Medical Marijuana Proven to Save Lives, Science Issue on Pain, November 4, 2016


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The entire issue is devoted to Pain 

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From “Pot and Pain” page 566:

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Analyzing Medicare drug prescription data from 2010 to 2015 in states where medical marijuana is legal, David and Ashley Bradford at University of Georgia in Athens found significant differences in prescription of medications for anxiety and nausea. “But one condition stood out from the rest: ‘The effect for pain was 3 to 4 times larger than all of the others.'”

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“In medical marijuana states, each physician prescribed 1826 fewer doses of conventional pain medicines each year.” The reduction in pain prescriptions is even more dramatic in the younger Medicare Group.  [presumably disabled by pain]

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Marcus Buchhuber, previously at the Veterans Affairs Medical Center in Philadelphia, examined death certificates in all 50 states between 1999 and 2010. In states that permitted marijuana, there were nearly 25% fewer deaths from opioid drug overdose.

In 2010 alone, “that translated into 1729 fewer deaths” from overdose. And the effects grew stronger in the 5 to 6 years after medical marijuana was approved.

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Further information on Marijuana here.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

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This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

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

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Please ignore the ads below. They are not from me.

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Medication Summary for Intractable Pain, CRPS/RSD


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  Medication Summary for

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Intractable Pain, CRPS/RSD

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I spoke only briefly this morning at the RSDSA conference but there is so much to add. Most importantly, thanks to RSDSA for helping so many people with CRPS. They fund pain research, they are starting a free children’s camp, and now offer physicians one hour free CME teaching about CRPS.

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Holistic view, 36 points – that’s how I view caring for brain and nerves, very similar to the details used by UCLA Alzheimers Research Unit. In June 2015, I posted on their work on memory loss, dementia. We know chronic pain means inflammation in the brain, excess of proinflammatory cytokines. CT scans show memory loss and brain atrophy in those with chronic low back pain.  Can this inflammation lead to Alzheimers? Even if it doesn’t, why not maximize what we know we can do to help brain. As I view it, simply be meticulously detailed in giving the central nervous system (CNS) the best chance to relieve or prevent pain or disease.

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Below is a brief list.

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To find detail and sometimes depth, check the alphabetical lists on either side column until you see the category or tag when I first posted on that. Or simply plow through 7.5 years of detail with references. You do the work to check the side columns as I have no time to embed links below, taken from throughout this site.

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For now just a list of medication players that may be strikingly important in trying to bring intractable pain into remission even after 20 years. Yes, even chronic for decades.

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The list applies to intractable pain of all causes. I omitted listing standard interdisciplinary approaches commonly used by every pain specialist around the world. My patients have failed all those.

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Some patients with CRPS combine my medications with ketamine infusions.

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For those who remain on opioids, ultra low dose naltrexone (10 to 60 mcg three times daily) can significantly reduce pain, reduce opioid induced hyperalgesia, reduce windup, and thus reduce the dose of opioid needed to give improved relief.

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Opioids cause pain and trigger pro-inflammatory cytokines that create more pain.

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I strongly recommend slowly, gently tapering off opioid, and remaining off for 3 weeks before the following is trialed:

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 1. Vitamin D is anti-inflammatory. Important. Helps pain, depression. If bone loss is an issue, you will not absorb calcium from food if D is low. Mayo Clinic’s publication in 2012 showed more morphine is needed for pain if D is low. Huge literature of its benefit for depression. First topic I posted on – it is that important.

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2. Vitamin B6 can cause burning pain from scalp to toe, a toxic neuropathy. It can be toxic to brain. It is loaded in tons of soft drinks, “energy” drinks, supplements.

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3. MTHFR mutation may be present. Body cannot process  the B12 and folic acid you are eating or taking in supplement. A simple blood test, costly. Treatment is as simple as buying methyl folate and methyl B12 – no prescription needed. Folic acid in particular is profoundly important for one of the major energy cycles in the body. Can cause multiple conditions, some fatal, all from one single cause.

