Do You Have ANT’s? How Awareness Helps Avoid Negative Thoughts

By Dr. David Hanscom, PNN Columnist  

This is the third in a series of columns on awareness -- a meditative tool that can be used to calm the nervous system to reduce pain and anxiety.  In my previous columns, I looked at environmental awareness (how mindfulness lowers stress hormones) and emotional awareness (how moods affect how we feel physically). 

The third level of awareness I’d like to introduce you to revolves around judgment and storytelling. On this level, you create a “story” or a judgment about yourself, another person or a situation. These judgments tend to be criticisms that are rough and inflexible. The brain has a bad habit of focusing on negative judgments that ramp up our emotions. 

We can categorize these negative thoughts into ten “errors of thinking” outlined by Dr. David Burns in his book “Feeling Good.” Burns calls these thoughts “ANTS,” which stands for automatic negative thoughts.

For example, imagine someone at work walked by you and didn’t acknowledge you. You might think they’re upset with you about a situation that occurred the day before. The error in thinking in this case would be “mind reading.” You can’t read other people’s minds. 

It’s possible that the other person had just received some bad news and wasn’t engaging with anyone. But you don’t really know. If you make assumptions, you’re wasting a lot of emotional energy.

Labeling 

Then there is the error of labeling. For example, a frequently late spouse becomes “inconsiderate.” A forgetful teenager becomes “irresponsible.” In the act of labeling, especially negative labeling, you’re overlooking circumstances and someone’s good qualities, limiting your capacity to enjoy being with them. 

Then there are the labels we have for ourselves: you knock something over and call yourself “clumsy.” If a lover breaks up with you, then you’re “unlovable.”  

Rehashing these critical judgments in our minds turns them into deeply embedded stories. Such stories are much harder to move on from than single judgments. Once a judgment sets into a story, you tend to lose all perspective. Over time, faulty thinking can become your version of reality. 

In my own experience, whenever I have an “ANT,” I become either angry or anxious (or both). I am also sometimes more reactive or impulsive. These emotions fuel negative thought and it becomes repetitive. As the thought keeps whirling around, it becomes stronger, along with my emotions. They quickly destroy my day and negatively affect my relationships. 

I’ve heard this thought pattern described as a vicious cycle or whirlpool. These kinds of thoughts, or stories, can become recurrent and might last for years. They take on a life of their own even though they are often fairly outrageous.  

Regardless of what sets these patterns of thinking off, they are a universal part of the human experience. This is true whether chronic pain is involved or not. With chronic pain you have the added frustration of the physical stimulus to keep these circuits really spinning.  

Self-Perceived Flaws 

To better understand the story concept, consider common situations where the brain focuses on a self-perceived flaw that is not physically painful. It might be your height, weight, the shape of your body, or even an individual body part. Or it might be some particular quality, such as a lack of intelligence, athletic skill, musical talent, etc.  

Thinking about these flaws over and over snares you in a destructive cycle of spinning neural circuits. For example, many years ago I had a patient with neck pain who was absolutely convinced that he was “stupid.” His self-labeling wasn’t rational, as he was clearly a bright guy. I don’t know if his view of himself somehow triggered it, but he eventually developed a significant chronic burning sensation around his mouth. 

Something similar often happens in the entertainment industry, where performers commonly focus only on their negative reviews. My wife, who is a tap dancer, has seen this in her profession for years. She pointed out to me that a performer might have 99 positive reviews but will fixate on the one that’s negative. It’s a common saying among entertainers that, “You’re only as good as your worst critic.” 

ANT’s and Relationships 

Another common phenomenon is focusing on a spouse or partner’s negative traits. The other person usually has innumerable positive qualities that are forgotten in the face of their “flaw.” Over time the “story” we tell ourselves can become so strong it can break apart an otherwise great relationship. 

One particular event from my own life comes to mind. It shows how creating stories has the power to disrupt your peace of mind and detract from your enjoyment of life. 

One day my wife and I were taking my father for a ride up to beautiful Point Reyes, located on the coast north of San Francisco. About 20 minutes into our trip I noticed that the car’s low-tire-pressure light had come on. It was a brand new car with only a thousand miles on it, so I thought it was probably just a malfunctioning light.  

I wasn’t convinced that we’d made the correct decision to buy this car in the first place -- it was more expensive than I was comfortable with -- so I was more than a little frustrated that the warning light had a glitch. 

I stopped to put a little air in the tire, just in case, and then kept driving for another 45 minutes. As we approached Point Reyes in the early afternoon, we realized that the tire was really low, so I pulled over to change it. But when I opened the trunk, there was no spare.  

The story in my head was starting to ramp up as I wondered in frustration why a new car wouldn’t have a spare. I called the car company’s roadside assist line and they told me these new cars had “run-flat” tires that should be good for 150 miles at a maximum speed of 50 miles per hour.  

I felt a little insecure about that concept. We were a long way from the last large town we’d passed and I thought that we should turn back. My wife thought that since my father rarely made it to California from the East, we should go out to dinner. So, we headed toward a restaurant. About three miles down the road the tire exploded. 

It was now about four o’clock in the afternoon and we were miles and miles from anywhere. Our only option was to get towed courtesy of AAA. It was hard for me to accept the fact that I had to get my new car towed for a flat tire.  

The tow truck driver showed up to take us to the service station and let the three of us ride in the cab, with my wife sitting on my lap. She started to complain about the bumpiness of the ride, which I found a little annoying. “I’m the one on the bottom, why are you complaining?” I thought.  

She wanted to have dinner in San Rafael and take a taxi home. I started to grind my teeth to keep my mouth shut. 

Magnifying the Problem

This is how the afternoon unfolded for me. Starting with the low tire, I’d made a decision to enjoy my time with my family in spite of the problem. I took note of my frustrations and concentrated on listening to the conversation and staying involved in the day. I was successful for a while -- until the tire blew up.  

Then my anger began to bubble. I became aware that in spite of everything I’d learned about dealing with stress, I was greatly magnifying the problem with the ANT thoughts in my head. I was thinking things like, “I can’t believe I got talked into buying this car” and “My wife made me buy it.” 

Although there might’ve been some truth in the things I was telling myself, I recognized that it wasn’t helping us get through the situation. Nonetheless, I wasn’t able to minimize my suffering through the stress relief techniques that had helped in the past, which was frustrating. I tried to talk myself out of it, but it didn’t work. 

Then I began to go really dark with thoughts like, “How can I be married to this woman?” I began to notice how irrational and big these thoughts had become. It felt like a bomb had exploded. I was miserable way out of proportion to the situation. 

I was guilty of multiple errors in thinking. They came in the form of labeling – “My wife is irresponsible”— and catastrophizing -- “Why did we get married?”  

