Alcohol And Nerve Damage Not To Be Underestimated

Today's post from diabetic2.tophealthychoices.com (see link below) looks at a widely underestimated cause of nerve damage and neuropathic complications and that is alcohol. Most people are well aware of the results of over-indulging in alcohol but may not be aware what it can do to your nervous system and neurological functions. This article looks at what it is, what the symptoms are and how it is treated, with the conclusion that like most forms of neuropathy, there is no cure. Once the damage is done, you're left with trying to control the symptoms. It also goes without saying that if you already have neuropathy, alcohol may help you temporarily forget but will only worsen the condition in the long run. Everything in moderation folks!

 Alcoholic Neuropathy – Symptoms, Causes and Treatment
17 Jul, 2015

As Dr. Siwek mentions in this week’s episode of the Pain Channel, April is Alcohol Awareness Month. When we think of alcohol awareness, the first things that pop into our minds are drunk driving, designated drivers, and sobriety tests, right? Popular culture has taught us to correlate drinking with driving consequences. But Alcohol Awareness Month is truly about the health consequences associated with alcoholism such as neurologic complications, vitamin deficiencies, liver disease, and much more.

Neurologic complications of alcohol abuse may also result from nutritional deficiency, because alcoholics tend to eat poorly and may become depleted of thiamine or other vitamins important for nervous system function. Persons who are intoxicated are also at higher risk for head injury or for compression injuries of the peripheral nerves. Sudden changes in blood chemistry, especially sodium, related to alcohol abuse may cause central pontine myelinolysis, a condition of the brainstem in which nerves lose their myelin coating. Liver disease complicating alcoholic cirrhosis may cause dementia, delirium, and movement disorder. _Healthline.com

What is Alcoholic Neuropathy?

Alcoholic neuropathy, also known as alcoholic polyneuropathy, is the direct result of overconsumption of alcohol over extended periods of time. Unfortunately, alcoholics to not eat right, nor exercise, so their bodies slowly become deficient in several nutritional areas. There is a continual debate over whether it is the alcohol itself, or malnutrition that accompanies alcoholism, which is the root cause of alcoholic neuropathy.

The causes of alcoholic neuropathy are extensive, from irregular lifestyles leading to missed meals and poor diets, to a complete loss of appetite, alcoholic gastritis, constant vomiting, and damaging of the lining of the gastrointestinal system. All of these symptoms cause nutritional deficiencies, and when the lining of the gastrointestinal system becomes compromised, the body is not able to absorb the proper nutrients.

Alcohol consumption in extremes can also increase the toxins within a person’s body such as ethanol and acetaldehyde, which many believe are directly linked to alcoholic neuropathy.

What are the Symptoms of Alcoholic Neuropathy?

In most cases, alcoholic neuropathy sets gradually into the body so that the individual does not realize they have this condition until it is deeply rooted within their system. While weight loss is an early warning sign, it is also a side effect of heavy drinking, so most individuals with alcohol conditions do not realize what their body is trying to tell them. Painful paralysis and motor loss is the first symptom that individuals tend to truly take notice of. According to Alcoholism-Solutions.com, the following is a list of possible symptoms of alcoholic neuropathy:

Normal symptoms can include:

loss of sensation
tingling in the feet/hands
weak ankles
weakened muscles and a burning feeling in the feet.

Gastrointestinal symptoms can include:

loose bowel movements
feelings of nausea, possibly vomiting and constipation.

Men may experience:

the inability to hold liquid (incontinence)
and even impotence in some cases.

In severe occurrences of alcoholic neuropathy:

the autonomic nerves are damaged
autonomic functions are involuntary, like the heart beat and respiration.

Because this chronic condition effects the brain and nerves, pain can be intense and constant, sharp and quick, or dull and prolonged, and cramping may occur in muscles without warning.

Treatment of Alcohol Neuropathy

Most pain doctors in Arizona will tell you that there is no known cure for alcohol neuropathy, but there are successful pain management and treatment methods to help patients get back into life. At this point, when a patient has been diagnosed with alcohol neuropathy, a pain doctor’s best intention is to control the pain. Once that damage has been done from this chronic condition, unfortunately it cannot be undone. However, the pain can be controlled.

Obtaining from alcohol consumption will be the pain doctor’s first course of treatment. Whether it’s through counseling, Alcoholic’s Anonymous meetings, or in-house psychological evaluations, kicking the habit is the first step. This will be the toughest step for anyone living with alcohol neuropathy.

Next, your pain doctor will want to manage your nutritional intake through medication and a strict diet. Using a multidisciplinary team of industry experts, your pain doctor will no doubt sit you down with a nutritionist to determine the best course to get you back on track with a healthy diet. Multivitamins are also a key aspect in nourishing your body.

Physical therapy is usually called for in cases of alcohol neuropathy due to the great damage that has been done to the nerves. Since motor loss is a symptom of this chronic condition, your pain doctor will want to bring blood flow and life back into the affected areas of your body. One of the best ways to do this is through exercise and physical therapy.

Most individuals who abuse alcohol are also at great risk for abusing pain medication while going through pain management treatment, which is always a concern for pain doctors in Arizona. According to NYTimes Health, the least amount of medication needed to reduce symptoms is advised, to reduce dependence and other side effects of chronic use.

Common medications may include over-the-counter analgesics such as aspirin, ibuprofen, or acetaminophen to reduce pain. Stabbing pains may respond to tricyclic antidepressants or anticonvulsant medications such as phenytoin, gabapentin, or carbamazepine.

