A New Therapy Can Help Relieve Painful Emotional Trauma

By Laurel Niep

If you’ve been to a therapist’s office in the past few years, there’s a good chance you’ve heard of eye movement desensitization and reprocessing, or EMDR, therapy.

Most commonly used for treating long-standing and acute traumas, EMDR is also being shown to help with some kinds of chronic pain.

A growing body of studies shows that EMDR can be used to effectively treat a variety of conditions, such as substance abuse, specific phobias and anxiety that occurs alongside symptoms stemming from a trauma. More studies are needed, but results so far are encouraging.

I’m a trauma therapist who was trained in EMDR in 2018. Since then, I have consistently used this approach with dozens of clients to work through trauma and deeply held negative core beliefs.

EMDR and Traditional Therapy

Eye movement desensitization and reprocessing was developed in 1987 by Dr. Francine Shapiro after she discovered that moving her eyes from her left foot to her right as she walked – in other words, tracking her feet with each step – resulted in lower levels of negative emotions connected with difficult memories, both from the more recent frustrations of the day and deeper events from her past.

Conventional treatments, such as cognitive behavioral therapy or dialectical behavioral therapy, rely on extensive verbal processing to address a client’s symptoms and struggles. Such therapy may take months or even years.

Depending on the trauma, EMDR can take months or years too – but generally, it resolves issues much more quickly and effectively. It is effective for both adults and children, and can be done remotely.

EMDR is an evidence-based therapy that can help people process trauma in ways that other forms of treatment cannot.

EMDR has the capacity to work faster by targeting negative thoughts and emotions in combination with what is called bilateral stimulation – that is, the use of eye movements, tapping, audio or tactile sensations to process the emotions.

The most common form of bilateral stimulation is when the patient holds their head steady and uses their eyes to follow the therapists’ finger movements back and forth. Patients may also wear headphones that alternate music from ear to ear, or a tone that goes back and forth. Another common technique is having the patient hold a small buzzer in each hand that alternates vibration back and forth. Sometimes, therapists alternate tapping on each of the client’s hands or knees.

Some practitioners equate it to adding conscious thought to what the brain is trying to do during rapid eye movement, or REM, sleep. During this stage of sleep, the eyes go back and forth under your closed eyelids as you’re dreaming.

How EMDR Works

Researchers are still working out exactly how and why EMDR is effective at helping patients heal from trauma.

Trauma is a physiological and psychological response to an event where one perceives a threat to their safety – or to someone close to them – that is so severe, it overwhelms their capacity to cope.

The traumatic event can give rise to various symptoms that affect daily life, such as anxiety, depression, mood swings, intrusive thoughts, hypervigilance, difficulty sleeping or changes in appetite or weight. Sometimes, the person has thoughts of self-harm or suicide.

The trauma can also leave one with various triggers – sights, smells, sounds, locations, phrases – that bring up memories of the event. This causes the person to relive the emotions or reactions they had when the trauma initially occurred, as if it’s happening again.

For example, on a stroll through a crowded mall, someone who had been assaulted months earlier might catch a whiff of the same cologne the perpetrator was wearing. As the smell of the cologne triggers them, they suddenly feel like they’re experiencing the assault again, including physical sensations and seeing images of the event.

Dislodging Trauma

Memories of traumatic events often become stuck in the brain’s limbic system, where the fight, flight and freeze response resides. This is not the place where memories are intended to be stored. Here, the memory is triggered by various experiences in daily life – a similar sound, smell, sight or sensation – that can make the client feel as if the trauma is happening again in that moment.

Targeting the traumatic memory while engaging in bilateral stimulation during EMDR allows the brain to highlight and move the memory from the limbic system – where it cannot effectively connect to other critical information or memory networks – to the prefrontal cortex and other cortical brain regions where the memory is better able to be processed and supported.

Certain places, disturbing noises or large crowds can trigger traumatic memories.

EMDR therapy is a multistep process. Together the patient and therapist first identify targets, meaning the specific traumatic memories to be addressed during the reprocessing phase.

Next, the patient is asked to associate the event with a negative thought about themselves linked to the trauma. For example, I might say, “And when you think about the worst part of that event, what is a negative thought you have about yourself?” Often something comes up along the lines of “I’m unlovable,” “I’m worthless” or “I’m not worth protecting.” The patient is also asked to identify and locate any physical sensations they might be having in the body.

Then the therapist will ask the client to focus on all three of those things – the specific trauma memory, the negative thought about themselves and where they feel it in their body – while applying some form of bilateral stimulation.

EMDR in Practice

Although trauma therapy is a very individualized experience, research shows that 80% to 90% of clients can process – meaning resolve – a singular traumatic event with only three sessions of this therapy. In one initial study study from 1998, past experiences such as post-traumatic stress disorder from combat were resolved in 77% of participants after 12 sessions. Other research suggests that for patients who have suffered chronic trauma or abuse, more treatment time is likely needed to resolve the symptoms stemming from the trauma they survived.

In this context, resolve means that the target thought or memory has been cleared and the impact should be greatly reduced – not that the person will no longer have any negative thoughts or emotions about it.

If a patient has multiple traumas, I’ll ask them to identify the memories that stand out the most. The therapist will start with the earliest of those memories and work toward present day. One memory at a time is focused on, and once it has been completely processed – there’s no more disturbance in the body when thinking of the memory – then the therapist and patient move on to the next one.

One of my patients had struggled with devastating childhood memories of verbal, emotional and physical abuse by their parents. This consistently affected their relationships with family and peers into adulthood. After working with EMDR, the patient was able to process the haunting memories, gain insight on setting boundaries with others, and provide comfort and guidance to the young child they once were.

Another patient was a high school student, afraid to leave the house after enduring an assault on the way home from school. Concrete, visible changes began after the second session. School attendance became more consistent; grades improved. “I don’t understand what’s happening,” said the patient. “It’s like magic. I’m not so scared anymore.”

But EMDR is not magic. It is a unique strategy that allows the client to approach the trauma in a different way. The client is able to think about the events they are affected by and engage with the support of the therapist without having to verbalize each detail of their trauma.

Finding EMDR Specialists

If you’re considering trying out eye movement desensitization and reprocessing therapy, find a therapist who is trained or certified for this treatment. The EMDR International Association website has a list of them, though there are many other qualified therapists not affiliated with that organization, and you could ask about a clinician’s credentials before beginning treatment with them.

If you’re struggling daily with past trauma or deeply held negative beliefs about yourself, are willing to delve into those difficult emotions and would like to try a different type of therapy backed by research, I would strongly recommend giving EMDR a chance.

Laurel Niep, LCSW, is a Trauma Therapist and Senior Instructor with the Stress, Trauma, Adversity Research, and Treatment (START) clinic in the Department of Psychiatry at the University of Colorado School of Medicine.

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

The Best Advice for Someone New To Chronic Pain: Sleep

By Crystal Lindell

If you’re new to chronic pain, try your best to get some sleep. 

Whether you use a pill, a sick day, a babysitter, or some combination of all three — your first priority is to get a really good, restful night of sleep. 

Nothing can be dealt with before that happens, but everything will feel more manageable when you wake up. 

