Pain Much Better off Opioids


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Patient disabled with CRPS/RSD markedly better after off opioids. The intense nerve pain began in his left ring finger eight years ago, not the dominant hand. Now he has pain everywhere below the neck. He has been bed-ridden for years.  Now his “bones feel like ice, freezing from the inside out and shaking.”

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Had been on Fentanyl patch 100 mcg/hr for years. Dose was lowered to 75 mcg/hr, then his pain specialist did an involuntary taper off in two short weeks. Both of those doses are far higher than the new CDC guidelines from 2016. Fentanyl is 100 times stronger than morphine.
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He says his pain is feeling much better off the opiates. He is quite surprised. On Fentanyl 100 mcg/hr patch, he rates his pain then as 6 to 8 on scale of 10.
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Pain is now  2 to 4 off opioids the last 3 to 4 weeks. Even the hands are not hurting as much..

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Initially after the abrupt taper, he spent 7 days in bed, then says he “started getting out a little bit, now hands are not hurting as much. Neuropathy even isn’t hurting as much.”

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I have seen several patients who said opioids caused pain, all over the body in places they never had pain before or since.

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Yes, clearly many are helped by opioids. But many are simply afraid to taper off. I understand this. The question then is, what will we do to treat pain? Most doctors have nothing else. Patients rightfully fear stopping opioids.

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We need to understand there is outstanding science that demonstrated years ago that opioids cause inflammation in the CNS (brain and spinal cord). Inflammation causes pain.

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Treat pain with glial modulators that relieve inflammation in the brain, neuroinflammation. These are off label and most of them must be compounded. Compounded medications are not covered by your insurance — thanks to pharmaceutical donations to congress.

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Cannabis (medical marijuana) can help some with spasm, pain, insomnia. Also not covered by your insurance — thanks to pharmaceutical donations to congress. But patients in New Mexico were able to get insurers to reimburse them for the cost of their medical cannabis.  Congress should allow dispensaries free access to banking systems and allow insurers to directly pay the cost for medical use. We all know the emperor has no clothes. Lets be real. Pain leads to desperate measures.

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Let me say right now, to all those who will send in comments attacking science, attacking me, attacking my clinical experience (my patient reports) on opioids, I will not post your attacks on these pages. I do prescribe opioids to select patients. I strongly believe all pain should be treated initially by glial modulators that relieve neuroinflammation before we begin causing pain and inflammation by ultimately having nothing else to turn to and then prescribe opioids. There is no better solution because pharma wants you on a drug for life. That’s money in the bank, forever, every single month for decades. It’s awful.

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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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PEA Capsules & PEA Cream from Vitalitus – Soothamide


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Palmitoylethanolamide (Pea in the US, PeaPure in Netherlands) is a glial modulator, analgesic, anti-inflammatory, neuroprotective and anticonvulsant  with mechanisms involving the innate immune system and mast cells. It binds to a receptor in the cell nucleus. The major focus of hundreds of publications on it has been inflammation, neuropathic pain states and mast cell related disorders from University of Oxford,  Journal of Arthritis Research and Therapy, Journal of Pain Research, University of Bologna School of Dentistry (a study for TMJD pain), etc.

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It is a food supplement. It is a naturally occurring lipid amide, i.e. the body makes it, plants make it. It is available as a capsule and a cream without prescription. It may take days to weeks to work, but I’ve seen the cream work in two minutes – shock!  The relief is amazing for someone who has failed everything for intractable pain.

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Soothamide Cream is 2% palmitoylethanolamide from Vitalitus in the US.

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It’s been fascinating to see the cream work for so many pain syndromes including severe CRPS/RSD nerve pain! arthritis, muscle and severe ligamentous strain – often in less than two minutes! Not everyone, not every pain benefits but it is well worth trying and very affordable for large amount.

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One senior whose osteoarthritis in finger joints has been painful, very stiff, and prevents him from only very slightly being able to bend four fingers on his right hand. It’s been years since he’s been able to touch tips of the fingers to his palm because of stiffness and pain. They just would not go.

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After applying Soothamide cream, in less than 20 minutes he was able to fully, easily and painlessly bend all four fingers to the palm without any trace of stifness – quite astonishing. And the next day, three of the four fingers still had complete 100% relief 20 hours later, but it did not last for the index finger, even applying it later to that finger over those 20 hours. Twenty hours relief is amazing for three fingers after years of severe stiffness and pain. Relief may have been hours longer, but he took off for the day and data like this is difficult to pay attention to, and then to make a memory note of how long.

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Another with knee pain and significant joint effusion (fluid that creates pressure inside the joint), had relief for 3 hours after one application in the office.

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I have seen the cream relieve low back pain completely in less than two minutes. This was the father of a patient who had tried it in the office and it failed to help that patient, but she had a little left on her hand and schmeared it across her dad’s back. All pain gone in less than two minutes!  I am assuming this was muscle strain, not deep mechanical structures in the spine.

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Another patient with RSD pain on the foot had no benefit, but she then applied the Soothamide to a very severe pain from torn ligament in the arm that was more painful than her RSD. It was gone in less than two minutes, to her shock and delight.

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The cream has only recently been available in the US, and I have seen it help so many patients including those with CRPS/ RSD nerve pain. Most relief from creams is short lived, but if you see 4 hours of relief, or 20 plus hours as the patient above, it is very special.

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The cream has been such fun! Having seen even the severe nerve pain of CRPS/RSD improve or be astonishingly gone -!- in less than two minutes -!- it helps doctors forget the pain of being unable to offer anything more. Here we have capsules and cream that do not require prescription. And even in the most extreme pain syndromes is worthy of a try.

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PEA capsules – open and place powder under tongue for instant relief of breakthrough pain.

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That was a blessing in the middle of last night for one of my patients with RSD who was having a severe flare of pain. In August, she had started PEA capsules 3 twice daily – always take with something fatty (milk, peanut butter, etc) to aid absorption. In 3 weeks it had reduced her lower limb pain from severe to mild-moderate while in bed. Now months later, after reducing another medication briefly due to side effects, pain flared severely. What to do?

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I instructed her to open the PEA capsule and place the powder under tongue to absorb there. She had relief. I don’t have data to relate more as yet but hope to post as I learn from her and hopefully other patients who write in their comments. How much is safe? I will try to find more information. We know the body makes it, plants make it and at doses of 6 capsules daily it causes no side effects.

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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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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.

~~
This site is not for email and not for appointments.

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

~~~~~

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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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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Complex Regional Pain Syndrome in Remission 6 years


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 Complex Regional Pain Syndrome

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Celebrating six years of complete remission

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Why ketamine should never be used alone

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I first posted her case here. 

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For years, pain below both knees was 8 to 9 on scale of 10, “like I had swallowed a fire burning.”

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She was unable to stand or walk for more than 4 years before seeing me. This week, I again saw this very healthy athletic RN who at almost 70 of age is very youthful, very energetic. She failed IV ketamine given first by Dr. Schwartzman daily for one week, then boosters for 8 months.

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After 8 months of ketamine, then no response at all. None. 

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That’s when I prescribed other glial modulators and rational polypharmacy that brought CRPS into remission. Then very very slowly tapered off all but one, leaving only low dose naltrexone (LDN) for the last 8 years. Zero pain. None. Hiking, working, fully active.

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When used in conditions with known neuro-inflammation, rats or human, LDN is a one of the most powerful, most effective glial modulators I have ever seen clinically in my patients in the last 15 years.

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Until proven otherwise clinically, LDN should be taken lifelong in those cases.

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This website is not for email.

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The advertising is not approved by me and

unrelated to anything on these pages.

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

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