AMA ‘Greatly Concerned’ By Rising Number of Opioid Overdoses

By Pat Anson, PNN Editor

The American Medical Association is once again urging states, regulators and policymakers to waive limits and restrictions on prescriptions for opioid medication and other controlled substances during the COVID-19 pandemic.

In a briefing paper released this week, the AMA said it was alarmed by an increasing number of reports of opioid-related overdoses, particularly from illicit fentanyl. The AMA cited recent reports from the Pacific Northwest that thousands of people were unexpectedly dying from causes other than COVID-19, such as fentanyl-laced counterfeit pills and medical conditions aggravated by delays in getting routine healthcare.    

“The AMA is greatly concerned by an increasing number of reports from national, state and local media suggesting increases in opioid-and other drug-related mortality—particularly from illicitly manufactured fentanyl and fentanyl analogs,” the AMA said. “More than 40 states have reported increases in opioid-related mortality as well as ongoing concerns for those with a mental illness or substance use disorder.”

The AMA urged states to adopt new DEA guidance giving more flexibility to physicians treating patients with opioid use disorder (OUD). The DEA has already waived federal requirements for in-person visits before prescribing addiction treatment drugs such as buprenorphine (Suboxone), methadone and naltrexone.

For patients in pain, the AMA recommended that states take a number of steps to make it easier to obtain pain medication during the pandemic:

• Authorize physicians to prescribe opioid medication to existing patients without an in-person visit

• Waive limits on prescriptions for opioids and other controlled substances, including limits on dose, quantity and refills

• Waive requirements on electronic prescribing; authorize prescriptions to be sent to pharmacies via telephone

• Waive drug testing and in-person counseling requirements for opioid refills; allow for telephone counseling

• Enhance home-delivery medication options for patients with chronic pain

The AMA urged many of these same measures be adopted in the early stages of the pandemic.

In a recent letter to the DEA, the AMA strongly recommended that the agency keep its relaxed prescribing guidelines in place indefinitely.

“There is an urgent need to ensure that patients with pain and patients with OUD receive evidence-based care, and this need will not cease with the end of the COVID-19 pandemic,” wrote James Madara, MD, Executive Vice President and CEO of the AMA..

“The AMA strongly recommends, therefore, that all of the flexibilities that have been put in place by DEA during the COVID-19 PHE (public health emergency) be kept in place at a minimum until both the COVID-19 and the opioid public health emergencies come to an end.”

Music and ‘Positive Suggestions’ Reduce Need for Opioids in Surgery Patients

By Pat Anson, PNN Editor

Studies have shown that long term opioid use and addiction are rare in patients given opioids for pain control during and after surgery.  Nevertheless, many hospitals are adopting policies that reduce or eliminate the use of opioids for postoperative pain; opting instead for non-opioid pain relievers such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs).

A new placebo-controlled study suggests that relaxing music and comforting words played during surgery might also be a substitute for opioids in some patients.  

Researchers at five German hospitals recruited 400 patients scheduled for elective surgery lasting 1 to 3 hours. While under general anesthesia and unconscious, half the patients listened through earphones to a tape that played soothing background music and “positive suggestions” for 20 minutes. The tape played repeatedly until surgery ended. The other patients were assigned to a blank tape and served as a control group.     

Researchers found that patients in the music group had lower pain scores and required lower opioid doses – about 2.8 MME less per patient -- in the first 24 hours after surgery. Over a third (37%) did not need opioids at all, compared to 26% in the control group.

“This study found a statistically significant reduction in use of postoperative opioids in patients who received therapeutic suggestions by audiotape during surgery, which comprised background music and mindful text. Furthermore, the number of patients who requested and received opioids was significantly lower after the intervention,” researchers reported in the British Medical Journal.

“A mean saving of 2.8 MME for each patient might seem unimportant; however, in most pain studies the focus is generally on relative saving and not the absolute dose, and an opioid dose reduction of 30%, as reported here, is considered relevant.”

In addition to less pain and need for analgesics, patients in the music group also had less nausea and recovered faster from surgery.

Connected Consciousness

The study findings also suggest that – even under general anesthesia – patients can still hear and process words subconsciously. This “connected consciousness” runs against long-held beliefs that patients under anesthesia don’t have thoughts and feelings. In an editorial, one researcher called this finding “astonishing.”

“Usually there is no reaction to auditory or other stimuli, including surgery, expected or observed in patients under general anaesthesia,” wrote corresponding author Ernil Hansen, MD, a professor of Anesthesiology at the University Hospital of Regensburg, Germany.

“This knowledge and appreciation of intraoperative perception should lead us to more thoughtful behaviour in the operating theatre, for example, what noise levels or potentially unnecessary conversations are we exposing patients to, and to consider a wide use of therapeutic communication as a feasible, non-drug support of medical interventions and an integral part of therapy and care.”

This isn’t the first study to find that music can be a useful tool to reduce pain and anxiety.

Mozart’s “Sonata for Two Pianos” has been found to be helpful in treating patients with epilepsy. And a 2006 study found that listening to music for an hour each day helped reduce pain, depression and disability in patients with chronic non-cancer pain.

Health Canada Is Hiding the Truth About Rx Opioids

By Barry Ulmer, Chronic Pain Association of Canada

True or false? Doctors triggered our overdose crisis. Duped by pharma, they overprescribed narcotic pain relievers and turned innocent patients into addicts. Now we have a black market of stolen prescription drugs — they remain the problem — with a little heroin and street fentanyl mixed in.

True, says Health Canada, whose policy since 2016, made behind the backs of doctors and patients, has been to squeeze prescription opiate supply. Never mind that two million Canadians with serious pain can’t get effective treatment anymore, since most don’t need it anyway.

False, says science. Bad pain can need opiates when nothing else works. By choking legal supply in its haste to curb overdose rates and raise its own ratings, government lit a match to an illicit supply (meth, cocaine, heroin, narcotics) on slow boil since at least 1980. Fierce prescribing cuts now drive a robust black market of cheap heroin and street fentanyl, and a parallel crisis of untreated pain and suicide.

Who’s right? Here are the facts: since 2011, opioid prescribing has tanked while deaths still climb. Street drugs kill. Prescribed drugs don’t. Slashing prescriptions to contain addiction is daft.

Why hide the truth? Why torture people with pain and ignore illicit drugs? Doesn’t government want to combat preventable deaths? For years, we’ve asked Health Canada just that.

They dodged us at every turn. (Just listen to our bizarre 2018 call with the Minister's office.) Eventually, they sent us a list of studies they said justified deprescribing. In June 2019, we sent back our evaluation of the list. It didn’t match theirs. They said they’d get an assessment from independent experts. They didn’t. Then they said they had more research, a big batch; they’d send that, too. They didn’t.

Our Freedom of Information Request

In February, we filed a freedom of information request. We asked for specifics — studies, research, correspondence — that back Health Canada’s claim, as of 2016, that prescribing leads to overdose deaths.

Since we know the medical literature, we knew not to expect much. But this past September, we got 2,928 pages — sort of.  About a third were redacted: long series of pages along with almost all study publication dates, bibliographic details, and online links. It was padded with stuff like a 466-page global report from the UN in three languages. Most of it had nothing to do with what we’d asked for.

Most of it was also published long after 2016 — so it can’t have led to the official start of deprescribing. Only a quarter of it was Canadian, mostly an echo chamber of federally-funded agency reports all quoting each other, with some government-funded guidelines thrown in.

