UK Study Shows Chronic Pain Patients Benefit from Cannabis

By Pat Anson, PNN Editor

Chronic pain patients who used a variety of cannabis products experienced less pain, better sleep and improved quality of life, according to a new UK study that found the most improvement in patients who used oil-based cannabis products.

Researchers at Imperial College London assessed the safety and efficacy of cannabis in over 700 pain patients enrolled in the UK Medical Cannabis Registry. Participants were divided into three groups that used either oil-based cannabis, smoked or vaporized dried flowers, or a combination of both (CBMP) for six months. The oil-based products included extracts, lozenges and capsules.

The study findings, published in the journal Expert Review of Neurotherapeutics, show symptom improvement in all three groups, with patients using cannabis oil either alone or in combination with dried flower reporting the most improvement.

Researchers think the CBMP group derived the most benefit because the cannabis was ingested through two different administrative routes, one absorbed straight into the blood stream through inhaling (dried flowers) and the other slowly absorbed through the digestive system (oil-based cannabis).

“The findings in this study demonstrate treatment with oil-based, dried flowers, or a combination of both CBMPs are associated with statistically significant improvements in pain relief and sleep quality after 6 months in chronic pain patients,” researchers reported.

“Additionally, patients prescribed oils or both types of CBMPs experienced reduced anxiety and an improvement in their ability to perform daily activities. Patients prescribed a combination of both CBMPs recorded improvements in their self-care and mobility abilities. Collectively, this evidence signals that initiation of CBMP treatment is associated with improved HRQoL (health related quality of life).

In addition to symptom improvement, participants in the CBMP group reported a small reduction (3.28%) in their use of opioid analgesics.

About one in every four patients had an adverse side effect, such as fatigue, somnolence and dry mouth. Adverse events were more common in females, former cannabis users and cannabis naïve (new) users.  

A previous study of patients enrolled in the UK Medical Cannabis Registry found significant improvement in their pain, discomfort and sleep quality after using cannabis oil.

A recent survey of U.S. adults with chronic pain found that nearly a third have used cannabis for pain relief. Over half of those who used cannabis said it also enabled them to decrease their use of opioids and other pain medications.

FDA Adds New Safety Warning to Rx Opioids

By Pat Anson, PNN Editor

Opioid-induced hyperalgesia (OIH) is a controversial medical theory, built on the premise that long term opioid therapy can heighten pain sensitivity and cause pain to grow worse.

Often confused with opioid tolerance, there is no clear medical definition for OIH and most of the research about it has been conducted on animals. Only a few dozen human cases of OIH have reported, even though millions of people take opioids every day. Perhaps most telling of all, there is no specific diagnostic code for OIH – meaning doctors can’t bill for it.  

All of which makes it puzzling why the Food and Drug Administration has decided to add hyperalgesia to its “black box” warning label for opioids. In an 18-page Drug Safety Communication that was quietly released on Thursday, the FDA urges doctors to decrease the dose if they suspect a patient has OIH or switch them to another opioid product.

“Based on our review of available data, FDA has also determined that a new warning is needed about opioid-induced hyperalgesia (OIH),” the FDA said. “Although OIH can occur at any opioid dosage, it may occur more often with higher doses and longer-term use. This condition can be difficult to recognize and may result in increased opioid dosages that could worsen symptoms and increase the risk of respiratory depression.”

What is the data that prompted the FDA alert? The agency said it identified 46 patients with symptoms of OIH, after searching through years of medical literature and the FDA Adverse Event Reporting System. That’s all they could find, although the FDA meekly claims “there may be cases about which we are unaware.”

In those 46 patients, cancer pain was the most common condition being treated. The FDA said patients reported improvement in pain after they stopped taking opioids, before admitting it had no real understanding of why they did.

“Though the mechanism of OIH is not fully understood, multiple biochemical pathways have been suggested,” the FDA said.

‘Insufficient Evidence’ 

“I am surprised the FDA is including a black box warning of OIH in the label with such flimsy data,” says Lynn Webster, MD, a pain management expert and past president of the American Academy of Pain Medicine. “My clinical experience suggests OIH exists, but clinically it is very difficult to differentiate it from pain-induced central sensitization.”

Webster is concerned the FDA’s updated warning label could lead to patients being diagnosed with OIH and taken off opioids without their consent.     

“Misdiagnosing OIH can lead to forced tapering, which they warn against because it can cause serious harm.  This will undoubtedly occur with the new label,” Webster told PNN. “I recognize that the FDA wants to provide prescribers with as much information as possible about the potential risks of opioids. That is good, but mentioning OIH in the box warning has a risk of overstating a disorder that is yet not well characterized or even accepted as clinical disorder.” 

Other doctors and researchers share Webster’s doubts about the frequency and clinical significance of OIH. A 2021 review of dozens of published studies of hyperalgesia found only 72 patient cases of OIH, all of which were easily managed.

“At present, there is insufficient evidence from well-designed clinical trials that OIH is a clinically relevant phenomenon. Hence, while there are other reasons to avoid long-term use of opioids, the potential for the development of hyperalgesia during chronic opioid treatment is not a sound rationale for deprescribing these drugs in patients with chronic pain,” Craig Svensson, PharmD, Dean Emeritus of the Purdue College of Pharmacy said in an op/ed recently published in the International Journal of Pharmacy Practice.

A large survey conducted over a decade ago found a “significant knowledge gap” among physicians on how to diagnose and manage OIH.  One reason hyperalgesia is so poorly understood is that it is often mistaken for drug tolerance, the tendency of patients on any medication to develop a tolerance over time. In many of those cases, the solution is to increase the dose, not decrease it. 

Coincidentally, the FDA’s label change comes just days before an April 19 public meeting of an FDA Advisory Committee, which is considering a requirement that drug makers evaluate the long-term efficacy and risk of OIH in new drug applications for extended-release and long-acting opioids. Such an evaluation would include a post-marketing analysis of a new drug once it is approved.

Even though opioid prescribing has been cut in half over the past decade and the vast majority of overdose deaths involve street drugs, the FDA remains under pressure from politicians and anti-opioid activists to further restrict opioid prescriptions.

“I'm sure because of the past problems associated with opioids, the FDA regulators feel it best to advise prescribers of every possible potential risk, even if the science is weak. You might say they are between a rock and a hard place,” Webster said.

Donating to Charity Helps Relieve Pain (Really)

By Pat Anson, PNN Editor

Would you believe me if I told you that donating money to Pain News Network would help relieve your pain? Or that the more you gave, the more relief you’d get?

I’m a bit skeptical myself, but that’s the conclusion of an unusual UK study that found donating to charity, volunteering your time, and engaging in “prosocial behaviour” have modest pain-relieving benefits.

Researchers at the University of London and Harvard University analyzed the responses of 35,000 people to the United Kingdom Household Longitudinal Survey (UKHLS) from 2011 to 2020. The UKHLS is conducted annually with a broad spectrum of people across the UK, who are asked about their health, work, education, income, family, and social life.

Among the many questions asked is whether respondents volunteered or donated to a charity, and whether their physical pain interfered with their work – which was assessed using a five-point scale of 0 (not at all) to 5 (extremely). The responses of each individual were tracked over a 10-year period.

