4 N’s That Can Help Lower Pain Levels

By Barby Ingle, Columnist

I have covered 28 treatments so far in my alphabet series on alternative therapies that can be used in the management of chronic pain. I am now moving on to the N’s of pain management -- two of which I have tried and two that I learned about while researching this article.

Nerve Blocks

A nerve block is the injection of an anesthetic or anti-inflammatory drug into a nerve or group of nerves to relieve pain. I had this procedure 37 times over a 3-year period, starting in 2005. In my case, the injections were made in my neck into a group of nerves called the stellate ganglion. The injections did not take away my pain, but they lowered the intensity of it and helped me function better for a limited time.

As with most therapies for pain, nerve blocks are not a lasting treatment or cure. They are only a tool to manage pain and can help diagnose where the pain is coming from. Diagnostic nerve blocks are typical done to determine if a longer lasting treatment or procedure could be more successful in treating pain.

My first nerve block gave me pain relief for only about 3 hours, but it also showed my doctors that I had sympathetically maintained pain -- a form of Reflex Sympathetic Dystrophy (RSD).

Some people receive a few nerve blocks and experience months to years of extended pain relief. For me, it was only a few hours, but when the blocks were later combined with radio frequency ablations, I would get up to 20 days of pain relief. The nerve blocks also helped me avoid additional surgery and having to take daily medications.

There are many types of nerve blocks that can be performed on different body areas. Injections can be made in the face, eyelids, scalp, forehead, upper jaw, nose and palate, neck, shoulder, elbow and wrist, as well as the abdomen and pelvis. The procedure can be painful, so many providers sedate patients or give them a local anesthetic. I was sedated for all of my nerve blocks except one, where the IV failed. 

Nitric Oxide

Another treatment I am hearing some alternative providers suggesting is nitric oxide, a gas that relaxes muscles and improves blood flow, especially in the lungs. Some intractable chronic pain conditions, such as chronic orofacial pain, can be helped by taking nitrous oxide supplements. These supplements don’t actually contain nitric oxide, but provide amino acids and other ingredients that increase nitric oxide production in the body.

Nitric oxide helps lower blood pressure, increases circulation, and improves cardiovascular and heart health. Athletes have used nitric oxide supplements for years to build muscle, and increase speed and endurance. The closest thing I have tried to a nitric oxide supplement is creatine, back in the day when I was a college athlete and coach. I was using it in a totally different setting and was monitored by trainers and team doctors, but I wonder now if creatine helped me more than I understood at the time. 

It is important to note that taking too much creatine or nitric oxide supplements can be harmful. But if you can find the correct dose and are closely monitored, they can be useful tools to help with some of the secondary effects of living with chronic pain, such as chronic fatigue. Some of the most common side effects from nitric oxide supplements are an increased urge to urinate, reduced dopamine levels (which we need for sleep), zinc deficiencies, nausea and stomach cramps. If you are a diabetic type 2, this is probably not a good option for you because blood sugar levels tend to go up as nitric oxide levels increase.

Neurotransmitter Regulation

A treatment I have used over the years is neurotransmitter regulation, which is the use of antidepressants and anti-anxiety medication to help manage depression, anxiety and other mood disorders. I no longer need these types of drugs, as I was able to learn through psychological counseling new coping skills to better manage my moods.

Mood disorders can be caused by chronic pain, which disrupts the production of neurotransmitters, the chemical messengers that our bodies produce to regulate our nervous systems. The four major neurotransmitters that regulate mood are Serotonin, Dopamine, GABA and Norepinephrine.

Medications can be used treat mood disorders. For example, anti-anxiety drugs that are receptor agonists – such as Valium, Xanax, Klonopin and other benzodiazepines -- bind to receptors and mimic the way a natural neurotransmitter decreases anxiety.

I can’t stress enough how common it is for people in pain to develop depression and anxiety, due to the challenging situations we face with our physical, emotional and mental health. Don’t be shy about discussing these needs with your provider. We must address all aspects of living with chronic pain and our mental stability is important to maintain.

Nabilone

The final option I looked at in the N’s is nabilone, a medication that is approved for treating or preventing nausea and vomiting caused by chemotherapy. A few studies have shown that low doses of nabilone can also be effective in managing chronic pain from fibromyalgia and multiple sclerosis, although that would be considered an “off label” use in the United States.

Nabilone is a synthetic cannabinoid that mimics tetrahydrocannabinol (THC), the primary psychoactive compound in marijuana. According to the studies I’ve read, researchers believe that nabilone can benefit patients not only by reducing pain, but in improving quality of life. In a head-to-head trial of nabilone and a weak opioid medication, nabilone had similar pain relieving effects in patients with chronic neuropathic pain.   

Once again, I hope that I was able to share something new with you. I encourage you to be open-minded when it comes to using alternative therapies. Always talk with your provider to make sure you are on the same page and that everyone involved in your care understands the treatment plan and the options you are choosing.

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.

Rising Cost of Arthritis Drugs Defies Economics

By Julie Appleby, Kaiser Health News

Renda Bower knows well the cost of drugs to treat rheumatoid arthritis – her husband, son and daughter all have the painful, disabling autoimmune disease. And the family’s finances revolve around paying for them.

Even with insurance, Bower’s family last year faced $600 a month in copayments for the drug, plus additional payments on another $16,000 in medical bills racked up in 2016 when a former insurer refused to cover all the doses her 9-year-old daughter needed.

Bowers, of Warsaw, Ind., said her family tries to keep up with prices by cutting back on her children’s sports and extracurriculars and skipping family vacations. She also works as a part-time teacher.

But financially, it’s hard. “The cost should not be this high,” she said.

Wholesale prices for Humira and Enbrel, the two most commonly used treatments for rheumatoid arthritis, known as RA, increased more than 70 percent in the past three years.

Since the first RA drug came to market a decade ago, nearly a dozen have been added. If basic economics prevailed, RA treatments and patients would have benefited from competition.

But, because of industry price-setting practices, legal challenges and marketing tactics, they haven’t. The first RA drug cost $10,000 a year. It now lists for more than $40,000 — even as alternatives have entered the U.S. market.

“Competition generally doesn’t work to lower prices in branded specialty drugs,” said Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes.

Humira is the world’s No. 1 prescription drug by revenue. AbbVie manufactures and markets the drug and is on track to reach revenue from the product of $17 billion this year.

Other RA treatments are also among the top 10 drugs by revenue sold in the U.S. Enbrel, made by Amgen, ranks as No. 3. Remicade, by Janssen Biotech, is fifth. Some RA medications are approved for other conditions, including psoriatic arthritis, Crohn’s disease and psoriasis.

About 1.5 million Americans have rheumatoid arthritis. The Bowers found some relief this year but not because prices dropped. Rather, Renda’s husband left his job at an engineering firm to work as a machinist at a medical device company that has an insurance plan with lower copayments. Her daughter was accepted into a clinical trial at Cincinnati Children’s Hospital. The trial covers the drug’s cost but not the associated expense of weekly travel, among other things.

Middlemen Benefit As Wholesale Price Rises

The complicated pharmaceutical supply chain in the United States means middlemen — such as pharmacy benefit managers (PBM) and, in some cases, hospitals and doctors’ offices — can gain financially by choosing more expensive drugs. That’s because PBMs usually get a rebate from the drugmakers on top of whatever profit they get from selling or administering the drug.

Those rebates often are based on a percentage of the list, or wholesale, price. So, the middlemen who get the rebates take in more money when drugmakers raise those sticker prices.

But who pockets the rebates? PBM firms, which oversee drug benefits for millions of Americans, say they share all or part of them with the insurers or employers who hire them. In some cases, the rebates go directly to specialty pharmacies, medical clinics or physicians dispensing the treatments.

The rebates rarely end up directly in patients’ pockets.

