Young Adults, Latinos and Low-Income Households Feeling Psychological Distress

By Pat Anson, PNN Editor

The COVID-19 pandemic appears to be taking a heavy toll on America’s mental health. A new survey conducted by researchers at the Johns Hopkins Bloomberg School of Public Health found that psychological distress among U.S. adults tripled — from 3.9 percent in 2018 to 13.6 percent in April 2020.

Psychological distress was even more acute among young adults aged 18­–29. Nearly one in four (24%) had symptoms of anxiety and depression.

Distress was also high among Latino adults (18.3%) and adults living in low-income households (19.3%) making less than $35,000 a year.

Nearly 1,500 adults were surveyed about their mental health between April 7 to April 13, when much of the country was still under a coronavirus lockdown. Researchers say their findings, recently published in JAMA, suggest the U.S. will face a wave of mental health problems even after the pandemic ends.

“We need to prepare for higher rates of mental illness among U.S. adults post-COVID,” said lead author Emma McGinty, PhD, associate professor in the Bloomberg School’s Department of Health Policy and Management. “The study suggests that the distress experienced during COVID-19 may transfer to longer-term psychiatric disorders requiring clinical care.

“It is especially important to identify mental illness treatment needs and connect people to services, with a focus on groups with high psychological distress including young adults, adults in low-income households, and Hispanics.”

Older adults seem to be handling the emotional challenges of the pandemic better, with only 7.3% of Americans aged 55 and older reporting psychological distress in April. So are people in households making over $75,000 a year. Only about 8% of Americans in that category reported distress.

Surprisingly, the survey found only a slight increase in feelings of loneliness, from 11 percent in 2018 to 13.8 percent in 2020, suggesting that loneliness is not driving the psychological distress people are feeling.

Zoloft Shortage

Increased demand for antidepressants during the pandemic has led to shortages of Zoloft and its generic version, sertraline. The Food and Drug Administration recently added the antidepressant to its list of drug shortages. Drug manufacturers say they “cannot support monthly demand” for sertraline, in part because of low supplies of its active ingredient. The shortages are expected to continue for the next few months.   

Sertraline is a selective serotonin reuptake inhibitor (SSRI) and the most commonly prescribed antidepressant. Over 49 million prescriptions for sertraline were written in 2018, according to the IQVIA Institute, making it the 11th most dispensed drug in the United States.

In the early stages of the pandemic, pharmacy benefit manager Express Scripts reported a spike in prescriptions for anti-anxiety medications such as Xanax and Valium, as well as antidepressants and anti-insomnia drugs.

Pain, Protests and Prejudice

By Dr. Lynn Webster, PNN Columnist

The Salt Lake Tribune recently published a story that distressed me. It said that Scott Senjo, a criminal justice associate professor at Weber State University in Utah, tweeted threats at people who were peacefully protesting the alleged murder of George Floyd.

Senjo’s incendiary comments are hard to accept, particularly in light of the criminal charges filed against the four Minneapolis police officers involved in Floyd’s death. The peaceful protestors that he threatened in his tweets were innocent of any crime.

Senjo was placed on probation and then resigned. He has since apologized for his tweets. But apologies don't correct the harm he intended.

People in pain can probably relate very personally to current events. They have been protesting online and in peaceful demonstrations for years about poor treatment and restricted access to pain medication, but their voices haven't been heard. Their suffering hasn't been sufficiently acknowledged or addressed. Their frustration and anger are similar in many ways to the feelings of those who are protesting George Floyd's death.  

Our First Amendment Right to Protest

Amazingly, peaceful protests can trigger anger in some people. Like Senjo, they are sometimes willing to suggest harming or even killing protestors.

It is even worse when political leaders specifically suggest using military force to "dominate" protestors. These perverted, authoritarian attitudes are attempts to deny Americans their First Amendment right to peacefully "assemble, and to petition the government for a redress of grievances."

George Floyd's death from asphyxiation by police officers lit a match to a tinder box of anger and frustration built up over centuries. The outrage has become national, and even international, in scope.

At the outset, the protests focused on anger about the injustice and police brutality levied against people of color. As the peaceful protests intensified, however, the actions became diffused by people who were committing acts of violence and unlawfulness. Some engaged in looting, arson and other crimes. These destructive actions nearly drowned out the voices of peaceful protesters who were trying to be heard.

Even Nonviolent Protestors May Be Demonized

Critics such as Scott Senjo may draw no distinction between the two groups, and may simply think of all protestors as criminals, radicals and revolutionaries. For some, it may not matter whether protests are peaceful or not -- anyone who opposes authority, in their opinion, should be met with a heavy-handed response.

You may remember the story of Francine Hughes, who stood trial for murdering her husband as he slept. The book and movie based on her experiences are called The Burning Bed. Hughes suffered years of domestic abuse, and the police refused to help her. Finally, she felt her survival depended on ending her abuser's life. Her violent protest of the brutality she suffered was wrong, but it was understandable. Outrage at oppression and the will to survive can elicit primal behaviors.

Today’s protestors are reacting to oppression, injustice, violence and racism that have never been adequately addressed. We, as a society, have continued to tolerate a criminal justice system that subjugates those who often lack the resources to defend themselves. It is easy to point fingers at abusive members of law enforcement without questioning how we, ourselves, contribute to the situation with our own behaviors.

It is a fallacy to think that even peaceful protests by people of color are accepted. Former NFL quarterback Colin Kaepernick kneeled during the national anthem in 2016 to protest police violence and social injustice. President Trump deemed his action to be disrespectful to our flag and heritage, and suggested that the NFL fire anyone who kneels during the national anthem.

Many Americans applauded President Trump's remarks. Indeed, Kaepernick apparently was blackballed from the NFL after his peaceful protest, and his football career effectively ended.

Peaceful protests of police brutality are, metaphorically, another form of kneeling during the national anthem. It is not disrespectful to kneel in protest, and it is not wrong to ask that those in power treat all people with dignity and respect. On the contrary: peaceful protesting shows respect for our flag and our First Amendment rights.