The peer-reviewed findings, published in the Journal of Psychosomatic Research, found a “modest correlation” between prosocial behaviour and pain relief, and suggest that the more money donated to a charity, the more physical pain was eased. Volunteering helped even more, but there was not a similar dose-dependent effect on the number of hours that were volunteered. Doing both — volunteering and donating — was the most beneficial.

journal of psychosomatic research

Prosocial behaviour has previously been linked to better mental and physical health, but until now, no study had investigated whether it was directly linked to reductions in physical pain.

The authors believe that positive emotions associated with donating and volunteering are key to the improvement. Volunteering was found to be strongly associated with social connection, which is a key predictor of mental and physical wellbeing.

“This research contributes to the new and fast-growing literature that studies pain from a socioeconomic, psychosocial, and behavioural perspective. The work provides useful information for the design and evaluation of public health policies by uncovering how engaging in prosocial behaviour, which can create powerful positive emotions and reduce negative mood like stress, can positively affect one’s pain,” wrote lead author Lucía Macchia, PhD, a Behavioral Scientist and Lecturer in Psychology at City, University of London.

Macchia and her colleagues also found that people who donated to charity reported a slower rise in pain over time, although this effect was not found for those who volunteered.

Of course, there are going to be caveats for a study like this. The authors say “reverse causality” may have influenced the findings, because people in more pain may not physically be able to volunteer and often have fewer economic resources. Individuals who donated were more likely to be married, employed and more educated; while people who did not were more likely to be unemployed, out of the labor force, and have less income.

Researchers concluded that the emotional benefits of being “prosocial” can have a positive impact on pain and overall health.

“Taken together these findings suggest prosociality may provide a novel behavioural strategy for reducing likelihood of experiencing or developing pain interference over time. Moreover, these findings suggest that, while different prosocial behaviours may vary in potency of effects on pain, effects may be due to underlying elements common across the behaviours, including kindness, compassion, or helping toward others, rather than to any specific behaviour per se,” they reported.

I won’t claim that donating to PNN will help ease your pain, but I can honestly say that your donations help keep this website and our newsletter free for everyone. We don’t hide behind a paywall, charge for subscriptions or limit the number of free stories you can see. To do this, PNN depends on reader donations -- large and small -- to continue publishing. Your donations helped us reach nearly 550,000 readers last year, the vast majority of them people in pain.

Can you chip in just $5, $10 or $25 to help? And make it a recurring monthly donation? 

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Researchers Find Possible Cause of Hypermobile EDS

By Crystal Lindell, PNN Columnist

Do we finally have a genetic link for hypermobile Ehlers-Danlos syndrome?

Researchers at Tulane University School of Medicine think so – and it could even point to an effective treatment that’s already available.

A variation of the MTHFR gene that causes a deficiency of folate – the natural form of vitamin B9 – could hold the key to hypermobility and a range of associated connective tissue disorders such as Ehlers-Danlos (EDS), according to preliminary findings published in the journal Heliyon.

“You’ve got millions of people that likely have this, and until now, there’s been no known cause we’ve known to treat,” said Gregory Bix, MD, director of the Tulane University Clinical Neuroscience Research Center. “It’s a big deal.”

People with the genetic variant can’t metabolize folate, which causes unmetabolized folate to accumulate in the bloodstream. The resulting folate deficiency in other parts of the body prevents key proteins from binding collagen to the extracellular matrix, which plays an important role in cell growth. This leads to more elastic connective tissue, hypermobility, and a potential cascade of associated conditions, researchers said.

The discovery could help doctors more accurately diagnose hypermobility and hypermobile EDS by looking for elevated folate levels in blood tests and the MTHFR genetic variant.

“Hypermobility is widespread and unfortunately under-recognized,” said Jacques Courseault, MD, medical director of the Tulane Fascia Institute and Treatment Center. “I’m excited about being able to treat the masses where people aren’t going their whole lives being frustrated and not getting the treatment they need."

Doctors discovered the connection between folate deficiency and the MTHFR gene by working with patients at Tulane’s Hypermobility and Ehlers-Danlos Clinic, the only clinic in the U.S. that focuses on fascia disorders. Blood tests of hypermobile patients revealed elevated levels of unmetabolized folate. Subsequent tests showed that most of those with elevated folate serum levels had the MTHFR genetic variant.

The good news is a treatment already exists. Methylated folate – folate that is already processed – is FDA-approved and widely available.

“It’s an innocuous treatment,” Bix said. “It’s not dangerous, and it’s a vitamin that can improve people’s lives. That’s the biggest thing: We know what’s going on here, and we can treat it.”

“We’ve discovered something in medicine that can help, not a small group of people, but potentially many across the world.”

— Dr. Jacques Courseault

Though more studies and clinical testing needs to be done, researchers say patients who have been treated with folate have shown improvement: less pain, less brain fog, fewer allergies and improved gastrointestinal function.

“We’ve discovered something in medicine that can help, not a small group of people, but potentially many across the world,” Courseault said. “This is real, it’s been vetted out well and clinically we’re noticing a difference.”

What Is Hypermobile EDS?

For those with hypermobile Ehlers-Danlos syndrome (EDS), the same conditions that create fragile connective tissue can cause a range of other symptoms that, on the surface, can seem unrelated: joint pain, chronic fatigue, thin tooth enamel, dizziness, digestive trouble and migraines, as well as psychiatric disorders such as anxiety and depression. Women with hypermobile EDS may also be at increased risk for endometriosis or uterine fibroids.

For years, researchers have struggled to find the cause of hypermobility and hypermobile EDS. Of the 13 subtypes of EDS, hypermobile EDS comprises more than 90 percent of cases. But until this study, hypermobile EDS was the only subtype without a known genetic correlate. As a result, symptoms have often been treated individually, without EDS being recognized as the likely cause.

Until now, hypermobility could only be diagnosed by the Beighton score, a somewhat controversial physical exam that involves measuring the bend of the spine, fingers and limbs. There has also been a historic lack of acceptance of hypermobility as a disorder that requires specialized treatment.

Many patients with hypermobile EDS never get a proper diagnosis. As a result, the number of people with hypermobility is unclear, though it could comprise more than half the world’s population.

“Hypermobility is not rare,” Courseault said. “Hypermobility is like a Ferrari that requires a lot of maintenance and the best synthetic oil. After knowing a patient's name and date of birth, I think it's prudent for clinicians to know which of these body types they have.”

Crystal Lindell is a freelance writer who lives in Illinois. After five years of unexplained rib pain, Crystal was finally diagnosed with hypermobile Ehlers-Danlos syndrome. She and her fiancé have 3 cats: Princess Dee, Basil, and Goose. She enjoys the Marvel Cinematic Universe, Taylor Swift Easter eggs, and playing the daily word game Semantle. 

Study Links Rx Opioids to Higher Suicide Risk

By Pat Anson, PNN Editor

Suicide is an all-too-common experience in the pain community. About one in every ten suicides in the U.S. involves chronic pain, and in a PNN survey of nearly 6,000 pain sufferers, an astounding 49% told us they thought about suicide because their pain was so poorly treated.