Those rebates affect the market in another way: They can make it harder for some companies to offer new treatments or they can thwart less costly rival products.

“We could give [our new drug] away for free and … it would still be more economically advantageous” for insurers and PBMs to send patients to Humira first, said Andreas Kuznik, a senior director at Regeneron Pharmaceuticals, at a conference examining the cost and value of RA treatments.

Thomas Amoroso, medical director for medical policy at Tufts Health Plan, said at the same March conference that he has found drug industry sales representatives to be persistent in tracking how their drugs are positioned on plan formularies.

If insurers decide to add a new, lower-cost drug as the preferred alternative, “our Humira rep would be knocking on our door next week and saying, ‘Hey, that rebate we gave you? We’re taking it back,’” Amoroso said.

The roundtable at which they spoke was part of an assessment of RA drug pricing convened by the Institute for Clinical and Economic Review, a nonprofit that evaluates the value of medical tests and treatments for insurers and other clients.

PBMs won’t disclose the rebates they provide to clients, but studies provide a clue. It’s a huge amount of money.

The Berkeley Research Group, a consulting firm that advises major employers, said that rebates and other discounts paid to insurers, PBMs and the U.S. government for brand-name drugs grew from $67 billion in 2013 to $106 billion in 2015.

Most RA drugs are a complex type of medication, called biologics, which are made in living organisms. Nearly identical copies of biologics are called biosimilars. They hold the promise of lower prices, just as generic drugs did for less complex medications.

While several biosimilar RA treatments have won Food and Drug Administration approval, including replicas of Humira, Enbrel and Remicade, most are tied up in court battles over patents. And those biosimilars that have made it to market are now the subject of new areas of legal challenge.

In mid-September, Pfizer filed what will be a closely watched antitrust lawsuit against Johnson & Johnson. The case alleges that J&J is using exclusionary contracts and the threat of withdrawing rebates to protect Remicade from Pfizer’s lower-priced biosimilar, Inflectra, which hit the market last winter.

J&J defends its contracts, saying they are “driving deeper discounts that will lead to overall lower costs.”

Arguments For And Against Rebates

Rebates are under increasing scrutiny, amid growing alarm about soaring prescription drug prices in the United States. But the Pharmaceutical Care Management Association, the PBM industry’s trade lobby, said that complaints that rebates help fuel higher prices are unfounded.

These rebates, the lobby says, help save the health system millions of dollars by shifting dollars back to insurers or other clients, who can then use them to lower future premium increases. This year, it commissioned a study that found no correlation between rebates and the rising list prices of the top 200 brand-name drugs, suggesting higher rebates didn’t necessarily drive higher prices.

“The rebate system exists because [insurers, employers and other clients] want discounts,” said Steve Miller, chief medical officer for Express Scripts, one of the nation’s three largest PBMs.

Express Scripts offers clients an option to give patients the discount directly, but most choose not to, he said.

“While individual patients would get the benefit, everyone else’s premiums would go up [because the rebate savings would not flow back to the insurer],” Miller said. “Changing where the rebate goes doesn’t lower the price of the drug.”

But rebates play a role in what some patients pay at the pharmacy counter.

It stems from a simple calculation: whether a patient’s insurance copayment is based on a percentage of the drug’s wholesale price or the drug’s price after rebates are given to the middlemen.

Heidi Barrett , a mother of five from Everett, Wash., faces a 10 percent copay whenever she or one of her four children who have RA, all of whom have been on medication for years, go for their monthly infusion of Remicade.

Although Barrett is shielded from much of the cost because she has good employer-based insurance through her husband’s job, the question of whether her monthly copayments are based on the wholesale price or the after-rebate price rankles her.

“I have asked that question of the insurance company. I’ve asked that of our union,” said Barrett, 47, a paralegal who isn’t working because she spends so much time on her children’s treatments. “I never got any answers back.”

Based on data analyzed by Bach’s group at Sloan Kettering to determine the cost of 100 milligrams of Remicade, it appears she is paying based on the pre-rebate price.

Here’s how that works: Barrett’s 18-year-old son recently received a 600 mg dose that required a copay of $655. That is close to 10 percent of Remicade’s average U.S. wholesale price for that dose of $6,450, the Bach analysis showed.

Barrett is not benefiting from the rebate that middlemen receive.

Rebates and discounts, however, drive down the price for pharmacy benefit managers, hospitals or doctors.

According to the analysis, the average net cost of a 600 mg dose is $4,140, once all discounts are calculated. If Barrett could use that base price as her copay, she would save more than $240. For her entire family — all her children and Barrett take similar doses — that equals a savings of $1,000 a month.

With her current insurance, Barrett quickly meets a yearly $12,900 deductible. She considers herself lucky that her insurer then picks up the drug’s full cost. But the experience has changed her motherly advice to her children, who are 10, 18, 19 and 25, about what to hope for in life.

“I tell them, you can be anything you want when you go grow up. But you need to go to a company with good health insurance, even before you look at the salary or whether you’ll be happy there, your first priority is health insurance,” Barrett said. “It’s an insane world we live in.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

10 Myths About the Opioid Crisis

By Roger Chriss, Columnist

There is no shortage of false statements being made about opioids. As the overdose crisis worsens, old and debunked claims reappear, while new claims rise up alongside them. Pundits, politicians and even physicians are perpetuating them, despite all evidence to the contrary.

So let’s set the record straight in order to promote an informed dialog about opioid medication, chronic pain, and the opioid crisis.

Myth 1: America has 5% of the world’s population but uses 80% of the world’s opioids.

Numerous politicians, such as Missouri Sen. Claire McCaskill and former New Jersey Gov. Chris Christie, as well as many journalists, have made this statement. It is demonstrably false.

In fact, the U.S. only uses about 30% of the world’s opioid supply. That estimate includes the addiction treatment drugs methadone and buprenorphine, both of which are opioids.

Myth 2: 80% of heroin addicts began by abusing prescription opioids.

This myth is pernicious because it is based on a kernel of truth. The number is correct but the implication is wrong. Only 4 to 6% of people who misuse prescription opioids go on to use heroin. And the number of people who start heroin without taking prescription opioids first has been rising in the past year.

Myth 3: Addiction starts with a prescription.

This claim persists despite decades of data to the contrary. A 2010 study found that only one-third of 1% of chronic pain patients without a history of substance abuse became addicted to opioids during treatment. Most abuse begins when people take medication that was not prescribed to them, using pills that were stolen, purchased illegally, or obtained from friends and family members.  

Myth 4: Opioid use leads to pain sensitization or ‘opioid induced hyperalgesia.’

Addiction treatment specialists like to repeat the claim that long-term opioid use makes patients hypersensitive to pain. But hyperalgesia is poorly understood and often confused with opioid tolerance. One study found that chronic pain patients on opioids had no difference in pain sensitivity when compared to patients on non-opioid treatments.    

Myth 5: Opioid overdoses are killing 64,000 people per year.

Nearly 64,000 Americans died from drug overdoses last year, according to the CDC, so that part is true. But opioids were involved in only about two-thirds of those deaths – and most of those overdoses involved heroin and illicit fentanyl.

Myth 6: Reduced opioid prescribing will end the overdose crisis.

Reduced prescribing is clearly not working.The number of opioid prescriptions has been in steady decline since 2010, yet fatal overdoses have risen sharply ever since.

Myth 7: Medical cannabis will cure the opioid crisis.

This is a recurring myth, made popular again in 2017. Unfortunately, not only does the recent data show that medical cannabis is not helping in states where it is legal, the underlying assumption of this myth is that chronic pain care is driving the opioid crisis. This is not the case.

Myth 8: Banning opioid medication will fix the opioid crisis.