As someone who writes about chronic illness, people often reach out to me when they or someone they love suddenly finds themselves dealing with a new health issue. And my first piece of advice is always the same: YOU NEED TO SLEEP. 

Chronic illness – especially chronic pain – has a way of eating away at your sleep like a party full of toddlers grabbing chunks of birthday cake. Even if you lay in bed all night long, true sleep can easily evade you. 

Lack of sleep will make you crazy so much faster than you think it will. It will make every problem you face impossible. And it will make every interaction you have with humans or pets infuriating. 

When I first started having chronic pain at age 29, I did not understand any of this. At the time, I was working two jobs, with one requiring a daily hour-long commute each way. I was secretly proud to be living on as little sleep as possible, long before I started having serious health issues.

I thought I was the type of person who could easily live on little-to-no sleep. But there’s a big difference between getting five hours of sleep, going to work, then coming home to crash for 10 hours versus getting less than two hours of sleep a night for multiple nights in a row.

I didn’t realize how much sleep my new pain was stealing from me. And I didn’t realize just how quickly it would start destroying my will to live.

During one early pain flare, before I had any of the tools I have now to manage such things, I was awake for like five days straight. I say “like” because that week is kind of a traumatic blur. It was only a few days, but it felt like a month. 

After one of the first rough nights, I showed up at my primary care doctor’s office before it even opened, begging for help. Another day, I went to an urgent care clinic. By the end of the week, I was laying on my living room floor planning ways to kill myself. 

It doesn’t take long to reach really dark places when you aren’t getting enough sleep. And lack of sleep will make almost any physical pain worse too. Combine those two things, and it’s easy to mistakenly start convincing yourself that being alive is the wrong choice. 

Eventually, a pain doctor gave me a strong antidepressant and sleeping aid called amitriptyline, and I finally got some real rest. Of course, like any strong sleep aid, it came with a lot of side effects. It made me very tired in the morning, sometimes making it impossible to get up for work. It made me gain unwanted weight. And it left me groggy throughout the day. 

But after going days without sleep, those were all side effects I was happy to accept. 

Bodies need the power reset that sleep is supposed to provide, both mentally and physically. When you don’t get that, things get scary glitchy fast.

So if you’re new to chronic pain, do whatever you need to do to get some sleep. And if you aren’t able to get the sleep you need with the tools you have at home, do not hesitate to go to the doctor or even the emergency room. Sleep is that important. 

After a few nights of real rest, then you can start to tackle the rest of the ways your newfound health issues are affecting you. Because trust me, there'll be plenty of time for all that in the morning. 

There’s Little Evidence That Massage Therapy Helps With Pain

By Crystal Lindell

It’s often touted as an alternative pain treatment, but it turns out there’s not much evidence showing that massage therapy actually helps with either chronic or acute pain. 

That’s according to new research published in JAMA Network Open that analyzed hundreds of clinical studies of massage therapy for pain. In a systematic review of those studies, the authors found little evidence that massage therapy actually helps relieve pain. In fact, most of the studies concluded that the certainty of evidence was low or very low. 

Notably, the researchers looked at studies involving many different types of pain, including cancer-related pain, chronic and acute back pain, chronic neck pain, fibromyalgia, labor pain, myofascial pain, plantar fasciitis, postpartum pain, postoperative pain, and pain experienced during palliative care. 

“There is a large literature of original randomized clinical trials and systematic reviews of randomized clinical trials of massage therapy as a treatment for pain,” wrote lead author Selene Mak, PhD, a researcher and program manager at the VA’s Greater Los Angeles Healthcare System. 

“Our systematic review found that despite this literature, there were only a few conditions for which authors of systematic reviews concluded that there was at least moderate-certainty evidence regarding health outcomes associated with massage therapy and pain. Most reviews reported low- or very low–certainty evidence.”

The results are especially concerning because massage therapy is often recommended as an nonopioid alternative for treating pain. In fact, in its revised 2022 opioid guideline, the CDC specifically mentions “massage” multiple times as a nonpharmacologic alternative. 

“Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient,” the guideline says.

Researchers involved in the current study found that “massage therapy” was a poorly defined category of treatment, which made it more difficult to analyze. For example, in some studies, acupressure was considered massage therapy, but at other times it was classified as acupuncture. 

“Massage therapy is a broad term that is inclusive of many styles and techniques,” Mak wrote. “This highlights a fundamental issue with examining the evidence base of massage therapy for pain when there is ambiguity in defining what is considered massage therapy.”

Researchers also found that it was difficult to do placebo-controlled massage studies because it’s difficult to compare massage with a sham or placebo treatment. 

“Unlike a pharmaceutical placebo, sham massage therapy may not be truly inactive,” they wrote. “It is conceivable that even the light touch or touch with no clear criterion used in sham massage therapy may be associated with some positive outcomes.… Limitations of sham comparators raise the question of whether sham or placebo treatment is an appropriate comparison group in massage therapy trials.”

The researchers said it might be better to compare massage therapy with other treatments rather than a placebo. They also called for more high-quality research to look into exactly how helpful massage therapy is for pain. 

All of this doesn’t mean that massage therapy offers zero benefits, and patients who get something out of it should continue to use it.  However, medical professionals (and guideline authors) should be more cautious about recommending massage as a substitute for proven pain treatments, such as opioids. Because the last thing people in pain need is to be given ineffective treatments while being denied effective ones..

Can a Smartphone App Relieve Fibromyalgia Symptoms?

By Pat Anson

It was a little over a year ago that the FDA authorized the marketing of the first smartphone app designed specifically to treat fibromyalgia. The Stanza app uses a form of cognitive behavioral therapy (CBT) to help patients improve their quality of life by lessening the pain, anxiety, fatigue and depression that often come with fibromyalgia.

New findings from a placebo-controlled Phase 3 study, recently published in the The Lancet, helped demonstrate Stanza’s potential benefits.  

“This novel, non-drug therapy, available using a smartphone, makes management of fibromyalgia more accessible and convenient. This offers new hope for people with fibromyalgia, who have continued to experience unmet treatment needs,” says lead investigator Lesley Arnold, MD, an Associate Professor of Psychiatry at the University of Cincinnati College of Medicine.

Arnold and her colleagues enrolled 275 fibromyalgia patients in a 12-week trial, with half randomly assigned to receive Stanza treatment and the other half serving as a control group. Participants were allowed to continue taking medications and any other therapies they were using before the study.

Fibromyalgia is a difficult condition to diagnose and treat, because it comes with a wide array of symptoms such as widespread body pain, headaches, fatigue, insomnia, brain fog and mood disorders. The FDA has approved only three medications for fibromyalgia -- duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica) – but many patients consider the drugs ineffective or have too many side effects.

Stanza uses a form of CBT called Acceptance and Commitment Therapy (ACT) to teach patients psychological skills to help lessen the impact of fibromyalgia on their lives. A daily 15–20-minute session includes ACT lessons on deep breathing, mindfulness and other self-management skills.   

The effectiveness of Stanza was measured by the patients themselves, through a self-assessment test known as Patient Global Impression in Change (PGIC), in which participants described changes in their overall well-being.  

After 12 weeks, over 70% of participants in the Stanza group had improvements in their PGIC score, compared to 22% in the control group. Stanza participants also had more significant improvement in their pain intensity, physical function, fatigue, sleep and depression. No adverse events were observed either group.

