“Heavy NSAID Use Linked to Higher Dementia Risk” – Exercise, Antidepressants Both Help Neurogenesis

NSAIDs are anti-inflammatory drugs used to treat pain, inflammation, or fever.  The only NSAIDs that are NOT associated with increased risk of heart attack or arrhythmia are naproxen (Aleve) or aspirin.  Taking high doses of aspirin has a greater risk of GI bleed than naproxen, which is why I usually recommend naproxen.


Several past studies have shown NSAIDs delay or prevent dementia, but there have been contradictory results.  Last year Neurology published a study of 49,349 patients’ usage ranging from ≤1 year to ≥7 years done at Boston University and Bedford VA. They showed long term use of NSAIDs protects against Alzheimers:

Compared with no NSAID use, the relative risk of Alzheimer’s disease decreased from 0.98 for ≤1 year of use (95% CI 0.95 to 1.00) to 0.76 for >5 years of use (95% CI 0.68 to 0.85).

Among patients who specifically cited use of ibuprofen, the risk of Alzheimer’s disease declined from 1.03 (95% CI 1.00 to 1.06) to 0.56 (95% CI 0.42 to 0.75).

Ibuprofen came out ahead in that study perhaps because it is the most commonly used.

They also sought to answer whether NSAIDs known to suppress Aβ1-42 amyloid would more likely protect .  Aβ1-42 amyloid is a major component of plaques found in Alzheimer’s Disease.

Aβ1-42 amyloid suppressors include ibuprofen, diclofenac, flurbiprofen — but as for suppressing Alzheimer’s, these were found to be no different than other NSAIDs, putting that theory to rest.


Risk of dementia and Alzheimer’s Disease with prior exposure to NSAIDs in an elderly community-based cohort:

This new study by Breitner  et al, from the University of Washington School of Medicine was published online April 22, 2009, before the print edition in Neurology.  

Their outcome contradicts earlier protective studies possibly because they started with an older cohort, healthy adults 65 and older, which “could be enriched for cases [of Alzheimer’s] that would otherwise have appeared earlier.”

They prospectively followed 2,736 persons in a Seattle health plan.  Before starting the study, they reviewed pharmacy records as much as 17 years earlier.


12.8% of the study participants [were] heavy NSAID users at baseline. Heavy use was defined as taking 500 or more standard daily doses over a two-year period.

Another 3.9% of participants became heavy users during follow-up.

Ibuprofen, naproxen, indomethacin, and sulindac accounted for about 80% of all NSAIDs used.

Through follow-up, 476 participants developed dementia; for 356 of them, it was Alzheimer’s disease.

After controlling for age, gender, education, APOE status, hypertension, diabetes, obesity, osteoarthritis, and physical activity, the risk of developing all-cause dementia was 66% higher among heavy users than among those with little or no NSAID use (HR 1.66, 95% CI 1.24 to 2.24).

The risk of developing Alzheimer’s disease was 57% higher (HR 1.57, 95% CI 1.10 to 2.23).

Strengths of the study: the community-based sample, biennial assessment of dementia, rigorous exposure classification, and large numbers of dementia cases, outweigh the limitations.

Limitations:  lack of generalizability to a younger patient population, the lack of exact dosing information, and the possibility of bias from unmeasured confounders.

Can we draw conclusions on one study alone? We know that exercise is protective against Alzheimer’s Disease and pain may have prevented this older age group from being active. Though they did control for that, this research needs to be supported by further studies. What is helpful is to remain as active as you can.  Keep and maintain every bit of function you can and get help for depression and anxiety as they may profoundly affect memory, morbidity and mortality.  For a review of the literature on the morbidity and mortality of stress and mood, refer to my post on Cognitive Behavioral Therapy and the importance of a positive outlook.

The brain makes new neurons – neurogenesis.  I will write more in the future on exercise, mood, stress, brain atrophy and memory loss.   Exercise improves depression and anxiety, and exercise stimulates neurogenesis.  It appears that the action of antidepressants also may be to stimulate neurogenesis.  Chronic low back pain has been reported to cause brain atrophy.  Chronic depression leads to brain atrophy and memory loss with atrophy occurring in the hippocampus, the area essential for memory.  This important publication from Vancouver reviews the topic in great detail and proposes a hypothesis:  Antidepressant effects of exercise: Evidence for an adult-neurogenesis hypothesis?