An Example of How We Can Heal

I want to close by sharing an example of the Randolph, Massachusetts Police Department. The photo below was taken a few minutes after a planned protest was scheduled to begin.

The protest in Randolph that day was peaceful. Perhaps that is at least partly because of how members of the police force greeted the protestors.

The Randolph Police Department evidently trusted that anyone who participated in a protest would do so in a spirit of peace and respect, and they felt a responsibility to respond in kind. They also wanted to demonstrate their solidarity with a statement made by Randolph Chief of Police William Pace:

“The Randolph Police Department will always be committed to providing the best possible service to the community in a dignified and equitable fashion. Officers are trained to approach every situation with respect, compassion and fairness, and these are all traits that were not present in the treatment of George Floyd.”

Thank you, Chief Pace, and your police force, for your service and your compassion. This is where our country's healing begins.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD

Tennant Foundation Launches Intractable Pain Research and Education Project

By Pat Anson, PNN Editor

One of the pioneers of pain management in the United States is hoping to draw more attention to intractable pain and how it differs from chronic pain. While chronic pain lasts for 90 days or more, intractable pain can persist for years, decades or even a lifetime. Many doctors fail to distinguish between the two, which leads to gaps in diagnosis and treatment.

“The pain field has been woefully negligent about this. They talk about symptomatic treatment of what to do to relieve chronic pain, but in order to deal with intractable pain syndrome you’ve got to treat the underlying cause,” says Dr. Forest Tennant, whose foundation has just released a new report called “The Intractable Pain Syndrome: A Call for Recognition and Prevention.”

“We’ve worked on it for quite some time with the goal of having every patient, doctor, nurse and family understand it. And to try and bring things out in language that is understandable by everybody.”

“This was a labor of love for all of us, born from a sincere desire to bring recognition, treatment and prevention to this devastating syndrome,” says co-author Ingrid Hollis, whose son was treated by Tennant for Arachnoiditis and Ehlers-Danlos Syndrome. “We have learned so much through the years, and I believe there is much that can be done to prevent intractable pain syndrome from developing and progressing when it occurs.”

“One of the reasons we’re doing this is to call for early recognition and vigorous treatment,” Tennant told PNN. “Someone who has this for two, five or twenty years, you can’t expect much reversal. But those people who have these conditions for six months or a year, they have a great ability to reverse a great deal of this. The earlier the treatment, the better the outcome.”

Left untreated, Tennant says intractable pain syndrome (IPS) can lead to chronic inflammation in the central nervous system that is difficult to reverse.  The inflammation not only causes constant pain, it leads to loss of brain tissue and creates dysfunction in the neurologic, cardiovascular, hormone and immune systems.  

“We’ve known for centuries that a painful injury will create what amounts to electricity. And too much electricity causes inflammation and inflammation causes tissue destruction,” says Tennant. “Intractable pain syndrome does change their basic physiology by virtue of altering physically the neurotransmitter systems that are in the brain and spinal cord. That is really the difference. And this is very objective. It’s measurable. It’s visible. It’s clear when its present.”

Tennant says these “pockets” of inflammation can be seen on MRI’s and brain scans. Someone suffering from simple chronic pain won’t have them, but people with intractable pain will.

There are five basic conditions that can cause IPS:

1. Arachnoiditis, a chronic inflammation of spinal nerves

2. Genetic connective tissue/collagen disorders such as Ehlers-Danlos Syndrome (EDS)

3. Reflex Sympathetic Dystrophy (RSD), also known as Complex Regional Pain Syndrome (CRPS)

4. Brain injuries caused by strokes or head trauma

5. Serious end-stage osteoarthritis of the spine, hips, knees or feet.

Other possible causes of IPS are porphyria, sickle cell disease, Lyme disease, interstitial cystitis, and some rare genetic disorders.   

IPS Can Be Reversed

Long recognized as incurable, Tennant says intractable pain can be reversed if diagnosed and treated early. He has pioneered some new treatments for IPS, including hormone supplements, physical therapy and better nutrition.

“Our project hopes to educate people about what they can do to reverse a lot of this,” Tennant told PNN. “Step number one is you’ve got to have vigorous treatment of the underlying cause of pain. The arachnoiditis has to be treated. The arthritis has to be treated. The RSD has to be treated. In other words, vigorous treatment of the underlying condition.

“Step number two, there are specific things they can do to slow down the inflammation inside the central nervous system. We know the body makes hormones inside the brain and spinal cord that can reduce the inflammation inside the central nervous system and regrow some of the tissue that’s been lost. People say you can’t do that, but oh yes, you can. There are studies that show this and we see this clinically.”

“I strongly believe that Dr. Tennant's concept of how intractable pain develops and progresses is absolutely correct.  His work in identifying the causes, developing diagnostic criteria, and figuring out a treatment protocol provides what doctors need to know to help people with intractable pain,” says co-author Kristen Ogden, whose husband Louis was treated by Tennant for a complex autoimmune condition.

“Louis' treatment with Dr. Tennant allowed him to improve so much in so many ways. Very effective pain control, greatly improved function and the best quality of life he ever had as an adult.  I am sure that very few people have any idea at all how much a seriously ill pain patient can improve and even regain lost function and capabilities if they have the right medical regimen that meets their needs.”

Tennant retired from clinical practice in 2018, the year after his home and office were raided by the DEA as part of an investigation into his opioid prescribing. No charges were ever filed against him. While Tennant no longer sees patients, he is continuing his research into the treatment of IPS – which notably downplays the use of opioids.

“The answer to opioid use is treating the syndrome rather than just giving symptomatic relief. Opioids are symptomatic drugs,” explains Tennant. “What we’re saying is, identify this and try to treat the condition. Don’t just throw a bunch of symptomatic antidepressants, opioids and other interventions at it. Start trying to look at it physiologically and pathologically, and treat it like we do other syndromes.”    

To learn more about the Tennant Foundation’s Intractable Pain Syndrome Research and Education Project, click here. 