Through it all, I negated her many positive qualities. To cite one, she’s great at keeping things light, no matter what the problem. And unlike me, she was able to keep her cool throughout the day. 

In the past, I would’ve remained in this agitated state of mind for days, with some carryover lasting for weeks. I wouldn’t have been able to separate my wife’s actions from my thoughts and realize that the problem wasn’t her, it was my reaction to the situation.  

It was a major step for me to become aware of how out of proportion the stories in my head had become. This degree of awareness changed the game for me. 

Eventually, we did get towed home. We went out to dinner. I still love my wife. And I learned yet another lesson in humility.

Dr. David Hanscom is a retired spinal surgeon. In his latest book -- “Do You Really Need Spine Surgery?” – Hanscom explains why most spine operations are unnecessary and usually the result of age-related conditions that can be addressed through physical therapy and other non-surgical methods.

A Cautionary Tale About Living Wills

By Dr. Lynn Webster, PNN Columnist

If you become sick and incapacitated, who will decide what type of medical treatment you receive?

Many people don’t want to leave it to chance. They document their end-of-life preferences in an advance healthcare directive – also known as a living will -- believing that will ensure that their wishes are followed.

However, too often that doesn't happen. As The New York Times reported, the language in advance healthcare directives is often unclear, so doctors and family members may not know what their legal obligations are under specific circumstances. Having an advance healthcare directive may also provide a person a false sense of comfort -- if nobody knows it exists.

One woman’s story is an example of how end-of-life wishes can be ignored. “Frances” was estranged from her family, so she asked her longtime business associate, Eleanor, to be her health care proxy.  If there ever came a time when Frances couldn't make her own decisions, Eleanor would do so as proxy. They signed the paperwork, but then Eleanor lost track of Frances.  

After an incapacitating stroke, Frances was placed in an assisted living facility. She suffered from aphasia and, perhaps, dementia. She no longer had a voice in where she was, what happened to her home or what medication she was given. All control of her life had been ceded to an unknown and potentially self-serving guardian.

States can legally give strangers control over a debilitated person's money, home and medical care. Court-appointed guardians are professionals who handle the affairs of the elderly or infirm when there are no family members to take on that responsibility and no paperwork leading to anyone else who is willing to do so.

Guardians may be honest and very much interested in the best for the incapacitated person, but this is not guaranteed. The guardian may have minimal accountability, and the person placed under guardianship can be at the mercy of this individual. Loss and abuse may follow.

A HuffPost article likened this situation to a “con game” that has led to “a silent epidemic of elder abuse.”

According to AARP, court-ordered guardianship "often leads to isolation and exploitation of older Americans." Approximately 1.3 million adults, most of them older than 65, are currently under guardianship in the United States. Frances is one of them. Her story strikes a chord with me, because people of a certain age or those with a disability, can so easily find themselves in that position.  

The Missing Health Care Proxy Document 

A neighbor remembered Frances had once appointed someone named Eleanor (whose last name was unusual enough and whose profile was high enough that she could be found online) as her proxy. The neighbor tracked Eleanor down, hoping she would be able to legally advocate for Frances.  

Eleanor was unable to find her copy of the healthcare proxy document. However, she drove eight hours to the assisted living facility where Frances had been placed and was able to ascertain that Frances was relatively comfortable and safe.  

Eleanor was still worried that the court-appointed guardian had questionable motives for getting involved in the case and was brokenhearted to know that the advance healthcare directives Frances had put in place had not been honored. No one besides Eleanor knew what they were and she was not allowed to participate in the decision-making process.  

"Frances had a will, a trust, a health care power of attorney, and other documents executed. She chose me as her health care proxy because I have extensive experience in finance administration. We'd worked in the same industry for decades and had a mutually trusting relationship. But we both failed to do what we needed to do to be sure Frances's preferences were honored,” Frances explained. 

Difficult Conversations Can Make All the Difference 

At some point in our lives, many of us may find ourselves in a position where we can't communicate our preferences. It can be helpful to think through the type of medical care you will and will not want to receive in various situations, and commit your wishes in writing by filling out your state's advance directive form.  

Unfortunately, if the probate court (or whatever it is in your area) chooses, the judge can set these arrangements aside and institute whatever she or he deems necessary, which usually includes appointing a professional guardian. This is most likely to happen when trustees or guardians cannot be located, so do your best to cover your bases in advance.  

It is important to have conversations with your closest family members, friends and healthcare providers about the medical care you would prefer in the most difficult situations. Give them copies of the paperwork.  

Avoid creating a vacuum that a professional guardian may be ordered to fill by firming up your own support network now—while you still have time.

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.

3 Tips for Living With Chronic Pain

By Barby Ingle, PNN Columnist

A bunch of people on social media have been asking what my best tips are for the pain community.

With my health being so poor, as I am going through Valley Fever on top of all the chronic illnesses I live with, my thoughts immediately turned to health.  So many friends have helped me over the past few months with prayers and positive thoughts, or sending food or someone to help clean the house. It is all so appreciated and has shown me that people really care how others in the community are doing.

Here are three tips I’ve learned:

1. Share your pain story

2. Control your outlook, stress and pain levels as best you can

3. Keep a journal

We all have something that we are dealing with on a daily basis and sharing our stories provides hope to others by letting them know they are not alone. It doesn’t matter if you are sick or healthy, rich or poor, we all have challenges to face in life.

I share my experiences to let others know there are other options and reasons for hope. There is always something else to try. I may not always have immediate access to it, but I can work on a plan to create access.

Learning and practicing self-care is also key. It could be remembering to take deep breaths or meditate to help lower cortisol and other stress hormones. This helps me with relaxing, sleeping and stress reduction. This past year was very stressful for me, so I was taking daily walks to reduce stress and increase endorphins, which help lower pain.

I don’t drink alcohol or smoke, but drank two sodas a day for most of my life. I am currently abstaining from soda -- partially because of my last hospital visit and partially because I have no other vice in my life and wanted to see how long I can go without soda.

My husband has to have his coffee every day or he is cranky — and I was wondering if cutting out soda would do something positive for me. Sadly, it has not. But when I have encountered two stressful situations recently, I wanted that soda. My mind knew that it would soothe me, like a beer would for someone else. Soda is something that would help me feel better, but now I know I can live without it.  Just knowing that is a mental comfort.

Find your comforts, and if they are not already healthy ones, consider changing them to see if you can be soothed by something else that will be better for you in the long run. 

My final tip for patients is to track your pain level, medications, intake and activities every day in a journal for at least 120 days. This helps you and your providers see patterns, and you can adjust your treatment plans and goals more appropriately. Keeping a journal not only helps me see patterns, but it helps me communicate more effectively with my providers about my needs.

