Drug Tests Show Pain Patients on Opioids Less Likely to Use Illicit Drugs

By Pat Anson, PNN Editor

In an effort to reduce soaring rates of drug abuse and overdoses, many physicians have taken their pain patients off opioids and switched them to “safer” non-opioid drugs like pregabalin, gabapentin and duloxetine. Others have encouraged their patients to try non-pharmacological treatments, such as acupuncture, massage and meditation.

That strategy may be backfiring, according to a large new study by Millennium Health, which found that pain patients prescribed opioids are significantly less likely to use illicit drugs than pain patients not getting opioids.

The drug testing firm analyzed urine drug samples from 2019 to 2021 for nearly 55,000 patients being treated by U.S. pain management specialists. About 80% of the patients were prescribed an opioid like oxycodone or hydrocodone, while the other 20% were not prescribed opioids.

Millennium researchers say detectable levels of illicit fentanyl, heroin, methamphetamine and cocaine were far more likely to be found in the urine of non-opioid patients than those who were prescribed opioids. For example, illicit fentanyl was detected in 2.21% of the patients not getting an opioid, compared to 1.169% of those who were. The findings were similar for heroin, methamphetamine and cocaine.

“In all cases, we found that the population that was not prescribed an opioid was significantly more likely to be positive for an illicit drug than those patients who were prescribed opioids,” said lead author Penn Whitley, Director of Bioinformatics at Millennium. “(There was) a 40 to 60 percent increase in the likelihood of being positive if you were not prescribed an opioid.”

Illicit Drug Use By Pain Patients

MILLENNIUM HEALTH

What do the findings mean? Are pain patients getting ineffective non-opioid therapies so desperate for relief that they’re turning to illicit drugs? That’s possible, but the study doesn’t address that specifically.

Another possibility is that patients on opioids are simply being more cautious and careful about their drug use. Opioid prescribing in the U.S. has fallen by 48% over the past five years, with many patients being forcibly tapered or abandoned by doctors who feel pressured to reduce their prescribing.  

“Unfortunately, a lot of people with chronic pain have learned that it’s a bit tenuous, that their doctors are feeling pressure, and if they want to maintain their access (to opioids), they need their PDMP (Prescription Drug Monitoring Program) and their drug tests to look the way they need to look, so their doctor can feel comfortable continuing to prescribe,” said co-author Steven Passik, PhD, VP of Scientific Affairs and Head of Clinical Data Programs at Millennium. “I do think they realize that they’re on a treatment and that access to it is not guaranteed.”   

Preliminary findings from the study were released today at PainWeek, an annual conference for pain management providers. The findings mirror those from another Millennium study earlier this year, which found that pain patients have lower rates of illicit drug use than patients being treated by other providers.     

“If your main way of protecting people in pain from getting involved in substance abuse is to limit their access to opioids, there’s at least a hint here that’s not the right approach,” Passik told PNN. “It’s not a definitive statement by any stretch of the imagination, but it’s an approach to patient safety that leaves a bit to be desired.”  

Another recent study at the University of Texas also found that restricting access to opioids is “not a panacea” and may even lead to more overdoses.  Researchers found that in states that mandated PDMP use, opioid prescribing decreased as intended, but heroin overdose deaths rose 50 percent.

“Past research has shown that when facing restricted access to addictive substances, individuals simply seek out alternatives rather than limiting consumption,” said lead author Tongil Kim, PhD, an assistant professor of marketing at University of Texas at Dallas. “In our case, we measured overdose deaths as a proxy and found a substantial increase, suggesting that the policy unintentionally spurred greater substitution.”

My Renewed Fight for Disability

By Mia Maysack, PNN Columnist

There are millions of people who are figuratively standing in line, waiting to be granted benefits under Social Security Disability Insurance or SSDI. It usually begins with a person filing a disability application on their own behalf, declaring that they are unable to work, followed by the certification of medical professionals. They are the first baby steps in what can be a very long process. My application took four years before it was approved.

To get it, I represented myself in a court of law and essentially begged on my knees, pleading with detailed reasoning as to why my personal situation affects and at times strictly prohibits any version of what could be considered my working “ability,” let alone “normalcy.”

Not too long ago, I received a notice that a decision was to be made on whether or not I still live with a post-bacterial meningitis related traumatic brain injury that causes intractable and chronic mega-migraines, along with cluster headaches and nerve damage. I do, in case anybody was wondering.

But after two Social Security assigned medical reviews, it was declared that I am no longer disabled. News to me! The memo must have gotten lost because my body has yet to receive it.

Having worked since the age of 14, up until a few years ago, and only after pushing myself almost to the point of death, the disability checks I’ve been receiving consist of money I contributed to the taxpayer pot. I was grateful for it, knowing that many others have it worse in their own ways, even though the dollar amount is limited to covering a shelter over my forever hurting head.

The gift has been not to have to wrack my brain any further, figuring out where I can live. This has been a blessing, because I am then able to promote the full-time job that is self-care demanded by my ailments.

Constructing a non-mainstream path and not allowing challenges to completely dictate or entirely limit my overall quality of life does not lessen what I endure. Nor does it suggest having been cured or even improved.

It is generally understood that a governing “system” is in place to protect those of us who are not attempting to cheat or scheme to get disability. But let me tell you, our skeletal, muscular, nervous, endocrine, cardiovascular, lymphatic, respiratory, digestive, urinary and reproductive systems are continuously being violated and discriminated against by that very same “system.”  

The mourning of past lives and broken dreams is a permanent condition for me. The trauma of living and reliving what has transpired never ends. My symptoms are chronic and unpredictable, which inconveniences no one more so than it does me.

My body, my rights?  My ass.

Whether I can walk on the date of my upcoming appeal or have to crawl, I’ll fight however I can to make these points heard on behalf of everybody.           

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. She 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. Mia is also the recipient of the International Pain Foundation’s “Hero of Hope” award for 2022.

CRPS Is a Bad Name for a Painful Disease

By Dr. Forest Tennant, PNN Columnist

A few years ago, the “pain powers” of the day decided to change the name of a mysterious painful disease called Reflex Sympathetic Dystrophy (RSD) to Complex Regional Pain Syndrome (CRPS). 

Not long after the name change, I received a telephone call from a reporter who mistakenly believed that “CRPS” meant that chronic pain statistics were now going to be kept by geographical regions.  He wanted to know which regions had the least and worst pain problems.  He sounded rather despondent when I informed him the regions weren’t geographic areas, but referred to parts of the body. 