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

Study Critical of Hydroxychloroquine Withdrawn by Medical Journal

By Pat Anson, PNN Editor

One of the world’s most respected medical journals has issued a rare retraction, essentially disowning a controversial study published last month that claimed the use of hydroxychloroquine and chloroquine for treating COVID-19 had no benefit for hospitalized coronavirus patients.

The Lancet issued the retraction after receiving a letter from the study’s authors saying they were unable to complete an independent audit of the data underpinning their analysis. As a result, the authors concluded they “can no longer vouch for the veracity of the primary data sources.”

The study looked at data from nearly 15,000 patients with COVID-19 who received the antimalarial drugs hydroxychloroquine or chloroquine. They were compared to a control group of over 81,000 patients who did not take the drugs. The study included patients being treated at 671 hospitals in North America, Europe, Asia, Africa, South America and Australia.

The study concluded that chloroquine and hydroxychloroquine significantly increased the risk of death for COVID-19 patients, particularly when taken with an antibiotic.

However, soon after publication, critics began questioning the legitimacy of data used in the study, pointing to inconsistencies such as five Australian hospitals reporting more coronavirus deaths than had been found on the entire continent.

In a letter to The Lancet, study authors Mandeep Mehra, Frank Ruschitzka, and Amit Patel said they could not get full access to the data and could not conduct an independent peer-review of their own research:

“After publication of our Lancet Article, several concerns were raised with respect to the veracity of the data and analyses conducted by Surgisphere Corporation and its founder and our co-author, Sapan Desai, in our publication. We launched an independent third-party peer review of Surgisphere with the consent of Sapan Desai to evaluate the origination of the database elements, to confirm the completeness of the database, and to replicate the analyses presented in the paper.

Our independent peer reviewers informed us that Surgisphere would not transfer the full dataset, client contracts, and the full ISO audit report to their servers for analysis as such transfer would violate client agreements and confidentiality requirements. As such, our reviewers were not able to conduct an independent and private peer review and therefore notified us of their withdrawal from the peer-review process.

We always aspire to perform our research in accordance with the highest ethical and professional guidelines. We can never forget the responsibility we have as researchers to scrupulously ensure that we rely on data sources that adhere to our high standards. Based on this development, we can no longer vouch for the veracity of the primary data sources. Due to this unfortunate development, the authors request that the paper be retracted.

We all entered this collaboration to contribute in good faith and at a time of great need during the COVID-19 pandemic. We deeply apologise to you, the editors, and the journal readership for any embarrassment or inconvenience that this may have caused.”

The Lancet’s retraction is likely to lead to more claims and conspiracy theories that the coronavirus has been “politicized” by mainstream medicine and left-leaning media to embarrass President Trump.

In recent months, the president and conservative media have touted hydroxychloquine as a possible "game changer" in the treatment of COVID-19. Trump took the drug as a preventative treatment last month after two White House staff members tested positive for coronavirus. A statement from the president’s doctor yesterday indicated he suffered no ill effects.

“I’m not going to get hurt by it. It’s been around for 40 years,” Trump said last month. “For malaria, for lupus, for other things. I take it. Front-line workers take it. A lot of doctors take it."

Hydroxychloroquine is only approved for the treatment of autoimmune diseases such as lupus and rheumatoid arthritis. The FDA has warned against using hydroxychloroquine as a treatment for COVID-19 outside of a hospital or clinical study because of “serious and potentially life-threatening heart rhythm problems.”

The FDA's Adverse Events Reporting System lists over 10,000 reported cases involving hydroxychloroquine in the past decade, many of them serious or resulting in hospitalizations. Nearly 600 people have died since 2010, including 48 deaths so far this year.

A study published yesterday in The New England Journal of Medicine, found that hydroxychloroquine was no better than a placebo in preventing COVID-19 infections.

Covid-19 Is More Complex Than We Thought

By Roger Chriss, PNN Columnist

Covid-19 initially seemed like a respiratory illness, with symptoms similar to a nasty flu. But it was quickly recognized as more transmissible and deadly, and with the added feature of being novel, meaning that no one had any natural resistance to it.

Now it is becoming clear that Covid-19 is more complex.

Although some people experience a short course of influenza-like symptoms, others also have neurological problems. According to Neurology Advisor, common symptoms associated with COVID-19 include anosmia and dysgeusia -- the impaired ability to smell or taste normally.

In one case study from Italy, reported on by IFL Science, a young woman had a persistent cough and loss of smell as her first symptoms. MRI results showed a “viral brain invasion” that caused inflammation in her olfactory bulb, the part of the brain involved in the sense of smell. Fortunately, the brain inflammation and other symptoms cleared up 28 days later.

A recent study in The BMJ looked at over 20,000 patients hospitalized with Covid-19 in the UK. Researchers found that many had pre-existing conditions, such as chronic cardiac disease (31%), diabetes without complications (21%), and non-asthmatic chronic pulmonary disease (18%).  

Less than half the patients (41%) made it out of the hospital alive, 26% of them died, and the remaining 34% were still in the hospital when data collection ended, so their outcomes remain to be seen. Being male or obese were associated with a higher risk of death, along with underlying health problems.

Notably, being over the age of 50 was substantially more hazardous than any other comorbidity – meaning the inflection point for risk is 50 years of age, not the oft-cited 65 seen in the U.S.  

Younger People Affected

Washington State is seeing a rapid rise of Covid-19 in young adults. Early in the outbreak, more than two-thirds of patients were older, but between March 1 and May 3, over a third of new cases (39%) were seen in people aged 20 to 39. It is not clear why this is happening, and deaths remain concentrated among people who are older.

Children may be at greater risk than previously thought. The CDC has recognized multisystem inflammatory syndrome in children as a “rare but serious complication” of Covid-19. The condition causes different body parts to become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, and gastrointestinal organs.

Work to find underlying factors that create this complexity is ongoing. A potential role for the ApoE gene has been identified in work by Biobank. The Guardian reports that people with two variants of the gene, which are associated with heart disease and dementia, had more than double the risk of severe Covid-19.