No matter where you are in your health journey, remember that you deserve access to proper and timely pain care and that you can find a way to get the care you need. It will take time and effort, but it is also possible.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website. 

Public Officials Ignorant About Overdose Crisis

By Christopher Piemonte, Guest Columnist

A recent Washington Post article highlights an ongoing debate between the Drug Enforcement Administration and some public officials, who are demanding that DEA further reduce the supply of opioid medication. DEA has responded that, without more precise data, such a reduction would be ineffective and dangerous for Americans that need opioids.

At the center of the debate is the Aggregate Production Quota (APQ) for Schedule I and II opioids and other controlled substances. Every year, the DEA sets the maximum amount for each substance that can be produced. DEA began cutting the opioid supply in 2017 and has proposed further cuts in 2020.  

Congressional lawmakers and state attorneys general argue that the APQ for opioid medication is still too high, and the excess supply leads to overdose deaths. In a recent letter to the Acting Administrator of DEA, six attorneys general claim that the APQ does not account for opioids diverted to the black market, which “factor in a substantial percentage of opioid deaths.”

Citing data from the CDC, they assert that in 2016 “opioids obtained through a prescription were a factor in over 66% of all drug overdose deaths.”

There’s a problem with these claims: They’re wrong.

When asked about the accuracy of the letter, a spokesperson for CDC said prescription opioids were a factor in “approximately 27% of all drug overdose deaths,” a figure nearly 40% lower than that presented in the letter.

It would be one thing if this error were simply a typo or miscalculation. But these state officials, as well as many lawmakers, are insisting on a specific policy response without having made the effort to dig into the data and understand the nature of the problem itself. Specifically, they cite inaccurate data to support the incorrect notion that “prescription opioids have been a dominant driver in the growing crisis.” What’s worse, that false notion is the basis for their intransigent insistence on a blanket reduction in the supply of all prescription opioids.

Experts in law enforcement, medicine and policy agree that the attorneys general made an erroneous factual conclusion, and that an arbitrary opioid quota reduction would be both ill-informed and dangerous.

“There is no question that the DEA, or any agency, attempting to come up with valid quotas for controlled substances will find it difficult if not impossible. One of the problems with interpreting overdose death information is that illicit fentanyl and heroin deaths are frequently lumped together with oxycodone- and hydrocodone-related deaths,” said John Burke, President of the International Health Facility Diversion Association and a former drug investigator for the Cincinnati Police Department.

“The vast majority of people prescribed controlled substances take them as directed. Proposed cuts in quotas will negatively impact Americans who have a legitimate medical need for opioids, causing them even more discomfort and distress. These patients are routinely overlooked when considering the prescribing and dispensing of controlled substances, and it is a tragedy.”

Increased Demand for Street Drugs

Other experts warn that further reducing the supply of opioid medication will lead to drug shortages and increase demand for illicit drugs.   

“On the surface, it appears that limiting the quotas…could, in fact, provide a means to address the overdose crisis,” said Marsha Stanton, a pain management nurse, clinical educator and patient advocate. “That, however, will do nothing more than to minimize or eliminate access to those medications for individuals with legitimate prescriptions. We have already seen the effects of back-ordered medications, which create significant barriers to appropriate patient care.”

“Patients who lose access to prescriptions for opioids, have, in some cases, turned to street drugs as an alternative. This has led to increased morbidity and mortality since street drugs have uncertain content and are often used in a comparatively uncontrolled manner,” said Stuart Gitlow, MD, an addiction psychiatrist and past president of the American Society of Addiction Medicine.

“We, therefore, cannot afford to use a crude blunt instrument such as a quota change to address the drug abuse problem. Rather, we must focus on each patient individually and, through education of clinical professionals, ensure that each patient receives medically reasonable treatment.”

By continually insisting on cuts in opioid production, public officials demonstrate a lack of understanding of America’s overdose crisis. Put simply, they’ve failed to do their homework.

“For more than a decade, experts have urged government officials to focus on much more than reducing the opioid-medication supply. Yet, they remain fixated in intellectual laziness,” said Michael Barnes, Chairman of the Center for U.S. Policy and a former presidential appointee in the Office of National Drug Control Policy.

“Policy makers must reduce demand by prioritizing drug abuse prevention, interventions, and treatment. Prevention is the biggest challenge because it will require public officials to realize and respond to the socioeconomic underpinnings of drug abuse. The time is long overdue for politicians to get serious and do the work necessary to save lives and solve this crisis.”   

The disturbing reality is this: Despite rising death tolls and the shortcomings of recent responses, many officials involved in overdose-response policy misunderstand the complexity of America’s overdose crisis.

Until those individuals are educated about the nuances of the issue, they will continue to demand policy that does not adequately address the problem, and the crisis will carry on. Continued ignorance on the part of government officials would truly be, as Mr. Burke put it, a national tragedy.

Christopher Piemonte is a policy manager for the Center for U.S. Policy (CUSP), a non-profit dedicated to enhancing the health, safety and economic opportunity of all Americans. CUSP is currently focused on identifying and advancing solutions to the nation’s substance abuse, mental health and incarceration crises.

The Real Reasons People Become Addicted

By Dr. Lynn Webster, PNN Columnist

The Atlantic recently published an article, “The True Cause of the Opioid Epidemic,” that shares an underreported view of the complexities of the opioid crisis. The article acknowledges the epidemic is a multi-faceted drug problem that is largely driven by economic despair.

Yet most of the media remains focused on the large volume of opioids being prescribed, while ignoring the fact that opioids fill a demand created by deeply rooted, unaddressed societal problems.

As PNN reported, a recent study found that auto plant closures in the Midwest and Southeast created a depressed economic environment where drug abuse thrived. Poverty and hopelessness, more than overprescribing, were the seeds of the opioid crisis.

But those factors are only part of the issue. The prevalence of mental health disorders, the lack of immediate access to affordable treatment of addiction, and inadequately treated chronic pain — along with poverty and despair — have caused and sustained the continuing drug crisis.

One of the challenges in beginning to solve the crisis is to change how we view people with the disease of addiction. Rather than provide them with access to affordable healthcare, we stigmatize and criminalize them. This creates recidivism rather than rehabilitation. It affects people who use drugs for the wrong reasons, as well as people who use opioids for severe chronic pain.

Debunking Myths About Addiction

Many people make another false assumption. They claim that opioid addiction develops solely because of exposure to the drugs. That is untrue. Genetic and environmental factors determine who will become addicted. Exposure to an opioid — or any drug of abuse — is necessary for the expression of the disease, but by itself it is insufficient to cause it.

