Ice Packs and Tylenol: Why a New Study on Post-Operative Pain Falls Flat

By Pat Anson, PNN Editor

The prescribing of opioids to patients recovering from surgery is a hot topic these days. Fearing that patients may become addicted, a growing number of U.S. hospitals now send their surgery patients home with non-opioid analgesics like Tylenol. According to a recent study, the number of opioid pills prescribed to patients for post-operative pain has been cut in half since 2017.

Reducing the use of opioids has led to complaints from patients that their post-operative pain is poorly treated. It may have even led to a tragic mass shooting. Police say the patient who killed four people – including his surgeon – at a Tulsa hospital this month was angry about “the ongoing pain that came from the surgery” he had 13 days earlier.

A new study by researchers at McGill University in Montreal is likely to add further fuel to the debate over opioids. In a meta-analysis of 47 clinical trials – a study of studies – researchers concluded that opioids don’t work well for post-operative pain, and cause more harm than good.

“The study results indicate that prescribing opioids to manage postoperative pain after discharge is not only unnecessary, but harmful in many surgical settings. These findings… fill a critical gap in knowledge about how pain should be managed at home after surgery,” is how a McGill University press release summarized the findings.

It’s important to read the fine print here. The McGill study, published in The Lancet, has three major limitations that the press release either ignores or downplays.

First, most of the clinical trials that were studied were for dental procedures such as tooth extractions or for minor surgeries conducted in a physician’s office, such as removal of a skin lesion. None of the surgeries involved patients having major operations in a hospital, such as a cesarean section or appendectomy.

Second, much of the data was “largely derived from low-quality trials,” according to the authors.

Third, the primary goal of the study was to assess the pain relief provided by opioids and non-opioid analgesics for one day -- “on day 1 after discharge” – which hardly fills the “critical gap in knowledge” about post-operative pain that McGill claims to have been filled. What about the next 5 or 10 days a patient might need to recover from surgery? What about 13 days?

Despite these glaring limits on the quality of their analysis, McGill researchers came to some broad conclusions.

"We found that prescribing opioids had no impact on patient-reported postoperative pain compared to simple over-the-counter analgesics, but it significantly increased the risk of adverse events, such as nausea, vomiting, constipation, dizziness and drowsiness," said lead author Julio Fiore Jr., PhD, a non-practicing “surgical scientist” at McGill University Health Centre.

"Prescribing opioid-free analgesia may prevent these adverse effects, improve patients' recovery experience, and also help mitigate the opioid crisis by reducing the risk of postoperative opioid misuse, addiction and diversion."

Study Methodology Questioned

But critics of the study’s methodology point out that most patients had only modest pain scores and received very low doses of opioids. The median daily dose of 27 morphine milligram equivalents (MME) is far below cautionary levels recommended by the CDC — and hardly reflective of what a patient might need after a major surgery.

“Most of the surgeries were minor and probably required minimal post-op analgesia,” said Stephen Nadeau, MD, a professor of Neurology at the University of Florida College of Medicine. “In short, the generalization of their findings to all opioid treatment of post-operative pain goes far beyond what the data will support. The reviewers and Lancet editor should have taken them to task about this.”

Over $80,000 in taxpayer funding for the McGill study came from the Canadian Institutes of Health Research, which is Canada's federal agency for healthcare research.

“This is typical of the research that we have seen from Canadian researchers that have put Canadians in such a bad state. Their methods and reasons are suspect and the use of data mining continues to come up with false premises,” said Barry Ulmer, Executive Director of the Chronic Pain Association of Canada. “It is shocking and McGill should be ashamed, as should The Lancet. What is also shocking is the Canadian government continues to fund many of these over the wall studies.”

In a preview of the McGill study published in 2020, Fiore and his colleagues said they would exclude from their analysis any studies that evaluated the effectiveness of analgesia for chronic postoperative pain. In other words, they excluded studies of pain relievers that had outcomes running counter to their narrative. If a surgery patient developed chronic pain after their acute pain was only treated with Tylenol, they didn’t want to hear about it.   

"The quality of the selected studies was variable, and none of them addressed non-opioid analgesia during discharge from major or major-complex surgery," acknowledged co-author Charbel El-Kefraoui, a non-practicing “research trainee” at McGill University. "It will therefore be important to conduct studies on different surgical procedures and on different postoperative pain management regimens, including pharmacologic and non-pharmacologic interventions like expectation setting, relaxation and ice packs."

Good luck with that. Ice packs and Tylenol are probably a good way to recover from a toothache, which is basically what the McGill study looked at. They are not a good way to treat acute pain from a major surgery. Or a way to avoid future tragedies like the one in Tulsa.

Low-Dose Cannabis Inhaler Effective in Treating Chronic Pain

By Pat Anson, PNN Editor

Low-doses of medical cannabis delivered through an inhaler significantly reduced pain in patients with neuropathy, back pain and other chronic pain conditions, according to a new study.

Researchers assessed the efficacy of vaporized cannabis in 138 pain patients using the Syqe Inhaler, a pocket-sized device that delivers microdoses of aerosolized cannabis. The study was funded and conducted by Syqe Medical, a medical technology company in Israel that makes the inhaler.

Unlike smoking or traditional vaping, the Syqe inhaler heats the cannabis to a temperature below combustion and uses airflow controls to deliver precise doses of cannabis to the patient's lungs in less than 2 seconds. The mean dose in the study was 1.5 mg of aerosolized delta-9-THC, a fraction of what a typical cannabis user would get from a joint or vaporizer.

Participants in the study used the inhaler up to several times a day, depending on need, and were followed for up to a year.

The study findings, published in the journal Pain Reports, show that pain levels fell from an average of 7.3 (on a zero to 10 pain scale) to 5.5 after 120 days – a reduction of nearly 23 percent. For patients in severe pain, pain levels dropped over 28 percent.

Most participants also reported significant improvement in their quality of life, with 92% saying their lives were “better” or “much better.”  

Of the 43 patients who were using opioid pain medication at the start of the study, 58% reported using lower doses after initiating treatment with the inhaler.

Adverse events, such as dizziness and headache, were minor and usually lasted only a few minutes. About 17% of patients reported no decrease in pain intensity and 7% reported more pain.

SYQE MEDICAL IMAGE

“Medical cannabis treatment with the Syqe Inhaler demonstrated overall long-term pain reduction, quality of life improvement, and opioid-sparing effect in a cohort of patients with chronic pain, using just a fraction of the amount of MC (medical cannabis) compared with other modes of delivery by inhalation,” researchers reported.

“These outcomes were accompanied by a lower rate of AEs (adverse events) and almost no AE reports during a long-term steady-state follow-up. Additional follow-up in a larger population is warranted to corroborate our findings.”

The Syqe Inhaler is currently only available in Israel and Australia. The company said in an email that it plans to launch the device in Canada and New Zealand in the coming months. No timetable was offered on its availability in the United States.

“We believe it is our responsibility to reduce the pain and suffering of as many patients as possible in the fastest possible way, and we are determined to make medical cannabis treatment a standard of care utilizing advanced technologies,” said Sharon Cohen of Syqe’s Customer Experience Team.

