Will Bird Flu Be the Next Pandemic?

By Amy Maxmen, KFF Health News

Headlines are flying after the Department of Agriculture confirmed that the H5N1 bird flu virus has infected dairy cows around the country. Tests have detected the virus among cattle in nine states, mainly in Texas and New Mexico, and most recently in Colorado, said Nirav Shah, principal deputy director at the Centers for Disease Control and Prevention, at a May 1 event held by the Council on Foreign Relations.

A menagerie of other animals have been infected by H5N1, and at least one person in Texas. But what scientists fear most is if the virus were to spread efficiently from person to person. That hasn’t happened and might not. Shah said the CDC considers the H5N1 outbreak “a low risk to the general public at this time.”

Viruses evolve and outbreaks can shift quickly. “As with any major outbreak, this is moving at the speed of a bullet train,” Shah said. “What we’ll be talking about is a snapshot of that fast-moving train.” What he means is that what’s known about the H5N1 bird flu today will undoubtedly change.

With that in mind, KFF Health News explains what you need to know now.

Q: Who gets the bird flu?

Mainly birds. Over the past few years, however, the H5N1 bird flu virus has increasingly jumped from birds into mammals around the world. The growing list of more than 50 species includes seals, goats, skunks, cats, and wild bush dogs at a zoo in the United Kingdom. At least 24,000 sea lions died in outbreaks of H5N1 bird flu in South America last year.

What makes the current outbreak in cattle unusual is that it’s spreading rapidly from cow to cow, whereas the other cases — except for the sea lion infections — appear limited. Researchers know this because genetic sequences of the H5N1 viruses drawn from cattle this year were nearly identical to one another.

The cattle outbreak is also concerning because the country has been caught off guard. Researchers examining the virus’s genomes suggest it originally spilled over from birds into cows late last year in Texas, and has since spread among many more cows than have been tested. “Our analyses show this has been circulating in cows for four months or so, under our noses,” said Michael Worobey, an evolutionary biologist at the University of Arizona in Tucson.

Q: Is this the start of the next pandemic?

Not yet. But it’s a thought worth considering because a bird flu pandemic would be a nightmare. More than half of people infected by older strains of H5N1 bird flu viruses from 2003 to 2016 died. Even if death rates turn out to be less severe for the H5N1 strain currently circulating in cattle, repercussions could involve loads of sick people and hospitals too overwhelmed to handle other medical emergencies.

Although at least one person has been infected with H5N1 this year, the virus can’t lead to a pandemic in its current state. To achieve that horrible status, a pathogen needs to sicken many people on multiple continents. And to do that, the H5N1 virus would need to infect a ton of people. That won’t happen through occasional spillovers of the virus from farm animals into people. Rather, the virus must acquire mutations for it to spread from person to person, like the seasonal flu, as a respiratory infection transmitted largely through the air as people cough, sneeze, and breathe. As we learned in the depths of covid-19, airborne viruses are hard to stop.

That hasn’t happened yet. However, H5N1 viruses now have plenty of chances to evolve as they replicate within thousands of cows. Like all viruses, they mutate as they replicate, and mutations that improve the virus’s survival are passed to the next generation. And because cows are mammals, the viruses could be getting better at thriving within cells that are closer to ours than birds’.

The evolution of a pandemic-ready bird flu virus could be aided by a sort of superpower possessed by many viruses. Namely, they sometimes swap their genes with other strains in a process called reassortment. In a study published in 2009, Worobey and other researchers traced the origin of the H1N1 “swine flu” pandemic to events in which different viruses causing the swine flu, bird flu, and human flu mixed and matched their genes within pigs that they were simultaneously infecting. Pigs need not be involved this time around, Worobey warned.

Q: Can I get sick from contaminated milk?

Cow’s milk, as well as powdered milk and infant formula, sold in stores is considered safe because the law requires all milk sold commercially to be pasteurized. That process of heating milk at high temperatures kills bacteria, viruses, and other teeny organisms. Tests have identified fragments of H5N1 viruses in milk from grocery stores but confirm that the virus bits are dead and, therefore, harmless.

Unpasteurized “raw” milk, however, has been shown to contain living H5N1 viruses, which is why the FDA and other health authorities strongly advise people not to drink it. Doing so could cause a person to become seriously ill or worse. But even then, a pandemic is unlikely to be sparked because the virus — in its current form — does not spread efficiently from person to person, as the seasonal flu does.

Q: What should be done?

A lot! Because of a lack of surveillance, the U.S. Department of Agriculture and other agencies have allowed the H5N1 bird flu to spread under the radar in cattle. To get a handle on the situation, the USDA recently ordered all lactating dairy cattle to be tested before farmers move them to other states, and the outcomes of the tests to be reported.

But just as restricting covid tests to international travelers in early 2020 allowed the coronavirus to spread undetected, testing only cows that move across state lines would miss plenty of cases.

Such limited testing won’t reveal how the virus is spreading among cattle — information desperately needed so farmers can stop it. A leading hypothesis is that viruses are being transferred from one cow to the next through the machines used to milk them.

To boost testing, Fred Gingrich, executive director of a nonprofit organization for farm veterinarians, the American Association of Bovine Practitioners, said the government should offer funds to cattle farmers who report cases so that they have an incentive to test. Barring that, he said, reporting just adds reputational damage atop financial loss.

“These outbreaks have a significant economic impact,” Gingrich said. “Farmers lose about 20% of their milk production in an outbreak because animals quit eating, produce less milk, and some of that milk is abnormal and then can’t be sold.”

The government has made the H5N1 tests free for farmers, Gingrich added, but they haven’t budgeted money for veterinarians who must sample the cows, transport samples, and file paperwork. “Tests are the least expensive part,” he said.

If testing on farms remains elusive, evolutionary virologists can still learn a lot by analyzing genomic sequences from H5N1 viruses sampled from cattle. The differences between sequences tell a story about where and when the current outbreak began, the path it travels, and whether the viruses are acquiring mutations that pose a threat to people. Yet this vital research has been hampered by the USDA’s slow and incomplete posting of genetic data, Worobey said.

The government should also help poultry farmers prevent H5N1 outbreaks since those kill many birds and pose a constant threat of spillover, said Maurice Pitesky, an avian disease specialist at the University of California-Davis.

Waterfowl like ducks and geese are the usual sources of outbreaks on poultry farms, and researchers can detect their proximity using remote sensing and other technologies. By zeroing in on zones of potential spillover, farmers can target their attention. That can mean routine surveillance to detect early signs of infections in poultry, using water cannons to shoo away migrating flocks, relocating farm animals, or temporarily ushering them into barns. “We should be spending on prevention,” Pitesky said.

Q: What could happen to people who get the H5N1 bird flu?

No one really knows. Only one person in Texas has been diagnosed with the disease this year, in April. This person worked closely with dairy cows, and had a mild case with an eye infection. The CDC found out about them because of its surveillance process. Clinics are supposed to alert state health departments when they diagnose farmworkers with the flu, using tests that detect influenza viruses, broadly. State health departments then confirm the test, and if it’s positive, they send a person’s sample to a CDC laboratory, where it is checked for the H5N1 virus, specifically. “Thus far we have received 23,” Shah said. “All but one of those was negative.”

State health department officials are also monitoring around 150 people, he said, who have spent time around cattle. They’re checking in with these farmworkers via phone calls, text messages, or in-person visits to see if they develop symptoms. And if that happens, they’ll be tested.

Another way to assess farmworkers would be to check their blood for antibodies against the H5N1 bird flu virus; a positive result would indicate they might have been unknowingly infected. But Shah said health officials are not yet doing this work.

“The fact that we’re four months in and haven’t done this isn’t a good sign,” Worobey said. “I’m not super worried about a pandemic at the moment, but we should start acting like we don’t want it to happen.”