After a sigh and pause, he asked how many regions there were and where they were located on the body.  I finally had to admit that although I was familiar with legs, arms, buttocks and ears, I hadn’t been able to come to grips with exactly what the body’s regions were or where they were located, as they weren’t mentioned in Gray’s Anatomy.  The reporter apologized for bothering me and said he thought he would focus on prostate issues instead.

Not long after I disappointed the reporter, I attempted to obtain a prior authorization to pay for CRPS medications from a patient’s insurance company.  I had mistakenly assumed that the label CRPS had reached the bowels of the insurance industry, but a grouchy lady on the phone informed me that her insurance company didn’t recognize regional pain and only paid for legitimate painful diseases.  Furthermore, she questioned my ability and sanity, accusing me of creating a fraudulent diagnosis.  At this point, I rightfully decided the CRPS label may have problems!

These episodes underline the point that lots of people with CRPS are being poorly treated due to a name that doesn’t even sound like a legitimate disease or disorder. Their very real illness goes unrecognized and payment for treatment is often denied by their insurance.  At best, the CRPS label trivializes a condition that can be so severe as to force a person into bed, endure great suffering, and die before their time. 

The history of the name CRPS is most telling.  A British surgeon named Alexander Denmark wrote the first known description of a disease like CRPS in about 1812.  He described a soldier injured by a bullet this way:

“I always found him with the forearm bent and in supine position and supported by the firm grasp of the other hand. The pain was of a burning nature, and so violent as to cause a continual perspiration from his face.” 

Another physician who was working with wounded Civil War soldiers, Dr. Silas Weir Mitchell, published his findings in a 1864 monograph entitled “Gunshot Wounds and Other Injuries.” Mitchell described the basic injury as burning pain located in close proximity to the battle wound.  He also described the well-known characteristics of the disorder, including glossy red or mottled skin without hair, atrophic tissue, and severe pain caused by touch or movement. 

In his 1872 book, “Injuries of Nerves and Their Consequences,” Mitchell coined the term “causalgia” which he derived from the ancient Greek words kauaoc (heat) and oayoc (pain) to emphasize the nature of the disorder.

The term causalgia remained in place until about 1946, when Dr. James Evans, a physician at the Lahey Clinic in Burlington, Massachusetts, described 57 patients with injuries similar to those labeled causalgia by Dr. Mitchell.  Evans described his patients as having intense pain and clinical signs that he explained as being due to “sympathetic stimulation.” The patients experienced rubor (redness), pallor, and a mixture of both sweating and atrophy.

This syndrome would appear after fractures, sprains, vascular complications, amputations, arthritis, lacerations, or even minor injuries.  Evans found that sympathetic nerve blocks usually relieved the pain, so he rejected the term causalgia and gave it the name Reflex Sympathetic Dystrophy (RSD).

The name RSD pretty well replaced causalgia until 1994, when the International Association for the Study of Pain (IASP) changed it to Complex Regional Pain Syndrome (CRPS).  This change was led by the renowned pain specialist John Bonica, MD, who wanted to shift the focus away from the terms dystrophy, reflex and sympathetic back to pain. 

This argument for the change had validity, in that the condition doesn’t really have a reflex component and sympathetic blockades do not consistently relieve pain.  Also, dystrophy is medically defined as tissue degeneration, such as that caused by diseases of nutrition or metabolism. The IASP wanted the primary focus to be on pain.

Unintended Consequences

While the name changes from causalgia to RSD to CRPS were intended to bring better pain relief to needy patients, there have been several unintended consequences.  In fact, a reasonable argument can be made that the name change has been counterproductive. 

What should CRPS now be called?  It’s doubtful that a new consensus could be quickly developed, as the syndrome is complex and involves multiple issues. 

Frankly, I personally believe we should junk the term CRPS. It trivializes a most serious disorder, and I have found use of the name CRPS actually deprives some patients of the treatment they need.  I have often simply used the term “vascular neuropathy” to effectively educate pharmacies, families, insurance companies and patients about the condition.  At least this term sounds legitimate and serious!

Fortunately, regardless of its name, the syndrome appears to be diminishing both in incidence and severity.  Workplace injuries and vehicular accidents get immediate attention these days, while early medical and physical interventions usually prevent great severity. 

Also, there is now an understanding of centralized pain and its electrical discharges, which are greatly responsible for the so-called “sympathetic” symptoms of the disorder.  Treatments for centralized pain are clearly benefitting persons with this unfortunate disorder, regardless of whatever name you wish to call it.  I would call for a name change but I don’t know who to call!

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis through the Tennant Foundation’s Arachnoiditis Research and Education Project and the Intractable Pain Syndrome Research and Education Project.

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

A Pained Life: We’re Not ‘Normal’ So Don't Expect Us To Be

By Carol Levy, PNN Columnist

I recently contacted a local social service agency for help. They sent a social worker and wonderful lady, Margaret, to come to my home.

The first thing she did was a “depression inventory,” a questionnaire required by the service. The questions were pro forma, and if I was a “normal person” were probably an appropriate way to see if I was suffering from depression. For someone in chronic pain, not so much.

Margaret asked me, “Are you basically satisfied with your life?”

The choices were “Yes” or “No.” The questionnaire allowed for no other answer.

No, I am not satisfied with my life. I am mostly housebound, due to trigeminal neuralgia pain and the fear of triggering more pain if I go out. My reasons for being dissatisfied with my life are legitimate. It is not a sign of depression, but of my reality.

“Have you dropped many of your activities and interests?” Margaret asked. Yes, if you mean since the pain started 40 years ago. If you mean more recently, then the answer is no.

“Do you often get bored?” Of course, I do. I am home most of the time. My eye pain interferes with reading, writing or even watching a movie if there is a lot of movement on the screen. I spend a lot of time with the TV on, as background noise, and sitting in a chair or bed waiting for the hour hand to move so the day is closer to its end.

That sounds like depression. But for me, it's not. It's merely my life.

“Were my spirits good?” Easy answer. See the above.

My neurosurgeon told me there are no more treatments or surgical possibilities for me. They all have unknown risks and it’s not certain they would help. So, when I was asked, “Do you feel helpless?” and “Do you feel hopeless?'” my answer was yes to both questions. Because my situation is hopeless and helpless. The medical profession has told me so.

Margaret’s next question; “Do you prefer to stay at home rather than go out and do new things?” could have been two questions for me: "Do you prefer to stay at home?' No, I don't. "Would you prefer to be able to go out and do new things?" Yes, I would, but the pain won't let me.. 