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4. Minocycline 100 mg/day is the dose I use but higher doses could be given. It is used daily for decades for acne. I may prevent spread of CRPS if given before surgery, dental work, even minor procedures. I start 24 hrs before, and continue for days after full recovery from surgery.

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5. Testosterone  in either male or female is depleted by opioids, it may be depleted by stress. Low T is a risk for depression, weakness and osteoporosis.

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6. Naltrexone low dose (LDN) – profoundly important. A glial modulator. Lifelong use.

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7. Dextromethorphan – reduces hyperexcitable glutamate

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8. Oxytocin

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9. Memantine – double the Alzheimers dose for CRPS. Like ketamine, it blocks the NMDA receptor.

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10. Lamotrigine

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11. Palmitoylethanolamide (PEA, PeaPure) a glial modulator, also acts on mast cells. A food supplement. No Rx. Your body makes it. Plants make it. Capsules & cream

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12. Ketamine via nasal spray, under tongue combined with IV or not, works on glutamate-NMDA receptor. Not an essential drug. Where ketamine has stopped working, patients have become pain free after years of CRPS.

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13. Creams combinations, so many

most of my CRPS pts very much like   Mg++/guai  10% each.

You may or may not trial various combinations lido/keto/keta, etc. Numerous. DMSO 50%.

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14. Medical Marijuana (CBD, THC, terpenes) Marijuana saves lives. Entire issue of Science, November 4, 2016, devoted to pain.

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NAC and alpha lipoic acid are noted by research from the Netherlands.

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Appendicitis

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If it has not burst, treat it like the infection that it is. Surgery may never be needed. I posted details of publications early 2016 with a case report. That young man was being rolled into the OR, instead was discharged 100% better without surgery 2 days later.
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Medications target 3 main systems

as discussed at the conference

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The opioid receptor – opioids create pain. They trigger glia to produce pro-inflammatory cytokines. Opioid induced hyperalgesia may occur. Cannot be used with low dose naltrexone.

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The glutamate NMDA receptor – ketamine, memantine

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Glia, the innate immune system – glial modulators

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Before they see me, my patients have failed all prior therapies even ketamine coma. I view it like football. You have one guy running down the field with one ball. Do you want to win the game? You’ve dealt with this for years. Let’s not prolong it. Hit it with my main choice of meds all at once. Jump on it. What if you get 10% relief – will you even notice 10% after many years of severe pain? But if you get 10% from each of 5 meds, then you are talking 50% relief as a start. Address those 3 main pain systems – even without ketamine – and I have posted a case report after 20 years and 3 suicide attempts before seeing me, she has been pain free for about 4 years as I recall. A surgeon nicked her sciatic nerve when she was 27. Two years ago, pain free, running on her treadmill, she twisted her ankle. She has permanent foot drop from the sciatic nerve injury, but even spraining her ankle did not flare her CRPS. Twenty years of CRPS, pain free for about 4 years. And ultimately, years ago, she was tapered off all the drugs with one exception: LDN lifelong.

 

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Most importantly, I did not have time to relay a very special message from my patient in Brooklyn:

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.Surround yourself with friends and family who love you.

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.Never give up hope.

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She had her first 2 or 3 pain free days this week, as she slowly increases doses of medication. She’s not yet at maximal effect and even then there can be increases. Sending love and courage.

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MOVEMENT

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Watch this on the RSDSA video, afternoon speakers, the parents of young ones who had RSD discussed today all the toys and games they had to devise to slowly force yourself to move through the pain, every single day, several times a day, all day, begin to move the body as much as you can. Set goals and slowly, at a pace you set, do the work. Make progress. Go forward. Keep moving. Do whatever you can to keep moving.

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RSD support groups are essential and I am glad to see the RSDSA list of so many throughout the country.

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There is so much more. Indeed, at least 36 points discussed on June 2015.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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

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This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

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

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Please ignore the ads below. They are not from me.

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RSDSA Sponsors All Day Integrative Pain Conference November 6 in La Jolla – Register Now


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I posted weeks ago on the all day conference November 6, sponsored by RSD Association in La Jolla.

