WHO Recognizes Chronic Pain as Disease With New Coding System

By Pat Anson, PNN Editor

The World Health Organization has adopted a new classification system for chronic pain, assigning it the code ICD-11 in a revision of the International Classification of Diseases (ICD). It’s the first time the ICD will include a specific diagnostic code for chronic pain, along with sub-codes for several common chronic pain conditions. 

The new classification system is important because it treats chronic pain as a distinct health condition and as a symptom to an underlying disease. It also takes into account the intensity of pain, pain-related disability, and psychosocial factors that contribute to pain.

“The inclusion of the new classification system for chronic pain in ICD-11 is an important milestone for the pain field,” says Lars Arendt-Nielsen, MD, President of the International Association for the Study of Pain (IASP), which headed a task force that developed ICD-11.

The new coding system will make it easier for physicians to diagnose, classify and get treatment for chronic pain patients. Insurers will use the new codes to authorize payments and researchers can use them to more easily track and measure the effectiveness of therapies. That’s the good news. 

The bad news is that the ICD changes won’t formally take effect until January 1, 2022. 

Under the current system, chronic pain conditions are poorly categorized under the code ICD-10, which makes it difficult for complex conditions such as fibromyalgia and Complex Regional Pain Syndrome (CRPS) to be classified. That led some physicians to diagnose patients with unexplained pain as having a somatic symptom disorder. 

“A diagnosis of somatic symptom disorder implies that the pain is caused by a behavioral, that is, mental condition. However, it is not appropriate to diagnose individuals with a mental disorder solely because an alternative medical cause cannot be established,” Jaochim Scholtz, MD, an IASP task force member, explained in Practical Pain Management.  

Under the new coding system, patients with fibromyalgia or CRPS could be classified as having a “primary pain” disorder, one of seven new sub-codes for chronic pain conditions:

1. Chronic primary pain

2. Chronic cancer-related pain

3. Chronic post-surgical or post-traumatic pain

4. Chronic neuropathic pain

5. Chronic secondary headache or orofacial pain

6. Chronic secondary visceral pain

7. Chronic secondary musculoskeletal pain.

There is some overlap between the different diagnostic codes. For example, neuropathic pain can be a symptom of cancer or chemotherapy, while trigeminal neuralgia could fall under neuropathic or orofacial pain. The idea is to give physicians a range of codes to choose from instead of the limited choices they have today.

“The integration of chronic pain in ICD-11 sends a strong signal that pain will achieve appropriate representation in this international standard for reporting diseases and health conditions,” said Scholtz. “The coding system also provides fundamental information for the identification of health trends and healthcare planning. It is widely hoped that the new systematic classification of chronic pain in the ICD-11 will support epidemiological, and other research that is essential for the development of future health policies.”

The classification system was outlined in a free online article published in the January 2019 issue of PAIN.

American Pain Society Likely to File for Bankruptcy

By Pat Anson, PNN Editor

The board of directors of the American Pain Society (APS) is recommending to its members that the organization cease operations and file for bankruptcy, PNN has learned.

The APS is a non-profit, research-based organization that focuses on the causes and treatment of acute and chronic pain. Although many of its members are researchers and academics who are investigating non-opioid treatments for pain, the APS has been named as a defendant in numerous “spurious lawsuits” involving opioid prescriptions.

“Despite our best efforts, APS was unsuccessful in its attempts to resolve these lawsuits without the need for what will no doubt be lengthy and expensive litigation. The anticipated time-consuming and costly litigation combined with the declining membership and meeting attendance has created the perfect storm placing APS in a precarious financial position,” the board said in a letter sent to its members yesterday.

“Constrained by these unfortunate circumstances, we do not believe APS can continue to fulfill its mission and meet the needs and expectations of our members and community.”   

In order to proceed with a Chapter 7 bankruptcy filing, only 10% of the organization’s 1,173 active members need to approve the board’s recommendation. Assuming there are sufficient votes, an independent third party trustee would then be appointed by a bankruptcy judge and all lawsuits pending against APS will be subject to an automatic stay.

“This will allow APS to minimize legal expenses and maximize recoveries for its creditors, as opposed to future dissipation of assets in defending the lawsuits which have no end in sight,” the board wrote.

The APS membership vote will be tallied May 29th.

“Sad day for U.S. pain research, education, advocacy and patient care,” APS member and Stanford University psychologist Beth Darnall, PhD, tweeted to her followers.

In recent years, thousands of lawsuits have been filed by states, cities and counties seeking to recover billions of dollars in damages caused by the “overprescribing” of opioid pain medication. The lawsuits initially focused on Purdue Pharma and other opioid manufacturers, but have recently expanded to include opioid distributors, wholesalers, pharmacies and professional medical organizations like the APS as defendants.

If the APS files for bankruptcy, it would be the second pain management organization to cease operations in recent months. In February, the Academy of Integrative Pain Management (AIPM) shutdown, largely due to financial problems.  

“It's really sad that pain organizations are failing,” said Bob Twillman, PhD, the former Executive Director of AIPM. “I'm not clear about the extent to which this was an anticipated or desired outcome of the lawsuits against opioid manufacturers, but it strikes me that an effort to say that we've been harming people by treating pain the wrong way has now eliminated two organizations focused on treating pain the way every guideline now says it should be treated, and on discovering new treatments that might obviate the need for opioids.”

Twillman says the shutdown of APS and AIPM will cause “significant gaps in the field” of pain management.

“The unintended consequences here may end up being quite ironic," he added.

Guilt by Association 

Like other professional medical organizations, APS relied on corporate donors to help pay for its annual meetings and widely respected publication, The Journal of Pain. That meant accepting nearly $1 million in donations from Purdue Pharma, Janssen, Depomed and other opioid manufacturers.

It also meant being targeted by lawyers and politicians in a campaign of guilt by association.

