China Agrees to Crackdown on Fentanyl

By Pat Anson, Editor

China is finally taking steps to stop the production of illicit fentanyl, a synthetic opioid blamed for thousands of drug overdoses in the U.S. and Canada.

China’s National Narcotics Control Commission announced this week that it is “scheduling controls” against four fentanyl-class substances – carfentanil, furanyl fentanyl, valeryl fentanyl, and acryl fentanyl, starting on March 1, 2017.  The announcement came after several months of talks between the Chinese government and the U.S. Drug Enforcement Administration.

"Fentanyl-related compounds represent a significant and deadly component of the current opioid crisis.  These actions will undoubtedly save American lives and I would like to thank my Chinese counterparts for their actions on this important issue," said Acting DEA Administrator Chuck Rosenberg in a news release.

"It shows China's attitude as a responsible big country," Yu Haibin, the director of the Office of the National Narcotics Control Committee, told the Associated Press. "It will be a strong deterrent."

DEA officials say China’s move is a potential “game-changer” in the opioid epidemic, because it will close a loophole that allowed Chinese laboratories to manufacture fentanyl and its chemical cousins legally.

DEA PHOTO

The substances were then shipped to Mexico before being smuggled into the U.S. and Canada, where they were often mixed with heroin or used in the manufacture of counterfeit oxycodone and other painkillers. Traffickers also purchased pill presses from China, according to the DEA.

COUNTERFEIT OXYCODONE

“The counterfeit pills often closely resemble the authentic medications they were designed to mimic, and the presence of fentanyls is only detected upon laboratory analysis,” the DEA warned in a report last summer.

Fentanyl is up to 100 times more potent than morphine. It is legally prescribed in lozenges and patches to treat severe pain. Carfentanil is so potent it is used by veterinarians as an anesthetic on elephants.

Illicit fentanyl is mixed with heroin to increase its potency, but dealers and buyers may not know exactly what they are selling or ingesting. Massachusetts, Rhode Island, Ohio and other states have reported an “alarming surge” in fentanyl related deaths. In some states, the number of deaths from illicit fentanyl now exceeds those from prescription opioids.

Two public health researchers have speculated that a “malicious actor” could be behind some of those deaths.

“These highly potent pills could have been created by a malicious actor to intentionally poison consumers or attract the attention of law enforcement to redistributors,” wrote Traci Green, PhD, Boston University School of Medicine, and Michael Gilbert, MPH, Epidemico Inc., in a research letter published in JAMA Internal Medicine.

Waiting for My Pain Medication to Be Stripped Away

By Sheryl Donnell, Guest Columnist

Up until recently, I thought I was coming through this opioid crisis unscathed. My pain management doctor has been with a top clinic for many years and is highly respected and generally above reproach.

We did not have that dreaded conversation virtually everyone else with chronic pain I know has had -- until September 13th, 2016.

That night, I fell and broke 5 bones in my foot, which was already affected with Chronic Regional Pain Syndrome (CRPS). The pain was so incredibly severe.

I laid on the floor from 2 am to 10 am before I could stay alert enough, and not pass out from shock and pain, to get to a phone to call my husband upstairs for help (he is deaf in one ear). It took 4 paramedics to get me off the floor and into an ambulance.

Once at the hospital, even though I was writhing in agony and still passing out literally from pain, the doctor never examined me or my foot. She didn't care I had been on an ice cold floor for 6 hours. All she heard was "chronic pain patient" and she was done with me.

SHERYL DONNELL

I begged her to call the pain experts my doctor worked with so she could get some guidelines for treating me, but she didn't see a reason. I asked if she was familiar with CRPS, and she proudly said no and it didn't matter. She sent me for x-rays. No sooner did I get back in my room from another horrifyingly painful experience did she announce nothing was broken and to go home.

I sat there stunned. I had heard the bones break. I knew there were fractures. I begged the nurses to do something. I had not even been given a single Tylenol. This doctor firmly believed I was a drug seeker and wanted to bounce me.

The nurse started reading my discharge papers, which said, "Come back if you have any of these symptoms." I started crying harder. I said I have every one of those right now! She was practically in tears herself.

Then my husband asked, “What will he do when we get home? We can't even get her into the house!” The nurse told him to call the paramedics again to help get me back inside my home, which we did.

My husband called in 24-hour care workers to help me so I could manage a bit. It was agony going to the bathroom, even with a bedside commode my mother brought.

The following morning, the paramedics came back and helped me into the car. We went downtown for a pain injection to try to stop a progression of my CRPS. While there I insisted on new x-rays, which my pain doctor of 9 years grudgingly agreed to -- mostly to shut me up. He said come back in a week for another shot.

I asked for an increase in my pain medication. My biggest shock that day was his response. He said there was no reason for an increase! What? We went home to 24-hour care and instructions to start weight bearing exercises asap!

A full week later with not a single call, we returned to my pain management doctor for my second injection. He casually mentioned the results of my x-rays, which showed that I had 5 broken bones in my foot. No call for an entire week. I was left to think I was nuts and was trying to bear weight on a severely fractured foot!

I was not offered, nor were my requests for additional pain medication granted. I was told to come in every week for four more weeks (in great agony and great difficulty) for pain injections which did very little. However, I did not have a spread of my CRPS.

I did lose about 8 weeks of my life again. My pain levels were so extreme I did nothing but sit in my recliner and do a lot of crying. And realize how lucky I was to have family support, the ability to pay for 24-hour caregivers, and to be believed I was in the kind of pain I said I was in. My adult daughter moved home for a month to help me and my husband with caregiving duties.

What do other people do?

Even after my 6 weeks of pain injections, when I requested a short term increase in pain medication to help me rehab my still very painful foot once I was cleared by my orthopedist, I was again turned down by my pain management doctor.

