How the Epstein Barr Virus Causes Arachnoiditis

By Dr. Forest Tennant, PNN Columnist

The Epstein-Barr Virus (EBV) has long been known to cause autoimmune complications. For example, I described infectious mononucleosis in kidneys (glomerulonephritis) associated with EBV back in 1969, some 53 years ago.

Recently EBV has been shown to cause multiple sclerosis (MS), as well as certain cancers. Our studies have also revealed that many, if not the majority, of persons with adhesive arachnoiditis (AA) have extremely high EBV antibody levels. We now believe that EBV can cause AA as well as MS. 

Anything that boosts or helps a disorder to develop, is called a “co-factor.” In the case of EBV and AA, the “co-factors” or “co-partners” may include Ehlers-Danlos Syndromes, autoimmune diseases such as psoriasis, Lyme disease, and some other viruses like cytomegalus, coxsackie and covid.

‘Collagen Eaters’

Although almost everyone gets infected with EBV during their lifetime, some persons develop a large number of EBV antigens that literally attack and “eat away” or otherwise cause collagen to deteriorate and weaken. If the body creates large numbers of antigens, large numbers of antibodies are simultaneously made to hopefully counter them.

EBV collagen eating antigens like to attack tissues around the spine that have a lot of collagen. This includes intervertebral discs, cauda equina nerve roots, and the arachnoid-dural covering of the spinal canal. If collagen is weak or absent in spinal tissues, discs may slip, inflammation may form, and fluid leaks and cysts may develop.

Get Tested for EBV

All persons with confirmed or suspected AA should be tested for EBV antibodies.

Laboratories today do three types of tests for EBV. One is to tell if you currently have an active infection and the other two measure antibody levels to determine if you have had EBV in the past. If your antibodies are considerably above normal range, it suggests you have collagen eating antigens that put you at risk of developing AA.

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

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

How to Improve Pain Control with Adhesive Arachnoiditis

By Dr. Forest Tennant, PNN Columnist

Some persons with Adhesive Arachnoiditis (AA) feel that more pain relief drugs, particularly opioids, will solve their problem. The fact is that we regularly review cases in which persons with AA are taking 2 or 3 opioids or even have an implanted intraspinal canal pump that contains fentanyl or Dilaudid, but they still don’t get enough pain relief to get out of bed and function.

AA is an intraspinal canal inflammatory disorder in which cauda equina nerve roots are glued by adhesions to the inside of the spinal canal covering. This definition tells it all. AA is fundamentally intraspinal canal inflammation, so unless the initial inflammation is suppressed or extinguished, it will likely continue to spread and cause more pain.

In essentially every case of failing pain control, we find that the person is doing little or nothing to suppress intraspinal canal inflammation and repair damage to their nerve roots and spinal canal covering.

First Steps in Pain Control

Our research is clear. A person with MRI-documented AA can’t expect adequate pain relief unless they have a definite, daily routine to simultaneously suppress intraspinal canal inflammation and repair tissue damage to cauda equina nerve roots and the spinal canal covering.

Adequate pain control to have a good quality of life can be difficult to achieve. The first step is to obtain a list of drugs, botanicals, hormones, nutrients and physical measures that are popular in the AA community and that either suppress inflammatory or restore damaged tissue. Share your list with your family and medical practitioner. You may have to try multiple agents to develop a program that gives you better pain control.

Persons who have AA and poor pain control also need a blood test for inflammatory markers, glucose, and the hormones cortisol, pregnenolone, DHEA and testosterone.

If your pain is constant, review our Intractable Pain Syndrome website that is totally dedicated to relief from constant pain.

How to Diagnose AA

I’m pleased to announce the release of a new handbook that takes the mystery out of diagnosing AA with contrast MRI imaging once and for all. I have read hundreds of contrast MRI’s during my years in medical practice, and have found that the earlier a diagnosis is made and treatment is started, the better the prognosis is for the patient.

Unfortunately, many health care practitioners don’t know the telltale signs of AA when it appears in an MRI. As a result, AA is often misdiagnosed as “Failed Back Syndrome” or “Low Back Pain.”

“Handbook to Recognize Adhesive Arachnoiditis” is an essential read for all practitioners who are interested in treating patients with spine disorders and patients who suspect they may have AA. It’s presented in a clear and easy to read format as a “how to” guide for reading contrast MRI’s for the diagnosis of AA.

The book is filled with clearly diagrammed MRI images of documented cases of AA and should help practitioners diagnose AA and learn the difference between AA and other spine disorders with similar symptoms.

This book will also help those patients who suspect they may have AA receive a quick and proper diagnosis, thus preventing delays in effective treatment of this devastating spinal cord disease. AA is no longer rare. It is in every community, and health care practitioners can now learn how to diagnose and treat it. There is hope and help!

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. This column is adapted from a bulletin recently issued by the Arachnoiditis Research and Education Project. Readers interested in subscribing to the bulletins should send an email to tennantfoundation92@gmail.com.

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

Why Complicated Chronic Pain is Different

By Dr. Forest Tennant and Ingrid Hollis

As 2021 comes to a close, we wish to summarize what we personally consider to be the greatest issue in pain management. Physicians have observed for centuries that some chronic pain conditions are not only more severe than others, but some cause excruciating, constant pain that casts the poor suffering individual into a humbled, bed-bound state.

Unfortunately, throughout the past half-century or so, many concerned parties, whether intentional or not, have tried to lump all pain patients into one category, saying they all have persistent or chronic pain. This has led to calls for “one size fits all” treatment and inflated statistical figures on the number of pain patients who need help (i.e., 50 or 100 million Americans).

The Real Issue

Chronic pain has traditionally been defined as pain that continues past the normal healing time for an injury or disease, which is about ninety days. There has been no generally accepted separate classification as to the severity, constancy or periodicity of pain that lasts longer than 90 days. Consequently, chronic pain surveys and statistics always include persons with the common, mild to moderate painful afflictions such as bunions, carpal tunnel, fibromyalgia, headaches, TMJ, irritable bowel, back strains, plantar fasciitis, and mild neuropathies and arthropathies.