Most Americans are exposed to opioid medication at some point in their lives. In fact, the average person experiences a total of nine surgical and non-surgical procedures in a lifetime. An opioid analgesic is administered during most of these procedures and is often prescribed afterward for pain control. The lifetime risk for developing an opioid addiction is less than one percent of the population.

If exposure alone were responsible for addiction, then the 50 million Americans who undergo an operation every year, or those who undergo nine procedures in a lifetime, would develop an addiction.

Commonly, people who investigate and discuss opioid overdoses believe the deaths are exclusively due to the disease of addiction. But here again, they are mistaken.

An estimated 30 percent or more of overdoses are believed to be suicides. Why do some people choose to intentionally overdose? One driver is the despair that develops from inadequately treated pain. People in pain are almost three times as likely as the general population to commit suicide. They often use drugs rather than violent acts to end their lives.

In addition, efforts to curb opioid prescribing have pushed many people to the streets to purchase illegal and more lethal drugs. This is even true for people without a substance abuse disorder who are seeking pain relief.

Despite a more than 30 percent decline in opioid prescriptions over the past decade, there has been a continued surge in drug overdose deaths. We are seeing a shift in the reasons why people are dying from overdoses. Since 2018, the number of overdose deaths from methamphetamines has exceeded the number of deaths from prescription opioids. This underscores the fact that the problem is less about the supply of opioids and more about the demand for relief of psychological or physical pain.

Clearly, America’s drug crisis involves more than just the overprescribing of opioids — and this helps explain why interventions to reduce prescriptions have not succeeded. Understanding the actual causes of the problem may help us find real solutions. It also would change the focus from people in pain who find more benefit than harm in opioids to those who clearly are at risk of harm from them.   

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.

Questioning the New Cannabinoids

By Roger Chriss, PNN Columnist

A new cannabinoid similar to THC was announced last month in Scientific Reports. Dubbed tetrahydrocannabiphorol, or THCP for short, it is being hailed as a “breakthrough discovery” that is 30 times stronger than THC, the chemical compound in cannabis that causes euphoria.

Discovered by a group of Italian researchers, THCP has been shown to have a high affinity for the cannabinoid receptor (CB1) in the brain. Cinzia Citti from the Institute of Nanotechnology told Medical Cannabis Network that THCP likely has pain relieving effects, but pharmacological studies are needed to confirm it.

“Once all pharmacological profile of THCP has been established, I can imagine that THCP-rich cannabis varieties will be developed in the future for specific pathologies,” Citti said.

THCP’s chemical structure makes it nearly optimal for activity at the CB1 receptor. Studies on mice showed that THCP has psychoactive effects at low doses, but research is required to confirm how strongly THCP acts on the human brain.

‘Potential Game Changer’

There is already great enthusiasm for THCP, as well as cannabidiphorol (CBDP), another newly identified cannabinoid compound.

Vice states that “it’s possible these chemicals could treat certain conditions better than their counterparts,” THC and CBD.

Leafly went even further, predicting the new cannabinoids could have “immense therapeutic implications,” with THCP being a “potential game changer.”

Looking beyond the media hype, there appears to be no critical consideration of what a cannabinoid 30 times more potent than THC might mean. THC Is known to have significant negative effects on the human body. The National Institute on Drug Abuse lists side effects such as impaired breathing, increased heart rate, and mental effects such as hallucinations, paranoia and schizophrenia.

Moreover, THC is addictive. Health Canada reports that 1 out of 10 people who use cannabis will develop an addiction. The addiction odds increase to 1 out of 2 for people who use cannabis daily.

In other words, is THCP going to be 30 times more additive than THC? Will it cause 30 times more cognitive impairment? A 30-fold increase in ER visits and hospital admissions?

If THCP acts much more strongly on the CB1 receptor, then it may not really be a good thing for cannabis users or public health. These questions may seem absurd, but potent synthetic cannabinoids like K2/Spice have been a public health concern for many years. THCP may also have unknown side effects.

The difference between THC and CBD comes down to one chemical bond, but their respective effects are quite different. The apparent similarities between THCP and THC cannot be used to draw conclusions about effects in humans, good or bad.  

At present, very little is known about THCP. As Live Science points out, "while THC offers some medicinal effects, including pain and nausea relief, no one knows if THCP has these qualities."

It would be nice if even just one media outlet had mentioned the THCP could have some of the same problems that THC does, and at far lower concentrations.

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. 

The Truth About Chronic Pain

By Dr. Rachel Zoffness, PNN Columnist

I’ve never been an athlete, but I’ve always loved exercising because of how it makes me feel. One beautiful spring day, I went for a run. On the way downhill, I was stopped by a sudden pain in my knee. When I woke the next morning, I couldn’t step out of bed without burning pain radiating from my feet, up my leg and into my hip.

I was couch-bound for the better part of a year. I saw countless doctors, was prescribed many medications, and would’ve done anything to stop the pain. That was the beginning of a decade-long journey with chronic pain.

I’ve dedicated my life to understanding pain, and not just because of that injury.

I’m a pain psychologist and assistant clinical professor at UC San Francisco School of Medicine, where I teach pain neuroscience to medical residents. I also founded a private practice dedicated to people living with chronic pain.

One of my earliest patients was a teenager. He’d been bedridden with multiple medical diagnoses for four years, seen 12 physicians and tried 40 medications. But nothing worked.

Not surprisingly, he was depressed and anxious. He had no life, no friends and no hope.

DR. RACHEL ZOFFNESS

As a pain psychologist, I use cognitive behavioral therapy (CBT) as one of my primary treatment tools, so we started a CBT-for-pain program. In addition to other strategies, it involved “pacing” or resuming select activities one small step at a time.

It was hard work, but little by little, he got healthier. As his functioning and mood improved, his pain did, too. Within 6 months he resumed school and rejoined his soccer team. His pain wasn’t gone – but it was significantly reduced and he knew how to manage it. He says pain will never control his life again.

Many of us have noticed this link between how we feel emotionally and how we feel physically. That’s because pain is never purely physical. This is confirmed by neuroscience research indicating that pain is produced by multiple parts of the brain, including the cerebral cortex (responsible for thoughts), prefrontal cortex (which regulates attentional processes), and the limbic system – your brain’s emotion center.

Dialing Back Pain

Imagine that you have a “pain dial” in your central nervous system that controls pain intensity. The function of this dial is to protect you from danger or harm. It can be turned up or turned down by many factors, including:

1. Stress and anxiety

2. Mood

3. Attention (what you’re focusing on)

When you’re feeling stressed and anxious – your thoughts are worried, your muscles are tense and tight, and the pain volume is turned up.  

When your mood is low, you’re miserable and depressed, and your brain similarly amplifies pain volume. 

