Criminalizing Pregnant Women for Drug Abuse Is a Terrible Idea

By Dr. Lynn Webster, PNN Columnist

According to Guttmacher Institute, nearly half the states in the United States are willing to punish pregnant women in order to spare their babies the agony of being born with Neonatal Abstinence Syndrome (NAS). Ironically, their efforts are having the opposite effect.

Twenty-three states and the District of Columbia have passed legislation that criminalizes substance abuse during pregnancy. Additionally, 25 states and the District of Columbia require healthcare providers to report expectant mothers who may be illegally using substances. In 8 states, pregnant women who are suspected of substance abuse must also undergo drug testing.

The huge number of babies born to mothers dependent on opioids has driven policymakers to find ways to deter pregnant women from abusing opioids.

But new research points out there are unintended consequences to criminalization. And it provides lawmakers insight on how to create more effective policies that result in positive, not punitive, outcomes.

A study published recently in the journal JAMA Network Open examined 4.6 million births in the U.S. from 2000 to 2014. During this time, the diagnosis of NAS increased seven fold.

The study was conducted by the RAND Corporation, a nonprofit research institute that analyzed 8 states with punitive policies for drug-abusing pregnant women. The research was funded by the National Institute of Drug Abuse.

According to a RAND press release, Arkansas, Arizona, Colorado, Kentucky, Massachusetts, Maryland, Nevada and Utah adopted either punitive penalties for drug use during pregnancy or policies that required health care providers to report pregnant women with suspected illegal substance use.

RAND researchers found that the annual rate of NAS increased in the 8 states, from 46 cases per 10,000 live births to 60 cases per 10,000 after punitive policies were enacted. That is an alarming 30% increase in NAS cases.

This is not the first study that has shown political efforts to curb opioid addiction and overdoses have not had a positive impact. We have seen the harm associated with forced tapers and dose limits adversely affecting millions of pain patients.

It is hard to understand why these destructive policies are put in place, but it may be because policymakers are misinformed or biased. Regardless, it reflects a systemic flaw for governments to fail to evaluate the efficacy and outcomes of the very policies they create.

Addiction Is a Disease, Not a Crime

How best to address addiction has long been the subject of debate. For example, a state hospital in South Carolina illegally obtained the diagnostic tests of pregnant women in an effort “to obtain evidence of a patient's criminal conduct for law enforcement purposes” (this was the case of Ferguson v. Charleston).

Unfortunately, some people still believe that addiction is a volitional or character flaw that should be recognized as criminal behavior rather than a disease.

Indisputably, addiction is a complicated, life-threatening disease. Treating people with the disease as criminals is the worst possible approach. Most experts in the substance abuse treatment community have known this for years. Fortunately, the RAND Corporation has now provided evidence of how this applies to babies born to women who abuse opioids. 

Typically, lawmakers do not evaluate the impact of the policies they pass. There have been many policies over the past few years that were implemented by state legislatures, healthcare organizations and insurance companies that were intended to reduce harm from opioids. Almost no one has attempted to measure their effectiveness or unintended consequences.

Fortunately, in this case, we have an exception. We have a unique opportunity as a result. The RAND study should provide policymakers with insights on how to more effectively address the problem of substance abuse during pregnancy.

Threatening to punish a pregnant women does not decrease the number of women who abuse drugs. However, it does scare many of them away from seeking the treatment they need and can deter pregnant mothers from seeking prenatal care.

Pregnant women who are opioid-dependent frequently use other illegal substances that risk the health of their babies. There should not be more barriers for pregnant women to receive prenatal care. Infants born after exposure to opioids often require prolonged hospitalizations to manage their needs, with those cumulative costs totaling more than $500 million, according to the RAND study. More importantly, babies with NAS suffer needlessly.

It should go without saying that every policymaker wants to solve problems and not create additional harm for new mothers or to babies born to them. Hopefully, this study will be used as it is intended: to help create policies that actually reduce harm from opioids. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is the author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences or Pain News Network. 

Little Evidence to Support Rescheduling of Tramadol

By Roger Chriss, PNN Columnist

The consumer watchdog group Public Citizen has petitioned the FDA and DEA to “upschedule” the opioid painkiller tramadol. The DEA set tramadol as a Schedule IV drug in 2014, and the petition urges moving it to a more restrictive Schedule II, on the same risk level as hydrocodone and oxycodone.

The petition claims that tramadol is “an increasingly overprescribed, addictive, potentially deadly narcotic.” But the basis for this claim and the assumption that upscheduling will help are problematic.

The CDC reports that there were approximately 1,250 fatal overdoses involving tramadol in 2017, the most recent year for which data is available. Like most fatal overdoses, tramadol deaths often involve multiple drugs, so it’s hard to draw any conclusions from those deaths.

Tramadol is complex, with a highly variable patient response. Some patients have such a strong negative reaction to the drug that they refuse to take it again. Others find it too sedating at high doses or too weak to provide adequate pain relief. Abuse, addiction and overdose can also occur with tramadol.

Recently Harvard Health looked at a JAMA study on the risks of using tramadol versus other pain relievers. Tramadol was found to have a higher risk of death than anti-inflammatory medications such as naproxen (Aleve), while people treated with codeine had a similar level of risk.

“However, because of the study’s design, the researchers could not determine whether tramadol treatment actually caused the higher rates of death. In fact, the patients for whom tramadol is prescribed could make it look riskier than it truly is,” said Robert Shmerling, MD, an editor at Harvard Health.

Unintended Effects of Upscheduling

Understanding the effects of upscheduling is tricky. In 2014 the DEA reclassified hydrocodone (Vicodin) from Schedule III to the more restrictive Schedule II. The reclassification accelerated a trend that was already underway – hydrocodone prescriptions had been falling since 2011.

But there were unintended consequences to upscheduling. A recent University of Texas study found that decreases in hydrocodone prescribing after its rescheduling “were larger in patients being treated for cancer.”

Anotherr study found that upscheduling led to a substantial decrease in hydrocodone prescribing in hospital emergency departments, but that was offset by an increase in prescriptions for codeine and anti-inflammatory drugs.

Upscheduling hydrocodone has also had a negligible effect on overdoses, which are largely caused by illicit fentanyl, heroin and other street drugs, as well as non-opioid medications such as Xanax.

Similarly, predicting the impact of new prescription opioids is difficult. Breathless warnings about the opioid Zohydro, which was approved as a Schedule II drug in 2014, proved false. “There was no great surge of overdoses” after Zohydro was introduced, as Chris MacGreal wrote in his book “American Overdose.”

Fears about opioids are also delaying the introduction of safer medications. The experimental opioid NKTR-181 has less abuse potential than traditional opioids, but its approval is uncertain because the FDA has stopped all advisory committee meetings on opioid analgesics.