While it’s deemed impossible to reverse the damage already done to the body’s nerves, pain doctors can help patients living with alcoholic neuropathy reduce and control pain and get back into life. Of course, the best way to prevent this chronic condition is to respect your alcohol intake, but if you are suffering from this debilitating condition speak immediately to an Arizona pain specialist about your options at http://www.ThePainCenter.com.

http://diabetic2.tophealthychoices.com/alcoholic-neuropathy-symptoms-causes-and-treatment-96/

Why is Your Pain Neuropathy and Not Something Else

As always, every few weeks you'll see a general post about neuropathy here on the blog. Many people arrive at the blog with little or no information about what is happening to them and need a simply explained and accurate description of what their problem might be and how it may be treated. This very useful article from patient.co.uk (see link below) is exactly that. It's a U.K. article for a change and is a good basis from which to research further and ask questions of your doctors. However, even for experienced neuropathy patients, you may well read something here you didn't already know, or refresh your knowledge in some way (how many remember what nociceptive pain is for instance?)

Neuropathic Pain

Neuropathic pain (neuralgia) is a pain that comes from problems with signals from the nerves. There are various causes. It is different to the common type of pain that is due to an injury, burn, pressure, etc. Traditional painkillers such as paracetamol, anti-inflammatories and codeine usually do not help very much. However, neuropathic pain is often eased by antidepressant or anti-epileptic medicines - by an action that is separate to their action on depression and epilepsy. Other pain-relieving medicines and techniques are also sometimes used.

What is neuropathic pain?

Pain is broadly divided into two types - nociceptive pain and neuropathic pain.

Nociceptive pain

This is the type of pain that all people have had at some point. It is caused by actual, or potential damage to tissues. For example, a cut, a burn, an injury, pressure or force from outside the body, or pressure from inside the body (for example, from a tumour) can all cause nociceptive pain. The reason we feel pain in these situations is because tiny nerve endings become activated or damaged by the injury, and this sends pain messages to the brain via nerves.

Nociceptive pain tends to be sharp or aching. It also tends to be eased well by traditional painkillers such as paracetamol, anti-inflammatory painkillers, codeine and morphine.

Neuropathic pain

This type of pain is caused by a problem with one or more nerves themselves. The function of the nerve is affected in a way that it sends pain messages to the brain. Neuropathic pain is often described as burning, stabbing, shooting, aching, or like an electric shock.

Neuropathic pain is less likely than nociceptive pain to be helped by traditional painkillers. However, other types of medicines often work well to ease the pain (see below).

The rest of this leaflet is just about neuropathic pain.

What causes neuropathic pain?

Various conditions can affect nerves and may cause neuropathic pain as one of the features of the condition. These include the following:
•Trigeminal neuralgia.
•Postherpetic neuralgia (pain following shingles).
•Diabetic neuropathy - a nerve disorder that develops in some people with diabetes.
•Phantom limb pain following an amputation.
•Multiple sclerosis.
•Pain following chemotherapy.
•HIV infection.
•Alcoholism.
•Cancer.
•Atypical facial pain.
•Various other uncommon nerve disorders.

Note: you can have nociceptive pain and neuropathic pain at the same time, sometimes caused by the same condition. For example, you may develop nociceptive pain and neuropathic pain from certain cancers.

More about the nature of neuropathic pain

Related to the pain there may also be:
•Allodynia. This means that the pain comes on, or gets worse, with a touch or stimulus that would not normally cause pain. For example, a slight touch on the face may trigger pain if you have trigeminal neuralgia, or the pressure of the bedclothes may trigger pain if you have diabetic neuropathy.
•Hyperalgesia. This means that you get severe pain from a stimulus or touch that would normally cause only slight discomfort. For example, a mild prod on the painful area may cause intense pain.
•Paraesthesia. This means that you get unpleasant or painful feelings even when there is nothing touching you, and no stimulus. For example, you may have painful pins and needles, or electric shock-like sensations.

In addition to the pain itself, the impact that the pain has on your life may be just as important. For example, the pain may lead to disturbed sleep, anxiety and depression.

How common is neuropathic pain?

It is estimated that about 1 in 100 people in the UK has persistent (chronic) neuropathic pain. It is much more common in older people who are more prone to developing the conditions listed above.

What is the treatment for neuropathic pain?

Treatments include:
•Treating the underlying cause - if possible.
•Medicines.
•Physical treatments.
•Psychological treatment.

Treating the underlying cause

If this is possible, it may help to ease the pain. For example, if you have diabetic neuropathy then good control of the diabetes may help to ease the condition. If you have cancer, if this can be treated then this may ease the pain. Note: the severity of the pain often does not correspond with the seriousness of the underlying condition. For example, postherpetic neuralgia (pain after shingles) can cause a severe pain, even though there is no rash or sign of infection remaining.

Medicines used to treat neuropathic pain

Commonly used traditional painkillers

You may have already tried traditional painkillers such as paracetamol or anti-inflammatory painkillers that you can buy from pharmacies. However, these are unlikely to ease neuropathic pain very much in most cases.

Tricyclic antidepressant medicines

An antidepressant medicine in the tricyclic group is a common treatment for neuropathic pain. It is not used here to treat depression. Tricyclic antidepressants ease neuropathic pain separate to their action on depression. It is thought that they work by interfering with the way nerve impulses are transmitted. There are several tricyclic antidepressants, but amitriptyline is the one most commonly used for neuralgic pain. In many cases the pain is stopped, or greatly eased, by amitriptyline. Imipramine and nortriptyline are other tricyclic antidepressants that are sometimes used to treat neuropathic pain.