Walking Reduces Pain From Knee Osteoarthritis

By Pat Anson, PNN Editor

It may seem counterintuitive, but a new study suggests that walking may be the best medicine to reduce knee pain from osteoarthritis.

Nearly 40 percent of Americans over the age of 45 have some degree of knee osteoarthritis, a progressive joint disorder caused by inflammation of soft tissue, which leads to thinning of cartilage and joint damage. Osteoarthritis (OA) of the knee is not to be taken lightly, as studies have found that it is strongly associated with early death, high blood pressure, diabetes, elevated cholesterol and cardiovascular disease, particularly for women.

Moderate exercise like walking may help prevent all of those health problems.

In a multi-year study of 1,212 people over the age of 50, researchers at Baylor College of Medicine found that participants who walked for exercise at least 10 times had 40% less risk of developing frequent knee pain than non-walkers.

“Until this finding, there has been a lack of credible treatments that provide benefit for both limiting damage and pain in osteoarthritis,” said Grace Hsiao-Wei Lo, MD, assistant professor of Immunology, Allergy and Rheumatology at Baylor and lead author of the study published in Arthritis & Rheumatology.

“These findings are particularly useful for people who have radiographic evidence of osteoarthritis but don’t have pain every day in their knees,” Lo explained in a press release. “This study supports the possibility that walking for exercise can help to prevent the onset of daily knee pain.  It might also slow down the worsening of damage inside the joint from osteoarthritis.”  

Lo says walking for exercise has other health benefits, such as improved cardiovascular health and decreased risk of obesity, diabetes and even some cancers. Walking is also a free activity with minimal side effects.

“People diagnosed with knee osteoarthritis should walk for exercise, particularly if they do not have daily knee pain,” says Lo, who is chief of rheumatology at the Michael E. DeBakey VA Medical Center in Houston. "If you already have daily knee pain, there still might be a benefit, especially if you have the kind of arthritis where your knees are bow-legged.”

Avoiding Opioids During Surgery May Harm Patients

By Pat Anson, PNN Editor

Many U.S. hospitals have adopted policies that reduce or even eliminate the use of opioids during surgery, with the goal of lowering the risk of a patient later becoming addicted. That has resulted in greater use of spinal anesthesia as a substitute for general anesthesia.

During spinal anesthesia, non-opioid medications are used to numb the lower part of the body through an injection into the spinal column. During general anesthesia, a combination of opioids and other analgesics are administered intravenously or through a breathing tube to sedate patients.

But a large new study suggests that spinal anesthesia may actually increase the use of prescription opioids – at least when it comes to hip fracture surgeries.

In an analysis of 1,600 patients who had surgery to repair hip fractures, researchers at the University of Pennsylvania Perelman School of Medicine found that patients who received spinal anesthesia reported more pain in the 24 hours after surgery than those who receive general anesthesia. They were also more likely to be using prescription opioids 60 days after surgery.

“In our study, patients who got spinal anesthesia did get fewer opioids in the operating room, but they ended up having more pain, and more prescription pain medication use after surgery,” said lead author Mark Neuman, MD, an associate professor of Anesthesiology and past chair of the Penn Medicine Opioid Task Force.

“While our study can’t determine conclusively whether this was due to the spinal anesthesia itself or the fact that fewer opioids were given up front, this is a result that should make people examine some of the assumptions informing current care pathways.”

The study findings, published this week in The Annals of Internal Medicine, show patients had their worst pain the day after surgery. Spinal anesthesia patients rated their pain an average of 7.9 (on a zero to 10 pain scale), slightly higher than the average of 7.6 reported by those under general anesthesia.

Researchers say 25 percent of patients in the spinal anesthesia group were using prescription opioids 60 days after surgery, compared to 18.8 percent of patients in the general anesthesia group. There were no significant differences in prescription pain medicine use after six and 12 months, but Neuman is wary of what he saw.

“Even though the 180- and 365-day findings are not statistically significant, the 60-day finding is still concerning, since there could be medication-related harms like respiratory depression or over-sedation that could still occur over the short term,” Neuman said.

Neuman and his colleagues found no significant differences in patient satisfaction, pain levels or mental health status after 60, 180 or 365 days between the spinal anesthesia and general anesthesia groups.

More than 250,000 older Americans suffer hip fractures every year and nearly all are repaired through surgery. In the past, most would receive general anesthesia, but in recent years the use of spinal anesthesia has increased significantly, due in part to the belief by some anesthesiologists that it was safer for frail, older patients.  

Elimination of Opioids Has “Unintended Safety Risks’

There is a growing reluctance on the part of surgeons to eliminate the use of opioid anesthesia or to allow patients to opt out of opioids during surgery.

In an op/ed recently published in The Conversation, three physicians at the University of Michigan Medical School called opioid medication “an essential tool in the operating room.”  

“Opioids stand out among the typical sedatives and anesthetics used in the operating room by significantly reducing the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness,” wrote Drs. Mark Bicket, Jennifer Waljee and Paul Hilliard. 

“Whether or not patients receive opioids during surgery doesn’t affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.”  

Seven states currently allow patients to sign non-opioid directives telling their physicians not to treat them with opioids. Congress is considering bills in the House and Senate that would allow patients to make similar directives nationwide. Although both bills allow providers to override a patient’s directive in special circumstances, Bicket, Waljee and Hilliard are concerned the directives will lead to unsafe care.

“We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it difficult if not impossible to avoid harming patients,” they wrote.

Tips to Make Traveling Less Painful

By Victoria Reed, PNN Columnist

Now that summer is right around the corner, many people like to take a vacation to relax and enjoy the nice summer weather. Summer is my favorite season because I live in northeast Ohio, where the winters can be very cold and snowy. As someone who lives with chronic pain, having to go out in the blistering cold and navigate snow covered roads can make life even harder.

Recently I took a flight to California to attend a family member’s college graduation. It was a fairly long trip, lasting more than five hours. I’ve made trips to California from Ohio many times over the course of several decades. But over the years, as the comfort of riding on airplanes has diminished and as my back, joints and muscles have gotten sorer, the flight turned out to be less than pleasant. 

People in pain often have more to carry than the average person, and diabetics like me need to bring more medical supplies. I try to keep my carry-on backpack light, especially since rheumatoid arthritis (RA) has ravaged my shoulders, which frequently hurt.

Of course, I want to be comfortable when flying, so I regularly pack things such as a neck pillow and a blanket or two. In addition, I must bring snacks, prescription medications, a blood glucose testing kit, a small portable cooler and ice pack for my insulin, several insulin pens, and wrist braces for the inevitable in-flight RA flare. Add to that the standard personal items that I usually carry in my purse. I also like to bring my iPad (with noise canceling headphones) for entertainment.

Because of these necessities (and the not-so-necessary iPad), the backpack was quite heavy. By the time I arrived at my rental home-away-from-home with my dog, I was having a full-blown flare that involved joint pain, muscle pain and severe fatigue. 

