U.S. Overdose Crisis Could Be Worse Than We Thought

By Pat Anson, PNN Editor

The number of deaths attributed to opioid overdoses in the U.S. could be 28 percent higher than reported due to incomplete death records, according to a new study appearing in the journal Addiction. Researchers at the University of Rochester say nearly 100,000 overdose deaths may not have been counted because the opioid involved was not identified.

The discrepancy is pronounced in several states, such as Pennsylvania, Alabama, Mississippi, Louisiana and Indiana, where the actual number of overdoses caused by legal and illicit opioids could be twice as high as current estimates.

"A substantial share of fatal drug overdoses is missing information on specific drug involvement, leading to underreporting of opioid-related death rates and a misrepresentation of the extent of the opioid crisis," said senior author Elaine Hill, PhD, an economist and assistant professor in the University of Rochester Medical Center. "The corrected estimates of opioid-related deaths in this study are not trivial and show that the human toll has been substantially higher than reported, by several thousand lives taken each year."

Hill and her colleagues found that almost 72 percent of unclassified drug overdoses that occurred between 1999 and 2016 involved prescription opioids, heroin or illicit fentanyl — translating into 99,160 additional opioid-related deaths.

Researchers discovered the discrepancy while studying the economic, environmental and health impact of coal mining and oil and gas drilling. Appalachia and other regions of the country hit hardest by the opioid crisis overlap with areas where there is coal mining and shale gas development.

As a part of her research, Hill was attempting to determine whether the shale boom improved or exacerbated the opioid crisis. She discovered that close to 22 percent of all drug-related overdoses were unclassified, meaning the drugs involved in the cause of death were not reported.

A 2018 study at the University of Pittsburgh reached a similar conclusion, estimating that as many as 70,000 opioid related-deaths were not reported. Coroners and medical examiners in many states often did not specify the drug that contributed to the cause of death.  

Critics have long complained that overdose data reported by the CDC and other federal agencies is flawed or cherry-picked. CDC researchers admitted in 2018 that deaths attributed to opioid medications were “significantly inflated” because overdoses involving illicit fentanyl were erroneously counted as prescription opioid deaths. Toxicology tests cannot distinguish between pharmaceutical fentanyl and illicit fentanyl.

The overdose data is further muddied because multiple drugs are involved in almost half of all drug overdoses.

Poor Overdose Data Concentrated in Several States

In their study, Hill and her colleagues obtained overdose death records from the CDC’s National Center for Health Statistics. Using statistical analysis, they correlated information on unclassified overdose deaths with potential contributing causes, such as previous opioid use and chronic pain conditions.

While the overall percentage of unclassified deaths declined over time – apparently due to efforts to improve overdose data -- the number remained high in several states. In Pennsylvania, for example, the official number of opioid-related deaths was 12,374. Researchers estimate that the actual number of deaths was 26,586.

"The underreporting of opioid-related deaths is very dependent upon location and this new data alters our perception of the intensity of the problem," said Hill. "Understanding the true extent and geography of the opioid crisis is a critical factor in the national response to the epidemic and the allocation of federal and state resources."

The CDC recently reported that drug overdose deaths dropped 4.1% in 2018 – the first decline in nearly three decades -- led by a significant drop in overdoses involving hydrocodone, oxycodone and other painkillers. But deaths linked to illicit fentanyl, methamphetamines and psychostimulants are surging, threatening to reverse the overall trend.

“One thing that we’re seeing is that the decline doesn’t appear to be continuing in 2019. It appears rather flat, maybe actually increasing a little bit,” said Robert Anderson, PhD, Chief of the Mortality Statistics Branch, National Center for Health Statistics.

Drugs Kill in Other Ways

All of these studies miss the mark, according to research published in PLOS ONE, because they don’t include deaths caused by infectious disease, drunk driving, suicide, and cardiovascular disease — all of which are affected by drug use.

"The basic records being kept are annual reports on the number of deaths from drug overdose. But that's only part of the picture,” said Samuel Preston, a professor of sociology at the University of Pennsylavnia. "Drugs can kill in other ways."

In 2016, 63,000 deaths were attributed to drug overdoses, but Preston and his colleagues estimate that the actual number of drug-associated deaths was around 142,000. Drug use shaved off nearly a year-and-a-half of life for men and three-quarters of a year for women.

"It's not just about the supply of drugs, but that there's something else behind all of it that causes people to either use drugs or alcohol or commit suicide because they've lost interest in their life," said co-author Dana Glei, a Georgetown University demographer.

Patients with Arachnoiditis and Ehlers-Danlos Need Adrenaline for Pain Control

By Dr. Forest Tennant, PNN Columnist

In this era of opioid controversy and tragedy due to forced opioid reduction, the scientific information on adrenaline-type agents can help control constant, intractable pain and help reduce opioid use.

Overlooked in the opioid controversy is the key point that an adequate supply of adrenaline-related neurotransmitters – such as dopamine and norepinephrine – are necessary in the brain and spinal cord for pain relief. Unfortunately, constant intractable pain depletes the natural supply of endorphin, dopamine, adrenaline and noradrenalin, and their levels must be replaced to adequately control pain.  

Persons with a severe, intractable pain condition like Adhesive Arachnoiditis (AA) and/or a genetic connective tissue disorder like Ehlers-Danlos syndrome (EDS) will need an adrenaline agent, also called a stimulant, for pain control, maximal function, keeping opioid dosages stable, and preventing sedation and overdose. 

Adrenaline agents have long been known to boost or potentiate opioids, enhance pain relief, and allow less opioid to be used. A study by this author found that the simultaneous use of a stimulant and clonidine lowered opioid dosage by 30 to 50 percent. 

The use of a stimulant in this manner is not new. In the 1920’s, physicians at the Royal Brompton Hospital in London found that a stimulant was a necessary ingredient in the famous “Brompton Cocktail” for relief of severe pain. Today, modern pain relief agents often add caffeine as a stimulant to make the codeine and oxycodone more potent.

