmind Media, a UK company that specializes in online courses for managing pain, stress, anxiety and depression.

The 21-minute pain management course hosted at Meditainment.com (click here to see it) takes you into a “secret garden” of your own imagination, designed to help your pain seem less important. Tens of thousands of people have visited the site for pain relief.

““I was able to drift away and place myself somewhere else besides in my chair. I didn't think about the pain,” said Taber Fellows in an online post.

“Amazing! Way better than painkillers,” wrote Holly Maslen.

“Been fighting a migraine all day, and this helped tone it down to a more bearable level. Will check out the other meditations as well, thank you,” said Kristi Morningstar.

In all, Meditainment offers 18 different online courses (including one to help you sleep) that can take you anywhere from an island paradise to a mountain refuge to an arctic igloo – all without getting out of your chair. The first two courses you watch are free, but gaining access to the other 16 will cost you $15.

“When meditation is used as a form of relaxation when in pain, it can be of great benefit, reducing the fear aspect and emotional responses of experiencing pain as well as changing the contextual evaluation of stimuli, and sensory events,” said Rebecca Millard, Project Manager at Wellmind Media.

“Although we haven’t conducted any scientific research into this ourselves, there is increasing evidence to support meditation for the relief of pain. For us, the testimonials and comments on the pain management meditation speak for themselves.”

Online meditation and “mindfulness” cognitive therapy have been available for several years, and there is increasing evidence showing that they are effective in treating a broad range of mental health issues, including anxiety, depression and stress.

“Mindfulness is about paying attention to the present moment, non-judgmentally, with a gentle curiosity. It’s an awareness that emerges from paying attention on purpose to the present moment. It’s a mind-body approach, which involves paying attention to thoughts, feelings and body sensations,” said Millard in an email to Pain News Network.

“If we have more awareness and understanding of ourselves we can use this as a tool for pain management. Stress is linked to pain and too often pain is seen as something that the body experiences rather than linked to the mind.”

One study, published in the British Medical Journal, found that online mindfulness courses were often just as effective as face-to-face meetings with a therapist.

“The people choosing to use the course in this mode of delivery appear to be finding it helpful,” the study concluded. “That the levels of negative emotion reduced significantly on completion of the online mindfulness course and further decreased at 1 month follow-up is suggestive of significant improvements.”

You can try an online mindfulness course by visiting Be Mindful Online. The mindful and meditation programs mentioned in this story are offered by the UK National Health Service, but are available to anyone around the world.    

The Dangerous Game of Forced Opioid Reduction

By Forest Tennant, MD, Guest Columnist

A colleague who I highly respect just informed me of a woman with intractable angina who had multiple, inserted coronary splints and required a high daily dose of morphine. Without warning, her insurance company arbitrarily decided she did not need opioids. As one might expect, the forced cessation of opioids led to her death.

The forced reduction and/or cessation of daily opioids in stabilized patients have, in some corners of our country, reached the point of unscientific and inhumane hysteria. The craze to fight opioid abuse and force opioid dosages below 100 to 120 mg of morphine equivalents a day (MEQ) is now harming some patients who have been doing quite well on stable, daily opioid dosages. Some of the rhetoric and tac­tics being used to force opioid reduction are farcical if they weren’t so tragic in their consequences.

First, who is doing the forcing? There are multiple culprits: insurance companies, state legislators, regulators, and suppli­ers. Some of the tactics to force opioid reduction are indirect, such as limiting the amount of opioids a pharmacy can stock. Others are blatant, such as states that require physicians to seek a pain consultation if they continue to prescribe over a threshold MEQ level, even to patients who have been well maintained for a considerable time period. For example, in Washington State, a 120 mg/d MEQ threshold will trigger the prescribing physician to conduct, or refer the patient for, a pain consultation (exceptions and exemptions do exist). As noted by Stephen J. Ziegler, PhD, JD, “in some states, these thresholds appear in regulations, making the actions required actions, while in other states the thresholds appear in guidelines, making the actions merely recommended.”

Insurance companies are currently the most dangerous “forcers.” Neither patient, pharmacist, nor physician is pre­pared when a stable, opioid-maintained patient goes to fill a long-standing opioid prescription only to be told their insurance company has suddenly decided the patient should immediately cut their opioid daily dose by 30% to 70%, or even stop it altogether. The saddest aspect of this dan­gerous practice is that the motive is clearly greed, although the reduction may be accompanied by an “out-of-the-blue” statement that the forced reduction is for the patient’s safety. For example, insurance companies have recently informed long-standing, opioid-maintained patients that they have suddenly and capriciously decided they will no longer cover brand name opioids, injections, patches, compounded for­mulations, or a daily dosage above a specific level.

Insurance companies and some state guidelines are spitting out two illogical excuses for the forced reduction of opioids. One is that opioids dosages above 120 mg or so of MEQ are unsafe. Show me a study that indicates tissue toxicity of opioids at dosages over 120 mg in patients who have been maintained at a stable dosage for over 1 year. Patients who have been titrated up to dosages above 120 mg of morphine and periodically monitored by competent physicians almost always experience improved health and function, not the reverse. I have several patients who have been safely main­tained on high opioid dosages and led quality lives for over 20 years!! Why force these folks into sickness, suffering, and possibly death by suddenly and capriciously claiming their life-saving medication is dangerous?

The other straw-dog is “hyperalgesia.” Would someone please tell me how I’m to define and diagnose hyperalge­sia in a patient who has been well maintained on a stable opioid dosage—high or low—for over a year? Hyperalgesia has become a label and excuse to force down opioid dos­ages. Reputable and credible pain practitioners are not even sure it exists in a human who is well maintained on opioids. Whenever I see a patient who is on opioids and claims their opioids aren’t working as well as they used to, I take a hor­mone profile. Once I replace any deficient hormones, the patients’ opioids resume working.

My demand is for someone to send me the consensus doc­ument that tells me how to objectively diagnose hyperalge­sia in patients who have been well maintained on opioids over 90 days. What’s more, if hyperalgesia exists, what harm does it do? If we really believe that hyperalgesia is a problem with high-dose opioids, we must remove all intrathecal opi­oid pumps because these devices deliver a MEQ directly to the CNS receptors that is far in excess of any dosage we can achieve by peripheral administration!!

Readers of Practical Pain Management well know that severe, constant pain has far more risks than any stable, daily opioid dosage. Severe pain adversely affects the cardiovas­cular, endocrine, immune, and neurologic systems. It sends patients to bed in agony to lead a short, suffering life. There is no need to take these risks in a caring, concerned soci­ety, as a minute extract from the opium plant can prevent these complications and the pathetic, miserable death that a forced opioid reduction can bring.

So what do we do at this point? First, physician’s need to correct any false comments about the imagined dan­gers of stable, on-going opioid dosages. Whenever possible, pain practitioners should attempt to prescribe non-opioid pharmaceuticals that have come forward in recent years. In the latter category, I place ketamine, anti-epileptic agents (gabapentin, pregabalin, etc), and neurohormones (oxyto­cin, human chorionic gonadotropin, and progesterone). I’ve cut my patients’ opioid use by about 50% over the past 5 years by use of these new agents. I also recommend obtain­ing an opioid serum level in patients who take over 100 mg of MEQ. The presence of a reasonable opioid serum level indicates that the patient is ingesting opioids and is func­tioning well with a high opioid dosage.

Lastly, and most important, families of patients who must take a high daily opioid dosage need to become publicly active as advocates for their loved one. Unfortunately, but realistically, patients who must take a high opioid dosage always have a debilitating condition such as arachnoiditis, CRPS, traumatic brain injury, post-encephalitis headache, or facial neuropathy, and are too ill to fend for themselves. But their family can. Its time families demand the right of their suffering loved ones to obtain opioids, and their direct and blunt communication should go to State Medical Boards, insurance companies, wholesale suppliers, and their elected representatives.