There was no correspondence whatever and little independent research. The bulk of it wasn’t research at all, just a circle jerk of commentary and opinion.  Here’s what we got:

• Mostly US/some UK stuff — commentary, media reports, policy, guidelines, limited research

• Papers using CDC drug abuse stats that CDC corrected and downgraded long ago

• Studies using outdated definitions of “opioid use disorder” that make everyone a “substance abuser”

• Duplicated and even triplicated papers

• Foreign-language papers

• Pre-publication “author manuscripts,” some unproofed and incoherent

• Observational rather than experimental studies

• Papers whose data and fine print directly counter their conclusions

• Papers drawing “new” conclusions by cherry-picking old literature

• Researchers quoting their own work as authoritative

• Papers asserting without documenting the dangers of opiates

• Studies drowning in limitations (which their authors often acknowledge)

• Government statements on generalities, synthesizing other government statements on generalities

• Hand-wringing from six Ottawa-funded agencies, and research these agencies funded in turn

• Serial papers from a handful of Health Canada-preferred researchers

• Much heavily-redacted head-scratching on cannabis

• Studies on acute — not chronic — pain

• Papers blaming patients for their pain

 What on-point studies we got often champion opioids.

Those that don’t typically reiterate prevailing anti-opioid claims, downplay the devils in their details, hype their conclusions, and are compromised by their authors’ conflicts of interest. (These conflicts are usually disclosed, since joining the bandwagon is valued over bias risk.)

On-topic items make our case, not Health Canada’s:

• Half of Canadian adults with chronic pain (a third with “very severe” pain) have suffered for 10 years plus

• Five comprehensive studies of studies (Cochrane reviews) plus a large German review endorse opioids    for five types of chronic pain; four more Cochranes didn’t find useable studies on other pain types

• Two Cochranes plus Canadian research say drugs used to combat substance abuse don’t relieve pain

• Newfoundland’s OxyContin Task Force report on six OxyContin-involved deaths in four years concludes that properly-prescribed pain medications are safe and effective

• With doses now “under the recommended thresholds, most US providers are careful in their prescribing”

• British Columbia, Alberta and Ontario coroners find repeatedly that most overdose deaths involve street fentanyl

• Early prescription use does not predict addiction in Vancouver IV drug users, some of whom develop pain after they begin using

• US data can’t predict addiction and death rates in Canada

• “Dental Rx’s addict young people” is a tooth-fairytale, say three studies. In one, just one of 97,462 kids  who got prescribed opioids after wisdom tooth surgery died within a year — cause not specified

• A review of 38 studies pegs “problematic use” at “<1 to 81%” (it’s entirely redacted)

• Claims of “significant increases” in prescription opioid abuse aren’t quantified. One “huge increase” was of low-dose formulations

• Guesstimates and “author consensus” fill data gaps. An Ottawa-funded researcher’s three papers all call for continued prescription slashing while acknowledging a serious lack of data

• Canadian researchers who routinely disparage opiates for pain tend to be just two or three government- funded teams mining a single public Ontario database to write variations on their theme

• Physical dependence is routinely called “opioid use disorder.” Occasionally, the distinction appears in small print. Clarification by the head of the US National Institute on Drug Abuse is here but redacted

• Three Canadian reports plus one from Seattle say “one-size-fits all” dosing is dangerous and “significantly” hikes overdose risk; cuts to legal supply since 2016 risk destabilization of patients; prescription slashing leads to the end of care

• A 2020 Canadian investigation into bias in “pro-opioid” prescribing guidelines conveniently stops just short of investigating bias in the “anti-opioid” American and Canadian guidelines of 2016 and 2017

• A Canadian sociologist tracks 20 years of news to show how “overprescribing” became a hot button. Our top three news outlets didn’t mention “inadequate pain care” until 2016. “Legitimate users” were either “dependent” or had overdosed on their prescriptions

• “Twenty-five years of pain education research — what have we learned?”: All 13 pages redacted

A descriptive list of all the items we got, and the release itself, are available on request.

What we didn’t get are the many large studies that sandbag Health Canada’s deprescribing policy, like these:

• Risks of developing persistent opioid use after major surgery are tiny

• In a huge sample, mortality risk from overdose is just 0.022% annually

• Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in BC

• Illegal street drugs, not prescriptions, now powering opioid abuse

• New survey data confirm that opioid deaths don’t correlate with pain pill abuse or addiction rates 

Health Canada has ignored pertinent studies that don’t suit them and misread others. No careful, independent research endorses deprescribing for any reason, and certainly not as a means to contain overdoses.

Health Canada provided its research only after years of hedging, when we finally resorted to an FOI request— and then only after six months. We believe they had no list and compiled one retroactively, especially since they padded it with off-topic items and with items that postdated their policy.

Prescribing practice and regulation in Canada is now based on the low-quality “investigations” of partisan, government-paid researchers. Canadians deserve better. Now that quality research unequivocally endorses their treatments, Canadians with pain must have effective care restored to them NOW. 

Barry Ulmer is Executive Director of the Chronic Pain Association of Canada, a patient advocacy group

What to Expect When COVID Vaccines Roll Out

By Judith Graham, Kaiser Health News

Vaccines that protect against COVID-19 are on the way. What should older adults and people with chronic illness expect? Will there be enough doses for everyone who wants to be vaccinated?

The first vaccine candidates, from Pfizer and Moderna, could arrive before Christmas, according to Alex Azar, who heads the Department of Health and Human Services.

Both vaccines are notably effective in preventing illness due to the coronavirus, according to information released by the companies, although much of the data from clinical trials is still to come. Both have been tested in adults age 65 and older, who mounted a strong immune response.

Seniors in nursing homes and assisted living centers will be among the first Americans vaccinated, following recommendations last week by a federal advisory panel. Older adults living at home will need to wait a while longer.

Many uncertainties remain. Among them: What side effects can older adults anticipate and how often will these occur? Will the vaccines offer meaningful protection to seniors who are frail or have multiple chronic illnesses?

Here’s a look at what’s known, what’s not and what lies ahead.

Timetable for Vaccines

Pfizer’s vaccine will be evaluated by a 15-member Food and Drug Administration advisory panel on Thursday. Moderna’s vaccine is expected to go before the panel Dec. 17.

At least two days before each meeting, an analysis by FDA staff will be made public. This will be the first opportunity to see extensive data about the vaccines’ performance in large phase 3 clinical trials, including more details about their impact on older adults.

So far, summary results disclosed in news releases indicate that Pfizer’s vaccine, produced in partnership with BioNTech, has an overall efficacy rate of 95% and efficacy of 94% in people 65 and older. Moderna’s overall efficacy is 94%, with 87% efficacy in preventing moderate disease in older adults, according to Moncef Slaoui, chief science adviser to Operation Warp Speed, the government’s COVID-19 vaccine development program.

If the advisory panel gives a green light, the FDA will decide within days or weeks whether to authorize the Pfizer and Moderna vaccines for emergency use. Distribution of the vaccine has already begun, and health care providers are expected to begin administering it immediately after the FDA acts.

Who Gets Vaccinated First?

At a Dec. 1 meeting of the Advisory Commission on Immunization Practices (ACIP), which guides the Centers for Disease Control and Prevention on vaccines, experts recommended that people living in long-term care (primarily nursing homes and assisted living facilities) and health care workers be the first groups to get COVID-19 vaccines.

This recognizes the extraordinary burden of COVID-19 in long-term care facilities. Although their residents represent fewer than 1% of the U.S. population, they account for 40% of COVID deaths — more than 100,000 deaths to date.

The commission’s decision comes despite a lack of evidence that Pfizer’s and Moderna’s vaccines are effective and safe for frail, vulnerable seniors in long-term care. Vaccines were not tested in this population. Federal officials insist side effects will be carefully monitored.

