Wednesday, 26 October 2016

Opioids, Constipation And Chronic Pain

Today's post from (see link below) talks about opioid induced constipation and I dare say that many of you who take opioids regularly as the only means of keeping your neuropathic pain under control, will be fully and painfully aware of this unwanted side-effect. Please read the article, it will open up a whole new world of suffering thanks to nerve damage and the treatments used to suppress the pain and discomfort. Yet more pills needed to achieve the same effect then - sad but true!

The drug industry’s answer to opioid addiction: More pills
By Ariana Eunjung Cha October 16 2016

UNNATURAL CAUSES SICK AND DYING IN SMALL-TOWN AMERICA: Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it. Read the other stories in this series here.

Cancer patients taking high doses of opioid painkillers are often afflicted by a new discomfort: constipation. Researcher Jonathan Moss thought he could help, but no drug company was interested in his ideas for relieving suffering among the dying.

So Moss and his colleagues pieced together small grants and, in 1997, received permission to test their treatment. But not on cancer patients. Federal regulators urged them to use a less frail — and by then, rapidly expanding — group: addicts caught in the throes of a nationwide opioid epidemic.

Suddenly, Moss said, investors were knocking at his door.

“As clinicians, we wanted to help palliative patients,” said Moss, a professor and physician at University of Chicago Medicine. “The company that bought our work saw a broader market.”

Today, Moss’s side project is hailed as the next billion-dollar drug. And the once-disinterested pharmaceutical industry is bombarding doctors and the public with information about a serious, if previously unrecognized, condition common among the millions of Americans who take prescription painkillers. They call it “opioid-induced constipation,” or “OIC.”

The story of OIC illuminates the opportunism of pharmaceutical innovators and the consequences of a heavily drug-
dependent society. Six in 10 American adults take prescription drugs, creating a vast market for new meds to treat the side effects of the old ones.

[In a town where pills are currency, opioid addicts have few options]

Opioid prescriptions alone have skyrocketed from 112 million in 1992 to nearly 249 million in 2015, the latest year for which numbers are available, and America’s dependence on the drugs has reached crisis levels. Millions are addicted to or abusing prescription painkillers such as OxyContin, Vicodin and Percocet. Statistics from the Centers for Disease Control and Prevention show that, from 1999 to 2014, more than 165,000 people died in the United States from prescription-opioid overdoses, which have contributed to a startling increase in early mortality among whites, particularly women — a devastating toll that has hit hardest in small towns and rural areas.

The pharmaceutical industry’s response has been more drugs. The opioid market — now worth nearly $10 billion a year in sales in the United States — has expanded to include a growing universe of medications aimed at treating secondary effects rather than controlling pain.

There’s Suboxone, financed and promoted by the U.S. government as a safer alternative to methadone for those trying to break their dependence on opioids. There’s naloxone, the emergency injection and nasal spray carried by first responders to treat overdoses. And now there’s Relistor, the drug based on Moss’s work, and a competitor, Movantik, for constipation.

In colorful charts designed to entice investors, numerous pharmaceutical makers tout the “expansion opportunity” that exists in the “opioid use disorders population.”

Indivior, a specialty pharmaceutical company listed on the London Stock Exchange, sees “around 2.5m potential patients, the majority of whom are addicted to prescription painkillers,” as opposed to illicit drugs such as heroin. Another company, New Jersey-based Braeburn Pharmaceuticals, highlights “growth drivers” for the market, noting that millions of additional Americans not yet identified are also likely to be dependent on opioid painkillers.

Analysts estimate that each of these submarkets — addiction, overdose and side effects — is worth at least $1 billion a year in sales. These economics, experts say, work against efforts to end the epidemic.

If opioid addiction disappeared tomorrow, it would wipe billions of dollars from the drug companies’ bottom lines. 

A potent product

From a profit-making standpoint, opioids are a potent product. Chronic use can cause myriad side effects that usually are mild enough to keep people taking painkillers but sufficiently uncomfortable to send them back to the doctor.

Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, said this domino effect can turn a patient worth a few hundred dollars a month into one worth several thousand dollars a month.

“Many patients wind up very sedated from opioids, and it’s not uncommon to give them amphetamines to make them more alert. But now they can’t sleep, so they get Ambien or Lunesta. The amphetamines also make them anxious, paranoid and sweaty, and that means even more drugs,” said Kolodny, who also serves as chief medical officer to Phoenix House, a nonprofit organization that offers drug and alcohol treatment in 10 states and the District.

Women, in particular, are ideal customers. About 57 percent of working-age women who take opioids have four or more prescriptions, according to a Washington Post analysis of participants in the latest National Health and Nutrition Examination Survey. Among working-age women who don’t take opioids, 14 percent have four or more prescriptions, the analysis shows.

Among men, the numbers are significantly lower. About 41 percent of working-age men on prescription opioids have at least four prescriptions. Among men who don’t take opioids, 9 percent have four or more.

[Opiods and anti-anxiety medication are killing white American women]

Studies show that constipation afflicts 40 percent to 90 percent of opioid patients. As recently as a few years ago, doctors typically advised people to cut down the dosages of their pain meds, to take them less often, or to try non-drug interventions such as changing their diets or increasing physical activity.

By promoting opioid-induced constipation as a condition in need of more targeted treatment, critics say the drug industry is creating incentives to maintain the painkillers at full strength and add another pill instead.

“The pharmaceutical industry literally created the problem [of OIC],” Kolodny said. “They named it, and they started advertising what a serious issue it is. And now they’ve got the solution for it.” 

A Super Bowl ad

Opioid-induced constipation burst onto the biggest possible public stage in February, when AstraZeneca, maker of Movantik, aired a spot during Super Bowl 50 , one of the most expensive ad opportunities of the year. It featured a middle-aged man wistfully watching another man triumphantly adjusting his belt, a dog peacefully relieving itself under a tree and a woman striding by with a banner of toilet paper trailing victoriously from one high-heeled shoe.

“If you need an opioid to manage your chronic pain, you may be so constipated it feels like everyone can go — except you,” a narrator intones.

Play Video1:03
AstraZeneca's 2016 super bowl ad features a man looking for relief from constipation due to opioid use. (AstraZeneca)

That ad was aimed at men, but many others in the Movantik campaign target women, airing on “Good Morning America,” movies on the Hallmark Channel and specials about former first lady Jacqueline Kennedy, Princess Diana and singer Whitney Houston.

In one, a slightly overweight dark-blonde woman talks about “struggling to find relief.” In another, a giant cartoon pill looms sympathetically over a middle-aged brunette, who complains that opioids really helped with her pain but left her with some “baggage.”

“So awkward,” she sighs.

The Super Bowl ad, aired before an audience of more than 100 million people, quickly became the latest flash point in the country’s war against opioids. Vermont Gov. Peter Shumlin (D) called the ad “a shameful attempt to exploit America’s addiction crisis to boost corporate profits.” White House chief of staff Denis McDonough tweeted: “Next year, how about fewer ads that fuel opioid addiction and more on access to treatment.”

AstraZeneca and its marketing partner Daiichi Sankyo defended the commercials, calling opioid-induced constipation “a legitimate medical condition” affecting millions of Americans.

“The ad has driven good dialogue about OIC, and just as importantly, also added to the increasing and necessary conversation about the appropriate and safe use of opioids,” a spokeswoman said.

Paul Gileno, president of the U.S. Pain Foundation, a patient advocacy group that worked with AstraZeneca on the ads, notes that many people use opioids responsibly.