Also, pain patients and family members should start joining the emerging nationwide organizations that are now forming to fight back. While we physicians have little public voice left, families of pain patients can, should, and will be heard.

Dr. Forest Tennant is pain management specialist in West Covina, California who has treated chronic pain patients for over 40 years. He has authored over 300 scientific articles and books, and is Editor Emeritus of Practical Pain Management.

This column is republished with permission from Practical Pain Management.

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.

Controversial Montana Doctor Suspends Practice

By Pat Anson, Editor

A Montana doctor who has been at the forefront of the debate over opioid prescribing is closing his urgent care clinic and will no longer prescribe medication to pain patients. Dr. Mark Ibsen said he didn't do anything wrong, but was tired of facing regulatory scrutiny over his opioid prescribing practices.

“The clinic is closing today. I’m going to disappear for awhile,” said Ibsen, who owns and operates the Urgent Care Plus clinic in Helena.

Ibsen said he would stop practicing medicine “in solidarity” with Dr. Chris Christensen, another Montana doctor who was arrested last week and charged with 400 felony counts, including two negligent homicide charges, in connection with the overprescribing of opioids.

Ibsen himself was the target of a lengthy investigation by the Montana Board of Medical Examiners after he started treating many of Dr. Christensen’s former patients after Christensen’s Ravalli county clinic was shutdown. Many of the patients were in opioid withdrawal and went to Ibsen because he was one of the few doctors in the state still willing to prescribe pain medication.

“I’m the last man standing in Montana, I think. I don’t know if there is anyone else who will do it. I think not. Because they were all coming to me because they were abandoned by their doctors,” said Ibsen.

Although a state hearing examiner ruled this summer the medical board “did not meet its burden of proof” in the overprescribing case against Ibsen, he has not yet been formally cleared of charges.  The examiner recommended that Ibsen be put on probation for 180 days for poor record keeping.

Ibsen told Pain News Network he was under a lot of stress and was deeply in debt from the legal cost of defending himself and treating Medicaid patients at low reimbursement rates.

“This is not a protest. This is me saying I can’t do this. I’m working in a hostile regulatory environment. And I’m stopping,” Ibsen said.

dr. mark ibsen

“I’m frightened. They’ve got me scared. The DEA said to me two years ago, ‘Dr. Ibsen you are not only risking your license, you’re risking your freedom by prescribing to patients like these.’ And I said patients like what? And they said patients who might divert their pills. And I said might? And they said yes. I said that’s a law enforcement job. My job is to treat the patient in front of me and do what I think is best for them based on what they tell me and what my testing shows.”

Ibsen said his urgent care clinic treated about 30 to 60 patients a day for a variety of conditions and he regularly prescribed opioids to a “couple hundred” patients. He said he didn’t know where they would get their pain medication now.

“I have also deeply considered whether stopping prescribing opiates sends a message that I'm afraid I've done something wrong. Let me assure you I have done nothing wrong. I have upheld my oath as long as I can. The pressure is just too much and today in particular I cannot concentrate on these complex cases. Therefore my clinic is closed and I'm going home,” he said.

"Dr. Ibsen was unfairly targeted and helped Christensen's patients wean from high doses.  Who is going to wean Ibsen's patients now?" asked Terri Anderson, a chronic pain sufferer and patient advocate who lives in Hamilton, MT.

"Pain patients are ultimately the ones who suffer.  I try to look at it from all sides and if it were my brother who overdosed then I would be upset. However it is easy to judge and my first thought is that pain patients come with risk to the prescriber, because they often suffer many other health issues besides just pain, including anxiety, depression and PTSD (post traumatic stress disorder)."  

In the last month, Ibsen said three staff members had resigned from his clinic, which he likened to a “war zone” because of the stress of treating patients who had nowhere else to go.

“Maybe I will come back. But I’m rattled. I’m too rattled to think of the right blood pressure medication to give to a patient. I can’t concentrate. I don’t want any patient injured today because my concentration is so poor,” Ibsen said. “When I am well enough, and I feel safe to practice in the way I know how, I will return.”

Power of Pain: Changes in Family Dynamics

By Barby Ingle, Columnist

Chronic pain can be a lifelong situation that has a significant impact not only on the patient, but on family and friends as well. The condition may affect every aspect of the patient's life in varying degrees, including professional, social, and daily living activities. Everyone may have to make adjustments.

After health, patients are usually hit hardest by the financial aspects of the chronic disorder. Frequently, a leave of absence or early retirement from work is needed due to the inability to perform work-related tasks. Financial difficulties are acerbated by frequent visits to healthcare providers, medical-related expenses and unemployment.

To help reduce stress for everyone, it may be smart for the patient and their family to meet with a financial planner or insurance agent and devise a budget for future expenses.

With less money and mobility, there’s a tendency to give up favorite activities like hiking, sports, traveling, and participating in family events. Exercise becomes more difficult and everyday activities such as driving and shopping may need to be modified or given up.

Despite a wide range of treatment options available, a patient with chronic pain may not seek help and dismiss efforts by others.

Some reasons for this include fears of:

• Addiction to medications
• Lack of insurance coverage
• Not understanding insurance coverage
• Belief that nothing can help them
• Recurring pain will be worse
• Being seen as a "complainer"
• Side effects from treatments
• Tolerance to medications

It is important to discuss these concerns with family members, friends, physicians, or support service professionals (psychologist, social worker, etc.) in order to take advantage of options that are available and may actually lead to pain relief and improvement in the overall quality of life.

Planning is a key component to keeping stress levels down and a great way for family and friends to learn how they can help. Having the patient map out a plan of action for daily routines and responsibilities allows everyone to know when and where their help is needed and minimizes unexpected mishaps. Responsibilities that may need to be addressed include carpools, housework, cooking, holiday activities, laundry, leisure activities, jobs, pet care, planning meals, self-care, and shopping.

Pain patients should be encouraged to stay active, join a support group or seek psychological counseling if appropriate. Some patients find benefit in getting involved in volunteer work, which allows them to set their own hours and to feel they can contribute to others instead of just focusing on their own condition. Patients also be able counsel others with chronic pain.

Caregivers and friends can encourage the patient to do well and get treatments they are comfortable with. Find the balance between encouragement and pressure so the patient knows you love them and that no matter what they choose you will accept it.                                             

It can be difficult (or impossible) to imagine that someone can be in constant severe pain.  It's normal if you have not lived through it yourself. For a caregiver, it may be hard to stand by and accept that your loved one’s pain cannot be fixed or cured (although it may be eased). 

It may also be hard to accept that you cannot make it better. If you are in a close relationship with someone in chronic pain, you are likely to develop a variety of negative feelings like anger or resentment. This is a normal part of the process for both you and the loved one in pain. You are both victims of the pain problem.

Learn how to set the expectation as soon as you can as to what your needs are as a patient or caregiver, what progression the chronic illness is expected to take, what treatment options are available, and the best ways to communicate with each other what will make life easier for the patient, family and caregivers.

Turning to family and friends as caregivers and support outlets is important for everyone to have better daily living.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. She is a chronic pain educator, patient advocate, motivational speaker, best-selling author, and president of the Power of Pain Foundation.

More information about Barby can be found by clicking here.

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.

Reader Calls for Pain Patient 'Bill of Rights'

By Pat Anson, Editor

A North Carolina woman who suffers from Reflex Sympathetic Dystrophy and several other chronic pain issues wrote to us recently about a serious problem she had with a urine drug test (UDT) performed in her doctor’s office.

Her urine tested positive for oxycodone and hydrocodone, two opioid pain medications she did not have prescriptions for. So the doctor dropped Paulette Waters from his practice, informing her by registered letter that she would no longer be his patient after 12 years without any other issues.

