Gabapentin And Pregabalin Lyrica Really Are A Danger To Your Neuropathic Health!

Today's post from pulsetoday.co.uk (see link below) is an impassioned plea from a home doctor who is seeing the consequences of long-term gabapentin and pregabalin (Lyrica) use in his surgery. Finally, a doctor who stands up to the hype that the pharmaceutical companies use to promote their drugs! Many, many neuropathy patients across the world have been prescribed either gabapentin or pregabalin for their nerve pain and other symptoms. This blog has long warned of the dangers of Lyrica (pregabalin) and advised patient to have serious discussions with their doctors if they are being prescribed these drugs. This article explains why and in terms you can't ignore. These drugs aren't the first and they won't be the last to display dangerous side effects years after the profit on them has been made. As Dr Spence says: "If it quacks like a duck and looks like a duck, then it’s a ducking duck"!

Gabapentinoids - the new diazepam?
Posted by: Dr Des Spence 9 September 2016

The establishment ignores GPs. It prefers the advice and glamour of ‘expert’ or media doctors. But the deference shown to the ‘expert’ is creating overtreatment, medicalisation and iatrogenic harm.

GPs have to ignore this advice. We won’t prescribe statins to everyone because it is irrational and stupid. We don’t accept that ‘pain is what the patient says it is’, because common sense dictates that it isn’t.

And we have seen the damage when experts have free rein. Diazepam was peddled as a safe and effective treatment for anxiety by companies and experts alike. When I started work in the early 1990s the consequence of this advice was evident everywhere. Herds of middle-aged patients zonked out and dependent on benzodiazepines. And benzodiazepines were being widely abused by a younger generation. My surgeries were spent dealing with drug-seeking behaviours, lies, confrontation, rebound agitation, insomnia and withdrawal seizures. It took the establishment decades to realise the harms we caused. Even today, we are still dealing with it.

GPs are first to notice the danger posed by psychoactive drugs. In the past five years my sensor has been off the scale with the gabapentinoids (gabapentin and pregabalin). Patients are seeking them using the crude acting skills that I used to witness with benzodiazepines: anger, tears and threats; constant requests for dose increases; stories of lost scripts; and a tag-team approach with friends who ‘corroborate’ stories.

If you google ‘gabapentinoids’, it is clear they are being widely abused. Large quantities are taken as single doses. Users describe them as the ‘ideal psychotropic drug’ with effects of ‘great euphoria’, ‘disassociation’ and an ‘opiate buzz’ as they boost the effects of these drugs.[1,2]

I wrote an article in the BMJ in 2013[3] highlighting these concerns. Since then, prescriptions have nearly doubled in three years to 10 million scripts and more than £300m in costs.[4] Such rapid increases are the signature of inappropriate prescribing and iatrogenic harm. Many practices started prescribing gabapentinoids on the back of specialist endorsement, despite the existence of effective and less harmful alternatives.[5,6] But requests from pain clinics and psychiatry come thick and fast. We decline many, then weather the storm of protest.

Do we have a problem with gabapentinoid abuse? If it quacks like a duck and looks like a duck, then it’s a ducking duck. Pregabalin is already a controlled medication in the US and there is debate about controls in the UK. The research base for the benefits of gabapentinoids is of short duration and in a small, defined population where as few as one in 10 benefits.[7] We need to change our prescribing policy now and limit the use of gabapentinoids.[2]

We know the pattern: GPs will be blamed even if we just follow orders. I get tired that no one listens to generalists. This is déjà vu. Do we want another benzodiazepines disaster?

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

References Schifano F, D’Offizi S, et al. Is there a recreational misuse potential for pregabalin? Analysis of anecdotal online reports in comparison with related gabapentin and clonazepam data. Psychother Psychosom 2011;80:118-22
Advice for prescribers on the risk of the misuse of pregabalin and gabapentin. Public Health England, 2014
Spence D. Bad medicine: gabapentin and pregabalin BMJ 2013; 347 08 November 2013
NHS Prescription Cost Analysis data. NHS Business Services Authority, 2016
Wiffen P, Derry S, et al. Antiepileptic drugs for neuropathic pain and fibromyalgia - an overview of Cochrane reviews Cochrane Database Syst Rev 11 November 2013; (11):CD010567
Moore R, Derry S, et al. Amitriptyline for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2012 Dec 12;12:CD008242
Advice on the anticonvulsant drugs pregabalin and gabapentin. Advisory Council on the Misuse of Drugs, 2106 

http://www.pulsetoday.co.uk/views/blogs/gabapentinoids-the-new-diazepam/20032721.blog

EFFECTS OF HIGH RISK PARKINSONS MUTATIONS ARE REVERSIBLE

Researchers from the University of Sheffield have found vital new evidence on how to target and reverse the effects caused by one of the most common genetic causes of Parkinson's.

Mutations in a gene called LRRK2 carry a well-established risk for Parkinson's disease, however the basis for this link is unclear.

The team, led by Parkinson's UK funded researchers Dr Kurt De Vos from the Department of Neuroscience and Dr Alex Whitworth from the Department of Biomedical Sciences, found that certain drugs could fully restore movement problems observed in fruit flies carrying the LRRK2 Roc-COR Parkinson's mutation.

These drugs, deacetylase inhibitors, target the transport system and reverse the defects caused by the faulty LRRK2 within nerve cells. The study is published today (15 October 2014) month in Nature Communications.

Dr De Vos, a Lecturer in Translational Neuroscience at the world-leading Sheffield Institute for Translational Neuroscience (SITraN), said: "Our study provides compelling evidence that there is a direct link between defective transport within nerve cells and movement problems caused by the LRRK2 Parkinson's mutation in flies."

Co-investigator Dr Alex Whitworth explained: "We could also show that these neuronal transport defects caused by the LRRK2 mutation are reversible.

"By targeting the transport system with drugs, we could not only prevent movement problems, but also fully restore movement abilities in fruit flies who already showed impaired movement marked by a significant decrease in both climbing and flight ability."

The LRRK2 gene produces a protein that affects many processes in the cell. It is known to bind to the microtubules, the cells' transport tracks. A defect in this transport system has been suggested to contribute to Parkinson's disease. The researchers have investigated this link and have now found the evidence that certain LRRK2 mutations affect transport in nerve cells which leads to movement problems observed in the fruit fly (Drosophila).

The team then used several approaches to show that preventing the association of the mutant LRRK2 protein with the microtubule transport system rescues the transport defects in nerve cells, as well as the movement deficits in fruit flies.

Dr De Vos added: "We successfully used drugs called deacetylase inhibitors to increase the acetylated form of α-tubulin within microtubules which does not associate with the mutant LRRK2 protein. We found that increasing microtubule acetylation had a direct impact on cellular axonal transport.

"These are very promising results which point to a potential Parkinson's therapy. However, further studies are needed to confirm that this rescue effect also applies in humans."

Dr Beckie Port, Research Communications Officer at Parkinson's UK, which helped to fund the study, said: "This research gives hope that, for people with a particular mutation in their genes, it may one day be possible to intervene and stop the progression of Parkinson's.

"The study has only been carried out in fruit flies, so much more research is needed before we know if these findings could lead to new treatment approaches for people with Parkinson's.

Parkinson's is a degenerative neurological condition, for which there currently is no cure. The main symptoms of the condition are tremor, slowness of movement and rigidity.