A tricyclic antidepressant may ease the pain within a few days, but it may take 2-3 weeks. It can take several weeks before you get maximum benefit. Some people give up on their treatment too early. It is best to persevere for at least 4-6 weeks to see how well the antidepressant is working.

Tricyclic antidepressants sometimes cause drowsiness as a side-effect. This often eases in time. To try to avoid drowsiness, a low dose is usually started at first, and then built up gradually if needed. Also, the full daily dose is often taken at night because of the drowsiness side-effect. A dry mouth is another common side-effect. Frequent sips of water may help with a dry mouth. See the leaflet that comes with the medicine packet for a full list of possible side-effects.

Other antidepressant medicines

An antidepressant called duloxetine has also been shown in research trials to be good at easing neuropathic pain. In particular, duloxetine has been found to be a good treatment for diabetic neuropathy and is now often used first-line for this condition. Duloxetine is not classed as a tricyclic antidepressant but as a serotonin and norepinephrine reuptake inhibitor (SNRI). It may be tried for other types of neuropathic pain if a tricyclic antidepressant has not worked so well, or has caused problematic side-effects. The range of possible side-effects caused by duloxetine are different to those caused by tricyclic antidepressants.

Venlafaxine is another SNRI antidepressant medicine that is sometimes used to treat neuropathic pain. Another group of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). There is some evidence to suggest that medicines in this group may help to ease neuropathic pain but more research is needed to confirm this.

Anti-epileptic medicines (anticonvulsants)

An anti-epileptic medicine is an alternative to an antidepressant. For example, gabapentin, pregabalin, sodium valproate, oxcarbazepine and carbamazepine. These medicines are commonly used to treat epilepsy but they have also been found to ease nerve pain. An anti-epileptic medicine can stop nerve impulses causing pains separate to its action on preventing epileptic seizures. As with antidepressants, a low dose is usually started at first and built up gradually, if needed. It may take several weeks for maximum effect as the dose is gradually increased.

Opiate painkillers

Opiate painkillers are the stronger traditional painkillers. For example, codeine, morphine and related drugs. As a general rule, they are not used first-line for neuropathic pain. This is partly because there is a risk of problems of drug dependence, impaired mental functioning and other side-effects with the long-term use of opiates. Also, the medicines listed above tend to work better anyway for neuropathic pain. However, tramadol is often used.

Tramadol is a painkiller that is similar to opiates but has a distinct method of action that is different to other opiate painkillers. A recent research review concluded that tramadol may be a good option for neuropathic pain in certain situations.

Combinations of medicines

For example, sometimes both an antidepressant and an anti-epileptic medicine are taken if either alone does not work very well. Sometimes tramadol is combined with an antidepressant or an anti-epileptic medicine. As they work in different ways, they may compliment each other and have an additive effect on easing pain better than either alone.

Capsaicin cream

This is sometimes used to ease pain if the above medicines do not help, or cannot be used because of problems or side-effects. Capsaicin is thought to work by blocking nerves from sending pain messages. Capsaicin cream is applied 3-4 times a day. It can take up to 10 days for a good pain-relieving effect to occur.

Capsaicin can cause an intense burning feeling when it is applied. In particular, if it is used less than 3-4 times a day, or if it is applied just after taking a hot bath or shower. However, this side-effect tends to ease off with regular use. Capsaicin cream should not be applied to broken or inflamed skin. Wash your hands immediately after applying capsaicin cream.

Other medicines

Some other medicines are sometimes used on the advice of a specialist in a pain clinic. These may be an option if the above medicines do not help. For example, ketamine injections. Ketamine is normally used as an anaesthetic, but at low doses can have a pain-relieving effect. Another example is lidocaine gel. This is applied to skin, with a special patch. It is sometimes used for postherpetic (post-shingles) neuralgia (but note, it needs to be put on to non-irritated or healed skin).

Side-effects and titrating dosages of medicines

For most of the medicines listed above it is common practice to start at a low dose at first. This may be sufficient to ease the pain but often the dose needs to be increased if the effect is not satisfactory. This is usually done gradually and is called titrating the dose. Any increase in dose may be started after a certain number of days or weeks - depending on the medicine. Your doctor will advise as to how and when to increase the dose if required; also, the maximum dose that can be taken for each particular medicine.

The aim is to find the lowest dose required to ease the pain. This is because the lower the dose, the less likely that side-effects will be troublesome. Possible side-effects vary for the different medicines used. A full list of possible side-effects can be found with information in the medicine packet. Some people don't get any side-effects, some people are only mildly troubled by side-effects that are OK to live with, but some people are troubled quite badly by side-effects. Tell your doctor if you develop any troublesome side-effects. A switch to a different medicine may be an option if this occurs.

Physical treatments

Depending on the site and cause of the pain, a specialist in a pain clinic may advise one or more physical treatments. These include: physiotherapy, acupuncture, nerve blocks with injected local anaesthetics and transcutaneous electrical nerve stimulation (TENS) machines.