“This is where my horror story starts and has as of yet to end. The letter stated that I had broken the pain agreement and my doctor would not be seeing me anymore. The letter being generic and not including any details or UDT results,” wrote Paulette, who asked that Pain News Network not use her real name because she’s afraid of being blackballed by more doctors.

We’ve written before about these “point of care” (POC) urine tests. The immunoassay tests are often used by doctors to screen pain patients for the misuse or abuse of drugs – but they’re wrong about half the time. One study, for example, found that POC tests give false positives 41% of the time for oxycodone. Sometimes even a simple over-the-counter medication like ibuprofen can trigger a false positive for marijuana.

A more complex laboratory test that uses chromatography-mass-spectrometry to identify individual molecules is far more accurate than POC tests, but they cost thousands of dollars -- something many insurers and patients are unwilling or unable to pay for.

Instead of conducting additional tests or giving a patient the benefit of the doubt, some doctors take the easy way out by dropping patients like Paulette.

“The problem now has become that since this test, no pain clinic will see me, let alone let me tell my side of the story,” says Paulette, who has been struggling for the past year to clear her name and get the pain medication she needs.

“Knowing I have a legitimate chronic disease there is no cure for, why would I jeopardize myself by doing something that would put me in a position to not have the medicine I needed to help me live somewhat of a normal life?” she asks.

Paulette has called different lawyers and even the ACLU, but no one has taken her case. She’s also written to the state medical board, believing her doctor didn’t follow proper protocol before dismissing her.

“As of now a patient who legitimately suffers from chronic pain has no voice, recourse or method to keep them from being falsely accused of failing a urinary drug test,” she adds.

Patient Bill of Rights

Paulette thinks it’s long past time for a “Patient Bill of Rights” – one that spells out exactly what’s expected of doctors andpatients before, during and after a drug test, including:

1. Make patients aware that UDT’s can have false positives and false negatives.
2. Inform patients what kind of test they are taking.
3. Make sure the patient and doctor have a list of all prescription drugs the patient is taking, including over-the-counter meds, vitamins and supplements that could affect the test results.
4. Make patients aware what consequences they could face if a test result is abnormal.
5. Make sure the patient has a signed copy of their pain contract or drug agreement.
6. Allow the patient to observe the urine sample being sealed in front of them.
7. Make patients aware that insurance companies do not always pay for drug tests.
8. Make doctors follow guidelines if there is an abnormal test result. Have them tell the patient in person, instead of a generic letter dismissing them.
9. Allow at least one more reliable drug screen to be sure false positives or negatives did not occur.

Paulette says pain patients have paid a price for too long in the “War on Drugs” – becoming casualties of misguided policies they have no voice in. 

“All of these battles are between the DEA, insurance companies and doctors,” she says. “The one person that is left out is the patient who is the one suffering. that only has the option of seeing a doctor for their chronic pain. This leads them to such things as buying street drugs, depression, committing suicide, and other health problems because their legitimate chronic pain is not under control.”

5 Real-Life Tips for Traveling with Chronic Pain

By Crystal Lindell

One of the best things about my job is that after I got sick I got to switch over to a work-from-home arrangement. Honestly, if it wasn’t for this, I probably wouldn’t have a job right now.

However, there is one caveat. I have to travel. A lot. And while normal people probably think of business trips as a glamorous affair involving lots of great Instagram shots, anyone with chronic pain will tell you that they’d pick a day on the couch watching Netflix over a two-day business trip to North Carolina any day of the week.

But all of us have to go places sometimes, whether it’s a vacation to Mexico or a flight to the Mayo Clinic, so dealing with airports and the TSA isn’t always something we can avoid.

There are a few things I’ve learned on all those business trips that help me cope with it all.

So here’s some tips for navigating swollen feet, the medications in your carry-on, and window seats.

1.  Check your bag

This is definitely the most important tip I can give you.

Yes, on most airlines it costs a little more, but that’s why God invented Southwest and it’s free checked-bag policy.

And yes, sometimes you get to your hotel only to discover that the mirror in your $32 Urban Decay Naked Flushed compact somehow broke in transit. But there are other mirrors.

And not having to deal with luggage can be the difference between arriving in Phoenix feeling like you’ve just been involved in a plane crash, and arriving in Phoenix feeling like you just got up from a really great nap.

From a practical standpoint, checking your bag means you don’t have to drag it to your terminal or deal with lifting it up into the overhead bin while desperately looking around for help from the other travelers, hoping one of them has the magical ability to see your invisible illness. 

And it also means that you’re free to be one of those carefree people boarding the plane holding just a purse and a cell phone. Trust me, it’s the only way to fly.

2.  Put all your medications in your carry on.

No, seriously, all of them. Even that one you only take right before bed that you don’t think you’ll possibly need before you arrive. And that other one that you definitely don’t think you’ll need because you only take it on Wednesdays and today is Thursday.  

While regular people with regular health may think it’s a no brainer to carry-on all your pills, that’s not the case for us. People who deal with chronic pain have a legit chance of needing  23 different prescription bottles daily, so downsizing a carry-on bag by putting a couple of them in the checked luggage doesn’t seem so crazy. Unfortunately, there are so many things that can go wrong.

They could lose your luggage. Or you could miss your connecting flight. Or zombies could attack. So it’s just better to have that hydrocodone in your purse just in case.

And if any of the TSA agents try to give you crap about all that morphine you carry around, just show them your name on the prescription bottle and say, “No, yeah, these are mine. Sorry about that. Thanks for asking though. And also you’re doing a really great job here.”

Because you don’t want to be rude to a TSA agent — those guys have power over the terrorist watch list.   

3.  Buy the huge Fiji water bottle and drink all of it

The thing is, if you have chronic pain, all those warnings about drinking water to stay hydrated in the sky are even more pertinent.

Sleeping pills, nerve medications and opioids all have the fun side effect of dehydrating you all by themselves, so when you add in recycled air and cabin pressure suddenly you’re so thirsty even a caffeine-free, diet, generic Coke sounds good.

And, here’s what nobody tells you about that — all that dehydration and sitting on a plane in seats too small to bend your ankles makes your feet swell up. It’s a real thing. And it sucks.

So yeah, water, it’s important — especially if you’re planning to wear flip-flops on your trip.

But, as anyone who’s ever had to go through security at the airport will tell you, it’s impossible to get a bottle of any kind of water through the X-ray machine. So if you want to stay hydrated you have to buy something after the checkpoint. And personally, I like to use it as an excuse to splurge on one of those completely impractical square bottles of Fiji.

Hey, if you have to buy a bottle of water, you may as well buy the one that tastes like it came from the Garden of Eden.

4.  Pack dry shampoo and skip the showers

When you do finally get to L.A., the Mayo Clinic, or your grandma’s house, the very best thing you can do is skip the shower and just spray a crap ton of dry shampoo on your bangs. Seriously, this has been the BIGGEST lifesaver for me when traveling.

Chronic pain has this way of turning simple showers into some sort of extreme marathon mud run through the Amazon. And while normal people might think they should be fresh and clean when they have a business meeting, people with chronic pain know that it’s more important to actually show up to said business meeting.

Skipping the shower can preserve precious energy that will help you endure the trip, or, you know, maybe even have some fun later on — assuming your sleeping pill hasn’t kicked in yet.

5.  Go for the window seat

Even with the pain and the pills and the swollen feet and the missed connections, travel is still travel, and getting to ride on a plane is still pretty cool.

Honestly, window seats aren’t actually practical at all. It’s just that much harder to get up and use the bathroom after downing all that Fiji water, and you have nowhere to run when the old dude sitting next to you starts hitting on you hard core 5,000 feet in the air.  