Most observers believe that an adrenaline agent given to an intractable pain patient will automatically raise blood pressure and pulse rate. This is generally a myth, because the person with intractable pain often depletes their reserve of dopamine, noradrenalin and adrenaline.  

The use of an adrenaline agent will serve to replace these depleted neurotransmitters and will not generally cause blood pressure and pulse rate to rise. Periodic monitoring is, however, recommended to be continued.  

Multiple Benefits  

A person with intractable pain due to AA, EDS, Reflex Sympathetic Dystrophy (RSD), or another severe and tragic condition will usually have the following conditions – all of which will benefit by an adrenaline agent:

• Weight Gain

• Attention Deficit Disorder (ADHD)

• Depression

• Sedation

• Fatigue

• Memory Loss

Descending Pain

Recent research has learned that constant, intractable pain establishes a “biologic battery” in the brain and spinal cord. This “battery” sends electric currents down the autonomic (non-spinal cord nerves) nervous system. Symptoms of this descending pain include excess heat, muscle spasms, jerking, tremors, sweating and “all-over” pain.  

In contrast to other forms of pain, descending pain isn’t well controlled by opioids and anti-inflammatory agents. The drugs clonidine and tizanidine are less effective. Only adrenaline agents stop it. Some adrenaline agents for persons with AA and EDS include:

• Phentermine

• Adderall

• Phendimetrazine

• Methylphenidate

• Dexedrine

• Modafinil  

Every person with intractable pain due to AA, EDS, RSD, cancer or other painful disease, should educate themselves on adrenaline agents and discuss them with their medical practitioners in order to either lower their opioid dosage or keep it from escalating.   

Simply stated, a person with intractable pain needs at least a small dose of an adrenaline agent for pain relief and optimal function. 

Forest Tennant, MD, MPH, DrPH, has retired from clinical practice but continues his groundbreaking research on the treatment of intractable pain and arachnoiditis. This column is adapted from a bulletin recently issued by the Arachnoiditis Research and Education Project of the Tennant Foundation, and is republished with permission. Correspondence should be sent to veractinc@msn.com.  

Dr. Tennant and the Tennant Foundation have given financial support to Pain News Network and are currently sponsoring PNN’s Patient Resources section.  

Does Discrimination Cause Blacks to Feel More Pain?

By Pat Anson, PNN Editor

Racial and ethnic bias is a fact of life that impacts almost every aspect of our society – and healthcare is no exception. Research has shown that African-Americans are more likely to be undertreated for pain compared to white Americans, and that blacks are less likely to be prescribed opioid pain medication than whites.

Part of that stems from a false belief that there are biological differences between blacks and whites that cause African-Americans to feel less pain.

New research published in the journal Nature Human Behaviour disputes that stereotype, suggesting that African-Americans experience more pain due to the lasting effects of discrimination and other stressful life experiences.

In a small study led by researchers at the University of Miami, 28 African-Americans, 30 Latinos and 30 whites were subjected to a series of painful heat tests on their forearms while undergoing MRI brain scans.

The African-Americans not only rated their pain more intense and unpleasant than the other two groups, but the MRI’s found that the parts of their brains that process pain signals became more active than their counterparts’ as the temperature of the heat probes increased.

“There's evidence that both the general public and clinicians believe that African Americans are less sensitive to pain than non-Hispanic whites; yet research, including our own, shows exactly the opposite." said lead author Elizabeth Losin, PhD, an assistant professor of psychology at the University of Miami.  "Minorities, particularly African Americans, actually report more pain."

Losin began her research eight years ago while at the University of Colorado, recruiting volunteers in the Denver area. In addition to the heat tests and MRI scans, all participants completed questionnaires about various aspects of their lives, including unfair social treatment, discrimination and their trust in doctors.

Using the MRI brain scans, Losin and her colleagues identified two areas of the brain, the ventral striatum and ventromedial prefrontal cortex, which responded to pain more strongly in African Americans than the other two groups. Prior research has found that these two brain regions also respond more to pain signals in chronic pain patients.

“Our findings suggest that the link between chronic pain and ethnic differences in pain sensitivity may lie in the chronic stress associated with discrimination. Discrimination has been consistently associated with chronic stress and other adverse health outcomes in AA (African Americans) and other minority groups,” Losin wrote.

“It is also plausible that the higher pain sensitivity we and others have observed in AA compared to WA (White Americans) participants may be related to previous negative experiences with medical care in particular, which are more common in AA compared to non-Hispanic WA populations.”

Previous studies have found that childhood trauma, domestic violence and other stressful life situations can also increase the likelihood of chronic pain – so this new research does not prove that discrimination alone contributes to the increased risk of pain. Nevertheless, it lays the groundwork for future studies on the relationship between pain and discrimination.

"These findings exemplify how neuroimaging is teaching us that there are multiple contributions to pain," said co-author Tor Wager, PhD, a professor of neuroscience at Dartmouth College. "We need to consider the broader psychological and cultural setting when we think about what is underlying pain and how to address it."

Losin is continuing her research by studying the relationship between patients' trust in their doctors and their experience with pain.

"It's a common misconception that any difference you see between groups of people must be an intrinsic difference, rooted in our biology. But the differences we found in this study were related to people's life experiences," she said. "It reaffirms our similarities and provides hope that racial and ethnic disparities in pain can be reduced."

Current and Former Smokers Have More Pain

By Pat Anson, PNN Editor

There are many good reasons to stop smoking. Within hours, your heart rate and blood pressure will drop, you’ll cough less and feel more energy. Within a few months your lung function will start to improve. And after 20 years, your risk of dying from lung disease or cancer will be about the same as someone who never touched a cigarette.

Unfortunately, one thing that may not improve is your pain. According to a large new study in the UK, former smokers report higher levels of pain than people who never smoked, and their pain levels are similar to people who still continue to smoke.

