Doctor-journalist says pain doesn't fit on a scale of zero to 10

Illustration of the pain scale by iStock/Getty Images Plus, via KFF Health News

OPINION by Elisabeth Rosenthal
KFF Health News

Over the past two years, a simple but baffling request has preceded most of my encounters with medical professionals: “Rate your pain on a scale of zero to 10.”

I trained as a physician and have asked patients the very same question thousands of times, so I think hard about how to quantify the sum of the sore hips, the prickly thighs, and the numbing, itchy pain near my left shoulder blade. I pause and then, mostly arbitrarily, choose a number. “Three or four?” I venture, knowing the real answer is long, complicated, and not measurable in this one-dimensional way.

Pain is a squirrely thing. It’s sometimes burning, sometimes drilling, sometimes a deep-in-the-muscles clenching ache. Mine can depend on my mood or how much attention I afford it and can recede nearly entirely if I’m engrossed in a film or a task. Pain can also be disabling enough to cancel vacations, or so overwhelming that it leads people to opioid addiction. Even 10+ pain can be bearable when it’s endured for good reason, like giving birth to a child. But what’s the purpose of the pains I have now, the lingering effects of a head injury?

The concept of reducing these shades of pain to a single number dates to the 1970s. But the zero-to-10 scale is ubiquitous today because of what was called a “pain revolution” in the ’90s, when intense new attention to addressing pain — primarily with opioids — was framed as progress. Doctors today have a fuller understanding of treating pain, as well as the terrible consequences of prescribing opioids so readily. What they are learning only now is how to better measure pain and treat its many forms.

About 30 years ago, physicians who championed the use of opioids gave robust new life to what had been a niche specialty: pain management. They started pushing the idea that pain should be measured at every appointment as a “fifth vital sign.” The American Pain Society went as far as copyrighting the phrase. But unlike the other vital signs — blood pressure, temperature, heart rate, and breathing rate — pain had no objective scale. How to measure the unmeasurable? The society encouraged doctors and nurses to use the zero-to-10 rating system. Around that time, the Food and Drug Administration approved OxyContin, a slow-release opioid painkiller made by Purdue Pharma. The drugmaker itself encouraged doctors to routinely record and treat pain, and aggressively marketed opioids as an obvious solution.

To be fair, in an era when pain was too often ignored or undertreated, the zero-to-10 rating system could be regarded as an advance. Morphine pumps were not available for those cancer patients I saw in the ’80s, even those in agonizing pain from cancer in their bones; doctors regarded pain as an inevitable part of disease. In the emergency room where I practiced in the early ’90s, prescribing even a few opioid pills was a hassle: It required asking the head nurse to unlock a special prescription pad and making a copy for the state agency that tracked prescribing patterns. Regulators (rightly) worried that handing out narcotics would lead to addiction. As a result, some patients in need of relief likely went without.

After pain doctors and opioid manufacturers campaigned for broader use of opioids — claiming that newer forms were not addictive, or much less so than previous incarnations — prescribing the drugs became far easier and were promoted for all kinds of pain, whether from knee arthritis or back problems. As a young doctor joining the “pain revolution,” I probably asked patients thousands of times to rate their pain on a scale of zero to 10 and wrote many scripts each week for pain medication, as monitoring “the fifth vital sign” quickly became routine in the medical system. In time, a zero-to-10 pain measurement became a necessary box to fill in electronic medical records. The Joint Commission on the Accreditation of Healthcare Organizations made regularly assessing pain a prerequisite for medical centers receiving federal health-care dollars. Medical groups added treatment of pain to their list of patient rights, and satisfaction with pain treatment became a component of post-visit patient surveys. (A poor showing could mean lower reimbursement from some insurers.)

But this approach to pain management had clear drawbacks. Studies accumulated showing that measuring patients’ pain didn’t result in better pain control. Doctors showed little interest in or didn’t know how to respond to the recorded answer. And patients’ satisfaction with their doctors’ discussion of pain didn’t necessarily mean they got adequate treatment. At the same time, the drugs were fueling the growing opioid epidemic. Research showed that an estimated 3% to 19% of people who received a prescription for pain medication from a doctor developed an addiction.

Doctors who wanted to treat pain had few other options, though. “We had a good sense that these drugs weren’t the only way to manage pain,” Linda Porter, director of the National Institutes of Health’s Office of Pain Policy and Planning, told me. “But we didn’t have a good understanding of the complexity or alternatives.” The enthusiasm for narcotics left many varietals of pain underexplored and undertreated for years. Only in 2018, a year when nearly 50,000 Americans died of an overdose, did Congress start funding a program — the Early Phase Pain Investigation Clinical Network, or EPPIC-Net — designed to explore types of pain and find better solutions. The network connects specialists at 12 academic specialized clinical centers and is meant to jump-start new research in the field and find bespoke solutions for different kinds of pain.

A zero-to-10 scale may make sense in certain situations, such as when a nurse uses it to adjust a medication dose for a patient hospitalized after surgery or an accident. And researchers and pain specialists have tried to create better rating tools — dozens, in fact, none of which was adequate to capture pain’s complexity, a European panel of experts concluded. The Veterans Health Administration, for instance, created one that had supplemental questions and visual prompts: A rating of 5 correlated with a frown and a pain level that “interrupts some activities.” The survey took much longer to administer and produced results that were no better than the zero-to-10 system. By the 2010s, many medical organizations, including the American Medical Association and the American Academy of Family Physicians, were rejecting not just the zero-to-10 scale but the entire notion that pain could be meaningfully self-reported numerically by a patient.

In the years that opioids had dominated pain remedies, a few drugs — such as gabapentin and pregabalin for neuropathy, and lidocaine patches and creams for musculoskeletal aches — had become available. “There was a growing awareness of the incredible complexity of pain — that you would have to find the right drugs for the right patients,” Rebecca Hommer, EPPIC-Net’s interim director, told me. Researchers are now looking for biomarkers associated with different kinds of pain so that drug studies can use more objective measures to assess the medications’ effect. A better understanding of the neural pathways and neurotransmitters that create different types of pain could also help researchers design drugs to interrupt and tame them.

Any treatments that come out of this research are unlikely to be blockbusters like opioids; by design, they will be useful to fewer people. That also makes them less appealing prospects to drug companies. So EPPIC-Net is helping small drug companies, academics, and even individual doctors design and conduct early-stage trials to test the safety and efficacy of promising pain-taming molecules. That information will be handed over to drug manufacturers for late-stage trials, all with the aim of getting new drugs approved by the FDA more quickly.

The first EPPIC-Net trials are just getting underway. Finding better treatments will be no easy task, because the nervous system is a largely unexplored universe of molecules, cells, and electronic connections that interact in countless ways. The 2021 Nobel Prize in Physiology or Medicine went to scientists who discovered the mechanisms that allow us to feel the most basic sensations: cold and hot. In comparison, pain is a hydra. A simple number might feel definitive. But it’s not helping anyone make the pain go away.

Medical cannabis bill passes Senate, awaits House vote March 30

By Melissa Patrick
Kentucky Health News

A bill that would make medical marijuana legal for some in Kentucky has passed the state Senate for the first time and awaits a vote in the House, which has passed two similar bills in previous legislative sessions.