This was put forth again early in 2017 by New Hampshire attorney Cecie Hartigan. Setting aside the problem of banning illegal drugs like heroin and fentanyl analogues (they are already banned), opioids are simply too medically useful to give up. Moreover, prior experience with drug bans, from Prohibition to the current overdose crisis, shows that bans do not stop misuse or addiction.

Myth 9: There are lots of ways to treat chronic pain

This myth has become increasingly popular as states, medical facilities, and health insurers pursue policies to reduce opioid prescribing. Although some of these methods, from physical therapy to spinal cord stimulators, may prove helpful, that misses the fundamental point. Chronic pain disorders are so horrible that all effective options, including opioid therapy, need to be on the table.

Myth 10: Opioids are ineffective for chronic pain.

This is the biggest myth of all. There is an abundance of high-quality research showing that opioids can be effective for some forms of chronic pain. Here’s a partial list of recent studies:

• Benefits and Risks of Opioids in Arthritis Management

• Opioids for chronic pain: new evidence, new strategies, safe prescribing

• The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain

• Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects

Adding to these studies is a recent review in Medscape, in which Charles Argoff, MD, a professor of neurology at Albany Medical College, said that “in multiple guidelines and in multiple communications, we have a sense that chronic opioid therapy can be effective."

New myths appear regularly, but these persist despite all efforts to counter them. Like an ear-worm or viral meme, they cannot be eliminated. The only defense is knowledge.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

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.

Tylenol for Postoperative Pain?

By Margaret Aranda, MD, Columnist

I saw them do it to our veterans. Now they were going to do it to me.

I heard the veterans scream decades ago, when I was president of a pre-med club at a VA hospital in Los Angeles. There was a little local anesthetic, no oxygen, no vital signs and no anesthesiologist. The hematologist-oncologist did the bone marrow extraction herself.

Now I was about to have the same procedure myself, to get an early diagnosis of mastocytosis, an orphan disease.  No one was going to tell me that I won’t hurt. The veterans fought in a war, yet they screamed.

After taking my vital signs, the intake nurse interrogated me, eyes peering over her bifocals.

“When was the last time you took OxyContin?” she asked.

(My thoughts: We never asked such a scrutinizing question. They could draw an opioid blood level, to “check” and see if I was telling the truth. Sure, my blood levels would be low, because it’s been a week. I’m not a drug addict. Big breath. Don’t let your thoughts get negative. Just get through this day.)

Postoperative pain was a big concern for me.

“What will I get for post-op pain?” I asked the anesthesiologist.

(My thoughts: I don't want to cry. I don't want to hurt. I've had a lifetime of pain, and I live with it daily. Sores pervade me. They are all over my head, itchy ones that feel like cold sores mixed with chicken pox. If I scratch one, they all itch, including the sores on my arms and back. How much worse is my life about to get?)

"Tylenol. No post-op opioids for pain," was his reply.

You bet my world crashed.

"I can't do Tylenol. I need to save my liver. Everyone knows the smallest dose of Tylenol can hurt the liver. Besides, I don’t want to lose my empathy. Studies show acetaminophen causes a lack of empathy,” I said.

“Ibuprofen,” was his answer.

(My thoughts: How much lower can my world crash? What the heck? Do you really know I’m a doctor, too? Do you know how many patients I’ve personally intubated through a GI bleed so they could breathe?)

“I can’t do ibuprofen,” I told him. “I can’t have a GI bleed. Or a heart attack. Or a stroke.”

“Oh, okay! Morphine and fentanyl, a mixture. Morphine lasts longer," the anesthesiologist said.

(My thoughts: I can breathe again. Now I have to be the perfect patient.)

The pathologist was cheery, polite and smiled a lot. We went over the pathology of mastocytosis, WHO classifications, the systemic vs. cutaneous forms, early diagnosis, and the bone marrow procedure I was about to have. He asked if I had enough opioids for post-op pain. I did. I concluded that he does not write his own pain prescriptions.

Once on the operating table, the surgeon caressed my head, patting it before I fell asleep. I inwardly smiled as I laid straight on my right side. Cold prep solution dripped down my lower back as I sunk into sleep.

The surgeon bore into the ileum, then sucked out the bone marrow with a syringe.

When I woke up, my butt was numb and I did not need any more pain medication. But I was not given a prescription for postoperative pain for when I went home. I was told to use my existing opioid prescription for pain, which is reasonable, as long as my doctor doesn't "count" them against me.

(My thoughts: How do patients defend themselves to get opioids for during and after surgery? I mean, I’m a doctor and I had to stick up for myself. What if the patient does not even know to ask about postoperative pain at all? They must wake up screaming, an insult to any anesthesiologist. What has happened to patient care?

They profession of anesthesiology has changed.

Dr. Margaret Aranda is a Stanford and Keck USC alumni in anesthesiology and critical care. She has dysautonomia and postural orthostatic tachycardia syndrome (POTS) after a car accident left her with traumatic brain injuries that changed her path in life to patient advocacy.

Margaret is a board member of the Invisible Disabilities Association. She has authored six books, the most recent is The Rebel Patient: Fight for Your Diagnosis. You can follow Margaret’s expert social media advice on Twitter, Google +, Blogspot, Wordpress. and LinkedIn.

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.

Fentanyl & Heroin Deaths Lead Soaring Overdose Rate

By Pat Anson, Editor

Deaths from drug overdoses soared by 21 percent last year in the United States, with fentanyl and heroin now playing a bigger role in the overdose crisis than prescription pain medication, according to a new report from the Centers for Disease Control and Prevention.

The report estimates that 63,600 Americans died from drug overdoses last year, up from 52,400 in 2015. The soaring overdose rate helped lower U.S. life expectancy for the second consecutive year. A baby born last year is expected to live 78 years and 7 months, about two months less than a child born in 2014.

"If we don't get a handle on this, we could very well see a third year in a row. With no end in sight," CDC researcher Robert Anderson told the Associated Press.

About two-thirds of the drug deaths in 2016 involved opioids, a broad category that includes not only pain medication, but heroin and synthetic opioids such as fentanyl that are increasingly available on the black market. Fentanyl is up to 100 times more potent than morphine.

Fentanyl and its chemical cousins were blamed for over 19,000 deaths last year, followed by heroin (15,500 deaths) and prescription painkillers (14,500 deaths).

In the chart below, fentanyl is included in the category of "synthetic opioids other than methadone," while "natural and semisynthetic opioids" includes pain medications such as oxycodone and hydrocodone.

SOURCE: CDC

The CDC’s new report may actually underestimate the number of people dying from fentanyl and heroin. CDC researchers relied on data from International Classification of Disease (ICD) codes on death certificates, which merely list the drugs that are present at the time of death -- not the actual cause of death.

A more reliable way to list the cause of death is through toxicology blood tests, which often find that multiple drugs are involved in overdoses. Florida, Massachusetts, Pennsylvania and several other states that conduct their own toxicology reports have found that fentanyl, heroin and anti-anxiety medications are responsible for far more overdoses than prescription opioids. A recent study found that fentanyl or fentanyl analogues were involved in over half of the overdoses in 10 states.

Another recent study of emergency room admissions found that heroin overdoses exceeded those from prescription opioids by almost a 2 to 1 margin.

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

Although its own research shows that fentanyl and heroin are causing more overdoses than opioid medication, the CDC continues to focus on painkillers as the root cause of the overdose crisis.  As PNN has reported,  a public awareness campaign recently launched by the CDC only warns about the risks of prescription opioids, while completely ignoring the growing scourge of heroin and fentanyl.

But there is little evidence that awareness campaigns or prescription guidelines are reducing opioid addiction and overdoses, according to a recent op-ed in The New England Journal of Medicine.