Two key risk factors identified in the United States are ethnicity and socioeconomic status. According to Johns Hopkins, African Americans and other disadvantaged groups are experiencing infection and death rates that are disproportionately high for their share of the total population.

Work to discover the origins of the coronavirus continues. According to Ars Technica, U.S. researchers conducted a detailed analysis of the coronavirus genomes, and found an evolutionary path connecting them mostly with bats, but also with a key contribution from pangolins, an armadillo-like mammal.

All this points to a complicated future for the pandemic. Risks are spread more broadly across the population and symptoms and clinical course are more varied. At present the best we can do is reduce transmission to stay safe and healthy.

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. 

Most Patients Say Cannabis Effective for Musculoskeletal Pain

By Pat Anson, PNN Editor

The vast majority of people with musculoskeletal pain who have tried medical cannabis say it is an effective pain reliever and over half believe it works better than other pain medications, according to a new study released by the American Academy of Orthopaedic Surgeons.  

Researchers surveyed 629 patients being treated at orthopaedic clinics to see how widely cannabis is being used for chronic muscle and joint pain that can be caused by arthritis, fibromyalgia, osteoporosis and many other conditions.

“Over time, we’ve certainly seen an increase in the use of cannabis to manage musculoskeletal (MSK) pain,” said lead author Timothy Leroux, MD, an orthopaedic surgeon and assistant professor at the University of Toronto.

“There is definite interest to see if cannabis can be used to manage chronic MSK pain, as opposed to other conventional treatments such as anti-inflammatories and opioids. With this study, we wanted to get a lay of the land as to who is using it, what proportion are using and what they perceive the efficacy to be.”

One in five of the patients surveyed said they are currently using or have tried cannabis to manage their MSK pain. Of those, 90% said cannabis was effective, 57% believe it works better than other pain medications, and 40% said it decreased their use of other drugs.

Patients who used cannabis for MSK pain were more likely to have multiple conditions, including depression, back pain, chronic pelvic pain and chronic neck pain. They were also more likely to use muscle relaxants and opioids for pain relief.

The most common form of cannabis used was cannabidiol (39%) and the most common route of ingestion was CBD oil (60%). Over a third of patients said they spent at least $200 per month on cannabis products.

Among the cannabis users, only 26% received a recommendation from a physician. Most said they tried cannabis at the urging of a friend or family member.

“Most doctors, especially orthopaedic surgeons, don’t have prescribing power for cannabis, so there is minimal physician oversight when it comes to cannabis use to manage chronic MSK pain,” said Leroux. “To complicate things, it’s a little bit of a Wild West in the cannabis industry in terms of what you get in a product, namely actual vs. labelled composition, and consistency.

“Another challenge is that we don’t fully know what products, formulations, dosages, and routes of administration are best to manage chronic MSK pain. Given the high rate of use observed in this study and little physician oversight, there’s an impetus for us as a medical community to try to understand what role, if any, cannabis may serve in the management of chronic MSK pain.”

Even among non-users, there was a fair amount of interest in cannabis. Sixty-five percent reported an interest in trying cannabis for MSK pain. Common barriers to using cannabis were stigma and lack of knowledge about its efficacy, doses and routes of administration.

“We tend to associate cannabis with a younger age due to recreational use, but in our study, age was not a significant factor influencing use for the management of chronic MSK pain,” said Leroux. “Patients reported use well into their 80’s, many whom we assumed would want to use more conventional products.

“We’d like to repeat this study in the next few years to see how use and demographics change as people become more comfortable with the idea of cannabis as the norm as well as what role state legalization plays in patients’ attitudes towards its use.”

Nitrous Oxide Safe for Labor Pain, But Few Women Stick With It

By Pat Anson, PNN Editor

A new study is touting an older form of anesthesia for women going through labor pain. Researchers at the University of Colorado College of Nursing say nitrous oxide – commonly known as laughing gas – is a safe and effective option for pain relief.

Their study, published in the Journal of Midwifery & Women's Health, is based on a survey of 463 women who used nitrous oxide (N2O) during labor.

"Nitrous oxide is a useful, safe option for labor analgesia in the United States. And for some laboring mothers, that's all the pain relief they need,” said lead author Priscilla Nodine, PhD, a Certified Nurse-Midwife and Associate Professor with the University of Colorado College of Nursing.

Nitrous oxide was once widely used in American hospitals to relieve labor pain, but it fell out of favor as more Caesarean sections were performed and women opted for epidural injections and spinal blocks, known as neuraxial analgesia.

Some hospitals are now reintroducing nitrous oxide as a safer and less invasive option. The inhaled gas helps reduce anxiety and makes patients less aware of their pain, but does not eliminate it. 

While side effects from nitrous oxide were rare (8%), less than a third of the women studied stuck with it. Sixty nine percent wound up using neuraxial analgesia or opioids during labor. The reason most often cited (96%) for converting from N2O to another therapy was inadequate pain relief.

Women who had previously given birth vaginally were more likely to stick with nitrous oxide, while those who had a Cesarean section were six times more likely to use neuraxial analgesia. The odds of conversion from N2O tripled when labor was induced or augmented with oxytocin, a hormone that helps women bond with the baby and stimulates milk production.

“Understanding predictors of conversion from inhaled nitrous oxide to other forms of analgesia may assist providers in their discussions with women about pain relief options during labor," said Nodine.

The findings are similar to a 2019 study, which found that nearly 70 percent of the women who tried nitrous oxide switched to an epidural or another pain management method.  

Epidurals allow mothers to stay awake and alert throughout delivery. But they are not without risks. A poorly placed needle can damage the spine permanently, as Dawn Gonzalez learned years ago.

“The blind insertion of the epidural during birth is basically playing roulette for spinal damage. Normally birthing mothers are told the only side effect possible during epidurals is a spinal headache that lasts a few days,” said Gonzalez, who developed adhesive arachnoiditis, a chronic and disabling inflammation of her spinal nerves.  