But, window seats are something more important than practical — they’re fun. All you have to do is glance out the window and you’ll get a view most people in human history have never had the chance to experience — whether it’s a blanket of pure white clouds, a bird’s eye look at the people who call this planet home, or just a great play-by-play of the machine you’re riding in gliding toward the heavens.

It’s pretty incredible when you think about it.  

And sometimes, every once in a while, something almost magical happens, and you end up in a window seat, in an exit row, AND nobody sits next to you. It’s not quite first class, but it’s close enough.

And when you finally get to wherever you’re going, you can toss that empty bottle of Fiji into the recycling bin, grab your checked-luggage off the carrousel, throw on some sunglasses, and tackle your trip like the chronic pain warrior you are.

Bon Voyage!

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.

Wear, Tear & Care: Rating the Pain Creams

By Jennifer Kain Kilgore, Columnist

I am a connoisseur of pain creams. My idea of Christmas is when my friend’s mom mailed me a box filled with unopened packages of Bengay (true story). Every morning I slather on a layer of something containing menthol in order to numb my back. Then my cat decides to attack me. Why? Because cats love menthol (also a true story).

Anyway, I have tried many, many, many different topical anesthetics over the years. Here are my experiences with the common and unique brands:

Bengay: The gold standard. Whenever I use this brand, I generally gravitate toward the pain relief massage gel. However, my friend’s mom sent me the regular Bengay.

What, you thought I was kidding? Here’s a picture of my Bengay drawer.

There’s no doubt about it: Bengay is good. However, even the massage gel only contains 2.5 percent menthol, which is the active ingredient that transports your skin to the Arctic. It also has camphor, like what’s used in Vick’s VapoRub, to reduce pain and swelling.

While Bengay is good, it’s not great. Moving on!

Cryoderm has been my go-to for years, because it is, as they claim, “as cold as ice.” It has 10 percent menthol and also contains arnica and boswellia, the former of which has been used for centuries to control bruises and swelling. The latter is a solid anti-inflammatory agent. Cryoderm also makes a number of heat-producing products, one of which I own.

I use it on very cold winter days when the temperature makes me want to crawl back into bed. If I put it on during the rest of the year, I prematurely begin the process of menopause.

Anyway, just because I am a big fan of Cryoderm does not mean I haven’t tried other things, such as…

Emu oil: Last year I was at the Big E (only the greatest annual fair in the northeast, where all food is deep fried, even the Kool Aid) when, naturally, I gravitated toward a booth that was hawking pain relief products. They all centered around emus. Yes, that flightless bird from Australia. Apparently its oil can be used for anything, from cracked heels to unsightly patches on your skin. I used it for pain purposes, and I found it to be lacking. Not only was it difficult to apply, but it was ineffective. My search continued.

Arnica cream: This took the inactive ingredient in Cryoderm and went whole-hog by making it the active ingredient -- nay, the only ingredient. I think this would do a bang-up job of healing something acute, like bruises immediately following an injury. But for chronic, long-term pain, I was left wanting.

Lidocaine patches are available by prescription only, though there are some almost-as-powerful creams and patches online. I only get 10 at a time because they normally are not covered by my insurance.

These things are fantastic. If I could wrap myself in one like a big numb burrito, I would.

It contains 700 mg of lidocaine, which, based on the word’s suffix, you might recognize as a numbing agent similar to novocaine.

You can slap one on for 12 hours at a time; however, like any other sticky product, it can irritate the skin. These are perfect for very bad days, but what’s the next best thing if you can’t get your insurance to cover them?

Stopain. I have to admit, I was skeptical when my grandmother suggested this. Here is a close transcript our conversation:

“Honey, I saw this thing on TV that works on bad backs. You gotta get it.”

For reference, my grandmother is a Jew from Brooklyn in her upper eighties. She wears tracksuits with heels, always has makeup on, and has the best white Jewfro you could possibly imagine. Since friends and relatives are always suggesting pain relief products (which I do appreciate), I didn’t put much stock in what she said.

“Grandma, you can’t always believe that ‘As seen on TV’ stuff.'"

I didn’t actually say “stuff.” I said another word that starts with “S.”

“You watch your mouth with me, kiddo. Give it a try. C’mon, do it for me. The commercial said it really worked!”

So I bought it to humor her and let it sit in its packaging for about a week once it arrived. Then, when I ran low on my Cryoderm bottle, I gave it a whirl. I was prepared for it not to work, since the Cryoderm has 10 percent menthol and Stopain only has 8 percent, but... I was incredibly surprised.

I’ve been using it for a few weeks now, and I think it actually works better than the Cryoderm despite having less menthol. What it lacks in that ingredient, it makes up for in boswellia, arnica, eucalyptus oil, peppermint oil, and other things I can’t pronounce. It’s a veritable cornucopia of pain-relieving ointments.

So there you have it. Hopefully my experiences have saved you some time, and if not, at least you will smell delightful to any feline companions.

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.

You can read more about J.W. on 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.

Quell Device Relieves Variety of Pain Conditions

By Pat Anson, Editor

A new medical device that uses electrical nerve stimulation was effective in managing chronic pain in patients suffering from arthritis, neuropathy, fibromyalgia and other conditions, according to a small clinical study conducted by NeuroMetrix (NASDAQ: NURO), the device’s manufacturer.

Pain News Network recently featured the Quell Wearable Pain Relief device in a column by J.W. Kain, who reported that Quell “worked brilliantly” in relieving her chronic neck and back pain.

Eighty eight people were enrolled in a 60-day trial of Quell. All had chronic pain for at least year and nearly a quarter had more than 15 years of pain. Participants had “complex medical histories” with arthritis (61%), diabetic nerve pain (40%), sciatica (27%), and fibromyalgia (26%) as the most common conditions.

Over 80 percent of the participants said Quell relieved their chronic pain and improved their overall health. The largest measured changes were in pain relief, along with improved sleep, general activity, and walking ability.

Over two-thirds of the patients said Quell also reduced the amount of pain medication they were taking

image courtesy of neurometrix

"We are pleased with these results. They represent the first formal evaluation of self-administered wearable intensive nerve stimulation. Quell provided substantial pain relief and improvement in quality of life measures,” said Shai N. Gozani, MD, President and CEO of NeuroMetrix.

“We were not surprised that two-thirds of the subjects reduced their use of pain medications, as we have consistently received this anecdotal feedback from Quell users over the past several months.”

Quell is available over-the-counter and does not require a prescription. It relieves pain by using electric stimulation to “mask” pain signals before they reach brain, much like a TENS unit.  The device, which costs $249, is lightweight and designed to be worn over the upper calf during the day or night.

The marketing of Quell for the treatment of chronic pain was approved by the Food and Drug Administration in 2014, but NeuroMatrix did not begin shipping the device to healthcare providers until this summer. It is also available through the company’s website.

A study abstract, “Treatment of Chronic Pain with a Novel Wearable Transcutaneous Electrical Nerve Stimulator,” has been accepted for poster presentation at the annual PAINWeek conference next month in Las Vegas.

Pain Education Improves Opioid Prescribing

By Pat Anson, Editor

A safe opioid prescribing course --- aimed at filling in gaps in pain education at many medical schools -- can help reduce the abuse and misuse of opioids, according to a new study published in the journal Pain Medicine.

Boston University School of Medicine launched its Safe and Competent Opioid Prescribing Education (SCOPE) program in 2013, offering live or online courses in chronic pain and safe opioid prescribing practices.

A survey of over 10,000 doctors who took the SCOPE program found that two months after the training about two-thirds of participants reported greater confidence in their prescribing practices, and 86 percent improved how they prescribed opioids and monitored patients.

"Our program improved knowledge, attitudes, confidence and clinical practice in safe opioid prescribing," said corresponding author Daniel Alford, MD, associate professor of medicine at Boston University School of Medicine and course director of the SCOPE of Pain program.

