Anti Epileptic Drugs For Neuropathic Pain

Today's post from pallimed.org (see link below) will be of interest for those neuropathy patients being treated with anti-convulsion, anti-epileptic or seizure medications. The information using case studies, is meant for student or colleague doctors and nurses and as such is slightly more technical in nature but is nevertheless quite easy to follow. It's always interesting to know how your doctor is thinking when he or she prescribes a certain type of drug for your complaint. It also helps you understand why that particular drug has been chosen. Remember too, anti-epilepsy drugs are on the treatment list for neuropathy and if you aren't taking them now, they may well be prescribed for you in the future - it's worthwhile knowing what you may be dealing with.

Cases: Anti-epileptic Medicines for Pain Management
Posted by Christian Sinclair on Friday, August 30, 2013

 
Personal details in the case have been altered to protect patient privacy. These cases may reflect a composite image of many different cases to illustrate a teaching point.

Case: Mr. LF is a 58 year-old gentleman with a history of metastatic lung cancer with metastases to the bone including the sacrum. He is seen in a palliative care clinic for severe right lower extremity burning pain lasting several months. Noting LF’s pain appeared to be neuropathic in nature, LF’s primary care physician prescribed, in succession, duloxetine and then amitriptyline. Unfortunately, neither of these interventions decreased his pain. His oncologist prescribed a fentanyl patch and oxycodone 5-10mg as needed. LF reports the opioid pain medications make him tired but do not relieve his pain. He wonders if there is anything else to try for his pain.

Discussion: Tri-cyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and anti-epileptic drugs (AEDs) are the mainstays of adjuvant therapy for neuropathic pain. This Case of the Month will focus on oral anti-epileptic neuropathic pain analgesics. Due to lack of head-to-head data, evidence is presented as numbers needed to treat (NNT) and numbers needed to harm (NNH). For instance, an NNT of 5 for 50% pain reduction means for every 5 patients treated with a drug, only 1 of them would achieve a 50% reduction in pain. Gabapentin (Neurontin) and pregabalin (Lyrica) are considered first-line anti-epileptics for the treatment of neuropathic pain.

Gabapentin is effective in treating central and peripheral neuropathic pain. According to a 2011 Cochrane review of the effect of gabapentin on chronic neuropathic conditions (including post-herpetic neuralgia, painful diabetic neuropathy, mixed neuropathic pain), the NNT is 5.8 (4.8-7.2) to achieve at least moderate benefit. This NNT is more conservative than those previously published due to better definitions of efficacy outcomes and an increased number of participants and studies evaluated.

Adverse effects are frequent and include drowsiness, dizziness and edema. Typically, if the dose is increased slowly these side effects are tolerable (1). Gabapentin should be dose adjusted for renal dysfunction. It should be withdrawn gradually to avoid precipitating seizures (2).

Pregabalin is effective in treating peripheral and central neuropathic pain. Since both gabapentin and pregabalin are chemical analogs of GABA, they are not used simultaneously in clinical practice. There are no comparison studies of gabapentin versus pregabalin. Pregabalin’s effectiveness increases as the dose approaches 600 mg/day. Based on a recent meta-analysis, at a dose of 600 mg/day the NNT to decrease pain by 50% for the following conditions is: 3.9 (range 3.1-5.1) for post-herpetic neuralgia; 5.0 (range 4.0-6.6) for diabetic neuropathy; and 5.6 (range 3.5-14) for central neuropathic pain. There was no difference in incidence of side effects among participants taking pregabalin vs. placebo and no indication of a dose response to side effects (3 - Open Access (OA)).

Carbamazepine is effective in treating neuropathic pain, specifically trigeminal neuralgia, but is not considered first-line therapy due to its adverse effects. A 2011 meta-analysis focused on the use of carbamazepine for chronic neuropathic pain reported carbamazepine reduced pain compared to placebo (NNT of 1.7, range 1.5-2.0). However, adverse events occur frequently: NNH = 2.6, range 2.1-3.5 (4). Common side effects include leukocytosis, thrombocytopenia, dizziness, drowsiness, ataxia, nausea/vomiting and blurred vision. Additionally, there is a risk of agranulocytosis, aplastic anemia, and Stevens Johnson syndrome. Laboratory tests (BUN, complete blood count, sodium, liver function tests, urinalysis) and serum drug levels should be checked at baseline and during treatment. Oxcarbazepine is an analogue of carbemazepine which is equally effective at treating trigeminal neuralgia as carbemazepine (5) but with fewer side effects (6 - OA).

Valproic acid was evaluated in a 2011 meta-analysis for the treatment of neuropathic pain. There were insufficient data for reliable pooled analysis, and the authors recommend against its use as first-line therapy (7).

Several small studies (n less than 60) showed benefit of the use of valproic acid (maximum of 1200 mg/day in divided doses) over placebo in the treatment of diabetic neuropathy (8 - OA). However, this data is not convincing. Other studies of valproic acid have failed to find an effect (9). Adverse effects include liver function test abnormalities, dizziness, drowsiness and nausea (2).

Topiramate was evaluated in a 2010 systematic review for the treatment of neuropathic pain. Of four randomized placebo-controlled trials, three were negative and one positive for the treatment of painful polyneuropathy. No studies were found to evaluate its efficacy in the treatment of post-herpetic neuralgia, peripheral nerve injury or central pain (9). Serious adverse events thought to be related to topiramate included convulsion and bradycardia plus syncope. Additional adverse effects include sedation, nausea, diarrhea and metabolic acidosis (2).

Summary: Neuropathic pain remains best treated with TCAs, SNRIs, and the AEDs gabapentin and pregabalin. For patients who are intolerant to or who experience pain unresponsive to those medications, one can consider therapy with other anti-epileptics. However, these agents are associated with more side effects and lower rates of efficacy.

Resolution of the case: LF was started on gabapentin and titrated up to a dose of 900mg three times a day with moderate pain relief. His opioids were tapered and discontinued.

References:
Moore RA, Wiffen PJ, Derry S, McQuay HJ. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database of Systematic Reviews. 2011, Issue3, Art No.: CD007938. DOI: 10.1002/14651858.CD007938.pub2
Micromedex® Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database of Systematic Reviews. 2009, Issue 3. Art. No.: CD007076. DOI: 10.1002/14651858.CD007076.pub2. Open Access PDF
Wiffen PJ, Derry S, Moore RA, McQuay HJ. Carbamazepine for acute and chronic pain in adults. Cochrane Database of Systematic Reviews. 2011, Issue 1. Art. No.: CD005451. DOI: 10.1002/14651858.CD005451.pub2.
Zakrzewska J, Linskey M. Trigeminal Neuralgia. Clinical Evidence. 2009; 3(1207). Retrieved Nov 15, 2011 from http://clinicalevidence.bmj.com/ceweb/conditions/nud/1207/1207.jsp
Finnerup NB, et al. Algorithm for neuropathic pain treatment: An evidence based proposal. Pain. 12005; 18:289-305.PMID: 16213659. Open Access PDF
Gill D, Derry S, Wiffen PJ, Moore RA. Valproic acid and sodium valproate for neuropathic pain and fibromyalgia in adults.Cochrane Database of Systematic Reviews. 2011, Issue 10. Art. No.: CD009183. DOI: 10.1002/14651858.CD009183.pub2.
Kochar DK, et al. Sodium valproate for painful diabetic neuropathy: A randomized double-blind placebo-controlled study. Quarterly J Med. 2004; 97:33-8. PMID: 14702509 Open Access PDF
Finnerup NB, et al. The evidence for pharmacological treatment of neuropathic pain. Pain. 2010; 150: 573-581. PMID: 20705215

Original Case by Rene Claxton, MD, Edited by Christian Sinclair, MD
Originally posted at the Institute to Enhance Palliative Care,
University of Pittsburgh Medical Center
Original PDF

Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. It is published as a means to illustrate important teaching points in health care.

http://www.pallimed.org/2013/08/cases-anti-epileptic-medicines-for-pain.html

Leg Pain not always Neuropathy

This blog almost always relates HIV-related, foot and leg pain to Neuropathy but that's not always the case and it's always worth bearing in mind that there are other possible causes, before jumping to conclusions. When you're HIV positive, it's easy to pin a label on a problem at the first sign of trouble, after all, when it comes to secondary infections, virus, or drug related conditions, we're prone to almost everything (and they wonder why some people become hypochondriacs!) This article from Pain.com (see link below) outlines the commonest causes of leg pain. The true cause will eventually be discovered by your doctors but keeping an open mind before you get the diagnosis weeks or months later, is always advisable.

