DEA Gives Final Approval to Synthetic Marijuana Drug

By Pat Anson, Editor

The U.S. Drug Enforcement Administration has approved a synthetic form of THC (tetrahydrocannabinol) – the active ingredient in marijuana that makes people “high” – as a Schedule II controlled substance. The move is the final regulatory hurdle for dronabinol (Syndros), an oral solution already being prescribed for the treatment of nausea and vomiting in chemotherapy patients, and as an appetite stimulant for AIDS patients.

Schedule II substances include oxycodone, hydrocodone and other drugs that have an accepted medical use, but a high abuse potential.  

The DEA announced the scheduling of dronabinol in a notice quietly published in the Federal Register the day before Thanksgiving. The agency adopted an interim rule classifying dronabinol as a Schedule II substance in March, and the Food and Drug Administration approved a new drug application for dronabinol in July, recommending that DEA make its rule final.

This week’s action was not unexpected, but is weirdly ironic on several levels.

The classification of dronabinal as a Schedule II substance means that a synthetic version of marijuana can be legally prescribed throughout the country, while real marijuana is still classified as a dangerous Schedule I substance and remains illegal under federal law – except in the 29 states and the District of Columbia where medical cannabis is legal.

Dronabinol is sold under the brand named Syndros by Insys Therapeutics, a controversial Arizona drug maker beset by allegations that another one of its products – a potent fentanyl spray called Subsys – is responsible for hundreds of overdose deaths.

The DEA has been aggressively going after doctors who prescribed Subsys and accepted speaking fees from Insys, and several company officials have been indicted on fraud, racketeering and kickback charges.

Snydros is similar to Marinol, another medication derived from marijuana that comes in pill form.

insys therapeutics photo

The DEA's action is also notable because it gives Insys the exclusive right to manufacture and sell its liquid formulation of dronabinol without having to worry about competition. Any other synthetic version not sold as Syndros will still be considered a Schedule I substance, on par with LSD, heroin and marijuana.

 “It should be noted as a preliminary matter that any form of dronabinol other than in an FDA-approved drug product remains a schedule I controlled substance, and those who handle such material remain subject to the regulatory controls, and administrative, civil, and criminal sanctions, applicable to schedule I controlled substances set forth in the CSA (Controlled Substance Act) and DEA regulations,” the DEA said.

According to Healthcare Bluebook, a one-month supply of Syndros will cost about $2,000 at major pharmacy chains. A "fair price" for Syndros is listed as $1,000.

Insys Thereapeutics drew the ire of marijuana advocates last year when it donated $500,000 to a campaign against the legalization of marijuana in Arizona.

The company is worried about the medical use of “natural cannabis,” but has petitioned the DEA to reschedule another synthetic cannabidiol (CBD) that is derived from marijuana from Schedule I to Schedule IV.

4 M’s That Can Help Lower Pain Levels

By Barby Ingle, Columnist

This month I am looking at the 4 M’s of pain management as part of my series on alternative pain treatments: magnets, massage, mindfulness and music.  

Once again, I know and understand that these therapies will not help everyone. And when they do offer some relief, it will be temporary and vary in nature. That’s no reason not to try them.

Mindfulness

I found mindfulness helpful and now use mindfulness techniques in my daily life to assist in pain management.

When I first started to look at mindfulness, I turned to Melissa Geraghty, PsyD, for input on the benefits and techniques. Dr. Geraghty serves on iPain’s medical advisory board and is a chronic pain patient herself.

“It’s human nature to pull away from pain, whether that pain is physical or emotional. We inherently try to avoid pain or distract ourselves from pain,” she told me.

“Maybe in the short term we feel avoiding or distracting ourselves helps, but this is not sustainable with chronic pain. The pain will always be there, so we can either continue to be stuck in the cycle of fighting it, or we can accept that we have chronic pain and figure out how to engage in our lives.”

Mindfulness is used to reduce stress, depression, anxiety and pain levels, and can also be used in drug addiction counseling. Clinical studies have documented both physical and mental health benefits of mindfulness for different medical conditions, as well as in healthy adults and children.

Mindfulness involves several meditation exercises designed to develop mindfulness skills. One method is to sit comfortably, close your eyes, and bring attention to either the sensations of breathing in one’s nostrils or to the movements of the abdomen when breathing in and out. When engaged in this practice, the mind will often run off to other thoughts and associations. When this happens, one passively notices that the mind has wandered, and in an accepting, non-judgmental way, you return to focus on breathing.

Other meditation exercises to develop mindfulness include body-scan meditation, where attention is directed at various areas of the body and body sensations. You can also focus on sounds, thoughts, feelings and actions that are going on around you. A mindfulness session is typically done in short periods of about 10 minutes. The more you practice, the easier it is to focus your attention and breathing.

I recently had a mindfulness session with a therapist as part of a documentary I was filming. I noticed that having someone guide me through a session, as opposed to doing it on my own, was very beneficial. I got to focus on positive thinking, letting go of negatives that happen in life, and living life in the now.

“Mindfulness practice allows people with chronic pain to participate in the moment instead of watching life pass you by. Life may not flow in the way you expected it to before chronic pain, but living in an endless cycle of psychological misery isn’t living at all,” says Dr. Geraghty.

Massage Therapy

Massage therapy is another treatment that I use. My husband and I purchased a massage table back in 2005 at the suggestion of my physical therapist. I can do exercises on it or have my husband give me massages as needed. This is especially good for migraines, headaches and overall blood flow in my body.

There is conflicting information on whether massage helps relieve pain and others symptoms associated with nerve pain diseases. Much of the scientific studies show beneficial short term effects, and I agree with them based on my own experiences.

Not only do I find massage therapy helpful with my pain levels, it also helps me relax and let go of stress. My massage therapist told me that even a single massage session has been shown to significantly lower heart rate, cortisol and insulin levels --- which  reduce stress.

Massage can also improve posture, which helps reinforce healthy movement. Other benefits of massage are better breathing and training the body how to relax. Clinical studies have shown that massage may be useful for chronic low-back pain, neck pain and osteoarthritis of the knee.

Magnet Therapy

Magnet therapy dates back at least 2,000 years, according to New York University Langone Medical Center. Healers in Europe and Asia used magnets to treat many different ailments, believing that the magnets can draw disease from the body.

Typically, therapeutic magnets are integrated into bracelets, rings, shoe inserts, clothing and even mattresses. Despite a lack of scientific evidence that magnet therapy works, an estimated $1 billion a year is spent on the sale of therapeutic magnets worldwide. Makers of these products claim they help increase blood flow to areas of the body where the magnet is worn, which brings in more oxygen and helps tissues heal faster. While larger studies have shown little to no therapeutic value in magnets, some smaller studies have found some benefit.

Pain patient Elizabeth Kandu is a believer in magnet therapy, although she’s not sure how it works.

“Who really knows if it’s a placebo effect or really works in everyone,” she says. “For me, without at least the metal to skin in 2 or 3 places, I am an electric nightmare.”

Elizabeth is right that there may be some placebo effect in play, but if magnets provide some relief they may be worth a try. It will be interesting to hear from PNN readers who have tried magnets and if any therapeutic value was found.

Music Therapy

I have been using music to excite my soul since childhood. I now also use it to address physical, emotional, cognitive and social needs that come with living in pain.

According to Warrior Music Foundation’s Michael Caimona, music provides sensory stimulation, stirs emotional responses, facilitates social interaction and communication, and provides diversion from inactivity.  Music also helps us get through sad times and helps us heal from bad times.

I’ve found music to be an effective tool in reducing pain levels and anxiety, and it helps stimulate the brain. I have even had surgeons put on music during my procedures. Although I cannot hear it consciously under anesthesia, I am able to hear it subconsciously and believe in the positivity of it. I also use music during infusion therapy and on moderate pain days.

Another study I found reported that children who listened to music while having an IV needle inserted into their arms showed less distress and felt less pain than the children who did not listen to music. Research also shows that music therapy helps patients become more engaged in their treatment and physical therapy.

There are two different forms of music therapy, active and receptive. The patient can actively create music with instruments or by singing. In receptive therapy, the patient is more relaxed and is listening or participating in other activates while the music is being played.

I hope that spotlighting these alternative pain treatments will help readers understand that there are many forms of therapy, and it’s up to each patient to find what works for them. Many times as patients we feel we have tried everything. But until your pain is at a constant low number on the 1-10 pain scale or a zero, I encourage you to keep discussing options and trying new treatments.

The goal is to get the best living you can out of each day. I look forward to hearing what has and hasn’t worked for you.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the  . 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.

Let's Restore Reason and Sanity to Opioid Prescribing

By Sandie Hamilton, Guest Columnist

I am 62 years old and a full time worker employed in the social services area. I am a mother, grandmother, registered voter and taxpayer. I support this country and everything she stands for. I believe in our Constitution and in our Bill of Rights, which contain the basis for my point today: the pursuit of happiness.

I have been diagnosed with degenerative arthritis of the spine. The pain it causes makes doing my job, sitting through a movie or Sunday service, and driving in a car nearly impossible. I cannot sit for more than 20 minutes at a time, nor stand for prolonged periods of time. If it weren’t for my prescribed opioids, I would not be able to sit at this computer long enough to write this.

