Saturday, July 23, 2011

A rough week

I've had a pretty hard couple of weeks, but the past few days have been brutal.  My adhesive capsulitis and fibromyalgia have been acting up.  My pain level has left me almost incapacitated.  My daughter lives with me and has been taking care of the house, and I understand how much of a blessing she is.

I hope to get more readers for my blog and therefore some comments on the articles I post here.  I'm looking forward to having a better time next week.

The Stigma around aging and chronic pain

"Pain is a more terrible lord of mankind than even death itself." - Physician and humanitarian Albert Schweitzer (1875-1965)

When you're in pain, nothing else seems to matter. And if you're an older adult, you are not only more likely to have pain, but also to get less help for it than younger people are.

Chronic pain affects more Americans than diabetes, heart disease and cancer combined, and is the top-cited reason for seeking medical care. The relief of pain is the heart and soul of health care. And while always unwelcome, pain often has an important role to play. It can provide a warning that something is wrong, such as infection or undiagnosed disease. It is sometimes called the "fifth vital sign," as essential as temperature, heart rate, blood pressure and respiratory rate, for assessing health status.

The two kinds of pain
Doctors divide pain into two categories: "acute," which is generally event-related (such as pain from headache, broken bones, surgery or childbirth), and "chronic," often called "persistent" pain. Chronic pain arises from a variety of causes, including acute pain that was not relieved.

Persistent pain is one of modern medicine's more shameful shortfalls. An estimated 116 million Americans endure chronic pain, the most common cause of long-term disability, costing the United States at least $560-635 billion annually. The situation gets worse as we age: Today almost half of people over age 65 routinely live with pain.

"A disease in its own right"
Yet many persistent pain sufferers say their condition remains misunderstood and even stigmatized. The resulting care gap is serious enough that the Institute of Medicine (IOM) recently declared that we need a "transformation in how pain is perceived and judged both by people with pain and by the health care providers who help care for them."

Far from dismissing persistent pain as imagined, exaggerated or inevitable, the IOM report endorses the emerging view that, "because of the physiological and psychological changes that occur in people with chronic pain ... in many cases, chronic pain is a disease in its own right."

The International Association for the Study of Pain agrees, and last year declared access to pain management "a fundamental human right," adding, "there are major deficits in knowledge of health care professionals regarding the mechanisms and management of pain." Sadly, I concur, as would most practitioners, particularly those treating older patients.

Nearly three out of four older adults have multiple chronic illnesses, such as diabetes and arthritis, and often experience chronic pain from these and other disorders. These include back pain from spinal stenosis, cancer and cancer treatments. Yet there is little or no evidence-based care for this pain, as Ken Covinsky, M.D. of the University of San Francisco Medical Center, has persuasively argued. Likewise, pain that clouds the last days of life should always be aggressively treated; tragically, too many Americans still die in pain.

How can caring and competent physicians allow this suffering? For older adults with multiple conditions, the cause of pain can be hard to pin down. Similarly, older adults often take many medications, which put them at risk for adverse reactions, particularly if pain medications are added. Older adults themselves may compound the problem, being reluctant to "complain" to their doctors, who, through ageism, wrongly assume that pain is simply part of growing old. As a result, many physicians, who may not have had any formal education on pain management, may be overly cautious, and thereby not treat their older patients' pain.

Toxicity associated with commonly employed pain medications also complicates treatment. Widely used NSAIDS (such as over-the-counter ibuprofen [Advil]) that work by reducing inflammation, and prescription Cox-2 inhibitors (such as Celebrex) have side effects that may include increased rates of gastrointestinal bleeding, renal failure, heart failure, heart attack and stroke. A recent study by the American Geriatrics Society determined that 23 percent of older adult hospitalizations for drug toxicity implicated NSAIDS. Even opiates (morphine and others), when used to treat chronic pain disorders, increase risk for adverse outcomes and have only moderate effects on severe pain.

Doctors and patients have found some relief from the use of adjuvants (drugs approved for different use, such as anti-depressants and anti-convulsants). Drugs that target newly identified pain receptors are also in the research pipeline and may have better safety profiles than current analgesics, but their success or failure is still far in the future.

For now, we must use what we have, but the common exclusion of older adults from clinical studies means that we lack an evidence base documenting analgesic safety and effectiveness for them. Since older bodies metabolize and respond to drugs differently, results generated from studies of younger subjects are not necessarily interchangeable.

We should enroll older people, especially those with multiple health conditions, in clinical research. Older patients should also consider participating in "clinical registries," which make no changes in their care and involve no experimental drugs, but simply add their health statistics anonymously to a research database. And pain should be measured as an outcome of great interest in all research on new therapeutic agents.

Non-drug options for managing chronic pain
Finally, many older patients and their families want to know what can be done without drugs. The answer is, quite a bit. Chronic pain, like any chronic disease, is best tackled by an empowered and informed patient.

