FDA Expands Warning Labels on Opioids & Sedatives

By Pat Anson, Editor

The U.S. Food and Drug Administration is expanding the warning labels on all opioids and benzodiazepines – a class of anti-anxiety sedative that includes Xanax – because of the serious risk of overdose and death when the drugs are used together.

The FDA’s “black box” warning labels – the FDA's strongest warning – involve nearly 400 opioid analgesics, opioid-containing cough products, benzodiazepines and other central nervous system (CNS) depressants.  The risks associated with using the drugs simultaneously are fairly well-established and include extreme sleepiness, respiratory depression, coma and death.

The agency said the move is one of a number of steps the FDA is taking as part of its Opioids Action Plan, which is focused on policies “aimed at reversing the prescription opioid abuse epidemic, while still providing patients in pain access to effective and appropriate pain management.”

"It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together," said FDA Commissioner Robert Califf, MD. "We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines – or CNS depressants more generally – together outweigh these serious risks."

In addition to benzodiazepines, other CNS depressants include sedatives, hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and alcohol.

The new warning labels caution physicians to prescribe benzodiazepines or other CNS depressants “at the lowest effective dose” if a patient is already taking an opioid.  

The FDA said the number of patients who were prescribed both an opioid analgesic and benzodiazepine increased by 41 percent between 2002 and 2014, which translates to an increase of more than 2.5 million opioid analgesic patients receiving benzodiazepines.

From 2004 to 2011, the rate of emergency department visits involving non-medical use of both drug classes increased significantly, with overdose deaths involving the drugs nearly tripling.

Recent guidelines by the Centers for Disease Control and Prevention also urge doctors to use caution when co-prescribing opioids and benzodiazepines.

The prescribing of opioid pain medication in the U.S. has actually been in decline for several years, but the number of overdoses blamed on opioids – both legal and illegal – continue to rise. One explanation for that is that the co-prescribing of opioids and sedatives has not changed.

According to a 2015 study, over a third of the patients prescribed opioids for chronic musculoskeletal pain were given a sedative. And patients with a history of psychiatric and substance abuse disorders were even more likely to be co-prescribed opioids and sedatives.

In February 2016, the FDA received a citizen petition from the city of Baltimore and over 40 public health officials asking the agency to strengthen warning labels for opioids, sedatives and depressants. The FDA said it was already reviewing data on the simultaneous use of the drugs, but today’s action was a response to that citizen petition.

A Pained Life: Pennsylvania’s Opioid Law Ignores Us

By Carol Levy, Columnist

Recently I received an email update from my state senator. He wanted to let me know about  efforts in the Pennsylvania legislature to address the "opiate crisis.”

I have written before that I believe some of what has been proposed throughout the country makes sense, a prescription monitoring database, for instance. Much of what is being considered in Pennsylvania also makes sense to me:

• Labels on opioid prescription bottles warning of their addictive nature
• Written consent from parents in order for their children to receive prescription opioids
• A safe opioid prescribing curriculum in Pennsylvania’s medical schools to better educate future doctors about proper opioid prescribing practices
• Insurance plans to provide access and share the cost of abuse-deterrent opioids
• Mandatory reporting of all heroin and opioid overdoses where naloxone was administered
• Implementation of opioid prescribing guidelines developed by a state task force
• Healthcare providers to discuss the risks of opioid addiction and overdose with patients and to receive written consent from a patient before prescribing them

But there are two provisions of the law I find very concerning, one being a requirement that coroners and medical examiners report the death of any person resulting from a drug overdose.

One of the issues surrounding the reporting of deaths arising from opioids is that other medical conditions, such as the use of alcohol or illegal drugs, are often ignored and the death is counted as an opioid overdose.

That is not only poor research, but gives a false picture of what is the effectual cause of the death. Ignoring those other factors means ignoring other issues that the law needs to be addressing.

The second issue I have with the law is alarming: limiting the prescription of opioids to seven days. This ignores chronic pain sufferers and the long-term need for opioid medication, which is often our only or last available treatment.

The change we saw, in many states, was requiring a visit to the doctor for a new prescription every 6 months to needing one every 3 months. That was bad enough.  I recall needing to go only once a year, but that was in the 1970's and 80's.

If you have trouble moving, tolerating the weather or other issues, being forced to go see the doctor every three months is an issue. In addition, co-pays rise, insurance companies pay more for extra visits and may raise your rates as a result, and the cost to the state and federal government through increased Medicaid/Medicare billing soars.

I decided to research this. I found that New York State has imposed a 7-day limit on prescriptions, but the law contains exceptions for those with chronic pain or who are receiving hospice or palliative care for life threatening illnesses. Unfortunately, Pennsylvania legislators have decided to ignore those in chronic pain. The bill includes exceptions only for hospice and patients receiving palliative care.

The government has acted as doctor in many other instances; such as women's health care, declaring some drugs illegal, and allowing certain medications and procedures while denying others. I understand that. There needs to be limitations and oversight.

But this is not oversight or limitation.  This is a frenzied and illogical response to an “epidemic” that is not caused or perpetuated by those of us with chronic pain, but is nevertheless being taken out on us.

Politicians who point at us and claim they are handling the crisis are ignoring the real culprits, which is those who abuse drugs illegally.

The question has to be asked. 

How in the world does this law address the opioid epidemic, as opposed to merely blaming and punishing those with chronic pain?

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” 

Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

DEA Banning All Sales of Kratom

By Pat Anson, Editor

The U.S. Drug Enforcement Administration has announced plans to ban all sales of kratom, a popular herbal supplement increasingly being used as an alternative to opioids for relieving chronic pain.

The DEA filed notice in the federal register that it plans to classify two opioid-like chemicals in kratom as Schedule I drugs under the Controlled Substances Act – the same classification given to heroin, LSD and marijuana. Kratom is currently considered a food supplement, not a drug, but the move would effectively prohibit all sales of kratom, which comes from the leaves of a tree grown in southeast Asia.

The founder of the American Kratom Association told Pain News Network that her organization may go to court to block the DEA from carrying out its plan.

"This honestly was a complete and total shock for those of us involved in this issue," said Susan Ash. "We're weighing all of our options right now and one option of course is to seek a temporary restraining order."

The two main active ingredients in kratom, mitragynine and 7-hydroxymitragynine, act on the same receptors in the brain as opioids do, but are not currently approved as drugs.

The DEA said it needed to classify them temporarily as controlled substances “to avoid an imminent hazard to public safety.”

“Available information indicates that these opioid substances, constituents of the plant kratom, have a high potential for abuse, no currently accepted medical use in treatment in the United States, and a lack of accepted safety for use under medical supervision,” the DEA said.

“Consequently, kratom, which contains the main active constituents mitragynine and 7-hydroxymitragynine, is an increasingly popular drug of abuse and readily available on the recreational drug market in the United States. Attempted importations of kratom are routinely misdeclared and falsely labeled. This is similar to other attempts to import controlled substances or substances intended to mimic controlled substances.”

Although the DEA refers to mitragynine and 7-hydroxymitragynine as "opioids," they are actually alkaline compounds that are believed to act on natural opioid receptors in the brain.

"They're not opioids. An opioid is a synthetic version of the poppy plant, so that's just completely wrong," said Ash. "They are novel substances that I really don't think you can define, quite honestly. There's nothing else like them in medicine or nature."