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

Wild Orangutan Used Plant as Pain Reliever

By Pat Anson, PNN Editor

Humans have used natural remedies like cannabis, kratom and willow trees for thousands of years for pain relief. But other primates may have beaten us to the punch when it comes to using plants as medicine.

That’s one of the theories emerging after a wild orangutan in Indonesia was observed using a plant to help heal a facial wound. The orangutan, named Rakus by scientists, lost a chunk of flesh below his right eye, apparently during a fight with another male orangutan.

A wound like that could easily become infected in the damp rain forests of Sumatra, but Rakus had other ideas.

Scientists observed Rakus rubbing sap from a flowering vine called liana (Fibraurea tinctoria) directly on the wound and then chewing on its leaves to create a paste that he applied over the wound as a poultice.

Scientists say the wound never became infected and within a few days was completely healed.

Since liana leaves are not typically eaten by orangutans as food, it’s believed to be the first time that a big ape was observed self-medicating.

“The behavior of Rakus appeared to be intentional as he selectively treated his facial wound on his right flange, and no other body parts, with the plant juice. The behavior was also repeated several times, not only with the plant juice but also later with more solid plant material until the wound was fully covered. The entire process took a considerable amount of time,” says Isabelle Laumer, PhD, a researcher at the Max Planck Institute of Animal Behavior in Germany.

“Interestingly, Rakus also rested more than usual when being wounded. Sleep positively affects wound healing as growth hormone release, protein synthesis and cell division are increased during sleep.”

Rakus’ behavior raises several intriguing questions. Did he discover the healing powers of lianas on his own? Or was it something he learned from other orangutans and was passed down, from one big ape to another, over generations?

Indigenous people in Southeast Asia also use lianas as medicine. Are the plant’s medicinal properties something they learned while watching orangutans?

“This and related liana species that can be found in tropical forests of Southeast Asia are known for their analgesic and antipyretic (fever reducing) effects and are used in traditional medicine to treat various diseases, such as malaria,” said Laumer, who reported her findings in the journal Scientific Reports.

Like kratom, the pain-relieving effects of lianas comes from chemical compounds called alkaloids, which act on opioid receptors in the brain. The alkaloids in lianas also have antibacterial, anti-inflammatory, anti-fungal, and antioxidant properties that promote wound healing. In Borneo, native people have even used Fibraurea tinctoria to treat diabetes.

“It shows that orangutans and humans share knowledge. Since they live in the same habitat, I would say that’s quite obvious, but still intriguing to realize,” said co-author Caroline Schuppli, PhD, a primatologist at the Max Planck Institute.

“As forms of active wound treatment are not just human, but can also be found in both African and Asian great apes, it is possible that there exists a common underlying mechanism for the recognition and application of substances with medical or functional properties to wounds and that our last common ancestor already showed similar forms of ointment behavior.”

We only know about Rakus because he lives in an animal sanctuary where orangutans are closely monitored. In 21 years of observation, scientists there have not seen any other orangutans treat their wounds with lianas, although that may be due to the fact that they are solitary animals who spend most of their lives in trees and injured ones are rarely seen.    

Schuppli says Rakus may have learned how to treat his wound from his mother, by observing other orangutans, or through “individual innovation.” Orangutans eat hundreds of different fruits and plants, and it’s possible Rakus just stumbled onto the right one at the right time.

“As Fibraurea tinctoria has potent analgesic effects, individuals may feel an immediate pain release, causing them to repeat the behavior several times,” she said.   

Work Comp Claims for Opioids Down Significantly

By Pat Anson, PNN Editor

Workers’ compensation claims in the U.S. for opioids and other pain relievers fell significantly in 2023, one of the largest drops the work comp industry has seen in years, according to a new report.

San Diego-based Enlyte analyzes drug utilization and spending trends annually for property and casualty insurers. The company’s Drug Trends Report for 2023 estimates that overall opioid use per claim fell by 9.7 percent, with the use of sustained-release opioids such as oxycodone down more than 10 percent.

Surprisingly, work comp claims for non-opioid pain relievers also fell, even though they are increasingly prescribed as alternatives to opioids. Claims for non-steroidal anti-inflammatory drugs (NSAIDs) fell by 3% last year, with anticonvulsants like gabapentin down 7.4% and antidepressants such as duloxetine falling 6.1%. 

"This, by far, marks one of the largest drops in opioid utilization we've seen in years," Nikki Wilson, PharmD, senior director of clinical pharmacy solutions at Enlyte, said in a press release. "In addition, opioid alternatives commonly prescribed to manage acute and chronic pain also experienced decreases in utilization per claim, although to a lesser degree than opioids."

Enlyte said the decline in opioid use was “supported by prescribing guidelines,” noting that claims for high-dose opioid prescriptions have fallen for nine consecutive years. The 2016 CDC opioid guideline urged doctors not to prescribe doses higher than 90 morphine milligram equivalents (MME) per day. Although that recommendation is voluntary, it has taken root in many laws, regulations and insurance policies governing the use of opioids.

As a result, non-opioid analgesics and muscle relaxants are used more often than opioids for pain management during the first two years of a work comp claim. Only afterwards are sustained-release opioids used more frequently for chronic pain caused by job-related injuries.

Even though opioid use has fallen dramatically in recent years, opioids remain the top therapeutic class for claims, followed by NSAIDs, anticonvulsants, muscle relaxants, antidepressants and topical medications. Those six therapeutic classes represent over two-thirds of the prescription drug claims in 2023.

Respiratory and Migraine Drugs  

While the overall cost of prescription drugs fell slightly (down 0.2%) in 2023, the price of respiratory and migraine medications rose significantly, up 14.7% and 10.2%, respectively.

Newer migraine drugs that block calcitonin gene-related peptides (CGRPs) are some of the most expensive medications, with the average wholesale price of a Nurtec prescription reaching $1,916 and $1,654 for a Ubrelvy prescription.      

"Basically, what's driving these trends are the costs of the top three medications in their respective classes," Wilson said. "For instance, for migraine medications, Nurtec ODT is prescribed about 15% of the time yet makes up more than 31% of the total drug spend in this category. Similarly, respiratory medication like Trelegy Ellipta is prescribed about 10%, but accounts for nearly 19% of all respiratory medication total costs."

Enlyte reported the number of retail and mail order prescription drug claims is trending downward due to an “evolving work environment.” More people are working from home and as independent contractors, reducing the number of on-site job injuries and employee compensation claims.  

Blood Test Predicts Knee Osteoarthritis Years Before Symptoms Start

By Pat Anson, PNN Editor

An experimental blood test could give doctors and patients a leg up in diagnosing and treating knee osteoarthritis, years before joint damage occurs and becomes visible on X-rays.

"Currently, you've got to have an abnormal X-ray to show clear evidence of knee osteoarthritis, and by the time it shows up on X-ray, your disease has been progressing for some time," says senior author Virginia Byers Kraus, MD, a professor of Medicine, Pathology, and Orthopedic Surgery at Duke University School of Medicine.

Kraus and her colleagues have devised a test that looks for serum biomarkers in the blood that can predict – with a fair amount of accuracy – the development of knee osteoarthritis (OA) up to 8 years before joint damage occurs. Osteoarthritis is the most common form of arthritis, affecting about 10% of men and 18% of women over age 60.

In previous studies, the biomarker test demonstrated 74% accuracy in predicting knee OA progression and 85% accuracy in diagnosing knee OA. The current study further refined the test by narrowing down the number of biomarkers from a dozen to only six.

Using a UK patient database, researchers used the refined test to analyze the blood of 200 middle-aged women with no chronic knee pain; half of whom were later diagnosed with OA and the other half without the disease. The study findings, published in the journal Science Advances, show the test correctly predicted knee OA with 77% accuracy within 6 years.

"What our blood test demonstrates is that it's possible to detect this disease much earlier than our current diagnostics permit," Kraus said in a news release. "This is important because it provides more evidence that there are abnormalities in the joint that can be detected by blood biomarkers well before X-rays can detect OA.