Public Citizen ignores all this. It also fails to mention other actions the FDA could pursue, from making naloxone into an over-the-counter drug to improving access to medication-assisted therapy for opioid use disorder. There’s no petition to have the DEA “nix the wavier” for buprenorphine (Suboxone) to make it more widely available or to have the federal government promote the Pain Management Best Practices Inter-Agency Task Force report.

Finally, there’s no call to monitor outcomes. As PNN has reported, opioid tapering has had tragic unintended consequences. And a new Cochrane review on the effects of educational and regulatory efforts targeting prescribers was unable to draw any conclusions “because the evidence is of very low certainty.” The authors could find only two relevant studies that assessed prescribing policies adopted in the 1990’s.

There are good reasons to be cautious about tramadol. But there are probably better ways than upscheduling to reduce risks and improve outcomes. As a result, Public Citizen's petition seems quite narrow and unlikely to help with the overdose crisis.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

This column 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.

EPA Decision Will Stifle Animal Research on New Pain Treatments

By Dr. Lynn Webster, PNN Columnist

People in pain rely on scientific advances to find safer, more effective alternatives to opioids. Animal research is key to many of our advances in drug development.

But a recent announcement from the Environmental Protection Agency threatens to change that -- by inhibiting science’s ability to replace opioids and create new life-saving pain interventions.

EPA administrator Andrew Wheeler announced in September the agency's decision to "significantly curtail its reliance on the use of mammals in toxicological studies conducted to determine whether environmental contaminants have an adverse impact on human health."

The EPA plans to reduce funding for most mammal studies by 30% by 2025 and eliminate them altogether by 2035.

The agency also announced that five universities would receive $4.25 million in federal funding to develop alternatives to reduce or replace the use of animals in research.

Ostensibly, Wheeler worries about the potential mistreatment of animals used in testing. But Natural Resources Defense Council (NRDC) scientist Jennifer Sass believes he may be politically motivated.

“The Trump administration appears to be working on behalf of the chemical industry and not the public,” Sass said in an NPR interview.

Most likely, the American Chemistry Council, which represents chemical companies, would prefer to eliminate mammal studies that could prove the toxicity of their products. Wheeler, however, claims he hasn't talked to "a single chemical company about this."

According to The New York Times, the American Lung Association, the American Heart Association, and the American Medical Association disagree with Wheeler's strategy. Lab-grown cells and computer modeling can reduce the need for animal testing. But Penelope Fenner-Crisp, a former senior official at the EPA, believes 2035 may be too soon to ban all animal studies.  

"There's currently no substitute for [testing] some of the more complex and sophisticated toxicities, such as the effect of chemicals on animals' reproductive systems," she said.

The NRDC, an environmental advocacy group, also opposes the EPA's plan to ban animal testing on the grounds that it could make it harder to identify toxic chemicals and protect human health.

Animal research has played a key role in developing many new technologies, including MRIs, ultrasounds, CT scans, and new surgical techniques. It has also played an integral role in the development of vaccines, pain relievers and other medications, as well as life-saving emergency care.

“Virtually everything a doctor, nurse, veterinarian, veterinary technician, paramedic, or pharmacist can give the injured or sick was made possible by animal research," says Dr. Henry Friedman, a neuro-oncologist who leads the opposition to the EPA decision.

Dr. Friedman says sophisticated computers can be helpful in many areas of scientific research, but they "can't predict everything a new drug will do once inside you." He also maintains that laboratory animals are treated humanely under strict guidelines.

Speaking of Research, an international advocacy group that supports the use of animal research, believes the EPA's plan endangers human, animal and environmental health.

"This directive flies in the face of the EPA’s mission to 'protect human health and the environment' and 'to ensure that national efforts to reduce environmental risks are based on the best available scientific information.' Animal-based research and testing is critical for understanding how new chemicals and environmental substances affect human and non-human animals," the organization said in a statement.

Many of us in the scientific community oppose the EPA’s decision because it could slow drug development and threaten our ability to find safer and more effective treatments for pain, addiction and other diseases. If the EPA decision is sustained, it will be a major obstacle to the advancement of medical science.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is the author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences or Pain News Network.

How to Control Anxiety and Pain Through Meditation

By Dr. David Hanscom, PNN Columnist

Every sense in your body has a threshold that indicates danger – hot, cold, bitter, loud, bright, sharp, pressure, burning, nausea, etc. Without that immediate feedback from your senses, you could not protect yourself from whatever the danger is.   

When any physical threat is sensed, your body secretes chemicals and hormones to increase your chances of survival. They include cortisol, adrenaline and histamines. This chemical bath affects every cell in your body and you are on “high alert.” The feeling generated is anxiety and it is not a psychological reaction. 

Humans have a problem in that mental threats manifested by unpleasant thoughts are processed in similar area of the brain and cause the same hormonal response. But since we can’t escape our thoughts, we are subjected to sustained levels of these chemicals. One of the effects is increasing the speed of nerve conduction. All of our senses are heightened, including various types of pain.  

Environmental Awareness 

Being aware of your senses – known as environmental awareness –-- is a strategy that allows you to switch sensory input from racing thoughts to another sensation. It doesn’t matter which sense you choose.

I practice one that I call “active meditation” or “meditation on the run.” Being aware of your senses has a calming effect on your nervous system. Active meditation enabled me to be a calmer person and more effective in my work.  

As a retired spine surgeon with many years of experience, I was often referred complicated spine problems that required complex surgeries. Sometimes those surgeries resulted in complications for the patient. Although I was committed to having no complications from the first day I walked into the operating room, there was a point a few years ago when I faced up to the fact that I hadn’t been able to eliminate them. My own thoughts were interfering with my work.  

The most common interferences I felt during surgery were frustration, anxiety, distraction, complacency, and, especially, being in a rush to finish. They all detracted from the consistency of my performance. This led me to develop a somewhat defensive mindset. If I could get through the week without a surgical complication, it was a huge relief.  

Learning Active Meditation

Things changed when I decided to enlist the help of a performance coach to help me reduce any mistakes in surgery. That was a major turning point in my professional life. I brought my coach into the operating room and clinic so he could better understand my world. For 18 months, he and I underwent regular debriefings and coaching. I began to use active meditation in the operating room. 

This meditation model is not based on suppressing interference – for instance, if you’re frustrated, you don’t pretend otherwise – rather, you face these frustrations and then detach from them. Using tools and approaches that have been employed for centuries in the practices of meditation and mindfulness, I learned to identify any interference either before or during surgery, and then let go of it.  

This is how it worked: Each surgical morning, I woke up and assessed how I was feeling. Like everyone, my feelings ranged from calm and relaxed to tired and anxious. Then, I immediately started sensing every smell, touch and taste possible. I felt the water on my back in the shower. I smelled the coffee. I also reminded myself that although that day’s surgery is “just another case” for me, it’s one of the most important days of my patient’s life.  