Leg Pain
May 21, 2011

In addition to injuries and muscle cramps, various medical conditions can cause leg pain. This article covers some of the medical conditions that can cause leg pain. Medical conditions involving the cardiovascular system will be discussed in a separate article in this series about leg pain.

Peripheral neuropathy is not a disease in itself, but a symptom of nerve damage in the limbs that is caused by other medical conditions. Peripheral neuropathy is common in patients with diabetes, HIV/AIDS, vitamin B12 deficiency, cancer, lupus, syphilis, lyme disease, rheumatoid arthritis, sarcoidosis, hypothyroidism, toxic exposure, certain genetic diseases and so on. Peripheral neuropathy is a common symptom and it can be inherited, caused by an infection, caused by exposure to certain chemicals, experienced as a side effect of some medications, caused by metabolic disorders or nutritional deficiencies, caused by inflammatory diseases, caused by oxygen starvation or caused by trauma to a peripheral nerve.

Peripheral neuropathy commonly affects the feet and legs. If a nerve that carries sensation from the body to the central nervous system is damaged, a person may experience pain, burning, numbness or tingling in the leg or foot. Proprioception, or the ability to sense where a body part is without looking, can also be affected and a person can become more uncoordinated. If a motor nerve that supplies a muscle is damaged, a muscle becomes weak because it can not contract as well. It is possible for some muscles to become paralyzed, depending on the extent of the nerve damage. In some cases, muscles may cramp up instead of becoming flaccid and weak. Treatment of peripheral neuropathy involves treating the underlying cause of the problem, along with symptomatic care for pain and physical or occupational therapy if necessary.

Another possible medical cause of leg pain is a bone infection, called osteomyelitis. Osteomyelitis is a bacterial infection that can be caused by several different types of bacteria. People can contract a bone infection via a wound, such as when an open fracture occurs or when a person has surgery, or an infection can spread to the bone from a different part of the body. A type of skin infection called cellulitis can spread to underlying tissues and bones in the leg, or an internal infection like a bladder infection can spread to other parts of the body through the bloodstream.

Any patient with a suppressed immune system due to aggressive immunosuppressive therapy or an immune deficiency like HIV/AIDS is more likely to develop infections, including osteomyelitis. Treatment for osteomyelitis includes antibiotic medications to get rid of the infection and medications to control pain. If the infection is not treated early, it is possible for the infection to spread to other tissues in the leg, making amputation of the leg necessary. It is also possible for a person with an untreated infection to go into septic shock when the bacteria infect the bloodstream.

If your leg pain is in your joints, you may have arthritis, or joint inflammation. There are many different types of arthritis, including osteoarthritis, gout and rheumatoid arthritis. More information about the various types of arthritis can be found at http://pain.com/library/2011/05/01-arthritis-awareness-month/. Infections in the joint capsule itself can also cause joint pain. Osteoarthritis, the most common type of arthritis, is caused by “wear and tear” on the cartilage of the joint. Rheumatoid arthritis is an autoimmune disease. Gout is caused by having too much of a substance called uric acid in your body, which builds up in the joints and causes pain and inflammation. Common symptoms of many different types of arthritis include joint pain, joint stiffness or decreased joint mobility and joint swelling. Treatment for arthritis varies depending on the type of arthritis. Talk to your doctor if you think you may have arthritis pain.

Fibromyalgia is a medical condition that can cause muscle pain in the legs and in other parts of the body. In addition to muscle pain, people with fibromyalgia may also have chronic fatigue, sleep disorders, tension headaches and mood disorders. The cause of fibromyalgia is unknown, but researchers think that people with fibromyalgia have a lowered tolerance to pain because of abnormalities in the way that their brains process pain signals. Treatment for fibromyalgia is symptomatic and aims to control pain, improve sleep and treat mood disorders. Not all aspects of fibromyalgia can be treated medically; for example, the frustration that a patient with fibromyalgia may feel in not knowing how to deal with chronic pain and fatigue may benefit from counseling.

Peripheral neuropathy, infections, arthritis and fibromyalgia are just a sampling of the medical conditions that may cause leg pain. These conditions are not as common as muscle cramps and injuries, but a good proportion of older people develop some degree of osteoarthritis and peripheral neuropathy can be caused by a variety of medical conditions. Always talk to your doctor if you have persistent leg pain and you do not know what is causing it.

http://pain.com/library/2011/05/21-leg-pain-3/

How Good Is Methadone For Neuropathic Pain

Today's post from mypcnow.org (see link below) takes a look at methadone as an alternative to other opioids for controlling neuropathic pain. Methadone has had an extremely bad rap over the years, mainly because of its association with withdrawal from drug addiction programmes. However, it is an extremely cheap and effective drug for nerve pain and because only low doses are needed, the risks of side effects and addiction are much less than for instance morphine or oxycodone. That said, it is a powerful drug and once you begin, you need to be very careful when and if you want to taper off. Never go cold turkey with methadone - it will react almost instantly. Many doctors are reluctant to issue methadone prescriptions but that's often based on lack of experience rather than factual dangers. If a patient discovers over time that nothing else works, then methadone can be very effective in controlling nerve pain. Remember, all drugs for neuropathy have side effects, so don't be put off by what you may have heard - it all boils down to careful monitoring by your doctor. Discuss it with him or her if you find that almost nothing works for you in reducing the pain of neuropathy.

METHADONE FOR NEUROPATHIC PAIN
David E Weissman MD FAST FACTS AND CONCEPTS #171

Background Prescriptions for methadone have greatly increased in the past decade (1). The reason for this increase is likely related to two factors: reduced cost relative to other potent opioids and basic science data suggesting that methadone may be particularly useful in treating neuropathic pain. Two previous Fast Facts (#75, 86) reviewed methadone’s pharmacological properties. This Fast Fact examines the research base regarding methadone and neuropathic pain and reviews the rise in methadone-related deaths.

Historical Context

Prior to 1985, when long-acting morphine preparations were introduced, methadone was commonly prescribed for cancer-related pain as it had a longer duration of action than morphine. However, it was well appreciated that methadone had a higher risk of respiratory depression due to drug accumulation with chronic dosing – an effect not associated with other opioids, for which there is no drug accumulation in the setting of normal renal function.

Prior to 1990 there was a widespread belief that opioids were relatively ineffective in treating neuropathic pain. Since then, there been a much greater understanding that opioids are an effective part of neuropathic pain treatment.

Basic science data Methadone inhibits reuptake of norepinephrine and serotonin in a similar manner to newer anti-depressants, some of which are effective against neuropathic pain (e.g. duloxetine, venlafaxine). Also, methadone binds to the NMDA receptor, a known modulator of neuropathic pain. Finally, methadone has demonstrated efficacy in animal models of neuropathic pain (2).