I still needed to get some groceries, and after doing that and settling comfortably in bed, a sobering thought came to me: I can’t do this alone anymore.

The fact is, it has become too hard and exhausting. I love traveling, but airline travel is not what it was years ago. It used to be exciting to get on a plane, settle in a window seat and experience the beauty of being above the clouds and watching the mountains below them. But now airplanes are packed so tightly that there’s no room to be comfortable.  I try to book an aisle seat so that I have room to at least stretch my legs and get up to use the restroom without disturbing anyone.

Regardless, I would like to continue traveling because I love going to new places and exploring the beautiful United States. When the pandemic first became a thing, my husband and I purchased a camper, and we began taking trips to national and state parks with our dogs. It quickly became our preferred way of travel.

Because airline travel can be especially stressful for those of us with chronic illness, I recommend traveling by car or RV (if you can afford one). It is so much easier when you have everything you need in one place and are able to stop and stretch when you need to.

Also, if you need to take medications during your trip, they are easier to access than trying to get into your bag in an overhead bin or struggling to reach under the cramped airline seat. Road travel is also the best way for your pets to travel. Pets can be a great source of comfort to those suffering with pain.

However, if you must travel by airplane or just prefer to, there are things you can do to make it more comfortable. I recommend bringing items such as a blanket and a travel pillow. Wear comfortable shoes that can easily be taken off during the security process. Bring along a hoodie or sweater, as the plane tends to get chilly during the flight.

If you have severe mobility issues, arrange to have a wheelchair waiting at the airport or use one of the transport carts to get you to your gate. Pack some healthy snacks, as the ones they serve during the flight are very minimal and not very healthy. If you are a diabetic, pack some candy for those possible blood sugar lows. That way you don’t have to wait for the flight attendant with the drink cart containing sugary drinks.

If you have low back issues, bring an additional light banket to roll up and place behind your back. That could make a world of difference in your comfort level.

If you are traveling onboard with a pet, try to have a companion with you to assist. Having to carry the pet increases the load you already have to manage, and you lose the under-seat space where your purse or backpack is placed. Since many people bring their roller bags onboard, instead of checking them, trying to find overhead space for your personal bag is…well, trying!

Traveling these days can be a challenging experience, but it’s even more so for chronic pain sufferers. Taking a nice vacation or a weekend trip somewhere (if you can afford to) can be just what you need to relax, rejuvenate, boost your mood, and be a distraction from daily pain. With a little advanced planning, you can prevent it from becoming a miserable experience.

Victoria Reed lives in Cleveland, Ohio. She suffers from endometriosis, fibromyalgia, degenerative disc disease and rheumatoid arthritis. 

Opioid Tapering Raises Risk of Overdose and Mental Health Crisis

By Pat Anson, PNN Editor

Tapering patients to lower doses of opioid pain medication significantly raises the risk of opioid withdrawal, drug overdose and a mental health crisis such as depression, anxiety or suicide attempt, according to a large new study. For most patients, the risk remains elevated up to two years after their doses were reduced.

Opioid prescribing has fallen dramatically in the United States over the past decade, particularly after the release of the CDC’s controversial opioid guideline in 2016. Although millions of patients were affected, few efforts were made to study patient outcomes or what happens to those who have their opioid doses reduced or even stopped.

To address this knowledge gap, researchers at the University of California Davis School of Medicine analyzed health data for over 19,300 patients on long-term opioid therapy who had their doses reduced by at least 15 percent. In addition to medical and pharmacy claims, researchers looked at emergency room visits and hospital admissions for overdose, withdrawal or mental health crisis, both before and after tapering.

"We used an innovative observational study design to understand the patients' experience before and after opioid dose reduction. We compared outcome rates in pre- and post-taper periods with patients serving as their own controls," said co-author Daniel Tancredi, PhD, a pediatrics professor at UC Davis Health.

"While patients may struggle during the early tapering period, we reasoned that many may stabilize with longer-term follow-up and have lower rates of overdose and mental health crisis once a lower opioid dose is achieved," said lead author Joshua Fenton, MD, professor and vice chair of research at UC Davis School of Medicine.

But Fenton and his colleagues found patients continued to struggle long after their doses were cut. Their findings, published in JAMA Network Open, show a 57% increase in overdose or withdrawal incidents and a 52% increase in mental health crises 12 to 24 months after doses were lowered.

For every 100 patients during pre-tapering, there was an average of 3.5 overdose or withdrawal events and 3 mental health crises. After tapering, there were 5.4 overdose/withdrawal events and 4.4 mental health crises for every 100 patients. The risks associated with tapering were greatest in patients with the highest doses.

"Our findings suggest that, for most tapering patients, elevated risks of overdose and mental health crisis persist for up to two years after taper initiation," said Fenton. "We hope this work will inform a more cautious approach to decisions around opioid dose tapering."

An earlier study at UC Davis found that tapered patients were 68% more likely to be treated at a hospital for opioid withdrawal, overdose or alcohol intoxication, and were twice as likely to have a mental health crisis.

‘I Was Cut Off Cold Turkey’

The FDA warned in 2019 that rapid tapering or abrupt discontinuation was causing serious harm to patients. The CDC Director also pledged that year to evaluate the impact of the agency’s opioid guideline on patients and to “clarify its recommendations.”

Three years later, not a word of the CDC guideline has changed and the agency is slow walking efforts to revise it. A revised guideline draft, which cautions doctors to avoid rapid tapering or discontinuation, is not expected to be finalized until late this year. In the meantime, many doctors continue to taper patients – even those who’ve taken opioids safely and responsibly for years.

“Yesterday, I was cut off of one of my opioid medications, cold turkey. I've been given one last 30-day supply of the other, after 19 years of chronic pain treatment with opioid medication. I am bedridden,” a patient told us in a recent PNN survey on the impact of the 2016 guideline.

“Currently my pain management doctor is tapering everyone from schedule II (opioid) medications, even with years of good results and no side effects. This is dangerous when people are dealing with real pain,” said another patient.

“Before the guidelines, my pain was controlled with fentanyl patches and Vicodin for breakthrough pain. I was able to work, care for my home and family. That's all been taken away and now I spend my time either in bed or on my couch, in pain. Tapering down was 7 months of hell in my bedroom. It was cruel and unnecessary to take away medicine that allowed me to enjoy and participate in my life,” another patient wrote.

In an editorial also published in JAMA Network Open, two University of Alabama at Birmingham researchers who are studying the role of tapering in patient suicides urged doctors to be more cautious.

“Our view is that opioid dose reduction is likely to offer benefit for some, while harming others. The harms may include worsening pain, distress, or death,” wrote Stefan Kertesz, MD, and Allyson Varley, PhD. “Given this uncertain balance of harm and benefit, it would be wise for health systems to stop promoting this change to care. A policy of tapering all patients to doses lower than a specified threshold cannot be supported from available evidence.”

Kertesz and Varley are currently recruiting family and friends of patients who died by suicide to participate in a pilot study about the impact of opioid tapering on their loved ones. To participate in their study, click here to take an online survey or call 1-866-283-7223.