In 2018, APS was one of the medical societies and patient advocacy groups singled out by Missouri Sen. Claire McCaskill (D) in a Senate report that accused the organizations of being mouthpieces for opioid manufacturers. 

“Initiatives from the groups in this report often echoed and amplified messages favorable to increased opioid use — and ultimately, the financial interests of opioid manufacturers,” the report found.

McCaskill’s report failed to mention that she accepted nearly $500,000 in campaign donations since 2005 from the national law firm of Simmons Hanly Conroy, which represents many of the plaintiffs involved in opioid litigation. It has named the APS as a defendant in several of those lawsuits, along with American Academy of Pain Medicine and American Geriatric Society “for working with the manufacturing defendants in promoting opioids to doctors and patients.”

Simmons Hanly Conroy was the third largest contributor to McKaskill during her losing bid for re-election last year, donating over $400,000, an amount seven times larger than it gave to any other candidate in 2018, according to OpenSecrets.org.

According to its website, Simmons Hanly Conroy currently represents governmental entities in Illinois, Louisiana, Texas, and eight New York counties in opioid lawsuits. The law firm reportedly stands to collect one-third of the proceeds from opioid settlements, which could potentially reach $50 billion, according to a Bloomberg analyst.

‘Corrupting Influence’

APS is also mentioned in a congressional report released this week by Reps. Katherine Clark (D-MA) and Hal Rogers (R-KY). The “Corrupting Influence: Purdue and the WHO” report accuses the World Health Organization of being unduly influenced by Purdue Pharma and other opioid makers when it developed guidelines in 2011 and 2012 to treat pain in adults and children.

“The web of influence we uncovered, combined with the WHO’s recommendations, paints a picture of a public health organization that has been manipulated by the opioid industry,” the report said. “The investigation revealed that multiple organizations that claimed to be independent patient advocacy groups, including the American Pain Society, received significant payments from opioid manufacturers.”

The report does not mention that Rep. Clark has also accepted significant payments from drug makers. According to OpenSecrets.com, Clark has received over $522,000 in campaign donations from the healthcare industry since 2013, including donations from Pfizer, Celgene, Takeda, Biogen, Vertex, AstraZeneca and Sanofi.

Rep. Rogers has received over $581,000 in campaign donations from the healthcare industry during his 30 years in Congress.

Chronic Pain Causes Brains to Age More Rapidly

By Pat Anson, PNN Editor

Poorly treated or untreated chronic pain can lead to a number of other health problems, from high blood pressure and insomnia to depression and anxiety.

Now there is evidence that chronic pain also causes brains to age more rapidly, raising the risk of developing Alzheimer’s disease and other neurological problems associated with aging.

“Our findings highlight the need to address chronic pain, not just in older individuals but in potentially everyone, as pain may have unintended consequences in the brain that we don’t yet fully understand,” said lead author Yenisel Cruz-Almeida, PhD, a researcher at the University of Florida Institute on Aging.

Over a three-year period, Cruz-Almeida and her colleagues used magnetic resonance imaging (MRI) to measure the volume of gray and white matter in the brains of 47 older adults, ages 60 to 83.  The volunteers were free of neurological disorders and in generally good health, although 33 of them had some type of chronic pain.

Volunteers who did not have chronic pain had brains that appeared four years younger than their actual age.

Chronic pain sufferers had brains that appeared an average of two years older. They were also more likely to have greater pain intensity, have a “less agreeable personality” and be less emotionally stable, according to researchers.

The University of Florida produced this video on the study, which was recently published online in the journal Pain.

“Not everybody ages the same way,” said Cruz-Almeida. “I don’t want people to think, ‘Oh, I have chronic pain. I’m doomed.’ This is not the case. That is not the message we want to get out. There is more nuance than that.”

Interestingly, the volunteers who reported getting pain treatment in the last three months had younger-appearing brains compared to those that did not, suggesting that pain relief slows brain aging. Pain sufferers who had a happier outlook on life and were generally more upbeat also had younger-appearing brains.

“The pain experience is not just in your brain,” said Cruz-Almeida. “There appear to be avenues or things that could be done to change brain age.

“Our findings also suggest that both pain treatments and psychological traits may significantly mitigate the effect of pain on the aging brain and could further decrease the risk of age-related deterioration and death.”

Cruz-Almeida is planning additional research with a larger sample of older adults that will look at ways to alleviate accelerated brain aging.

‘Radical Shift’ Predicted in Fibromyalgia Diagnosis and Treatment

By Pat Anson, PNN Editor

New research has uncovered a previously unknown connection between fibromyalgia and the early stages of diabetes, which could dramatically change the way the chronic pain condition is diagnosed and treated.

In a small study of 23 fibromyalgia patients and two control groups, researchers at The University of Texas Medical Branch at Galveston (UTMB) were able to separate patients with fibromyalgia (FM) from healthy individuals using a common blood test for insulin resistance, or pre-diabetes. They then treated the fibromyalgia patients with a medication targeting insulin resistance (IR), which dramatically reduced their pain levels.

“Although preliminary, these findings suggest a pathogenetic relationship between FM and IR,  which may lead to a radical paradigm shift in the management of this disorder,” researchers reported in the online journal PlosOne.

Fibromyalgia is a poorly understood disorder that causes widespread body pain, fatigue, insomnia, headaches and mood swings. The cause is unknown, the symptoms are difficult to treat and there is no universally accepted way to diagnose it.

"Earlier studies discovered that insulin resistance causes dysfunction within the brain's small blood vessels. Since this issue is also present in fibromyalgia, we investigated whether insulin resistance is the missing link in this disorder," said Miguel Pappolla, MD, a professor of neurology at UTMB.

Pappolla and his colleagues found that patients with fibromyalgia can be identified by their hemoglobin A1c levels, a protein in red blood cells that reflects blood sugar levels. A1c tests are widely used to diagnose type 2 diabetes and pre-diabetes, and are routinely used in diabetes management.

