Communication is Key with Chronic Pain and Illness

By Jennifer Martin, PsyD, Columnist

Have you ever felt like the people in your life have no idea what you are going through?  Like they just don’t get it?

Your friends keep asking you to go out with them for a late night, even after you have told them a thousand times you can’t do things like that anymore. 

Your husband doesn’t understand why some nights you just don’t want to be touched. 

Your parents don’t get why you can’t do 10 things per day like you used to.

The truth is, unless it happens to them, your loved ones will never fully understand what you are going through.  And you can’t expect them to.  There are some things you can do however to try and ease some of your frustrations.  In my opinion, communication is key.  And if you are thinking right now, “All I do is communicate and they still don’t get it,” then maybe it is time to try a new tactic.

It is essential to find a way to communicate with your loved ones about your wants and needs. This is so essential because everyone’s wants and needs are different and we as humans are not mind readers. 

Your loved one may think he is helping you when he does the laundry so you don’t have to, but for you that may not be something you want help with.  It may be the one activity you can do without pain and it may help with your sense of purpose. 

Or you may want your very active family to slow down a little because you can’t keep up anymore without pain and exhaustion.  But you haven’t told them yet because you don’t want to change their way of life on account of you.

How are the people in your life supposed to know these things unless you tell them?

Or maybe you have tried to communicate these things and they just don’t get it.  What do you do then?

The first step is to find the right time to communicate.  Over drinks in a loud bar or right before bed when everyone is tired may not be the best time.  Find a time to have a sit-down conversation in a quiet room with your loved ones, whether it is one person at a time or all together.  Think about what you want to say beforehand and write down some notes, so you make sure to talk about everything you want to.

Next, if needed, educate them a little on your condition and how it affects you.  You may be surprised by how little people know about chronic illnesses, even those closest to you.  They may understand the basics about your condition, but not enough to help you in the way you need them to.  They may not understand how dramatically life has changed for you or how much you struggle.

Finally, talk to them about how they can support you.  Tell them what you want from them and what you need from them.  Mention some of the things they are doing that are very helpful and that you would like them to continue and then help them understand what you need them to do differently. 

For example: “It is really nice of you to help me with the laundry but that is something I would like to do on my own.  It gives me a sense of purpose and makes me feel like I am accomplishing something.  Instead, I would really like for you to help more with the dishes.  That is more difficult for me to do and it really hurts.”

It may take more than one conversation for your friends and loved ones to really begin making the changes you would like.  But if you keep gently reminding them what you want and need, it is likely that you will see some changes.

Jennifer Martin, PsyD, is a licensed psychologist in Newport Beach, California who suffers from rheumatoid arthritis and ulcerative colitis. In her blog “Your Color Looks Good” Jennifer writes about the psychological aspects of dealing with chronic pain and illness. 

Jennifer is a professional member of the Crohn’s and Colitis Foundation of America and has a Facebook page dedicated to providing support and information to people with Crohn’s, Colitis and Digestive Diseases, as well as other types of chronic pain.

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

Supplements Help Relieve Pain of Osteoarthritis

By Pat Anson, Editor

Two natural dietary supplements are effective at relieving pain and stiffness caused by osteoarthritis, without the side effects caused by non-steroidal anti-inflammatory drugs (NSAIDs), according to two new research studies.

One study found that a combination of glucosamine and chondroitin was effective in treating knee osteoarthritis (OA), while the other study examined an herbal treatment used for thousands of years in Chinese medicine to treat joint pain.

Osteoarthritis is a progressive joint disorder caused by painful inflammation of soft tissue, which leads to thinning of cartilage and joint damage in the knees, hips, fingers and spine.

The first study was a meta-analysis (a study of studies) involving over 16,000 patients with knee OA. Published in the journal Scientific Reports, it is the first study of its kind to compare glucosamine, chondroitin, and the two in combination, against the NSAID celecoxib or a placebo in the treatment of knee OA.

Researchers found that the combination of glucosamine and chondroitin was associated with significant improvement in pain relief and functional enhancement, compared to placebo, without the high rate of gastrointestinal side effects in patients who received celecoxib.

There was "no significant difference" in pain relief between celecoxib and the glucosamine/chondroitin combination.

"This comprehensive analysis provides us with a wealth of historical data supporting the safety and efficacy of glucosamine and chondroitin in the management of joint health. It is consistent with recent findings suggesting that the efficacy of this combination is comparable to celecoxib in terms of relieving pain and improving function," said lead author Chao Zeng, MD, of the Department of Orthopaedics at Xiangya Hospital at Central South University in Changsha, China.

"This is important news for patients requiring long-term treatment, as the potential side-effect associated with profiles of NSAIDs such as celecoxib warrant consideration of alternative treatment options that are safe and effective."

Glucosamine and chondroitin are both found in healthy cartilage, which acts as a cushion between the bones in a joint. In dietary supplements, glucosamine can be harvested from shells and shellfish or made synthetically. Chondroitin can also be made in a lab, or manufactured from cartilage found in cows, pigs, sharks and other animals.

Chondroitin and glucosamine are popular in supplements used to treat joint pain, but according to the Arthritis Foundation, “most studies assessing their effectiveness show modest to no improvement compared with placebo in either pain relief or joint damage.” The American Academy of Orthopaedic Surgeons also recommends against their use.

The second, smaller study examined the effectiveness of Arthrem, a dietary supplement made in New Zealand that contains an herbal extract from the plant Artemisia annua (Qinghaosu), which has been used in Chinese medicine for more than 2,000 years.

Forty-two people with osteoarthritis of the knee or hip were enrolled in the randomized, controlled study, which was published in the journal Clinical Rheumatology. Researchers say patients who took an Arthrem capsule twice a day for 12 weeks had a significant reduction in pain and stiffness and an increase in their physical function.

"The published results show that the natural product, Arthrem, has potential as an anti-inflammatory/analgesic in osteoarthritis," said Dr. Sheena Hunt, study co-author and principal scientist for Promisia Integrative, the company that makes Arthrem and conducted the study.

"Particularly positive results were observed in a subset of patients with mild to moderate osteoarthritis. In this subgroup, the average magnitude of pain after 12 weeks of taking Arthrem was less than half of the value at the start of the study. Arthrem at this dose was also well tolerated with no treatment-related side effects."