Researchers at University College London (UCL) analyzed health data from over 220,000 people in the UK who were asked to report how much pain they experienced during the previous 4 weeks and whether it interfered with their work.  

After adjusting for other health factors such as anxiety and depression, current and former daily smokers were more likely to report bodily pain compared to people who never smoked. The difference was small, but considered significant. Surprisingly, the association between smoking and pain was highest in the youngest group of smokers (aged 16 to 34).

The study was observational and did not establish a cause-and-effect relationship between smoking and pain. But researchers say their findings, published in the journal Addictive Behaviors, suggest that regular smoking at any age results in more pain.

“We cannot rule out that there is some other difference between former smokers and never smokers that is causing these surprising results, but we have to consider at least the possibility that a period of daily smoking at any time results in increased pain levels even after people have stopped smoking,” said lead author Olga Perski, PhD, a research associate in UCL’s Department of Behavioural Science & Health.

“This may be due to negative effects of smoking on the body’s hormonal feedback loops or undiagnosed damage to body tissues. This is certainly an issue that needs looking into.” 

Another possibility is differences in personality. People who take up smoking may handle the psychological stress of illness differently than non-smokers or have a lower level of pain tolerance, which makes them feel pain more acutely. A large study in Norway, for example, found that smokers and former smokers were more sensitive to pain than non-smokers, who had a higher pain tolerance.

Regardless of the reason, smoking is linked with many negative health consequences.

“The possibility that smoking may increase lifelong pain is another important reason not to take up smoking in the first place,” said Perski.

Studies have also found that smoking increases your chances of having several types of chronic pain conditions, such as degenerative disc disease.

A 2011 study of over 6,000 Kentucky women found that those who smoked had a greater chance of having fibromyalgia, sciatica, chronic neck pain, chronic back pain and joint pain than non-smokers. Women in the study who smoked daily more than doubled their odds of having chronic pain.

Research Links Auto Plant Closures to Opioid Overdoses

By Pat Anson, PNN Editor

A new study is adding to the growing body of evidence linking the opioid crisis to unemployment, depression, suicide and declining economic opportunities – the so-called epidemic of despair.

Researchers at the Perelman School of Medicine at the University of Pennsylvania and Massachusetts General Hospital looked at the closure of automotive assembly plants in the U.S from 1999 to 2016, primarily in the Midwest and Southeast. They found that opioid overdoses rose significantly in 29 counties where an auto plant shutdown.

Five years after the plants closed, opioid overdose rates among adults were 85 percent higher in counties where closures occurred compared to 83 counties where plants remained open.

"Major economic events, such as plant closures, can affect a person's view of how their life might be in the future. These changes can have a profound effect on a person's mental well-being, and could consequently influence the risk of substance use," said lead author Atheendar Venkataramani, MD, an assistant professor of Medical Ethics and Health Policy.

"Our findings confirm the general intuition that declining economic opportunity may have played a significant role in driving the opioid crisis."

The findings are published in JAMA Internal Medicine.

JAMA INTERNAL MEDICINE

The demographic group with the biggest increase in opioid overdose deaths after an auto plant closure was non-Hispanic white men between 18-34 years old, followed by non-Hispanic white men ages 35-65 years old. Opioid overdose rates also increased among young non-Hispanic white women.

Death rates involving heroin and other illicit opioids were higher for young white men and women than for prescription opioids, while older white men were more likely to die from prescription opioids.

"While we as clinicians recognize and take very seriously the issue of overprescribing, our study reinforces that addressing the opioid overdose crisis in a meaningful way requires concurrent and complimentary approaches to diagnosing and treating substance use disorders in regions of the countries hardest hit by structural economic change," Venkataramani said.

“Our findings should not be interpreted in such a way as to diminish the role of opioid supply, either from physician prescriptions or from illicitly made and supplied synthetic substances, in the US opioid overdose crisis.”

Princeton researchers Anne Case and Angus Deaton were the first to suggest in 2015 that the declining life expectancy of Americans was not caused by drug abuse alone, but linked to unemployment, poor finances, lack of education, divorce, depression and loss of social connections. They estimate that nearly half a million white Americans died due to a quiet epidemic of pain, suicide, alcohol abuse and opioid overdoses.

The epidemic of despair has also been cited as one of the reasons for the election of Donald Trump and for a “syndemic” of overdoses occurring in counties where the opioid crisis first erupted, particularly in mid-sized cities in Kentucky, Ohio and West Virginia. 

Humidity and Wind Affect Pain Levels, But Rain Doesn’t

By Pat Anson, PNN Editor

Many people with chronic pain strongly believe that rainy or cold weather aggravates their pain. Some even believe they can predict the weather based on their pain levels. 

But the results of a long-term study in the UK – recently published in the journal Digital Medicine -- show that weather conditions have only a modest effect on pain.

Researchers at the University of Manchester led a 15-month study of over 2,600 UK residents who recorded their daily pain levels with a smartphone app. The results were then compared with local weather conditions, based on the GPS locations of the participants’ phones.

Contrary to popular belief, rainfall was not associated with more pain. Results from the Cloudy with a Chance of Pain study showed that humid days were most likely to be painful, followed by days with low atmospheric pressure and strong winds. But the overall effect was modest, even when all three conditions were present.

“The analysis showed that on a damp and windy days with low pressure the chances of experiencing more pain, compared to an average day, was around 20%. This would mean that, if your chances of a painful day on an average weather day were 5 in 100, they would increase to 6 in 100 on a damp and windy day,” said lead author Will Dixon, PhD, Professor of Digital Epidemiology at the University of Manchester.

Dixon and his colleagues believe the study could be used to develop a “pain forecast” for people with chronic pain.

“This would allow people who suffer from chronic pain to plan their activities, completing harder tasks on days predicted to have lower levels of pain. The dataset will also provide information to scientists interested in understanding the mechanisms of pain, which could ultimately open the door to new treatments,” Dixon said.  