FTC Sues Footwear Company Over Pain Relief Claims

By Pat Anson, PNN Editor

The U.S. Federal Trade Commission has filed a lawsuit against a California footwear company, alleging it makes false claims that its shoes can relieve knee, back and foot pain. It’s the latest salvo in a long-running legal battle between the FTC and the Gravity Defyer Medical Technology Corporation.

According to the FTC complaint, Gravity Defyer and its owner, Alexander Elnekaveh, violated a 2001 order barring him from using deceptive advertising that makes unsupported scientific claims. The FTC says the company’s ads target people aged 55 and older, telling them its “pain defying footwear” made with “hybrid VersoShock technology” can relieve suffering from arthritis, joint pain, plantar fasciitis and heel spurs.

“Ignoring a prior Commission order, Gravity Defyer and its owner used false pain-relief claims to target older Americans and undercut honest competitors,” Samuel Levine, Director of the FTC’s Bureau of Consumer Protection, said in a statement. “Health-based claims require science-based proof, and faking it by misusing studies and customer reviews breaks the law.”

The 2001 FTC order stems from another company operated by Elnekave, which sold a magnetic fuel-line device that allegedly could reduce gasoline consumption by as much as 27 percent. The FTC says those claims were false and misleading.

Gravity Defyer sells an expensive line of athletic shoes, casual shoes, dress shoes, hiking shoes, boots and sandals for men and women.

They range in price from $140 for a pair of sandals to $235 for work boots.

The company sells the shoes on its website, Amazon and at retailers around the country, including The Walking Company, Hammacher Schlemmer, and Shoe City. It advertises its products on Arthritis Today and WebMD, as well as numerous other publications and websites.

Asked to comment on the FTC complaint, the company sent a statement to PNN claiming that its First Amendment right to free speech was being violated.

GRAVITY DEFYER AD

“Gravity Defyer apprised the FTC of the obvious logical flaws in its stance – and that its stance violates Gravity Defyer’s First Amendment right to disseminate, and consumers’ right to receive, truthful, non-misleading scientific information. The FTC was unrelenting in its strange position,” the company said.

In April, Gravity Defyer filed a lawsuit of its own against the FTC. Much of it hinges on a small 2017 study that the company has long used to justify its pain-relieving claims. The study, recently published the Journal of the American Podiatric Association, found that Gravity Defyer’s “shock-absorbing sole” reduces knee pain an average of 85 percent, significantly better than traditional soles.

The FTC says the study has “substantial flaws” because of its small size (52 participants) and duration (5 weeks), and because it relied on participants’ self-reported pain levels.

“It was also only designed to measure knee pain. Thus, the study was not sufficient to determine the effects of wearing Gravity Defyer’s footwear on knee, back, ankle or foot pain, or pain associated with the specific conditions claimed,” the FTC said.

The Commission, which voted 4-0 to file the complaint, is seeking an order permanently barring Gravity Defyer and Elnekaveh from making misleading or deceptive pain-relief claims, as well as civil penalties.

Critics Challenge Study That Found Little Evidence to Support Use of Cannabis

By Pat Anson, PNN Editor

Medical marijuana advocates are challenging the findings of a new study that found little clinical evidence to support the use of cannabis in treating chronic pain.

“The findings appear out of step with the real-world experience of millions of patients who have come to rely on cannabis for pain management,” said Paul Armentano, Deputy Director of NORML.

The federally-funded systematic review – essentially a study of studies – was conducted by researchers at Oregon Health & Science University (OHSU), who analyzed over 3,000 cannabis studies. They could find only 25 studies that met their criteria for review. Only placebo controlled clinical trials or observational studies lasting at least four weeks were included. The rest were deemed to be poor quality or flawed in some way.

“In general, the limited amount of evidence surprised all of us,” said lead author Marian McDonagh, PharmD, professor of medical informatics and clinical epidemiology in the OHSU School of Medicine. “With so much buzz around cannabis-related products, and the easy availability of recreational and medical marijuana in many states, consumers and patients might assume there would be more evidence about the benefits and side effects.”

‘Biased Findings’

Most of the 25 cannabis studies that met OHSU’s criteria for review were considered biased in some way — 30% of the clinical trials were considered to have “high risk of bias” and half had “medium risk of bias.”  Most of the observational studies were also considered biased.

Despite the limited evidence, the OHSU research team came to some sweeping conclusions. Their study, published in the Annals of Internal Medicine, found no evidence to support the use of cannabidiol (CBD) or cannabis leaves, buds and flowers in treating pain. Only synthetic cannabis products rich in tetrahydrocannabinol (THC) were found to provide short-term relief from neuropathic pain.

Curiously, the OHSU researchers included in their review studies that evaluated the effectiveness of dronabinol and nabilone, two cannabis-based medications that are only FDA-approved to treat nausea, vomiting and weight loss. They are not formulated to treat chronic pain. Similarly, another study looked at the effectiveness of a cannabis extract in treating muscle stiffness (spasticity) caused by multiple sclerosis.

“It would appear that authors' relatively narrow focus and emphasis on both synthetic cannabis formulations (which historically have not demonstrated similar efficacy to whole-plant cannabis) as well as upon extracts that were initially designed to target medical ailments other than pain management may have biased these findings,” Armentano said in an email to PNN. 

“Numerous controlled trials involving whole-plant cannabis and reviews of said trials have determined that there exists substantial evidence that cannabis is safe and effective in pain management, particularly for neuropathy.” 

Armentano said nearly two-thirds of people enrolled in state-run medical cannabis programs registered for the treatment of chronic pain.

“Controlled studies have further indicated that cannabinoids can act synergistically with opioids, resulting in patients requiring lower doses to achieve relief. This is likely why we now have dozens of studies finding that pain patients taking opioids who initiate medical cannabis use frequently reduce or eliminate their opioid use over time,” Armentanohe said.

More Studies Needed

The OHSU researchers say more high-quality studies are needed on the safety and efficacy of cannabis products, which are largely unregulated by the FDA.

“Cannabis products vary quite a bit in terms of their chemical composition, and this could have important effects in terms of benefits and harm to patients,” co-author Roger Chou, MD, director of OHSU’s Pacific Northwest Evidence-based Practice Center said in a press release. “That makes it tough for patients and clinicians, since the evidence for one cannabis-based product may not be the same for another.”

Chou is a controversial figure in the pain community. A prolific researcher and frequent critic of opioid prescribing, Chou co-authored the CDC’s controversial 2016 opioid guideline. Although he has acknowledged conflicts of interest, Chou remains as one of the co-authors of a revised CDC guideline, which is expected to be released later this year.

The cannabis findings are similar to those in another OHSU review, which found no clinical evidence to support the use of kratom, an herbal supplement used by millions of Americans to relieve pain, anxiety, depression and other medical conditions.     

The studies on cannabis, kratom and other plant-based treatments are potentially worth up to $1.4 million for OHSU, a public research university that the federal government often turns to for medical research. According to the website GovTribe, in the last five years OHSU has been awarded nearly $2 billion in federal research grants, much of it coming from the Agency for Healthcare Research and Quality (AHRQ).