Further medication is being tested to reduce neuronal cell death that leads to Alzheimer’s Disease, using a very simple compound that blocks free radicals and inflammation.  More on this later.

The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.


For My Home Page, click here:  Welcome to my Weblog on Pain Management!

Controversy on Medication Coverage – “step therapy” (also known as “fail first”)


Insurance Industry Opposes Physician’s Choice of Medication for Pain Relief

The best or just the cheapest?

Before I define “step therapy,” let me introduce Forgrace.org, a nonprofit organization “Dedicated to Ensuring the Ethical and Equal Treatment of All Women in Pain.”   Based in Los Angeles, the organization was formed in 2002 by John Garrett, Executive Director, and his partner Cynthia Toussaint, an accomplished ballerina who has suffered with CRPS (and later fibromyalgia) for 26 years. Thanks to their leadership advocating for health care reform in California, today they announce that

For Grace and HAAF’s bill, AB 1144, was heard by the California Assembly Health Committee in Sacramento yesterday (April 21) and it passed overwhelmingly with a vote of 14-2.  There was strong opposition from the health insurance industry – and this effort will be an uphill climb as we move the bill along to the Senate.

Also, today, ABC News national covered the issue of “step-therapy” (also known as “fail first”) along with our bill, that if signed by Gov. Schwarzenegger, will abolish this unethical prescription practice that negatively impacts women in pain.  Ms. Toussaint pitched this story, consulted and interviewed for it.

Because of its importance to every single one of my patients whose lives hang by the constant threat of an indifferent refusal by insurance carriers to continue providing medication that they require, I am posting almost the entire ABC News article titled Patients Irate With Insurers’ ‘Fail First’ Policy by Dan Childs

What Is Step Therapy?

The basic idea behind step therapy is to start with the most cost-effective and safest treatment, progressing to more costly or risky therapy only if the current treatment is not effective. In theory, proponents say, the strategy both minimizes risks to the patient and keeps overall costs under control.

Robert Zirkelbach, spokesman for America’s Health Insurance Plans, said that when it comes to the bigger picture, step therapy is a key element in making the country’s health care system more efficient by creating a standard system of care from state to state. He said that this saves costs, and it also ensures that patients get access to therapies that have been proved to be medically effective.

“We see individuals with the exact same illnesses get drastically different treatment depending on where they live,” he said. “Right now there is no correlation between the money being spent and the health outcomes being advanced. Our goal is to help guide the patient.”

Dr. Forest Tennant, head of the Veract Intractable Pain Clinic and editor of the trade magazine Practical Pain Management, is also Cook’s doctor. He agreed that in theory, step therapy is not a bad strategy. And he added that doctors have traditionally employed a form of step therapy, in which they would gradually increase the dose of a given medication for a patient who was not responding until they were able to achieve the desired effect.

Doctors Employ Different ‘Step Therapy’

And even when it comes to designing a course of treatment, Tennant agreed that a cheaper approach is preferable, as long as it works for the patient.

“Given the cost of some of the medications I prescribe, I also want the patient to try the cheaper medication first.”

But he said that the step therapy used by the health insurance industry is different in that it may actually place a preferred therapy out of reach of a patient. Particularly vulnerable may be pain patients like Cook and Toussaint, who have experienced success with a given medication but are switched to a different drug by an insurer.

“What we have today is a situation where a patient is knocked around in the system, usually after they’ve already tried something that works for them but which they can’t have,” he said. “All of a sudden, the drug that they have been taking for quite some time is pulled away from them — because it is more expensive, usually.

The Best — or Just the Cheapest?

According to data collected in 2006 by the health care analytics company Verispan, the drugs for which step therapy is most commonly used are anti-ulcer medications, with 58 percent of health insurance plans using step therapy for this class. The data also reveal that antidepressants are the fourth most common drugs subject to step therapy, with 45 percent of plans subjecting these to step therapy. Twenty-six percent of plans use step therapy for pain drugs, according to Verispan, and other drugs including heart medications and antipsychotics are also on the list.