Psychological treatments

Pain can be made worse by stress, anxiety and depression. Also, the perception (feeling) of pain can vary depending on how we react to our pain and circumstances. Where relevant, treatment for anxiety or depression may help. Also, treatments such as stress management, counselling, cognitive behavioural therapy, and pain management programmes sometimes have a role in helping people with chronic (persistent) neuropathic pain.

http://www.patient.co.uk/health/Neuropathic-Pain.htm

Chilli Patches Do They Help Or Not

Today's short post from neuropathydoctor.com (see link below) is written by Dr. Brandt R.Gibson, whose work has been featured on this blog before. Although it's from february 2012 and the story is not new, I'm publishing it in response to recent questions about both capsaicin cream and the capsaicin patches from NeurogesX. Do they work? Well, the American FDA says that the evidence is not sound enough to rate their approval, especially for people with HIV-related neuropathy but looking around the forums, it's clear that some people's (but by no means all) symptoms have been helped by using capsaicin (chilli pepper) derivatives, so as the doctor says; why deny yourself some relief if something genuinely helps! Watch out though; the cream must never get in your eyes or mouth, it can be very painful. Using thin, disposable, rubber gloves is advised. Similarly, the patches need to be administered by someone who knows what they're doing (a nurse or doctor) and although they can provide relief for some period of time, initially they will be painful. You should discuss this with your doctor before going ahead, in the knowledge that capsaicin will not 'cure' your neuropathy but may help to relieve the symptoms.

Chilli Pepper Patch May Not Work For HIV Neuropathy

by Brandt R. Gibson, DPM on 9 February 2012


A pain patch from NeurogesX Inc., made from chilli pepper has been questioned on efficacy by the FDA. This drug was designed for HIV patients with associated peripheral neuropathy. There is approximately 1.1 million people in the United States infected with HIV. Of these, approximately 1/3rd present with peripheral neuropathy either from the virus itself of the drugs utilized to treat it. According to the FDA, however, the efficacy was not shown yet in any of the studies, so it may not get approved until additional studies are done.

This is a big blow to the company, but a positive for HIV sufferers if the medication really has no efficacy. The problem I have with limiting access to drugs that may help is that peripheral neuropathy in other forms may benefit from this medication even when HIV associated neuropathy is not helped. Neuropathy varies with the causes and therefore varies with the treatment options. All neuropathy patients deserve a medication that can decrease or resolve the associated pain that can be very debilitating.

One small side note, Zostrix or Capsaicin creams are similarly made from red peppers and have been shown to be effective in peripheral neuropathy by overstimulating the nerves and creating a resolution of pain for a period of time. Although these treatments have not been shown to resolve neuropathy, they are valuable in the treatment of the pain in many individuals. If the drug made by NeurogesX Inc. were effective even in some respects it may be worth putting it on the market as an option.

Just my personal opinion…..

http://neuropathydoctor.com/http:/neuropathydoctor.com/chill-pepper-patch-may-not-work-for-hiv-neuropathy

rhNGF no its not a misprint

If you have been surfing the web looking for useful information about neuropathy, you may well have come across the unusually named, rhNGF as one of three proven effective treatments for neuropathic pain and problems. The other two are cannabis and capsaicin and have been extensively covered on this Blog but rhNGF is for most people, a complete mystery and when you try to research it on the Net, you can understand why!

Recombinant human nerve growth factor (rhNGF) is regarded as the most promising therapy in decades, for neurodegeneration of the central and peripheral nervous systems as well as for several other pathological conditions involving the immune system. However, rhNGF is not commercially available as a drug. For a start, it hasn’t been approved by the major, international medical authorities as yet, so any discussion at the moment is pretty much irrelevant but its day will come and it will be useful to have some idea of what it is and what it does.

At this point it might be advisable to avoid all websites ‘selling’ this as a product. It’s one of those things that attracts health and fitness fanatics, (like anabolic steroids for instance although there is absolutely no connection)and I have no idea why but because the national organisations haven’t as yet approved it for neuropathy treatment... you know the story for HIV patients... throwing any doubtful ‘variable’ into the mix is rarely advisable.

Giving a simple definition of rhNGF, is however, easier said than done because it is an extremely complex chemical structure. I certainly don’t understand much about it but will attempt here to simplify the information available on the Net. If you know better, or have any information to offer, please use the contact form at the top of the page, to put us all better in the picture.

First of all, the letters stand for Recombinant Human Nerve Growth Factor. ‘Recombinant means the new entity (e.g., gene, protein, cell, individual) that results from genetic recombination.

In short, NGF is a protein that is involved in the growth of peripheral nerve cells and was discovered 50 years ago as a molecule that promoted the survival and differentiation of sensory and sympathetic neurons. It is a small secreted protein that is important for the growth, maintenance, and survival of certain target neurons (nerve cells). It also functions as a signalling molecule.

While "nerve growth factor" refers to a single factor, "nerve growth factors" refers to a family of factors also known as neurotrophins. Neurotrophins represent an important family of regulatory proteins essential for sensory nerve development. Several neurotrophins have been identified, including nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and neurotrophin 3 (NT3). NGF is one of the most studied neurotrophins. It is a key regulator of sensory neurone excitability and an important mediator of injury-induced nociceptive and neuropathic pain.

It is an immensely complex biological process for the layman but NGF ‘s have shown very promising results in animal studies. Recombinant human nerve growth factor (rhNGF) has been in phase III trials (essentially meaning it's taken seriously!) and the results are also extremely encouraging.

Particular attention is given to a growing body of evidence that suggests that among other roles, NGF signalling, aids neuroprotective and repair functions. The analysis points to many interesting unanswered questions and to the potential for continuing research on NGF to substantially enhance our understanding of the mechanisms and treatment of neurological disorders.

The administration of nerve growth factor (NGF) has been found to prevent neuropathies induced by anti-cancer drugs such as cisplatin, vincristine and taxol. However, it is clinically important to know whether NGF is beneficial once the neuropathy is already established and this is one of the reasons why medical authorities are not yet ready to approve commercial drugs. It’s something with great potential and something which will require a lot more research and assessment.