It’s important to note the research was funded by Swing Therapeutics, the maker of Stanza, which calls it largest study ever conducted of a medical device for fibromyalgia.

“Fibromyalgia options are typically limited to a handful of pharmacological interventions that have limited efficacy and that can come with difficult-to-manage side effects,” says Mike Rosenbluth, CEO of Swing. “This publication validates Stanza as a guideline-directed non-drug approach that many patients previously couldn’t access due to few available trained clinicians, geographic limitations and cost.

Stanza is intended for use five to seven days per week, for a standard treatment period of 12 weeks. After that, Stanza can be used as needed. Previous studies have found that improvements in fibromyalgia symptoms can last up to 12 months after Stanza therapy.

Although it’s a self-guided app, Stanza requires a prescription and the supervision of a medical professional trained in its use.  Currently, Stanza clinicians are only available in the states of Illinois, Michigan, Missouri, Nevada, Ohio, Pennsylvania, Tennessee and Texas.  Medicare Part B and some private insurers cover Stanza treatment.  

Making a Monkey Out of Western Medicine

By Pat Anson

When it comes to using plants to self-medicate, chimpanzees and other primates may be a whole lot smarter than their human counterparts.

The latest evidence comes in a new study published in PLOS ONE, which found that wild chimpanzees consume plants and trees with medicinal properties that relieve pain, reduce inflammation and fight infection. The chimp study follows right on the heels of another recent observational study, about an orangutan that used a plant to help heal a facial wound.  

An international team of researchers spent 8 months following two groups of chimpanzees in Uganda’s Budongo Forest, recording what plants and trees the chimps ate, and whether they were sick or injured. They also analyzed the animals’ feces and urine to check for parasites and elevated levels of immune cells.

The researchers identified 13 plant species with little nutritional value that the chimps seem to instinctively know would help them feel better and recover from illness. The animals would either swallow the leaves whole or chew on bitter bark and tree sap.  

One adult chimp with a severe hand injury was observed moving away from his group to spend a few minutes alone eating a fern called Christella parasitica. When researchers later tested the fern, they found it had “highly anti-inflammatory properties” that may have reduced pain and swelling in the chimp’s hand.

Other chimps with gastrointestinal problems were seen chewing on the bark of the Alstonia boonei tree, which has long been used by indigenous natives to treat snake bites, asthma and wounds.

Notably, both Christella parasitica and Alstonia boonei are cyclooxygenase-2 (COX-2) inhibitors, the same enzyme that is targeted by aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and relieve pain and fever.

Rather than banning or restricting plant-based medicines -- as we have seen with cannabis, kratom and opium -- researchers say we should be looking at “forest pharmacies” for ways to benefit our own healthcare.

“Our findings of strong antibacterial growth inhibition across numerous plant species growing in Budongo have promising implications for our ability to discover novel compounds in existing forest habitats,” researchers said.

“As we learn more about the pharmacological properties of plants ingested by chimpanzees in the wild, we can expand our understanding of their health maintenance strategies. Our results provide pharmacological evidence, from in vitro assays of plant parts consumed by wild chimpanzees collected in situ, for the presence of potent bioactive secondary plant metabolites in Budongo chimpanzee diets for a variety of potential illnesses.”

Whether medicinal plants are consumed intentionally or unwittingly by chimps and other animals remains an open question. But the field of “zoopharmacognosy” – the study of animals using plant-based medicine – could be the answer to many chronic illnesses that Western medicine can’t cure or treat effectively.

“For this to happen, however, it is imperative that we urgently prioritize the preservation of our wild forest pharmacies as well as our primate cousins who inhabit them,” researchers concluded.

The Best Remedy for Low Back Pain? Go for a Walk

By Pat Anson, PNN Editor

Almost everyone experiences low back pain at some point in their lives. Repeated episodes of acute low back pain are also very common, with 70% of people who recover from one episode having another one within a year.

Is there any reliable way to end the cycle before low back pain turns chronic?

A new Australian study suggests the best and most cost-effective way to keep low back pain from returning is simple: Go for a walk.

Researchers at Macquarie University’s Spinal Pain Research Group enrolled 701 adults who recently recovered from low back pain in a clinical trial. Half were randomly assigned to an individualized walking and education program led by a physiotherapist for six months; while the other half served as a control group, receiving no treatment at all.

Participants in the walking group were encouraged to walk five times a week for at least 30 minutes, but were free to do more or less. Most gradually increased their walking, with the average amount of walking time doubling in the first 3 months.

Both groups were then followed for at least one year, with researchers tracking any recurrences of low back pain lasting at least 24 hours that were severe enough to limit daily activities.

The study findings, recently published in The Lancet, show that participants in the control group had a recurrence of low back pain after 112 days on average, while those in the walking group were pain free nearly twice as long, a median of 208 days. The overall risk of having a new episode of low back pain fell by 28% for the walkers.

“We don’t know exactly why walking is so good for preventing back pain, but it is likely to include the combination of the gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and release of ‘feel-good’ endorphins,” said senior author Mark Hancock, PhD, a Professor of Physiotherapy at Macquarie University.

"And of course, we also know that walking comes with many other health benefits, including cardiovascular health, bone density, healthy weight, and improved mental health.”

Another benefit is cost. A significantly higher percentages of participants in the control group sought treatment from massage therapists, chiropractors, physiotherapists and other healthcare providers.

While it’s hard to assign a dollar number to quality of life, researchers estimate the total cost-effectiveness of walking vs. no treatment at AU$7,802. In U.S. dollars, that’s $5,190.    

“It not only improved people’s quality of life, but it reduced their need both to seek healthcare support and the amount of time taken off work by approximately half,” said lead author Natasha Pocovi, PhD, a Postdoctoral Fellow at Macquarie University.

In 2023, the World Health Organization (WHO) released its first guideline for managing low back pain, recommending treatments such as exercise, physical therapy, and patient education. Pocovi and her colleagues say a regular program of walking would be a cheaper alternative to joining a gym or hiring a trainer.

“The exercise-based interventions to prevent back pain that have been explored previously are typically group-based and need close clinical supervision and expensive equipment, so they are much less accessible to the majority of patients,” Pocovi said. “Our study has shown that this effective and accessible means of exercise has the potential to be successfully implemented at a much larger scale than other forms of exercise.”

Low back pain is the leading cause of disability worldwide. According to a 2022 Harris Poll, nearly 3 out of 10 U.S. adults live with chronic low back pain. On average, the typical back pain sufferer seeks relief from at least three healthcare providers, with many treatments proving ineffective.   

Seniors Surprisingly Eager To Try Virtual Reality Therapy for Pain

By Pat Anson, PNN Editor

When it comes to using new technology or acquiring new skills, older people have a reputation for being a little slow on the uptake. A Baby Boomer nearing 70, for example, might not rush out to buy the latest iPhone, while someone from GenZ or a Millennial would.

A new study of virtual reality (VR) therapy is proving how misguided that assumption is. Older people can indeed learn new things and benefit from them.

In a secondary analysis of a placebo controlled clinical trial, people over 65 were significantly more likely to use RelieVRx, a virtual reality program that distracts patients with back pain by immersing them in a “virtual” environment where they can swim with dolphins, play games or enjoy beautiful scenery.   