Although illegal in a handful of states, kratom is widely available online and in health stores, where it is sold as dried or crushed leaves, powder, capsules, tablets, liquids and gum. Users tout kratom's pain relieving benefits, and say it also reduces stress, depression and cravings for other drugs.  Recent policies that discourage the prescribing of opioid pain medication have increased interest in kratom as an alternative treatment.

Ash is a recovering opioid addict who uses kratom as a deterrent.

"I have no cravings for narcotics. No part of me ever desires to put narcotics back into my body because of kratom. There is no need because it works so well and it eliminates cravings," said Ash, who used the addiction treatment drug Suboxone for about a year while in recovery.

"I went off of Suboxone using kratom. There is no way I would ever put myself back on Suboxone. But where do I go for help with pain now?" she asked.

Ash first had an inkling that the federal government was preparing to take broader action against kratom when the Centers for Disease Control and Prevention issued a report last month claiming that kratom was "an emerging public health threat." The CDC cited kratom-related calls to U.S. poison control centers, which jumped from 26 calls in 2010 to 263 in 2015.

"I'm sorry, but I don't consider 263 calls to poison control an emerging public health threat. I don't think anyone does," said Ash. 

Few Kratom Studies

Although kratom has been used medically for hundreds of years, few studies have been done on its safety or to see how it actually works.

“Mitragyna speciose (kratom) has a psychostimulant effect like coca and a depressive effect like opium and cannabis, which seem to be contradictory. It is also reported that it is weaker than morphine, has a milder withdrawal syndrome compared to opioids, and is less harmful than cocaine,” is how one study explained it.

The Food and Drug Administration has been trying unsuccessfully to stop the importation and sale of kratom.  Last year the FDA issued an import alert that allows the agency to seize kratom supplements without even physically examining them.

Earlier this month, FDA agents seized more than 100 cases of products labeled as kratom in Grover Beach, California. The products are distributed by Nature Therapeutics Inc. under the name Kratom Therapy.  The FDA said the company was illegally selling kratom products as drugs to treat various medical conditions.

“The FDA will continue to take aggressive enforcement action to safeguard the public from harmful drug products illegally marketed as treatments for which they have not been studied or approved,” said Melinda Plaisier, the FDA’s associate commissioner for regulatory affairs.

The DEA says the ban on kratom chemicals would take effect at the end of September. Earlier this month, the agency also said it would not change the classification of marijuana as a Schedule I controlled substance.

Animal Studies Show Promise for Safer Opioids

By Pat Anson, Editor

Animal studies currently underway could hold the key to developing new opioid therapies that relieve pain without the risk of addiction, overdose and other harmful side effects.

Researchers at Wake Forest Baptist Medical Center in North Carolina have developed a pain killing compound -- called BU08028 – that relieves pain in monkeys without causing physical dependence. BU08028 is similar to buprenorphine, an opioid currently used to treat both pain and addiction.

"Based on our research, this compound has almost zero abuse potential and provides safe and effective pain relief," said Mei-Chuan Ko, Ph.D., professor of physiology and pharmacology at Wake Forest Baptist and lead author of the study published in the Proceedings of the National Academy of Sciences.

"This is a breakthrough for opioid medicinal chemistry that we hope in the future will translate into new and safer, non-addictive pain medications."

This study, which was conducted on 12 monkeys, targeted a combination of mu opioid receptors in the brain – the same receptors targeted in humans by existing opioid pain medication.

The Wake Forest researchers examined behavioral, physiological and pharmacologic factors and found that BU08028 blocked pain signals without the side effects of respiratory depression, itching or adverse cardiovascular events. In addition, the study showed pain relief lasted up to 30 hours in the monkeys and repeated administration did not appear to cause physical dependence.

"To our knowledge, this is the only opioid-related analgesic with such a long duration of action in non-human primates," said Ko. “Given the decades-long effort aimed at developing abuse-free opioid analgesics, BU08028 represents a major breakthrough for opioid medicinal chemistry.”

Ko plans further animal studies on related compounds to see if they have the same safety profiles as BU08028. If those studies are successful, he hopes to begin studies on humans with the ultimate goal of getting FDA approval for a new class of opioid medication.

The research is funded by the National Institutes of Health and National Institute on Drug Abuse.

Rat Study Targets Peripheral Nerves

Another animal study is taking a different approach to pain relief – by targeting nerves in peripheral tissue – not the mu opioid receptors in the brain and spinal cord.

In findings published in Cell Reports, researchers at the University of Texas found that targeting delta opioid receptors on sensory neurons in the peripheral tissue of laboratory rats produces fewer side effects and with much lower abuse potential.

"Being able to increase the responsiveness of peripheral opioid receptor systems could lead to a reduction in systemic opioid administration, thereby reducing the incidence of side effects," says senior study author Nathaniel Jeske of the University of Texas Health Science Center at San Antonio.

One complication is that delta opioid receptors in peripheral tissues only become activated in the presence of inflammation. Because it has not been clear how to overcome this need for an inflammation trigger, the development of drugs that target peripheral nerves has been limited.

Jeske and his colleagues discovered a protein called GRK2 that binds to and prevents delta opioid receptors on rat sensory neurons from responding normally to opioids. But when those peripheral nerves were exposed to a natural inflammatory molecule called bradykinin, GRK2 moved away from the delta opioid receptors, setting off a biochemical reaction that restored the functioning of these receptors.

In addition, rats with reduced GRK2 levels in peripheral sensory neurons regained sensitivity to the pain-relieving effects of a drug that activates delta opioid receptors, and without the need for an inflammatory trigger.

The researchers hope to replicate the same findings using human tissues.

"By shedding light on how inflammation activates delta opioid receptors, this research could potentially lead to the development of safer, more effective opioids for the treatment of pain," said Jeske, whose work is funded by the National Institutes of Health.

Freedom: A Pain Patient’s Lost and Found

By Pat Akerberg, Columnist

Chronic pain takes away many things: our health, wealth, mobility, relationships and careers, to name a few. It’s not a stretch to consider our personal freedom as another major loss. 

Freedom is defined (according to Google) as the power to act, speak, or think as one wants without hindrance or restraint. And unrelenting pain is definitely a hindrance or restraint! 

Despite that harsh reality, there’s an implication that we still have some freedom of choice in how we react. But on those really bad days when it’s all a pain patient can do to get out of bed, the notions of freedom, choice, or power seem wholly non-applicable to us. 

Compared to being autonomous and independent, the setbacks or functional losses we experience threaten any determination or self rule we have left.  You would think that more than ever we’d err on the side of self care and triage. 

Instead, we can be unduly hard on ourselves.  Why?  We still desire to be productive in some way yet can’t be, causing guilt, frustration and even doubts about our purpose.

Even the NFL knows enough to sideline their injured players to PUP (physically unable to perform) status without shame or recrimination until they can function better.

To be kinder to ourselves, there’s an important freedom we can exercise.  We hold the power to choose how we look at freedom altogether. A more lenient twist would be to view it through the lens of the medically compromised.

That twist of perception provides us with 2 types of modified freedom.  One of them involves those things we are now “free from” and can do less of.  The other involves those that we are now “free to” do more of.   