It is now 5 months after I broke my foot and I cannot complete my rehabilitation because my pain is still so intense. I know if this had happened 5 years ago, I would not be suffering like this.

Even though my pain has worsened and I need to rehabilitate my injury, the CDC has arbitrarily changed the rules and I must suffer. My doctor's hands are tied.

I lose more and more days spent doing things I enjoy or need to do because the CDC’s “experts” sat in a room and made decisions based on flawed data and street drugs; not real patients who follow the rules of their pain contracts and don't seek out multiple doctors or illegal methods to get medication. I follow all the rules, just like 99.5% of my peers.

We are suffering and living in fear that we will be next to have our medication stripped away from us, through no fault of our own. And then the real terror begins.

Sheryl Donnell lives in Illinois. She suffers from CRPS and fibromyalgia.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

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

Magnetic Implant Could Someday Deliver Medication

By Pat Anson, Editor

Over the years scientists have developed a variety of drug delivery systems designed to help patients take medications more safely – from pumps to implants to pills made with abuse-deterrent formulas.

Researchers at the University of British Columbia have now developed one of the strangest ones yet -- a magnetic drug implant -- that could offer an alternative for pain patients who don’t like pills or injections and fear the idea of having a pain pump installed.

“This could one day be used for administering painkillers, hormones, chemotherapy drugs and other treatments for a wide range of health conditions. In the next few years we hope to be able to test it for long-term use and for viability in living models,” said Mu Chiao, PhD, a professor of mechanical engineering at UBC.

COURTESY UBC

The magnetic device – a silicone sponge with magnetic carbonyl iron particles wrapped in a polymer layer – is just six millimetres (about a quarter of an inch) in diameter. The drug is injected into the device and then surgically implanted in the area being treated.

Researchers tested the device on animal tissue in the lab using the prostate cancer drug docetaxel. They found that it was able to deliver the drug on demand even after repeated use. The drug also produced an effect on cancer cells comparable to that of freshly administered docetaxel, proving that drugs stored in the device remain effective.

Passing a magnet over the patient’s skin activates the device by deforming the sponge and triggering the release of the drug into surrounding tissue.

The University of British Columbia released this short video to show how it works:

“Drug implants can be safe and effective for treating many conditions, and magnetically controlled implants are particularly interesting because you can adjust the dose after implantation by using different magnet strengths. Many other implants lack that feature,” said Ali Shademani, a PhD student in the biomedical engineering program at UBC, who was lead author of a study published in the journal Advanced Functional Materials.

Implants such as Probuphine – which was approved last year by the Food and Drug Administration to treat opioid addiction -- cannot be adjusted to deliver different medication levels once they are implanted.

The UBC researchers say actively controlling drug delivery is important not only for treating pain, but for conditions like diabetes, where the required dose and timing of insulin varies from patient to patient.

“This device lets you release the actual dose that the patient needs when they need it, and it’s sufficiently easy to use that patients could administer their own medication one day without having to go to a hospital,” said co-author John Jackson, a research scientist in UBC’s faculty of pharmaceutical sciences.

An Epidemic of Fake Opioid News

By Roger Chriss, Guest Columnist

The New England Journal of Medicine recently published a study called “Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use.” It looked retrospectively at Medicare patients and found that some emergency room physicians prescribed up to three times more opioids than others did.

The article did not even mention words such as “abuse” or “addiction” in any context. Moreover, the data was for the period between 2008 and 2011, long before the 2016 CDC opioid guidelines or the various efforts by the FDA, DEA and state governments to restrict opioid prescribing.

The result of this study has been a surprising explosion of fake news about the opioid crisis. It is almost ironic that the spread of this news looks more like an epidemic than the actual opioid crisis does.

The New York Times published the article "Long-Term Opioid Use Could Depend on the Doctor Who First Prescribed It” on February 15, marking the first step in the outbreak of this new opioid meme.

The article noted that the study looked at elderly people in the opening paragraph, but did not mention the decline in opioid prescribing between the study period and the present.

Moreover, the article stated that "as the opioid epidemic continues to devastate communities around the country, the study was the latest attempt to identify a starting point on the path to excessive use.” This was stated despite the fact that all the study showed is that people who take opioids are more likely to become dependent or addicted to them. Clearly this result is both axiomatic and not a priori interesting.

A day later there were more articles, such as “Physicians’ opioid prescribing patterns linked to patients’ risk for long-term drug use” from the Harvard School of Public Health and “How Long You Stay On Opioids May Depend On The Doctor You See In the E.R.” from the Kaiser Family Foundation.  

Both articles add more drama to the study’s results, though each does mention that the study was done on Medicare patients. Oddly, the Harvard article waited until almost the very end to tell us that, as if this is an incidental point with respect to the study and its results.

On February 16, the fake news took a turn toward the dramatic and dire. The Chicago Tribune came up with an article called "Your ER doctor could determine your likelihood of long-term opioid use."  We are told that "physicians are often reluctant to change treatment regimens when patients are happy with what they have,” as an explanation for why doctors were resisting not prescribing opioids.

Vox took the fake news to a whole new level with an article called "Certain doctors are more likely to create opioid addicts. Understanding why is key to solving the crisis."  The Vox reporter provides a quote from the lead author of the study:

“'For patients, Barnett said the message is clear: “Patients should ask their physicians, ‘What are the side effects of me taking this opioid and do you think my pain could be treated effectively [another way], because I know how dangerous these medicines can be."

Opioids have now become dangerous medications.

Now imagine that the first headline from The New York Times had said “Medicare Patients Receive Different Amounts of Pain Medication depending on ER Physician.” That would be a fair a description of what was reported in the original NEJM article.

