PeaPure – Palmitoylethanolamide for Nerve Pain or Migraine


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PeaPure is a glial modulator. It is available in Italy and the Netherlands as a food supplement and has been studied in multicenter clinical trials in Europe for several years. It is well tolerated with no side effects and is very helpful for neuropathic pain, headache, and osteoarthritis. It is anti-inflammatory and neuroprotective.

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Because it inhibits astrocyte activation and the over-expression of pro-inflammatory molecules and signals, it is being investigated in Alzheimer’s Disease.

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The mechanism of action of PEA was discovered in 1993 by Nobel laureate Rita Levi-Montalcini in her work on nerve growth factors. She found it is involved in metabolism of mast cells and published a series of papers on its self-healing effect of the body in response to inflammation and pain. Two recent publications from Jan M Keppel Hesselink, MD, PhD, and his colleagues at the Institute for Neuropathic Pain, Amsterdam, The Netherlands, describe case reports, one of which is the case of a woman with CRPS.

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The purpose of this post is to clarify dosing of PeaPure and how to take it for a sudden flare of pain. My apologies for failing to recall the source of these instructions which I believe was from the manufacturer and from here and here. The latter includes an excellent review of its mechanism.

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Description of PeaPure® 400 mg capsules
PeaPure® is a food supplement based on a natural and fatty-acid like compound.
The substance palmitoylethanolamide (PEA) is a physiologically active molecule that the body produces naturally.
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What the user should know prior to ingestion:
•    There are no known significant side effects.
•    PeaPure® can be taken simultaneously with other medicine. In case of doubt, it is recommended to first consult your doctor or a pharmacist.
•    Use during pregnancy is NOT recommended.
•    PeaPure® does not contain sugar, yeast, allergens, sorbitol, magnesium stearate, povidone or other ingredients.

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Dosage and administration – please refer to the manufacturer.

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UPDATE SEPTEMBER 2014

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It is with a heavy heart that I report this news:

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Palmitoylethanolamide is

now available only from the Netherlands,

sold as PeaPure, a food supplement.

  It is no longer able to be imported by a pharmacy, but we are hoping

that may change if we can interest a supplement manufacturer to make it available for the US.

Patent rights, attorneys are far beyond the resources of my local pharmacy.

 

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I have published this year, 2014, on the treatment of

vulvodynia and proctodynia with PeaPure and a topical cream.

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There are no studies to show us how often it may relieve nerve pain, but it is astonishing when it works. No toxicity, no side effects. Your brain makes it, plants make it. There is a growing literature on it and I have posted on some of its mechanisms. And in particular, its Anti-inflammatory, Analgesic, Neuroprotective Mechanisms.

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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.

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Please understand that it is not legal for me to give medical advice without a consultation.

If you wish an appointment, please telephone my office or contact your local psychiatrist.

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

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Ketamine Inhaler – Bipolar Child NPR – Review of Ketamine for Depression


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NPR reported yesterday on the beneficial effects of ketamine for depression, this time reporting on a ketamine inhaler prescribed by Demitri Papolos, MD.

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Dr. Papolos is Associate Professor of Clinical Psychiatry at the Albert Einstein College of Medicine and Director of Research of the Juvenile Bipolar Research Foundation.

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He “is one of a handful of psychiatrists in the world who began to see and to speak out about the possible deleterious effects of antidepressants and stimulants in the population of children within the bipolar spectrum.”

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This NPR report described a syndrome Dr. Papolos has identified of Bipolar children & adolescents consumed by fear. They described a boy who had extreme attacks of rage for decades, and horrific violent nightmares.

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The boy had attempted suicide at age 5. He was hospitalized in a psychiatric unit at age 12 and strapped down in a padded room, terrified. He failed many medications for years, some made him worse, and he was literally never able to complete a meal at table with the family without flying off in a rage or someone leaving.

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in 2010, the boy tried Dr. “Papolos’ ketamine treatment. He says he’ll remember the day for the rest of his life. ‘I think we did two puffs, and I remember I sat up and I just started laughing,’ he says. Then his mother picks up the story: ‘You said you had an internal feeling of calm that you had never had before in your life. And when we came home that night, that was the first night that we ever all had dinner at the table without somebody leaving.'”