Injectable Gel Shows Promise as Treatment for Back Pain

By Pat Anson, PNN Editor

An experimental gel shows promise as a treatment for low back pain caused by degenerative disc disease (DDD), according to the results of a small study being presented at the annual meeting of the Society of Interventional Radiology in Boston.

Hydrogels have been used for years to treat DDD, but this is the first time that Hydrafil – an injectable gel developed by ReGelTec – has been tested on humans.

Hydrafil was injected into the discs of 20 people in Colombia with chronic DDD, who had average pain levels of 7.1 on a 10-point pain scale. None of the participants had found more than temporary, mild relief from treatments such as rest, analgesics, physical therapy and back braces.

“We really have no good treatments for degenerative disc disease, aside from conservative care,” said lead investigator Douglas Beall, MD, a medical advisor to ReGelTec and chief of radiology services at Clinical Radiology of Oklahoma.

“Surgery is statistically no more effective than conservative care and can potentially make things worse; nerve ablation is appropriate for only a few patients; and existing hydrogels are inserted through an incision as a soft solid, which can pop out of place if you’re not highly skilled in placing it.”

Because Hydrafil is injectable, it requires no incision and is minimally invasive, although patients are sedated for the procedure. Researchers heat the gel to become a thick liquid and then use a 17-gauge needle to inject it directly into the affected discs, using fluoroscopic imaging to guide them. The gel fills in cracks and tears in the disc, and then hardens, restoring the disc’s structural integrity. The procedure takes about 30 minutes.

This promotional video by ReGelTec demonstrates how Hydrafil works:

Six months after the injection, all 20 participants in the study reported significantly less low back pain, with their pain levels declining to an average of 2.0 on the 10-point pain scale. They also reported significantly better physical function.

“If these findings are confirmed in further research, this procedure may be a very promising treatment for chronic low back pain in those who’ve found insufficient relief from conservative care,” said Beall. “The gel is easy to administer, requires no open surgery, and is an easy procedure for the patient.”

In 2020, Hydrafil received the FDA’s breakthrough device designation, which allows for an expedited review of an experimental product when there is evidence it provides more effective treatment than current options.

ReGelTec is currently recruiting 50 people with DDD in Canada for a new clinical trial of Hydrafil.

Degenerative disc disease is one of the leading causes of chronic low back pain. Healthy discs cushion the spine’s vertebrae, facilitating movement and flexibility. But with activity and normal aging, discs can wear out and cause the bones of the spine to rub together and pinch nerves, causing pain and numbness. By age 60, most people have at least some disc degeneration in their spines.

Should Opioid Prescriptions Have an Expiration Date?

By Pat Anson, PNN Editor

Almost every food item you buy in a grocery store has an expiration date. Milk, bread and other perishable items have a “use by” or “sell by” date a few weeks into the future, while a can of beans may have a “best by” date that could be years away.

Should prescriptions for opioids and other controlled substances also have expiration dates? A date when they are no longer valid and can’t be filled?

That’s the premise behind a recent study in JAMA Network Open that looked at over 20 million opioid prescriptions written by U.S. dentists and surgeons in 2019. These were prescriptions primarily intended for short-term acute pain caused by operations or dental procedures.

Over 194,000 of the prescriptions (0.9%) were filled by a pharmacy 30 days or more after they were written – a sign they may have been used for something besides pain from a wisdom tooth extraction.

“Our findings suggest that some patients use opioids from surgeons and dentists for a reason or during a time frame other than intended by the prescriber,” said lead author Kao-Ping Chua, MD, a pediatrician at the University of Michigan Medical School, Ann Arbor.  “These are both forms of prescription opioid misuse, which in turn is a strong risk factor for opioid overdose.”

A misuse rate of about 1% for surgeons and dentists is low, but Chua and his colleagues found the delayed filling of prescriptions was even more common for scripts written by other medical specialists, such as internal medicine doctors (5.6%), family medicine practitioners (7.1%) and nurse practitioners (6.3%).  

Most states already limit the time window between writing and filling a prescription for a controlled Schedule II substance like hydrocodone – usually it’s 120 or 180 days. Eight states allow such prescriptions to be filled up to a year later. A few have no limits at all.  

“It’s perplexing that states would allow controlled substance prescriptions to be filled so long after they are written,” said Chua.

In 2019, Minnesota enacted one of the toughest dispensing laws in the nation, requiring all opioid prescriptions to be filled within 30 days. Delayed dispensing declined significantly in Minnesota soon afterward, before the law was repealed in 2020 out of concern it may have “unintended consequences” for chronic pain patients during the Covid-19 pandemic.  

Chua and his colleagues say more uniform laws should be adopted nationwide that limit the time frame for opioid dispensing only when prescriptions are written for acute pain. They also suggest that prescribers can reduce delayed dispensing themselves by including specific instructions for pharmacists not to dispense opioids after a certain time period.

Why Intractable Pain Treatment Requires a Stimulant

By Dr. Forest Tennant, PNN Columnist

In 1896, Dr. Henry Snow was the chief cancer surgeon at the Royal Brompton Hospital in London. He recognized and agonized over the immense pain and suffering of his patients when they developed constant pain and approached their end of life.

Dr. Snow wanted to relieve their suffering, so he administered the drugs that were available one at a time: morphine, cocaine and alcohol. With each he managed to get some pain relief, but didn’t obtain the relief he wanted and patients were still suffering. Not to be deterred, he made a profound discovery.

Dr. Snow mixed morphine and cocaine in liquid alcohol and administered the solution to his patients. Then he found formidable and humane pain relief. This three-drug mixture gave rise to the concept of “synergy of constituents,” which means that the simultaneous administration of multiple pain-relieving drugs added up to more than each one alone. In other words, two and two equaled six rather than four. 

The success of Dr. Snow’s discovery spread rapidly to other hospitals and countries, and became known as the “Brompton cocktail.” In France and elsewhere, physicians discovered they could add an antihistamine, antipsychotic or cannabis oil to the mixture and get even more pain relief.  

The Brompton cocktail was used until the 1970’s, when it gave way to the convenience of opioid tablets, capsules and injections, rather than the time and cost of making a liquid that contained multiple drugs. 

The Amphetamine Discovery 

Fortunately, after the demise of the Brompton cocktail, a handful of researchers weren’t about to forget the “synergy of constituents” and the pain-relieving potency of stimulants like cocaine. An example of the pain-relieving capability of stimulants is caffeine, which in the 1960’s was added to a variety of pain relievers such as aspirin and codeine to obtain synergy. 

Amphetamine was discovered in the 1930’s and promoted as “Benzedrine” to stay awake while driving. Because amphetamine produced alertness, it became known as a stimulant. Clinical reports began to surface in the 1940’s that amphetamine and its derivatives also helped depression, weight loss, mental alertness, hyperactivity and attention span. They soon began to be marketed and labeled for those conditions.  

Clinical studies on amphetamine derivatives for pain relief were finally started in the 1980’s, and they clearly showed that they provided a great deal of pain relief.  