Researchers say pre-diabetics with slightly elevated A1c levels carry a higher risk of developing widespread body pain, a hallmark of fibromyalgia and other chronic pain conditions.

"Considering the extensive research on fibromyalgia, we were puzzled that prior studies had overlooked this simple connection," said Pappolla. "The main reason for this oversight is that about half of fibromyalgia patients have A1c values currently considered within the normal range.

“However, this is the first study to analyze these levels normalized for the person's age, as optimal A1c levels do vary throughout life. Adjustment for the patients' age was critical in highlighting the differences between patients and control subjects."

After identifying the fibromyalgia patients with elevated A1c levels, researchers treated them with metformin, an oral medication that manages insulin resistance by restoring normal blood sugar levels. The patients showed dramatic reductions in their pain levels, with half (8 of 16 patients) having a complete resolution of pain.

“Our data provides preliminary evidence suggesting that IR may be a pathological substratum in FM and sets the stage for future studies to confirm these initial observations. If confirmed, our findings may translate not only into a radical paradigm shift for the management of FM but may also save billions of dollars to healthcare systems around the world,” researchers reported.

Social Support Key to Recovery from Suicidal Thoughts

By Pat Anson, PNN Editor

Hardly a day goes by that I don’t get an email or a comment left on this website about suicide.

Recently a young military veteran named “Joe” reached out. Joe is depressed and unable to work because he has chronic back and leg pain

“The thing is, I’m just about to turn 28 and can’t fathom how I’m supposed to go on like this for another year or two let alone trying to live my life for the next 60-70 years,” Joe wrote. “I’m not going to do anything yet but I have been seriously looking into euthanasia. I haven’t been able to have a real conversation with anybody about it, not even one of my 5 therapists or my wife, because I already know their reactions.”

Joe said he felt very rational about his decision but was anxious to talk about it “without being thrown into a straightjacket.”

Joe’s instinctive urge to talk with someone could be the key to working through this difficult time in his life, according to a new study by researchers at the University of Toronto. They analyzed a survey of 635 Canadians with chronic pain who had seriously thought about suicide to find out what qualities made those thoughts go away. Suicide “ideation” disappeared in about two-thirds of them.

Having a social support network – someone to talk to – was the key.

“The biggest factor in recovery from suicidal thoughts was having a confidant, defined as having at least one close relationship that provide the person in chronic pain a sense of emotional security and well-being,” said lead author Esme Fuller-Thomson, PhD, a Professor of Social Work, Medicine and Nursing and Director of the Institute for Life Course & Aging.

“Even when a wide range of other characteristics such as age, gender and mental health history were taken into account, those with a confidant had 87 percent higher odds of being in remission from suicidal thoughts compared to those with no close relationships."

People with pain who stopped having suicidal thoughts were also significantly more likely to be older, female, white, better educated, and more likely to use prayer and spirituality to cope with daily problems.

Living in poverty and struggling to pay basic living expenses were barriers to recovery from suicide ideation. Poverty can severely limit access to healthcare, transportation and social activity.

"Clearly we need targeted efforts to decrease social isolation and loneliness among those experiencing chronic pain. These participants reported that pain prevented some or most of their activities, so they were particularly vulnerable to social isolation,” said Fuller-Thomson. “More awareness by the general public that mobility limitations associated with chronic pain can make it difficult for individuals to socialize outside the household, could encourage friends and family to visit and phone more and thereby decrease loneliness."

PNN’s recent survey of over 6,000 patients and healthcare providers shows how pervasive suicide is in the pain community. Nearly half the patients said they have considered suicide, while nearly one in four practitioners said they have lost a patient to suicide.

The good news is that public health agencies are finally starting to pay attention to these issues. Last week the U.S. Food and Drug Administration warned doctors not to abruptly discontinue or rapidly taper patients on opioid pain medication because of the risk of suicide.

“(FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide,” the agency said.

If you or a loved one are having suicidal thoughts, support is just a phone call away. The Suicide Prevention Lifeline has trained counselors on duty 24/7 at 1-800-273-TALK.

1 in 5 Multiple Sclerosis Patients Misdiagnosed

By Pat Anson, PNN Editor

Nearly one in five patients who are told they have multiple sclerosis are misdiagnosed with the autoimmune disease, according to a new study of patients referred to two MS treatment centers in Los Angeles. The patients spent an average of four years being treated for MS before receiving a correct diagnosis.

MS is a chronic disease that attacks the body’s central nervous system, causing pain, numbness, difficulty walking, paralysis, loss of vision, and fatigue. The symptoms are similar to those of several other chronic conditions – including neuropathy, migraine and fibromyalgia – which often leads to a misdiagnosis.

Researchers at the Cedars-Sinai Multiple Sclerosis and Neuroimmunology Center analyzed the cases of 241 patients who had been diagnosed by other physicians and then referred to the Cedars-Sinai or UCLA MS clinics.

Their findings, published in the journal Multiple Sclerosis and Related Disorders, indicate that 43 of the 241 patients (18%) with a previous diagnosis of MS did not meet the criteria for the disease.

"The diagnosis of MS is tricky. Both the symptoms and MRI testing results can look like other conditions, such as stroke, migraines and vitamin B12 deficiency," said lead author Marwa Kaisey, MD. "You have to rule out any other diagnoses, and it's not a perfect science."

The most common correct diagnoses was migraine (16%), radiologically isolated syndrome (RIS) (9%), spondylopathy (7%), and neuropathy (7%). RIS is a condition in which patients do not experience symptoms of MS even though their imaging tests look similar to those of MS patients.

The misdiagnosed patients received approximately 110 patient-years of unnecessary MS disease modifying drugs. Nearly half received medications that carry a known risk of developing progressive multifocal leukoencephalopathy, a potentially fatal brain infection.