Next in line likely would be essential workers who cannot work from home, such as police, firefighters, teachers and people employed in food processing and transportation, according to commission deliberations Nov. 23 that have not come to a formal vote.

Then would be adults with high-risk medical conditions such as diabetes, cancer, kidney disease, obesity, heart disease and autoimmune diseases and all adults age 65 and older.

Although states typically follow ACIP guidelines, some states may choose, for instance, to vaccinate high-risk older adults before some categories of essential workers.

Left off the list are family caregivers, who provide essential support to vulnerable older adults living in the community — an unpaid workforce of tens of millions of people. “If someone is providing day-to-day care, it makes sense they should have access to the vaccine, too, to keep everyone safe,” said Beth Kallmyer, vice president of care and support for the Alzheimer’s Association.

Priority Groups

The priority groups constitute nearly half of the U.S. population — 21 million health care workers, 3 million long-term care residents, 66 million essential workers, more than 100 million adults with high-risk conditions and 53 million adults age 65 and older.

With initial supplies of vaccines limited, setting priorities will be inevitable. Practically, this means that hospitals and physicians may try to identify older adults who are at the highest risk of becoming seriously ill from COVID-19 and offer them vaccines before other seniors.

A study of more than 500,000 Medicare beneficiaries age 65 and older provides new evidence that could influence these assessments. It found the conditions that most increase older adults’ chances of dying from COVID-19 are sickle cell disease, chronic kidney disease, leukemias and lymphomas, heart failure, diabetes, cerebral palsy, obesity, lung cancer and heart attacks, in that order.

“Out of all Medicare beneficiaries, we identified just under 2,500 who had no medical problems and died of COVID-19,” said Dr. Martin Makary, co-author of the study and a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health in Baltimore. “We knew risk was skewed toward comorbidity [multiple underlying medical conditions], but we didn’t realize it skewed this much.”

Supplies Available

Both the Pfizer and Moderna vaccines require two doses, administered three to four weeks apart. The companies have said about 40 million doses of their vaccines should be available this year, enough to fully vaccinate about 20 million people.

After that, 50 million doses might become available in January, followed by 60 million doses in both February and March, according to Dr. Larry Corey, a virologist who heads the COVID-19 Prevention Trials Network.

That translates into enough vaccine for another 85 million people and should be sufficient to vaccinate older adults in addition to medical personnel on the front lines and many other at-risk individuals, Corey suggested at a recent panel on COVID-19 sponsored by the National Academy of Medicine and American Public Health Association.

He acknowledged these were estimates, based on information he has been given. Pfizer and Moderna have not yet specified how much vaccine will be delivered and when. Nor is it clear when other vaccines under investigation will become available — 13 are in phase 3 clinical trials — or what their monthly production capacity might be.

Distribution Issues

As Pfizer’s and Moderna’s vaccines are rolled out, a very vulnerable group may have difficulty getting them: 2 million seniors who are homebound and another 5.3 million with physical impairments who have problems getting around.

The reason: handling and cold storage requirements.

Pfizer’s vaccine needs to be stored at minus 70 degrees Celsius, calling for special equipment not available in small hospitals, clinics or doctors’ offices. Moderna’s vaccine needs long-term storage at minus 20 degrees Celsius.

Landmark Health provides in-home medical care to more than 120,000 frail, chronically ill homebound seniors in 15 states. “We don’t have the capabilities to store and distribute these vaccines to our population,” said Dr. Michael Le, the company’s co-founder and chief medical officer.

Instead, he said, Landmark is working to arrange transportation for its patients to centers where COVID-19 vaccines will be administered and educating them about the benefits of the vaccines. “Given the trust, the bond we have with our patients, we can play a big role as advocates,” Le said.

Addressing Mistrust

Advocates have a big job ahead of them. According to a recent poll from the University of Michigan, only 58% of older adults (ages 50 to 80) said they were very or somewhat likely to get a COVID-19 vaccine. A significant number of older adults, 46%, thought they’d get the vaccine eventually but wanted others to go first. Only 20% wanted to get it as soon as possible.

Most important in making decisions is knowing how well the vaccine works, according to 80% of the 1,556 older adults surveyed. Just over half (52%) said a recommendation from their doctor would be influential.

Dr. Sharon Inouye, a geriatrician at Hebrew Senior Life in Boston and a professor of medicine at Harvard Medical School, is among the physicians impatiently awaiting the publication of data from Pfizer’s and Moderna’s phase 3 clinical trials.

Among the things she wants to know: How many older adults with chronic health conditions participated? How many participants were 75 and older? Did side effects differ for older adults?

“What I worry about most is the side effects,” she said. “We may not be able to know about serious but rare side effects until millions of people take them.”

But that’s a gamble she’s willing to take. Not only will Inouye get a vaccine, she just told her 91-year-old mother, who lives in assisted living, to say “yes” when one is offered.

“My whole family lives in fear that something will happen to her every day,” Inouye said. “Even though there’s a lot we still don’t know about these vaccines, it’s compelling that we protect people from this overwhelming illness.”

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

7 Ways to Treat Intractable Pain Syndrome

By Forest Tennant, PNN Columnist

Intractable Pain Syndrome (IPS) requires a care program custom-made for each individual person, depending on their underlying painful condition and clinical severity.

There are therapeutic, pharmacologic, dietary and physical measures you can take that specifically target the cause of IPS. Step One in finding relief and recovery is to target the cause of the pain, and not just take the “shotgun” approach with only symptomatic pain relievers. A multi-faceted approach is needed.

The 7-component treatment outlined here is to aid patients, families and medical practitioners in formulating an individualized IPS care program

1) Suppression of Inflammation

Underlying Cause: The injury or disease that originally produced the pain may continuously generate inflammation that requires suppression by a variety of means. Common measures to reduce inflammation include anti-inflammatory agents, electromagnetic therapies, local injections or topical agents.

Central Nerve Inflammation: IPS is caused by central nervous system (CNS) inflammation (neuroinflammation) that destroys or damages neurotransmitter systems. Only some treatment agents cross the blood brain barrier and suppress neuroinflammation. Some common agents: naltrexone, ketorolac, indomethacin, methylprednisolone, acetazolamide and  dexamethasone.

2) Sleep Restoration

It is during sleep that the CNS regenerates the neurotransmitters you need for pain control. Adequate sleep is necessary for this to occur. Some common agents: Ambien, trazadone, temazepam (Restoril), amitriptyline, melatonin and Benadryl.

3) Control of Electric Currents

Some drugs now called “neuropathic” normalize electric current conduction, which is erratic due to nerve damage. Some common agents: gabapentin (Neurontin), pregabalin (Lyrica) and benzodiazepines (Klonopin and Valium).

4) Pain Control

The constant pain of IPS is composed of two types of pain: ascending and descending. IPS control requires agents for both types.

Ascending Pain: Some common agents: cannabinoids, opioids, ketamine, clonidine, kratom and naltrexone (if not already on opioids).

Descending Pain: Some common agents: amphetamine salts (Adderall), phentermine, modafinil, methylphenidate, mucuna. 

5) Hormone and Neurotransmitter Supplementation

Groups of hormones now known as neurosteroids, and biochemical molecules known as neurotransmitters, are made in the brain and spinal cord. Their function includes suppressing inflammation, rebuilding damaged tissue and to provide pain control. Analgesic/pain-relieving drugs will not be effective if any neurosteroid or neurotransmitter is deficient. Neurotransmitter testing is now available.

Hormones: DHEA, pregnenolone, testosterone, progesterone.

Neurotransmitters: dopamine-noradrenaline, serotonin, GABA.