Here are a few freedoms from certain things I have come to appreciate in my particular form of captivity with trigeminal neuralgia:

Type 1: Freedom From

• Attending obligatory, unappealing outings
• Taking all phone calls (talking is a huge pain trigger)
• Trying everything suggested as my cure-in-waiting
• Superficial small talk
• Grocery shopping, laundry, heavy cleaning or distance driving
• Strenuous physical exercise
• People who choose to judge my misfortune as an inferiority and their good fortune as superiority
• Unfulfilling, needy relationships
• Noisy, crowded places and boisterous people
• Educating people about my rare neurological condition, pain, etc.
• Being the initiator, mediator or helper at large

Here are some of my freedoms to. They’re permissions that I grant to myself:

Type 2: Freedom to

• Say no to outings, places, and activities that exact a painful price physically
• Avoid invasive treatments and lab rat experiments
• Express my views about the injustices surrounding inadequate pain care
• Avoid anything that demands my energy after 4 pm
• Not judge myself because mindfulness meditation, exercise, and other touted pain management strategies fell short for me
• Ask for what I need and want when help is offered
• Receive gratefully without guilt or the pressure to reciprocate if I can’t
• Cancel appointments/plans if I am unable to keep them
• Stay in my pajamas if I’m unable to do otherwise
• Practice comforting self-care: baths, massage, good books, TV binging, adult coloring books, sending note cards, and an occasional indulgent dessert
• Make an effort to look my best occasionally, even if it will work against me

It’s helpful to add to and review my list during my worst times to remind myself what freedoms I’m not missing or can give myself. 

Hopefully you’ll consider your particular Type 1 and Type 2 freedoms too and share some with us.  When we do that with each other, it expands our viewpoints and learning. 

After all, we’re each other’s “people,” the group we belong to now. And it takes our own to honestly understand the kind of work-a-rounds that we’re forced to come up with and the life quality compromises we endure.  We know how we can isolate or shield our loved ones when we’re plagued by fears, misgivings or unsettling worries.

I am telling both a lost and a found story about my modified version of freedom now.  It acknowledges that the freedoms I’ve lost have also given way to some new found gains. It’s not meant to suggest that any of this can reduce our pain or restore our undeniable losses, but at least it helps us see the glass isn’t rendered totally empty.

Sometimes it can take a revolution of sorts to hold onto to our freedom or mitigate our losses.  Mine started with giving myself permission to revolt against standardized one-size (that don’t fit all) ways of looking at important things like freedom. 

We can choose to replace any ill fitting lens with one that accounts for the unique and complex anomalies that happen to people just like us.

Pat Akerberg suffers from trigeminal neuralgia, a rare facial pain disorder. Pat is a member of the TNA Facial Pain Association and is a supporter of the Trigeminal Neuralgia Research Foundation.

Pat draws from her extensive background as an organizational effectiveness consultant who coached and developed top executives, mobilized change initiatives, and directed communications.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Miss Understood: How I Won My Disability Case

By Arlene Grau, Columnist

Early March of this year my second hearing was set with Social Security regarding my disability claim. I had previously been denied and we appealed.

The judge wanted one of their rheumatologists to come in and read my blood tests, doctors’ notes and other medical records, because he said he couldn't decipher them.

Two weeks before our hearing date we got word that the specialist they selected was actually a kidney doctor.

My lawyer wrote the judge informing him that we wanted someone else because we felt that the doctor wasn't qualified for my case. We never heard back from the judge, but the doctor excused herself.

The day of the hearing the judge was as harsh as ever and upset because no one in his office told him about the doctor. He wanted to reschedule my hearing until they got another specialist.

But my lawyer wasn't ready to give up and I was so frustrated at that point that I begged him to let us say our peace. Reluctantly he did.

I suffer from rheumatoid arthritis, lupus and other autoimmune diseases. We were able to prove that I had missed numerous days from work due to hospitalization, surgeries or illness based on time sheets and hospital records. I also have numerous doctors’ appointments every month and had the medical records to prove it. Basically everything the judge had a question for, we had supporting documentation.

I had walked in thinking the judge was going to deny me again, because he had stated that rheumatoid arthritis and lupus aren't disabling diseases. I had plenty to tell him about that, but he just brushed off everything we had to say.

The second time around, he was very different.

I honestly believe that prayer works. That and being prepared. Having all your bases covered and making sure you have all your paperwork squared away. I got a print up of all my doctors’ visits and built a graph of them by month and year. Then I did the same thing for my hospitalizations. I also got a print up of my work time sheets and graphed the days I missed by month and year. For some reason the judge liked the graphs more than the print ups themselves.

In the end, the judge awarded me close to three years of disability that I was owed in retro pay. I’m also now receiving Medicare. Although it took 3 years, I'm glad I didn't give up and that I had so much positive support from friends and family. My family and I are finally able to put this behind us.

Arlene Grau lives in southern California. She suffers from rheumatoid arthritis, fibromyalgia, lupus, migraine, vasculitis, and Sjogren’s disease.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Why Opioid Addiction Treatment Often Fails

By Percy Menzies, Guest Columnist

The two most contagious factors linked to addiction are accessibility of the drug and price. If there is easy access to the drug (and this includes alcohol), the number of people exposed is going to increase and a higher number will become addicted.

Every single epidemic has followed this principle. Let’s look at the present problem in the U.S. with the abuse and addiction to prescription opioids.

For decades access to prescription opioids was restricted to patients in acute pain and the only exception was terminal cancer pain. We did not have a major health crisis with opioids in the 1980’s and early 1990’s. 

Then in the mid 1990’s, articles and papers started appearing in the media and medical journals about the under-treatment of chronic pain. Respected clinicians and researchers made a strong case for using opioids to treat chronic pain. They insisted that opioid medication had little or no potential for abuse.  Clinicians were expected to treat chronic pain as the “fifth vital sign” and use opioids as a first-line treatment. The access door was thrown wide open and, for most patients, insurance covered the prescription cost.

When the alarm bells sounded years later and physicians cut back on prescribing, some patients who use opioids medically and many others who use them to get "high" found an alternative: heroin.  This illegal drug was relatively easy to obtain and the price was substantially lower than prescription opioids. 

Now heroin is becoming the gateway drug.  The potency of street heroin is increasing and there are many reports of heroin being laced with the very potent opioid fentanyl to increase the high. The DEA also tells us that hundreds of thousands of counterfeit pain medications made with illicit fentanyl are on the black market.

How do we fight this? Look at how we've reduced access to alcohol and cigarettes.

Access to alcohol is restricted by age, taxes on alcoholic beverages, licensing restrictions, campaigns against drunk driving and other measures. Policies to reduce smoking have also had dramatic results. The smoking rate in the U.S. has dropped from 50% to about 19% in the last twenty years. How was this achieved? By tightening access: no cigarette vending machines, no sale of single cigarettes, limits on places where people can smoke, and substantially higher taxes on tobacco products.

Look at addiction to cocaine. Cocaine was once glamorized as a drug that was only psychologically addicting. The abuse of cocaine and later crack cocaine skyrocketed in the 1980’s. In response, very harsh and discriminatory criminal measures were instituted, but with little effect. Some groups even advocated legalization.

The government promised effective treatments for cocaine addiction, including vaccines, but to date we have neither the treatments or vaccines. Yet addiction to cocaine is way down. Why? Because of reduced access. The countries growing coca came under increased international pressure and destroyed coca crops by spraying them with herbicides.  What would have happened if cocaine was legalized?

Legalization of a drug greatly increases accessibility and increases the number of people exposed to it.  The increased legalization of marijuana has made cannabis accessible to millions of people who never would have considered using it before. There are projections of marijuana becoming a $70 billion plus product in the next 5 to 10 years!

