Grieving a Former Life

By Pamela Jessen, Guest Columnist

Once upon a time, there was a woman named Pamela. She was a strong, vibrant woman who worked as an operations administrative assistant for a company called FGL Sports, which operated a chain of sporting goods stores in Canada. Pamela took care of the administrative needs of the director and senior management team. 

Unknown to these people, Pamela lived with fibromyalgia and osteoarthritis. She did her job so well that she was able to keep these illnesses hidden for a long time, but they gradually started to get in the way of her work. Pamela eventually had to leave her job and go on permanent disability.

That was really devastating for Pamela because work was her life! She loved everything she did, from organizing training meetings and corporate functions to keeping her boss’s life on track. 

Once she was no longer working, a lot of negative feelings started to dwell up inside Pamela. She started feeling depressed, angry, sad and lonely. These were natural responses to having a chronic illness, but it was also frustrating to have to deal with them on top of not actually having a job to go to.

Pamela felt herself getting more depressed and sometimes it was easier to just stay in bed and sleep rather than get up and face life. She knew this wasn't good, but there really wasn't any reason to get up anymore.

Well, of course, that woman was me. It was a difficult phase of my life, as work had always been my passion. I was an administrative specialist in retail support for most of my career and I loved what I did. Every day was a treat. Unfortunately, my body just couldn’t keep up with me. The pain and exhaustion that goes along with fibromyalgia and osteoarthritis took over my body and I had to surrender to it. There simply was no other choice. 

After some time, I took a chronic pain management course and started feeling better mentally. This course explored the various stages of grief we go through when you experience a job loss because of illness and disability, and I realized that was exactly what had happened to me. I had been grieving. 

There are five stages of grief: denial, anger, bargaining, depression and acceptance. The instructor asked us what we had to give up in our lives because of chronic illness. He had us make a list and to really think about what was on that list. Mine, of course, was my job and the volunteering that I loved to do. 

I knew going back to work wasn't going to happen again, but I was sure there must be a way I could use my volunteer skills on my terms. Then one day I noticed an advertisement in my local paper for an organization called Patient Voices Network in British Columbia and it looked perfect for me. The group was looking for volunteers who could be the voice of the patient when health care providers needed that voice in their engagements. I attended an orientation session and before I knew it, was attending my first assignment! I loved it from the start and have been an active participant ever since. 

Currently, I am the co-chair of the Oversight & Advisory Committee for Patient Voices Network. I also sit on the Clinical Resources Committee for the BC Emergency Physicians Network. 

It’s amazing how getting involved again in something you love can bring the grieving process full circle to acceptance. I realized that I had given up a lot because of fibromyalgia and osteoarthritis. But by accepting my new limitations, I actually gained a whole lot more.

Pamela Jessen lives in Langford, British Columbia. She has a blog called There Is Always Hope, where she writes about living with invisible illness.

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.

Long-Term Opioid Use Rare After Wisdom Teeth Removed

By Pat Anson, Editor

Anti-opioid activists have long claimed that thousands of young people have become addicted to opioid pain medication after having their wisdom teeth removed.

“Would you give your child heroin to remove a wisdom tooth?” is how a provocative 2016 anti-opioid billboard in New York City’s Times Square put it.

But a large new study published in JAMA found that the risk of long-term opioid use after wisdom tooth removal is relatively rare – although still a cause for concern.

The study of over 70,000 teens and young adults found that only 1.3% were still being prescribed opioids months after their initial prescription by a dentist. The risk of long-term use was nearly 3 times higher for young people prescribed opioids than for those who were not (0.5%).

Although the overall risk of long-term use is small, researchers say the sheer number of wisdom tooth removals warrants caution when prescribing opioids.

"Wisdom tooth extraction is performed 3.5 million times a year in the United States, and many dentists routinely prescribe opioids in case patients need it for post-procedure pain," said lead author Calista Harbaugh, MD, a research fellow and surgical resident at the University of Michigan’s Institute for Healthcare Policy and Innovation.

"Until now, we haven't had data on the long-term risks of opioid use after wisdom tooth extraction. We now see that a sizable number go on to fill opioid prescriptions long after we would expect they would need for recovery, and the main predictor of persistent use is whether or not they fill that initial prescription."

Harbaugh and her colleagues looked at insurance claims for opioid prescriptions between 2009 and 2015. Hydrocodone (70%) was the most common opioid prescribed after wisdom tooth removal, followed by oxycodone (24%). Long-term opioid use was defined as two or more prescriptions filled in the year after wisdom tooth removal.

But other factors besides dental surgery raised the risk of long-term opioid use. Teens and young adults who had a history of chronic pain or mental health issues such as depression and anxiety were more likely to go on to regular use after filling their initial opioid prescription.

"These are some of the first data to the show long-term ill effects of routine opioid prescribing after tooth extractions. When taken together with the previous studies showing that opioids are not helpful in these cases, dentists and oral surgeons should stop routinely prescribing opioids for wisdom tooth extractions and likely other common dental procedures," said senior author Chad Brummett, MD, co-director of the Michigan Opioid Prescribing and Engagement Network.

There are no specific prescribing guidelines for wisdom tooth removal. The American Dental Association recommends that dentists first consider non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. It also supports the CDC opioid guidelines, which recommend that opioids be limited to no more than 7 days' supply for acute pain.

A small 2016 study found that over half the opioids prescribed to patients after wisdom tooth removal or dental surgery go unused, with many of the leftover pills being abused or stolen by friends and family members. On average, dental patients received 28 opioid pills and – three weeks later – most had pills leftover.

How Common Is Opioid Addiction?

By Roger Chriss, PNN Columnist

As the opioid crisis continues to worsen, there is increased scrutiny of both prescribing levels and fatal overdose rates. The goal of reducing opioid prescriptions is to decrease the exposure to opioids, on the theory that medical use of opioid analgesics is closely linked with addiction and overdose risk.

But how valid is that theory? A key issue in the crisis is opioid addiction rates, which can be divided into medical and non-medical addiction.

Medical Opioid Addiction Rates

The National Institute on Drug Abuse (NIDA) reports that 8 to 12% of patients on long-term opioid therapy develop an opioid use disorder.

“The best and most recent estimate of the percentage of patients who will develop an addiction after being prescribed an opioid analgesic for long-term management of their chronic pain stands at around 8 percent,” NIDA Director Nora Volkow, MD, told Opioid Watch.

The NIDA estimate is well-researched and widely accepted. But there are other estimates, each with important qualifications.

Cochrane found in a major review of studies of long term opioid therapy for non-cancer pain that only 0.27% of participants were at risk of opioid addiction, abuse or other serious side effects.