Opioid pain medication was not the first thing my doctor prescribed. It was the last. I did spinal epidurals, nerve blocks, chiropractic manipulation, physical therapy, ultra-heat therapy, deep tissue massage, and yoga (which sent me back to the doctor). I also used topical creams, ointments, essential oils, lots of prayer, and of course NSAIDs -- until peptic ulcers led to stomach bleeds and vomiting.

Then my doctor put me on a low dose of opioids. I am now able to continue working, sit here and write this column. And all the other little things most folks take for granted.

SANDIE HAMILTON

My dose could be a little higher and probably needs to be adjusted, but I don’t dare ask my doctor. He told me once that “they” have made him feel like a criminal for what he does do. It’s a shame that I can’t talk to him and he is afraid to do more to help me because of this crazy manufactured opioid crisis. Not to say prescribing hadn’t gotten too liberal, maybe it had. But that was before I needed help.

I seriously believe the liberal prescribing days are over. Way over. Where I live most people aren’t getting anything, unless they’re dying. And that is excessive. Because of opioids I am a productive taxpaying citizen, not a housebound miserable invalid drawing my little disability check and getting free medical care.

Because of opioids, I am not a burden to the state. I am able to exercise my right to the pursuit of happiness, which for me means getting some relief from the constant pain. More could be done, but I am afraid to ask and my doctor is afraid to offer. That is wrong.

Something within reason needs to be done for the millions of pain patients who live in fear of losing or who have already lost their one lifeline to normal living -- a prescribed medication that works. But that’s not possible with all the tightened opioid guidelines and the number of drug overdoses rising.

Hopeless people unable to accept their pain have committed suicide. And I understand why. Others have turned to the black market and are trying things coming in from Mexico that can kill them. Of course, a lot of people choose to do drugs to get high, and it is their misuse and abuse of our medication that has caused a lot of the issues and overdosing.

We are being called addicts and drug seekers, and lumped right in there with the thrill seekers, which we aren’t. We are people with varying conditions that cause pain. Chronic untreated pain kills people too. It has been documented the effect it has on the brain, the stress on your heart, and the drain on your emotions.

Did people take advantage of opioids and turn from medicinal to recreational use? Yes they did. But the overprescribing has stopped. In some hospitals, you can’t even get opioids now if you’re having surgery! That’s ridiculous.

If we are diagnosed by a physician who wants us treated with opioids, we should be able to get them in whatever degree we need them. People are different. What works well for one may work differently for another, but the doctor should be able to determine what his patient needs and prescribe accordingly.

Please stop this war on pain patients. I want to be able to talk to my doctor and not live in fear that what is working for me today might be taken away tomorrow. There should be pain management specialists, pain sufferers and patient advocates on government commissions that deal with pain. How can you possibly decide what we need or don’t need if you aren’t talking to us?

Please hear us. Restore some reason and sanity to prescribing regulations and give us back the doctor-patient relationship.

Sandie Hamilton lives in Oklahoma.

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.

Tennant Patients Say DEA ‘Attacked a Good Man’

By Pat Anson, Editor

Ryle Holder wants the DEA to know that he’s not a drug dealer or a money launderer.

And he’s doesn’t think his physician, Dr. Forrest Tennant, is one either.

“They’ve gone and attacked a good man. He’s such an empathetic person for so many people. You just can’t find doctors that care like he does,” says Holder.

As PNN has reported, Tennant’s home and pain clinic in West Covina, California were raided last week by DEA agents, after a judge signed off on a search warrant that alleges Tennant is part of a drug trafficking organization and running a pill mill.

The raid stunned the pain community nationwide, because the 76-year old Tennant is widely known and respected for his willingness to see intractable pain patients who can’t find effective treatment elsewhere.  

“It’s not like he’s just giving out high doses of medication and running a pill mill, like they said. That to me was the most asinine statement in that whole search warrant,” says Holder.

FOREST TENNANT, MD

Like many of Tennant’s patients, Holder suffers from adhesive arachnoiditis and Reflex Sympathetic Dystrophy (RSD), two chronic and painful conditions that are considered incurable.  For the last three years, the 48-year old Georgia man has been flying to California every few months to see Tennant.

Although Holder is not identified by name in the search warrant, it strongly implies that he and a handful of other patients were selling the opioid pain medication that Tennant prescribed and diverting the profits back to Tennant.

“For them to even remotely think I’m out on the streets selling this stuff is a joke. It makes me angry,” says Holder, who is a licensed pharmacist. “I’ve got a license to protect. That’s the last thing I’d do.

“It’s like everything else they do. They don’t talk to any patients. They don’t talk to any doctors. They just go and throw all this stuff out there and making all these incriminations against people. They don’t have any evidence that I’ve sold anything. It’s just ludicrous.”

Also named in the search warrant is United Pharmacy of Los Angeles and pharmacist Farid Pourmorady of Beverly Hills, the owner of United. Click here to see a copy of the search warrant.

“Investigators believe that United, Tennant, and various medical practitioners are profiting from the illicit diversion of controlled substances, including the powerful narcotic fentanyl, which are prescribed and dispensed other than for a legitimate medical purpose,” DEA investigator Stephanie Kolb states in lengthy affidavit.

stephanie kolb

Although Tennant has been under investigation for nearly three years, much of the evidence against him appears circumstantial. Kolb and medical consultants hired by the DEA identified “very suspicious prescribing patterns” that include high doses of opioids that were regularly prescribed to patients who live out-of-state.

“My review of the data shows what I recognize to be red flags reflecting the illicit diversion of controlled substances,” said Kolb, who according to her LinkedIn profile was self employed as a dog walker and pet groomer before she started working for the DEA in 2012.

“Many patients are traveling long distances to see Dr. Tennant, some as far away as Maryland and Louisiana,” Dr. Timothy Munzing says in the affidavit. "These prescribing patterns are highly suspicious for medication abuse and/or diversion. If the patients are actually using all the medications prescribed, they are at very high risk of addiction, overdose, and death.”

Dr. Munzing is a family practice physician who has worked as a medical consultant for the DEA since 2014. Munzing doesn't hide his strong feelings about opioids and says in his Medscape profile that he wants to be "involved with law enforcement in trying to attack the opioid crisis."

Munzing has established a lucrative business for himself as a consultant for the federal government. According to GovTribe, a website that tracks payments to federal contractors, Munzing is paid $300 an hour by the DEA to testify as an expert witness and reviewing patient records. Munzing was paid about $45,000 by the DEA during the period Tennant's prescribing records were under review.   

timothy munzing, md

"Many well-meaning physicians prescribed high-dose opioids because of a lack of, or erroneous, education and experience, being naïve or exceedingly busy, or not recognizing the dangers that existed," Munzing wrote in a recently published paper. "This resulted in drug overdoses and death. A very small proportion of patients began selling their prescribed opioid medications for profit."

No Patients Harmed

Unmentioned anywhere in the affidavit is that it is common for Dr. Tennant to prescribe high doses of  medication to his patients because most are in extreme pain and some are dying.  Many travel from out-of-state simply because Tennant is the only doctor willing to see them.  Also unmentioned is any evidence that a patient overdosed or was harmed while under Tennant’s care.  Nor is any evidence presented that a patient sold their medication.

The omission of those important details from Kolb’s affidavit – whether by design or ignorance -- may have influenced Judge Alicia Rosenberg’s decision to sign the search warrant on the afternoon of November 13. Coincidentally, that was the same day Tennant was testifying 1,200 miles away in Montana as a defense witness in the trial of Dr. Chris Christensen, another doctor accused by the DEA of prescribing too many opioids.

Tennant and his wife Miriam returned home the next evening to find the front door of their house had been kicked in by DEA agents.

“We can’t tell you how very sorry we are that you are a new DEA target! We feel somewhat responsible for this travesty, since they obviously knew you were in Montana on our behalf,” Dr. Christensen and his wife wrote in an open letter to Tennant posted on Facebook.

“It’s our very firm belief that the DEA’s course is to attack all those practitioners, who stand in opposition to their intrusion into the practice of medicine.  It is my contention that the DEA will spare no effort to conceal its catastrophic failure to interdict the flow of counterfeit pharmaceuticals into the United States over the past decade. Therein lies the true cause of increasingly severe opioid addiction and opioid related deaths.”

The DEA raids on Tennant's home and pain clinic were widely publicized in Montana after his testimony, just as a jury was about to begin deliberations in the Christensen case. Yesterday the jury found Christensen guilty of negligent homicide in the deaths of two patients.

Subsys Connection  

A major part of the DEA’s case against Tennant hinges on nearly $127,000 in speaking fees that he was paid by Insys Therapeutics, a controversial Arizona drug maker that makes a potent fentanyl spray called Subsys.

Several company officials have been indicted on federal charges that they bribed doctors with kickbacks and lucrative speaking fees to get them to promote Subsys, which has been implicated in hundreds of overdose deaths.  

Tennant says he stopped taking payments from Insys in 2015 and was dropped from the company’s speaker’s bureau last year.

“What money we did make, we put in the clinic and used it to support the patients,” he told PNN.