For example, it might be suitable for patients who experience chronic pain to find an appropriate supervised activity program, such as yoga or tai ch'i at a senior center or other community organization, and get moving. Programs such as Stanford University's Chronic Disease Self-Management program offer peer support and coaching, and increase one's ability to manage chronic pain successfully. A version of the program called Better Choices, Better Health is available nationwide.

Patients and their families can help educate their doctors about the possible power of exercise and self-management as a means of managing pain and might suggest they prescribe it to their patients.

The mind and the body both play an important role. As M. Cary Reid, M.D., Ph.D., a researcher working on improving pain management options for older adults at Weill Cornell Medical Center, and recipient of the Paul B. Beeson Career Development Award in Aging Research, puts it, "I have seen the truth of the old saying that 'the best analgesic is an occupied mind.' My patients convince me of it every week."

Chronic Pain In Homeless Managed By Using Street Drugs

Chronic pain is managed particularly poorly among homeless people, who tend to use street drugs to ease the pain, according to new research.

Dr. Stephen Hwang, a researcher at the St. Michael's Hospital’s Centre for Research on Inner City Health, analyzed data from 152 homeless people with chronic pain and found that over a third of them suffered from Chronic Pain Grade IV, the highest level, indicative of a high level of disability. Nearly half of participants reported using street drugs to manage the pain, and about 30 percent said they used alcohol.

Even though half of participants were being treated for their pain by a doctor, 77 percent of the doctors were having a tough time managing patients’ pain because of drug addiction and mental illness.

"Our study demonstrates the need for improved approaches to the management of chronic pain in the homeless population," said Hwang, as quoted by ScienceDaily. "Clinicians should also inquire about barriers to pain management such as financial ability to obtain appropriate over-the-counter and prescription medications. The adverse effects of homeless people's living and sleeping conditions should also be considered."

He added, "A lot of patients expect a pill, when often what they really need is physiotherapy, which they can't afford and isn't covered by insurance."

From the point of view of the homeless chronic pain sufferers, barriers to managing their pain include the price of prescription medication, poor sleeping conditions and stress from living in shelters.

The research results were published in the online journal BMC Family Practice.

Friday, July 22, 2011

Some days are better than others

Some days are tolerable, some are enjoyable, and some are just bearable.  Having a chronic pain condition is never easy.  Please comment on my posts and enliven the discussion on this site.

Thursday, July 21, 2011

Addiction survey leads to troubling questions

After reading the article below, I was left with questions on how this information will be used.  I am worried it will be used to deprive chronic pain patients of helpful medications that manage their symptoms.

Other studies have shown that approximately 10 percent of the general public are addicts, so it is not surprising that a population taking opioid medications for long periods of time would have a significantly higher rate of addiction.  I wonder if dependence on a medication is sufficient reason to discontinue it if it is working to alleviate symptoms, however.

Newswise — DANVILLE, Pa. - A new study by Geisinger Health System researchers finds a high prevalence of prescription pain medication addiction among chronic pain patients. In addition, researchers found that the American Psychiatric Association’s (APA) new definition of addiction, which was expected to reduce the number of people considered addicts who take these medicines, actually resulted in the same percentage of people meeting the criteria of addiction.

Published in the Journal of Addictive Diseases, the study found that 35 percent of patients undergoing long-term pain therapy with opioids like morphine, OxyContin, Percocet and Vicodin, meet the criteria for addiction.

“Most patients will not know if they carry the genetic risk factors for addiction,” said study lead Joseph Boscarino, senior investigator II, Geisinger Health System. “Improper or illegal use of prescription pain medication can become a lifelong problem with serious repercussions for users and their families.”
Boscarino added that “genetic predisposition to addiction further exacerbates the risks associated with misuse of prescription pain medication.”

Using electronic health records, a random sample of outpatients undergoing long-term opioid therapy for non-cancer pain was identified and 705 participants completed telephone interviews from August 2007 through November 2008.

When comparing the APA’s newly revised criteria for addiction with the old criteria, researchers were surprised to find the prevalence of and risk factors for addiction to be virtually the same. It was determined that different symptoms now qualify the same patients for inclusion who would have been excluded under the previous classification system.

The study states that pain medication addiction often happens in people under 65, with a history of opioid abuse, withdrawal symptoms and substance abuse treatment. Risk factors for severe pain medication addiction also include a history of anti-social personality disorder.

“Ultimately, we hope our research will aid the development of newer classes of medications that don’t negatively impact the brain and therefore avoid addiction entirely,” Boscarino said.
Researchers from New York University also contributed to the study.

About Geisinger Health System

Geisinger is an integrated health services organization widely recognized for its innovative use of the electronic health record, and the development and implementation of innovative care models including ProvenHealth Navigator, an advanced medical home model, and ProvenCare program. The system serves more than 2.6 million residents throughout 42 counties in central and northeastern Pennsylvania. For more information, visit

Suffering from chronic pain from RSD/CRPS? This meeting is for you. -

Suffering from chronic pain from RSD/CRPS? This meeting is for you. -

Article on fibromyalgia's double burden

I am unable to access the full article.  For those of you with access here is the abstract.