“Do you think most people are better off than you?” was the last question. And the hardest for me to answer. In one sense, yes, because most people don't have chronic pain and they're not housebound. But I am in good shape physically, absent the eye and face pain, and my brain and mind work well. I am independent. So no, they are not better off than me. 

It all depends on the slant of the questions and the slant of the answers. 

Most of Margaret’s questions are not intended for people in pain. I don't expect them to make ones specific for the pain community and I'm not sure, given the spectrum of chronic pain and disability, if that is even feasible.  

We need to be seen for what we are. We are not “normal,” so please stop expecting that of us. 

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.

Heavy Metals and Plastic Residue Found in Many CBD Products

By Pat Anson, PNN Editor

Yet another study has found evidence that cannabidiol (CBD) products are frequently mislabeled, with over half of the edibles and topicals tested containing significantly more or less CBD than their labels indicated. Researchers at the University of Miami School of Medicine also found that many CBD products are contaminated with low-levels of heavy metals and plastic chemicals.

“Because the cannabis plant is recognized as a bioaccumulator, which is highly effective at absorbing and retaining contaminants (e.g., heavy metals) in soil, it is important to characterize the degree of contamination in CBD products and their label accuracy to better estimate potential health benefits and risks associated with consumption,” researchers explained in the journal The Science of the Total Environment. 

Investigators analyzed 516 CBD products that were purchased online or at retail stores and had them tested at Ellipse Analytics in Denver. About a quarter of the CBD products were edibles.

Less than half of all the products tested had CBD concentrations within 10% of their label claims. Forty percent of the products contained significantly less CBD than claimed by the manufacturer, while 18% contained significantly more CBD.

Of the edible products analyzed, 42% tested positive for the presence of lead, 37% tested positive for mercury, 28% tested positive for arsenic, and 8% tested positive for cadmium. Most contained only trace amounts of heavy metals, but four edibles had lead levels that exceeded California’s recommended limit for daily lead consumption.

THE SCIENCE OF THE TOTAL ENVIRONMENT

Many of the edibles also contained low levels of plastic chemicals – known as phthalates – that are designed to make plastics more flexible. Phthalates leach off plastic and have become pervasive in the air, soil and water. Some phthalates have affected the reproductive systems of animals, although their impact on human health is not clear.

The percentage of CBD edibles with detectable phthalate concentrations ranged from 13% to 80% across four phthalates, with DEHP being the most prevalent. DEHP has been linked to cancer, birth defects and other reproductive harm. Federal law prohibits the manufacture and sale of children’s toys and child care products containing DEHP at levels greater than 0.1%. 

“Low-level contamination of edible CBD products with heavy metals and phthalates is pervasive. There is substantial discrepancy between the product label claims for CBD potency and the amount measured in both edible and topical products, underscoring the need for tight regulations for CBD product label integrity to protect consumers,” researchers concluded.

“Given that the consumer demographic purchasing CBD products includes those afflicted with pain, insomnia, anxiety, and other health conditions, these findings could give consumers and medical practitioners hesitation about the benefits and potential harm of CBD use.”

The study was funded by Jazz Pharmaceuticals and the Clean Label Project, a non-profit that seeks to improve food and consumer product labeling.

Previous studies have also found that many CBD products are mislabeled. A recent study at the University of Kentucky College of Medicine found that only half of the CBD oil products had concentrations of cannabidiols that were within 10% of their label claims. Researchers also found that most CBD oils contained trace amounts of THC (tetrahydrocannabinol), the psychoactive substance in cannabis, including some oils that were labeled "THC Free."

Time to Reject the Label ‘Failed Back Surgery Syndrome’

Dr. Forest Tennant, PNN Columnist

In our research studies on Adhesive Arachnoiditis (AA), a high percentage of patients tell us that their doctors have said the cause of their pain is “Failed Back Surgery Syndrome” (FBSS).

This misnomer and poor excuse for a diagnosis has fortunately been rejected “out-of-hand” as a cause of pain by most upscale physicians. After all, FBSS is neither a disease nor a symptom. We can do better in 2022.

Some three or four decades ago, FBSS became a popular moniker used by most physicians, including this author. Why? Patients who had back pain underwent surgery, which was technically and expertly done, but the pain didn’t go away. This situation was a mystery in times past, but the label FBSS should never be used or applied in this day and age.

Today, magnetic resonance imaging (MRI) has advanced so much since its invention in the late 1980’s that painful disorders and diseases of the spine can almost always be diagnosed. There is now a technique called “contrast MRI” that allows a clear distinction to be made between spinal fluid and solid tissues, including the spinal cord, discs, nerve roots and covering of the spinal canal.

In our recent research studies, we have reviewed contrast MRIs in well over 200 persons who have been labeled as having FBSS. Every person had one or more obvious reasons to have chronic pain, despite well-done, competent surgery. For example, our reviews have found discs that have protruded, adhesive arachnoiditis, epidural fibrosis, spondylolisthesis, Tarlov Cysts, arthritic vertebra or other good, solid reasons to have pain, regardless of surgery.

Let’s be clear. Spine surgery may be necessary for a number of reasons, the most common being significant herniation of a disc or collapse of vertebrae that may dangerously compress the spinal canal. It also may be fair to say that a lot of surgery can now be avoided, since eminent danger and need for surgery is pretty clear cut on modern, contrast MRI’s.    

In addition to contrast MRIs, we now have good diagnostic tests for inflammation, autoimmunity and genetic connective tissue disorders, which are emerging as legitimate causes of severe, chronic back pain that hasn’t responded to chiropractic, physical therapy, anti-inflammatory agents and corticosteroid injections.

Put simply, the diagnostic evaluation of severe chronic back pain needs a contrast MRI and specific diagnostic tests rather than a non-descript, “wastebasket” diagnosis like FBSS.

Perhaps the worst thing about the label FBSS, is that it is easy to apply and avoids the time, money and knowledge to make a specific diagnosis. These excuses to avoid a specific diagnosis must now be rejected because we have the diagnostic and treatment measures to better the lives and health of those who suffer from severe chronic back pain.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis through the Tennant Foundation’s Arachnoiditis Research and Education Project and the Intractable Pain Syndrome Research and Education Project.

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

DEA Warns of ‘Rainbow Fentanyl’ Targeting Kids

By Pat Anson, PNN Editor

At first glance, they look like candy. Brightly-colored tablets in shades of pink, purple, yellow and green. Not unlike a bag of Skittles or a bowl of Fruit Loops.