Good Shoes Are A Neuropathy Patients Best Friend

Today's post from neuropathydr.com (see link below) talks once again about the importance of good shoes for neuropathy patients. We've said it before and we'll say it again, your feet have to carry you through life and if the nerves in the feet are damaged, it's vitally important that you find the best footwear you can afford to help them do just that. This article reinforces the message. These days, supportive footwear doesn't necessarily mean ugly and unfashionable - you need to look around and find what suits you best but you still always get what you pay for - buying the best you can afford will pay off in the long run.

The Importance of Great Shoes in Neuropathy Treatment Posted by john on September 24, 2012
 
The shape of your feet changes with age, swelling, as well as peripheral neuropathy.

Are your shoes supporting your feet properly?

One of the issues we see very frequently in the neuropathy patient is fitting shoes comfortably.

It is very easy to take for granted the role that proper footwear has on your level of comfort. That is of course unless you suffer from peripheral neuropathy.

There are all a whole host of other conditions that occur with neuropathy that can slow down or complicate recovery. This includes common things such as flatfoot or having conditions like plantar fasciitis.

There are however some very simple things you can do. Number one, visit a traditional foot and shoe store and have your feet properly measured.

The reason for this is the shape of your feet changes with age, swelling, as well as peripheral neuropathy. Muscle changes, which accompany neuropathy, are responsible for this.

The neuropathy patient should take advantage of the expertise of their clinician too. Ask questions about the most appropriate footwear for you. Learn some basics about proper shoe construction such as the shape of the last and the strength of the heel counter.

Sometimes, “diabetic” shoes better holds inserts, which your clinician may prescribe. These may also allow for better circulation and less neuropathy pain.

We find that many neuropathy patients have excellent relief by wearing running shoes most of the time. The reason for this is the combination of shock absorption and breathability is helpful for many patients suffering from peripheral neuropathy.

This is one area where consulting the properly trained neuropathy treatment specialist can be of huge benefit!

Do not ignore your shoes!

These are in fact the foundation of your daily recovery homecare programs and are very important in getting you active again, back on your feet!

You will also find our recent radio show on http://beatingneuropathy.com and the associated videos on http://YouTube.Com/NeuropathyDoctor very helpful.

Recover faster from your neuropathy treatment by wearing the very best shoes you can find!

http://neuropathydr.com/the-importance-of-great-shoes-in-neuropathy-treatment/

What Nourishes You Most Deeply Are You Listening Four keys and four herbs for October transitions

I Know The Way You Can Get 

I know the way you can get 

When you have not had a drink of Love: 

 Your face hardens, Your sweet muscles cramp. 

Children become concerned 

About a strange look that appears in your eyes 

Which even begins to worry your own mirror 

And nose. 

Squirrels and birds sense your sadness

And call an important conference in a tall tree. 

They decide which secret code to chant 

To help your mind and soul. 

 --Hafiz, excerpt

~~~~~~~~~~~~~~~~~~~~~~

Did your heat come on this morning? Did you feed the wood stove?

Mine came on for the first time of the season. I smelled the metallic air when I woke, and I knew to grab socks and a sweater.

There was a misty haze of cold dew along the fields, and a quietness of busy people slightly more withdrawn.

The poetry of the horizon speaks of geese pushing time and of leaves blushing red and setting sail.

There is much work of medicine and magic to be done, still.
I feel the stirring of our ancestors asking more of us, and the longing of the Earth for more response-ability.

I watch the squirrel heed these laws every time he digs to bury a nut.

Nature calls us to heed rhythms.

Are you listening? What do you hear?

Four Keys and Four Herbs for October Transitions:

~~~~~
Temperature:
==========

How is the temperature in your body? Do you wake feeling cold, hot, or uncomfortably mixed? What do you do support your comfort?


Ginger
Ginger root helps to warm our circulation and regulate our 'triple heater', making temperature adaptation easier for our bodies. Instead of hot cocoa, try a cup of gently simmered fresh ginger root, with a little bit of honey. Or, make ginger root hot cocoa :)


Daylight and Moonlight:
==========

How is your rest & activity feeling? Are you sleepier or more energized than you were in the summer?

Seaweed
Seaweed is mineral rich giving our bodies the ability to be fully awake, and fully asleep, at the appropriate times. Seaweed is also brimming with both lunar and solar energies .... as it is fed by the sun and nourished by the moon and her watery tides. As perhaps the fastest growing vegetation in the world, seaweed feeds our wholeness and ability to be strong during periods of growth and change.


Your muse:
==========

How is your creative self? Engaged, disowned, tired, longing or restless? Your sense of divine connectedness to your life and your daily expressions of self? Your time for self care and reflection, meditation, or nourishing touch?

Cardamom
Cardamom is just sensual. It's sweet and spicy, gentle and strong, loving and clear. Cardamom in my warm milk, on my warm apple compote, or in a spicy soup, cardamom just makes me feel inspired. I often combine it with my other favorite muse herbs like Damiana and Kava Kava, but on her own she can re-awaken the imagination and playful self. When our senses and our mind are both playing, we can experience intense creative satiation.


Your footing:
==========

Do you feel steady, sure footed, and solid? Or frail and precarious? Are you the river, or are you the glass bottle floating down the river, headed for rapids? What is the message in your glass bottle, waiting to be freed, so that you may flow?