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This boy, George McCann, now at age 22 is finally able to begin a more normal life. He needs the medication only every third day. “Papolos has treated about 60 young people with ketamine so far and says all but two have had dramatic responses.”

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“The number of patients treated so far is small, and the approach is so new it hasn’t been tested by other researchers yet. Papolos says he’s hoping a study he published late last year will help persuade other researchers to try the drug on other children.”

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“In the meantime, George McCann continues to inhale a prescribed dose of ketamine every third day. The fear and anger that once dominated his life are gone, he says, adding that his mind is free now to work….”

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The relief with ketamine from the prison of mood disorders is deeply important. Severe mood disorders such as Major Depression and Bipolar Disorder can destroy the lives of patients and their loved ones. At worst, they can be lethal.

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A review of published cases of intravenous ketamine for depression asks : “Ketamine for depression: where do we go from here?

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I think the answer is we need to simplify the method of treatment using inhaled ketamine and begin to give their lives back to the patients we see. It is one of the safest medications I have ever prescribed. It does not cause weight gain or loss. It does not cause sexual dysfunction. And although it may increase sedation when used in combination with other sedating medications, at the low doses needed to treat mood disorders, I do not see ketamine interfere with other medication.

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Ketamine can relieve depression from one second to the next. And this young man needs the medication every third day. Is that too much to ask to gain a life?

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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.

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Please understand that it is not legal for me to give medical advice without a consultation.

If you wish an appointment, please telephone my office or contact your local psychiatrist.

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

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Spinal Cord Stimulators


For some reason my two browsers do not show the comments sent to this post, below, and therefore I am posting them now. I would emphasize the last comment by a very experienced nurse who has seen many complications of spinal cord stimulators. For persons with CRPS/RSD, I have seen many others. The saddest are those who had stimulators inserted and now the pain of CRPS is worst at the site of the “stim.” If the leads are ripped out from under the skin, the track of those leads may forever be the worst pain on the body.

10 Responses to “RSD – CRPS – Complex Regional Pain Syndrome – Long Distance Patients”

  1. Robyn H Says:
    08/04/2010 at 8:16 am  
    I broke my hip and wrist during a fall at a local skating rink in my hometown in Georgia. The hip healed fine after surgery and two weeks later, surgery was performed on my right wrist. Immediately after surgery, the pain was different. I was soon diagnosed with RSD and put on several medications and therapy three times a week. After many weeks of oxycontin, oxycodone, neurotin, topamax, klonopin, robaxin and paxil and four nerve blocks (SGB), it was suggested I receive the spinal cord stimulator. Through research on the internet, I found Jim Broatch with the RSDSA organizaton who advised me there were other alternatives in treating RSD. I discovered Dr. Nancy Sajben in San Diego. She has been treating RSD with oral ketamine and naltrexone. I saw Dr. Sajben in her office July 19th and began treatment. Since beginning treatment, I have been able to go off the opiods and have had a 70% improvement in my range of movement of fingers and arm and decreased pain levels to the extent that I can now tolerate physical therapy. I have had no “flare ups” since beginning treatment. Dr. Sajben has changed my life for the better and given me hope for the future. Thank you, Dr. Sajben!

    • Nancy Sajben MD Says:
      08/04/2010 at 6:00 pm   Remarkably, in one and one-half days, she no longer needed high dose oxycodone which she decreased 95% on her own as pain was 40% better. That was before ketamine reached a dose where it began to have an effect and before naltrexone was prescribed. The later addition of those two helped even more. By the start of week two, she was able to discontinue the last 5% of oxycodone and is 70% better off opioids. She was started on a few other medications than mentioned in her comments: rational polypharmacy. Since January, she was unable to move her fingers, unable to write or pick up anything with the right hand. Less than ten days after we started treatment, the fingers had regained modest motion. She could hold a pen, write, pick things up with the fingers, fold laundry, pack luggage, and best of all her seven year old daughter said: “Mommy, I can hold your hand for real now.” Allodynia and hypersensitivity of the hand is so much better that she is likely to be able now to make progress in physical and occupational therapy. It was too painful prior to her visit. There has not been one flare of CRPS since day one on July 19, 2010, despite using the hand in ways not possible for seven months.