SCOPE was the first program to receive funding from the Food and Drug Administration’s Risk Evaluation and Mitigation Strategy (REMS), which requires opioid manufacturers to fund continuing education programs in pain management.

"While education cannot be the only strategy to combat this national crisis, it can help improve clinician behaviors and be a major part of the solution,” said Alford.

An earlier survey of physicians by Boston University found that many lacked confidence in managing patients on opioids. Over a quarter (28%) said they had not completed certified medical education (CME) in safe opioid prescribing. Many also said they lacked the time or staff to implement an opioid monitoring system for patients, such as drug testing and pill counts.

Only a quarter of the doctors surveyed said they were very confident about their ability to safely manage chronic pain with opioids.

Pain education for doctors – or the lack of it – is such a concern that the National Pain Strategy considers it a top priority.

“Many health professionals, especially physicians, are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain,” a draft version of the report states. “Core competencies in pain care are not fully developed and generally do not inform undergraduate curricula in health professions schools or graduate training programs, even those in pain medicine.”

A 2012 study published in the Journal of Pain  called pain education in the U.S. and Canada “lackluster” and warned that unless steps were taken to improve the training of pain physicians, “the crisis in pain care and resultant deaths from opioid abuse will only spiral upwards.”

The study of 117 U.S. and Canadian medical schools found that less than 4% required a course in pain education and only one in six schools offered a pain elective. A large number of U.S. medical schools do not have any pain courses and many of those that do have less than five hours of classes.

Migraine Device Reduces Headache Pain

By Pat Anson, Editor

A device that looks like a space age tiara not only helps prevent migraine attacks, but also relieves headache pain once a migraine starts, according to the results of a small clinical trial.

In a study of 20 migraine sufferers, published in The Journal of Headache and Pain, the Cefaly device provided "statistically significant" pain relief, as well as an 81 percent reduction in the number of migraine attacks. Patients in the study also said they used less migraine medication.

Cefaly was approved last year by the U.S. Food and Drug Administration as the first transcutaneous electrical nerve stimulation device specifically authorized for use prior to the onset of migraine pain.  Previous studies of the device only focused on migraine prevention.

"This is great confirmation on what we thought about the high efficacy of Cefaly," said Dr. Pierre Rigaux, chief executive officer of Cefaly Technology, a company based in Belgium. "We knew Cefaly to be very safe and with minimal side effects, but now we learn that it's not just the frequency of migraine days that's reduced for every four out of five patients, but the intensity of pain during a migraine attack is reduced as well."

IMAGE COURTESY OF CEFALY TECHNOLOGY

The battery-powered device, which is worn over the forehead like a headband, uses tiny electrical impulses to stimulate the trigeminal nerve, which has been associated with migraine headaches. Cefaly requires a prescription and costs about $349. The device is only available through the company’s website and is not covered by insurance. It’s been available in Europe and Canada for several years.

It was on a trip to Canada that Maria Coder learned about Cefaly and – at the urging of her boyfriend Jay– reluctantly agreed to buy one.

“At the time my boyfriend and I got into a big fight because he wanted me to use it right away and I didn’t really like the idea. I’d never heard of it and I was nervous about using it,” said Coder, who has suffered from migraine for nearly two decades.  

The device sat in its box for about a week before she finally tried it.

“I was alone in the apartment and put on the headband and loved it. I fell in love with it. I started to feel better, but I thought beginner’s luck,” Coder told Pain News Network. “I tried it a few more times and then it took on a life of its own. Now I feel like a wimp when I get a migraine because I don’t get them hardly ever compared to before. It’s down to maybe 3 to 5 a month, whereas for almost ten years it was chronic, almost daily.”

Coder, who works in public relations, wrote a letter to Cefaly Technology that eventually turned into a job as a publicist for the company. She also recently married her boyfriend – wearing the Cefaly device for her daily 20-minute session during a break after the ceremony and before her reception.

“I really love and I really believe in it. I didn’t believe in it at first, when I got it. And then the more that I used it, the more I couldn’t deny the results,” she said.

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

maria coder

In 2013, the FDA approved the marketing of another device -- the first transcranial magnetic stimulation (TMS) device approved for the relief of migraine pain. The Cerena TMS is placed at the back of the head to release a pulse of magnetic energy to the brain’s occipital cortex, which may stop or lessen pain caused by migraine headaches.

The Painful Truth: How Patients Are Treated Shamefully

Lynn Webster, MD, is past President of the American Academy of Pain Medicine, vice president of scientific affairs at PRA Health Sciences, and one the world’s leading experts on pain management. He treated people with chronic pain for more than 30 years in the Salt Lake City, Utah area.

Dr. Webster’s new book, “The Painful Truth,” is a collection of stories involving several of his former patients, who struggled with the physical, emotional and financial toll that many chronic pain sufferers experience.  

Pain News Network editor Pat Anson recently spoke with Dr. Webster about his book.

The interview has been edited for content and clarity.

Dr. Lynn webster

Anson: Dr. Webster, you’re no longer practicing medicine, but you’re still very involved in the pain community and in research. Why write this book now at this stage of your career?

Webster: It takes a lot of time to write a book, as you can imagine, and it’s taken me four years to get to this point.  I think that at this stage in my career I can look back and put together a story about the people who I’ve taken care of for most of my career that I’m not sure I could’ve done in the middle of it. I think that’s given me the ability to look back and reflect and feel the heartache that patients have, and my inability to deliver to them everything that I wanted to deliver to them, because of all of the barriers and obstacles in healthcare.

I’m hoping that my book is going to be a seed that will contribute to a cultural change, a social movement that will bring some dignity and humanity to a large population of our country.

Anson: In your book you said the painful truth is that people in pain are treated shamefully. What did you mean by that?

Webster: When I was growing up on a farm I observed something as a young boy that always puzzled me and that was watching the injured or sick animals. We had all sorts of animals; cows, pigs, sheep, and chickens, and I could see that the injured somehow were always separated from the healthy ones. It wasn’t that the sick separated themselves from the healthy, but the healthy separated themselves from the injured or the ill.

I see that to some degree in people and I wonder if this hasn’t been a biological aspect of survival for man from the beginning. We as humans are better than that; we’re better than we may have been thousands of years ago.

Today, I think that it is shameful that people are stigmatized because they have pain, they’re isolated, and they’re denigrated often. Because of our healthcare system, at least in this country, they’re viewed as addicts, lowlife’s, and druggies. That’s rarely true and it absolutely prevents, it really contributes to the harm that pain sufferers feel towards themselves and their inability to get the type of care they need. I think that it hurts our society in so many different ways, but most importantly the people in pain.

Anson: A lot of your book is dedicated to telling the stories of some of the pain patients that you treated. Virtually every one went through what you just described, where they had trouble getting proper treatment, they had trouble with their jobs, with their families, and with their friends. Is that why you write the book in this way, so that their stories get across the point you’re trying to make?

Webster: Absolutely. It’s less important that a physician tells a story than a patient tells their story. I wanted this book to be felt by the readers, to understand what people in pain experience and the struggles they have.

Anson: You wrote that, “People in pain need to be both treated by medical professionals and supported by all the important people in their lives.” Is that happening?

Webster: No, of course not. There are some patients that have pain who have great support structures in their personal life. For example Alison, she is an individual who had what I thought was the quintessential family support. Were it not for her mother, father and sister, she could’ve gone down the path that too many others take, which would be resignation rather than resilience. It’s one where drugs are used to cope and to escape the pain, physical but also the emotional.

Too many people are separated and too few have the structure of the support system that Alison had.  Our healthcare system is abominable. It shamelessly abandons them with limited resources, limited access and actually a labeling of the individual as if they’re a leper; they have a disease that is contagious.

Anson: Is the average physician in U.S. prepared to treat chronic pain?