"Early-stage osteoarthritis could provide a 'window of opportunity' in which to arrest the disease process and restore joint health."

There are currently no diagnostic blood tests for OA and there is no cure. Treatment is limited to pain relievers and anti-inflammatory drugs that slow progression of the disease.

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Patients Blame DEA for Drug Shortages, Not Monopolies or Middlemen

By Pat Anson, PNN Editor

Two federal agencies are getting more than they bargained for when they asked the public to comment on record shortages of prescription drugs.

In February, the Federal Trade Commission (FTC) and the Department of Health and Human Services (HHS) made a joint Request for Information in the Federal Register, asking how wholesalers and other “middlemen” in the drug supply chain were contributing to persistent shortages.

“When you’re prescribed an important medication by your doctor, and you learn the drug is out of stock, your heart sinks,” HHS Secretary Xavier Becerra said in a press release. “This devastating reality is the case for too many Americans who need generic drugs for ADHD, cancer, and other conditions. (This) announcement is part of the Biden-Harris Administration’s work to tackle healthcare monopolies and lessen the impact on vulnerable patients who bear the brunt of this lack of competition.”

Nearly 10,000 comments have been received so far, with many blaming the federal government for the drug shortages -- not monopolies, middlemen or lack of competition. Drawing the most criticism is the Drug Enforcement Administration (DEA), which sets annual production quotas for opioids, stimulants and other controlled substances. The CDC and FDA also came under fire from frustrated patients.

“The heavy-handed failure of the FDA/DEA to properly and ethically manage the uptick in ADHD prescriptions is creating a crisis on par with their equally underhanded failure in managing the opioid crisis,” wrote Matti Dupre. “Hardworking Americans are left looking at the individuals leading these organizations as a source of pain rather than as a means of support.”

“Millions of people are having a hard time getting their prescription opioid medications filled at pharmacies now. Why? Because the DEA have cut production down so low, pharmacies can't get what they need to fill our prescriptions,” said Candi P. “Wake up! Stop playing with our lives!”

“The government has gone way too far, with their guidelines and regulations regarding opioids,” wrote Julie Anuskewic, who has a painful immune system disorder. “My pain is not controlled because the CDC has scared all doctors into not prescribing. It’s bad enough that they have destroyed the doctor-patient relationship. Now they are destroying the patient-pharmacist relationship.” 

Notably lacking in the FTC and HHS statement about drug shortages is any mention of the National Opioid Settlement, which has forced major drug wholesalers and big chain pharmacies to ration opioids and other controlled substances or risk losing their DEA licenses. Some manufacturers are also cutting back on production of generic opioids because the profit margins are low and the risk of further litigation is high.

A recent PNN survey found that 90% of patients with opioid prescriptions had trouble getting them filled, with one in five unable to get their pain medication even after contacting multiple pharmacies.  

“The FTC is looking in the wrong places for reasons for drug shortages, at least as far as opioids and stimulants are concerned,” wrote Andrea MacNary. “In those cases, the shortages are a direct result of the DEA's policies – with input from the FDA – that have seen annual reductions in the amount of drugs that manufacturers are allowed to produce.

”This results in patients being unable to obtain their legally prescribed medications in a timely manner. Because pharmacies have shortages, patients are then forced to call around to different pharmacies looking for their meds. This is extremely difficult, because not only do pharmacies not want to disclose whether they have the drugs in stock, but if the patient does find them, they must obtain a new prescription from their doctor.”

‘Broken Quota System’

One critic sees the public outreach by the FTC and HHS as a ham-handed attempt to coverup the DEA’s “crude and inadequate system” for regulating controlled substances   

“I believe the FTC is only trying to find cover for the Drug Enforcement Administration.The DEA is the only governmental agency that sets production and distribution quotas for every drug company manufacturing controlled medication,” William Dodson, MD, wrote in a recent op/ed in ADDitude. “This problem traces its roots and long tendrils back to the DEA alone. No other agency has the authority to create and prolong it. 

“The time has long since passed for the DEA to admit its fault and fix its broken quota system. There has already been too much needless suffering by innocent people who did nothing to cause the DEA’s restrictions.”

That’s not how the DEA sees it. This month a top DEA official compared the growing demand for Adderall and other ADHD stimulants to the early stages of the opioid crisis. Matthew Strait claimed the problem isn’t tight supplies, but excessive prescribing of stimulants.

“I’m not trying to be a doomsday-er here,” said Strait, deputy assistant administrator in the DEA’s diversion control division. “It makes me feel like we’re at the precipice of our next drug crisis in the United States.”

If you’d like to make a comment in the Federal Register on the FTC and HHS Request for Information, click here. Comments will be accepted until May 30. 

How ‘Injectrode’ Could Change Treatment of Chronic Pain

By Pat Anson, PNN Editor

An experimental “injectrode” is showing potential as a new neuromodulation treatment for chronic pain, after the first human clinical trial demonstrated the device’s safety and effectiveness in stimulating nerves in the lower back.

The injectrode is a thin and flexible lead wire that is injected by a needle through the skin and placed near an injured nerve. The wire can then be charged by an externally worn stimulator that sends mild electrical impulses to the nerve to block pain signals.

The injectrode is being developed by Cleveland-based Neuronoff, Inc. as a treatment for many types of chronic pain, such as peripheral nerve pain, phantom limb pain and lower back pain. It all depends on the nerve being targeted.

“You can treat knee pain, shoulder pain, lower back pain by stimulating nerve fibers that are providing proprioceptive input sensory input into the spine and thereby help with a reduction of pain perception,” said Manfred Franke, CEO of Neuronoff, who compares the injectrode wire to a Slinky, a toy once popular with Baby Boomers.

“It’s like a spring, like a Slinky, that’s stuck inside a needle,“ he told PNN. “And when that Slinky comes out of the needle, it folds over and it can conform to the anatomy. If you want to take out the injectrode, all you have to do is pull at any point along its length and then the entire injectrode will come out. Nothing is at risk of being left behind.”

This video produced by Neuronoff demonstrates how the device is injected:

Because the injectrode is easy to install in an out-patient procedure, it could potentially be a low-cost competitor to more invasive neuromodulation devices, such as spinal cord stimulators, and reduce the need for pain medication, steroid injections and procedures such as nerve ablation.

“The injectrode represents a paradigm shift in the field of neuromodulation. Its unique flexible design allows for optimal customization to the patient's anatomy and has the potential to be both a temporary and permanent solution without an internal pulse generator,” said Hesham Elsharkawy, MD, an anesthesiologist and clinical advisor to Neuronoff. “The entire procedure takes just 5-10 minutes, making it highly efficient and accessible for patients seeking relief from chronic pain."

In the investigational pilot study, 10 healthy volunteers had injectrodes placed in their lower back and tested. After 30 days, there were no serious adverse events and the injectrodes were removed without analgesics or sutures.

Because the injectrodes work similarly to transcutaneous electrical nerve stimulators (TENS) already on the market, Franke is hopeful the devices will be cleared by the FDA for marketing without more clinical trials, perhaps as soon as early 2025. The key will being getting insurers to cover the injectrodes, which will cost a few thousand dollars, far less than spinal cord stimulators.

“Which is an advantage to the insurance company. And any advantage that you can provide to the insurance company is a benefit for the patient because you're more likely to be receiving prior approval,” Franke said. “The goal is to be cost efficient enough to the insurance companies, so you can replace repeat drug injections or nerve ablations.”   

In addition to pain, Franke says the electrodes have the potential to treat other medical conditions, such as overactive bladders and hypertension. In tests on animals, the devices significantly lowered blood pressure when they stimulated nerves in the neck.

Not Your Parents’ Pot: Cannabis Is More Potent Now

By Dr. Ty Schepis

Eventually, most adults reach a point where we realize we are out of touch with those much younger than us.