A demographically diverse group of over 1,000 patients with chronic low back pain participated in the 8-week trial, with the goal of spending a few minutes at home each day watching a RelieVRx program.

By the end of the study, pain scores were reduced by an average of 2 points on a zero to 10 pain scale.

The positive results were across the board, regardless of a person’s age, sex, ethnicity, income or education.

What stood out to researchers is that seniors were significantly more likely to use the devices daily – 47 times on average – compared to those under age 65 (37.6 times)

APPLIEDVR IMAGE

“We had the opportunity to do a deeper dive, and really see how the results were unfolding in younger adults versus older adults, and really found very good engagement with older adults 65 or older,” says Beth Darnall, PhD, Chief Science Advisor for AppliedVR, which makes the RelieVRx headset and programming. 

“What's important about this study and also interesting is that it challenges a very common misperception about older adults. That older people are low tech, disinterested in engaging with newer innovations. We actually saw great engagement among the older adults, as well as a great reduction in symptoms. It suggests that older adults are much more receptive to this type of an approach and that it's also very effective in this population.” 

There are a few caveats to the findings. Many older people are retired and have more time on their hands to participate in a home-based study like this. And since all the patients were recruited online, they may have already been tech savvy enough to wear the VR headset and make it work for them.

RelieVRx is currently being used in hundreds of hospitals and in the Veterans Affairs (VA) system. Patients who’ve tried VR seem to like it, regardless of their backgrounds.

“The VA patients are generally pretty different than the rest of the civilian populations,” says Josh Sackman, president and co-founder of AppliedVR. “The usage is fairly consistent, even with a VA patient prescribed by a doctor who has no exposure to what VR is ahead of time.” 

VR therapy is a form of mindfulness or cognitive behavioral therapy. It doesn’t cure or relieve physical pain, but distracts patients long enough that their symptoms seem less severe. A 2022 study found that VR therapy has long-lasting benefits up to six months after treatment stopped.

The FDA has authorized the marketing of EaseVRx for chronic low back pain in adults, the first medical device of its kind to receive that designation. EaseVRx is only available by prescription and can’t be purchased directly by consumers.

In the coming months, AppliedVR hopes to expand coverage of the device through Medicare, Medicaid, and at least one large commercial insurer.

New Drug Shows Promise in Treating Sjogren's Disease

By Pat Anson, PNN Editor

Sjogren's disease – also known as Sjogren's syndrome – is one of the most frustrating and painful autoimmune conditions. Often accompanied by rheumatoid arthritis, lupus and other immune system disorders, Sjogren's usually begins with dry eyes and a dry mouth, and then slowly progresses to a chronic illness that causes fatigue, muscle and joint pain, and organ damage.

Most frustrating of all is that there are few ways to stop Sjogren's progression and complications that can result in an early death. Eyes drops, anti-inflammatory drugs and pain medication only mask the symptoms temporarily.

“There are currently no disease-modifying therapies for Sjogren's, so current treatment is usually aimed at reducing symptoms," says E. William St. Clair, MD, a Professor in the Division of Rheumatology and Immunology at Duke University School of Medicine.

That could be changing, thanks to a new drug being developed by Amgen and an international research team. In a Phase 2 randomized clinical trial, 183 adult patients with moderate-to-severe Sjogren's received intravenous infusions of dazodalibep (DAZ), a drug that blocks the signals that drive the autoimmune reaction to Sjogren's.

The study findings, published this month in the journal Nature Medicine, show that patients who received DAZ therapy had a significant reduction in disease activity. They also had reduced symptoms of dryness, fatigue and pain.

"This is hopeful news for people with Sjögren's," says Clair, the study’s lead author. "DAZ is the first new drug under development for the treatment of Sjögren's to reduce both systemic disease activity and an unacceptable symptom burden.”

DAZ therapy was generally safe and well tolerated, with mild adverse events such as diarrhea, dizziness, respiratory tract infection, fatigue and hypertension.

Phase 2 studies are only meant to test a drug’s safety and efficacy. Amgen is currently recruiting about 1,000 patients with moderate-to-severe Sjögren's for two larger Phase 3 studies of DAZ therapy. Both are expected to take about two years to complete.  

Dazodalibep is also binge studied as a therapy for rheumatoid arthritis and glomerulosclerosis, a rare kidney disease. The drug was originally developed by Horizon Therapeutics, which Amgen purchased last year for $27.8 billion.

Animals Have Long Used Plants to Treat Pain and Heal Wounds

By Adrienne Mayor

When a wild orangutan in Sumatra recently suffered a facial wound, apparently after fighting with another male, he did something that caught the attention of the scientists observing him.

The animal chewed the leaves of a liana vine – a plant not normally eaten by apes. Over several days, the orangutan carefully applied the juice to its wound, then covered it with a paste of chewed-up liana. The wound healed with only a faint scar. The tropical plant he selected has antibacterial and antioxidant properties and is known to alleviate pain, fever, bleeding and inflammation.

The striking story was picked up by media worldwide. In interviews and in their research paper, the scientists stated that this is “the first systematically documented case of active wound treatment by a wild animal” with a biologically active plant. The discovery will “provide new insights into the origins of human wound care.”

To me, the behavior of the orangutan sounded familiar. As a historian of ancient science who investigates what Greeks and Romans knew about plants and animals, I was reminded of similar cases reported by Aristotle, Pliny the Elder, Aelian and other naturalists from antiquity.

A remarkable body of accounts from ancient to medieval times describes self-medication by many different animals. The animals used plants to treat illness, repel parasites, neutralize poisons and heal wounds.

The term zoopharmacognosy – “animal medicine knowledge” – was invented in 1987. But as the Roman natural historian Pliny pointed out 2,000 years ago, many animals have made medical discoveries useful for humans. Indeed, a large number of medicinal plants used in modern drugs were first discovered by Indigenous peoples and past cultures who observed animals employing plants and emulated them.

What We Learned by Watching Animals

Some of the earliest written examples of animal self-medication appear in Aristotle’s “History of Animals” from the fourth century BCE, such as the well-known habit of dogs to eat grass when ill, probably for purging and deworming.

Aristotle also noted that after hibernation, bears seek wild garlic as their first food. It is rich in vitamin C, iron and magnesium, healthful nutrients after a long winter’s nap. The Latin name reflects this folk belief: Allium ursinum translates to “bear lily,” and the common name in many other languages refers to bears.

Pliny explained how the use of dittany, also known as wild oregano, to treat arrow wounds arose from watching wounded stags grazing on the herb. Aristotle and Dioscorides credited wild goats with the discovery. Vergil, Cicero, Plutarch, Solinus, Celsus and Galen claimed that dittany has the ability to expel an arrowhead and close the wound. Among dittany’s many known phytochemical properties are antiseptic, anti-inflammatory and coagulating effects.

According to Pliny, deer also knew an antidote for toxic plants: wild artichokes. The leaves relieve nausea and stomach cramps and protect the liver. To cure themselves of spider bites, Pliny wrote, deer ate crabs washed up on the beach, and sick goats did the same. Notably, crab shells contain chitosan, which boosts the immune system.