In another large study, The BMJ reported that only about 3% of previously opioid naïve patients (new to opioids) continued to use them more than 90 days after major elective surgery.

Other addiction rates include numbers as low as 1% and as high as 40%. But details matter. Much of the difference in addiction rates stems from three factors:

1. How well screened the patient population is

2. How carefully monitored the patients are during opioid therapy

3. How the criteria for opioid use disorder are applied

In other words, a well-screened and closely monitored population of adults with no risk factors may well have an addiction rate of 1%. The recent SPACE study by Erin Krebs, MD, in which over 100 people with knee osteoarthritis and low back pain were put on opioid therapy for a year, saw no signs of misuse, abuse or addiction. There were also no overdoses.

Non-Medical Opioid Addiction Rates

It’s also important to look at the percentage of people who become addicted to opioids without ever having an opioid prescription. Here the addiction rates are much higher.

A 2009 study in the American Journal of Psychiatry found that among treatment-seeking individuals who used OxyContin, 78% had not been prescribed the drug for any medical reason. The OxyContin was “most frequently obtained from nonmedical sources as part of a broader and longer-term pattern of multiple substance abuse.”  

The 2014 National Survey on Drug Use also found that about 75% of all opioid misuse starts outside medical care, with over half of opioid abusers reporting that the drugs were obtained “from a friend or relative for free.”

Heroin is considered highly addictive, with nearly one in four heroin users becoming dependent. Importantly, most people who try heroin already have extensive experience with other substances, including opioid medication, and many have serious mental illness. There is no research on the addictive potential of heroin in drug-naive people.

Relatively little is known about the complex and concealed world of nonmedical opioid use. Researchers like UCSF’s Daniel Cicerone are working to fill this gap by collecting information on overdoses to get a more accurate picture on the type of opioids being used.  

Risk Management

Opioids remain an essential part of modern medicine, from trauma and battlefield medicine to surgery, end-of-life care and long-term management of chronic, progressive degenerative conditions. This makes risk management vital.

Current tools to screen patients include the long-standing COMM tool and the new NIDA TAPS tool. Novel approaches using genetic testing for opioid risk may eventually help clinicians better assess risk, too. And improved data analytics may also help reduce addiction.

"Understanding the pooled effect of risk factors can help physicians develop effective and individualized pain management strategies with a lower risk of prolonged opioid use," says Ara Nazarian, PhD, a researcher at Beth Israel Deaconess Medical Center.

The Krebs SPACE study achieved an admirable level of safety by carefully screening and monitoring patients during opioid therapy. A similar patient-focused approach that acknowledges the low rate of medical opioid addiction and works to minimize it further is likely to bring benefits to both individuals and society at large.

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.

I Have No Life Without Pain Medication

By Teresa Brewer, Guest Columnist

In 2003, I developed a rare illness called retroperitoneal fibrosis, also known as Ormond’s disease. Many have died from this progressive and painful disease when their abdominal organs became blocked by a fibrous mass.

I have a fibrous mass in my right abdominal area that extends into my back and right leg. The mass was about the size of a soccer ball when it was found during a cat scan and exploratory surgery. The mass is smaller now, but I still have severe chronic pain. And because of the opioid crisis, I was weaned off pain medication in March.

TERESA BREWER

My doctor sent my medical records and referral letters to 17 pain doctors. So far, none have accepted me. Many pain doctors are so busy they're not taking new patients, and many don’t know anything about retroperitoneal fibrosis or won’t take the time to learn about it.

I've been told, "I don't know about your illness and therefore I can't help you!” It’s devastating to hear that.

I do have an appointment at a pain clinic in September to talk with a nurse, get a physical and go over my records. Maybe then I’ll get an appointment to see a doctor. I HOPE! But then who knows, that could be another month or two. The lady who called said they have been overrun with new patients and were trying to see all they can.  But they have a 3-month backlog.

Because I was taken off pain medication, I missed my daughter’s wedding. That really upset and depressed me. She lives in another state and I was looking forward to seeing her get married. She called to tell me she was engaged, and we talked many times over the phone about the wedding. She set up appointments to get my hair and makeup done and even bought me two dresses. 

It totally devastated me to call her in April to tell her I wouldn't be able to make it. We both cried, and I cried almost every day until her wedding day. My son used FaceTime so I could at least watch the wedding, but it was not the same as being there in person. I was heartbroken. 

I also can't see my grandchildren until something is done about the pain. I have a grandson and recently have a new granddaughter, who was born in July. I haven’t seen her yet and haven’t seen my grandson since March. I love my grandson and granddaughter with all my heart!  I have no life. 

Doctors are taking many patients, including cancer patients, off pain medication because they fear losing their medical licenses. And some hospitals aren't giving pain medication to surgery patients. Instead they’re getting Tylenol or Aleve. That is not right! If anyone has surgery, and I've had six surgeries, you need something stronger for pain management.

Why let people suffer?  Many individuals who have abused pain medication are switching to heroin, meth or cocaine. A real drug addict will always find something to take. I've always hated taking medication, even for a headache, but when I became ill, I had no choice.

It seems they are more worried about addicts dying than about people who really need pain medication. I'm not talking just about me. Many people who live with retroperitioneal fibrosis have been taken off pain medication and are suffering.

An individual has no life when they are at home in major pain. It's very hard to get ready to go anywhere or do anything. Many of us are bedridden due to chronic pain. 

Is anything being done about this problem? If so, I'd like to hear it! 

Teresa Brewer lives in Arkansas.

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.

Mayo Clinic: Opioid Prescribing Has Not Changed

By Pat Anson, Editor

Numerous studies have shown that opioid prescriptions are falling. The trend started in 2011 and appears to have accelerated since the release of the CDC’s 2016 opioid prescribing guidelines.

The volume of opioid medication filled last year fell by 12 percent, the largest decline in 25 years, according to the IQVIA Institute.  Prescriptions for hydrocodone – once the most widely prescribed drug in the country – have fallen by a third since their peak. Even the CDC has reported that opioid prescriptions have dropped by about 5% each year between 2012 and 2016.

Anecdotally, many patients tell us opioids are harder, if not impossible, to obtain. Nearly half of the 3,100 patients PNN surveyed last year said they were getting a lower dose. And one in four said they were no longer prescribed opioids.

But according to Mayo Clinic researchers, opioid prescribing hasn't changed that much and remains at high levels. In a study published in the British Medical Journal (BMJ), they report that opioid prescriptions for Medicare and privately insured patients have remained relatively stable over the past few years. And the average daily dose of opioids is well above what it was 10 years ago.

“If you’re hearing the message that prescription opioid use is starting to decline, I think we need to counter that message and say in most populations it really isn’t moving very much.” says lead author Molly Jeffery, PhD, scientific director of the Mayo Clinic Division of Emergency Medicine Research. “Our data suggest not much has changed in prescription opioid use since about five years ago.”