“People ask, ‘Why are you helping addicts?’ That’s not the case,” Gileno said. “We are trying to help people who are suffering from chronic pain to be able to continue on their medicines and live their lives.” 

A ‘brilliant’ pitch

Each tiny pink pill of Movantik retails for about $10, and most insurance plans cover it. Since the Super Bowl, prescriptions have jumped from 6,600 to 8,800 a week, AstraZeneca recently reported.

Movantik holds the dominant market share, but Canada’s Valeant Pharmaceuticals — one of the companies under fire by Congress for jacking up prices of old drugs — won approval in July from the Food and Drug Administration to sell Relistor, its version of the pill. Analysts estimate that as many as six other drugs may be on the market by 2019.

Investors have been talking about the “blockbuster potential” of these drugs since at least 2008, when Movantik had been tested on only a small number of human subjects, and long before it received FDA approval in 2014. While it is illegal to market a drug before approval, it is fine to market the condition the drug is designed to treat. And so “OIC” was born.

The branding began around 2010, when “OIC” began appearing in papers in some of the top medical journals, in poster presentations and on the lips of panelists speaking at major medical conferences. “Opioid-induced constipation” suddenly replaced what had been a vast vocabulary used to describe the problem, including terms such as “bowel dysfunction” and “gut motility.”

Last year, after it won government approval to sell Movantik, AstraZeneca rolled out a number of free continuing-education classes. Doctors and nurses must take such classes to remain licensed. The titles included: Opioid-induced Constipation: A Neglected Complication and Unmet Needs in Opioid-Induced Constipation.

The companies have also asked pain doctors to show patients a chart about stool “health,” with diagrams to help assess shape and clumpiness.

Adriane Fugh-Berman, a researcher at Georgetown University Medical Center who studies drug marketing, called the Movantik strategy “brilliant.” She compared it to other recent “disease awareness” campaigns focused on “premenstrual dysphoric disorder” (treatable with a new version of Prozac packaged in pink instead of blue) and “binge-eating disorder” (for which there is a new pill called Vyvanse).

The OIC campaign created the perception of great need for the drug when the market should be “vanishingly small,” Fugh-Berman said — certainly not big enough to justify ads during the Super Bowl.

“The best way to treat opioid-induced constipation,” she said, “is to prevent it in the first place by not overusing opioids.”

Moss reluctantly continued to test a constipation-easing drug he was developing on opioid addicts, rather than cancer patients, at the behest of the Food and Drug Administration. It became Valeant’s Relistor. (Lucy Hewett)

William Chey, director of the Gastrointestinal Physiology Laboratory at the University of Michigan, helped design and execute the first large-scale human study for a competing drug that became Movantik, the first drug on the market specifically approved to treat opioid-induced constipation. (Nick Hagen)
Potential for good and bad

Constipation is different for people on opioids. Opioids bind to a receptor that makes the gastrointestinal tract go awry, decreasing the secretion of fluids and inhibiting the muscle contractions that propel waste. As a result, stool gets “stuck.”

While mostly a nuisance, the condition can be serious, especially among people already weakened by end-stage cancer. Some patients have been rushed to the emergency room to have the material removed from their bodies.

In the early 1990s, Moss and his colleagues at the University of Chicago began working on a drug that would block what are known as mu opioid receptors, which are responsible for the side effect. The drug showed promise, and Moss was devastated when investors told him the potential profits were too small to be worth the risky investment.

“If you’re a drug company, who wants to make a drug for people who weren’t going to be around in a couple of months? They wanted to aim for something people could take for 10, 20 years,” recalled Moss, who specializes in anesthesiology and critical care.

The researchers decided to fund the work without industry help but ran into another roadblock: The FDA said it was too risky to continue testing the experimental drug on cancer patients. Regulators suggested a different population: opioid addicts being treated with methadone.

Moss was reluctant. He considered the idea a detour that would slow down his work. “Our hearts really sank,” he said.

Thinking that he had no choice, Moss began the testing, and the results were published in JAMA, the Journal of the American Medical Association, in 2000. Pharmaceutical companies immediately came calling.

Moss’s drug was picked up by a biotech company and, after changing hands a few times, eventually became Valeant’s Relistor. Nearly all the profits will go to the companies. The licensing deal through the University of Chicago calls for Moss and four colleagues to receive a modest initial payment in the thousands of dollars, plus a tiny slice of sales royalties. They also get “milestone payments” when the drug reaches a certain stage of approval or a certain market size.

Parallel efforts took off at other companies. Nektar Therapeutics, a small San Francisco firm specializing in drug research and development, had been working on a drug known as NKTR-118, which was aimed at limiting opioid penetration of the central nervous system and reducing side effects such as dizziness and sleepiness. But researchers found that it also helped with constipation.

In 2009, AstraZeneca bought the rights for the drug and recruited William Chey, director of the Gastrointestinal Physiology Laboratory at the University of Michigan, to help design and execute the first large-scale human study. The results, published in the New England Journal of Medicine in 2014, were a crucial part of pushing Movantik over the FDA finish line. Last year, it became the first drug on the market specifically approved to treat opioid-induced constipation.

Chey said that he has seen many patients with cancer and other serious illnesses suffering from the condition and that he believes Movantik can improve their quality of life. However, Chey said he also recognizes the concern that Movantik could enable chronic opioid use and worsen the nation’s epidemic of addiction.

“I’ve thought a lot about the potential good and bad,” he said. “Used responsibly, this is an incredibly valuable drug. Hopefully, people will use it that way.”

Dan Keating contributed to this report.

Ariana Eunjung Cha is a national reporter. She has previously served as the Post's bureau chief in Shanghai and San Francisco, and as a

correspondent in Baghdad.

Tuesday, 25 October 2016

Acupuncture Is One Of The More Difficult To Prove Neuropathy Therapies

Today's short post from (see link below) invites you to visit the Facebook page to find out why acupuncture is becoming more and more acceptable in the treatment of neuropathy and why would you not? (This blog avoids Facebook like the plague but accepts that it is a major information source in the medical world of today). Acupuncture, like so many so-called alternative treatments needs all the evidence it can find and produce, if it's to convince cynical neuropathy patients who've heard it all before. However, even more important that word of mouth evidence, is hard fact brought about by success stories across the spectrum. Like all therapies though, it's important that you trust both your practitioner and the basis behind his or her therapies and that requires a certain amount of research to establish some facts. The success of a therapy is often dependent on the fact that you're convinced by the theory, even if it doesn't seem to be working for you. By using the Search button you'll find many more articles on the subject here on the blog.

Acupuncture treats peripheral neuropathy
Maureen Lamerdin, O.M.D.

Peripheral neuropathy has become a more prominent complaint by many who suffer from varying conditions such as diabetes, spinal injuries, alcoholism, HIV, vitamin deficiencies and from adverse side-effects of specific drugs, most notably chemotherapy drugs. This debilitating condition can cause such symptoms as feeling like walking on glass, severe burning, numbness and tingling, weakness and flaccidity of the muscles which can lead to further injury.

This neurological disorder is caused by the abnormal functioning of the sensory, motor and/or autonomic nerves. Peripheral neuropathy typically affects the extremities, including the arms, legs, hands and feet. The time of day and one’s activity level can affect the frequency of the symptoms with this neuropathic condition. Some people may experience symptoms throughout the day, but have increased sensations in the evenings. Typically, applying pressure (such as from walking) will significantly aggravate the condition. There are many other factors that can exacerbate this condition such as stress. When treating this condition it’s important to treat the whole body for successful abatement of this disease.