"I've seen patients suffering side effects from the medication they were taking for a disease they didn't have," Kaisey said. "Meanwhile, they weren't getting treatment for what they did have. The cost to the patient is huge — medically, psychologically, financially."

The cost of disease modifying medications for an MS patient in the U.S. exceeds $50,000 a year. Investigators estimated that the unnecessary treatments identified in this study alone cost almost $10 million. 

Researchers hope the results of the study will lead to new biomarkers and improved imaging techniques to help prevent future MS misdiagnoses.

A similar study in 2016 also found that MS patients were often misdiagnosed. One third of the patients were misdiagnosed for a decade or longer, most took unnecessary and potentially harmful medication to treat a disease they didn't have, and some even participated in clinical trials for experimental MS therapies. About a third suffered from morbid thoughts of death.

Menopause Linked to Chronic Pain

By Pat Anson, PNN Editor

It’s no secret that middle-aged women are far more likely than men to have chronic pain and to feel its effects more severely. A large new study tells us some of the reasons why.

VA researchers analyzed the health data of over 200,000 female veterans between the ages of 45 and 64 and found that women with menopause symptoms were nearly twice as likely to have chronic pain and multiple chronic pain diagnoses.

"Changing levels of hormones around menopause have complex interactions with pain modulation and pain sensitivity, which may be associated with vulnerability to either the development or exacerbation of pain conditions," says JoAnn Pinkerton, MD, Executive Director of the North American Menopause Society (NAMS). "This study suggests that menopause symptom burden may also be related to chronic pain experience."

Hormonal change alone wasn’t the only thing many of the women had in common. Those who were overweight, obese or had a mental health diagnosis were also more likely to have chronic pain. Eighteen percent of the female veterans had been diagnosed with post-traumatic stress disorder (PTSD), 13 percent suffered from depression and 15 percent had anxiety.

Common changes related to menopause and aging include weight gain, decreased physical activity, impaired sleep and negative mood, which can contribute to chronic pain and are also known to affect pain sensitivity and tolerance.

“Both chronic pain and menopause symptoms are strongly and consistently associated with psychosocial factors and health risk behaviors prevalent in and after the menopause transition,” said lead author Carolyn Gibson, PhD, San Francisco VA Health Care System. “Consideration should be given to integrated approaches to comprehensive care for midlife and older women with chronic pain, such as targeted cognitive behavioral therapy coordinated with interdisciplinary care providers.”    

The study findings are published in the journal Menopause.

A large 2018 study also found a strong association between menopause and symptoms of rheumatoid arthritis (RA). Researchers at the University of Nebraska Medical Center found that post-menopausal women with RA had a significant increase in functional physical decline. Menopause was also associated with worsening progression of the disease.  

Putting a Pin into Pain

By Pat Anson, Editor

As a social media platform, Pinterest is best known as a place to share recipes or get tips about fashion and home decorating — topics that appeal to its core audience of women.

But over the years Pinterest has quietly evolved into a surprisingly good place to learn about chronic pain and to network with others in the pain community, according to researchers at Virginia Commonwealth University. Their study, “Pinning to Cope: Using Pinterest for Chronic Pain Management,” was recently published in the journal Health Education & Behavior.

“We’re seeing that Pinterest is being used by patients to really support each other, to provide information for each other, and to just find an outlet for dealing with chronic pain,” said Jeanine Guidry, PhD, who studies social media and mobile technology.

Guidry and co-author Eric Benotsch, PhD, a psychology professor at VCU, analyzed 502 posts on Pinterest about chronic pain and found – not surprisingly -- that nearly all referred in some way to the severity of pain.

But rather than just complaining about their pain, many of the posters shared or “pinned” positive tips on self-care and pain management, along with tips for caregivers and friends. About 18% of the posts used humor as a coping mechanism.

“Our findings show that, first of all, people are talking about chronic pain on Pinterest,” Guidry said. “But second of all, our findings show that the vast majority of posts were by individuals.”

Relatively few of the posts originated with healthcare or public health organizations, and researchers said there was “cause for concern” about the lack of information from reputable health sources. A key finding was that posts about chronic pain on Pinterest have a higher level of user engagement than most other healthcare topics.

“Knowing that this conversation about chronic pain is taking place on Pinterest, health communication professionals should consider using Pinterest [more] because they can really reach out to the people who are trying to manage chronic pain,” Guidry said.

Pinterest has about 250 million active users and 80 percent of them are women. Guidry says the social media platform could be leveraged more to communicate with pain sufferers.

“Is it the biggest platform for these kind of topics? No, but it’s obvious it’s being used,” she said. “And it’s an outlet we should use as health communicators.

“When you look at these Pinterest posts, you see people trying to manage pain and trying to help each other and trying to provide support to each other. That is something that could be turned into an effective tool for health care providers and for communicators.”

Guidry said the study’s findings are encouraging because they suggest that people with chronic pain are posting about healthy coping mechanisms and other people are engaging with them.

“Chronic pain posts have a strong presence on Pinterest, and health care professionals should both consider utilizing the platform in order to reach a population they might not otherwise reach, as well as broadening this field of study to determine a clearer picture of the potential uses of this and other social media platforms,” she said.

To visit PNN on Pinterest, click here.

Ambroxol: A Potential New Treatment for Chronic Pain

By A Rahman Ford, PNN Columnist

Researchers say a drug long used in cough syrup and cold medicines shows potential for treating some types of neuropathic pain.

A small study recently published in the journal Headache found that topical administration of ambroxol in a cream could significantly decrease pain in patients with trigeminal neuralgia, a chronic facial condition that can make even routine tasks such as brushing one’s teeth excruciatingly painful. 

In their review of the medical records of five trigeminal neuralgia patients, German researchers reported that all five patients experienced pain reduction with ambroxol 20% cream being applied within 30 minutes of a pain flare, with pain relief lasting from 4 to 6 hours.  In one case, pain was eliminated completely in one week.  