Zirkelbach argued that in most cases, patients are allowed to switch drugs if the recommended option is not working for them, and if the drug that the patient is switching to is supported by medical evidence.

“If there is a good medical reason to switch to drug A versus drug B, health plans typically allow that to happen,” he said.

But he noted that how long a patient is required to stay on a given medication before making a switch varies from case to case. Doctors who prescribe a drug that is unapproved by the insurance company risk receiving what Tennant calls a “tantrum letter” from insurance companies.

“The insurance companies hire auditing firms, and they demand to know why I prescribe [patients] certain drugs,” he said.

The net effect, Tennant said, is a grave imposition on the doctor-patient relationship.

“I have to say [to patients], ‘I can’t tell you what you should take. I can only get you to get what your insurance can pay for, and I’ll design a regimen,'” he said. “For the expensive medicine, the doctor no longer chooses what he wants.”

And according to a Thomson Reuters study published in the February issue of The American Journal of Managed Care, step therapy may actually be more expensive for insurance companies, at least when it comes to patients receiving medication for high blood pressure.

Step Therapy May Not Be Cheaper

In the study, which was sponsored by Pfizer, researchers looked at insurance claims for 11,851 people with employer-sponsored health coverage that incorporated a step therapy protocol for high blood pressure drugs. These patients’ claims were compared with those of 30,882 patients on similar medication who did not participate in a step therapy program.

What the researchers found was that the group of patients treated for hypertension under the step therapy program had 3.1 percent lower drug costs. But these savings appear to have been wiped out by the apparent increase in hospital admissions and emergency room visits. Over two years, the step therapy patients incurred $99 more in healthcare costs per quarter, on average, than the control group.

Hope for Step Therapy?

If indeed California passes anti-step therapy legislation, it would not be the first to do so. New Jersey already prohibits such plans. And even the Centers for Medicare and Medicaid Services may be considering regulations to limit step therapy by health plans available to Medicare patients.

But Robert Taketomo, president and CEO of the Glendale, Calif.-based managed care contracting services organization Ventegra, warned that if such legislation passed in the state, patients may find that other parts of their coverage will be cut back to compensate.

“As long as healthcare is a benefit, and not a right, then measures such as step therapy are important means of preserving pharmacy benefits,” he said. “If step therapy were to be prohibited through legislative means, there are other means through which a payor — whether they be government, health insurer or employer — could limit their cost exposure in pharmacy.

“These could include removal from formulary, increases in copayment, addition of deductibles (and increasing them), or ‘carving out’ pharmacy altogether and just cover medical expenses.”

Tennant said he believes the true solution to the problem does not lie with new laws.

“There has to be some goodwill meeting of the minds for the people who practice medicine, those who need the help, and the people who are paying for it,” he said. “Most of the [insurance companies] are trying to develop formularies comprehensive enough to get the job done without compromising patient care too much.”

But Cook said that as long as her insurance adheres to a step therapy policy, she and other pain patients will worry about her medication one day becoming unaffordable.

“We all know that our lives could change at a moment’s notice if the insurance companies say, ‘Change,'” she said.

To view some of Ms. Toussaint’s presentation to the media, including her “fail first” experiences… on the second page of their “Videos” go here.

Her focus has now shifted to bringing a single-payer, universal health care plan to all in California which will provide a model for the rest of the country.

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

Cognitive Behavioral Therapy – Being Positive


I don’t know how the Great Recession may be affecting your mood, but for those with chronic pain, it is often difficult to nurture and maintain a positive attitude.  At times when we need the most help, we may be most reluctant to appreciate the benefits of Cognitive Behavioral Therapy, but that’s how we get help to reorder our thoughts in positive ways that are healing.

A Randomized Trial of a Cognitive-Bahavior Intervention

Compared to information giving and educational approaches, the risk for developing a long-term disability was lowered nine-fold for the cognitive-behavior intervention group. The cognitive-behavior group also demonstrated a significant decrease in physician and physical therapy use as compared with two groups receiving information, in which such use increased. These findings underscore the significance of early interventions that specifically aim to prevent chronic problems.

More recent research is reported by London’s syndication, The Independent, that tells us how much our attitude is harming ourselves.  Don’t forget, it harms everyone you love and constricts their lives too.  But the right frame of mind can lower your pain and other health risks.