Most people believe once the nerve fibers are damaged they can’t heal and so most people take pain relieving medication or drugs that specifically affect the nerves such as Lyrica or Neurontin. At best these treatments may help manage the pain, however they don’t help the regeneration of the nerves. Research shows the body does indeed have the ability to regenerate nerves. A lizard can regenerate nerves after the loss of an appendage and can actually recreate the extremity. Much of the human skeleton and nerve makeup maintains the ancient segmental pattern present in all vertebrates such as a lizard.

Numerous research has been published on the effectiveness of acupuncture treatment for peripheral neuropathy some of which include the European Journal of Neurology, JAMA, Sloan-Kettering Cancer Center and of course numerous studies in China. A study published in “Experimental and Toxicologic Pathology” showed electro-acupuncture was effective for regenerating nerve cells in rats who had experienced spinal cord injuries. The researchers reported electro-acupuncture restored partial function to paralyzed limbs in the injured rats. In a 10-week study conducted by the European Journal of Neurology patients were treated with acupuncture at determined points as determined by the practitioner. Patients had symptom relief as well as improved nerve conduction over the course of treatment, leading the researchers of the study to speculate acupuncture caused nerves to regenerate.

Peripheral neuropathy is considered a chronic disease which can be perplexing and involve diligent and consistent therapy to help the patient recover. Traditional Chinese medicine can help improve symptoms and offer people with peripheral neuropathy a better quality of life over time. Treatment of neuropathy should be considered as a long-term therapy and not just a short course of 10 sessions, as is usually implied with acupuncture.
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Monday, 24 October 2016

Opioids For Neuropathic Pain: Judge The Treatment Not The Patient

Today's post from (see link below) is an excellent assessment of the current situation regarding opioid prescription for chronic pain. If only all doctors took such a careful and measured approach. If you read this article, you are learning how your doctor should approach prescribing opioids for you (or not, as the case may be). The questions should always be: are opioids suitable for you and if they are; are you likely to abuse them in the future? No blame attached to the patient here because depending on how you react to a certain opioid should determine whether it is safe for you to have them. I have always maintained that if ever the doctor/patient relationship is important, it's in the prescription of opioids. The doctor needs to be able to trust in his or her judgement that you are a suitable recipient (meaning the drugs will work for you...not that he thinks you're a potential junky) and you need to trust in the fact that the doctor will take care of you and monitor you while you are on those drugs. If those conditions are met, then opioids are an excellent nerve pain killer. Read the article; it may help to clarify your own views on the subject.

Pain expert: Judge the opioid treatment, not the patient

By AMA staff writer Troy Parks 6/28/2016, 4:05 PM

With medications that carry significant risks, such as opioids, appropriate prescribing practices are critical to patient safety. One physician in Boston lives by a mantra that puts patients first: Judge the treatment, not the patient.

We need to start re-conceptualizing chronic pain as a chronic disease, said Daniel P. Alford, MD, associate professor of medicine at the Boston University School of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program.

“Acute pain is a symptom, and it’s life-sustaining—and you need to feel acute pain in order to survive,” Dr. Alford said. But “there is no advantage to chronic pain. Chronic pain really is a malfunctioning of the nervous system and requires, like other chronic diseases, a multimodal approach.”

Assessing whether opioids are the appropriate course of treatment

Many potential physical, psycho-behavioral, procedural and pharmacologic options exist for managing chronic pain. Dr. Alford follows a process that helps him to make the appropriate clinical judgment regarding whether or not opioids are an appropriate course of treatment for each individual patient:

1. Determine whether the patient has a pain process that is likely to respond to opioid therapy. For a lot of chronic pain disorders, opioids are probably not the answer, Dr. Alford said. “For example, chronic migraine headaches, fibromyalgia and back pain … tend to be less opioid responsive, and so I’d be reluctant to start them.”

For non-cancer chronic pain, opioids are indicated when pain is severe, has significant impact on function and quality of life and other treatments have been inadequate. “When you’ve tried other things and they haven’t been successful,” he said, “a trial with an opioid is appropriate.”

2. Prior to prescribing opioids, do a risk assessment. Attempt to evaluate how risky it might be to prescribe opioids to the individual patient, Dr. Alford said. “There are opioid misuse risk stratification tools … including the opioid risk tool (ORT),” which are intended to classify patients as low, moderate and high risk for opioid misuse. But you cannot rely on these tools alone because they have not been rigorously tested

They can help start the conversation about other known risk factors and predictors for problematic prescription opioids with the patient so that they’re informed about their risk, Dr. Alford said. “[This conversation] also helps you determine how to structure therapy and monitor them for safety—that is, if they’re at higher risk or misusing their opioids, then they need to be monitored more closely.”

3. Use universal precautions. Because no one can predict problematic behavior with absolute certainty, you have to “assume that every single person who’s prescribed opioids carries some risk for misusing that opioid,” Dr. Alford said. “Every one of my patients on chronic opioid therapy gets that initial risk assessment but also needs to be monitored for adherence and misuse.”

“The frequency of doing all those things,” he said, “is going to be based on your initial and ongoing assessment of their response to therapy, particular risks and behavior.”

4. Structuring care and monitoring the patient for safety.
Over time, monitor the patient for adherence using objective information including checking the prescription drug monitoring program (PDMP), urine testing, pill counts and making sure the interval between visits is appropriate. “If the patient is doing well based on pain relief, function and daily activities,” he said, “then I’m going to be less worried about their potential misuse of opioids.”

At least a 30 percent improvement in pain and function is a reasonable goal.

“Even if the person appears to be benefitting,” he said, “if you start to get a sense that they are misusing the opioid—that is, loss of control, compulsive use, continued use despite harm, they keep running out early, showing up in the emergency room, calling the on-call service, or they become so focused on the drug they can’t even imagine doing anything else for their pain, or they’re having some negative consequences from the opioid but still want more—I would probably end up tapering that opioid because I just feel that it’s too unsafe.”

“These are all very difficult decisions to be made,” he said.

5. Prescribing opioids for chronic pain at the lowest dose possible.
Dr. Alford said you should initiate therapy in a way that the patient understands that it is a test or a trial to see whether or not they will benefit from the treatment.

“If they’re not benefitting, then they may be in the portion of patients who are never going to benefit from an opioid because their pain is just not responsive to opioids” and the risks are too high, he said. “If they are responding, that’s encouraging—but I’m going to be very reluctant to increase the dose.”

As you increase the dose, the risk for overdose and other complications increases, Dr. Alford said. “If the patient is benefitting on the opioid, I want to try to maintain them on the lowest dose possible … keeping in mind that [with chronic pain] like other chronic diseases, I want to try to [use] other therapies concurrent to it, whether it be other medications, using rational polypharmacy or other non-pharmacological treatments like acupuncture, behavioral and physical treatments.”

Judge the treatment not the patient

Conceptually, treating chronic pain with opioids has to be viewed through the same lens as treating any other chronic disease with any other medication, Dr. Alford said. “That is, when I put someone on an antihypertensive for their blood pressure, I’m judging whether or not the treatment is working by measuring the person’s blood pressure and checking for adverse effects.”

“If it isn’t working, I’m not blaming the patient, saying this medication should work, but that patient is a bad person; they can’t take it right,” he said. “I’m judging the treatment both from a benefit and risk perspective.”

“Apply the same thing to opioids for pain,” he recommends. “Are the opioids helping the patient more than they’re hurting the patient? If that’s not the case, if I can’t be satisfied that the person is benefitting more than being harmed, then the treatment has failed—not the patient. … And it’s time to consider something else.”