The results were similar to those of previous German studies and were so significant that researchers recommended that ambroxol “should be investigated further as a matter of urgency.”

Similarly, a recent study in the journal Pain Management found that application of topical ambroxol reduced spontaneous pain in several patients with complex regional pain syndrome (CRPS), a little understood nerve condition that causes chronic pain after a significant injury or surgery.  Notably, ambroxol therapy improved several other neuropathy-related conditions in CRPS patients, including edema, allodynia, hyperalgesia, skin reddening, motor dysfunction and skin temperature.

An Old Drug with a New Purpose

With a pharmacological history that can be traced back to Indian ayurvedic medicine, ambroxol was initially approved in 1978 as a medication to break down mucus and make it easier to eliminate by coughing.  It is generally administered in tablet or syrup form. 

Ambroxol is also used to treat a sore throat associated with pharyngitis, thus its potential role as a potent local anesthetic.  The drug’s anesthetic properties stem from its ability to block sodium and calcium channels that transmit pain signals.

Although the idea that ambroxol can treat a sore throat is widely accepted, its application to other forms of pain is more recent.  

Previous studies using animal models of neuropathic pain have been promising.  In a 2005 study, researchers effectively reduced – and in some cases eliminated – chronic neuropathic and inflammatory pain in rats. Indian researchers also found ambroxol effective in treating neuropathic pain in rats, attributing its success to its antioxidative and anti-inflammatory properties.  Unfortunately, human studies are few at this point.

Ambroxol and Fibromyalgia

A 2017 Clinical Rheumatology study showed that ambroxol can play a key role in treating chronic pain associated with fibromyalgia.  As reported by Fibromyalgia News Today, researchers from Mexico added ambroxol to the treatment regimens of 25 fibromyalgia patients, three times a day for one month.  At the end of the study, pain scores decreased significantly and there was also noticeable improvement in sleep disturbances, stiffness and autonomic nervous system dysfunction.  No major adverse events were reported. 

Another 2017 study supported these findings, with the authors concluding that “fibromyalgia treatment with ambroxol should be systematically investigated” because the drug “is the only treatment option used thus far that has the potential to address not just individual but all of the aforementioned aspects of pain.”

Although data on its effectiveness in humans are limited, ambroxol shows great potential in treating painful conditions for which there are currently few safe and effective options.  It is particularly attractive because it has few significant side effects, is not addictive and can be administered topically in some instances.

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

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

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

Hormones & Pain Care: What Every Patient Should Know

By Forest Tennant, MD, Guest Columnist

As we start the year 2019, every chronic pain patient needs to know the status of hormones and pain care. Unfortunately, the recent hysteria over opioids has obscured the positive advances in the understanding and application of hormonal care to the relief and recovery of pain patients.

In fact, research and clinical experience is starting to revolutionize the way I personally think about pain care. Hormones are showing us the natural, biologic way the body deals with pain and injury. They are clearly the way forward.

Why the Excitement Over Hormones?

Hormones have recently been discovered to be made in the brain and spinal cord (central nervous system – CNS). Some hormones are made that have the specific job and function to protect (“neuroprotection”) CNS tissue from injury and to regrow the injured tissue (“neuroregeneration”). These hormones are collectively called “neurohormones.”

Intractable, chronic pain is actually a type of poisonous, electromagnetic energy that causes injury by producing inflammation (“neuroinflammation”) in the CNS and implanting the pain (e.g. “centralization”) so as to make it constantly (“24/7”) present.

The process is similar to dropping acid on your skin which burns and causes inflammation to be followed by tissue destruction and scar formation. Fortunately, some neurohormones are made in the CNS to stop the pain, inflammation, tissue destruction and scarring process and rebuild the nerve cell network in the CNS.

Until recently, we physicians didn’t have a clue on how to enhance the natural, biologic hormonal system to help pain patients.

Excitement over neurohormones has really been enhanced by research in rats that had their spinal cords cut so that they walked around their cages dragging their hind legs. They were given some neurohormones which healed their spinal cords to the point that they could normally walk.

Other animal research studies using different test models with CNS tissue have also shown the power of specific hormones to heal and regrow brain and spinal cord nerve cells. This author can’t speak for others, but, in my opinion, these research studies are so compelling that hormone use in pain care has got to be fully investigated.

Are We Making Headway?

Absolutely, yes! First, eight specific hormones made in the CNS have been identified that produce healing effects in animals and show benefit in early clinical trials with chronic pain patients. These early trials indicate that some neurohormones can reduce pain and produce healing and curative neuroregeneration effects.

Six of these hormones are collectively known as “neurosteroids.” Don’t let the term “steroid” raise your eyebrows as it refers only to the chemical structure and not the complications of cortisone-type drugs. Some of the neurosteroids are known to the lay person such as estradiol, progesterone, and testosterone.

Two of the hormones produced in the CNS that control pain but are not classified as a “neurosteroid” are human chorionic gonadotropin (HCG) and oxytocin.

CENTRAL NERVOUS SYSTEM HORMONES

• ALLOPREGNANOLONE
• ESTRADIOL
• DEHYDROEPIANDROSTERONE (DHEA)
• HUMAN CHORIONIC GONADOTROPIN (HCG)
• OXYTOCIN
• PREGNENOLONE
• PROGESTERONE
• TESTOSTERONE

Due to all the controversies surrounding opioids and pain treatment, one would never know we have, in the past couple of years, made serious headway with hormones and pain care. Medical science has discovered which hormones reduce chronic pain and how the hormones can be prescribed. The overall hormone advance in pain care can, however, be generally summarized in that one or more of the neurohormones can be administered to provide some curative and regenerative benefit in essentially every chronic pain patient.

Replenishment of Deficient Hormones

The production of hormones made in the CNS can be assessed by blood tests which are available in every commercial, community laboratory. The amount of hormone in your blood stream is a pooled amount of hormone made in the CNS and in the glands; adrenals, ovary, and gonads (ovary and testicles).