"National trends show that we do not yet understand how to stem the tide of opioid overdoses by changing physicians’ prescribing practices. Although the volume of opioid prescriptions has fallen by 12% since its peak in 2012, the rate of overdose deaths continues to increase faster than ever, driven by an influx of potent synthetic opioids such as fentanyl. How and when decreased prescribing will translate into fewer deaths is unclear," wrote lead author Michael Barnett, MD, assistant professor of health policy management at the Harvard T.C. Chan School of Public Health.

"In the meantime, there is a real danger that aggressive opioid-prescribing policies could drive more people to use more dangerous injection opioids or force patients to live with inadequately treated pain. We simply do not know which policies will strike the right balance between promoting safe opioid use and avoiding unintended consequences."

No, I Don’t Want a Spinal Cord Stimulator

By Crystal Lindell, Columnist

There’s a word that my best friend came up with that we now use when someone is being obscenely awful: J-hole.

It’s a mix between a jack [redacted] and an [redacted] hole. Get it? J-hole. You’d be surprised how useful it is. Especially around kids.

And can I just tell you something? The pain specialist I saw yesterday? He was a real J-hole.

I used to think I just had a string of bad luck when it came to doctors and it was some weird coincidence that most of the ones I met were J-holes.

But now I’m starting to wonder if there’s something about the medical profession that has a way of attracting an above average number of J-holes.

Yes, there are good ones. I think I’ve met two of them — in six years with chronic pain. But most of the doctors I see? Well, they’re J-holes. And this guy was one of the ones that prove the rule.

He is obsessed with me getting a spinal cord stimulator. But I do not want to get a spinal cord stimulator. It’s created some friction.

This was only my second time meeting with him. He oversees a local pain clinic where I now get my weekly lidocaine infusions. It’s been great, because before I found this place, I had to drive two hours each way to the closest university hospital for the infusions. And I am too sick to drive afterward, so I was always begging people for rides. This place is about a half hour from my house, and right by my mom’s work, so it’s super convenient.

But every single time I go in, they try to sell me on this spinal cord stimulator thing. And I’m just not interested.

I usually see another doctor, a woman. Technically, I think she’s a nurse practitioner. And she at least has the ability to read a room. She presents the spinal cord stimulator every week like one of those cashiers at Kohl’s who is required by corporate law to ask if you want to sign up for a credit card, but who knows just as well as you do that you’re never going to be interested. And then we both move on. 

She’s in Mexico for Christmas though, so yesterday I had to see the J-hole guy. And he’s not someone who likes to hear the word no.

He asked me if I was interested in the stimulator, and I told him I wasn’t. Then he asked why not, so I told him I talked to my primary care doctor and he didn’t recommend it, which was true.

My PCP, who is an internal specialist at a university hospital — so you know, qualified — said I probably wouldn’t get much more relief than I get from the infusions, and that I would probably still need to take hydrocodone.

He also told me that a fair number of the patients he knows who got a stimulator ended up getting infections from it. And so for now, he recommends that I stick with the lidocaine infusions.

I trust this guy. He’s been my PCP for like five years and he has always taken my pain seriously. He’s one of the two doctors I’ve met who is not a J-hole.

And you know what this pain specialist said when I told him what my PCP said?

“Well that guy doesn’t know what he’s talking about.”

Ok. Cool.

So then I told him that I write for a pain site online and I’m pretty connected to the pain community and I have heard nothing but bad things about these stimulators. They’re hard to remove. The batteries die. They don’t work that well.

His response to that was, “You can’t believe everything you read online.”

Always a good thing to say to someone who just told you they write for an online publication, am I right? My sister was in the room and told me later she wanted to laugh in his face when he said that.

Then he tried to lecture me about getting weekly infusions and said insurance wasn’t going to be willing to cover those forever, and in my head I was like, OK, did my insurance tell you that? Or are you just annoyed that I come in here every single week and give you hundreds of dollars in revenue for what is basically a simple IV, and you would prefer that I stop? Because I can always go back to the hospital for infusions, where they at least offered me graham crackers every week.

His main selling point was that the stimulator would free up my life, so that I wouldn’t have to deal with the weekly infusions. It’s an argument that makes sense to healthy people, but what he doesn’t understand is that the infusions are what have freed up my life.

Before the lidocaine, I was lucky to get one good day a year. Now I spend one day each week dealing with an IV drug that makes me nauseous and tired and then I get the whole rest of the week to live my best life. It’s amazing! Plus, I get the added benefit of not having to have surgery on my spine.

Look, at the end of the day, the idea of getting something implanted into my spine just doesn’t sit well with me, even if complications are rare. Especially since I have a bad habit of having rare medical issues.

And it’s hard to take a doctor seriously when you know he stands to make thousands of dollars if I get the stimulator. But for now, I’m stuck going to this pain clinic for my infusions because everyone else in town says they are too risky to do.

But no, I’m not going to be getting a spinal cord stimulator. Maybe I’ll change my mind though. After all, you can’t believe everything you read online.

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.

One Million Australians Abuse Rx Drugs

By Pat Anson, Editor

Like the United States, Australia is struggling to find answers to a growing addiction and overdose crisis – and restricting access to opioid pain medication is the favored solution.

A new report by the Australian Institute of Health and Welfare (AIHW) found that a million Australians -- about 4.7% of the population – abused a prescription drug in 2016. That’s up from 3.7% in 2007.   

‘Over the past decade, there has been a substantial rise in the number of deaths involving a prescription drug, with   drug-induced deaths more likely to be due to prescription drugs than illegal drugs,’ said AIHW spokesperson Matthew James.

In 2016, there were 1,808 drug overdose deaths in Australia, but the leading cause was not pain medication. Benzodiazepines, a class of anti-anxiety medication that includes Xanax and Valium,  were involved in 663 overdoses -- compared to 550 deaths linked to opioid medications such as oxycodone and codeine.

Recent reports from Florida and Pennsylvania also show that overdoses linked to "benzos" outnumber those from pain medication, although you rarely hear about that in today’s anti-opioid climate.

Unlike the United States, where prescriptions for opioid medication have been in decline for several years, in Australia they rose by 24% from 2010 to 2015 – driven largely by a 60% increase in the rate of prescriptions for oxycodone.

Like their American counterparts, Australian regulators and health officials are responding to the overdose crisis by reducing access to opioid medication. Starting in February 2018, Australians will need a prescription for codeine, which is now widely available in over-the-counter analgesic and flu medications.  Australia is also introducing a national prescription drug monitoring system.

Economic despair and social isolation appear to be playing major roles in Australia's overdose crisis, just as they are in the United States. Earlier this year, a nationwide survey found that people living in remote, rural areas of Australia were almost twice as likely as those living in major cities to use pharmaceutical drugs for non-medical purposes.

“This finding also held true for Australians living in the most disadvantaged socio-economic areas, with 6 percent having recently misused pharmaceuticals compared with 4.2 percent of those in the most advantaged areas,” James said.

Australians who misused prescription drugs were also more likely to experience mental illness, chronic pain and psychological distress compared with those who did not misuse them. 

What’s the Difference Between Opiates and Opioids?

Rochelle Odell, Columnist

Like many of you, I use the words opioids and opiates interchangeably. I incorrectly thought one was singular and the other plural. It pays to look up definitions before using a word!

Merriam Webster defines opiate as “a drug containing or derived from opium and tending to induce sleep and alleviate pain.”  The first known use of the word “opiate” was in the 15th century. Natural forms of opiates include morphine, codeine, heroin and opium.  

Merriam Webster defines opioid as “possessing some properties characteristic of opiate narcotics but not derived from opium.”  Interestingly, the first known use of the word “opioid” was not until the 1950’s. Two of the most widely prescribed pain medications, oxycodone and hydrocodone, are opioids.

Just Believe Recovery, an addiction treatment center in Florida, has a straightforward explanation of the difference between opiates and opioids on its website:

“Opiates are alkaloids derived from the opium poppy. Opium is a strong pain relieving medication, and a number of drugs are also made from this source.”