A 2017 study by Australian researchers at The George Institute for Global Health also found that damp weather increases pain. But because the symptoms disappeared as soon as the sun came out, researchers believe they could be influenced by psychological factors, not the weather itself. Previous studies on back pain, osteoarthritis and weather at The George Institute had similar findings.

The Greek philosopher Hippocrates in 400 B.C was one of the first to note that changes in the weather can affect pain levels. Although a large body of folklore has reinforced the belief that there is a link between weather and pain, the science behind it is mixed.

Do Selfless People Feel Less Pain?

By Pat Anson, PNN Editor

Are you selfless? Do you show concern for other people and take an interest in their well-being?

If the answer is yes, then your brain may be hardwired to feel less pain than people who tend to act more selfishly.

That’s the conclusion of a novel study conducted at China’s Peking University, where researchers performed MRI brain scans on nearly 300 people to learn about the biological reasons for altruistic behavior. They wanted to know why “performers” act selflessly in a crisis – such as food shortages or a natural disaster – even when there may not be a direct or indirect benefit from helping others.  

Their findings, published in the journal Proceedings of the National Academy of Sciences, showed that selfless behavior reduced activity in regions of the brain that process pain signals.  

“Our research has revealed that in adverse situations, such as those that are physically threatening, acting altruistically can relieve unpleasant feelings, such as physical pain, in human performers of altruistic acts from both the behavioral and neural perspectives,” wrote lead author Yilu Wang. “Acting altruistically relieved not only acutely induced physical pain among healthy adults but also chronic pain among cancer patients.”

Altruistic behavior has long been cherished in human society because it enables group members to collectively survive earthquakes, famines, floods and other crises. However, behaving selflessly also puts people at risk because it means giving away food, shelter and other resources.  

The MRI findings shed light on this paradox – and the psychological and biological mechanisms behind selfless behavior. 

“Engaging in altruistic behaviors is costly, but it contributes to the health and well-being of the performer of such behaviors,” Wang said. “Our findings suggest that incurring personal costs to help others may buffer the performers from unpleasant conditions.

“Whereas most of the previous theories and research have emphasized the long-term and indirect benefits for altruistic individuals, the present research demonstrated that participants under conditions of pain benefited from altruistic acts instantly.”

Heroic behavior isn’t necessary to reduce pain. Sometimes all it takes is a little empathy. 

According to a small 2017 study, just holding hands can reduce pain levels. Researchers found that when a woman was exposed to mild heat pain, her pain levels dropped when she held hands with a male partner. The more empathy the man showed, the more her pain subsided.     

Minorities in Oregon Less Likely to Get Emergency Pain Care

By Pat Anson, PNN Editor

Oregon’s treatment of chronic pain patients came under fire this year when state health officials drafted a controversial plan to forcibly taper thousands of Medicaid patients on long-term opioid therapy. The proposal was scaled back after nationwide criticism from patient advocates and pain management experts, who said it would “exacerbate suffering for thousands of patients.”

Minorities in Oregon needing emergency treatment for pain may also be suffering unnecessarily, according to a new study by Portland State University researchers.

"We found evidence that the odds of receiving a lower quality of care from EMS providers are higher among racial minorities in Oregon, when compared to white patients in Oregon, after experiencing traumatic and painful injuries," said Jamie Kennel, a PhD student and lead author of the study published in the journal Medical Care.

PSU researchers analyzed nearly 26,000 health records of patients who received emergency care for traumatic injuries in Oregon between 2015 and 2017.

Only about one in five white patients received opioids or other types of pain medication from EMS responders in Oregon. But the odds were 32% lower for black patients, 24% lower for Asian patients and 21% lower for Latino patients. This was despite the fact that black and Latino patients reported higher average pain scores than white patients.

ODDS OF GETTING EMS PAIN MEDICATION

• White Patients 20.1%

• Latino Patients 17.2%

• Asian Patients 14.2%

• Black Patients 13.9%

"This is very large, concerning and should be motivating for change," said Kennel. "Like most healthcare providers, EMS providers don't desire to provide inequitable healthcare but often have never been exposed to evidence suggesting these disparities are taking place."  

The researchers also found that Asian and Latino patients were less likely to have their pain assessed – a simple procedure in which patients are asked to rate their pain on a scale of zero to 10.

While previous studies have found racial and ethnic disparities in medical care, this was the first to look at both pain assessment and pain medication during emergency care in a large statewide database. Researchers did not look at what caused the inequities in pain treatment, but speculated that racial stereotypes and difficulty in communicating with patients with limited English played a role.

“Although it has been shown conclusively that there are no medically significant biological differences between individuals of different races/ethnicities, there is evidence that medical providers nevertheless believe race/ethnicity to be a medically relevant factor and may be adjusting their clinical actions accordingly,” researchers concluded.  

"We hope that, when exposed to this new evidence, individual EMS providers will work with their agencies to better understand, and take steps to mitigate, this phenomenon in their community." 

A large 2016 study found that black patients who visit hospital emergency rooms are significantly less likely to receive opioid prescriptions than white patients. Opioids were prescribed for blacks at about half the rate for whites with back and abdominal pain.

Another large study of VA patients found that African-Americans on long-term opioid therapy were more likely to be drug tested and significantly more likely to have their opioid prescriptions stopped if an illicit drug was detected.

How to Avoid the Holiday Blues

By Pat Anson, PNN Editor

For many of us, the holiday season wouldn’t be complete without Christmas cookies, jelly donuts, plum pudding, chocolate babka, or even the much-maligned fruit cake.

But if you're prone to depression or have an inflammatory condition, you might want to avoid those sweet treats. Or at least enjoy them in moderation.

New research by clinical psychologists at the University of Kansas suggests that dietary sugars found in many holiday foods can trigger metabolic, inflammatory and neurobiological processes that can lead to insomnia, digestive problems and depression – which all enhance physical pain.