This is also true when your attention is focused on pain. When you’ve stopped going to work, seeing friends and engaging in hobbies, your prefrontal cortex (which controls attention) sends a message to your pain dial, turning it way up. 

However, the opposite is also true. 

When stress and anxiety are low – your body is relaxed, your thoughts are calm and you’re feeling safe. Your cerebral cortex and limbic system send messages to your pain dial, lowering the volume so that pain feels less bad. 

When your mood is high, your thoughts are positive, you’re feeling happy and you’re engaged in pleasurable activities. Your brain determines that little protection is needed, so pain volume is reduced. 

And finally, when you’re distracted – you’re absorbed in activities, like watching funny movies with friends. The pain dial is turned down, so pain is less bad. 

In summary, when you’re relaxed, happy, distracted, and feeling safe, your pain volume is lower. The pain is still there -- it hasn’t magically disappeared -- but it’s quieter. Softer. Less. 

The truth about chronic pain is this: Your thoughts, beliefs, emotions and attention can all adjust pain volume. 

This does not mean that pain is “all in your head.” It isn’t. Your pain is real, as real as mine, and no one should ever tell us otherwise. It does mean that there are many ways to change pain. One is medication. Multiple medications have been shown to effectively turn down the pain dial.  

There are other methods for lowering pain volume, too. CBT, mindfulness and biofeedback are three biobehavioral approaches to pain management that research suggests can be helpful. They aren’t magic cures and they take time. But if you’ve never tried to manage your pain with these techniques, consider them. They’ve helped me immensely on my chronic pain journey. 

When I was learning about mindfulness, I remember thinking, “What could mindfulness possibly have to do with physical pain?”  

And then something fascinating happened.  

During the first year of my practice, my pain changed. It didn’t go away entirely and I wasn’t cured. But the pain changed. It became less intense, less frequent, less distracting, and got less in the way of the rest of my life. 

Rachel Zoffness, PhD, is a pain psychologist and assistant clinical professor at the UCSF School of Medicine. Rachel serves on the Steering Committee of the American Association of Pain Psychology, where she founded the Pediatric Division. She is the author of The Chronic Pain and Illness Workbook for Teens. You can find Rachel on Twitter @DrZoffness.  

Back to the Future in Pain Care

By Carol Levy, PNN Columnist

The start of another year started me thinking about my 42-year fight against trigeminal neuralgia (TN) and how things have changed in its diagnosis and treatment.

I was 26 when the pain started. It came out of the blue, like a lightning bolt inside the skin of my left temple. It was horrendous, lasting maybe 20 seconds or so, and then it subsided. After a clinic doctor diagnosed it as trigeminal neuralgia, I was repeatedly told it could not be TN because I did not meet the criteria for the diagnosis.

At that time, it was very simple: TN pain had to be in a specific anatomical area. Mine was. The pain also had to be spontaneously triggered by touch, no matter how slight. Mine was. But you had to be at least 60 years old or, if you had multiple sclerosis, over age 40 to have TN. I was only 26. Too young.

So, regardless of the pain being in the right place and occurring in the proper fashion, it had to be something else, although they had no idea what that might be. It took more than a year before someone finally recognized it as trigeminal neuralgia, despite my youth.

Over the years the definition and diagnostic criteria for TN have changed. There are now two recognized types of TN:

• Trigeminal Neuralgia 1: Intense, stabbing pain attacks affecting the mouth, cheek, nose, and/or other areas on one side of the face.

• Trigeminal Neuralgia 2: Less intense but constant dull aching or burning pain.

You can have both types of TN. I have constant pain, as well as spontaneous and triggered pain. Neither type includes an age factor. This makes it easier for a young person to be diagnosed with TN today. 

Changing Treatments

Not only has the definition changed, but so too have the treatment options. When mine started, there were less anti-convulsants to try, the first line of treatment for TN. Now there are many new medications, including botulinin (Botox) injections.  

Over the years I had many operations, some of them no longer in use. Now there are gamma knife and cyber procedures, things not even a glimmer in someone's eye when I was first diagnosed or being treated. 

Reflex Sympathetic Dystrophy (RSD) is another pain disorder which has come a long way. Even the name was changed, from RSD to CRPS (Complex Regional Pain Syndrome).

In 1981, I entered a residential pain program. There were only 8 of us. One was named Joanne, who had very weird, unbelievable symptoms and complaints, so weird even the doctor had trouble believing her.

Joanne said she had tremendous pain throughout her body, and trouble controlling her bowels and bladder. She insisted it all started right after a statue had fallen on her foot. It sounded fanciful at best. She seemed a perfect example of pain being psychological. 

If that happened today, Joanne’s complaints might be taken more seriously and she could be diagnosed with CRPS. But at that time, it was a disorder that did not appear on anyone's radar. 

Since then many new medications and treatment options have been devised or added to the armamentarium against CRPS, such as ketamine infusions, intrathecal pain pumps, hyperbaric oxygen therapy and bisphosphonates. The same is true for many of the other pain disorders. Research is ongoing, new medications and surgeries are being developed. 

We often lament that nothing new is being done for us. Where is the research? Where is the treatment that will finally give us relief? 

It can be hard to see sometimes where we have been vs. where we are now, much less where we may be going. But history shows that more progress is being made than most of us may realize. And that is a good thing. We have to look to the past to see not only how far we have come, but how much farther we still have to go.   

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The Devil We Know

By K. Grahame, Guest Columnist

I was on opioid medication for over 10 years as treatment for acute and chronic pain in 27 diagnosed pain conditions, including herniated lumbar discs, arthritis, spinal stenosis, and torn muscles and tendons in my lower back. 

Now I've been involuntarily taken off opioids by my pharmacy. Guess what? There is NOTHING available that treats pain like opioids.

I am 66. The pain has driven my blood pressure up into the 200/90 range, and since I've already had both heart surgery and malignant melanoma surgery, I'm on so much blood pressure medication that I cannot walk.

The government would not let a human treat a dog like this. The rest of my life looks, at this point, to be short and a piece of hell, thanks to the media blitz on 67,000 annual overdose deaths -- of which only 17,000 were overdoses from prescription opioids. That’s fewer deaths than happen from common falls in the home.

While I'm at it, there were 72,000 alcohol related deaths in 2017. And the Surgeon General estimates that 440,000 people die every year from tobacco-related health conditions. Where are you, FDA and CDC on that?

The reason I care about this so much is not only how it affects my life. In 1978, my mother died in mortal agony from bone cancer, without much in the way of painkillers. The hospital refused repeatedly to give her opioids for pain relief because they were afraid she’d become addicted!

I watched the angel of my life pass away looking like a victim of Nazi Germany death camps, after she begged me to find something that she could poison herself with.