I recommend a hormone blood test panel of these 6 hormones: cortisol, DHEA, estradiol, pregnenolone, progesterone, and testosterone. If any are low, they should be replenished. Why? Severe chronic pain may overwhelm the production of one or more of these hormones.

If you take opioids and other symptomatic pain medications such as antidepressants and muscle relaxants, you may actually suppress the production of some hormones, particularly testosterone, DHEA, and pregnenolone.

“I highly recommend that every chronic pain patient have a hormone blood panel test at least twice a year and replenish any hormone that is low in the blood stream.”

— Dr. Forest Tennant

The reason you must replace any deficient hormone is because all 6 of them activate pain centers (“receptors”) in the CNS to reduce pain and produce a healing and curative effect. These hormones act as sort of a co-factor or “booster” of symptomatic pain relievers such as opioids and muscle relaxants. I highly recommend that every chronic pain patient have a hormone blood panel test at least twice a year and replenish any hormone that is low in the blood stream.

The Pregnancy Connection

A couple of years ago I was presenting a scientific poster at a medical meeting on some of my hormone research. An old friend came up and asked, “What took you so long?”

I initially thought he was insulting me. He wasn’t. He was lamenting, along with me, a sad fact. We should have long ago been studying the pregnancy hormones, HCG and oxytocin, for everyday pain care.

Why? HCG in pregnancy is the hormone that grows the CNS in the embryo and fetus. Oxytocin is the natural pain reliever in pregnancy that allows a big “tumor” to grow in the abdomen without death-dealing pain. Also, oxytocin surges at the time of delivery to make sure that pain doesn’t kill the expectant mother.

With such obvious knowledge about natural pain relief in pregnancy, we should have tested these hormones for severe, chronic pain problems before now. Do they work? Yes. Long-term HCG use (over 60 days) is proving most effective in reducing pain and restoring function in some patients with adhesive arachnoiditis and other severe pain problems. Oxytocin is an effective short-term pain reliever that can be taken for pain flares. It can even be taken with symptomatic pain relievers like aspirin, acetaminophen, or a stimulant to help a patient avoid opioids.

Goodbye Symptomatic Treatments

Until the hormones came our way, you never heard much about “symptomatic” versus “curative” care. Why? Up until the discovery that hormones are made inside the CNS and produce curative effects, about all we could do was prescribe symptomatic pain relievers such as opioids, muscle relaxants, and anti-seizure (“neuropathic”) agents. There was no need or hope that we can permanently reduce severe chronic pain, much less hold out a hope for cure or near cure.

Chronic pain patients are beginning to use DHEA, pregnenolone, testosterone, estradiol, progesterone, and HCG on a long-term basis. Dosages are beginning to be determined. For example, DHEA requires a dosage of 200 mg or more each day. Pregnenolone requires 100 mg or more. Patients report reduced levels of pain, fatigue, and depression.

Although few controlled studies have yet been done, the open-label clinical trials are impressive and clearly call for chronic pain patients to get started with the neurohormones that are being found to be beneficial. Neurohormones have changed our thinking and old-hat beliefs.

Every severe chronic pain patient needs to know they can probably do a lot of mending with hormonal care. Be, however, clearly advised. Hormones can mend a lot of damaged nerve tissue, but they can’t fix scar tissue once it sets in.

“So far at my clinic site, we have around 60 to 70 people on oxytocin. Early results look good so far. Many are also on DHEA and pregnenolone as well. The treatment seems to be working.”

— Nurse practitioner

Unfortunately, millions of severe, chronic pain patients have had no option in the past couple of decades except to take symptomatic medication and use such devices as electrical stimulators.

Even long-standing severe chronic pain patients who are on opioids, however, can almost always benefit from one or more hormones. Most important, I am finding that hormone administration is the best way in most chronic pain patients to reduce opioid dosages but still get good pain relief.

Therapeutic Trials

One of my major purposes in writing this report is to encourage all chronic pain patients to embark upon a search for one or more hormonal treatments that will reduce their pain, need for opioids, and yield a better life. Don’t wait for your medical practitioner to offer hormone testing or treatment. To many overworked medical practitioners, such a request may be considered a real nuisance or even a threat.

Be prepared. Check with other patients in your social media group. Know what you need. Make it easy on your medic. Please share with your social media group this report and any materials you have about hormones and pain care. Most MD’s, NP’s, and PA’s will appreciate your preparation and desire to try something new on a short-term, trial basis.

Every chronic pain patient needs to know that all the hormonal agents described here can be safely tried for one month. This is known as a “therapeutic trial.” Specifically ask your medical practitioner for a one-month, therapeutic trial. In this manner you can find out if the hormone is right for you and whether you should continue with it past one month.

Forest Tennant, MD, MPH, DrPH, recently retired from clinical practice but continues his groundbreaking research on the treatment of intractable pain and arachnoiditis. To download a complete copy of Dr. Tennant’s report on hormones and pain care, click here.

This report is provided as a public service by the Arachnoiditis Research and Education Project of the Tennant Foundation and is republished with permission. Correspondence should be sent to veractinc@msn.com

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

Why a Bad Night’s Sleep Causes More Pain

By Pat Anson, PNN Editor

It’s no secret that chronic pain makes sleeping difficult. And lack of sleep often makes pain worse.  But how exactly does poor sleep cause more pain?

For the first time, scientists at the University of California, Berkeley, have identified neural glitches in the sleep-deprived brain that can intensify and prolong pain. Their findings, published in the Journal of Neuroscience, help explain the self-perpetuating cycles that contribute to pain and sleep loss.

“Anyone who has had persistent back pain knows that they don’t sleep well when they are in pain. They also know that when they don’t sleep well, it hurts more the next day,” said senior author Matthew Walker, PhD, a UC Berkeley professor of neuroscience and psychology.