“Every woman deserves to know that when she opts for any kind of invasive spinal anesthesia, the risks are very grave and by far much more common than anybody realizes.”

The American Society of Anesthesiologists has defended the use of epidurals, calling them “one of the most effective, safest and widely used forms of pain management for women in labor.”

Prescriptions for Hydroxychloroquine Surge, But Drop for Hydrocodone

By Pat Anson, PNN Editor

Prescriptions for the antimalarial drugs hydroxychloroquine and chloroquine surged dramatically over the last few months, likely due to their off-label use for treating COVID-19, according to a new analysis published in JAMA. The study also found a significant decline in prescriptions for the opioid painkiller Vicodin and other hydrocodone/acetaminophen combinations.  

Researchers at Brigham and Women's Hospital studied prescription drug data from over 58,000 chain, independent and mail-order pharmacies in the U.S. from February 16 to April 25, and compared them to prescriptions over the same period in 2019.

Prescriptions for hydroxychloroquine and chloroquine spiked in mid-March – rising over 2,000 percent in one week -- soon after President Trump began touting the drugs as a possible treatment for the coronavirus. Brigham researchers estimate there were close to half a million additional prescriptions filled for hydroxychloroquine/chloroquine in 2020 compared to the year before.

SOURCE: JAMA

Hydroxychloroquine is only approved by the Food and Drug Administration to treat autoimmune diseases such as lupus and rheumatoid arthritis. Increased demand for the drug and government stockpiling soon led to spot shortages of hydroxychloroquine.

"There have been indications that hydroxychloroquine (HCQ) prescribing had increased and shortages had been reported, but this study puts a spotlight on the extent to which excess hydroxychloroquine/chloroquine prescriptions were filled nationally," said corresponding author Haider Warraich, MD, an associate physician in the Division of Cardiovascular Medicine at the Brigham.

"This analysis doesn't include patients who were prescribed HCQ in a hospital setting -- this means that patients could have been taking the drugs at home, without supervision or monitoring for side effects."

Last month President Trump took hydroxychloroquine for about two weeks with a doctor’s permission, even though the FDA warned that hydroxychloroquine should not be used as a treatment for COVID-19 outside of a hospital or clinical study because it could aggravate heart problems. The drug has been linked to at least 48 deaths in the U.S. so far this year, according to an FDA database.

On Sunday, the White House announced the U.S. supplied Brazil with 2 million doses of hydroxychloroquine. Brazil reported a record 33,274 new cases of the coronavirus over the weekend. Its death toll now ranks only below the United States, Britain and Italy.

Other Drugs Impacted by Pandemic

Brigham researchers say prescriptions for hydrocodone/acetaminophen fell by nearly 22 percent over the study period. There were also notable declines in prescriptions for the antibiotics amoxicillin and azithromycin, the blood pressure drug lisinopril, and the nerve drug gabapentin. Researchers said there are a variety of reasons why the drugs are being prescribed less often.

“The modest decline for most common long-term therapies after peak could represent reduced contact with prescribing clinicians, restricted access to pharmacies, pharmacist rationing, loss of insurance from unemployment, or replete supplies from early stockpiling,” researchers said. “Steep declines for amoxicillin and azithromycin appeared out of proportion to expected seasonal declines and could represent fewer outpatient prescriptions for upper respiratory tract infection symptoms.”

The pandemic appears to be taking a toll on the nation’s mental health. In the early stages of the outbreak, pharmacy benefit manager Express Scripts reported a surge in prescriptions for anti-anxiety medications such as Xanax and Valium, as well as antidepressants and anti-insomnia drugs.

A recent survey by the Kaiser Family Foundation found that nearly half of Americans said that they or a family member had cancelled or postponed medical care because of the pandemic. About one in every ten said the person’s medical condition worsened as a result of the delayed care.

A Pained Life: What Price Would You Pay for a Cure?

By Carol Levy, PNN Columnist

I recently had my deep brain stimulator removed. The implant made my trigeminal neuralgia pain much worse. As much as I hated the implant for the entire 7 months I had it, I knew I had to give it a try. I was obsessed with finding a cure.

I was looking for something mindless to watch on TV that would help get my mind off the failed implant. I saw a listing for a movie called “PAINLESS.” The name was interesting and so was the plot, about a man unable to feel physical pain:

“Born with a rare condition that leaves him alienated… a man becomes obsessed with finding a cure. A need for normalcy leads him down a dark path, and he must decide if finding a cure is worth paying the price for it.”

For many of us with chronic pain, that is our story too. I was also desperate for a cure.

Because of my very long and involved medical history, my doctor told me I was pretty much out of options. The only choices left were the implant or two risky surgeries.

Now those are the only options left. One surgery is dangerous and with possible complications too great to even consider. The other is essentially a mini-lobotomy that would leave me cognitively impaired.

“You would still have the pain. You just won’t care that you do,” the doctor explained.

Because of my pain, I am about 80% housebound. I have been for decades. The movie character knows this reality of alienation, as I do. Work helps you create a family and network if you don’t have one. No work and staying home most of the time equals alienated and alone.

Like most people, I want to have a “normal” life.  Sometimes the idea of going to the other side, and being “painless” seems like a good thing. And yet, people who can’t feel physical pain have to be even more careful then we do.

We know what triggers our pain and try to avoid those things. Someone who can’t feel any pain has to be on constant lookout that they don’t get injured in any way. They could cut themselves with a knife and not know it. They could get burned touching a hot stove because they can’t feel it.

We are two sides of the same coin. We want to get rid of the pain. The movie character actually longs for the sensation. He even has surgery without anesthesia.

Ultimately, we all have to decide how far will we go in our quest to find a cure. What price are you willing to pay?

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.”

A Tribute to My Father and the Greatest Generation

By Dr. Lynn Webster, PNN Columnist

When I was a little boy, we planted roses, geraniums, chrysanthemums and tulips at the graveside of my grandparents every Memorial Day.