Why the discrepancy? Jeffrey says most of the previous studies only looked at market-level data – the amount of opioids that drug makers reported producing and selling. She and her colleagues dug a little deeper, looking at insurance claims for 48 million U.S. patients between 2007 and 2016.  

Over that 10-year period, the rate of opioid use by privately insured patients remained relatively flat at 6 to 7 percent. The average daily dose for that group, about two pills of 5-milligram oxycodone, remained the same.

The rate of opioid use by Medicare patients 65 and older peaked at 15% in 2010 and decreased slightly to 14% by 2016. Their average daily dose, three 5 mg pills of oxycodone, also remained relatively unchanged.

Rates of opioid use by disabled Medicare patients also haven't changed much, peaking at 41% in 2013 and falling to 39% in 2016. Their average daily dose remains relatively high, about eight 5 mg oxycodone pills. 

“Our research of patient-level data doesn’t show the decline that was found in previous research,” says Jeffery. “We wanted to know how the declines were experienced by individual people. Did fewer people have opioid prescriptions? Did people taking opioids take less over time? When we looked at it that way, we found a different picture.”

The Mayo study includes an interesting disclaimer. While the researchers looked at data from patient insurance claims, they never surveyed or spoke to any patients about their opioid use. The researchers said they would “engage” with patients in future blog posts and press releases.

You can share your views with Molly Jeffery by email at jeffery.molly@mayo.edu or @mollyjeffery on Twitter.

Indiana Paramedics Use Laughing Gas to Treat Pain

By Pat Anson, Editor

They say laughter is the best medicine, but an Indiana fire department has taken that cliché a step further by using “laughing gas” to treat emergency patients.

This week paramedics in the Indianapolis suburb of Fishers became the first in the state to use nitrous oxide for pain management when a patient suffers a broken bone, sprain or some other injury.  The goal is to reduce the use of prescription fentanyl – a potent opioid – and run the risk of a patient becoming addicted.  Fentanyl is currently used to manage pain in about 10 percent of Fishers’ emergency transports.

“It really comes down to the number of overdoses that we respond to. Fishers is not immune to that problem and we're trying to look at any and all ways that we can prevent people becoming addicted to opioids," Fishers Fire Captain John Mehling told WTTV. “If we can take even a little piece of that out of the care for the patients that we deal with, that might be that one step that keeps them from becoming addicted.”

Fire officials say patients must be alert enough to administer the gas themselves by holding a mask over their face while under the supervision of a paramedic. It takes about 2 to 3 minutes for the nitrous oxide to reduce pain and anxiety.    

“This is an effective and responsible adjustment to the care of our patients without the introduction of opiates into their system when possible,” said Fisher Fire Chief Steven Orusa.

Nitrous oxide has long been used to manage pain during dental procedures and is commonly used in European and Australian ambulances. It’s use by paramedics in the United States is relatively new.

Laughing gas is also making a comeback in some U.S. hospitals, where it is offered as an alternative to epidurals for labor pain. St. Joseph’s Regional Medical Center in New Jersey has incorporated nitrous oxide into its “Alternative to Opiates” program, along with dry needles, nerve blocks and music therapy. St. Joseph’s has drawn international attention for significantly reducing the use of opioids in its emergency room, but is rated as one of the worst hospitals in the country by patients, who complain of poor pain care and long wait times.

Although nitrous oxide is considered safer than opioids, it has a long history of being abused for its euphoric effects. The gas was first used in “laughing gas parties” 200 years ago in Great Britain and is still used today by recreational drug users. When inhaled without oxygen mixed in, nitrous oxide can cause blood pressure to drop suddenly and lead to fainting and heart attacks.

How Rx Opioids Saved My Firefighter Husband

By Sonia Bodie, Guest Columnist

A captain at a very busy fire department, a Homeland Security employee, and an instructor with the South Carolina Fire Academy. That was my husband’s life for 17 years. Brent and I both had busy careers in public safety. I'm a paramedic and a firefighter. 

One morning nine years ago, after getting off a particularly grueling 24-hour shift, we decided to drive to some property we own and place a trail camera to observe the wildlife. We drove our off-road vehicle many times before, but that day a grave mistake was made. Whether we were tired, careless or just from a sense of invincibility, I'll never know, but up an extremely steep hill we went!

Almost at the top, the four-wheeler lurched and rolled, throwing us both violently off. I sustained a lower leg fracture that had to be surgically repaired. Brent fractured three vertebrae in his neck. His neck was broken and life as we knew it came to a screeching halt. 

It was like a nightmare that just wouldn't end. Brent needed extensive surgery that included cadaver bones to replace his fractured ones, pins and screws, and a halo neck brace. This sort of thing happens to the people we care for, but this time it was the protector who needed protection. 

Brent’s career was put on hold, but in his mind if he did exactly what the physicians said to the letter, it would be just a matter of time before he would be back to work. He began physical therapy. Four to five days a week he attended. But the pain continued.

He was prescribed anti-inflammatory drugs, a TENS unit, ice and heat therapy. Brent tried them all, thinking his career was just a short step away. 

BRENT AND SONIA BODIE

I recovered and went back to work. But my strong, never-sick husband was slowly becoming a man I barely knew. The pain in his neck was mind boggling, along with severe numbness and constant tingling in his right arm and hand. The severity of the pain completely changed him. 

After a year, Brent’s neurosurgeon gently told him that his part in the healing was over and that he wouldn't sign any medical clearance for him to return to full time firefighting duty.  Brent looked at the doctor with something between shock, horror and bewilderment.  With tears streaming down his face, in a voice so soft and cracking, Brent asked, "What do I do now? I've been a fireman since I was 18 years old. When will this non-stop agony end?" 

I couldn't believe things could get any worse, but they did. Talk of suicide started swirling. He shut down. I cannot count how many times I'd come home from my 24-hour shifts to find Brent curled up in a ball on the floor in so much pain.  

The straw breaker occurred one cold, windy morning.  I came home from work to find Brent sitting at the kitchen table with a pistol beside him. I was frozen in fear. I couldn't find my voice! He said, in a tone I'd never heard from him, "I will NOT continue to live another day, not one single more, in this much suffering and torture! I'm done!" 

I immediately contacted the doctor, who got Brent to see a pain specialist that day.  This was the beginning of a new life for us. I’m so thankful and grateful for this physician. I cannot say that Brent’s agony ended on the spot, but after three months of trying different pain relievers and doses, they found a medication regimen that worked for him. 

Brent goes there monthly. There are urine drug tests and visits with a psychologist before he sees the physician. This is a new season, one that includes opiates. They are taken exactly as prescribed and kept secure, locked in a fire safe.