Accessibility undermines recovery.  The conventional treatment approach is to send patients away to residential programs for weeks and months.  The thinking is that behavioral and life skills learned during “rehab” will protect patients from relapsing when they return home. Does this really happen? Can patients successfully navigate the plethora of cues and triggers greeting them when they return home?  Will they be able to resist or ignore the ringing of the bell of Pavlovian conditioning?

It is not likely to work because of a well-researched phenomenon called Conditioned Abstinence or the Deprivation Effect. When a patient is sent away and deprived of access to a drug or alcohol, the addiction goes into an internal “incubator” where it is nourished by anxiety, exchange of war stories with other patients, and ruminating about drug use.

When the patient returns home to the familiar environment of past drug use, the fortified addiction powerfully reemerges from the incubator, leading the patient into relapse.

Repeated attempts at incarceration and long-term residential treatment have failed to curb high relapse rates, especially for opioid addiction.  This led to a wrong and highly controversial conclusion that addiction is a brain disease and the only approach is palliative treatment with other opioids, often for life.

The common and inappropriate analogy is to diabetes. Rather than looking at access as the contributing factor to relapse, patients are told they need opioids like methadone and buprenorphine to ease their withdrawal pains, much like diabetic patient needs insulin.  A clever but unproven theory called the “metabolic syndrome” was put forward to explain this. Patients are left feeling hopeless, helpless and resigned to their fate.

We need look no further than the U.S. soldiers that got addicted to heroin in Vietnam to debunk this theory. The addiction of some soldiers was spawned by cheap and easy access to heroin in villages and hamlets. Our country was in a state of panic about these soldiers continuing their heroin use when they returned home. There was even fear that their weapons training would be used to obtain the drug.

To everyone’s surprise, less than five percent of the soldiers continued using heroin when they returned home. Did these soldiers not suffer from the metabolic syndrome?  They did not continue their heroin habit because they had no easy access to heroin when they came back. If they had been sent back to Vietnam, many would have relapsed because they would have easy access again to heroin.

Compare this to the soldiers returning from Iraq and Afghanistan. Many have been able to continue the addiction because they have easy access to opioids and heroin in the U.S.

Palliation or substitution with methadone or buprenorphine has done little to blunt the heroin epidemic. We have not found a way to reduce access and indeed it is growing. A record quantity of potent heroin is flowing into this country from Mexico. The other two major producer countries, Afghanistan and Burma, are politically unstable and their poppy acreage has grown at alarming rates. It is only a matter of time before the heroin from these countries will start trickling in.

There are no easy answers. Unlike cocaine, products made from the opium poppy are essential for the treatment of pain. There is little we can do to reduce access to heroin. We need to seriously relook at the present treatment infrastructure. Addiction treatment often is episodic, non-medical, punitive, expensive and ineffective. Few patients are sent home on medications like naltrexone to protect them from relapsing in the first days and weeks after rehab. Medications like naltrexone and Vivitrol that give patient a fighting chance of long-term recovery are rarely used.  

We are woefully unprepared to deal with the present situation and the bigger problems to come. One thing is certain: legalization of heroin is not the answer. Decriminalization and standardized treatment with non-opioid drugs can be.

Percy Menzies is the president of the Assisted Recovery Centers of America, a treatment center based in St Louis, Missouri. He is a passionate advocate of evidence-based medical treatment for addictive disorders.

He can be reached at: percymenzies@arcamidwest.com

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Did Untreated Pain Lead Veteran to Commit Suicide?

By Pat Anson, Editor

Two congressmen are asking for an investigation into the apparent suicide of a Navy veteran suffering from chronic back pain outside a veteran’s hospital in New York.

76-year old Peter Kaisen of Islip was found dead inside his car in a parking lot Sunday at the Veterans Affairs Medical Center in Northport. He suffered a fatal gunshot wound to the head.

Kaisen’s wife told Newsday that he suffered from back pain and was unable to sit for more than a few minutes. She said doctors at the VA hospital told her husband there was nothing more they could do to ease his suffering.

The VA this year implemented the Centers for Disease Control and Prevention’s opioid guidelines, which discourage doctors from prescribing opioid pain medication for chronic pain. Since those guidelines were adopted, several veterans have complained to Pain News Network that their opioid doses have been reduced or stopped altogether. It's not clear if that's what happened to Kaisen.

The VA provides health services to 6 million veterans and their families. Over half of the veterans treated by the VA have chronic pain.   

A longtime friend and fellow veteran told the Associated Press that Kaisen visited the VA hospital once or twice a month. He lives about 30 miles away.

"We all think there is probably some depression," said Tom Farley said. "Maybe he wanted meds. Maybe he wanted to sit and talk. I don't know. None of the family knows."

A spokesman for the hospital declined to discuss Kaisen's medical history, but said the hospital had no evidence that he sought treatment at the emergency room on the day he died.

"The Northport VA stands ready to cooperate with any investigative body that believes more information is needed," the hospital's director, Philip Moschitta, said in a statement. "At no point did the staff in this facility fail to do the right thing by our patients."

PETER KAIsEN

But two hospital employees told The New York Times that Kaisen had been frustrated he could not see a doctor in the emergency room, where he went to seek help related to his mental health.

“He went to the E.R. and was denied service,” one employee said. “And then he went to his car and shot himself."

“Someone dropped the ball. They should not have turned him away,” another worker said.

Congressmen Peter King and Steve Israel sent a letter to the FBI and the Department of Veterans Affairs on Thursday asking for a "transparent" investigation into Kaisen’s death.

"It is critical that our nation's veterans feel they can trust the services provided by their VA medical facilities, and that their health and wellbeing is of the upmost priority," they wrote.

Kaisen’s wife told Newsday her husband served on a Navy supply ship, the USS Denebola, from 1958 to 1962.

According to a 2014 Inspector General’s study, more than half of the veterans being treated at the VA have chronic pain, as well as other conditions that contribute to it, such as post-traumatic stress disorder.

Because veterans are at high risk of opioid abuse and overdose, the VA implemented an Opioid Safety Initiative in 2013 to discourage its doctors from prescribing the drugs. The number of veterans prescribed opioids fell by 110,000, but alarms were raised when some vets turned to street drugs or suicide to stop their pain.

According to a VA study released in July, an average of 22 veterans commit suicide each day.

CDC: Fentanyl Urgent Public Health Problem

By Pat Anson, Editor

The Centers for Disease Control and Prevention is finally acknowledging that the U.S. has a fentanyl problem that is growing worse by the day. And that more people are dying in some states from overdoses of illicit fentanyl than from prescription opioids.

“An urgent, collaborative public health and law enforcement response is needed to address the increasing problem of IMF (illicitly manufactured fentanyl) and fentanyl deaths,” CDC researcher Matthew Gladden, PhD, said in the agency’s Morbidity and Mortality Weekly Report.  

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine. It is prescribed legally in patches and lozenges to treat chronic pain, but in recent years there has been a surge in overdoses linked to illicit fentanyl obtained on the black market, where it is often mixed with heroin.

In a new analysis of opioid overdoses in 27 states, the CDC identified eight “high burden” states where fentanyl overdoses sharply increased, even though fentanyl prescriptions were relatively stable.

Those states are Massachusetts, Maine, New Hampshire, Ohio, Florida, Kentucky, Maryland and North Carolina.

In six of the eight states, the CDC said fentanyl was the “primary driver” of synthetic opioid deaths – meaning they outnumbered overdoses from legal synthetic opioids. That is a major concession by the agency, which has long maintained that prescription opioids were primarily responsible for the nation’s so-called opioid epidemic.