Sen. Stephen West

"It is time for Kentucky to join the other 37 states in the United States that allow medical marijuana as an option for their citizens," said Sen. Stephen West, R-Paris, in presenting his bill to the Senate, adding later, "It is understood that this is a very complex issue and if passed, will be a work in progress." 

Senate Bill 47 passed late Thursday night on a 26-11 vote. The House gave the bill its first of three required readings the same night, which will allow enough time for it to pass out of the House when the lawmakers return March 29 and 30.

Last year, after a House-passed bill again got no hearing in the Senate, Gov. Andy Beshear used his pardon power to allow people with 21 specified medical conditions and a doctor's certificate to possess up to eight ounces of marijuana bought legally in another state. (Illinois is the only adjoining state where nonresidents can legally buy cannabis.) Beshear signaled Thursday that he would sign the bill.

West, who said he has worked on such legislation for about five or six years, told the Senate, “This is one of those issues where you take out the ledger and you list the pros and cons. It’s a long list on both sides, but for me personally, the pros outweigh the cons.”

The 124-page bill would not allow medical marijuana to be smoked, require users to be 18 or older or be a caretaker for a child, limit supply, and not take effect until Jan. 1, 2025.

The medical marijuana would be allowed for certain "qualifying medical conditions," including all cancers regardless of the stage; chronic, severe, intractable or debilitating pain; epilepsy or any other tractable seizure disorder; multiple sclerosis, muscle spasms or spasticity; chronic nausea or cyclical vomiting syndrome that has proven resistant to other conventional medical treatments; post-traumatic stress disorder; and any other medical condition or disease for which the new Kentucky Center for Cannabis Research at the University of Kentucky determines would benefit from medicinal marijuana.

West and other lawmakers praised the advocacy of Eric and Michelle Crawford, a quadriplegic who has long searched for another option to manage his pain. They also praised the ongoing work of advocate Jamie Montalvo, who suffers from multiple sclerosis, toward getting this bill passed. 

 Sen. Phillip Wheeler, R-Pikeville, said the Crawfords and Montalvo don't want to break the law: "These are people that are willing to work hard and make sacrifices to comply with the law. What they are looking for is a pathway forward to make sure that people can get a safe product." 

Sen. Stephen Meredith, R-Leitchfield, said it was important to show those who are suffering from  debilitating diseases  "just a little bit of mercy" and that was why he voted yes.   

“Will this be abused by some folks?  It certainly will," he said. "But again, if we can benefit just one person, one child, I think it’s worthwhile."

Only Republicans voted against the bill: Gary Boswell of Owensboro, Danny Carroll of Benton, Donald Douglas of Nicholasville, Rick Girdler of Somerset, President Pro Tem David Givens of Greensburg, Chris McDaniel of Ryland Heights, Robby Mills of Henderson, John Schickel of Union, President Robert Stivers of Manchester, Mike Wilson of Bowling Green, and Max Wise of Campbellsville. 

Marijuana is a "scourge of the earth," Boswell said. "I urge my colleagues to vote no. If you are going to violate federal law, at least tighten up the bill to include only the critically ill." 

Douglas, a physician, said, “With the different growing techniques and the increased concentration of these chemical compounds, I’m not really convinced that this drug is safe. But we do have some research going on out there, and I really want to thank the University of Kentucky. I hope we have some other institutions doing research who will give us good information.”

Senate President Robert Stivers, leading foe of medical cannabis in Kentucky, suggests he could be for it in end-of life cases

By Al Cross
Kentucky Health News

State Senate President Robert Stivers suggested Monday night that he might be willing to approve medical marijuana in Kentucky on a very limited basis, to relieve patients' pain at the end of their lives. But he cast fresh doubt on whether relief actually comes from cannabis, or rather from expectation that it will.

"I am working with others see how we could get to a 'yes' to take care of those who are at the end of life," Stivers said on KET's "Kentucky Tonight." It was the first sign of compromise on the issue from Stivers, who has been the major obstacle to medical-cannabis bills passed by the state House.

Robert Stivers (file photo)

"I've seen family members go through cancer treatments; in no way do I want to be unsympathetic," Stivers said as he began discussing the issue. After repeating his desire to see more research on it and making other points, he said the use of cannabis in palliative care can easily be defended under the old "choice of evils" principle of English common law. In such cases, "I don't think you would ever be arrested; I don't think you would be convicted," he said.

A Manchester attorney, Stivers briefly noted without explanation a National Geographic story published online Jan. 6. It cited a study that found "67 percent of the relief from pain reported by people treated with cannabinoids was also seen among those who received a placebo," Meryl Davids Landau wrote for the magazine. "This suggests that the pain reduction was not due primarily to compounds found in cannabis but to people’s expectations that it would help. And that positive expectation was based in part, say the authors, on over-enthusiastic media coverage. Reputable studies so far have not found that cannabinoids sufficiently reduce pain, which led the International Association for the Study of Pain in 2021 to decline to endorse these drugs."

Even as he cast new doubt, Stivers suggested what a medical-cannabis system could look like. He said the state could require names of all owners of cannabis dispensaries to be public, "to prevent abuse," and have a computer network to monitor cannabis prescriptions and how the drug is ingested, saying marijuana smoke has 50% more carcinogens than tobacco smoke.

Last year, after the Senate again declined to take up a House bill that would have legalized medical marijuana, Stivers pushed through a bill for cannabis research at the University of Kentucky. "There's indicators out there that certain things are helped," he said on KET. "Let's research the issue."

After last year's legislative session, Gov. Andy Beshear named a group to study the issue, then used his pardon power in an executive order allowing people with a medical provider's statement saying they have at least one of 21 specified medical conditions to possess up to eight ounces of cannabis for medical purposes in Kentucky, if bought legally in another state.

Cannabis is not legal in Indiana and Tennessee, and the medical-cannabis laws of Ohio and West Virginia do not apply to out-of-state residents. Missouri and Virginia have passed laws to legalize cannabis for recreational use, but the Missouri law is not expected to take effect until at least February, and Virginia is not expected to have cannabis dispensaries until next year. That means Illinois is the only bordering state where Kentuckians can use Beshear's order.

Beshear, a Democrat seeking re-election, says the better alternative to Illinois would be passage of a medical-cannabis law by Kentucky's Republican-controlled legislature. But leaders in the two chambers disagree on which one should deal with the legislation first; House leaders say it should start in the Senate, since their chamber has passed it twice, but Senate Majority Floor Leader Damon Thayer of Georgetown says the House should still go first. Stivers did not give his opinion on that point during the KET program, which touched on several legislative issues.

Some Democratic House members want the legislature to offer voters a constitutional amendment on the issue, but Stivers said some of the UK research "will be back before the constitutional amendment could even go on the ballot" in November 2024.

Using his pardon power, Beshear lets people with certain certified health conditions possess up to 8 ounces of medical marijuana

Beshear displayed a map showing in green the adjoining states where medical cannabis is legal.

By Al Cross
Kentucky Health News

Kentuckians who meet a detailed set of requirements would be able to possess up to 8 ounces of marijuana for medical use starting Jan. 1, under an executive order Gov. Andy Beshear signed Tuesday.

The drug would have to be bought in a state where the sale of cannabis is legal, and the person would need the receipt and a certification from a health-care provider saying that they have at least one of 21 specific conditions, including cancer, epilepsy, Parkinson's disease, Crohn's disease, sickle-cell anemia, severe and chronic pain, post-traumatic stress disorder, fibromyalgia, glaucoma or a terminal illness.