Perhaps it is a pop culture reference that sparks the realization. For me, this moment happened when I was in my late 20s and working with adolescents in school settings to help them quit smoking. When other drugs would occasionally come up, I didn’t understand some of the slang terms they used for these drugs. Many people may have that feeling now when the topic of cannabis comes up – especially in its different and newer forms.

As a professor of psychology, I focus my research on substance use in adolescents and young adults. A major change during my time in research is the legalization and explosion of cannabis availability across the U.S.

There are arguments for and against increasing legalization of cannabis for adult use in the U.S., but expanded access to legal cannabis also may have unintended consequences for adolescents. These consequences are compounded by the increasing potency of some cannabis products.

I use the word “cannabis” since it refers to the plant from which the drugs are derived. It also serves as a catch-all term for any substance with chemical compounds from cannabis plants and addresses concerns that the word marijuana has some long-standing racist overtones.

Cannabis now comes in a larger variety of forms than it used to. When most people over 40 think of cannabis, they imagine its dried form for smoking. This cannabis was not particularly strong: The average THC concentration of cannabis seized by the Drug Enforcement Agency in 1995 was 4%, while it was roughly 15% in 2021.

In addition to the smoked form, some might remember an edible form, often baked into a dessert like a brownie, or hashish, which is derived from more potent parts of the cannabis plant.

Today there are many different cannabis concentrates that have high levels of THC, typically ranging from 40% to 70%, and more than 80% in some cases, depending on the method of extraction. These include oils that can be vaporized by vape or dab pens, waxier substances and even powders.

Differences in Cannabis Products

THC and cannabidiol, or CBD, are the most common chemicals in cannabis. Each one interacts with the brain in different ways, producing different perceived effects.

CBD does not produce the same “high” that THC does, and cannabidiol may have benefits as a medication for severe epilepsy, as well as other potential but as yet unproven medical uses. The differences between THC and CBD come from how they interact with cannabinoid receptors – the proteins onto which these drugs attach – in the brain and body.

However, CBD can also make people sleepy, alter mood in unintended ways and cause stomach upset. Never use a CBD product without consulting a physician.

THC is the chemical most strongly associated with the high from cannabis. By increasing the amount of THC, concentrated products can increase blood levels of THC rapidly and more strongly than nonconcentrates such as traditional smoked cannabis.

Cannabis concentrates also come in many different forms that range from waxy or creamy to hard and brittle. They are made in a variety of ways that may require dry ice, water or flammable solvents such as butane.

The myriad names for cannabis concentrates can be confusing. Concentrate names include “budder,” which refers to a yellowish paste like frosting; “shatter” is made similarly to budder but comes in a thin, brittle and translucent form; there’s also “wax” or “crumble,” which confusingly is not waxy but is more like a powdery or grainy substance; and “keef” or “kief,” which is powdery in nature and derived from the most potent parts of the cannabis plant. It is similar to hashish.

The names change regularly and can vary by guide or from person to person. It is best to ask what a term means from an open and curious place than to act as if you know all the terminology.

Many concentrates are vaporized and inhaled. Vaporizing is different than smoking, as vaporizing heats the concentrate until it becomes a gas, which is inhaled. Smoking involves burning the compound to produce an inhaled gas.

Many who vaporize concentrates call it “dabbing.” This refers to the dab of concentrate to heat, vaporize and inhale. Another way to vaporize cannabis concentrates is to use a vape pen. Vape pens are sometimes also called dab pens, depending on the local terms.

Cannabis and Adolescents

One of the reasons why young people are drawn to these sorts of products is that vaping or dabbing the concentrated form makes it easier to hide cannabis use. Vaping cannabis does not create the typical smell associated with weed.

A 2021 systematic review found that past-year cannabis vaping nearly doubled from 2017 to 2020 in adolescents - jumping from 7.2% to 13.2%. A more recent study in five northeastern U.S. states found that 12.8% of adolescents vaped cannabis in the past 30 days, a more narrow time frame that suggests potential increases in use. In addition, a 2020 study found that one-third of adolescents who vape do so with cannabis concentrates.

Cannabis use by adolescents is scary because it can alter the way their brains develop. Research shows that the brains of adolescents who use cannabis are less primed to change in response to new experiences, which is a key part of adolescent development. Adolescents who use cannabis are also more likely to experience symptoms of schizophrenia, struggle more in school and engage in other risky behaviors.

The risks of cannabis use are even greater with concentrates because of the high levels of THC. This is true for both adolescents and adults, with greater risk for symptoms of schizophrenia such as hallucinations and delusions, mental health symptoms and more severe cannabis use.

The best analogy is with another drug – alcohol. Most people know that a 12-ounce beer is much less potent than 12 ounces of vodka. Cannabis in smoked form is closer to the beer, while a concentrate is more like the vodka. Neither is safe for an adolescent, but one is even more dangerous.

These dangers make early conversations with kids about cannabis and cannabis concentrates critically important. Research consistently shows that expressing disapproval of drug use makes adolescents less likely to start drug use.

Start these conversations early – ideally before middle school. You can find some helpful online resources to guide the conversation.

While these conversations can be uncomfortable, and you can look like the out-of-touch adult, they can be a major step toward preventing adolescents from using cannabis and other drugs.

Ty Schepis, PhD, is a Professor of Clinical Psychology at Texas State University. His research receives funding from the Food and Drug Administration and the National Institute on Drug Abuse.

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

Risk of Chronic Pain Doubles for People From Lower Socioeconomic Backgrounds

By Pat Anson, PNN Editor

People from lower socioeconomic backgrounds are twice as likely to develop chronic pain after an acute injury, according to UK researchers who found that smoking, fear of movement, and poor social support also raise the risk of chronic musculoskeletal pain (CMP).

The study, published in PLOS One, adds to a growing body of evidence linking economic, social and emotional stress to some chronic pain conditions.   

Researchers at the University of Birmingham analyzed over a dozen systematic reviews of clinical studies involving nearly half a million people with CMP. Their goal was to see what biopsychosocial factors are associated with CMP and potentially make pain treatment more difficult.

“The mechanisms of CMP are different to acute pain in that pain exists despite there no longer being evidence of ongoing healing, but rather due to a sensitized nervous system that creates a continued or repeated experience of pain despite no evidence of actual or potential tissue damage,” wrote lead author Michael Dunn, from the School of Sport, Exercise and Rehabilitation Sciences at University of Birmingham

“This transition from acute to chronic MSK pain is associated with the presence of many biopsychosocial factors such as fear avoidance, low mood, and work satisfaction or strain. Despite this, healthcare services conventionally utilize approaches to treat CMP based on understandings of acute MSK pain, with focus often on identifying and treating perceived injured or irritated MSK structures.”

Dunn and his colleagues say many treatments for MSK pain, such as physical therapy and surgery, work no better than a placebo. That is because they only focus on the injured body part, and fail to account for psychological and social factors that contribute to acute pain becoming chronic.

“Put simply, current healthcare approaches do not address all the reasons people do not get better,” Dunn said in a news release. “Not only are current healthcare approaches inadequate, they may also be discriminatory, with current healthcare approaches that are orientated around the injured body part being geared towards those from higher socioeconomic backgrounds who are less likely to experience these psychological or social factors.”

In addition to socioeconomic factors, Dunn says stress and depression also raise the risk of developing CMP. He doubts that any single risk factor is the sole cause of chronic pain, but a combination of them make recovery from an acute injury more problematic.

Dunn’s findings mirror those of several U.S. studies that found social and economic factors were intertwined with the prevalence of chronic pain. In a 2021 study, for example, nearly 45% of people living below the federal poverty level reported having back pain. Another study found that people who did not complete high school were significantly more likely to have joint pain from arthritis.   

People with less education often have blue-collar jobs requiring manual labor that may contribute to musculoskeletal pain. They also tend to have lower incomes and less access to healthcare.