Many of those patients lost access to opioid pain medication after the CDC released its opioid guideline in 2016. The resulting backlash against opioids by regulators and law enforcement had predictable results on people in pain, resulting in an untold number of suicides by mothers, husbands, veterans, advocates and others – that the CDC didn’t even bother to track.

Just a few months ago, a Georgia man and his wife died by suicide after the doctor who was treating the husband had his license to prescribe opioids suspended by the DEA.

A new study is now casting doubt on the association between suicide and cutbacks in opioid prescribing. Researchers at Columbia University Mailman School of Public Health looked at U.S. prescription data from 2009 to 2017 and found the suicide rate was significantly higher in census regions where there was more high-dose, long-term opioid prescribing.

“The relationship between opioid prescribing and suicide risk is a complex one. This is particularly the case when people have their opioids tapered,” said Mark Olfson, MD, professor of epidemiology at Columbia School of Public Health.

“People can become desperate if their pain is not well controlled. Yet opioids also pose a greater risk of overdose than any other drug class and approximately 40 percent of overdose suicide deaths in the U.S. involve opioids. At a population-level, the national decline in opioid prescribing over last several years appears to have reduced the number of people who died of suicide.”

The study findings, published in the American Journal of Psychiatry, are surprising because they cover a period when the U.S. suicide rate was steadily rising, fueled by factors such as mental illness, substance abuse, economic hardship and social isolation. The study ignores those societal issues and focuses solely on opioid medication as the driving force behind suicides.   

Olfson and his colleagues found that geographic regions with the biggest declines in opioid prescriptions tended to have the largest declines in suicide deaths, including suicide overdoses that involved opioids. If the national decline in opioid prescribing had not occurred, they estimate there would have been 3% more suicide deaths overall, and 10.5% more suicide deaths involving opioids.

“It is not surprising that regional declines in opioid prescribing were found to ameliorate local trends in suicide deaths. These findings reinforce the importance of safe opioid prescribing practices and proper disposal of unused opioids,” they reported. “While some patients with pain need and benefit from opioids without risk, those for whom opioids are prescribed should be evaluated and, if necessary, treated for co-occurring mental health disorders that might otherwise increase their risk of suicide.”

‘Confusing and Contradictory’ Findings

The new study is at odds with recent research in British Columbia, which found that tapering or stopping opioid therapy significantly raises the risk of a patient dying from an accidental or intentional overdose. A large 2021 study of U.S. patients on long-term opioid therapy also found that tapering raises the risk of a non-fatal overdose and attempted suicide.

There are “serious methodological problems” with the Columbia study, according to Stefan Kertesz, MD, an associate professor at the University of Alabama at Birmingham, who is leading a federally funded study of pain patient suicides. Kertesz says the study’s reliance on prescription data overlooks all the other issues in a community that may contribute to suicide.

“Let’s use common sense: If communities can change their level of opioid prescriptions, then surely they can change in countless other ways that might bear on community-level suicide risk. Some communities might have a decline in economic well-being. Others might invest in crisis centers,” Kertesz told PNN by email. “However, this paper’s statistical choices require us to assume that none of the 886 regions changed in any respect that would affect suicide, other than the number of opioid prescriptions.”

Kertesz is concerned the study findings could be used to justify further cuts in opioid prescribing.

“Unfortunately the paper offers a confusing, unnecessary and internally contradictory message about the application of its findings to individual patients, one that distracts from the work of the authors and is likely to be misapplied in ways that put patient safety at risk,” he said.

The study was funded by the National Institute on Drug Abuse.

Studying suicides is difficult for researchers because many suicide deaths are misreported as accidental or of undetermined cause, making much of the data unreliable. Drug experts say up to 30% of opioid overdose deaths listed as accidental may have been intentional.

A Pained Life: I Was a Platypus

By Carol Levy, PNN Columnist

Have you ever seen a platypus? The semiaquatic mammal from Australia that lays eggs and is duck-billed, beaver-tailed and otter-footed?

It’s hard to believe it is actually one animal. In fact, the first European scientists to examine the body of a dead platypus thought it was fake, made from the parts of several different animals that were sewn together.

To many doctors, people in pain are platypuses.

When my first symptoms of trigeminal neuralgia started many decades ago, a patient had to have three specific diagnostic signs.

The pain had to be spontaneous and triggered. Mine was. It had to be in a very specific anatomical area of the face. Mine was. You also had to be over 60 years of age. Or, if you were in your 40's or 50’s, you had to have multiple sclerosis.

I wasn't in my 60's and didn’t have multiple sclerosis. Therefore, because of my youth – I was 26 at the time -- it could not possibly be trigeminal neuralgia. “It looks all the world like trigeminal neuralgia. But it can't be, because you're too young,” one doctor told me.

Two of my symptoms were by the book, but the last one, my age, was like the otter's feet. I was a platypus.

Things have changed a lot over the years, The criteria for a trigeminal neuralgia diagnosis have changed significantly. The pain can have a number of different characteristics and the association with old age was completely wrong. Even toddlers and newborns can have it. Age doesn't matter.

Complex Regional Pain Syndrome and other chronic pain disorders have us presenting many different symptoms to our doctors that, on the face of it, don't make sense. Many of us complain, rightfully so, that the doctor didn't listen when we described our symptoms. Some may fit a specific disease or disorder, while others do not.  

The doctor seemed to listen, but heard only one or two of the symptoms while ignoring others -- the ones that didn't fit their preconceived notion of what we might have. Or didn't fit the textbook description. As a result, we often don’t get the correct diagnoses, and without the right one there is no way to treat the condition or pain correctly. 

When pain became a specialty of its own, when doctors started opening practices solely for those of us living with chronic pain, it seemed like a godsend. We would finally be seen for the singular entity we were -- persons living with pain --- not some platypus that doctors saw as too bizarre to be real. We would be legitimized. 

Unfortunately, since they started taking the “war on opioids” out on the chronic pain community, making us the villains, it seems our legitimacy was lost. 

We are not like patients with other diseases like cancer or diabetes, where the diagnosis is straightforward. We still have to fight to be believed, and to be heard.

It took time for platypuses to be seen as real, more than just an oddity of nature. Let’s hope that someday we will also be believed and accepted. 

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.

Online Health Programs Help Reduce Pain

By Pat Anson, PNN Editor

Online health programs can help patients with chronic pain conditions learn how to manage their pain and other symptoms, according to two new studies. One “e-health” program even helped patients reduce their use of opioids.

Online pain self-management programs have proliferated in recent years due to the pandemic and greater acceptance of telemedicine, but few studies have assessed their effectiveness. The programs provide content similar to what a patient might receive from a pain psychologist — in-person treatment that often is not accessible or affordable for everyone.

In a small study at the University of California, Irvine (UCI), researchers recruited sickle cell patients through advertisements on Facebook, Reddit and other social media sites. Sickle cell disease is a painful genetic disorder that primarily affects people of African or Hispanic descent. Many sickle cell patients face stigma when they seek treatment for pain flares and have learned to distrust the healthcare system.

“Before the study, we were told sickle cell researchers thought online outreach to patients would not work as patients wouldn't trust the process,” said Sean Young, PhD, a professor in UCI’s Departments of Emergency Medicine and Informatics. “Surprisingly, we found it worked really well.”