Burdock
Burdock to me is a water root. Dug from the wet earth and cooked in soups we are centered deeply in our water-bone humanness. We become grounded, centered, yet not stagnant. Burdock root nourishes our ability to be stable in our bodies, in our truth-speaking, and in our hearts.

~~~~~~~~~~~~~~

Perhaps you open my newsletter or blog expecting to be more formally taught about herbs.

By now you've probably realized that isn't entirely how I roll.

I could teach you about just herbs, but if you don't have the willingness to listen to your body, herbs aren't going to do much.


I don't teach answers, I teach questions.

I give possibility and options and resources and catalysts .... the answers belong to you. Answers can change over time.

And our bodies are part of nature. In listening to nature, we hear our bodies. In listening to our bodies, we hear nature.

In being honest about our senses, intuitions, impulses, and callings, we access a deep and perhaps ancestral strength that can empower our lives in profound and meaningful ways.

My wish for you is to continually have access to, and connection with, your true source.

May you have a blessed day, dear one.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Ready to embark on an intentional journey of self discovery and pleasure medicine?

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I seemed an unlikely candidate for the LSR but with so much change in my life, I felt a bit untethered and felt that I needed to nourish, to care for myself during this difficult time. So I signed up and almost immediately started regretting my indulgence (where do we learn such thinking?)

Until I received the first month’s materials and herbal goodies… The content is thoughtful and challenging; each month I was asked to consider just how empowered I am on the inside.  Are my beliefs and actions aligned? What do I truly know to be true about myself? How do I perceive my place in this complex world?    How much do I trust myself, my values, my intuition?  In addition, multiple resources are offered for future pondering.  Working through each month’s topic was just that – work. Some topics were easier than others; all of them contributed to a deeper appreciation of my gifts and me.

My reward each month came in a small box that fit perfectly into my mailbox. Even in my best DIY attempts, I doubt that I could replicate the unique creams, balms, oils, elixirs and perfumes. Ananda’s unique approach to scents and taste delighted me each month.  She truly offers an artisan approach to her creations, and I quickly developed a ritual of sitting, sniffing, tasting, and massaging the products immediately upon their arrival.

Ananda’s wisdom and love are expressed throughout the LSR program.  I am moving forward with renewed energy and know that I will continue to return to the content on those days when defeat seems to be looming.  During this past year of incredible change in my life, the LSR proved to be a very wise investment in myself.  A luxury for so many women…self-care is seldom on our To-Do list.  

The Lady's Slipper Ring is a wonderful reminder of why it needs to be at the top of our lists.

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By taking this year long course I have transformed a lot of my self-care habits and shifted my priorities to taking better care of myself. I love the new relationship I have formed with nourishment and self-care and I love the end result of being less stressed and finding more joy in my every day life. 

Plus, just getting that incredible package of treasures each month was a beautiful experience within itself. Ananda makes some of the best herbal products I've ever experienced! Self-care and nourishment are some of our most powerful tools for health and longevity, I am really grateful that I prioritized these qualities in my life through the Lady's Slipper Ring."

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Methow Valley Herbs 

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Are Painkillers Through The Skin As Effective As Pills

Today's post from dailyrx.com (see link below) discusses whether topical creams and gels are as good as or better than analgesics in pill form. Many people find taking pills every day a difficult task and the rise in topical gel preparations provides a good alternative. The problem with topical gels and creams is that people have less trust in them than in a pill and have a tendency to over do the application, possibly leading to more of the drug being absorbed than is necessary. People living with neuropathy have long known about certain creams and patches which are meant to help with neuropathic symptoms but they too are not without controversy. Capsaicin cream and high strength patches can be painful and even cause burning and although many people have gained benefit from them, equally as many haven't. Because most people have symptoms in their feet and legs (or hands and arms), the topical creams can be applied at the source of the pain but the source of peripheral neuropathy pain can actually be elsewhere (in the spine or brain for instance); it's just the symptoms manifest themselves most commonly at the ends of nerve pathways (feet and hands). It's always advisable to get the best medical advice possible and ask to be monitored as to how these creams are working but with advances in preparations, they may well turn out to be effective alternatives to popping pills in the future.

Creams Versus Pills for Pain
Author Info: Charles E. Argoff, MD, of the Department of Neurology at Albany Medical College, Reviewed by: Joseph V. Madia, MD By:Laura Dobberstein March 2013


Pain relievers applied to the skin can be just as effective as those taken orally
(dailyRx News) Gel and cream pain relievers are gaining in popularity. This method of pain relief has fewer side effects than their pill counterparts and may work just as well.

A recent review looked at the use of pain relievers absorbed through the skin to manage pain.

The review found that the pain relieving medications diclofenac and ibuprofen were effective in treating muscle, tendon and ligaments and joint conditions like osteoarthritis when absorbed through the skin.

The medication lidocaine also effectively treated nerve-related pain when applied to the skin.
"Ask your doctor if topical analgesics are best."

Charles E. Argoff, MD, of the Department of Neurology at Albany Medical College, searched existing databases for studies on topical analgesics (pain relievers absorbed through the skin). Dr. Argoff identified a total of 65 studies that associated long-term, short-term and neuropathic pain with topical analgesics.

Neuropathic pain is a type of pain caused by nerve damage and often seen in patients with trauma, diabetes and amputations.

The most common drugs included in the studies were nonsteroidal anti-inflammatory drugs (NSAIDs) including diclofenac, ibuprofen, ketoprofen, piroxicam and indomethacin. The next most common drugs were lidocaine, capsaicin, amitriptyline, glyceryl trinitrate, opioids, menthol, pimecrolimus and phenytoin.

Eighteen of the studies used the pain relievers for short-term soft tissue injuries, 17 studies involved neuropathic pain and six involved pain induced for the purpose of the experiment only. Five of the studies used the pain relievers for long-term joint related conditions, five involved skin or leg ulcers and two used the medication for chronic knee pain.

Dr. Argoff concluded ibuprofen relieved chronic knee pain and short-term soft tissue injuries pain just as effectively when applied to the skin as when ingested.

The use of diclofenac topically to treat joint pain was shown in a study of temporomandibular joint disorder, a painful condition of the jaw. The study showed diclofenac applied to the skin worked just as well as when taken orally.

Lidocaine was the only drug in the studies that effectively relieved neuropathic pain.

No other drugs included in the review showed strong evidence of relief when used topically.

Pain relievers applied through the skin had fewer side effects, such as stomach and heart irritation, than orally administered pain relievers.

Dr. Argoff recommended the further study of NSAIDs and lidocaine for short-term and long-term pain relief.

The study was published in Mayo Clinic Proceedings.

Financial support for the study was provided by Mallinckrodt Inc., a company that manufactures pharmaceuticals and other health-related items.

Dr. Argoff is associated with over a dozen pharmaceutical companies and health research groups.

http://www.dailyrx.com/pain-relievers-applied-skin-can-be-just-effective-those-taken-orally

Are Neuropathy Patients Likely To Be Heavy Smokers Or Vice Versa

Today's post from medscape.com (see link below) seems not to be sure on which side of the fence it sits. The statistics show that far more people with nerve pain smoke heavily than those with nociceptive pain (pain caused by injury and external factors). The article seems to suggest a link between the light analgesic qualities of tobacco/nicotine and that pattern - as if to say that nerve pain patients use cigarettes as a mild pain killer. Yet it is patently clear that the harmful effects of nicotine far outweigh the benefits so it is doubtful that patients consciously make the choice to smoke to chemically ease their pain. Is it not more likely that people with nerve pain are so stressed out by the nature of their symptoms that cigarettes perform their traditional role of 'comforter' in much the same way that over-eating and over-drinking do? The vast majority of neuropathy articles also point to smoking as a cause of neuropathy, so where does that leave us? Whatever the truth, the fact remains that there are more heavy smokers among neuropathy sufferers than those with other forms of pain - the question remains as to why!