And consider this alternate interpretation of The Chicago Tribune quote about happy patients: These patients are elderly, at low-risk of addiction, and being treated successfully with a well-known medication. This is not something to worry about, especially since the opioid crisis is being driven by illicit substances used primarily by younger people and outside of medical settings.

Forgotten in all of this reporting is the data from the CDC and other government agencies, which clearly shows that opioid prescribing is down considerably compared to just a few years ago, while at the same time the number of overdoses and deaths involving opioids used illicitly has risen.

The data also shows that most people who abuse opioids are young, not elderly. In other words, physician prescribing is not a major driver in the opioid crisis and Medicare patients are not representative of substance abusers at all.

In a matter of days, an article in a respected medical journal describing a retrospective study of the Medicare population has morphed into some doctors being more likely than others to create opioid addicts and unlucky patients are getting hooked.

This is an epidemic spread of fake news, of a dangerous meme, and of a new challenge for chronic and intractable pain patients. Accurate information is the best defense, but that takes work.

Roger Chriss suffers from Ehlers Danlos syndrome. Roger is from Washington state, where he works as a technical consultant who specializes in mathematics and research.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

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

The 411 on Calmare Scrambler Therapy

By Michael Cooney, DC, Guest Columnist

As a chiropractor who treats various pain conditions caused by injury or disease, my biggest frustration is when our therapies do not achieve a successful patient outcome.

Often, “treatment-resistant” patients are forced to seek out more invasive procedures – surgeries, spinal cord stimulators, or powerful narcotics such as ketamine − where success has been uneven, but side effects can be significant.

I wasn’t comfortable recommending these “next level” neuropathic pain treatments for my patients. So my partner Dr. Robert Kelly and I spent two years looking for a non-invasive therapy that didn’t cause pain or come with added side effects.

Through a contact in Italy, we discovered Calmare scrambler therapy, which treats several types of drug and treatment-resistant pain, a big plus for our practice. After undergoing clinical training to use the machine and eventually testing it on patients, we saw results after just a few treatment sessions, in the majority of cases.

I’ll be honest, our aim in adding Calmare to our treatment offerings was designed to help our patients who were not responding to traditional pain therapies. No one was more surprised than I to experience the global interest in this alternative treatment option.

We have been performing Calmare Therapy since 2011, treating patients from coast-to-coast and as far away as Australia, the UK, South Africa and Brazil.

Today, we treat children, adults and seniors battling CRPS/RSD, fibromyalgia, neuropathy after chemotherapy treatment, and pain that develops after surgery or from diabetes. We have also treated many people with neuropathic pain after a shingles diagnosis.

How Scrambler Therapy “Talks” With the Brain

The brain’s reaction to pain can be compared to learning to play the piano or memorizing a poem. The more the body processes pain, the stronger the connections between pain nerves and the brain become.

When someone is injured, the brain sets up a process to heal the injury. For example, cells carry away dead tissue or it increases blood flow to the injured area. Eventually, the brain realizes the injury has healed, and cuts off the pain message.

But for some people, the brain never sends the all-important message: “There’s no more injury here. You can stop sending that pain signal.”

That’s where Calmare scrambler therapy comes in.

Using small electrodes (think EKG pads) judiciously placed in the region of the injury, the device sends a mild electric signal to the brain through the electrodes.

This message overrides the brain’s confused pain signal and corrects it to a “there’s no pain here” message.

We recommend a series of 10 daily scrambler treatments. But in many cases, the pain is lessened for the patient as soon as the first treatment.

The machine we use, the MC-5A Calmare device, has been tested in clinical trials at some of the most prestigious research institutions, including the Massey Cancer Institute at Virginia Commonwealth University, the Mayo Clinic, and the American Society of Clinical Oncology. Their studies reported significant reductions in pain associated with cancer treatment and other chronic pain conditions.

The Value of Alternative Medicine in Treating Neuropathy

The majority of patients we treat with scrambler therapy come to us frustrated and exhausted by the endless search for pain relief. They have often resorted to unproven surgeries, experimental procedures, or have used powerful pain medications that leave them mentally and physically debilitated by the drug’s side effects.

I encourage people with treatment-resistant neuropathy and their families to research and consider less invasive, alternative solutions to combat the effects of chronic pain. In some cases, the cost can be comparable to prescription medications and in-patient co-pays. The outcome can be life-changing.

Regardless of the pain therapy you choose, keep in mind there are treatments that do not involve narcotics, surgery or invasive procedures, which can result in more pain and discomfort.

Keep looking -- network with people who have your medical condition, conduct your own research, and reach out to doctors who understand the value of alternative therapy. Ask the provider to put you in touch with another patient who had the treatment. We enthusiastically offer this service through our Patient-2-Patient program.

There may very well be a solution out there to minimize your pain. But often, it’s up to you to discover it.

Michael J. Cooney has been a doctor of chiropractic for more than 30 years at Rutherford Allied Medical Group and Calmare Therapy NJ in Rutherford, New Jersey. He is one of six certified providers of Calmare in the U.S. Dr. Cooney can be emailed at calmarenj@gmail.com.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

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

How Have the CDC Opioid Guidelines Affected You?

By Pat Anson, Editor

Next month will mark the one year anniversary of opioid guidelines released by the Centers for Disease Control and Prevention – guidelines that discourage primary care physicians from prescribing opioids for chronic non-cancer pain.

At the time of their release, the CDC estimated that as many as 11.5 million Americans were using opioid medication daily for pain relief. Many of those patients now say their doses have been abruptly lowered or they are unable to obtain opioids at all.