Researchers recruited 32 young adult patients with sickle cell to watch a 20-minute video that taught mindfulness meditation. Afterward, participants were emailed links to additional audio recordings for ongoing practice. Patients rated their pain intensity, anxiety and depression before and after the mindfulness training.

“Patients with sickle cell disease struggle with pain, and unfortunately, they have few options for relief,” said Young. “We developed and tested a brief online intervention to teach them mindfulness and found that it helped their pain both immediately and for six weeks after they viewed the mindfulness exercise.”

The study findings, recently published in the journal Cureus, show that after six weeks of mindfulness training, pain intensity declined an average of 1.3 points, anxiety decreased by 1.8 points, and depression declined by 1.7 points.

Researchers think younger sickle cell patients feel more comfortable participating in e-health programs. About 97% of participants watched the full mindfulness video and a little over half listened to additional recordings.

Reduced Opioid Use 

The second study of an e-health program, published in the journal Pain, involved over 400 pain patients on long-term opioid treatment who were recruited by researchers at Washington State University. Half the participants watched a pain self-management program and the other half received treatment as usual, serving as a control group.

Patients in the e-health group watched an online course designed by a psychologist, called Goalistics Chronic Pain Management, which aims to help people manage their pain through cognitive behavioral therapy, exercise and relationship advice, as well as information about opioid use and risks.

After six months, over half the patients in the e-health group (53.6%) were able to reduce their opioid dose by 15% or more, compared to 42.3% of patients in the control group.

There was not much change in pain levels in either group. Pain intensity declined by at least two points in only 14.5% of e-health participants, and in 6.8% of the control group.

"These were very encouraging findings: not only were they reducing opioids but also their pain was not becoming worse," said lead author Marian Wilson, PhD, an Associate Professor of Nursing at WSU. "Some people are hesitant to stop their opioid medication because they fear their pain will increase, but we found that at least on average in this population, they could reduce their opioids a bit and not have increased pain symptoms."

Wilson and her colleagues also observed the e-health patients improved their knowledge about pain, confidence in managing it, and their coping skills.

"The idea is to put the patient in the driver's seat because we can give them a prescription for opioids, and that will work for a little while, but over time for chronic pain, it's not usually going to be the solution to fix all their troubles," she said.

The Goalistics e-health program currently has a monthly $30 fee, which usually is not covered by insurance. In addition to pain management, Goalistics also has an online self-management program for depression.

Polypeptides: A Promising Treatment for Intractable Pain

By Dr. Forest Tennant, PNN Columnist

We have long noted that persons with adhesive arachnoiditis (AA) and other causes of intractable pain who follow a high protein diet and take amino acid supplements usually have better treatment outcomes. They need fewer opioids, function better, and have a good quality of life.

Protein is composed of about two dozen separate building blocks called amino acids. Once ingested, they chemically join together and cause specific effects in the body. When two or more amino acids combine and partner, they are called polypeptides. Two polypeptides that relieve pain and heal damaged tissue are KPV (lysine-proline-valine) and Body Protection Compound or BPC-157.

KPV is useful primarily for pain relief and to reduce inflammation in the brain and spinal canal. It activates the neurotransmitters endorphin and melanocortin, which are stored in the hypothalamus. 

BPC-157 is a chain of 15 amino acids. Its primary function is to regenerate and heal tissue, including neural tissues, receptors, arachnoid membrane, cartilage and intervertebral discs. We believe it also helps heal spinal fluid leaks. BPC has a great effect on the stomach and intestine. 

Because polypeptides (PP’s) are fundamentally a conglomeration of food particles, when swallowed they are digested in the stomach and lose much of their effectiveness. That is why KPV and BPC-157, like insulin, are often taken by subcutaneous injection. Both PP’s are also available in non-injection formulations. KPV comes in an oral or nasal spray, while BPC-157 is available as sublingual tablet taken under the tongue or as a spray. 

A list of several companies that supply PP’s online is available in this bulletin.  

Who Should Take Polypeptides  

We have long-recommended a three-component medical protocol for AA and other causes of intractable pain to (1) suppress inflammation and autoimmunity, (2) regenerate tissue and (3) relieve pain. Our starting protocol for AA is now changed and anchored with KPV and BPC-157.  

To start, we recommend daily use of a polypeptide for a week. After a week, use it 3 to 5 days a week. Some persons with AA like to use KPV daily as it greatly reduces pain. Others can become tolerant to polypeptides, so skipping some days will keep the polypeptide active and effective.  

All persons with AA and/or intractable pain should, in our opinion, try the two PP’s provided here to enhance pain relief, promote tissue regeneration and healing, and reduce the use of potent medications, including corticosteroids, ketorolac, benzodiazepines, and opioids.  We also believe PP’s can reduce the use of risky surgery and invasive procedures.  

Several other polypeptides are being studied, and the Tennant Foundation will keep you apprised of new discoveries and developments. We consider polypeptides a major advance in the treatment of AA and other intractable pain conditions. 

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 bulletins recently issued by the Tennant Foundations’s 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.  

Why Chronic Fatigue Is Common for Older Adults

By Judith Graham, Kaiser Health News

Nothing prepared Linda C. Johnson of Indianapolis for the fatigue that descended on her after a diagnosis of stage 4 lung cancer in early 2020.

Initially, Johnson, now 77, thought she was depressed. She could barely summon the energy to get dressed in the morning. Some days, she couldn’t get out of bed.

But as she began to get her affairs in order, Johnson realized something else was going on. However long she slept the night before, she woke up exhausted. She felt depleted, even if she didn’t do much during the day.

“People would tell me, ‘You know, you’re getting old.’ And that wasn’t helpful at all. Because then you feel there’s nothing you can do mentally or physically to deal with this,” she told me.

Fatigue is a common companion of many illnesses that beset older adults: heart disease, cancer, rheumatoid arthritis, lung disease, kidney disease, and neurological conditions like multiple sclerosis, among others. It’s one of the most common symptoms associated with chronic illness, affecting 40% to 74% of older people living with these conditions, according to a 2021 review by researchers at the University of Massachusetts.

This is more than exhaustion after an extremely busy day or a night of poor sleep. It’s a persistent whole-body feeling of having no energy, even with minimal or no exertion.

“I feel like I have a drained battery pretty much all of the time,” wrote a user named Renee in a Facebook group for people with polycythemia vera, a rare blood cancer. “It’s sort of like being a wrung-out dish rag.”

Fatigue doesn’t represent “a day when you’re tired; it’s a couple of weeks or a couple of months when you’re tired,” said Dr. Kurt Kroenke, a research scientist at the Regenstrief Institute in Indianapolis, which specializes in medical research, and a professor at Indiana University’s School of Medicine.

When he and colleagues queried nearly 3,500 older patients at a large primary care clinic in Indianapolis about bothersome symptoms, 55% listed fatigue -- second only to musculoskeletal pain (65%) and more than back pain (45%) and shortness of breath (41%).

Separately, a 2010 study in the Journal of the American Geriatrics Society estimated that 31% of people 51 and older reported being fatigued in the past week.

The impact can be profound. Fatigue is the leading reason for restricted activity in people 70 and older, according to a 2001 study by researchers at Yale. Other studies have linked fatigue with impaired mobility, limitations in people’s abilities to perform daily activities, the onset or worsening of disability, and earlier death.