People With Neuropathic Pain Twice as Likely to Smoke Cigarettes
Stephanie Doyle February 18, 2008

February 18, 2008 (Kissimmee, Florida) — Results of a new study suggest that people with chronic neuropathic pain are twice as likely to smoke cigarettes as those who have chronic nociceptive pain.

The study, led by Toby N. Weingarten, MD, from the Mayo Clinic College of Medicine in Rochester, Minnesota, showed that of the 205 smokers who participated in the study, 62% had been diagnosed with neuropathic pain, whereas only 33% had been diagnosed with nociceptive pain.

"To us that is surprising — we were surprised that smoking would influence what type of pain smokers had," Dr. Weingarten told Medscape Neurology and Neurosurgery.

The results were presented here at the American Academy of Pain Medicine 24th Annual Meeting.

Poor Response to Medications

Nociceptive pain is the common discomfort experienced as a result of injury, such as a broken bone or appendicitis. Neuropathic pain is associated with injury to a nerve or the central nervous system. Such injuries can give rise to paresthesias, such as numbness, tingling, or electrical sensations.

Nociceptive pain typically responds to anti-inflammatory agents and opiates, whereas neuropathic pain often responds poorly to such medications.

In the current study, the authors aimed to determine the percentage of community subjects with chronic neuropathic pain who smoke. Subjects were recruited from a large population-based study to assess the prevalence of chronic pain.

These adults had self-reported neuropathic pain, were identified from patient charts as having neuropathic pain, or had a positive score on the self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), a tool designed to identify patients with neuropathic pain. They also self-reported current smoking status.

The percentage of participants confirmed as having neuropathic pain by clinical assessment who also smoked was 21%, compared with 13% in the overall sample (P = .009). Smoking was twice as common (62% vs 33%) in subjects who were diagnosed by clinical assessment as having neuropathic pain as nociceptive pain.

The percentages of those who smoked varied by positivity on screening tests for neuropathic pain: 18% for a positive S-LANSS score, 12% with self-reported neuropathic pain, and 8% of those with select ICD-9-CM codes from patient charts.

"The possible physiologic relation between smoking and development of chronic neuropathic pain deserves further evaluation," the authors conclude.

Not Advocating Smoking

"This study is intriguing," said Todd Sitzman, MD, MPH, president of the American Academy of Pain Medicine. "Clinical studies have shown a modest analgesic effect from nicotine. Although there is an association between nicotine and neuropathic pain, there is no direct causative effect."

However, Dr. Sitzman, who was not involved with the study, told Medscape Neurology and Neurosurgery: "I caution advocating smoking as a perceived treatment for neuropathic pain, since it is clear that the adverse risks of smoking outweigh any potential benefit."

Funding was provided by AstraZeneca and the National Institutes of Health. Dr. Weingarten has disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 24th Annual Meeting: Abstract 100.

Medscape Medical News © 2008

http://www.medscape.com/viewarticle/570347

Just How Effective Are Opioids In Neuropathy Treatment

Today's post from medpagetoday.com (see link below) is an interesting review of a large-scale study of the effects of opioid treatment on people with neuropathy. It concludes that opioid use has its limitations but there is no evidence that it is either, over-prescribed by doctors, or abused by patients. This removes it immediately from the current hysteria concerning opioid medication and recognises that people with severe neuropathy have very few options. As a result, it calls for new medication development, not to remove the 'evils' of opioids but to provide a better alternative for patients in chronic pain. Definitely worth a read though maybe a little disheartening for people who rely on opioids to dampen their symptoms, having already exhausted all other options.

Long-Term Opioids May Not Help in Polyneuropathy
by Kristin Jenkins Contributing Writer, MedPage Today May 23, 2017 Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner last updated 05.23.2017
 
Action Points

Long-term opioid therapy among patients with polyneuropathy appears to increase the risk of adverse outcomes without benefiting functional status, according to a retrospective population-based study.
Note the data agree with prior studies showing opioid use disorders are more prevalent among those receiving long-term opioid therapy, but did not indicate that long-term opioid therapy significantly increases mortality among patients with polyneuropathy as it does among broader populations of patients reported elsewhere.


Long-term opioid therapy in patients with polyneuropathy appears to increase the risk of adverse outcomes without benefiting functional status, researchers said.

Data from a retrospective, population-based cohort study showed that 18.8% of 2,892 patients with polyneuropathy received opioids continuously for at least 90 days compared to 5.4% of 14,435 controls. They were also more likely to rely on gait aids and have difficulty climbing stairs (adjusted HR 1.7) and experience depression (adjusted HR 1.53), opioid dependence (aHR 2.85), and opioid overdose (aHR 5.12) compared to controls, Christopher J. Klein, MD, of the Mayo Clinic in Rochester, Minn, and colleagues reported online in JAMA Neurology.

"By showing that polyneuropathy increases the risk of long-term opioid therapy and that long-term opioid therapy is not associated with improved functional status but is associated with adverse outcomes, this study provides useful information to counsel patients with polyneuropathy who are considering or are already receiving opioid therapy," the researchers said. "Furthermore, it provides evidence that could influence treatment guidelines and health policy."

The researchers also reported that a diagnosis of opioid abuse among patients with polyneuropathy who were taking opioids for any length of time was observed in less than 2% of patients and that there was no significant association with overall mortality. However, there was a 7.2% rate of opioid dependence and a 2.6% rate of opioid overdose, they pointed out, adding that this "underscores that abuse and dependence are not synonymous."

"Thus, our results agree with those of prior studies citing that opioid use disorders are more prevalent among those receiving long-term opioid therapy, but we did not find that long-term opioid therapy significantly increases mortality among patients with polyneuropathy as it does among broader populations of patients reported elsewhere.

Importantly, the study also showed that neurologists and pain physicians were only prescribing long-term opioid therapy in a small percentage of patients, a finding consistent with national trends, the researchers noted. "Therefore, it is likely that discussing potential benefits, as well as adverse outcomes, of long-term opioid therapy will fall to the primary care clinician," Klein and colleagues said.

For the study, the Rochester Epidemiology Project (REP) database was searched for prescriptions given to patients with polyneuropathy and for those given to controls in ambulatory practice. All data came from participants who resided in Olmsted County from Jan. 1, 2006, to Dec. 31, 2010 and were reported previously. The latest follow-up ended Nov. 25, 2016.

Patients with polyneuropathy receiving 90 days or more of opioid therapy were more likely to be female (57%) than those receiving short-term opioid therapy (P<0 .001="" 46="" 69="" age="" also="" although="" between="" br="" common="" commonly="" differences="" documented="" for="" groups="" in="" indication="" long-term="" median="" most="" musculoskeletal="" no="" of="" opioid="" oxycodone="" p="0.13)." pain="" patients="" polyneuropathy="" prescribed="" prescribing="" significant="" similar="" starting="" the="" therapy.="" there="" trends="" two="" versus="" were="" with="" xycontin="" years="">
Although rates of lower limb complications were comparable between the two groups, patients with polyneuropathy used non-opioid analgesics more often than controls.

In an accompanying editorial, Nora Volkow, MD, of the National Institute on Drug Abuse, and Walter Koroshetz, MD, of the National Institute of Neurologic Disorders and Stroke, noted that opioids in this study were prescribed more often for treatment of non-neuropathic indications. However, this finding doesn't change the evidence behind current guidelines advising against opioids as first-line treatment in most cases of neuropathic pain because of long-term safety concerns, they said.

The study also highlights the limited alternatives for managing chronic pain, and the urgent need to develop new medications, the editorialists said. Recent work in animal models demonstrate that innovative opioid peptides and biased opioid agonists may provide equivalent pain relief with less tolerance and fewer adverse effects while success with biologics for inhibiting pain at the its source may shift the focus to prevention, they said.

"In the meantime, structural changes in the healthcare system, including training of physicians in the screening and management of pain, as well as coverage by insurance of comprehensive pain management programs, are needed to ensure that patients receive the most effective treatments for their chronic pain conditions," Volkow and Koroshetz said.

Limitations of the study include the fact that it was based on prescription data without confirmation that prescriptions were filled or taken as intended.