Arthrem recently became available in the United States. Those who qualify can sign up for a free, no obligation, two month trial online at www.Arthrem.com.

Compared to pharmaceuticals, the U.S. Food and Drug Administration loosely regulates the $35 billion dietary supplement industry and many manufacturers' claims about their products are unverified.  The agency recently announced plans to tighten enforcement of the industry by creating a dietary supplement office.

The World Health Organization estimates that about 10% of men and 18% of women over age 60 have osteoarthritis.

Power of Pain: Growing Older with Chronic Pain

Barby Ingle, Columnist

I am another year older. At 43, I should be in my prime, but I live with chronic pain. Chances are I passed my peak health on the proverbial mountain and am headed back down when it comes to my health.

My friends are getting older as well. I hear more complaints about painful knees and hips, backs, and breathing difficulties. Those are common symptoms among older adults, with about 30% of adults 65 and older reporting knee pain or stiffness and 15% reporting hip pain or stiffness.

There has to be a way to lessen the blow of growing old, even for those of us with chronic pain. Although they are not taught well in society, there are actually life choices we can make that will lessen the pain and limitations.

Where should we start? Exercise is a good place, but don’t overdo it. Good eating habits are essential, but remember to splurge a couple of times a month. Increase your water consumption too, unless advised by a healthcare provider to limit fluids. Another challenge for me and probably you is getting enough sleep.

There has to be a way to lessen the blow of growing old, even for those of us with chronic pain. Although they are not taught well in society, there are actually life choices we can make that will lessen the pain and limitations.

Where should we start? Exercise is a good place, but don’t overdo it. Good eating habits are essential, but remember to splurge a couple of times a month. Increase your water consumption too, unless advised by a healthcare provider to limit fluids. Another challenge for me and probably you is getting enough sleep.

Posture is another area. When we are young we see the elderly hunched over. When we are in pain we tend to do the same tuck and comfort position. If you pay attention to your posture, it will be a great benefit to staying upright and breathing deeper, providing more oxygen and helping maintain a healthy body weight.

Living with all of this in mind is difficult, but important. The goal should not only be to live a long, happy and productive life, but do it well. Moments of prevention, especially in our youth and young adulthood, can add up to additional life experiences that you would have missed. Work on your strength (physical and mental), moderate your lifestyle, and practice balance, endurance and flexibility skills.  

I have to remind myself to take a break. Even if I can’t sleep, I go into a quiet dark area and let my brain have a break from all of the stimuli in our environment. Living with pain is a pain in itself, but luckily for us there are safe and effective ways to manage it. It is important to learn what is available and what we need to make available for better daily living.

Aches and pains are NOT a normal part of aging. If we learn how to recognize our bad behaviors and practice better ones, we can overcome many of the battles of growing older with chronic pain. Learn how to recognize, understand and properly treat your pain.

This takes a little work to get started, but once it becomes habit, it gets easier and easier. Be sure to use the resources available to you: providers (develop a team), pharmacists, caregivers, positive people, local churches and community centers. One of the things we did for my mother before she passed was get local high school kids to come in and check on her, and help her with tasks that needed done around her house. Many high schools now have mandatory volunteer hours for graduation. Check your local resources, support groups, and community groups for tools you can use to better your life.

When pain lasts for more than a few months it usually has an underlying disease that is the cause. For the elderly, two widespread causes are diabetes and arthritis. Both can be warded off with proper care throughout the life cycle. If you find yourself already in pain while reading this, it’s never too late to start. It is important to pay attention and admit that you are feeling bad. The sooner you take care of yourself the better your outcomes will be over time.

Working on the core lifestyle actions; posture, nutrition, good behaviors (limited or no smoking/drinking), and exercise will go a long way when it comes to prevention and maintenance of your body.

Also take into consideration what treatments you are willing to participate in. Doing noninvasive treatments first, unless in an acute health situation, is important. The less stress and trauma you bring to yourself the better off you will be. Some noninvasive options would be warm baths, relaxation, moderate physical activity, or non-prescription pain relievers.

Always let your providers know if you have a change in the pain’s location, intensity, and sensation. Be sure to rule out any other underlying causes. Providers may also try medications, herbal or supplemental products, medicated lotions, acupuncture/pressure, chiropractic, massage, physical therapy, occupational therapy, nerve blocks, radio frequency ablations, and other surgical procedures. As a pain patient I have learned that we are all different, what works for me doesn’t always work for my best friend, or even family members who suffer with chronic pain.

I will leave you with some important pain facts for the elderly. If a person has pain, even at the end of life, there are ways to help. It’s best to focus on making the person comfortable, without worrying about possible addiction or drug dependence.

Many older people have been told not to talk about their aches and pains because it is a part of getting older. But it is not a given that since we are getting old we will have pain.  Don’t put off going to see a doctor because you think the pain is just part of life. Early and proper care is best when working to address the pain and its cause.

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 and the International 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.

Medical Necessity or Addiction?

By Lisa Davis Budzinski, Guest Columnist

All of the issues surrounding the CDC’s opioid guidelines and opioid pain medication being compared to heroin are quite stressful to those of us who are disabled and seeking quality of life on a daily basis.

Does everyone understand that there are “healthy” people that take prescribed medications just to deal with life?

That there are young adults who experiment with prescription meds that were not prescribed to them by a doctor?

That there are people who buy on the street the same prescription drugs that we use?

And that there are people who get injured but heal and no longer need pain prescriptions?

We all see the abuse and misuse of pain medications, but what about those of us who will not or cannot ever heal again? It’s one thing to break a limb and know you are going to heal up in 6-8 weeks. But what about those of us who are not ever going to heal? 

I had a stroke that damaged my central nervous system, leaving me with Central Pain Syndrome, a neurological condition that causes constant pain. There is no cure and few treatments help. I do not have a diagnosis of being better a few months down the road. And I’ve had to come to the realization that I will have pain every day of my life.

I can have some quality of life and get the pain scale down to a 6-7 by taking Tramadol daily. Using Robaxin keeps my muscles from stiffening up or being spastic every hour of every day. I also take Zoloft because it has been clinically proven to help ease chronic pain and to work in conjunction with my bio-identical hormones.  

