A Modernized Drug Crisis Goes Unchecked

By Roger Chriss, PNN Columnist

The overdose crisis just keeps getting worse. According to the CDC, the U.S. saw over 96,000 overdose deaths in the year ending in March, 2021. The numbers are expected to rise further, with 2021 likely to see over 100,000 drug deaths.

The main driver is illicit fentanyl, which now accounts for over 70,000 drug-involved deaths. Illicit fentanyl is separate from pharmaceutical fentanyl. It is manufactured, distributed, and sold illegally in ever increasing quantities. Vice recently reported that Mexican authorities confiscated 1,225 kilos of fentanyl through September 2021. That’s compared with a total of 1,523 kilos seized over the past two years combined.

There is simply no way to understate the impacts of illicit fentanyl. If current trends persist, deaths from illicit fentanyl will likely exceed alcohol-related deaths within a couple of years, which by recent CDC estimates represents about 95,000 fatalities.

This means that for the first time in history, a synthetic drug will kill more people than “natural” substances do. Throughout the 20th century, tobacco and alcohol were the biggest public health scourges. By comparison, all other drugs combined didn’t kill as many people as alcohol, which only killed a fraction of the people that tobacco did.

That is changing fast. Modernized drugs and illicit markets for them pose unprecedented risks. It is fashionable to talk about the three waves of the overdose crisis or to blame Purdue Pharma and the Sackler family for igniting the opioid epidemic, but the rise of fentanyl and the associated spike in overdose fatalities illustrates a fundamental shift. Designing, manufacturing and distributing drugs has never been easier or more lucrative.

“We live in a world where creative chemists can rapidly design new psychoactive substances when others become hard to get and where the internet can make them almost immediately available around the world,” Maia Szalavitz notes in her recent book “Undoing Drugs.”

Such substances include brorphine and isotonitazene, which have never even been formally tested in humans and have unknown risks and harms. Novel synthetic cannabinoids, opioids and hallucinogens are popping up every month, according to the Center for Forensic Science Research & Education.

Drug fatalities increasingly involve multiple substances, often with incidental exposure via tainted products.

“Most of fentanyl overdoses are in combination with other drugs like heroin, cocaine and methamphetamine," NIDA director Nora Volkow told USA Today. "It is all over the place from the East Coast, West Coast and the center of the United States."

The country is ill-prepared and unequipped for a modernized drug crisis. Risks and harms cannot be properly quantified using existing techniques. Deaths cannot even be properly coded on death certificates because the International Classification of Disease (ICD) codes used by the CDC do not distinguish between prescribed opioids and illicit ones.

“The result is a system that obscures the actual cause of most drug overdose deaths and, instead, just tallies the number of times each drug is mentioned in an overdose situation,” researchers recently reported in the journal Cureus. “We examined the CDC's methodology for coding other controlled substances according to the ICD and found that, besides fentanyl, the ICD does not distinguish between other licit and illicitly manufactured controlled substances. Moreover, we discovered that the CDC codes all methadone-related deaths as resulting from the prescribed form of the drug.”

Further, non-fatal risks and harms are rising. Modernized methamphetamine, called “P2P meth” in reference to the chemicals involved in its manufacture, poses novel long-term neuropsychiatric risks to users.

“The spread of P2P meth is part of a larger narrative—a shift in drug supply from plant-based drugs such as marijuana, cocaine, and heroin to synthetic drugs, which can be made anywhere, quickly, cheaply, and year-round. Underground chemists are continually seeking to develop more potent and addictive varieties of them. The use of mind-altering substances by humans is age-old, but we have entered a new era,” Sam Quinones, author of the book “Dreamland” about the opioid crisis, writes in The Atlantic.

The impacts of this modernized drug crisis are just starting to be felt and there are no easy options for addressing it. As the RAND Corporation noted in a 2019 report on fentanyl and other synthetic opioids, “resolution of this crisis might require approaches or technologies that do not exist today.”

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. 

Rare Disease Spotlight: Asplenia

By Barby Ingle, PNN Columnist 

If you have been following my series on rare diseases or read any of my books, you already know that I live with multiple rare diseases.

I was fortunate to live to the age of 29 before developing any symptoms. Others are not as lucky. There are over 7,000 rare diseases, and I find that the ones that catch my attention the most are those that affect infants and young people, such as asplenia and Alexander disease. 

One of the people I met while advocating for chronic and rare diseases in Arizona is Allison. Her son Travis passed away at the age of four due to complications of asplenia. In his memory, she started a nonprofit called TEAM 4 Travis.

Allison’s son was a bright, smiling little boy who was born without a functional spleen, an organ that helps filter the blood as part of the immune system. That is what asplenia means; the absence of a spleen. If Travis had been checked during newborn screening, he might still be alive today.  

My stepsister Melanie lost her spleen in an auto accident at the age of six, but was able to live into her early thirties. She passed away due to complications of one of the same rare conditions that I have, Reflex Sympathetic Dystrophy (RSD).  

TRAVIS AND ALLISON

Those who have had a splenectomy (Melanie) or are born with missing or nonfunctional spleen (Travis) are immunocompromised, which puts them at increased risk for severe and overwhelming bacterial infections, particularly from encapsulated bacteria.

Melanie's doctors knew she no longer had a spleen, so she was able to take medications that took on the role of a spleen. Travis was not so fortunate and lost his life due to an infection. It was only discovered after he passed away that he had asplenia.

Every time I go with Alison to talk to our legislators and hear the story of Travis, it gets me emotionally because this is a loss that could be prevented. That is why we advocate for newborn screenings in Arizona and other states.

Alexander Disease

The other spotlight I wanted to shine this month on a rare disease that affects children is Alexander disease. There is not a lot of talk about this condition or how it affects a family on a personal level. I can imagine that it would be quite difficult to lose your child to a neurodegenerative condition.  

Alexander disease is a genetic disorder that primarily affects infants and young children. If symptoms begin before the age of two, chances are the child will pass before their sixth birthday. In cases of adult and juvenile-onset, one can live and manage Alexander disease longer. However, as with RSD, infants, youths and adults have different symptoms, onsets and challenges.  

An infant with Alexander disease will show symptoms like an enlarged brain and/or head size. They may also have seizures, dystonia, and developmental delays that are easy to spot by providers and parents.

In adult-onset Alexander disease, symptoms can be fluid. The brain may show signs of swelling, but it will come and go, causing atrophy over time. Doctors will see lesions in the brain stem and upper spinal cord under contrast enhancements. When earlier stages of the disease are not treated, it can lead to vocal cord paralysis. 

You can learn more Alexander disease and asplenia by visiting the National Institutes of Health. There are also clinical trials developing new treatments for both of these conditions.

If you need support for Alexander disease as a patient or caregiver, you can turn to the United Leukodystrophy Foundation. If you need support for asplenia, please check out Allison’s TEAM 4 Travis Foundation.

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.

How People With Pain Can Benefit From Pet Ownership

By Victoria Reed, PNN Columnist

Having chronic pain causes significant and daily challenges that can make life miserable, leading to depression and anxiety. As many people discovered during the pandemic, adopting a pet can be therapeutic, positively enhance your life, and may even reduce pain levels.