  2. Lori Morris Says:
    01/11/2011 at 6:45 pm   I would first like to thank you for your specialization in CRPS. My husband was diagnosed with CRPS in March 2010. He suffers in his lower left extremity (left foot/ankle) with all the signs of CRPS. He has gone through extensive pain management since that time. He has used oral meds, morphine, oxycontin, and now methadone, and also takes lyrica and nortriptylene along with lortab as needed. He has had no relief with these meds. He has had one nerve block with no relief, so a second block was not attempted. On Friday Jan. 7th the SCS trial was done and today Jan. 10th removed due to it causing pain in his lower back and side. The jolting the SCS caused in these areas could not be over come with reprogramming the SCS. Today, his pain management doctor discussed the Drug Delivery Therapy, which is not crazy about doing and after reading your information regarding SCS and Pumps I too am having second thoughts. However, the doctor did mention that there were 2 clinics that specialized in CRPS. One at John Hopkins and the other at UCLA. His doctor recommends the UCLA clinic and that is how I got to your page. I have been doing my research on CRPS since my husband was first diagnosed and am always looking for anything new in the medical field. I have read all your information regarding the Ketamine and Naltroxene treatments your patients have received and will be discussing these with his local pain management doctor. So, again I just want to thank you in advance for your specialization and your web page. Who knows, we just may meet some day.

    • Nancy Sajben MD Says:
      01/15/2011 at 6:17 pm   CRPS is unlike any other pain syndrome because it can be spontaneous or triggered by something very slight. Pain can involve the entire body. There is a high incidence of suicide. Despite that, there is a hope that it may be entirely reversible or, at least, put into remission. What a joy to see that happen and to share in the recovery!!!

  3. Traci Says:
    03/29/2011 at 6:01 am I posted on your main blog, but haven’t heard back. I know you wanted information regarding issues or problems with Spinal Cord Stimulators, so here is some information that you can add to your file. I can also be contacted for additional information because this issue continue to date.

    In one of your posts you asked for input from patients that currently have a SCS. I currently have a Medtronic SCS it was implanted early 2010 and I ended up having swelling in my Lt (affected) foot/ankle every time I would charge the “re-chargeable battery”. No one at Medtronic could figure out the issue. I turned into their “human lab rat”. After several months of this I was told to switch from a rechargeable battery to a non-rechargeable batter. Thus another operation… which I did. After this surgery (I have a paddle with 16 electrodes) all 8 electrodes on the Lt side that used to supply stimulation to my Lt foot/ankle now hit my pelvic area – thus I can no longer utilize these electrodes. And out of the 8 electrodes on the Rt 2 are providing stimulation to my Lt foot and the other 6 are hitting the wrong areas. In addition to this I have had continual instances where I am getting a very sharp pain/ sharp twinge (like a jolt) around where the electrodes area. When this happens if I turn off the SCS the pain immediately stops. I’ve been on a conference call with a Senior Engineer of Medtronic and a local Rep in person with me to do reprogramming… The Engineer only wanted to know if the electrodes were putting out stimulation. He didn’t want to know what the amperage was at before I could feel it or in what part of the body the stimulation was felt. These should have been critical pieces of information. All he wanted to state was that the electrodes were working. As for the Sharp Pain / Sharp Twinges that continue to occur in the electrode area their Senior Engineer has no idea what is causing this. He asked me to run an experiment the next time it happened – I did exactly what he wanted and reported back the findings. I have yet to hear back from Medtronic. They do not want to back up their product and they are not willing to admit that their is a problem. Although I have 2 doctors including a Neurosurgeon that feel there is some type of fault in their product or that it is faulty. Hopefully this gives you some additional information you were seeking. Please feel free to email me if you would like to discuss further. I am continuing my uphill battle with Medtronic.