“Opioids are synthetic or partly-synthetic drugs that are manufactured to work in a similar way to opiates. Their active ingredients are made via chemical synthesis. Opioids may act like opiates when taken for pain because they have similar molecules.”

But neither opiates or opioids make pain go away – what they do is temporarily block pain signals.  

"Both of these types of drugs alter the way that pain is perceived, as opposed to making the pain go away. They attach onto molecules that protrude from certain nerve cells in the brain called opioid receptors. Once they are attached, the nerve cells send messages to the brain that are not accurate measures of the severity of the pain that the body is experiencing. Thus the person who has taken the drug experiences less pain," is how Just Believe Recovery explains it.

The problem with this definition is that it fails to address why an addict uses heroin and other narcotics. It's not to relieve physical pain, it's for the euphoric effect or high. Big difference.

I can attest to that feeling. Years before I developed Complex Regional Pain Syndrome (CRPS), I was hit by a beginner snow skier, who caused a nasty spiral leg fracture. I screamed in pain for what seemed like hours, until a Demerol shot was given. It still hurt, a lot, I just didn't care that it hurt.

A week after the accident, I received a call from my orthopedist (who ultimately saved my left leg) informing me I must get to the hospital for immediate surgery. It turned out that my broken leg had not been reset and cast properly. A rod was inserted to correct the problem, but the post-op pain was excruciating.

I was on strong opioids for the next three weeks, until I had to go back to work and stopped cold turkey. I needed to work with a clear mind, and it was going to hurt whether I was at home or work. I had no cravings for pain medication and no addiction developed. Simply didn't need them.

However, after I developed CRPS and slowly titrated up on Dilaudid, the pain was different than it was from the broken leg. The relief obtained was not the "I don't care" reaction, but one of the pain is less, now I can do what needs to be done at work or at home. That’s the classic difference between acute, short term pain and chronic pain.

"When people use these medications only to treat pain as directed and for a short time, they are less likely to become addicted. Prescription drug addiction occurs when patients develop a tolerance for the level of medication they have been described and no longer get the same level of relief," is how Just Believe Recovery explains it.

"They may not have the same expectations for relief as their physicians and may equate the term ‘painkillers’ with the medication being able to take away all of their pain, while their doctor may be thinking in terms of pain management, which means bringing the pain to a level where they can function at a reasonable manner. When expectations do not match, patients may take more of the pain medication than prescribed to get a higher level of relief and in turn develop a drug addiction issue."

The CDC and several states have now decided to establish what acute pain is and how long it should be treated with opioids, be it three or five or seven days.

But if you suffer from a chronic pain disease or condition, a few days’ supply won’t cut it. You require the medication long term in order to function. Not addicted mind you, you just want the pain at bay. We all know pain medication does not “kill” the pain. It just becomes tolerable. Most pain patients do not increase their pain medication and many, including me, have been on stable doses of opioids for many years.

We also know pain patients are not the driving force in today's misguided opioid crisis or public health emergency or whatever you wish to call it. Illicit drug users are, and they are primarily young adults who snort, smoke or inject heroin and illicit fentanyl. Many are addicts who are in methadone clinics, and they still abuse not only the methadone but other drugs as well.

It's like everyone in power or who is affiliated with rehab has blinders on. Pain patients have become the issue, yet statistics clearly show we are not the problem. The rate for opioid abuse in pain patients is at or less than 5 percent.  Why are patients singled out in this battle?  Even the CDC admits opioid prescriptions are no longer the driving force in the overdose crisis. I believe they never were.

Opiates and opioids are not the same, and should be addressed separately. Instead, they have become interchangeable. We don’t have a heroin or opiate epidemic; we have an “opioid epidemic.”  The government usually lumps them together as one. And, as we all know, what the government decides somehow becomes set in stone.

Rochelle Odell lives in California. She’s lived for nearly 25 years with Complex Regional Pain Syndrome (CRPS/RSD).

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.

Medicare Paid Millions for Bogus Lab Tests

By Fred Schulte, Kaiser Health News

Five years ago, Companion DX Reference Lab hoped to cash in on cutting-edge genetic tests paid for by Medicare.

The Houston lab marketed a test to assess how a person’s genes affect tolerance for drugs such as opiates used to treat chronic pain. It also ran DNA tests to help treat cancer and urine screens to monitor drug abuse.

But the lab went bust last year after Medicare ordered it to repay more than $16 million for genetic tests health officials said were not needed.

Companion Dx is one of at least six clinical labs mired in bankruptcy court after Medicare alleged they improperly billed the government for unnecessary urine, genetic or heart disease tests expected to cause hundreds of millions dollars in losses to taxpayers, an investigation by Kaiser Health News found.

As the nation’s bill for drug and genetic tests has climbed to an estimated $8.5 billion a year, there’s mounting suspicion among health insurers that some testing may do more to boost profit margins than help treat patients.

Medicare has slashed fees for urine tests and tightened coverage of some genetic screens, which can cost Medicare $1,000 or more per person. Private insurers, who mostly have paid these bills without question, also are taking a more penetrating look at spending on the controversial lab work.

Yet, getting these firms to repay Medicare and private insurers remains a formidable challenge. While some doctor-owned labs have dodged collection efforts for years, several testing firms deeply in debt to Medicare appear to have few assets to repay overcharges dating back years, court records show.

COURTESY PAIN EXHIBIT

“Medicare shouldn’t be paying for dubious tests, but the time to catch that is in the very beginning when [labs] are asking for payment,” said Steve Ellis, vice-president of Taxpayers for Common Sense, a budget watchdog group. “They need to increase oversight so the dollars don’t go out the door in the first place.”

A spokesman for the federal Centers for Medicare & Medicaid Services (CMS) had no comment. Neither did the Department of Justice, which represents the government’s interests in court.

Labs can run a range of genetic and drug tests using a saliva sample, blood or urine specimen. The price tag to Medicare can mount quickly, especially when doctors order highly specialized tests for large numbers of patients. Two bankrupt labs that federal officials say routinely overused tests to detect rare heart ailments in the elderly, for instance, could end up owing the government a total of more than $200 million, court records show.

Some labs have kept operating in bankruptcy while others liquidated equipment and sold off assets. Several bankruptcy trustees, whose duty is to ferret out assets, are suing suppliers, insurers and some doctors to recover funds.

Whether they can raise the pile of cash needed to repay Medicare is doubtful.

Companion Dx, according to bankruptcy records, had $117,497 cash on hand at the end of September. Medicare is seeking the return of $16.2 million paid to the company for services “not considered medically necessary,” according to a January court filing.

The Texas lab had no comment, but in court filings has blamed its collapse on disagreements with Medicare over the merits of its tests and government audits that retroactively disallowed claims. Medicare pays only for services it deems “medically necessary,” and audits typically take many years to complete.

Companion Dx opened in January 2012 expecting to “capture favorable profit margins that existed in connection with this cutting edge technology,” the company wrote in its bankruptcy filing.

However, starting in 2013, Medicare began having second thoughts about the validity of some tests and ultimately decided to cover them on just 1 percent of patients, according to the company. The lab declared bankruptcy in July 2016. The case is pending.

Iverson Genetic Diagnostics Inc. is another lab that turned to bankruptcy court as Medicare tried to reclaim $19.7 million, court records show. The case is pending.

Medicare took aim at the Seattle firm in November 2013 after reviewing “numerous” complaints of billings for genetic tests that patients “had not actually received,” federal officials wrote in a court filing.

A later federal audit concluded that Iverson had charged Medicare for tests that were “not reasonable and necessary.” In September 2015, about two months after Medicare called for the refund, the lab filed for bankruptcy.

Iverson denied overbilling Medicare and is appealing the Medicare decision, which it said in a court filing “was not based upon sufficient or proper evidence.” And Iverson denied wrongdoing in court filings.