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The conference may be helpful to all with chronic nerve pain. For information and registration:

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All with Chronic pain – CRPS Event in La Jolla Nov 6 – RSDSA Integrative Health Conference

 

 

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Please come!

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Dilaudid & Prenisone do not work for CRPS. It must be stopped or this will fail


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There is a young woman 3000 miles away who will soon be bitterly disappointed. This therapy will fail. It will be her choice to fail because she does not want to taper off Dilaudid and high dose prednisone. She has discarded physical therapy long ago, but needs it. She narcotizes her brain with Dilaudid and high dose prednisone and has given up on life the last 6 years.

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Let me be very clear. It will fail unless you get off those drugs. I will not start new ones because I guarantee you will be bitterly disappointed. All these weeks of work and what progress coming off? Send me reports regularly. What kind of doctor sits back and watches this?

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It’s a sin to take part in guaranteeing failure. I cannot allow my conscience to do that. As time goes by and you stay on failed drugs, there is a shrinking chance this treatment could help. I said last year, get off the narcotics. They do not work for CRPS. It is a delusion to think they work: you have been housebound 6 years. Love yourself. Give science a chance. Science shows how they create pain. It also shows how to modulate inflammation they have created in the brain.

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Just because the medical system doesn’t evolve with science, does not mean you continue known harm.

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It’s magical thinking to believe you can do the opposite of what science has been teaching us.

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Calling all angels to help her. Tell her your experience. Say a prayer. Keep her in your heart. And if you can, watch the movie Pay It Forward streaming now on Netflix. You will love it. It will open your heart. Everything about it is great, the acting, music, dialogue, story, really great. Every time you think it will be dopey, it gets better.

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So be honest. It ain’t easy living with nerve pain. It is possible no treatment will work. Some things may partially work. But there are things worth doing right. This is one of them.

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I will not participate in a sham. Do not nurse stale delusions. There are reasons to choose opioids. CRPS is not one of them. Be fearless. Meditate on the heart of a lion.

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To succeed requires great inward resolution. This is not the time to leave town. Either begin the work as directed, begin the P.T. immediately or recognize you are undermining that too. You know October will postpone everything even more.

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No one can help you. You must help you. This is what we taught every patient at UCLA Anesthesiology Comprehensive Pain Center in the 1980’s.  It is still true.

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Our entire medical system has been poisoned and deluded by the multi-billion dollar opioid factories supported by FDA, Congress and NIH. They prove it by decades of action. They have done nothing for your reality.

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Addendum September 2, 2016

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I am being attacked for posting the above. This article is not about dialogue. Go to some other site. This is educational.

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There is no dialogue because you can pick any doctor in the country who will give you opioids. But when you tire of chronic severe pain despite all those opioids, and your’re ready to try something else, some case reports of remarkable people have been posted on this site. Remarkable. I’ve never seen anything like it. But it’s not uncommon. What are the chances of that when they’ve failed everything? And yes, I do prescribe opioids to a few patients. There are indications. Opioids kill. Bodies age. What if they need acute painful surgeries? When will we get something better. I think ketamine is. It is shamefully underused in favor of drugs that trigger pro-inflammatory cytokines in the brain and that causes more pain.

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We will never move pain control forward until we begin to work with the science that’s immensely changed the way I can help patients become pain free or at least markedly better. Not every patient — I see very complex, extreme pain conditions. I will keep this site on the level of science, education and real breakthroughs. These complex medications I prescribe have been a huge breakthrough. My patients have failed everything before they see me. If they are still on opioids that never helped, I ask them to taper weeks or months before they see me. You cannot continue to make war on the system when you are aiming to make peace. To restore balance. To modulate the inflammation.

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My First Ketamine Patient 

Ketamine in Outpatient Use

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I had the wonderful memory tonight of my first patient. I actually handed ketamine to someone to use at home for pain. This was about 2000, 2001. She was a very enlightened clear soul who had 7 or 8 spine surgeries with 30 years of sciatic and back pain rated 10 on scale of 10. Failed all known procedures in the greater L.A. area. Then she got a painful neuropathy evolving in less than 2 weeks, burning pain below elbows and knees.