6) Anabolic Measures (Tissue Building)

In IPS, tissue degeneration is constantly present due to inflammation. Some genetic connective tissue/collagen diseases such as Ehlers-Danlos Syndrome (EDS) have a built-in, constant tissue degenerating component (catabolic).

Tissue building (“anabolic”) measures are essential to counteract tissue degeneration, and several agents have been identified that do this: nandrolone, human chorionic gonadotropin (HCG), colostrum, deer antler velvet, and amino acid/collagen supplements are recommended.

7) Disease Specific Exercise

Spinal fluid circulates in and around the brain and spine. It washes out biologic waste products such as inflammation. It also brings nutrients to the inflamed and/or damaged nerves for healing.

Exercises that enhance spinal fluid flow include walking, rocking in a chair, and gently bouncing. Practice exercises and stretches that will prevent tissue shrinkage, paralysis and dysfunction of your extremities or other organs that are specific for your underlying condition. 

All seven of these components should be considered for inclusion in an IPS care program. 

Forest Tennant is retired from clinical practice but continues his groundbreaking research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

The Tennant Foundation has given financial support to Pain News Network and sponsors PNN’s Patient Resources section.  

Caution Recommended on Cannabis Use Before Surgery

By Roger Chriss, PNN Columnist

The U.S. House of Representatives voted last week for the first time to legalize marijuana at the federal level. While passage by the Senate appears unlikely, the historic House vote on the MORE Act shows how much public attitudes about marijuana have changed.

A recent Gallup poll found that 68 percent of the country now favors having legal access to marijuana. Last month voters in four states approved recreational cannabis measures, raising to 15 the number of states where cannabis is completely legal. Thirty-six states have approved it for medical use.

As cannabis use becomes more accepted and widespread, healthcare providers need to take cannabis into consideration when treating patients, especially those undergoing surgery.

The Perioperative Pain and Addiction Interdisciplinary Network (PAIN) recently convened a panel of 17 experts to develop new guidelines on the care of cannabis-consuming surgery patients. The result is a set of recommendations that include cannabis weaning before surgery and close monitoring during surgery, particularly for heavy cannabis users.

Because of the potential for cannabis to interfere with anesthesia, the guidelines recommend that patients who use a cannabis product more than 2 or 3 times per day should be considered for tapering or cessation several days before surgery. That includes patients who use more than 1.5 grams per day of smoked cannabis, more than 300 mg per day of CBD oil, or more than 20 mg per day of THC oil. Cannabis users may also need additional medication for postoperative nausea and vomiting.

There is only limited research on how cannabis interacts with analgesics and other medications. But the few studies that have been done suggest caution is warranted.

A 2006 study done in Germany looked at patients after surgery. None of the patients was able to achieve sufficient pain relief at any dose of Cannador, a cannabis plant extract. Several experienced significant side effects, including sedation and nausea. And the study had to be halted because of a severe adverse event in one patient.

A recent study at the University of Michigan looked at cannabis use and surgical outcomes in 1,335 adults undergoing elective surgery. About half reported using cannabis medically, recreationally or both. The results are concerning.

"On the day of surgery, cannabis users reported worse pain, more centralized pain symptoms, greater functional impairment, higher fatigue, greater sleep disturbances and more symptoms of anxiety and depression versus non-cannabis users,” the researchers said.

Medication use, including opioids and benzodiazepines, was also higher in the cannabis group. The study authors concluded that "cannabis users have higher clinical pain, poorer scores on quality of life indicators, and higher opioid use before and after surgery."

Another recent study at the University of Colorado Hospital was smaller and more specific, looking at 118 patients who had surgery for a broken leg. About one-fourth of the patients reported prior cannabis use. Although cannabis use was not associated with a higher dose of the anesthetic propofol during surgery, it was associated with more post-operative pain. Cannabis users also required significantly more pain medication than the control group.

Lead study author Ian Holmen, MD, told Practical Pain Management that it was important for clinicians to ask patients about their cannabis use before any surgical procedures.

“A provider just needs to know if the patient uses cannabis or not. It doesn’t matter if it’s a daily situation, just so [providers] are aware that the post-operative and possibly interoperative period are going to appear different in a patient who’s using cannabis than one who is not,” Holmen said.

Further study is needed to better understand how cannabis use affects surgical outcomes and how the effects may change at various doses of cannabis products. But the concerns of the Perioperative Pain and Addiction Interdisciplinary Network appear well-founded. Guidelines for the perioperative management of cannabis use are a necessary and useful step forward as cannabis use becomes more common.

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. 

PROP Plans to Hire New Executive Director

By Pat Anson, PNN Editor

An influential anti-opioid activist group -- Physicians for Responsible Opioid Prescribing (PROP) – is raising money to hire a new Executive Director to replace Dr. Andrew Kolodny, PNN has learned.

There is no indication that Kolodny is leaving PROP, a volunteer organization that he founded in 2011 to “turn the tide of opioid overprescribing.” But in an unsigned email sent to supporters this week, PROP asked for donations so it could hire a new Executive Director, a position long held by Kolodny.

“We’ve retrenched and brainstormed and have great plans to expand our reach and impact. Our next big step is to hire a paid staff person. Will you help to make this plan a reality? We are trying to raise $100,000 by December 31st to ensure that we can hire an executive director with resources to take PROP's work to the next level. Please help by donating what you can,” the email said.

Supporters who click the donate button on the email will be taken to a PayPal account operated by the Steve Rummler Hope Foundation, which is PROP’s “fiscal sponsor.” PROP is not a charity, but can collect tax deductible donations under the foundation’s non-profit status.

Like PROP, the Rummler foundation’s main goal is to reduce opioid prescribing. Kolodny works closely with the organization and serves on its Medical Advisory Committee, along with PROP President Dr. Jane Ballantyne.   

Kolodny declined to talk with this reporter about what his future role with PROP will be.

“I haven’t had a good experience answering questions from you in the past, so I’m not going to talk with you,” Kolodny told me in a brief phone call.

‘Heroin Pills’

It would be hard to overstate the influence that Kolodny and PROP have had on opioid prescribing in the United States. A psychiatrist who specializes in addiction treatment and former Chief Medical Officer at Phoenix House, Kolodny is the public face of PROP. He lobbied Congress and federal health agencies for years to limit opioid prescribing, and gives frequent media interviews on opioid-related issues.

In a 2015 C-SPAN interview, Kolodny called opioid painkillers “heroin pills” and suggested pain patients shouldn’t trust their own doctors.  

“I wish I could tell you that you should trust your doctor and talk to your doctor about this, but that may not be the case,” he said. “We have doctors even prescribing to teenagers and parents not recognizing that the doctor has just essentially prescribed the teenager the equivalent of a heroin pill.”

PROP achieved its greatest success in 2016, when the CDC released its controversial opioid prescribing guideline, which several PROP members helped draft. Although voluntary, the guideline was soon adopted as mandatory policy by many states, insurers, law enforcement and health organizations

DR. ANDREW KOLODNY

Opioid prescriptions were declining even before the guideline was released and now stand at their lowest level in over a decade. But overdoses keep rising, fueled largely by illicit fentanyl and other street drugs, not pain medication.

PROP’s fundraising pitch takes credit for the decline in prescriptions and doesn’t even mention the role of street drugs in the overdose epidemic.

“PROP has helped turn the tide of opioid overprescribing.The good news is that opioid prescribing has decreased. The bad news is that the US still leads the world in opioid consumption, drug companies continue to undermine progress, and -- since the SARS CoV-2 pandemic -- opioid overdose deaths are on the rise again while prescription opioid use remains a route to opioid addiction and death,” the PROP email states.