“We need to put our clinician cap on and avoid becoming a police officer, or a DEA agent or a judge when it comes to opioids and chronic pain,” Dr. Alford said. “Chronic pain is a chronic disease, and opioids are one tool that benefits some patients but carries a whole lot of risk. And we should just treat it that way.”

Naloxone also can be a way to start the broader conversation about the risks that opioid medications carry without contributing to the stigma that surrounds overdose and substance use disorders.

For more on treating patients with chronic pain using opioid therapy treatment:

How to talk about substance use disorders with your patients
3 steps for talking with patients about substance use disorder
Physicians team up to treat addiction in rural areas
3 things every physician should do when treating pain

Sunday, 23 October 2016

The Mindfulness Solution For Chronic Nerve Pain

Today's post from (see link below) will have the cynics amongst you spluttering into your cornflakes because mindfulness techniques are among the most mocked medical treatments you can imagine. I understand your scepticism but would also pose the question: 'how's the standard medication treatment working for you'? If the answer is 'just fine' then you probably don't suffer from neuropathic symptoms any more and you probably don't need mindfulness as an extra tool. However, I suspect that 90% of you haven't found much relief from modern medicines and drugs, so maybe looking at something else to add to the arsenal against nerve pain problems, is not such a daft idea after all! The theory is that we can use the brain to help us get on top of persistent pain and by using certain techniques we can literally 'calm our pain down'. Now wouldn't that be wonderful, if we didn't need so many pills to achieve the same effect. The only thing that's required is patient compliance and at the very open mind. Okay, I'm not totally convinced myself yet but I'm a work in progress too!

4 Tips for Using Your Brain to Calm Pain Written by:Beth Darnall, PhD Posted On Friday, 14 October 2016

About 100 million Americans, one in three people, suffer from ongoing pain that impacts their daily lives. Chronic pain has fuelled a pain treatment crisis resulting in the over-prescribing of risky opioids.

The tragic deaths of celebrities such as Prince have brought the issue to public awareness in a way that statistics can’t.

The CDC recently recommended prescribers drastically limit opioids for pain; even for pain after surgery. This is a dire situation for patients who desperately need ways to relieve their short- and long-term pain without dangerous medications.

The most frequently overlooked pathway to pain relief is the patient.

There are powerful cognitive behavioral skills that the everyday patient can begin putting to immediate use for personal pain relief. Calming your nervous system is the key to reduction of pain, distress, and suffering.

Below are practical tips for using your brain to calm pain work over time to reduce pain naturally.

1) Quiet Your “Harm Alarm”

Think of pain as your harm alarm: a warning to escape danger. This warning registers in your nervous system and is distressing. Relaxation skills soothe your brain and body, making both less reactive to pain. To quiet your harm alarm, sit down in a quiet place and practice diaphragmatic breathing.

How to do it: Take a slow breath in through the nose, breathing into your lower belly for a few minutes. Simply be present with your breath as you allow your breath to slow and deepen. Imagine that you are expanding each breath down into your lower belly as your breathe. Allow any thoughts to float away as you guide your awareness back to your breath.

2) Understand Your Pain: It’s More than It Seems

Since you feel pain in your body, you tend to assume it’s just a physical sensation. Not true. Studies show that pain is a negative sensory and emotional experience. All pain is processed in your nervous system, which includes your brain and spinal cord. Your emotions, stress levels, expectations, beliefs, choices and thoughts -- your whole psychology -- affects your pain. This is why negative thoughts and emotions worsen pain.

3) Harness the Hidden Power of Your Thoughts

Brain scan studies show that when your attention is focused on pain, the pain grows in your brain; it actually gets worse. Negative thoughts make your “harm alarm” ring louder. Calming thoughts soothe your “harm alarm” and calm your nervous system, lessen distress and reduce pain.

Helpful: Make a list of your negative thoughts and next to each one, write a competing, positive thought. For example, negative thought: “My back is killing me and it’s getting worse.” Positive reframe: “I’m going to do what I can, right now, to make the pain as low as possible."

4) Take Your Mind-Body Medicine Daily

Using the mind-body skills described in steps 1-3 will help you reach your goal. Remember, many of the medicines prescribed by your doctor don’t take effect with the first pill. Most medicines are taken daily and build up in your body over time. Mind-body medicine is the same; it works over time. The feeling of calm will also happen over time, increasing the more frequently you practice your skills.

Become empowered to increase your comfort and ability to do the things you love.

*The Opioid-Free Pain Relief Kit includes these and many other steps that will help you live beyond chronic pain... naturally.

Beth Darnall, PhD

Beth Darnall, PhD, is a Clinical Associate Professor in the Division of Pain Medicine at Stanford University and treats individuals and groups at the Stanford Pain Management Center.

Darnall’s approach teaches patients to reduce their own pain and suffering, thereby reducing need for doctors and pills. She is the author of the The Opioid-Free Pain Relief Kit: 10 Simple Steps to Ease Your Pain, which includes a CD to induce deep relaxation.

She is also the author of Less Pain Fewer Pills; Avoid the Dangers of Prescription Opioids and Gain Control Over Chronic Pain, which provides concrete, evidence-based psychological and behavioral alternatives for pain control.


Saturday, 22 October 2016

Cannabis With Low THC Component Effective For Nerve Pain

Today's post from (see link below) discusses an interesting cannabis study directed at people living with significant neuropathic pain. The conclusions are: that compared with the placebo and after taking into account the psychoactive effects of vaporised cannabis, trial participants experienced a marked reduction in pain and that from a relatively low THC dosage. That's nothing new you might think; we've accepted that cannabis is an effective analgesic a long time ago but it is rare to see trials specifically for neuropathy patients and for that reason, it's worth publishing on this blog. The more concrete evidence, the better!

Medical Marijuana: Low THC Sufficient for Neuropathic Pain
Aug 29, 2016 | Caitlyn Fitzpatrick

Study results on the analgesic effect of cannabis have been mixed over the years. However, many states allow prescriptions for medical marijuana for a variety of health conditions, including pain. A recent study published in The Journal of Pain looked at the effect of marijuana treatment on neuropathic pain.

A team of researchers based in California conducted eight-hour human analyses to determine pain level outcomes with the use of vaporized cannabis. The cohort included 42 patients with neuropathic pain related to an injury or disease of the spinal cord. Although most of the participants were also on a traditional treatment, they were still experiencing pain.

The patients were randomized to take four puffs of vaporized cannabis that contained either placebo, 2.9%, or 6.7% delta 9-tetrahydrocannabinol (THC). Three hours later, the participants took another four to eight puffs – the number of puffs was decided by the patient in order to reduce the placebo effect.

An 11-point numerical pain intensity rating scale showed that the vaporized cannabis produced a significant analgesic response.

“When subjective and psychoactive side effects (eg, good drug effect, feeling high, etc) were added as covariates to the model, the reduction in pain intensity remained significant above and beyond any effect of these measures,” the report said.

Psychoactive side effects did occur as a result of the delta 9-THC, which is expected as marijuana is a brain-altering drug. The researchers said that neuropsychological performance was challenging to measure because many of the participants had disabilities.

Nevertheless, two of the highlighted findings included:

There was significantly more pain relief with active cannabis than placebo.
The two active doses did not have significantly different outcomes when it came to analgesic potency.

Since the higher active dose didn’t appear to provide more pain relief, the authors advise that patients with neuropathic pain associated with spinal cord injury or disease should be provided with the lower dose in order to avoid potential risks.