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I had been reading ketamine publications for 3 years and had a whole big stack of them. The most exciting thing I’d ever seen for almost every known pain, central pain, all pain. I attached that article on this site May 26, 2009. A review by Cousins, one of the world’s most highly rated pain specialists.

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I couldn’t bear not being able to help. I interviewed many psychiatrists who began the experiments with ketamine at NIMH in 1991, called as many researchers as I could, and a neurologist who had done work in this area ketamine/brain. He was just appointed head of an institute. He precisely spelled out the arguments against those who fear do not use due to brain issue in primates. I am very cautious with patients. No one was doing this. In fact I did get harshly attacked for giving someone ketamine.

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I instructed a very slow start. Two weeks later, she called me and said she thought she had died. I will never forget I was parked in the doctor’s parking lot, exact time, sunny morning, one of those perfect clear days of early summer when it’s not too hot, my breathing stopped. “But I hadn’t been pain free in 30 years and I didn’t remember what it felt like.”

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It is rare to get 100% with ketamine.

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The patients I see are complex. They have failed everything. The things they have been through and renowned specialists they have seen, even ketamine coma does not last. It is a short lasting drug. How much time do you want to spend on procedures vs convenience of using a medication when your body needs it. Even that is idealized.

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Chronic pain, especially nerve pain, is most difficult to treat. It is never all about medicines. Never. You must learn tools to give the power of conviction to your mind that you can be strong. You cannot afford to fall apart because that makes pain worse. Tools you use or else pain. Once we know, we can take action. Same with muscles that have been inactive for years. Tools we all learn – the entire family together can be taught what it takes for physical therapy. We cannot help all people. They need family help to bathe and dress.

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For CRPS especially, we want to prevent spread, mirroring, appearing in the other limb and areas. I like to think of it like a football game. You’ve failed everything known, that makes it potentially harder. But you’ve gotta win this game. You have one guy running down the field with a football, how many guys are you going to send after him? What if 3 or 4 guys only partially help? Add that up and you may have extra 30 or 40% relief. Hit is hard, selectively chosen glial modulators and others with mechanisms on these pathways, get it to zero – or give it the best chance to get it near zero pain. That’s the first goal.

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Nothing is perfect. Nothing in medicine is perfect. It is still an art, not a science. But it is a gift to be able to use these tools that I’ve put together the last 15 years. And thrilling to see the science come out explaining even more the power of the innate immune system, the glia. Had the practice of medicine evolved, we’d have developed the timing of the circadian clock in these cells to prevent postoperative chronic pain, or minimize sending the inflammation into overdrive. Opioids damage the balance of inflammation in a system already exploding with pain. It would be a miracle if “they” ever stop reaching for opioids first. Do they even understand they are doing the opposite of  relieving pain, or care that better choices exist? Perhaps, but it would take a multi-zillion dollar study. Pain is only taught in 3% of medical schools. It loses money for the schools.

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All with Chronic pain – CRPS Event in La Jolla Nov 6 – RSDSA Integrative Health Conference


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I hope you will attend this event on November 6 for all with chronic pain.

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The amazing and wonderful RSD Association announced a pain conference in La Jolla on November 6. The executive director, Mr. James Broatch, will be there that day. I will be one of the speakers.

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They also announced other events all across the country. Please join in their efforts.

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Their work applies to most people with pain, and is not specific to Complex Regional Pain Syndrome, CRPS or RSD. Pain management can be very difficult. I hope you will attend. They fund outstanding research and help so many people. They announce:

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Individuals with CRPS, are they being treated in a way that optimizes wellness? What can we do to treat the whole person not just the CRPS? Join us for brunch, discussions, and dialogue on treating the Whole Person and Optimizing Wellness. We are bringing together exceptional health professionals who understand how and sincerely attempt to find better way to live with CRPS. We will discuss the latest in integrative health approaches and innovative treatments that build and strengthen the body’s ability to function more effectively.

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  • Date:  Sunday, November 6, 2016
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  • Location:  La Estancia Hotel La Jolla, La Jolla, CA
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  • Time:  10:00 am – 3:30 pm (PDT)
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  • Registration/Details:  Registration is now open, please REGISTER NOW!