Patient data Small non-controlled case series and two small randomized study (methadone vs. placebo) have demonstrated that methadone can reduce neuropathic pain in both cancer and non-cancer patients (3-6). There is no data, for or against the proposition, that methadone is superior to other opioids for neuropathic pain. A 2007 Cochrane Collaborative review found, “there is no trial evidence to support the proposal that methadone has a particular role in neuropathic pain of malignant origin” (7). Furthermore, the review cautioned clinicians about the danger of methadone-induced respiratory depression due to its long terminal half-life.

Methadone deaths There is a growing awareness that the increased prescription of methadone is being paralleled by a similar increase in methadone-related deaths. Methadone has been implicated in 30% to 40% of opioid related deaths in the US, even though methadone remains a small minority of opioids prescribed (8). The US Department of Health and Human Services convened an expert panel in 2003 to investigate the rise in methadone deaths and concluded that the rise was largely due to the increasing use of methadone as an analgesic (9). The Center for Disease Control published a report detailing data from Utah in 2005, suggesting that part of the problem was due to increased prescribing (10). The current data seem to suggest that the general increased supply of methadone, via legitimate prescribing, is leading to deaths due to accidental overdose through improper prescribing or illicit diversion/recreational use. In addition to concern about respiratory depression, there has been an observation that methadone, unlike morphine or hydromorphone, can prolong the QTc interval and lead to serious cardiac conduction abnormalities especially when coadministered with antiretrovirals in HIV patients (11). Note: the overall number of opioid-related deaths has increased, not just from methadone. Note: there are no data on untimely deaths related to methadone prescribing in hospice/palliative care patients.

Summary The renewed interest in an old drug holds exciting promise of benefit for the many patients with neuropathic pain. However, clinical research has yet to confirm or deny a unique clinical role for methadone compared to other opioids. The risk of respiratory depression should give clinicians pause before prescribing methadone based solely on the theory that it is a superior opioid in neuropathic pain. Coadministration of methadone with antiretrovirals may pose a particular risk for cardiac arrhythmias and therefore should be avoided if at all possible., Given that diversion of legitimate opioid prescriptions to the illicit market can occur, even in the practice of hospice and palliative care, physicians and hospice agencies need to recognize they also have a larger social responsibility to the public welfare, and prescribe methadone with care and caution.

References

Warner M, Chen LH, et al. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief. 2011; 1-8.

Foley KM. Opioids and chronic neuropathic pain. NEJM 2003; 348:1279-1281.

Morley JS, et al. Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial. Pall Med. 2003; 17:576-587.

Altier N, et al. Management of chronic neuropathic pain with methadone: a review of 13 cases. Clin J Pain. 2005; 21:364-369.

Gagnon B, et al. Methadone in the treatment of neuropathic pain. Pain Res Manage. 2003; 8:149-154.

Moulin DE, et al. Methadone in the management of intractable neuropathic non cancer pain. Can J Neuro Sci. 2005; 32:340-343.

Nicholson, AB. Methadone for cancer pain. Cochrane Database Syst Rev 2007; 4.4.

Centers for Disease Control and Prevention (CDC). Vital signs: risk for overdose from methadone used for pain relief – United States, 1999-2010, Morb Mortal Wkly Rep 2012; 61:493-497.

Increase in poisoning deaths caused by non-illicit drugs--Utah, 1991-2003. MMWR Weekly. 2005; 54:33-36.

US Department of Health and Human Services – Division on Pharmacologic Therapies. Report on Methadone Mortality (http://dpt.samhsa.gov/reports/methodone_mortality-05.htm - no longer publicly available). Updated Report available at: http://www.dpt.samhsa.gov/pdf/MethadoneBackgroundPaper_72007_2_.pdf.

Kao D, Bartelson BB, et al. Trends in reporting methadone-associated cardiac arrhythmia, 1997-2011. Ann of Int Med 2013;158: 735-740.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in December 2006. Version copy-edited in April 2009: web-links updated. Revised again in July 2015 by Sean Marks MD: references and epidemiological data updated.

Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.

Copyright: All Fast Facts and Concepts are published under a Creative Commons Attribution-NonCommercial 4.0 International Copyright (http://creativecommons.org/licenses/by-nc/4.0/). Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know!

Disclaimer: Fast Facts and Concepts provide educational information for health care professionals. This information is not medical advice. Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Health care providers should always exercise their own independent clinical judgment and consult other relevant and up-to-date experts and resources. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

http://www.mypcnow.org/blank-ari0c

How Effective Is Carbamazepine For Neuropathy Pain

Today's post from onlinelibrary.wiley.com (see link below) is an objective assessment of the effects of carbamazepine on neuropathic pain and as such is always useful for neuropathy patients looking for confirmation that what they're being prescribed is what the doctor says it is. Carbamazepine has become increasingly popular recently, as an alternative to other anti-epilepsy drugs such as Lyrica, which has a possibly deserved bad press. However, does the research show that it works? This article suggests that it does...for some people but with caveats. Pretty much the same as all other drugs used to treat neuropathic pain then! Worth a read if you're on Carbamazepine, or likely to encounter it in the course of your treatment options.

Carbamazepine for chronic neuropathic pain and fibromyalgia in adults 
Philip J Wiffen1,*, Sheena Derry1, R Andrew Moore1,Eija A Kalso2,3
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 10 APR 2014
Assessed as up-to-date: 7 FEB 2014

DOI: 10.1002/14651858.CD005451.pub3

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
The Cochrane Library
Read a clinical summary of this review on

Abstract

Background

This is an update of a Cochrane review entitled 'Carbamazepine for acute and chronic pain in adults' published in Issue 1, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review considers the treatment of chronic neuropathic pain and fibromyalgia only, and adds no new studies. The update uses higher standards of evidence than the earlier review, which results in the exclusion of five studies that were previously included.

Objectives

To assess the analgesic efficacy of carbamazepine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse events reported in the studies.

Search methods

We searched for relevant studies in MEDLINE, EMBASE and CENTRAL up to February 2014. Additional studies were sought from clinical trials databases, and the reference list of retrieved articles and reviews.

Selection criteria

Randomised, double blind, active or placebo controlled trials (RCTs) investigating the use of carbamazepine (any dose, by any route, and for at least two weeks' duration) for the treatment of chronic neuropathic pain or fibromyalgia, with at least 10 participants per treatment group. Participants were adults aged 18 and over.

Data collection and analysis

Two study authors independently extracted data on efficacy, adverse events, and withdrawals, and examined issues of study quality. Numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) with 95% confidence intervals (CIs) were calculated from dichotomous data.

We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention-to-treat analysis without imputation for dropouts, at least 200 participants in the comparison, at least 8 weeks' duration, parallel design), second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison, and third tier from data involving small numbers of participants that was considered very likely to be biased or used outcomes of limited clinical utility, or both.

Main results

Ten included studies (11 publications) enrolled 480 participants with trigeminal neuralgia, diabetic neuropathy, and post stroke pain. Nine studies used a cross-over design, and one a parallel group design. Most of the studies were of short duration, lasting four weeks or less.

No study provided first or second tier evidence for an efficacy outcome. Using third tier evidence, carbamazepine generally provided better pain relief than placebo in the three conditions studied, with some indication of pain improvement over mainly the short term, but with poorly defined outcomes, incomplete reporting, and in small numbers of participants. There were too few data in studies comparing carbamazepine with active comparators to draw any conclusions.

In four studies 65% (113/173) of participants experienced at least one adverse event with carbamazepine, and 27% (47/173) with placebo; for every five participants treated, two experienced an adverse event who would not have done so with placebo. In eight studies 3% (8/268) of participants withdrew due to adverse events with carbamazepine, and none (0/255) with placebo. Serious adverse events were not reported consistently; rashes were associated with carbamazepine. Four deaths occurred in patients on carbamazepine, with no obvious drug association.