Subsys is only approved by the FDA for the treatment of cancer pain, but Insys aggressively marketed the spray to have it prescribed “off label” to treat other pain conditions. It’s perfectly legal for physicians to prescribe a drug off-label – in fact it’s a common practice – but Tennant drew additional scrutiny because he prescribed Subsys to several of his non-cancer pain patients.

Subsys is an extremely expensive drug – a single prescription for one of Tennant’s patients cost over $21,000. According to the DEA, nearly $2 million in prescriptions for Subsys were written by Tennant for just five patients. One of them was Ryle Holder.

“It did help a little bit, but it wasn’t doing anything more than what I was already taking,” says Holder, who stopped using Subsys after six months. He was shocked to discover how much his insurance was billed for Subsys.

“I was absolutely blown away. I’ve never in my life as a pharmacist seen anything price-wise even remotely like that. I don’t know if that’s the true price or not, or if they were inflating the price. Who knows? I was shocked when I got it and saw that’s what they had billed,” Holder said.

“I certainly had no comprehension of how expensive this thing had become,” said Tennant, who bristles at the notion that Subsys should be limited to patients with cancer pain.

“It was an excellent product. It still is, for some people it’s just essential,” says Tennant. “Every doctor in the country should be disturbed about this. Are they saying off label use is now a crime?”    

Patients Support Tennant

Tennant has not been charged with a crime and can still practice medicine. But he’s been informed by the DEA that medical records seized from his pain clinic will not be returned directly to him. Patients must request a copy of their records from the DEA if they wish to continue seeing Tennant.

Many are vowing to do just that.

“Before seeing Dr. Tennant I was in and out of the emergency room constantly. I had no idea what was wrong with me at the time and it was not only extremely painful, but I really just wanted to die,” says Dawn Erwin, who Tennant diagnosed with arachnoiditis.

courtesy montana public radio

“He took time to explain it. He told me he could help get it under control. And he has! Not by opiates, but by anti-inflammatory meds, magnets, copper, vitamins, hormones. This has all been life changing for me. I no longer am in the emergency room. I no longer wish to die. I have some of my life back and I have Dr. Tennant to thank. This man has literally saved my life.”

“I remember the first time I told my doctor I felt like I had bugs crawling under my skin. He looked at me like I was crazy, but not Dr. Tennant. He said yes that is all part of the adhesive arachnoiditis and we can see what we can do to help with that,” says Candy Eller. “The creams he recommended, the blood work and hormones he prescribed, the magnet therapy and light therapy, and exercises that he prescribed have helped so much with getting my pain under control.”

“Dr. Tennant is the only doctor that I have found that is willing to treat my rare, complex, incurable medical issues,” says Erin Taylor, who lives with Ehlers-Danlos Syndrome and an autoimmune disease. “I saw over 20 doctors, tried over 15 different invasive treatments, and tried well over 40 different medications in an effort to improve my quality of life. I was most often met with doctors that had no interest in working with such a complicated case.

“To restrict Dr. Tennant’s ability to practice would have a devastating impact on my life, my family’s life, and lives of many more.  Please know that if you chose to eliminate the one doctor that is working to help my debilitating illness, you will be taking away my ability to be mother, wife, daughter, friend, and functioning member of society. I will be bed bound, just a shell of who I use to be.”

For the record, Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

Florida’s Deadliest Rx Drug is Not a Painkiller

By Pat Anson, Editor

A new report from Florida’s Medical Examiners Commission is debunking a popular myth about the overdose crisis.

The most deadly prescription drugs in the state are not opioid painkillers, but benzodiazepines – a class of anti-anxiety medication that includes Xanax (alprazolam) and Valium (diazepam).  Xanax alone killed more Floridians last year (813) than oxycodone (723).

The medical examiners analyzed toxicology and autopsy results for 11,910 people who died in Florida in 2016, noting not only what drugs were present at the time of death, but which drug actually caused the deaths.

The distinction is important and more accurate than the death certificate (ICD) codes often used by the CDC, which merely list the drugs that were present. Critics have long contended that CDC researchers cherry pick ICD data to inflate the number of deaths "involving" or "linked" to opioid medication, in some cases counting the same death twice.   

Florida made an effort to get the numbers right.

“Florida’s medical examiners were asked to distinguish between the drugs determined to be the cause of death and those drugs that were present in the body at the time of death. A drug is indicated as the cause of death only when, after examining all evidence, the autopsy, and toxicology results, the medical examiner determines the drug played a causal role in the death,” the report explains.  “A decedent often is found to have multiple drugs listed as present; these are drug occurrences and are not equivalent to deaths.”

The five drugs found most frequently in Florida overdoses were alcohol, benzodiazepines, cocaine, cannabinoids and morphine. The medical examiners noted that heroin rapidly metabolizes into morphine, which probably led to a substantial over-reporting of morphine-related deaths, as well as a significant under-reporting of heroin-related deaths.

Benzodiazepines also played a prominent role as the cause of death, finishing second behind cocaine as the drug most likely to kill someone.  Benzodiazepines were responsible for almost twice as many deaths in Florida in 2016 than oxycodone. Like opioids, benzodiazepines can slow respiration and cause someone to stop breathing if they take too many pills.

DRUG CAUSED DEATHS IN FLORIDA (2016)

Source: Florida Medical Examiners Commission

As in other states, deaths caused by cocaine, heroin and illicit fentanyl have soared in Florida in recent years. In just one year, the number of overdose deaths there jumped 22 percent from 2015 to 2016.

"We don't talk about it much now there's the opioid crisis, but cocaine and alcohol are still a huge issue, there are still a lot of deaths due to those things," Florida addiction treatment director Dustin Perry told the Pensacola News Journal.

Florida is not an outlier. Several other states are also using toxicology reports to improve their analysis of drugs involved in overdose deaths and getting similar findings.  In Massachusetts, deaths linked to illicit fentanyl, benzodiazepines, heroin and cocaine vastly outnumber deaths involving opioid medication.  Prescription opioids were present in only 16 percent of the overdose deaths in Massachusetts during the second quarter of 2017.

SOURCE: MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

Although it is becoming clear that many different types of drugs -- opioids and non-opioids -- are fueling the nation’s overdose crisis, politicians, the media and public health officials still insist on calling it an “opioid epidemic” or an “opioid crisis” -- diverting attention and resources away from other drugs that are just as dangerous when abused.  We never hear about a Xanax epidemic or a Valium crisis.

President Trump's opioid commission recognized the need to improve drug overdose data when it released its final report this month.

"The Commission recommends the Federal Government work with the states to develop and implement standardized rigorous drug testing procedures, forensic methods, and use of appropriate toxicology instrumentation in the investigation of drug-related deaths. We do not have sufficiently accurate and systematic data from medical examiners around the country to determine overdose deaths, both in their cause and the actual number of deaths,” the commission found.

I Would Not Be Alive Without Dr. Tennant

(Editor’s note: As PNN has reported, last week the DEA raided the home and offices of Dr. Forest Tennant, a prominent pain physician in California.  The DEA search warrant alleges that Dr. Tennant is part of a “drug trafficking organization” and prescribes excessive amounts of opioid pain medication. Dr. Tennant treats about 120 patients with intractable chronic pain, including many from out-of-state who can’t get effective treatment elsewhere. Kimberley Comfort is one of them.)  

By Kimberley Comfort, Guest Columnist

My Dad searched the country for help for me, as I have spent my life since September 2010 in 24/7 intractable pain. I ended up having two major surgeries trying to help. None helped with the severe intractable pain.

My Dad finally found Dr. Tennant and flew me on three plane seats, while he sat in another row, so I could remain laying down to reach California in January 2014.

Dr. Tennant saw me for over 12 hours in two hour sections in the morning and afternoon. He was essentially a charity. It was 12 hours of full one-on-one attention for $100. He did extensive examinations, blood tests, a genetic test, and trying out different very mild exercises once he diagnosed my adhesive arachnoiditis. He explained some treatments that might help if I ever had my spinal cord stimulator removed.

KIMBERLEY COMFORT

Dr. Tennant did prescribe me some additional opioid medication, while awaiting the results from genetic testing, along with vitamins, minerals, anti-inflammatory drugs, and a water reduction pill that mainly concentrated on the spine.

He agreed that I try a drug combination from a doctor in France that my Dad had researched and spoken with. Opioids were Dr. Tennant's last choice and high dose opioids were for those who metabolized the opioids much too fast.

Dr. Tennant thought I should return monthly, but we explained that the flight was just way too much for me to handle. So Dr. Tennant explained that palliative care was all that remained. He wrote letters to my pharmacy in Florida explaining my disease and why I was requiring such high amounts of opioids. He wrote my primary care provider and explained everything to him, offering to help in any way he could.

Dr. Tennant had recommended injectable Dilaudid, but my doctor would not give me that. Instead, it took him another 15 months and 4 different opioids to get me to a point where I was not in intractable pain 24/7.

I would not be alive today if it were not for Dr. Tennant. There is no way I could or would survive the pain I have without my high dosage of opioids. The genetic test showed I was a very fast metabolizer of opioids.