Princeton researchers Angus Deaton and Anne Case were the first to report on the role socioeconomic issues play in so-called “deaths of despair,” which linked financial and social stress to rising rates of pain, suicide, substance abuse, and death in middle-aged white Americans.

Low-Carb Diets More Effective than Medication for IBS

By Pat Anson, PNN Editor

Diets low in carbohydrates are more effective than medication in treating irritable bowel syndrome (IBS), according to a new study that found over 70% patients had significantly reduced symptoms after changing their eating habits.

IBS is an intestinal condition that causes abdominal pain, cramps, bloating, gas and diarrhea. An imbalance in gut bacteria is suspected as a possible cause of IBS, and symptoms can be aggravated by stress or eating a large meal.

Researchers at the University of Gothenburg in Sweden enrolled over 300 people with severe or moderate IBS symptoms in a randomized clinical trial, dividing them into three groups.

The first group was given traditional IBS dietary advice, while also focusing on a low intake of fermentable carbohydrates, known as FODMAPs. Foods such as lactose, legumes, onions and whole grains were avoided because they are poorly digested, tend to ferment in the colon, and cause IBS pain.

The second group also had a diet low in carbohydrates, but high in protein and fat. In the third group, there were no dietary changes and laxatives, antidiarrheals, antibiotics and other medications were given based on the patient's symptoms. The treatment period for all three groups was four weeks.

The study findings, published in The Lancet Gastroenterology & Hepatology, show that 76% of participants in the FODMAP group had significantly reduced IBS symptoms. That compares to 71% of patients in the low-carb/high protein and fat group, and only 58% in the medication-only group. All three groups reported better quality of life, and less anxiety and depression.

Even after six months, when participants partially returned to their previous eating habits, a large proportion still had significant symptom relief: 68% in the FODMAP group and 60% in the low-carb/high protein and fat group.

“Although we found evidence that dietary treatments were more efficacious than medical treatment after 4 weeks, all three treatment options showed significant and clinically meaningful efficacy,” wrote lead author Sanna Nybacka, PhD, a researcher and dietician at the University of Gothenburg.

“The sustained positive effects of dietary interventions suggest their potential as first-line treatments for IBS, although patient preference, compliance, cost-effectiveness, and effects on nutritional status and the gut microbiota would need to be accounted for.”

Dietary advice for IBS typically includes sitting down during meals, chewing foods thoroughly, and avoiding excessive intake of coffee, alcohol, fizzy drinks, and fatty or spicy foods.

Foods low in FODMAPs include rice, potatoes, quinoa, and gluten-free pasta and bread, as well as a variety of vegetables, fruits, fish, beef and chicken.

Red Cabbage Juice Improves Gut Health

A new study by researchers at the University of Missouri found that juice from red cabbage can also improve gut health and ease inflammation in the digestive tract caused by Inflammatory Bowel Disease (IBD).

Symptoms of IBD and IBS are similar, but in IBD they become chronic, causing anemia, bleeding, weight loss and fever. About three million Americans live with IBD, including Crohn’s disease and ulcerative colitis.

In studies on laboratory mice with IBD, red cabbage juice relieved their intestinal inflammation. Mice are often used to study IBD because colitis in mice closely resembles ulcerative colitis in humans.

“Red cabbage juice alters the composition of gut microbiota by increasing the abundance of good bacteria, resulting in increased production of short chain fatty acids and other bacteria derived metabolites ameliorating inflammation,” said lead author Satyanarayana Rachagani, PhD, an Associate Professor of Veterinary Medicine & Surgery at the University of Missouri

“Its ability to modulate gut microbiota, activate anti-inflammatory pathways and enhance immune regulation underscores its potential as a valuable therapeutic agent for IBD and related inflammatory disorders.”

The study is published in the International Journal of Molecular Sciences.

Red cabbage juice is rich in antioxidants and Vitamin C, and has long been used as a natural remedy to reduce inflammation and improve overall health. It is also a good source of dietary fiber.

Few Take Advantage of Medicare’s Chronic Care Program

By Phil Galewitz and Holly Hacker, KFF Health News

Carrie Lester looks forward to the phone call every Thursday from her doctors’ medical assistant, who asks how she’s doing and if she needs prescription refills. The assistant counsels her on dealing with anxiety and her other health issues.

Lester credits the chats for keeping her out of the hospital and reducing the need for clinic visits to manage chronic conditions including depression, fibromyalgia, and hypertension.

“Just knowing someone is going to check on me is comforting,” said Lester, 73, who lives with her dogs, Sophie and Dolly, in Independence, Kansas.

At least two-thirds of Medicare enrollees have two or more chronic health conditions, federal data shows. That makes them eligible for a federal program that, since 2015, has rewarded doctors for doing more to manage their health outside office visits.

But while early research found the service, called Chronic Care Management, reduced emergency room and in-patient hospital visits and lowered total health spending, uptake has been sluggish.

Federal data from 2019 shows just 4% of potentially eligible enrollees participated in the program, a figure that appears to have held steady through 2023, according to a Mathematica analysis.

About 12,000 physicians billed Medicare under the CCM mantle in 2021, according to the latest Medicare data analyzed by KFF Health News. By comparison, federal data shows about 1 million providers participate in Medicare.

Even as the strategy has largely failed to live up to its potential, thousands of physicians have boosted their annual pay by participating, and auxiliary for-profit businesses have sprung up to help doctors take advantage of the program. The federal data showed about 4,500 physicians received at least $100,000 each in CCM pay in 2021.

Through the CCM program, Medicare pays to develop a patient care plan, coordinate treatment with specialists, and regularly check in with beneficiaries. Medicare pays doctors a monthly average of $62 per patient, for 20 minutes of work with each, according to companies in the business.

Without the program, providers often have little incentive to spend time coordinating care because they can’t bill Medicare for such services.

‘It Was Put Together Wrong’

Health policy experts say a host of factors limit participation in the program. Chief among them is that it requires both doctors and patients to opt in. Doctors may not have the capacity to regularly monitor patients outside office visits. Some also worry about meeting the strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly copayment if they don’t have a supplemental policy.

“This program had potential to have a big impact,” said Kenneth Thorpe, an Emory University health policy expert on chronic diseases. “But I knew it was never going to work from the start because it was put together wrong.”

He said most doctors’ offices are not set up for monitoring patients at home. “This is very time-intensive and not something physicians are used to doing or have time to do,” Thorpe said.

For patients, the CCM program is intended to expand the type of care offered in traditional, fee-for-service Medicare to match benefits that — at least in theory — they may get through Medicare Advantage, which is administered by private insurers.

But the CCM program is open to both Medicare and Medicare Advantage beneficiaries.

The program was also intended to boost pay to primary care doctors and other physicians who are paid significantly less by Medicare than specialists, said Mark Miller, a former executive director of the Medicare Payment Advisory Commission, which advises Congress. He’s currently an executive vice president of Arnold Ventures, a philanthropic organization focused on health policy. (The organization has also provided funding for KFF Health News.)

Despite the allure of extra money, some physicians have been put off by the program’s upfront costs.

“It may seem like easy money for a physician practice, but it is not,” said Namirah Jamshed, a physician at UT Southwestern Medical Center in Dallas.

Jamshed said the CCM program was cumbersome to implement because her practice was not used to documenting time spent with patients outside the office, a challenge that included finding a way to integrate the data into electronic health records. Another challenge was hiring staff to handle patient calls before her practice started getting reimbursed by the program.

Only about 10% of the practice’s Medicare patients are enrolled in CCM, she said.

Jamshed said her practice has been approached by private companies looking to do the work, but the practice demurred out of concerns about sharing patients’ health information and the cost of retaining the companies. Those companies can take more than half of what Medicare pays doctors for their CCM work.

Physician Jennifer Bacani McKenney, who runs a family medicine practice in Fredonia, Kansas, with her father — where Carrie Lester is a patient — said the CCM program has worked well.