Authors' conclusions

Carbamazepine is probably effective in some people with chronic neuropathic pain, but with caveats. No trial was longer than four weeks, had good reporting quality, nor used outcomes equivalent to substantial clinical benefit. In these circumstances, caution is needed in interpretation, and meaningful comparison with other interventions is not possible.

Plain language summary

Carbamazepine for chronic neuropathic pain and fibromyalgia in adults

Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain.

Carbamazepine was developed to treat epilepsy, but it is now used to treat various forms of chronic pain. We performed searches (up to February 2014) to look for clinical trials where carbamazepine was used to treat neuropathic pain or fibromyalgia. We found 10 studies involving 418 people involved in testing carbamazepine. Studies were not generally of very good quality. Most were very small, as well as of short duration. Studies lasting only one or two weeks are unhelpful when pain can last for years.

There was not enough good quality evidence to say how well carbamazepine worked in any neuropathic pain condition. Pooling four small studies showed that it was better than placebo, but the result cannot be relied upon. There was not enough information from these studies to make any reliable comment on adverse events or harm.

Carbamazepine is probably helpful for some people with chronic neuropathic pain. It is not possible to know beforehand who will benefit and who will not. 


http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005451.pub3/abstract

Breast Pain During Pregnancy

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How Can You Train Your Pain Away

Today's post from catherinecarrigan.com (see link below) discusses what Eckhart Tolle calls the 'pain body'. Now depending on your attitude towards mindfulness, alternative healing and ancient treatment techniques, you may either read this with horror, or allow yourself to be open to other ways of thinking about your chronic pain. I swing both ways in that regard and freely admit that I need to be in the mood for this sort of article. However, that doesn't mean that it doesn't have value - I think it does and if you can read the article and open yourself to new ways of approaching your pain, you may gain a great deal of benefit from it. A great many people have benefited from this sort of looking at your body,  so don't be too quick in dismissing it as mumbo-jumbo. It's an interesting article, that after you've read it, seems to make perfect sense. Worth a read: it may get you thinking and if the pills aren't working at the moment, what have you got to lose?.

What Is The Pain Body?
Posted on Apr 4, 2016 by Catherine Carrigan in Blog

To free yourself from pain and suffering, you must have a deeper understanding of your pain body and the way it actually works.


What Your Body Really Is

To understand your pain body, you would need to understand the way that I, as a medical intuitive healer, view your whole body:

You have a physical body, which includes your muscles, bones, glands and organs.
You have an energy body, which includes your chakras, your acupuncture meridians and your breath.
You have an emotional body, which includes your emotions and all your feelings including the ones you do not have words for quite yet.
You have an intellectual body, which includes your mind, your thoughts and your beliefs.
Finally, you have a spiritual body, which is the part of you beyond all space and time. Many people refer to this as your soul.

Simply put, your pain body is the same thing as your emotional body.

Emotions can shut down literally any other level of your being.

Don’t believe me?

A Story of How Emotional Pain Changed Me Physically

Let me tell you a story.

In 2004 I was on vacation in Los Angeles.

I was driving a rental car in Santa Monica on the way to attend a yoga class when my cell phone rang.

My beloved professor from Brown University, Kermit Champa, had just died.

Up until that point, I had spoken to him virtually every week of my life for 24 years. He had brought me through the hard times, the good times, he had helped me understand myself and been the father I always wanted and never had. And then he was gone.

Even though I was well rested, well fed and eager to practice yoga, when I arrived at the class, all I could do was lie on my mat barely able to move.

Suddenly I felt like all my energy had evaporated.

Perhaps you can relate a similar experience where a sudden emotional experience changed literally everything about you!

What Controls What In Your Body

Here’s how this all works together:
Your spiritual body controls your intellectual body.
Your intellectual body controls your emotional body.
Your emotional body controls your energy body.
Your energy body controls your physical body.

Simply understanding this fact can save you years of pain and suffering.

The Levels of Power In Your Body

You can think of each of these bodies as levels of power:

Your soul controls your mind. That’s why, as we develop our spirituality, we can become mentally stronger and more capable of withstanding the vicissitudes of life. That is why many frail elderly people have become like spiritual warriors. Even though they may not be as physically strong as they used to be, they become a great source of strength for their entire community.
Your mind controls your emotions. As you look for the wisdom rather than the hurt in all life’s challenges, you can save yourself tremendous emotional pain. That’s why thinking positively, looking on the bright side, having a sense of humor and reframing your challenges can soften the blows you feel emotionally.
Your emotions control your energy. You can learn how to feel your feelings and let them go – as opposed to either running away from them through addictions like drugs (legal and illegal), alcohol, sex, overworking and the hundreds of other ways you can ignore what’s really going on. A good way to think of emotions is that they are a process. As you develop healthy stress management skills you can process through the inevitable hurts more easily. I often work with young teens and have tremendous compassion because they have not yet learned how to handle all their emotions and can quite easily be derailed by disappointment, divorce, death and the challenges of growing up. No matter what our age, the more you develop healthy methods of handling your emotions, the healthier you will be in every way. You can download a FREE chart about how stress affects your body at this link on my website. It’s quite humbling to learn what ailments are related to our inability to cope with the stress in our lives.

Your energy body, which includes your chakras, your acupuncture meridians and your breath, controls your physical. That is why when your chi is depleted you can feel so physically weak.

Your Physical Body Is Simply Your Result

Your physical body is simply the densest part of who you are.

A good way to think of your physical body is that it is the result.

Your physical body is the result of your energy, your emotions, your mind and your soul.

By the time you experience pain and suffering, the causes of that pain and suffering have been with you for some time.

That’s because energy enters in through your spiritual, filters down into your mind, then your emotions, then your energy body and finally congeals in your physical body.

If I am working with a client to relieve pain and suffering, I have to reverse the process.

That means you have to move the vibration of pain and suffering back out of your physical, through your energy, through your emotions, through your mind and all the way past your spiritual self.

Simply put, pain comes in through your spiritual, past the gateway of your mind, into your emotions where things can get quite tumultuous, through your energy and finally into your physical organs, glands, bones and muscles.

To get rid of pain, you have to reverse the process.

That’s why – if you have only been working to get rid of pain through your physical body – you may not have been too successful.

You have to honor who you really are and take into account all five bodies to get rid of your pain and suffering.

How Energy Flows In Your Body

Yesterday I was working with a new client who had been suffering from chronic low back pain.

Although she had worked regularly with a chiropractor, massage therapist and cranio sacral therapist, improved her nutrition and started practicing yoga, nothing could get rid of the chronic nagging pain on the right side.

She came to me for a medical intuitive reading.

Very quickly I explained that 30 percent of her pain was due to a low functioning right kidney, 40 percent due to severe adrenal burnout and the last 30 percent due to spiritual loneliness as her soul was longing for companionship of like-minded people.

Even though she is happily married, has two well-behaved children and a fulfilling part-time job, she admitted she had been longing for people she could really talk to about the things that her soul had begun to perceive.

“If you think I’m tired now you should have seen me years ago,” she told me.

Her self care and great attitude had indeed made a difference, but not cleared her low back pain completely.

I explained to her the way energy flows in the body:
Energy enters at the crown of your head through the bahui point.
The hara line is a vertical electrical current running through the bahui all the way down into the center of the earth. Any breaks, blowouts or disruptions in your hara line can lead to major disruptions in the flow of your energy. I can heal your hara line and also teach you how to perceive it and heal it yourself.
Your hara line feeds energy into your chakras. People who practice energy exercise such as yoga, tai chi and qi gong are doing themselves a wonderful favor by balancing the energy centers in their bodies. This is why I have taught yoga for 20 years and practiced and taught qi gong for about as long. Although these forms of exercise may be gentle, their benefits are quite profound. The more balanced your chakras, the more balanced your endocrine system and every organ system in your body will be. In addition to energy exercise, you can visit a highly trained energy healer such as myself to clean out and repair your chakras.