I have suffered with pain since I was a teenager.  Even back then, I was given opioids with Valium. My primary care provider still gives them to me today. If a doctor told me my liver was dying and they needed to cut back on my opioids, my answer would be the same now at age 52, as it was at 16.  I would much prefer a shortened life with manageable pain than to live a long torturous life with intractable pain. Frankly, I believe my heart would give out if I faced intractable pain again 24/7.

The opioid doses that the CDC recommends are far less then I have been on since the day adhesive arachnoiditis hit me like a Mack truck.

As for the money Dr. Tennant received from Insys Therapeutics, it is very little compared to some doctors. Doctors often get paid for speaking, get free lunches for the staff and themselves, and airfare to conferences where they will speak. Dr. Tennant is far from the only doctor to do this.

One can go online to ProPublica’s Dollars for Docs and see how much your internist, orthopedic surgeon, neurologist, etc. got from pharmaceutical and medical device companies. It shows that from 2013 to 2015, Dr. Tennant received $127,000.

Compare that to the highest paid doctor. Dr. Roger Jackson, an orthopedic spine surgeon, was paid $54,100,000 during that same time period.

DR. FOREST TENNANT

Dr. Tennant basically works for nothing. You should see how hard and long he works, speaks to educate doctors, and does research to help those of us who would very likely be dead if not for him. To me, Dr. Tennant is a saint!

The DEA should be going to Dr. Tennant, not to raid his offices, but to learn from him. My understanding of U.S. medicine is that a doctor had to be a Doctor of Public Health (DPH), as Dr. Tennant is, to have prescribed pain medication back in the 1960’s. Dr. Tennant was sent the worst of the worst pain patients back then, when “learning to live with it” was impossible for severely injured patients. Pain patients from all walks of life were referred to him for help that the other doctors could not give.

Dr. Tennant is far more educated than most any doctor left today, except perhaps other DPH doctors who have kept up with the times. In my Dad’s research, we found no other doctor specializing in intractable pain. Dr. Tennant has more than 35 years of prescribing pain medication under his belt. He knows what works and what doesn’t. He is the doctor the DEA and the Department of Justice should be calling as an expert witness in the treatment of pain, not going after.

This is nothing more than a smear campaign to try to ruin Dr. Tennant. All these government agencies, Physicians for Responsible Opioid Prescribing (PROP), and the news media have mixed up illicit drug use with needed intractable and chronic pain relief. They are mixing apples with oranges. Pain patients do NOT get a high from opioids. If we are lucky, we get some relief. Some get more relief than others and can go back to living a fairly normal life with opioids.

The crackdown on pain medication isn’t going to stop an addict from looking for that next high. Overdoses will continue even if the DEA, FDA, CDC and DOJ totally eliminate opioid medication. People will find something else to get high with and we will still have overdoses.

The intractable pain patient who has followed the law and their prescription directions will never get high and will, if they’re lucky, be able to have some semblance of a life. Take away their opioid medication and you will murder these people by forcing them to take their own life or waiting until their body fails from the extreme stress of the pain. Our blood will be forever on your hands.

You are trying so hard to take down any doctor who follows the Hippocratic Oath they took to render care to those who need it. You are too ignorant to not recognize the bad science used by the greedy doctors trying to get more money for rehabilitating illicit drug users. You fail to listen to the experts in the treatment of pain and instead only care about the treatment of addicts.

We, the intractable and chronic pain patients, need and depend on the assistance of the few remaining doctors willing to help. Let Dr. Tennant continue to be the highly educated pain doctor he is. Let him continue to help us stay alive and be with our loved ones.

We all are suffering, some worse than others. Without Dr. Tennant and those good doctors you have already tossed to the curb or worse, you will be responsible for our screams of pain and our forced intentional suicides. It will be murder by proxy.

Kimberly Comfort lives in Florida.

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.

Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

The FDA Got it Wrong on Stem Cells

By A. Rahman Ford, Columnist

In August, FDA Commissioner Scott Gottlieb, MD, signaled that his agency would move in the direction of enhanced regulation of stem cell therapies.  He said the action was justified because of “unscrupulous actors” who deceive patients with what he described as “dangerously dubious products.” 

Although the FDA referred to its prospective actions benignly as “enforcement” and “protection,” the likely impact seemed obvious – safe and effective therapies that have been healing patients for years would become less available and more expensive. 

Those concerns have now been made real.

This week the FDA released its final guidance on regenerative medicine and stem cell therapy, an approach that relies extensively on more regulation.

“We’re at the beginning of a paradigm change in medicine with the promise of being able to facilitate regeneration of parts of the human body, where cells and tissues can be engineered to grow healthy, functional organs to replace diseased ones; new genes can be introduced into the body to combat disease; and adult stem cells can generate replacements for cells that are lost to injury or disease,” Gottlieb said in a statement.

“We’re adopting a risk-based and science-based approach that builds upon existing regulations to support innovative product development while clarifying the FDA’s authorities and enforcement priorities. This will protect patients from products that pose potential significant risks, while accelerating access to safe and effective new therapies.”

Unfortunately, from both a patient and policy perspective, the FDA’s guidance is distinctly retrograde, drifting backward against a cosmic tide of scientific discovery that should be propelling post-modern medicine forward.  Not only are the FDA’s actions potentially detrimental to the health of Americans who suffer from chronic illnesses that could be treated or even cured by stem cells, they could cripple the entrepreneurship, ingenuity and cost-effectiveness of regenerative medicine. 

For the next 36 months, Gottlieb says FDA will adopt a “risk-based approach” in enforcement of the new rules, “taking into account how products are being administered as well as the diseases and conditions for which they are being used.”  While this grace period seems reasonable, the final guidance makes clear that the FDA will prioritize the oversight of clinics that deliver stem cells via intravenous infusion, in part because “use of these unapproved products may cause users to delay or discontinue medical treatments that have been found safe and effective.”

But intravenous stem cell administration has been safely used to treat patients suffering from painful autoimmune diseases like multiple sclerosis.  I have personally had intravenous stem cell therapy, and found it to be both safe and effective. 

‘Minimal Manipulation’ Test Tough to Pass

While well intended, the FDA’s guidance suffers from unduly restrictive definitions of “minimally manipulated” and “homologous use” -- key standards that will determine the availability of future stem cell therapies. 

Stated simply, stem cells that are “minimally manipulated” will not need to be approved by the FDA via clinical trial.  But that’s a tough test to pass and would seem to rule out mesenchymal stem cells, which help reduce inflammation in orthopedic and autoimmune conditions, conditions that cause unbearable pain for countless Americans.  The FDA’s conception of “minimally manipulated” is simply too limited.

The “homologous use” definition is likewise flawed.  Even if a stem cell product passes the “minimally manipulated” test, the cells used must “perform one or more of the same basic functions in the recipient as the cells or tissues performed in the donor.”  Under this definition, blood stem cells can be transplanted into a person with a disorder affecting their blood system, but cannot be used to repair damaged tissue, as in the case of a child’s cerebral palsy or a wounded veteran’s traumatic brain injury.

However, in a cruel twist, adipose (fatty) tissue used for cosmetic procedures like breast reconstruction and augmentation do satisfy the “homologous use” test and do not require a clinical trial.

Essentially, under these guidelines, the FDA strong-arms the child with cerebral palsy and the war veteran to the back of the medical bus, while giving breast augmentation the VIP treatment and ushering it to the front.  Sorry FDA, big breasts are not more important than curing diseases. 

FDA Should Respect Privacy Rights

Additionally, as I have written about previously, Americans have a constitutionally-protected privacy right in their own cells.  The FDA’s new rules completely ignore this right.  It is a basic right that emanates from established Supreme Court case law and fundamental principles of personal liberty and autonomy, and protections against undue intrusions upon bodily integrity. 

One’s body and one’s health are indeed intimate and personal matters that federal agencies must respect.  Instead of being overly preoccupied with a cell’s “same basic function,” the FDA needs to be concerned with a person’s “fundamental basic right” to use their own cells as they see fit.

In fact, one could easily argue that sufficient government regulation and patient protections already exist in federal and state law, as well as medical ethics boards.  The truth is that additional federal regulations are unnecessary, unduly burdensome, and infringe upon the sanctity of the physician-patient relationship and our right to control our own bodies. 

Commissioner Gottlieb’s declaration that patient safety is of paramount concern is a pleasure to hear.  However, in practice, the FDA’s regulatory efforts will likely serve to retard medical innovation and force Americans to travel abroad for life-saving stem cell therapies. They also preserve a “clinical trial” approach to treatment that, when applied to stem cells, has proven itself to be unduly burdensome, unreasonably slow, and unbelievably expensive.

Ultimately, what is abundantly clear is that the American people have spoken.  Their voices are filled with pain and they must be heard.  Retrograde stem cell policy is inimical to curing disease and is an affront to the elimination of pain. 

A. Rahman Ford, PhD, is a freelance researcher and writer on the issues of politics, policy and health. He is a graduate of Rutgers University and the Howard University School of Law, where he served as Editor in Chief of the Howard Law Journal. He earned his PhD at the University of Pennsylvania.

Rahman lives with chronic inflammation in his digestive tract and is unable to eat solid food. He has received stem cell treatment in China.  

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.

Fed Assault on Pain Patients Continues

By Jane Babin, Guest Columnist

The alphabet soup of federal agencies continues their full-frontal assault on pain patients and the opioid “epidemic.”