God in heaven, nobody should have to watch someone they love beg them for death! It simply boggles my mind that this is happening in America.

I'm going to die soon, most likely of a heart attack or stroke, and that's what will show on my death certificate. It won't show that I was doing just fine, taking care of myself and the pets who are the joy of my life, while I was taking opioids. The only side effect I had to deal with was constipation, and a GI doctor fixed that for me with simple OTC meds.

I don’t really want to die before my pets, but this ain’t living, people!

The government should be outed as the killers they are, because it sure as hell isn't the legally prescribed and supervised opioids. As for the 17,000 people that died from prescription opioids in 2017, the stats aren't available on how many were deliberate overdoses, if alcohol or other substances were involved, or even if they had a prescription.

Those stats should be provided, because that information should make a BIG difference in how the governments, state and federal, make their decisions.

Please don’t tell me that cognitive behavioral therapy or hypnosis are going to cure the pain in my much-damaged back. Or the arthritis, tendonitis and bursitis. Or the pain from my cancer surgery-severed nerves.

There is just so much to tell people that isn’t known or hasn’t been communicated. It’s the devil you know versus the devil you don’t. I really do think the devil we know is trying to reduce the expensive medical costs associated with the Boomer generation. What happens when death is made cost-effective for the government?

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

Do Pain Patients Really Get High on Rx Opioids?

By Roger Chriss, PNN Columnist

The standard narrative of the opioid crisis is built on the idea that people feel euphoria or get “high” when exposed to opioids and almost immediately become addicted. Some assert that opioid medications should have no role outside of trauma, surgical, palliative and end-of-life care due to their high risk and side effects.

But reality is more complex.

Euphoria is widely believed to be inevitable with opioids, and increases the risk for misuse and addiction. But in fact, euphoria is not common.

"I think that the notion that opioids [always] cause pleasure is a myth," Siri Leknes, principal investigator at the University of Oslo in Norway, told Live Science.  "I think it's especially important to point out that opioids do not reliably cause pleasure or relief of subjective stress and anxiety in the lab or in stressful clinical settings."

Leknes’ research found that patients receiving remifentanil – a potent, short-acting synthetic opioid -- felt high, but the experience was unpleasant.

"Not everyone experiences the same level of euphoria from opioids, and not everyone that uses opioids will develop an addiction or opioid use disorder,” says Brian Kiluk of Yale School of Medicine.

Major cognitive side effects are often thought to be inevitable with opioids. But a review of 10 clinical studies on older adults with chronic pain found that most “demonstrated no effect of opioid use on cognitive domains.” Only at high daily doses did opioids worsen memory, language and other cognitive skills.

In other words, long-term opioid therapy may cause side effects at doses well above what most people ever receive and beyond thresholds recommended by the CDC and state governments.

The risks of overdose are similarly nuanced. For instance, a study on opioids and mortality looked at a nationally representative sample of over 90,000 people, among whom 14% reported at least one opioid prescription. There were 774 deaths during the study period, with the death rate slightly higher among those taking opioid prescriptions.

However, after adjusting for demographics, health status and utilization, the authors concluded there was “no significant association” between opioids and sudden death. “The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination," they said.

On the efficacy of opioid therapy, a major review in Germany looked at 15 studies with 3,590 patients with low back, osteoarthritis and neuropathic pain. The quality of evidence was low, but the authors concluded long-term opioid use was appropriate for patients who experience “meaningful pain reduction with at least tolerable adverse events."

Pain Patients Used As ‘Guinea Pigs’

Instead, we have an intense focus on prescribing statistics. States like Minnesota tout a 33% decrease in opioid prescribing for Medicare patients, while ignoring how those poor and disabled people are faring.

“My cat gets better pain management than I do after surgery,” one man wrote to state health officials.

In Ohio, opioid prescriptions have declined by 41% since 2012. Some wonder if the cutbacks went too far.

“There needed to be an adjustment and maybe it did go overboard a bit. I feel bad for the people in chronic pain because they're going to be the guinea pigs for how we get it back to the middle," Ernest Boyd, executive director of the Ohio Pharmacists Association, told the Akron Beacon Journal

So the medical needs of people with cancer, sickle cell disease and other chronic painful conditions are going unmet. And some doctors are even avoiding such patients entirely.

Naturally, there is a need to safeguard the entire opioid supply chain, and to carefully screen and monitor people on any form of opioid therapy. But we also need to track the rapidly evolving policy landscape surrounding prescription opioids to make sure that pain patients with chronic medical needs are being not harmed.

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.

Flushing Out the Truth About Disposing of Unused Pain Medication

By Dr. Lynn Webster, PNN Columnist

According to a 2016 survey, most Americans choose not to dispose of their leftover opioid pain medication because they want to keep it for potential future use. This is entirely understandable.

People have little incentive to dispose of their unused pain medication. It is expensive to replace drugs, and the person who owns the prescription has already paid for it. Also, a growing number of people are concerned that, should they someday need pain treatment, they will find it difficult to obtain opioid medication. They may even be accused of being a drug seeker if they ask for it.

So people don't necessarily have nefarious reasons for holding onto unused medication. However, leftover pain medication has been blamed for causing much of the opioid crisis because it can be easily diverted.

Leftover drugs can end up on the streets or in the wrong hands, such as family members or friends. In all cases, they can cause harm. Let's look at some numbers.

In 2013, nearly 9 billion pills containing hydrocodone were produced for prescription purposes. Other opioids added to the supply. Although this was several years ago and opioid production quotas have significantly reduced the supply of opioids, leftover pills are still a potential problem. Of those that are prescribed after surgery, more than 40% percent go unused.

Opioid drugs lose only about 1 percent of their potency per year. This means prescription opioids have a half-life of more than 50 years. These potent medications can remain viable (or toxic) for nearly a lifetime. 

At any given time, billions of opioid pills that still retain their potency are available for diversion and non-medical use. That is a problem.

Conflicting Information About Safe Disposal

A public education campaign may convince some people who are reluctant to give up their extra medication that it would be better for society if they get rid of the drugs. However, even if people were persuaded to dispose of their unused medication, they may not know how to do so safely.

A recent report by Time suggests that even pharmacists do not know how patients should dispose of their leftover drugs. Of 900 pharmacists surveyed, only 23 percent correctly told callers how to safely dispose of opioids according to FDA guidelines.

The pharmacists' confusion is understandable. Various authorities have delivered different messages over the years about the best way to dispose of unused drugs.

The FDA recognizes that there are environmental concerns about flushing medicines down the toilet. However, the agency also believes that the risks associated with narcotic medicine outweigh any potential risks associated with flushing. The FDA includes hydrocodone, oxycodone, methadone and other opioids on a lengthy list of medicines that should be flushed down a toilet if no other safe disposal options are available.