Beshear's order is in the form of an advance, conditional pardon. He had not mentioned such a device in his seven months of public deliberation about the issue, which began when the state Senate again refused to hear a House-passed bill to legalize medical cannabis. Republicans control both chambers.

The highest-quality health care is a human right," the Democratic governor asserted. Noting that Kentucky has high rates of cancer and painkiller overdoses, he said "There's another way to manage the pain without the threat of addiction."

Beshear created a Medical Cannabis Advisory Committee that held several public hearings on the issue. It received more than 3,500 comments, 98.6% of which favored of legalizing medical cannabis, he said.

"Kentuckians are leaving this state to access medical cannabis," he said. "Some of them are leaving this state for good." The drug is legal in 37 states.

One commission member, Justice Secretary Kerry Harvey, said cannabis is "a treatment that's already available to the overwhelming majority of Americans but not Kentuckians," some of whom have declined to use the drug because they don't want to violate the law: "What an awful choice that must be."

Jared Bonvell, a veteran from Northern Kentucky, said his use of cannabis gave him "a change of life that is just absolutely astounding," allowing him to stop taking 13 medications.

Paducah contractor Craig Manley said in a video that nothing took away his pain except THC, the psychoactive ingredient in cannabis.

State and federal law define marijuana as containing Delta-9 THC. Products containing Delta-8 THC, a less potent form, are on the market legally. Beshear signed another order regulating Delta-8 THC and said it would provide the legal framework for regulating cannabis if the legislature legalizes it.

Beshear's cannabis order notes that 8 ounces is the most marijuana that can be possessed under Kentucky law without being a felony, and says the health-care provider's certification "shall not constitute a prescription for medical cannabis."

The order allows the cannabis to be possessed by a caregiver, defined as someone at least 21 and with "significant responsibility for managing the well-being of the individual on whose behalf the cannabis was purchased."

"Today's actions are not substitutes for much-needed legislation," Beshear said. "What we're trying to do is take a measured step to help those who are struggling."

State Rep. Jason Nemes, R-Louisville, who sponsored the unsuccessful bills, called Beshear's order an “unprecedented power grab” that “cannot stand,” WDRB reports, adding, "Nemes says he invites the governor to work with lawmakers to develop a legal medical marijuana program." Beshear said he would keep working to legalize medical cannabis with a law.

John Cheves of the Lexington Herald-Leader reports, "There may yet be legal challenges to Beshear’s actions. House and Senate leaders did not immediately respond to requests for comment Tuesday. But the office of Republican Attorney General Daniel Cameron, who often clashes with Beshear, said he’s studying the orders."

New text-messaging program launches in Kentucky and four other states to help curb misuse of opioids for pain

The Partnership to End Addiction has announced plans to launch a personalized text messaging program to help curb opioid misuse this summer in Kentucky, Idaho, Tennessee and North and South Carolina. 

The program, called RxAware, is designed to educate parents, caregivers and individuals about available non-opioid pain relievers, as well as ways to reduce risks associated with prescribed opioid medications. 

To use the program, participants will text  RXAWARE to 55753, where they will be asked to answer a short series of questions about their own – or a loved one's – pain management needs. The participant will then receive personalized messages vetted by health professionals that provide educational information, resources and actionable support, says the news release.

In Kentucky, the program is supported by Walmart and Operation UNITE, a regional anti-drug coalition fighting substance misuse in Appalachian Kentucky. The acronym UNITE stands for Unlawful Narcotics Investigations, Treatment and Education.

"Prevention is the most effective tool to avoid problems resulting from opioid misuse," Nancy Hale, president and CEO of Operation UNITE, said in a news release. "UNITE is pleased to take the lead for this project in Kentucky. RxAware provides another opportunity to share factual information and resources with the citizens of the commonwealth through our vast network of partners. This collaboration creates additional avenues to prevent addiction and overdoses, and ultimately to save lives."

Medical marijuana appears to have more traction than ever in Ky.

UPDATE: The House sent the bill to the Senate March 17 by a vote of 59-35.

Rep. Jason Nemes (CJ photo by Joe Sonka)

Kentucky looks closer than ever to joining the 37 states that allow prescriptions for marijuana, or cannabis.

Thursday evening a state House committee approved a bill that would allow doctors to prescribe cannabis to people who have certain ailments, "along with a new bureaucracy to strictly regulate it from plant to processor to dispensaries," which sponsor Jason Nemes, a Louisville Republican, says will be the strictest medical program in the country," Joe Sonka reports for the Courier Journal.

The ailments are cancer, "chronic, severe, intractable, or debilitating pain; epilepsy or any other intractable seizure disorder; multiple sclerosis, muscle spasms, or spasticity; and nausea or vomiting." Nemes said he will support a floor amendment by Rep. Rachel Roberts, D-Newport, to add post-traumatic stress syndrome.

"A similar medical cannabis bill led by Nemes easily cleared the House chamber for the first time in 2020 with 65 votes, but stalled in the Senate because of the Covid-shortened session" and lack of support by Republican leaders, Sonka notes. "However, medical marijuana advocates are now optimistic," due to new support from Senate Judiciary Committee Chairman Whitney Westerfield, "who met many times with Nemes over the past year to amend it into legislation he could back."

Sen. Whitney Westerfield
(Legislative staff photo)

"You can't overestimate how important he is," Nemes said after the House Judiciary Committee approved House Bill 136 15-1. Voting no was Rep. Kim Moser, R-Taylor Mill, who cited opposition from doctors, including concerns about the lack of guidelines for prescribing and dosing cannabis.

Westerfield, a Republican from Crofton in Christian County, said he still has concerns about youth access to cannabis, but “I’ve heard too many stories in my district, and out, from those long suffering, and their loved ones left behind, that marijuana brought comfort and relief when nothing else worked.”

Nemes said "I feel good about where we are in the Senate," but Sonka reports that to pass, the bill would need a majority of the 30 Republicans in that chamber, and the top two Republicans, "Senate President Robert Stivers and Majority Floor Leader Damon Thayer, have both expressed skepticism about medical marijuana in the past and said more research was needed, though the legislation has never received a thorough debate within the chamber's GOP caucus room." Those debates are private.

The bill would allow county governments to impose fees on cannabis businesses "to compensate for any additional public safety impact" and prohibit medicinal cannabis sales by voter referendum, but if a county's voters did so, city governments could exempt themselves from the prohibition.

The bill also includes a 12 percent tax on cannabis sold to dispensers, mainly to cover the costs of regulating it; 13.75% of the revenue would be returned to dispensaries to subsidize purchases of cannabis by those who can't afford it.

Proposed new CDC guidelines for treating pain would encourage use of non-opioid therapies first, avoid one-size-fits-all approach

Centers for Disease Control and Prevention map, adapted by Ky. Health News, shows opioid-prescribing rates in counties that ranked highest and those surrounded or nearly surrounded by them.

By Melissa Patrick
Kentucky Health News

The Centers for Disease Control and Prevention has proposed new guidelines that would move away from a one-size-fits-all approach to managing pain, to one that encourages doctors to use their best judgment when prescribing opioid painkillers and encourage them to use "non-opioid therapies" first.

The guidelines are especially important in Kentucky, a smaller-than-average state that ranks fifth in the nation for opioid prescriptions and saw an increase of 49% in overdose deaths in 2020, the last year reported. 