When my children were young, we adopted a senior dog from the local animal shelter. Bringing home Albert, a lab mix, turned out to be one of the best decisions we ever made for our family.

He instantly bonded with us, in particular with the youngest child. Albert became like an emotional support animal for her, as she suffers from severe anxiety and panic attacks. During times of stress, Albert was always there to calm her down. He just had a way of making her feel better and quickly became a valuable member of our family.  

We enjoyed seven great years with Albert before his health started to take a turn and, unfortunately, we had to say goodbye. Because we knew from the beginning that our time with him would be limited, we always appreciated Albert and tried to make the most of our time with him. He definitely gave us more than we ever could give him! 

Since my kids are mostly grown up now, I decided to adopt another pet and had hoped to re-create the bond that my daughter had previously with Albert.  

Lacey, a tiny poodle mix, has been everything I had hoped for. Not only is she a great little companion, but during bad days, when my rheumatoid arthritis or fibromyalgia are bothersome, she is always nearby, providing comfort, love and affection. She goes everywhere with me and has become an important part of my life.  

According to Dr. Steven Richeimer, a professor of anesthesiology at USC’s Keck School of Medicine, pets help relieve chronic pain by keeping us active and making us feel less stressed. 

“In my practice as a pain management specialist, I've heard numerous accounts of pets improving the lives of patients living with chronic pain and diminishing the depression that often accompanies it,” Richeimer wrote in Spine Universe. “There's no doubt in my mind that having a pet — or interacting with a trained therapy dog or cat — can improve a pain patient's quality of life. Animal companionship is a natural pain reliever, and a substantial body of research supports this theory.” 

One study of fibromyalgia patients found that just 10 to 15 minutes of petting a therapy dog lowered levels of cortisol, a stress hormone. Patients also reported significant improvement in their pain, mood and distress after a therapy dog visit.  

Chronic pain patient Jodi Tuckett found that fostering a dog named Suzy helped her recovery after she was seriously injured in a collision with a dump truck.  

“Having a little mangy mutt to look after shifted my focus away from me, my pain and my therapy team. She helps me when my neck, back and hips are hurting. I take her for a walk. Moving and keeping my joints loosened up makes me feel better. Suzy takes me out – out of the house, out of myself and out of my pain,” Tucket explained in Pain Pathways. 

Getting a pet, if you are financially and physically able to provide for one, can be beneficial to you physically and can improve your emotional state. There are many animals living in shelters and on the street that are in need of good homes!  

Rescued animals have so much love and affection to give, that you might wonder who’s doing the rescuing! I know that Albert and Lacey gave us many years of love, comfort and enjoyment, and I hope that other chronic pain patients will consider adding a pet to their lives. The benefits could surprise you! 

Victoria Reed lives in Cleveland, Ohio. She suffers from endometriosis, fibromyalgia, degenerative disc disease and rheumatoid arthritis. 

Where Are the Chronic Pain Support Groups?

By Carol Levy, PNN Columnist

For many years I was alone with my trigeminal neuralgia. There was no one to talk to about it, no one else who had it, and no one who could understand the terror of it. I longed for someone I could talk with, another person who would nod understandably and share their own stories of how TN was affecting them.

Years later, I was in the car listening to the radio and heard the announcer say “trigeminal neuralgia.”

My heart did a somersault and I yelled out, “Listen to that! They said trigeminal neuralgia!”

I calmed down and listened carefully as the announcer said, “The trigeminal neuralgia support group meets once a month at the City Hospital.”

It’s what I had been praying for.

I went to a few of the meetings. The people were nice and, to my amazement, the group was very large. There were 20 or 30 people, sometimes more, including spouses, family and friends of the person with TN.

There was support and encouragement, interspersed with speakers who spoke about various treatments, explanations for the pain, and even crackpot theories -- which thankfully the members objected to. Little by little, the group grew smaller; more often than not the support lessened and the number of speakers grew.

For quite some time it seemed that the group had simply vanished. Then I started getting email notices again announcing the date and time of the meetings. They had returned, but now there were only 6 or 10 people, always the same ones, and the support seemed to be more of a get-together for these now friends.

Once in a while, someone new came and spoke about their pain. They did get support, before the group turned back to its core members talking with one another. The new person rarely returned.

Then the meetings went from monthly to just 6 times a year, 3 in the spring and 3 in the fall. It was usually two meetings with speakers or information about ways to deal with the pain. The third meeting was only for “sharing.”   

For me, the support felt lacking.

I decided to go to the phone book (in my area we still get one) and look up support groups. I was gladdened to see at least 150 listed. But I was dismayed when I found not one was for chronic pain. The closest any of them came was for specific diseases that have pain as a symptom, such as multiple sclerosis or lupus.

There are many support groups on Facebook, but that’s not always the best place to find support. Some are terrific and the members are truly there for each other, but too many others become an arena for back stabbing, misinformation and drama.

There is something to be said for meeting in person with the people you have gone to for support. But why is it so hard to find a support group for “just” chronic pain? The cries for support are loud and clear, but the willingness to start the groups or go to them doesn't seem to be.

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.

More Evidence That Rapid Opioid Tapering Is Harmful

By Roger Chriss, PNN Columnist

The overdose crisis has motivated a sea change in prescribing practices. Opioid tapering is seen as a part of this change. But the risks and harms of tapering often outweigh its potential benefits, especially when tapering is rapid.

The risks of rapid tapers are well known. The CDC warns providers to “avoid abrupt tapering or sudden discontinuation of opioids,” with a dose decrease of 10% per month a “reasonable starting point.”

But more rapid tapers are very common. A new study looked at retail pharmacy claims for over 810,000 patients taken off high-dose opioids in 2017 and 2018, finding that 72% were tapered more rapidly than recommended by clinical guidelines. Rapid tapering was significantly more common among Medicare patients than in commercially insured ones. Critically, the study also found that counties with high overdose rates had more rapid opioid discontinuation.

The U.S. military health system has also significantly reduced opioid prescriptions. Among active-duty members, a recent study found a 69% decline in prescriptions filled for opioids at daily doses of 50 morphine milligram equivalents (MME) or more.

The Departments of Defense and Veterans Affairs adopted guidelines in 2017 that urge military doctors to taper or discontinue opioids for patients on high doses. But a recent Washington Post investigation found that the VA’s Opioid Safety Initiative was associated with a 75% increase in suicides among veterans living in rural areas and a 30% increase in suicides for veterans in urban areas.

Further, a recent JAMA investigation found that in a study of over 113,000 patients on stable, high-dose opioid therapy, tapering was “significantly associated with increased risk of overdose and mental health crisis.”

“This study highlights important potential harms that are associated with prescription opioid tapering in people with chronic pain,” Beth Darnall, PhD, director of the Stanford Pain Relief Innovations Lab at Stanford University, told Practical Pain Management. “While work remains to understand these associations in greater detail, these findings reveal that patients with chronic pain need better protections within the healthcare system.”