The data analyzed was from 2013 and 2014. More recent reports from several states indicate the fentanyl problem has significantly worsened. The DEA recently reported the U.S. is being “inundated” with counterfeit prescription drugs made with fentanyl.  

“This finding coupled with the strong correlation between fentanyl submissions (laboratory tests) and fentanyl-involved overdose deaths observed in Ohio and Florida and supported by this report likely indicate the problem of IMF is rapidly expanding,” Gladden wrote. “Recent (2016) seizures of large numbers of counterfeit pills containing IMF indicate that states where persons commonly use diverted prescription pills, including opioid pain relievers, might begin to experience increases in fentanyl deaths because many counterfeit pills are deceptively sold as and hard to distinguish from diverted opioid pain relievers.”

The CDC hasn’t been completely silent about the fentanyl problem. In October 2015 the agency issued a health advisory to public health departments, healthcare providers and medical examiners to be on the alert for fentanyl overdoses.  Warnings to the public, however, have been scarce as the agency focused instead on controversial guidelines that discourage doctors from prescribing opioids for chronic pain.

Even the U.S. Surgeon General appears to be neglecting the fentanyl problem. This week Surgeon General Vivek Murthy, MD, said he would be sending letters to over two million physicians urging them to follow the CDC guidelines and pledge to safely prescribe opioids. Nowhere in the letter or on a website promoting the “Turn the Tide” campaign is fentanyl even mentioned.  

Critics of opioid prescribing have long maintained that opioid pain medication is often a gateway drug to heroin and other illicit substances, but recent research indicates that is not true.

"Although the majority of current heroin users report having used prescription opioids non-medically before they initiated heroin use, heroin use among people who use prescription opioids for non-medical reasons is rare, and the transition to heroin use appears to occur at a low rate," researchers reported in the New England Journal of Medicine.

Another recent study of military veterans found there was no significant link between heroin use and legally prescribed opioids or chronic pain.

Further compounding the problem is that some heroin and fentanyl deaths are falsely reported as overdoses from opioid pain medication due to inadequate or nonexistent toxicology tests.

Surgeon General Launches Anti-Opioid Campaign

By Pat Anson, Editor

U.S. Surgeon General Vivek Murthy, MD, has partnered with two non-profit health organizations in an ambitious and unusual campaign against the abuse of prescription opioids.

Murthy is taking the unprecedented step of sending a letter to 2.3 million physicians and prescribers, asking them to take a pledge to “turn the tide” against opioid abuse. Included in the letter is a “pocket card” that summarizes guidelines released by the Centers for Disease Control and Prevention, which discourage primary care physicians from prescribing opioids for chronic pain.

“Years from now, I want us to look back and know that, in the face of a crisis that threatened our nation, it was our profession that stepped up and led the way. I know we can succeed because health care is more than an occupation to us. It is a calling rooted in empathy, science, and service to humanity,” Murthy says in the letter.

The two-page pocket card generally follows the CDC guidelines, stating that opioids only provide short-term benefits for moderate to severe pain and that "scientific evidence is lacking" for opioids to treat chronic pain.

“In general, do not prescribe opioids as the first-line treatment for chronic pain,” the pocket card states.

The card also urges physicians to prescribe no more than a 3-day supply of opioids for acute pain and to “avoid” prescribing doses of more than 90 mg (morphine equivalent) a day. 

surgeon general vivek murthy, MD

To take the pledge, physicians are asked to visit TurnTheTideRx.org and promise to educate themselves about treating pain safely and effectively; to screen patients for “opioid use disorder” and provide them access to treatment; and to talk about addiction “as a chronic illness, not a moral failing.”  

Physicians are also asked to give their full names, zip code and an email address to “stay connected” with the Turn The Tide campaign. The website was created in partnership with Public Health Foundation Enterprises and the Institute for Healthcare Improvement.

“The Surgeon General realized that in order to raise awareness and reach people in all communities, he wanted to partner with non-profits that were in the public health space to help advance the messaging around the opioid crisis in the United States,” said Blayne Cutler, MD, president and CEO of Public Health Foundation Enterprises. 

“We thought it was a very important campaign because the data surrounding opioid addiction in this country has been very concerning and worsening over time. This is one of the few areas in public health where we see the number going in the wrong direction.”

No Mention of Fentanyl Crisis

Murthy's letter and the website focus exclusively on prescription opioids and don’t even mention opioid overdoses caused by heroin or the surge in illicit fentanyl deaths now sweeping the country, which the DEA has called an unprecedented crisis. Some states have reported over half of their overdoses are now caused by fentanyl.

In explaining the omission, Cutler said Murthy wanted to focus on how people are introduced to opioids and how they become addicted.

“He’s taking a broad look at how prescribers are thinking about opioids in the context of their patients and what can we do to make sure we effectively treat pain and also make sure we are doing no harm in that process. So it’s a tricky balance,” Cutler told Pain News Network.

“Blaming prescription opioid prescribing for all the overdoses is not going to help solve the problem,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine. “Of course every unintentional or accidental overdose is a tragedy beyond belief but so are the suicides by people who have been told they can no longer receive opioids for their pain.  

“Why do we ignore the people in pain? Most overdoses are not people recently prescribed an opioid. It is very harmful to send a message to providers that doesn't reflect the honest crisis that exists.” 

Webster says he receives an email nearly every day from a pain patient crying for help because a physician has already taken them off opioids or lowered their dose.

“Dr. Murthy will worsen this crisis with his letter,” Webster said in an email to PNN. “Abandonment is not humane. I know he is well intended but he obviously doesn't understand the crisis.”

My Wife Had Ehlers-Danlos and Didn’t Know It

By John Ferman, Guest Columnist

We were married for 41 years.  You’d think after all of that time you would know everything there was to know about a person.

I knew Carol as a loving wife who would do anything she could for the kids and the family. She was a social worker and very concerned about the comfort of others. She didn’t complain and didn’t want others to worry about her.

Carol’s symptoms started shortly after we were married in 1967.  Carol was very energetic, had just graduated with a master’s degree in guidance and counseling, and was anxious to start her new career. She also was somewhat of a “perfectionist” who wanted to keep the house clean and organized, but started to develop some pains as a result.

I remember attending Lamaze classes in 1969, when she was pregnant with our first daughter. The instructor commented on how “flexible” Carol seemed to be during the exercises. Our first daughter Deborah was 4 weeks premature and the second daughter Deanna was 7 weeks premature. We joked that if she got pregnant again we would have to carry around a basket to be ready for the next one.

CAROL FERMAN

Carol’s joint pain got more severe in the 1980’s. She was the first director of a new crisis hotline in the Cleveland, Ohio area and was working unusually long hours.  With all of the mental and physical stresses she was going to a chiropractor monthly and then weekly.  She was also getting massages on a regular basis.

Initially, Carol’s neck, back and shoulders were the major issues. The doctors did not seem to understand her pain and could only recommend ointments and pain medication.  It did not seem to help. She was diagnosed with Thoracic Outlet Syndrome, TMJ and maybe fibromyalgia, but they were not sure. 

I was taking over the household tasks of cleaning, doing the dishes and the laundry.  Some family members commented that they thought Carol “looked perfectly okay” but was weak, lazy and taking advantage of my help. I knew there was a problem with her pain but I did not know what it was or what else to do to help.  

In addition, Carol had severe allergies, IBS symptoms and an extremely sensitive stomach, so she avoided certain foods, spices, and medications. Her allergies often limited where we went for social activities and even restricted purchasing certain items if they had chemical smells, dust, or cigarette odors.