Friday, 21 October 2016

Early Neuropathy Detection Can Pay Off Big Time

Today's post from (see link below) looks at the condition known as pre-diabetes, which if identified in time can be treated so that there is much less lasting nerve damage than if it was ignored. By using skin biopsies to identify nerve damage progress. the severity of the neuropathy in the long run may be limited by swift action. It's a complex subject and the truth is that still relatively few skin biopsies are carried out because the symptoms are a very good indicator of active nerve damage and to save money, diagnoses are made based on  the symptoms and lifestyle of the patient and little more. Skin biopsies however, can reveal so much more information and lead to much better treatment. This article is definitely worth a read and maybe worth a little pressure on your doctor to do the most thorough tests possible.

Nerve damage in neuropathy progresses sooner than previously thought, lending urgency to earlier detection and treatment.
By David Glenn
The Fire Within

“If we wait until these patients have large-fiber neuropathy, we’ve needlessly lost time and nerve function. This is one more reason to be aggressive about controlling patients’ glucose levels.”

William Loughran retired from his job as a bank director in northeast Maryland in 2014, when he was 68. Like many new retirees, he vowed to ramp up his exercise routine.

“I started going to the gym three or four times a week and walking every day,” he says. “I felt better than I had in years.”

But then, after a long day of walking with his son during a visit to California, it began: “I went to bed, and the soles of my feet felt like they were on fire,” Loughran recalls. “It was jabbing pain, pins-and-needles pain, and it was pretty severe.”

Within weeks, Loughran’s feet had become so painful that driving his car was a struggle. “Just the slight pressure from the pedals was too much to tolerate,” he says. For months, he spent almost all of his time at home, in bare feet.

Loughran had developed peripheral neuropathy, a condition shared by hundreds of thousands of Americans. Peripheral neuropathy often begins with damage to the unmyelinated small-fiber nerves, resulting in numbness, tingling and lightninglike shooting pains, most commonly in the feet and hands. The best-known causes of peripheral neuropathy are type 2 diabetes and chemotherapy, but there are several other potential culprits. Vitamin B12 deficiency, high cholesterol, smoking and HIV/AIDS have all been implicated. Roughly one-fifth of peripheral neuropathy cases have no clear cause at all.

After several false starts with physical therapists, podiatrists and other specialists, Loughran realized that he needed to see a neurologist. He searched online and learned that Johns Hopkins has a prominent research program in peripheral neuropathy.

In early 2016, Loughran found himself in the Johns Hopkins office of Mohammad Khoshnoodi, an assistant professor of neurology. Here at last he received a thorough workup. “Dr. Khoshnoodi did much more extensive blood work than anyone else had done,” Loughran says. “He did nerve conduction studies to see if I had damage to the large-fiber nerves, which I didn’t. And he took three skin biopsies from my leg.” The idea of having skin samples extracted sounded odd at first, Loughran says. But if that was what was required, he was game.

The technique of using skin biopsies to assess peripheral neuropathy was pioneered at Johns Hopkins in the early 1990s by Justin McArthur, who now chairs the Department of Neurology, and the late John Griffin, one of the best-known neurologists in Johns Hopkins history. A major advantage of these biopsies is that they permit objective, quantifiable measurement of nerve damage. They can be taken sequentially from the same sites over a period of months or years, allowing researchers to see exactly how a patient’s nerves and their supporting structures change over time, and how that neurological damage is affected by changes in the patient’s underlying condition (whether that be diabetes, chemotherapy exposure or something else).

Sequential skin biopsies have become an increasingly powerful tool for uncovering the mysteries of neuropathy. Last spring, Khoshnoodi and five Johns Hopkins colleagues published a much-discussed study in JAMA Neurology that offered some provocative findings. The study considered skin biopsies that were taken sequentially from 52 patients with neuropathy at Johns Hopkins between 2002 and 2010, along with biopsies from 10 healthy volunteers for purposes of comparison.

The study’s first striking finding was that patients with impaired glucose regulation—a condition often known as prediabetes—saw their neuropathies progress just as aggressively as patients with full-blown diabetes. The second finding was that nerve damage increased just as fast at sites on the patients’ upper thighs as it did on patients’ toes and feet, where they actually perceived their symptoms.

“This study reinforces the idea that early neuropathy tends to progress,” says Michael Polydefkis ’93, a professor of neurology and the paper’s senior author. “Primary care doctors should always take it seriously, even if the patient is just talking about slight numbness.”

The fact that prediabetes can cause neuropathies just as severe as full-blown diabetes is relatively well-known among neurologists and endocrinologists, Khoshnoodi says, but it isn’t sufficiently appreciated by generalist primary care doctors. The sequential skin biopsy study should be a wake-up call, he says. “If we wait until these patients have large-fiber neuropathy, we’ve needlessly lost time and nerve function,” he says. “This is one more reason to be aggressive about controlling patients’ glucose levels.”

Left unattended, Polydefkis says, peripheral neuropathy can advance to more severe kinds of neurological dysfunction, including problems with balance, blood pressure regulation and difficulties in walking. In this study, 14 of 52 patients with small-fiber neuropathy progressed to mild large-fiber neuropathy, meaning that their ankle reflexes were reduced and they were less sensitive to the vibrations of a tuning fork. Such problems are often a prelude to more severe deficits in motion and sensation.

Though Loughran arrived at Johns Hopkins too late to take part in that particular sequential skin biopsy study, the three specimens taken from his ankle confirmed that his skin had a significantly reduced density of small-fiber nerves—the classic sign of small-fiber peripheral neuropathy.

Loughran says he was grateful to have a definitive diagnosis after months of confusion and anxiety. While there are currently no treatments that readily reverse neuropathy in Loughran’s situation, peripheral neuropathy pain can be relieved with various combinations of anti-seizure medications, antidepressants and opioid pain relievers.

“We’ve seen some dramatic improvements over time in these patients’ nerves. It’s an example of a severe form of peripheral neuropathy, a fatal form, that appears to be changing before our eyes.”

None of those drugs can cure the condition or even slow its progression. What can slow neuropathy’s progression—at least for many patients—is correction of the underlying cause. If the patient’s neuropathy is caused primarily by diabetes or prediabetes, strict control of blood glucose levels through diet, exercise and medication can do the trick. If the neuropathy is caused by vitamin B12 deficiency, that is usually simple to correct. If chemotherapy is the villain, the patient and his or her oncologist may want to consider a change in treatment.

“Skin biopsies can tell us exactly how much neuropathy you have, but they don’t tell us anything about the cause,” says Ahmet Hoke, a professor of neurology and another of the study’s authors. “The blood work becomes key. The blood work helps us establish the etiology.”

In Loughran’s case, the blood work strongly suggested prediabetes. He is acting accordingly. “I’ve cut out sodas,” he says, “and I’m trying to get back to exercising.”

For many patients, that last step is easier said than done. “We tell them to exercise,” Polydefkis says, “but exercise can be intolerable because of the burning pain and electric shocks in their feet. That’s why it’s so important to find the right combination of medications to get the neuropathy symptoms under control. Those medicines won’t cure the neuropathy, but they’ll allow patients to be more active, which in turn helps with glucose control when diabetes is a factor.” Swimming and other nonweight-bearing exercises are often the best options, Polydefkis adds.