There is, in other words, a clear pattern of harm here. Rapid tapers are destabilizing individual patients and are associated with increased rates of overdose and suicide. The goal of tapering was to reduce opioid-related risks and harms, but the data to date suggests the opposite is happening.

In general, the overdose crisis is getting worse fast. The latest data from the CDC shows over 96,000 drug overdose deaths in the 12 months ending in February, 2021. Opioid tapering has coincided with the rise in drug overdose deaths, though how and to what extent this happens is an open question that urgently requires attention.

There are, of course, risks to prescription opioids and patients may benefit from consensual tapering as described in a federal guideline for dosage reduction. Some people may also do better with non-opioid approaches to pain management.

But the current tapering efforts seem geared toward satisfying a statistical need to reduce prescriptions at the expense of individual welfare. As more and more public health data shows increasing harms without attendant benefits, it’s time to reconsider tapering practices and slow down deprescribing.

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. 

What Pain Patients Should Know About the GABA Neurotransmitter

By Forest Tennant, PNN Columnist

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

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

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

GABA Surrogates

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

• Gabapentin (Neurontin)

• Carisoprodol (Soma)

• Diazepam (Valium)

• Alprazolam (Xanax)

• Lorazepam (Ativan)

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

• Valerian root

• Ashwagandha

• Taurine

• Brahmi

• Bacopa

Glutamine: GABA’s Precursor

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

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

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

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

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

Holistic Therapy Won’t Cure You, But It Can Help

By Mia Maysack, PNN Columnist 

To mark the end of Pain Awareness Month,  I'd like to share a few holistic therapies that have proven helpful on my journey. 

I’m not suggesting they are magic remedies or that they're the right choices for everyone. Many of us who live with chronic or intractable pain have our minds closed off to new things. And after all we've been through, who could blame us?   

There is an endless amount of misinformation and misinterpretation regarding holistic and preventative medicine, and no shortage of judgement. I'll be honest by confessing that I have also been a skeptic to some extent about holistic therapy, but it has ultimately helped me more than two decades of “mainstream" traditional medicine.  

I'd like to think I have established credibility as it pertains to my own personal experiences, just as I honor anyone else's. Here is what I have learned about holistic therapy:   

Having an open mind and willingness to expand consciousness about the limitations that pain imposes on our lives -- and taking leadership in our own journey – means coping, managing, adapting, transcending and evolving as best we can.  

These therapies don't really work until WE WORK ‘EM and add them to a tool box full of different things to pull from.  Allow yourself the curiosity of what could be possible if you were to try something new. If there are still doubts or if you tried and failed with them in the past, then ask yourself: When’s the last time anything went perfectly right the first time?   

We cannot know unless we try. To have found anything that's assisted, helped or if you're lucky enough to have something that actually works would not be possible without an attempt to try it in the first place.  

The great thing I have found about these holistic therapies is that they have positive side effects, are healthy and habit forming.  

Soaking in Warm Water:  I use generous amounts of Epsom salt (magnesium sulfate) in a bathtub. It creates a soothing buoyancy that makes the body seem weightless.  

Massage Therapy:  Manipulation of soft tissues of the body, consisting primarily of manual techniques, such as applying fixed or movable pressure, holding, and moving muscles and body tissues. 

Mindfulness:  A mental state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations. 

Energy Healing:  Also known as Reiki or Qigong, energy healing offers the potential for a positive shift in physiological state and present moment awareness that may alter the perspectives that sustain the burden of symptoms. 

Yoga:  A mind and body practice. Various styles of yoga combine physical postures, breathing techniques, and meditation or relaxation to promote mental and physical well-being. There are several types and many different disciplines. 

None of these are meant to replace any existing care plan, but rather contribute to a well-rounded approach to our whole being and health. Imagine committing the same amount of energy spent fighting against these concepts into exploring ways to incorporate them into your life. You just might find that they help.          

Mia Maysack lives with traumatic brain injury, migraine disease, cluster headache and fibromyalgia. Mia is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill. 

Mia was recently chosen as a recipient of the 2021 iPain Community Impact Award for her advocacy work.

Epidemiological Sleuthing During the Pandemic

By Roger Chriss, PNN Columnist

How do we figure out what is really going on with Covid-19? Amid the ongoing surge of Covid cases from the delta variant of SARS-CoV-2, this is very important.

As hospitals are overwhelmed with patients, beds are unavailable, supplies of monoclonal antibody drugs are limited, and frontline healthcare workers are strained. Understanding what is really happening becomes vital to an effective response.

One of the tools most widely used to track the severity of the pandemic is the number of patients that are hospitalized. According to the CDC, we’re currently seeing an average of 9,636 new admissions every day, which is about 14% less than a week ago.   

New Hospital Admissions for Covid-19

But how reliable are these numbers? And just how sick are the patients?

A recent preprint study of VA patients before the delta surge suggested that almost half of hospitalized Covid-19 cases had mild or asymptomatic symptoms. This finding prompted The Atlantic to conclude that the significance of the hospitalization gauge “can easily be misinterpreted.”

As often happens with public health data in the US, information is missing. SFGate recently investigated Covid-19 hospitalizations in the Bay Area and found that simply tracking patient numbers was unreliable. Three major hospital systems -- San Francisco General, Kaiser Permanente and Sutter Health -- could not say if mild and asymptomatic cases made up a large proportion of their Covid patients.

In other words, in many cases hospitals simply don’t have the data needed to assess the severity of outbreaks. We need better ways to validate hospitalization counts and assess local conditions in near real time.  

Fortunately, we have them. Broadly speaking, these include community surveillance, hospital monitoring and indirect signals. Each of these comprises multiple sources of information, and when combined, the result is a deep assessment of Covid conditions.

Carnegie Mellon University’s COVIDCast gives early indicators, including doctor’s visits and symptoms in communities across the nation. This can be paired with public behaviors like masking and distancing, visits to bars or restaurants, local vaccination rates, and searches on Google for Covid symptoms. All of this helps build a risk profile for a community that can be confirmatory for hospitalization data.

Similarly, wastewater epidemiology provides a close look at something all communities produce. For instance, the Sewershed Surveillance Project in Missouri has tracked virus levels in effluent for a year, with spikes often warning of possible outbreaks in cities and counties throughout the state. Wastewater epidemiology is already used in Europe and many parts of the US to help track drug use and disease activity.  

Next comes personnel. Hospital staff is in constant flux, and job postings provide valuable clues about what hospitals are expecting or confronting. For instance, travel nurses move around the US in response to calls for supplementary staff, so job boards like TravelNurse Source offer valuable insight for assessing a hospital’s needs.

The same for respiratory therapists, imaging technicians, and other frontline healthcare workers. Hospitals know their everyday needs, which can be readily found in reports from the American Hospital Association’s Data & Insights database. These reports include the number of staffed beds, admissions, and outpatient visits for most hospitals in the US. If we know what hospitals typically have and see, that allows us to check if they are experiencing a Covid surge.

Further, we have drug and equipment orders. Hospitals have to track all orders for financial and regulatory reasons. So new orders for fentanyl to sedate patients who need intubation, requests for ECMO respiratory machines, or just reordering PPE equipment and other supplies are all readily monitored via federal and state databases.