Webster: No. I think it’s been reported that medical schools average less than 10 hours of education on pain and even less for addiction. Yet this is the number one public health problem in America and it’s not recognized by the CDC like many other disease states have been.

And so very few physicians understand what pain is. In fact, many think that it’s just a symptom and you never die from pain which is categorically wrong. As I write in my book, pain can be as malignant as any cancer and it can be just as devastating. It can take the soul but it also takes the life of some individuals when we ignore it and when we’re unable to provide them the relief that they deserve.

Anson: If you were a young man again in medical school and trying to decide what specialty to go into, knowing what you know today, would you go into pain medicine?

Webster: Without a doubt, there is no hesitancy in this response; I love the field that I’ve been in. As an anesthesiologist I could’ve stayed in the operating room and honestly the compensation of doing that would have been far better than the path that I chose. But the rewards I’ve received from trying to make a difference and the thank you’s that I’ve received will never be matched by any kind of financial or professional recognition in any other areas.

The most rewarding part of life is really to be able to make a difference in someone else’s life. And I think I’ve been able to do that with hundreds, if not thousands of individuals. That actually is the reason for the book. I’m hoping the book is going to make a difference for more people than I could physically touch in my clinic.

Most of the people that I saw as patients were already experiencing a large amount of pain, they’ve been through the mill and many had their chronic pain for years before they came to see me. We are basically going to be taking care of them the rest of their life. We do get to know them, much like a primary care person does to a family they’ve been caring for, and so we get to know them well. They get to know us. We also begin to see the struggles that they have in the system and with the rejection of their families sometimes, their friends, the isolation. And we become the only source that’s grounded, that gives them potential hope. I took that very seriously and I think that’s why it was so rewarding for me.

Anson: You wrote that you’re neither pro-opioid or anti-opioid. What do you mean by that?

Webster: My focus has never been about making opioids available or that they should be used. In fact ten years ago I started the first national campaign about the risk of opioids. My campaign was called Zero Unintentional Overdose Deaths and you can still find that on the Internet. I did a lot of work at trying to understand the potential risks and mitigate those risks so we can prevent people from harm because I knew one day that if we couldn’t prevent people from being harmed from opioids that there would be political response to this that could be very harmful to a large number of people who are not harmed by opioids.

I think the focus should always be about what’s best for a patient and not about whether a drug or a certain treatment is good or bad. All treatments have potential risks and complications, and we need to evaluate whether or not the potential benefit outweighs the potential risk or harm and it has to be patient centered. So my focus has never been about really any treatment, but it’s always been about what’s best for the patient. I’m more anti-pain than I am pro or anti-opioid.

Anson: You prefer a multi-disciplinary approach to pain treatment?

Webster: Yes, it’s been demonstrated that for people with moderate to severe chronic pain, the type that’s not likely to be resolved, it is best managed in a multi-disciplinary, integrative approach. I see the need for more cognitive behavioral therapy. We should always tap into the different treatments that have low risk associated with them before we ever tap into something that has more risk, for example opioids or even interventional treatments we as anesthesiologists and some of the other pain specialists can provide.

Much about pain is really learning how to cope, how to deal with it from day to day and how to manage the stress that’s associated with it because stress augments all pain. And so it’s really important that we use all of the resources that we have to manage the pain and not just a single modality, certainly not opioids or spinal cord stimulators, but look at how we can manage this in a more mindful way, even as clinicians. I use that word intentionally because mindfulness is really what the doctor needs to use as much as the patient in order to optimize the treatment with the lowest risk.

Anson: Has the pendulum swung too far against use of opioids?

Webster: I think there’s too much focus on opioids by almost everyone. And what it has done is it’s forgotten about people. Opioids can cause a great deal of harm, we see way too many people harmed from opioids. But certainly a vast majority of people who have been exposed to opioids are not harmed by them and there are countless number of people, a huge number of individuals who have been on opioids for decades, that believe very strongly that they’ve improved their lives and they could not live without them.

I think the focus is in the wrong place. Our focus should not be on opioids and whether they should or should not be prescribed, but what is the best treatment for the patient? And if opioids are inappropriate as a pain treatment, then I say all of the anti-opioid people as well as the individuals who are interested in helping people with pain should come together and demand that we have more money invested in research so we can replace opioids entirely.

We cannot always know who’s going to have an addiction triggered by exposure. As I pointed out in my book, Rachel just went in for an appendectomy and that initial opioid that she received lead her down a serious, dreadful path because she didn’t have the social support to keep her from taking that path.

I think that the anti-opioid people and those of us who are interested in bringing some dignity and humanity to a large population of people in pain need to come together and insist that we have a Manhattan Project basically and to discover safer and more effective therapies that are not addictive.

Anson: The final version of National Pain Strategy will soon be released, with the goal of advancing pain research, healthcare and education in the U.S.  From what you’ve seen and heard so far about it, are they on the right track?

Webster: Yes, I think it’s an important step forward. I think that it brings most importantly the government into the picture, recognizing the need that we do something on a national scale and that alone is a big step forward.

It’s kind of like in my book there are three important words, “I believe you.” This is really the way the government can say, “I believe you.”  There is a problem in this country with the way in which we treat pain and the National Pain Strategy is about how they’re going to address that. Having the federal government say I believe you, there is a problem, let’s see if we can change the way pain is treated in this country is a huge step forward.

Anson: Thank you, Doctor Webster.

You can follow Dr. Webster on his blog, and on Twitter @LynnRWebsterMD, Facebook and LinkedIn.

Life in the Waiting Room

By Pat Akerberg, Columnist

I wonder how much of our lives we spend standing in lines or sitting in rooms waiting.  Thanks to the intractable pain of trigeminal neuralgia and severe surgical complications, it seems that my life has morphed into one big waiting room.  

For the last few years I’ve had lots of cause and reason to speculate about what purpose waiting might serve, besides trying ones’ patience in a world where everything is measured by speed, action, progress and the like. 

Usually waiting brings those things to a halt temporarily.  In fact, Webster describes waiting as a form of being “temporarily undone.”  We consider that kind of short interruption typical.   However, when being temporarily undone turns into becoming permanently undone, how one lives and copes presents a major challenge.

Normally, when we wait we stay in a place of readiness or anticipation until something expected happens or someone arrives.  Things that fit this kind of waiting are sitting in doctor’s offices waiting to be seen, waiting for our reservation at a restaurant, or waiting to advance to the front of a line.  

So expectation, anticipation, and hopefulness are typically attached to our investment in waiting. But those very hopes also have the capacity to backfire if the outcomes we desire have been thwarted or become unattainable.     

It occurs to me that the combination of chronic pain and waiting then becomes a form of “endurance” training.  Note the root word “endure." Much like the “blue plate special,” it involves accepting everything on your plate with no substitutions.  You get what you get; or as those of us who have been physically compromised phrase it, “It is what it is.” 

I wait and hope for sleep to come, real sleep without pain strikes.  I wait for my next Rx to be filled, wait for my medication to take hold, and wait to be able to speak or get nutrition in me without triggering facial pain.  I wait to schedule an appointment or test, and then wait until the day comes.  Then there’s waiting to actually see the doctor and get the test results.

Always I wait in the hopes of discovering something that might provide relief, give some encouragement, or suggest a possible new option.  

There are extra long waits for the neuropathy in my arms to calm down enough for me to type.  It takes days of waiting to be well enough to leave the house for a medical appointment or have a friend visit, along with artful calendar management. Afterwards, I often wait until the high price that those exacted subsides.   

It seems I’m always waiting, watching, and wondering all the while how I will continue to carry out this vigil of unrelenting pain day after day, after week, after month.   Scary thoughts like that can produce anxiety in even the most peaceful person.  And just like riding a wave, I wait for those thoughts to recede.