On Tuesday, the DEA raided the offices and home of Dr. Forest Tennant, an outspoken critic of federal efforts to regulate opioid prescribing.

Last week the DEA finalized plans for another 20 percent cut in the supply of opioid medication, apparently acting at the behest of 16 U.S. senators.

And this week FDA commissioner Scott Gottlieb declared a public health advisory over the increasing use of the herbal supplement kratom, telling people they should use FDA-approved medications instead. 

Well, Dr. Gottlieb, people don’t have access to the FDA-approved pain medications they need and it’s getting worse each day.  Fewer people might look for alternatives for their pain and/or addiction if they were treated adequately, with the dignity and respect they deserve, and without mistrust, denigration or a pound of flesh.   

I’ve never bought into the narrative that the opioid “epidemic” was caused by prescription drugs or that the inevitable consequence of opioid pain treatment is addiction. 

The problems are far too complex to assign blame to any one factor, person or group, and the simplistic solution of cutting opioid prescriptions flies in the face of not only my own experiences with opioids, but also that of millions of Americans with acute or chronic pain, and scores of respected pain specialists.

I was incredulous when the CDC proposed “voluntary” opioid prescribing guidelines in the dark, with a secret panel of wholly biased “experts,” most never having treated a patient for pain and perhaps never even being in the same room with one.  I was even more outraged when it assembled a new CDC-friendly review committee and utilized a puppet scientific advisory committee to rubber stamp their approval.  

After reports of fentanyl-related deaths appeared in the media, my reaction was two-fold: 

1. This explains the surprising surge in deaths of regular heroin users who are usually adept at managing their doses to avoid overdosing.
2. This couldn’t solely be due to the diversion of prescription fentanyl, because it’s not easy to steal large quantities of transdermal patches and redistribute the fentanyl to heroin and pills. 

Then, when carfentanil and other fentanyl analogues emerged, I thought the DEA, CDC and FDA would have to acknowledge that the “epidemic” wasn’t a prescription drug epidemic, because carfentanil isn’t prescribed to humans and is very tightly controlled.  I was wrong.

What is even more concerning is their dogged refusal to consider the complexities of opioid addiction and alternative explanations for many opioid overdoses.  If a person dies with a combination of alcohol, heroin, benzos, meth, and a trace of the Vicodin they took three days ago in their system, does that make it a prescription opioid death? 

Yes, according to CDC analyses.

Seeking Answers

I wanted to know how the CDC's distinguishes between a prescription opioid death and those caused by  incorrect coroner determinations, polypharmacy, counterfeit drugs, history of drug abuse, and even deaths from severe pain. 

So I wrote to Deborah Dowell, MD, co-author of the CDC guideline and lead author of a recent article published in JAMA, which analyzed underlying factors in drug overdose deaths. 

In that paper, Dowell acknowledges that “although increased heroin use and risk taking likely contribute, available data suggest contamination of the heroin supply with illicitly manufactured fentanyl as the overwhelming driver of the recent increases in opioid related overdose deaths.”

Which made me wonder what data was “available” and why they would need to qualify their conclusions.

deborah dowell, md

“There are limited data about the effectiveness of interventions to prevent overdoses related to illicitly manufactured fentanyl,” Dowell explained. “However, interventions that reduce opioid use disorder and opioid overdoses are likely to reduce overdoses related to illicitly manufactured fentanyl. Unnecessary exposure to prescription opioids must be reduced to prevent development of opioid use disorder in the first place.”

Ah ha! So fentanyl is bad and they aren’t sure if they can save people from overdosing on fentanyl, so they want to target prescription opioids instead. Because, of course, all pain patients who take opioids inevitably develop opioid use disorder (at least they do after the American Psychiatric Association rewrote the definition of addiction.  

I emailed Dowell and asked the following questions about her analysis of opioid deaths:

• How many different drugs did the decedents have in their bodies at death? What was the numerical range and average number? If other drugs were found, what were they?
• How many had a verifiable diagnosis or history of addiction? How many had a history of receiving opioid prescriptions for pain and for how long?
• Do prescription records validate a conclusion that the drug causing or contributing to death was a prescribed opioid?  
• Were all causes of death considered, or was a death concurrent with detection of opioids presumed to be an overdose?
• In how many cases were police or coroner's findings considered and found consistent with the cause of death reported on the death certificate?

The response I received was astonishing.  Less than 8 hours after emailing Dowell, I received a message from CDC’s Office of General Counsel.  I had struck a nerve! They saw I was a lawyer and thought I was preparing for litigation.

After clearing my questions with CDC’s legal team, Dowell replied a week later.  Her response should send a shiver down the spine of any pain patient who has been denied opioids, titrated down, or dismissed by his or her physician: 

“The reality is that many of the answers to these highly specific and technical questions cannot be answered in a definitive manner based on available data.” 

The bottom line is CDC does not have a grip on what’s really happening. CDC is targeting pain patients who are increasingly tortured by a medical profession scared silly by investigations and law enforcement. Yet they press on, with very little effect, continuing to blame prescription opioids and pain patients as the root cause of the opioid “epidemic” they aren’t responsible for.

The failure of the federal government’s efforts, particularly since the CDC guideline was issued, creates a justification to double down – no opioids for chronic pain and fewer opioids for acute pain -- all because pain never killed anyone and so there is no harm in forcing patients to suck it up.

The reality is that they can’t fix a problem they won’t acknowledge or attempt to understand, and they don’t have the data to understand it.  They can’t manipulate data to support an agenda and then expect solutions based on faulty conclusions to ever reach a desired end. 

Until they acknowledge what the real problems are, they will never solve them.

Jane Babin, PhD, is a molecular biologist and a biotechnology patent attorney in southern California. Jane has worked as a consultant for the American Kratom Association, a pro-kratom consumer group.

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.

DEA Raids Dr. Forest Tennant’s Pain Clinic

By Pat Anson, Editor

Agents with the Drug Enforcement Administration have raided the offices and home of Dr. Forest Tennant, a prominent California pain physician, confiscating patient records, appointment books and financial documents.

In a lengthy search warrant, the DEA alleges that Tennant prescribed such high doses of opioids and other medication that his patients must be selling them.  It also alleges that Tennant took financial kickbacks from Insys Therapeutics, a controversial Arizona drug maker that is under federal investigation.

An affidavit by a DEA investigator makes no mention of a patient overdosing or being harmed in any way while under Tennant's care.

“It’s very lengthy and it goes into things in my past which are totally irrelevant but are obviously designed to smear me and make me look like a bad person. I see what they’re doing,” Tennant told PNN.

dr. forest tennant (courtesy montana public radio)

Tennant, who has not been charged with a crime, believes Tuesday's raid is part of a broader effort to smear not only his reputation, but to discredit and intimidate other doctors who prescribe opioids to pain patients.  

“They’re not just going after me, they’re going after patients," said Tennant. “I think the country better understand what they’re doing here. They’re saying that regulations don’t count, standards don’t count, and they’ll decide who can get drugs and how much.

“I’d be worried about every pain patient right now, not just mine.”

Also named in the search warrant is United Pharmacy of Los Angeles and pharmacist Farid Pourmorady of Beverly Hills, the owner of United. Court documents indicate the DEA's investigation began in 2015 and targets a "drug trafficking organization" (DTO) that includes United and "multiple physicians whose prescriptions are filled at United, focusing in particular on Tennant."

"The crimes perpetrated by the DTO include the sale of powerful prescription narcotics such as oxycodone and fentanyl, along with other dangerous and addictive controlled drugs often sought in combination with narcotics, based on invalid prescriptions issued by practitioners including Tennant," the documents say. "United has been submitting millions of dollars in fraudulent Medicare prescription drug claims, namely, claims for the cost of filling invalid narcotic prescriptions, including those issued by Tennant."

The search warrant identifies about $2 million in prescriptions written by Tennant that were filled at United for just five patients, three of whom live out-of-state. Tennant told PNN in a phone interview that the allegations were bizarre.

"I have no financial relationship with anybody. My clinic is fundamentally almost a charity," he said.

Tennant is a revered figure in the pain community because of his willingness to see patients with intractable chronic pain who are unable to find effective treatment elsewhere or have been abandoned by their doctors. At 76, Tennant could have retired years ago, but regularly sees about 120 patients at his modest pain clinic in West Covina, a Los Angeles suburb. Many patients travel from out-of-state to see him, and some are in palliative care and expected to die within a year.   

Tennant, along with his wife and office manager, Miriam, jokingly refers to their clinic as a “mom and pop” operation, although in actuality he practices on the frontlines of pain management and has developed treatment protocols for difficult and incurable conditions such as adhesive arachnoiditis, Ehlers-Danlos syndrome and Reflex Sympathetic Dystrophy (RSD).

Those treatments sometimes require high doses of opioid pain medication, but they also include hormone replacement, anti-inflammatory drugs and other therapies that help patients reduce their use of opioids.

Tennant says he carefully screens his patients and follows all regulations. He has been an outspoken critic of efforts to limit opioid prescribing and recently appeared on a Las Vegas TV station saying the federal government doesn't care if pain patients suffer and die.