That could be a good thing, depending on your point of view about the nation’s so-called “opioid epidemic.” Former CDC director Thomas Frieden, MD, has called the guidelines an “excellent starting point” to stop an epidemic fueled by “decades of prescribing too many opioids for too many conditions where they provide minimal benefit.”

Many pain patients disagree, saying they’ve used opioids safely and effectively for years. They say the guidelines have had a chilling effect on many of their doctors and are being implemented in ways that go far beyond what the CDC intended.  

“Last year, when the CDC ‘recommendations’ came out, the entire building of the only doctor's office I can go to decided they were rules, and cut me from 210 mg/day morphine to 90 mg. Now they say they can only give me 60 mg/day,” wrote Eli, one of hundreds of patients we’ve heard from in the past year.

“I'm in so much pain I can't properly care for myself, nor get to town for supplies when I need them. I've become increasingly more disabled and dependent on others.”

“My pain management doctor told me that the CDC required that all morphine be taken away from all Americans,” wrote a California woman who suffers from severe back pain. “He even stated that surgeons were sending home their post-surgery patients with Motrin, nothing else.

“What are you people in the CDC doing? Don't you realize how paranoid doctors can get? You may think using the term ‘guideline’ will help them understand what you are trying to do, but you have created a bunch of neurotic paranoids. Stop it. Do something before you kill all of us.”

“I am a 76 year old intelligent woman who is not an addict or an abuser, yet I am denied relief from unremitting pain even after 20 years of trying every drug and treatment modality available,” wrote Roberta Glick. “I am at a total loss as to what to do, how to fight, etc.  My physician is a strong supporter.  He is not the problem. He also is a victim of misguided CDC attempts to curb drug addiction.”

Are the CDC guidelines voluntary or mandatory? Have they improved the quality of pain care? Are patients being treated with safer and better alternatives? Most importantly, are soaring rates of opioid abuse and addiction finally being brought under control?

Those are some of the questions Pain News Network and the International Pain Foundation (iPain) are asking in an online survey of patients, doctors and other healthcare providers.

“I strongly believe that as these guidelines are implemented by doctors and hospitals around the country there are important lessons to learn from those who are affected by them,” says Barby Ingle, president of iPain and a PNN columnist.

“I hope that pain patients and providers participate in this survey so that we can begin to show how deep the impact actually is to the chronic pain community one year later.” 

The online survey consists of less than a dozen multiple choice questions, which should take only a few minutes to complete. Please take time out of your busy day and complete the survey by clicking here.

The survey findings will be released on March 15th, the first anniversary of the CDC guidelines. By taking the survey, you can also sign up to have the results emailed to you.

A Deadly Mix: Opioids and Alcohol

By Pat Anson, Editor

Taking one oxycodone tablet together with alcohol significantly raises the risk of respiratory depression and possible death, according to a new study by Dutch researchers. Elderly people were more likely to experience this complication, researchers found.

The study, published in the journal Anesthesiology, is one of the first to address the effect of alcohol and opioids on respiratory depression, which causes breathing to become extremely shallow or stop altogether.

"Unfortunately, we're seeing more fatalities and people in emergency rooms after having misused or abused legally prescribed opioids, like oxycodone, while having consumed alcohol," said lead author Albert Dahan, MD, a professor of anesthesiology at Leiden University Medical Center in the Netherlands.

"Respiratory depression is a potentially fatal complication of opioid use. We found alcohol exacerbated the already harmful respiratory effects of opioids."

Dahan and his colleagues studied the effects of oxycodone and alcohol on breathing in 12 healthy young volunteers (ages 21 to 28) and 12 elderly volunteers (ages 66 to 77). On three separate occasions, the volunteers were given one 20 mg oxycodone tablet combined with an intravenous infusion of ethanol (alcohol).

The amount of alcohol was increased until blood-alcohol levels reached 0.5 g/L on the second visit and 1.0 g/L on the third visit, as measured through the volunteers' breath. A man would need to consume about 5 alcoholic drinks to reach the latter level.

Taken alone, one oxycodone tablet reduced respiratory ventilation – the amount of air the volunteers breathed per minute -- by 28 percent. Adding 1.0 g/L of alcohol caused ventilation to further decrease by another 19 percent - a total decrease of 47 percent.

The combination of alcohol and oxycodone also caused a significant increase in the number of times volunteers temporarily stopped breathing. This was especially true in the elderly volunteers, who were more likely to experience repeated episodes where they temporarily stopped breathing.

"We hope to increase awareness regarding the dangers of prescription opioids, the increased danger of the simultaneous use of opioids and alcohol, and that elderly people are at an even greater increased risk of this potentially life-threatening side effect," said Dahan. "Ultimately, people should know that it is never a good idea to drink alcohol with opioids."

Although warning labels for oxycodone and other opioids caution against using them with alcohol, it’s common for the two to be mixed. A recent study by the Centers for Disease Control and Prevention found that alcohol was involved in about 15 percent of drug overdoses, including deaths associated with oxycodone, hydrocodone, morphine and fentanyl. 

New Guidelines Offer Little Relief for Back Pain

By Pat Anson, Editor

“Take two aspirin and call me in the morning” doesn’t cut it anymore for low back pain. In fact, very little does.

One in four adults will experience low back pain in the next three months, making it one of the most common reasons for Americans to visit a doctor. But when it comes to treating low back pain, the American College of Physicians (ACP) says the evidence is weak for many pharmaceutical and non-drug therapies.

In fact, the best treatment for acute low back pain may be none at all.

"Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment," said Nitin Damle, MD, president of ACP. "Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients."

An ACP review committee analyzed dozens of clinical studies to arrive at new guidelines for treating acute back pain (pain lasting less than 4 weeks), subacute back pain (pain lasting 4 to 12 weeks) and chronic back pain (pain lasting more than 12 weeks).  