In the beginning, we only had my maternal grandfather’s and paternal grandmother’s graves to decorate. Since they were about 100 miles apart, decorating their graves was a full-day event. It was a ritual that most of the immediate family participated in. Over the years, the number of graves grew and the number of decorators dwindled. 

People have used flowers to decorate graves for thousands of years. It is not clear when or why the practice first started. For my family, adorning graves with flowers was a way to remember and honor the people we loved and missed.

This past Memorial Day weekend, we visited and decorated their graves yet again, just as millions of Americans do to recognize the men and women who have served our country in the military. 

My father, Raymond L. Webster, risked his life serving in the South Pacific during World War II. He is one of those people we recognize on Memorial Day -- and, hopefully, every day -- for his heroism as a Marine, father and grandfather.

RAYMOND L. WEBSTER

We frequently hear that members of the military sacrifice their lives for their country, but that is not the primary reason my father risked his life.

My father was part of what has become known as the “Greatest Generation.” Of course, he was a proud American, but he often said he was willing to give his life for his buddies. He fought for his "brothers," just as the soldiers depicted in the 2001 film, "Band of Brothers." Patriotism was a background element.

My dad did not always know the reasons for his military missions. He spent his time in the Pacific Theater of Operations as part of the military police, serving in the Bismarck Archipelago, Solomon Islands, Guam and Marianas Islands campaigns.

At War with a Pandemic

I'm proud of my dad's commitment to his fellow warriors and the country. He's part of the great American history we must always remember.

Today, we battle a new enemy that is no less difficult than prior foes. We ultimately may win the war against the coronavirus, but we are not meeting each battle with the same resolve that members of the Greatest Generation did. Lack of a national plan and widespread disregard of our scientists’ recommendations suggest we are not meeting this threat the same way we arose to the occasion in previous wars.

Maybe it is because we don’t have the same willingness to sacrifice for our fellow citizens as those who came before us did. I don't know for certain.

But the coronavirus is a formidable foe. It has already caused more American deaths than we suffered in the Vietnam, Afghanistan, and Iraq wars combined.

The Greatest Generation modeled self-sacrifice, and doing the right things for the right reasons. We have the freedoms we enjoy today because of their selfless actions.

We can't know for certain what members of the Greatest Generation would say about our response to the pandemic, because few of them are here to tell us. However, I am certain they would say that we will get through this if we care enough about each other.

We can come out of this as a better, stronger nation. Putting the welfare of others ahead of our own needs worked before. Why wouldn't it work again?

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD.

Study: Using Cannabis for Pain Relief Reduces Risk of Opioid Overdose

By Pat Anson, PNN Editor

Illicit drug users who use cannabis for pain relief are less likely to experience an opioid overdose or use heroin, according to a Canadian study recently published in the online journal PLOS ONE.

Researchers at the University of British Columbia (UBC) the BC Centre on Substance Use (BCCSU) interviewed nearly 900 illicit drug users in Vancouver who reported using cannabis between 2016 and 2018. Participants were asked whether they used cannabis to relieve pain, improve sleep, address nausea or for recreation. Most said they used cannabis for a medically therapeutic reason.

"We're seeing more and more in our research that people are using cannabis for therapeutic reasons," says lead author Stephanie Lake, a doctoral candidate at UBC's School of Population and Public Health. "We're also seeing that, for some individuals in our study, this therapeutic use corresponds with either less use of illicit opioids or a reduced risk of overdose."

Participants who used cannabis for pain relief had lower odds of a non-fatal opioid overdose and for injecting heroin daily. Previous research from the BCCSU found that many people at risk of overdose, particularly those living with pain, may be using cannabis to reduce their reliance on illicit opioids.

Another key finding of the study was that therapeutic cannabis users relied on illicit sources for their cannabis supply – even though medical marijuana was fully legalized in Canada in 2013. About half of study participants said that illegal dispensaries were their most important source of cannabis.

"The mounting evidence related to the motivations behind people's cannabis use strongly suggests that improving access to cannabis for therapeutic purposes could help reduce overdose risk associated with illicit opioid use," says M.J. Milloy, PhD, a research scientist at BCCSU who was senior author of the study.

"Authorities should pause their efforts to close unregulated sources of cannabis and eliminate the illicit market until barriers to legal cannabis are addressed, especially during the overdose crisis."

Vancouver was the first major North American city to be hit by a wave of overdoses involving illicit fentanyl, heroin and other street drugs. A public health emergency was declared in British Columbia in 2016. Since then, Vancouver has become a laboratory of sorts for novel ways at addressing addiction, such as providing a “safe supply” of prescription opioids and prescription heroin to illicit drug users.

“Our community and many others across Canada and the United States are experiencing an opioid overdose crisis rooted, in part, in inadequately or inappropriately-managed chronic pain and sparked by widespread exposure to an unregulated illicit opioid supply contaminated with potent opioid analogues,” researchers concluded. “Our finding may also reflect an opioid-sparing effect of cannabis, whereby opioids are not replaced, but the dosage or frequency of opioid required for analgesia is reduced with the use of cannabis.”

Other studies have debunked the idea that medical cannabis reduces opioid use. Two large studies published last year found no evidence that legalizing cannabis reduces prescription opioid use, overdose or mortality.

“We tested this relationship and found no evidence that the passage of medical marijuana laws — even in states with dispensaries — was associated with a decrease in individual opioid use of prescription opioids for nonmedical purposes," researchers found.

A 2018 study suggested that cannabis legalization could actually make the opioid crisis worse, concluding that “cannabis use appears to increase rather than decrease the risk of developing nonmedical prescription opioid use and opioid use disorder.”

Nerivio: What’s All the Buzz About?

By Mia Maysack, PNN Columnist

If you have migraines and are open to more holistic approaches to treating them, I’d like to share my experience with Nerivio. It’s the first smartphone-controlled neuromodulation device for the treatment of migraine, with or without aura. I was provided one of the devices, which is worn on the arm, at no cost by the manufacturer, Theranica Bio-Electronics.