“I understand what (DEA is) after. They figure if they go after the big guy, then no one will prescribe,” Tennant told PNN. “If they’re going to hurt me, no doctor is going to be willing to prescribe or do anything. That’s what they’re attempting to do. They’re attempting to neutralize me if they can. And I think there needs to be an outcry.

"The time has come. Is this country going to treat pain patients or not? Are they going to let people die in pain or are they not?"

Ironically, the raid on Tennant’s offices and home occurred the day after he testified in Montana as a defense witness in the trial of another doctor accused of negligent homicide in the overdoses of two patients. The Tennants arrived home Tuesday night to find the front door to their home had been kicked in by DEA investigators.

“It seems like a coincidence, doesn’t it?” Tennant said.

Insys Payments

Tennant acknowledges getting about $126,000 from Insys Therapeutics, payments that were primarily for speaking at events sponsored by the company.

Insys makes an oral spray called Subsys that contains fentanyl, a potent synthetic opioid. Subsys is only approved for the treatment of cancer pain, but Insys aggressively marketed Subsys to have doctors prescribe it “off label” to treat other pain conditions, allegedly resulting in hundreds of overdose deaths.

Several company officials, including Insys’ billionaire founder, have been indicted on federal charges that they bribed doctors with kickbacks and lucrative speaking fees to get them to promote Subsys.  

Tennant says he stopped taking payments from Insys in 2015 and was dropped from the company’s speaker’s bureau last year.

“What money we did make, we put in the clinic and used it to support the patients,” he said.

Tennant says he can still operate his clinic, but has been informed by the DEA that his charts and patient records will not be returned directly to him. Tennant is asking all of his patients to contact the DEA and request a copy of their medical records so that he can continue treating them. 

The DEA's contention that Tennant's patients are selling their opioid medication is preposterous, according to 64-year old Gary Snook, a Montana man who lives with adhesive arachnoiditis, a painful inflammation in his spinal nerves.

“The last thing I’m going to do is sell my medication,” says Snook, who was on an extremely high dose of opioid medication before he started seeing Tennant. “Dr. Tennant has me on such a low dose that I’m just barely getting through the month anyway. I don’t have any to sell.  

“He’s actually been able to lower my dose by about 80 percent, with his hormone therapy and stuff. I’m afraid these guys are sadly mistaken because he’s been moving patients in the opposite direction than they’re suggesting.”

Snook has a genetic condition that makes him a “high metabolizer” of opioids – meaning he has to take a high dose to get any kind of pain relief. His current daily dose is still about three times more than the highest amount recommended by the CDC.

 “I’m not selling mine. I’m just taking it to survive because it’s the only thing that works for my pain. I’ve tried all the modalities and unfortunately this is the only thing that works,” Snook said.

For the record, Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

The Death of Pain Management

By Janice Reynolds, Columnist

The art and science of pain management is more than just opioids.  It is knowing what pain is and how pain works, the harmful effects of pain, different reasons for pain, how individuals react differently to pain, which medications may work and how they work, what non-pharmacological interventions may be appropriate, the difference between “acute” and “chronic” pain, understanding that guidelines are not written in stone, and the importance of listening to the patient and treating the whole patient.

While many physicians, nurses and pharmacists may not know all of this, they should be willing to research it or ask for help from someone who is knowledgeable.  Above all, it requires compassion, belief and faith in the patient.  It’s complicated, but that is why I call it an art and a science.

There have always been those who are bigoted against people in pain, do not believe pain is all that important, and that people need to gut it out. They’d rather 1,000 people suffer in pain than be fooled by one. They see pain management as a money-making endeavor.

Others take the values of beneficence (doing good), non-maleficence (not doing harm), veracity (truth telling), and equable justice (all are treated fairly) seriously, and don’t try to warp these ethical values to support their own beliefs.

Unfortunately, the tide has turned against pain sufferers and pain management providers, and they are being overwhelmed with falsifications and even hate. Some would cite the so-called “opioid epidemic” as the cause, and while it has certainly acerbated the problem, the seeds were planted long ago.

What this “crisis” has done is escalate the terrorism of the DEA by driving providers out of pain management or punishing those who still treat pain. There has been a lack of due process, with providers found guilty until they can prove themselves innocent, damned by innuendo, and with no thought or care for the collateral damage to their patients.

The media and anti-opioid zealots have also made claims that pain management experts are all tools of the pharmaceutical industry and anyone who advocates for appropriate pain management is spreading lies.

The crisis in pain management can be traced back, in part, to the Joint Commission’s accreditation standards for pain.  Healthcare organizations were first held accountable to them in 2001.  My friend, Dr. June Dahl (a professor of pharmacology) and Dr. Patricia Berry (a nurse) wrote the initial standards.  Our belief was these standards would “make pain visible” and pain would no longer be ignored.

The standards essentially said that healthcare organizations should have a plan to assess the presence of pain, that pain should be treated, and that providers should be educated on pain and pain management. This turned out to be wishful thinking.  Negative comments we heard included variations of “If you ask them about pain they will have it” or “People will only exaggerate their pain.” My favorite one (asked by an emergency room doctor) was “Do you really think this pain thing is all that important?”

Dr. Andrew Kolodny and Physicians for Responsible Opioid Prescribing (PROP) have also had a huge impact on pain management. Seldom mentioned is the fact that PROP is a small group with only a handful of practicing physicians. Many, like Kolodny, have links to addiction treatment centers.

When the FDA wouldn’t go along with a PROP petition to change opioid warning labels, PROP found a home at the Centers for Disease Control and Prevention, where they helped draft the CDC’s opioid prescribing guideline. The guideline has severely damaged pain management by forcing providers to essentially ignore pain and commit malpractice. PROP has done more to murder pain management than any other entity.

Another large contributor to the death of pain management is the use of McCarthyism to spread fear and innuendo.  Doctors are afraid to provide appropriate pain management either because of the CDC guideline or a realistic fear of the DEA.  Providers are abandoning pain management or leaving practices entirely. Nor can they be faulted, as there is little support for them by politicians, the government or the media.  Even professional medical organizations, such as the American Pain Society, American Society of Anesthesiologists and American Academy of Neurology, have abandoned them.

Now we are seeing a bastardization of pain education, as well as a debasing of pain management itself. Education in medical schools and continuing education for providers should center on pain syndromes, pharmaceutical interventions, non-pharmaceutical therapy, and the consequences of poorly managed pain.  It should be evidence based, as well as ethical, and should not include the CDC guideline, which is neither. It should not just focus on addiction or the evils of opioids. 

There are now efforts to standardize pain management through the development of “best practices.”  President Trump’s opioid commission, the VA, Medicare, and other government agencies are creating them with input from addiction treatment advocates and insurance payers, without input from pain management experts or people in pain.

Will the art and science of pain management survive these assaults? I certainly want it to. But it will be difficult to re-educate providers and bring back into practice those who have been persecuted by the DEA and the media.

The narrative needs to change. We need to refocus on the harmful effects of inadequate pain management, the maltreatment of people in pain, and what forces are behind this butchery of adequate pain management.

Pain management, according to the World Health Organization, is a human right.  What kind of world and country do we live in when this right is blatantly ignored and the health of many placed in jeopardy by the death of pain management?  

Janice Reynolds is a retired nurse who specialized in pain management, oncology, and palliative care. She has lectured across the country at medical conferences on pain management, and is co-author of several articles in peer reviewed medical journals. Janice has lived with persistent post craniotomy pain since 2009. 

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

FDA Issues New Kratom Warning

By Pat Anson, Editor

The Food and Drug Administration has issued a public health advisory about kratom, an herbal supplement used by millions of Americans to self-treat pain, anxiety, depression and addiction.

In a lengthy statement, FDA Commissioner Scott Gottlieb, MD, said the agency has “significant concerns” about the increasing use of kratom and its potential health risks – especially when it is used to treat opioid addiction.

“At a time when we have hit a critical point in the opioid epidemic, the increasing use of kratom as an alternative or adjunct to opioid use is extremely concerning. It’s very troubling to the FDA that patients believe they can use kratom to treat opioid withdrawal symptoms,” Gottlieb wrote.

“There is no reliable evidence to support the use of kratom as a treatment for opioid use disorder. Patients addicted to opioids are using kratom without dependable instructions for use and more importantly, without consultation with a licensed health care provider about the product’s dangers, potential side effects or interactions with other drugs.”

Kratom comes from the leaves of a tree that grows in southeast Asia, where it has been used for centuries for its medicinal properties. The leaves are usually ground up to make tea or turned into powder and used in capsules.

Most kratom users say the herb has a mild analgesic and stimulative effect, similar to coffee.

In his statement, Gottlieb claimed that kratom was addictive and was being used recreationally for its euphoric effects. But he also acknowledged that the herb could have legitimate medical uses.   

“The FDA knows people are using kratom to treat conditions like pain, anxiety and depression, which are serious medical conditions that require proper diagnosis and oversight from a licensed health care provider,” he wrote. “I understand that there’s a lot of interest in the possibility for kratom to be used as a potential therapy for a range of disorders. But the FDA has a science-based obligation that supersedes popular trends and relies on evidence.”