She had flat feet and was prescribed orthotics. Her feet always hurt and finding comfortable shoes was challenging.  She had very sensitive hearing and was a very light sleeper. The slightest noise would wake her.  Pain and disturbed sleep meant she always woke up exhausted!

Carol would describe affected parts of her body as shifted, twisted, crooked, and her favorite word "discombobulated" (meaning everything was zig-zag and out-of-whack). Her pain was achy and throbbing, and she also had episodes of radiating pain, stabbing, pinched nerves and numbness. She would say things like, "I will hurt myself if I reach or stretch for that item, or if I bend that way or if I twist my body."

She had a lot of extra pain if she tried to carry something that was awkward or too heavy. My daughters could carry heavier items than my wife, and the kids and I did a lot of the fetching, carrying and cleaning for her. I made most of the meals and got the kids off to school.

As a result of her non-restorative sleep and pain, Carol was often in bed until the kids got off the bus from school. The girls would run upstairs to the bedroom, eager to spend some quality time with mom, as she was getting out of bed in the middle of the day. The girls remember it as a special time. Moments like these with her girls gave her some comfort and support, but the girls were sometimes embarrassed. They could not tell anyone that their mother was in bed all day.

Carol’s muscles were always tight, and she often described her pain as if "one part of her body was pulling at another.” The only exercise she could tolerate was very slow walking. She loved walking at sunset in the park.

She had pain driving a car and searched extensively to find the most comfortable car so she could remain independent. It was very stressful for her to be a passenger in a car. She would try to brace herself for the starts, stops, bumps, and turns.  If I was driving, she would request alternate routes for straighter roads. We would sometimes go 3 or 4 miles out of our way to find a smooth straight road for her to travel on.

We didn’t know at the time that these were telltale symptoms of Ehlers-Danlos Syndrome (EDS).

Carol was very discouraged that the doctors did not believe her and she stopped telling them about her pain because the tests came back “normal” and there was no treatment or even a reason for her pain. They just told her she was overly-sensitive, exaggerating, or “it’s all in your head.” 

It really bothered her that her medical records said all those bad things about her "mental state.”  She tried at times, in vain, to get the records changed. She knew that when she was depressed, it was due to fatigue, lack of sleep and pain. Not because she was making up things to be sad about.

She could only sustain working for a few more years part time, and then it got to be too much for her physically.

We continued to play out that very difficult lifestyle until Carol was diagnosed with breast cancer in 2002. The continuing pains, surgeries and chemotherapy took their toll on her and she had a major struggle with clinical depression.  She was on so many medications that they masked many of the symptoms.

Carol passed away in 2008 of breast cancer as a result of some prescribed medication, the same year my daughter Deanna was diagnosed with EDS.  In her early 20’s, Deanna developed many of the same symptoms and pain as her mom. They often talked about the similarities and offered each other comfort and understanding.

EDS is a genetic defect in collagen protein -- the “glue” that supports and holds the body together. It causes chronic pain, joint hyper-mobility (double-jointedness and fragile joints) and affects multiple other body systems. There is no fix -- no medicine or surgery -- that resolves this condition. However, it is important that EDS be diagnosed and managed, so that symptoms can be controlled and appropriate preventive measures can be taken.

If only someone had told Carol about EDS. It would have saved both mother and daughter much suffering, loneliness and judgment.  I don't have room in this article for all the details about how undiagnosed EDS harmed my wife and daughter's lives.  Just believe me when I say emphatically that if they had known about EDS, their lives would have been dramatically different!

DEANNA HAMM

Ehlers-Danlos Syndrome is not rare. It is rarely diagnosed.  It is estimated that EDS affects more than 1 in 5,000 people worldwide, but only 5% are correctly diagnosed with one of the 6 major forms of EDS.  In the United States alone, 650,000 sufferers go undiagnosed every year due to physician mistakes or lack of knowledge about the condition.

Many afflicted with EDS - and the people who care for them – don’t know where to turn for information, advice and help with issues such as treatments, therapies, practitioners and products to assist in managing the symptoms. The majority of those who are undiagnosed do not know this disorder exists and are left on their own, struggling to find a reason and a name for the pain and suffering they are experiencing. They suffer for many years and die – never knowing why they had the pain.

Tell someone about EDS today and every day. I do! You could improve a life or even save one!

John Ferman and his daughter Deanna Hamm are co–founders of EDS Awareness, a non-profit online resource for the Ehlers Danlos Syndrome community. John is a full time volunteer managing the program. Deanna is a pre-med graduate with Hypermobile EDS. She leads the Cleveland Ohio EDS Support Group.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

EpiPen Price Scandal Overshadows Opioid Tax

By Pat Anson, Editor

The high cost of prescription drugs has been a hot topic this year for many Americans struggling to pay the soaring cost of healthcare. But a scandal over the price of a lifesaving medication provides a lesson on how tangled money, family and politics can get -– and how low the price of opioid painkillers ranks on the totem pole of public outrage.

The scandal involves the CEO of Mylan Pharmaceuticals -- who happens to be the daughter of a U.S. senator – whose financial compensation has ballooned right alongside the inflated price of the EpiPen, a drug injector that reverses allergic reactions to things like peanuts and bee stings.

According to NBC News, Mylan CEO Heather Bresch took home nearly $19 million in salary, stock and other compensation last year, amounting to almost a 700% raise over eight years.

During the same time period, Mylan jacked up the price of the EpiPen by over 400%. The pocket sized injector that sold for $56 in 2007 now costs $317 wholesale.

sen. joe manchin

Bresch is the daughter of West Virginia Senator Joe Manchin (D), perhaps the biggest critic of opioid prescribing in Congress, who has alleged that pharmaceutical companies that make opioids have too cozy a relationship with the Food and Drug Administration.   

According to OpenSecrets.org, Manchin has accepted over $127,000 in campaign contributions from donors affiliated with Mylan, making the company the senator’s second largest corporate contributor. Mylan makes a wide variety of pharmaceutical products, including opioids.

There is no indication Manchin has ever acted on behalf of Mylan while in Congress, but his daughter’s involvement in the EpiPen scandal has created an embarrassing situation for the senator with many colleagues, including fellow Democrats.

"I demand that Mylan take immediate action to lower the price of EpiPen's for all Americans that rely on this product for their health and safety," Connecticut Sen. Richard Blumenthal (D) wrote this week in a letter to Bresch. “My office has been contacted by dozens of concerned Connecticut residents, families, school nurses, and first responders who urgently require your life-saving product but fear that its skyrocketing price has put it out of reach.”

“This outrageous increase in the price of EpiPens is occurring at the same time that Mylan Pharmaceutical is exploiting a monopoly market advantage that has fallen into its lap,” chimed in Sen. Amy Klobuchar (D), who called for a federal investigation of Mylan.

“Patients all over the U.S. rely on these products, including my own daughter. Not only should the Judiciary Committee hold a hearing, the Federal Trade Commission should investigate these price increases immediately,” Klobuchar said in a press release that claimed the Minnesota senator has “championed efforts to address the high cost of prescription drugs.”

Klobuchar’s concern about the cost of prescription drugs only goes so far. She is co-sponsoring legislation with Sen. Manchin that would establish a tax on all opioid pain medication.

If approved, it would be the first federal tax on a prescription drug levied directly on consumers.  Eight other senators are sponsoring the Budgeting for Opioid Addiction Treatment Act, also known as the LifeBoat Act, which would raise an estimated $2 billion annually to fund addiction treatment programs.