What about my husband, who suffered a horrible accident 35 years ago that damaged his right lower leg beyond repair? What about his daily pain levels from his shin bone that stays broken from bone infections?  Why shouldn’t he have quality of life on a daily basis? His leg will never heal and it will never stop causing him pain.

We aren’t taking prescription medications that makes us sit and drool, or knock us out without knowing what’s going on around us. We take medications so we can be alert and live daily life the best that we can while we are here.

No one can imagine a life of chronic pain that will never go away until they live it themselves. We are not talking about pain that comes from getting a scuffed knee or elbow. We aren’t talking about pain that comes and goes like indigestion. We aren’t talking about the pain of creaky joints that comes from getting older, although we have that as well.

Why must those of us who struggle to live a quality life be ridiculed and ruled by government agencies that do not even deal with these issues? Shouldn’t that be decided by our medical doctors who have put in years learning their profession? Who took an oath not to harm us but to help us?

It’s not logical to compare a prescribed pain medicine to heroin or any other illegal drug you can buy on the street.  

We are living a life of “medical necessity” and not one of addiction. We are law abiding citizens that just want quality of life.

Lisa Davis Budzinski is a cancer and stroke survivor who suffers from Central Pain Syndrome.

Lisa is a delegate to the Power of Pain Foundation, Vice President of the Central Pain Syndrome Foundation, and author of "At The End of The Day."

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.

Vitamin D Lowers Inflammation from MS

By Pat Anson, Editor

A new study is adding to the growing body of evidence that Vitamin D supplements can be used to treat multiple sclerosis (MS) and other inflammatory chronic pain conditions.

The pilot study published by Johns Hopkins physicians in the journal Neurology found that taking a high dose of vitamin D3 is safe for people with MS and may help regulate the body’s hyperactive immune response.

“These results are exciting, as vitamin D has the potential to be an inexpensive, safe and convenient treatment for people with MS,” says study author Peter Calabresi, MD, director of the Johns Hopkins Multiple Sclerosis Center and professor of neurology at the Johns Hopkins University School of Medicine. “More research is needed to confirm these findings with larger groups of people and to help us understand the mechanisms for these effects, but the results are promising.”

MS is a chronic and incurable disease which attacks the body’s central nervous system, causing numbness in the limbs, difficulty walking, paralysis, loss of vision, fatigue and pain.

Low blood levels of vitamin D – known as the “sunshine vitamin”-- have been linked to an increased risk of developing MS.

People who have MS and low levels of vitamin D are also more likely to have greater disability and more disease activity.

In the Johns Hopkins study, 40 people with relapsing-remitting MS received either 10,400 international units or 800 international units (IU) of vitamin D3 supplements every day for six months. Patients with severe vitamin D deficiency were not included in the study. The current recommended daily allowance of vitamin D3 is 600 IU.

Blood tests at the start of the study, and after three and six months, measured the amount of vitamin D in the blood and the response in the immune system’s T cells, which play a key role in MS.

Participants taking the high dose of vitamin D reached optimal levels of Vitamin D in the blood (40 to 60 ng/ml), while the group taking the low dose did not reach that target. The people taking the high dose also had a reduction in the percentage of inflammatory T cells related to MS severity. The people taking the low dose did not have any noticeable changes in the percentages of their T cell subsets.

“We hope that these changes in inflammatory T cell responses translate to a reduced severity of disease,” says Calabresi. “Other clinical trials are underway to determine if that is the case.”

Another recent study in Neurology by Danish researchers found that MS patients who spent time in the sun every day during the summer as teenagers developed the disease later in life than those who spent their summers indoors. Ultraviolet rays in sunlight are a principal source of Vitamin D, which has a wide range of positive health effects, such as strengthening bones and inhibiting the growth of some cancers.

Low levels of serum vitamin D have also been linked to fibromyalgia. In a study of over 1,800 fibromyalgia patients published in the journal Pain Physician, researchers at National Taiwan University Hospital found a “positive crude association” between chronic widespread pain and hypovitaminosis D, which is caused by poor nutritional intake of Vitamin D, inadequate sunlight or conditions that limit Vitamin D absorption.

Pain News Network columnist Crystal Lindell began taking Vitamin D supplements when her blood levels were found to be very low. Within a few months she was feeling better, exercising more, and losing weight. You can read Crystal’s story by clicking here.

CDC ‘Not Aware’ of Website Issues

By Pat Anson, Editor

The start of the New Year means the deadline is fast approaching for people to submit their comments about the opioid prescribing guidelines proposed by the Centers for Disease Control and Prevention (CDC). The deadline is January 13th to comment on the draft guidelines, which discourage primary care physicians from prescribing opioids for chronic pain.

So far, nearly 1,500 comments have been received at the regulations.gov website, and while the process appears to have gone smoothly for most users, some have complained to Pain News Network about the website loading slowly, not accepting comments, "internal errors" and other “technical difficulties.”

One couple even sent us a series of screen shots showing some of the problems the website was having around Christmas.

“I have multiple screen shots for days of being told the site was experiencing technical difficulties and to send an email. Another saying due to internal error they were unable to retrieve docket info, etc.,” wrote Jerry and his wife Sharon, who asked that we not use their last name.

The CDC says the website was undergoing maintenance the weekend of December 19-20, but the agency is unaware of any other period when the website was down.

“CDC is not aware of issues with submitting comments via Regulations.gov. People should be able to submit a comment through the docket without any issues. Once submitted, they should receive a receipt confirming the submission. There might be a slight delay in comments appearing online given the holiday,” said CDC spokesperson Courtney Leland in an email to PNN. She urged anyone experiencing a problem to call the Regulations.gov help desk (1-877-378-5457).

The delay in posting comments has contributed to the frustration of some posters, especially those who were already suspicious of the CDC, given the agency’s secrecy and lack of transparency when the guidelines were first drafted.

“My comment wasn't posted on the CDC opioid issue – I’m not surprised,” said David Becker, who submitted a lengthy comment accusing the agency of trying to “subjugate people in pain to forces beyond their control.”

Becker complained to the CDC and his comment appeared on the website the next day.