‘Killer Kolodny’

Kolodny has drawn the ire of many pain patients, who blame him for their increased suffering, loss of access to opioids, and anecdotal evidence of a rising number of suicides in the pain community.  A small group of patient advocates recently staged a “Killer Kolodny Rally” outside Brandeis University, where he co-directs opioid research at the Heller School for Policy and Management.   

Kolodny dismissed the rally, telling the Brandeis student newspaper that the protestors who want him fired worked for the opioid industry or had fallen under its sway, and were “trying to controversialize science.”      

“There were climate change scientists who were similarly attacked and their universities stood by them, and I think that Brandeis would stand by science,” Kolodny said. 

Many pain patients believe Kolodny has enriched himself by promoting the use of Suboxone, an addiction treatment drug. That unproven allegation led Kolodny to ask for and receive a letter from Indivior, Suboxone’s manufacturer, stating that he does not have a financial interest in the company.    

As PNN has reported, Kolodny has made a substantial amount of money working as a consultant and expert witness for law firms involved in opioid litigation. During Oklahoma’s lawsuit against Johnson & Johnson, Kolodny testified that he was being paid $725 an hour and would collect up to $500,000 for his services in that trial alone.  

Kolodny has not always been upfront about who is paying him. Last year he revised his conflict of interest statements on two medical journal articles to include his work in malpractice lawsuits. The articles were co-authored with former CDC director Thomas Frieden.

Living With Chronic Pain and Finding Happiness During a Pandemic

By Victoria Reed, Guest Columnist

These are trying times. For those of us struggling with chronic pain, we know what it means to be tough. We battle our own bodies, doctors and even unsympathetic family members every day. We know what it’s like to struggle and make sacrifices -- because that’s what we have to do to survive.

With the arrival of Covid-19, it has added another layer to our already complex lives. But how do we learn to live with this virus and find happiness in the face of overwhelming adversity? I don’t have all the answers, but I do know what’s working for me and what brings me joy. 

I have lived with chronic pain for all of my adult life. My first problem began during my teens, when I developed persistent, unexplained pelvic pain. After many doctor visits and three exploratory surgeries, a sympathetic and kind OB/GYN reproductive endocrinologist finally gave me the answer: endometriosis.

Receiving treatment for endometriosis, which included hormone therapy and surgery to remove adhesions, didn’t take all of the pain away, but it did restore my fertility and allow me to eventually have babies.

Then, during my mid 20’s, my back suddenly went out. I had had no falls, accidents or injuries that I could recall. That would set the stage for another type of pain to take over my life, which there really was no cure for. I got a diagnosis of degenerative disc disease at age 27.

I managed the pain with physical therapy to tighten my core muscles, regular use of ice and heat, rest and pain medication. I also had a caudal nerve block. But by age 32, I began having new symptoms of joint swelling in random joints. Back to the doctor I went!

During that visit with a rheumatologist, I had requested to be tested for rheumatoid arthritis (RA) because my twin sister had recently received that diagnosis. Sure enough, blood tests confirmed that I did indeed have antibodies specific to RA. For those of you who have RA, you know that it is.a.beast.

VICTORIA REED

Over time, beating back RA became like a full-time job; take this medication, take that medication, inject this, apply that. Eventually, after trials of several expensive biologic medications and DMARD’s (disease-modifying antirheumatic drugs), we found one that worked. I get it by IV infusion about once a month at the Cleveland Clinic.

Biologics suppress the immune system to help bring down the inflammation that damages the joints, heart and lungs. RA also causes chronic, debilitating fatigue. It’s like you haven’t slept in a month and got run over by a truck, not like the tiredness you feel when you only had a few hours of sleep the night before.

Then a year or two later, during a routine visit with my rheumatologist, she listened to me as I described being sore all over. After a thorough exam, I received the diagnosis of fibromyalgia, another chronic and painful condition.

Here we go again! When will it stop? Some people might just want to give up, but I had three kids to raise, and it was important for me to fight for my health for them. My 18-year marriage had become a casualty and giving up was not an option!

With the diagnosis of fibromyalgia, I had to adapt to the reality that I was never going to be free of pain and fatigue. They had become my constant companions. I managed, and my kids grew up watching my struggle. They are now 16, 19 and 21 and are happy, well-adjusted individuals, but they’ve had to watch me deal with pain their entire lives. 

Since it was obvious that my body hated me, why would it stop assaulting and insulting me? Guess what? It did not. I have since been diagnosed with FOUR more autoimmune and related disorders: Hashimoto’s thyroiditis (thyroid attack), Sjogren’s syndrome (mucous membrane attack), Raynaud’s phenomenon (small artery abnormality) and the loveliest of all: LADA (Latent Autoimmune Diabetes of Adulthood), a form of Type 1 diabetes that is primarily treated with insulin.

Fast forward to 2020. Covid-19 arrives? No problem! I’m used to challenges. I’m used to pills, needles, pain and fatigue. Wearing a mask is the least of my worries, as I’ve been fighting to stay alive and healthy for all of my adult life and a few of my teenage years.

These days, I make time to do the things that please me, such as riding my 2-wheel Italian scooter, gardening, camping and traveling. I even learned how to ride a motorcycle at age 50! I do not dwell on my pain.

Living in northeast Ohio limits year-round sunshine, but when it is warm and sunny outside, that’s where you’ll always find me! Peace comes when I am at one with nature. Happiness is a state of mind. We can choose to be miserable or we can choose to be happy, and despite my health challenges, I am grateful and thankful for the blessings that I do have.

So, to all of you pain warriors, hang in there! Look for and hold onto the positive. Surround yourself with positive people. Cut out those friends and family that are negative energy (I did). Make time to do things you enjoy. It’s not easy, but it is possible to find peace and happiness in the face of overwhelming adversity.

Let’s hope that Covid-19 will someday be a thing of the past. But if not, we’ll be alright. 

Victoria Reed lives in Cleveland, Ohio.

PNN invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org.

Grin and Bear It: Why Smiling Makes Vaccine Shots Less Painful

By Pat Anson, PNN Editor

Over the next few months, tens of millions of people around the world will be getting the first injections of COVID-19 vaccines, with some getting a vaccine that requires two shots to be effective.

Whether it’s a shot for the flu, pneumonia, shingles or COVID, no one looks forward to stabbing pain from the oversized needles often used in vaccinations. Is there anything you can do to help relieve the sting from a needle prick?

An unusual study led by researchers at the University of California, Irvine, found an unexpected way to dull the pain: Put a big smile on your face.

Researchers say that a broad smile -- one that elevates the corners of the mouth and creates crow's feet around the eyes -- can reduce the pain of a needle injection by as much as 40 percent. That genuine smile, known as a Duchenne smile, can also lower your stress and heart rate during a needle injection.

If you find the idea of smiling during an injection a little silly, then feel free to grimace instead. Grimacing uses the same facial muscles as smiling and is just as effective at pain relief, according to researchers.

"When facing distress or pleasure, humans make remarkably similar facial expressions that involve activation of the eye muscles, lifting of the cheeks and baring of the teeth," says lead investigator Sarah Pressman, PhD, a professor of psychological science at UCI. "We found that these movements, as opposed to a neutral expression, are beneficial in reducing discomfort and stress."

To test their theory, Pressman and her colleagues found 231 healthy volunteers who self-reported their levels of pain, emotion and distress while being injected in the upper arm with saline from a 25-gauge needle — the type often used in a flu shot.

Before and during the injection, participants were randomly selected to use either a Duchenne smile, a small smile, a grimace or a neutral expression. All four facial expressions were facilitated by holding chopsticks in their teeth.