In addition to prioritizing non-opioid therapies such as ibuprofen and other non-steroidal anti-inflammatory drugs, the proposed guidance drops previous recommended limits for dosing and encourages the use of immediate-release opioids, as opposed to long-acting ones, when possible.

It also offers extensive guidance for how to treat acute and chronic pain and how doctors should address patients who test positive for illicit substances.

"This clinical-practice guideline provides recommendations only," the proposal says. "It does not replace clinical judgment and individualized, patient-centered decision-making."

The guidelines, which are still in draft form, would update the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, which were designed to slow the prescribing of opioids like OxyContin, which fueled the opioid epidemic.

Synthetic opioids like the rarely prescribed fentanyl and its analogues in the illegal drug supply now fuel most of the drug-overdose deaths in Kentucky, but the state ranks high in opioid prescriptions. Stroudwater Associates reported that Kentucky had the fifth highest opioid prescribing rate in the nation in 2020, with Perry, McCracken, Clark, Owsley, Whitley, Bell, Floyd, Pike, Clay and Fayette counties making up the top 10. Stroudwater is a health-care consultancy that says it focuses on rural and community hospitals, health-care systems and large physician groups.

The new CDC guidance was prompted by unintended consequences of the 2016 recommendations, which created barriers for care of people with chronic or severe pain, many of whom relied on opioid doses far higher than the recommended amount. The 2016 guidance also resulted in some people who no longer had access to these painkillers switching to heroin, and some physicians stopped caring for pain patients for fear of criminal and civil penalties.

The report on the guidelines adds that other misapplications of the 2016 rules included extension of them to patients not covered in the guidelines, like those with cancer or palliative care; the abrupt discontinuation of the drugs in some patients; duration limits by insurers and pharmacies; and patient dismissal and abandonment.

"These actions are not consistent with the 2016 CDC Guideline and have contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior," the report says.  It notes that many states have passed laws based on the 2016 guidance, even though the rules were meant to "support, not supplant, individualized, patient-centered care." 

The Kentucky General Assembly has passed several opioid-control laws in recent years, including one to limit opioid prescriptions for acute pain to a three-day supply, with exemptions. 

The new guidelines recognize the dangers associated with opioids, but also recognize their value in treating pain. It offers 12 recommendations for clinicians who are prescribing opioids for adult outpatients with pain. They do not apply to patients suffering pain from cancer or sickle-cell disease, or those in end-of-life or palliative care.   

The report says the recommendations are "based on a systematic review of the available scientific evidence while considering benefits and harms; patients’, caregivers’, and clinicians’ values and preferences; and resource allocation."

The first guideline recommends that providers use non-opioid alternatives whenever possible, stating, "Clinicians should only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient." 

Non-opioid treatments include things like over-the-counter medications like ibuprofen and acetaminophen; prescription medications like gabapentin; physical therapy; massage, and acupuncture. 

After weighing the benefits and the risk of using an opioid to treat pain, the draft guidance says the provider is encouraged to start with the lowest effective dose and to prescribe them for only as long as the patient is experiencing "pain severe enough to require opioids." 

The report says, "It is imperative that people with pain receive the most appropriate and effective pain treatment with careful consideration of the benefits and risks of all treatment options."

It also discourages clinicians from abruptly discontinuing opioids in patients already receiving high doses of the drugs, or dismissing such patients from their care; and urges them to ensure appropriate care if the patients has an opioid-use disorder.

The CDC is seeking public comment on these changes through April 11. “This comment period provides another critical opportunity for diverse audiences to offer their perspective on the draft clinical practice guideline. We want to hear many voices from the public, including people living with pain and the health care providers who help their patients manage pain," Christopher M. Jones, director for the National Center for Injury Prevention and Control, said in a news release.

He added, "The ultimate goal of this clinical practice guideline is to help people set and achieve their personal goals to reduce their pain and improve their function and quality of life. Getting feedback from the public is essential to achieving this goal." 

Submit your comments at https://www.federalregister.gov/public-inspection/2022-02802/proposed-2022-clinical-practice-guideline-for-prescribing-opioidsexternal icon.

13 Ky. hospitals are suing over 40 opioid makers and sellers, alleging they misrepresented painkillers as safer than they were

Thirteen Kentucky hospitals are suing more than 40 opioid manufacturers, distributors and sellers for using "a false narrative marketing scheme" that understated the risks associated with opioids and "precipitated the crisis," Sarah Ladd reports for the Louisville Courier Journal.

NPR.org photo

The complaint, filed in Warren Circuit Court in Bowling Green Aug. 21 and amended Sept. 5, alleges that more than 40 companies, including Walmart, Purdue Pharma and Johnson & Johnson misrepresented opioids as safer than they were and were part of a conspiracy to benefit "both independently and jointly from their wrongful conduct."

"Through a massive marketing campaign premised on false and incomplete information, the marketing defendants engineered a dramatic shift in how and when opioids are prescribed by the medical community and used by patients," says the complaint, which Ladd reports is more than 300 pages.

The complaint adds that the progression of prescription opioids to the use of illicit drugs is well documented and that "approximately 75 percent of heroin users reporting that their initial drug use was through prescription." It also cites the uptick in opioid-related deaths in Kentucky, from one in 100,000 people in 1999 to 10 in 100,000 people in 2017 and says, "No state has been hit harder by the opioid epidemic than Kentucky."

Further, it says opioids have "endangered public health in Kentucky even beyond addiction and overdose. Addicts who are not killed by drug addiction experience a variety of health consequences (including non-fatal overdoses) and engage in a variety of risky drug-seeking behaviors."

Ladd reports that the lawsuit asks for judgement to be taken against the defendants as well as monetary damages. She adds that the Kentucky suit follows thousands of others across the nation in recent months and that Attorney General Andy Beshear has filed nine such lawsuits.

"In August, Oklahoma won $572 million in a suit against Johnson & Johnson that sought to hold the company accountable for the opioid crisis. Also in August, it was reported that OxyContin maker Purdue Pharma was offering a settlement worth $10 billion to $12 billion to resolve claims that it bears responsibility for the nation's opioid crisis after it faced more than 2,000 lawsuits, some involving state and local governments," Ladd notes.

Who is suing? Ladd reports these 13 health systems, with 23 hospitals: Baptist Healthcare System and one of its subsidiaries, Baptist Health Madisonville; Bowling Green-Warren County Community Hospital Corp. and two of its subsidiaries, The Medical Center at Albany and The Medical Center at Franklin; the Grayson County Hospital Foundation in Leitchfield; Harrison Memorial Hospital in Cynthiana; Highlands Hospital Corp. in Paintsville; Pikeville Medical Center; St. Elizabeth Medical Center in Covington; St. Claire Medical Center in Morehead; Taylor County Hospital District Health Facilities Corp. in Campbellsville; and ARH Tug Valley Health in South Williamson.

The defendants, other than Walmart, Johnson & Johnson and Purdue Pharma and several members of the Sackler family that own it, include Abbott Laboratories, AmerisourceBergen Drug Corp., Cardinal Health Inc., CVS Health Corp., Miami-Luken Inc., Richie Pharmacal, Rite Aid Of Maryland and Walgreen Co.