Your chakras feed your acupuncture meridians. I practice acupressure (without needles) as well as Reiki and other forms of energy healing. A block in your acupuncture meridians may be the cause of your pain.
Your acupuncture meridians feed your organs. In the case of my client, after all her chiropractic, massage, craniosacral therapy, yoga and good nutrition, it was a surprise for her to hear that her right kidney and right adrenal gland was partially the source of her pain. Energy work – whether it be energy exercise or energy healing – can build the chi in your organs.
Your organs feed your muscles. If you have a chronic muscle pain, you can learn which organs that muscle is related to. If you want to understand the health of your organs, you can download this FREE assessment on my website at this link. The healthier your organs, the less pain you will feel.

Your entire body is like one big hologram with each aspect deeply interrelated to other aspects of yourself.

When you suffer pain, the more you inquire about how these different aspects correlate, the more likely you are to root out the causes and resolve the issue.

Every Organ Carries Emotions That May Be Adding to Your Pain Body

If you visit my website, you can download a FREE chart that lists out the emotions that correlate with the major organs in your body. Just click on this link.

Let’s just take one organ for example.

Your large intestine acupuncture meridian of course relates to your colon.

The muscles that it correlates with include your quadratus lumborum muscle in your lower back as well as your hamstrings. If you have low back pain, more than likely these muscles are highly involved in your suffering.

That is why if you came to me for corrective exercise and therapeutic yoga for low back pain, more than likely I would recommend exercises to lengthen your hamstrings and balance the two sides of your quadratus lumborum muscles.

The emotions associated with your large intestine include:
Guilt
Grief
Regret
Release
Self worth (or lack thereof)
Enthusiasm
Depression
Letting go
Indifference
(Un)merciful
Compassion
Sadness
Apathy

Now Here’s the Truth: What You Experience Is In You, Not Out There

Most of the time we believe that world outside of us is the cause of the emotions that we feel.

As a long-time medical intuitive healer, I am here to tell you the truth.

What you feel is inside of you.

If you feel angry, you will look out into the world and find things to feel angry, bitter and upset about.

If you feel depressed, you will look out and find 100 reasons to feel sorrowful.

As you change your inner experience, the world you experience changes also.

You Can Not Get Rid Of Your Pain Until and Unless You Shift Your Emotions

If I am doing a healing – no matter whether that healing is to get rid of the pain in your back, help you improve your business, get to the bottom of your money issues or to improve your relationship with your mother – after setting the goal, the very next thing I do is find the emotion or emotions that have kept your suffering in place.

Why is this so important?

Simply put, you can not get rid of your pain until and unless you have resolved the emotions that have held it in place.

If you don’t, you simply morph that energy from one part of the body to another.

You fix your hurt knee, your wrist goes wonky.

You fix your knee and your wrist and then your foot starts hurting.

And so on.

Emotions Are Vibrational Patterns

You can think of emotions like vibrational patterns.

You can download a FREE chart on my website to understand the relative heaviness or lightness of specific emotions. Click on this link to learn more.

The lowest vibration emotions, from least to most damaging, include:
Affirmation
Scorn
Hate
Craving
Anxiety
Regret
Despair
Blame
Humiliation

All True Healing Must Include Emotional Healing

As you resolve these emotions in yourself, you stop carrying the vibration.

As you stop feeling these emotions, you stop lighting up the parts of your brain related to the acupuncture meridians.

As you clear this energy from all parts of your body, you start feeling lighter and less bothered by the pain.

This is why integrated holistic healing is a must in this day and age.

This is why, as a medical intuitive healer, I work on all five bodies – your spiritual, intellectual, emotional, energetic and physical self.

A Personal Story

In in the fall of 2015, I was practicing my yoga when I noticed that my left wrist was hurting. I had just come out of a full wheel. Even though I had learned the correct form so as not to strain my wrist, I felt a sharp shooting pain.

As busy as I was, I didn’t pay much attention until a few months later when I was practicing qi gong.

I lifted my left wrist and noticed a large protruding bump – a ganglion cyst.

It turns out that my mother also has a ganglion cyst, also known as a Bible bump because an old timey remedy is to hit it with a large heavy Bible to get rid of the bump. Turns out her ganglion cyst is in the exact same place as mine only hers isn’t hurting any longer.

“I’m 57 years old and I can still blame something on my mommy,” I joked with my yoga class.

Indeed, many of the vibrational patterns that cause our pain and suffering did not in fact start with us. These are called:
Genomes, or genetic thought patterns.
Miasms, or beliefs, habits and thought patterns that we picked up from the culture we grew up in.

I identified the emotion behind my wrist pain and began taking a flower essence to resolve the feelings.

Even if the pattern had in fact started with my mother, it was now in my own cells and if I wanted to resolve the pain I had to deal with it.

As I did so, I also received chiropractic adjustments as my carpal bones had become misaligned.

Eventually the pain lessened.

Then one day I noticed I had run out of the flower essence I had been taking to resolve the emotions behind my wrist pain.

Thinking I may be over it by now, I didn’t bother to start on my second bottle.

A few days after I ran out, I noticed my wrist pain had returned!

I immediately began taking the second bottle and continued to process the emotions that had made me hurt so badly.

To Get Rid of Pain, You Must Take An Integrated Approach

You can take an aspirin, call your chiropractor, visit your medical doctor for an Xray or an MRI. I strongly support all these approaches and can also recommend many natural healing remedies for pain.

But when you really want to get rid of pain and suffering, you will want to take an integrated approach.

Ask yourself:
Where did my pain start?
What are the emotions I am feeling?
How are my spiritual, intellectual, emotional, energetic and physical bodies involved in this pain?

By taking an integrated approach, you can supercharge your healing, resolve your emotions, shift the vibration and empty out your pain body.

What is healing?

Healing happens when you honor who you really are as a human being and take advantage of this deeper knowledge to address all aspects of yourself.

http://catherinecarrigan.com/what-is-the-pain-body/

Is Methadone An Option For Neuropathic Pain

Today's post from eperc.mcw.edu/ (see link below) was last revised in 2009 but nevertheless sums up current thinking regarding the use of methadone to control neuropathic symptoms. If you Google the subject you will come up with many other articles, including studies, about using methadone as a specific opioid to control nerve pain but this one is relatively easy to understand and sums up the dilemmas that doctors and specialists face in the current climate, where opioid prescription is coming under both social and legal scrutiny, especially in North America. Methadone's efficiency as an analgesic is somewhat clouded by its reputation, as a substitute for morphine, heroine and other opiate-acting drugs but that may be unfair. It seems however, that more and more people are finding that relatively low-dose methadone use can bring relief from their neuropathic pain and it may be worth discussing the possibility with your specialist or doctor, especially if all else seems to have failed. Methadone may well be a good alternative to Tramadol and Oxycodone but it is essential that the decision to take it is taken in complete agreement with your doctor. Just as with all other opioids and strong painkillers, ensuring that your progress will be monitored is also essential to avoid overdose and addiction potential. This article is not the full story but provides useful background information to help with your decision making.
Never attempt to self-medicate with Methadone or other opioids.

Methadone for Neuropathic Pain
Author(s): David E Weissman MD FAST FACTS AND CONCEPTS #171 PDF

Background Prescriptions for methadone have greatly increased in the past six years (1). The reason for this increase is likely related to two factors: reduced cost relative to other potent opioids and basic science data suggesting that methadone may be particularly useful in treating neuropathic pain. Two previous Fast Facts #75, 86) reviewed methadone’s pharmacological properties. This Fast Fact examines the research base regarding methadone and neuropathic pain and reviews the rise in methadone-related deaths.