Those in the Duchenne smile and grimace groups reported 40% and 39% less pain, respectively, during the injection than the neutral group, while participants in the small smile group had 26% less pain.

The Duchenne smile and grimace groups (images C and D) were also associated with slightly lower stress and heart rates.

“Why did these two disparate expressions perform so similarly? As discussed previously, this overlap could be explained by the fact that similar muscle groups are activated in both expressions,” researchers reported in the journal Emotion.

“Grimacing has long been used as a nonverbal indicator of pain and has been manipulated unintentionally via common medical practices from the Middle Ages that tell individuals to ‘bite down’ on pieces of wood and leather during painful procedures. To our knowledge, this is the first experimental test showing that this natural response to pain is helpful in improving the subjective pain experience.”

The researchers aren’t suggesting a return to the Middle Ages or that you bite down on chopsticks the next time you’re vaccinated. But they do think that “device-in-mouth manipulation” and “creative paradigms to manipulate facial expressions” are worthy of future pain research.     

"Our study demonstrates a simple, free and clinically meaningful method of making the needle injection less awful," Pressman said. "Given the numerous anxiety- and pain-provoking situations found in medical practice, we hope that an understanding of how and when smiling and grimacing helps will foster effective pain reduction strategies that result in better patient experiences."

Help Us End the Suffering of Chronic Pain Patients

By Anne Fuqua, Guest Columnist

In 2014, a good friend of mine suffered a heart attack after his opioid pain medications were stopped abruptly. This was despite the fact his records showed that he was a responsible and compliant patient who worked full-time.

Following his death, I started logging the deaths I became aware of on a spreadsheet. Initially, this was just my version of a memorial. I have pain too, and at times wondered if I’m going to wind up on this same memorial.

Every month for the past six years, I have had to add at least one more name to that list, sometimes multiple names. I knew many of these patients and considered them to be my friends.

Some had no quality of life and chose to end their suffering. Some fought to live with all the strength they could muster, but fell to heart attacks, strokes and ruptured aneurysms that occurred after their medication was involuntarily tapered, stopped abruptly or during periods of severe uncontrolled pain. 

For others, the cascade of physiologic changes that help our bodies respond to stress can become harmful in themselves if left unchecked, causing effects that may shorten life even if the person does not suffer one specific event like a heart attack or stroke.

ANNE FUQUA

Still others were desperate to live but also desperate to get relief. They went to the illicit drug market when they failed to get the surgery, physical therapy or medication that they felt could improve their quality of life. 

There is a name for abandoned pain patients, left to fend for themselves. Dr. Steve Passik coined the term “opioid refugee” in 2012. Tragically, some of these opioid refugees have died in their quest for relief. They sought relief that would allow them to get restful sleep, enjoy quality time with loved ones, and give them the ability to fulfill responsibilities to their family and society.

CSI Opiods Survey

In 2016, I was fortunate enough to become friends with Dr. Stefan Kertesz, a physician I respect immensely. Dr. Kertesz and his colleague, Dr. Allyson Varley, assembled a team of some of the most respected healthcare providers and thought leaders in the field to advise and support their work. Their goal is to understand what exactly happens when a person with chronic pain dies by suicide. 

After over 2 years of tireless efforts to obtain funding, they have begun a pilot project, a survey of people who have lost someone to suicide. I am helping them understand how to reach out to the people who have lost loved ones. The project has the support of the Department of Medicine at University of Alabama at Birmingham. 

If you would like to know more about Drs. Varley or Kertesz, I would encourage you to Google them so you can see for yourself the quality of their work and their dedication to underserved populations. You may also want to check out Dr. Kertesz’s Tedx Birmingham talk on suicides in the pain community.

Our initial work is a pilot study, We wish to learn how many surviving family members and close friends are willing to come forward and complete a survey after losing a loved one to suicide. For now, we are examining suicides where the patient who died had experienced a change in their opioid medication prior to their death, whether it was decreased, increased or stopped. 

If you have lost a loved one, there are two ways that you can participate. We have a brief online survey you can complete that’s entirely confidential. You can take the survey by clicking here or on the banner below. If you are unable to complete this survey all at once, click “save and return later” and you will be able to save your responses and return to the point you left off at a later time. 

If you would feel more comfortable speaking with someone, you can call toll-free (866) 283-7223. There is no payment for doing the survey. Official study information, approved by a University Institutional Review Board, is online at the survey website.

We may eventually get funding to study other types of deaths. We are asking anyone who has lost a loved one to suicide following a change in opioid dose to consider responding to our survey. If enough people do come forward, it will help to make the case that these terrible losses need to be studied closely, rather than ignored.

I recognize this initial effort has a narrow focus. There are many grieving families who want their loved one’s death to be counted even if it was not a suicide. The way the survey is set up, if you report that the person you lost did not die by suicide, it is going to ask for your contact information. You can provide the research team with your contact information so you can be notified about future studies. 

I still keep my own list of deaths as I learn about them, my memorial. It’s important to know that my list is private. Dr. Kertesz and Dr. Varley do not take names off my list. That’s because university research can only be done with consent. If you have a name for my list, whether they died by suicide or not, contact me and I will add your friend or loved one. I make statistics about the deaths -- but no names -- available to policymakers and patients involved with advocacy work. The list itself will not be made public. 

If you are like me, you are apprehensive about what will happen next. I think most of us are exhausted from the fight for better pain care and desperate for change. Change cannot come soon enough when you are the one who is suffering. This is the first step towards ending needless suffering and loss of life.

Anne Fuqua is from Birmingham, Alabama. She lives with her cat Gabby and has primary generalized dystonia and arachnoiditis.

No Blessing Is Too Small

By Mia Maysack, PNN Columnist

People have asked me and goodness knows, I ask myself sometimes: How am I going continue living this life?  

Please don't ever think I made it to this place overnight. Blood, sweat and tears are only the beginning of what it has taken. There aren't enough words to properly convey or explain what it's like to be in pain each moment of every day. Unless that's relatable to you, others just don't get it because they ain't got it, right?  

The ongoing situations I experience sound insane when I attempt to explain them. It's not logical to never have a break from discomfort; for your insides to feel as though they're climbing their way out, while the outside shrivels into a condensed version of identity that exists some days more than others, and at some points seems to disappear altogether.  

My conditions, whether we're referring to my relentless hurting head or the agony of damaged nerves, cause symptoms far beyond the ailments themselves. Persistent exhaustion has brought me to tears because the extent of the tiredness legitimately frightens me, convinced I must be slowly dying. But isn't that ultimately what we're all doing?

That acknowledgement isn't meant to be grim, but rather to shed a light on what has made it possible for me to even be here to write this:  Gratitude. Even for the smallest blessings.

Although I'm thankful to have made it to see another day, it began at an unreasonable hour this morning. As I lay there defenseless, a brutal migraine attack wreaked havoc out of nowhere, causing a wide array of less than positive emotions while I attempted to fight back.  Those are the moments when I wonder how I'll ever continue to possess what's needed to survive. When I cannot even manage to get myself out of bed.

Pre-COVID, most people smirked at the idea of “lounging around all day” and how nice it must be. So, maintaining that same logic, next time you're ravished with a relentless flu or tummy bug, just reflect on how nice it is to lie around and you'll feel much better. Not.

Remain mindful as to what you wish for and the way you judge a life you haven't lived. I don't even get a shot at normalcy, because the trigger of stabbing pains has already been pulled as I wake to attacks and flare ups. 

We continue on despite our pain. If we didn't, we obviously would no longer be here. There are times I contemplate slamming my head against the wall. Considering it already feels as though I have, that seems counterproductive.  