The CDC says it is not trying to censor or silence anyone – but is reviewing all comments for personal information, inappropriate language and other issues before posting them. That delay causes a discrepancy between the numbers of comments received and the number posted on the website.

 “There were comments pending posting while CDC contacted individuals who had included personal, private information in their comments. CDC contacted the commenters to ensure that they agreed to have their personal information publicly posted. CDC has completed contacting those commenters and their comments have been posted. The only comments currently waiting to post are those that the docket managers need to review and catalog before public posting,” said Leland, adding that no comments had been rejected as inappropriate for posting.

Another issue that has led to frustration is the limit on characters, not words, used in comments. The limit is 5,000 characters, including spaces, something the CDC says it is unable to change, and posters say is too limiting and confusing.

“The site certainly isn’t very (user) friendly is it?” asked Janice Reynolds, a retire nurse and pain sufferer. “I read ‘words’ when it actually said characters.  So even though it looked like I was under the ‘word’ limit it would say I had too many characters.  I finally recognized what it was saying and divided the paper in two (pain patient and pain management nurse) and did them separately.  That worked however it still wouldn’t let me download a file.  It was frustrating.  So it was really operator error with a poor instruction manual.”

Still another issue that has raised concern is efforts by some organizations to get their followers to submit form letters as comments. Physicians for Responsible Opioid Prescribing (PROP), for example, sent a newsletter last week to supporters urging them to submit comments in favor of the guidelines. In his “urgent request” to supporters, PROP founder Andrew Kolodny, MD, even had several suggestions on what to write.

But in its “Tips for Submitting Effective Comments,” the government says that tactic won’t work. It’s not the number of comments that come in, pro or con, but the quality.

“Many in the public mistakenly believe that their submitted form letter constitutes a ‘vote’ regarding the issues concerning them. Although public support or opposition may help guide important public policies, agencies make determinations for a proposed action based on sound reasoning and scientific evidence rather than a majority of votes. A single, well-supported comment may carry more weight than a thousand form letters,” the regulations.gov website states.

The public comment period on the CDC's prescribing guideline continues until January 13th. You can make a comment by clicking here. 

The draft guidelines and the reasoning behind them can be found in a 56-page report you can see by clicking here.

All Things Considered: Except Patients

By Pat Anson, Editor

National Public Radio’s All Things Considered is one of the most respected radio programs in the country, reaching nearly 12 million listeners each week.

So when All Things Considered aired a two-part series this week on the opioid prescribing guidelines being developed by the Centers for Disease Control and Prevention (CDC), many expected an in-depth and balanced report on America’s love-hate relationship with opioids – how a medicine that gives pain relief to millions is also responsible for the deaths of thousands who abuse it.

Host Robert Siegel said the nation was at a “turning point” in its complicated relationship with opioids. The broadcast interviewed pain specialists, a family physician, and various experts who said the CDC guidelines either go too far or are long overdue.

“We have a moral responsibility to address pain and suffering. And we do have a responsibility not to do harm, but you can do harm in either direction,” said Richard Payne, MD, of Duke University.

“The number of deaths is only the tip of the iceberg, that's just indicating the pyramid of problems that lies beneath,” said Jane Ballantyne, MD, President of Physicians for Responsible Opioid Prescribing (PROP).

Completely missing from the report was the voice of pain patients. Many noticed the omission and left comments on NPR’s website.   

“Please consider interviewing real chronic pain patients. Everyone seems to be making decisions about our treatment but no one asks us how these medications work for us,” wrote one pain sufferer.

“Sorry but NPR screwed up majorly on this piece – they had no panel of patients to give their thoughts – considering how terrible pain patients are treated, that would have been a good angle,” wrote Cary Brief.

“The recent public discussion on opiates, which paints all opiate users as addicts or drug-seeking, is not only unhelpful, it is exceedingly harmful to patients like myself who take their medications as prescribed,” said a woman who suffers from chronic back pain.

“I am amazed at my beloved NPR not doing their homework on this,” wrote Kristine Anderson. “You have just labeled yourself another media outlet getting your information from only the CDC (other than Dr. Payne perhaps) and creating feed off of their press releases, timely sent just as the guidelines comments were reopened and soon to close.”

Anderson also wrote she was disappointed that the broadcast included a lengthy interview with Ballantyne, a retired pain specialist who has recently emerged as a controversial figure in the debate over opioids. As Pain News Network has reported, Ballantyne is one of five PROP board members who are advising the CDC and her inclusion in a secret panel of experts is one of the reasons the agency delayed implementing the guidelines and reopened a public comment period.

Critics have said Ballantyne is biased, has a financial conflict of interest, and should be fired from her academic position at the University of Washington School of Medicine for advocating that pain intensity not be treated.

None of that was reported by All Things Considered, which gave Ballantyne a prominent role in the broadcast. Ballantyne told the program that during her lengthy career in pain management she and other doctors were sometimes abused and insulted by “awful” pain patients when they tried to wean them off opiates.

“If you give people opiates, they think you're the best thing since sliced bread. They love you. They just worship the ground you walk on. The moment you suggest that you want to try and get them down on their dose or, worse still, say you can't carry on prescribing - not that I do that myself; I never cut people off; I don't think people should be cut off, but I do try and persuade them to come down on their dose - they are so awful,” Ballantyne said.

“And you can see why people who are not seeped in this stuff - the young primary care physicians just don't know what to make of it. They don't want to be abused. They want to be loved like everybody else does. We go into medicine to try and help people. And when you get abused and, you know, insulted, you can see why it perpetuates itself.”

Ballantyne said patients on high doses of opiates “were absolutely miserable, were not doing well, were medically ill and always had severe pain." It was then that she and her colleagues began to think "the opiate wasn't helping, and maybe it was harming.”

You can listen to Ballantyne in the first part of NPR’s story, by clicking here.

The second part -- an interview with Dr. Wanda Filer, president of the American Academy of Family Physicians -- can be heard by clicking here.

Hospital’s Opioid Guidelines Had Significant Impact

By Pat Anson, Editor

An opioid prescribing guideline adopted in 2013 at Temple University Hospital in Philadelphia may provide a sneak peek at the possible impact of similar guidelines being considered by the Centers for Disease Control and Prevention (CDC).