Cries of undertreatment of these common chronic pain problems ring hollow, since every community has a plethora of medical practitioners, pharmacies, health food stores and fitness centers that tend to vast number of persons who have these common pain problems.

It may also be why all of the recent lobbying and advocating for “chronic pain” doesn’t seem to connect with the body politic, because the vast majority of chronic pain patients are getting adequate care. This is not to say that treatment for their common, mild to moderate conditions can’t be improved, or that their treatment isn’t needed.

The real issue, however, is that there is a sub-set of chronic pain patients who develop what can justifiably be called “complicated chronic pain.” Most have tried a plethora of treatment options but are left with severe, constant pain that has a specific set of pathologic complications. It is this group that is undertreated, poorly understood and needs advocacy, attention and treatment for their complicated chronic pain.

The Complications

The hallmark of complicated chronic pain is constant pain which is associated with cardiovascular, metabolic and hormonal abnormalities. Complications include hypertension, tachycardia, glucose elevations (pre-diabetes, and diabetes), and adrenal-gonadal hormone deficiencies including cortisol, estradiol and testosterone, among others. These complications can lead to heart attack, stroke, heart failure, autoimmunity, diabetes, obesity, depression, dementia and other health problems.

Thanks to modern research and science, we have a better understanding of why some unfortunate individuals transform from a mild, periodic chronic pain, to a constant, ferocious and disabling pain state. We now know that injured or diseased tissue from whatever initiating cause can generate bioelectricity that may enter the spinal cord and brain -- the central nervous system (CNS) – causing destructive inflammation that damages critical tissue sites that normally eliminate or control pain.

This development is called “neuroinflammation.” The transformation process in now often called “centralization” or “central sensitization.” Some pain specialists prefer to call complicated chronic pain “neuropathic pain.”

We Need a Name

A syndrome is a clinical state in which one pathologic defect causes multiple abnormalities and symptoms. Hence, we recently began calling the complicated chronic pain state the Intractable Pain Syndrome (IPS). The term intractable was first used by British physicians in the last century who championed treatment of severe incurable pain. The term intractable is now used in some laws and is in popular use in some pain circles.

There may be a better name than Intractable Pain Syndrome. Maybe we should just call it “Complicated Chronic Pain.” Regardless, understanding that inflammation can develop in the CNS and cause complicated constant pain is essential, as these patients need a different treatment approach from the more common, uncomplicated chronic pain patient.

Going forward into 2022, we define Intractable Pain Syndrome as “an inflammatory disorder of the central nervous system that causes constant severe pain and is associated with cardiovascular, metabolic and hormonal complications.”

Furthermore, we will advocate that this tragic syndrome be understood, and that its proper treatment demands not only symptomatic pain relief, but specific treatment of the disease that originated the syndrome, along with specific treatment of its complications. 

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on intractable pain and arachnoiditis. Ingrid Hollis chairs the editorial committee of the Tennant Foundation Research and Education Projects. She is also a family caregiver and advocate for those who suffer from rare diseases and intractable pain. The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.     

Why Oral Opioids Can Give Poor Pain Relief

By Forest Tennant, PNN Columnist

Every day, our Research and Education Projects hear from persons with a serious pain problem who can’t obtain enough relief. There are multiple reasons, but a major one is that they are trying to relieve their pain with oral opioids. It appears to us that there is a gross misunderstanding and ignorance about the inability of oral opioids to ever provide good pain relief in many persons who have Intractable Pain Syndrome (IPS).

A person who has constant pain from adhesive arachnoiditis, Ehlers-Danlos Syndrome (EDS), Reflex Sympathetic Dystrophy (CRPS/RSD), cervical neck neuropathy, or another disease that causes constant pain with cardiovascular and endocrine abnormalities will often have impairment of the stomach and intestine. This affects their ability to properly dissolve, digest and place enough opioid into the bloodstream to get pain relief. This occurrence is technically called “opioid malabsorption” or “opioid maldigestion.”

All the conditions listed above cause dysfunction of the many nerves that go from the spinal cord to the stomach and intestine. The nerves carry the bioelectricity that activates the stomach and intestines so that the acids and enzymes from them will fully dissolve and digest tablets, capsules and liquids. EDS, diabetes and autoimmune diseases may also erode or degenerate the collagen matrix of the small intestine, so it won’t properly function, which impedes digestion.

Stomach and intestinal malfunction due to many severe painful diseases may manifest differently at different times. For example, on some days function will be good, and on others, almost non-existent. Another example is “maximal ability.” In this case, the impaired stomach and intestine will allow only a maximal amount of opioid to be digested. For example, 4 tablets will provide some relief, but 6 or 8 won’t do any better.

Review your situation. Do you have some days when you got relief, but not others? Does increasing your oral dose give you no more relief?

If you have IPS, don’t always count on oral opioids to give you the pain relief you need. Start looking into opioid injections, suppositories, patches, topicals, sublingual (under-the-tongue), or buccal (inside the mouth-upper cheek). Also, start probiotics and/or intestinal enzyme preparations, as they sometimes help oral opioids do their job.

Injectable and Suppository Opioids

Why aren’t injectable and opioid suppositories the standard care for severe pain flares? They used to be. For example, the 1956 Merck Manual (9th Edition) states “more severe pain requires the oral or subcutaneous use of narcotics.”

Today, most doctors somehow have the irrational and false idea that injectable opioids always cause overdoses and/or will be diverted into illegal channels. Most doctors are hardly aware that opioid suppositories are available from the local pharmacy and that they are far more effective for flares or breakthrough pain than oral opioids.

At best, an oral opioid will need 30 to 60 minutes to provide pain relief. Opioids administered by injection or suppository work much faster, bypassing the stomach, intestines and liver, and going right to the blood brain barrier.  Pain relief will usually occur within 5 to 10 minutes. Pain relief is also much better, even at a fraction of the oral dose, because the entire dosage reaches the endorphin receptors without being filtered by the stomach, intestines and liver.