‘Alarm Signal That Something Is Wrong’

What often happens is older adults with fatigue stop being active and become deconditioned, which leads to muscle loss and weakness, which heightens fatigue.

“It becomes a vicious cycle that contributes to things like depression, which can make you more fatigued,” said Dr. Jean Kutner, a professor of medicine and chief medical officer at the University of Colorado Hospital.

To stop that from happening, Johnson came up with a plan after learning her lung cancer had returned. Every morning, she set small goals for herself. One day, she’d get up and wash her face. The next, she’d take a shower. Another day, she’d go to the grocery store. After each activity, she’d rest.

In the three years since her cancer came back, Johnson’s fatigue has been constant. But “I’m functioning better,” she told me, because she’s learned how to pace herself and find things that motivate her, like teaching a virtual class to students training to be teachers and getting exercise under the supervision of a personal trainer.

When should older adults be concerned about fatigue? “If someone has been doing OK but is now feeling fatigued all the time, it’s important to get an evaluation,” said Dr. Holly Yang, a physician at Scripps Mercy Hospital in San Diego and incoming board president of the American Academy of Hospice and Palliative Medicine.

“Fatigue is an alarm signal that something is wrong with the body but it’s rarely one thing. Usually, several things need to be addressed,” said Dr. Ardeshir Hashmi, section chief of the Center for Geriatric Medicine at the Cleveland Clinic.

Among the questions physicians should ask:

• Are your thyroid levels normal?

• Are you having trouble with sleep?

• If you have underlying medical conditions, are they well controlled?

• Do you have an underlying infection?

• Are you chronically dehydrated?

• Do you have anemia, an electrolyte imbalance or low levels of testosterone?

• Are you eating enough protein?

• Have you been feeling more anxious or depressed recently?

• Are medications you’re taking contributing to fatigue?

“The medications and doses may be the same, but your body’s ability to metabolize those medications and clear them from your system may have changed,” Hashmi said, noting that such changes in the body’s metabolic activity are common as people become older.

Often No Obvious Cause

Many potential contributors to fatigue can be addressed. But much of the time, reasons for fatigue can’t be explained by an underlying medical condition.

That happened to Teresa Goodell, 64, a retired nurse who lives just outside Portland, Oregon. During a December visit to Arizona, she suddenly found herself exhausted and short of breath while on a hike, even though she was in good physical condition. At an urgent care facility, she was diagnosed with an asthma exacerbation and given steroids, but they didn’t help.

Soon, Goodell was spending hours each day in bed, overcome by profound tiredness and weakness. Even small activities wore her out. But none of the medical tests she received in Arizona and subsequently in Portland — a chest X-ray and CT scan, blood work, a cardiac stress test — showed abnormalities.

“There was no objective evidence of illness, and that makes it hard for anybody to believe you’re sick,” she told me.

Goodell started visiting long covid web sites and chat rooms for people with chronic fatigue syndrome. Today, she’s convinced she has post-viral syndrome from an infection. One of the most common symptoms of long covid is fatigue that interferes with daily life, according to the Centers for Disease Control and Prevention.

Managing Fatigue

There are several strategies for dealing with persistent fatigue. In cancer patients, “the best evidence favors physical activity such as tai chi, yoga, walking, or low-impact exercises,” said Dr. Christian Sinclair, an associate professor of palliative medicine at the University of Kansas Health System. The goal is to “gradually stretch patients’ stamina,” he said.

With long covid, however, doing too much too soon can backfire by causing “post-exertional malaise.” Pacing one’s activities is often recommended: doing only what’s most important, when one’s energy level is highest, and resting afterward. “You learn how to set realistic goals,” said Dr. Andrew Esch, senior education advisor at the Center to Advance Palliative Care.

Cognitive behavioral therapy can help older adults with fatigue learn how to adjust expectations and address intrusive thoughts such as, “I should be able to do more.” At the University of Texas MD Anderson Cancer Center, management plans for older patients with fatigue typically include strategies to address physical activity, sleep health, nutrition, emotional health, and support from family and friends.

“So much of fatigue management is about forming new habits,” said Dr. Ishwaria Subbiah, a palliative care and integrative medicine physician at MD Anderson. “It’s important to recognize that this doesn’t happen right away: It takes time.”

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

More States Should Require Insurers to Pay for Medical Cannabis

By Paul Armentano, Guest Columnist

Should health insurance programs reimburse patients for their use of medical cannabis products? In a growing number of states, the courts are saying “yes.”

In the most recent example, a Pennsylvania Appellate Court ruled that workers’ compensation plans must cover cannabis-related expenditures when an employee uses it to recover from a workplace-related injury. The court ruled that employees in Pennsylvania possess “a statutory right” to be reimbursed for medical marijuana expenses that are reasonable and necessary to treat a work injury.  

“The MMA (Pennsylvania Medical Marijuana Act) specifically mandates that no medical marijuana patients be denied any rights for (the) lawful use of medical marijuana,” the Court said.

The Pennsylvania Court is not the first to issue an affirmative verdict in this matter. Courts in several states, including Connecticut, New Hampshire, New Jersey, New Mexico and New York, have provided similar opinions – determining that the denial of compensation claims would be antithetical to the legislatures’ express findings that cannabis is a state-legal therapy.

By contrast, courts in some other states, including Minnesota, have issued contradictory opinions – finding that it would be inappropriate for insurers to reimburse claimants for their use of a federally illegal substance. Federal law still classifies marijuana as a Schedule I controlled substance, placing it in the same legal category as heroin.

In most states, however, the law is largely silent on the issue. But don’t expect that to be the case for much longer. As scientific consensus and public attitudes surrounding the safety and efficacy of medical cannabis continue to evolve, the way insurers approach patients’ use of marijuana is likely to change too.

For example, lawmakers in Massachusetts recently introduced legislation explicitly providing that injured employees be reimbursed for their medical marijuana-related costs. In New York, lawmakers just advanced legislation, A. 4713, requiring public insurance plans to treat medical cannabis like any other medication. 

Thirty-eight states and the District of Columbia currently regulate the production and dispensing of cannabis for medical purposes. No state government has ever repealed or even rolled back these laws. That’s because these policies are widely accepted among both the public and among health professionals.

In fact, according to nationwide survey data recently compiled by the Centers for Disease Control and Prevention, over two-thirds of practicing physicians acknowledge the efficacy of medical cannabis and over one-quarter say that they have recommended it to their patients. 

Tens of millions of Americans are now using cannabis therapeutically. The number has doubled over the past decade, as peer-reviewed data that support the use of medical cannabis for the treatment of pain, multiple sclerosis, and other ailments has continued to grow. In many instances, patients are replacing their use of opioids, benzodiazepines and other prescription medications with cannabis because they find it more effective and with fewer adverse side effects. 

In short, most patients, most physicians, and most state laws view cannabis as a legitimate therapeutic option. Therefore, the millions of Americans who rely upon medical cannabis products ought to be afforded the same entitlements as those who use other conventional medications and therapies. Those privileges should include insurance-provided reimbursement for medical cannabis treatment.  