Temple University’s guidelines, which discourage opioid prescribing for many emergency room patients suffering from acute or chronic pain, resulted in an “immediate and sustained impact” on rates of opioid prescribing, according to research published in the Journal of Emergency Medicine.

In a study of over 13,000 patient visits, the rate of opioid prescribing was quickly reduced by about a third, falling from nearly 53% of emergency room visits before the guideline to about 34% a year later. The patients were being treated for dental, neck, back and chronic non-cancer pain.

The opioid guidelines were supported by all 31 of the hospital’s emergency room physicians who completed a survey on their prescribing practices. Most of the doctors (97%) felt the guideline facilitated discussions with patients when opioids were withheld, and nearly three-quarters said they encountered “less hostility” from patients since adoption of the guideline.

temple university hospital

Only 13% of the doctors believe patients with legitimate reasons for opioids were denied appropriate care. A large majority – 84% of the doctors -- disagreed or strongly disagreed that patients were denied appropriate pain relief.

The researchers did not ask any pain patients what they thought about their hospital care.

“Emergency physicians have identified themselves as targets for patients who seek opioids for nonmedical purposes, yet it can be difficult for clinicians to distinguish drug seeking behavior from legitimate need. Recognizing the importance of clinician discretion at the bedside, adherence to our guideline was voluntary,” said Daniel del Portal, MD, Assistant Professor of Clinical Emergency Medicine at the Lewis Katz School of Medicine at Temple University, who was principal investigator of the study.

The CDC also considers its draft guidelines voluntary for primary care physicians, although many experts believe they will quickly be adopted as “standards of practice” by all doctors who prescribe opioids – just as they were at the hospital.

The Temple University guidelines differ from those of the CDC because they are designed specifically for emergency room physicians. They discourage doctors from prescribing opioids for dental pain, back pain, migraines, gastroparesis or chronic abdominal pain; and recommend that patients not be discharged with more than 7 days supply of opioids (the CDC recommends 3 days supply). The hospital’s guidelines also recommend that long acting opioids such as OxyContin, morphine and methadone not be prescribed; and that “less addictive therapies” such as NSAIDs or acetaminophen be used instead for pain relief.  

“We acknowledge the myriad challenges to addressing issues of chemical dependence and opioid abuse. We do not pretend that a guideline alone will solve this problem, but rather we believe that guidelines are one of a number of tools that should be considered in parallel,” said del Portal.

“In contrast to electronic prescription drug monitoring programs, which show promise but require significant infrastructure and regulation, an easily implemented guideline empowers physicians and protects patients from the well documented dangers of opioid misuse.”

He also acknowledged that limits on opioid prescribing may result in more drug abuse and addiction.

“Heroin overdose deaths have continued to rise, even more dramatically since the plateau of nationwide opioid prescriptions
after 2011. While experts point to the rise in opioid prescriptions as a major contributor to heroin deaths, we are mindful that limiting the supply of opioids may provide a catalyst for drug substitution,” he said. 

The public comment period on the CDC's draft guideline continues until January 13th. You can make a comment by clicking here. 

The proposed prescribing guidelines and the reasoning behind them can be found in a 56-page report you can see by clicking here.

Imaging Identified as Most Wasteful Medical Test

By Pat Anson, Editor

Should you get an MRI for your headache?

What about a CT scan for low back pain?

Or a bone-density scan for someone under the age of 65?

In most cases, the answer to all of those questions is no, according to the Choosing Wisely campaign of the ABIM Foundation, which seeks to reduce the use of hundreds of unnecessary and costly medical tests. Experts say an MRI or CT scan of the lower back can cost over $1,200 and does nothing to relieve your back pain.

Since Choosing Wisely was launched in 2012, over 370 wasteful procedures have been identified by over 70 medical societies, such as the American Academy of Sleep Medicine and the American Academy of Neurological Surgeons. Each organization was asked to identify an initial list of five medical services that may be unnecessary. Many societies went far beyond that, returning with two or even three lists.

A neurologist at the University of Michigan says the list of recommendations from the American Academy of Neurology (AAN) only scratches the surface. Brian Callaghan, MD, has identified 74 tests and procedures related to neurology that are often unnecessary. Many involve the use of imaging.

“The two biggest areas that might be done more than they should are imaging for low back pain and imaging for headaches,” Callaghan said. “It’s a big problem and it costs a lot of money – we’re talking a billion dollars a year on just headache imaging.”

According to a recent study at the University of Michigan, one in eight visits to a doctor for a headache or migraine end up with the patient going for a brain scan. Often a doctor will order a CT or MRI scan to ease a patient’s fear that they may have a brain tumor or some other serious issue causing their pain. Physicians could also order a scan to protect themselves legally in case of a future lawsuit.

In most cases, however, the brain scan will be useless. Previous research found that only 1 to 3 percent of brain scans of patients with repeated headaches identify a cancerous growth or aneurysm that's causing the problem. Many of the issues that a scan might identify don’t pose a serious threat or may not require treatment right away. There is also the risk of a false positive that could generate unnecessary fear and alarm.

“These are all areas where lots of physicians agree that you’re more likely to get harmed by doing the procedures,” said Callaghan, whose study was recently published in the journal Neurology.

Callaghan isn’t encouraging you to say no if your doctor wants to image your brain or lower back, but he hopes his research will inspire a thoughtful discussion between doctors and patients about the purpose of the test and its value

“Ordering an MRI for a headache is very quick, and it actually takes longer to describe to the patient why that’s not the best route,” Callaghan said. “These guidelines are meant for physicians and patients both, to trigger a conversation.”

Besides imaging, another treatment that is widely questioned is the use of opioid pain medication to treat headaches and migraine. The Choosing Wisely campaign recommends that opioids only be used as a last resort for severe headaches, including migraine. Overuse of any pain reliever – even over-the-counter medications -- are known to make headaches worse.

Chronic Pain? There’s an App for That

By Pat Anson, Editor

Smartphones have revolutionized the way we communicate. And they are fast becoming a tool in the treatment of chronic pain.