I see the opioid crisis daily. I give my all as a medic to save those who have chosen to snort, ingest or smoke opioids, most of them illegal, for a life-ending high.  Then I come home to a beloved spouse, whose opioid medication literally saved his! 

I'm very fearful what will happen if Brent’s medication is lowered or stopped because of the new, yet antiquated, opioid prescribing laws. The persecution of the innocent, who require these life-giving medications, must cease.  My husband, who saved so many lives, depends upon it. And he's important too! 

Sonia and Milton “Brent” Bodie live in South Carolina.

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.

Chronic Pain Patients Caught in Debate Over Opioids

By Will Stone, KJZZ

It started with a rolled ankle during a routine Army training exercise. Shannon Hubbard never imagined it was the prologue to one of the most debilitating pain conditions known to exist, called ­­­­­­­complex regional pain syndrome.

The condition causes the nervous system to go haywire, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.

For Hubbard, it manifested years ago following surgery on her foot — a common way for it to take hold.

“My leg feels like it’s on fire pretty much all the time. It spreads to different parts of your body,” the 47-year-old veteran said.

Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It’s red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.

“That started as a little blister and four days later it was like the size of a baseball,” she said. “They had to cut it open and then it got infected, and because I have blood flow issues, it doesn’t heal.”

She knows it’s likely to happen again.

Over the past three years, I’ve been prescribed over 60 different medications and combinations; none have even touched the pain,” she said.

Hubbard said she’s had injections and even traveled across the country for infusions of ketamine, an anesthetic that can be used for pain in extreme cases. Her doctors have discussed amputating her leg because of the frequency of the infections.

“All I can do is manage the pain,” she said. “Opioids have become the best solution.”

For about nine months, Hubbard was on a combination of short- and long-acting opioids. She said it gave her enough relief to start leaving the house again and do physical therapy.

But in April that changed. At her monthly appointment, her pain doctor informed her the dose was being lowered. “They had to take one of the pills away,” she said.

Hubbard knew the rules were part of Arizona’s new opioid law, which places restrictions on prescribing and limits the maximum dose for most patients. She also knew the law wasn’t supposed to affect her — an existing patient with chronic pain.

Hubbard argued with the doctor, without success. “They didn’t indicate there was any medical reason for cutting me back. It was simply because of the pressure of the opioid rules.”

Her dose was lowered from 100 morphine milligram equivalents daily (MME) to 90, the highest dose allowed for many new patients in Arizona. She said her pain has been “terrible” ever since.

“It just hurts,” she said. “I don’t want to walk, I pretty much don’t want to do anything.”

Hubbard’s condition may be extreme, but her situation isn’t unique. Faced with skyrocketing drug overdoses, states are cracking down on opioid prescribing. Increasingly, some patients with chronic pain like Hubbard say they are becoming collateral damage.

New Limits On Prescribing

More than two dozen states have implemented laws or policies limiting opioid prescriptions in some way. The most common is to restrict a patient’s first prescription to a number of pills that should last a week or less. But some states like Arizona have gone further by placing a ceiling on the maximum dose for most patients.

The Arizona Opioid Epidemic Act, the culmination of months of outreach and planning by state health officials, was passed earlier this year with unanimous support.

It started in June 2017, when Arizona Gov. Doug Ducey, a Republican, declared a public health emergency, citing new data, showing that two people were dying every day in the state from opioid overdoses. He has pledged to come after those responsible for the rising death toll.

He has pledged to come after those responsible for the rising death toll.

“All bad actors will be held accountable — whether they are doctors, manufacturers or just plain drug dealers,” Ducey said in his annual State of the State address, in January 2018.

The governor cited statistics from one rural county where four doctors prescribed 6 million pills in a single year, concluding “something has gone terribly, terribly wrong.”

Later in January, Ducey called a special session of the Arizona legislature and in less than a week he signed the Arizona Opioid Epidemic Act into law. He called it the “most comprehensive and thoughtful package any state has passed to address this issue and crisis to date.”

The law expands access to addiction treatment, ramps up oversight of prescribing and protects drug users who call 911 to report an overdose from prosecution, among other things.

Initially, Arizona’s major medical associations cautioned against what they saw as too much interference in clinical practice, especially since opioid prescriptions were already on the decline.

Gov. Ducey’s administration offered assurances that the law would “maintain access for chronic pain sufferers and others who rely on these drugs.” Restrictions would apply only to new patients. Cancer, trauma, end-of-life and other serious cases were exempt. Ultimately, the medical establishment came out in favor of the law.

Pressure On Doctors

Since the law’s passage, some doctors in Arizona report feeling pressure to lower patient doses, even for patients who have been on stable regimens of opioids for years without trouble.

Dr. Julian Grove knows the nuances of Arizona’s new law better than most physicians. A pain doctor, Grove worked with the state on the prescribing rules.

“We moved the needle to a degree so that many patients wouldn’t be as severely affected,” said Grove, president of the Arizona Pain Society. “But I’ll be the first to say this has certainly caused a lot of patients problems [and] anxiety.”

“Many people who are prescribing medications have moved to a much more conservative stance and, unfortunately, pain patients are being negatively affected.”

Like many states, Arizona has looked to its prescription-monitoring program as a key tool for tracking overprescribing. State law requires prescribers to check the online database. Report cards are sent out comparing each prescriber to the rest of their cohort. Clinicians consider their scores when deciding how to manage patients’ care, Grove said.

“A lot of practitioners are reducing opioid medications, not from a clinical perspective, but more from a legal and regulatory perspective for fear of investigation,” Grove said. “No practitioner wants to be the highest prescriber.”

Arizona’s new prescribing rules don’t apply to board-certified pain specialists like Grove, who are trained to care for patients with complex chronic pain. But, said Grove, the reality is that doctors — even pain specialists — were already facing pressure on many fronts to curtail opioids — from the Drug Enforcement Agency to health insurers down to state medical boards.

The new state law has only made the reduction of opioids “more fast and furious,” he said.

Grove traces the hypervigilance back to guidelines put out by the Centers for Disease Control and Prevention in 2016. The CDC spelled out the risks associated with higher doses of opioids and advised clinicians when starting a patient on opioids to prescribe the lowest effective dosage.

Psychiatrist Sally Satel, a fellow at the American Enterprise Institute, said those guidelines stipulated the decision to lower a patient’s dose should be decided on a case-by-case basis, not by means of a blanket policy.

“[The guidelines] have been grossly misinterpreted,” Satel said.

The guidelines were not intended for pain specialists, but rather for primary care physicians, a group that accounted for nearly half of all opioids dispensed from 2007 to 2012.

“There is no mandate to reduce doses on people who have been doing well,” Satel said.