Democratic presidential nominee Hillary Clinton is another fan of Manchin’s opioid tax. In May, during a roundtable discussion about opioid overdoses in West Virginia, Clinton called the tax “a great idea” and said it was “one of the reasons why I am such an admirer of Sen. Manchin.”

Raising prices on opioids is one thing, but hiking the cost of EpiPens is apparently another. Today Clinton called the injector price hikes “outrageous” and “the latest troubling example of a company taking advantage of its consumers.”

Several weeks ago Pain News Network asked the Donald Trump campaign where the Republican nominee stood on the opioid tax. We have yet to get a response.

EpiPen Heather Bresch's "Baby"

Sen. Manchin has been in tangled situations before involving his daughter. In 2007, the Pittsburgh Post Gazette reported that West Virginia University bent the rules to give Heather Bresch a master’s degree in business administration – even though she had only completed about half the credits needed to earn it.

There is no indication that Manchin, who was then West Virginia’s governor, pulled any strings for his daughter, but the resulting scandal led to the resignation of several school officials and Bresch’s MBA degree was revoked.

That didn’t stop Mylan from promoting her to chief operating officer, then president, and now CEO.

Manchin was further embarrassed when Mylan took advantage of a tax loophole and moved much of the company's business to the Netherlands, where there are lower taxes and Dutch law made it easier to fend off a hostile takeover from a rival drug maker. Manchin told The National Journal that what his daughter did should be illegal.

Manchin has not commented publicly about the EpiPen pricing scandal, which Bresch played a major role in starting.  According to STAT, Bresch called the EpiPen her "baby" and spearheaded efforts to widen its use.

heather bresch

Mylan spent tens of millions of dollars in lobbying and advertising efforts that culminated in passage of a federal law that gives preferential treatment to schools that stockpile EpiPen injectors.  Sales of the EpiPen soared as a result and so did its price, even though the amount of epinephrine – the generic drug inside the injector – is only worth about $1 according to Bloomberg.

The EpiPen now generates $1.2 billion in sales for Mylan, which issued a long statement that vaguely blamed the injector’s soaring price on “changes in the healthcare insurance landscape.”

“This current and ongoing shift has presented new challenges for consumers, and now they are bearing more of the cost. This new change to the industry is not an easy challenge to address, but we recognize the need and are committed to working with customers and payors to find solutions to meet the needs of the patients and families we serve,” the company said.

The EpiPen scandal has enraged so many people that a MoveOn.org petition, called Stop Immoral Price Gouging for Life-Saving EpiPen, had garnered over 150,000 signatures.

Meanwhile, a petition drive aimed at scuttling the opioid tax has drawn a little over 1,600 signatures.

Pain Companion: How to Live Better With Nerve Pain

By Sarah Anne Shockley, Columnist

I’ve lived with severe nerve pain for the past eight years and have, through trial and error, found simple ways to help reduce and quiet it down on a daily basis. 

Some of these methods may be obvious if you already live with nerve pain. I include them all here because I know that it certainly would have served me well to have had this information early on, instead of having to work it all out for myself.

The first thing I learned was to think about my situation differently. For a long time, I thought about my nerve pain as its own thing, separate from me. It was something I didn’t want to have around, as if it was its own entity. It was me against the pain.

I’ve come to understand that my nerve pain is an aspect of my body, and possibly myself, that is so raw, so irritated, so sensitive and so volatile that it does not serve to try to make it get better.

My nerves in pain don’t want to be poked or prodded or touched or manipulated into wellness. Even alternative treatments seem like too much to handle. I am a strong believer in acupuncture, but the idea of needles when my nerves are already screaming is not something I want to contemplate. Sometimes even light massage is too much.

When I began to accept the pain as part of my whole life experience, not something that could be extracted or aimed at and annihilated, I began to see that my approach to easing it was going to have to be much more holistic.

I found the best way to do that was to work with creating more well-being in the body around the nerve pain. 

Often, I found that trying to deal directly with my nerve pain actually made it worse, but this indirect approach, over time, was much more effective in helping to ease it.

Here are some methods to help the body feel the best it can around the pain:

Relax and de-stress as much as possible. Limit interaction with things that would normally “get on your nerves,” such as stressful situations, toxic people, crowded stores, and rush hour traffic.

Stay on an anti-inflammatory diet and try to avoid inflammatory situations that activate fright, tension, or adrenaline rushes, such as argumentative people or being argumentative yourself.

Get more rest and sleep by staying calm. Make doing less a priority. You might use herbal teas, such as chamomile, to help with sleep or read yourself to sleep while listen to relaxing music. Avoid staying up late on the internet.

Choose activities that not only suit your physical limitations, but also soothe the mind and soul, such as meditation, listening to beautiful music, singing, walking in nature, talking with loved ones, and reading inspiring words.

Spend time every day in nature walking and focusing your attention on the soothing feeling of the air on the skin, the breeze, the sunlight, and the sound of birds. Bare feet on the ground or in sand can be exquisitely soothing to the nerves.

Take long soaks in bath salts or products using aromatherapy. Let your body relax into the warmth and the delicious smells.

Keep moving in any way you can that doesn’t exacerbate the pain. It’s important to keep the blood and oxygen flowing to keep your muscles from stiffening up and adding to the pain. Stagnant blood and stagnant energy do not help you heal.

Aside from helping your body feel better physically, I also recommend taking care of yourself emotionally.  Here are some pointers:

Find the little pleasures and things you enjoy and appreciate. Don’t wait for the pain to leave before you enjoy yourself and your life. Find the places that don’t hurt and revel in them. If there aren’t any, look beyond your body and find the things you can take pleasure in around you, including nature, the creative arts, the community, and your family.

Don’t try to turn your life off to avoid feeling pain. Don’t close down your ability to laugh or have fun. This is still your life. It is the only one you have. Make the most of it, even if you have to include pain in the equation. Just let it be there. Even invite it along.

Be kinder to yourself. Create a self-love routine around taking care of your body and your emotions. Wash yourself with soothing hands. Buy things that have soothing smells, not sharp chemical odors. Indulge your need for more softness and kindness in your life. Wear clothes that feel soft against your skin. Talk to yourself using soothing words. Give yourself a break more often.

Finally, consider making friends with your painful nerves. Talk to them kindly. Tell them it’s safe to calm down.  Tell them that you’re paying attention to your body and you’re doing the best you can to heal.

Let them know that you hear them, you honor them and you respect what they have to say to you through the pain. Understand that they are in alarm mode right now, but you have heard them, and it’s okay to tone it down a little. It’s okay to let their message be carried to you a little more softly, a little more quietly.

I think one of the tricks to working with nerve pain is to understand that we have one central nervous system that lives throughout the body. Even if we are feeling nerve pain mostly in the face, neck or hands, it relates to and affects the entire nervous system and therefore the entire body.

I believe we can positively affect nerve pain in any part of the body by treating the whole body with calming, soothing, relaxing, and restoring activities and approaches. I’ve found that they work.  And anything we can do to bring the pain down a notch or two is well worth it.

Sarah Anne Shockley suffers from Thoracic Outlet Syndrome, a painful condition that affects the nerves and arteries in the upper chest. Sarah is the author of The Pain Companion: Everyday Wisdom for Living With and Moving Beyond Chronic Pain.