Wearable medical devices linked to smartphones can not only do simple things like track your pulse and blood pressure, they can help relieve some types of chronic pain without the use of drugs. Several of these new medical devices are being showcased next month at the 2016 International Consumer Electronics Show (CES) January 6-9 in Las Vegas.

One device making its debut at the trade show is the iTens, the first FDA-cleared wireless TENS device that works via an iPhone or Android based app.

Transcutaneous Electrical Nerve Stimulation (TENS) has been used for decades to relieve pain by using electrical stimulation to block or mask pain signals. But the old TENS units typically come with many wires, are anything but portable, and could only be used for limited 30-minute periods.

images courtesy of itens

“The iTENS device was created for people who are in need of a portable, convenient method of pain management that doesn't involve taking prescription medication,” says iTENS CEO Joshua Lefkovitz. “We designed the iTENS to be thin, flexible, discreet, and easy to operate with the push of a button from the iTENS app.”

The iTens uses peel ‘n’ stick gel pads that can be directly applied to painful areas. The pads are powered by a lithium-ion rechargeable battery that can provides relief for up to 24 hours.  During that time, the iTENS app measures a user’s pain scale, tracks their results, and charts their progress.

“We’ve got the first clearance from the FDA that has a Bluetooth enabled app,” Lefkowitz told Pain News Network. “There are other wireless TENS devices out there, but none of them are app-enabled.

“It’s really cool, because with an app you can roll in new settings. We’ve got body part settings, condition-specific settings, and you’ve got manual settings so you can pre-program whatever settings you want.”

The iTens device will become commercially available in March for $89.95. No prescription is needed and the device is “FDA-cleared” – meaning the Food and Drug Administration has approved iTens’ safety, but not necessarily its efficacy.

Device makers have a huge advantage over pharmaceutical companies because they are held to a lower regulatory standard and often can get fast track approval from the FDA without any clinical studies – as long as the new device is substantially the same as an old device already on the market.

One disadvantage to that approach is that without full FDA approval, few insurance companies are likely to offer reimbursement for a wearable medical device and physicians are less likely to recommend them.

That conundrum will be addressed at the CES trade show in a panel discussion titled “Roadmap to FDA Approval.” One of the speakers is Shai Gozani, President and CEO of NeuroMetrix Inc., maker of the Quell pain relief device, a neurostimulator worn below the knee

“If wearable technology is going to achieve its tremendous potential it must move beyond wellness to tackling fundamental health problems such as chronic pain, diabetes, and heart disease. This necessarily implies regulation by the FDA,” said Gozani. “I hope this panel will start to demystify the regulatory process and encourage technology companies to embrace the opportunity of consumer medical technology.”

The FDA issued guidance earlier this year on the types of apps that would be subject to regulatory review. The agency said it was not trying to stifle innovation and the regulations would only apply to a  “small subset of mobile apps that are medical devices and present a greater risk to patients if they do not work as intended."

The goal is not to regulate “wellness” apps that keep track of things like fitness and nutrition, but apps that make specific claims about diseases and conditions.

According to industry estimates, by 2018 over half of the world’s 3.4 billion smartphone and tablet users will have downloaded mobile health applications

Most Patients Still Prescribed Opioids After Overdose

By Pat Anson, Editor

The vast majority of chronic pain patients continue to be prescribed opioids after a non-fatal overdose, usually from the same doctor who prescribed the pain medication that led to the overdose, according to new research published in the Annals of Internal Medicine.

In the study of nearly 2,850 patients who were treated for an opioid overdose, 91% were prescribed another opioid within 300 days of the overdose. About 70% of the prescriptions were written by the same provider. Data for the study was collected from insurance claims filed from 2000 to 2012.

"Our finding that almost all patients continue to be prescribed opioids after overdose is highly concerning,” wrote lead author Marc Larochelle, MD, Boston Medical Center. “The overdoses we detected were captured in routine claims data and treated in emergency departments or inpatient settings and thus represent identifiable events when information sharing might lead to improved care and outcomes. Further research is needed to determine whether providers continuing to prescribe opioids after an overdose are aware of the event and, if so, how they respond in counseling patients.”

The researchers found that about 7% of pain patients had a second overdose and those who were prescribed high doses of opioids had twice the risk of a repeat overdose.

Even more disturbing is that over half of the overdose patients (58%) were prescribed benzodiazepines, anti-anxiety medication that includes brand names such as Valium and Xanax.

Benzodiazepines are known to greatly increase the chances of an overdose. A recent CDC study found that about 80% of unintentional overdose deaths associated with opioids also involved benzodiazepines.

Due to limits in the data, researchers had no way of knowing why physicians continued to prescribe opioids after their patients overdosed.

“We could not determine reasons for the treatment patterns after the overdose; however, some prescribers may have been unaware that the opioid overdose had occurred,” said Larochelle. “In some cases, overdoses may have reflected therapeutic error rather than opioid misuse. In these and other cases, providers may have believed that the risk–benefit ratio favored continued opioid prescribing.”

In an editorial published in the Annals of Internal Medicine, Jessica Gregg, MD, called the study’s findings “astonishing.”

“Prescribing guidelines are clear that adverse events, such as overdose, are compelling reasons to withdraw prescription opioids. Therefore, it is tempting, and it would be easy, to attribute these results to poor care, bad decisions, or sloppy prescribing,” wrote Gregg, who is an associate professor of medicine at Oregon Health & Science University. “However, the problem goes well beyond individual prescribers' practices. These prescribing behaviors occur in a context in which substantial -- even deadly -- mistakes are inevitable. For instance, it is likely that many of the prescribers in the study did not know about their patients' overdoses.

“There are currently no widespread systems in place, either within health plans or through governmental organizations, for notifying providers when overdoses occur. Until such systems exist, providers will be left to act with dangerously limited knowledge. They will be unlikely to decrease or withdraw a patient's opioid prescription after an overdose if they have no knowledge that the event occurred.”

To make doctors more aware that their patients may have had overdoses, the researchers recommend that overdose data be included in prescription drug monitoring programs (PDMPs) which are now currently used to track prescriptions.