She said having a system to keep in touch with patients at least once a month has reduced their use of emergency rooms — including for some who were prone to visits for nonemergency reasons, such as running out of medication or even feeling lonely. The CCM funding enables the practice’s medical assistant to call patients regularly to check in, something it could not afford before.

For a small practice, having a staffer who can generate extra revenue makes a big difference, McKenney said.

While she estimates about 90% of their patients would qualify for the program, only about 20% are enrolled. One reason is that not everyone needs or wants the calls, she said.

Outsourcing Chronic Care

While the program has captured interest among internists and family medicine doctors, it has also paid out hundreds of thousands of dollars to specialists, such as those in cardiology, urology, and gastroenterology, the KFF Health News analysis found. Primary care doctors are often seen as the ones who coordinate patient care, making the payments to specialists notable.

A federally funded study by Mathematica in 2017 found the CCM program saves Medicare $74 per patient per month, or $888 per patient per year — due mostly to a decreased need for hospital care.

The study quoted providers who were unhappy with attempts to outsource CCM work. “Third-party companies out there turn this into a racket,” the study cited one physician as saying, noting companies employ nurses who don’t know patients.

Nancy McCall, a Mathematica researcher who co-authored the 2017 study, said doctors are not the only resistance point. “Patients may not want to be bothered or asked if they are exercising or losing weight or watching their salt intake,” she said.

Still, some physician groups say it’s convenient to outsource the program.

UnityPoint Health, a large integrated health system based in Iowa, tried doing chronic care management on its own, but found it administratively burdensome, said Dawn Welling, the UnityPoint Clinic’s chief nursing officer.

For the past year, it has contracted with a Miami-based company, HealthSnap, to enroll patients, have its nurses make check-in calls each month, and help with billing. HealthSnap helps manage care for over 16,000 of UnityHealth’s Medicare patients — a small fraction of its Medicare patients, which includes those enrolled in Medicare Advantage.

Some doctors were anxious about sharing patient records and viewed the program as a sign they weren’t doing enough for patients, Welling said. But she said the program has been helpful, particularly to many enrollees who are isolated and need help changing their diet and other behaviors to improve health.

“These are patients who call the clinic regularly and have needs, but not always clinical needs,” Welling said.

Samson Magid, CEO of HealthSnap, said more doctors have started participating in the CCM program since Medicare increased pay in 2022 for 20 minutes of work, to $62 from $41, and added billing codes for additional time.

To help ensure patients pick up the phone, caller ID shows HealthSnap calls as coming from their doctor’s office, not from wherever the company’s nurse might be located. The company also hires nurses from different regions so they may speak with dialects similar to those of the patients they work with, Magid said.

He said some enrollees have been in the program for three years and many could stay enrolled for life — which means they can bill patients and Medicare long-term.

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

Pain Patients Challenge DEA’s ‘Bogus Judicial System’

By Pat Anson, PNN Editor

Patients of a California doctor whose license to prescribe opioids and other controlled substances was suspended by the DEA have launched another long shot legal bid to get his license reinstated.

DEA administrator Anne Milgram suspended the license of Dr. David Bockoff in 2022, largely based on allegations that five of his pain patients were receiving dangerously high doses of opioids. Bockoff’s abrupt suspension left 240 patients – including many who suffer from severe and incurable pain conditions -- scrambling to find new providers and pain medication.

At least three of those patients have since died, including one who committed suicide with his wife and another who died after buying opioid medication in Mexico.

“Every time you take away a doctor's license without giving them any opportunity to fight it, you put a patient on the street who's a chronic pain patient and they've just been abandoned. No explanation or anything,” says attorney John Flannery. “And the government doesn't give a damn. They don't care at all.”

Flannery represents nine Bockoff patients who have tried repeatedly to gain legal standing as interested parties in the DEA case against the Beverly Hills doctor. Their efforts so far have failed. An Administrative Law Judge would not let them attend DEA hearings on the case, and a federal judge refused to grant a temporary restraining order that would have restored Bockoff’s license while he appeals his suspension.

Recently, a three-judge panel on the District of Columbia’s U.S. Court of Appeals declined to intervene in the case, saying the patients provided the court with “no credible factual submissions” that document how they were harmed by Bockoff’s suspension. The judges’ order makes no mention of the patients who died.

‘We Were Entirely Hamstrung’

Part of the problem is the closed administrative system that the DEA uses to discipline doctors, in which the agency essentially serves as the prosecutor, judge and executioner. Flannery calls it a “bogus judicial system” that the DEA created for itself. Even the rulings of a supposedly independent Administrative Law Judge (ALJ) can be rejected by the DEA Administrator.

“There is much talk about how the government is ‘open’ and transparent, but DEA’s proceedings are entirely opaque to patients and the public,” Flannery wrote in his latest appeal, in which he asks the full DC Court of Appeals for an en banc review of the case.

“We were entirely hamstrung to proceed to seek review in any DEA proceedings as we had no right to review any pleadings, to attend any hearings, to monitor the proceedings, to review any of the ‘evidence,’ to hear the arguments, and the only decision made available to us by the ALJ related to the (unsuccessful) motion to intervene.”

Flannery says federal law allows any “interested persons” or “person aggrieved” by the DEA to have a legal standing in its administrative hearings. If the Appeals Court accepts that argument, it would set a major precedent that would affect all future DEA cases against doctors by giving their patients a seat at the table.

Flannery says the DEA’s disciplinary actions against Bockoff and other doctors interfere with the practice of medicine.

“I hate to say it’s a witch hunt, but I think we found a witch and the witch is the present DEA administrator,” Flannery told PNN. “She's part of a machine that just keeps chugging along, hurting and hurting and hurting. How does one go into government to do that? Who do they think they're saving? They found five patients that they claim were harmed, and so the other 235 patients, they have no idea about them, and they just cut them off. How do you justify that?”

Flannery’s appeal also cites the DEA’s “flimsy evidence” against Bockoff, most notably the agency’s expert witness, Dr. Timothy Munzing, a family practice physician who has launched a lucrative second career for himself as a government witness against doctors accused of overprescribing opioids. Munzing has made over $3.4 million testifying for the federal government in dozens of cases against doctors. In an Ohio case, a judge declared a mistrial after Munzing contradicted himself during testimony.

“The DEA’s expert, Dr. Timothy Munzing, was, by any fair review, ‘damaged goods’ by DEA’s overuse of his ‘skills,’” Flannery wrote. “On information and belief, this impeachment material involving Dr. Munzing, the DEA’s sole expert witness, was withheld from Dr. Bockoff in the DEA Administrative proceeding.”

A protracted legal challenge of this kind is expensive and a GoFundMe campaign has been created by the nine Bockoff patients to help support it. Over $10,000 has been raised so far.

“Please know that we'll be working as hard as we can to keep this fundraiser and our effort going,” said Kristen Ogden, the wife of one of the patients. “Our donors are helping so much in this effort to make a difference for chronic pain patients and doctors. As John (Flannery) says, we are doing something that hasn't been done before... seeking to intervene so that patients can have a voice.”

How Gut Bacteria Changes the Immune System

By Dr. Narveen Jandu  

The human immune system changes with age. Immune responses start to become less robust as people get older, which makes them more vulnerable to certain infections and diseases.

However, immune system aging looks different from person to person. Research has shown that changes to the composition and diversity of the microorganisms in the gut may explain these differences in immune system aging.

The gut microbiome — the population of microorganisms that lives in the gastrointestinal tract — helps the body maintain a stable internal environment when it is faced with external changes. This is known as homeostasis. The gut microbiome supports homeostasis in different ways, such as through helping to keep the immune system alert, and digesting dietary fibre into short-chain fatty acids to strengthen the intestinal wall.

The gut microbiome also helps us to regulate our inflammatory reactions. Inflammation helps the body fight microorganisms that cause disease, and helps repair damaged tissues. However, as the composition of our gut microbiome changes with age, a low level of inflammation can become constant throughout the body. This is called inflammaging.