Neither the lab, now located in Charleston, S.C., nor its lawyers would comment.

‘No Cash Left’

In another case, Pharmacogenetics Diagnostic Laboratory LLC in Louisville exited bankruptcy in late October without repaying Medicare $26.3 million for disallowed genetic tests. The lab, set up in 2004 by two University of Louisville professors, strongly disputed Medicare’s findings but said they were the “primary reason” for the bankruptcy, court records show.

Charity Neukomm, a lawyer for the lab, said another medical group agreed to purchase all its assets “free and clear of liens.” That left nothing for the government.

There’s also little chance that Natural Molecular Testing Corp., a defunct genetic testing lab, will repay the $71 million it owes Medicare, according to John Kaplan, an attorney for the bankruptcy trustee.

Kaplan said the lab near Seattle, which opened in 2010, was “printing money from billing Medicare” until the government suspended payments in April 2013. The company filed for bankruptcy in 2013 in the face of a Medicare audit of its billing and concern over its business practices, such as paying some doctors who ordered its tests as much as $10,000 a month in consulting fees, according to court records.

Five years in, the bankruptcy case is expected to settle next year, but there’s likely to be “no cash left” to repay Medicare, Kaplan said.

Critics argue that Medicare has been slow to assess the benefits of new and controversial tests and technologies — even when soaring costs signaled a warning of possible overuse.

Spending on genetic testing, for example, shot up from about $167 million in 2013 to more than $466 million a year later, according to Medicare billing data. In 2015, the program spent about $317 million on the tests and some $165 million last year. Government auditors credit tighter oversight for the sharp decline in billing.

Ellis, the budget watchdog, said the “huge jump” in these bills should have “sent out a red flag.”

Medicare officials don’t routinely verify that the sales claims labs make to doctors are rooted in scientific evidence. Some labs have hawked genetic tests as a tool for making pain management safer. The labs contend the tests can pinpoint the proper drugs and dosage for each patient based on their genetic makeup, thus reducing the threat of overdose or other injury.

However, many experts argue that the science hasn’t caught up to the sales pitch — and that some high-priced tests may do little to diagnose or treat illness.

Genetic tests “are not ready for prime time,” said Charles Argoff, professor of neurology at Albany Medical College in New York. He said their impact on medical care “hasn’t been measured.”

Court records show that the legal battles to recover assets from failed labs often plod on for years, especially when trustees believe labs paid illegal fees or other kickbacks to persuade doctors to order dubious tests.

“Some of these cases never go away,” said David Schumacher, a Boston health care lawyer who has defended doctors against these claims. Still, he said that even after years of legal wrangling Medicare often is unlikely to “be made whole and fully repaid.”

The trustee for Heart Diagnostic Laboratory, which marketed a panel of blood tests to detect heart disease and other illnesses before its June 2015 bankruptcy, has filed more than three dozen lawsuits to recover money paid to doctors and medical offices, including suspect consulting fees.

“Our analysis is that all of these payments were tainted and therefore we’re entitled to go after them,” said Richard Kanowitz. He added: “It’s an uphill battle.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

12 Great Gifts of Knowledge About Chronic Pain

By Pat Anson, Editor

Still looking for a special gift for a loved one over the holidays? If they live with chronic pain -- or if you have pain and want a friend or relative to have a better understanding of what you're going through -- here are 12 books that would make great gifts.

These and other books can be found in our Suggested Reading section. I recently added new books about kratom and medical cannabis, along with a novel based on a true story about a pain physician whose reputation and practice were ruined by prosecutors.

Click on the book's cover to see price and ordering information. Pain News Network receives a small amount of the proceeds -- at no additional cost to you -- for orders placed through Amazon.

Kratom Book by Katharine Gideon

In this beginner's guide to kratom, Katharine Gideon explains how the leaves of a tree that grows in southeast Asia have been used for centuries as a natural remedy to manage pain and depression. She explains the different strains of kratom and how they can be used in capsules, extracts, teas and powders to treat a variety of medical conditions.

Cannabis for Chronic Pain by Rav Ivker, DO

Dr. Rav Ivker is a family physician and holistic healer who learned about the pain relieving benefits of medical marijuana while treating his own severe case of shingles. He offers step by step instructions on the benefits and appropriate use of medical marijuana to treat arthritis, back pain, migraines, fibromyalgia and other chronic pain conditions.

Back in Control by David Hanscom, MD

Spine surgeon Dr. David Hanscom has helped hundreds of back pain sufferers by teaching them how to calm their central nervous systems without the use of drugs or surgery. Hanscom shares the latest developments in neuroscience research and his own personal history with pain, which at one point led him to consider suicide.

Pain on Trial by J.Z. Gassko

J.Z. Gassko bases this novel on the true story of a well-respected doctor whose reputation and practice were ruined by overzealous prosecutors. The book describes the complex world of pain management and how the "relentless war" against opioid addiction impacts both patients and medical professionals.

Crooked: Outwitting the Back Pain Industry by Cathryn Jakobson Ramin

Investigative journalist and back pain sufferer Cathryn Jakobson Ramin spent six years looking at the pros and cons of surgery, opioids, chiropractic care, epidural steroid injections and other types of treatment for back pain. Her conclusion? You're better off with a structured exercise program. 

The Painful Truth by Lynn Webster, MD

Pain specialist Dr. Lynn Webster shares the inspirational stories of patients struggling with chronic pain, and examines the benefits and risks of opioid medication, the importance of caregivers, and how patients can have fulfilling lives even in the worst pain situations. The Painful Truth offers a path toward awareness, hope and healing.

A Nation in Pain by Judy Foreman

Award-winning health journalist Judy Foreman spoke with doctors, scientists, policy makers and patients for her sweeping account of the chronic pain crisis in America. Foreman examines possible solutions -- such as better pain education in medical schools -- and the misguided demonization of opioid medication and pain sufferers.

Drug Dealer, MD by Anna Lembke, MD

Stanford psychiatrist Anna Lembke -- a board member of Physicians for Responsible Opioid Prescribing (PROP) -- looks at the origins of the opioid epidemic and the role played by drug makers in promoting the use of opioid pain medication. Lembke says the healthcare system is broken and focuses too much on pills, procedures and patient satisfaction over wellness.

The Opioid-Free Pain Relief Kit by Beth Darnall, PhD

Pain psychologist Beth Darnall offers ten simple steps to relieve pain without the use of opioids, including ways to "quiet" pain through meditation and stress reduction. The book includes an innovative 20-minute CD that uses binaural sound technology to help listeners relax and "deamplify" pain signals.

No Grain, No Pain by Peter Osborne

An expert on gluten sensitivity and food allergies, Dr. Peter Osborne explores how a grain-heavy diet can cause chronic pain by triggering an autoimmune system response. He offers a 30-day, grain-free diet plan to help readers "heal yourself from the inside out."

Noah the Narwhal by Judith Klausner

Author Judith Klausner, who grew up with chronic migraines, wrote this children's book to help kids cope with headache pain. It tells the story of Noah, a narwhal whale, who suffers from daily bouts of chronic pain. “My head feels like it’s full of sea urchins," Noah says.

Paindemic by Melissa Cady, DO

Osteopathic physician Melissa Cady believes opioids should not be a first-line treatment for chronic pain, and that there are many other unnecessary and risky interventions that provide little benefit. She advocates an "antiPAIN lifetstyle" that focuses initially on physical therapy and exercise.

Genetics Play Significant Role in Post-Surgical Pain

By Pat Anson, Editor

An important new study has confirmed that a patient’s genes really do play a role in determining whether they develop chronic pain after surgery.

Researchers in China collected blood samples from 1,152 surgical patients to look for genetic variations in 54 "pain-related" genes which have been associated with pain sensation. Patients were then contacted a year later to see if they had chronic post-surgical pain.