By the time the last century folded, a core of pain researchers knew that not only cocaine but amphetamine derivatives such as methylphenidate and phentermine relieved pain. What they didn’t know was why. This answer was to come 15-20 years later. 

Stimulants Initially Rejected 

I became quite excited about the clinical trials that showed stimulants relieved pain, and in the late 1990’s gave a group of intractable pain patients the weak stimulant and weight loss drug phentermine, in combination with clonidine. The opioid dosages for these patients dropped 40 to 50 percent within six weeks and they got even better pain relief.

I presented my findings to colleagues at some national professional meetings. Much to my surprise, I was summarily informed that the new long-acting opioid formulations of the fentanyl patch (Duragesic), oxycodone (Oxycontin), morphine (MS Contin) and the implanted intrathecal (spine) opioid pump eliminated any need for stimulants or the concept of “synergy of constituents.”

By the turn of the century, the use of these new long-acting opioids and implanted opioid pumps became the standard of the day. Stimulants and their synergy were essentially forgotten, and they were rarely used for intractable pain again until about 2010. 

The Rebirth of Synergy 

After the year 2000, I don’t recall ever being referred an intractable pain patient who had not already been started on one of the long-acting opioids and/or an implanted opioid pump. They were referred to me simply because they were not getting adequate pain relief. Almost every one of these patients had found that their opioids quit working well, regardless of dosage or even if a second or third opioid was added to the mix.  

Somewhat out of desperation, about 12 years ago I recalled Dr. Snow, the Brompton cocktail and the “synergy of constituents.” I also remembered my study on phentermine and clonidine, so I started giving patients on opioids who were doing poorly my favorite stimulant, phentermine, or occasionally methylphenidate (Ritalin).  

Later the narcolepsy drug modafinil (Provigil) and a mixture of amphetamine salts (Adderall), came on the market. They too proved to be excellent “synergists” with opioids. I found that every intractable pain patient who received one of these stimulants not only got better pain relief and were either able to “hold the line” or reduce their opioid dosage.  

Phentermine continued to be my favorite stimulant to relieve pain and reduce the use of opioids because it additionally kept weight down and helped the patient keep moving and functional. 

Why Stimulants Work 

Although stimulants have been clinically known to relieve pain since Dr. Snow’s experiments in 1896, researchers didn’t provide us with the biologic “why” until recently. 

In the past decade, some outstanding researchers determined that there are about half a dozen different neurotransmitters in the brain and spinal cord that relieve pain. The three major neurotransmitters are endorphin, dopamine and gamma amino butyric acid (GABA). These neurotransmitters relieve pain by activating trigger points in the central nervous system called receptors. 

These astute researchers also determined that intractable pain may deplete endorphin, dopamine and GABA. Consequently, a substitute drug may have to be administered to obtain adequate pain relief.  

If you have constant, intractable pain, you may likely need the “synergy of constituents,” which will include an opioid, stimulant, and GABA substitute. Popular GABA substitutes include diazepam (Valium), carisoprodol (Soma), pregabalin (Lyrica), gabapentin (Neurontin), clonazepam (Klonopin), topiramate (Topomax) and alcohol. 

Which Patients Should Receive a Stimulant?

Stimulants have well-known abuse and addiction potential, so they should only be given to patients who have a well-documented disease or injury that is known to cause severe intractable pain. The most common diseases in this category are adhesive arachnoiditis, stroke or head trauma, reflex sympathetic dystrophy (RSD/CRPS), Ehlers-Danlos syndrome, and some autoimmune-collagen disorders.  

In most cases, patients who need a stimulant are clearly debilitated and require some family and caretaker support to function and carry out activities of daily living.  

Intractable pain patients have several dopamine substitutes available: 

• Amphetamine Salts (Adderall)

• Methylphenidate (Ritalin)

• Dextroamphetamine

• Phentermine

• Phendimetrazine

Misunderstood Objections

Many medical practitioners are not yet aware of the new research on stimulants and hesitate to prescribe them, even to needy, legitimate patients. The fear of abuse, diversion or dependence by the intractable pain or palliative care patient, while understandable, should not cause reluctance to prescribe a stimulant to these patients. No intractable pain patient will give away something that works so well.

In addition, the dosage of stimulants for pain relief is considerably lower than the usual level needed for abuse. Only small dosages are clinically needed in most cases and pharmacies today only issue limited quantities. Another safety factor in controlling adverse consequences of stimulants is that the severe intractable pain patient will usually have close family or caretaker support who can safely store and administer stimulants.

There is an unfounded fear of hypertension if a stimulant is prescribed. This is rarely the case, since the pain patient is dopamine deficient. A stimulant drug in an intractable pain patient may actually lower blood pressure since it may be elevated due to pain.

There is the belief that Adderall, Ritalin and some other stimulants are only for attention deficit hyperactivity disorder (ADHD). What is misunderstood is that ADHD is universal among intractable pain patients. Every person with intractable pain has reduced attention span, hypertension and agitation. One could argue that every intractable pain patient should be on a stimulant just for their ADHD. 

Dr. Snow and the Royal Brompton Hospital had the right idea. The severe, intractable pain patient needs an opioid to replace endorphin, a stimulant to replace dopamine, and a substitute for GABA.  

It’s time we bring back the “synergy of constituents” to humanely get better pain relief and simultaneously lower opioid dosages in the intractable pain patient. 

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his studies on the treatment of intractable pain through the Arachnoiditis Research and Education Project. A bibliography on stimulants for intractable pain treatment can be found here  

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

Patient in Tulsa Hospital Shooting Was Angry About Pain Care

By Pat Anson, PNN Editor

The gunman who killed four people Wednesday at an Oklahoma hospital recently had back surgery and was angry about his post-operative pain not being treated, according to police and media reports.

Michael Louis shot and killed Dr. Preston Phillips, the surgeon who performed the operation, as well as another doctor, a medical receptionist and a bystander who took his wife to an appointment at Saint Francis Hospital in Tulsa. The 45-year-old Louis fatally shot himself as police closed in.

“What we currently know is that Louis was in pain, Louis expressed that he was in pain and was not getting relief and that was the circumstance surrounding this entire incident,” said Tulsa Police Chief Wendell Franklin. “He blamed Dr. Phillips for the ongoing pain that came from the surgery.”

Phillips was an orthopedic surgeon who specialized in spinal surgery and joint reconstruction. He graduated from Harvard Medical School in 1990.

No details have been released on what type of back surgery Louis had or what kind of pain medication he was given. According to a niece, he suffered from back pain for “a long time.”

“We are aware that he has been experiencing back pain for a long time but [there is] no reason for this senseless act,” the niece told The Daily Beast. “We are a Christian-based family. We have never experienced this before.”

Police say Phillips operated on Louis on May 19. Louis was released from the hospital on May 24, but called “several times over several days complaining of pain and wanted additional treatment,” according to Franklin. Louis had an appointment with Phillips on Tuesday, the day before the shooting, but it’s not clear if any further pain relief was offered to him.

In the days following his surgery, Louis was living in the home of his ex-wife, Dr. Edith Lubin, a family practice physician. Her lawyer released a statement saying Lubin had no knowledge of her former husband possessing a gun or having “any intent of harming anyone.”