But they’re not sweet treats. They’re the latest version of “Mexican Oxy” – counterfeit oxycodone pills laced with fentanyl, stamped with an “M” on one side and “30” on the other. Typically blue in color – like authentic oxycodone – the pills increasingly come in a variety of colors, what law enforcement agencies call “rainbow fentanyl.”

In recent weeks, rainbow fentanyl has been found in 18 states, including an August 17 bust at the Arizona border with Mexico, where over 15,000 of the colorful pills were found strapped to a smuggler’s leg.

It was the second consecutive day rainbow fentanyl was intercepted at the port of Nogales, a possible sign that drug cartels are targeting younger users.

“Rainbow fentanyl — fentanyl pills and powder that come in a variety of bright colors, shapes, and sizes — is a deliberate effort by drug traffickers to drive addiction amongst kids and young adults,” DEA Administrator Anne Milgram said in a statement that warns of the “alarming emerging trend.”

HOMELAND SECURITY IMAGE

The DEA says rainbow fentanyl is being seized in multiple forms, including blocks that resemble the chalk a child might use to color a sidewalk. A recent drug raid in Portland, Oregon turned up several powdered blocks of rainbow fentanyl, along with meth, heroin, hundreds of fentanyl pills and a small armory of guns.

“Deputies are particularly concerned about rainbow fentanyl getting into the hands of young adults or children, who mistake the drug for something else, such as candy or a toy, or those who may be willing to try the drug due to its playful coloring. The powdered fentanyl found during this investigation resembles the color and consistency of sidewalk chalk,” the Multnomah County Sheriff’s Office said in a statement.

“We are seeing more powdered fentanyl that is dyed in various colors. The strength can vary but is typically stronger than pressed pills,” said Kelsi Junge, Harm Reduction Supervisor for Multnomah County.

Some colors are believed to be more potent than others, a claim that has not been confirmed by DEA laboratory tests.  

No matter the color or shape, rainbow fentanyl is dangerous. Fentanyl is a synthetic opioid that is 50 times more potent than heroin and 100 times more potent than morphine. Just two milligrams of fentanyl, similar in size to 10-15 grains of salt, is considered a lethal dose. 

Because illicit fentanyl is cooked up in makeshift laboratories by amateur chemists, the potency of the pills or powder varies considerably.

MULTNOMAH COUNTY SHERIFF

The DEA says most of the illicit fentanyl in the United States is supplied by two Mexican drug cartels, the Sinaloa and Jalisco New Generation cartels, although there is no shortage of Americans willing to transport the drugs or turn them into tablets with pill presses.

“The men and women of the DEA are relentlessly working to stop the trafficking of rainbow fentanyl and defeat the Mexican drug cartels that are responsible for the vast majority of the fentanyl that is being trafficked in the United States,” said Milgram.

Fentanyl is a potent analgesic that is prescribed legally for severe pain, but it is illicit fentanyl and its analogues that are responsible for the vast majority of drug deaths. According to the CDC, over 107,000 Americans died of drug overdoses in 2021, with two-thirds of the deaths linked to fentanyl.

FDA Conducting Review of Opioid Regulations

By Pat Anson, PNN Editor

The U.S. Food and Drug Administration has launched an extensive review of its opioid regulations, with the goal of reducing overdoses and making revisions “to support appropriate use of opioid analgesics.”

In a blog post, FDA commissioner Robert Califf, MD, acknowledged the overdose crisis has “evolved beyond prescription opioids” and is now largely driven by illicit fentanyl and other street drugs. But he was vague about whether FDA would loosen restrictions on opioid pain medication or tighten them further.

“While the FDA’s previous strategies have largely focused on opioid use and overdoses, the evolving nature of the overdose crisis calls for both a new approach and honest reflection about what the FDA can do differently moving forward,” Califf said. “For example, during my confirmation process, I committed to undertaking a review of our opioid decisions, including labeling. We have initiated this review with the intended goal of understanding what revisions are needed to support appropriate use of opioid analgesics. Our ‘lessons learned’ will actively inform our future approach.”

One of the lessons learned by the CDC over the past few years is that rigid opioid prescribing guidelines have been harmful to patients and need to be “individualized and flexible.” The agency is currently in the process of revising its 2016 opioid guideline, with the goal of releasing an updated guideline late this year.

It’s not clear if the FDA is moving in a similar direction. One of the priorities for the agency’s new Overdose Prevention Framework is to “improve pain management and patient outcomes” – not by making opioids more accessible, but by reducing “unnecessary initial prescription drug exposure and inappropriate prolonged prescribing.” 

Califf said the agency was studying the need for mandatory prescriber education about opioids, including a national continuing education program about the use of opioids to manage pain. Most medical schools in the U.S. and Canada do not require a course in pain education and few even offer pain management as an elective.

The FDA may also tighten the rules for getting new opioids approved, including a requirement that drug makers demonstrate that their products offer material safety advantages over existing opioid analgesics. At the same time, the agency is planning to release new guidance to speed up the development of non-opioid and non-addictive treatments for chronic pain.

This is the 70-year old Califf’s second stint as FDA commissioner, having previously served in that role during the Obama administration. He was confirmed for a second time by the U.S. Senate last December by a narrow 50 to 46 vote. At the time, he promised an extensive review of the FDA’s opioid regulations to counteract complaints that the agency did little to prevent opioid misuse and was too accommodating to drug makers.

Federal efforts to reduce drug overdoses by limiting opioid prescriptions have largely failed. While opioid prescribing has fallen by 48% over the past five years, overdoses soared to a record 107,000 drug deaths in 2021, driven primarily by illicit fentanyl.

A recent study found no “direct correlation” between opioid prescribing and overdoses. Another analysis of overdose deaths in 2020 found that prescription opioids ranked well behind illicit fentanyl, alcohol, cocaine, methamphetamine and heroin as the leading cause of drug deaths.   

The ‘Parallel Pandemic’ of Long Covid

By Liz Szabo, Kaiser Health News

The latest covid-19 surge, caused by a shifting mix of quickly evolving omicron subvariants, appears to be waning, with cases and hospitalizations beginning to fall. Like past covid waves, this one will leave a lingering imprint in the form of long covid, an ill-defined catchall term for a set of symptoms that can include debilitating fatigue, difficulty breathing, chest pain, and brain fog.

Although omicron infections are proving milder overall than those caused by last summer’s delta variant, omicron has also proved capable of triggering long-term symptoms and organ damage. But whether omicron causes long covid symptoms as often — and as severe — as previous variants is a matter of heated study.

Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, is among the researchers who say the far greater number of omicron infections compared with earlier variants signals the need to prepare for a significant boost in people with long covid.

The U.S. has recorded nearly 38 million covid infections so far this year, as omicron has blanketed the nation. That’s about 40% of all infections reported since the start of the pandemic, according to the Johns Hopkins University Coronavirus Research Center.

Long covid “is a parallel pandemic that most people aren’t even thinking about,” said Akiko Iwasaki, a professor of immunobiology at Yale University. “I suspect there will be millions of people who acquire long covid after omicron infection.”

Scientists have just begun to compare variants head-to-head, with varying results. While one recent study in The Lancet suggests that omicron is less likely to cause long covid, another found the same rate of neurological problems after omicron and delta infections.

Estimates of the proportion of patients affected by long covid also vary, from 4% to 5% in triple-vaccinated adults to as many as 50% among the unvaccinated, based on differences in the populations studied.

One reason for that broad range is that long covid has been defined in widely varying ways in different studies, ranging from self-reported fogginess for a few months after infection to a dangerously impaired inability to regulate pulse and blood pressure that may last years. Even at the low end of those estimates, the sheer number of omicron infections this year would swell long-covid caseloads.

“That’s exactly what we did find in the UK,” said Claire Steves, a professor of aging and health at King’s College in London and author of the Lancet study, which found patients have been 24% to 50% less likely to develop long covid during the omicron wave than during the delta wave.

“Even though the risk of long covid is lower, because so many people have caught omicron, the absolute numbers with long covid went up,” Steves said.

Reinfections Raise Risk

A recent study analyzing a patient database from the Veterans Health Administration found that reinfections dramatically increased the risk of serious health issues, even in people with mild symptoms. The study of more than 5.4 million VA patients, including more than 560,000 women, found that people reinfected with covid were twice as likely to die or have a heart attack as people infected only once. And they were far more likely to experience health problems of all kinds as of six months later, including trouble with their lungs, kidneys, and digestive system.

“We’re not saying a second infection is going to feel worse; we’re saying it adds to your risk,” said Dr. Ziyad Al-Aly, chief of research and education service at the Veterans Affairs St. Louis Health Care System.

Researchers say the study, published online but not yet peer-reviewed, should be interpreted with caution. Some noted that VA patients have unique characteristics, and tend to be older men with high rates of chronic conditions that increase the risks for long covid. They warned that the study’s findings cannot be extrapolated to the general population, which is younger and healthier overall.

“We need to validate these findings with other studies,” said Dr. Harlan Krumholz, director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. Still, he added, the VA study has some “disturbing implications.”

With an estimated 82% of Americans having been infected at least once with the coronavirus as of mid-July, most new cases now are reinfections, said Justin Lessler, a professor of epidemiology at the University of North Carolina Gillings School of Global Public Health.

‘Breathing Through a Straw’

Of course, people’s risk of reinfection depends not just on their immune system, but also on the precautions they’re taking, such as masking, getting booster shots, and avoiding crowds.

New Jersey salon owner Tee Hundley, 43, has had covid three times, twice before vaccines were widely available and again this summer, after she was fully vaccinated. She is still suffering the consequences.

After her second infection, she returned to work as a cosmetologist at her Jersey City salon but struggled with illness and shortness of breath for the next eight months, often feeling like she was “breathing through a straw.”

She was exhausted, and sometimes slow to find her words. While waxing a client’s eyebrows, “I would literally forget which eyebrow I was waxing,” Hundley said. “My brain was so slow.”

When she got a breakthrough infection in July, her symptoms were short-lived and milder: cough, runny nose, and fatigue. But the tightness in her chest remains.

“I feel like that’s something that will always be left over,” said Hundley, who warns friends with covid not to overexert. “You may not feel terrible, but inside of your body there is a war going on.”

Although each omicron subvariant has different mutations, they’re similar enough that people infected with one, such as BA.2, have relatively good protection against newer versions of omicron, such as BA.5. People sickened by earlier variants are far more vulnerable to BA.5.

Several studies have found that vaccination reduces the risk of long covid. But the measure of that protection varies by study, from as little as a 15% reduction in risk to a more than 50% decrease. A study published in July found the risk of long covid dropped with each dose people received.

For now, the only surefire way to prevent long covid is to avoid getting sick. That’s no easy task as the virus mutates and Americans have largely stopped masking in public places. Current vaccines are great at preventing severe illness but do not prevent the virus from jumping from one person to the next.

Scientists are working on next-generation vaccines — “variant-proof” shots that would work on any version of the virus, as well as nasal sprays that might actually prevent spread. If they succeed, that could dramatically curb new cases of long covid.

“We need vaccines that reduce transmission,” Al-Aly said. “We need them yesterday.”

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

Raising Lazarus: Another Take on the Opioid Crisis

By Pat Anson, PNN Editor

Beth Macy’s bestselling book “Dopesick” – and the Hulu series based on it -- helped shape the popular narrative on the origins of the opioid crisis: that Purdue Pharma and the Sackler family duped physicians into prescribing highly addictive OxyContin to millions of pain patients, setting off a public health and overdose crisis that continues to this day.

Macy’s new book “Raising Lazarus” focuses on many of the same themes, but with an important new addition. She recognizes that opioid hysteria and fear of addiction went too far, depriving many people in pain of the medications they need to lead functional and productive lives.

“In recent years, law enforcement agencies, the CDC, and other medical authorities had overreacted to the first wave of the opioid crisis by clamping down too hard on opioid-prescribing,” Macy wrote. “Some doctors responded to the revised 2016 CDC opioid-prescribing guideline – and their fear of DEA prosecution – by declaring draconian caps and essentially abandoning their patients.

“People who needed opioids were refused access. Others with decades-long chronic conditions like extreme rheumatoid arthritis were abandoned by doctors and were now left bedbound. Some who were denied the opioids they’d been taking for decades attempted suicide or resorted to illegal drugs.”  

Those are welcome words from a noted critic of opioid “overprescribing.” But that passage – which is buried halfway through a 373-page book – doesn’t represent what Raising Lazarus is all about. Macy’s new book primarily deals with Purdue’s corporate greed and the ongoing struggles of working-class people in Appalachia to overcome addiction and a healthcare system that simply doesn’t work for them.

Macy is a bit defensive and resorts to gaslighting when she acknowledges past criticism from pain patients for Dopesick “drawing too much attention to overprescribed opioid pills.” Many of their complaints are valid, she admits, “if sometimes over-the-top and oblivious to the root causes of the crisis.”