University of Louisville to hold free event in Oldham County on May 10 to discuss aging, pain management and addiction

Kaiser Health News photo

The University of Louisville Trager Institute will offer a free community event to discuss the dangers of medication misuse and addiction for older adults, alternative solutions to chronic pain management and advocacy for making alternative pain strategies accessible for older adults.

“There is often a stigma around talking about pain and pain management, in addition to lack of understanding of options beyond opioids,” Mona Huff, the institute's community organizer, said in a news release. “Good health starts with self-care and loving yourself. It means asking for help when you need it. Asking for help is not a sign of weakness, but rather a sign of strength.”

The event, "Reconciling Pain and Giving Hope to Seniors,” will be held Monday, May 13 from 10 a.m. to 3 p.m. at the John W. Black Community Center in Oldham County.

Lunch will be provided for those who RSVP to the symposium by May 7. For more information contact Mona Huff at 502-845-6849 or rjhuff01@louisville.edu.

This event is held in partnership with the Kentucky Coalition for Healthy Communities, Tri-County Community Action Partnership, Barren River Area Development District, and the Kentuckiana Regional Planning and Development District.

Court of Appeals OKs release of court records that could reveal more about how company promoted OxyContin, opioid epidemic

The state Court of Appeals on Friday upheld a Pike County judge’s ruling to release secret records about the marketing of OxyContin, the branded form of oxycodone that "has been blamed for helping to seed today’s opioid addiction epidemic," reports Stat, the medicine-and-science publication of The Boston Globe, which fought to get the records.

Purdue Pharma is privately held. (AP photo by Douglas Healey)

In the court file is a deposition of Richard Sackler, a former president of Purdue Pharma, the family-controlled company that makes OxyContin and pleaded guilty in federal court to fraudulently marketing of as less addictive than other painkillers.

The deposition "is believed to be the only time a member of the Sackler family has been questioned under oath about the marketing of OxyContin and the addictive properties," Stat's David Armstrong and Andrew Joseph report. "Other records include marketing strategies and internal emails about them; documents concerning internal analyses of clinical trials; settlement communications from an earlier criminal case regarding the marketing of OxyContin; and information regarding how sales representatives marketed the drug."

The Pike County case was a lawsuit filed in 2007 by then-Attorney General Greg Stumbo, alleging similar fraud and increased costs to the state for drug treatment and health care. It was transferred to federal court, where it lingered for several years under then-AG Jack Conway, who got it transferred back to Pike Circuit Judge Steven Combs. Depositions were taken, and in December 2015, as one of his last official acts, Conway settled the case and agreed to destroy 17 million pages of documents he had obtained through discovery.

However, some copies of the documents remained on file in Pike County, and Stat asked for them. in May 2016, Combs ordered them released, but stayed the order pending Purdue's appeal. He wrote, “The court sees no higher value than the public (via the media) having access to these discovery materials so that the public can see the facts for themselves.”

Jack Conway

Almost a year and a half after oral arguments in the case, the three-judge panel of the appeals court unanimously agreed, saying it was the only way to hold Conway accountable for his actions. Without naming Conway, Judge Glenn Acree wrote, “Some agent of the government compromised the claim against Purdue; i.e., some agent sold the people’s property. . . . Without access to court records, how can the public assess whether a government employee’s decision to compromise a valuable claim of the people adequately protected their interest or maximized the claim’s value?”

Conway told the Louisville Courier Journal Friday, “Kentucky got many times over what any state has gotten from Purdue Pharma. After eight and a half years, I thought it was best to get what we could. I hope it all comes out, (that) all of the documents eventually get released, and sooner rather than later.”

Purdue has 30 days to appeal. It indicated that it would, either to the state Supreme Court or through a rehearing by the appeals court. Either could refuse to allow further action.

“It's taken a long time, but we're now very optimistic that these records will see the light of day very soon,” Stat Managing Editor Gideon Gil, a former health reporter and regional editor for the Courier Journal, told Kentucky Health News.

Louisville lawyer Jon Fleischaker, who represented Stat, told the publication, “Really what the court is saying is these are public records. The public has an interest in them, and the public has a right to them.”

Stat Editor Rick Berke said, “More than two years after we filed this suit, the scourge of opioid addiction has grown worse, and the questions have grown about Purdue’s practices in marketing OxyContin. It is vital that that we all learn as much as possible about the culpability of Purdue, and the consequences of the company’s decisions on the health of Americans.”

Panel at health policy forum cites alternatives to opioids for pain, and the need for a culture shift on the topic

By Melissa Patrick
Kentucky Health News

Kentucky has a new law restricting painkiller prescriptions to three days for acute pain, but an anecdotal story from one of the state's leading doctors suggests that it has a ways to go: the child of a friend recently got wisdom teeth extracted and was given a 30-day supply of pain medicine.

"They don't need that many. They may only need -- zero!" said Dr. Philip Chang, chief medical officer at UK HealthCare. "I don't know how well that [law] is followed, to be honest with you."

Chang also discussed proven ways to reduce opioid use, and still relieve pain, during the "Alternatives to Opioids" panel at the Howard L. Bost Memorial Health Policy Forum held Sept. 24 in Lexington by the Foundation for a Healthy Kentucky. The meeting's theme was "Kentucky's Substance Use Epidemic: A Solutions Update."

Comprehensive EAP photo

The law, passed in 2017, limits painkillers to a three-day supply if prescribed for acute pain, but doesn't apply to chronic pain and has a long list of other exemptions -- and allows a prescriber to override the new rule by documenting a justification.

At the end of the session, Dr. Mel Pohl, chief medical officer of Las Vegas Recovery Center, noted that Nevada doesn't have this problem because its laws on opioid prescriptions are very strict.

"If people prescribe opioids for more than three days for a minor and seven days for a major surgical procedure, they will be brought before the medical board," he said. "It's too bad that we had to be punished and threatened into changing our behavior as prescribers, but we did. And now it's happening and I think that the paradigm shift is in place."

Chang said it was important for providers to get on board with the new law because opioids have adverse consequences. He pointed to research that shows a one-week prescription of opioids to patients who have never used pain pills before increases their risk of becoming addicted by 15 percent in one year, and a 30-day prescription increases that risk to 35 percent.

He also cited research that found a combination therapy of ibuprofen and acetaminophen is much more effective for treating pain than opioids. "This is the information we need to get out there, so they know that this doesn't come without a costs," he said. "The misconception that opioids are always better is not true."

Chang, a trauma surgeon, also noted a pilot study that he led, which basically didn't allow providers to prescribe any pain-medication prescriptions unless the patient had exhausted all other means of pain-control medications available to them, like ibuprofen, Tylenol and muscle relaxers.

He said that in just two years' time, they were able to drop the overall opioid-prescribing rates for trauma patients 50 percent, with the best results in the "opioid naive" patients.

The pilot was so promising that the policy has been implemented hospital-wide, with results over the last two years showing a steady decline in the amount of daily morphine prescribed, resulting in 250,000 fewer pills per year, and no changes in patient-described pain scores. "None at all!" he said.

"We can do this," Chang said. "We can get away from this trend of prescribing opioids and more opioids and more frequent and different kinds of opioids. We can get away from it."

Dr. Danesh Mazloomdoost, medical director at Wellward Regenerative Medicine in Lexington, told the group that we need a culture change when it comes to pain management and that the question shouldn't be how can we manage opioids more effectively, but to ask if they are even effective.