“Dr. Lubin is praying for the families of all those affected. She acknowledges everyone’s concerns in understanding what happened, but she is at a loss for an explanation, other than the effect of continuing pain to Mr. Louis during his recovery,” the lawyer said in a statement to a KJRH-TV reporter.

Louis bought a handgun on Sunday and a semiautomatic rifle on Wednesday afternoon, just hours before the shooting. Both weapons were legally purchased, according to police.

Franklin said a letter found on Louis after the shooting “made it clear that he came in with the intent of killing Dr. Phillips and anyone who got in his way.”

Asked whether opioids were involved in Louis’ treatment, Franklin said investigators have only established that he was in pain and that other details about his care were still being investigated, according to The Washington Post.

‘Just a Matter of Time’

In recent years, many U.S. hospitals have stopped or reduced the use of opioids after surgery, fearing patients may become addicted. Non-opioid analgesics and over-the-counter pain relievers such as Tylenol are increasingly being used to treat post-operative pain.

"Out of all the hospital systems in Oklahoma, I have heard the most about the horrible pain treatment at St. Francis,” said Tamera Lynn Stewart, an Oklahoma patient advocate and Policy Director for the P3 Political Action Alliance. “I know so many who have had surgery there and received Tylenol only or who see doctors there that claim they aren’t allowed to prescribe." 

Opioid addiction is actually rare after surgery. Studies have found that less than 1% of patients are still taking opioids a year after major surgery or were later diagnosed with opioid dependence.  

With their pain poorly treated or left untreated, Stewart says some desperate patients in Oklahoma have threatened to kill themselves on the steps of the state capitol to make a statement. The mass shooting at the Tulsa hospital, while tragic, was not unexpected to her. 

“While our hearts are grieving with the families and victims, few in our grassroots communities built to advocate for appropriate treatment of pain without government or third-party interference can say this was completely unexpected. Veterans have committed suicide at VA’s across the country for the same reason,” Stewart told PNN. 

“Most of us knew it was just a matter of time before someone who could no longer bear the unrelenting pain did something more drastic in order to get the attention needed to end the restrictions (on opioids) and begin the much-needed process of swinging the pendulum back to a more neutral position.” 

Long before Tulsa, there were other cases where people in pain resorted to drastic action. In 2017, a man suffering from chronic back pain shot and wounded two people at a Las Vegas pain clinic before taking his own life.   

That same year, an Indiana doctor was fatally shot by a man who was upset because the physician refused to prescribe opioids to his wife, who suffered from chronic pain.

Seniors Often Slow to Recover From Long Covid

By Judith Graham, Kaiser Health News

Older adults who have survived covid-19 are more likely than younger patients to have persistent symptoms such as fatigue, breathlessness, muscle aches, heart palpitations, headaches, joint pain, and difficulty with memory and concentration — problems linked to long covid.

But it can be hard to distinguish lingering aftereffects of covid from conditions common in older adults such as lung disease, heart disease, and mild cognitive impairment. There are no diagnostic tests or recommended treatments for long covid, and the biological mechanisms that underlie its effects remain poorly understood.

“Identifying long covid in older adults with other medical conditions is tricky,” said Dr. Nathan Erdmann, an assistant professor of infectious diseases at the University of Alabama-Birmingham’s school of medicine. Failing to do so means older covid survivors might not receive appropriate care.

What should older adults do if they don’t feel well weeks after becoming ill with the virus? I asked a dozen experts for advice. Here’s what they suggested.

Seek Medical Attention

“If an older person or their caregiver is noticing that it’s been a month or two since covid and something isn’t right — they’ve lost a lot of weight or they’re extremely weak or forgetful — it’s worth going in for an evaluation,” said Dr. Liron Sinvani, director of the geriatric hospitalist service at Northwell Health, a large health system in New York.

But be forewarned: Many primary care physicians are at a loss as to how to identify and manage long covid. If you’re not getting much help from your doctor, consider getting a referral to a specialist who sees long covid patients or a long covid clinic. Also, be prepared to be patient: Waits for appointments are lengthy.

At least 66 hospitals or health systems have created interdisciplinary clinics, according to Becker’s Hospital Review, an industry publication. For people who don’t live near one of those, virtual consultations are often available. For specialist referrals, ask whether the physician has experience with long covid patients.

Also, more than 80 medical centers in more than 30 states are enrolling patients in a four-year, $1.15 billion study of long covid that is being funded by the National Institutes of Health and is known as RECOVER (Researching COVID to Enhance Recovery). Older adults who choose to participate will receive ongoing medical attention.

Seek Comprehensive Care

At the University of Southern California’s covid recovery clinic, physicians start by making sure that any underlying medical conditions that older patients have — for instance, heart failure or chronic obstructive pulmonary disease — are well controlled. Also, they check for new conditions that may have surfaced after a covid infection.

If preexisting and new conditions are properly managed and further tests come back negative, “there is probably an element of long covid,” said Dr. Caitlin McAuley, one of two physicians at the Keck School of Medicine clinic.

At that point, the focus becomes helping older adults regain the ability to manage daily tasks such as showering, dressing, moving around the house, and shopping. Typically, several months of physical therapy, occupational therapy, or cognitive rehabilitation are prescribed.

Dr. Erica Spatz, an associate professor of cardiology at the Yale School of Medicine, looks for evidence of organ damage, such as changes in the heart muscle, in older patients. If that’s detected, there are well-established treatments that can be tried. “The older a person is, the more likely we are to find organ injury,” Spatz said.

At the Shirley Ryan AbilityLab in Chicago, a rehabilitation hospital, experts have discovered that a significant number of patients with breathing problems have atrophy in the diaphragm, a muscle that’s essential to breathing, said Dr. Colin Franz, a physician-scientist. Once inflammation is under control, breathing exercises help patients build back the muscle, he said.

For older adults concerned about their cognition after covid, McAuley recommends a neuropsychological exam. “Plenty of older patients who’ve had covid feel like they now have dementia. But when they do the testing, all their higher-level cognitive functioning is intact, and it’s things like attention or cognitive fluency that are impaired,” she said. “It’s important to understand where deficits are so we can target therapy appropriately.”

Become Active Gradually

Older patients tend to lose strength and fitness after severe illness — a phenomenon known as “deconditioning” — and their blood volume and heart muscles will start shrinking in a few weeks if they lie in bed or get little activity, Spatz said. That can cause dizziness or a racing heart upon standing up.

In line with recent recommendations from the American College of Cardiology, Spatz advises patients who have developed these symptoms after covid to drink more fluids, consume more salt, and wear compression socks and abdominal binders.

“I often hear that going for a walk feels awful,” Spatz said. When returning to exercise, “start with five to 10 minutes on a recumbent bicycle or a rower, and add a couple of minutes every week,” she suggested. After a month, move to a semi-recumbent position on a standard bike. Then, after another month, try walking, a short distance at first and then longer distances over time.