State legislators ought to see to it that this is a right provided for and protected in jurisdictions where medical marijuana is legally available under the law. 

Paul Armentano is the Deputy Director for NORML, the National Organization for the Reform of Marijuana Laws.

Why Positivity and Gratitude Beat the Alternative

By Mia Maysack, PNN Columnist

As I write this, I am 33 years old.  And I've lived in pain every day for almost 23 years.

My pain has only gotten more complicated over time, more difficult to deal with and manage. It is intractable, as well as incurable. There have never been treatment options for me that truly worked, only those that temporarily masked the pain or worsened the symptoms and caused irreversible complications.

Those of you who at any point gained access to something that worked or alleviated your discomfort to any extent are privileged. Because some of us have literally not experienced that.

As a 10-year old child whose life was forever changed by a bacterial infection and near death experience, there was no other option for me than to cling desperately to the concept of  "positivity." The only other choice at that point would've been a defeatist, victim mentality:  Why did this happen to me?  I don’t deserve it. My life is ruined. There’s no hope for the future.

I still have those thoughts at times, but I consciously choose not to accept them as the final say or whole picture.  Life hadn't even begun for me when I was stricken, yet I was strong enough to stand firm in my Truth:  I'm not yet ready to die or give up on my quality of life.

As time went on, things got even harder and without any dependable relief. I was often pushed to what felt like my breaking point. It dawned on me that a “positive” attitude was not going to be enough to survive, so my thought process and mindset had to evolve.

Looking at the bright side, being thankful I wasn't dead, and acknowledging that things could have been worse (and might still be) wasn't sufficient to peel my fragmented sense of self off the cold hard floor. So, my focus in life turned to gratitude. 

I became grateful for that cold hard floor, where I could curl up in a fetal position and count my blessings. At least I was still above ground and could find solace in the ability to live on for the sake of other people, so that they wouldn't feel as rejected, alone, forsaken and shunned as I was.

This approach worked, until it didn't.

When even the “attitude of gratitude” didn't suffice, I had to re-examine it and take it all back to basics, recalling things I'd often skip over and take for granted, such as the gift of my senses, the ability to fill my lungs with air, and possessing access to endless knowledge at my fingertips.

Of course, I could never lose sight of the fact that I was incredibly lucky to still be alive, even when it didn’t feel like it.  But these beliefs were undeniable pillars that held me up through times when I couldn't move, think straight, or do anything but stay in bed and cry.

More recently, even this approach was falling short. I was sick and tired, nearing the point of no return. All the motivational tools I cultivated on my own were falling short. What do I do now?  Where do I turn?

These efforts do not come easily and certainly do not represent an absence of intrusive thoughts or negative feelings. Remaining consumed in the darkness has almost cost me everything, on more occasions than I'm able to keep track of. 

But it dawned on me early on that I had a choice. Instead of investing energy in my ailments, I could focus on my response to them. It was a no-brainer to realize that fixating on all that was wrong in my life doesn't improve it or help me feel any better. To choose that kind of suffering is far more toxic and tragic than my pain ever could be.

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. 

Fibromyalgia Treatment Is a Real Gas

By Pat Anson, PNN Editor

Immersing fibromyalgia patients in high levels of oxygen is more effective at treating their pain and other symptoms than two medications commonly prescribed for the disorder, according to a new study.

Researchers at Tel Aviv University have been studying hyperbaric oxygen therapy (HBOT) for years as a possible treatment for fibromyalgia, a poorly understood condition characterized by widespread body pain, headaches, fatigue, depression and insomnia.  

Hyperbaric medicine is a form of treatment in which patients stay in a pressurized chamber and breathe 100% oxygen to help them heal faster. HBOT has long been used to treat infections, severe burns, carbon monoxide poisoning, and even scuba divers recovering from decompression sickness. The higher air pressure allows lungs to gather more oxygen than they would normally, and promotes the growth of new blood vessels and neurons in the brain.

In a 2015 study, researchers found that HBOT can also induce neuroplasticity in the brain and significantly reduce fibromyalgia pain.

"Until 15 to 20 years ago, there were doctors who believed that it was a psychosomatic illness and recommended that patients with chronic pain seek mental health care¸” said Shai Efrati, MD, of the Sagol Center for Hyperbaric Medicine and Research at Shamir Medical Center. “Today we know that it is a biological illness, which damages the brain's processing of the signals received from the body. When this processing is malfunctioning, you feel pain without any real damage in related locations.”

Efrati and his colleagues recruited 64 adults who suffer from fibromyalgia as a result of a traumatic head injury, and randomly assigned them to two groups.

One group was exposed to 100% pure oxygen in a hyperbaric chamber for 90 minutes, five times a week for three months; while the second group received either pregabalin (Lyrica) or duloxetine (Cymbalta), two FDA-approved medications for fibromyalgia.

The study findings, published in PLOS One, show that HBOT induced significant improvement in pain levels, quality of life, and emotional and social function. The clinical changes were correlated with increased brain activity in the frontal and parietal regions of the brain, which are associated with function and emotional processing.

A HYPERBARIC oxygen CHAMBER. 

"The results were dramatic," said Efrati. "At the end of the treatment, 2 out of 5 patients in the hyperbaric treatment group showed such a significant improvement that they no longer met the criteria for fibromyalgia. In the drug treatment group, this did not happen to any patient.

"In the group that received hyperbaric treatment, you could see the repair of the brain tissue, while in the control group there was only an attempt to relieve the pain -- without treating the damaged tissue -- and of course the medication group experienced the side effects associated with drug treatment.”

Duloxetine is an anti-depressant and pregabalin is an anti-seizure medication. Neither drug was initially developed to treat fibromyalgia, but were later repurposed as pain treatments.

"These drugs are not very effective,” said lead author Jacob Ablin, MD, from the Tel Aviv Sourasky Medical Center. "As a whole, existing treatments are not good enough. It is a chronic disease that significantly affects the quality of life, including young people, and hyperbaric medicine meets an acute need of these patients.”

Ablin says other non-pharmacological treatments are also beneficial for fibromyalgia, such as aerobic activity, hydrotherapy, cognitive-behavioral therapy and Tai Chi. He said quite a few patients request treatment with medical cannabis.

The studies are preliminary, and researchers say more long-term studies are needed to gauge the effects of HBOT after one, two and three years. But they’re encouraged by what they’re finding.

"This is a difference in approach: to cure instead of just treating the symptoms,” says Efrati. “Our goal as doctors is not only to treat the symptoms but to treat as much as possible the source of the problem, thus improving the quality of life of fibromyalgia patients."

DEA Gaslights Pain Patients Over ‘Unwillingness’ to Find Doctors

By Pat Anson, PNN Editor

Faced with record high overdoses, a fentanyl crisis, medication shortages and corruption within its own ranks, you’d think the Drug Enforcement Administration would have better things to do than gaslight chronic pain patients.

You’d be wrong.

In a blatant case of victim-blaming, a Department of Justice attorney claims that patients of a California doctor whose license to prescribe opioids was suspended last year by the DEA were not making any effort to find new physicians.

The DEA’s suspension of Dr. David Bockoff effectively shuttered his practice and left 240 patients – including many who suffer from rare and chronic health conditions – scrambling to find new providers and pain medication.