When elephants accidentally swallowed chameleons hidden on green foliage, they ate olive leaves, a natural antibiotic to combat salmonella harbored by lizards. Pliny said ravens eat chameleons, but then ingest bay leaves to counter the lizards’ toxicity. Antibacterial bay leaves relieve diarrhea and gastrointestinal distress. Pliny noted that blackbirds, partridges, jays and pigeons also eat bay leaves for digestive problems.

Weasels were said to roll in the evergreen plant rue to counter wounds and snakebites. Fresh rue is toxic. Its medical value is unclear, but the dried plant is included in many traditional folk medicines. Swallows collect another toxic plant, celandine, to make a poultice for their chicks’ eyes. Snakes emerging from hibernation rub their eyes on fennel. Fennel bulbs contain compounds that promote tissue repair and immunity.

According to the naturalist Aelian, who lived in the third century BCE, the Egyptians traced much of their medical knowledge to the wisdom of animals. Aelian described elephants treating spear wounds with olive flowers and oil. He also mentioned storks, partridges and turtledoves crushing oregano leaves and applying the paste to wounds.

The study of animals’ remedies continued in the Middle Ages. An example from the 12th-century English compendium of animal lore, the Aberdeen Bestiary, tells of bears coating sores with mullein. Folk medicine prescribes this flowering plant to soothe pain and heal burns and wounds, thanks to its anti-inflammatory chemicals.

Ibn al-Durayhim’s 14th-century manuscript “The Usefulness of Animals” reported that swallows healed nestlings’ eyes with turmeric, another anti-inflammatory. He also noted that wild goats chew and apply sphagnum moss to wounds, just as the Sumatran orangutan did with liana. Sphagnum moss dressings neutralize bacteria and combat infection.

Nature’s Pharmacopoeia

Of course, these premodern observations were folk knowledge, not formal science. But the stories reveal long-term observation and imitation of diverse animal species self-doctoring with bioactive plants. Just as traditional Indigenous ethnobotany is leading to lifesaving drugs today, scientific testing of the ancient and medieval claims could lead to discoveries of new therapeutic plants.

Animal self-medication has become a rapidly growing scientific discipline. Observers report observations of animals, from birds and rats to porcupines and chimpanzees, deliberately employing an impressive repertoire of medicinal substances. One surprising observation is that finches and sparrows collect cigarette butts. The nicotine kills mites in bird nests. Some veterinarians even allow ailing dogs, horses and other domestic animals to choose their own prescriptions by sniffing various botanical compounds.

Mysteries remain. No one knows how animals sense which plants cure sickness, heal wounds, repel parasites or otherwise promote health. Are they intentionally responding to particular health crises? And how is their knowledge transmitted? What we do know is that we humans have been learning healing secrets by watching animals self-medicate for millennia.

Adrienne Mayor is a research scholar in the Classics Department and History and Philosophy of Science Program at Stanford University. She studies the history of "folk science" in ancient myths and oral traditions.

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

Little Evidence That Antidepressants Work for Chronic Pain

By Drs. Hollie Birkinshaw and Tamar Pincus

About one in five people globally live with chronic pain, and it is a common reason for seeing a doctor, accounting for one in five GP appointments in the UK.

With growing caution around prescribing opioids – given their potential for addiction – many doctors are looking to prescribe other drugs, “off-label”, to treat long-term pain. A popular option is antidepressants.

In the UK, doctors can prescribe the following antidepressants for “chronic primary pain” (pain without a known underlying cause): amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine and sertraline. Amitriptyline and duloxetine are also recommended for nerve pain, such as sciatica.

However, our review of studies investigating the effectiveness of antidepressants at treating chronic pain found that there is only evidence for one of these drugs: duloxetine.

We found 178 relevant studies with a total of 28,664 participants. It is the largest-ever review of antidepressants for chronic pain and the first to include all antidepressants for all types of chronic pain.

Forty-three of the studies (11,608 people) investigated duloxetine (Cymbalta). We found that it moderately reduces pain and improves mobility. It is the only antidepressant that we are certain has an effect. We also found that a 60mg dose of duloxetine was equally effective in providing pain relief as a 120mg dose.

In comparison, while 43 studies also investigated amitriptyline (Elavil), the total number of participants was only 3,372, indicating that most of these studies are very small and susceptible to biased results.

The number of studies and participants for the other antidepressants are:

• Citalopram (Celexa): five studies with 209 participants

• Fluoxetine (Prozac): 11 studies with 622 participants

• Paroxetine (Paxil): nine studies with 960 participants

• Sertraline (Zoloft): three studies with 210 participants.

The evidence for amitriptyline, citalopram, fluoxetine, paroxetine and sertraline was very poor, and no conclusions could be drawn about their ability to relieve pain.

This is particularly important as UK prescribing data shows 15,784,225 prescriptions of amitriptyline in the last year. It is reasonable to assume that a large proportion of these may be for pain relief because amitriptyline is no longer recommended for treating depression.

This suggests that millions of people may be taking an antidepressant to treat pain even though there is no evidence for its usefulness. In comparison, 3,973,129 duloxetine prescriptions were issued during the same period, for a mixture of depression and pain.

In light of our findings, which were published in May 2023, the UK’s National Institute for Health and Care Excellence (Nice) recently updated its advice to doctors on how to treat chronic pain.

The updated Nice guidance now suggests 60mg of duloxetine to treat [chronic primary pain] and the same drug and dose to treat nerve pain.

Limited Treatments Options

GPs often report frustration at the limited options available to them to treat patients experiencing chronic pain. Amitriptyline is cheap to prescribe – only 66p per pack (US 82.5 cents) – which may explain the high number of prescriptions for this drug.

This is an example of how the gap between evidence and clinical practice could harm patients. Although our review was unable to establish the long-term safety of antidepressant use, previous research has highlighted the high rates of side-effects for amitriptyline, including dizziness, nausea, headaches and constipation.

It’s important to bear in mind, though, that pain is a very individual experience, and the evidence in our review is based on groups of people. We acknowledge that certain drugs may work for people even when the research evidence is inconclusive or unavailable. If you have any concerns about your pain medication, you should discuss this with your doctor.

Hollie Birkinshaw, PhD, is a Research Fellow at University of Southampton. She specializes in research involving chronic musculoskeletal pain, and the integration of psychology in pain and health services. Birkinshaw receives funding from the UK’s National Institute for Health and Care Research (NIHR).

Tamar Pincus, PhD, is a Professor of Health Psychology at University of Southampton. Her research focuses on the psychological aspects of chronic pain. Pincus receives funding from NIHR, Medical Research Council and Versus Arthritis.  

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

Support for Spouse with Chronic Pain Is Helpful, But Not Always Welcome

By Pat Anson, PNN Editor

Support for a spouse or romantic partner with chronic pain can help reduce depression and improve their mood, according to new study. But researchers say some people in pain have poor psychological health regardless of the support they receive.     

A Penn State research team conducted a series of interviews with 152 long-term couples over the age of 50 in which one of the partners had knee pain from osteoarthritis.

Nearly 40% of middle-aged Americans have knee osteoarthritis, a progressive and painful joint disorder that causes thinning of cartilage and joint damage. The condition is strongly associated with early death, high blood pressure, diabetes and cardiovascular disease, particularly in women.