Interestingly, Macy never actually quotes one of those “over-the-top” pain patients in Raising Lazarus, but she did interview Stanford pain psychologist Dr. Beth Darnall about the reluctance of doctors to prescribe opioids.

“Doctors are so concerned about being flagged, concerned about their license and their livelihood, they don’t want to take (chronic pain patients) on, and so you end up with patient abandonment, and iatrogenic harms that can create a medically dangerous situation,” Darnall told Macy.    

‘The Cruel World of Purdue Pharma’

Greed, no doubt, is one of the primary causes of the opioid crisis and Macy describes in detail how the Sacklers manipulated the political and legal system, paying their chief counsel the handsome rate of $1,790 an hour to gum things up as best he could to preserve the family fortune and prevent them from going to prison.

But she gives a free pass to others who have profited from the opioid crisis, often at the expense of pain patients, most notably the private plaintiff law firms suing drug makers on behalf of cities, counties and states.

Macy credits the late attorney Paul Hanly as being “the first to crack open the cruel world of Purdue Pharma” without pointing out that his law firm, Simmons Hanly Conroy, boasts that it “effectively invented large-scale, multi-defendant opioid litigation” and stands to make billions of dollars in contingency fees from settlement money.  

Also unmentioned is the $400,000 in campaign donations given by Simmons Hanly Conroy to former Sen. Claire McCaskill (D-MO) in 2018, who conveniently produced a well-publicized report that year critical of drug makers and medical pain societies that the law firm was suing. Overwhelmed with legal fees defending themselves, two of those pain societies filed for bankruptcy, a loss that pain management specialists, researchers and patients could ill afford.

Macy does quote anti-opioid activists like Dr. Andrew Kolodny and Dr. Anna Lembke, but doesn’t mention that they testified as paid expert witnesses for Hanly and other plaintiff law firms, making well into six figures for their testimony, which they often failed to disclose in conflict of interest statements.  

“The opioid-litigation money is a once-in-a-generation opportunity,” Macy writes, with unintended irony.

Macy is hopeful the settlement money – once estimated at $50 billion -- will go towards addiction treatment and better healthcare for communities ravaged by the opioid crisis. Unfortunately, much of it has already been spent on legal fees, media and public relations campaigns, and political donations. That’s not counting shady industries that have grown and prospered due to the opioid crisis; from drug testing and stem cell providers to cannabis promoters and drug cartels.  

Even though fentanyl and other street drugs are responsible for the vast majority of overdoses, Macy still clings to the tired notion that opioid pain medication started it all.

“A quarter century into the crisis, many people with OUD (opioid use disorder) have long since transitioned from painkillers to heroin, methamphetamine, and fentanyl, the ultra-potent synthetic opioid. And we now have a generation of drug users that started with heroin and fentanyl,” she writes. “Death by drugs is now a national problem, but the crisis began as an epidemic of overprescribed painkillers in the distressed communities that were least likely to muster the resources to fight back.”

I look forward to Macy’s next book and hope that she hears more from the distressed community of pain patients. They need a champion to fight for them too, not more gaslighting.

'Bend or Break' Raises Awareness About Invisible Illness

By Madora Pennington, PNN Columnist

Even though he was just a kid, people called Mitch Martow lazy. Too exhausted to maintain friendships and falling asleep in school, his classmates thought he was strange. Specialists couldn’t find a medical reason for his complaints, and psychiatrists had no answers either. Even morphine didn’t ease the pain that tortured him in his early teens.

One day, worn out from physical suffering that was compounded by so many doctors saying his pain was a mental issue, Mitch attempted suicide. He cried when he awoke in the ICU because he had not succeeded.

This is the story told in the documentary “Bend or Break.” Based mainly on Mitch’s blog posts, the film features interviews with Mitch and his family about how his mysterious illness turned their lives upside down and how a correct diagnosis changed all of that.

Mitch has Ehlers-Danlos Syndrome (EDS), a term for a number of similar, poorly understood disorders where the body fails to make stable collagen. As a result, the person has extreme flexibility, to the extent that their joints can bend backward.

With no obvious outward signs, many of us with EDS go decades without a diagnosis, despite frequently seeking care for its debilitating and perplexing symptoms.

MITCH MARTOW

When he was finally diagnosed correctly, Mitch’s family was troubled because EDS is under-researched and lacks effective treatments. For Mitch, his diagnosis made him happy: he was not crazy and could find others like him, which meant everything. It was the end of isolation.

To tell the story, Bend or Break showcases a young contortionist and dancer, Toria Summerville. Toria also has Ehlers-Danlos Syndrome, so she is capable of astounding feats of flexibility. Interspersed with the interview segments are Toria’s beautifully choreographed dances that express the emotionality of the Martow family’s experience.

‘I Felt Very Alone’

Toria was 19 when she participated in the documentary, but her performance has the maturity and depth of someone much older. From childhood, she always knew she was different but didn’t know why. With no understanding of what was wrong, it was up to her to get by and cope with unacknowledged and unaddressed symptoms.

When she was 5 or 6 years old, Toria would be awake all night, crying in pain. Doctors said it was growing pains. When she was in the 6th grade, she was put on medication for anxiety and depression. Doctors assumed she had an eating disorder, but she was allergic to many foods, a common problem with EDS.

“I felt very alone growing up and very confused with myself. I knew something was going on, but I didn’t know what,” Talia says.

She struggled with brain fog and fatigue. Her differences attracted comments from other kids, which felt like bullying. In dance class, others would laugh at her inability to control her superhuman flexibility.

Toria was often getting injured with dislocating joints and easy bruising. Concerned guidance counselors would ask if anyone was abusing her. Well-meaning adults put her in a peer support group, but she could not relate to the other kids. There, therapists offered helpful tools, but they were not what Toria needed, so it felt even more isolating.

At a performing arts high school, Toria found understanding. Her circus coach instinctively understood her and took her under his wing. “We worked on abilities that my body could do,” she says.

For Bend or Break, Toria dedicated herself to understanding and demonstrating what the Martow family experienced, a process that was emotionally challenging, not only because of what Mitch went through but because much of it hit close to home. She walked a fine line.

“I had to be sensitive that it was Mitch’s story, not mine. I had to be in tune with all the milestones he was going through and portray that with my movements and facial expressions,” she explained.

In one sequence, she dances in a straitjacket, an idea she came up with from the feeling of being trapped by so many misdiagnoses herself.