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  • Contact:  Jim Broatch at 877.662.7737 or info@rsds.org

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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.

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

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    The advertising below is not recommended by me.

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Neuropathic Pain Medications – review & metanalysis of 229 studies


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This review was done by many of the best pain specialists from all over the world. You will not find answers in that large review if neuropathic pain has already failed tricyclic antidepressants (Elavil, amitriptyline, Norpramin desipramine, others), gabapentin (Neurontin), pregabalin (Lyrica), lidocaine, capsaicin, or opioids. That is the current paradigm. A new paradigm – glial modulators  – that I discuss on this site, may or may not give relief.

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A member of the International Association for Study of Pain, IASP, published a brief critique of that comprehensive review of 229 trials of medications for neuropathic pain published in Lancet Neurology February 2015. The critique is posted below, done by a member of the Neuropathic Pain Special Interest Group, NeuPSIG.

 

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To understand the metanalysis of these 229 trials, you need to understand the simple concept of number needed to treat, NNT.

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NNT is an estimate of “the number of patients that need to be treated in order to have an impact on one person.”

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The smaller the number, the more effective the drug. Example, NNT of 7.2 for gabapentin means you need to treat  7.2 people before a response. If 3, need to treat 3 before a response.

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Barsook (Harvard, ref. below) reviewed ketamine studies in 2009:  “they did show a level of efficacy (of ketamine) based on NNT that equals or betters most drug trials for this condition.”

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“NeuPSIG has just published an up to date systematic review on the effectiveness of pharmacotherapy in Lancet Neurology. They have negotiated with the journal to make it available beautifully open access. You can download it for free here.”

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Neil O’Connell, Brunel University London

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“This is a comprehensive review, containing 229 trials of the full range of pharmacological agents using robust methods, to synthesize, summarise and make value judgements about the quality of the available evidence. So what are the take home messages?”

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“Using a primary outcome of achieving at least 50% pain relief trial outcomes were described as “generally modest”. The number of patients needed to treat with the drug compared to a placebo for one more person to achieve this outcome ranged from a relatively rosy 3.6 (95% confidence interval 3 to 4.4) for tricyclic antidepressants such as amitryptiline, 4.3 (95%CI 3.4 to 5.80 for strong opioids to a less impressive 7.2 (95%CI 5.9 to 9.21) for gabapentin, and 7.7 (6.5 to 9.4) for pregabalin (often sold under the brand-name Lyrica). It’s interesting, at least to me, how much better the older more traditional agents seem to have fared compared on effectiveness to the more modern (and commonly more expensive) agents although the safety and tolerability of gabapentin seems superior.”

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“The spectre of publication bias also raises its head. The reviewers carefully took a number of routes to try to unpick this notoriously difficult issue and estimate that there has been overall a 10% overstatement of treatment effects. Published studies reported larger effect sizes than did unpublished studies. This is not a problem restricted to the field of pain trials. It is a burning issue across the world of clinical trials. It is very important because if we fail to base our clinical recommendations on the totality of relevant evidence (because some data are hidden from us) we are in danger of mis-estimating the benefits and the harms and as a result patients are put at risk. If you think that is pretty important then there are ways that you can help. Check out the All-Trials campaign.”

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“Overall what does this mean? Many drugs are effective but not as effective as we would wish them to be. No pharmacological agent really impresses and for any drug the most probable outcome is failure to produce 50% pain relief. There are various potential reasons for this. The first is that the drugs may only be moderately or marginally effective, another is that neuropathic pain includes quite a mixed bag and our ability to accurately diagnose and to target drugs to specific mechanisms in the clinic is currently fairly poor.”

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“The NeuPSIG review team formulate a number of recommendations for revision of their clinical guideline for managing NP pain, balancing the benefits, harms, costs and strength of the evidence.”

  • a strong recommendation for use and proposal as a first-line treatment in neuropathic pain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin;

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    • a weak recommendation for use and proposal as a second line treatment for lidocaine patches, capsaicin high-concentration patches, and tramadol; and a weak recommendation for use and proposal as third line for strong opioids and botulinum toxin A. Topical agents and botulinum toxin A are recommended for peripheral neuropathic pain only.