Historical Context
 
Prior to 1985, when long-acting morphine preparations were introduced, methadone was commonly prescribed for cancer-related pain as it had a longer duration of action than morphine. However, it was well appreciated that methadone had a higher risk of respiratory depression due to drug accumulation with chronic dosing – an effect not associated with other opioids, for which there is no drug accumulation in the setting of normal renal function.

Prior to 1990 there was a widespread belief that opioids were relatively ineffective in treating neuropathic pain. Since then, there been a much greater understanding that opioids are an effective part of neuropathic pain treatment.

Basic science data Methadone inhibits reuptake of norepinephrine and serotonin in a similar manner to newer anti-depressants, some of which are effective against neuropathic pain (e.g. venlafaxine). Also, methadone binds to the NMDA receptor, a known modulator of neuropathic pain. Finally, methadone has demonstrated efficacy in animal models of neuropathic pain (1).

Patient data Small non-controlled case series and at least one small randomized study (methadone vs. placebo) have demonstrated that methadone can reduce neuropathic pain in both cancer and non-cancer patients (2-5). There is no data, for or against the proposition, that methadone is superior to other opioids for neuropathic pain. A 2004 Cochrane Collaborative review found, “there is no trial evidence to support the proposal that methadone has a particular role in neuropathic pain of malignant origin” (6). Furthermore, the review cautioned clinicians about the danger of methadone-induced respiratory depression due to its long terminal half-life.

Methadone deaths There is a growing awareness that the increased prescription of methadone is being paralleled by a similar increase in methadone-related deaths. Florida, Utah, North Carolina, Oregon, Indiana, Maryland, Alabama and West Virginia have all reported a spike in deaths related to methadone since 2000 (7,8). The US Department of Health and Human Services convened an expert panel in 2003 to investigate the rise in methadone deaths and concluded that the rise was largely due to the increasing use of methadone as an analgesic (9). The Center for Disease Control published a report detailing data from Utah in 2005, suggesting that part of the problem was due to increased prescribing (10). The current data seem to suggest that the general increased supply of methadone, via legitimate prescribing, is leading to deaths due to accidental overdose through improper prescribing or illicit diversion/recreational use. In addition to concern about respiratory depression, there has been a relatively recent observation that methadone, unlike morphine or hydromorphone, can prolong the QTc interval and lead to serious cardiac conduction abnormalities. Note: the overall number of opioid-related deaths has increased, not just from methadone. Note: there are no data on untimely deaths related to methadone prescribing in hospice/palliative care patients.

Summary The renewed interest in an old drug based on new science holds exciting promise of benefit for the many patients with neuropathic pain. However, clinical research has yet to confirm or deny a unique clinical role for methadone compared to other opioids. The risk of respiratory depression should give clinicians pause before prescribing methadone based solely on the theory that it is a superior opioid in neuropathic pain. Furthermore, given that diversion of legitimate opioid prescriptions to the illicit market can occur, even in the practice of hospice and palliative care, physicians and hospice agencies need to recognize they also have a larger social responsibility to the public welfare, and prescribe methadone with care and caution.

References
Foley KM. Opioids and chronic neuropathic pain. NEJM. 2003; 348:1279-1281.
Morley JS, et al. Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial. Pall Med. 2003; 17:576-587.
Altier N, et al. Management of chronic neuropathic pain with methadone: a review of 13 cases. Clin J Pain. 2005; 21:364-369.
Gagnon B, et al. Methadone in the treatment of neuropathic pain. Pain Res Manage. 2003; 8:149-154.
Moulin DE, et al. Methadone in the management of intractable neuropathic non cancer pain. Can J Neuro Sci. 2005; 32:340-343.
Nichloson AB. Methadone for cancer pain: Review. Cochrane Database of systematic reviews. 2004;2:CD003971.
Google Search: ‘Methadone deaths.’ December 2007.
Finn S, Tuckwiller S. Feds act on methadone deaths. West Virginia Gazette. July 23 2006.
Increase in poisoning deaths caused by non-illicit drugs--Utah, 1991-2003. MMWR Weekly. 2005; 54:33-36.
US Department of Health and Human Services – Division on Pharmacologic Therapies. Report on Methadone Mortality (http://dpt.samhsa.gov/reports/methodone_mortality-05.htm - no longer publicly available). Updated Report available at: http://www.dpt.samhsa.gov/pdf/MethadoneBackgroundPaper_72007_2_.pdf.
Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in December 2006. Current version re-copy-edited in April 2009; web-links updated.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE. Methadone for Neuropathic Pain. Fast Facts and Concepts. December 2006; 171. Available at: http://www.eperc.mcw.edu/FastFactsIndex/ff_171.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_171.htm

Can Marijuana Be Moved To The Less Restricted List For Chronic Pain Patients

Today's post from webmd.com (see link below) takes the discussion about medical marijuana a little further and looks at the dilemmas doctors face when confronted by patients' valid questions regarding their pain treatment and the laws that cloud the picture and make them uncertain as to whether they're doing the right thing. It's a call for considerably more research to be done at official drug-enforcement levels and asks for a further loosening of restrictions to enable an unbiased and science-based evaluation of the benefits of marijuana for various conditions. It's a valid point because we already allow several drugs which have the potential to be far more addictive (oxycodon, morphine and many others) to help patients with chronic pain but it seems that marijuana has so many pre-judged labels attached that law enforcers just can't see beyond the decades-old criminality issues. Worth a read.

What DEA Pot Rule Change May Mean for Research WebMD News from HealthDay
By Dennis Thompson HealthDay Reporter TUESDAY, May 10, 2016
 
Agency could move marijuana to a less strictly regulated class of drugs

 (HealthDay News) -- Most doctors approach medical marijuana with a great deal of uncertainty, because drug laws have hindered researchers' ability to figure out what pot can and can't do for sick patients.

That could soon change.

The U.S. Drug Enforcement Administration (DEA) is weighing whether to loosen its classification of marijuana, which would remove many restrictions on its use in medical research.

If that occurs, doctors could start getting answers to the questions they regularly receive from patients regarding marijuana's clinical benefits.

"I am asked as a practicing doctor even in a rural area about medical marijuana use, and I want to make sure I can give patients advice that's evidence-based," said Dr. Robert Wergin, board chair of the American Academy of Family Physicians. "We need those kinds of studies to help us give informed advice to our patients who ask about it now," he explained.

The DEA has said it will decide this summer whether marijuana should be lowered from a Schedule I drug to a Schedule II drug, according to an April memo from the agency to Congress.

Schedule I drugs are considered drugs "with no currently accepted medical use and a high potential for abuse," the DEA says on its website. Heroin, LSD and ecstasy stand alongside marijuana on the DEA's Schedule I list.

On the other hand, Schedule II drugs have a high potential for abuse, but "there is the recognition that they have some medical value as well," said Dr. J. Michael Bostwick, a professor of psychiatry at the Mayo Clinic, in Rochester, Minn.

"This could be an important softening of regulations that make it difficult to do marijuana or cannabis research in this country," Bostwick said.

Morphine, methamphetamine, cocaine and oxycodone are all Schedule II drugs, "because they have medical applications," Bostwick said. "So, it's not as if we don't have precedent for substances that are dangerous from an addictive point of view being useful in certain medical situations."

Studies have shown that marijuana might help decrease chronic pain and nausea, ease seizures, improve the appetite or be useful in psychiatric treatment, Wergin and Bostwick said.

But none of those studies has been large-scale and a definitive clinical trial. The reason: because marijuana's DEA drug status prevents scientists from using large quantities of the plant in medical research, Wergin and Bostwick said.