I continued this process in the operating room. I carefully arranged the room, talked to each member of the surgical team, and reviewed the imaging studies. I was focused and immersed in what’s right in front of me, when previously I’d rush into the operating room at the last minute just before making the incision. 

During surgery, awareness allowed me to perform my next move at an optimum level. I felt my grip pressure on each surgical tool; noticed the shape of the contours of the anatomy; felt my shoulder and arm muscles stay relaxed; and just watched the flow of the case.  

If I felt any disruptive emotions intrude into my state of mind, I quickly practiced my environmental awareness techniques in order to re-focus. I learned to be more fully engaged on a higher percent of cases, so I could “program” myself into the “zone.” 

Since I started practicing active meditation, my complication rate in surgery noticeably decreased. For instance, from 1999 until 2003 I had an “acceptable” 9% rate of inadvertently entering the dural sac (a sack of fluid surrounding the brain and spinal cord). After I started using meditation, I made this mistake only two or three times a year, which is less than one percent. 

Surgery became a wonderful experience for me. I eagerly looked forward to Monday instead of Friday. I committed to getting a good night’s sleep before my surgeries.  If I woke up “wired” and uneasy, I slowed down until I felt relaxed, no matter how many things were on my to-do list.  

I continue to practice active meditation daily. Environmental awareness is more difficult outside the operating room, in the less controlled areas of my life, but it is still my go-to active meditation.   

One tool I use to practice awareness is my “to do” list. I remind myself that this list is an expression of my life, and so I practice being aware as I go about each item. For instance, when I have an appointment with a patient, I listen to myself talk to him or her.  I feel the pen on the paper as I jot down notes.  I also practice meditative techniques. such as watching the disruptive thoughts of “need to finish up here, I have other things to do” enter my consciousness and then leave.  

I remember that my goal is to engage and enjoy every second of my “to do” list. It doesn’t always work, but it’s surprising how often it does.

Environmental awareness engages me in the present moment regardless of the circumstances. It is not positive thinking, but just switching the sensory input. With repetition, it has become somewhat automatic. It is a simple strategy that can help the quality of your life, regardless of the level of your pain.  

Dr. David Hanscom is a retired spinal surgeon who has helped hundreds of back pain sufferers by teaching them how to calm their central nervous systems without the use of drugs or surgery.

In his latest book, Do You Need Spine Surgery?, David explains why spinal surgeries are often risky and unnecessary.

This column 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.

Can Melatonin Put Your Chronic Pain to Sleep?

By A. Rahman Ford, PNN Columnist

Melatonin is popularly known as the sleep hormone. Less known is its potential to alleviate chronic pain and inflammation.

Melatonin is a natural hormone produced by the pineal gland in the brain. During the day the pineal gland is inactive, but at night it begins to produce melatonin and helps us sleep.

As a supplement, melatonin is widely promoted for its efficacy as a sleep aid. However, its role in reducing inflammation – a major contributor to chronic pain – may be much more important. Many chronic pain conditions are a result of underlying inflammation.

In a recent Nature article, melatonin was called a “master regulator” of inflammation. Several studies have shown that melatonin can regulate activation of the immune system, reducing chronic and acute inflammation.

Research shows that melatonin supplements can modulate inflammation by acting as powerful antioxidants and free radical scavengers. Uncontrolled free radicals in the body can lead to oxidative stress, which can cause inflammation and culminate in diseases that cause chronic pain.

There is a large body of evidence that melatonin is a potent antioxidant, even more potent than vitamins C and E.  It’s been successfully used to treat fibromyalgia and irritable bowel syndrome, diseases associated with high levels of oxidative stress.

Melatonin is also a strong antimicrobial, and emerging research shows that some chronic inflammatory conditions may be caused by infections. One study found melatonin effective in treating certain drug-resistant bacteria such as Staphylococcus aureus, Pseudomonas aeruginosa and Acinetobacter baumannii. Similar results were found when testing ten different pathogens, including Escheria coli and Salmonella typhinurium, with melatonin.

Melatonin and Chronic Pain

A therapeutic role for melatonin in the treatment of painful autoimmune conditions has been theorized.  A 2013 study noted that melatonin plays a role in the pathogenesis of conditions such as multiple sclerosis and systemic lupus. In animal models of these diseases, melatonin supplements were found to have protective effects. A 2019 review concurred, concluding that melatonin can serve as a new therapeutic target in treating autoimmune diseases.

A review of the scientific literature on chronic pain syndromes found evidence of melatonin’s efficacy as an analgesic in several conditions including fibromyalgia, irritable bowel syndrome and chronic back pain. Studies also showed melatonin’s effectiveness in treating cluster headaches ad tension headaches.

A small clinical trial of 63 females with fibromyalgia found that melatonin, alone or in combination with the antidepressant amitriptyline, significantly reduced pain when compared to amitriptyline use alone. The authors concluded that the melatonin treatment had a direct effect on the regulation of pain.

There has been some evidence that melatonin supplements can help reduce lower back pain. In a 2015 study, researchers found a significant reduction in pain intensity during movement and at rest in patients with back pain.

Melatonin has also been successful in treating migraines. In an open-labeled clinical trial of 34 patients suffering from migraine, 30 mg of melatonin given 30 minutes before bedtime was found to reduce headache intensity as well as frequency and duration, with significant clinical improvement after one month.

Although the scientific evidence is only slowly emerging, melatonin is a widely-available, inexpensive and safe supplement that may aid you in your fight against chronic pain.

A. Rahman Ford, PhD, is a lawyer and research professional. He is a graduate of Rutgers University and the Howard University School of Law, where he served as Editor-in-Chief of the Howard Law Journal.

Rahman lives with chronic inflammation in his digestive tract and is unable to eat solid food.

The information in this column 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.

An Open Letter to a Loved One From a Chronic Pain Sufferer

By Mia Maysack, PNN Columnist

The sun is shining and the birds are singing. It’s a beautiful day.

I open the door to let my doggy daughter out and the brightness peers through like a lightning strike straight to the hypothalamus. I'm struck by intense searing pain that feels like a hot poker through my eye -- otherwise known as a cluster headache attack.

I try not to dwell on the inevitable reality of the hearty serving of migraine that's sure to make its encore appearance soon.

The next plan of action is to get my head into an ice bucket, but I first must draw all the blackout curtains in every room.  The day is done, at least for now, and I am at the mercy of these ailments. There's no way of knowing how long they'll last so I focus on breathing, as I attempt to calm my nervous system.

Me writhing in pain is the unfortunate greeting my loved one often receives after his long days of working in the world, while I’ve remained inside this cave, putting in long hours at the hardest job I've ever had -- surviving this. 

When we initially got engaged, I planned the entire wedding in only two weeks because I must take full advantage of the moments when I'm at my most able. At the time, I was still making a nursing salary and able to contribute my fair share to the festivities.

Much like any other couple, we had plans. To begin a family, travel the world and support one another in making our dreams come true.  