"That's really the key to understanding how we're going to fix this pain issue," he said. "We've got to stop thinking that we can cure everything or symptom-manage everything with a pill, and start getting an understanding of what the physiology of our bodies is, how our bodies function and how we're going to get healthy to feel better."

Mona Carper, a physical therapist and professor at UK, said it is long past time for her profession to have a seat at the table when it comes to discussing pain management.

She said access to physical therapy within the first 14 days of injury is critical for decreasing the need for opioids and for decreasing the long-term cost of care.

Pohl, an addiction specialist who treats co-occurring pain and addictions with the goal of getting patients off opioids, said, "When we take people off opioids, guess what happens to their pain? It goes down."

Pohl gave several suggestions for alternatives to opioids, including several specific types of therapy, including cognitive behavioral therapy, complementary alternative therapies like nutritional interventions and acupuncture, and mindfulness practices.

He spent much of his time talking about the benefits of practicing mindfulness daily, which he said is a type of meditation that involves focusing on an object, like breathing. He said the practice of mindfulness allows people to "detach from thoughts, feelings and physical sensations" and thus better tolerate or manage their pain.

Pohl noted two studies that spoke to the effectiveness of the practice, including a three-month study of adults 27 and older that found practicing mindfulness, or meditation, resulted in less pain, improved attention, enhanced well-being, and improved quality of life. The second one found that just four days of mindfulness training decreased pain and feelings of unpleasantness by half.

He added that results from his own clinic show a 20 percent reduction in pain scores among his patients who practice mindfulness. He said, "That is efficacious as most opioids."

As feds crack down on clinics accused of being pill mills, patients are left without their painkillers, and sometimes nowhere to turn

Courier Journal photo by Beth Warren

Thousands of patients with chronic pain in the Louisville area have been displaced by local, state and federal crackdowns on clinics accused of being pill mills, defrauding Medicaid, or both, and it's likely to get worse, Beth Warren reports for the Courier Journal.

One of those patients is retiree Michael Anderson, 67, who suffers from occipital neuralgia: electric-shock-like chronic pain in the neck and back of the head. He told Warren that depended on opioids to manage his pain, and his supply was abruptly cut off when investigators raided his pain clinic. "I'm in dire need," he said.

Such cases are likely to become more common, Warren writes, because Russell Coleman, U.S. Attorney for the Western District of Kentucky, says more investigations are underway as part of a national effort. Attorney General Jeff Sessions created a task force in February to target opioid abuse, including over-prescribing of pain and addiction medicines.

"Doctors say the federal raids on medical clinics lead to unintended consequences — patients thrust into painful withdrawals and left vulnerable to suicide or dangerous street drugs," Warren writes.

Dr. Kelly Clark, a Louisville addiction specialist who heads the American Society of Addiction Medicine, told Warren there aren't enough addiction or pain specialists to accommodate the influx of patients from clinic closures, and the problem will only get worse.

Dr. Wayne Tuckson, president of the Greater Louisville Medical Society, told Warren that area physicians are working on a coordinated response to help these patients, including creating a hotline with a list of resources, including pain-management physicians willing to care for them.

When investigators "go in with a sledgehammer and shut down a practice without consulting community physicians, suddenly we have patients thrown loose," Tuckson told Warren. "We do have a significant overdose problem and we have to do something about that. But we have to be careful that our actions do not jeopardize the care of patients."

Displaced patients may have trouble finding new doctors because investigators have seized their patient histories and doctors are wary of getting caught up in the crackdown. Many general practitioners who haven't received pain-management training refuse to prescribe high doses of narcotics, largely out of fear of losing their licenses, Tuckson said.

"Docs are very much afraid when it comes to writing pain medications," he told Warren.  "We don’t want patients to become addicted. And we don’t want to have our licenses — and therefore our livelihoods — at stake."

Clark told her, "If a practice is closed, the patients who are legitimately taking their medications as prescribed can be in a dire situation. They look and feel extremely sick."

He added, "Some patients likely will end up in emergency rooms from opioid withdrawals, which can cause cramps, chills, sweats, vomiting, diarrhea, sleeplessness and dehydration. For patients who are dependent — not addicted — they will feel better after a few days of withdrawals. Those who are addicted wouldn't be able to voluntarily taper off and going through withdrawals wouldn't stop cravings."

"Kentucky Substance Use Epidemic: A Solutions Update" is title of Bost Health Policy Forum to be held in Lexington Sept. 24

As Kentucky continues to struggle with the health and economic impacts of the opioid epidemic, the Foundation for a Healthy Kentucky's 16th annual health policy forum will explore medical marijuana and other alternative pain therapies, as well as the rise in infectious disease associated with the crisis.

"We need to understand the truth behind the push for medical marijuana, hear the facts about whether it works to relieve pain, and learn the risks associated with its use," foundation president and CEO Ben Chandler said in a news release. "This year's speakers will give us the latest updates on the causes and impacts of Kentucky's substance use crisis, and will zero in on how we're doing in addressing what continues to feed the crisis and the resulting symptoms."

The 2018 Howard L. Bost Memorial Health Policy Forum is titled "Kentucky's Substance Use Epidemic: A Solutions Update." The forum is sponsored by the foundation with support from Centerstone and Bluegrass.org, organizations that care for patients with mental, developmental and behavioral issues. It is named for Dr. Howard L. Bost, who helped create Medicare and Medicaid, developed the Appalachian Regional Hospitals system, improved mental-health services in Kentucky, and created the vision for the foundation.

It will be held at the Griffin Gate Marriott Resort on Newtown Pike in Lexington on Monday, Sept. 24. Attendance is free, but registration is required. Click here to register.

This year's keynote speaker is Pulitzer-Prize-winning reporter Barry Meier, the author of Pain Killer: An Empire of Deceit and the Origin of America's Opioid Epidemic. Meier's book chronicles the aggressive marketing of the highly addictive drug OxyContin by Purdue Pharma, and the role it played in creating the nation's opioid crisis.

The forum will feature two morning panels, one titled "Kentucky's Addiction Burden," which will provide the latest updates on how substance addiction is impacting both the heath and economy of Kentucky, and the other "Agency Exchange: Views from the Front Lines," which will discuss various approaches being used by the state to deal with the crisis.

Attendees will be able to attend two of the three afternoon breakout sessions: "Infectious/Chronic Diseases Caused by Addiction," "Medical Marijuana: What is the Truth?," or "Treating Chronic Pain: Alternatives to Opioids. "

The full agenda and speaker biographies are available on the foundation's website. All speaker presentations will be made available on the website after the forum. Meier will also be available to sign copies of his book, which will be for sale at the forum.

McConnell files bill to better inform doctors and pregnant women about alternatives to opioids, boost grant money for it

Senate Majority Leader Mitch McConnell of Kentucky introduced a bill Thursday to require the Centers for Disease Control and Prevention to develop educational materials to give doctors and expecting mothers better information about alternatives to opioids, and to authorize more money for a competitive federal grant to help organizations address that aspect of the opioid epidemic.

The Louisville Republican said in a floor speech that the would-be Protecting Moms and Infants Act “continues our years-long efforts to protect the most vulnerable. . . . Medical professionals, law enforcement officials and many others across Kentucky are working every day to bring an end to the misery of the opioid epidemic. This legislation will continue that fight.” 

McConnell said Second District U.S. Rep. Brett Guthrie, R-Bowling Green, is sponsoring companion legislation in the House.