In the rush to address the nation’s opioid overdose crisis, she said, the CDC’s guidelines have become the model for many regulators and state legislatures. “It’s a very, very unhealthy, deeply chilled environment in which doctors and patients who have chronic pain can no longer work together,” she said.

Satel called the notion that new prescribing laws will reverse the tide of drug overdose deaths “misguided.”

The rate of opioid prescribing nationally has declined in recent years, though it still soars above the levels of the 1990s. Meanwhile, more people are dying from illicit drugs like heroin and fentanyl than prescription opioids.

In Arizona, more than 1,300 people have died from opioid-related overdoses since June 2017, according to preliminary state numbers. Only a third of those deaths involved just a prescription painkiller.

Heroin is now almost as common as oxycodone in overdose cases in Arizona.

A Range Of Views

Some physicians support the new rules, said Pete Wertheim, executive director of the Arizona Osteopathic Medical Association.

“For some, it has been a welcome relief,” he said. “They feel like it has given them an avenue, a means to confront patients.” Some doctors tell him it’s an opportunity to have a tough conversation with patients they believe to be at risk for addiction or overdose because of the medication.

The organization is striving to educate its members about Arizona’s prescribing rules and the exemptions. But, he said, most doctors now feel the message is clear: “We don’t want you prescribing opioids.”

Long before the law passed, Wertheim said, physicians were already telling him that they had stopped prescribing, because they “didn’t want the liability.”

He worries the current climate around prescribing will drive doctors out of pain management, especially in rural areas. There’s also a fear that some patients who can’t get prescription pills will try stronger street drugs, said Dr. Gerald Harris II, an addiction treatment specialist in Glendale, Ariz.

Harris said he has seen an increase in referrals from doctors concerned that their patients with chronic pain are addicted to opioids. He receives new patients — almost daily, he said — whose doctors have stopped prescribing altogether.

“Their doctor is afraid and he’s cut them off,” Harris said. “Unfortunately, a great many patients turn to street heroin and other drugs to self-medicate because they couldn’t get the medications they need.”

Arizona’s Department of Health Services is working to reassure providers and dispel the myths, said Dr. Cara Christ, who heads the agency and helped design the state’s opioid response. She pointed to the recently launched Opioid Assistance and Referral Line, created to help health care providers with complex cases. The state has also released a set of detailed prescribing guidelines for doctors.

Christ characterizes this as an “adjustment period” while doctors learn the new rules.

“The intent was never to stop prescribers from utilizing opioids,” she said. “It’s really meant to prevent a future generation from developing opioid use disorder, while not impacting current chronic pain patients.”

Christ said she just hasn’t heard of many patients losing access to medicine.

It’s still too early to gauge the law’s success, she said, but opioid prescriptions continue to decline in Arizona.

Arizona saw a 33 percent reduction in the number of opioid prescriptions in April, compared with the same period last year, state data show. Christ’s agency reports that more people are getting help for addiction: There has been about a 40 percent increase in hospitals referring patients for behavioral health treatment following an overdose.

Shannon Hubbard, the woman living with complex regional pain syndrome, considers herself fortunate that her doctors didn’t cut back her painkiller dose even more.

“I’m actually kind of lucky that I have such a severe case because at least they can’t say I’m crazy or it’s in my head,” she said.

Hubbard is well aware that people are dying every day from opioids. One of her family members struggles with heroin addiction and she’s helping raise his daughter. But she’s adamant that there’s a better way to address the crisis.

“What they are doing is not working. They are having no effect on the guy who is on the street shooting heroin and is really in danger of overdosing.” she said. “Instead they are hurting people that are actually helped by the drugs.”

This story is part of a partnership that includes KJZZ, NPR and Kaiser Health News. It is republished with their permission.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Oregon Opioid Plan Would Do 'Substantially More Harm'

By Pat Anson, Editor

A proposed change in Oregon’s Medicaid program would result in the forced tapering of many pain patients off opioid medication and do “substantially more harm than good,” according to a group of pain physicians, academics and patient advocates.

At issue is a recommendation by a task force to limit Oregon Health Plan coverage of opioids to just 90-days for five broad chronic pain conditions – including fibromyalgia and chronic pain caused by trauma.  Medicaid patients with those conditions taking opioids beyond 90 days would lose coverage for the pain relievers and be encouraged to use alternative pain therapies such as yoga, acupuncture and physical therapy, which would be covered under the plan.

“We recently learned of efforts by the Oregon Medicaid Pain Task Force to deny coverage of opioids beyond 90 days for most chronic pain conditions and, effectively, to mandate the taper of current patients receiving opioid therapy. We believe that such efforts risk doing substantially more harm than good,” wrote Kate Nicholson, a civil rights attorney and pain patient, in a letter to Oregon health officials. The letter was co-signed by over a dozen  physicians, academics and advocates.

“An across-the-board denial of opioid therapy for the huge umbrella category of chronic pain is as destructive as is liberally prescribing opioids for all types of chronic pain,” the letter warns. “The denial of coverage to the Medicaid population, in particular, is likely to have a disproportionate impact on individuals with disabilities, on the sickest patients and those with multiple chronic conditions.”

Oregon’s Health Evidence Review Commission will review the proposal at its August 9th meeting. The commission could give final approval as early as October, but the opioid restrictions would not go into effect until 2020, according to the Bend Bulletin.

“Individuals with chronic pain really face debilitating conditions that impact quality of life, yet we’re faced with this significant opioid epidemic where we know there’s a lot of misuse and overprescribing,” Dr. Dana Hargunani, chief medical officer for the Oregon Health Authority, told the Bulletin. “We’re trying to use evidence to guide us, but we really welcome public input into the process. I know it’s a really significant issue for many individuals.” 

Opioid prescribing in Oregon has been declining for years – as it has nationwide – yet the state has “one of the highest rates of prescription opioid abuse in the nation,” according to the Oregon Health Authority. An average of three Oregonians die every week from an opioid overdose. However, many of those deaths involve the “non-medical” use of opioid pain relievers by drug abusers, not patients.

The 2013 National Survey on Drug Use and Health found Oregon to have the highest rate of non-medical use of prescription pain relievers in the country.

“I’m very sad for the people who OD’d,” pain patient Steve Hix told the Bulletin. “But what’s that got to do with me?”

Older Americans Rarely Abuse Opioid Medication

By Pat Anson, Editor

Three out of four older Americans who are prescribed opioid pain medication say they take it less often or in lower amounts than prescribed, according to a new national poll. Only 6 percent said they took opioids more frequently or in higher doses than prescribed.

The online survey of over 2,000 adults between the ages of 50 and 80 was conducted in March by the University of Michigan's Institute for Healthcare Policy and Innovation.  The poll was sponsored by AARP and Michigan Medicine, U-M's academic medical center.