Some say that life is a school full of learning lessons.  Deep down I’ve always disliked that theory.  Having to experience what didn’t go well so you can learn more for “later” seems so backwards in benefit at times. 

That’s because in retrospect I’m aware that some things we learn don’t always offer a mulligan, a do-over, or an apparent way to benefit from the learning.  But despite that hard reality, I still suspect that our pain and waiting must have something to offer or teach us.

Time spent waiting can be repurposed into a personal workout regimen that involves active, conscious heavy lifting of a different kind.  Let’s face it – self care doesn’t just happen; it takes work!

We can learn to make our lessons learned work for us, instead of lying in wait feeling frustrated and held captive by them.  We can resolve to better prepare and focus on what we need from appointments, figure out how to better advocate for our needs, establish some boundaries, and take the hard actions that will best serve us going forward.

Remember the old question, “So, what are you waiting for?”  That question implied a sense of urgency to act and get on with it, whatever “it” represented.  Maybe our particular “getting on with it” is about learning how to step up and master a new set of skills that will strengthen our internal core to better cope with waiting in pain. 

Instead of being permanently undone by waiting, we can turn that time into honoring non-action as a selective way to wisely conserve energy.  Occasional pity parties can be replaced with reflection about what really matters to us.  We can tenderize the resistance that keeps us blocked and willingly open up, allowing ourselves to be nudged toward flexibility and tolerance.  Or use deep breaths and time-outs to relax enough to go with what is for now.     

We can apply all of this while still fervently holding on and searching for better pain relief, waiting for something hopeful to make itself known. 

In the meantime, to quote the famous Austrian poet, Rainer Maria Rilke: “The point is to live everything. Live the questions now.  Perhaps you will, gradually, without noticing it, live along some distant day into the answer.”    

Pat Akerberg suffers from trigeminal neuralgia, a rare facial pain disorder. 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.

Debate Grows over Spinal Injections

By Pat Anson, Editor

A controversial government funded study critical of epidural steroid injections has been republished in the Annals of Internal Medicine, fueling a growing debate over the effectiveness and safety of spinal injections.

A prominent pain specialist called the study’s publication in a peer-reviewed journal “an insult to thousands of physicians across the world."

In a systematic review of 30 placebo controlled trials, researchers found that epidural steroid injections (ESI’s) offer limited or no relief from radiculopathy and spinal stenosis, two conditions that cause low back pain. The study was funded by the Agency for Healthcare Research and Quality (AHRQ) and conducted at the request of the Centers for Medicare and Medicaid Services.

“Epidural corticosteroid injections for radiculopathy were associated with early improvements in some outcomes versus placebo interventions, but effects were small and unsustained, and epidural corticosteroid injections had no clear effects in patients with spinal stenosis,” wrote lead author Roger Chou, MD, a Professor at Oregon Health & Science University (OHSU) School of Medicine and a staff physician in the Internal Medicine Clinic at OHSU.

Epidural injections using analgesics have long been used to relieve pain during childbirth, but spinal injections with steroids are also widely used for back pain. Although the Food and Drug Administration has never approved the use of steroids to treat back pain, several million ESI’s are performed “off label” in the U.S. annually.

The shots have become a common and sometimes lucrative procedure at many hospitals and pain management clinics. Costs vary from a few hundred dollars to over $2,000 per injection.

“Evidence on the effects of using different approaches, corticosteroids, or doses on effectiveness of epidural corticosteroid injections was limited, but indicated no clear effects,” said Chou, who was the principal investigator and author of several other studies published in peer reviewed journals.

“It is a travesty that Chou et al continue to publish these types of manuscripts. It is an insult to thousands of physicians across the world who perform these procedures and millions of patients who have received relief from them,” said Laxmaiah Manchikanti, MD, chairman and CEO of the American Society of Interventional Pain Physicians.

Manchikanti, who is medical director of a pain clinic in Paducah, Kentucky, conducted several of the studies reviewed by Chou and his colleagues.

“Consumers need to understand that the design of their systematic review is flawed and that significant bias exists in the reporting of the results,” Manchikanti wrote in an email to Pain News Network. “It is like eating 2 bananas from different countries and saying both are equally sweet, so neither is sweet. They also are looking for the differences in improvement between both groups rather than how a patient has improved from before the treatment to after the treatment."

Chou’s study also came under fire when it was released by the AHRQ. The Multisociety Pain Workgroup (MPW), a coalition of 14 different societies representing anesthesiologists, surgeons and pain management doctors, sent a lengthy letter to the AHRQ, calling the report's analysis on the effectiveness of ESI's "flawed” and “absurd.”  .

"I don't think its surprising that people who do these injections might disagree or not be happy with the results. Some of the comments seem to demonstrate a poor understanding of how to look at interventions in scientific research," Chou told Pain News Network. "I think people are afraid that they're not going to get paid for doing these types of things. It's not surprising, when people's pocketbooks are threatened, this how they respond."

Chou and his colleagues found the only significant benefit of ESI’s was temporary relief from back pain that usually lasts for only a few days. He attributes much of the pain relief to a placebo effect.

"It's clear that interventions for back pain have a very high placebo effect. We've known that for decades and its been demonstrated over and over again," said Chou.

Manchikanti says most of his patients get pain relief that lasts for several weeks.

“Each patient should be selected individually. They should understand the risks and the off-label nature of these drugs in the epidural space,” he said. “Epidural corticosteroids have been shown to be risky, come with a warning from the FDA, and are an off-label use of these powerful anti-inflammatories.

“For a patient, if they choose to have the procedures done with local anesthetic alone, or with local anesthetic and steroids, they should measure their progress. If they do not improve with the first procedure, they should carefully think about the second procedure; however, there is no reason to have any more than 2 procedures if they do not improve.”

The Choosing Wisely campaign of the ABIM Foundation, which seeks to reduce or eliminate unnecessary medical procedures, also recommends that doctors do not to repeat the injection if a patient shows no sign of improvement.

A number of prominent pain doctors have told Pain News Network the shots are overused, with some patients getting dozens of injections.  

Terri Anderson says repeated shots gave her temporary pain relief from a bulging disc in her back.

“I did receive immediate and short-term benefits over a 3 year time frame. However, I am here to tell you that the injections did not save me from surgery as the disc ultimately failed,” she said.

Anderson now suffers from arachnoiditis, a chronic and painful inflammation of the spinal column that has left her permanently disabled. The Hamilton, Montana woman believes the condition was brought on by too many injections.

“If I had the opportunity to go back in time, I would have stayed away from intervention and lived with the pain I had which was chronic, but it was manageable,” Anderson said.

“The government and professional medical societies have been keeping chemically induced adhesive arachnoiditis hidden from public awareness. Why is that? There is too much profit at stake for hospitals and pain clinics throughout the country. If a physician were to provide their patients with true informed consent (and explain the horrors of arachnoiditis), then no one in their right mind would undergo an epidural steroid injection.”

Purdue Pharma's 'Misleading' Websites

By Pat Anson, Editor

Days after launching a new website promoting abuse deterrent technology, drug maker Purdue Pharma has reached a settlement with New York’s Attorney General in which the company agreed to be more transparent about how it promotes itself in “unbranded” websites.

The maker of OxyContin also admitted its sales representatives contacted doctors who were on a “No Call List” -- even after they were red flagged for possible abuse and diversion of opioids.

“Over the past two decades, New York has experienced a sharp increase in opioid addiction,” said Attorney General Eric Scheiderman.  “My office will work to ensure that prescription drugs are marketed and prescribed responsibly.”

The Attorney General’s investigation found that one of Purdue’s websites, In the Face of Pain, could “mislead consumers” by suggesting that its content was neutral and unbiased, when in fact nearly a dozen “advocates” who appeared on the site and in YouTube videos were paid nearly a quarter of a million dollars by Purdue.