    I have spoke with Medtronic as recently as yesterday and they can not explain the continual sharp pain/sharp twinge that I continue to get where the paddle that holds the electrodes is placed. The “Patient Relations Rep” that has been assigned to me, (at one point she tried to tell me she was from their “Legal Department” and she was later introduced by a team member as a “Patient Relations Representative”), doesn’t feel this is a big issue. She told me yesterday that this is “just medicine” and sometime they can get it right and other times it just doesn’t work out… The Senior Engineer at their company can not figure out what the problem is, so he just wants to reset the “INS”. I asked exactly what the “INS” was and the Patient Relations Rep couldn’t answer that question. I have already had my system reset numerous times (too many to count) and reprogrammed numerous times.

    The trial was aproximately $25,000; the hospital expenses alone and cost for the SCS implant were over $150,000 and the secondary surgery to replace the rechargeable battery with a non-rechargeable battery was aproximately $53,000. This is all for a system the now has 2 out of 16 electrodes that hit the correct area, creates an intermitent sharp pain/sharp twinge in the spinal area where the electrodes/paddle is placed, and they aren’t sure how to resolve this issue. But I was told yesterday that their system was working properly by their rep.

    • Nancy Sajben MD Says:
      04/01/2011 at 2:48 am  Traci, thank you for your comments and for placing your second comment in this section where others with CRPS may be more likely to see it.

      One of the simplest ways to respond to the issues you pose is to say that a renowned pain specialist colleague, trained in Anesthesia Pain at Harvard 40 years ago, does not put in spinal cord stimulators, does not recommend them and does not refer patients for them. He trained in how to use them when they came out, just as he trained for morphine pumps. He has never placed either in a patient.

      The common sense question is: Show us the data. Five year long term data with complications. Invasive procedures do have potential risks.

      The body tissue of a person with CRPS is very volatile, very different than any other condition I know. Any surgery, any procedure in that person is a risk not to be taken lightly. Just a needle stick for blood draw or vaccine can trigger CRPS.

      There is no question it is a big money maker. Several can be placed in many patients in a few hours. In no time at all, it has become an industry. And that kind of wealth can control the way pain management is practiced in this country. It doesn’t pay to do anything else. NIH doesn’t try. Show us the research.

      Nothing interests me more than the neuropharmacology approach I use for CRPS and “intractable” pain from the many conditions my patients have. I wish you lived nearby.

  4. Maureen Says:
    01/22/2012 at 5:57 am   
    I just had the scs implanted two weeks ago. I am getting that sharp pain and burning near the battery site. It happens with the scs on or off. I really am wishing I never got it. I feel that the small relief that I am getting is not worth it. Are you telling me that the leads can never come out and no MRI ever? I do believe they can be removed.

    • Nancy Sajben MD Says:
      01/24/2012 at 4:41 pm   
      I believe they can be removed, but they may become tethered to the spinal cord itself. I presume that may occur when they have been in for some time. I do not implant these, but one of the foremost anesthesiology pain specialist in the country, Harvard trained in pain management, will not put these in and will not refer patients for them.

    • Nancy Sajben MD Says:
      01/24/2012 at 4:43 pm   editAgain, specifically, if tethered to the spinal cord, or some other complication, they cannot be removed.

  5. Barb Fosdick Says:
    06/07/2012 at 11:25 pm   editI have been a surgerical nurse for 40 years and have seen many patients receive SCS…and many, many fail, or return to surgery for fractured electrode wires, misplaced wires, or infected battery pockets, besides complicated problems, or “lack of positive results, or battery revisions, or electrode repositionings.” Some patients have even developed spinal fluid leaks when the spinal dura layer has been torn during implanting the electrode wires, and they develop severe headaches, and have to return to surgery for the leak to be repaired. Many pain management doctors are convincing patients that this is a great way to treat their pain, and they find out in 2-6 months that they wish they never had agreed to it. Sure, there are some patients that get some relief, but this procedure has been pushed on the population of chronic pain patients, when they are at their worse condition, and willing to try anything….at any expense, and the companies and implanting doctors are getting the money. More patients need to learn the truth about these devices! Anomymous…. and never allowed them to put one of those things in me…but many tried!

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