The ACP recommends that doctors start with non-drug therapies, such as exercise and superficial heat with a heating pad, along with massage, acupuncture, spinal manipulation (chiropractic), tai chi, and yoga. The evidence for the effectiveness of exercise and superficial heat was considered moderate, while the evidence for the other non-drug treatments was considered low quality.

Only when non-drug treatments have failed does the ACP recommend medication for chronic low back pain, starting with non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin. Tramadol (a mild acting opioid) and duloxetine (Cymbalta) are recommended as second line therapies. The ACP says physicians should only consider stronger opioids as a third line therapy when all other treatments have failed.

The evidence for the effectiveness of NSAIDs and opioids was classified as moderate, while the evidence for acetaminophen, benzodiazepines and systemic steroids was considered low-quality.

"For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another," Damle said.

The ACP guidelines say surprisingly little about the documented risks associated with NSAIDs, such as cardiovascular and gastrointestinal problems. The guidelines refer only vaguely to “moderate quality evidence” that NSAIDs have “adverse effects.”

Short-term use of opioids for low back pain was linked to increased nausea, dizziness, constipation, vomiting, somnolence and dry mouth. Interestingly, addiction and overdose were not listed as potential risks because they were not studied.

“Studies assessing opioids for the treatment of chronic low back pain did not address the risk for addiction, abuse, or overdose, although observational studies have shown a dose-dependent relationship between opioid use for chronic pain and serious harms,” the guideline states.

The ACP guidelines were released one week after Australian researchers released their own evaluation of NSAIDs in treating back pain. Their study found that NSAIDs reduced pain and disability somewhat better than a placebo, but the results were not statistically important (see “Ibuprofen No Better Than Placebo for Back Pain”).

The ACP calls itself the largest medical specialty organization in the United States. ACP members include 148,000 internal medicine physicians (internists), related sub-specialists and medical students.

The new guidelines are published in the Annals of Internal Medicine.

Four Years of Chronic Pain

By Crystal Lindell, Columnist

This month marks four years since I first woke up with random pain in my right ribs.

Sometimes it feels shorter than that. Sometimes, it feels so much longer.

I didn’t want to write this column. I didn’t want to acknowledge this anniversary.

I’ve been doing so much better lately. The pain, which is likely intercostal neuralgia, is way more under control than it used to be, thanks in large part, I believe, to getting my Vitamin D levels into the normal range.

But it lingers, it’s always there, like a black shadow and a heavy cinder block, pulling me back.

And after taking myself from 60 mg of opioids a day down to 5 mg, I decided this month to go back up a bit because the pain has been too much to bear. After talking with my doctor, we decided to go with 10 mg a day.

It feels like defeat.

I don’t know why the pain seems to be worse these days. It could be stress, it could be the weather, or it could just be because I wear Mac red lipstick almost daily now — it all really does feel that arbitrary.

And even though I try to manage all the possible triggers, sometimes it just flares up and leaves me unable to get out of bed. On those days, even the hydrocodone doesn’t touch it.

It’s frustrating. And I thought maybe if I didn’t write this column — if I just ignored the four-year mark — I could pretend I was actually all better.

I’m not though. Obviously, I’m not.

The pain still impacts so much of my daily life. I still factor in time to rest after a shower. I still make careful calculations about how much driving I can really do in a day before the pain gets too bad. And I still take lots of sick time from work.

I spend more time than I should counting hydrocodone pills and figuring out which bras hurt the least and avoiding hugs.

I do feel like I’m better than I was though. I’m completely off morphine, which feels like a victory. And most of the time, the pain is completely manageable with a very small dose of hydrocodone. Also, I’m lucky in that I can fake being well long enough that most of the time it doesn’t really impact how others see me. Most people have no idea I struggle with health issues unless I outright tell them.

It’s been a long four years. And I wouldn’t wish chronic pain on anyone. All of the good things — all of the ways I’ve learned to be more compassionate, all of the writing it has inspired, all of the bonds it helped me cement with family and friends who helped me out — I would give it all back if I could live without pain.

Alas, that is not my fate. This is my fate. A constant battle between living like a healthy person and feeling like a sick person. Medical bills. Driving two hours each way to see specialists. Sleeping only on my left side. This is my life. 

But at least I have my Mac red lipstick. Even the rib pain can’t take that away from me.

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.

Does Changing Your Diet Help With Fibromyalgia?

By Lana Barhum, Columnist

Having lived with fibromyalgia most of my adult life, I know my diet may worsen or improve my pain and other fibromyalgia symptoms. I am not alone in this belief, but the research disagrees. 

Most studies have not shown any specific evidence that fibromyalgia patients should avoid certain foods or add any to their diets to manage symptoms.  Nonetheless, it is still a good idea to take a look at how some foods influence how you feel.

MSG, Gluten and Vitamin D

At least 42% of fibromyalgia patients have reported worsening symptoms after eating certain foods, according to a study in Clinical Rheumatology.  Other studies on fibromyalgia and diet have focused on food additives, gluten, and vitamin D, and found some evidence that they may affect fibromyalgia pain.  

A 2012 study published in Clinical Experimental Rheumatology, assessed fibromyalgia and irritable bowel syndrome (IBS) patients who had excluded monosodium glutamate (MSG) and aspartame from their diets.  After four weeks, 84% of the study participants reported their symptoms had improved by about a third.  Adding MSG back into their diets resulted in a return of symptoms.

The researchers concluded that MSG did, in fact, have an adverse effect on some fibromyalgia patients and removing it from their diets was an easy solution.

"This novel research implicates glutamate as a major adverse excitotoxin in some FM (fibromyalgia) patients. Dietary manipulation is a relatively simple and low cost non-pharmacological intervention that warrants further exploration," reported lead author Kathleen  Holton, PhD.