A surprising number – one out of five patients – still experienced pain at the wound site, and 33 percent of them said their pain was severe.  Patients with pain also reported problems with their overall health, as well as daily activities such as mood, walking, relations with others, sleep, and quality of life.

Aside from genetic factors, the study also found patients younger than 65, males, and those with a prior history of chronic pain were at increased risk. The study is published online in the journal Anesthesiology.

"Our study not only shows there are common genetic variations among people that may help to identify whether they are at high-risk for developing chronic pain after surgery, but it also helps explain why only a fraction of patients ever even experience persistent pain," said lead researcher Matthew T.V. Chan, MD, at the Chinese University of Hong Kong.

"Until now, the genetic variations associated with chronic post-surgical pain have not been well identified."

One genetic variation in particular - a gene found in the nervous-system called brain-derived neurotrophic factor (BDNF) - was found to be most frequently associated with chronic post-surgical pain. Researchers confirmed the finding in a study on laboratory mice.

The researchers also found that genetic variations account for a higher percentage of chronic post-surgical pain (between 7 percent and 12 percent) than other risk factors such as age, sex, smoking history or anesthesia technique (between 3 percent and 6 percent).

Chronic post-surgical pain is one of the most common and serious complications after surgery. Previous studies have found that chronic pain was common after abdominal hysterectomies (25.1%) and heart or lung surgery (37.6%).

“Considering that more than 230 million surgeries are performed each year worldwide, the data would imply that millions of patients will continue to suffer wound pain, months to years after their surgery,” researchers said.

The study comes at a time when many U.S. states have adopted or are enacting laws that would limit the supply of opioid medication to just a few days for acute short-term pain. Minnesota, for example, is close to adopting strict guidelines that would limit the dose and supply of opioids to three days for acute pain and seven days after a major surgery.

Teen Misuse of Rx Opioids at Historic Lows

By Pat Anson, Editor

Misuse of opioid pain medication by American teenagers is at an historic low, according to a nationwide survey that also found prescription painkillers have become increasingly harder for teens to obtain.

Nearly 44,000 students in 8th, 10th or 12th grade were questioned about their drug use in the University of Michigan’s annual Monitoring the Future (MTF) survey. Overall, the number of teens drinking, smoking and abusing drugs is at the lowest level since the 1990’s, although marijuana use spiked upward in 2017.

While the so-called opioid epidemic continues to make national headlines, misuse of prescription painkillers by teenagers has been steadily falling for over a decade.

The survey found that 4.2% of 12th graders used “narcotics other than heroin” in the past year, down from 9.4% in 2002.

Only 35.8% of high school seniors said the drugs were easily available in the 2017 survey, compared to more than 54 percent in 2010.

“We’re observing some of the lowest rates of opioid use that we have been monitoring through the survey. So that’s very good news,” said Norah Volkow, MD, director of the National Institute on Drug Abuse. "The decline in both the misuse and perceived availability of opioid medications may reflect recent public health initiatives to discourage opioid misuse to address this crisis."

The misuse of the painkiller Vicodin continues a decade long decline, falling to 2.9% of high school seniors in 2017. That’s down from 10.5% of seniors in 2003. Similar declines were reported in the misuse of OxyContin.

Marijuana use by teenagers rose by 1.3% to 24 percent in 2017, the first significant increase in seven years.

“This increase has been expected by many,” said Richard Miech, lead investigator of the study. “Historically marijuana use has gone up as adolescents see less risk of harm in using it. We’ve found that the risk adolescents see in marijuana use has been steadily going down for years to the point that it is now at the lowest level we’ve seen in four decades.”

For the first time, the survey asked students about vaping.  Nearly 28 percent of high school seniors said they had used a vaping device in 2017. A little over half said the mist they inhaled was "just flavoring," about a third said they inhaled nicotine, and 11% said they vaped marijuana or hash oil.

After years of steady decline, binge drinking appears to have hit bottom. Nearly 17 percent of 12th graders said they had five or more alcoholic drinks in a row sometime in the last two weeks. That’s a lot, but it's down from 31.5% in 1998.

ER Safety Tips for Ehlers-Danlos Syndrome Patients

By Ellen Lenox Smith, Columnist

People living with Ehlers-Danlos Syndrome (EDS) are often afraid to go to a hospital emergency room, due to a lack of understanding in the ER staff on how to safely care for them. I myself recently had another negative experience, one that almost killed me.

In the process of being admitted, after passing out over and over due to low blood pressure, things went terribly wrong. While being transferred from the ambulance to the hospital stretcher, my hip was dislocated. This dislocation was unintentional, but avoidable, as it was a direct result of the rough manner in which the transfer was managed.

On top of this, they gave me no IV fluids for several hours, which should have been the first thing done to help elevate my blood pressure. Complicating matters even further, no food was brought to my room that I could safely eat and metabolize for the two days I was there.

And then, when a nurse thought I had stopped breathing, she compressed my chest to stimulate my heart, even though I was wearing two medical bracelets warning I shouldn’t be given chest compressions. Three months later, I am still paying for these mistakes.

As a result of my traumatizing and life threatening experience, I sent a letter to the hospital in the hopes of never having another EDS patient experience what I did. I was shocked to receive a call that resulted in the hospital taking me up on my offer to meet with their doctors and nurses to help them understand how to properly handle us.

To prepare for this meeting, I asked other EDS patients to submit suggestions to enhance my program. I hope that this list will be helpful to both patients and hospital staff.

How to Treat Ehlers-Danlos Patients

• Consider having a generic EDS protocol for staff to get a quick understanding of this condition with new patients.
• Put notes or a bulletin board or patient chart to share information and keep the patient safe from shift to shift.
• Be cautious, for EDS is an “invisible condition” so remember to do no harm. Understand that touching and moving us can create more problems, so listen to the patient. Tread lightly using chest compressions, because our ribs sublux, dislocate and break easily. Allow EDS patients to position themselves safely before any procedure.
• Subluxations are a real thing. Don't just take a quick x-ray and tell us, "It's nothing, you're fine.” When a joint feels wrong, there's an injury worth finding some relief for.
• Because we bruise easily, don’t rush to judgement with EDS children before reporting abuse.
• If someone arrives with an ID warning bracelet, please read and respect what is says!
• If a patient has low blood pressure, elevate their bed to a 30% angle. Hook up IV fluids quickly and approve the patient’s BP medication in time for their next dose. Consider using a PICC line if the IV does not hold.
• Many EDS patients are drug reactive, so respect if a DNA drug test has been done or listen to what medications have not worked in past. Pain relief is difficult to achieve with EDS so please believe the person.
• Some of us use compounded medications that need to be accepted in place of what you have in stock in the pharmacy. Some also use supplements, so please respect the use of them. Many are using the Cusack Protocol supplement routine.
• If a patient is using cannabis for pain control, consider allowing CBD use in the hospital in an oil, tincture, topical or pill form.
• Many of us are food reactive, so send your dietician to the room to meet the patient and create a safe meal plan.
• If a patient sleeps with CPAP or BPAP mask, be sure that it gets brought in and worn during sleep.
• Have on staff a physical therapist that can use manual energy techniques for re-alignment or allow an EDS manual therapist on the floor.
• If there is a need to draw blood, use a butterfly or small pediatric needle.
• If there is a need for intubation, be careful with movement of the neck and use small equipment. If an EDS patient presents with a neck fusion, do intubation using the fiber optic glidescope.
• If stitches are needed, try to using natural products over synthetic.
• Many of us have wound healing issues, so please be careful with the choice of tape and its removal. Some of us have skin that is fragile and easily tears.
• All types of EDS are at increased risk for scary vascular events. Any sudden or severe chest or abdominal pain needs a scan to rule out an aneurysm or another serious condition.