“Osteoarthritis in the knee can be a challenging condition,” lead author Suyoung Nah, PhD, said in a press release “People with the condition will eventually need support managing their pain. What is more, they are likely to continue needing assistance managing their pain for the rest of their lives.”

Nah and her colleagues asked each couple about the pain management support they received from a spouse or partner, such as assistance in taking pain medication or help standing up.

Most participants who received good support felt loved and grateful, and had fewer signs of depression; while those who felt a lack of support had more negative moods and were more likely to be depressed.

A small group of respondents reported feeling angry or resentful — even when they received good support from a partner.

“Almost everyone has times in their life when they do not want to accept help because it makes them feel helpless or because they think they do not need it,” said co-author Lynn Martire, PhD, a Professor of Human Development and Family Studies at Penn State’s Center for Healthy Aging.

Researchers wanted to see if people’s perceptions of the support they receive changed over time, so 18 months later they surveyed the same couples again. Those who felt anger or resentment at the start of the study – regardless of the support they received -- continued having negative moods.

That finding demonstrates the need for good communication between couples when one partner has chronic pain. Providing support – and accepting it -- can be complicated in those relationships.

“Receiving care is not always beneficial to every aspect of a person’s life,” said Nah, who is currently a Postdoctoral Fellow at the Virginia Tech Center for Gerontology. “Additionally, it may be difficult for couples to discuss and negotiate care. As a society, we need to make sure that older people understand their partner’s needs and desires regarding care so that both partners can maximize their physical, emotional and relational quality of life.”

Previous research by Martire found that couples typically don’t have conversations about the type of support that is wanted or needed. Clear communication about expectations and feelings can improve the quality of life for a partner who needs care.

“My main interest is in late-life family relationships — especially couples — navigating chronic illness,” Martire said. “Most older adults have at least two or three chronic illnesses, so helping them find better ways to help each other is really important.”

The study was published in Journal of Aging and Health.

A 2017 study found that criticism from a spouse can make chronic back pain worse. People with back pain who felt they were criticized had more anxiety, anger and sadness, and their pain levels increased for as long as three hours. The study also found that when a partner was supportive – expressing concern about a spouse’s pain or giving “helpful” suggestions – the interaction was still perceived as negative by some pain sufferers.

Millions Lose Medicaid Benefits, Including Disabled

By Daniel Chang, KFF Health News

Jacqueline Saa has a progressive genetic condition called Ehlers-Danlos syndrome that leaves her unable to stand, walk on her own, or hold a job.

Every weekday for four years, Saa, 43, has relied on a home health aide to help her cook, bathe and dress, go to the doctor, pick up medications, and accomplish other daily tasks. She received coverage through Florida’s Medicaid program, until it abruptly stopped at the end of March.

“Every day the anxiety builds,” said Saa, who lost her home health aide for 11 days, starting April 1, despite being eligible.

The state has since restored Saa’s home health aide service, but during the gap she leaned on her mother and her 23- and 15-year-old daughters, while struggling to regain her Medicaid benefits.

“It’s just so much to worry about,” she said. “This is a health care system that’s supposed to help.”

Medicaid’s home and community-based services are designed to help people like Saa, who have disabilities and need help with everyday activities, stay out of a nursing facility

JACQUELINE SAA

But people are losing benefits with little or no notice, getting bad advice when they call for information, and facing major disruptions in care while they wait for the issue to get sorted out, according to attorneys and advocates who are hearing from patients.

In Colorado, Texas, and Washington, D.C., the National Health Law Program, a nonprofit that advocates for low-income and underserved people, has filed civil rights complaints with two federal agencies alleging discrimination against people with disabilities. The group has not filed a lawsuit in Florida, though its attorneys say they’ve heard of many of the same problems there.

Attorneys nationwide say the special needs of disabled people were not prioritized as states began to review eligibility for Medicaid enrollees after a pandemic-era mandate for coverage expired in March 2023.

“Instead of monitoring and ensuring that people with disabilities could make their way through the process, they sort of treated them like everyone else with Medicaid,” said Elizabeth Edwards, a senior attorney for the National Health Law Program. Federal law puts an “obligation on states to make sure people with disabilities don’t get missed.”

At least 21 million people nationwide have been disenrolled from Medicaid since states began eligibility redeterminations in spring 2023, according to a KFF analysis.

The unwinding, as it’s known, is an immense undertaking, Edwards said, and some states did not take extra steps to set up a special telephone line for those with disabilities, for example, so people could renew their coverage or contact a case manager.

As states prepared for the unwinding, the Centers for Medicare & Medicaid Services, the federal agency that regulates Medicaid, advised states that they must give people with disabilities the help they need to benefit from the program, including specialized communications for people who are deaf or blind.

The Florida Department of Children and Families, which verifies eligibility for the state’s Medicaid program, has a specialized team that processes applications for home health services, said Mallory McManus, the department’s communications director.

People with disabilities disenrolled from Medicaid services were “properly noticed and either did not respond timely or no longer met financial eligibility requirements,” McManus said, noting that people “would have been contacted by us up to 13 times via phone, mail, email, and text before processing their disenrollment.”

Benefits Cut Without a Call

Allison Pellegrin of Ormond Beach, Florida, who lives with her sister Rhea Whitaker, who is blind and cognitively disabled, said that never happened for her family.

“They just cut off the benefits without a call, without a letter or anything stating that the benefits would be terminating,” Pellegrin said.

Her sister’s home health aide, whom she had used every day for nearly eight years, stopped service for 12 days.

“If I’m getting everything else in the mail,” she said, “it seems weird that after 13 times I wouldn’t have received one of them.”

Pellegrin, 58, a sales manager who gets health insurance through her employer, took time off from work to care for Whitaker, 56, who was disabled by a severe brain injury in 2006.

Medicaid reviews have been complicated, in part, by the fact that eligibility works differently for home health services than for general coverage, based on federal regulations that give states more flexibility to determine financial eligibility. Income limits for home health services are higher, for instance, and assets are counted differently.

RHEA WHITAKER

In Texas, a parent in a household of three would be limited to earning no more than $344 a month to qualify for Medicaid. And most adults with a disability can qualify without a dependent child and be eligible for Medicaid home health services with an income of up to $2,800 a month.

The state was not taking that into consideration, said Terry Anstee, a supervising attorney for community integration at Disability Rights Texas, a nonprofit advocacy group.

Even a brief lapse in Medicaid home health services can fracture relationships that took years to build.

“It may be very difficult for that person who lost that attendant to find another attendant,” Anstee said, because of workforce shortages for attendants and nurses and high demand.

Nearly all states have a waiting list for home health services. About 700,000 people were on waiting lists in 2023, most of them with intellectual and developmental disabilities, according to KFF data.

Daniel Tsai, a deputy administrator at CMS, said the agency is committed to ensuring that people with disabilities receiving home health services “can renew their Medicaid coverage with as little red tape as possible.”

CMS finalized a rule this year for states to monitor Medicaid home health services. For example, CMS will now track how long it takes for people who need home health care to receive the services and will require states to track how long people are on waitlists.