People showing dispositional optimism may be better able to cope with pain and need less medication. A study at Michigan State University on cancer patients shows that those who were more optimistic tended to report less severe pain. A study at the University of Alabama showed that patients who were optimistic used less medication for pain relief. “More optimistic adolescents are better able to match their medication use to their pain severity. Future research should examine how other psycho-social factors might influence pain medication use in adolescents and adults, and clinicians should take into account psychosocial factors when working with pain populations.”


Women who are happy and optimistic may have a lower risk of developing breast cancer. The research also show that adverse life events, such as loss of a loved one or divorce , can increase the risk. Results from the study at Ben Gurion University in Israel show that exposure to more than one adverse life event was associated with a 60 per cent increased risk of disease, while happy and optimistic women were 25 per cent less likely to have the disease. “A general feeling of happiness and optimism seems to play a protective role,” say the researchers. “The relationship between happiness and health should be examined in future studies and possible relevant preventive initiatives should be developed,” say the researchers.


A review of research into the association between positive wellbeing and mortality shows a signifciant link. The University College London analysis of 35 studies showed that positive psychological wellbeing was associated with an 18 per cent reduced mortality in healthy people and a 24 per cent lower risk in sick people. “Positive feelings – emotional well-being, positive mood, joy, happiness, vigour, energy – and life satisfaction, hopefulness, optimism, sense of humour, were associated with reduced mortality. Results suggest that positive psychological wellbeing has a favourable effect on survival in both healthy and diseased populations.


The positive-minded have a 55 per cent lower risk of dying from heart disease, according to the results of a study which followed 500 men aged 54 to 84 for 15 years. “Our results demonstrate a strong and consistent association between dispositional optimism and lower risk of cardiovascular mortality,” says the researchers from The Netherlands Institute of Mental Health, Delft. Just how low optimism may lead to cardiovascular death, is, say the authors, an intriguing, but unanswered question. One possible mechanism, they say, is that optimism is related to better coping behaviour. Another study at the University of Pittsburgh, and based on 200 women diagnosed with thickening of the arteries, showed that over a 15-year period, the disease progressed more slowly in those women classed as optimists. Other research has shown that optimists have a lower risk of rehospitalisation after coronary artery bypass graft surgery.

The article also covers the field of research as it applies to blood pressure, longevity, infections, even the common cold……..

Practice makes perfect.  Take time out to give yourself some love.  Doctors too.

And read Diana’s blog to see how the addition of 3 kittens have added so much to her family’s mood.  Even if you can’t have a pet, you can still enjoy a friend’s.

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

Medical Library

This page at the National Library of Medicine or Medical Librarymay be useful to you, allowing you to search for the explanation of Medical Conditions, Medications, Procedures, Tests, and general questions.

Other active links – click to open

Merck Manual

End of Life Care Resources

Tool Kit for Health Care Advanced PlanningAdvance Directives & Do Not Resuscitate Orders


Caregiving a parent with dementia

Multiple Sclerosis

Caregiving a person with Multiple Sclerosis

Clinical Research Protocols at NIH

Clinical Trials at NIH

Complementary and Alternative Medicine

First Aid – CPR

First Aid for Seizures

Smoking Cessation


Other  organizations include American College of Emergency Physicians, National Hospice and Palliative Care Organization, Family Caregiver Alliance, American Bar Association Commission on Law & Aging.


For My Home Page, click here:  Welcome to my Weblog on Pain Management!

This service should not be used in place of a visit, call, consultation with or the advice of your healthcare provider.

Communicate promptly with your provider with any health related questions or concerns.


Lumbar Epidural Injections & Sympathetic Nerve Blocks

Nerve Block Therapy for Low Back Pain: Show Me the Money and the Science, is the title of an article published in 2002, in the American Pain Society journal Pain.  The author reviewed current studies and questioned the value of lumbar epidural injections and sympathetic nerve blocks.

The scientific evidence to prove efficacy simply was not there.  More importantly, even with fluoroscopy and accurate placement of the needle, the solution reached the desired area only 26% of the time.  The author called for research to test efficacy.