Opioid injections and suppositories help patients remain below the CDC guideline’s recommended daily limit of 90 morphine milligram equivalent (MME).

Injectable opioids are used subcutaneously or intramuscularly, not intravenously, for at home use. Injectable
opioids should only be used for flares.

Our enthusiasm for injectable opioids has been enhanced by the development of compounded hydromorphone. This innovation allows a micro dose of only .1cc (5mg), which can be taken subcutaneously with a small needle.

Opioid injections have traditionally been prescribed by local primary care practitioners who know the patient is responsible, and not a street person or substance abuser. Patients and their families should also be trained and warned to keep the injectable away from children, pets and guests. We are not aware of a single case of injectable opioid reaching the street or causing an overdose death in a bona fide IPS patient who was trained with their family.

IPS patients and families can inquire at their local pharmacy as to which injections and suppositories are available. Then approach your personal MD, DO, or NP about starting an opioid injection or suppository for pain flares. 

Every IPS patient needs to achieve some pain free hours so they can walk, physically exercise their arms and
legs, do activities of daily living, and be able to mentally concentrate enough to be able to read and write. These hours of zero or very little pain help strengthen the cardiovascular and endocrine systems so some tissue regeneration can occur and permanently reduce their constant pain. Injectable opioids provide the best opportunity at achieving some pain free hours.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here. The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.     

What Pain Patients Should Know About the GABA Neurotransmitter

By Forest Tennant, PNN Columnist

“GABA” is short for the neurotransmitter, gamma aminobutyric acid. GABA is the natural (endogenous) biochemical substance in the brain, spinal cord, and all nerves that control electrical conduction.

Without proper GABA function, we experience pain. New research also shows that low levels of GABA make it harder to keep negative emotions such as fear, worry, anxiety and depression in check. 

All Intractable Pain Syndrome (IPS) patients have nerve damage somewhere in their brain, spinal cord, or nerves. Consequently, IPS patients will either need extra GABA or a GABA surrogate to force damaged nerve tissue to correctly function and relieve pain. 

GABA Surrogates

Without realizing it, you may already be taking a GABA surrogate. And you may have found that your pain gets worse without one. Here are the most effective prescription surrogates:

• Gabapentin (Neurontin)

• Carisoprodol (Soma)

• Diazepam (Valium)

• Alprazolam (Xanax)

• Lorazepam (Ativan)

There are also herbs and amino acids available without a prescription that can be used as GABA surrogates:

• Valerian root

• Ashwagandha

• Taurine

• Brahmi

• Bacopa

Glutamine: GABA’s Precursor

The term “precursor” refers to nutrients or raw material that help make a neurotransmitter. Glutamine is the precursor of GABA. A dose of 2000 mg or more of glutamine a day when taken on an empty stomach with vitamin B6 (2mg or more), will increase your natural level of GABA and probably reduce your pain levels. 

Pure GABA is available as a tablet, capsule or in sublingual (under-the tongue) form in most health food stores or online. Unfortunately, when swallowed in tablet or capsule form, GABA may be digested just like food or fail to cross the blood-brain barrier, and be rendered ineffective.

But sublingual GABA is well absorbed by the body and should be given a thorough trial by every person with IPS. You can take 100 to 300mg sublingual GABA to treat pain flares, or 100 to 200mg of GABA simultaneously with an opioid medication or GABA surrogate for added pain relief.

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

Researchers Urge Caution on Using Steroid Injections for Pain

By Pat Anson, PNN Editor

Doctors and patients should be more cautious about using corticosteroid injections for pain relief, according to new studies that warn of rare, but serious long-term complications for patients who receive epidurals during childbirth or high doses and multiple injections in their hips.

Researchers at Kaiser Moanalua Medical Center in Hawaii looked at health data for nearly 700 patients with hip osteoarthritis and found that those who received steroid injections were 8.5 times more likely to develop rapidly destructive hip disease (RDHD), a condition that causes the loss of blood flow and death of bone tissue in the hip.

Higher rates of RDHD were especially apparent in patients receiving multiple and/or high-dose injections of the steroid triamcinolone. The risk of RDHD following a single, low-dose injection was about two percent, but rose to five percent following multiple low-dose injections or a single high-dose injection, and up to 10 percent following multiple high-dose injections.

“While the risk of RDHD following a single low-dose (40 mg or less) triamcinolone injection is low, the risk is higher following high-dose (80 mg or more) injection and multiple injections. These findings provide information that can be used to counsel patients about the risks associated with this common procedure. In addition, caution should be taken with intra-articular hip injections utilizing 80 mg of corticosteroid and multiple injections,” wrote lead author Kanu Okike, MD, of Hawaii Permanente Medical Group in Honolulu.

As they became more aware of a possible link with RDHD, orthopedic surgeons at the hospital started ordering fewer hip corticosteroid injections. In subsequent years, the number of RDHD cases decreased. The hospital also added a discussion of post-injection RDHD to the informed consent process for patients and stopped performing high-dose corticosteroid injections.

The study, recently published in The Journal of Bone & Joint Surgery, is believed to be the largest to date of patients with post-injection RDHD.

Epidural Injections

Two new studies have also found that women receiving epidural injections for pain relief during labor are at high risk of long-term headaches and chronic back pain if the needle accidentally punctures the dural lining of the spinal cord. Dural punctures or “wet taps” cause the leak of spinal fluid, which can result in serious neurological complications.  

“I’ve likely performed more than 10,000 epidurals in my lifetime, and I still have wet taps from time to time,” Pamela Flood, MD, a professor of anesthesiology at Stanford University School of Medicine, told Anesthesiology News. “But no matter how many we’ve seen, we still feel terrible about each one. We’re trying to relieve people’s pain and give them a wonderful childbirth experience, and the last thing we want to do is cause them complications.”

A study published in the journal Anaesthesia found that over half of women (58%) with an accidental dural puncture were still experiencing headaches 18 months after the epidural, and nearly half (48%) suffered from chronic low back pain. A recent study in the British Journal of Anaesthesia had similar findings.    