Staff turnover and vacancies at local Medicaid agencies have contributed to backlogs, according to complaints filed with two federal agencies focused on civil rights.

The District of Columbia’s Medicaid agency requires that case managers help people with disabilities complete renewals. However, a complaint says, case managers are the only ones who can help enrollees complete eligibility reviews and, sometimes, they don’t do their jobs.

Advocates for Medicaid enrollees have also complained to the Federal Trade Commission about faulty eligibility systems developed by Deloitte, a global consulting firm that contracts with about two dozen states to design, implement, or operate automated benefits systems.

KFF Health News found that multiple audits of Colorado’s eligibility system, managed by Deloitte, uncovered errors in notices sent to enrollees. A 2023 review by the Colorado Office of the State Auditor found that 90% of sampled notices contained problems, some of which violate the state’s Medicaid rules. The audit blamed “flaws in system design” for populating notices with incorrect dates.

Deloitte declined to comment on specific state issues.

In March, Colorado officials paused disenrollment for people on Medicaid who received home health services, which includes people with disabilities, after a “system update” led to wrongful terminations in February.

Another common problem is people being told to reapply, which immediately cuts off their benefits, instead of appealing the cancellation, which would ensure their coverage while the claim is investigated, said attorney Miriam Harmatz, founder of the Florida Health Justice Project.

“What they’re being advised to do is not appropriate. The best way to protect their legal rights,” Harmatz said, “is to file an appeal.”

‘So Many People Are Calling’

But some disabled people are worried about having to repay the cost of their care. Saa, who lives in Davie, Florida, received a letter shortly before her benefits were cut that said she “may be responsible to repay any benefits” if she lost her appeal.

The state should presume such people are still eligible and preserve their coverage, Harmatz said, because income and assets for most beneficiaries are not going to increase significantly and their conditions are not likely to improve.

The Florida Department of Children and Families would not say how many people with disabilities had lost Medicaid home health services.

But in Miami-Dade, Florida’s most populous county, the Alliance for Aging, a nonprofit that helps older and disabled people apply for Medicaid, saw requests for help jump from 58 in March to 146 in April, said Lisa Mele, the organization’s director of its Aging and Disability Resources Center.

“So many people are calling us,” she said.

States are not tracking the numbers, so “the impact is not clear,” Edwards said. “It’s a really complicated struggle.”

Saa filed an appeal March 29 after learning from her social worker that her benefits would expire at the end of the month. She went to the agency but couldn’t stand in a line that was 100 people deep. Calls to the state’s Medicaid eligibility review agency were fruitless, she said.

“When they finally connected me to a customer service representative, she was literally just reading the same explanation letter that I’ve read,” Saa said. “I did everything in my power.”

Saa canceled her home health aide. She lives on limited Social Security disability income and said she could not afford to pay for the care.

On April 10, she received a letter from the state saying her Medicaid had been reinstated, but she later learned that her plan did not cover home health care.

The following day, Saa said, advocates put her in touch with a point person at Florida’s Medicaid agency who restored her benefits. A home health aide showed up April 12. Saa said she’s thankful but feels anxious about the future.

“The toughest part of that period is knowing that that can happen at any time,” she said, “and not because of anything I did wrong.”

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

Non-Opioid Analgesic Gets Another Poor Grade for Pain Relief

By Pat Anson, PNN Editor

An expensive analgesic drug that’s often touted as a safer alternative to opioids is not reliable or effective as a pain reliever, according to a new study.

Exparel is an injectable form of liposomal bupivacaine, a non-opioid local anesthetic used for post-operative pain and as a nerve block to numb parts of the body during surgery.

Because Exparel is a proprietary formulation of bupivacaine, Pacira BioSciences has priced it 10 times higher than generic bupivacaine. A 20 milliliter vial of Exparel costs about $376, compared to $38 for a same size vial of bupivacaine.

Some anesthesiologists have questioned whether Exparel is actually worth the higher cost, saying its effectiveness in relieving post-operative pain is “clinically unimportant” and no different than other local anesthetics.  

To see if they might be right, researchers at the Medical University of Vienna recruited 25 healthy volunteers for a blinded clinical study in which participants received two nerve blocks about a month apart, one with plain bupivacaine for pain control and the other with liposomal bupivacaine (Exparel).

"Since the combination of both forms of bupivacaine is recommended, little was known about the effectiveness of the use of liposomal bupivacaine alone in pain therapy during and immediately after surgery," wrote lead author Peter Marhofer, MD, a Professor of Anesthesia and Intensive Care Medicine at MedUni Vienna.

The study findings, recently published in the journal Anesthesiology, show that Exparel alone blocked pain in less than a third of the volunteers, compared to everyone who received plain bupivacaine.

“Given complete sensory blockade in merely 32% of cases, as compared to 100% with plain bupivacaine, liposomal bupivacaine does not emerge from our study as a suitable ‘sole’ local anesthetic for intraoperative regional anesthesia,” said Marhofer.

Those who did get pain relief from Exparel say it reduced their post-operative pain for up to 3.5 days. But because its effects varied widely from subject to subject, researchers don’t consider it a reliable analgesic when used alone.

"Our study showed unpredictable effects of liposomal bupivacaine in terms of nerve block and associated pain relief. Based on our findings, the substance cannot currently be recommended for use in pain therapy during and after surgery," said co-author Markus Zeitlinger, MD, an Associate Professor of Clinical Pharmacology at MedUni Vienna.

Pacira did not respond to a request from PNN for comment on the study. In the past, the company has aggressively promoted Exparel and used hardball tactics to silence critics.

In 2021, Pacira filed a lawsuit against the American Society of Anesthesiologists for publishing “false and misleading conclusions” in the journal Anesthesiology that said Exparel worked no better than other bupivacaine products. The lawsuit was later dropped.

In 2014, Pacira took the unusual step of filing a lawsuit against the FDA, after the agency sent a warning letter to Pacira for off-label marketing of Exparel. Pacira won that case in an out-of-court settlement when the FDA withdrew its warning letter and approved the use of Exparel for more types of post-operative pain.

Over the years, Pacira has paid nearly $34 million to doctors to help promote Exparel, according to Open Payments. That strategy backfired In 2020, when Pacira paid $3.5 million to settle allegations that it gave kickbacks to doctors in the form of fake research grants.

Pacira has also been active politically, spending over $3 million on lobbying and campaign donations since 2018, according to OpenSecrets. In 2019, the company hired former New Jersey governor Chris Christie as a consultant for $800,000 and lucrative stock options. Christie had recently chaired President Trump’s opioid commission, which issued a report recommending that hospitals use more non-opioid pain relievers.

Pacira is also bankrolling Voices for Non-Opioid Choices, an advocacy group that is lobbying the Biden administration for early implementation of the NOPAIN Act. Passed by Congress in late 2022, the law requires Medicare and Medicaid to pay for Exparel and other non-opioid treatments in outpatient surgical settings, starting in 2025. Supporters of the bill want the timetable moved up to 2024, which would generate millions of dollars in additional revenue for Pacira. 

Regulations Should Be Eased for Cannabis and Psilocybin

By Dr. Kevin Boehnke  

The U.S. Drug Enforcement Agency announced in late April 2024 that it plans to ease federal restrictions on cannabis, reclassifying it from a Schedule I drug to the less restricted Schedule III, which includes drugs such as Tylenol with codeine, testosterone and other anabolic steroids. This historic shift signals an acknowledgment of the promising medicinal value of cannabis.