Regarding our own situation as HIV patients with neuropathy, recombinant human nerve growth factor (rhNGF) was used in a multicenter, placebo-controlled, randomized trial by Justin McArthur of Johns Hopkins University and colleagues to evaluate its efficacy as a treatment for HIV-associated peripheral neuropathy. Nearly 300 individuals were randomized to receive two different doses of nerve growth factor or placebo. After 18 weeks of randomized treatment, there was a significant difference in average and maximum pain intensity favouring rhNGF. However, there were no differences in terms of mood, analgesic use, or epidermal nerve fibre density between the groups.

Giovanni Schifitto of the University of Rochester and colleagues reported on data from the 48-week open-label phase of the rhNGF study described above. After the randomized phase, 200 of the 235 eligible patients continued taking either 0.1 or 0.3 mcg/ kg of rhNGF. Neurological and quantitative sensory testing was performed at baseline and at week 48. Consistent pain improvement was observed in all groups, with the high-dose recipients demonstrating better outcomes than low-dose participants.

I'm sorry, I don't understand enough about it to be able to describe it more simply and for once, research on the Web leads you to very complicated scientific journals and papers which are way above my head. So why write a post about it you may ask? The reason is that a) you will probably see it mentioned in passing (but not in detail) and b) if it is one of three things they are pretty sure about, then it's only a matter of time before it becomes available in an approved format. It's a treatment for the future then and the more questions patients ask, the more likely the whole treadmill will turn more quickly, to everyone's benefit.

Good luck looking for information and if you do find something useful to share with us, please do - knowledge is always power, especially concerning medical issues.

TALK THERAPY NOT MEDICATION BEST FOR SOCIAL ANXIETY DISORDER

While antidepressants are the most commonly used treatment for social anxiety disorder, new research suggests that cognitive behavioral therapy (CBT) is more effective and, unlike medication, can have lasting effects long after treatment has stopped.

Social anxiety disorder is a psychiatric condition characterized by intense fear and avoidance of social situations and affects up to 13 percent of Americans and Europeans. Most people never receive treatment for the disorder. For those who do, medication is the more accessible treatment because there is a shortage of trained psychotherapists.

The findings of the study, a network meta-analysis that collected and analyzed data from 101 clinical trials comparing multiple types of medication and talk therapy, are published online Sept. 26 in The Lancet Psychiatry.

"Social anxiety is more than just shyness," says study leader Evan Mayo-Wilson, DPhil, a research scientist in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. "People with this disorder can experience severe impairment, from shunning friendships to turning down promotions at work that would require increased social interaction. The good news from our study is that social anxiety is treatable. Now that we know what works best, we need to improve access to psychotherapy for those who are suffering."

The research was a collaboration between the Johns Hopkins Bloomberg School of Public Health, Oxford University and University College in London, where Mayo-Wilson formerly worked.

For the study, Mayo-Wilson and his colleagues analyzed data from 13,164 participants in 101 clinical trials. The participants all had severe and longstanding social anxiety. Approximately 9,000 received medication or a placebo pill, and more than 4,000 received a psychological intervention. Few of the trials looked at combining medication with talk therapy, and there was no evidence that combined therapy was better than talk therapy alone.

The data compared several different types of talk therapy and found individual CBT was the most effective. CBT is a form of treatment that focuses on relationships between thoughts, feelings and behaviors. It helps people challenge irrational fears and overcome their avoidance of social situations, Mayo-Wilson says.

For people who don't want talk therapy, or who lack access to CBT, the most commonly used antidepressants -- selective serotonin reuptake inhibitors (SSRIs) -- are effective, the researchers found. But they caution that medication can be associated with serious adverse events, that it doesn't work at all for many people, and that improvements in symptoms do not last after people stop taking the pills.

The researchers acknowledge that medication remains important but say it should be used as a second-line therapy for people who do not respond to or do not want psychological therapy. The group's analysis has already led to new treatment guidelines guidance in the U.K. and, Mayo-Wilson says, it could have a significant impact on policymaking and the organization of care in the U.S.

Social anxiety disorder typically begins in adolescence or early adulthood, and it can severely impair a person's daily functioning by impeding the formation of relationships, by negatively affecting performance at work or school, and by reducing overall quality of life. Because it strikes people at critical times in their social and educational development, social anxiety disorder can have important and lasting consequences.

"Greater investment in psychological therapies would improve quality of life, increase workplace productivity, and reduce healthcare costs," Mayo-Wilson says. "The healthcare system does not treat mental health equitably, but meeting demand isn't simply a matter of getting insurers to pay for psychological services. We need to improve infrastructure to treat mental health problems as the evidence shows they should be treated. We need more programs to train clinicians, more experienced supervisors who can work with new practitioners, more offices, and more support staff."

Prescription Drug Misuse Declining Or Not

Today's post from pain-topics.org (see link below) follows on from yesterday's post in that it looks at the results of prescription drug availability and abuse. It seems, according to the report, that non-medical drug abuse has and is falling in the USA while prescription drug abuse is clearly rising. The report highlights medical drug abuse as being a big problem for now and the future but as Dr Leavitt's commentary below suggests, it may not be as cut and dried as it seems. Either way, as neuropathy patients who are on opioid and opium family drugs well know, the potential for addiction is always there and patients need to be carefully and regularly monitored by their doctors, to try to minimize the risk.

Rx Pain Reliever Misuse Declining?
Posted by SB. Leavitt, MA, PhD: Thursday, January 10, 2013

A new United States government report shows that prescription drug misuse decreased in 10 states between 2009 and 2011, and did not increase in any other states during that time. Yet, the government seems unimpressed by these results, and there could be biases in the reporting that are distorting the evidence to make the problems loom larger than reality as well as overlooking underlying causes.