Dural punctures during epidurals are relatively uncommon. Women are usually warned there is a risk of short-term headaches, but not about long-term health problems.

“While this information has been creeping into our consciousness in the form of retrospective trials, only this year has it been confirmed with two large prospective trials,” Flood said. “Unfortunately, clinicians have been slow to hear this, perhaps because we don’t want to admit that the short-term concern that we have been discussing for years carries long-term consequences in a significant percentage of women.”

The two most common types of medications used during epidural injections are anesthetics (lidocaine or bupivacaine) or corticosteroids (betamethasone, dexamethasone, hydrocortisone, methyl-prednisolone, triamcinolone). 

In addition to treating labor pain, epidural steroid injections are widely used for back pain. About 9 million epidural steroid injections are performed annually in the U.S., even though they are not FDA-approved. The FDA has warned that injection of steroids into the epidural space can result in rare but serious neurological problems, including loss of vision, stroke and paralysis. Some patients have also developed arachnoiditis, a chronic and painful inflammation of the spinal cord, after getting steroid injections for back pain.

Electro-Medical Therapy Can Help Treat Intractable Pain

By Forest Tennant, PNN Columnist

To maximize relief and recovery from Intractable Pain Syndrome (IPS), it is advisable to employ one or more electro-medical (EM) therapies. All persons with IPS are highly encouraged to try a variety of EM therapies, but only as an adjunct or add-on to their current medical treatment.

Electric Current Devices

Electric current (EC) therapy is probably the best known of the EM therapies. Electric currents primarily have an anesthetic effect, much like a local anesthetic such as lidocaine. They anesthetize nerves or spinal cord nerve roots and provide temporary pain relief. In some cases, EC therapy may even bring about long-term pain relief because electric currents sometimes reset electrical conduction of nerves.

EC devices can vary, like light bulbs, in power and frequency. One advance is called “micro current.” This is a low power frequency in which the current can be transmitted through the earlobe or scalp to treat headaches or central pain.

Electric currents of various powers and frequencies are now combined in products and devices such as transcutaneous electrical nerve stimulators (TENS units), Calmare “Scrambler” therapy, and spinal cord stimulators. Devices with multiple currents usually bring a superior result compared to a single current device.

Unfortunately, only a therapeutic trial will tell you which EC therapy will help you. Many self-help TENS units are available for home use, and they should be tried. All persons who have IPS from a stroke or traumatic brain injury should consider a trial with micro-current therapy.

If you find an EC device that gives you relief, don’t use it every day. As with drugs, you may become tolerant, and the device will become ineffective. Give at least a day between treatments.

Electromagnetic Devices

Electromagnetic (EMT) devices are new to pain treatment and are quite different from EC devices because they use energy that is 50% electric and 50% magnetic. The energy is comprised of sub-atomic particles not usually visible to the naked eye.

EMT energy is generated by devices that manipulate the electric current that is found in every battery or household electrical socket. The energy is condensed into a wave that can be sent into human tissue with a transmitter wand, probe or plate. The energy wave can be administered in different frequencies and wave lengths that vary from a very slow, long wave to a very fast, short wave.

The three major types of EMT are laser, infrared and radio. Infrared is a low-frequency long wave, while radio has long, slow waves. Lasers can put out infrared waves, and also emit visible high energy frequencies which can cut, dissolve or ablate tissue.

In medical administration, long slow waves may penetrate several inches into the human body, while the short high frequency waves of laser and infrared will not normally penetrate human tissue by more than an inch. Some devices pulse the waves to get deeper tissue penetration. These devices are known as “Pulsed Electromagnetic Energy Frequency“ or PEMF.

Lasers may be able to totally remove or dissolve a pain “trigger.” For example, an experienced practitioner may be able to identify a pain trigger along the spine, or neuropathy in the face or extremity, and actually cure the condition with laser treatment.

Infrared is the most effective EMT for pain relief of a recent injury to the spine, joint or soft tissue. It is quite effective for contusions or joint swelling. Infrared can also help drive medication through the skin, so it is very effective if a cortisone cream is applied to the skin during infrared treatment.

Radio waves penetrate deeply. Their best use appears to be for spinal conditions, including herniated discs and other spinal inflammatory conditions, such as arachnoiditis. Deep penetrating radio waves will probably, at least in some cases, reach the interior of the spinal canal.

Major Take Home Point

Patients with IPS are constantly bombarded with the pitch that they need an electromagnetic “savior” such as an implanted electrical stimulator, or an expensive multi-electric current or electromagnetic course of treatment. The parties who sell and promote these devices are invariably unknowledgeable about the serious, relatively rare condition of IPS.

EC and EMT devices are made for acute or short-term pain and injury problems, not constant incurable pain with cardiovascular, endocrine and autoimmune complications.

Implanted electrical stimulators may be a “godsend” to some IPS patients, but they may not work or even cause more pain for others. This is why trials are done prior to implantation. The big problem is that there is so much money to be made with implanted stimulators that some unethical practitioners don’t tell you that they are mainly for breakthrough or flare pain.

There are many risks to implanted stimulators, so every IPS patient needs to remain on a 3-component medical program that combines suppression of inflammation, repair of damaged tissue and pain control.

Once you are on this 3-component protocol and have a good nutritional and physical program solidly in place, then give electromedical measures a try. Simple measures like water soaking or magnets may  also be very helpful. Electromagnetic administration is relatively new and shows great promise!

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

How to Recognize and Treat Intractable Pain Syndrome

By Forest Tennant, PNN Columnist

About one year ago we launched our Intractable Pain Syndrome (IPS) Research and Education Project to bring awareness, diagnosis and treatments to persons who have this merciless condition. Much has been learned in the past year. 

Our original impetus and investigation of chronic pain revealed that some rare patients transform from a state of periodic pain to constant, never-ending pain. Once this constant intractable pain begins, patients often deteriorate, become reclusive, have a shortened life, and some may even commit suicide. Why and how this transformation occurs remained a mystery for many years. 