 Sarah also writes for her blog, The Pain Companion.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Prescribed Opioids Not Linked to Veterans’ Heroin Use

By Pat Anson, Editor

A new study of U.S. military veterans found a strong link between heroin use and the abuse of opioid pain medication, but with an important caveat:  the heroin use was associated with the non-medical use of opioid painkillers.

Having chronic pain was also not found to be a significant risk factor for heroin use.

The ten-year study by researchers at Brown and Yale Universities followed nearly 3,400 veterans at nine Veterans Affairs facilities who were participating in the Veterans Aging Cohort Study (VACS).

Of the 500 veterans who started using heroin during the study, 386 of them also began using prescription painkillers non-medically.

"Our findings demonstrate a pattern of transitioning from non-medical use of prescription opioids to heroin use that has only been demonstrated in select populations," said study co-author David Fiellin, a Yale public health and medical professor and director of the VACS study.

"Our findings are unique in that our sample of individuals consisted of patients who were receiving routine medical care for common medical conditions."

Even after statistically accounting for other risks -- such as race, income, use of other drugs, post-traumatic stress disorder (PTSD) and depression -- researchers found that veterans who began misusing painkillers were 5.4 times more likely to begin using heroin. Other major risk factors for heroin use include being male (2.6 times greater risk) and abusing stimulant drugs (2.1 times greater risk).

Veterans who received a short-term prescription for an opioid medication had a 1.7 times greater risk of starting heroin. But having a long-term prescription for opioids was not found to be a significant risk factor. And neither was having chronic pain.

“In our final model, pain interference in daily life was not a significant predictor of heroin initiation,” said lead author Brandon Marshall, an assistant professor in the Brown University School of Public Health.

Despite those findings, researchers recommend that all veterans should be screened for painkiller abuse, including those with legal prescriptions.

"This paper shows that, as a general clinical practice, particularly for this population which does experience a lot of chronic pain and other risks for substance use including PTSD, screening for non-medical painkiller use, whether you are prescribing an opioid or not, may be effective to prevent even more harmful transitions to heroin or other drugs," said Marshall, adding that veterans have a "constellation of risks" for substance abuse.

The study, published in the journal Addiction, did not identify the source of the opioids that were used non-medically. The National Institutes of Health and the U.S. Department of Veterans Affairs supported the study.

Under a federal spending bill passed by Congress and signed into law last year by President Obama, the Veteran’s Administration is required to follow the CDC's “voluntary” opioid guidelines, which discourage opioid prescribing for chronic pain. Since those guidelines were adopted, many veterans have complained to Pain News Network that their opioid doses have been reduced and they live in daily pain.

“They just cut my meds to one oxycodone every 12 hours, which gives me absolutely no relief,” wrote Harvey Williams, a Vietnam vet. “There must be something that the Veterans Administration can do to treat severe pain in the Vets. It's not fair for us to be sprayed with Agent Orange, return back to the United States, develop diabetes and in turn have severe neuropathy and pain for the rest of our lives and not be treated.”

“My VA doctors did not exam me prior to (cutting) my prescriptions,” wrote retired Army Capt. William Green, a Desert Storm veteran. “I asked how they decided to start reducing when I was reporting ongoing 6-8 on 10 pain scale. He didn't even consult with the doctor I do get ongoing treatment from. The doctor said, ‘We don’t care. We are following CDC guidelines.’”

The VA provides health services to 6 million veterans and their families. Over half of the veterans treated by the VA have chronic pain.   

Disability Resources You May Not Know About

By Barby Ingle, Columnist

Over the past 20 years I have had many ups and downs with my health and my finances. After losing my job and company, I had to rely on food stamps, church food banks, and county mental health support groups.

While speaking with others in the support group, I found out that there are a wide variety of disability benefits that come from federal, state and private sources, such as worker’s compensation for people injured on the job and military benefits for soldiers and veterans.

We need to invest time to make sure that the resources available to us are being utilized. There are Social Security programs, Medicare, Medicaid, state assistance programs, utility company programs, handicapped bus passes and car licenses, to name some of them.

Too many of my friends either didn’t know about them or felt embarrassed to ask for assistance.

Knowing what each one is and how it can be used is important. For instance, Supplemental Security Income (SSI) comes from general tax revenues, not social security tax funds.

SSI is designed to help aged, blind, and disabled people who have little or no income. It provides cash to meet basic needs for food, clothing, and shelter. Typically, you quality if you have a medical condition that has prevented you from working or is expected to prevent you from working for at least 12 months.

Social Security Disability (SSD) comes from federal social security taxes that people pay into in case of long-term disability. You must have worked and paid Social Security taxes long enough to qualify. Depending on the state you live in, you can complete the application through the mail, over the phone, or even online.

If you receive SSD, you can quality for Medicare 24 months after becoming eligible for disability.  In my case, I became eligible for Medicare almost immediately, as it was a few years into my disability and they retroactively changed my disability date.

For others who apply sooner, you typically will receive your information several months before you are eligible to start Medicare coverage. I highly suggest that you fill out your papers immediately and return them. There are different requirements in each state for financial and disability levels. Medicaid services can included preventive care, immunization, screening, treatment, doctor visits, hospital visits, and vision and dental care.

Many states offer specific programs that can help you through daily living. It is important for chronic care patients to maintain independence to sustain their full range of experiences, rights and desires. Programs that provide training and support appropriate to the needs of each disabled person can be found in every state.

People disabled by pain may not realize at first that they are eligible for many of these services. They don’t think that their condition is debilitating enough to require handicapped parking, and underestimate the benefit of closer parking or how much energy it saves.

We should always be mindful of our energy penny bank. Handicapped permits and passes allow a disabled person to run errands, shop, go to doctor appointments, travel, and participate in other activities without wearing themselves out within the first few minutes of arriving at a destination.

If you have a disabling pain condition which may allow you to have a handicapped parking permit, talk to your doctor about it. Do not wait for your doctor to bring it up. Doctors are very busy and it is unlikely that this is foremost on their minds. Your doctor should not hesitate to sign the paperwork for you to get a handicapped parking placard if you are eligible under your state regulations.

Also be sure to get a bus pass for disabled riders. They are available in most states and typically give you free or discounted rides.

I used to take the bus often. If you find yourself in a city needing to take the bus, be sure to learn the schedule and let the bus driver know if you have any disabilities or need assistance. Ask him to remind you to get off the bus at your final destination or transfer location. I would forget my stop far too often. You learn to speak up when this happens and you miss a doctor’s appointment.

Patient transportation services are also available for some Medicaid and Worker’s Compensation patients. These companies ensure that patients are transported with the right level of medical expertise in the most appropriate vehicle, such as specialty vans that accommodate wheelchairs. Other modes of transport include ambulatory, wheelchair, stretcher, and air ambulance.

The insurance company is directly billed with a detailed invoice as to miles driven, time of transport, and drop off locations. Services are typically available every day of the year. You can set up this service with your claims adjuster or care manager. I know many who already use this service and love it. One of the iPain board members actually owns a company in Kansas and Missouri that operates this service. If you quality, ask for the help.  

No matter what resource you need, don’t hesitate to ask for them. Get the help you need to become the most active person you can be. Not treating pain is unethical and immoral. When you qualify for assistance, it means you have earned it and it is there to help you help yourself.

For a list of other free or low cost services available to you, checkout the Patient Resources section of Pain News Network. We all pray it is short term assistance, but if long term or life assistance is needed, be the best you can be and take advantage of the help that is available to you.

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation (iPain). She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found by clicking here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.