There are also indirect signals. Hospitals redirecting patients to other facilities, requesting ambulance or helicopter transport, arranging for at-home care for patients they might otherwise admit, or activating emergency plans are all publicly visible, as are signals such as requests for mobile morgues or National Guard assistance.

The above information can be combined to create a reasonably accurate profile of a hospital’s situation. Better, however, is to use such information proactively in order to avoid the severe surges seen in the South over the summer or in Idaho and Montana at present.

Early attempts to use wastewater epidemiology proactively have met with some success. When a wastewater sample from a dorm at the University of Arizona came back positive last year, the school quickly tested all 311 people who live and work there and found two asymptomatic students who tested positive.

All of the above is not limited to the pandemic. The same approach could be used for other infectious diseases, drug overdoses and other areas of public health. If the data streams and information analysis are combined and coordinated, the results could be that much better and more useful.

We cannot and should not rely on a single number, not with so many other tools available to be used. Hopefully we’ll see these tools put to use fast.

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. 

Rare Disease Spotlight: Sarcoidosis

By Barby Ingle, PNN Columnist

This month’s rare disease spotlight is on sarcoidosis. I have many friends living with this complex, autoimmune disorder, which affects about 200,000 Americans.

One of the first visible signs of sarcoidosis is for red bumps and patches called granulomas to form on the skin. Granulomas can also develop in the lungs, lymph glands and other internal organs, causing shortness of breath, abnormal heart rhythm, swollen glands and painful joints. The symptoms often appear suddenly and vary from person to person, depending on which organs are affected.

Although the symptoms usually go away on their own after a few months, the patients I know have lived with sarcoidosis long term. Some are less affected than others, but most people living with chronic sarcoidosis have major changes in every aspect of their body and life activities.

I think it is best to spotlight some of the people in my life who live with sarcoidosis on a daily basis. Frank Rivera and Kerry Wong have a website called Stronger Than Sarcoidosis. Karen Duffy shared her journey with sarcoidosis in one of my favorite books, "Backbone: Living with Chronic Pain without Turning into One."

You’ll see by reading their responses that sarcoidosis is tough to have, but they are tough, too.

How long have you lived with sarcoidosis?

Wong: “I was diagnosed in 2015, but that was after an 8-year search for answers … so I would say probably closer to 14 years.”

Duffy: “I have been living with sarcoidosis for 23 years! It took about 2 years to get a diagnosis of exclusion.”

Rivera: “I have been living with sarcoidosis since 2004, 17 years, but fully diagnosed in 2011. So, 10 years since diagnosis.”  

In what ways has living with sarcoidosis affected your life?

Duffy: “Sarcoidosis has impacted my life in countless ways. I live with neuro-sarcoidosis and I have severe pain issues. I also have Complex Regional Pain Syndrome. I find that the principles of stoic philosophy have really helped me accept that I cannot control what happens, I can only control how I respond.”

Rivera: “I am on disability now due to the bone and joint involvement and the pain I live with is a 6-7 pain level on a pain scale of 1-10, daily.”

Wong: “Oh, so many ways! Because the symptoms can be both severe and so unpredictable, I’m no longer able to work, and have been on disability since 2014. I’ve had to cancel plans with friends and family more times than I can count. And I’ve had to depend on my husband for so much more, for even the little things. But I’m so grateful for how he has stepped up as an incredible caregiver.

And that’s not to mention the emotional toll of the physical manifestations, the anxiety and depression that come from living with chronic pain, fatigue, and disability.”

Have you found anything that was helpful for the symptoms of sarcoidosis?

Duffy: “I believe in the power of the placebo. In Latin, placebo means "I Shall Please." I try to be useful, so I keep up with my volunteer projects. I find reading to help when I am roped to my sofa like Gulliver. On days when I am released from the grip of chronic pain, I love to walk. I follow my doctors’ advice and take my prescription meds.

I have found a pain cream called Tribe Revive---and it works for me! I no longer wear a pain patch, I just rub this CBD infused cream and the relief is instant. I have no connection to the company that makes the pain cream, I am just a very grateful customer. I buy so much of it and give out jars.”

Rivera: “Prednisone helped some, but the side effects almost killed me. Gave me a hole in my colon and diabetes as well as brittle bones.”

Wong: “Yes, thank goodness! Even after all this time, we are still working on finding the right treatment combination to help with my symptoms, but there are a few things that have helped. IVIG (Intravenous Immunoglobulin) therapy; heat and cold therapy; TENS (transcutaneous electric nerve stimulation); eTNS (electric trigeminal nerve stimulator); acupuncture and acupressure; and medical marijuana in a variety of forms.

Aside from that, probably the most helpful thing is learning to listen to my body. When it says I have to rest, I have to rest. Pushing myself to do more, which is what I have always done before, will only make me suffer that much more and that much longer afterward.”

Do you think there is a societal stigma on people living with sarcoidosis and other rare diseases?

Duffy: “I find that living with a chronic, invisible illness has its challenges. The pain from the nerve damage is cataclysmic, and it can be confusing that some days I can walk my dog, go for walks, and socialize with friends. Then other days, I am wiped out and live a smaller, quieter life. On these days, I read and write.”

Wong: “I am not sure if stigma is the word I would use, but there is definitely an additional problem for us. Because most people have never heard of sarcoidosis, they find it hard to understand and try to compare it to things they know. How often do we hear, ‘At least it’s not cancer?’  And because most of our symptoms are invisible, they find it hard to believe what they don’t see. That lack of understanding can have a tremendous impact on both personal and professional relationships.”

Rivera: “Yes, because from the outside we look fine. It is called an invisible illness because it works from the inside out.”

Is there anything you wish the world knew about sarcoidosis?

Wong: “Honestly, the thing I would love for people to understand most is how unpredictable the disease can be. Our symptoms can vary from day to day or hour to hour. That means what we are able to do varies as well. We always see inspirational examples of people who ‘didn’t let xyz stop them,’ but that is just not how it works with an incurable rare disease.

I always strive to do as much as I can to help others, but some days, the symptoms do win. That is not a character flaw or weakness; it is just the fact of the disease. Once those symptoms ease up and I am able to do more, I will always bounce back with purpose.”

Duffy: “I know it can be overwhelming to live with a rare, complicated, multisystem disorder. I have a serious illness, but I do not take it too seriously. Having a painful diagnosis and having a great life is possible. I am grateful for every day.”

Rivera: “Sarcoidosis is when a person's white blood cells become over active from an environmental accelerant. And instead of fighting off colds or foreign substance in the body, they clump together and form masses anywhere in the body as well as skin. This disease is a very painful disease and attacks the physical and mental health of a person.

With sarcoidosis, no two patients are alike. They call it the snowflake disease because no two patients are the same. That makes it very difficult to diagnose as well as treat because each temporary medicine does not work the same for each patient as well. So trying to help a sarcoidosis patient is very tough.”