Give and Take Needed on CDC Guidelines

By Fred Kaeser, Guest Columnist

I wish we could all get along. Millions of people in chronic pain usually need opioids in adequate supply in order to manage their day and have some semblance of a quality of life. At the same time, tens of thousands of people's lives are destroyed, ruined, and ended each year from the very same drugs we pain sufferers find comfort from.

Looking objectively at the situation, there needs to be humane action on both sides of this conundrum. Whatever the result of the CDC's new prescribing guidelines, people in chronic pain must not be denied adequate access to opioids when absolutely needed, and yet some action needs to occur to reduce the outrageous rates of opioid addiction.

Think of what has happened in 15 very short years. We have gone from thinking that long term opioid use should only be provided for end-of-life care; to thinking that it is appropriate and acceptable to provide opioids on a regular basis for a myriad of pain causing illnesses and syndromes; back to thinking they are too dangerous and should be sharply limited. All within a 15-year period.

Yes, opioids reduce pain, just what all of us pain sufferers want. And yes, opioids destroy lives, something none of us want.

The truth is there have been no studies of long term opioid usage. And we know very little about just who is more prone to succumbing to the addictive aspects of these drugs once they are used for any length of time.

I do think there has got to be some give and take on both sides. The CDC has to understand that many, many chronic pain sufferers do indeed improve the quality of their lives by taking opioids. And I do think that we pain patients have to show a good faith effort that we are doing all we can to mitigate our pain through alternative pain treatments.
If you look at the CDC survey results attached to this website, you will see that almost 100% of pain respondents report little or no relief from alternative pain strategies. Over half of us say alternative strategies don't work and over a third of us say that they provide little relief.

Yet, if one explores the rich empirical research that exists on exercise, yoga, mind-body techniques like meditation and guided imagery, and their various permutations, we see that they can have a profound effect on reducing pain and discomfort. There is a huge body of research that supports just how powerful of an effect these modalities can have on reducing pain. Yet, almost all of us say they have little if any effect.

So, how can this be? I can only speak for myself, but when my pain started to become constant and severe I too did not think any of these alternative techniques were worth it. The time, energy, and sometimes additional pain that went in practicing them just didn't seem worth it. After all, I could find significant relief in 20 minutes or so just by taking 10 milligrams or so of oxycodone.

So why go through all that other stuff when I could be feeling relief in less than a half hour? But as my pain became every day, all day, I decided that I wasn't going to walk hand-in-hand the rest of my life with a drug that could very easily do more harm to me than the medical condition I was taking it for.

Days, weeks, and months went by of every day hard work. Exercise, stretching, yoga techniques, learning different meditation strategies, etc. were not easy. Amazingly, none of it cost much in terms of money, but the cost in terms of energy and time that went into practicing them was considerable. BUT, there came a time when it all started to pay off.

The research is correct: alternative pain techniques do work. Maybe not for YOU, but enough so that many of us could be finding significantly more relief than just from our medication. And it doesn't necessarily mean that we still don't need pain medication to get through our pain, but it will likely mean we'll need less of it.

I do think this is what is needed. Some give and take from both sides of the equation.

Fred Kaeser, Ed.D, has suffered from back pain, osteoarthritis and other chronic conditions for most of his life. He recently wrote a column about how he uses exercise to manage his pain.

Fred is the former Director of Health for the NYC Public Schools. He taught at New York University and is the author of "What Your Child Needs to Know About Sex (and When): A Straight Talking Guide for Parents." Fred enjoys exercising, perennial gardens, and fishing.

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.

Finding the Right Strain of Medical Marijuana

By Ellen Lenox Smith, Columnist

As a medical marijuana patient and caregiver since 2007, I would like to share some thoughts and observations about a recent survey by Care by Design, a medical cannabis company based in California.

They surveyed 621 patients who had been using medical marijuana for over 30 days, asking them about:

1. The conditions for which they are taking cannabidiol (CBD) rich cannabis

2.  The ratio of CBD-to-THC (tetrahydrocannabinol) they are using

3. The impact of CBD-rich cannabis therapy on their pain, discomfort, energy, mood, and overall well being

I would like to address three areas about the survey findings, based on my personal use of medical cannabis and the patients we assist as caregivers.

“Patients with psychiatric or mood disorders and patients with diseases of or injuries to the CNS (central nervous system) system favor CBD-dominant cannabis therapies,” the survey found. “Patients with pain and inflammation favor CBD-rich cannabis therapies with more equal levels of CBD and THC.”

I have to agree with this personally and also through observation of the people we have helped find their correct medical marijuana strain. I now sleep better at night using a night oil made with a high CBD ratio. I found that when I used another strain that has a higher THC ratio, I experienced some strange head sensations that I did not enjoy. But when I use the higher CBD mix, I do not experience those odd sensations and can safely get out of bed without concerns.  

One patient, who has numerous medical issues including depression and post-traumatic stress disorder (PTSD), has found she does well mixing a day sativa plant with the highest CBD plant we have (24% CBD/1% THC) called ACDC. She uses this mixture both day and night and finds it addresses her levels of pain more effectively. Just using the high CBD strain does not address her pain.

Another patient, a scientist, was just thrilled switching to the new high CBD plants we grow. He has found that his mood is calmer and his PTSD is under control. He is a thriving, productive worker again with no negative side effects

I correspond with many people online and one person who uses legally pure CBD found that it did address her pain. Many will not be that successful with just pure CBD and most need some THC to address pain.

The Care by Design report also states that “THC matters. A higher ratio of CBD to THC does not result in better therapeutic outcomes. Patients using the 4:1 CBD-to-THC were the most likely to report a reduction in pain or discomfort, and improvements in mood and energy.

“Patients using the 2:1 CBD-to-THC ratio reported the greatest improvement in overall wellbeing. This finding is consistent with scientific research indicating that CBD and THC interact synergistically to enhance one another’s therapeutic effect.”

I have to totally agree with the above statement. Most will not be lucky and find success without some THC in their medicine.

People tend to have a negative attitude towards THC because it makes them high and think medical marijuana strains work better without THC or lower ratios of it. But we have not had one patient that just uses the highest CBD plant alone. They appreciate the fewer “head issues” that come from reduced THC, but quickly find that their medical problems are not being addressed successfully until they use a mixture with more THC.