“The website failed to disclose that from 2008 to 2013, Purdue made payments totaling almost $231,000, for speaker programs, advisory meetings and travel costs, to 11 of the Advocates whose testimonials appeared on the site. The videos on YouTube also fail to disclose Purdue’s payments to the Advocates. Purdue’s failure to disclose its financial connections with certain Advocates has the potential to mislead consumers by failing to disclose the potential bias of these individuals,” the settlement states.

The agreement calls on Purdue to disclose financial relationships with any individuals, including doctors and other healthcare professionals, that endorse the benefits of pain treatment.

Purdue removed the profiles of the paid “Advocates” from In the Face of Pain in April 2015, after the attorney general’s investigation was well underway.

The settlement also takes Purdue to task for its sales practices. Purdue admits that its sales representatives on at least three occasions contacted doctors on a “No Call List” of 103 physicians in New York state who the company suspected may have been involved in the abuse and diversion of opioids. The calls were made to promote OxyContin.

Purdue sales representatives, who amazingly were not required to check the company's No Call List, made about 1,800 sales calls to doctors on the list over a six year period, “some quite extensively,” even buying meals for about a third of them.  It's not clear if the sales calls were made before or after the doctors were added to the list. Some of those doctors were later arrested or convicted for illegal prescribing of opioids.

A company spokesman told Pain News Network that sales calls could have also been made to doctors on No Call Lists outside of New York.

Under the terms of the settlement, Purdue agreed to adopt more “red flags” to identify doctors who may be prescribing opioids inappropriately or illegally. Sales representatives will also be required to check the No Call List before contacting a provider and will be disciplined if they don’t

As part of the settlement, Purdue Pharma will also pay $75,000 in fines and costs.

“Rather than pursuing an expensive, lengthy and uncertain litigation-based approach, the Attorney General’s initiatives will yield immediate and improved efforts to address issues designed to enhance public health,” said Robin Abrams, Vice President and Associate General Counsel for Purdue Pharma.

“For more than a decade we’ve implemented industry-leading programs designed to reduce the abuse and diversion of prescription medicine. We’ve relied on the input and encouragement of law enforcement officials, like the Attorney General, to continually upgrade and improve our programs.”

Purdue’s New Website

Early this week, Purdue introduced Team Against Opioid Abuse, a new website designed to help healthcare providers and laypeople learn about different abuse-deterrent technologies that make opioid medications harder to misuse and abuse.

Like In the Face of Pain, Team Against Opioid Abuse is not clearly identified as a Purdue Pharma website, except by a small copyright notice at the bottom.

“Using clear graphics and easy to understand language, the website features sections about why it's critical to deter abuse and how all the members on the healthcare team can make a difference,” Purdue said in a press release announcing its newest website.

In the wake of the New York settlement, the company said it would review the website, listen to feedback and incorporate any necessary modifications. 

Purdue was also in the news recently after the U.S. Food and Drug Administration quietly approved OxyContin for use by children aged 11 to 16 who suffer from chronic pain and who are already being treated with opioids.

The FDA’s move angered many anti-addiction advocates because the agency did not consult with an outside advisory panel or hold any public hearings before making its decision.

“We've known for a long time how immoral this company is.  As far as Purdue's role, this comes as no surprise; they have had this idea for some time now, as it represents a very lucrative market for them.  We've also known for a long time how unethical the FDA is.  This brings both truths out in the open,” said Pete Jackson, president of Advocates for the Reform of Prescription Opioids, who lost his 18-year-old daughter Emily to a single dose of OxyContin in 2006.

OxyContin was introduced to the U.S. in 1996 and soon became a blockbuster drug for Purdue,  reportedly generating profits in excess of $10 billion. Many believe it also helped fuel an “epidemic” of opioid addiction and overdoses, leading to the deaths of thousands of people.

In 2007, a class action lawsuit against Purdue for deceptive marketing ended when several company executives pleaded guilty to a felony count of misbranding OxyContin, by playing down its addictive and abusive side effects. The company and its executives were fined $634 million.

Power of Pain: Check Your Medical Bills for Errors

By Barby Ingle, Columnist

According to a study from The American Journal of Medicine, nearly two out of three bankruptcies stem from some sort of medical debt. How much of this debt is due to errors in medical bills?

According to a recent report by ABC News, one expert claimed to be finding errors on between 80–85% of the medical bills they reviewed. The Joint Commission on Accreditation of Healthcare Organizations and Medical Billing Advocates of America, national associations that check bills for consumers, say 8 out of 10 hospital bills its members scrutinize contain errors.

We tend to budget and work to slash our grocery, clothing, entertainment, and other spending, but forget to cut out-of-pocket medical costs. You can start saving money by checking your medical bills for errors and correct overcharges. Overcharges are fairly common, and correcting them can save you thousands of dollars.

While you may have no control over increases in premiums, co-payments, and deductibles, there's no reason to pay more than you should because of billing errors. Bills from doctors' offices and labs tend to have fewer mistakes, but they do happen. Mistakes can result from typos or deliberate overcharges. 

The National Health Care Anti-Fraud Association, a Washington, D.C.-based group of health insurers and state and federal law-enforcement officials, estimates that at least 3 percent of all health-care spending -- or $68 billion – is lost to fraud.

With a little time and perseverance, you may be able uncover overcharges by keeping a treatment log and reviewing bills as they arrive. Create a log of every test, treatment, and medication you receive. If you don't feel well enough to keep your own record, ask a relative or friend to do it. Even a limited list will make it easier to decipher your billing statements. 

There's no single list of fees you can check as to what your share of the cost is for insurance coverage. Insurers have a separate contract with each of your providers that determines how much they will pay. Therefore, after you schedule a procedure, test, or lab work, phone the providers to ask what they will charge and which Common Procedural Terminology (CPT) codes they will be submitting to your insurer.  

The next step is to call your insurance company to ask for an estimate of the amount your plan will cover and what you'll be responsible for paying. It’s good to get it in writing as verification or, at the minimum, ask the name of the representative and note the date and time of the phone call.  

The first statement you are likely to get is an explanation of benefits (EOB) from your insurance company or Medicare. The EOB statement will tell you the total amount being charged for your procedures, the amount your insurer is paying, and the amount you owe in deductibles and co-payments.

When bills begin to arrive from your doctors, compare the list of procedures with your notes. If you have a question about an item on a bill, phone that provider's office directly for an explanation. If charges are grouped together in broad categories—for example, all lab tests are lumped under one charge -- ask for an itemized bill if further clarification is needed.

If you find a mistake, first call your provider, explain the error, and ask someone in the billing department to make the correction. For each call you make, keep a record of the time, the name of the person you spoke with, and what you were told.

Those may be the only steps you have to take to get the matter settled. If that doesn't work, call an account representative or the fraud department of your insurance company. Next, I would suggest based on personal experience an appeal to your state consumer-protection agency or your state attorney general's office.  

If you can't get the problem resolved before the bill is due, you should pay the part of the bill not in dispute. If you find the disputed bills on your reports as unpaid accounts, write to the credit bureaus to explain the ongoing dispute. Also provide them copies of the EOB, doctor statement and any payments you did make on non-disputed charges. The bureaus must review your complaint and correct your report when proper documentation is provided.

Help protect yourself and your pocketbook so that you can help prevent the dreaded medical bankruptcy situation. So many times people just don’t get the treatment they need because they do not understand our medical billing system, or they get the treatment and overpay or get swamped with medical bills leading to bankruptcy.

Take the steps to protect yourself. A little work today will give you a more stable financial tomorrow and help you get proper and timely access to care as needed.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. She is a chronic pain educator, patient advocate, motivational speaker, best-selling author, and president of the Power of Pain Foundation.

More information about Barby can be found by clicking here.

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.