Getting Help

If you need help with sarcoidosis, you should set up appointments with specialists to add to your treating team. These professionals would include a primary care provider, rheumatologist, pulmonologist, ophthalmologist and dermatologist.

Steroids are usually used to treat sarcoidosis. They reduce inflammation, and can stimulate tissue growth and repair. If steroids don’t work, immunosuppressant medications might be tried to reduce the immune system response. Pain medications may also be prescribed.  

Although the cause of sarcoidosis is unknown, the most widely known theory is it may be due to an immune reaction to a trigger, such as an infection or chemicals in those who are genetically predisposed. I look forward to the day that better testing and treatments exist for this rare disease.

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.

Another Drug Shortage Caused by Covid-19 Has Me Worried

By Victoria Reed, PNN Columnist

I recently read a news article about the Food and Drug Administration issuing an emergency use authorization for Actemra (tocilizumab) for the treatment of hospitalized covid-19 patients. The medication was originally developed as a treatment for rheumatoid arthritis (RA), one of the chronic pain conditions I live with.  

Actemra is a biologic drug that calms down overactive immune systems by blocking the interleukin-6 (IL-6) receptor. Persistent dysregulated expression of the IL-6 receptor is involved in the pathogenesis of RA and other chronic inflammatory and autoimmune diseases. It is believed that this over-activation of the IL-6 receptor is also responsible for the so-called “cytokine storm” that causes severe illness and death in covid-19 patients.

The symptoms of RA are pain, fatigue and swelling in the lining of the joints and other parts of the body, including the heart, lungs and eyes. This inflammation can lead to disability, joint destruction and cause serious damage to the lungs and heart.

I have had long-term success controlling my RA symptoms with Actemra and have been getting the drug by IV infusion monthly for about 8 years. Prior to that, I didn’t have good control with other biologic meds such as Enbrel and Orencia.

When I read that news story, I was initially only mildly concerned about Actemra becoming unavailable. Nevertheless, I contacted my doctor for confirmation that I was still on track for my upcoming monthly infusion. However, she did not and could not confirm that the medication would be available to me. Why?

Actemra has now been hijacked by doctors treating covid-19 patients, and this has created a major shortage. I have been informed that its availability for RA patients is uncertain for the foreseeable future. This is really very upsetting!

Covid-19 patients are using up resources in hospitals across the country. The overwhelming needs of these severely ill patients are causing other patients who need surgery or have treatable illnesses to die from a lack of available resources. Hospitals in hard-hit areas are short on everything -- staff, meds, beds and time. As a result, many chronic pain patients like me are being denied the treatments that we rely on to have functional lives. I must say that this seems patently unfair.

What’s even more disconcerting is that Genentech, Actemra’s manufacturer, can’t say when the shortage will end and expects “additional intermittent periods of stockouts (lack of supply) in the months ahead, especially if the pandemic continues at the current pace.”

RA and lupus patients saw this happen earlier in the pandemic when word got out that Plaquenil (hydroxychloroquine) might help treat covid-19. That medication also became scarce and was inaccessible to patients with autoimmune conditions for a while.  

One thing for sure is we are all very tired of the covid virus and its variants. I understand that doctors and scientists are desperate to find things that work, and they want to save lives. But I rely on Actemra to help relieve my pain and fatigue and keep damaging inflammation down. It is the mainstay of my treatment.  

Due to the Actemra shortage, I may have to consider other medications that might not work as well or just wait out the shortage and hope my disease activity doesn’t become unbearable.  

If the pandemic continues, many more people are going to lose their lives from covid infections. However, all patients deserve an equal chance at receiving the care they need, including chronic pain patients. The pain community is already suffering from opioid hysteria and many of us have to fight to stay on these pain medications. We shouldn’t have to fight for our other meds too! 

RA is a serious, systemic and often misunderstood condition that can shorten a lifespan by many years if not treated aggressively and with the proper medications.  Patients sometimes go through many trials of medications before finding one that relieves symptoms and arrests disease activity.  

I truly hope this shortage is short-lived -- for myself and others like me -- who rely on Actemra to remain functional and productive.  

Victoria Reed lives in Cleveland, Ohio. She suffers from endometriosis, fibromyalgia, degenerative disc disease and rheumatoid arthritis.

A Pained Life: False Narratives About the Opioid Crisis

By Carol Levy, PNN Columnist

The common belief that any patient who takes opioids for pain relief soon becomes addicted seems to have started in 2003, when The Orlando Sentinel published a front-page series under the headline "OxyContin Under Fire: Pain Pill Leaves Death Trail.”

The newspaper used the term "accidental addict" to describe patients who "put their faith in their doctors and ended up dead, or broken."

This characterization quickly became the go-to description for most news articles on the emerging “opioid crisis.” An innocent person, often a teenager on the cusp of life, suffers a painful injury. Their doctor prescribes OxyContin or some other highly addictive opioid and their lives are forever changed. They take higher and higher doses, become addicted, and die from an overdose.

Four months after publication, the Sentinel printed a correction. Two patients profiled in the series as “victims” were not newcomers to opioids, as they had been portrayed. They were using illegal drugs and abusing prescriptions long before their first dose of OxyContin. The Sentinel series also grossly overstated the number of overdose deaths that were caused solely by oxycodone, the active ingredient in OxyContin.

The problem was that the presentation of someone falling so far so fast due to prescription opioids remained irresistible to the media. It became the common narrative, especially in “recovery” stories about someone becoming addicted due to thoughtless opioid prescribing by a doctor or dentist.

This helped create the false belief that people in pain become addicted, very quickly and easily, to opioids. The lie took hold, even though a 2008 study found that chronic pain patients taking opioids had a rate of abuse and addiction of only 0.19% — less than one percent.

In 2015, another study was released that reinforced the false narrative. People in chronic pain on long-term opioid therapy had a “misuse” rate between 21 to 29 percent; and their addiction rates averaged between 8 and 12 percent.

Those are horrible numbers. And very misleading. Shortly after the study was published, the researchers admitted they may have exaggerated the potential for addiction.

“We agree that opioid use is not inherently risky, most patients seem to use opioids without misuse or addiction,” said lead author Kevin Vowles, PhD, a Professor of Psychology at the University of New Mexico.

But that kind of clarification we do not hear in the news. Instead, the story is still about patients prescribed opioids becoming addicted and fueling the opioid crisis.

Often ignored by the media is that opioid prescriptions have been declining for a decade and that most overdoses are cause by street drugs. Or that medical students now get more training in pain management. This may actually be the best and safest time to prescribe and receive opioid prescriptions. 

Most of us bemoan and rant against the CDC opioid guideline, and because many of our doctors feel intimidated by the DEA and state medical boards, fearing arrest and prosecution if they prescribe opioids. 

Maybe, though, the place we need to start is with the media, and getting them to tell the true narrative: most pain patients do not become addicted. 

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.

Finding Life in the Midst of ‘The Pain-Cancer Connection’

By Cynthia Toussaint, PNN Columnist

In 2019, when I first heard my worst diagnosis, Triple-Negative Breast Cancer – yes, the rare and aggressive kind – I instinctively knew it was tied to my 37 years of high-impact pain. Indeed, for a couple of decades, I’d commented often to my partner, John, that I didn’t understand how my body could take the toll of never-ending torture without getting terminal cancer.