Hoke notes that the sequential skin biopsy study also shed light on the still-unsettled question of why exactly diabetes and prediabetes tend to damage the nerves. Some theories have emphasized the fact that the longest sensory neurons, which extend all the way from the spine to the toes, have huge metabolic needs because of their extreme surface-to-volume ratios. The metabolic dysfunctions associated with diabetes, according to this theory, make it difficult for the long neurons to balance their energy requirements, and they eventually stop working properly. Other scientists have emphasized a simpler, more mechanical model. Diabetes, they say, slowly damages the blood vessels that supply nerves with oxygen and nutrients. Diabetic neuropathy, in this view, is mostly a problem of the vasculature.

For Mark E. Rubenstein, It’s Personal

Much of the recent Johns Hopkins research on peripheral neuropathy, including this year’s high-profile study of sequential skin biopsies, has been financially supported by Mark E. Rubenstein, a trustee emeritus of The Johns Hopkins University and Johns Hopkins Medicine.

This sort of gift is nothing new for Rubenstein. For decades, he has supported several lines of medical research at Johns Hopkins. This one, however, is more personal for him than others, as he himself has contended with one of the most severe types of diabetic neuropathy.

Rubenstein, who retired in 2004 as chief executive of the Rubenstein Company, a major commercial real estate firm, was diagnosed with type 2 diabetes more than 40 years ago. He has long experience with the common symptoms of diabetic neuropathy, including numbness, tingling and shooting pains in the feet. In 2011, those symptoms suddenly blossomed into something much more severe. “Over a period of two weeks, I lost 15 pounds,” he says, “and the muscles in my left leg started to waste away.”

Those were the hallmarks of diabetic amyotrophy, which is sometimes known as Bruns-Garland syndrome. The condition often recedes on its own but sometimes leads to full-blown paralysis in the affected limb. Rubenstein went to see Michael Polydefkis at Johns Hopkins, who prescribed new medications to manage the pain and, more importantly, referred Rubenstein to expert physical therapists for an exercise program that allowed him to rebuild the lost muscle in his leg.

“He’s a fantastic doctor,” Rubenstein says. “He has great empathy for patients. He really got me through this.”

Polydefkis, for his part, is grateful for the research support Rubenstein has provided in the last few years. “For an ambitious program like ours,” he says, “it makes an enormous difference to have this kind of open-ended support.”

The Johns Hopkins studies tend to support the metabolic theory, Hoke and Polydefkis say (though both add that vascular problems probably contribute). “What’s so interesting,” Hoke says, “is that we see damage that is just as bad in prediabetes as in diabetes. That suggests that it isn’t the overall amount of glucose that is causing the neuropathy, but instead that it’s rapid fluctuations in glucose levels. There’s something about those fluctuations that the nerve cells can’t tolerate.”

What about patients who have been diagnosed with diabetes or prediabetes but don’t have any symptoms of neuropathy? “If I were in that situation, I would be vigilant,” Polydefkis says. “There’s reason to believe that nerve damage is already occurring in such patients. I would be very careful about trying to keep my glucose levels stable.”

Howell Todd’s story began much like Loughran’s. He retired as a university president in 2001, moving to a 55-acre farm in rural Tennessee. He looked forward to spending his days reading and raising crops. Not long after retirement, however, he began to notice odd tingling in his feet when he exercised on his elliptical trainer.

“At first, it was just uncomfortable,” he says. “Then, it began to progress. It got to the point where I would wake up at 2:30 in the morning with my feet flaming.”

In 2012, he flew to Johns Hopkins for a workup. Like Loughran, Todd had skin biopsies that clearly indicated peripheral neuropathy. Unlike Loughran, however, Todd turned out to have no identifiable underlying cause—no diabetes or prediabetes, no hyperlipidemia, no B12 deficiency. His is one of the roughly 20 percent of peripheral neuropathy cases that are classified as idiopathic.

These are the cases that Polydefkis finds most frustrating. All he can do as a neurologist is suggest medications to keep the symptoms in check. (He recommended that Todd start a daily regimen of pregabalin and tramadol, a combination that Todd says has served him well for four years.)

Todd says that he is glad he made the trek to Johns Hopkins, even if there is no miracle cure at hand. “Dr. Polydefkis had an excellent bedside manner,” he says. “He and everyone there took the time to talk with me. I’ll be 73 this fall, and I’m still able to do maintenance work on the farm, as long as I watch my limits. I don’t think I could have done that without the medications he suggested.”

While there are currently no treatments that readily reverse peripheral neuropathy, Johns Hopkins researchers are looking at a number of potential molecular targets for medications and are also actively involved in planning clinical trials.

Hoke has been studying medications that might offer protection to cancer patients’ nerve cells before they begin chemotherapy. In 2014, he and his colleagues screened thousands of compounds from a Johns Hopkins drug library. They discovered that ethoxyquin—an antioxidant that is sometimes used as a pet food additive—seems to protect nerves exposed to paclitaxel and cisplatin, two of the most notoriously neurotoxic chemotherapeutic drugs. In recent months, Hoke and Polydefkis have also tested ethoxyquin in animal models of diabetic neuropathy, with promising results. To bring these studies closer to human clinical trials, the team recently received one of the inaugural grants from the Louis B. Thalheimer Fund for Translational Research, a new Johns Hopkins effort to accelerate the development of university discoveries.

“Skin biopsies can tell us exactly how much neuropathy you have, but they don’t tell us anything about the cause. The blood work becomes key.”

Polydefkis is also involved in an international clinical trial of a new medication that may be effective against a rare and devastating inherited neuropathic disorder. The condition, known as transthyretin familial amyloid polyneuropathy, affects roughly 10,000 people worldwide, usually striking in middle age.

“The transthyretin protein normally has a four-leaf clover structure,” Polydefkis says. “But in people who inherit this condition, it has a malformed structure and clumps within the nerves. When those deposits build up, peripheral nerves start to malfunction, and the patient experiences peripheral neuropathy. The disease eventually involves sensory, motor and autonomic nerves, and it is fatal.”

The ongoing clinical trial is assessing a medication known as patisiran, which inhibits the liver’s production of the malformed proteins. Polydefkis and his colleagues have a specific role: to examine skin biopsies sent every few months from trial participants around the world. “We’ve been getting biopsies from Brazil, from Norway, from all sorts of places,” Polydefkis says. “We’ve seen some dramatic improvements over time in these patients’ nerves. It’s an example of a severe form of peripheral neuropathy, a fatal form, that appears to be changing before our eyes.”

Loughran, meanwhile, has signed up for a study that will closely monitor patients’ neuropathic status, glucose control, blood pressure and a wide variety of other variables, with an eye toward developing a deeper understanding of how these factors affect each other.

“My symptoms are gradually improving,” he says. “I’ve finally gotten to the point where I can at least do some exercise. It was initially both feet—front, back, everywhere. Now it’s regressed to just the bottom of the feet. And now that I’ve heard about this possible prediabetes, I’m going to get back to the gym.”

Thursday, 20 October 2016

How Good Is Methadone For Neuropathic Pain?

Today's post from (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.

David E Weissman MD

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.

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.


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 ( - no longer publicly available). Updated Report available at:

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 ( 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.