Nerivio requires a prescription from a doctor. I was able to be seen via telemedicine through Cove for my appointment, which was convenient. A script was written for 12 treatments, which are thought to be most beneficial within the first 30 minutes of experiencing aura or the onset of pain.

Given that my head hurts 24/7/365, I was hesitant to even try Nerivio, but ultimately decided it was worthwhile due to the low risk of side effects. I've tried different types of neuromodulation devices before, without success, and went into this with an open mind and minimal expectations.

Nerivio didn't take any of my discomfort away, but it did cultivate a decent enough distraction. Despite my blaring head pain, I love loud music. I realize that could seem odd, but I figure since it hurts anyway, turn it up! Anything to switch up the frequency of this migraine that's stuck on repeat. 

I view Nerivio similarly. You have to chill out for the treatments, which are 45 minutes in length. Though it is possible to go about daily activities during treatments, I found it more comfortable not to. I'd take deep breaths and visualize the armband just like music, disrupting the head pain and transmitting restorative waves.   

Much like the beloved 12" subwoofer in Ophelia (my car), I controlled the volume, using my smartphone to dictate the intensity of Nerivio.

When it’s on, Nerivio delivers small electric impulses into the upper arm that disrupt pain signals in the brain. I first compared the feeling of neuromodulation to that of a tingle or itch, but after becoming more familiar, I'd label it as vibrational. It doesn't hurt, and the sensation is a welcome change of pace for anyone experiencing head pain 

It's important to remember there is a weak current of electricity, so fingers shouldn't be directly placed on the device when it's on, nor should it be used in any place other than your arm. 

The device costs about $100. That can be a significant amount of money, especially for those of us unable to maintain any sense of normalcy regarding employment or income. But I’ve paid out of pocket far more than that, regularly, for co-pays and uncovered treatments, not to mention pills that demanded Benjamin Franklin’s face for not even a week’s worth of treatment.   

What I appreciate about Nerivio is that it’s something I can do on my own. I altered the arms I used it on and always incorporated relaxation with my experiences to whatever extent I could.  It worked nicely in conjunction with mindfulness breaks, as well as first thing upon waking up or last thing before bed. 

IMAGES COURTESY OF THERANICA

It’s also relieving to literally be holding the “power” in the palm of my hands. If there’s a need to halt a session, there is a pause button. Although I didn’t get around to utilizing it, Nerivio also has a feature that assists in promoting guided imagery and meditation as a further enhancement.   

For each treatment, all that’s necessary is to hit the power button on the armband and ensure it has synced up to your device. Within the first few moments when starting, a questionnaire pops up on the screen asking how you’re feeling. This acts similarly to a virtual diary to track symptoms and hopefully improvement. This step isn’t necessary, although never a bad idea to monitor or check in as to where you’re at.

All in all, I’d have to say if you’re curious enough and able to, go ahead and give Nerivio a try.  I believe it could be beneficial for other migraine conditions not as complex as mine.  

I haven’t been paid or endorsed at all for this review and offer these words solely as a resource for those who are considering it.  Feel free to follow up with questions, as I’m honored to help navigate the Nerivio process with you in any way I am able.

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. Mia is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill.

Nearly Half of Americans Delayed Medical Care Due to Pandemic

By Elizabeth Lawrence, Kaiser Health News

As the coronavirus threat ramped up in March, hospitals, health systems and private practices dramatically reduced inpatient, nonemergency services to prepare for an influx of COVID-19 patients. A poll released Wednesday reveals that the emptiness of medical care centers may also reflect the choices patients made to delay care.

The Kaiser Family Foundation (KFF) poll found that 48% of Americans said they or a family member has skipped or delayed medical care because of the pandemic, and 11% of them said the person’s condition worsened as a result of the delayed care.

Medical groups have noted a sharp drop-off in emergency patients across the country. Some, including the American College of Emergency Physicians, American College of Cardiology and American Heart Association, have publicly urged people concerned about their health to seek care.

Dr. William Jaquis, president of the American College of Emergency Physicians, said the anecdotes he’s heard of people delaying care have been troubling, with patients suffering heart attacks or strokes at home. He urged people not to skip going to the emergency room, and pointed out the many safety precautions hospitals are taking to curb the spread of the coronavirus.

“Don’t sit at home and have a bad outcome,” Jaquis said. “We’re certainly there and in many ways very safe, and, especially with low volumes in some places, we’re able to see people quickly. Come on in, please.”

According to the poll, nearly 7 in 10 of those who had skipped seeing a medical professional expect to get care in the next three months.

Despite a significant number of adults saying they delayed care, 86% of adults said their physical health has “stayed about the same” since the onset of the outbreak in the U.S.

Nearly 40% of Americans, however, said stress related to the coronavirus has negatively affected their mental health. Women were more likely than men to say the coronavirus has had a negative impact on their mental health, and those living in urban and suburban areas were more likely to say this than those living in rural areas. Nearly half of those living in households that have experienced income or job loss said the pandemic had a negative effect on their mental health.

The findings are similar to those from a PNN survey of over 2,200 people with chronic pain or chronic illness conducted in April. Forty-two percent in that poll said they were worried about their mental health due to the pandemic. Over 70 percent say they had cancelled or postponed a medical appointment. (See “Chronic Pain Patients ‘Hanging on by a Thread’ During Coronavirus Lockdown”).

The KFF poll further reports on some of the economic consequences of the pandemic. It found that about 3 in 10 adults have had trouble paying household expenses, with 13% expressing difficulty paying for food and 11% paying medical bills. Nearly 1 in 4 adults said they or a family member in the next year will likely turn to Medicaid, the federal-state health insurance program for low-income residents.

Medicaid continues to show strong support among Americans. About three-quarters said they would oppose efforts by their states to cut the program as part of cost reductions.

The poll was conducted May 13-18 among 1,189 adults. The margin of sampling error is +/-3 percentage points for the full sample.

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.