A major research advance in the past year is the role of autoimmunity, which is the presence of antibodies in the blood that attack one’s own tissues. Autoimmunity is so universal in IPS that we now believe that autoimmunity, plus excess electrostimulation from a disease or injury,  to be the root cause of transformation from simple chronic pain to IPS.  

Recognition of IPS 

The number one challenge in managing and controlling chronic pain is to determine if a person has transformed from simple chronic pain to IPS. Although the scientific documentation is quite sound, there is some resistance in the medical community to the discovery that chronic pain can cause a profound biologic change in multiple bodily systems. These changes may be called “alterations” or “complications,” but the fact is that a chronic pain condition can morph into IPS with cardiovascular, endocrine, and autoimmune manifestations.

The table below shows some of the differences between IPS and simple chronic pain:

The Importance of an IPS Diagnosis

The most common complaint that we receive from persons with IPS is that they can’t get enough opioid and other pain relief medications. The federal government, state medical boards, malpractice insurance carriers, and other health insurers often restrict the number of pills and dosages that can be prescribed and dispensed. As a result, many pain clinics and specialists will only do interventional procedures such as injections or implant stimulators, and will only prescribe limited amounts of opioids, if any.

In order to obtain opioids and some other drugs, particularly benzodiazepines, persons with IPS will need diagnostic tests and a specific, causative diagnosis to prove they have a legitimate medical disorder that will permit their physician to prescribe limited amounts of opioids and benzodiazepines. The major causes of IPS are:

• Adhesive Arachnoiditis

• Connective tissue or collagen disorder (Ehlers Danlos Syndrome)

• Stroke or traumatic brain injury

• Arthritis due to a specific cause

• Neuropathy due to a specific cause (CRPS, cervical, autoimmunity)

Less prevalent, but serious causes of IPS are sickle cell disease, porphyria, pancreatitis, abdominal adhesions, interstitial cystitis, and lupus. 

Your primary diagnosis will have to be validated by MRI, X-ray, biopsy, and/or photographs. Medical records must document the diagnosis. You should have a hard copy and hand-carry a set of your records to all medical appointments.

These diagnoses will not usually be acceptable to obtain opioids because they are too “non-specific” or general:

• Failed back syndrome

• Degenerative spine

• Fibromyalgia

• Central pain

• Headache

• Neuropathy.

How to Cope with Opioid Restrictions

Most local physicians are still able to prescribe two weak opioids: tramadol and codeine-acetaminophen combinations. While weak, they are better than nothing, and you may be able to build a pain control program with one or both medications.

If you have good medical records that document the causes and complications of your IPS, some medical practitioners will prescribe these opioids: 

1. Hydrocodone-acetaminophen (Vicodin, Norco) 3-4 a day 

2. Oxycodone-acetaminophen (Percocet) 3-4 a day 

3. Oxycodone alone, 2 to 3 a day

You may be able to boost the potency of opioids with what is called potentiators and surrogates. These drugs and supplements have opioid-like effects known in pharmacology as “opioid activity.” They can be taken separately between opioid dosages, or they can be taken at the same time, to make your opioid stronger and last longer.

• Kratom

• Palmitoyethanolamide (PEA)

• Cannabis/CBD

• Taurine

• Amphetamine Salts (Adderal)

• Tizanidine

• Methylphenidate (Ritalin) 

• Clonidine

• Diazepam 

• Carisoprodol

• Ketamine

• Oxytocin

Although the restrictions on opioids and benzodiazepines are perhaps unfair and an over-reach for legitimate persons with IPS, there are steps you can take to function with these restrictions.

One is to build a comprehensive, healing, and tailor-made program that will allow you to cope with fewer opioids and benzodiazepines. We’ve written previously about the importance of an IPS nutrition program. Pain relief medications are not very effective unless you have good nutrition.

There are also exercises and physical measures you can take that enhance pain control, such as walking, arm and leg stretching, water soaking, deep breathing, rocking, and gentle bouncing. Supplements can also be taken to help suppress inflammation and autoimmunity, regenerate nerve tissue and provide some pain relief.

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

How Chronic Pain Can Lead to Autoimmunity Problems

By Forest Tennant, PNN Columnist

Every chronic pain patient must know and understand autoimmunity and how to combat it. Research on chronic pain has unequivocally determined that the chronic inflammation and tissue destruction caused by a painful disease or injury will produce autoimmunity.

Autoimmunity is a biologic phenomenon in which certain antibodies in the blood -- called autoantibodies -- turn against the body and attack one’s own tissues. Autoantibody means “self-attack.” This is in stark contrast to “immunity” which means antibodies only attack an invading virus, bacteria, poison or contaminant to protect the body.

Chronic pain that causes inflammation and tissue degeneration generates cellular destruction that can shed tissue particles into the blood stream. These tissue particles are considered foreign and unwanted by the body’s immune system, so it makes autoantibodies against them. Unfortunately, these autoantibodies may then attack normal tissue, giving the patient unexpected symptoms and more pain.

The symptoms and sequelae of autoimmunity can be mysterious and overwhelming. Such disorders as traumatic brain injury, Ehlers-Danlos Syndrome, adhesive arachnoiditis, post-viral, and stroke are particularly prone to the development of autoimmunity.

Although antibodies may attack any tissue in the body, autoantibodies seem to attack the soft tissues such as membranes around organs, ligaments, cartilage, small nerves and intervertebral discs. Another common target is the body’s natural immune protection system, including lymph nodes, thymus gland, mast cells and spleen.

The complications of autoimmunity usually begin without warning. Common clinical manifestations of autoimmunity and the presence of autoantibodies include allergies, skin rash, fibromyalgia, psoriasis, thyroiditis, carpal tunnel syndrome, and arthritis of the joints including the temporal mandibular, elbow and hand joints.