From the current review, we must conclude that lumbar epidural steroid injections and sympathetic nerve blocks produce a large amount of money, with very little science to support their application. Does this mean they are useless? Obviously not; these techniques have some value in acute pain management and should not be completely abandoned. However, their use as a mainstream ( almost knee-jerk ) intervention for acute or chronic low back pain does not appear to be at all justifiable at the scientific level.

The fundamental recommendation is quite obvious. Those pain specialists who use these techniques on a regular basis need to support and initiate some clinical research trials that adequately test these procedures’ efficacy. Without this, the routine application of epidural steroid injections and lumbar sympathetic nerve blocks for acute or chronic low back pain is not evidence based. Therefore, when can it be recommended remains an empirical question.

More recently in March 2007, the American Academy of Neurology studied the issue in depth and published  Practice Guidelines on the Use of Epidural Steroid Injections to Treat Radicular [sciatic] Lumbosacral Pain.

They also found no Level A quality research and did not recommend routine use:

Based on the available evidence, the Therapeutics and Technology Assessment subcommittee concluded that

1) epidural steroid injections may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection, compared to control treatments (Level C, Class I-III evidence). The average magnitude of effect is small and generalizability of the observation is limited by the small number of studies, highly selected patient populations, few techniques and doses, and variable comparison treatments;

2) in general, epidural steroid injection for radicular lumbosacral pain does not impact average impairment of function, need for surgery, or provide long-term pain relief beyond 3 months. Their routine use for these indications is not recommended (Level B, Class I-III evidence);

3) there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain (Level U).

This subject will be an intense topic of interest for the Anesthesiology Subcommittee at the annual meeting of the American Pain Society that meets in San Diego May 2009.   At best, epidural injections and nerve blocks are temporizing measures.  If the first one is less than effective, they are often done in a series of three.  One risk of frequent steroid injections is osteoporosis.


The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.


For My Home Page, click here:  Welcome to my Weblog on Pain Management!


Poetry of Pain By Emily Dickinson

There is a pain — so utter

There is a pain — so utter —

It swallows substance up —

Then covers the Abyss with Trance —

So Memory can step

Around — across — upon it —

As one within a Swoon —

Goes safely — where an open eye —

Would drop Him — Bone by Bone.

Pain—expands the Time

Pain—expands the Time—

Ages coil within

The minute Circumference

Of a single Brain—

Pain contracts—the Time—

Occupied with Shot

Gamuts of Eternities

Are as they were not—


After Great Pain, a Formal Feeling Comes

After great pain, a formal feeling comes

The Nerves sit ceremonious, like Tombs

The stiff Heart questions was it He, that bore,

And Yesterday, or Centuries before?

The Feet, mechanical, go round

Of Ground, or Air, or Ought

A Wooden way

Regardless grown,

A Quartz contentment, like a stone

This is the Hour of Lead

Remembered, if outlived,

As Freezing persons recollect the Snow

First-Chill-then Stupor-then the letting go

Pain — has an Element of Blank —

Pain — has an Element of Blank —

It cannot recollect

When it begun — or if there were

A time when it was not —

It has no Future — but itself —

Its Infinite contain

Its Past — enlightened to perceive

New Periods — of Pain.

The Master

He fumbles at your spirit
As players at the keys
Before they drop full music on;
He stuns you by degrees,

Prepares your brittle substance
For the ethereal blow,
By fainter hammers, further heard,
Then nearer, then so slow

Your breath has time to straighten,
Your brain to bubble cool,–
Deals one imperial thunderbolt
That scalps your naked soul.

When winds take Forests in their Paws–
The Universe is still.

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Carry On —> Inspiration


This is a Cinderella story that will melt the most cynical heart.

Susan Boyle, the British singer, is an instant sensation!

Over 85.2 million viewers have seen her on YouTube in just one week – a record –

to watch her sing “I Dreamed A Dream from Les Miserables.

Born with brain damage, she was taunted all her life because she is slow.

Asked how she had the confidence to sing in front of a large audience, she says:

” I just had the ability to keep going.  You have to keep going.”


…..a beautiful, inspiring video

of Nick Vujicic, born with no limbs, speaks to students

whose tears run down their cheeks, whose love pours out to him.

Nick has found the purpose of his life and has become strong

through the agony of learning how to overcome what had defeated him from birth.

The miracle we are looking for is inside each of us.·

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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