Bend or Break concludes with interviews of others with EDS. Like Mitch, they look perfectly healthy. No one would guess how debilitating their EDS problems are. The documentary drives home the difficulty of having an invisible illness — one not indicated by obvious signs of impairment. People with invisible illnesses and disabilities have a hard time getting believed.

Toria hopes Bend or Break will spread awareness about EDS to the general population and medical professionals in every field. Had she been diagnosed correctly at an earlier age, Toria could have avoided many injuries and gotten better help in school.

“We need to cut back the time to get a diagnosis. My life would have been a lot easier if I had known about EDS sooner,” she says.

Mitch has seen firsthand the positive effects Bend or Break is having. Medical doctors have thanked him for the film because it helped them understand patients with EDS or other invisible illnesses. He’s also spoken to psychology students who have watched the film and is hopeful that when they start working as mental health professionals, they’ll be cautious about insisting that a patient’s chronic pain is psychosomatic.

The film encourages healthcare providers to be careful with diagnoses like "conversion disorder," where a symptom is assumed to be mental because no physical cause can be found. Being treated that way nearly destroyed Mitch’s life. “I tried to use suicide to escape from it,” he says.

Madora Pennington is the author of the blog LessFlexible.com about her life with Ehlers-Danlos Syndrome. She graduated from UC Berkeley with minors in Journalism and Disability Studies. 

Ketamine and Oxytocin Provide Pain Relief for Arachnoiditis

By Dr. Forest Tennant, PNN Columnist

Nearly every day we receive an email from someone who is having trouble getting enough pain medication to give them a good quality of life.  In this age of opioid restrictions, there is hope. 

In the past, opioids and gamma amino butyric acid (GABA) substitutes such as diazepam (Valium) and gabapentin (Neurontin) have been the mainstays for pain control of adhesive arachnoiditis (AA). Today, there are alternatives that can enhance your current program to give you better pain control.

Low dose naltrexone is the initial pain reliever recommended to newly diagnosed AA cases. There are two other potent pain relievers that can be used with both naltrexone and opioids to achieve better pain relief: ketamine and oxytocin. Either agent is a good opioid substitute.

Ketamine provides pain relief primarily by suppressing a nerve receptor called N-methyl-d-aspartate. It can be taken by several non-oral routes of administration: nasal, injectable, sublingual or troche (dissolvable tablet).

Oxytocin (not to be confused with oxycodone or OxyContin) is a hormone that is a natural pain reliever. It surges in a woman’s body at the time of delivery to provide pain relief. It acts by activating the endorphin (opioid) receptors and by blocking nerve impulses between the brain and spinal cord.

Every community now has one or more pharmacies that will compound or “make” formulations of ketamine or oxytocin. We favor under-the-tongue (sublingual) or buccal (cheek) formulations.

Ketamine and/or oxytocin can be taken between opioid dosages or within 5 to 10 minutes before or after an opioid dosage to make the opioid stronger and last longer.

Ketamine and oxytocin can be used separately or used as combination therapy. Starting dosages of ketamine are 10-15 mg and oxytocin 10-20 units, which are administered within 10 minutes of each other. Dosages can later be raised above the starting dose.

We find the combination of ketamine and oxytocin to provide equal or better pain relief that most prescription opioids. Neither ketamine nor oxytocin are opioids, so there is no bias or resistance to their use. Also, overdoses are essentially not known to occur with regular dosages.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. This column is adapted from a bulletin recently issued by the Arachnoiditis Research and Education Project. Readers interested in subscribing to the bulletins should click here.

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

Misuse of Rx Opioids by Young Adults Falls to Record Lows

By Pat Anson, PNN Editor

The misuse of prescription opioids by young adults has fallen to the lowest levels ever recorded, according to an annual survey that’s been tracking drug use in the U.S. since 1975. The Monitoring the Future (MTF) survey also found that use of marijuana and hallucinogens by young adults rose to an all-time high last year.

The MTF survey and annual report is a joint project of the National Institute on Drug Abuse (NIDA) and the University of Michigan. Over 28,000 people were surveyed last year, including young adults aged 19 to 30 and adults aged 35 to 60.

Only 1.7% of young adults reported using “narcotics other than heroin,” a poorly named category that refers to the non-medical use of prescription opioids such as hydrocodone and oxycodone. Misuse of prescription opioids has been in a steep decline since reaching a peak of 8.9% in 2006.

NON-MEDICAL USE OF Rx OPIOIDS BY YOUNG ADULTS AGED 19-30

Source: Monitoring the Future

“One of the best ways we can learn more about drug use and its impact on people is to observe which drugs are appearing, in which populations, for how long and under which contexts,” said Megan Patrick, PhD, a research professor and principal investigator of the MTF study. 

“Monitoring the Future and similar large-scale surveys on a consistent sample population allow us to assess the effects of ‘natural experiments’ like the pandemic. We can examine how and why drugs are used and highlight critical areas to guide where the research should go next and to inform public health interventions.”

The MTF survey reflects the declining role that prescription opioids have in the U.S. drug epidemic, which is primarily fueled by illicit fentanyl and other street drugs. According to the IQVIA Institute, a healthcare data tracking firm, prescription opioid use has fallen by 48% over the past five years and now stands at levels last seen in 2000.

Once the most widely prescribed drug in the United States, hydrocodone (Vicodin) prescriptions have plummeted since the opioid was reclassified as a Schedule II Controlled Substance in 2014 and became harder to obtain.

According to the MTF survey, only 1.3% of young adults reported using Vicodin last year, down from a peak of 9.2% in 2009.

VICODIN USE BY YOUNG ADULTS AGED 19-30

Source: Monitoring the Future

Marijuana and Hallucinogens

While fewer younger adults are misusing prescription opioids, they are using marijuana and hallucinogens far more often.

Daily marijuana use (use on 20 or more occasions in the past 30 days) in 2021 reached the highest levels ever recorded since the MTF survey started monitoring it in 1988. Daily marijuana use was reported by 11% of young adults last year, up from 8% in 2016 and 6% in 2011.

In 2021, 8% of young adults reported using a hallucinogen such as LSD, ecstasy or psilocybin, an all-time high since the category was first surveyed in 1988. By comparison, only 3% reported using hallucinogens a decade earlier.

“As the drug landscape shifts over time, this data provides a window into the substances and patterns of use favored by young adults. We need to know more about how young adults are using drugs like marijuana and hallucinogens, and the health effects that result from consuming different potencies and forms of these substances,” NIDA Director Nora Volkow, MD, said in a news release.

“Young adults are in a critical life stage and honing their ability to make informed choices. Understanding how substance use can impact the formative choices in young adulthood is critical to help position the new generations for success.”