Like so many of us with pain, my chronic depression kept me wondering if that scenario might be a blessing. In fact, my greatest struggle was endlessly debating whether life with pain was worth living. 

Here’s the stunner! After hearing my grim diagnosis, I ultimately deduced it was. So much so, not only did I choose to fight, I took a deep dive into discovering the best chance at surviving my cancer well with the quality of life I still had intact. In short order, I armored myself with a boatload of education and committed to using integrative care all the way. Making bold, unconventional treatment decisions upped my chances to stay on the planet.

I won’t sugar-coat it; fighting breast cancer while trying to keep 19 overlapping pain and fatigue conditions in check was the hardest thing I ever did, and the jury’s still out as to whether I’ll survive. But I’m damn happy and proud to be here today, and want to share what I’ve learned.

Enter “The Pain-Cancer Connection,” the theme of For Grace’s 2021 Women In Pain Conference on Friday, September 24.

Last year when I sat down via Zoom with my sisters in pain that make up For Grace’s event planning committee, I was in the midst of chemo, bald and very ill. After pitching the theme and telling these badass women about the connection between pain and cancer, I was deeply touched that they wanted to move ahead.

None of these women have had a serious cancer diagnosis, and executing a conference, especially in the midst of COVID, is damn-near impossible work. I love these women! They play a critical part in helping me turn suffering into meaning, my primary life force.

CYNTHIA TOUSSAINT

As some wise woman shared, “All good things come in time.” As such, this virtual conference is a year late due to my rough recovery. That’s another thing about my sisters – they unconditionally supported, even insisted on, my need to take time to ramp up to this frenetic pace.

Well, here we are, and what a first-of-its-kind day we’ve got in store.   

After a warm welcome from our Director, John Garrett, I’ll start by divulging my cautionary tale with cancer treatment. Oh boy, I’ve got a ton to say about western medicine failing miserably at every turn – and how taking control of my cancer care got me this far.

Next up, integrative oncology chaplain Michael Eselun will share a touching, personal story about loss and letting go. Michael is a gem of a storyteller who brings his audience to laughter and tears, whilst stepping into the dark side with ample tenderness.  

Sprinkling in some For Grace vibe, woman in pain and comedian Anna Polack will drop a witty take on the self-help movement. Later, she’ll host interactive “fun breaks” to bring in lightness.

Also, throughout our day, we’ll spotlight woman in pain and artist Radene Marie Cook’s exquisite pieces that depict the pain-cancer experience in endless passion and color.

Then we’ll launch into our four themed sessions: Problem, Solution, Experience and Moving On.

Dr. Wayne Jonas, Executive Director of the Samueli Foundation’s Integrative Health Programs, will present the “Problem” – how the inflammation of pain can lead to cancer and how cancer treatment can spark persistent pain. Dr. Jonas will also delve generously into the benefits of integrative care. His brilliant, positive take on healing is eye-opening, and I’m forever grateful for his steady guidance.

The “Solution” session will kick-off with one of my all-time favorite people, Christin Veasley, co-founder of the Chronic Pain Research Alliance. Simply put, Chris is the best, full of information and care. She’ll explore effective tips about how to become your own best advocate, including how to partner with your practitioner for best outcome.

Next up, one of my heroes, Dr. Keith Block, founder of the Block Center for Integrative Cancer Treatment, will go in-depth about how to keep one’s “terrain” healthy throughout active cancer treatment as well as the all-important post period to avoid a recurrence. Tragically, western medicine doesn’t acknowledge the terrain, but this is the stuff that saved me! In fact, Dr. Block’s book, Life Over Cancer, was my bible during treatment.

Dynamite wellness expert and fellow sister in pain, Dr. Susan Nyanzi, will follow with how common-sense, self-care lifestyle choices can help prevent most cancers. I say, “Amen to that, Dr. Nyanzi!” Just wish I’d heard this talk five years ago.

A dynamic panel of real-life pain and cancer patients will make up our “Experience” session. Moderated by the no-holdin’-back Rhonda Smith, breast cancer survivor and executive director at California Black Health Network, these folks will share, with us and each other, inside advice about getting best care, handling adversity, the importance of self-management, and improbable “gifts” along the way.         

We’ll end with the inspiration to “Move On” despite the challenges of these epic diseases. Yes, it’s all about hope and movement with Dr. Melissa Cady, DO. Also known as “The Challenge Doctor,” this force-of-nature will teach us how to reframe illness and use movement to find joy and less suffering.   

To put a bow on the day, cancer survivor and Bump In the Road podcaster, Pat Wetzel, will share how illness and misfortune drove her to transform her life into one of helping others, traveling the world and prompting folks to hit the road to find wellness and meaning. Seriously, there are no brakes on this full-speed-ahead woman, guaranteed to inspire! 

There’s no denying that cancer and pain are upending, life-altering, sometimes terminal diseases. But as this conference will illuminate, we can fight the good fight with dignity and grace.

Last year, during my darkest hours of chemo and COVID, when I actually forgot why I wanted to live, people from my circle of support bolstered me by phone, email, text and good ol’ snail mail, to keep me keepin’ on. Truly, I don’t know if I would have made it without them.

I want this conference to be that kind of support system for those who are wrangling with pain, cancer or both. I want its shared education to make it possible for one disease not to springboard into another. I want the day to remind us that there’s enough love in this world to make life worth fighting for.

Seeing so many beautiful people come together, volunteering their time to help others avoid my fate, humbles me – and makes my heart swell.    

I look forward to connecting with you on Friday, September 24 at 9am PDT (12pm EDT). You can watch the entire conference for free on our YouTube channel.      

Cynthia Toussaint is the founder and spokesperson at For Grace, a non-profit dedicated to bettering the lives of women in pain. She has lived with Complex Regional Pain Syndrome (CRPS) and 19 co-morbidities for nearly four decades, and became a cancer survivor in 2020. Cynthia is the author of “Battle for Grace: A Memoir of Pain, Redemption and Impossible Love.”

Misogyny in Medicine Harms Fibromyalgia Patients

By Dr. Denise Phan, Guest Columnist

Anyone who has practiced medicine or been involved in women's health in the past 50 years has encountered fibromyalgia in one form or another. Many of us have seen the fibromyalgia pendulum swing from under-recognition to over-diagnosed, and back to under-diagnosed again.

Although the course of fibromyalgia mirrors our society's recognition and treatment of pain in general, this particular disorder is also handicapped by its association with women. Since women were not part of the medical and research establishment until recently, diseases that affect women exclusively or predominantly have often been ignored or downplayed. 

Admittedly, fibromyalgia is not an easy diagnosis to make and has no reliable treatments. It is also not progressive, does not cause permanent muscle or joint damage, and does not directly cause early death. Until recently, there were no easy blood markers for fibromyalgia as with other rheumatologic diseases. No x-rays or MRI findings can help diagnose it. 

But the main problem with fibromyalgia was that the vast majority of patients who present with this syndrome of widespread pain and tender points are women.