I'm overjoyed for whoever can continue to carry on, there are just days that I can't. Part of how I had even gotten myself this ill is by pushing myself too far. Singlehandedly operating a business, attending school and successfully running a hospital floor tending to the needs of others.

I'm no stranger to hard work; incurable ailments and a lifelong illness are the toughest jobs I’ve ever had!  Self-care wasn't something that existed in my world. Despite the fact it required hitting a wall first, learning self-care to tend to myself properly and unapologetically has been a gift that keeps giving.    

A difficult aspect of all this for me is that others seemingly forget who you were. I'm seen in a light now, almost as if I'm not living up to my potential and definitely pick up on vibes that being chronically ill somehow makes me "less" of a person.

I do not accept that and here's why: Anyone that has a negative opinion regarding your situation either cannot relate or doesn't understand, so always consider the source. I am thankful for their health and celebrate that mine isn't any worse.  

As people enduring these circumstances, we experience pain levels that would bring others to their knees. Free yourselves from judgement of self and others. Remain prideful. We know what it has taken to make it to this point and only we know what's best for us. My choice is to continue inching closer toward acceptance of the current moment and remain faithful in future possibilities.

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.

New Drug Could Improve Effectiveness of Stem Cell Therapy

By Pat Anson, PNN Editor

Scientists have developed an experimental drug that can lure stem cells to damaged tissues and help them heal -- a discovery being touted as a major advancement in the field of regenerative medicine.

The findings, recently published in the Proceedings of the National Academy of Sciences (PNAS), could improve the effectiveness of stem cell therapy in treating spinal cord injuries, stroke, amyotrophic lateral sclerosis (ALS), Parkinson’s disease and other neurodegenerative disorders. It could also expand the use of stem cells to treat conditions such as heart disease and arthritis. 

“The ability to instruct a stem cell where to go in the body or to a particular region of a given organ is the Holy Grail for regenerative medicine,” said lead author Evan Snyder, MD, director of the Center for Stem Cells & Regenerative Medicine at Sanford Burnham Prebys Medical Discovery Institute in La Jolla, CA. “Now, for the first time ever, we can direct a stem cell to a desired location and focus its therapeutic impact.”

Over a decade ago, Snyder and his colleagues discovered that stem cells are drawn to inflammation -- a biological “fire alarm” that signals tissue damage has occurred. However, using inflammation as a therapeutic lure for stem cells wasn’t advisable because they could further inflame diseased or damaged organs, joints and other tissue.

To get around that problem, scientists modified CXCL12 -- an inflammatory molecule that Snyder’s team discovered could guide stem cells to sites in need of repair— to create a drug called SDV1a. The new drug works by enhancing stem cell binding, while minimizing inflammatory signals.

“Since inflammation can be dangerous, we modified CXCL12 by stripping away the risky bit and maximizing the good bit,” Snyder explained. “Now we have a drug that draws stem cells to a region of pathology, but without creating or worsening unwanted inflammation.”

To demonstrate its effectiveness, Snyder’s team injected SDV1a and human neural stem cells into the brains of mice with a neurodegenerative disease called Sandhoff disease. The experiment showed that the drug helped stem cells migrate and perform healing functions, which included extending lifespan, delaying symptom onset, and preserving motor function for much longer than mice that didn’t receive the drug. Importantly, the stem cells also did not worsen the inflammation.

Researchers are now testing SDV1a’s ability to improve stem cell therapy in a mouse model of ALS, also known as Lou Gehrig’s disease, which is caused by a progressive loss of motor neurons in the brain. Previous studies conducted by Snyder’s team found that broadening the spread of neural stem cells helps more motor neurons survive — so they are hopeful that SDV1a will improve the effectiveness of neuroprotective stem cells and help slow the onset and progression of ALS. 

“We are optimistic that this drug’s mechanism of action may potentially benefit a variety of neurodegenerative disorders, as well as non-neurological conditions such as heart disease, arthritis and even brain cancer,” says Snyder. “Interestingly, because CXCL12 and its receptor are implicated in the cytokine storm that characterizes severe COVID-19, some of our insights into how to selectively inhibit inflammation without suppressing other normal processes may be useful in that arena as well.”

Snyder’s research is supported by the National Institutes of Health, U.S. Department of Defense, National Tay-Sachs & Allied Disease Foundation, Children’s Neurobiological Solutions Foundation, and the California Institute for Regenerative Medicine (CIRM).

“Thanks to decades of investment in stem cell science, we are making tremendous progress in our understanding of how these cells work and how they can be harnessed to help reverse injury or disease,” says Maria Millan, MD, president and CEO of CIRM. “This drug could help speed the development of stem cell treatments for spinal cord injury, Alzheimer’s, heart disease and many other conditions for which no effective treatment exists.”

Intractable Pain Syndrome Has 2 Kinds of Pain

By Forest Tennant, PNN Columnist

A major reason that persons with Intractable Pain Syndrome (IPS) experience such misery is that when pain is the constant, 24/7 variety, it has two parts: ascending and descending pain. Both types need to be treated for relief.

Picture your body running on electric currents. In your house, electric currents are conducted by wire. Although there is no good reason to avoid the term “wire” when it comes to the human body, we usually refer to our biologic wires as nerves, nerve roots or neurons.

Unfortunately, any disease or injury to one or more of our “wires” blocks the electric currents that normally flow through the nerves, nerve roots or neurons, and diverts electricity into the surrounding tissue to produce inflammation and pain.

Ascending Pain is caused when pain electricity travels from the disease or injury site up the nervous system to the brain. This is the most common type of pain. For example, if you have a sore knee, pain signals travel from the knee to the brain.

Descending Pain is caused when severe pain from any number of diseases and injuries sends so much electricity into the brain and spinal cord that it accumulates. Areas of inflammation develop and destroy and/or damage the dopamine-noradrenaline neurotransmitter systems that control descending pain.

The excess electricity from these inflamed sites travels down the nervous system into muscles, skin, tendons, joints, fatty tissues, and the large and small peripheral nerves. Small nerve endings in the skin can “burn out” due to all the descending electricity and a skin biopsy will probably show small fiber neuropathy.

How do you know if you have descending pain? You have muscle aches all over which are often labeled as fibromyalgia. You hurt everywhere and experience episodes of overheating, sweating, and cold hands and feet, often at the same time!

Tips to Reduce Descending Pain

The critical point is that usual pain treatment only treats ascending pain, not descending pain. Opioids, antidepressants, anti-inflammatories and muscle relaxants do not usually do much for descending pain.

Each person with IPS must adopt a few simple but specific medical, physical, and dietary measures to attain some relief and recovery from both kinds of pain. You must maintain your dopamine-noradrenaline neurotransmitter systems daily, or you will have increased pain and misery, and believe that more drugs like opioids are the answer.

The understanding of blocked and diverted electric currents has led to the identification and labeling of a group of treatment agents that help normalize electric currents. These are known as neuropathic agents. The neurotransmitter most responsible for the proper conduction of electric currents is called gamma aminobutyric acid (GABA for short). It is synthesized by the body from the amino acid glutamine.

Neuropathic medications include gabapentin, pregabalin, carisoprodol, topiramate, duloxetine, and benzodiazepines.

In addition to neuropathic agents, there are simple “age-old” remedies that still work for most people because they help modulate electric currents so that they don’t divert, accumulate, and cause more inflammation and pain:

• Water Soaking

• Epsom or Herbal Salts

• Magnets

• Acupuncture

• Copper Jewelry

• Walking Barefoot

• Dry Needling

• Petting Fur

• Magnesium

Every person with IPS needs a daily program of neuropathic agents and age-old remedies to minimize the consequences of accumulated electricity.