Wednesday, 19 October 2016

Vitamin B Overdosing A Potentially Serious Problem For Neuropathy Patients

Today's post from (see link below) reinforces the message that you should be careful with how much and how many Vitamin B variants you swallow in an attempt to reduce neuropathy symptoms. The common theme you'll find all over the internet is that nerve damage is often caused by a vitamin B deficiency and although people are warned to get their vitamin B levels tested first to see if this is true; many head straight for the supplement store and pile in extra B12 and Vitamin B compounds without really checking if they're doing the right thing or not. It's a common-held misconception that all vitamin supplements are good for you and while this may be partially true if your lifestyle leads to vitamin deficiencies, you can definitely overdose on many vitamins, causing unnecessary and sometimes serious problems as a result. This article should serve as a warning but in this case, only regarding B9 (folate/folic acid). However, the message applies to all vitamin supplements - check first if you actually need them before supplementing and then stick to the maximum daily intake (at the most).

High folate intake linked with nerve-damage risk in older adults with common gene variant
Date:October 12, 2016 Source:Tufts University

Consuming too much folate (vitamin B9) is associated with increased risk for a nerve-damage disorder in older adults who have a common genetic variant. Although variable by race or ethnic background, an estimated one in six people in the U.S. carry two copies of a genetic variation in TCN2, a gene that codes for a vitamin B12 transport protein. For some of these individuals, the TCN2 variation (referred to as GG) can lead to conditions related to vitamin B12 deficiency even if they consume normal amounts of B12. In an epidemiological study involving 171 adults aged 60 and older, a team led by scientists from the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts (USDA HNRCA) found that individuals with the GG variant of TCN2 were three times more likely to have peripheral neuropathy -- nerve damage commonly associated with vitamin B12 deficiency -- when compared to individuals without the variant.

Among study subjects who consumed more than twice the Recommended Dietary Allowance (RDA) of 800 micrograms per day of folate, individuals with the GG variant had seven-fold higher odds for peripheral neuropathy compared to those without. The team found no significant difference in odds among individuals who consumed less than 800 micrograms of folate a day.

The findings were published in the American Journal of Clinical Nutrition on Oct. 12.

"Due to the prevalence of the TCN2 variant, and because the average daily folate intake for U.S. adults over 50 is already more than twice the RDA, we believe that our findings highlight a potential concern for a large proportion of older Americans," said senior study author Ligi Paul, Ph.D., scientist in the Vitamin Metabolism Laboratory at the USDA HNRCA. "Our data suggest that older adults should keep folate intake close to the recommended amounts, and try to get nutrients from a balanced diet rather than depending on supplements."

Older individuals are at particular risk for vitamin B12 deficiency due to decreased stomach acid production and use of certain medications, which interfere with the absorption of the vitamin from food. Long-term B12 deficiency can cause a range of symptoms, including anemia and peripheral neuropathy -- damage to the peripheral nervous system marked by lack of coordination, weakness, or pain, tingling, and numbness in the hands and feet.

Consumption of folate -- the term for both naturally occurring food folate and folic acid, the synthetic form of folate found in fortified foods and supplements -- is known to alleviate anemia associated with B12 deficiency. However, previous studies have found evidence that excess folate intake could potentially worsen associated neurological deficits, including peripheral neuropathy, in older adults. The new findings now reinforce these observations and suggest that older adults should pay particular attention to their folate intake, especially from supplements or fortified foods.

"Folate is a necessary vitamin and no one should think that it needs to be avoided. But in certain situations, very high intake of folate may be harmful," said lead author Hathairat Sawaengsri, Ph.D., who conducted the study while a doctoral student in the biochemical and molecular nutrition program at the Friedman School of Nutrition Science and Policy at Tufts University and a member of the Vitamin Metabolism Laboratory at the USDA HNRCA. "Vitamins and minerals should be consumed at an optimal level -- not too high and not too low."

The authors caution that the design of the study does not allow for the determination of a cause and effect relationship -- high folate intake is associated with increased risk of peripheral neuropathy, but is not identified as a direct cause. The prevalence of the TCN2 variant differs depending on ethnic background, but the team did not find that it affected the observed association between TCN2 polymorphism and peripheral neuropathy in this study. In addition, increasing sample sizes could improve the accuracy of their findings. The odds ratios for peripheral neuropathy were calculated based on 31 individuals with the GG variant out of 171 individuals in the total study population.

The results, however, add to growing evidence that both low and high folate intake can be associated with negative health outcomes. In previous work, Paul and her colleagues found that excess folic acid consumption is associated with shortening of protective structures (telomeres) on human chromosomes and can reduce the ability of the immune system to destroy cells infected by viruses in aged mice.

Insufficient folate intake by pregnant women can cause birth defects such as spina bifida and neural tube defects, and the Food and Nutrition Board of the National Academies of Sciences, Engineering, and Medicine recommends that all women of childbearing age should get the RDA (400 micrograms) of folate, or 600 micrograms if they are pregnant.

According to the National Institute of Health's Office of Dietary Supplements, approximately 35 percent of people in the U.S. consume folic acid in dietary supplements. Some population groups, particularly adults aged 50 and older, are at risk of consuming excess folate. The federal government's Dietary Guidelines for Americans advises that nutrients are best obtained from natural food sources.

Story Source:

Materials provided by Tufts University. Note: Content may be edited for style and length.

Journal Reference:
H. Sawaengsri, P. R. Bergethon, W. Q. Qiu, T. M. Scott, P. F. Jacques, J. Selhub, L. Paul. Transcobalamin 776C->G polymorphism is associated with peripheral neuropathy in elderly individuals with high folate intake. American Journal of Clinical Nutrition, 2016; DOI: 10.3945/ajcn.116.139030

Tuesday, 18 October 2016

Neuropathy Patients Hate Exercise But They Mustn't Avoid It

Today's short post from (see link below) is a response from a doctor to a question most of us with neuropathy hope the answer to, will be a resounding "No". Unfortunately, the answer is yes to the question as to whether exercise helps with neuropathy. So we need to be prepared to put our bodies through yet more pain and discomfort for their benefit in the long run. The key is, making exercise something that is so obviously valuable that we can't ignore it and making it as pleasurable as possible. You can groan all you want (I do too) but the fact is that neuropathy weakens our muscles and joints to such an extent that it makes the pain considerably worse, never mind the fact that we can't do simple tasks any more. Read the article and think about your best strategy but don't overdo it and listen to your body when it tells you that you're doing just that.

Departments: Ask the Experts
You Ask. We Answer:

Is exercise helpful for peripheral neuropathy?
Ensrud, Erik MD
Neurology Now: October/November 2016 - Volume 12 - Issue 5 - p 31 doi: 10.1097/01.NNN.0000503487.82934.2d
Q Is exercise helpful for PERIPHERAL NEUROPATHY?


Yes, as long as you aren't overdoing it. The same benefits that anyone gets from exercise—improved cardiovascular function, increased mobility, a boost in mood—are realized by people with peripheral neuropathy, regardless of its cause. People with neuropathy may also experience an improvement in function and quality of life, as well as a decrease in pain.


Peripheral neuropathy is a general term for a group of diseases that affects motor and sensory nerves outside the brain and spinal cord. There are different types of neuropathy, and each has different causes and effects. Focal neuropathy, for instance, usually affects just one nerve or group of nerves. A common example is carpal tunnel syndrome, which involves nerve damage in the wrist. Any exercise that involves repetitive motion directly on the joint, such as playing tennis or texting or typing for hours on end, could aggravate the condition. Proximal neuropathy can reduce muscle strength in the legs and hips, so patients with this type of neuropathy might try riding a recumbent bike to avoid putting too much force on a compromised leg or hip joint.


When people think of exercise, they often think of the intense workout regimens of Olympic athletes like Michael Phelps and Katie Ledecky. But for most people, intense exercise is counterproductive. For people with neuropathy in particular, overstressed muscles may not recover as well because of existing nerve problems. A good rule of thumb during exercise is the talk test: If you can maintain a conversation without becoming breathless while exercising, you are likely at the right exertion level.