This study was funded by the Mayo Foundation for Medical Education and Research, Mayo Clinic Center for Individualized Medicine, and the National Institutes of Health (NIH). The study authors disclosed no conflicts of interest. The editorialists disclosed no funding or conflicts of interest.

https://www.medpagetoday.com/neurology/painmanagement/65497

I Have Sciatica Why Are You Grabbing My Foot

It is 5 am in Badwater, CA. There are approximately 100 runners toeing the chalked line. There is 135 miles, over 10,000 ft in elevation gain and 120 degree heat under the Death Valley sun between them and the finish line. I see my runner crossing the horizon towards our support car, his stride looks shortened, but smooth for mile 60. Over the next 75 miles we take turns passing off race essentials. At 4 am, as a team, we cross the finish line at Whitney Portal.

So how did this journey begin?

From the moment I met him I could hear the “thud”. It was the sound that his foot made as it he walked through the clinic.  He tells me he is a runner, but not just a runner, but he is running in the Badwater Ultramarathon in July. 135 miles of “thudding” into the ground! To bring the pressure up a notch, this is going to be his 11th consecutive finish. As I watched him move and walk, I can't stop focusing on the stiffness of his foot which is causing the "thud". But how do I explain his lack of foot mobility is contributing to what he is actually coming to see me for… SCIATICA?

What is Sciatica?

Sciatica is a general term used to describe inflammation of the sciatic nerve or nerve roots which comprise it. Sciatica can be caused by a disc injury or stenosis (narrowing of spaces of the spine), which puts pressure on the nerve roots. When our foot hits the ground force is transferred up the leg and into our lower back. Our foot is designed to pronate upon impact to allow for shock absorption.  The bony anatomy of our foot and ankle causes a biomechanical chain reaction. This generates a rotation in the leg then into the pelvis which helps to recruit the gluteals to provide the stability of the back. However, if the foot remains supinated, ground reaction force is transferred into the spine instead of being absorbed through the foot and leg. When the mobility of the foot is limited, the lower back is forced to move more to compensate for the lack of motion. The increase motion of the back decreases the amount of space the nerve has to pass through the spine.

When the foot pronates it causes a rotation up the leg which
helps to dissipate force and maintain good motion of the back.

When the foot remains supinated the foot remains rigid forcing
the back to rotate more which decreases space for the nerves.

To improve his foot mobility I begin to facilitate pronation of his foot. IT worked! His sciatic pain decreased.  I worked on it some more and his pain was gone! He was able to walk and jog in the clinic without his symptoms. 

From the moment I helped his foot become more supple and pronate, his sciatic pain got better.

So when you foot hits the ground: is it supple (pronated) or rigid (supinated)?

             

You can even see from the pictures above the difference in the position of the pelvis.

Techniques

Mobility

The technique is performed to increase mobility of the foot to reduce stress to the lumbar spine. This will help minimize your risk of sciatica. Stenosis is narrowing of the canal in which the nerves exit the spine. If you have a herniated disc, this is NOT a technique for you.

For forefoot runners, it is also important to have a mobile foot. The motion of supination and pronation occurs in the forefoot instead of the mid and rear foot.

Strengthening
After mobilizing the foot, it is important to retrain the muscles and joints in this new motion. This allows the newly acquired motion to be recognized as a movement path. If your body doesn't use this motion, the foot and ankle will become stiff again.

Here are examples of exercises which use the muscles and joints in all 3 planes of motion to retrain the body.

Please consult with a health care professional prior to performing these exercises. If it increases your pain, STOP!

Testing Pain Are You Believed

Today's excellent post from vox.com (see link below) talks about something that many people living with neuropathy are very much aware of and that is how their doctors perceive their pain experience. The feeling that you're not believed, or taken seriously, is far too common and it comes down to the fact that the methods of testing pain are inherently deficient. The article looks at what it's like to be disbelieved and then goes on to explore new possibilities of more accurate pain testing, with an emphasis on brain imaging, which may be very helpful in the future. Well worth a read.
 

The pain test
Doctors have no idea how much their patients are suffering. That's about to change. 
by Susannah Locke on October 15, 2014

Ally Niemiec could have lost a kidney because doctors didn't believe she was in pain. It was last fall, and one of at least a dozen times that her rare kidney disease had sent her to the emergency room. She recognized the pain. She knew something was wrong.

But when she turned up in an Atlanta emergency room that Saturday afternoon, vomiting and doubled over, no one believed her. They looked at her pain medication records and decided she had a drug abuse problem.

"They told my mother that I needed to go to rehab and was a drug addict," she says. The hospital wouldn't give her any narcotic pain medication and refused to do an x-ray, ultrasound, or CT scan.

That time, Niemiec was lucky enough to have other options. She left for another hospital, where they treated her pain and then removed her kidney stone the next morning.

This discouraging experience was nothing new. For many years, she was used to doctors not trusting her. "There's nothing more horrific than a doctor looking you in the eye and saying there's nothing wrong with you when you're in debilitating pain"

One problem has been that her kidney disorder, renal tubular acidosis type 1, is described in medical journals as not painful. But to her, it was. Since she was 13, she's had about 100 kidney stones and 18 surgeries to remove them. At one point, her pain was so bad that she couldn't drive and had to leave her job. She went from doctor to doctor trying to get help. When her pain got really bad, she didn't find adequate treatment for three long years.

"There's nothing more horrific than a doctor looking you in the eye and saying there's nothing wrong with you when you're in debilitating pain," she says. "To me, it's a form of torture."

Eventually, she got a spinal cord implant that uses electrical signals to block her kidney pain. Now she's 24 years old and works at a tech startup. But many others continue to suffer.

Approximately 100 million Americans have chronic pain. That's about a third of the population. Yet the most cutting-edge test for pain is a doctor holding a piece of paper with a bunch of frowny and smiley faces on it or asking you how bad you feel on a scale of 1 to 10, with ten as the worst pain imaginable. It seems a much better test of imagination than of pain.




And as Niemiec can attest, the subjectiveness of the scale causes problems — it only works if the doctor believes you, and relying only on trust can threaten people's lives.

There must be a better way to test if someone is in pain. "That would completely have changed my experience," Niemiec says. "It could have saved me three years of my life."

Right now, such a test doesn't exist. But it's looking likely that it might someday soon. In several key studies, scientists have used brain-scanning machines to accurately predict if someone is in pain.

A more objective pain test could transform pain medicine and lead to new treatments for people who suffer. It could weed out people lying in order to get drugs. And it could prove to doctors that people like Niemiec are really in pain.

But this new technology also raises all kinds of ethical and legal questions. It might also end up as faulty mind-reading that could be used to deny care and insurance coverage to those who are truly in distress.
What is pain?

"Pain is so wonderful because it is so bad," says Sean Mackey, the chief of pain medicine at Stanford's medical school, who was the first to show that pain can be gauged using a brain scan. "It keeps us out of harm and out of danger."

Mackey's right: pain teaches people to stay away from hazards and tells them when they're injured or sick. It trains us to keep our hands away from hot stoves. It lets us know when our appendix has burst. Or when we're having a heart attack. Pain is so important that people who cannot feel pain encounter repeated injuries and have shorter life spans.

Despite pain's importance, it is quite difficult to define. And that difficulty underlies much of the disagreement about whether objective pain testing is even possible.

Today, pain is understood as a type of subjective experience. The International Association for the Study of Pain states that pain is "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

So although the mechanisms for what usually causes pain — certain receptors on certain neurons — are fairly well known, pain is still not defined as a physical thing that your body does. Your neurons could be firing off pain signals like crazy, but as long as you don't feel pain (like if you've popped an Advil or are under anesthesia), you're not in pain. If you feel pain, you are in pain.


But brain imaging can put an image to the invisible.
It can give them something to see. 

Why the world needs a better pain test

Mackey, the Stanford pain specialist, got his PhD in electrical engineering and also an MD. "Coming out of medical school, you probably couldn't find anyone more mechanistic or linear in their thinking than me," he says. "I ended up going into pain medicine because I was intrigued about the opportunities of really making a difference in people's lives."