Forest Tennant is retired from clinical practice but continues his groundbreaking research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

The Tennant Foundation has given financial support to Pain News Network and is currently sponsoring PNN’s Patient Resources section.  

Tarantulas May Help Develop New Pain Medication

By Pat Anson, PNN Editor

Venom from a bird-catching Chinese tarantula may hold the key to medications that could someday block pain signals in humans, according to a new study at the University of Washington School of Medicine. Researchers say the oversized, hairy spiders inject a toxin into the birds that quickly immobilize them.

"The action of the toxin has to be immediate because the tarantula has to immobilize its prey before it takes off," said William Catterall, PhD, a professor of pharmacology and lead author of a study published in the journal Molecular Cell.

Catterall and his colleagues were curious how the venom works, so they used a high-resolution cryo-electron microscope to get a clear molecular view of its effect on nerve cells.

They found that tarantula venom contains a neurotoxin that locks the voltage sensors on sodium channels, the tiny pores on cell membranes that generate electric signals to nerves and muscles.

Locked in a resting position, the voltage sensors are unable to activate and the spider’s prey is essentially paralyzed.

"Remarkably, the toxin plunges a 'stinger' lysine residue into a cluster of negative charges in the voltage sensor to lock it in place and prevent its function," Catterall said. "Related toxins from a wide range of spiders and other arthropod species use this molecular mechanism to immobilize and kill their prey."

In humans, sodium channels known as the Nav1.7 channel are essential for the transmission of pain signals from the peripheral nervous system to the spinal cord and brain.

UNIVERSITY OF WASHINGTON

In theory at least, drugs modeled after tarantula venom could be used to target and immobilize the Nav1.7 channel. Previous research has shown that people born without Nav1.7 channels due to genetic mutation are indifferent to pain – so blocking those channels in people with normal pain pathways could form the basis for a new type of analgesic.

"Our structure of this potent tarantula toxin trapping the voltage sensor of Nav1.7 in the resting state provides a molecular template for future structure-based drug design of next-generation pain therapeutics that would block function of Nav1.7 sodium channels," Catterall explained.

While venom-based medicine may sound impractical and more than a little creepy, it’s not unheard of. A pharmaceutical drug derived from cone snail venom is already being used to treat chronic pain. Prialt is injected into spinal fluid to treat severe pain caused by failed back surgery, trauma, AIDS and cancer. Like tarantula venom, Prialt blocks channels in the spinal cord from transmitting pain signals to the brain.  

12 Holiday Gifts on Life With Chronic Pain

By Pat Anson, PNN Editor

If you live with chronic pain or illness and want to have a friend or family member get a better understanding of what you're going through -- here are 12 books and videos that would make great gifts over the holidays. Or you can always “gift” one to yourself.

Click on the cover to see price and ordering information. PNN receives a small amount of the proceeds -- at no additional cost to you -- for orders placed through Amazon. As an Amazon Associate, we earn from qualifying purchases. 

Finding a New Normal: Living Your Best Life with Chronic Illness by Suzan Jackson

For nearly 20 years, Suzan Jackson has lived with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) — a condition she shares with two of her sons. In this book, Jackson shares what she and her family have learned about living well with chronic illness and finding a “new normal” through strong relationships, healthy emotions and finding joy in everyday life. The emphasis is on living life, not just enduring it.

War on Us by Colleen Cowles

Lawyer Colleen Cowles looks at how the war on drugs and myths about addiction have created a dysfunctional drug policy that prosecutes doctors for treating pain and stigmatizes patients for seeking relief. The U.S. has spent over a trillion dollars fighting the war and has little to show for it except some of the highest rates of addiction, overdose and incarceration anywhere in the developed world.

Ketamine Infusions: A Patient’s Guide by Berkley Jones

Berkley Jones looks at the increasing use of ketamine, a non-opioid analgesic, in treating chronic pain, depression, post-traumatic stress disorder and anxiety. This book is a useful guide if you are considering ketamine infusions and want to know how to select a provider, what to expect during infusions and possible side effects. Although primarily used to treat depression, some pain patients say ketamine is effective in treating neuropathy and CRPS.

Bitten: The Secret History of Lyme Disease and Biological Weapons by Kris Newby

Author Kris Newby began looking into the origins of Lyme disease after she was bitten by a tick and became seriously ill. Her research led her to a secret U.S. government program during the Cold War that used insects as biological weapons to spread disease. Newby believes the Lyme outbreak that began 50 years ago and has infected millions of Americans may have been the result of a military experiment gone wrong.

Vagina Problems: Endometriosis, Painful Sex and Other Taboo Topics by Lara Parker

A memoir by Lara Parker that explores — with unflinching honesty — her battle with endometriosis, a chronic vaginal condition that makes daily life difficult and sex painful. As a teenager, doctors initially dismissed Parker’s pain as “bad period cramps” and suggested her pain was psychological. She nearly checked herself into a mental institution before finally getting a proper diagnosis.

A Quick Guide to CBD by Dr. Julie Moltke

CBD won’t cure you of chronic pain, but Dr. Julie Moltke says cannabidiol can reduce pain, inflammation, anxiety and insomnia — and help make life more livable. This handbook is intended for beginners who want to learn how and when to take CBD, and are puzzled by all the hype surrounding vapes, oils, gummies and edibles on the market.

Pain Warriors by Tina Petrova

A documentary produced by patient advocate Tina Petrova that examines the poor treatment and medical neglect faced by millions of pain sufferers in North America. The film is dedicated to Sherri Little, a chronic pain patient who committed suicide after one last attempt to get effective treatment. Available on DVD or for streaming on Amazon Prime.

Together: The Healing Power of Human Connection by Dr. Vivek Murthy

This timely book by former U.S. Surgeon General Dr. Vivek Murthy looks at the importance of human connections and how loneliness affects our health and society at large. To combat loneliness, Murthy recommends spending at least 15 minutes each day connecting with people we care about and to give them our undivided attention.

Bottle of Lies: The Inside Story of the Generic Drug Boom by Katherine Eban

Wonder why that generic drug you take doesn’t seem to work? About 90% of pharmaceutical drugs are generic and most are manufactured overseas. While generics are promoted as cheaper alternatives to brand name drugs, journalist Katherine Eban found the generic drug industry rampant with greed, fraud and falsified manufacturing data — resulting in many patients consuming drugs that are ineffective or have dangerous side effects.

In Pain: A Bioethicist’s Personal Struggle with Opioids by Travis Rieder, PhD

Travis Rieder is a professor of bioethics at Johns Hopkins University who severely injured his foot in a motorcycle accident and became dependent on opioids while recovering from surgery. In this book, he shares his frustration with the healthcare system and how it often abandons patients to pain, addiction or both. Rieder serves on a CDC advisory panel that is helping the agency prepare an update of its controversial 2016 opioid guideline.

The Chronic Pain Management Sourcebook by David Drum

A comprehensive guide about chronic pain by medical journalist David Drum, who summarizes the many causes, types and treatments of pain. Drum also has tips on managing stress, anxiety, lack of sleep and depression. The book is easy to understand and would be a useful resource for family members, friends and caretakers who want to understand and help someone living with chronic pain.

A Little Book of Self Care: Trigger Points by Amanda Oswald

This well-illustrated book provides 40 simple, step-by-step exercises you can use to manage back pain, migraine and other painful conditions. Author Amanda Oswald explains how “trigger points” — small knots of muscles and connective tissue — can be relieved through self-massage and the “power of touch” without visiting a chiropractor or physical therapist.

These and other books and videos about living with chronic pain and illness can be found in PNN’s Suggested Reading section.