All marijuana available for research purposes in the United States is grown at the University of Mississippi, which has an exclusive contract with the U.S. National Institute on Drug Abuse (NIDA) to provide the nation's entire research supply, according to the DEA's memo to lawmakers.

In any given year, NIDA sends shipments of marijuana to a small handful of researchers, usually eight or nine, but sometimes as many as 12, the memo states. Researchers must go through a detailed registration process to gain access to the pot.

The American Medical Association (AMA) has come out in favor of loosening drug laws to "develop a special schedule for marijuana to facilitate study of its potential medical utility in prescription drug products," according to a statement its officials provided ABC News.

"While studies related to a limited number of medical conditions have shown promise for new cannabinoid-based prescription products, the scope of rigorous research needs to be expanded to a broader range of medical conditions for such products," the AMA added.

Back in December 2014, the American Academy of Neurology lamented the lack of solid marijuana research in a position paper.

Due to strict drug laws, researchers have not been able to determine whether medical marijuana could help treat neurological disorders such as epilepsy, multiple sclerosis and Parkinson's disease, the academy said.

The academy's paper concluded with a call to deschedule marijuana and open it up to more research.

Expanded research wouldn't necessarily lead to more people smoking pot for medical purposes, Wergin and Bostwick said.

Instead, it's more likely that researchers would focus on how the components of marijuana, such as THC or cannabidiol, interact with the body in ways that might help ease symptoms or illness.

An entire system of receptors has been discovered throughout the body that responds to different components of cannabis, Bostwick said.

"Almost any system you name in the body has a potential cannabinoid receptor that could be manipulated in a way that could be useful," he said. "When the drug was outlawed in 1970, we knew almost nothing about it. In the intervening 45 years, science has shown this endocannabinoid system actually exists. None of that was known when the drug was made illegal."

Such research could result in medications derived from marijuana that would treat conditions without a "high," Wergin said.

Wergin sees two main potential benefits from the descheduling of marijuana and any resulting boom in research.

First, he'd know what to tell patients about pot's particular benefits. And second, he'd feel confident issuing a prescription for a marijuana-based medication, knowing that it's a drug regulated by the U.S. Food and Drug Administration.

"This would result in higher-quality standardized product that's FDA-approved," Wergin said. "If I prescribe you an antibiotic, I'm very confident of what's in it because of the FDA regulations on it. I don't know how to prescribe marijuana to you, or what's even in it."

Paul Armentano, deputy director of the marijuana legalization group NORML, said that at this point a reclassification by the DEA would fall "well short of the sort of federal reform necessary to reflect America's emerging reefer reality."

Armentano added that even with descheduling, federal law still would require researchers to buy pot from NIDA's University of Mississippi marijuana cultivation program.

"Simply rescheduling cannabis from I to II does not necessarily change these regulations, at least in the short-term," Armentano said.

View Article Sources

http://www.webmd.com/mental-health/addiction/news/20160510/what-a-change-in-deas-pot-rules-might-mean-for-medical-research

Sciatica pain relief exercises during pregnancy

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Accepting Your Chronic Pain

Today's post from painpathways.org (see link below) is a short but useful article suggesting ways to handle the pain that may be dominating your life. Sometimes the first step to making pain less of a feature in your life is accepting it for what it is. Sounds glib but it may well be true. As soon as we experience chronic pain, we try to deny it, remove it, or allow it to overwhelm us but making peace with the fact that it's there and for a reason, allows us to relax and work on ways to reduce its influence. Worth a read.

Pain And Acceptance

Dr Rosemary Fish Posted: June 2, 2014
 
Dr. Rosemary Fish and her associates state that chronic pain acceptance “involves experiencing ongoing pain without attempts to avoid, reduce or otherwise control it … and engaging in everyday activities of value to the individual in the presence of pain, and disengaging from the struggle to limit contact with pain.”Acceptance is generally described as having two parts: pain willingness and activity engagement.

(1) PAIN WILLINGNESS

Pain willingness refers to being willing to live with pain, to reduce frustrating attempts toward making the pain go away (while continuing those that help), to understanding that pain is part of who you are now. It is leaving behind the pressing need you likely had at the beginning of your pain problem that drove you to find a diagnosis, a treatment, a cure.

(2) ACTIVITY ENGAGEMENT

Activity engagement reflects the idea that you are moving on with your life, doing the things that matter as best you can, even though you have pain. It is being willing to do things even though you may hurt while doing them. It is recognizing that you can either stay home and hurt or go out and hurt. Researchers have found that acceptance seems to be generally helpful and has been associated with reduced pain severity, less distress and lower pain interference and disability.

A key factor in acceptance seems to be the state of mind of avoidance versus engagement. When you strive to control, get rid of, manage, find a cure for pain, you have an avoidance mindset. You are struggling and fighting and perhaps putting your life on hold until you can end your pain. Needless to say, this is a very stressful state of affairs that puts most of your focus and your energy on your pain— and it gets in the way of living. The engagement mindset has a very different “feel” to it. You are not pretending that you don’t have pain; rather you are saying to yourself, “Yes, I know I have pain and I wish I didn’t, but I will work to engage my life, my goals and my friends and family anyway.”It is not denying that you have pain. It is choosing to move your focus away from pain—onto living.

You may be skeptical about everything that you just read. You may think your pain is too severe or that you are too disabled or that it isn’t possible to accept living with pain. I agree: these are challenging ideas. I hope you will take sometime to think about them. I think they are worth thinking about. You may find that acceptance actually brings some relief to your suffering and opens doors that you thought were locked. {PP}

http://www.painpathways.org/pain-acceptance/

HIV And Neuropathic Pain Vid

Today's video is the second this week discussing neuropathy as a result of HIV or its treatment and as this is the core subject of this blog, it is worth viewing for those who find themselves in that position (from between 33% and 50% of all sufferers). Although neuropathy is much the same problem, with many of the same symptoms, irrespective of the cause, there are reasons why people with other conditions such as diabetes, cancer and HIV, are more prone to suffering nerve damage. This may help people living with HIV better understand why they seem to have been landed with yet another serious problem.

Neuropathic Pain in HIV Disease
PAINClinician Uploaded on 23 Feb 2012

David M. Simpson, MD
Professor of Neurology
Mount Sinai School of Medicine





https://www.youtube.com/watch?v=FDzbkYx_LKU

How The Antibiotic Ceftriaxone Can Reduce Chronic Pain

Today's short post from news-medical.net (see link below) looks at the potential for an antibiotic being used for analgesic purposes. Studies have shown that a dose of Ceftriaxone, an antibiotic used to kill microbes before surgery, has a significant effect on pain thresholds after the surgery. A small Italian study is mentioned here, involving 45 patients undergoing neuro surgery of one form or another. Those patients who had been injected with a single dose of the antibiotic prior to surgery could withstand post operative pain significantly better than those who did not. There are implications for the future treatment of neuropathic pain, if the process can be further refined and better targeted. This sort of study may mean little to the casual reader but it does illustrate the process of getting a new treatment into general practice. First, as is the case here, a success story has to be spotted and then others will take the idea or theory and try to apply it to other general situations. It may take years but at least you now know that an antibiotic can perform an analgesic function and may provide an alternative pain prevention tool in the future.

Study explores analgesic activity of ceftriaxone in humans

Published on June 26, 2013

A single dose of the antibiotic ceftriaxone given for antimicrobial prophylaxis prior to surgery enhanced patient pain thresholds after the procedure, according to a study published in The Journal of Pain, the peer review publication of the American Pain Society, www.americanpainsociety.org.

Previous studies have shown that drugs with a mode of action to enhance glutamate clearance might be effective in the treatment of chronic pain. In animals, repeated does of the antibiotic ceftriaxone have reduced both visceral and neuropathic pain. The drug induces activation of the GLT-1 gene. This is the first study to explore the analgesic activity of ceftriaxone in humans.