The report issued by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) on January 8, 2013 [available here] notes that 22 million people used prescription pain-relieving drugs for “nonmedical purposes” since 2002. And, such Rx-drug misuse is just behind marijuana as the country’s most widespread drug problem, according to SAMHSA.

At the same time, however, the report states that comparisons of combined 2009-2010 data with combined 2010-2011 data show that past year nonmedical use of prescription pain relievers among persons aged 12 or older decreased in 10 states (Kentucky, Louisiana, Massachusetts, Mississippi, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, and West Virginia), and leveled-off during that timeframe in all other states on average.

Iowa had the lowest rate of nonmedical prescription drug use, at 3.6%, while Oregon had the highest rate — 6.4%. Seven of the 10 states with the highest levels of prescription analgesic misuse were in the West: ie, Washington, Oregon, Nevada, New Mexico, Idaho, Colorado, and Arizona. Two other high ranking states were in the South (Arkansas and Delaware), and one was in the Midwest (Indiana).

The national rate for the overall U.S. population declined between 2009-2010 and 2010-2011 — from 4.9% to 4.6%. The rates also decreased nationally during those time periods among persons aged 12 to 25, but remained unchanged overall among persons aged 26 or older. This older group already had analgesic misuse rates significantly lower than teenagers and young adults, but even among older persons there were declines in many states.

Data for the report were from the National Survey on Drug Use and Health (NSDUH), which asks persons aged 12 or older questions related to their nonmedical use of prescription pain relievers during the past year. Such “nonmedical use” is defined as (a) use of the analgesics without a prescription, or (b) use that occurred simply for the experience or feeling the drug caused; over-the-counter (OTC) drug use and legitimate use of prescription analgesics are not included.

In a news release [here], Pamela S. Hyde, SAMHSA Administrator, stated…

“Addressing prescription drug misuse remains a top public health priority, as we’ve seen inconsistent progress in addressing the issue across the states. Data from this report helps us better understand geographic variations in use, and should help with the development of more targeted and effective prevention and treatment programs. The key is educating the public on the serious health risks involved, and ensuring that we are providing the necessary treatment to those who need it.”

COMMENTARY: This report is significant news, since nonmedical use has declined even as the rate of analgesic prescribing overall has been increasing. Yet, the government often appears to emphasize the negative side of such data in continuing to portray an “epidemic” of prescription drug misuse, rather than lauding the remarkable progress that has been made.

Importantly, definition of the problem may be contributing to misperceptions that inflate the data. “Nonmedical use” of prescription analgesics is conflated with abuse, and includes using the drugs either for recreational purposes to get “high”OR using the drugs as intended for pain, but without appropriate authorization — a form of “medical misuse.”

In other words, someone who once “borrowed” a prescription pain reliever from a relative or friend for a toothache, and answered honestly on the NSDUH survey, would be categorized as a nonmedical user (abuser). This is the same category as someone who stole prescription pain pills from their parents’ medicine cabinet to get high at a party. Yet, the motivations are strikingly different, even though both uses could be quite hazardous, and solutions to the respective problems also would be very different.

For example, some time ago in an UPDATE article [here] we reported on a large survey of high school seniors that found 12.3% of them used opioid analgesics for “nonmedical” reasons at some time. Yet, on closer inspection, 45% of the “misusers” actually took the drugs for self-medicating physical pain. This was similar to other studies finding that roughly half of so-called “nonmedical use” among students was to relieve pain; albeit, such use was unauthorized due to the person not having a prescription of their own.

As we noted in that earlier UPDATE, an important public health question might be, “Why are so many young persons suffering from untreated (or mistreated) physical pain, causing them to seek remedies on their own?” Perhaps, it is more convenient for them to borrow a few pills from a friend than go to a healthcare provider. Or, are there access-to-care and undertreatment of pain problems among these youngsters that need to be addressed?

It is interesting to observe in the latest SAMHSA data that the group with the highest rates of analgesic misuse are young adults 18-to-25 years old. Surely, this is an active time of life that may be filled with sports injuries and acute physical aches/pains of various types, as well as a period of experimentation with many life experiences — including drugs. Although the data do show some significant declines in drug misuse in this age group, as in the other groups, these young persons might represent a special target for prevention and education efforts.

Meanwhile, in older persons, with the lowest rates of “nonmedical” analgesic use in the SAMHSA data, one might speculate that such misuse more often than not is for the unauthorized self-treatment of pain. Furthermore, the use of marijuana among older age groups could be more often for pain than purely recreational use. We need better ways of capturing and categorizing such data, and then addressing the true underlying problems; although, the government has not shown any interest in doing this in the past. What do readers think?

http://updates.pain-topics.org/2013/01/rx-pain-reliever-misuse-declining.html

To Cane Or Not To Cane For Neuropathy

Today's article from neuropathy.org (see link below) examines a problem that many people living with long-term neuropathy eventually have to face and that is whether to take advantage of walking aids like canes. It's very often a matter of pride. You don't want to be seen needing a walking cane and you put it off as long as possible while running the constant risk of misstepping or losing your balance. Most people who invest in a cane see the benefits immediately. It's like having a third leg that helps to stabilise you whilst walking and before you know it you forget that people may be looking at you differently. Certainly the benefits can outweigh what you may see as stigma.