"If poor sleep intensifies our sensitivity to pain, as this study demonstrates, then sleep must be placed much closer to the center of patient care, especially in hospital wards.”

In a small study involving 25 healthy young adults, Walker and his colleagues found that nerves that process pain signals and activate the body’s pain relief hormones are disrupted by insufficient sleep. Study participants were given MRI brain scans twice – once after a good night’s sleep and once after a night of no sleep – and then subjected to a thermal pain test in the laboratory  

“We found some surprising changes. The sleep-deprived brain seems to let more pain in,” Walker said.

Brain imaging showed increased activity in the brain's somatosensory cortex, but there was less activity in the nucleus accumbens, a region of the brain's reward circuitry that increases dopamine levels. Dopamine is a neurotransmitter that’s been called the “feel-good hormone” because it is associated with feelings of euphoria and happiness.

Another key brain region found to slow down in the sleep-deprived brain was the insula, which evaluates pain signals and prepares the body to respond.

"This is a critical neural system that assesses and categorizes the pain signals and allows the body's own natural painkillers to come to the rescue," said Adam Krause, lead author of the study and a doctoral student in Walker's Center for Human Sleep Science lab at UC Berkeley.

To further test the sleep-pain connection, researchers surveyed more than 230 adults of all ages nationwide. Respondents were asked to report their nightly hours of sleep, as well as their day-to-day pain levels. The results showed that even minor shifts in sleep patterns were correlated with changes in pain sensitivity.

"The results clearly show that even very subtle changes in nightly sleep -- reductions that many of us think little of in terms of consequences -- have a clear impact on your next-day pain burden," Krause said.

"The optimistic takeaway here is that sleep is a natural analgesic that can help manage and lower pain," said Walker. "Yet ironically, one environment where people are in the most pain is the worst place for sleep -- the noisy hospital ward."

Walker's goal is to work with hospitals to create more sleep-friendly patient facilities.

"Our findings suggest that patient care would be markedly improved, and hospital beds cleared sooner, if uninterrupted sleep were embraced as an integral component of healthcare management," he said.

Several previous studies have found that getting a good night’s sleep helps reduce sensitivity to pain. Researchers in Norway measured pain sensitivity in more than 10,000 adults and found a strong link between pain and insomnia.

Another study in Norway found that women who have trouble sleeping are at greater risk of developing fibromyalgia – although it’s not clear if there’s a cause and effect relationship between the two symptoms.

Is Pain a Self-Fulfilling Prophecy?

By Pat Anson, PNN Editor

Getting out of bed, taking a shower, doing the dishes and other simple chores can be painful experiences for someone with intractable chronic pain. But some of that pain may be self-fulfilling: Getting out of bed hurts because you expect it to.

That's the theory behind a new brain imaging study published in the journal Nature Human Behaviour, which found that false expectations about pain can persist even when reality demonstrates otherwise.

"We discovered that there is a positive feedback loop between expectation and pain," said senior author Tor Wager, PhD, a professor of psychology and neuroscience at the University of Colorado Boulder.

"The more pain you expect, the stronger your brain responds to the pain. The stronger your brain responds to the pain, the more you expect."

Wager and his colleagues recruited 34 people for a heat test to see if the expectation of pain can cause changes in neural mechanisms of the brain.

Participants were taught to associate one symbol with low heat and another with painful heat. Then, the subjects were placed in a functional magnetic resonance imaging (fMRI) machine, which measures blood flow in the brain as a proxy for neural activity.

For 60 minutes, subjects were shown the low or high pain cues (the symbols “Low” and “High” or the letters L and W), and then asked to rate how much acute pain they experienced as heat was applied to their forearms or legs. Unbeknownst to the participants, heat intensity was not actually related to the preceding cue.

The study found that when subjects expected more heat, brain regions involved in threat and fear were more active as they waited for the heat to be applied. Regions involved in the generation of pain were also more active when they received the stimulus.

The result? Participants reported more pain with high-pain cues, regardless of how much heat they actually got.

"This suggests that expectations had a rather deep effect, influencing how the brain processes pain," said lead author Marieke Jepma, PhD, a researcher in Wager's lab who is now a researcher at Leiden University in the Netherlands.

Many subjects also demonstrated a high degree of confirmation bias -- a tendency to learn from things that reinforced their beliefs, while discounting those that didn’t. If they expected high pain and got it, they might expect even more pain the next time. But if they expected high pain and didn't get it, nothing changed.

"You would assume that if you expected high pain and got very little you would know better the next time. But interestingly, they failed to learn," said Wager.

Researchers say the study was the first to demonstrate the dynamics of a feedback loop between pain expectations and neural mechanisms that cause pain. Although the test only involved short-term acute pain, researchers say the findings may help explain why chronic pain can linger long after damaged tissues have healed.

"Our results suggest that negative expectations about pain or treatment outcomes may in some situations interfere with optimal recovery, both by enhancing perceived pain and by preventing people from noticing that they are getting better," said Jepma. "Just realizing that things may not be as bad as you think may help you to revise your expectation and, in doing so, alter your experience.”

Childhood Abuse Raises Lupus Risk for Adult Women

By Pat Anson, PNN Editor

Women who experienced physical or emotional abuse as children have a significantly higher risk of developing lupus as adults, according to new research presented at the annual meeting of the American College of Rheumatology.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that causes inflammation in multiple organs. Most patients have times when the disease is active, followed by times when the disease is mostly quiet and in remission. Lupus is far more common in women than men.

“In prior work, exposure to stress and stress-related disorders, notably post-traumatic stress disorder, has been associated with increased risk of subsequently developing autoimmune diseases, including lupus,” said lead author Candace Feldman, MD, an Assistant Professor at Brigham and Women’s Hospital/Harvard Medical School.

“Exposure to adverse childhood experiences has specifically been associated with higher levels of inflammation, as well as with changes in immune function.”