Serious painful and life-threatening autoimmune conditions may also occur, which include the kidney (glomerulonephritis), liver (hepatitis), nerves (neuropathy), spinal canal (arachnoiditis), adrenal gland and the pituitary gland. We now believe that autoimmunity, along with excess neuroelectric stimulation, to be the cause of Intractable Pain Syndrome (IPS).

How To Tell If You Have Autoimmunity

Every chronic pain patient needs to do a self-assessment to determine if their basic pain problem has caused autoimmunity. A failure to control autoimmunity will likely result in progressive complications, misery and probably an early death. As with most other medical conditions, the earlier the recognition, the better the control, suppression and outcome.

Patients should review the following list of some common autoimmune symptoms or conditions. If you have two or more, an assumption can be made that you have autoimmunity and must take actions to control and suppress it:

• Joint pain

• Carpal tunnel

• Histamine episodes or mast cell stimulation

• Cold hands (Raynaud’s)

• Allergies

• Mild recurring fever

• Neuropathy

• Medications stop working

• Irritable Bowel Syndrome (IBS)

• Food or Medication Sensitivity

• Hashimotos Thyroiditis

• Brain Fog

• Fibromyalgia

• Diarrhea, gastric upset, heartburn

• Periodic flushing and itching

• Herniated disc

• Constipation

• Psoriasis

• Exhaustion and Weakness

If you have two or more of these conditions, a laboratory blood test can help confirm it. Autoimmunity and its close association with chronic inflammation, immune suppression and allergy will almost always result in elevations of one or more of the following blood tests:

• C-reactive protein (CRP)

• Lymphocytes or eosinophiles

• Anti-nuclear antibody (ANA)

• Erythrocyte sedimentation rate (ESR)

• Interleukins-cytokines       

• Thyroid peroxidase antibodies (TPO)

• ASO Titer

• Tumor necrosis factor

Automimmunity may also result in decreased immunoglobulins and an altered albumin-globulin ratio.

At this time there is no specific, published treatment for chronic pain-induced autoimmunity. Based on our early investigations, we recommend patients take vitamins, supplements, low dose corticosteroids, low dose naltrexone (LDN) and hormone therapy to control and suppress autoimmunity. Further details can be found here.  

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up here.

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

Why Good Nutrition Is Needed for Intractable Pain Syndrome

By Forest Tennant, PNN Columnist

If you have Intractable Pain Syndrome (IPS) or a condition that commonly causes IPS, such as arachnoiditis, adhesive arachnoiditis, cauda equina syndrome, Ehlers-Danlos Syndrome, traumatic brain injury, stroke or Complex Regional Pain Syndrome (CRPS), you should underpin your treatment program with a nutritional one.

Our research and experience clearly tell us that a proper nutrition program is essential for pain relief and to prevent the progression of IPS. Without a good nutritional program, neither medication or other medical measures will be very effective.

Persons who have IPS develop what is known as a “catabolic state.” The term means that the cellular matrix of the body is slowly degenerating, rather than its normal state of constant cellular regeneration, known as an “anabolic state.”

In IPS, cells and tissues inside and outside of the brain and spinal cord (CNS) progressively degenerate because of IPS’s combined effects of inflammation, hormonal deficiencies, and autoimmune attacks on tissues. If one has a genetic connective tissue/collagen disorder (EDS or other), then cellular catabolism or deterioration is grossly multiplied.

Cellular deterioration in IPS initially attacks small nerve fibers and the small cells in the CNS and skin, but later other tissues may be involved. Muscle mass deteriorates and is replaced by fatty tissue, so weight gain occurs. In late stages of catabolism, severe muscle loss may occur, giving the patient the appearance of starvation and emaciation. Weakness and fatigue set in. Memory, reading ability and logical thinking decline. Medications, including opioids, may not be as effective as they once were.

Persons with IPS must daily attempt to control catabolism through proper nutrition, which helps stop disease deterioration, reduces inflammation, regrows damaged nerves (neurogenesis), alkalizes body fluids, and improves pain relief and energy.

There are five basic components of an IPS nutrition program:

1. Eat protein every day and include protein in ALL meals.

2. Eat green vegetables, and select fruits and nuts

3. Control cholesterol and glucose

4. Daily multi-vitamins and minerals

5. Daily supplements for nerve regrowth and inflammation

Protein is Key

The most critical component of an IPS nutrition program is protein. IPS tends to decrease a desire for protein and promotes a craving for sugar and starches. The major protein foods are beef, pork, lamb, chicken, turkey, seafood, cottage cheese and eggs. Protein drinks and bars can also be used as alternatives.

Why is protein so important? It contains all the fuel (amino acids) needed by the body to make more endorphin, serotonin, dopamine, norepinephrine, insulin and other hormones. Protein builds tissue, repairs cells and helps stabilize blood sugar. Meals with no protein will likely increase pain and inflammation, which prevents healing.

Foods that are mainly sugar and starches (carbohydrates) cause sugar (glucose) to rise in the blood. Fatty foods cause cholesterol to raise in the blood. New research shows that high levels of glucose and fat may cause inflammation and damage to the neurotransmitters and receptor systems that control pain. 

IPS patients should have their glucose and cholesterol levels tested on a regular basis. If abnormally high or low, work with your medical practitioner to normalize them.  

You can help by reducing sugars and fats in your diet, and by eating meals on a regular schedule, even if you are not hungry. This will help balance your glucose and lessen your pain over time.   

You may also want to consider a gluten free trial. Stop eating bread, cereal, noodles and other foods containing gluten for one week to see if you feel better. 

Green Is Good 

Vegetables, fruits and nuts can also help reduce inflammation, alkalinize your body fluids, and promote tissue healing. The best green vegetables are broccoli, kale, brussel sprouts, asparagus, green beans, spinach, snap peas, chard, mustard greens, turnip greens, collards, and cabbage. Avoid eating potatoes and corn, which are loaded with carbohydrates. 

The best fruits are blueberries, pineapple, raspberries, blackberries, cherries, oranges, plums, apples, strawberries, and peaches. Avoid eating bananas. The best nuts to eat are pistachios, almonds and peanuts. 