The FDA even recommends flushing unused fentanyl lozenges (ACTIQ). The disposal instructions are very complicated. They require both a pair of scissors and wire-cutting pliers, and are roughly as convoluted as Walter White's method of making crystal meth in television's "Breaking Bad." I suspect that not everyone who is prescribed ACTIQ would be willing or able to follow all of those steps.

Evidently, the FDA believes that the risk of harm from overdose is greater than the danger the drugs present to the environment and to our water supply. 

The Time story cites a 2017 U.S. Geological Survey and EPA report that found hundreds of drugs, including prescription opioids, in 38 streams across the country.

“Many of the drugs identified in the 2017 study are known to kill, harm the health of, or change the behavior of fish, insects and other wildlife. This, in turn, can impact the food chain, and eventually harm humans as well,” Time reported.

The FDA’s guidance on how to safely dispose of drugs can be confusing. Some medication is flushable, while other leftover drugs should be put in a sealed container or plastic bag with an “unappealing substance such as dirt, cat litter, or used coffee grounds” before being thrown out in the trash.

Take Back Programs

Drug take-back programs are intended to reduce the supply of excess prescription opioids and destroy the pills in an ecologically safe way. The FDA has a list of permanent take-back sites where people can dispose of unused medication. The DEA also has Drug Take Back Days, temporary collection sites for the safe disposal of prescription drugs.

However, not all take-back programs collect controlled substances. And it is estimated that fewer than 2 percent of unused drugs are returned. Also, these take-back programs are costly to implement.

The messaging around disposal of pain medication is conflicting. In a perfect world, all unused medication would be easily disposed of without causing negative consequences to the environment or the community. Also ideally, people in pain would not have to worry they might not receive a prescription for medication if they need one. Unfortunately, neither of those propositions is true. 

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

The 2019 Event With Major Impact for Millions of Pain Patients

By Dr. Lynn Webster, PNN Columnist

The demise of the American Pain Society (APS) in June of 2019 was a major blow to pain patients, their providers and pain research. For 42 years, APS enjoyed an unimpeachable reputation as an academic, scholarly organization and an icon of scientific integrity.

However, with an opportunity to make billions of dollars, opioid plaintiffs' attorneys targeted professional medical organizations like APS as complicit in creating the opioid crisis. They labeled them as front organizations for deceptive opioid manufacturers and distributors.

As implausible as the claims were, it was a real problem for APS and other professional organizations and individuals who care for patients with pain. There were more than a thousand lawsuits filed against myriad defendants. I don't know the exact number of claims filed against APS, but I was named in several hundred of them.  

The plaintiffs required records about, and responses to, each claim. Complying with that many demands proved to be such a financial burden that APS could not survive. I, too, have struggled to deal with these baseless attacks on my integrity and resources.

Law firms representing over 2,000 states, counties and municipalities, along with national media, have judged and found blameworthy those who have devoted their careers to helping people in pain.

Even deep-pocketed companies such as Purdue Pharma are not always able to weather the financial and administrative burden of responding to thousands of legal claims. The manufacturer of OxyContin, Purdue Pharma filed for bankruptcy in September 2019.

It strikes me as an injustice when small organizations like APS cannot defend themselves in court due to the overpowering financial and political forces alleging spurious conspiracies and dubious claims of wrongdoing. 

In the past decade, the number of doctors and other providers who have been criminally charged for prescribing controlled substances without a legitimate medical purpose has increased dramatically. Some were appropriately charged, but others were caught up in a social fever to cast blame for the destruction that substance abuse can cause.

Providers are easy targets. It is much simpler to accuse doctors and pharmacists of wrongdoing than it would be to try to correct social disparities that drive the demand for drugs of abuse. I have attempted to defend many such providers, who eventually decided to plea bargain because of the enormous legal costs they would incur if they continued their defense.

Justice for Some

Attorney Bryan Stevenson shines a light on the naked injustices that treat the rich and guilty better than the poor and innocent in his memoir, Just Mercy. Stevenson shows that racial prejudice fuels injustice, but the lack of resources to secure adequate defense makes the process painfully unfair and the outcome predestined. 

Another injustice was in the national news some years ago. You may remember that Richard Jewell was unfairly accused of a bombing at the 1996 Atlanta Olympics. The media essentially convicted Jewell before he was charged with anything. After several months of cruel media persecution and harassment, the truth emerged and Jewell was exonerated. A movie about what happened to Jewell is currently playing in theaters. 

Veteran newscaster Tom Brokaw recently apologized for suggesting to viewers that Jewell was guilty. NBC reportedly paid Jewell $500,000 for contributing to his suffering, but this is a rare consequence when such injustices occur. APS is not likely to receive either vindication or reparations.  

Groundless accusations, media hysteria and the enormous financial backing of a false narrative exploit the weaknesses of our civil and criminal justice systems. 

Two of the most powerful forces in America are the media and the government. When they join together to fight evil, they can strengthen a democracy and serve the people well. But if they combine forces to propagate a false narrative, it is nearly impossible for the innocent to survive the damage on a personal or professional level. The catastrophic results can undermine the integrity of our legal system and free press. 

The media's framing of an issue, whether factual or not, changes attitudes and even public policies if it is repeated often enough. The media has certainly carried the water for the plaintiffs against organizations like APS. 

Most disheartening is that, in the case of APS, the harm goes far beyond the organization and its members. One hundred million Americans with pain and their families are the ultimate victims of APS's collapse. The harm will not be confined to 2019 but will extend for decades into the future.  

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

Emotional Awareness: How I Learned to Connect with Life and Disconnect from Pain

By Dr. David Hanscom, PNN Columnist

Last month I wrote about the importance of environmental awareness – being aware of your moods, anxiety and other senses and learning how to calm them through active meditation.

In this column we’ll look at emotional awareness – living a life full of rich relationships and satisfying endeavors. You must understand the nature of someone else’s emotional needs before you can interact with them in a meaningful way.

In the presence of chronic pain however, this is a problem. When you are in pain, you are justifiably angry, which can block emotional awareness. You are just trying to survive and don’t have the capacity or energy to reach out to others.

Another problem with pain-induced anger is that it not only disconnects you from others, but also from yourself. You are so used to being in this agitated state that you feel it is the norm.

I am quite aware of this scenario, as this was my experience. I was constantly agitated, but did not perceive it as anger. I thought I could hear what others were saying and see issues through their eyes. I was idealistic and thought I was right – but was so wrong.

It wasn’t until I had every layer stripped away in the midst of suffering from severe chronic pain, that I could see the problem. Meanwhile, I lost my marriage.