Researchers at University Sapienza in Rome analyzed whether a single dose of ceftriaxone given for antimicrobial prophylaxis prior to surgery could enhance patient pain thresholds after surgery. Forty-five patients undergoing surgery for carpal tunnel syndrome or ulner nerve compression disease participated in the study. They were randomized in three treatment groups: IV doses of saline, saline with ceftriaxone and saline with cefazolin. Injections were administered one hour prior to surgery, and mechanical pain thresholds were measured 10 minutes before the injections and 4 to 6 hours following surgery. No analgesic drugs were allowed in the first six hours after surgery.

Results in the human subjects showed that those treated with saline and cefazolin showed no change in mechanical pain thresholds six to seven hours after surgery, but pain thresholds in patients given a single preoperative does of ceftriaxone increased significantly.

This is the first study showing analgesia resulted from administration of an antibiotic in humans. The authors concluded that ceftriaxone should be the drug of choice for surgical prophylaxis in situations when pain does not rapidly resolve following surgery or when strong pain is expected to occur after surgery.

SOURCE American Pain Society

http://www.news-medical.net/news/20130626/Study-explores-analgesic-activity-of-ceftriaxone-in-humans.aspx

Can Poor Sleep Patterns Cause Chronic Pain In Older People

Today's article from sciencedaily.com (see link below) looks at the link between restless and disturbed sleep patterns and chronic pain, especially amongst older people. I think almost everybody living with chronic pain can identify with that. A bad night's sleep almost always results in more pain in the morning. Whether it's the pain that causes the poor sleep, or the other way around, is the question.
 

Could Restless Sleep Cause Widespread Pain in Older People? 
Date:
February 13, 2014
Source:
Wiley
 
Summary:
Researchers in the U.K. report that non-restorative sleep is the strongest, independent predictor of widespread pain onset among adults over the age of 50. According to the study anxiety, memory impairment, and poor physical health among older adults may also increase the risk of developing widespread pain. Muscle, bone and nerve (musculoskeletal) pain is more prevalent as people age, with up to 80% of people 65 years of age and older experiencing daily pain. Widespread pain that affects multiple areas of the body —- the hallmark feature of fibromyalgia —- affects 15% of women and 10% of men over age 50 according to previous studies.

Researchers in the U.K. report that non-restorative sleep is the strongest, independent predictor of widespread pain onset among adults over the age of 50. According to the study published in Arthritis & Rheumatology (formerly Arthritis & Rheumatism), a journal of the American College of Rheumatology (ACR), anxiety, memory impairment, and poor physical health among older adults may also increase the risk of developing widespread pain.

Muscle, bone and nerve (musculoskeletal) pain is more prevalent as people age, with up to 80% of people 65 years of age and older experiencing daily pain. Widespread pain that affects multiple areas of the body -- the hallmark feature of fibromyalgia -- affects 15% of women and 10% of men over age 50 according to previous studies.

Led by Dr. John McBeth from the Arthritis Research UK Primary Care Centre, Keele University in Staffordshire, this newly published population-based prospective study identified factors that increase the risk of the development of widespread pain in older adults. The team collected data on pain, psychological and physical health, lifestyle and demographic information from 4326 adults over the age of 50 who were free of widespread pain at the start of the study (1562 subjects reported no pain and 2764 had some pain). These participants were followed up three years later for the development of widespread pain.

Results show that at follow-up, 800 (19%) reported new widespread pain. The development of new widespread pain was greater in those with some pain at the start of the study; 679 (25%) of those with some pain and 121 (8%) of those with no pain at the start developed new widespread pain at three year follow-up.

Analyses determined that pain status, anxiety, physical health-related quality of life, cognitive complaint and non-restorative sleep were associated with increased risk of widespread pain development, after adjusting for osteoarthritis (OA). Increasing age was associated with a decreased likelihood of the development of widespread pain.

"While OA is linked to new onset of widespread pain, our findings also found that poor sleep, cognition, and physical and psychological health may increase pain risk," concludes Dr. McBeth. "Combined interventions that treat both site-specific and widespread pain are needed for older adults."

Story Source:

The above story is based on materials provided by Wiley. Note: Materials may be edited for content and length.

Journal Reference:
John McBeth, Rosie J Lacey, Ross Wilkie. Predictors of new onset widespread pain in older adults Results from the prospective population-based NorStOP study. Arthritis & Rheumatology, 2013; DOI: 10.1002/art.38284

http://www.sciencedaily.com/releases/2014/02/140213083711.htm

Two Anti Depressants For Nerve Pain How Did They Do

Today's short post from alert.psychnews.org (see link below) reports that a new study has shown both Duloxetine (Cymbalta and others) and Venlafaxine ( ‎Effexor, Trevilor, Lanvexin, others) to be reasonably effective treatments for nerve pain. Well reasonable in the sense that they performed better than other pills...when compared to placebos. These two serotonin-norepinephrine reuptake inhibitors (anti-depressants) are already widely prescribed for neuropathic pain but as we know, what works for one patient, doesn't necessarily work for others, which leads to patient frustration and difficulties for researchers and studies to come to definitive conclusions. The article also states that pregabalin is FDA approved for neuropathic pain - it's not! The FDA goes as far as to demand that warnings about the side effects be placed on boxes. It's a minefield for patients wondering whether what their doctor has prescribed is a)going to work and b) going to be safe. It is safe to say that almost all drugs prescribed to limit neuropathic pain can have side effects and therefore it's vitally important that you have a serious discussion with your doctor before embarking on a course of drugs. Together you need to weigh up the benefits and risks and even then there's no guarantee that your symptoms will diminish. However, maybe that shouldn't stop you trying - anything is better than that relentless pain...right! But your doctor should monitor your progress on any given drug, with great care and if necessary change the treatment.
 

Duloxetine, Venlafaxine May Be Most Effective at Reducing Diabetic Nerve Pain
Posted by Psychiatric News Monday, March 27, 2017

The serotonin-norepinephrine reuptake inhibitors duloxetine and venlafaxine appear to have the best evidence for being effective at reducing nerve pain in people with diabetes, according to a meta-analysis published in Neurology. Duloxetine is FDA-approved for treating pain in diabetic neuropathy, though venlafaxine is not.

The researchers pooled together data from 106 clinical studies published between 2011 and 2015 examining the effectiveness of pharmacologic approaches to improving pain in patients with diabetic peripheral neuropathy. The analysis compared outcomes in patients taking 21 different medications, though the authors were unable to draw conclusions for any head-to-head drug comparisons due to insufficient evidence.

The researchers found moderate evidence to suggest that duloxetine and venlafaxine were more effective at reducing neuropathy-related pain than placebo. Tricyclic antidepressants, botulinum toxin, the opioids tramadol and tapentadol, and the anticonvulsants pregabalin and oxcarbazepine were also found to be more effective than placebo, but the evidence base for these medications was weak.

In contrast, the anticonvulsant gabapentin, mood stabilizer valproate, and capsaicin cream were all found to be no more effective than placebo; these findings run contrary to guidelines for treating diabetic peripheral neuropathy published by the American Academy of Neurology in 2011, which listed all three agents as probably effective.

“Our findings generally support the effectiveness of the three drugs approved by the Food and Drug Administration (FDA) for the treatment of pain in diabetic peripheral neuropathy: duloxetine, pregabalin, and tapentadol,” wrote Julie Waldfogel, Pharm.D., of the Johns Hopkins Hospital and her colleagues. “Additional studies evaluating longer term outcomes are needed to better inform clinical decision-making, patient choice, and clinical practice guidelines.”

http://alert.psychnews.org/2017/03/duloxetine-venlafaxine-may-be-most.html

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