Poll: 24% of Kentucky adults know someone with a pill problem and 16 percent know someone with a heroin or meth problem

By Melissa Patrick
Kentucky Health News

Whether it's the misuse of prescription pain relievers, heroin or methamphetamine, the latest Kentucky Health Issues Poll findings indicate that many Kentuckians have a drug problem.

The poll, conducted Oct. 24 to Dec. 2, found that nearly one in four Kentucky adults, or 24 percent, said they knew someone who had experienced problems as a result of prescription pain relievers. That number has remained largely the same since 2013, but it indicates the depth of the problem.

"Misuse of opioids such as OxyContin, Vicodin, Percocet and codeine remains a critical public health and safety issue for Kentucky," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll, said in a news release. "Not only are we losing more than 1,600 lives a year to overdoses, we are facing incredible losses in quality of life, workplace productivity, and business competitiveness."

The good news: Kentuckians said they are being prescribed pain relievers less often. In 2011, the poll found that 55 percent of Kentucky adults said they had been prescribed a pain reliever in the past five years; in the latest poll, the number dropped to 34 percent.

"Perhaps all of the education that's being done about the dangers of over-prescribing narcotic pain relievers is starting to make a difference, both in the number of people getting prescriptions and the amount of the pain medication they receive," Chandler said.

Seven percent of those polled said they weren't prescribed enough pills to control their pain; 21 percent said they were prescribed the right amount; and 6 percent said they were prescribed more than needed.

The poll also found regional differences in prescribing. The highest percentage of Kentucky adults who said they had been prescribed a pain reliever in the past five years was in the Louisville area (41 percent) and Northern Kentucky (40 percent). In was 37 percent and 36 percent in Lexington and Western Kentucky, respectively. The lowest share, 26 percent, was in Eastern Kentucky. That is the region where problems with drug addiction and overdoses are greatest, so the numbers could indicate that users are using illegal drugs or getting prescription medicines from illegal sources.

Click on any chart to view a larger version of it.

The poll found that 16 percent of Kentucky adults said they knew someone who had problems as a result of using methamphetamine or heroin. Both numbers were unchanged from the prior poll.

The poll shows that problems with heroin increased steadily between 2013 and 2016, but remained steady over the last year. Meth problems have remained steady since 2013.

Responses to these questions also varied by region with the percentage of adults who said they knew someone with problems due to heroin highest in Northern Kentucky (29 percent) and lowest in Western Kentucky (11 percent). The percentage of adults who said they knew someone with problems due to methamphetamine was highest in Eastern Kentucky (22 percent) and lowest in the Lexington area (13 percent).

Since 2013, the percentage of Kentucky adults who said they knew someone with a heroin problem has remained about the same in Northern Kentucky, which is often called ground-zero for this issue. However, this number has risen significantly in Louisville (from 8 percent in 2013 to 23 percent in 2017), Lexington (from 9 percent to 18 percent) and Eastern Kentucky (from 8 percent to 14 percent), with a lesser increase in Western Kentucky (from 7 percent to 11 percent).

Since 2013, Kentucky adults reporting they knew someone with a meth problem increased in Louisville (from 6 percent in 2013 to 16 percent in 2017) and Northern Kentucky (11 percent to 17 percent) and declined in the Lexington area (19 percent to 13 percent). The numbers remained about the same in Eastern and Western Kentucky.

"This poll is yet another piece of evidence that Kentucky's focus on resolving the drug abuse crisis must continue," Chandler said. "And it must involve multiple sectors of our society working together to engage all individuals struggling with addiction."

The news release about the poll notes that a National Vital Statistics Report shows meth use may be rising to problematic levels similar to heroin use; the National Institute on Drug Abuse reports that Kentucky had the fifth highest death rate due to drug overdose in 2016; and a CDC report found opioids, including prescription drugs, are the most common cause of overdose deaths.

Kentucky passed a law last year that generally limits painkiller prescriptions to a three-day supply if prescribed for acute pain, which lines up with the Centers for Disease Control and Prevention's guidelines for prescribing opioids. The limit does not apply to prescriptions for chronic pain.

This year the legislature passed a law to require pharmacists to tell patients how to safely dispose of unused opioids and other controlled substances, and either provide or offer to sell them a product designed to neutralize the drugs for disposal, or provide on-site disposal. Nearly 80 percent of Americans using heroin, including those in treatment, reported misusing prescription opioids first, according to the National Institute on Drug Abuse.

The poll was funded by the foundation and Interact for Health, a Cincinnati-area foundation. It surveyed a random sample of 1,692 Kentucky adults via landlines and cell phone. The poll's margin of error for each statewide result is plus or minus 2.4 percentage points.

After decades of addiction and legal action, OxyContin's maker says sales staff won't visit doctors' offices to market the opioid

Photo by The Associated Press

Purdue Pharma, the manufacturer of OxyContin, says it will no longer market its opioid drugs with visits to doctors' offices and its halving its sales force. The move comes "after years of criticism and mounting lawsuits . . . claiming its sales practices are partly responsible for the opioid epidemic," reports Ben Poston of the Los Angeles Times.

"It's pretty late in the game to have a major impact," Brandeis University researcher Dr. Andrew Kolodny, a longtime critic of the pharmaceutical industry's role in the opioid epidemic, told Poston. "The genie is already out of the bottle. Millions of Americans are now opioid-addicted because the campaign that Purdue and other opioid manufacturers used to increase prescribing worked well. And as the prescribing went up, it led to a severe epidemic of opioid addiction." The drug went on sale in 1996; in 2007, in federal court in southwest Virginia, Purdue paid $635 million in fines to end an investigation by the U.S. Department of Justice.

Poston writes, "One remaining question is whether other opioid makers will follow suit and cease marketing the drugs to doctors, said Kolodny, executive director and co-founder of Physicians for Responsible Opioid Prescribing."

"In an attempt to stem the abuse of OxyContin, Purdue spent a decade and several hundred million dollars developing a version of the painkiller that was more difficult to snort, smoke or inject," Poston notes. "Since those 'abuse-deterrent'  pills debuted seven years ago, misuse of OxyContin has fallen and the company has touted them as proof of its efforts to end the opioid epidemic. But a study released in January 2017 found that rather than curtail deaths, the change in OxyContin contributed heavily to a surge in heroin overdoses across the country and that, as a result, there was 'no net reduction in overall overdose deaths'." States with the most OxyContin abuse rates had the largest increases in heroin deaths. Kentucky is among them.

The chronic pain of fibromyalgia, often worse in the winter, can still be effectively managed and treated, doctor writes

Winter can be tough for people with fibromyalgia, "a complex, long-term illness that causes severe musculoskeletal pain and fatigue," and affects women more than men, Dr. Indhira Bisono-Jimenez of KentuckyOne Health Rheumatology Associates writes for the Lexington Herald-Leader.

Dr. Indhira Bisono-Jimenez

"Chronic feelings of intense joint or muscle pain and increased fatigue are the most prominent symptoms of fibromyalgia," Bisono-Jimenez writes. "Other symptoms might include depression, anxiety, stress, sleep deprivation, headaches or migraines, tingling or numbness in the hands and feet, and problems with the digestive system, such as constipation and irritable bowel syndrome."