Working with pain patients, he often found himself using needles to block pain. (One common treatment for chronic pain is a temporary injection of anesthetic into the body, which stops pain signals from reaching the brain.) But it wasn't working for everyone. "There was large numbers of people that I wasn't helping with that approach," he says. "What really was helping them was listening to them, hearing about their fears, their anxieties, their beliefs about their pain."

Those observations got him interested in the brain side of things, the psychology side, and how things like anxiety, fear, and empathy influence pain. "It was around this time that this field of neuroimaging was being established, which allows us to open up windows into people's brains to see where pain is processed and perceived."

He wanted to use the technology to learn about how people experience pain differently and how thoughts and emotions affect pain, hoping to be able to better tailor therapies to people for better treatment. Along the way, it began to seem possible to create a test that would correlate with someone's pain levels.

A pain test could help all kinds of people. One main group is those who can't speak for themselves. For example, even into the 1980s, some doctors didn't believe that babies felt pain and so routinely did surgery on them using just muscle relaxants to keep them still. And today, some people can't tell others what they're feeling, including small children, some adults with developmental disorders, and people in coma.

And even among people who can communicate fully, not everyone's word is regarded as truth. Researchers have documented discriminatory patterns in how health-care workers treat pain. Women are more likely to have their pain dismissed as not real. And one study found that female emergency room patients with abdominal pain were less likely to be given strong pain meds than men were. Papers have found similar phenomena for racial minorities.

And until the last couple of decades, doctors thought that many people with chronic pain were faking it. Roger Fillingim is a psychologist at the University of Florida who studies pain. He describes patients saying that just the feeling of a long-sleeved shirt on their arm was painful: "We used to call that crazy." Now, doctors know that a lot of chronic pain is actually real. For example, fibromyalgia, which causes pain throughout the body, was in the crazy category, too. Now it's known to affect roughly 15 million people in the United States.
The problems with pain medication

Drug abuse is another reason a better pain test could come in handy. That abuse has led narcotic painkillers to become more tightly controlled in recent years, sometimes so tightly that people with real pain problems have trouble getting their medication.

There's no question that there's a prescription-drug abuse problem in this country. Each year, more people die in the United States from prescription painkillers than from heroin and cocaine combined. And some, but not all, of the people abusing these drugs are people who do not have an actual pain problem.

One recent review on the topic found that about 20 percent of chronic pain patients given opiate drugs long-term had either none of the drug or a non-prescribed opiate in their urine during screening tests, which suggests that they might be selling or giving the drugs away rather than taking them responsibly. (The study also found that very few — 3 percent — of all of the patients personally ended up with an addiction or abuse problem related to these drugs. If patients with a history of drug abuse are excluded, this number drops below one percent. However, screening people out doesn't always happen in today's hectic health-care environment.)

It's difficult to balance what regulations will get pain meds to patients who need them while keeping them from people who don't. You can see where these objectives collide in the recent battle over Zohydro ER. This new drug is an extended-release version of the opiate hydrocodone and the only hydrocodone for sale without another drug in it.

It's also somewhat analogous to OxyContin, which became a preferred drug of abuse in the late 1990s and early 2000s — at least until 2010, when its manufacturers made OxyContin difficult to snort or inject, with pills that were hard to crush and that turn into a gel when wet. "If you could somehow measure pain, would that be helpful? It would be helpful to me because I want to know if my patients are legitimate."

However, Zohydro ER, like every opiate on the market except for OxyContin, has no such anti-abuse features built into its pill. For some with chronic pain, it's their only chance for relief. To others, it's death in a bottle.

In October 2013, the FDA approved Zohydro ER against the recommendation of its independent advisory panel. In the spring of 2014, Massachusetts governor Deval Patrick banned it, but a judge struck the ban down just a month later. And in August, several governors petitioned the US Department of Health and Human Services to undo the decision.

Concerns about abuse have also led to changes in regulation and enforcement that pressure doctors, wholesalers, and pharmacists to give out fewer narcotic painkillers.

For example, in Florida, crackdowns to combat a previously growing problem with pain-medication deaths has made it difficult for legitimate pain patients to actually get their prescribed medication, says Jeffrey Fudin, a pharmacist who specializes in pain treatment and is an adjunct associate professor at Western New England University.

A better pain test is one thing that could help real pain patients prove themselves — and weed out the liars. "If you could somehow measure [pain] would that be helpful? It would be helpful to me because I want to know if my patients are legitimate," Fudin says.
The research on brain imaging

Recent advances in brain-imaging technology have shown that the mind's secrets are sometimes surprisingly readable. For example, some researchers have used brain scanning to guess with some accuracy what shapes people are looking at or what type of object they were dreaming of: a building, a car, a person.

The main technique researchers are using is functional magnetic resonance imaging, or fMRI. An fMRI machine employs a giant magnet that can read where blood is in the brain. And because blood flows more to active brain areas, an fMRI scan can measure brain activity.

In the past few years, researchers have published studies showing that fMRI could determine whether someone is in pain.

In 2011, in a small study of 24 people, Mackey's group used advanced computer algorithms to show whether someone was receiving a painfully hot stimulus to his or her forearm with 81 percent accuracy. The observed differences in brain activity weren’t clustered in only one area, but in many, many places across the entire brain.
A pain test could help all kinds of people. One main group is those who can't speak for themselves.

In 2013, a paper led by Tor Wager, a neuroscientist at the University of Colorado Boulder, confirmed those findings in a bigger study published in a very prestigious journal: The New England Journal of Medicine. It involved 114 participants and correctly guessed whether someone was in pain about 95 percent of the time. Even more impressive was that the brain patterns seemed somewhat universal — that is, the algorithms were developed on one set of volunteers and then worked on another set that had never been scanned before.

Then in 2014, Mackey published another paper that looked at patients with chronic back pain, using still MRI images to examine brain structures rather than brain activity. He was able to produce an algorithm that guessed with 76 percent accuracy whether or not a brain was from a chronic back pain patient. A similar study published the same year identified people who had chronic pelvic pain with 73 percent accuracy.

Still images of brain structure like these could someday help chronic pain patients justify their condition, even though they don't show brain activity itself.

All of these new studies are still firmly in the realm of science, not medicine. These tools are not ready for use on patients to determine a course of treatment. Mackey estimates that that might be 10 years away.

The tests can't yet accurately predict someone's exact level of pain. And they've only been demonstrated within the confines of well-controlled laboratory studies.

In addition, most researchers don't believe that there's just one pain brain-activity pattern, but that different kinds of pain will end up producing different patterns. So, touching something hot might look different than the muscle pain of fibromyalgia, which might look different than chronic back pain. And that means that a lot more research will be needed before such technology could be used on the wide variety of painful health issues that exist.
The problems with an 'objective' pain test

Both Mackey and Wager see a lot of potential in using brain imaging as a research tool to better understand the various causes and types of pain — and to develop new ways to treat it. They think that such scans should only be used to confirm someone's pain, but never to go against their word and deny that they're in pain when they say that they are. That's because pain is defined as a subjective experience. And the brain scan is objective. So, to them, the brain scan is merely an objective marker of possible pain.

Another reason for that stance is that a person could be feeling a kind of pain that they haven't found the brain signature for yet. "It might not look like other people's pain, but it might be their pain," says Wager.