Nearly a third of those surveyed said they received an opioid prescription in the past two years, usually for arthritis, back pain, surgery or injury. About half of those had leftover medication.

While most were cautious about their use of opioids, what they did with the leftover meds was cause for concern. The vast majority (86%) said they kept it in case they had pain again. Only 9% threw their opioids in the trash or flushed it down the toilet, and 13% returned it to an approved location.

"The fact that so many older adults report having leftover opioid pills is a big problem, given the risk of abuse and addiction with these medications," said Alison Bryant, PhD, senior vice president of research for AARP. "Having unused opioids in the house, often stored in unlocked medicine cabinets, is a big risk to other family members as well.”

The researchers suspect that many older adults fear that they will not be able to obtain pain medication when needed because of laws and guidelines that discourage opioid prescribing. Several states now mandate that initial opioid prescriptions for acute pain be limited to a few days’ supply.

Ironically, while many older Americans may worry about losing access to opioid medication, nearly three out of four (74%) support restrictions on the number of days and pills that can be prescribed. And nearly half would support laws that require leftover medication to be returned.

The poll also found that doctors do not consistently warn patients about the risks associated with opioids. While 90% of those surveyed said their prescribing doctor talked with them about how often to take pain medication, only 60% were warned about side effects and less than half of the doctors cautioned patients about the risks of addiction and overdose or what to do with leftover pills.

A full report on the National Poll on Healthy Aging can be found by clicking here.

Chronic Pain Patients Left Out of the Equation

By Mary Cremer, Guest Columnist

I love math. And I was thinking the other day that chronic pain patients are often left out of the equation.

Many of us have chronic health conditions. We spend hours each day scheduling appointments, being tested, having surgeries, getting injections, undergoing dialysis, going to chemotherapy, doing physical therapy and so much more. Let’s not forget fighting with insurance companies and the time that takes.

Many of us on are on opioid medication and sign pain contracts. We have to go to the doctor’s office and subject ourselves to drug testing. We have to pick up paper prescriptions, go to the pharmacy and hope they have our meds.

Some of us work, some of us do not. But honestly, being sick is a full-time job all by itself.

I think many chronic pain patients are too busy being sick to notice what is happening to our rights. I turned on the television recently and heard about the “opioid crisis.” To me, it was bothersome, as I think of it as an illegal drug issue.

I did some research on the leading causes of death in United States. Here are the top ten and number of deaths in 2015, according to the CDC:

1. Heart Disease: 633,842
2. Cancer: 595,930
3. Chronic Low Respiratory Disease: 155,041
4. Accidents: 146,571
5. Stroke: 140,323
6. Alzheimer’s Disease: 110,561
7. Diabetes: 79,535
8. Influenza & Pneumonia: 57,062
9. Nephritis (kidney disease): 49,959
10. Suicide: 44,193

But wait! Where are the opioid overdoses? They didn’t make the top 10! With the constant drumbeat in the news about overdoses, you’d think they’d be high on the list. 

Then I found that the CDC reported 33,091 opioid deaths in the U.S. in 2015. But, that was ALL opioid deaths, including illegal drugs and legal medications. And many times, if someone had opioids in their system at death, they also had other drugs. 

The hot topic from elected officials is how can we save all of these people from overdosing. But, why isn’t heart disease or cancer the hottest topic? Surely there are many other conditions that need attention. Could money be a factor? 

Many politicians believe opioid medication is the problem and the solution is to restrict access to it. That’s the worst thing that could happen to chronic pain patients. Let’s be honest, drug addiction will always exist and illegal drugs will always exist.  

There have been a lot of misconceptions, misinformation and lies about pain medication. We have been told new laws, insurance coverage and addiction problems are why our meds are being reduced or cut off. But, who is thinking of us? Once again, we’re out of the equation. 

According to The Washington Post, more than 25 million Americans suffer with chronic pain. Some estimates put the number even higher.  Why are our voices not screaming? Perhaps because there is a stigma attached to taking pain meds. Many of us are afraid our employers, friends and even family will find out we use them.

Some patients that still have their meds don’t realize how serious this issue has become.  Others that have lost their meds may be speaking out, but few are listening. Again, we are left out of the equation. 

One equation you can be sure of.  When patients lose access to pain medication, there will be an increase in additional health problems that will cost this country more. Disability, unemployment and suicides will increase tremendously, and the doctor/patient relationship will be forever compromised. I predict a doctor shortage in the future. 

The weakest among us now face the biggest fight of our lives. 

In order to get us back into the equation, pain patients need to proactively contact our elected officials. We need to tell our stories from the heart. We need to present real statistics and facts. We need to be calm and hopeful. We need to ask elected officials for help. Let’s put ourselves back in this equation and fight. 

Mary Cremer lives with her family in Missouri. She has Ehlers-Danlos syndrome and Chiari Malformation.

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.

Do Cultural Activities Reduce Risk of Chronic Pain?

By Pat Anson, Editor

Lose weight and get regular exercise are two health tips we’ve all heard before. But has anyone told you that going to a museum or concert could reduce your risk of developing chronic pain?

It’s true, according to a novel study published in the Journal of Pain.

Researchers looked at data from a 10-year study that tracked the progression of pain in over 2,600 older adults living in England. None of the participants suffered from chronic pain at the start of the study, but after ten years over 42 percent had experienced moderate to severe chronic pain.

Women (60%) were more likely to report chronic pain, along with those who lived alone, had less education, less wealth, slept poorly or were depressed. No surprise there, as many studies have found those conditions are often associated with chronic pain.

Researchers also wanted to know how often people exercised or participated in social events, such as community groups (political parties, trade unions or sports clubs) or cultural activities (visiting museums, art galleries or concerts).

Interestingly, moderate physical exercise appeared to have no effect on the incidence of chronic pain, but regular vigorous activity such as stretching and endurance training reduced the risk of developing pain, especially when it was combined with cultural activities.

“This study also found evidence that psychosocial factors may be protective against the development of chronic pain, in particular engagement in cultural activities such as going to museums, art galleries, exhibitions, concerts, the theatre or the opera,” wrote lead author Daisy Fancourt, PhD, a senior research associate at University College London. "It is notable that the odds ratios for cultural engagement were directly comparable with those of vigorous physical activity, suggesting a reduction of 25-26% in risk of chronic pain incidence."

Fancourt and her colleagues believe that going to a museum or concert provides not only gentle physical activity, but psychological benefits that come from social engagement and having positive cultural experiences.

“Notably, these positive psychological benefits have not been found consistently for community group membership, which could explain the differences in association with chronic pain found in this study. Indeed, it is notable that for participants who experienced widespread pain, only psychosocial factors, not physical factors, were found to be risk-reducing,” said Fancourt.