As things worsened through the years and pain levels heightened, my condition reached a point where even hugging hurt me. This was a very difficult loss and forced me to reflect on the situation – and what being and having a soul-mate looked like.

There are days it is almost impossible to take care of myself, and as heartbreaking as the realization initially was, the decision not to commit my life to another was made. 

This didn't change the fact that this person is my best friend. We have shared the purest form of intimacy, which is remaining present for one another throughout the worst of times -- when it's not ideal, convenient and downright hard.

Whether in the form of sleepless nights at the ER, helping to brush my hair, holding onto me to help my balance, or slowing his pace so I can keep up -- regardless of an official relationship or title that others understand -- he is and always will be my family.

I appreciate him for many reasons, one being that he accepts there's only so much I can do. He does not consistently attempt to “fix” me, because we've both learned the importance of surrendering to the current moment while always maintaining hope in better ones to come.

By remaining devoted to his presence in my life, he's making a conscious effort to reassure me that I am not alone — never losing patience or becoming resentful no matter how many times I have to postpone plans or cancel commitments.

He sees me as more than just the "Sick Girl." He's complimentary of who I am outside of these illnesses, as well as the warrior I've become as a result of them.  

Perhaps I won't ever have a glorious wedding and maybe this isn't going to be a white picket fence fairy tale. But to have someone who understands what I have to offer and what I don't, respects my need for freedom, and displays selfless acts of sacrifice is one of the greatest gifts in my life. Shouldering these burdens together is the truest testament to love I have ever experienced. 

It's beautiful to have that mutual acceptance, free from judgement or expectation, to simply just be who and what you feel. I thank the universe for this person, as well as the others in my support system.

Mia Maysack lives with chronic migraine, cluster disease, fibromyalgia and arthritis. Mia is a patient advocate, the founder of Keepin’ Our Heads Up, an advocacy and support network, and Peace & Love, a wellness practice for the chronically ill and those otherwise lost or hurting.

The information in this column 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.

Survey Repudiates Canada’s Pain Care Policies

By Dr. Lynn Webster, PNN columnist

A recent survey by the Chronic Pain Association of Canada (CPAC) demonstrates all too well that our Canadian neighbors are sharing in the misfortune of America’s man-made crisis in pain care.

The online survey was distributed to patients via social media during a two-month period in the summer of 2019. CPAC received 740 responses from all 10 provinces and the territory of Nunavut. Key findings add to the growing evidence that people in pain are suffering from policies aimed at reducing access to pain medication.

• Almost two-thirds of respondents (64%) reported they have not had adequate pain control in the past two years

• A similar number (66.2%) feel discriminated against and degraded because they require opiate medicines to cope with severe pain

• A third of patients (33.5%) have either been abandoned by their doctors or their doctors have refused to continue prescribing for them

• Close to half (47.8%) have been forced against their will to taper their doses

• Nearly 45% either have deteriorated relations with their medical providers or no longer have a doctor

• Almost 40% were not adequately treated for pain in emergency rooms

Substitutes for opiates have not helped. About 70% of patients surveyed say they are more disabled, can do less with their lives, and their quality of life has declined.

Desperate Solutions

Almost 40% of patients have considered suicide because of the increased pain, while 5.4% have actually attempted suicide. A third of respondents (33.5%) reported that they know of someone who did commit suicide because of increased pain.

One other “desperate solution” is that nearly 10% of patients have substituted dangerous street drugs for what they previously received as safe prescriptions. Nearly a third of respondents (30.8%) reported they know patients who are purchasing street drugs for this reason.

Based on these findings, CPAC Executive Director Barry Ulmer penned a letter to Canada's Minister of Health.

"I’m writing on the first day of Canada’s National Pain Week, when the country notes the tragedy of chronic pain, the right of all Canadians to have their pain relieved, and government’s obligation to ensure appropriate and timely care,” Ulmer wrote.

“Yet two million Canadians with ongoing pain serious enough to warrant treatment with opioid analgesics still suffer profoundly — and pointlessly — because federal policy dismisses their needs. In today’s opioid-averse regulatory climate, their access to care shrinks precipitously as Canada’s pain specialists vanish from practice, and especially from prescribing."

Ulmer's letter further describes how people in pain feel that they are being erroneously blamed for Canada’s overdose problem. Many are being forced to taper or discontinue their pain medications. 

The CPAC findings mirror the results of a U.S. survey by Pain News Network which was released on the third anniversary of the 2016 publication of the CDC opioid prescribing guideline.  

In a critique of Canada’s 2017 opioid guideline – which was modeled after the CDC’s -- the Canadian Family Physician reports the guideline has left the Canadian health care system unable to manage its high-dose opioid patients:  

“However well-meaning they are, the 2017 Canadian opioid prescribing guidelines were introduced to a health care system ill equipped to care for patients with chronic pain. 

Without a clear and implementable patient-oriented strategy, combined with universal training in safe and effective chronic pain and addiction management for all health care providers, well-meaning documents like the 2017 Canadian guidelines might inadvertently harm the very people they hope to help."

As in the U.S., Canadian doctors are refusing to prescribe the opioids that patients need and alternative treatments are insufficient. The pharmaceutical industry is being villainized and health care professionals who prescribe opioids are under pressure to inappropriately adhere to a one-size-fits-all solution for pain patients.  

It is understandable that politicians want to reduce the harm from inappropriate use of opioids, but it should not be at the expense of people in pain. This is a human rights issue that must not be ignored.   

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences or Pain News Network.

What We Can Learn from Germany About the Opioid Crisis

By Roger Chriss, PNN Columnist  

Germany doesn’t have an opioid crisis. As NBC News reported, 10 times as many Americans as Germans die from drug overdoses, mostly opiates. And while opioid addiction rates in the U.S. have risen dramatically, in Germany they’re flat.

The story of Germany challenges much of the narrative about the American opioid crisis. If addiction moves in lockstep with opioid prescribing, then Germany should have high addiction rates. If prescription opioids lead to heroin use, then Germany should be seeing rising rates of heroin use. And if overdoses are an inevitable consequence of addiction, then Germany should have high overdose rates.

But this is not what is happening. According to a recent PLOS One study, opioid prescriptions in Germany are rising, but there is no “opioid epidemic.”

“Even though patterns of opioid prescription follow trends observed in other developed countries, there are no signs of an opioid epidemic in Germany. Therefore, this review could currently not find a need for urgent health policy interventions regarding opioid prescription practices,” the study concluded.

A report from the European Monitoring Centre for Drugs and Drug Addiction shows that drug overdoses in Germany are falling. There were 1,926 overdose deaths in Germany in 2006 and 1,272 in 2017. Overdoses peaked in Germany over a decade ago.