Finally, they survey report states that, “CBD-rich cannabis’ does not appear to have a significant impact on energy levels (as compared to pain, discomfort or mood).”

I am living proof of that, as are all the patients we have worked with using medical marijuana. When I need a boost on a tough pain afternoon, I find vaporizing or using tincture from the high CBD plant does not provide an increase in energy. However, when I use the 2:1 ratio that includes more THC, I not only get pain relief but also increased energy and interest in being involved with life again.

As the study found and we have found, you still have to experiment with dosage and ratios to find the correct type of medication strain to successfully alleviate your issues.

Using medical marijuana will never be like it is going to the pharmacy. One pill does not fit all and one strain does not fit all. No single ratio is right for all people, even when dealing with the same conditions.

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

For more information about medical marijuana or to contact the Smith's, visit their website.

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

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

Don’t Blame CDC for Poor Pain Care

By David Becker, Guest Columnist

Doctors have been undertreating and mistreating people in pain long before the Centers for Disease Control and Prevention (CDC) started recommending guidelines for opioids. Doctors have been doing such since at least the 1970’s.

The CDC doesn't tell doctors to provide half the pain care to blacks and Latinos that white folks obtain -- they do that all by themselves.

The CDC doesn't tell doctors to misdiagnose migraines, interstitial cystitis, RSD, fibromyalgia, and Lyme disease -- doctors do that all by themselves.

The CDC doesn’t tell doctors to tell elderly people that they should be in pain or that children’s pain is inconsequential -- they do that all by themselves.

The CDC doesn't tell pain specialists to ignore marijuana or triptolides or triterpenes or deoxy glucose or intrathecal hydrogen or stem cell therapy for pain -- doctors do that all by themselves.

Doctors were sold on the idea of using opioids for pain because pain specialists were connected to opioid manufacturers, as Sen. Grassley’s Finance Committee ascertained.

What they could have and should have done is require all doctors to have adequate education in pain care and make the best use of all pain treatments for people in pain. Doctors were so averse to having education in pain care that even after the FDA required drug manufacturers to provide free education on opioids, less than 20% of doctors obtained such.

Once doctors have complete education in pain care, then they can be held to a higher standard, and obviously they are opposed to such. Even the pain specialty organizations that allegedly care so much about pain patients didn't support legislation in New York state requiring doctors to have education in pain care.

Poor pain care in any nation is not merely a function of providing opioids or not. That is the reductionist thinking medicine and pharmaceutical companies have promoted. And how often do you see those same organizations promote the use of marijuana or the full use of all resources to treat pain? How often do they even mention stem cell therapies or stacked therapies or treat to target?

The CDC is essentially no different than the FDA, National Institutes of Health or pain specialty organizations -- or the 80 so-called experts that created the National Pain Strategy to essentially promote a simplistic one-size fits all approach. They care little for the input or needs of individuals in pain.

Until individuals in pain have more rights and a greater say over their care, doctors, pain specialists and the CDC will continue to impose their visionless plans on the public and patients.

Too many individuals in pain remain stuck in a Kafkaesque theater of the absurd pain care system with big brother calling the shots. Frankly, to accuse the CDC of being the bad guy misses the fact that too many other organizations in the health care system and in government have done a poor job of caring for individuals in pain.

Without the CDC or with the CDC, pain care will remain poor until real reforms are made in the whole pain care system.

David Becker is a social worker, patient advocate and political activist in New York.

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.

Purdue Settles OxyContin Lawsuit for $24 Million

By Pat Anson, Editor

Purdue Pharma has agreed to pay the state of Kentucky $24 million for misleading consumers about the risks of addiction to OxyContin. The settlement is the latest chapter in Purdue’s seemingly endless string of lawsuits over its popular and potent painkiller.

“Purdue Pharma created havoc in Kentucky, and I am glad it will be held accountable,” said Kentucky Attorney General Jack Conway. “Purdue lit a fire of addiction with OxyContin that spread across this state, and Kentucky is still reeling from its effects.”

Purdue did not admit to any wrongdoing in the settlement.

OxyContin was introduced in 1996 and soon became a blockbuster drug for Purdue, reportedly generating profits in excess of $10 billion. Many critics believe the drug also helped trigger an “epidemic” of opioid addiction and overdoses, causing the deaths of thousands of people nationwide.

Kentucky filed suit against Purdue in 2007 after company executives pleaded guilty in Virginia federal court to a felony count of falsely marketing OxyContin. Company sales representatives were encouraged to tell doctors the pain medication wasn’t additive and was less likely to be abused.

Purdue settled that case for $634 million and offered $500,000 to Kentucky, which the state refused.

This week’s $24 million settlement is over 50 times what Kentucky was originally offered. The money will be used to fund addiction treatment programs in Kentucky.

Purdue is still fighting a similar OxyContin lawsuit in Chicago. Another case in California was dismissed over the summer.

The original version of OxyContin could be easily crushed and liquefied by addicts to inject or snort for a quick high. OxyContin is now sold in an abuse deterrent formula that is harder to abuse.

“We are pleased to resolve this matter that arose from alleged conduct dating before July 2001, and long before we reformulated OxyContin to include abuse-deterrent properties.  This enables Purdue to focus on bringing additional innovative abuse-deterrent medicines to patients,” stated Philip C. Strassburger, Purdue Pharma’s General Counsel.

The reformulation hasn’t stopped the abuse of OxyContin. According to a large nationwide survey of nearly 11,000 opioid addicts who entered a treatment facility in 2012, over a quarter had used OxyContin at least once to get high in the previous 30 days.

Nearly 1,100 people died of overdoses in Kentucky last year, giving the state the dubious distinction of having the 4th highest overdose rate in the country. Many of those deaths are blamed on heroin, as well as prescription opioids.

Purdue as recently as this year was still trying to rein in aggressive marketing by its sales staff. In August, Purdue reached a settlement with New York’s Attorney General, admitting that its sales representatives contacted doctors in New York who were on a “No Call List.” The doctors had been red flagged by the company for possible abuse and diversion of opioids.

Purdue’s sales representatives, who amazingly were not required to check the company's No Call List, made over 1,800 sales calls to doctors on the list, even buying meals for about a third of them.  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 Purdue 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