"A large subset of people with depression have high levels of systemic inflammation,” said lead author Stephen Ilardi, PhD, an associate professor of clinical psychology at KU. "When we think about inflammatory disease we think about things like diabetes and rheumatoid arthritis - diseases with a high level of systemic inflammation. We don't normally think about depression being in that category, but it turns out that it really is.

“We also know that inflammatory hormones can directly push the brain into a state of severe depression. So, an inflamed brain is typically a depressed brain. And added sugars have a pro-inflammatory effect on the body and brain."

Depression Causes Sugar Cravings

Dwindling daylight in winter can worsen depression and prompt people to consume more sweets, which provide a temporary emotional lift.

"One common characteristic of winter-onset depression is craving sugar," Ilardi said. "So, we've got up to 30% of the population suffering from at least some symptoms of winter-onset depression, causing them to crave carbs - and now they're constantly confronted with holiday sweets.

"When we consume sweets, they act like a drug. They have an immediate mood-elevating effect, but in high doses they can also have a paradoxical, pernicious longer-term consequence of making mood worse, reducing well-being, elevating inflammation and causing weight gain."

The KU research team analyzed a wide range of studies on the physiological and psychological effects of sugar, including the Women's Health Initiative study, the NIH-AARP Diet and Health Study, and studies of Australian and Chinese soda-drinkers. Their research is published in the journal of Medical Hypotheses.

Ilardi says consuming high amounts of sugar could be as physically and psychologically harmful as drinking too much liquor.

"We have pretty good evidence that one alcoholic drink a day is safe, and it might have beneficial effect for some people," Ilardi said. "Alcohol is basically pure calories, pure energy, non-nutritive and super toxic at high doses. Sugars are very similar."

The average American gets about 14% of their calories from added sugars – the equivalent of 18 teaspoons of sugar each day. Most people know a high-sugar diet can lead to diabetes, obesity and cardiovascular problems.

Another way to look at sugar is to think of it as fuel for bacteria.  

"Our bodies host over 10 trillion microbes and many of them know how to hack into the brain," Ilardi said. "The symbiotic microbial species, the beneficial microbes, basically hack the brain to enhance our well-being. They want us to thrive so they can thrive.

“But there are also some opportunistic species that can be thought of as more purely parasitic - they don't have our best interest in mind at all. Many of those parasitic microbes thrive on added sugars, and they can produce chemicals that push the brain in a state of anxiety and stress and depression. They're also highly inflammatory."

Ilardi recommends eating a minimally processed diet rich in fruits, vegetables, fish and whole grains, while avoiding red meats, refined grains, fructose and other unhealthy foods. As for sugar, the KU researcher urges moderation -- not just during the holidays, but year-round.

Valley Fever Spreading in U.S. Southwest

By Barbara Feder Ostrov and Harriet Blair Rowan, California Healthline

Valley fever cases are on the rise in California and across the arid Southwest, and scientists point to climate change and population shifts as possible reasons.

California public health officials documented 7,768 reports of confirmed, suspected and probable new cases of the fungal disease as of Nov. 30, 2019, up 12% from 6,929 in the first 11 months of 2018.

The increase is part of a recent trend in the nation’s Southwest dating to 2014, with outbreaks most prevalent in California and Arizona. Nationally, public health officials reported 14,364 confirmed cases of valley fever in 2017, more than six times the number reported in 1998, according to the U.S. Centers for Disease Control and Prevention.

Valley fever is caused by a Coccidioides fungus that lives in the soil of California’s Central Valley, Arizona and areas of other Southwestern states prone to desert-type conditions.

Animals and people can contract the infection by breathing in dust that contains the microscopic fungus spores. The infection is not transmitted from person to person.

Symptoms can include fatigue, cough, fever, headache, muscle aches or rash. While the majority of people infected experience mild flu-like symptoms or no symptoms at all, as many as 10% develop serious, sometimes long-term lung problems, including pneumonia.

‘I Am So Tired’

PNN columnist and iPain founder Barby Ingle – who lives in Arizona -- came down with valley fever last month. It was originally diagnosed as bacterial pneumonia, but when Barby’s fever, coughing, headache and joint pain persisted for weeks, her doctors ordered another round of tests.

“A CT scan was ordered that showed that it was actually valley fever pneumonia and that it had spread from the right lung to both lungs and lymph nodes,” Barby explained in an email. “I am told it will be up to a year of treatment and that they will do x-rays, CT scans and blood tests monthly, that there will be permanent scars on my lungs, and that it can turn to meningitis and/or can cause death if not treated.

“I am so tired. I feel like someone really big is sitting on my chest. I have learned that when breathing is compromised, the pain I deal with daily has becomes secondary. The brain concentrates on just breathing.”

BARBY INGLE

Barby has been on oxygen therapy since early November and recently started taking anti-fungal medication. Her immune system was already compromised by Reflex Sympathetic Dystrophy (RSD) and other chronic illnesses.  

“I asked my pulmonologist if I should move and she said if you go to another region, you will just get what they have there. It may not be valley fever, but every region has something like this that people with poor immune systems are more susceptible to,” said Barby. “She told me to ride with my car on recirculated air instead of outside fresh air setting. That is most likely where I was exposed.”   

About 200 Americans die from valley fever every year, according to the CDC. Researchers are working to develop a vaccine for both humans and animals.

Federal health officials say the infections likely are underreported because not every state requires public disease reporting for valley fever and because some infected people never develop symptoms or seek medical care.

Dr. Royce Johnson, a valley fever expert, recalls treating about 250 to 300 cases a year when he arrived in rural Kern County in the 1970s. As of Nov. 30 this year, Kern County — now a hot spot for the disease — reported more than 2,700 confirmed, suspected or probable cases, according to the California Department of Public Health.

“This is a major, major health problem, and it’s growing,” said Johnson, medical director of the Valley Fever Institute at Kern Medical in Bakersfield. “The extent of the endemic area is increasing, and the number of cases in the whole Southwest is going up.”