Rates of drug use in Germany show that cannabis and MDMA (ecstasy) have been trending upward in recent years, amphetamine use is stable, and cocaine use is falling among young adults. In people seeking drug treatment, addiction to cannabis and cocaine are rapidly rising, but opioid addiction fell sharply in 2016 after a rise in the preceding decade.

Yet Germany has the second-highest prescription opioid rate in the world. And if current downward prescribing trends hold in the United States, Germany will have the highest rate by late 2020.

Easier Access to Rx Opioids

But Germany simply isn’t having an opioid crisis, which one expert attributes to the country’s well-established social security network and full health insurance coverage.

“Many specialist pain treatment centres by now will report cases of chronic pain patients with inappropriate opioid therapy, who then have to be weaned off the medication. However these are only isolated cases and there is no increase in inappropriate use of opioids in Germany in general,” Lukas Radbruch, a palliative care physician at University Hospital Bonn in Germany, explained in the BMJ.

Radbruch belongs to an expert committee that regulates and monitors opioid use in Germany.

“In Germany regulations for opioid prescription have been changed throughout the years to allow easier access to these medicines - for example, extending the maximum amount per prescription or the maximum duration of each prescription,” he wrote. “There is consensus in the committee that there is no indication of anything similar to the opioid crisis in the US, and no indication of an increase in inadequate prescribing of opioids in Germany.”

Rhetoric about prescription opioid risks rarely includes the details of prescribing. But it turns out that if patients are given non-opioid options first, then screened and monitored during opioid therapy as is done in countries like Germany, the risks are far lower. The risks are lower still when problems of misuse and signs of addiction are caught early and addressed medically.

In other words, maybe the U.S. has an opioid crisis as a result of doing virtually everything wrong. From excess pharmaceutical marketing and poor patient management to a lack of multimodal pain treatment and addiction care, we almost couldn’t not have had an opioid crisis.

And once the crisis got started, we failed to respond quickly with best practices, in particular the overdose rescue drug naloxone and harm reduction policies. Instead, we embraced doomed tactics like abstinence programs and forced tapering of medications.

The most recent data from the CDC does show some encouraging news. From March 2018 to March 2019, the overdose death rate fell by 2.2 percent. The provisional counts for 2019 show an overall flattening of overdose deaths, but no sustained downward trend.

Most of this progress is in fewer fatalities linked to prescription opioids. But illicit fentanyl is spreading westward, and from San Diego to Seattle a rise in overdose deaths has been seen throughout 2019, much of it caused by counterfeit medication. So the “gains” of last year may quickly evaporate. Fentanyl is cheap to make, easy to distribute, and getting into the entire drug supply. Meth and cocaine are resurging, too.  

The drug overdose crisis is evolving fast. Most overdoses involve multiple substances, often with inadvertent exposure or as a result of counterfeit or tainted drugs. And some are suicides. Now in the vaping outbreak we are seeing the impact of new technologies and new chemicals used in novel ways.

As the RAND Corporation noted in its September report on fentanyl, we need new options fast. Germany’s preventative healthcare, proactive public health monitoring, and coordinated harm reduction policies may provide sound ideas for a sensible response to the rapidly evolving drug crisis in the U.S.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

This column 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.

Can We Forget About Chronic Pain?

By Ann Marie Gaudon, PNN Columnist

I recently came across a clinical report which describe two patients with a lengthy history of chronic pain severe enough to warrant opiate therapy. Both patients experienced sudden memory loss and forgot about their pain – literally.

Central sensitization is a process known to occur in the spinal cord and brain where if short-term acute pain is allowed to persist, then changes occur within the central nervous system which can lead to chronic or intractable pain.

That’s what happened to me. I have a diagnosis of a visceral pain syndrome, as opposed to a progressive pain condition. I experienced one vicious organ assault and after more than 30 years of it being healed, I remain in pain.

Other patients who have experienced painful trauma may relive painful episodes that evoke recurring memories -- they experience their pain over and over again. That is a classic symptom of post-traumatic stress disorder (PTSD). Think of a war veteran or survivor of sexual violence.

Either way, neurophysiologic changes which relate to learning, memory and pain can result in a maladaptive learning process which leaves one in chronic pain. These intricacies happen outside of conscious awareness. We are not aware of or in control of this dysfunctional process while it is occurring within our brain and spinal cord circuits.

Here is an overview of the two patients discussed in the report:

Patient #1

The first patient is a 47-year old female with complicated health problems. She had undergone multiple surgeries and treatment modalities for gastric ulcers, endometriosis, thyroid cancer, hypothyroidism, seizure disorder, malnutrition and chronic abdominal pain over 10 years.

Her pain was managed with high doses of opiate medications in various forms, including intravenous, transdermal and oral. During a complex 12-month hospital stay, she had at least five seizures and suffered memory loss so severe she could not remember her entire stay in the hospital.

She did eventually become fully alert and oriented to the present, but she no longer complained of her pain symptoms and no longer demonstrated a need for consistent pain medication.

Six months after discharge, the patient was living at home in stable condition and only occasionally using tramadol. She reported her symptoms as minimal and 1-2 on the pain scale. She still has no memory of many aspects of her long hospitalization.

Patient #2

A 57-year old male was described as a “highly functioning architect” with a 10-year history of low back and right extremity pain. He had undergone many unsuccessful treatments for pain, including surgery, and was being admitted to hospital to have an intrathecal pump surgically implanted for pain control. He was taking no less than nine medications for pain including high doses of opiate therapy.

Initially after the pump was placed, he reported having a partial reduction of pain in his leg. However, in the next six months he was requesting higher doses of intrathecal as well as oral opiates.

One month after this, the patient was in a minor motor vehicle accident where he did not lose consciousness, but inexplicably had partial memory loss. His physicians felt the accident was not the cause, as the memory loss symptoms occurred long afterward. The cause of the amnesia was unknown and tests including a brain MRI showed as normal.

The patient could not remember the names of his doctors, where he lived, what type of work he did, or why he had a pain pump implanted. He was weaned off opiates without any complaint of increased pain and subsequently had the pump removed at his request.

Eight months later, this patient was found minimally responsive in his home. It is not known what occurred, but there was a suspicion that he had fallen and incurred a head injury. The patient experienced profound memory loss, with no memory of who he was, his family members or his back pain.

His pain medications were discontinued with no complaint of pain, but he required placement in a long-term care home due to severe amnesia. Over the next two years, this patient regained partial memory, along with some back and leg pain. He has not requested or required opiate therapy.

Emotions, Pain and Memory

We know pain perception can be caused by nociceptive stimuli, yet we also know that emotional and psychological factors can increase our perception of pain. A complex play of nerve fibers which transmit messages to the brain and spinal cord suggest there is a relationship between emotions, pain and memory. The best evidence that memory plays a role in pain is that of phantom limb pain.

The two cases presented here suggest that memory may influence the perception of pain, and that amnesia can be accompanied by a loss of or significant reduction of pain in the absence of any physical factors.