While Bockoff appealed his suspension, nearly a dozen of his patients went to the U.S. Court of Appeals in Washington DC, asking the court to let them intervene in the case – which would essentially give patients and their lawyers a seat at the table while the DEA decides whether to make Bockoff’s suspension permanent. 

It’s an unusual legal strategy that the DOJ and DEA are resisting. Last week Anita Gay, the DOJ’s lead attorney, filed a 6-page motion to have the patients’ case dismissed, saying they have no legal right to intervene in a DEA case against their doctor. Then she gaslighted Bockoff’s patients, blaming them for the life-threatening predicament that the DEA created for them. 

“Petitioners have had since October 25, 2022, to find a new physician and their unwillingness to do so does not warrant intervention,” wrote Gay, who works in the Criminal Division of the DOJ’s Narcotic and Dangerous Drug Section.

The alleged “unwillingness” to find new providers angered many of the patients, who have struggled for years to find doctors willing to treat their pain with high-dose opioids. Some traveled thousands of miles from out of state to see Bockoff.  

Patients say Gay was either misinformed or misleading judges in her motion to the DC Court of Appeals. Even her reference to “October 25, 2022” was puzzling, because patients didn’t learn about Bockoff’s suspension until November 1. Some went to his office that day for appointments and were turned away.  

“Ms. Gay’s assertion that patients are unwilling to find other providers to assist them in continuing successful treatment or even tapering their medication could not be further from the truth,” says Anne Fuqua, a disabled nurse in Alabama who lives with painful dystonia and arachnoiditis. Fuqua was able to find a palliative care doctor in Florida to take her as a patient. Others have not been as fortunate.

“The 60 plus patients I have spoken with who have been unable to find a new source of care have searched extensively for a new health care provider,” Fuqua told PNN. “The problem is that physicians are loathe to accept any new patients, much less those whose physician was the subject of a DEA investigation.” 

“Ms. Gay is aware of the medical environment that her office created. We have diligently tried to locate a pain management physician, but all of them fear losing their freedom and who can blame them with the current frenzied atmosphere?” said Dustin Parker, who also suffers from the painful spinal disease of arachnoiditis.

“It was awful, calling each time was full of anxiety, the little hope that we held onto was quickly extinguished each time we dialed. I began feeling an impending doom build. I thought if I could lose access to medical care, how would I care for my family, would I ever achieve my goals, and my dream of earning a retirement?”

‘To Say We’re Not Trying Is Absurd’ 

Gay did not respond to an email request for comment. Her assertion that patients were unwilling to find new providers seems particularly cruel, because two of Bockoff’s patients died after his suspension – not because of his medical care, but from the lack of it. 

Danny Elliott and his wife Gretchen were so distraught over his inability to find another doctor that they both committed suicide in their Georgia home on November 7.  Four weeks later, Jessica Fujimaki died at her home in Phoenix after unsuccessful attempts to find proper pain care.

Both Elliott and Fujimaki had incurable conditions that cause severe pain and needed high dose opioids to have any quality of life. 

“To say that this group of patients hasn’t made efforts to find alternative medical care is just bullshit. The last door open to them was slammed shut by the DEA.”

— Jim Elliott, brother of deceased patient

“To say that this group of patients hasn’t made efforts to find alternative medical care is just bullshit. The last door open to them was slammed shut by the DEA,” said Jim Elliott, Danny’s brother  

“It’s not like Jessica wasn’t trying to look for another doctor, because we tried. And no one would take her in the state of Arizona,” said Tad Fujimaki, Jessica’s husband. “The doctors don’t want to deal with (high dose opioid patients) because they know they’re going to get exposed. They’re going to be put under the microscope by DEA.” 

The Fujimakis were so desperate for pain medication that they made three trips to Mexico to buy opioids for Jessica – a risky move because counterfeit medication has been found in some Mexican pharmacies that cater to U.S. visitors.  

“For them to say we’re not trying is just absurd,” Fujimaki said. “It’s not just Jessica. All the other patients went through multiple doctors before they got to Dr. Bockoff. And they got denied, denied and denied. No one would take them as patients. And then finally Dr. Bockoff took them.”

Little has been revealed publicly about the DEA’s investigation of Bockoff. DEA agents first searched his office in September, 2021 and confiscated the medical records of all 240 patients. They determined that five of them were in “imminent danger” from Bockoff’s prescribing practices, but then waited over a year to suspend his license.

Much of the government’s case against Bockoff appears to be dependent on the opinions of Dr. Timothy Munzing, a family practice physician and outspoken critic of opioids, who has a lucrative sideline working as a consultant and expert witness for the DEA and DOJ. According to GovTribe, a website that tracks federal contracts, Munzing has made over $3.4 million in recent years working for the government.

In court documents, the DEA said Munzing was prepared to testify that Bockoff’s treatment of the five patients “fell below the standard of care in California” and was “not for a legitimate medical purpose.” But the DEA has produced no evidence that any of Bockoff’s patients overdosed, became addicted or harmed in any way while under his care. The 80-year old Bockoff has practiced medicine for over 50 years in California, and according to the state medical board has no prior record of disciplinary action or complaints.

Bockoff is appealing his suspension to a DEA Administrative Law Judge, but a final ruling could be months away. It would be unusual for the courts to intervene and give his patients a seat at the table, but many consider it a life-and-death issue. In their eyes, the “imminent danger” is from the DEA, DOJ and their attorneys.

“I’d like to ask Ms. Gay if this was willful ignorance or does her affluent position afford her an alternate to my reality?” said Parker. “It’s offensive saying that it’s a patient’s fault for not trying hard enough.”

Is Cannabis Harmful During Pregnancy and Adolescence?

By Hilary Marusak, Wayne State University

Cannabis is a widely used psychoactive drug worldwide, and its popularity is growing: The U.S. market for recreational cannabis sales could surpass $72 billion by 2023.

As of early 2023, 21 U.S. states and the District of Columbia have legalized cannabis for recreational use for people age 21 and up, while 39 states plus the District of Columbia have legalized it for medical use.

The growing wave of legalization and the dramatic increase in cannabis potency over the past two decades have raised concerns among scientists and public health experts about the potential health effects of cannabis use during pregnancy and other vulnerable periods of development, such as the teen years.

I am a developmental neuroscientist specializing in studying what’s known as the endocannabinoid system. This is an evolutionarily ancient system found in humans and other vertebrates that produces natural cannabinoids such as THC and CBD.

Cannabis and its constituents interact with the body’s endocannabinoid system to product their effects. THC and CBD are the most commonly known cannabis extracts and can be synthesized in a lab. My lab also studies the risks versus potential therapeutic value of cannabis and cannabinoids.

Potential Health Risks

People often assume there’s no risk when using cannabis or cannabinoids during vulnerable periods of life, but they’re basing that on little to no data. Our research and that of others suggests that cannabis use during pregnancy and adolescence can present myriad health risks the public should be aware of.

Data shows that many people who use cannabis continue to do so during pregnancy. But there are health risks. More and more pregnant people are using cannabis today compared with a decade ago, with some studies showing that nearly 1 in 4 pregnant adolescents report that they use cannabis.