Coming Around to Using a Cane
By Elizabeth Byleen June 2013

"The amazing thing about the cane is that it is teaching me to walk differently. With the cane, I have loosened up. My stride has become longer and more relaxed. It takes less effort to walk, so I walk more. I have become physically stronger. This new strength and my more relaxed gait carry over even when I’m not using the cane."

Support Your #1 Cause: The Fight
Against Neuropathy!

My inherited peripheral neuropathy has me walking in my father’s footsteps. Just like him, it’s difficult to stay on my half of the sidewalk. In fact, as I walk to work, many people don’t pass me on the sidewalk, but walk out in the street around me. My gait is unpredictable; I wobble and weave, and my balance is a problem. My proprioception (or perception of knowing where I am in space) is off, especially when I’m in low light. But just like my dad, I keep moving. I’m ambulatory, and that feels great.

Several years ago, when I lost my balance and fell in my bedroom— pushing my hand through a glass window and bruising my face on the nightstand—a friend suggested I use a cane at night. “Oh, not me! Not even in the privacy of my own home,” I said to myself. A few years later, when my doctor suggested a cane, I was insulted, even though I careened off a wall as I left his office. A cane was a symbol of giving up and admitting defeat. I was in my early fifties, and not willing to send out that message.

The summer after my doctor suggested a cane, I stopped in to visit with my 90-year old neighbor, Hazel, who was sitting on her front porch. Rather exhausted after a long walk, I shared with Hazel that I was discouraged by how I walked; in fact, two people along the way had asked me if I was okay. She offered to let me borrow one of her canes for a while and see how it worked for me. Out of politeness, I said I would.

On the short walk home, even though the cane was not the correct height, I noticed immediately how helpful it was. I didn’t lean into it, but with just a light touch, I got more feedback about where I was, making it much easier to navigate. That week, my daughter and I took long walks in the evenings. I walked straighter and taller. I was more confident, and I didn’t obsess about every crack in the sidewalk that might trip me up.

The amazing thing about the cane is that it is teaching me to walk differently. Because of the fear of falling, the fear of running into people, and the fear of being perceived as drunk or somehow not quite right, over the years I had developed a real tightness to my walk. I tensed everything up: my mind, my shoulders, my arms, my hips, and my legs. With the cane, I have loosened up. My stride has become longer and more relaxed. It takes less effort to walk, so I walk more. I have become physically stronger. This new strength and my more relaxed gait carry over even when I’m not using the cane.

Our resistance can be so fierce. While I once thought a cane was only a symbol of my decline, it’s proving to be a very helpful tool, especially in crowds, unfamiliar places, and over long distances. Having that extra point of contact—basically acting as a tripod—provides me much more stability. An unexpected benefit is that my cane sends a quick visual signal to others to give me more space and time to maneuver. I had to overcome incredible resistance to eventually arrive at something that works so well for me.

http://www.neuropathy.org/site/News2?page=NewsArticle&id=8393

Statins Bad News For Neuropathy Patients Or Not

Today's post from neuropathy.org (see link below), is the first of two, looking at statins and their potential role in neuropathy development. Statins are one of the fastest growing drug groups around at the moment and have been proved to be very successful in reducing 'bad' cholesterol levels. Cholesterol problems are unfortunately a feature of the modern age as our diets become more and more fats-based but neuropathy patients have long been advised not to take them for fear of worsening their symptoms. Similarly, there are thousands of cases where statins have been given the blame for actually causing neuropathy in the first place. What's the truth? This article suggests that statins may not be as harmful to the nervous system as first thought. Tomorrow's post suggests the opposite. The best advice has to be to discuss the issue very carefully with your doctor and don't leave until your satisfied that these drugs are not going to bring your nerve problems. In the end you may need to trust your doctor's opinions but be aware of possible beginning or worsening of symptoms.

“Ask the Doctor” Column: Influence of Statins on Neuropathy

This is a column in which leading clinicians answer your questions about neuropathy – usually one question per issue, and more when we are able. Please send your questions to “Ask the Doctor” c/o Neuropathy News, The Neuropathy Association, 60 East 42nd Street, Suite 942, New York, NY 10165.

Dear Doctor: I have just read the part of Dr. Weimer's article (on www.neuropathy.org website) dealing with the influence of statins on neuropathy--most helpful. But a recent article (2007) I found on Google suggests that for people with controlled type 2 diabetes the use of statins may actually retard the progression of neuropathy. Do you have a comment on this please? Thank you. - Michael S.

Dr. Louis H. Weimer Answers: In clinical medicine, an occasional dilemma occurs when two well designed and well-conducted large trials produce seemingly contradictory results. This situation arose in June regarding the correlation between statins and neuropathy as reported in an earlier study conducted in Denmark and a recently announced Australian study.

The Danish study concluded that patients taking statin-class cholesterol-lowering drugs were more likely to have neuropathy, especially if they took the drugs for a longer time period or had definite evidence of neuropathy. One criticism of the Danish study was that no assurance was given that some of the patients taking statins did not have mild and unrecognized forms of diabetes or simple glucose intolerance, now recognized to be risk factors for neuropathy. In addition, the lipid disorders prompting the statin use in the first place are under scrutiny as a neuropathy risk factor as part of the metabolic syndrome—the study's authors acknowledged this limitation. This one study was the primary basis for the widely publicized concerns of statins and toxic neuropathy. Beyond this study, there have been a small but recognized number of individual patients who appear to develop neuropathy soon after starting a statin and then improve after stopping the drug.