A University of California study examining the financial toll of valley fever on California estimated the direct and indirect lifetime costs of 2017 cases at about $700 million, when considering treatment expenses, lost productivity and mortality.

Researchers attribute the spike in cases to a number of factors. There’s more awareness of the disease because of media coverage and public health campaigns. California has earmarked $2 million for a public awareness campaign, and employers in regions of the state where workers are at higher risk for the disease will be required to educate them about the disease.

Population growth in the American Southwest, where the fungus is endemic, also plays a role, both because of the increased pool of patients and development that disturbs the soil. In Kern County, which reports the majority of California’s cases, the population has grown 65% since 1990.

But the most significant factor may prove to be climate change, which expands the ecosystems where the fungus can flourish. Using climate models, UC-Irvine researchers projected that by 2100 the expanse of areas with hot, dry conditions favored by the fungus could double and the number of valley fever cases could grow by 50%.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Additional content was added by PNN.

Health Risks of NSAIDs Led to ‘Significant Under-Treatment of Pain’

By Pat Anson, PNN Editor

The opioid crisis has been blamed on a lot of things, everything from pharmaceutical marketing to poor medical education to an epidemic of despair.

Now we can also blame NSAIDs.

A new study by researchers at Boston University School of Public Health (BUSPH) found that a decline in prescriptions for non-opioid analgesics — mostly non-steroidal anti-inflammatory drugs and COX-2 inhibitors -- coincided with a marked increase in opioid prescribing for people with chronic musculoskeletal pain.

Concerns about the cardiovascular side effects of Vioxx and other COX-2 inhibitors first came to light in the early 2000s. More was also being learned about heart disease, strokes and gastrointestinal problems associated with NSAIDs.

"While the opioid epidemic is complex and has many possible causes, our findings suggest that health risks associated with NSAIDs were one factor that led to increased prescribing of opioids," says lead author Dr. Andrew Stokes, assistant professor of global health at BUSPH.

Stokes and his colleagues looked at 1999-2016 prescription data for over 7,200 U.S. adults with back pain, neck pain or arthritis. Increases in opioid prescriptions matched the decrease in prescribing for non-opioid analgesics (predominantly NSAIDs and COX-2 inhibitors) between 2003 and 2006.

"We realized that the point at which increasing opioid prescriptions crossed over with the decrease in non-opioid prescriptions occurred when the cardiovascular risks of COX-2 inhibitors led to rofecoxib (Vioxx) coming off the market. The gastrointestinal risks of NSAIDs were also well-recognized by then,” says senior author Dr. Tuhina Neogi, a professor of epidemiology at BUSPH and Chief of Rheumatology at Boston Medical Center.

“Thus it appeared to us that an increase in opioid prescribing during that time was, at least in part, an unintended consequence of COX-2 inhibitors coming off the market and concerns about NSAID risk.”

‘Unmet Need for Pain Management’

The study, published in JAMA Network Open, also found that growing recognition of the opioid crisis after 2013 led to decreases in opioid and non-opioid analgesic prescriptions for people with chronic musculoskeletal pain, particularly among those with less education and lower socioeconomic status.

"Care is needed to ensure that our response to the opioid crisis does not leave people living with chronic pain behind. The abrupt decline in prescribing to those of low socioeconomic status is concerning given that these same individuals also face the greatest barriers to accessing alternative pain treatments, such as physical therapy," Stokes says.

"There's so much talk now about transitioning people away from opioids. But if that's happening without considering the barriers to non-pharmacologic treatments, there may be a significant problem of under-treatment of pain," adds study co-author Dielle Lundberg, a research fellow at BUSPH.

Between 2013 and 2106, researchers found an 11% decrease in prescriptions for both opioid and non-opioid pain relievers, suggesting a significant amount of pain was going untreated.

“Care is needed to ensure that our response to the opioid crisis does not leave people living with chronic pain behind.”

— Dr. Andrew Stokes

“The fact that the present study was restricted to patients with potential needs for pain management also raises the concerning possibility that an unmet need for pain management has increased over this period. Such a trend would be alarming given evidence that untreated chronic pain may prompt patients with chronic pain to seek out illicit heroin or fentanyl,” researchers concluded.

“In addition, several recent studies based on data from the National Violent Death Reporting System have found a high rate of chronic pain among suicide decedents, and recent research and commentary on opioid discontinuation have suggested that recent increases in the suicide death rate may be linked to changes in pain treatment.”

U.S. Facing ‘Syndemic’ of Opioid Overdoses

By Pat Anson, PNN Editor

The U.S. opioid crisis is a lot more complex than many people think. Instead of a single “epidemic” fueled by prescription opioids, researchers say there are three types of opioid epidemics occurring in different parts of the country simultaneously.

A team of researchers at Iowa State University studied death certificate data from all 3,079 counties in the lower 48 states and found distinct regional differences in the opioids that caused the most overdoses.

Cities in New England have been hit hard by illicit fentanyl and other synthetic opioids; the Rockies and Midwest are plagued by heroin; and a prescription opioid epidemic still lingers in many rural counties in the South and West.

A fourth epidemic – dubbed a “syndemic” by researchers – involves multiple drugs and exists in counties where the opioid crisis first erupted, particularly in mid-sized cities in Kentucky, Ohio and West Virginia. 

About 25 percent of all U.S. counties fall into one of these epidemic categories.   

“Our results show that it’s more helpful to think of the problem as several epidemics occurring at the same time rather than just one,” said co-author David Peters, PhD, an associate professor of sociology at Iowa State University. “And they occur in different regions of the country, so there’s no single policy response that’s going to address all of these epidemics. There needs to be multiple sets of policies to address these distinct challenges.”

LEADING CAUSE OF OPIOID OVERDOSES

Overdose deaths linked to prescription opioids peaked nationwide in 2013 and have fallen in recent years. But researchers say some counties with poor economies continue to struggle with prescription drugs. Over one-third of the counties in Tennessee, Oklahoma, Nevada and Utah fall into this category.