The evidence is lacking, in large part, because kratom and its active ingredients are natural substances that cannot be patented and have less potential for profit. That discourages pharmaceutical companies from investing in research and clinical studies to prove kratom's safety and efficacy.

"To date, no marketer has sought to properly develop a drug that includes kratom," said Gottlieb. "We believe using the FDA’s proven drug review process would provide for a much-needed discussion among all stakeholders. Until then, I want to be clear on one fact: there are currently no FDA-approved therapeutic uses of kratom."

Last year, the Drug Enforcement Administration attempted to list kratom as a Schedule I controlled substance, which would have made it a felony to possess or sell. The DEA suspended its plan after an outcry and lobbying campaign by kratom supporters.

The DEA said at the time that kratom was linked to several deaths, as well as psychosis, seizures and an increased number of calls to poison control centers. Gottlieb renewed those claims today and said the FDA was “aware of reports” of 36 deaths associated with kratom. But he did not go into detail about where or when those deaths occurred.

The American Kratom Association (AKA) – a pro-kratom consumer group – has strongly disputed recent autopsy reports linking kratom to sudden deaths in Florida, Georgia and New York, calling them a "rush to judgement."

The AKA filed a dispute resolution petition challenging the "weak scientific basis" of the FDA advisory and asked that it be withdrawn.

“For years, the FDA has published scientifically inaccurate information on the health effects of consuming kratom, directly influencing regulatory actions by the DEA, states, and various local government entities.  AKA believes the FDA health advisory on kratom will lead to more state and local bans, all based on discredited, incomplete, and mischaracterized scientific claims," the AKA said in a statement.

In a survey of 6,150 kratom consumers by Pain News Network and the AKA, over 90% said the herb was “very effective” in treating their medical condition, whether it was pain, anxiety, depression or addiction. Many predicted that if kratom were classified as a controlled substance and made illegal, it would only increase the use of alcohol, marijuana, prescription opioids and illegal substances like heroin.

Senators Pressed DEA to Cut Rx Opioid Supply

By Pat Anson, Editor

A group of 16 U.S. senators played an influential role in getting the Drug Enforcement Administration to make further cuts in the supply of opioid pain medication, the latest example of how politicians have inserted themselves into the healthcare choices of Americans.

As PNN reported, the DEA published an order last week in the Federal Register that cut the 2018 production quotas for Schedule II opioid painkillers by 20 percent. It’s the second year in a row the DEA has ordered steep reductions in the supply of opioids. The move affects several commonly prescribed medications that millions of pain patients rely on for relief, such as oxycodone, hydrocodone, morphine and codeine.

The DEA acted even after drug makers and patients warned the agency that the cuts were so severe they could lead to shortages of pain medication. Under federal law, the DEA sets production quotas for manufacturers of opioid medication and other controlled substances. This year the agency reduced the amount of almost every Schedule II opioid medication by 25 percent or more.

The 16 senators – 15 Democrats and one independent – have been urging the DEA for months to go even further to reduce the risk of opioid painkillers being abused.

“As the gatekeeper for how many opioids are allowed to be sold legally every year in the United States, we commend DEA on taking initial steps last year to lower production quotas for the first time in a generation,” Democratic Sen. Dick Durbin of Illinois wrote in a letter to DEA Acting Administrator Chuck Rosenberg on July 11.

“However, the 2017 production quota levels for numerous schedule II opioids remain dramatically higher than they were a decade ago.  Further reductions, through DEA’s existing quota-setting authority, are necessary to rein in this epidemic.”

SEN. DICK DURBIN

Durbin’s letter was co-signed by 15 of his Senate colleagues: Sherrod Brown (D-OH), Amy Klobuchar (D-MN), Edward Markey (D-MA), Joe Manchin (D-WV), Dianne Feinstein (D-CA), Claire McCaskill (D-MO), Patrick Leahy (D-VT), Tammy Baldwin (D-WI), Jeanne Shaheen (D-NH), Kirsten Gillibrand (D-NY), Catherine Cortez Masto (D-NV), Maggie Hassan (D-NH), Richard Blumenthal (D-CT), Al Franken (D-MN) and Angus King (I-ME).

Durbin followed up with a personal meeting with Rosenberg at DEA headquarters on August 3. The meeting was also attended by Senators Brown, Shaheen, Manchin, Markey and Hassan.

“I commend Administrator Rosenberg for acknowledging that the DEA can do more to keep dangerous painkillers off our streets,” Durbin said in a statement after the meeting.  “In today’s meeting, I asked him to continue this effort and further lower the opioid quotas for 2018.  Fewer pills on the market means less addiction and, hopefully, fewer deaths.”   

The August 3 meeting is important, because the very next day the DEA announced it would publish a notice in the Federal Register that it was planning a 20% reduction in Schedule II opioids for 2018.

rosenberg (left) meeting with durbin and other senators

The notice opened up a 30-day public comment period on the DEA’s proposal. Over a hundred people wrote in, most of them pain sufferers who warned the DEA it was going too far.

“The quotas for 2017 caused some shortages at pharmacies. I do not understand the reasoning behind more aggressive production quotas for 2018. People I know who are long term chronic pain patients have gone to the pharmacy for their prescription and are told that it will be a week or 10 days to fill the prescription,” wrote Marjorie Zimdars-Orthman. “It is cruel to implement quotas that will cause pharmacy shortages.”

“This is just beyond insane. Far too many people are already suffering and committing suicide due to not being able to get proper pain management,” said Eric Busch. “Even those that find a doctor willing to actually treat the pain humanely and write a prescription, might not be able to fill said prescription if there are artificial quotas and shortages.”

“How can the government ensure that these quotas will not adversely affect pain patients?” asked Brian Teer, whose wife has suffered from chronic pain for nearly 20 years. “I implore you to consider the medical needs of unfortunate patients like my wife, who face the burden of untreated intractable pain. Please do not reduce the production of the very medications that she needs to continue living. Please do not take her life.”

The DEA said three unidentified drug makers also made comments, warning that the 2018 quotas for codeine, fentanyl, hydrocodone, methadone, morphine, oxycodone and oxymorphone “were insufficient to provide for the estimated medical, scientific, research, and industrial needs of the United States.”   

The only comment left in support of the 2018 production quotas included a second letter from Durbin and his colleagues, warning that opioid supplies “remain far too high.”

“Given everything we now know about the threat posed by opioids and DEA’s downstream efforts to tackle this problem, there is no adequate justification for the volume of opioids approved for the market,” the letter said.

In the end, the DEA sided with the 16 senators, ruling that the 2018 opioid quotas were “sufficient” to meet the needs of patients. The agency dismissed the comments from pain sufferers as medical complaints that were “outside of the scope” of its final order.

“These one hundred and six comments did not provide new discrete data for consideration, and do not impact the original analysis involved in establishing the 2018 aggregate production quotas,” wrote Robert Patterson, who became acting head of the DEA after Rosenberg resigned unexpectedly in September.

Opioid Quotas Should ‘Continue to Come Down’

Sen. Durbin and his colleagues are apparently not done yet, and may seek to rein in the supply of opioids even further in 2019.

Durbin recently joined with Sen. Markey in introducing the Opioid QuOTA Act, a bill that seeks more transparency from the DEA in disclosing how it sets opioid production quotas. The legislation would require the agency to list on its website the production quota for each opioid manufacturer, information that the DEA now considers confidential.

“The public deserves the right to know which drug companies are manufacturing these opioids, how many they are producing each year, and their justification for asking the DEA to approve their ever-increasing quota requests,” Durbin said in a statement.

“Our work will not be done until these quotas continue to come down, doctors become more judicious in their prescribing, drug companies stop misleading the public about their products, and we do more to help those who are currently addicted get treatment.”

Along with Durbin and Markey, the legislation is co-sponsored by Senators Manchin, Brown, Shaheen and Hassan – the same group of senators that met with the DEA administrator in August and pressed him to make further cuts in the opioid supply.

Managing Emotions While Living with Chronic Pain

By Barby Ingle, Columnist

Before navigating through the minefield of the healthcare system, we need to get our own lives in order first.

It is important to learn the tools to manage chronic pain in a biological, psychological, social and spiritual approach. This can be quite tricky to do, if you don’t put effort into each area.

The one area most skipped over is the psychological challenge that comes with living in chronic pain. One of the things that negatively affected my healthcare was not having my emotions under control when going into a doctor’s office. I would go in expecting them to fix me and answer in broad sweeping terms that did not help them help me. I would typically cry, because I was in so much pain and trying to get someone else to understand was quite a challenge.

There were five major areas psychologically that I worked on: managing my conditions, avoiding peer pressure, figuring out tools that I was comfortable with, respecting the roles of everyone involved in my care, and setting expectations with my family and friends.

Once I became my own best advocate and learned to present my symptoms in ways that helped them understand, I finally started down the path to a team approach to managing my pain.

The first step was getting my emotions under control and taking responsibility for what happens between appointments. That meant making sure that I was organized, learned about my diseases and treatment options, and understood how my insurance worked. Getting organized really helped me get my emotions under control, let go of anxieties, and focus on maximizing my care and energy.

I also learned each provider has their own way of treating pain, and if that provider was not on board with me, I’d find a new one who was willing and able to help me accomplish my goals.