To help regrow damaged or diseased tissues, take daily supplements containing vitamins B12 and C, collagen, amino acids and natural hormonal agents such as colostrum or DHEA. A daily multi-vitamin and mineral tablet is also helpful, along with a daily plant-based anti-inflammatory agent such as curcumin/turmeric or quercetin. 

Ask yourself: Is what I am eating right now helping or hurting? If you don’t know or want more information, the IPS Research and Education Project has just published a 12-page nutritional program designed specifically for people with IPS. You can download a free copy by clicking here.  

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

Why Do Opioids Stop Working?

By Forest Tennant, PNN Columnist

One of the most common complaints that we receive from people with intractable pain syndrome (IPS) is that opioids quit working when they previously provided good pain relief. They usually report that increasing the dosage was ineffective as well. The cause is known as “opioid receptor failure.”

Every person with IPS who takes daily opioids needs to carefully review the information given here. Once your opioid quits working, it will likely not work again. You can be left without good pain control options.

Patients are at risk for opioid receptor failure if they use a long-acting opioid such as a fentanyl patch, or oxycodone, morphine, hydromorphone or methadone. Intrathecal pump administration of any opioid also raises the risk for opioid receptor failure.

The reason for this is that long acting and intrathecal opioids never leave the blood and spinal fluid. Consequently, they continually coat opioid receptors, and with prolonged use they literally render the receptor incapable of pain relief.

A good analogy is stretching a rubber band too long and seeing it lose its elasticity. The receptors may become permanently altered. Short acting opioids leave the blood and spinal fluid for a time and that lets the receptors recuperate and re-energize, so opioids usually stay effective over a long-time period.

How to Keep Opioids Working

1. Opioid receptors hold up better in patients who take vitamin and mineral supplements, and have diets low in sugar and starch, and high in proteins and green vegetables.

2. Hormone levels must be normal to keep opioids effective. Opioid receptors require adequate blood levels of testosterone, cortisol and pregnenolone.

What To Do If Opioids Quit Working

Here are six recommendations to try, but remember when opioids quit working, they may not work again.

1. Get a hormone test for testosterone, cortisol and pregnenolone. If you have a deficiency, start hormone therapy and continuously raise the dosage over a 6-week period until your hormone level is normal.

2. Start a nutrition program with vitamins, minerals, and a low sugar/starch, high protein/green vegetable diet.

3. Switch to a short acting opioid, if possible.

4. The addition of an adrenaline or dopamine stimulant such as Adderall or Ritalin may help.

5. Get an injection of ketorolac to determine if this potent anti-inflammatory analgesic may provide some pain relief.

6. Take taurine 4,000-8,000 mg per day for 5 days. If there is improvement, continue at 2,000 to 4,000 mg per day.

If you are doing well on a long-acting or intrathecal opioid, don’t stop. Some persons on long acting and intrathecal opioids do well for years. But don’t get overconfident. Opioid receptor failure can be sudden and unexpected. 

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

Inflammation Cascades Cause Intractable Pain Syndrome

By Forest Tennant, PNN Columnist

The greatest research breakthrough in recent years that will provide much hope for persons with intractable pain syndrome (IPS) has been the discovery of the “inflammatory cascades” inside the central nervous system (CNS). Now that this is known, there are specific measures to take to reduce or halt this process.

Most persons with IPS have two inflammatory cascades, one in the brain and the other in the lower spinal canal. They are called cascades because one area of inflammation can ignite another in a continuous chain reaction and spread.

Excess electric currents enter the brain from a bodily site of damage or diseases. In response to tissue injury, inflammation initially begins around receptors and spreads to other parts of the brain, just like the inflammation that causes cellulitis on the skin.

Inflammation in the lower spinal canal usually starts in a protruding intervertebral disc or due to a puncture, infection or injury to the dura-arachnoid covering of the spinal canal.

Once inflammation starts in either the brain or inside the spinal canal, it may not ever cease or burn-out. It may even silently continue to spread and damage CNS tissue with progressive pain and disability.

How to Control Inflammation

While pain relief is always the first thing on the mind of an afflicted person, measures to control and suppress the inflammatory cascade are essential. Normal anti-inflammatory agents don’t usually enter the brain or spinal canal in adequate amounts to be very helpful. You must use multiple agents that cross the blood brain barrier.

Every person with IPS must be on a daily program that include three measures to control the cascades of CNS inflammation or your condition will likely deteriorate. This can be done through diet, vitamins and supplements that help prevent inflammation; medications that reduce inflammation; and movements that help keep spinal fluid flowing.

Review the three measures listed here with your family and medical practitioners. Select the nutrients, medications and exercises to develop a program that best fits you.

You must continue daily cascade control for as long as you have pain. Opioids and other analgesics, by themselves, do not control the inflammatory cascades. Without a cascade control program, you can expect that your pain relievers will diminish in effectiveness and may totally stop working.

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

Do You Have Central Sensitization or Intractable Pain?

By Forest Tennant, PNN Columnist

Chronic pain patients may now be told by their doctor, nurse practitioner or pharmacist that they have “central sensitization” (CS). This vague, non-descriptive term is unfortunate in many ways. Nevertheless, it appears to be here to stay. 

Since Intractable Pain Syndrome (IPS) is a far more serious condition that requires an aggressive, multi-component treatment approach, it is essential to know the difference between IPS and CS. 

Going forward, we believe that it will be increasingly difficult to obtain some medications unless you have IPS. Therefore, it is of vital importance to not only know if you have IPS, but you must be able to clearly explain it to your physicians, family and insurance carrier. If you have simple chronic pain or CS, you could be quite limited in obtaining many prescription medications. 

Definition of Central Sensitization: Amplification or heightened pain above what would normally be expected from tissue damage or injury. 

CS occurs when brain tissue starts to alter due to excess electric currents that originate in damaged or injured tissue. Brain tissue alteration is referred to as neuroplasticity. CS can often be recognized if pain advances, because it begins to cause insomnia and requires daily, rather than “as-needed” medication. 