“We find that prescription-related epidemic counties, whether rural or urban, have been ‘left behind’ the rest of the nation. These communities are less populated and more remote, older and mostly white, have a history of drug abuse, and are former farm and factory communities that have been in decline since the 1990s. Overdoses in these places exemplify the ‘deaths of despair’ narrative,” researchers reported in the journal Rural Sociology.

“By contrast, heroin and opioid syndemic counties tend to be more urban, connected to interstates, ethnically diverse, and in general more economically secure. The urban opioid crisis follows the path of previous drug epidemics, affecting a disadvantaged subpopulation that has been left behind rather than the entire community.” 

The study found heroin overdose deaths clustered along two major corridors, one linking El Paso to Denver and another linking Texas and Chicago. Those findings correspond with known drug routes used by cartels smuggling heroin into the U.S. from Mexico.

The study only looked at death certificate data up to 2016, missing the full impact of the CDC opioid guideline, as well as the widening scope of the fentanyl and counterfeit drug crisis. As PNN has reported, hundreds of people have died on the west coast this year after ingesting counterfeit oxycodone laced with fentanyl.

“We are waiting to obtain the 2017 and 2018 data from CDC, but I expect the number of Rx opioid epidemic counties have transitioned to the synthetic+Rx epidemic and the opioid syndemic,” Peters told PNN in an email. “Fentanyl mixtures are replacing Rx pills and heroin in many places, mainly because fentanyl analogs are cheap to produce and generate more profits for drug traffickers.”

Given the expanding nature of the opioid crisis, Peters and his colleagues say tighter regulation of opioid prescribing and dispensing will have little effect on overdoses. The same is true for law enforcement efforts to stop drug traffickers and smuggling.

Instead they recommend expanding access to addiction treatment, as well as long-term investment in struggling communities to reduce both economic despair and the demand for drugs.  

Domestic Abuse Survivors Have Twice Risk of Fibromyalgia

By Pat Anson, PNN Editor  

Ava Shypula had a difficult childhood growing up in communist Poland. She was physically abused by her father and was left home alone for hours, sometimes days at a time. Ava became chronically ill at a young age. 

“My symptoms began very early, almost as far as I remember. They started with joint pain, chills and constant flu like symptoms, with a sore, inflamed throat,” Ava recalls. 

Even after marrying a doctor and leaving Poland to begin a new life in New York City, Ava’s symptoms persisted. 

“My then-husband ignored my symptoms, focusing on his own career and studying in order to re-certify his medical diploma,” she said. “The fear of failure, pride and ambition to succeed only advanced the illness, which at that time was diagnosed as chronic fatigue syndrome.” 

Only after her marriage ended in a nasty divorce did Ava begin to understand her illness and the role played by stress. She was diagnosed with fibromyalgia – a poorly understood disease characterized by widespread body pain, fatigue, poor sleep, anxiety and depression. 

A neurologist prescribed Lyrica and Ava’s symptoms began improving. 

“For many years women with undiagnosed fibromyalgia had been dismissed as hysterics having emotional issues,” she said. “Together with a fantastic help from my psychiatrist, my symptoms slowly but noticeably diminished, not fully, but they have become more manageable.”

Abuse Causes Physical and Psychological Stress

Ava Shypula’s story is not unique. In fact, it is all too common, according to a large new study that found female survivors of domestic abuse have nearly twice the risk of developing widespread body pain and chronic fatigue syndrome (CFS).

Researchers at the Universities of Birmingham and Warwick in the UK examined the medical records of over 18,500 women who suffered domestic abuse and compared them to 74,000 women who did not. Health data was collected from 1995 to 2017.

The study, published in the Journal of Interpersonal Violence, is one of the first designed to assess the relationship between women who have been abused and the likelihood of them developing long-term illnesses such as fibromyalgia.

"Survivors of domestic abuse can experience immense physiological and psychological stress,” said Professor Julie Taylor of the University of Birmingham's School of Nursing. “The changes that happen in the body as a result of such stress can lead to a multitude of poor health outcomes such as what we see in our study here.

"This is a very complex relationship and it is important to emphasize that not all women who have been abused will develop fibromyalgia or CFS, and that having these conditions does not mean there has been domestic abuse in the past."

Previous research has found that about one in every four women in the UK have experienced some form of domestic abuse, with a large proportion of those cases being violence at the hands of an intimate partner. Globally, about one in three women suffer domestic abuse.

"Considering the prevalence of domestic abuse, and the fact that patients experiencing fibromyalgia and CFS often face delays in diagnosis due to a limited understanding generally of how these conditions are caused, it is important for clinicians to bear in mind that women who have survived abuse are at a greater risk of these conditions,” said Dr. Joht Singh Chandan of the University of Birmingham's Institute of Applied Health Research and Warwick Medical School.

"We hope these first of their kind research findings will change healthcare practice and will be of assistance in the early diagnosis of fibromyalgia and CFS in women who have been abused."

Ava Shypula hopes that sharing her story will help other women understand their illness, get treatment and make lifestyle changes to reduce stress. She’s learned that avoiding cold temperatures, staying warm and getting a good night’s sleep will reduce her symptoms. 

“Encourage them to fight back instead of resigning and living with pity and depression, which I have experienced at different points of my life,” she told PNN. “I have found that emotional support plays a major role to fight with this illness.”

Consumer DNA Tests Do Not Accurately Predict Disease

By Dr. Lynn Webster, PNN Columnist

Three years ago, I gave my family members DNA kits as Christmas gifts. I thought the genetic health aspects of the test would be an entertaining exercise -- a bit like visiting a psychic who would read tarot cards to predict the future. I didn’t think of it as a serious medical test, and I made sure my family understood that.

These kits have become very popular. More than 26 million people have taken an at-home genetics test, hoping to learn more about their ancestral background, along with their risks of developing certain diseases. But the tests may not live up to either of those expectations.