The study was observational in nature and does not prove that cultural experiences can prevent chronic pain. But unlike dieting and exercise, it does suggest an alternate way to lower the risk of chronic pain that most people would find enjoyable.  And maybe that's the most important lesson.

"This study is the first to explore simultaneously potential physical and psychosocial protective factors for the development of chronic pain in older adults. Our results demonstrate that both vigorous weekly activity and regular cultural engagement appear to reduce risk of incident chronic moderate-severe pain," the researchers concluded.

Obese Adults More Likely to Have Chronic Pain

Another way to reduce your risk of chronic pain is to maintain a healthy weight, according to a recent Washington State University study. Researchers there looked at data from 9 large studies conducted in different countries to calculate the odds of chronic pain among adults with an overweight body mass index (BMI).

They found that adults with a BMI of 25 or more, which is considered overweight or obese, were 14 to 71 percent more likely to suffer from chronic pain than those with a BMI below 25.

“Previous studies have shown that weight gain often precedes the development of chronic pain by many years, so I think our job as medical providers is to educate our patients early on and say, ‘You have a high BMI, your risk of one day developing a chronic pain condition, in addition to heart disease, is much higher,’” says Teresa Bigand, a doctoral student in the WSU College of Nursing.

“I think we need to do a better job of educating overweight people about their risk of potentially developing a chronic pain condition.”

More than 69 percent of the U.S. population and 1.9 billion people worldwide are overweight. For those who are already overweight and suffering from a chronic pain, Bigand says it’s not too late to take action. Research shows people who lose the largest amount of weight have the largest drop in their pain intensity.

“Essentially, weight loss is the best thing to do, however some patients aren’t quite ready for that,” Bigand said. “Patients with the highest and most severe levels of pain intensity struggle the most to lose weight. In those cases, we have to think about how we can help patients get their other symptoms under control that might be exacerbating the pain before we can start thinking about treating their overweight or obese status.”

A recent University of Michigan study, published in The Journal of Pain, found that obese participants who lost at least 10 percent of their body weight had less overall body pain.

“It’s been known for some time that people who are obese tend to have higher levels of pain, generally speaking,” says Andrew Schrepf, PhD, a research investigator at Michigan Medicine’s Chronic Pain and Fatigue Research Center. “But the assumption has always been the pain is going to be in the knees, hips and lower back — parts of the body that are weight-bearing.”

Schrepf and his colleagues found that losing weight not only lowered pain levels in the knees and hips, but in unexpected areas such as the abdomen, arm, chest and jaw. Study participants who could reach the goal of losing 10% of their weight also reported better mental health, improved cognition and more energy. Men in particular showed improvements in their energy levels.

A Reality Check for CBD Oil

By Roger Chriss, PNN Columnist

The Food and Drug Administration’s recent approval of the anti-seizure medication Epidiolex has attracted a lot of new attention for CBD (cannabidiol). But enthusiasm was already on the rise. CBD is being promoted as a “new medical elixir” and marketed in everything from cosmetics to bottled water.

CBD was isolated in marijuana in 1940 and its chemical structure was characterized in 1963. It does not have euphoric effects and is increasingly being used in oils, edibles and other forms to treat medical conditions such as pain.

Last November the World Health Organization released its “Cannabidiol Pre-Preview Report”) stating that “CBD is generally well tolerated with a good safety profile.” The WHO report found “no evidence of recreational use of CBD or any public health related problems associated with the use of pure CBD.”

Last month the FDA approved Epidiolex, a CBD-based drug, to treat seizures caused by two rare forms of childhood epilepsy, Dravet syndrome and Lennox-Gestaut syndrome.  It was the first -- and so far only -- marijuana-based drug to be approved by the agency.

“In terms of solid evidence, the one thing we really know about CBD is that it can be helpful for rare childhood seizure disorders,” Ryan Vandrey, PhD, a cannabis researcher and associate professor of psychiatry at Johns Hopkins University, told Health.com. “There’s not yet sufficient evidence to support its use for any other reason.”

This is not for lack of effort. Zynebra Pharmaceuticals recently tested a topical CBD product for osteoarthritis knee pain with mixed results. The Phase 2 clinical study did not meet its primary endpoint of reducing the average pain score, although there were some indications it improved function and reduced pain severity.

A small clinical trial of CBD for Crohn’s disease in Israel in 2017 was also negative, finding “CBD was safe but had no beneficial effects.”

GW Pharmaceuticals, the manufacturer of Epidiolex and Sativex, conducted a clinical trial in 2012 on CBD oil for pain due to spinal cord injury. The outcome was disappointing. The treatment arm of the study (55 subjects) and placebo arm (59 subjects) showed essentially the same level of improvement in neuropathic pain.

A 2015 study on CBD extracts for childhood epilepsy had puzzling results. Researchers reported in the journal Epilepsy & Behavior that “relocating to Colorado had a significant effect on response rates.” Drugs are not normally affected by zip code or time zone.

A recent review of studies on CBD oil and other forms of cannabis for the management of neurologic disorders was more positive, finding “there is strongest evidence to indicate benefits in treatment of spasticity and neuropathic pain in multiple sclerosis.”

CBD Safety Questions

But there are also cautions. Thorsten Rudroff, PhD, a professor of Health and Exercise Science at Colorado State University, told Neurology Advisor that more studies of CBD were needed.

“While cannabis seems to be effective for the treatment of MS symptoms like pain and spasticity, there are so many unknowns. For example, we don't know much about interactions with other drugs. Also, based on my own research, it seems that cannabis may further impair cognitive function in people with MS, especially in older adults,” Rudroff said.

There are safety issues as well. CBD oil has a good safety profile, but according to Food Safety Magazine, CBD oil products have problems with labeling accuracy, product quality and contaminants.

People with serious medical problems who want to use CBD oil need to reliably source a quality product. Medical users may have allergies, chemical sensitivities and, in the case of cancer patients or people with autoimmune disorders, a compromised immune system. For such people, purity and dose matter.

In addition, there are drug interactions to be aware of. Medline lists nearly a dozen medications that potentially interact with CBD, such as amitriptyline, ibuprofen and meloxicam, which are frequently used by people with health problems.

The decision to use CBD oil for medical purposes needs to be based on science, not marketing. As David Cassaret, MD, notes in his book, Stoned: A Doctor’s Case for Medical Marijuana: “Medical marijuana is becoming too widespread, and the risks are too great, to leave the patient to fend for himself, and to let the buyer beware.”

At present, however, CBD oil is very much a buyer beware world. And the current hype is not helping.

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.