CS is the forerunner or precursor of IPS. Almost all persons with IPS have had or currently have CS. There is a movement among medical practitioners to recognize CS and treat it with drugs like duloxetine (Cymbalta) or pregabalin (Lyrica) to prevent it from advancing to IPS. 

Definition of Intractable Pain Syndrome: Constant, incurable pain with cardiovascular, endocrine and autoimmune complications.

Only some medical conditions cause IPS. The most common are arachnoiditis, Ehlers-Danlos syndrome, brain injury and Reflex Sympathetic Dystrophy (RSD or CRPS). 

Levels of estradiol and testosterone often go down with IPS, causing symptoms which include amenorrhea in women (missed menstrual periods), impotence in men, fatigue, loss of sex drive, osteoporosis and loss of teeth.

Your autoimmune system will also be affected by IPS, causing elevation of inflammatory markers, cytokines, proteins, and white blood cells.

This could result in symptoms of fibromyalgia, thyroiditis, carpel tunnel syndrome, TMJ, mast cell activation, and migratory joint pains.  

Pain from IPS will cause elevations of pulse and blood pressure. Cortisone and insulin levels will also go up, causing elevations in glucose and cholesterol.

“Going forward, we believe that it will be increasingly difficult to obtain some medications unless you have IPS... If you have simple chronic pain or CS, you could be quite limited in obtaining many prescription medications.”

— Forest Tennant

It is up to the pain patient with IPS to educate all concerned parties that their CS has turned into IPS and that it is a serious syndrome with cardiovascular, endocrine, and auto-immune complications. 

Each person with constant pain needs to catalogue the above manifestations and make a record to give to your medical practitioners and pharmacist. If you haven’t had blood tests for hormone and autoimmune dysfunction, you must request these be done. Please review our website and obtain materials on IPS for your medical practitioners and pharmacist. 

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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

Is Your Spinal Pain Inflammatory or Neuropathic?

By Forest Tennant, PNN Columnist

Every person with Adhesive Arachnoiditis (AA) or other spinal canal disorder needs to determine if their pain is primarily inflammatory, neuropathic or both. Why? The treatments are different.

AA is fundamentally an inflammatory disease that involves two different intraspinal canal tissues: the cauda equina nerve roots and the arachnoid-dural covering of the spinal canal. The inflammation causes damage to the nerve roots, so electricity either can’t pass or it doesn’t pass in a smooth, natural flow.

Nerve damage that blocks or alters electricity conduction is called “neuropathic” pain. AA usually has both inflammatory and neuropathic pain, but the inflammation may resolve and leave behind damaged nerve roots and neuropathic pain.

The inflammatory and neuropathic pain of AA may also develop into Intractable Pain Syndrome, which is constant, incurable pain with cardiovascular, endocrine (hormonal) and autoimmune complications.

Persons with AA usually need to treat both kinds of pain – inflammatory and neuropathic --   but one type may be predominant. A blood test for inflammatory markers is helpful, but not totally diagnostic.

If your pain improves with a trial of ketorolac (1 or 2 injections) or a corticosteroid (Medrol Dose Pak or dexamethasone), you have active inflammation that must be treated. We also recommend botanical anti-inflammatory agents, such as curcumin/turmeric, Andrographis and serrapeptase.

Prescription medications for neuropathic pain include gabapentin (Neurontin), diazepam, carisoprodol, topiramate, Lyrica and Cymbalta.

Every person with AA of the cervical and/or lumbar spines should experiment with topical medications, such as the Salonpas patch, lidocaine gel or patch, Voltaren gel and diclofenac (prescription needed).

Topical medication that is applied and massaged into the skin may dissolve through the tissues to the inflamed or damaged area. On average, you can expect 10 to 25% additional pain relief, plus the potential to permanently reduce your pain. Sometimes topical  medication will relieve painful areas that other drugs taken orally or by injection cannot reach.

Forest Tennant is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. This column is adapted from bulletins recently issued by the Arachnoiditis Research and Education Project. Readers interested in subscribing to the bulletins should send an email to tennantfoundation92@gmail.com.

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

Low Dose Naltrexone Emerging as Treatment for Intractable Pain

By Forest Tennant, PNN Columnist

A major advance in pain management is the discovery of low-dose naltrexone (LDN), a non-opioid medication used to treat substance abuse. When prescribed off-label, LDN not only relieves pain, but has anti-inflammatory and immune boosting properties on brain and spinal cord tissues. It is now the preferred, first drug of choice for people living with constant, intractable pain.

Only those persons who are not currently on daily opioids should take LDN. A major purpose of LDN is to prevent the necessity of daily opioids, including buprenorphine/Suboxone.

A starting dosage of LDN is usually 0.5 – 1.0 milligrams taken twice a day. The average maintenance dose is about 3 – 5mg given twice a day. The maximum dose is about 7mg taken twice a day.

LDN should ideally be a part of a multi-drug program. A nerve conduction blocker (neuropathic) agent such as gabapentin or diazepam will almost always boost pain relief. A dopamine surrogate such as Adderall, Ritalin or mucuna, is also very helpful.  Routinely recommended are standard anti-inflammatory (e.g., Ketorolac) and tissue healing anabolic agents (e.g., DHEA).

A pain flare medication should also be handy and ready. Some patients taking LDN can occasionally take a low dose of tramadol, codeine or hydrocodone for pain flares. Other flare medications include ketamine, CBD, medical marijuana, ibuprofen (800mg), oxytocin, kratom and ketorolac.

Caution and Warning

Persons who currently take daily opioids must withdraw from opioids before starting LDN. In our studies, patients sometimes became deathly ill if they took LDN while still on opioids. Severe withdrawal may set in, pain relief will diminish and, at worst, a cardiac-adrenal crisis may be precipitated.

If one has Intractable Pain Syndrome and is currently on a regimen including opioids that satisfactorily reduces pain, there is no medical reason to switch to LDN.

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

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