The U.S. Government Accountability Office (GAO) sent a report to Congress in 2010 alleging that some DNA testing companies used deceptive marketing and other questionable practices. 

The GAO stated that results from DNA tests were “misleading and of little or no practical use.” Their investigation also uncovered the fact that different DNA testing companies provided different results from the same sample. 

Not only were the test results dubious, but the companies made some deceptive claims. One company alleged the results from their testing could help cure diseases. Another claimed the data could predict at which sports a child would excel.

Admittedly, the accuracy of the tests has improved since 2010, but the tests still are, at best, imperfect.

Our genome (the whole of our hereditary information, encoded in our DNA) contains about three billion genes. Of those, only about 20,000 are responsible for disease. But we are more than our genes. Whether or not we will get most diseases depends on a combination of our genes and environment. This interaction of environment and genes is what we call a phenotype.

Of course, there are genetic mutations that are responsible for specific diseases. Single-gene mutations are responsible for about 10,000 diseases, the majority of which are considered rare. Some of the more common single-gene disorders include sickle cell anemia, cystic fibrosis, phenylketonuria, and Huntington's disease.

However, there is no guarantee that direct-to-consumer DNA kits are capable of detecting all common single genetic mutations. Moreover, the absence of a reported mutation from these kits does not mean the mutation does not exist.

Testing may uncover some benign and interesting traits, though. For example, some genetic kits (but not all) can tell you if you have a gene associated with how your earlobes are shaped, whether your urine has an offensive odor after you eat asparagus, or if you are inclined to dislike cilantro.

The accuracy of the health-related portion of the tests is improving. It is now possible to test for genes that predict a person's risk for certain types of breast and prostate cancers. However, placing too much weight on the results of those tests can be dangerous. For example, the tests do not screen for all types of breast cancer, which can lead consumers to falsely conclude their risk of all breast cancers is low if their test results do not indicate a gene mutation associated with breast cancer.

At best, the types of DNA tests that provide information on single-mutation diseases should be accompanied by appropriate genetic counseling. Since most diseases are based on multiple genes and environment, a genetics counselor can help put the test results into perspective.

Deciding how to use the information may be more important than knowing the results of the test. In medicine, we never order a test unless it will help us provide better care for our patient. This may be an important principle to apply here as well.

Privacy Is a Big Concern

We should also be very concerned about how our DNA data will be stored and used. The testing companies' DNA databases can be hacked by people with nefarious motives, or shared with insurance companies or law enforcement. Laws protecting consumers are evolving, but clearly, at-home DNA tests expose consumers to unknown and, perhaps, unintended consequences.

DNA tests were first pitched to consumers as a way in which they could learn about their ancestry. However, the reference data sets were largely European and less accurate in showing lineages in other areas of the world. If your roots were Asian or African, the reports were less likely to accurately reflect where your ancestors lived.

Over time, the data sets have improved and expanded, so consumers with non-European ancestry may get more accurate information about their heritages now than they would have previously. That trend will likely continue.

Whether DNA kits are mostly a gimmick, I cannot say. But it is important to recognize their limitations in providing trustworthy information about our health or ancestry. Certainly, we should not base health decisions on their results, and I would think twice about paying for the privilege of delivering my DNA profile to a for-profit company.

Maybe this year I’ll just give everyone tarot decks.

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

You can find Lynn on Twitter: @LynnRWebsterMD.

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

U.S. Life Expectancy Still Declining

By Pat Anson, PNN Editor

After decades of progress with Americans living longer and healthier lives, a disturbing new study has documented how life expectancy in the U.S. has declined for three consecutive years.

The drop in life expectancy was most pronounced in young and middle-aged adults. Starting in 2014, midlife mortality increased across all racial groups, largely due to drug overdoses, alcohol abuse, suicide, and chronic illnesses such as hypertension and diabetes. Researchers said prescription opioids were more of a symptom than a cause of premature deaths.

In 2014, Americans were expected to live to 78.9 years of age. By 2017, the average life expectancy had fallen to 78.6 years.

The U.S. now has the worst midlife mortality rate among 17 high income countries, even though it spends more on healthcare per capita than any other nation.  

“This is an emergent crisis. And it is a uniquely American problem since it is not seen in other countries. Something about life in America is responsible,” lead author Steven Woolf, MD, reported in a Special Communication published in JAMA.

The largest increases in midlife mortality occurred among adults with less education and those living in rural areas.  Changes in life expectancy were greatest in upper New England, the Ohio Valley, and Appalachia – regions where economic distress, lower social mobility and the so-called epidemic of despair contributed to rising rates of suicide and drug and alcohol abuse.

“While it’s a little difficult to place the blame on despair directly, the living conditions causing despair are leading to other problems,” said Woolf, who is director emeritus of the Center on Society and Health at Virginia Commonwealth University. “For example if you live in an economically distressed community where income is flat and it’s hard to find jobs, that can lead to chronic stress, which is harmful to health.”

While life expectancy increased in a handful of Western states, midlife mortality rose in Ohio and West Virginia – states often called ground-zero of the opioid crisis.  A sharp increase in opioid overdoses came in three waves; starting with the introduction of OxyContin and the overuse of prescription opioids in the 1990s, followed by increased heroin use, and then the emergence of illicit fentanyl – which triggered another wave of opioid overdoses starting in 2013.

“However, the increase in opioid-related deaths is only part of a more complicated phenomenon and does not fully explain the increase in midlife mortality rates from other causes, such as alcoholic liver disease or suicides. Opioid-related deaths also cannot fully explain the U.S. health disadvantage, which began earlier (in the 1980s) and involved multiple diseases and nondrug injuries,” Woolf said.

The tsunami of fentanyl overdoses has yet to dissipate. According to a new study by the Massachusetts Department of Public Health, 93% of opioid related overdoses in the state in the first nine months of 2019 involved fentanyl. Deaths involving prescription opioids such as oxycodone and hydrocodone peaked in 2014 and are now linked to only about 10% of overdose deaths in Massachusetts.