Treatments that reduce “pain memories” in the brain and spinal cord, along with a focus on preventing pain to reduce or eliminate these memories, may someday have a more widespread role in the management of chronic pain. To have a treatment or ability to effectively erase a maladaptive pain memory leaves me with just three words:

Count me in.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management. 

Ann Marie has been a chronic pain patient for over 30 years and works part-time as her health allows. For more information about her counseling services, visit her website.

This column 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.

Documentary Champions Holistic Approach to Chronic Pain

By A. Rahman Ford, PNN Columnist

A new, eye-opening documentary is challenging conventional wisdom about chronic pain treatment. Rather than treat pain as a purely biomedical issue, On a Scale of 1 to 10: The Silent Epidemic suggests a holistic, multi-disciplinary approach to pain treatment that addresses the physical, social, psychological and spiritual dimensions of who we are as human beings.

According to the film’s website, the motivation to make the documentary was to show people “a different path to regain their quality of life” without the use of prescription opioids and surgery. The film features clinics and wellness centers that use new diagnostic tools, innovative research and advanced products and therapies. 

The film was produced by Citrus Pie Media Group and was written and directed by Laurent Goldstein and Executive Produced by Jennifer Unruh.

To set the inspirational tone for the film, Goldstein opens with his own personal story. As a result of a herniated disc, he had lower back pain so severe he could not walk, sit or stand without intense agony. He found his freedom from pain in chiropractic, spinal decompression treatments and a targeted anti-inflammatory regimen.

With this holistic approach, Goldstein was able to avoid surgery. His personal struggle and triumph over chronic pain, as well as the stories of other patients, motivated him to make the film.

Goldstein’s passion is particularly evident in the scenic snapshots of Canadian landscapes and seascapes that he strategically places throughout the film. They amplify and reinforce the film’s emphasis on natural modalities of healing.

The nearly two hour long documentary is well made and chock full of information, but also thoughtfully introductory in its tone, making it understandable to those new to holistic and integrative methods of healing. The film provides enough detail about what these treatments are and how they work, but not so much that it overwhelms the viewer with medical minutia and jargon.

The messages and themes in the film are compelling. Although it does get technical in some areas, the documentary is far from clinical in its presentation. On the contrary, the emotional success stories told by everyday people who have conquered their chronic pain make the film personal and relatable.

They made the conscious decision to liberate themselves from mainstream medicine because they were fed up with misdiagnosis, mistreatment and crippling financial expense.

Experts and Influencers in Alternative Health

Goldstein interviews health and wellness influencers such as psychiatrist Daniel Amen, Dr. Michael Klaper, Dr. Neal Bernard, psychologist Beth Darnall and Barby Ingle of the International Pain Foundation (iPain). Through conversation with these experts, a wide range of alternative medical approaches are discussed. These include nutrition, physical exercise, immune system function, hormone balancing, digestion, and vitamin/mineral supplementation.

Other therapies include laser therapy, stem cell therapy, medicinal herbs, sound/vibration therapy, floating therapy, light therapy, hypnosis, meditation and energy healing. All of these approaches are aimed at healing the underlying condition, not just masking the symptoms.

For example, a key focus of the film is the nutrient-deficient American diet, which is seen as a primary culprit in causing chronic pain. Meat and dairy are especially bad for human health, with one expert recommending “meat abstinence.” One pain sufferer was able to get off of all medications with a diet of fruits, vegetables, berries, nuts and seeds, and has remained medication-free for ten years.

All in all, the documentary is a thought-provoking window into the multifaceted causes of chronic pain and the novel approaches that fed-up pain sufferers are turning to. The film takes an expansive view of what pain is and challenges viewers to summon the courage to abandon preconceived notions of health and wellness, and to open themselves up to new avenues of healing.

On a Scale of 1 to 10: The Silent Epidemic will open the International Pain Summit in Los Angeles on November 14. iPain has recognized the film with its 2019 Community Impact Award.

A. Rahman Ford, PhD, is a lawyer and research professional. He is a graduate of Rutgers University and the Howard University School of Law, where he served as Editor-in-Chief of the Howard Law Journal.

Rahman lives with chronic inflammation in his digestive tract and is unable to eat solid food.

The information in this column 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.

How CBD Helped End My Insomnia

By David Eaton, Guest Columnist

Due to a decrease in my opioid pain medication (to fall within the CDC guideline), my pain level increased to the point that I was unable to sleep. Of course, lack of sleep affects your overall health and so I began a downward spiral and needed something to break that cycle.

My son, who has been suffering acute pain from scoliosis in his neck, was having similar insomnia issues. He tried CBD oil and recommended that I do the same.

I knew little about CBD, so I talked to the very knowledgeable and helpful manager of a local CBD store. His recommendation was that I begin by researching CBD myself and then talk about it with the doctor at my pain clinic -- advice that impressed me as being very responsible.

After spending a day or two reading online articles, including some here on Pain News Network, I ran the idea past the physician’s assistant at my pain clinic.  She thought it was a great idea and asked me to try it before my next appointment with her in 4 days.

I placed another call to the manager at the CBD store and he recommended starting with a CBD infused "candy bar." My wife went there the next day and paid $25 for a white chocolate, peach and hazelnut flavored candy bar containing 120 mg of CBD.

DAVID EATON

The chocolate bar was scored in such a way that it can be divided into 4 servings, each with 30 mg of CBD. The manager’s suggestion was for me to try a single piece the first night and then take one and a half sections the following 2 nights. So that's what I did. 

Prior to trying the CBD, I had experienced a lot of pain-induced insomnia and found it difficult to sleep for more than an hour at a time.  It was not uncommon for me to wake up 10 times during a 12-hour effort to sleep. 

Most people do not realize how important a good night's sleep is to your health and well-being.  After my insomnia got severe, I installed an app on my phone (Sleep as Android) to track how much I slept each night.

After taking my nighttime meds and my last "dose" of CBD chocolate, I fell asleep around 8 pm.  According to the sleep app, which amazed me by its accuracy, I slept until 3 am, waking up feeling very rested and refreshed.

I decided to stay awake long enough to write this article before going back to sleep at 4 am. I slept until 10:45 that morning.

In all, I got about eleven and a half hours of deep sleep over the course of about 13 hours!   

As far as I am concerned, the use of CBD to reduce my pain and promote relaxation is an overwhelming success. I will be investing in a bottle of CBD oil on my next trip to town. 

David Eaton is disabled by chronic pain caused by degenerative disc disease, migraines and arthritis. He lives in Georgia.

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

The information in this column 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.

Seeing Red: How Colors Affect Pain

By Dr. Lynn Webster, PNN Columnist

It is a myth that the matador’s red cape -- the muleta -- incites rage in the bull and causes him to charge. The truth is, all cattle are colorblind.  The bull does not charge because of the color, but because of the movements of the matador and his cape.