Chronic Pain and Opioids Impact Sexual Health

By Pat Anson, Editor

What’s more important to you?  Pain relief or an active sex life?

The question is not as frivolous as it sounds. According to a recent study published in Pain Medicine, chronic pain patients who take opioid medication are significantly more likely to experience a lack of desire and to be less satisfied with their sex lives, especially if they take opioids long-term.

Of course, anyone with a chronic illness is more likely to have sexual health issues – whether its desire, function or attracting another partner.  But the issues seem more pronounced with those who take opioids.  

Danish researchers surveyed over 11,500 randomly chosen adults. Slightly more than half the women and a little less than half the men said they suffered from chronic non-cancer pain.

Pain sufferers who did not use opioids were 38% more likely to be unhappy with their sex lives and 46% more likely to report a lack of desire than people who were pain free. So just being in pain is a big factor by itself.

But long-term opioid users were 69% more likely to report dissatisfaction with their sex lives and were twice as likely to experience low or no sexual desire.

Short-term opioid users were 35% more likely to be unhappy with their sex life and 82% more likely to have less desire.

“Patients suffering from chronic non-cancer pain should be aware that it can have a negative impact on their sexual desire and satisfaction with sex life, and that using opioids, especially long-term, can add an additional negative impact on their sex life,” lead author Hanne Birke, an oncology researcher at Rigshospitalet (Copenhagen University Hospital) told Reuters.

Only 57 percent of people on long-term opioids reported having sex during the past year.  That compares to 62% of pain patients on short-term opioids, 68% of pain sufferers not taking opioids and 77% of people who were pain free.  

Short-term opioid use was defined as having one prescription filled in the previous year, while long-term use was having opioid prescriptions dispensed in at least six months during the previous year.

Chronic pain and opioid use has long been linked to sexual health problems.

“Chronic pain ‘highjacks’ sensory nerve fibers, thereby making it harder or impossible for pleasurable stimuli to elicit a response,” said Anne Murphy, a researcher at Georgia State University in Atlanta, who wasn’t involved in the study. “On top of that, opiates suppress the activation of sensory nerve fibers which would have an obvious impact on sexual pleasure.”

But many people who were pain free also reported sexual health issues. About 19% of men and 14% of women without chronic pain were unhappy with their sex lives. And 7% of men and 19% of women without pain reported a lack of sexual desire.

Pain Management Not the Same as Addiction

By Marvin Ross, Guest Columnist

It's bad enough that mental illness is, for some strange reason, paired with addiction. But now the Canadian Mental Health Association (CMHA) wants to include pain management as part of its “National Pain and Addictions Strategy.”

Addiction is a terrible affliction for the person addicted, for their family and for society. Of that, there is no question. But it is now considered a mental illness and I have no idea why. As I wrote once before, “Addictions at some point involve choice. You made a decision to go into a bar and start drinking or to snort coke, take opioids or inject heroin. No one has a choice to become schizophrenic, bipolar, depressed or any other serious mental illness. There is no choice involved whatsoever.” 

I also cited smoking, which most people of my generation did and most of us quit. I smoked two  packs a day and quit because my wife has asthma and was pregnant. I was motivated.

I also pointed out that during the Vietnam War, 40% of troops used heroin and the government was fearful of what would happen when they came back. Fortunately for all, 95% of those troops gave up heroin without any intervention whatsoever. They were no longer in a dangerous war zone trying to escape anyway they could.

Chronic pain patients are generally neither addicts nor mentally ill. What they are addicted to is being as pain free as they can be. Chronic pain results from any number of valid medical conditions, severe trauma and/or botched surgical procedures. For many, opioid medication is necessary to have any quality of life.

But CMHA sees opioid prescribing as an inevitable bridge to addiction:

“CMHA is currently collaborating with research partners to explore the efficacy of multidisciplinary care teams and their role in pain management and opioid tapering. CMHA also believes that creating a National Pain Strategy that includes addictions would allow for more effective training and would better prepare physicians and primary care providers to treat pain in Canada.”

CMHA is correct when they say that pain is poorly managed in Canada and not well understood. But what expertise do they have to make recommendations on how pain should be treated? Their primary recommendation is that we should find alternatives to opiates. And, if we must give patients opiates, there should be an exit strategy, so they do not take them for too long.

This is based on the false assumption that addiction is being fueled by those with chronic pain, even though overdose deaths in Canada are predominantly among males aged 30-39 and involve illicit fentanyl. Contrast that to the demographics of chronic pain, which is mostly seen in women and older adults over the age of 56.

Those are two totally separate populations!

If opioid medication is a contributor to this problem, then why did opioid prescriptions in Canada decline by over 10% between 2016 and 2017, while opioid overdose deaths rose by 45% over the same period? 

The CMHA calls for an increase in alternative therapies to treat chronic pain. This is the definition of alternative medicine from the New England Journal of Medicine:

“There cannot be two kinds of medicine -- conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.”

Opioids work for chronic pain, as found in a 2010 Cochrane Review and by a more recent review in the Journal of Pain Research.

Jason Busse, the chiropractor who helped draft Canada’s 2017 opioid guideline, told me in a Twitter debate that this second study was only for 3 months so it is not relevant for the long term use of opioids. However, Prozac was approved for use by the U.S. Food and Drug Administration after two clinical trials of 6 and 8 weeks duration. Many people use Prozac for years.

Neither chiropractic, massage or acupuncture have been shown to be effective for chronic pain. Many doctors are also pushing anti-epilepsy drugs like gabapentin (Neurontin) as an alternative to opioids, but they do not always work and have major side effects. The same is true for its sister drug, pregabalin (Lyrica).

There is some evidence that medical cannabis may help with chronic pain, but it is very expensive and, even when prescribed, is not covered by public or most health plans.

Members of my family suffer with chronic pain and they do not want a National Pain and Addictions Strategy. What they want is continued access to the pain medication that has helped them carry on as normal a life as possible. There is no euphoria when they take these meds, other than the euphoria that comes from reducing their pain levels sufficiently so they can enjoy a trip to the cinema, theatre, dinner with friends and whatever else gives pleasure.

In June, I attended a meeting in Oshawa, Ontario arranged by chronic pain patients with a representative of the College of Physicians and Surgeons of Ontario. About 30 pain patients attended from all over Ontario and told the doctor how much they were being forced to suffer because their medication was reduced. One woman said she is not capable of getting out of bed to care for her children and would consider suicide if it weren't for them. Similar comments were made by others, but the doctor was unmoved and left early.

If CMHA (and others) can call for decriminalizing drugs and providing the addicted with safe drugs, why can no one be willing to provide pain patients with the same? It is inhumane.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He has been writing on chronic pain for the past year and is a regular contributor to the Huffington Post.

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.