When inflammaging develops in the gut, it leads to a decrease in immune responses, which puts people at a higher risk for infection and disease.

Let’s take a closer look at the gut microbiome and how it changes with age.

Diversity of Bacteria Decreases with Age

Our gastrointestinal tract can be compared to a densely populated city inhabited by a variety of different bacteria, fungi, archaea and viruses collectively called the gut microbiota. In fact, compared to other parts of the body, the gut microbiome has the largest number of bacteria. In a healthy gut microbiome, there are four dominant families (or phyla) of microorganisms, including Firmicutes, Bacteroidetes, Proteobacteria and Actinobacteria.

Firmicutes and Bacteroidetes make up around 80 to 90 per cent of the gut microbiota in the digestive tract. Firmicutes help with the production of short-chain fatty acids to support intestinal health and the secretion of mucus to improve intestinal wall defence. Bacteroidetes metabolize complex carbohydrates into vitamins and nutrients, and help promote glycogen storage to improve glucose metabolism.

The gut microbiome and immune system work closely together. The microorganisms in the gut send out signals that are detected by immune sensors. This allows the immune system to regulate the beneficial bacteria in the gut, helping maintain immune homeostasis. Through this interaction, the adaptive immune system also receives stimuli from harmful substances called antigens, which trigger an immune reaction.

However, as people age, the composition and balance of microorganisms in the gut changes. This gives rise to microbial dysbiosis, which means there is a reduction in the number of beneficial bacteria in the gut, alongside a higher number and pro-inflammatory organisms and bacteria that can cause disease. In addition to this, research has also shown that the general diversity of bacteria in our gut also decreases with age.

Over time, the shortage of beneficial bacteria such as Firmicutes in older adults starts to compromise the integrity of their intestinal barrier, causing it to become leaky. This is because the Firmicutes family plays a very important role in keeping the intestinal wall healthy and strong by producing a short-chain fatty acid called butyrate. Short-chain fatty acids such as butyrate help provide nutrients to strengthen the intestinal wall, inform immune responses and lower inflammation.

When intact, the intestinal barrier works to prevent harmful bacteria from passing through the intestinal wall, entering the circulatory system and reaching important organs. However, when there are not enough gut bacteria to produce the short-chain fatty acids that are needed for the intestinal wall to function, bacteria are able to enter the bloodstream. This contributes to the formation of intestinal inflammaging, which refers to a low level of inflammation that becomes steady throughout the body with age.

Inflammaging creates an environment that is prone to inflammation, which is caused and maintained by several factors. These can include microorganism imbalances in the intestines (microbial dysbiosis), psychological stress, physical inactivity, poor nutrition and chronic infections.

When the body is exposed to these factors on a regular basis, cellular senescence occurs. Cellular senescence is a state in which cell growth is permanently arrested, which means that cells are no longer able to self-renew. Eventually, this leads to a decrease in immune responses, which are important to prevent foreign substances and pathogens from entering the body.

How to Maintain a Healthy Balance of Bacteria

There is a common saying that claims “you are what you eat.” Indeed, nutrition and diet play an important role in regulating the number of different microorganisms that live in the gut. This means that diet may also play a key role in the immune function of older adults.

The Mediterranean diet, known for its lower intake of refined carbohydrates, saturated fats, dairy products and red meat, has been shown to have a positive effect on the balance of microorganisms in the gut and the strength of the intestinal barrier. The Mediterranean diet has also been linked to a lower risk of Type 2 diabetes in older adults, allowing these individuals to live a longer and healthier life.

The use of probiotics and prebiotics can also help fight age-related inflammation. Probiotics, such as Lactobacilli and Bifidobacteria, are live microorganisms that can be consumed to support overall health. More specifically, probiotics help improve the function of the intestinal barrier and regulate immune responses by modifying the composition of the gut microbiome. However, there is still some debate around whether the acidic conditions in the stomach allow probiotics to survive long enough to be able to move into the intestine.

It is clear that the immune system has an intricate relationship with the gut microbiome. A healthy and well-balanced gut microbiome will strengthen the intestinal barrier, which helps to reduce inflammation throughout the body and support the immune system.

To achieve this, it is important to maintain a healthy and well-balanced lifestyle as we grow older. This can include lower intake of dairy products and red meats, and harnessing the benefits of probiotics and prebiotics.

Narveen Jandu, PhD, is a faculty member with the School of Public Health Sciences at the University of Waterloo in Canada. As a biomedical researcher, Dr. Jandu’s research has focused on studying the cellular mechanisms and pathophysiological consequences of infectious diseases.

This article was co-authored by Flore Van Leemput. a student in health sciences at the University of Waterloo.

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

Meet the Chronic Pain Patient Running for Arizona Legislature

By Barby Ingle, PNN Columnist

As a rare disease and chronic pain patient, I have spent over 20 years advocating for others and myself in the pain community. I’ve worked on legislation to help patients in more than 30 states, including my home state of Arizona, where two of the bills I supported have become law.

I am now running for the Arizona House of Representatives from District 7, which includes Pinal, Gila, Coconino and Navajo counties, as well as the cities of Flagstaff and Apache Junction, where I live.

My campaign focuses on healthcare access, pain management and disability rights. I believe that everyone should have access to individualized healthcare and proper pain management. This can get people working again and participating in society, which would ultimately save taxpayers money.  

In a recent interview with the Arizona Liberty Podcast, I shared my experiences running for office as a chronic pain patient. I explained that I was running to help make a difference in my community and to create positive change for those often overlooked by the political system. 

As a patient with algoneurodystrophy, a severe nerve disease also known as Complex Regional Pain Syndrome (CRPS), running for office is not an easy task. I have faced many challenges during my campaign, including physical limitations and the need for frequent breaks. Sometimes I have to sit down while everyone around me is standing.  

I am determined to push through these challenges to make a difference. I believe my unique perspective as a chronic pain patient can inspire others to engage in the political process and advocate for their needs. 

In addition to my campaign work, I am a motivational speaker, author, and the immediate past president of the International Pain Foundation. Over the years, I have used my platform to raise awareness about chronic pain and to advocate for better treatment options. Education and awareness are crucial to improving the lives of those with chronic pain. 

My campaign has made waves in my district and garnered attention from the pain community, with financial support and endorsements from patients and providers. Volunteers are also helping me get the word out about my candidacy.

I want laws that restore the patient-provider relationship and give pain management providers the ability to treat each patient individually.

I want to change Arizona’s “red cap” law, which requires all Schedule II opioids dispensed by a pharmacist to have a red cap, in addition to a warning label about potential addiction. The label is fine, but the red cap stigmatizes pain patients and the medications they need. 

We are also currently short about 5,000 healthcare providers in Arizona, a state that attracts many senior citizens and patients with chronic or rare diseases who need specialized care. We must address that so all Arizonans can get the healthcare they deserve.

I hope my dedication and perseverance will inspire others to fight for their communities and better healthcare options. Despite the adversity we all face, positive change is possible.

You can learn more about me and my campaign at barbyingle.com.  I hope to get your vote in the Republican primary on July 30, 2024. 

U.S. Drug Shortages Reach Record Levels

By Pat Anson, PNN Editor

Shortages of opioids and other medications reached a record level in the U.S. during the first quarter of 2024, according to the American Society of Health-System Pharmacists (ASHP). The 323 medications listed in short supply are the highest number since the ASHP began tracking drug shortages in 2001.

Some of the most acute shortages are for basic, life-saving injectable drugs used in hospitals for pain control, sedation and chemotherapy.

Most of the drug manufacturers contacted by the ASHP did not provide a reason for the shortages, but some blamed supply/demand issues (14%), manufacturing problems (12%), business decisions (12%) and raw material issues (2%).