It is not a myth, however, that color can affect the moods of humans. Researchers have studied how colors affect psychological states, such as anxiety, in people.

We now know that color also affects how people perceive pain. In this month’s issue of Pain Medicine, authors Karolina Wiercioch-Kuzianik and Przemyslaw Babel present “Color Hurts: The Effect of Color on Pain Perception,” exploring how color can affect the perception of pain.

A 2007 study reported more intense pain when a painful stimulation was preceded by a red color than a blue one. The new study builds on that work through two experiments.

In the first, 30 volunteers were shown six colors, one at a time, followed by mild electric shocks to their forearms – seven shocks with each color.

The participants, who knew in advance what the research would involve, reported their pain on a scale of 0 to 10 following each stimulation.

A black image was the control to which all the colors were compared. Black was chosen as the control because it is regarded as the absence of color.

The investigators found that the color red produced the most intense pain, followed by green and blue. Other colors were associated with less pain.

The results are not necessarily intuitive. Red may bring people joy when it takes the form of blooming roses, succulent berries, or wonderful memories of Christmas. But in this study, red increased pain levels.

The second experiment was designed to assess whether colors would affect the expectation of pain and pain intensity. Participants viewed a color and then received a series of mild electric shocks. Again, pain intensity was rated higher with some colors, particularly with red, blue and green. The investigators did not observe that specific colors influenced the participants' expectation of pain intensity.

Much has been written about how and why colors can affect our cognition and behavior. Our reactions to colors seem to be a result of biology and cultural imprinting. Interestingly, many people are aware that individuals supposedly have a “personality color.” Human resource professionals have even used color personality tests to assess job applicants.

Our folklore and traditions bestow certain meanings to colors. Snow White represents purity and innocence, while Edgar Allen Poe used a black raven to symbolize death. The Great Gatsby and other stories use the color gold to suggest greed.

Colors affect us psychologically and physically. As the authors of the Pain Medicine study concluded, colors can also influence our perception of pain. Thus, it may be important for researchers and clinicians to recognize that a patient's reported pain could be affected by the colors of the exam room or even the ambiance of a clinic.

It may be time to for people in pain to consider how their choices of clothes, furnishings, and even paint and wallpaper may factor into their levels of comfort.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.

My Doctor Was Fired for Not Treating My Chronic Pain

By Chris Jolley, Guest Columnist

I was with my pain doctor for 20 years at the same clinic and on the same dosage until April 2017, when the medication that controlled my pain was stopped.  I had gone for a routine follow-up when a new doctor I had never seen walked into the exam room to tell me he was stopping all pain medication for each patient within one month.  

I have spina bifida, scoliosis, fibromyalgia, chronic kidney stones, and more. My worst pain is from migraines, including chronic cluster migraines, several ruptured discs from a back injury, and severe disc degeneration.  

Because of the migraines, my husband created a dark room and I spend most of my time in there.  My back pain makes me change positions every hour.  I do not get much sleep.  

Last year I had one of the worst cluster migraines. On its 5th day, I had a flare up from my disc rupture and my chronic kidney stones started dropping. I was in horrific pain.

I have a pain contract, so my son called the clinic to let them know he was taking me to the emergency room.  He was told he could take me, but under no circumstances could they give me any pain medication.

CHRIS JOLLEY

My son called 3 more times and on the third call was told we needed permission from the doctor, who had already left for the day. The next day, my son was told the same thing. The ER could not treat my pain.

No one should suffer horrific pain. But pain patients are being abandoned by doctors and profiled by pharmacists who refuse to fill our prescriptions, even for cancer.  A family pet would never be allowed to live in such pain.

Before April 2017, I was happy, able to work, involved in many craft projects, and saw my daughter and grandchildren often, even though they live 40 miles away.  

After months of appointments with the new doctor, I told him that I think about suicide every day and sometimes every hour because of the pain.  He did not even look at me and walked out the door.

This doctor was fired for what he did to me, and the doctor who replaced him put me back on pain medication. I was shocked by this.  

I took the new prescriptions to 3 large pharmacy chains and they refused to fill them, citing the 2016 CDC opioid guideline as law.  Fortunately, a few months later, I found a local pharmacy that had no problem filling the prescriptions. I am doing so much better now.

Chris Jolley lives in Utah.  

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

The information in this column 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.

More Bad Data on Rx Opioids from Health Canada

By Marvin Ross, PNN Contributor

Canadian health officials are still blaming opioid prescriptions for Canada’s overdose crisis. A new report by the Canadian Institute for Health Information (CIHI) that was funded by Health Canada points out that more than 9,000 people died from opioid-related overdoses between January 2016 and June 2018.

“While many of these harms may be due to the use of illicit opioids, such as heroin or fentanyl, prescription opioids are also contributing to the public health issue,” the CIHI report found.

The data the report presents shows significant declines in opioid prescribing, but no evidence that prescriptions are to blame for the overdoses.

For example, the total quantity of opioids prescribed in Canada between 2016 and 2017 dropped more than 10 percent, while the number of prescriptions fell more than 400,000.

From 2013 to 2018, there was an 8% decrease in the number of people prescribed opioids.

Fewer Canadians are taking opioids long-term and the number on daily doses over 50 MME (morphine milligram equivalent) also declined, which is likely the result of people being tapered.

There were signs of aggressive tapering. The proportion of patients taking over 90 MME fell significantly, from 25.7 percent to 16.6 percent. And more people stopped taking opioids for at least 6 months than ever before.  

But there was no discussion anywhere in the CIHI report of whether these decreases were medically beneficial for the patients involved -- which surely must be a consideration. Healthcare should be about improving care for people, not just cutting them off.  

We do know anecdotally that these changes are making pain care worse. I personally experienced the reluctance to treat pain when I recently cracked a knee cap.

“What about pain control?” I asked the ER doc. Over-the-counter Tylenol was her answer. She said Tylenol 3 – which contains codeine -- would give me constipation, so she would not prescribe it. Anything stronger, she said, would make me fall down and that would not be to my benefit.

The Toradol shot she gave me worked for a few hours. Fortunately, I had some Tylenol 3 at home leftover from a tooth extraction. Thank goodness for dentists, but taking the Tylenol 3 for something other than what it was prescribed for made me an opioid abuser.

Evidence Lacking

As for prescriptions being a significant cause of the crisis, the CIHI report provided a footnote to a report from the Public Health Agency of Canada, which states that illicit fentanyl and its analogues appear to be fueling the crisis. Males between the ages of 30 and 39 were the most prevalent victims of overdose death. Further, 82% of the deaths involved multiple drugs.

What do those figures have to do with chronic pain patients who tend to be older and female?

Here is their proof: In 2016, over 20 million prescriptions for opioids were dispensed, which is equivalent to nearly one prescription for every adult over the age of 18, making Canada the second-largest consumer of prescription opioids in the world after the United States.