To identify what kind of childhood trauma raises the risk of lupus, Feldman and her colleagues looked at health data for over 67,000 women participating in the Nurses’ Health Study II, an ongoing study of female nurses that began in 1989. There were 93 diagnosed cases of lupus among the women.

In detailed questionnaires, the women were asked whether and how often as children they experienced physical abuse from a family member, or yelling, screaming or insulting remarks from a family member. The women were also asked to recall incidents of sexual abuse by either adults or older children.

Researchers found that physical and emotional abuse were associated with a more than twofold greater risk of developing lupus. But the data did not reveal a statistically significant association between sexual abuse and lupus risk.

“The study’s findings suggest that the effects of exposure to physical and emotional abuse during childhood may be more far-reaching than previously appreciated,” said Feldman. “The strong association observed between childhood abuse and lupus risk suggests the need for further research to understand biological and behavioral changes triggered by stress combined with other environmental exposures. In addition, physicians should consider screening their patients for experiences of childhood abuse and trauma.”

This is not the first study to find an association between childhood trauma and chronic illness in adults. A recent study of 265 adults in New York City found that those who experienced more adversity or trauma as children were more likely to have mood or sleep problems as adults -- which in turn made them more likely to have physical pain.

Another study found that children who witness domestic violence between their parents are significantly more likely to experience migraine headaches as adults. A large survey also found that nearly two-thirds of adults who suffer from migraines experienced emotional abuse as children.

New Lyme Disease Test Could Lead to Earlier Treatment

By Pat Anson, PNN Editor

At long last, scientists are close to developing a new test to detect Lyme disease weeks sooner than current tests -- allowing patients to begin treatment earlier.

Lyme disease is a bacterial illness spread by ticks. Left untreated, it can lead to chronic conditions such as joint and back pain, chronic fatigue, fibromyalgia and neuropathy.

Borrelia burgdorferi was first identified as the bacteria that causes Lyme disease in 1983.  The antibody tests currently used to detect Borrelia were developed a decade later and have a number of shortcomings. They can take up to three weeks to get results and cannot distinguish between an active infection or an old one.

A team of scientists recently reported in the journal Clinical Infectious Diseases that advances in molecular diagnostics should make a new DNA test for Borrelia technically feasible.

“These direct tests are needed because you can get Lyme disease more than once, features are often non-diagnostic and the current standard FDA-approved tests cannot distinguish an active, ongoing infection from a past cured one,” said lead author Steven Schutzer, MD, a physician-scientist at Rutgers New Jersey Medical School.

“The problem is worsening because Lyme disease has increased in numbers to 300,000 per year in the United States and is spreading across the country and world.”

Early symptoms of Lyme disease include fever, chills, headaches, fatigue, muscle and joint aches, and swollen lymph nodes. A delayed rash often appears at the site of the tick bite, which resembles a ring or bulls-eye. When there is no rash, a reliable laboratory test is needed to detect an active disease.

“The new tests that directly detect the Lyme agent’s DNA are more exact and are not susceptible to the same false-positive results and uncertainties associated with current FDA-approved indirect tests,” said Schutzer.

Lyme disease is usually treated with antibiotics, but some patients experience complications that lead to Lyme disease syndrome (PTLDS), with long-term symptoms such as fatigue, muscle and joint pain and cognitive issues. Autoimmune diseases have also been associated with chronic Lyme disease.

Lavigne Keeps ‘Head Above Water’ with Lyme Disease

By Pat Anson, PNN Editor

Lady Gaga isn’t the only celebrity speaking out about her battle with chronic pain and illness.

Pop star Avril Lavigne has released a new album called “Head Above Water” that was inspired by her battle with Lyme disease -- a bacterial infection usually spread by ticks that can lead to severe pain and chronic fatigue if it’s not treated and diagnosed early.

That’s what happened to Lavigne, who thought she just had the flu when she started having symptoms in 2014. It took several months for her to get a correct diagnosis.

“I was seeing every specialist, literally the top doctors, and they would pull up their computer and (say) ‘Chronic fatigue syndrome’ or “Why don’t you try to get out of bed Avril and just go play the piano? Are you depressed?’” Lavigne said in an emotional interview on Good Morning America.

“This is what they do to a lot of people that have Lyme disease. They don’t have an answer for them, so they tell them they’re crazy.”

The 33-year old singer eventually found a Lyme specialist who diagnosed her correctly. By then she was bedridden.

“One night, I thought I was dying, and I had accepted that I was going to die. My mom laid with me in bed and held me. I felt like I was drowning,” Lavigne wrote on her website.

AVRIL LAVIGNE

“Under my breath, I prayed ‘God, please help to keep my head above the water.’ In that moment, the song writing of this album began. It was like I tapped into something. It was a very spiritual experience. Lyrics flooded through me from that point on.”

Although the single “Head Above Water” is about Lyme disease, anyone bedridden or housebound by chronic pain or illness can probably relate to it.

Lavigne went public about her battle with Lyme disease in 2015, but it was another two years before she was well enough to sit at a piano and started composing music again.

“I fought Lyme disease on antibiotics and herbs for two years. I tried to have a life, but was in bed the majority of the time, and it was very up and down with good days and bad days,” Lavigne explained.

“When you’re in bed for the better part of two years, you lose muscle mass and your entire body gets weak. I’ve had to work to get my endurance up. ‘Head Above Water’ was the first song that I sang. I was fresh off not singing for two years. I thought my voice would be weak, it ended up being stronger than ever. The break happened to actually be good for my vocal cords.”

“Head Above Water” is the sixth album for the Canadian born singer, who has been nominated for eight Grammy Awards. Her single “Girlfriend” was the first music video to reach 100 million views on YouTube. Her foundation – the Avril Lavigne Foundation – raises awareness and supports people with Lyme disease and other chronic illnesses.