If physical activity feels like a chore or is inconvenient, you'll eventually stop doing it. Decide what you like to do—swimming, biking, walking, dancing, yoga, tai chi—and how you like to do it—with friends, at home, in nature, as part of a class—and you're more likely to stick with it. The goal is to create a positive association with exercise so you do it more often. Consider an activity tracker, which logs your steps every day; seeing the steps add up can be very motivating for some people.


Before beginning any exercise program, talk to your doctor. You want to be sure you don't have any conditions that may affect the type of exercise you can do or how long you can safely do it. Once you get the all-clear, start out with five to 20 minutes of exercise three times a week. As your fitness improves, gradually add minutes, distance, or intensity. A good way to start is by walking around a large indoor shopping mall or store. The surface is level, the temperature is comfortable, you can use a shopping cart for stability, and it's free—unless, of course, you buy things.

Dr. Ensrud is director of neuromuscular disease rehabilitation at St. Luke's Rehabilitation Institute in Spokane, WA. He is also a member of the American Academy of Neurology.

© 2016 American Academy of Neurology

Monday, 17 October 2016

Physiotherapy For Neuropathy? Worth A Shot

Today's post from (see link below) promotes the use of physiotherapy as part of your neuropathy treatment. It's important at this point to distinguish between physical therapy and chiropractic therapy because in general, chiropractors can have little effect in improving your neuropathy symptoms. Physiotherapy will also do nothing to make your neuropathy better but what it can do, is address the weakness and loss of muscle strength, plus eventual joint problems, that arise due to the effects of nerve damage. In that sense it can make your neuropathy experience more comfortable by improving your physical ability to carry out tasks that have been compromised by nerve damage. Most neuropathy patients will have noticed a marked decrease in muscular function: partly because the pain of neuropathy discourages exercise but also because decrease in muscle density has a direct link to damage of the nerves that stimulate it. Another advantage of physiotherapy is that most insurance covers across the world will at least cover enough sessions to find out whether physio is something for you. Maybe worth consideration: talk it over with your doctor.

Did You Know? Physiotherapy can help with Peripheral Neuropathy!
October 5, 2016 by Christine Campbell, Physiotherapist

Physiotherapists play a vital role in helping individuals improve and maintain functions that may be limited by Peripheral Neuropathy (PN). PN has a variety of causes, types and symptoms and therefore it is essential for each treatment plan to be tailored to help address each patient address their specific needs and goals. Physiotherapy may be helpful in maintaining strength, mobility, and function regardless of the underlying cause of PN.

Research has shown that strengthening exercises for peripheral neuropathy moderately improve muscle strength in people with PN. In addition, exercises to help peripheral neuropathy, when done regularly, may reduce neuropathic pain and can help control blood sugar levels.

The goals and treatment options associated with Peripheral Neuropathy are as follows: 

Decrease pain and numbness
There are many different treatment options to help manage the patient’s symptoms, such as hands-on soft tissue work, stretching, and nerve glides. Nerve gliding/flossing are effective exercises to help ‘unstick’ the affected nerves. This type of treatment helps manage mononeuropathies (peripheral neuropathy where only one nerve is affected) 

Improving overall function by maintaining or improving range of motion
This can be achieved through hands-on soft tissue work, passive range of motion or home exercises/stretching
A physiotherapist can also recommend moderate-intensity exercises that are best suited for the patient, which will help improve their physical function 

Maintain or improve strength
A specific series of exercises would be taught given a patient’s current strength, endurance and tolerance 

Prevention of falls
Balance training and coordination exercises will be prescribed, as well as discussing strategies for home to help prevent a future fall
Physiotherapists can also recommend braces and/or splints to enhance balance and posture 

Your physiotherapist may educate the patient on how to safely manage PN. The education will vary based on individual needs, and may focus on improving safety, preventing further complications, and finding alternative ways to perform certain tasks.

Sunday, 16 October 2016

Watch Out For Commercial Neuropathy Sites: They May Not Be All They Seem

Today's post from (see link below) promotes a new website claiming to be a valuable resource for people suffering from neuropathy. It is created by a 'group of neuropathy professionals' but it is not clear who they are and after a very generalised opening article that seems promising to neuropathy sufferers, it actually turns out to be a commercial site promoting their own supplement products. Now let me say here that the information on this site regarding neuropathy may be perfectly accurate and informative but I take issue with companies that first give the impression that they are independent distributors of information about a disease that afflicts millions and having sucked you in, then go on to blatantly sell their own products with claims that they will help. They may help....who knows but this is just the latest in a long line of subtle and subliminal marketing tricks to get you to part with your money and sorry...long suffering neuropathy patients deserve better than that. If you want to promote your product, fine but don't hide behind a sort of façade that suggests something completely different. In the end it always boils down to 'let the buyer beware' but be aware that advertising is very sophisticated these days.

Neuropathy Professionals Launch Nerve Pain and Neuropathy Relief Website
October 14 02:50 2016

A group of neuropathy professionals has announced the launching of a new website,, that will bring together recommendations for trustworthy products and informative articles that will help those afflicted with chronic nerve pain regain their normal lives through neuropathy relief.

New York, NY – A group of neuropathy professionals has announced the launching of a new website,, that will bring together recommendations for trustworthy products and informative articles that will help those afflicted with chronic nerve pain regain their normal lives through neuropathy relief. Having the right information about a problem like nerve pain is the first step towards seeking the proper treatment. The new website hopes to both inform those suffering from constant discomfort due to nerve pain of the causes and symptoms of the problem, as well as pointing them towards leading options for pain relief.

Kelly Ableman, a spokesperson for the new website, has this to say, “This website hopes to assist people in discovering the truth that lies behind nerve pain and neuropathy. Comprehending the nature underlying the problem is a great first step in finding pain relief methods that work well. Neuropathy is both debilitating and common. Yet many of those who suffer from nerve pain are poorly informed about their condition and their treatment options. We hope to meet a strong need for an informational resource of this nature.” will have everything regarding nerve pain. It will give insights and education that will help those afflicted learn more regarding current conditions, what creates nerve pain, what one can do to manage it, and the ways it affects those suffering and their loved ones. This is irrespective of the pain coming from diabetes, fibromyalgia, or any other range of maladies. This searing, burning, and shocking form of pain could leave people feeling miserable and helpless; which is unacceptable in the eyes of the website’s founders.

Unfortunately, most general physicians have little training where treating nerve pain is concerned. As a last ditch resort, they often prescribe anti-inflammatory medication. These are not effective against nerve pain, prolonging unhappiness, and discomfort for patients. On the website, differing treatment options available include natural methods, medications, supplements, and nutritional support. The website and its social media associates, Facebook and Twitter, aspire to provide diverse reviews and information about solutions and treatments.

The articles and reviews presented here will give patients and caretakers solutions, not only about diverse painkilling medications, but also about various side effects that might come with certain prescriptions. One example is a situation where someone suffering chronic pain could begin to rely too much on painkillers, leading to an addiction. Information available also features vitamins and supplements indicating what role these play to those with nerve damage. Also, there will be insights into various therapies that overcome the discomfort.

The newly launched website,, is a valuable resource to those who are suffering from chronic pain relating to the nerves. This type of pain can be debilitating and is often not easily treated. The new website is based on all things related to neuropathy relief, including information about various forms and causes of nerve pain and natural remedies and therapies.



Kelly Ableman