That’s an interesting fact, but it does not show that prescribing to people who need analgesics has fueled the increase in overdose deaths. It only means there are a lot of Canadian adults in pain.

They also cite a 2015 survey, which found only 2% of those who had a prescription for opioids misused them. A more recent 2017 survey found that nearly a third of people who used opioid medication did not have a prescription. That proportion increased to almost 50% for teens under the age of 18, and 88% of those were illegal drug users.

As for the source of these unprescribed drugs, the Public Health Agency states:

“There are many routes that allow for prescription opioids to be diverted for nonmedical use, including sharing with family members, ‘double doctoring,’ prescription fraud and forgery, street drug markets, thefts and robberies and Internet purchases, making it difficult to estimate the proportion diverted. Through its surveys, Health Canada found that the most common source of opioids used without a prescription was a family member.”

They have no idea how these drugs get out there and admit there are many routes, but conclude that most come from family members who have a prescription for them.

What proof do they put forth? This is the reference they provide in a footnote to prove something that is contentious and disputed:

“Health Canada. Baseline survey on opioid awareness, knowledge and behaviours for public education research report. Ottawa (ON): Prepared by Earnscliffe Strategy Group for Health Canada; 2017. Unpublished report.”

When they say unpublished, I assume that this report was never submitted to a peer reviewed journal. Or if it was, then it was rejected. Scientific research should be published in peer reviewed journals where a panel of experts in both methodology and subject matter determine if the study is any good and will add to our collective knowledge of the topic. That is how science is advanced.

Regardless, the Earnscliffe report is buried on a government website and they tell us it cost almost $100,000. The report is largely based on an online survey with self-selected participation. Because of this, “no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population.”

In other words, they cannot claim that any of their findings are valid. Just saying that opioid prescriptions are diverted from family members does not make it true. As the report indicates, even the teens who participated in the survey were conflicted about where illicit prescription opioids come from:

“The most common way of obtaining opioids illegally was from a friend or relative with a prescription, and the most common reason for taking them was pain relief. When teens were asked where they thought people their age get illegal opioids, the most common source was a drug dealer or other stranger.”

So much for the alleged proof that the illegal market is mostly comprised of drugs diverted from legal prescriptions. The findings here are similar to my experience, where I used a prescription given for tooth pain for a knee fracture. If I did not have the pills leftover, I would have obtained what I needed from a relative.

The initial published report went on to disprove their own hypothesis on the role of opioid prescriptions by saying that about 2% of Canadians used illegal drugs in 2015, including the “use of crack, cocaine, ecstasy, speed or methamphetamines, hallucinogens or heroin and therefore was not specific to opioids.”

The Canadian government is simply blowing smoke when it comes to proof that prescribing is fueling opioid overdoses. Canadians can only hope that after the federal election we get a new health minister who is a bit more logical. But I am not holding my breath.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He is a regular contributor to the Huffington Post.

The information in this column 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.

A Day in the Life of a Chronic Pain Sufferer

By Katie Burge, Guest Columnist

My day usually begins around 3 a.m., whether I want it to or not.  No matter what time I went to bed or how tired I am, I wake up in those pre-dawn hours, overwhelmed by excruciating pain and trembling from a panic attack caused by the pain. I wake up because I hurt too bad to stay asleep.

Don't get me wrong. I'm happy enough just to wake up at all - but what I wouldn't give some time to actually get a good night's sleep.

I grab a cup of coffee and debate whether or not I can "afford" to take a pain pill that will give me some modicum of relief. I have to be extremely careful with my medication.  I can't just take a dose because I'm in agony and need it. I don't get enough to allow myself that luxury. My monthly prescription for pain medication allows me to survive semi-comfortably for just over half the month.

It feels like I'm on an evil roller coaster ride, where my pain levels off for 3 or 4 hours, then spikes exponentially over the next few hours until I can take another dose.

As my day progresses, I try to choose the optimum time to take my pain medication, depending on what I need (or attempt) to accomplish for the day.  I struggle to take a shower, do the dishes or fix something to eat. Some of my time is spent writing.

One of the most important things in my life right now is advocating for better treatment for all chronic pain patients. I would like to be physically able to go to the state capitol or even to Washington DC to lobby for more compassionate treatment and to convince the bureaucrats there that pain patients are not to blame for the "opioid epidemic."

But that will have to wait until I can get my own pain reliably controlled.

When I do sleep, I dream about being able to do theater again, travel somewhere other than to a doctor's appointment or to run -- do any of a hundred things I’d like to do if I could exist away from the recliner that I essentially live in. It's the only place where I can find some degree of comfort.

For the past 20 years I have been dealing with increasingly severe chronic pain from a plethora of conditions like degenerative disc disease, failed back syndrome, spinal stenosis, spondylolisthesis, osteoarthritis, myofascial pain syndrome and fibromyalgia.

Any one of these conditions can generate enough pain to make a grown man cry like a little girl.  Combined, they can transform a normally relaxing shower into a study in torture -- where the droplets of water hitting my skin feel like daggers.

KATIE BURGE

Over the years, I think I've tried every treatment offered by medical science, as well as many alternative treatments - anything that might have the potential to take my pain down a notch or two. Once, I even started studying medical texts, trying to gain enough of an understanding of the logistics of pain that I could design a visualization exercise that would help me control it.

I never wanted to end up taking opioids. The pain medication I take is what's known as a "short-acting" or "immediate release" opioid, a type of drug that's actually designed for temporary acute pain, not round-the-clock chronic pain like I have.

Unfortunately, doctors are afraid to use the extended release medications that were actually designed for continuous pain.  This is the result of legal and political pressure from politicians who think they can solve the opioid epidemic by torturing pain patients. Somehow, they believe they can keep recreational drug users from overdosing by denying pain sufferers the legitimate medical use of opioids.

Short-acting opioids offer pain relief for a period of about four hours.  I am expected to make it a full 8 hours inbetween doses. That's where the evil roller coaster comes in. I take my medication, which gives me up to 4 hours relief, and then the pain spikes over the next 4 hours — making me feel worse than I did to start with.

It's up and down, up and down all day long and it's exhausting! If I was allowed to take the medication as it was made to be taken (every 4 hours), it would afford me more enough pain control that I could build a more normal life for myself. Doctors used to say it was safer and better that way, but that was before they became so afraid.

When it starts getting dark each day, I can feel the panic rising in my chest because soon it will be time to sleep and that means more pain. The depression and shame tend to crop up when it gets dark as well. The depression comes from being so isolated. As a person in pain, you spend a lot of time alone.

The shame comes from just being in pain in the first place, as society seems to tell us that we should be able to control our pain mentally, without medical or pharmaceutical intervention.

This is my day... EVERYDAY.

It's starting to get dark now, and the panic is boiling up again.

Katie Burge lives in Mississippi.  

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

The information in this column 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.