Many cannabis-using people may have not known they were pregnant and stopped using when they found out. Others report using cannabis for its touted ability to ease pregnancy-related symptoms, like nausea and anxiety. However, studies do not yet confirm those health claims. What’s more, the potential harms are often downplayed by pro-cannabis marketing and messaging by dispensaries, advocacy groups and even midwives or doulas.

In addition, physicians and other health care providers often are not knowledgeable enough or don’t feel well equipped to discuss the potential risks and benefits of cannabis with their patients, including during pregnancy.

While research shows that most people who are pregnant perceive little to no risk in using cannabis during pregnancy, the data show there is clear cause for concern. Indeed, a growing number of studies link prenatal cannabis exposure to greater risk of preterm birth, lower birth weight and psychiatric and behavioral problems in children. These include, for example, difficulties with attention, thought, social problems, anxiety and depression.

Cannabis and Brain Development

When cannabis is inhaled, consumed orally or taken in through other routes, it can easily cross through the placenta and deposit in the fetal brain, disrupting brain development.

A recent study from my lab, led by medical student Mohammed Faraj, found that cannabis use during pregnancy can shape the developing brain in ways that are detectable even a decade later.

We used data from the National Institutes of Health Adolescent Brain Cognitive Development Study, which is the largest long-term study of brain development and child and adolescent health in the U.S. It has followed more than 10,000 children and their families from age 9-10 over a 10-year period.

Through that analysis, we linked prenatal cannabis exposure to alterations in functional brain networks in 9- and 10-year-old children. In particular, prenatal cannabis exposure appeared to disrupt the communication between brain networks involved in attentional control, which may explain why children who were exposed to cannabis in utero may develop difficulties with attention or other behavioral issues or mental disorders as they develop.

While alcohol abuse has steadily declined among adolescents since 2000 in the U.S., cannabis use shows the opposite pattern: It increased by 245% during that same period.

Data reported in 2022 from the Monitoring the Future survey of over 50,000 students in the U.S. found that nearly one-third of 12th grade students reported using cannabis in the past year, including cannabis vaping. Yet only about 1 in 4 12th grade students perceive great harm in using cannabis regularly. This suggests that many teens use cannabis, but very few consider it to have potential negative effects.

Research shows that the adolescent brain is primed to engage in high-risk behaviors such as experimenting with cannabis and other substances. Unfortunately, owing to ongoing brain development, the adolescent brain is also particularly susceptible to the effects of cannabis and other substances. Indeed, many neuroscientists now agree that the brain continues to develop well into the second and even third decade of life.

In line with this vulnerability, research shows that, relative to those who did not use cannabis during adolescence, those who started using it during adolescence are at increased risk of developing depression, suicidal ideation, psychosis and reductions in IQ during adolescence and adulthood. Neuroimaging studies also show residual effects of adolescent cannabis use on brain functioning, even later during adulthood.

‘No Amount Is Safe’

Despite common misconceptions that cannabis is “all natural” and safe to use during pregnancy or adolescence, the data suggests there are real risks. In fact, in 2019, the U.S. surgeon general issued an advisory against the use of cannabis during pregnancy and adolescence, stating that “no amount … is known to be safe.”

Cannabis may be harmful to the developing brain because it disrupts the developing endocannabinoid system, which plays a critical role in shaping brain development from conception and into adulthood. This includes neural circuits involved in learning, memory, decision-making and emotion regulation.

While much of this research has focused on cannabis use, there is also other research that comes to similar conclusions for THC and CBD in other forms. In fact, although CBD is widely available as an unregulated supplement, we researchers know almost nothing about its effects on the developing brain. Of note, these harms apply not only to smoking, but also to ingesting, vaping or other ways of consuming cannabis or its extracts.

In my view, it’s important that consumers know these risks and recognize that not everything claimed in a label is backed by science. So before you pick up that edible or vape pen for stress, anxiety, or sleep or pain control, it’s important to talk to a health care provider about potential risks – especially if you are or could be pregnant or are a teen or young adult.

Hilary Marusak, PhD, is an Assistant Professor of Psychiatry and Behavioral Neurosciences at Wayne State University. She directs the WSU THINK Lab, which focuses on pediatric anxiety and understanding the impact of childhood trauma on neural development. Dr. Marusak receives funding from the National Institutes of Health and the State of Michigan.   

This article originally appeared in The Conversation and is republished with permission.

Monitor Helps Improve Pain Levels During and After Surgery

By Pat Anson, PNN Editor

With an increasing number of surgery patients being sent home from U.S. hospitals with little more than Tylenol for pain relief, it’s more important than ever to make sure that surgeries and post-operative recovery periods are as pain-free as possible.

A medical device that monitors anesthetized patients during surgery may do just that, letting doctors know when they should reduce or increase the use of pain medication. The PMD-200 monitor has been available in Canada, Europe and the UK for several years, but was just recently cleared by the FDA for marketing in the U.S.

Made by Medasense Biometrics, a medical technology company based in Israel, the monitor measures a patient’s nociception level (NOL) – their physiological response to pain -- through the use of a wearable finger probe that tracks their heart rate, blood pressure, sweat and movement. The monitor then uses machine learning to analyze the data and gauge a patient’s pain. Since fully anesthetized patients can’t speak or communicate during surgery, their NOL level essentially does the talking for them.

“We call it the signature of pain,” says Galit Zuckerman-Stark, CEO of Medasense. “During the surgery, if a physician sees the (NOL) number rising for more than one minute, he or she needs to consider giving more pain medication.”

The reverse is true as well. Surgeons may find that a patient doesn’t need as much medication as someone else who is more sensitive to pain. The goal is to provide individualized care -- the right dose at the right time for each patient.  

“We are very, very different from each other, both in terms of how the body responds to pain and also to medication. There can be a major difference between one patient and another,” Zuckerman-Stark told PNN.

In clinical studies in Europe, Medasense found that patients who had their opioid use guided by NOL were 70% less likely to have severe pain in the first 90 minutes after surgery. This was attributed to more objective and personalized opioid dosing during the surgery itself. 

Less pain during and immediately after surgery means patients will need fewer pain relievers when they are sent home – a key objective for many U.S. hospitals that are under pressure to reduce their opioid use.

"The anesthesia community has needed a technology like NOL for a long time," says Frank Overdyk, MD, a South Carolina anesthesiologist and consultant for Medasense.

"We have devices that monitor depth of anesthesia, we have TOF cuffs to check for patient movement, but the missing piece of the puzzle is a way to monitor the effect of the opioid or opioid sparing analgesia. Relying on patient's heart rate and blood pressure is neither specific nor sensitive enough to pain. This technology as an adjunctive to clinical judgment will provide a window into the patient's nociceptive state during surgery so we can personalize the way we administer analgesia, improving the patient's recovery."

This promotional video was produced by Medasense to help explain how the PMD-200 works:

In recent years, the amount of opioids prescribed in the U.S. for post-operative pain has plummeted, falling by 50% since 2017.

While many hospitals now send patients home from minimally invasive surgeries with acetaminophen or even gabapentin, most Americans still believe that opioids are necessary for pain after surgery. A 2021 Harris Poll found that 65% are more concerned about pain relief after surgery than opioid addiction and 60% prefer strong prescription painkillers over OTC pain relievers.