Fortunately, the doctor writes, fibromyalgia can be "effectively treated and managed," with "narcotic medications used to relieve intense pain, duloxetine or milnacipran to treat pain and fatigue, pregabalin for nerve pain, and over-the-counter medications such as ibuprofen, aspirin or naproxen.
A series of therapeutic treatment options are often recommended to alleviate pain. Massage therapy, chiropractic therapy, movement therapy and acupuncture are all recommended as a supplement to reducing pain and treating fibromyalgia. Physical and occupational therapy are often recommended as well, along with counseling to help sufferers learn strategies to better manage stress."

Aside from medicine and therapy, doctors may also recommend lifestyle changes to help treat and manage fibromyalgia. Those include "getting plenty of sleep and exercising regularly," Bisono-Jimenez writes. "Walking, biking or swimming at least 30 minutes a day, five days a week is often recommended. Maintaining a proper diet, getting enough sleep and modifying workloads are also key to effectively managing fibromyalgia."

Appalachia has high rates of hereditary pancreatitis; relatively new surgery to treat it is available to children 4 and older

People from Appalachia have some of the highest rates of hereditary pancreatitis in the nation, which often means living a life of uncontrollable pain, but a relatively new treatment may offer some hope.

The pancreas produces enzymes that help break down and digest food, and also insulin that controls blood sugar levels. Inflammation of the pancreas is called pancreatitis.

Pancreatitis can be caused by outside factors, like gallstones or alcohol abuse, but it can also be hereditary, which is common in Appalachia.

"In my first year working at Kentucky Children's Hospital, I saw more cases of hereditary pancreatitis than in 14 years at my previous institution," Dr. George Fuchs, a pediatric gastroenterologist, wrote in an article for UK HealthCare, republished in the Lexington Herald-Leader.

Dr. George Fuchs and Mackenzee Walters, an 11-year-old
with hereditary pancreatitis who underwent an innovative
surgery. (UK HealthCare photo)

One of Fuchs's patients with hereditary pancreatitis is 11-year-old Mackenzee Walters from Kenova, W.Va.

In January, Mackenzee underwent a new surgical procedure at Cincinnati Children's Hospital to treat the disease and it has already changed her life, making it one "free of sharp, unrelenting pain," Fuchs reports. Cincinnati Children's is one of the few children's hospitals in the nation to offer this innovative procedure.

The surgery, known as a total pancreatectomy with islet autotransplantation (TPIAT), "involves removing the entire pancreas, saving the islet cells, which produce insulin, and then re-planting those cells in the liver, where they take up residence and ideally resume their essential function," Fuchs wrote.

"The surgery is a new offering for pediatric patients ages 4 and older expecting a life of pain stemming from the disease," UK HealthCare says in a separate article about Mackenzee and the procedure. It described Mackenzee's life before the surgery as one of pain and hospitalizations that required her to miss many school days. She has had to follow a strict diet since she was 3, consisting mostly of liquids.

The story explains that most of MacKenzee's relatives, including her mother, died early in life from complications related to the hereditary pancreatitis. Kim Walters, Mackenzie's current mother and biological aunt, is the oldest surviving family member with the disease.

"Hereditary pancreatitis is pretty much all we've ever known in my family," Walters said. "It's very excruciating every day. I had my children naturally without an epidural; I would rather have a child every day for the rest of my life than live with this disease."

In December 2015, after seeing many doctors around the country, Walters consulted with Fuchs at Kentucky's Children's Hospital because Mackenzee "was suffering from unmanageable pain and taking a potentially dangerous level of medications without much relief," UK HealthCare reports. Fuchs recommended her for the 12-hour TPIAT surgery and after much consideration, Walters and Mackenzee agreed to it.

“I came to the conclusion, if nothing else if she would just be pain-free,” Walters said. “If God chose to take her six months later, at least she would have six months of no pain. And that was our goal: to make her not have pain and be able to play and do what normal kids do.”

Since the surgery, Mackenzee's islets are producing insulin, and every day the amount of supplemental insulin she needs has dropped. Now she no longer requires pain medication, UK HealthCare reports.

“I would predict she has a very high likelihood of becoming insulin-independent,” Fuchs said. “She will no longer live in the hospital, which is what these children do before the procedure because they are in so much pain. I anticipate she will get on with her life, including getting into mischief as most kids do when they become teenagers. Hopefully go on to have a productive, full life.”

Fuchs said he hopes to extend this treatment to all who qualify for it in Eastern Kentucky and surrounding areas.

Author of Dreamland, on opioid epidemic, says it began with easy answers to complex problems, and trying that again won't work

By Al Cross
Kentucky Health News

The opioid epidemic began with a desire for "easy answers to complicated problems," and the solution to it needs to avoid similar mistakes, the author of the seminal book on the topic said Sunday on KET's "Connections with Renee Shaw."

"As a culture we need to learn patience. It took us a long time to get into this and it will take a long time, I fear, to get out of it," said Sam Quinones, author of Dreamland, which made many "best books of 2015" lists, including Gov. Matt Bevin's.

Quinones said the epidemic was created partly by the attitude "I want my problems to be fixed with a pill and I don't want to be part of the solution," and by "a one-size-fits-all-magic bullet for everybody, which is narcotic pain killers . . . . in quantities that were just excessive."

Pharmaceutical companies capitalized on a growing medical consensus that treatment of pain was more important than previously thought. They adopted "a new business model, quadrupling their total sales force in a 10-to-12-year period and taking advantage of physicians who were increasingly in a hurry and eager for quick solutions, Quinones said.

"Had they stopped a third of the way into that we wouldn't be here," he said, "the problem was they kept pushing," and making the argument that the drugs weren't addictive.

Quinones said he was part of the phenomenon several years ago, after an appendix operation. He said it took two days for the pain to subside, but he had been given a 60-day supply of Vicodin, a mixture of acetaminophen and hydrocodone, an opioid synthesized from codeine. "The message in that bottle is that these are not addictive," he said, "and I'm quite sure I could have gotten another refill and maybe two."

The epidemic has expanded to illegal drugs, users of which tend to form communities, Quinones said. He said people need to be aware of warning signs of heroin use, which include dropping old friends, shunning family, and having new friends from uncertain places.

As the epidemic has grown, Quiniones said, "You see more and more politicians understanding the depth of this problem." He noted an article he did for The New York Times in June, on how more than 20 Kentucky jails have started "therapeutic communities" for inmates with addictions.

"That is one of the most interesting ideas to come out of this epidemic," he told Shaw, because "Jail was the great missed opportunity," the moment inmates realize realize the error of their ways and this the best time to begin recovery."

At the same time, Quinones said he sees an over-reaction to the epidemic from some physicians, who simply stop prescribing painkillers for people who need them for chronic pain rather than tapering them off and working with them.

One way to taper them off is with different forms of opioids. "Medically assisted treatment of addiction now recognized as very important and essential," Quinones said. "The term is not medical treatment for addiction, it's medically assisted treatment." He said that is important to remember, because of the fear that the approach will "give suboxone to everyone without therapy, without this community feel" that is needed to improve the chance of maintaining recovery.

Slome have suggested the legalization of marijuana, at least for medical purposes, because some users have found it useful to treat pain. Quinones said he once favored it, but since growers now produce much more potent varieties, he is against legalizing "such a potent form" because not enough studies have not done on the drug's effect on developing brains. "There are probably very great medical benefits we can get from marijuana," he said, "but there are also very significant downsides."