Self-Discovery

The problem with becoming emotionally aware is that you have to allow yourself to feel unpleasant emotions, such as anxiety, sadness, vulnerability, shame and so on. If you don’t allow yourself to feel the dark side of life (which is core to the human experience), then you won’t be able experience deep joy, happiness and love.

My strategy for most of my life was to suppress all negativity and keep my emotions on an even keel. One of my nicknames was “The Brick.” At the time, I thought it was a compliment because it meant I was tough.

It all worked until it didn’t. At age 37, I began to experience severe anxiety in the form of panic attacks. They came out of the blue and I had no idea what had hit me. I didn’t emerge from this hole for another 13 years.

Unless you actively choose a journey of self-discovery, you can’t connect with your true emotional state. You must commit to stepping outside of your mind and looking at yourself from a different perspective.

Ask yourself these questions: Am I open? Am I coachable? Can I really listen and feel?

That is a starting point. Once you get in touch with what’s going on in your mind, you can embark on a powerful journey. Allowing yourself to feel your emotions is a learned skill with many ways of accomplishing it. You will fail endlessly, but the key is remaining open and persistent.

Many people choose not to take this journey. But they make that choice at their own peril. It is what you’re not aware of that will run your life. The result may be a lot of physical and emotional suffering for the individual and especially for those close to him or her.

Why don’t more people pursue a path of self-discovery? It may be because in our culture most of us spend a lot of emotional energy trying to look good to people around us. We also try to look good to ourselves.  

Truly connecting with your emotions is an act of humility. Most people don’t want to do something so difficult and unpleasant. However, it’s also extremely rewarding and makes life so much easier in the end. It was the beginning of my recovery from my own chronic pain.

Dr. David Hanscom is a retired spinal surgeon. In his latest book -- “Do You Really Need Spine Surgery?” – Hanscom explains why most spine operations are unnecessary and usually the result of age-related conditions that can be addressed through physical therapy and other non-surgical methods.

New Think Tank Seeks to Reduce Pain and Improve Lives

By Stephen Ziegler, PhD, Guest Columnist

Millions of men, women and children in the United States and around the world are dying of cancer, and some die in severe pain because they have limited or no access to essential palliative medicines. Much of that suffering is avoidable.

Opioids and other palliative medicines are powerful drugs that are deemed essential by the World Health Organization. They provide comfort and relieve suffering at the end of life and for those who face serious medical conditions. Unfortunately, these very same drugs also have the potential for abuse, misuse, overdose and exploitation by the illicit market.

According to the 2017 Lancet Commission Report, governments around the world adopted “overly restrictive legislation” that focused more on preventing abuse than ensuring safe access to essential medicines. The problem is not limited to developing countries. Well-intentioned government policies to reduce opioid prescriptions across the United States have resulted in unintended harms for those who are recovering from painful surgeries or who were functioning well on opioid therapy.

Unfortunately, governments rarely investigate whether the drug control policies they create actually work and whether their policies are effective in preventing abuse while providing access to the drugs for those who need them.

But with your help we can change that.

I am proud to announce the creation of the Center for Effective Regulatory Policy and Safe Access (CERPSA), a new nonprofit think and do tank sponsored by the Colorado Nonprofit Development Center.  

CERPSA is a non-partisan, science-based research organization that focuses on the reduction of human pain and suffering by improving the regulation of - and safe access to - palliative medicines and treatments.  

Our mission is to eliminate unnecessary physical pain and suffering, and to help governments and communities create and maintain effective drug control policies that improve people's lives. We believe that there are good public health reasons for controlling drugs, whether in the form of prescription opioids, antibiotics, or even medical cannabis. We do not seek the elimination of regulation, only its dramatic improvement so that drug control policies can ensure access while at the same time prevent abuse.  

CERPSA represents a bold new effort to help reduce pain and improve people’s lives through research, education and outreach. Now more than ever, we need science-based initiatives that can fundamentally help change the way drugs are controlled.  

You can become part of the movement. Please join us by visiting our website and donating to CERPSA and help us reduce human pain and suffering in the nation and around the world. 

Dr. Ziegler has been trained as both a social scientist and attorney, has been involved in pain treatment and drug policy for almost two decades, and was both a Mayday Pain Scholar and Fellow.

Opioids, Off-Label Prescribing and the Road Not Taken

By Lynn Kivell Ashcraft, Guest Columnist

So much of the conversation about the use of opioids and other medications to treat various conditions has made it sound like doctors are doing something wrong when they utilize a treatment in an off-label fashion. 

Off-label prescribing is not a crime. The federal Agency for Healthcare Research and Quality (AHRQ) estimates that 1 in 5, or 20 percent, of all prescriptions are written for off-label use.

In fact, off-label use of a drug often represents the standard of care. The Food and Drug Administration never intended for its drug approval and labeling process to be the sole determining factor in how a drug is to be used in a clinical setting. 

It is left to physicians themselves to determine the ultimate clinical utility of pharmaceuticals, biologicals and medical devices in treating their patients.

Epidural Steroid Injections Are Off-Label

Some off-label use, however, is controversial. Many accepted protocols for treating back and neck pain include the use of epidural steroid injections (ESIs), despite a lack of rigorous supporting clinical evidence. As many as 9 million ESIs are performed in the U.S annually, yet few patients are told the injections are an off-label use of both the medication (corticosteroids) and the route of administration (an injection into the epidural space of the spine).

In 2014, after hearing about serious neurological problems in patients who received ESIs, the FDA required a label warning that injections of corticosteroids into the epidural space may result in rare but serious neurological events, including "loss of vision, stroke, paralysis, and death."  

Anxious not to lose a treatment that they believed in, professional societies of anesthesiologists, pain medicine physicians, rehabilitation specialists, neurosurgeons, surgeons, radiologists and interventional pain specialists wrote guidelines to prevent complications from ESIs that were published in the journal Anesthesiology in 2015. 

A coalition of doctors also formed the Multisociety Pain Workgroup (MPW) to defend the use of ESI’s. The MPW called an AHRQ study “flawed” and “absurd” because its questioned the effectiveness of ESI’s for treating low back pain. It also lobbied unsuccessfully to have the FDA tone down its warning.

Since 2017, according to OpenSecrets.org, the American Society of Interventional Pain Physicians has spent nearly $1.5 million on campaign donations and lobbying — much of defending the use if ESIs.

Where was the same type of outcry from the medical profession defending the use of opioid medication when the 2016 CDC guideline was released? Why have so many doctors stood by silently while insurers, states and the DEA began implementing the guideline as policy?

Lynn Kivell Ashcraft is an analytic software consultant and writer who lives in Arizona. Lynn has lived with chronic intractable pain for almost 30 years and works with Dr. Forest Tennant as part of the Arachnoiditis Research and Education Project.