Thus, it was easier for the arrogant and sexist wing of medicine to relegate fibromyalgia to the "histrionic" or "psychogenic" disorders that predominantly affect women. 

DR. DENISE PHAN

Other examples of severe disabling painful conditions that affect women more than men are endometriosis, pelvic pain, polymyalgia rheumatica, migraine, lupus, scleroderma, and trigeminal neuralgia. Some of these disorders are just now being recognized, researched and beginning to get treated. 

Though the term fibromyalgia was first coined in the 1970s, the disease can be traced back thousands of years to biblical times. When I was going through medical school and residency training in the 1980s, many of my attending physicians refused to recognize fibromyalgia as a "real" disorder and often did not offer any treatment for it. 

To some degree, this was due to our poor understanding of how the nervous system affects musculoskeletal tissue. But in the vast majority of cases, the refusal to acknowledge fibromyalgia stemmed from the undercurrent of misogyny that permeates medicine even today. 

Learning How to Treat Fibromyalgia

There were others in the medical community who recognized fibromyalgia and taught me what it was, how to diagnose it, and how to treat it -- despite our very limited, almost non-existent treatment options at the time.

In the 1990s, when I started my private practice in California’s San Fernando Valley, my practical education of fibromyalgia was furthered by the multiple women who presented in my office with this puzzling, intractable disease. Since there were no FDA-approved treatments yet, we would try every and any off-label treatment possible to see if we can get any long-term or even short-term relief of symptoms. 

There were the traditional trials of NSAIDs, tricyclics like amitriptyline, trazodone, SSRI's, low dose opioids, muscle relaxants, warm water physical therapy, trigger point injections; and then the non-traditional treatments like guaifenesin, anti-inflammatory diets, acupuncture, yoga, tai-chi, sauna, infrared therapy, cannabis, low dose naltrexone and moving to a warm, dry climate. 

Although none of these treatments are highly effective; when they did work it was a tremendous relief to restore function to these long-suffering patients. Despite this, I would still occasionally learn of suicide threats and attempts by fibromyalgia patients who did not respond to any of these treatments. 

These patients pushed me and other doctors to treat pain seriously; so that it does not become a cause of other morbid pathologies such as depression, fibro fog, cervicogenic headache, irritable bowel, overactive bladder and chronic fatigue. It also emboldened us to use stronger opioids, if necessary, to control chronic pain. This coincided with the release of longer-acting opioids like MS Contin, fentanyl patches and OxyContin. 

As the recognition of fibromyalgia went mainstream in the 2000s, so did the push to control pain more aggressively with higher doses of opiates. Laws were passed and guidelines were published, urging physicians to treat pain seriously. Physicians were taught, in one seminar after the other, that longer-acting opioids would control pain throughout the day with less need for pill-popping. This would provide more stable blood levels and less euphoria, making opioids less habit-forming and minimize addiction potential. 

In the late 2000s, Lyrica was the first medication specifically approved for the treatment of fibromyalgia, followed in quick succession by Savella and Cymbalta. Fibromyalgia patients benefited from the increased recognition and treatment of their disorder and the aggressive approach to pain control. 

Many of my patients who didn't respond to off-label treatments achieved remission with the new FDA-approved meds. Some who didn't were eventually stabilized on higher doses of hydrocodone, oxycodone, Dilaudid, methadone, buprenorphine, morphine or fentanyl. Some of the more severe cases were able to get off oral meds and restore normal daily function after we implanted subcutaneous pain medicine pumps. 

A New Betrayal

Then in the early 2010s, reports of rising death tolls from opiate overdoses began coming in, often involving drug seekers who were crushing and snorting OxyContin tablets to get high. It was also recognized that patients on chronic opioids were at risk of accidental overdose.

In response, more cautious opioid prescribing guidelines came out from state medical boards and the CDC; followed by the DEA prosecuting pharmacies and pain management doctors. One pain clinic after another started closing down, their patients were often red-flagged and unable to find new doctors. Vast numbers of patients became collateral damage as the news media and legal profession fanned the flames of the war against opiates. 

For chronic pain patients in general, the lack of access to pain meds required them to make serious adjustments to their lifestyles, like not getting out of bed, not holding a job, and not taking care of their family. For many fibromyalgia patients, it was as if the doors to treatment were slammed shut. 

The latest betrayal for these patients is coming from the medical and academic community itself. I was horrified and shocked at my last pain management seminar when the young professor lecturing on the topic of fibromyalgia stated aloud the official current policy of the medical community is that there is no role for opioids in treating fibromyalgia. 

When asked what we should do for patients who have failed all the recommended treatments, FDA-approved and otherwise, he could only recommend yoga. That was when I realized that misogyny was back in style. The medical community has been cowed by “opiate hunters” into toeing the line and spouting what is essentially a ludicrous theory: the idea that we should not use pain medicine in the treatment of chronic pain. 

This is what is being taught today in medical schools all over the country. The next generation of physicians is being trained to think that it's okay to leave people in chronic pain day after day, when there are good medicines available that, when used judiciously, may be able to restore life and function to an incapacitated patient. 

Obviously, there is the risk of serious side effects from opioids, just as there are for any powerful medications. But that is what we are trained to do, to take into account these side effects for each individual patient, to evaluate the risks versus benefits of each treatment, and to monitor them as best we can. That is what my Hippocratic Oath tells me to do. 

Now, if only we can get through to the other less misogynistic side of the medical community. The ones with enough courage to speak truth to power. There are some of them in medical schools and ivory towers everywhere, who can recognize injustice and who will speak common sense to our future doctors. 

Dr. Denise Phan is an Internal Medicine physician in Los Angeles. She works in private practice in the San Fernando Valley and is on staff at Valley Presbyterian Hospital. Dr. Phan is active in the annual missions of the mobile health units of the Social Assistance Program for Vietnam and the International Humanitarian Mission.

How I Learned To Live With and Manage Chronic Pain

By Beth Thorp, Guest Columnist

The CDC estimates that 50 million Americans – just over 20 percent of the adult population – have chronic pain.  About 20 million have “high-impact chronic pain,” which is defined as pain severe enough to frequently limit life or work activities. I am one of the “high-impact” ones.

For a long time, I did not believe that I had enough expertise or a unique enough story to share my experiences with pain, except with those closest to me.  But because of how often people tell me, “I don’t know how you do it!”; I began to believe that sharing my struggle to live with and manage chronic pain might help others who also suffer from it.

Like many others with severe chronic pain, I have had experience with using opioids.  Given the crackdown on doctors prescribing these medications, I felt that sharing all the other skills I use to manage my pain might be useful to other patients. 

I believe there are three aspects of our health which must be addressed if we are to have full and productive lives despite our pain. These are physical health, mental health and socialization.

Three-Part Model for Pain Management

Physical Health

When pain begins, the first and logical area to address is our physical health. It’s important to me to rely not just on pain medication, but a wide range of other modalities. These include:

• Physical therapy, including heat, ice, ultrasound, stretching, exercises, TENS

• Injections of steroids and analgesics

• Neuromodulation devices such as spinal cord stimulators

• The use of support tools, such as canes, walkers, wheelchairs, etc.