Alcohol remains the most-used substance among young adults, by far, with nearly 82% reporting alcohol use last year, unchanged from 2020. However, binge drinking (five or more drinks) rebounded to 32% in 2021 from an historic low in 2020, during the early stages of COVID-19 pandemic. 

Fewer Opioids and Weaker Doses for Cancer Patients

By Pat Anson, PNN Editor

Another study has documented how opioid guidelines over the past decade have led to fewer and weaker opioid prescriptions for cancer patients --- even though the treatment guidelines typically state they are not intended for patients suffering from cancer pain.

In findings recently published in PLOS ONE, researchers at Johns Hopkins Bloomberg School of Public Health and the University of Michigan analyzed pharmacy claims for up to 53 million privately insured U.S. adults from 2012 to 2019. During that period, opioid prescribing fell from 49.7% to 30.5% for people with chronic non-cancer pain (CNCP) and from 86% to 78.7% for people with cancer.

While the drop in prescribing appears minor for cancer patients, a closer look at the numbers shows a significant decline in high dose prescriptions and in the number of days opioids were prescribed.

In 2012, for example, the average daily dose for a cancer patient was 62.4 morphine milligram equivalents (MME). By 2019, that had fallen to 44.7 MME – a decline of over 28 percent.

The percentage of cancer patients getting over 90 MME — a ceiling recommended by the CDC for chronic non-cancer pain — fell from 26.2% to just 7.6% -- a 71 percent decrease.

The average number of days per year a cancer patient received opioids also fell, from 34.8 days to 22.3 days – a 36 percent decline.

“While clinical guidelines continue to endorse prescription opioid treatment for cancer-related pain, declines in receipt of any opioid prescription were observed for people with cancer diagnoses, though these declines were smaller in magnitude than those observed among people with CNCP diagnoses. Future research is needed to understand the clinical implications of this decline, as well as observed decreases in MME/day and days’ supply of opioid prescriptions, among cancer patients,” researchers reported.

In short, cancer patients are getting smaller and fewer doses of opioids, which researchers admit could be making their cancer pain worse. However, they stopped short of sounding the alarm over that trend and suggest it could be beneficial – by helping to reduce the risk of cancer patients overdosing.  

“On the one hand, this finding may signal a cooling effect on opioid prescribing that could contribute to poorly controlled cancer pain. On the other hand, this finding may suggest reductions in high-risk opioid prescribing practices, such as high dosage prescribing, which are shown to contribute to increased risk of opioid overdose death among cancer patients,” they wrote.

Oncology experts have been warning for years that opioid prescribing guidelines are being misapplied to cancer patients, even to women with advanced breast cancer.

In 2019, a Rite Aid pharmacist refused to fill an opioid prescription for April Doyle, a California woman with Stage 4 terminal breast cancer.  A tearful video she posted online went viral and the pharmacy apologized to Doyle, who later died.

That same year, the Cancer Action Network warned there has been “a significant increase in cancer patients and survivors being unable to access their opioid prescriptions.” One out of four said a pharmacy had refused to fill their prescriptions and nearly a third reported their insurer refused to pay them.

Part of the confusion about what’s appropriate for cancer pain is that the CDC’s opioid guideline says the recommendations are intended for patients “who have completed cancer treatment, are in clinical remission, and are under cancer surveillance only.”  Experts say the inclusion of cancer survivors is a mistake because it is not uncommon for pain to persist long after the cancer is treated or even because of the treatment itself.  

A revised draft version of the CDC guideline attempts to clear up some of the confusion by explicitly stating the recommendations are not intended for patients undergoing “cancer pain treatment” and for those in palliative or end-of-life care. The updated version of the CDC guideline is expected to be published late this year.

Should Gabapentin Be Used for Dental Pain?

By Pat Anson, PNN Editor

Since it was first approved as an anti-seizure medication in the 1990’s, gabapentin (Neurontin) has become one of the most widely studied and prescribed drugs in world.  Although gabapentin is only approved by the FDA for epilepsy and postherpetic neuralgia (shingles), it is widely prescribed off-label for fibromyalgia, neuropathy and many other types of pain.

Hundreds of clinical trials have been conducted to find new uses for gabapentin -- for everything from asthma and obesity to alcoholism and improving your sex life. Gabapentin has been pitched for so many different conditions that a drug company executive infamously called it “snake oil.”

Now gabapentin is being touted as a “promising alternative” to opioids for dental pain. In a new study at the University of Rochester Medical Center’s Eastman Institute for Oral Health (EIOH), researchers found that gabapentin, when combined with ibuprofen or acetaminophen, was more effective than opioids in relieving pain after tooth extractions.  

“We hypothesized that using a combination of the non-opioid pain medications and adding gabapentin to the mix for pain would be an effective strategy to minimize or eliminate opioids for dental pain,” said Yanfang Ren, DDS, a dentistry professor at EIOH.   

Ren and his colleagues treated over 7,000 patients at an urgent dental care clinic with different combinations of opioids, ibuprofen, acetaminophen and gabapentin after tooth extractions. The “failure rates” of the medications were determined by how often patients returned to the clinic for additional pain relief.

The study findings, published in JAMA Network Open, found that non-opioid medications, including those with gabapentin, had failure rates significantly lower than opioids.      

Dental Pain Failure Rates

• 0.9% Acetaminophen/ibuprofen

• 3.4% Gabapentin/acetaminophen

• 5.3% Gabapentin/ibuprofen

• 9.2% Codeine/acetaminophen

• 19.4% Hydrocodone/acetaminophen

• 31.3% Other opioid combinations

Providers at the dental clinic have already put their findings into practice by sharply reducing the use of opioids. Prior to that, about 1,800 patients at the clinic were treated each year with opioids. Researchers estimate the reduced opioid prescribing may have prevented 105 of those patients from developing a problem with “persistent opioid use.”

“This study represents continued efforts by our team and other dentists to minimize the use of opioids for dental pain,” said Eli Eliav, DMD, the director of EIOH. “Additional studies, preferably randomized controlled clinical trials, are needed to confirm the safety and effectiveness of this approach. It is our duty to continuously seek safe and effective treatment for our patients in pain.”

Gabapentin has issues of its own. Patients prescribed gabapentin often complain of mood swings, depression, dizziness, fatigue and drowsiness, and a 2019 review found little evidence gabapentin should be used off-label to treat pain. There are also many reports that gabapentin is being abused and sold on the streets because it can heighten the effects of other drugs.