This “go slow” advice also applies to older adults with cognitive concerns after covid. Franz said he often recommends restricting time spent on cognitively demanding tasks, along with exercises, for brain health and memory. At least early on, “people need less activity and more cognitive rest,” he noted.

Reset Expectations

Older adults typically have a harder time bouncing back from serious illness, including covid. But even seniors who had mild or moderate reactions to the virus can find themselves struggling weeks or months later. 

The most important message older patients need to hear is “give yourself time to recover,” said Dr. Greg Vanichkachorn, director of the Mayo Clinic’s Covid Activity Rehabilitation Program in Rochester, Minnesota. Generally, older adults appear to be taking longer to recover from long covid than younger or middle-aged adults, he noted.

Learning how to set priorities and not do too much too quickly is essential. “In this patient population, we’ve found that having patients grit their teeth and push themselves will actually make them worse” — a phenomenon known as “post-exertional malaise,” Vanichkachorn said.

Instead, people need to learn how to pace themselves.

“Any significant health event forces people to reexamine their expectations and their priorities, and long covid has really accelerated that,” said Jamie Wilcox, an associate professor of clinical occupational therapy at the Keck School of Medicine. “Everyone I see feels that it’s accelerated their aging process.”

Consider Vulnerabilities

Older adults who have had covid and who are poor, frail, physically or cognitively disabled, and socially isolated are of considerable concern. This group has been more likely to experience severe effects from covid, and those who survived may not readily access health care services.

“We all share concern about marginalized seniors with limited health care access and poorer overall health status,” said Erdmann, of UAB. “Sprinkle a dangerous new pathology that’s not well understood on top of that, and you have a recipe for greater disparities in care.”

“A lot of older [long covid] patients we deal with aren’t accustomed to asking for help, and they think, perhaps, it’s a little shameful to be needy,” said James Jackson, director of long-term outcomes at the Critical Illness, Brain Dysfunction, and Survivorship Center at Vanderbilt University Medical Center in Nashville, Tennessee.

The implications are significant, not only for the patients but also for health care providers, friends, and family. “You really have to check in with people who are older and vulnerable and who have had covid and not just make assumptions that they’re fine just because they tell you they are,” Jackson said. “We need to be more proactive in engaging them and finding out, really, how they are.”

Kaiser Health News is a national newsroom that produces in-depth journalism about health issues.

Virtual Reality Shows Long Term Benefits for Chronic Low Back Pain

By Pat Anson, PNN Editor

Critics of virtual reality therapy often say it’s a poor treatment for chronic pain because it only distracts patients from their pain and that the effects are temporary, at best.

But new research suggests that the benefits of virtual reality (VR) can last six months after treatment has stopped – at least for patients with chronic low back pain.

The study, published in the Journal of Medical Internet Research, followed 188 people with chronic low back pain who had an average pain intensity score of 5 on a zero to 10 point scale.

Half the participants were given an EaseVRx headset to watch 3-D programs daily for 8 weeks, immersing themselves in a “virtual” environment where they can swim with dolphins, play games or enjoy beautiful scenery. The goal is help patients learn how to manage pain through cognitive behavioral therapy.  

The other patients also used the EaseVRx headset, but only watched routine nature scenes as a placebo or sham VR treatment.  

JOURNAL OF MEDICAL INTERNET RESEARCH

Patients were followed for six months after treatment was stopped. Participants in both groups reported improvement in their pain and other symptoms six months after treatment, but the improvements were more significant in those who received VR therapy. Pain intensity was 31% lower for patients in the VR group, compared to 16% in the sham group. Physical function, mood, sleep and pain-related interference in activity were also better in those who received VR therapy. No adverse side effects were reported in either group.

“We have been pleasantly pleased and surprised that patients are maintaining clinically meaningful changes in pain intensity and interference 6 months after returning the device. It appears people are actually acquiring skills in a relatively short period that they continue to retain/apply months after treatment,” said Josh Sackman, co-founder and president of AppliedVR, which makes the EaseVRx headset.

AppliedVR is planning more research to see how patients respond long-term to VR treatment. A brain imaging study is being conducted to measure brain activity before, during and after treatment. Patients are also being recruited for a large clinical trial to see how VR therapy impacts pharmacy and medical claims.  

“In order to drive real acceptance, we are committed to extensive research to address any skepticism people may have,” Sackman told PNN.

The EaseVRx headset was given a Breakthrough Device Designation by the FDA in 2020 for fibromyalgia and low back pain. Last year the agency authorized the marketing of the headset for chronic low back pain in adults, the first medical device of its kind to receive that designation.

EaseVRx headsets are currently being used for pain management in over 200 hospitals and healthcare systems. A full commercial launch for home-based use is not expected until next year.

A Pained Life: Do I Stay or Do I Go?

By Carol Levy, PNN Columnist

I have become housebound 90% of the time. I don't want to go out if the pain has already started. And if it hasn't, I don’t want to go out and risk setting it off.

I have looked for groups to join, online and preferably in “real life.” Each one I find invariably involves an activity that triggers my trigeminal neuralgia and causes eye pain.

I love to read, but a book club requires reading a chosen book within a specific period. Then at the meetings, looking through it as certain passages, paragraphs and pages are referenced.

I thought of trying to find a hiking or walking group. I need exercise and I enjoy walking. But if it is breezy or, even worse, windy or very sunny, those are triggers for the face and eye pain.

I adore cooking. But cooking groups require cooking together and reading recipes, which requires a lot of eye movement and usage, which are my personal recipe for causing severe pain.

Before Covid I found a local choral group. I wanted to be a singer when I was young and moved to New York in my early 20's in search of a career as a singer. But six months after I got to NYC, the pain started and brought a halt to all my hopes and dreams of a singing career.  

The choral group offered a chance to sing and, more importantly, to be with others who love to sing. But it is a horror in terms of having to use my eyes to read the music and to follow the choral director's hand movements as she directs the timing.

The other night we had a concert. We only go to nursing homes, so the audience is happy to see us and accepts that we are kind of raggedy. I was excited that I would be performing with the group, but I was also very afraid. I would have to use my eyes continuously and the lighting may be too bright (another source of severe pain for me).

Like many of us, I don't like taking opioids. I have found through the years that none work for me, so my doctors and I agreed on codeine. I take it because it makes me feel as though I am doing something about the pain, something that gives me a false sense of control over it, a small amount of succor. But it’s no help for the pain.

So what do I do? Do I tell the director I can't do the concert? That would be very unfair to her and the other members (there are only 11 of us). Or do I try to smile, sing and not grimace through the ever-increasing pain?

Most people's lives are based on decisions. Do I take the car or the bus? Do I have the steak or the vegetable plate? Do I buy the house or rent an apartment? Do I tell the boss I quit? Many of the decisions we have to make are often life-changing or life-altering.

Outside of decisions regarding medical treatments that have potential risks, our choices are rarely life-altering. And yet, they can be just as devastating. Do I go and make the pain worse? Or do I stay home and regret not going? Is it easier to hide from life or easier to face the pain?

That is a conundrum that has no easy answer.

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.” Her blog “The Pained Life” can be found here.