Some activities, like stretching, might be easy to incorporate into your daily life.  Exercise might take some trial and error to find types that help with pain and that you enjoy. Others, like using a wheelchair, might take overcoming the burden of stigma.   

For me, the idea of getting a wheelchair was initially out of the question.  But then my pain doctor suggested that it would be better to use one to travel in places like airports, museums and zoos so that I can better enjoy the experience, and have less pain during and afterwards.  Once I thought of it this way, it was an easier choice.

Mental Health

As my pain persisted, despite many physical and medical treatments, it became clear to me that I needed some additional resources to help my mind and spirit.  These treatments used to be considered outside of traditional Western medicine.  Additionally, these methods often require out-of-pocket payment. Some examples are:

• Counseling, talk therapy, hypnosis, Reiki

• Meditation and mindfulness

• Participation in activities designed to distract from the pain

• Antidepressant medications

• Focusing on the positive

There are other therapies which address both physical and mental health, including yoga, Pilates, acupuncture, therapeutic massage and tai chi. 

I rely more on distraction than on any other technique.  If one activity does not work, then I will go to another.  When I first heard about distraction, I did not believe that it would work -- but it really does.  Even getting out of one environment into another can help. 

I am still working on the technique of focusing on the positive rather than the negative.  I know this sounds a bit Pollyanna, but I believe it is important to move ahead with a good quality of life.  The goal is to be grateful for the things I can do, not ruminating on the things I have lost or can no longer do. Some examples of this are:

• Take “one day at a time.”  If today is bad, tomorrow is likely to be better

• Try new activities that fit within the scope of your current abilities

• Learn new skills or explore new areas to learn by taking classes, in person or online

• Find others who suffer from chronic pain and share ideas for living better

• Most of all, don’t give up! 

Socialization

The longer pain goes on, the more isolating it can be. I’ve experienced loneliness and solitude. Our world gets smaller as the number of things we can do shrinks and the things we can do become very restricted. 

One of the hardest things for many of us is to ask for help. Similarly, we don’t want to be a burden, so we don’t reach out to ask our friends and family to come over and spend time with us. 

In order to maintain a good quality of life, we must find our own ways to become or stay involved with others.  For example:

• Phone calls or Skype, FaceTime and Zoom meetings with family and friends

• Group activities such as book clubs, crafting circles, games nights, group lunches

To address mental health as well as socialization, joining a religious group, community organization or chronic pain support group can be very helpful.  You can also combine socialization and physical health with activities such as exercise classes or Silver Sneaker programs.

Three Changes Needed

I believe that there are three changes to our healthcare system which must be pursued in order to respond to the opioid crisis in ways that help patients with pain, not hurt them.

First, don’t punish patients by removing access to opioid medications. For some of us, they are the only thing that works. Work with us to help us take them responsibly. 

Second, the pharmaceutical industry should develop safe, effective and non-addictive pain medications for those of us with high impact chronic pain. 

Third, insurance companies should be required to pay for alternative treatments such as massage, acupuncture, yoga, etc. that are often recommended as alternatives to opioids. Those options are not really available to most patients with pain.

Chronic pain may last a lifetime.  Thus, it is critical to find ways to live a full and happy life despite the pain.  Different methods work for different people.  I believe that the most important thing is to try everything you can.  If one doesn’t work, try another.  Be sure to include physical, mental and social solutions.  And try to stay as positive as possible.  That’s how I do it.  You can do it too! 

Beth Thorp has lived with chronic pain from sciatica, neuropathy and osteoarthritis for almost 25 years. She’s had multiple back surgeries, including two implanted stimulators.

Beth worked for 34 years in the pharmaceutical industry, including as a partner in her own consulting firm. She is now retired and spends her time with her family, as well as knitting, quilting, reading and exercising.

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

Infighting in the Pain Community Made Me Leave Advocacy

(Editor’s note: The pain community lost another one of its advocates this week – not to chronic pain or illness, but to frustration and despair. In a Facebook post, Caylee Cresta said she would no longer be an advocate for people in pain because of chronic infighting and toxicity in the pain community.   

For those who don’t know Caylee, who we profiled in a 2018 PNN article, she is the creator of a series of videos on YouTube and TikTok that explore everything from makeup and relationships to the stigma faced by pain patients and their fear of pharmacists. Caylee’s entertaining videos offer a way for people outside the pain community to see how opioid hysteria has disrupted pain care for millions of patients. Her Facebook post is republished here with Caylee’s permission.) 

By Caylee Cresta 

For my fellow spoonies: I’m going to address this once, and once only. I hear you guys, I know you’re waiting for chronic pain content; but unfortunately, it’s not coming (at this time, at least).  

Rare disease, chronic pain, and the stigma surrounding opioid medications have plagued my life for over a decade at this point. I am not nearly alone in that, and hundreds of thousands of people are suffering daily. That cause is so close to my heart, and will forever be, and it is still something I deal with daily as well.  

When my life was turned upside down as a result of that stigma, I found a community advocating, fighting, and spreading awareness. I met some of my favorite people as a result and made what I believed at that time would be lifelong friends.  

However, that community is by far the most toxic I have ever seen in my life. There is a power struggle that will swallow any attempt at good, and an ugliness that will destroy progress. It will scare any true advocate enough to walk away. The lies I heard spread about myself, my character, and my family were enough to make me sick.

CAYLEE CRESTA

I want you to ask yourself, if someone is fighting for a cause they truly believe in, should they have to defend themselves more vehemently than the crisis at stake? The toxicity doesn’t allow anyone to focus solely on the action of advocacy, and you beat each other down more than any opposition ever could.  

I don’t expect a word of this to change anything, but I do feel as though I owe many of you an explanation for my absence. I can only hope that I will be able to create some change at some point on my own, but that is not a decision I will make today.  

I love creating more than anything in the world, and I let the toxicity of the chronic pain community rob me of that for years. The chronic pain community caused me more pain than the stigma I hoped to fight.  

I remember my first days in the chronic pain community clearly. I remember people saying that they never made any progress. While I hate to be blunt, I think the answer is abundantly clear.  

You will never have the numbers because you constantly let people be torn down and excommunicated. Your viscous behavior will take any passion for this cause and swallow it whole, all before spitting out the shell of someone who was once excited to advocate. You don’t see passion as inspiration, you see it as competition. 

I spent my own resources, offered my assistance to all, and spent hours in hopes of offering support and change, and instead I got hate. I see everyone post the suicide rate with grave concern, and yet you will encourage it with rumors, falsehood, and lies.  

The very people that once called asking for help became my enemy without a word, question, or otherwise. And while I could go on forever, I only ask this: If you see another passionate advocate excited to create change, protect them and don’t let them be destroyed as you did me.  

This isn’t about me, it’s about patients, but the chronic pain community seems too often be about anything but. 

If you take anything from this post, let it be this: you have to care more for this cause than you hate one another. And with this, I close that chapter of my life forever, and I wish you all continued love, happiness, and comfort.