Avoid Peer Pressure

You may face some peer pressure from others in the pain community to try whatever they are doing. Remember to research and only do what you are ready to do for yourself. If it’s not right for you, then it’s not right for you. The stress of allowing others to pressure you into trying a treatment that you are not comfortable with can create a bad situation for you.

Don’t be misguided by the pressure to fit in with others who have the same disease as you. Be sure to stand up for yourself and the care you deserve.

Take Responsibility

We are taught from childhood that doctors fix sick people. Providers and parents make decisions for us about our medications and treatments. But as we age, it is important to learn that we are responsible for our own care, and to think through and develop our own solutions. This is an essential life skill for everyone, but when you are chronically ill it is even more important to develop.

Respect that pain takes a toll on us physically and emotionally, and that we must devote time, effort and energy to improve our living situation and be as mentally healthy as possible. So many times, I wanted to scream or have a tantrum. Can’t they hear me? Can’t they help me? Can’t they do something for me?

Finding more positive ways to say what I was going through and productive ways to communicate helped me get the best care possible in the worst of situations. No one helped me when I let my negative emotions lead me. I have learned to respect myself and others to get the care I need, know when to walk away, and when to find a better way.

Set Expectations Early

Most of my family understood that I was living with chronic pain and that it was not by choice. But not all of my husband’s family understood, and took the word of a nurse who said that I was acting up, looking for attention and nothing was wrong with me. Over the years most of them have come around, after I learned to be patient and stay consistent in my drive and determination.

I have only had to cut a few people out of my life and most of that happened because I was unable to set expectations. Now it is something I have learned to do at the start of any relationship. There is so much less frustration when I have to say sorry I can’t make it because of a pain flare or seizure. They know I want to be there, there just are times that my body doesn’t allow it.

Having chronic pain will challenge you in ways that you never imagined. Preparing for daily activities and pain flares becomes a must. So does searching for small ways to boost your own self-confidence.

Managing the emotional side of chronic pain can be done -- it just takes understanding, effort, and learning to choose your battles.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of 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.

DEA Cutting Rx Opioid Supply in 2018

By Pat Anson, Editor

The U.S. Drug Enforcement Administration is going ahead with plans to reduce the supply of many opioid painkillers by 20 percent next year. That’s in addition to steep cuts in opioid production quotas the agency imposed in 2017.

In a notice quietly published this week in the Federal Register, the DEA said it would reduce the supply of many commonly prescribed Schedule II opioid painkillers, including oxycodone, hydrocodone, oxymorphone, hydromorphone, morphine, codeine, and fentanyl. The agency said demand for the medications had dropped.

In proceeding with the cuts, which were first proposed in August, the DEA dismissed warnings from three drug makers that the reduced supplies of opioids “were insufficient to provide for the estimated medical, scientific, research and industrial needs of the United States.”

The DEA received over 100 public comments on its proposal, most of them expressing concern that any further reduction in opioids would adversely impact the availability of prescription painkillers.

“I am 75 years old, have metastatic prostate cancer in my bones and have to take high doses of fentanyl patches and morphine tablets for the chronic, intractable pain. Please do not further reduce the supply of my critical medicine,” wrote Bill Daniel.

“Please stop this misguided attempt to save people from themselves. If demand is down, it's because you bullied physicians into prescribing less, not from a genuine market conditions,” wrote one anonymous poster.

“You want to cut my access to the medication I'm legally prescribed by my pain management doctors! Would you consider the same for people deemed disabled due to other illnesses? You are going to cause millions of us to either commit suicide due to unbearable pain or turn to street drugs,” said Christa Rood.

The DEA said comments such as these dealt with medical issues that were “outside of the scope” of its order and did not offer any new data for the agency to consider.

Under federal law, the DEA sets production quotas for all manufacturers of opioid medication and other controlled substances. This year the agency reduced the amount of almost every Schedule II opioid medication by 25 percent or more. The 2017 quota for hydrocodone, which is sold under brand names like Vicodin, Lortab and Lorcet, was reduced by a third.

Those cuts were not sufficient to stop the opioid epidemic, according to two letters sent to the DEA by a group of U.S. senators. The first letter, sent in July, urged that "further reductions... are necessary to rein in this epidemic.”

A second letter, sent in September, said there was "no adequate justification for the volume of opioids approved for the market." The senators asked to DEA to make the 2018 cuts in the opioid supply at least as deep as they were in 2017. 

Opioid prescriptions have actually been in decline for several years.  According to the Centers for Disease Control and Prevention, opioid prescribing in the U.S. has fallen by 18 percent since 2010.  

In recent years, heroin and illicit fentanyl have emerged as the driving forces behind the overdose crisis, which killed an estimated 64,000 Americans in 2016. Despite that, federal efforts to prevent overdose deaths remain largely focused on reducing the use of prescription painkillers.

The CDC, for example, is spending $4.2 million on an Rx Awareness campaign in four states; running ads on billboards, radio, newspapers and online that warn about the risks of prescription painkillers. Although a recent CDC study found fentanyl was involved in over half the overdoses in ten states, the agency says it has no plans to include fentanyl or heroin in its awareness campaign.

“Our aim with this campaign is to prevent prescription opioid overdose deaths, since prescription opioids continue to be involved in more overdose deaths than any other drug. Based on studies of people entering treatment, the majority of people with opioid use disorder (including heroin use disorder) still start with prescription opioids,” CDC spokesperson Courtney Lenard said in an email.

Panic! At the Toilet: Dealing With a Panic Attack

By Crystal Lindell, Columnist

When I read the notes from the paramedics, I couldn’t help but laugh.

“Pt. was sitting on toilet. Began to hyperventilate,” they wrote.

I finally found a title for my future autobiography! Hey, it’s my panic attack. I can make jokes if I want to.

The whole thing happened about a week ago and, as you can tell by the notes from the EMTs, it happened while I was going to the bathroom. There aren’t a lot of good places to have a panic attack, but I can tell you from experience that the toilet is an especially bad one.

Nothing brought it on. I had literally just woken up. And I was in the middle of a text conversation with my best friend about how insanely expensive humidifiers are when it hit.

It’s not as though I was contemplating the meaning of life or freaking out about the idea of being single forever, or even thinking about our current president any more than usual. I was literally just trying to find the best way to wake up without dry sinuses.

For the lucky ones out there who aren’t aware of what happens during a panic attack, let me explain.

The first thing to know is that the whole thing is scary as hell. If you don’t know what’s happening, you might think you’re dying. As in, this is it. This is how it all ends. On the toilet. Like Elvis.

It starts with this weird urge to hyperventilate. For no reason. Literally. No. Reason. That, in turn, causes chaos.

I started screaming. Then, sweat suddenly drenched my entire body. And soon after that, things started to shut down, as my body rushed blood to the most important areas, like my heart, assuming extremities were expendable. So, my feet and then my calves went numb and then they started cramping. My hands curled under and stopped functioning. And eventually my tongue also went numb.  

Saying it’s really effing scary is an understatement. 

Thankfully, my brothers were both home and heard me screaming. When they came to check on me, I mumbled with my non-functioning tongue that I needed them to call 911. I live two doors down from the fire department, so the paramedics got to my house pretty quickly. That was helpful. 

And, I have to say, they were insanely good at dealing with the situation. 

One of them rushed in and knelt down in front of me, grabbed my hands, looked me in the eye and said, “Crystal, what’s happening to you is completely normal. I need you to try to breathe with me.” And then he guided my breaths while another paramedic got some oxygen ready. Once they put that on me, I was able to regain function in my limbs again. My hands slowly started to uncurl and I was able to kind of calm down. 

That’s about when I also regained the wherewithal to really understand exactly what was happening. Three young paramedic guys, in my bathroom, helping me breathe, while I sat on the toilet, in a T-shirt and hot pink underwear wrapped around my ankles. 

I’ve had better moments. 

I declined to go the hospital mostly because I knew that I would be ok after I calmed down. But it’s likely I had such a severe reaction because I was dehydrated, and IV fluids probably wouldn’t have hurt. Instead, I just drank some Gatorade.

Afterward, I was completely drained of energy and ended sleeping the rest of the day. I can tell you that I also have spent every day since genuinely concerned that I would have another panic attack any time I went to the bathroom. So that’s fun. 

And honestly, I have been struggling to process the emotional trauma of losing control of my body. Just writing this column, and remembering everything that happened, has been enough to make my heart race with fear. But I am seeing my psychiatrist in a couple days to talk about future coping strategies, so hopefully that will help.

I know this is the “Pain" News Network, and I struggled with whether I should write about a panic attack in this space. But panic attacks are really painful in lots of ways, and many people living with chronic pain also deal with anxiety. 

And I while I had one 7 years ago, I didn’t actually know that it had been a panic attack until I heard one of favorite YouTuber beauty bloggers describe something similar happening to her. I was like, “Oh, wow. That’s exactly what happened to me!”

And I can tell you that the most important thing to realize during a panic attack is that it is just that: a panic attack. Because a stroke or heart attack seem pretty similar. And thinking you’re going to die doesn’t help calm you down. So maybe this article will help someone else who unexpectedly finds themselves hyperventilating on the toilet someday. If nothing else, it’s a good reason to clean your bathroom. 

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.