The ASHP also cited reduced DEA production quotas and the fallout from opioid litigation settlements, which have curtailed the supply of opioid medication at many pharmacies.

“New DEA quota changes, along with allocation practices established after opioid legal settlements, are exacerbating shortages of controlled substances,” the ASHP said in its latest report.

The Drug Enforcement Administration has been cutting opioid production quotas for nearly a decade, reducing the supply of oxycodone by over 68% and hydrocodone by nearly 73% since 2015. The DEA says it acts on the advice of the Food and Drug Administration, which projected a 7.9% decline in the “medical need” for opioids in 2024, months before the new year even began.

Many pain patients question whether the demand for opioids is really going down. In a recent PNN survey, 90% of patients with an opioid prescription said they had trouble getting it filled at a pharmacy. Nearly 20% were unable to get their pain medication, even after contacting multiple pharmacies.

“The pharmacist said they could not get my medication because the supplier informed them that they had reached their yearly max and the DEA would not let them supply anymore medication,” one patient told us.

“I am terrified of the cuts being pushed by the DEA,” said another patient. “Several times I have had to wait over a week until my local CVS got my medication back in stock. Honestly, I have such intolerable pain I had no choice but to turn to illicit street drugs to fill in the gaps.”

Shortages of stimulants used to treat attention-deficit/hyperactivity disorder (ADHD) get far more attention than shortages of opioids, which the FDA and DEA have largely ignored. The DEA modestly raised production quotas for ADHD drugs in 2024, but they remain in short supply.

About 12% of the 323 drugs currently listed in shortage by the ASHP are controlled substances regulated by the DEA because they are potentially addictive.

University of Utah Drug Information Service

“I can’t say for sure that every single controlled substance shortage is due to quota issues, but it’s a contributing factor for some,” says Erin Fox, PharmD, Senior Pharmacy Director at University of Utah Health, which tracks drug shortages for the ASHP. “DEA changed their quota process to try to help with ADHD drug shortages, but didn’t take into account how their change affects injectable manufacturers.”

Fox shared a recent letter sent by Pfizer to U.S. hospitals warning of “additional supply interruptions and potential stock outs” due to DEA quota changes. The letter warns of limited supplies of several injectable medicines made by Pfizer, including meperidine (Demerol), hydromorphone and morphine.  

“I understand that DEA is working to prevent drug diversion and was under fire for the ADHD medication shortages, but injectable manufacturing is very different than oral products and DEA did not take into account all of the special processes that are required for injectables,” Fox said in an email to PNN.

Nearly half of the drugs on the ASHP’s shortage list are injectables. Opioids, stimulants and other drugs that affect the central nervous system are the leading class of medication in short supply, followed by antibiotics, hormonal agents, and chemotherapy drugs.

The FDA, which uses a different system to track drug shortages, currently lists only 153 medications in short supply, less than half the number listed by the ASHP.

Painful Choices About a Safe Space

By Cynthia Toussaint, PNN Columnist

It’s no secret. For me, there’s no better medicine than self-care.

To that point, I’m a proud member of my local YMCA. In fact, it’s been my ultimate safe-space for 15 years: around the block, accessible, a generous lap swimming pool, topped by a loving community of warm and caring people. A lot of perfect for someone who can’t walk a block due to Complex Regional Pain Syndrome, but can swim a mile.

To give back some, I’ve done quite a bit of fundraising to provide low-cost memberships for families in need, and landed one of the Y’s aquatic teachers a national ABC News print piece, the angle being the benefits of pool therapy for women in pain as I believe devotedly in the healing power of water.

All was going swimmingly, until COVID. When we returned in mid-2021, my heart sank when I spied a new member, Annie, who I sensed was going to be trouble with a capital T. What little lap swimming she did was overwhelmed by her excessive yelling and joke-telling mid-pool with the lifeguard.

Day after day, I became increasingly stressed while others rolled their eyes and donned ear plugs. To make matters worse, Annie soon blew past personal boundaries by jumping in on my conversations, often physically pulling friends away from me. My place of serenity was turning into a high-decibel scrum.      

CYNTHIA TOUSSAINT

It dawned on me that what was driving Annie’s aberrant behavior was a boatload of childhood trauma. She was deregulated and manic, showing earmarks of a deeply wounded woman. Annie flouted pool rules by wearing inappropriate, oversexualized swimwear (shorts and a braless t-shirt) with no cap for her long, black locks.

In one of the few encounters with Annie before things went south, she boasted about freezing her brother out, emphasizing all the legal folk he had to circumvent to get to her. Annie’s cackle as an exclamation point, her pure joy of hurting another person, was darkly disturbing.                     

One day, out of the blue, a deep freeze set in as Annie began avoiding me. This was terribly awkward, compounded by the Y pool and dressing room being an intimate place where everyone knows everyone’s business. I continued basic pleasantries until Annie yelled me down for doing so.

Next day, in an attempt to fix things, I asked Annie if I’d done something to offend her. Without looking my way, she briskly responded, “No, nothing’s wrong. We’re fine.” But I knew better.

Bad turned to worse when, at that point, Annie completely shut me out. It was as though I didn’t exist as she avoided eye contact altogether. This tactic was deeply uncomfortable and hurtful as she appeared to be in good standing, even sweet, with others. 

Due to Annie’s puzzling cruelty, I started dreading going to my “safe space.” My lower-body pain amp’d and my nervous system was in fight or flight mode before I’d head out to the Y. Even my anticipation the day prior was becoming unhealthy, and I often woke in the night with worry.

Because I couldn’t bear to lose my beloved pool and community, I went to a therapist whose assessment provided strong insight. She suspected Annie was “negatively transferring,” meaning that because I remind her of an abusive person in her childhood, she’s delusional about my power over her. My psychologist advised that this is a targeted psychotic process and, for safety sake, I swim elsewhere.  My close friends seconded that emotion. 

With heavy heart, I tried other Ys and fitness centers. In the end though, none of them worked because of my pain and limitations, e.g., I had to use my wheelchair to get to the pool, there were no exit stairs, and/or my partner and caregiver John couldn’t run necessary errands because we were far from home.

When I fearfully returned to my now toxic Y, John accompanied me in the pool to rehab an injury and offer support in the event of an encounter. Annie’s behavior immediately escalated when she spread a nasty rumor about me to a fellow swimmer who I adore. Zoe shared the gossip out of concern for my well-being, along with being disturbed by the grim energy now shrouding our community.

Before entering the pool the next day, Annie yelled at me twice and, for the first time, physically threatened me by raising her hand to my face. That was it. I went to member relations and made a thorough complaint. Luckily, Zoe, who’d witnessed the happenings, made one as well.

Fortunately, since the Y spoke to Annie, her behavior has simmered. While still avoiding conversation and eye contact, she’s not threatening me, though I’m aware her anger’s just below the surface. Better, but far from okay. What was once heavenly, now casts a pall.

If I was a fully functional person without high-impact pain, I’d have left this Y many moons ago and created a healthy community elsewhere. But because of limitations and specific needs, my only choice is to tolerate an unsafe, dysfunctional situation, to make the best of a bad.

Let’s face it. My choice was really no choice. And that’s the way it is with folk hammered by pain and disability. Pickings are slim and the best solutions are generally the ones that are physically do-able. This not only applies to our places of exercise and community, but also where we live, shop and work. Really, everything we do.   

But let’s not let a bully bury the lead. Come hell or high water, I’m continuing to swim, which is one of the best self-care cards I hold. And when it comes to wrangling with the pitfalls of pain and chronic illness, holding onto what health we can maintain and preserve, is always our best choice.               

Cynthia Toussaint is the founder and spokesperson at For Grace, a non-profit dedicated to bettering the lives of women in pain. She has lived with Complex Regional Pain Syndrome (CRPS) and multiple co-morbidities for four decades, and has been battling cancer since 2020. Cynthia is the author of “Battle for Grace: A Memoir of Pain, Redemption and Impossible Love.”