If surgery is needed, be sure to have your anesthesiologist do a pre-op interview before any procedures. Be careful about joint positioning and manipulation when performing anesthesia. Yes, that "jaw thrust maneuver" may make intubation easier or more comfortable, but it's not worth the months of rehab from a dislocated jaw.

Please reassure your orthopedic residents that we'd prefer to avoid surgery, too. Having them share their fears out loud that they don't want to operate on EDS patients because “that'll just make things worse" may be true, but it's not helpful. Nobody wants to feel like an untouchable leper. Instead, please focus on what you can do to help. It might be as simple as helping to reposition the joint to a more neutral spot, and then bracing or splinting it there to give things a rest before starting physical therapy

Ehlers-Danlos can be a very painful, isolating and heartbreaking condition to live with. We would love to come to a hospital for emergency help and not be afraid to be sent home in worse shape. Let’s all work to educate the medical field and improve the future for us all coping with this condition. May this list be a start for you!

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis. Ellen and her husband Stuart are co-directors for medical marijuana advocacy for the U.S. Pain Foundation and serve as board members for the Rhode Island Patient Advocacy Coalition.

For more information about medical marijuana, visit their website.

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

Enthusiasm for Medical Marijuana Ahead of Science

By Roger Chriss, Columnist

There is a tsunami of enthusiasm for medical cannabis. Rolling Stone is touting “medical pot” as the best hope to fight the opioid crisis. Newsweek has introduced the world to the “father of marijuana research” and even offered suggestions for using cannabis in holiday cooking.

But underlying all this cannabis coverage are confusing claims about the efficacy of medical marijuana for chronic pain and other conditions.

Although still in its infancy, the science behind medical cannabis is growing rapidly.  ClinicalTrials.gov lists 139 research studies underway. PubMed.gov lists 5,615 articles about “medical cannabis” and over 25,000 articles about “marijuana.” By comparison, PubMed lists only 112 articles about kratom.

The results of these thousands of studies involving scores of medical conditions are mixed, with an extensive list and reviews of clinical studies available on Cannabis-Med.org.  

The National Academy of Science released “The Health Effects of Cannabis and Cannabinoids” report in January 2017, stating that there is “evidence to support that patients who were treated with cannabis or cannabinoids were more likely to experience a significant reduction in pain symptoms.”

But a review article from September 2017 called "Cannabinoids in Pain Management and Palliative Medicine" concluded that public perceptions about the effectiveness of cannabis in providing pain relief “conflicts with the findings.”

"There is limited evidence for a benefit of THC/CBD spray in the treatment of neuropathic pain. There is inadequate evidence for any benefit of cannabinoids (dronabinol, nabilone, medical cannabis, or THC/CBD spray) to treat cancer pain, pain of rheumatic or gastrointestinal origin, or anorexia in cancer or AIDS," German and Canadian researchers reported.

This apparent contradiction is often a result of limited research findings. Studies on medical cannabis are usually small-scale, preliminary, methodologically poor and statistically underpowered, and thus of limited value for drawing general conclusions.

The biggest issue in many studies is the lack of a good placebo for marijuana, as described in a recent JAMA Internal Medicine article: “Many trial subjects can distinguish between active cannabis and placebo.” This means that blinding subjects to obtain unbiased results is difficult, which makes the findings insufficient to get FDA approval as a medication.

"Unfortunately, there are almost no uses of medical marijuana that have been subjected to the kind of rigorous testing you'd want for a pharmaceutical," says Dr. Kenneth Mukamal, associate professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center.

But there is progress. As the JAMA Internal Medicine study noted, “Some of the strongest evidence is for neuropathic pain, spasticity associated with multiple sclerosis, and anorexia in the setting of serious illness.”

A recent phase III clinical trial supports this.  Nearly 250 patients with moderate to severe neuropathic pain from multiple sclerosis saw “clinically relevant” reductions in pain intensity due to dronabinol, a synthetic marijuana derivative.

Marijuana Not Risk Free

Studies are also showing that medical cannabis is not risk-free. Some media reports state that there is no known instance of a fatal overdose involving marijuana. This is accurate, but fatal overdose is not the only measure of risk for a substance. Non-fatal toxicity, including cannabinoid hyperemesis syndrome (recurring nausea, vomiting and stomach pain), and other side effects are not trivial risks.

“Chronic effects of cannabis use include mood disorders, exacerbation of psychotic disorders in vulnerable people, cannabis use disorders, withdrawal syndrome, neurocognitive impairments, cardiovascular and respiratory and other diseases,” researchers warned in a 2014 article in the journal Current Pharmaceutical Design.

Research on the long-term effects of daily marijuana use is also limited. Fortunately, the National Institutes of Health is sponsoring major research on medical cannabis, including a 5-year study to see if medical cannabis reduces opioid use in adults with chronic pain. Similar efforts are underway at the UCLA Cannabis Research Initiative and elsewhere.

Therefore, it is premature to assume that medical cannabis is a thoroughly understood substance that will safely solve all chronic pain problems. Chronic painful conditions are complex, and the treatments that work for one condition may be contraindicated for another. Moreover, not everyone tolerates cannabis, just as not everyone tolerates NSAIDs or opioids. And a person’s medical condition and treatment plan may or may not be able to accommodate cannabis.

Medical cannabis has the potential to become another resource for pain management. It is showing promise for some neuropathic pain disorders, but does not seem to be as effective for visceral or rheumatic pain. In time, we will know how to use medical cannabis safely and reliably. But the present enthusiasm is running ahead of the science, and conclusions are preceding analysis.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

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.

Painkillers Raise Risk of Obesity and Hypertension

By Pat Anson, Editor

Commonly prescribed painkillers such as opioids and gabapentinoids  -- a class of pain medication that includes Lyrica and Neurontin – significantly raise the risk of obesity and high blood pressure, according to a large new study published in PLOS ONE.

British researchers analyzed health data on over 133,000 people, comparing the Body Mass Index (BMI), waist circumference, blood pressure and sleeping habits of patients taking pain relievers to those who did not. The study is believed to be the largest to look at the effects of painkillers on overall health.

“In the last two decades there has been a significant increase in the number of people being prescribed both opioid and non-opioid medications to treat chronic pain,” said lead author Sophie Cassidy, PhD,  a research associate at the Institute of Cellular Medicine, Newcastle University. “We already know that opiates are dependency-forming but this study also found patients taking opiates have the worst health. Obesity rates are much higher and the patients reported sleeping poorly.”

Those taking opioids were 95% more likely to be obese, 82% more like to have a “very high” waist circumference and 63% more likely to have hypertension compared to the control group.  

“There could be a number of possible mechanisms by which opioids might be associated with weight gain. Sedation might decrease physical activity and therefore reduce energy expenditure, those in our cohort taking opiates were less active, and those taking both opiates and other sedative drugs were the least active. Opioids have also been shown to alter taste perception with a craving for sugar and sweet foods described,” Cassidy wrote.

“These results add further weight to calls for these chronic pain medications to be prescribed for shorter periods.”

Patients who took gabapentinoids were also more likely to be obese, have a bigger waist and higher blood pressure compared to those not taking the drugs.

Gabapentinoids are commonly prescribed as alternatives to opioids to treat neuropathy, shingles and fibromyalgia, although many patients complain about side effects such as weight gain, depression and anxiety.

As PNN has reported, gabapentinoids are also coming under scrutiny because they are increasingly being abused. Lyrica (pregabalin) and Neurontin (gabapentin) are being reclassified as controlled “Class C” substances in the UK, following a spike in the number of deaths involving the medications.

Last week, the West Virginia Board of Pharmacy designated gabapentin as a “drug of concern,” after overdoses in the state involving gabapentin rose from 36 deaths in 2012 to 106 in 2016.  Ohio, Pennsylvania and Kentucky have also reported increases in fatal overdoses involving gabapentin.