And, says Mackey, "There is the potential for abuse. There's always the potential for people misusing this technology for insurance purposes to deny care."

However, both researchers do support using the technology someday on people who can't say if they're in pain or not, like babies or some people with developmental disabilities. Because any evidence is better than nothing at all.

Another problem is that pain might be something that cannot be reduced to a bunch of neurons firing. "Some people believe that pain isn't simply some sum or algorithm of brain activity, it's an emergent property of brain activity," says Fillingim. "And maybe we won't figure out how the experience of pain emerges from some pattern of brain activity. And maybe the formula is different for different people."

"Could we similarly look at someone's brain and tell you how happy they are, how satisfied with life?" he asks. "These are all pretty high level experiences."

Another problem could come from brain-scan pain tests getting used in court. Some people approximate that awards for pain and suffering make up about half of personal injury damage awards. So there's big money on the line. "The legal system has a tremendous need for more objective ways of measuring pain," says Adam Kolber, a professor at Brooklyn Law School who has written extensively about the future ethical and legal implications of pain testing. "There is the potential for abuse. There's always the potential for people misusing this technology for insurance purposes to deny care."

He's not that concerned about how pain tests will be used in the long run. He notes that there are standards in place to stop new technology from becoming admissible evidence until it's fully developed. And he focuses on the positive side of what the technology could do: "This is a possibility of better compensating people who are in pain. I think that's promising."

But not everyone agrees. And Mark Sullivan is one of them. He's a psychiatrist and bioethicist at the University of Washington who specializes in treating patients with chronic pain. He's been one of the most vocal opponents of the drive to find objective measures of pain.

He's debated both Mackey and Wager in person at pain research meetings and debated on paper in the Journal of Pain in 2013. And he says he's concerned about people who are truly ill being denied workers' compensation and social security because nothing can be found on a brain scan: "You could easily see a situation where someone says, ‘Well, I can't work because I have terrible back pain.' And you stick them in an MRI scanner and it's ‘I don't see any evidence that you're in pain. So we're not going to give you disability payments anymore.'"

Whether it leads to good or bad outcomes, computing power, fMRI resolution, and data from patients will keep increasing. Technology will march on, and someday, someone is going to start selling something called an objective pain test, whether or not that's actually what it's capable of.

And no matter how accurate the test is or isn't, the images it produces could help pain become a more visible problem in health care. Pain isn't something that someone can see, like a physical wound. It can take numerous forms, making it easier for medical practitioners to ignore.

44-year-old Californian Elizabeth Schenk is one of the many patients who've had doctors ignore her agony. She used to be a pilates instructor, but her chronic pain has brought her into a new career counseling people with pain problems. At its worst, her pain has been excruciating: "like someone was dragging a knife down my thigh," and "like someone taking a hammer to my thumb," and "a chisel to my spine."

"What I've experienced in the medical world is that if they don't see anything, they won't do anything," she says. But brain imaging can put an image to the invisible. It can give them something to see.

http://www.vox.com/2014/10/15/6895171/how-doctors-measure-pain-brain-scan-fmri

Are Neuropathy Sufferers Fear Avoidance Cyclists

Today's post from psychologytoday.com (see link below) is an interesting article that directly applies to the neuropathy sufferer who's movement is impaired by the symptoms of nerve damage. The more your feet, or legs, or hands, or arms or involuntary organs play up, the less inclined you are to put them to the test by moving more than necessary. It's called the 'fear avoidance cycle' and neuropathy patients are classic sufferers. I'm fully aware, I bore you to tears with constant posts about exercise but if you read this article you may come to realise that however painful some form of exercise may seem, your body and mind will thank you for it later. Worth a read to avoid the slippery slope down to inactivity...and even more pain.

A Day Without Pain 
Treating Chronic Pain to Improve Function
A holistic approach to the healing process
Mel Pohl M.D., FASAM Posted Jul 30, 2013

Unlike other injuries, chronic pain is unrelenting, lasts longer than six months, and is characterized by decreased function. The desire to avoid feeling more pain or aggravating the pain one does feel leads patients to avoid movement, which, over time, erodes function. The old “use it or lose it” mantra is definitely applicable here.

It’s understandable that patients with chronic pain fear worsening their pain by moving, but what most people don’t realize is that maintaining mobility is essential if function is to be preserved for the present and the future. Body parts that go unmoved for any length of time eventually become “frozen.” This can happen with the back, the abdomen, the joints (e.g., knees and shoulders), etc. Furthermore, with decreased movement, circulation decreases, scar tissue eventually forms, and pain increases.

The consequences of this are not merely limited to decreased mobility and lingering pain. Avoidance of movement ultimately leads to complete non-function. When people are limited, they may become ashamed of their disability and want to hide, want to do nothing. If I can’t get my shirt on by myself in the morning, why would I want to go out in public and expose any other problems I have to friends and strangers alike? This response to pain, this avoidance, leads to feelings of depression and helplessness that only feed into the cycle of immobility and worsening pain until the patient is entirely non-functioning. This is called the Fear Avoidance Cycle.

Now, some people will try to function around all of this by taking drugs. If I go to a physician or a prescriber and I say that my shoulder or back hurts, what will I be prescribed? Painkillers in the form of opioids (narcotics). Many people who take these medications and as a result feel less pain assume that their treatment is working for them. Successful treatment of chronic pain must include improvement of function as well as reduction of the level of pain.

When people whose only treatment has been medication to reduce the pain come to treatment at my center, I notice that their function is deceased and they are sleepy, less active, and cognitively impaired. This lethargy affects all aspects of their life, from digestion to social interactions. We see people medicated for pain, but their function overall has suffered as a consequence. This is not the proper treatment of chronic pain.

The root of this problem is fear. People need to be supported to walk through their fear of pain. Numerous studies that have proven that if someone is afraid of a certain activity, he or she will avoid that activity, and as a consequence won’t progress in his or her treatment. If we expose the person to the activity with support and gentle movement, the fear slowly diminishes. If fear diminishes, pain does as well, and the person regains mobility and confidence. There is a direct correlation between fear, anxiety, and pain. The solution for Fear Avoidance is increased movement, which will cause some discomfort initially. But it is on a temporary basis because at first patients are breaking up the fibrous tissue that has built up as a result of their inactivity. But with increased mobility we get increased function, and improved self-esteem and lower social isolation. The person overall becomes healthier.

When using medications, it is essential to make sure that the function of the patient improves. Simply taking the pain away and putting someone to bed for 20-plus hours a day is bad pain treatment. Unfortunately that is the cycle that people get into. They can’t sleep because of their pain meds, and then they are given sleeping pills. This makes them anxious during the day, so they are given anti-anxiety pills, and then pills to wake up. The result is that they are over-medicated and they are not living life to the fullest. Their quality of life is diminished. The solution is to decrease or eliminate the use of these medications until overall function improves and life gets better even though there is pain present. It is this delicate balance that defines pain recovery.

https://www.psychologytoday.com/blog/day-without-pain/201307/treating-chronic-pain-improve-function

Are You Strong Enough To Change Your Diet To Reduce Your Pain

Today's challenging post from health.clevelandclinic.org (see link below) looks at what they call 'elimination diets' for reducing chronic inflammatory pain. Now given that neuropathy probably falls into this category, what are the chances that if you change your diet, your symptoms will improve? Promising, according to some and a waste of time, according to others but the biggest question is: can you change your diet in any of the ways described below? Think giving up smoking or drinking and you're pretty much appreciating the challenge here and remember...there are no guarantees that it will work. However, it is worth considering, even if you only half believe but always make a doctor's appointment first to check whether cutting out certain foodstuffs may actually harm you rather than help. The biggest advantage is that no chemical drugs are involved. Worth a read to get you thinking.