The more recent Australian study found that diabetes patients were less likely to have neuropathy if they received a statin or fibrate. For statins, the reduction in neuropathy rates was found to be about 35%. Fibrates, a separate class of lipid-lowering drugs, had a similar effect, suggesting that improved lipids and cholesterol could be more important than an independent effect of the drugs. However, exactly why these drugs are beneficial or harmful to nerves is poorly understood. The Australian study tracked almost 1,300 diabetic patients over eight years. Its findings also reported significantly higher rates of neuropathy in untreated patients. The study's findings have not yet been published in a medical journal, but they were announced and discussed at this year's American Diabetes Association annual medical meeting.

It is too early to know if these protective effects are valid and can be duplicated by other studies. Also unknown is if these effects will be applicable to patients without diabetes. It is well accepted that any toxic nerve effects of statins are quite rare: some of these patients may have developed neuropathy for the reasons mentioned above despite the statin treatment while others may have a rare sensitivity to the drugs. In addition to the findings from these two studies, there is also experimental animal study evidence that appears to support both contentions of toxicity and protection—adding to the uncertaintybut there is better evidence for neuroprotection than toxicity.

The critical decision for neuropathy patients is whether statins are more beneficial to their overall health than whether they are potentially harmful. There is well-established and convincing evidence for the benefits of these agents and now possibly added nerve protection for patients with diabetes. The evidence for nerve toxicity remains less clear. Patients with existing neuropathy and a lipid or cardiac condition known to benefit from statins probably should not avoid these agents simply for the rare neuropathy risk. The situation is more complex for the rare patients who worsen soon after starting new treatment or patients who develop neuropathy while taking statins for an extended period. Further studies will be needed to address all of the outstanding questions.

Dr. Louis H. Weimer is associate clinical professor of Neurology at Columbia University. He is also co-director of the Peripheral Neuropathy Center of Excellence at Columbia.

http://www.neuropathy.org/site/News2?id=7161

A Neuropathic Pet Is Also For Life And Not Just For Christmas

Today's post from petmd.com (see link below) highlights a little-known fact that dogs, cats and other domestic mammals can also suffer from neuropathy. Now if you suffer from nerve damage, you can tell others how you're feeling but even then, it can be difficult describing your symptoms. Imagine then how long a dog or cat might be suffering before you notice something's wrong! They can't tell you and you can't question them! This article provides a list of symptoms to look out for, which is helpful. It's also pretty astonishing to learn that one of the common treatments is Gabapentin, which as you know is also prescribed for humans (with or without side effects). Spare a thought for your pets this festive season - they don't have special orthopedic footware as they walk through the mud and cold but you can imagine what they may be going through if they suffer from neuropathy. If you're concerned, a trip to the vet may be in order.

Neuropathic Pain in Dogs 
Pain from the Nervous System in Dogs

Neuropathic pain commonly results from an injury or disease relating to the body’s nerves and how they function, or within the spinal cord itself. This particular kind of pain is difficult to pinpoint, especially in patients that are unable to respond to specific inducements.

Symptoms and Types

Damage to the tissues of the body, and the nerves running through them, creates a constant (chronic) pain that is brought on by a light touch to the affected area and/or a heightened perception of pain. Pain originating within the spinal cord causes problems with mobility and various functions of the body.

Some of the symptoms of neuropathic pain may include:

Limping or dragging a limb
Shaking or twitching of the skin
Chewing on the affected area
Muscle wasting (atrophy)
Crying out (vocalizing)
Decreased appetite
Urinating and defecating inappropriately (incontinence)

Causes

Neuropathic pain may result from an injury to body tissues or a growth (tumor) in the spinal cord. Diseases that affect the spinal cord, such as intervertebral disc disease (IVDD), may cause pain in different areas of the body, depending on which part of the cord is affected. Another potential cause of neuropathic pain is amputation of a limb. Phantom limb pain results in the impression of pain coming from a leg that has been surgically removed.

Diagnosis

In general, neuropathic pain is diagnosed by ruling out other causes of pain and performing reflex tests to evaluate the nervous system. Basic blood tests can help rule out infectious and disease-related causes. X-rays and special imaging may be necessary to search for tumors in the bone or spinal cord. Finally, a good discussion of your dog's medical history and previous symptoms will help lead to the proper diagnosis.

Treatment
Analgesic medications (those that relieve pain) are used as the initial treatment for neuropathic pain. The amount given may need to be changed until the best effect is achieved. Other types of pain relievers may be tried until the one that works best for your dog is found. Some veterinarians may choose to use several pain medications at one time and then taper off until only one is being given.

One medication that has been used with success for long-term pain is gabapentin. This anti-seizure drug has analgesic properties that are particularly effective for reducing neuropathic pain in dogs. Gabapentin is given once daily for pain control and can be given with or without food. The particular side effects of this drug include sedation, weight gain and stumbling (ataxia). Diarrhea may also be seen in some animals.

Living and Management

Dogs with chronic pain may gain considerable relief from analgesic medications. The quality of life for these animals can be much improved, as long as the underlying condition causing the pain is under control.

In dogs with kidney problems, the dosage of gabapentin may be reduced, as the drug is processed through the kidneys and they must be functioning properly for the drug to be removed from the body. Animals that are pregnant should not be treated with gabapentin. When discontinuing the medication, gabapentin should be slowly tapered off to prevent seizures from occurring after long-term use.

http://www.petmd.com/dog/conditions/neurological/c_dg_neuropathic_pain

Opioids For Neuropathic Pain Judge The Treatment Not The Patient

Today's post from ama-assn.org (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

http://www.ama-assn.org/ama/ama-wire/post/pain-expert-judge-opioid-treatment-not-patient