The move comes in tandem with growing interest in the use of psilocybin, the active component in magic mushrooms, for treatment of depression, chronic pain and other conditions. In 2018 and 2019, the U.S. Food and Drug Administration granted a breakthrough therapy designation to psilocybin, meant to expedite drug development given that preliminary studies suggest it may have substantial therapeutic value over currently available therapies for treatment-resistant depression and major depressive disorder.

Both of these developments represent a dramatic change from long-standing federal policy around these substances that has historically criminalized their use and blocked or delayed research efforts into their therapeutic potential.

As an assistant professor of anesthesiology and a pain researcher, I study alternative pain management options, including cannabis and psychedelics.

I also have a personal stake in improving chronic pain treatment: In early 2009 I was diagnosed with fibromyalgia, a condition characterized by widespread pain throughout the body, sleep disturbances and generalized sensory sensitivity.

I have seen and experienced firsthand the ways that clinicians and patients talk about chronic pain medications, and find them to generally be disempowering to the patient, clinician, and drugs themselves. My goal in this article is to help provide a new and more useful lens to think about medications, especially given the poor treatment outcomes for people with chronic pain, the frustration providers express about treating these ‘challenging patients,’ and the ongoing opioid overdose crisis.

I see cannabis and psilocybin as promising therapies that can contribute to bridging that need. Given that an estimated 50 million Americans have chronic pain – meaning pain that persists for three months or more – I want to help understand how to effectively use cannabis and psilocybin as potential tools for pain management.

Cannabis History

Cannabis, also known as marijuana, is an ancient medicinal plant. Cannabis-based medicines have been used for at least 5,000 years for applications such as arthritis and pain control during and after surgery.

This use extended through antiquity to modern times, with contemporary cannabis-based medications for treating certain seizure disorders, promoting weight gain for HIV/AIDS-related anorexia and treating nausea during chemotherapy.

As with anything you put in your body, cannabis does have health risks: Driving while high may increase risk of accidents. Some people develop cyclical vomiting, while others develop motivation or dependence problems, especially with heavy use at younger ages.

That said, lethal overdoses from cannabis are almost unheard of. This is remarkable considering that nearly 50 million Americans use it each year.

In contrast, opioids, which are often prescribed for chronic pain, have contributed to hundreds of thousands of overdose deaths over the past few decades. Even common pain medications like nonsteroidal anti-inflammatory drugs, such as ibuprofen, cause tens of thousands of hospitalizations and thousands of deaths each year from gastrointestinal damage.

Furthermore, both opioids and nonopioid pain medications have limited effectiveness for treating chronic pain. Medications used for chronic pain can provide small to moderate pain relief in some people, but many ultimately cause side effects that outweigh any gains.

These safety issues and limited benefit have led many people with chronic pain to try cannabis as a chronic pain treatment alternative. Indeed, in survey studies, my colleagues and I show that people substituted cannabis for pain medications often because cannabis had fewer negative side effects.

However, more rigorous research on cannabis for chronic pain is needed. So far, clinical trials – considered the gold standard – have been short in length and focused on small numbers of people. What’s more, my colleagues and I have shown that these studies employ medications and dosing regimes that are far different from how consumers actually use products from state-licensed cannabis dispensaries. Cannabis also causes recognizable effects such as euphoria, altered perceptions and thinking differently, so it is difficult to conduct double-blind studies.

Despite these challenges, a group of cannabis and pain specialists published a proposed guideline for clinical practice in early 2024 to synthesize existing evidence and help guide clinical practice. This guideline recommended that cannabis products be used when pain is coupled with sleep problems, muscle spasticity and anxiety. These multiple benefits mean that cannabis could potentially help people avoid taking a separate medication for each symptom.

Since the Controlled Substance Act was passed in 1970, the federal government has designated cannabis as a Schedule I substance, along with other drugs such as heroin and LSD. Possession of these drugs is criminalized, and under the federal definition they have “no currently accepted medical use, with a high potential for abuse.” Because of this designation and the limits placed on drug manufacturing, cannabis is very difficult to study.

State and federal regulatory barriers also delay or prevent studies from being approved and conducted. For example, I can purchase cannabis from state-licensed dispensaries in my hometown of Ann Arbor, Michigan. As a scientist, however, it is very challenging to legally test whether these products help pain.

Reclassifying cannabis as a Schedule III drug has the potential to substantially open up this research landscape and help overcome these barriers.

Emerging Role of Psychedelics

Psychedelics, such as psilocybin-containing mushrooms, occupy an eerily similar scientific and political landscape as cannabis. Used for thousands of years for ceremonial and healing purposes, psilocybin is also classified as a Schedule I drug. It can cause substantial changes in sensory perception, mood and sense of self that can lead to therapeutic benefits. And, like cannabis, psilocybin has minimal risk of lethal overdose.

Clinical trials combining psilocybin with psychotherapy in the weeks before and after taking the drug report substantial improvements in symptoms of psychiatric conditions such as treatment-resistant depression and alcohol use disorder.

Risks are typically psychological. A small number of people report suicidal thoughts or self-harm behaviors after taking psilocybin. Some also experience heightened openness and vulnerability, which can be exploited by therapists and lead to abuse.

There are few published clinical trials of psilocybin therapy for chronic pain, although many are ongoing, including a pilot study for fibromyalgia conducted by our team at the University of Michigan. This treatment may help people develop a healthier relationship with their pain by eliciting greater acceptance of it and decreasing rumination often related to negative thoughts and feelings around pain.

As with cannabis, some states, such as Colorado and Oregon, have decriminalized psilocybin and are building infrastructure to increase accessibility to psilocybin-assisted therapy. One recent analysis suggests that if psychedelics follow a similar legalization pattern to cannabis, the majority of states will legalize psychedelics between 2034 and 2037.

Challenges Ahead

These ancient yet relatively “new” treatments offer a unique glimpse into the messy intersection of drugs, medicine and society. The justifiable excitement about cannabis and psilocybin has led to state policies that have increased access for some people, yet federal criminalization and substantial barriers to scientific investigation remain. In the years ahead, I hope to contribute toward pragmatic studies that work within these difficult parameters.

For example, our team developed a coaching intervention to help veterans use commercially available cannabis products to more effectively treat their pain. Coaches emphasize how judicious use can minimize side effects while maximizing benefits. Should our approach work, health care providers and cannabis dispensaries everywhere could use this treatment to help clients in chronic pain.

Approaches like these can supplement more traditional clinical trials to help researchers determine whether these drug classes offer benefit and whether they have comparable or less harm than current treatments. As our society connects to the rich history of healing using these ancient drugs, these proposed changes may offer safer and substantive options for the 50 million Americans living with chronic pain.

Kevin F. Boehnke, PhD, is an Assistant Professor in the Department of Anesthesiology and the Chronic Pain and Fatigue Research Center at the University of Michigan.  He receives funding from the National Institutes of Health, the State of Michigan Veteran Marijuana Research Program, and has received grants from Tryp Therapeutics and Journey Biosciences.

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

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.