Should You Switch to an Elimination Diet to Fight Chronic Pain?
Pain management specialist answers 7 key questions April 14, 2016 / By Chronic Conditions Team

People rave about elimination diets for easing chronic pain, but do they work? Experts say, sometimes they do help. In many cases, it’s worth a visit to your doctor to see if an elimination diet could be right for you.

Pain management specialist Hong Shen, MD, suggests discussing an elimination diet with your doctor if you have:

Neck pain
Back pain
Fibromyalgia or any chronic pain condition
Complex regional pain syndrome (serious pain that develops and lingers after an injury)

Here, she answers common questions about how elimination diets work. 

1. How can an elimination diet relieve pain?

Inflammation is the root cause of chronic pain. Some foods are highly inflammatory, especially sugar, hydrogenated oil and highly processed food.

Many patients can develop sensitivity to gluten, dairy, corn and soy. Those foods can trigger your body’s immune response and cause pain, so eliminating the problematic foods can sometimes ease your pain.

2. What foods are usually eliminated?

The first foods Dr. Shen recommends that you eliminate include gluten, dairy, sugar, packaged foods and processed foods. If you’re still having pain, you may also need to eliminate corn, eggs, shellfish, beef, pork, coffee, tea and chocolate.

“Not everyone needs to eliminate all of these foods,” says Dr. Shen. “It just depends on what you’re eating on a regular basis.”

RELATED: 7 Simple Swaps That Will Transform Your Diet
 
3. How long should you eliminate these foods?

It depends on the type of problem you’re having.

If you’re on a strict elimination diet that includes avoiding all or most of the problematic foods, Dr. Shen recommends that you restrict them for between four and six weeks. If you’re on a diet that’s free of gluten, dairy or sugar, you can stay on it indefinitely.

RELATED: Gluten-Free Diets — The Straight Skinny
 
4. How do you determine which food is causing the problem?

“The elimination diet serves both diagnostic and treatment purposes,” Dr. Shen says. “I will have my patients eliminate certain foods for four to six weeks, or, ideally, eight weeks.”

After eight weeks, if all your symptoms resolve, you can start reintroducing one food at a time and try it for three days. Dr. Shen recommends eating a significant amount of the targeted food at least twice in those three days.

If you develop discomfort, stop the new food until the symptoms completely disappear again. Then reintroduce the food a second time. If the same symptoms reappear, you stop it again and reintroduce a different food.

“From this test, you can find which food gives you pain,” she says.

RELATED: New Dietary Guidelines Target Added Sugars, Healthy Eating Patterns
 
5. How effective are elimination diets?

According to Dr. Shen, 30 to 40 percent of patients put on elimination diets get better just from changing their diets alone. Sometimes the changes are gradual. Other times, they’re more dramatic.

“You can have headaches for your entire life, then be pain-free after four to six weeks on an elimination diet,” she says.

In one study, 246 fibromyalgia patients followed either a gluten-free or dairy-free diet.

“Many responded to treatment, although some quicker than others,” says Dr. Shen. “The results of the study were similar to the 30 to 40 percent success rate we see at Cleveland Clinic.”

How effective an elimination diet will be for you will depend on your condition. And everyone is different, so it also depends on how well your body responds.

6. Are elimination diets used along with other treatments?

Treating pain is often complicated, Dr. Shen says, so it must be addressed on an individual basis. Doctors sometimes recommend other treatments as well, including:

Pain medications
Mind-body medicine (using your mind to influence your body)
Guided imagery (a technique that focuses on mental images to help relieve pain)
Hypnosis
Meditation
Yoga
Reiki (a healing technique in which touch channels energy to activate the natural healing processes of your body)
Acupuncture
Chiropractic medicine
Massage
Herbal supplements
Addressing other nutritional issues (e.g., potential deficits)

7. Why should I see a doctor before beginning an elimination diet?

In some instances, eliminating certain foods affects treatments for other health conditions.

“If you’re on diabetic medications, blood pressure medications or blood thinners (e.g., Coumadin), you may need to have your medication adjusted, depending on what you’re eliminating,” Dr. Shen says.

If you have food sensitivities, even healthy foods may trigger symptoms. Treating chronic pain requires a multi-level approach. “It’s not just diet alone,” she says.

Stress reduction is also important, as is exercise and getting a good night’s sleep.

RELATED: 7 Health Foods That Can Ruin Your Diet

https://health.clevelandclinic.org/2016/04/switch-elimination-diet-fight-chronic-pain/

Are We Close To Restoring Neuropathy Nerve Damage

Today's post from journals.lww.com/ (see link below) is a doctor's answer to a patient's query about the possibility of ever repairing damaged nerves. His answer suggests that gene therapy may well be the answer in the future. He also quite rightly says that more research is urgently needed but research needs funding. Well worth a read.
 

What's on the horizon for restoring nerve function in peripheral neuropathy?
Smith, A. Gordon M.D. Neurology Now:
April/May 2014 - Volume 10 - Issue 2 - p 34
  doi:10.1097/01.NNN.0000446167.75771.61


 Q What's on the horizon for restoring nerve function in peripheral neuropathy? Will there ever be a way to quiet the faulty nerves, as opposed to masking the pain with drugs like gabapentin and oxycodone?

DR. A. GORDON SMITH RESPONDS:

A It is estimated that more than 20 million Americans have peripheral neuropathy, making it one of the most common neurologic conditions. Peripheral neuropathy is caused by damage to the peripheral nervous system, which is responsible for sending information back and forth between the brain and spinal cord to every other part of the body. The condition often causes weakness, numbness, and pain in the hands and feet, but it may also occur in other areas of the body. Because peripheral neuropathy is not a single disease but rather a symptom with many possible causes, it may be difficult to diagnose and to treat.

However, different forms of peripheral neuropathy may also share common mechanisms of nerve injury. This means that discovery of a treatment for one form of peripheral neuropathy might benefit others.

Diabetes is the most frequent cause of peripheral neuropathy. In many cases, the cause of peripheral neuropathy is never known (called idiopathic peripheral neuropathy). Patients, physicians, and researchers are all interested in discovering effective therapies to slow progression, improve pain control, and hopefully reverse nerve injury in peripheral neuropathy.

Recent advances in uncovering the genetics of peripheral neuropathy have been made. Researchers have discovered that some people with painful idiopathic peripheral neuropathy have a mutation in a particular gene. This discovery has led to new studies—including planned human trials—exploring these genetic mutations as potential targets for treatment.

In addition, patients are being actively recruited for a number of exciting clinical trials including studies of growth factors (groups of proteins that stimulate the growth of specific tissues) delivered using gene therapy technology, which allows targeted delivery for peripheral neuropathy caused by diabetes. (Read more on these therapies at bit.ly/1eaBc0H.)

For many neuropathies caused by an immune attack of the nerves, good therapies already exist and others are in development. The outlook for these forms of peripheral neuropathy is even more hopeful. For patients with chronic inflammatory demyelinating polyradiculoneuropathy (a rare and chronic condition characterized by gradually increasing weakness of the legs and, to a lesser extent, the arms), the use of corticosteroids or intravenous immunoglobulin (IVIg)—alone or in combination with immunosuppressant drugs—is effective. However, better treatments are needed for patients who do not respond to currently available approaches.

There is even hope for patients with certain types of genetic neuropathies. Several promising experimental treatments are being studied for familial amyloid polyneuropathy, a rare genetic condition where impaired nerve function is caused by amyloid protein deposits in peripheral nerves.

While the lack of a recognized underlying cause for idiopathic peripheral neuropathy is frustrating, we have learned a great deal about this disorder over the past decade. A number of studies now link obesity and its related metabolic consequences (such as insulin resistance and elevated lipids in the blood) with peripheral neuropathy. In addition, several studies suggest that successful diet and exercise can improve nerve regeneration and improve symptoms including pain. This provides a non-drug treatment approach that would immediately benefit many people with peripheral neuropathy.

Despite all of this good news, more research is urgently needed. Relative to the number of patients who have neuropathy, very few research grants are funded. To help change this, consider joining one of the patient advocacy organizations focused on neuropathy. For example, the Neuropathy Association has many programs to encourage involvement and advocacy: www.neuropathy.org.

© 2014 American Academy of Neurology

http://journals.lww.com/neurologynow/Fulltext/2014/10020/What_s_on_the_horizon_for_restoring_nerve_function.15.aspx