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“This email [from IASP’s NeuPSIG] is also published as a blogpost at www.bodyinmind.org”

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References

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Finnerup NB, Attal N, Haroutounian S et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14:2:162-73.

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Glial modulators – another paradigm

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From my January 2012 brief review of publications on ketamine, only one of a handful of glial modulators, this author says reviews “show a level of efficacy based on NNT that equals or betters most drug trials for this condition.

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Ketamine and chronic pain – Going the distance, David Barsook, Director, P.A.I.N. Group, Massachusetts General, McLean and Children’s Hospitals, Harvard Medical School, Boston, MA;

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This paper covers essential points not mentioned by many, thus quoted at length below:

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Our current therapeutic armamentarium is quite limited in terms of analgesic efficacy in controlled trials. Some would argue that the small efficacy (both at a population level and the magnitude of change in VAS score) this is related to the fact that we need to consider mechanistic approaches to chronic pain subgroups. However, patients and clinicians find themselves in a position of “what to do now”.

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Ketamine, brain function and therapeutic effect – neuroprotective or neurotoxic

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With the onset of chronic pain (including CRPS) a number of changes in brain function occur in the human brain including but not limited to: (1) central sensitization ; (2) functional plasticity in chronic pain and in CRPS; (3) gray matter volume loss in CRPS ; (4) chemical alterations ; and (5) altered modulatory controls. Such changes are thought to be in part a result of excitatory amino acid release in chronic pain. Excitatory amino acids are present throughout the brain and are normally involved in neural transmission but may contribute to altered function with excessive release producing increased influx of calcium and potentially neural death. Here lies the conundrum the use of an agent that potentially deleteriously affect neurons that may already be compromised but may also have neuroprotective properties by mechanisms that include reducing phosphorylation of glutamate receptors resulting in decreased glutamatergic synaptic transmission and reduced potential excitotoxicity . Alternatively, ketamine may affect glia regulation of glutamate and inhibit glutamate release within glia. However, by whatever mechanism ketamine acts on CRPS pain, there does seem to be a dose/duration effect in that longer doses at levels tolerated by patients seem to prove more effective in terms of the duration of effects.

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So what could be happening in the brain and what is required to alter brain systems and reverse the symptomatic state? Ketamine may diminish glutamate transmission and “resets” brain circuits, but it seems that a minimal dose and/or duration of treatment is required. Alternatively, ketamine may produce neurotoxicity and damage or produce a chemical lesion of affected neurons. These two issues are important to be understood in future trials. Reports from patients who have had anesthetic doses have included prolonged pain relief for many months. While the authors did not address issues such as the effect of dosing duration or repetitive dosing at say 6weeks, they did show a level of efficacy based on NNT that equals or betters most drug trials for this condition.”

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Conclusions

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As a community we have a major opportunity to define the efficacy and use of a drug that may offer more to CRPS (and perhaps other) patients than is currently available. This is clearly an opportunity that needs urgent attention and a number of questions remain to be answered. For example, is ketamine more effective in early stage disease? How does ketamine provide long-term effects? Further controlled trials evaluating dose, duration, anesthetic vs. non-anesthetic dosing are needed. Few of us really understand what it is like to suffer from a chronic pain condition such as CRPS. Ketamine therapy may be a way forward that can be brought into our clinical practice through further controlled studies that will allow for appropriate standards for use in patients.

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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.

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

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Ketamine Survey for MD’s from RSDSA – Please Help


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Jim Broatch, Executive Director of RSDSA requests help from doctors giving IV Ketamine to treat CRPS. Please ask your doctor to do the survey. 

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 https://www.surveymonkey.com/r/ZPP9BXY

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And remember, if you shop Amazon, you can direct Amazon to contribute a portion to RSDS.org —- many thanks! 

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This site is educational, not for email.

Relevant comments are welcome.

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Advertising on this free website, below, is not endorsed or sanctioned by me.

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