But another study, published in Rheumatology International, found no relationship between MSG and fibromyalgia pain and symptoms.  The researchers reported no symptom improvement in the group that removed MSG and aspartame from their diets and the group that did not.

While there has been little specific evidence pointing to gluten as a fibromyalgia trigger, some research shows patients respond well when they avoid eating gluten.  Spanish researchers reported in Rheumatology International that fibromyalgia patients who removed gluten from their diets showed notable improvements in pain and symptoms.                                                           

There may also be a link between fibromyalgia pain and low levels of vitamin D, according to a 2014 study out of Austria. That research, reported in the journal Pain, found that study participants who took vitamin D supplements experienced less pain and morning fatigue.   

A 2015 report from the journal Pain and Therapy, also makes a case for a link between Vitamin D deficiency and pain. "Significant improvements in assessment of sleep, mood, pain levels, well-being, and various aspects of quality of life with vitamin D supplementation have been shown,” said researchers Elspeth and Edward Shipton.

More research is needed to further determine if diet and fibromyalgia are actually related.  But doctors do agree eating healthy foods can help patients to feel better and tweaking your diet may improve symptoms.

Making Diet Changes

Here are some ways to help you figure out which foods help and which ones hurt.

Keep a Food Journal.  Many people with fibromyalgia have food sensitivities, but specific “trigger” foods will vary from person to person.  A good way to identify which foods worsen fibromyalgia symptoms and pain is to keep a food journal.  If you find your symptoms consistently worsen after eating certain foods, try eliminating those foods from your diet and see if your symptoms improve.

Eat Healthy. It makes sense for everyone to eat healthy, not just people with fibromyalgia.  Eat a diet that is rich in fruits and vegetables, whole grains, and lean proteins. 

A balanced diet will also give you more energy and improve overall health.

Pick the Right Foods. There are certain foods that may help improve fibromyalgia symptoms and minimize flares.  Vitamin D is one, as studies show deficiency can cause joint and muscle pain.

Vitamin D is one, as studies show deficiency can cause joint and muscle pain. Foods rich in vitamin D include fatty fish (tuna and salmon), dairy products fortified with vitamin D (orange juice, milk, and cereal), beef liver, and egg yolks. Foods containing omega 3 fatty acids, which are found in fatty fish, walnuts and flax seed, may also ease fibromyalgia symptoms by reducing soreness and inflammation.  

My Take

I am strong believer in taking your health into your own hands and experimenting with alternative treatments, including a healthy diet.  Through trial and error, I have figured out which foods help and which foods hurt as I continue to learn how to successfully cope with fibromyalgia. 

Aspartame (Nutrasweet), food additives (especially MSG), sugar, fructose, simple carbohydrates, caffeine, gluten, fried and junk food, dairy and nightshades (tomatoes, peppers, and potatoes) are all foods that I have either eliminated or minimized from my diet.  Cutting them out of my diet has made fibromyalgia flares less frequent. 

In addition, I take vitamin D supplements, since my levels are often low, and eat foods rich in omega 3 fatty acids, such as fish, walnuts, and eggs, to manage inflammation, as I also suffer from rheumatoid arthritis.

While I don’t know for certain if my diet is the reason for fewer flare-ups, I do know that avoiding certain foods and eating healthy ones benefits my overall health.  And when my body feels healthier, I am better able to cope with fibromyalgia pain and symptoms.

The specific foods that help and hurt will be different for you, but a healthy diet can help you manage fibromyalgia symptoms and pain and improve your health overall.  And, it is definitely worth a try to find out. 

Lana Barhum is a freelance medical writer, patient advocate, legal assistant and mother. Having lived with rheumatoid arthritis and fibromyalgia since 2008, Lana uses her experiences to share expert advice on living successfully with chronic illness. She has written for several online health communities, including Alliance Health, Upwell, Mango Health, and The Mighty.

To learn more about Lana, visit 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 represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Should I Tell Someone About My Invisible Illness?

By Barby Ingle, Columnist

It can be tricky deciding when to tell someone about your chronic pain or invisible illness. You can never take back information once it is shared.

If you choose to disclose that you have a chronic condition or disability, you should decide when and how to do it. Take the time to think about different situations and how you wish to handle them.

Many people feel it is not their place to ask about your physical conditions, but knowing about your pain and limitations could help them understand where you are coming from with your thoughts and actions.

I know a chronic pain patient who liked a neighbor and was interested in dating him.  He often helped around her house with handyman projects, and she would see him out on his porch and go out and talk to him. Eventually, he asked her out and they had a great time.

Over the next few months, they had dates scheduled but she ended up canceling a lot of them. She was just in too much pain. He began to think she was not interested in him and started to pull away.

Friends encouraged her to tell him about her medical condition and what she was going through. She did, and he stuck around for a while, but in the end it did not work out. However, they remained friends and it helped her see that she could still have a social life.

If you’re in this or another social situation, you should think about the following when deciding whether to disclose your condition and how it affects you:

• Are you able to participate in activities using your coping skills and tools?
• Do you need accommodations?
• Are you able to perform the activity safely if you choose not to disclose?
• Do you think the other person will react in a way that’s appropriate for where you are?

If you are not sure about the latter, you may want to wait until you are in a private setting.

If the situation becomes an intimate relationship, it is very important to share even if it means losing that person. It is not fair to them or you to hold that information back.

If your disability is in remission or typically under control, is there a reason to disclose? It is possible that flare-ups may keep you from future activities, so it would be a good thing to disclose ahead of time. The education you give them may also help someone else they meet along the way.