Sex Bias Persists in Pain Research

By Pat Anson, PNN Editor

It’s long been known that women are more likely than men to have chronic pain conditions such as fibromyalgia, rheumatoid arthritis, irritable bowel syndrome (IBS) and migraine. Women are also more likely to feel more severe, recurring and longer lasting pain.

Why then are women less likely to receive pain treatment? And why are some treatments less effective for women?

One obvious reason is that men and women have different biology and process pain differently. Another is a “blind spot” in pain research, which is more focused on studying males than females, according to a new review published in the journal Nature Reviews Neuroscience.

"The pain literature is biased such that, because of the overwhelming use of male animals in experiments, we are increasingly learning about the biology of pain in males. And wrongly concluding that this is the biology of pain. It's only the biology of pain in males," says author Jeffrey Mogil, PhD, a Professor of Psychology and Anesthesia at McGill University in Montreal.

Mogil reviewed over 1,000 research articles published in the journal Pain between 2015 and 2019, and found a distinct change in the sex of laboratory animals used in research. In 2015, for example, 80 percent of the studies only used male rodents. By 2019, half of studies were male-only.

SOURCE: Nature Reviews Neuroscience.

The trend towards using both male and female animals may sound like a promising change in research design. But when Mogil looked more closely at sex differences in pain literature, he found clear evidence that a male bias still exists in pain research.

"The very ideas we come up with for experiments, are based on experiments in males and therefore they work in males and not in females,” says Mogil.

Even in studies that included both male and female rodents, Mogil found that the research was often geared toward the males’ response. In experiments that “worked out” -- meaning the scientific hypothesis being tested was found to be true -- over 72% of the male rodents had a positive response, while only about 28% of the female rodents did. That strongly suggests the research was biased even before the experiments began.

"If there were no bias in the literature and there were a number of papers where the experiment worked in one sex and not the other, it should work in females just as often as in males,” explained Mogil. “Why has this happened? Because the hypothesis that that experiment tested out was generated based on prior data from experiments on only males. So, of course, it only worked in males."

The bias in research can have lasting effects on pain treatment and may help explain why some analgesic medications are more effective when taken by men.

"This research suggests that lots of what's in the pipeline right now, if it works in anyone at all, will largely be men. Whereas the clear majority of chronic pain patients have been and continue to be women," Mogil said.

Steps have been taken to reduce bias in pain research. If they want to get government funding, researchers in the United States, Canada and several European countries are now required to evaluate both sexes in their research. Mogil is optimistic those policies will eventually make a difference, but it may take awhile to undo decades of research that focused primarily on male animals.

“Performing biomedical experiments in both sexes is not only the ethically correct thing to do but also the scientifically correct thing to do, especially if we wish to reverse the particularly unimpressive track record of clinical trial success in the past few decades,” Mogil wrote.

Pain Warriors: A Civil Rights Movement for Our Time

By Pat Anson, PNN Editor

A long-awaited documentary about chronic pain in North America is shining a light on the other side of the opioid crisis – how chronic pain patients and their doctors have been marginalized and persecuted in the name of fighting opioid addiction.

“Pain Warriors” is being released by Gravitas Ventures. It is available for streaming on Vimeo, iTunes and Amazon Prime or on DVD.

The 80-minute film takes an intimate look at the lives of four chronic pain patients and their loved ones, including an 11-year old boy living with cancer pain and a doctor who nearly lost his medical license due to allegations he overprescribed opioids.

Two of the “pain warriors” featured in the documentary commit suicide after losing all hope that their pain will be properly treated.   

“That captures the essence of our film -- invisible, shunned and disbelieved. This is the story of their fight. Pain Warriors is a civil rights movement for our time,” says Tina Petrova, who produced and directed the documentary along with filmmaker Eugene Weis.  

“Doctors have been incarcerated, committed suicide, gone broke standing up for appropriate treatments for intractable pain. Families have lost loved ones due to suicides from chronic pain and medical complications such as spinal leaks. This is no small disease. It steals husbands and wives, sons and daughters.”

Pain Warriors is dedicated to Sherri Little, a California woman who took her life at the age of 53 after a last desperate attempt to get treatment for her fibromyalgia and colitis pain. (See “Sherri’s Story: A Final Plea for Help”). Sherri was a good friend of Petrova, who is well-acquainted with the issues faced by chronic pain patients – because she’s one herself.

“I began pre-interviews for the film around 2014, gathering collections of heartbreaking, compelling stories. A pain patient struggling with her own pain demons donated money to the cause, wanting her story told alongside others, and we began making the film in earnest,” she told PNN.

“Has it been easy? I’d say it’s been a hell of a lot of painstaking work by all involved, including the cast, who bravely offered up their vulnerability and very intimate stories. Has it been worth it? Absolutely.”

You can see a preview of Pain Warriors here:

The release of Pain Warriors was initially delayed due to funding problems, and then because Petrova suffered a severe back injury during physical therapy. She was bedridden and housebound for over a year.

“I’m hopeful that I’m on the mend at long last, and will be able to take the film across North America, once COVID restrictions are lifted, and lead in-person screenings with the people the film was made for -- chronic pain patients and the healthcare professionals that sometimes risk everything fighting for their rights,” says Petrova.

Dr. Mark Ibsen plays a prominent role in the film. The Montana Board of Medicine suspended Ibsen’s medical license in 2016, a decision that was reversed two years later when a judge ruled the board made numerous procedural errors.

Ibsen’s legal battles have not ended. The Board of Medicine has refused to formally close his case, leaving Ibsen in professional limbo. Pharmacists won’t fill his opioid prescriptions and he was forced to close his urgent care clinic in Helena. Now he travels the back roads of Montana writing prescriptions for medical marijuana.

“I’ve been marginalized,” says Ibsen, who plans to sue the Board of Medicine for monetary damages. “Anything the board would say would not completely clear me. I need the judge to say, ‘This is bogus. Stop it. Dismiss the case.’”   

Pain Warriors is featured in PNN’s Suggested Reading section, where you can buy the DVD through Amazon.