Finally, how will you address misconceptions about your chronic condition when you disclose? Some people do not believe in treating pain with narcotic medications or had a bad experience with someone else in their life with chronic pain.   

Not disclosing is wrong if you are in a situation that can cause others harm. For instance, when getting on a plane, you shouldn’t be sitting in the exit row. If assigned by mistake, notify the flight crew.

When choosing situations and activities where you do not want to disclose your disability, take time to carefully analyze the activities you are able to do and plan accordingly. Remember, you can always reveal more information later as needed.

Sex, Poverty and Education Linked to Chronic Pain

By Pat Anson, Editor

If you are female, poor and never finished high school, you are much more likely to suffer from chronic pain than other Americans, according to a new study published in the journal Pain.

“Women, the less educated, and the less wealthy experience not only more pain, but also more severe pain, as well as greater disability, said Hanna Grol-Prokopczyk, an assistant professor of sociology at the University of Buffalo.

Grol-Prokopczyk studied over 12 years of data from nearly 20,000 Americans aged 51 and over, who participated in the national Health and Retirement Study from 1998 to 2010.

Her research uncovered some unexpected findings about chronic pain in the United States.

She found that the severity and frequency of pain is increasing in older adults. People who were in their 60’s in 2010 reported more pain than people who were in their 60’s in 1998.

“There are a lot of pressures right now to reduce opioid prescription,” says Grol-Prokopczyk. “In part, this study should be a reminder that many people are legitimately suffering from pain. Health care providers shouldn’t assume that someone who shows up in their office complaining of pain is just trying to get an opioid prescription.

“We have to remember that pain is a legitimate and widespread problem,” she added.

The study is among the first to measure chronic pain by degree. Participants were asked whether their pain was mild, moderate or severe, and if they were “often troubled with pain.” Participants were followed for over 12 years, as opposed to most studies that follow patients over a much shorter period.

“I found that people with lower levels of education and wealth don’t just have more pain, they also have more severe pain,” she says. “I also looked at pain-related disability, meaning that pain is interfering with the ability to do normal work or household activities.  And again, people with less wealth and education are more likely to experience this disability.”

About one out of every four people who didn’t finish high school said their pain was severe, while only 10 percent of those with college graduate degrees did so.

About 8 percent of African Americans and Hispanics said their pain was severe, compared to about 5 percent of whites.

“If you’re looking at all pain – mild, moderate and severe combined – you do see a difference across socioeconomic groups. And other studies have shown that.  But if you look at the most severe pain, which happens to be the pain most associated with disability and death, then the socioeconomically disadvantaged are much, much more likely to experience it,” said Grol-Prokopczyk.

More research needs to be done to understand why pain is so unequally distributed in the population, and Grol-Prokopczyk says it’s critical to keep the high burden of pain in mind as the nation grapples with an overdose epidemic.

“We don’t have particularly good treatments for chronic pain. If opioids are to some extent being taken off the table, it becomes even more important to find other ways of addressing this big public health problem,” she said. “If we as a society decide that opioid analgesics are often too high risk as a treatment for chronic pain, then we need to invest in other effective treatments for chronic pain, and/or figure out how to prevent it in the first place.”

How We Can Stop Medicare’s ‘Big Brother’ Opioid Policy

By Rick Martin, Guest Columnist

How many readers who leave comments on PNN are doing more than just commenting?

Change takes work if the pain community is going to stop the Centers for Medicare and Medicaid Services (CMS) from making the CDC’s opioid prescribing guidelines mandatory for millions of Medicare patients, including a ban on daily doses higher than 90 mg morphine equivalent (see “Medicare Planning to Adopt CDC Opioid Guidelines”).

We don’t need CMS and the insurance industry dictating what medication a physician can prescribe for pain or the appropriate amount of medication needed (see "Insurers Behind Medicare's 'Big Brother' Opioid Policy").

In my opinion, this is what needs to be done:

We have to start a chain letter.

I propose a form letter that everyone can copy and paste, forward, fax and mail to friends, family, caregivers, bloggers, Facebook, Twitter, and any other viable means of communication.  

You have to send it to at least 10 people. And ask them to send it to 10 people they know.

The letter also needs to be sent to patient advocacy groups like the U.S. Pain Foundation, American Chronic Pain Association, International Pain Foundation and the Alliance for Balanced Pain Management, a coalition of advocacy groups. They can post it in their newsletters and alert their members to what CMS is doing. This is the only way to reach a huge amount of people in a short amount of time. 

Here are their email addresses:

• U.S. Pain Foundation:  contact@uspainfoundation.org 
• American Chronic Pain Association:  acpa@theacpa.org 
• International Pain Foundation:  info@internationalpain.org 
• Alliance for Balanced Pain Management:  info@alliancebpm.org

We need to rein in CMS from dictating how we should live and the ability of our physicians to treat us. It won’t be easy. It took me 27 letters to the CDC to get a response from Dr. Debra Houry, who helped draft the agency’s guidelines.  

CMS is only accepting emailed public comments to their proposal until March 3, 2017. They will publish the final rules on April 3, so there is not much time. We must all act NOW.

Here is what I am emailing to CMS at this email address: AdvanceNotice2018@cms.hhs.gov

To Whom It May Concern:

I oppose the Centers for Medicare and Medicaid Services’ plan to align its policies with the CDC Guideline for Prescribing Opioids for Chronic Pain.

The CDC guideline is voluntary and gives physicians discretion in determining what is right for their patients. However, your policy as presently drafted will make the guidelines mandatory for all doctors, patients and pharmacists, and impose a ceiling on the highest dose of opioids that can be prescribed. That was never the CDC’s intent. 

On June 1, 2016, Dr. Debra Houry, Director of the CDC’s National Center for Injury Prevention
and Control, wrote the following:

“The Guideline is a set of voluntary recommendations intended to guide primary care providers as they work in consultation with their patients to address chronic pain. Specifically, the Guideline includes a recommendation to taper or reduce dosage only when patient harm outweighs patient benefit of opioid therapy. The Guideline is not a rule, regulation, or law. It is not intended to deny access to opioid pain medication as an option for pain management. It is not intended to take away physician discretion and decision-making.”

The following are additional quotes from the CDC Guideline itself:

"Clinicians should consider the circumstances and unique needs of each patient when providing
care.”

"Clinical decision making should be based on a relationship between the clinician and patient,
and an understanding of the patient's clinical situation, functioning, and life context."

"The Guideline provides recommendations for primary care providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life-care."

Your policy does not provide an exception for palliative care, only patients receiving cancer treatment or end-of-life care. In my opinion, that is a blatant omission.

The facts are also available showing there has been collusion between the insurance industry and CMS in drafting your new “Opioid Misuse Strategy.”

For all of these reasons and more, CMS should not adopt or align your agency’s policies with the CDC Guideline, as it is apparent you have misinterpreted them.

Sincerely,

Rick Martin

Feel free to copy my letter or make changes to express your own views. It also might be helpful to attach a copy of Dr. Houry’s letter in your email. If anyone wants a copy of her letter, click here to download it.

Time is running out if we want to put a stop to this.

Rick Martin is a retired pharmacist in Nevada who was disabled by chronic back pain.

Pain News Network invites other readers to share their opinions and stories with us.  Send them to:  editor@PainNewsNetwork.org. 

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

Ibuprofen No Better Than Placebo for Back Pain

By Pat Anson, Editor

When it comes to treating back pain, anti-inflammatory drugs such as ibuprofen work no better than a placebo, according to new Australian study.

Researchers at the University of Sydney conducted a meta-analysis (a study of studies) of 35 clinical trials involving over 6,000 people with back pain, and found that non-steroidal anti-inflammatory drugs (NSAIDs) provide little benefit. The study was published in the Annals of the Rheumatic Diseases.

“NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo,” wrote lead author Gustavo Machado, PhD, of The George Institute for Global Health. “There is an urgent need to develop new drug therapies for this condition.”

Back pain is the world’s leading cause of disability, with about 80 percent of adults experiencing back pain at some point in their lives.

Opioids are usually not prescribed for simple back pain, leaving patients little alternative but over-the-counter pain relievers such as NSAIDs, a class of drugs that includes both aspirin and ibuprofen. NSAIDs are known to raise the risk of gastrointestinal and cardiovascular problems.

The Australian study found that NSAIDs reduced pain and disability somewhat better than a placebo or dummy medication, but the results were not statistically important.

"NSAIDs do not provide a clinically important effect on spinal pain, and six patients must be treated with NSAIDs for one patient to achieve a clinically important benefit in the short-term," wrote Machado. “When this result is taken together with those from recent reviews on paracetamol (acetaminophen) and opioids, it is now clear that the three most widely used, and guideline-recommended medicines for spinal pain do not provide clinically important effects over placebo.”

The study did not evaluate non-pharmacological treatments for back pain, such as exercise, physical therapy or chiropractic care.

NSAIDs are widely used to treat everything from fever and headache to low back pain and arthritis. They are found in so many different products -- such as ibuprofen, Advil and Motrin -- that many consumers may not be aware how often they use NSAIDs. 

Misuse of Opioid Medication a Worldwide Problem

By Pat Anson, Editor

We hear often about the recreational or “non-medical” use of prescription drugs, particularly opioids, in the United States and Canada. But a new study published in the journal World Psychiatry suggests the abuse and misuse of opioids is a problem around the world.

Researchers at Columbia University's Mailman School of Public Health studied surveys of teenagers and young adults in Europe, Latin America, Asia, Middle East and the U.S.  They found that from 2000 to 2014, there was a 200 percent increase worldwide in overdose deaths due to opioids.

“Data on high school or university students from the Middle East or Arab world indicate that nonmedical use of prescription drugs warrants closer attention,” said lead author Silvia Martins, MD, associate professor of Epidemiology at Columbia University's Mailman School of Public Health.

“In Beirut, Lebanon, past-year nonmedical use of any prescription drugs was 21.6% among private university students and 10% among high school students. In both populations, prescription opioids were the drugs most commonly used nonmedically. In Saudi Arabia, a recent school-based survey showed a lifetime prevalence of 7.2% for the nonmedical use of any prescription drug.”

The growing misuse of opioid medication in some countries comes at a time when there is less misuse in the United States. A recent large survey found that 4.8% of American high school seniors had misused an opioid pain reliever in the past year, down from a peak of 9.5% in 2004. In the past five years, misuse of opioid pain medication by American 12th graders has declined by 45 percent.

Martins and her co-author say the availability of prescription opioids can vary widely from one country to another. Societal attitudes about medications and the misconception that they are “safe” can also contribute to misuse.

“The biggest challenge is balancing a country’s need to make available prescription drugs to those in need (i.e., those with chronic pain), while simultaneously curbing diversion and nonmedical use,” Martins wrote. “Another challenge is controlling the top most reported sources of supply, including parents, doctors and friends.”

A recent DEA report said the diversion of prescription opioids in the U.S. has fallen dramatically in the last few years, with less than one percent of legally prescribed opioids being diverted. The prescribing and abuse of opioid medication is also declining, along with the number of admissions to treatment centers for painkiller addiction. Despite these trends, which are rarely reported in the mass media, overdoses from heroin and other illegal opioids are soaring.

The DEA is planning to cut the supply of opioids even further in 2017, by reducing the supply of hydrocodone and other Schedule II opioids by 25 percent or more.