Living with a double burden: Meanings of pain for women with fibromyalgia
– Source: International Journal of Qualitative Studies of Health and Well-being, Jul 13, 2011

By P Juuso, et al.

Living with fibromyalgia (FM) means living with a chronic pain condition that greatly influences daily life.

The majority of people with FM are middle-aged women. The aim of this study was to elucidate meanings of pain for women with FM.

Fifteen women with FM were interviewed about their pain experiences and a phenomenological hermeneutic interpretation was used to analyze the interview texts.

The findings show that meanings of pain for women with FM can be understood as:

• Living with a double burden; living with an aggressive, unpredictable pain and being doubted by others in relation to the invisible pain.

• The ever-present pain was described as unbearable, overwhelming, and dominated the women's whole existence.

• Nevertheless, all the women tried to normalize life by doing daily chores in an attempt to alleviate the pain.

In order to support the women's needs and help them to feel well despite their pain, it is important that nurses and health care personnel acknowledge and understand women with FM and their pain experiences.

Source: International Journal of Qualitative Studies of Health and Well-being, Jul 13, 2011. PMID:21765861, by Juuso P, Skar L, Olsson M, Soderberg S. Division of Nursing, Department of Health Science, Lulea University of Technology, Lulea, Sweden.

Tuesday, July 19, 2011

Clinical trials website

For those of you interested in taking part in clinical trials, there is a website where you can register (it's free) and search for clinical trials you may be interested in.  You can find the website here.

Marijuana trial shows modest pain relief for smokers

In a small study, people who had chronic pain as a result of damage to the nervous system reported feeling less pain, as well as less depression and anxiety, when they smoked marijuana compared to when they smoked a drug-free placebo.

The pain reduction was "modest" - less than 1 point on an 11-point scale for the strongest marijuana - and patients reported no overall difference in their quality of life based on what they smoked.

The results support a limited number of trials that have suggested marijuana may be helpful for people suffering from chronic pain, but that it also has its limitations.

"This offers another potential tool in the tool box for treating chronic neuropathic pain," Dr. Mark Ware, a neuroscientist at the McGill University Health Center in Montreal and the study's lead author, told Reuters Health. But there are still questions about marijuana's long-term safety as a pain reliever, he said.

Ware and his colleagues recruited 21 adults who were suffering from chronic neuropathic pain after an injury or surgery. Three times a day, for five days, participants took a 25 milligram hit of one of four treatments: marijuana that was 2.5 percent, 6 percent, or 9.4 percent tetrahydrocannabinol (THC) or a 0 percent placebo. All patients rotated in random order through the four different treatments, with a nine-day break between each one.

During each treatment, participants were asked about their pain, sleep patterns, mood, and overall quality of life.

Patients smoking 9.4 percent THC marijuana reported lower pain scores than when smoking the placebo - on average, 5.4 versus 6.1 on a scale from 0 ("no pain") to 10 ("worst possible pain"). They also reported that they slept better, and were less anxious and depressed than when they were on the placebo.

When smoking marijuana with moderate doses of THC, participants generally reported improved symptoms, but there was no significant difference in their relief from these doses compared to relief from the placebo treatment. There was also no difference in the quality of life or mood scores that participants reported when they were on any of the four treatments.

The highest dose of THC produced the most side effects, which included headaches, dry eyes, and a burning sensation in the regions where patients had pain.

In the second, third and fourth rounds of treatment, most - but not all - patients were able to tell when they had been on either the highest THC dose or the placebo. Most patients did not report feeling "high" at any point during the study.

About 1 to 2 percent of adults in the U.S. suffer from chronic neuropathic pain - pain that occurs when nerve fibers are damaged by injury or disease, and lingers even after the original wound has healed. The condition is treated with a range of different medications, including drugs usually intended for people with depression and epilepsy. But these don't work for all patients, and some also have uncomfortable side effects.

"A lot of the treatments that are used for neuropathic pain ...might also be associated with disruptions in sleep," Dr. Andrea Hohmann, who studies marijuana and pain at the University of Georgia and was not involved with the current study, told Reuters Health. For that reason, the finding that marijuana may actually help improve patients' sleep, she said, is "particularly noteworthy."

The cannabinoid family, which includes marijuana, is "emerging as an interesting new class of drugs for pain management," Ware said. But, "we also know that treating chronic pain of any kind requires more than just (drugs)," he said. No matter what kind of medication they're on, these patients should also be getting behavioral and physical therapy, he said.

The study's five-day treatment sessions also leave questions about patients with chronic conditions who might need treatment for months or years. "The trial did not last long ... so the authors cannot really say whether any response would be sustained," Dr. Henry McQuay, who studies pain and pain relief at the University of Oxford, wrote in an editorial accompanying the study.

Ware agreed that more research is needed. "What about long-term safety issues?" he asked. "These need to be considered before the drug becomes prescribable."

SOURCE: Canadian Medical Association Journal, online August 30, 2010

Monday, July 18, 2011

More on brain fog in CFS and FMS

Board certified internist and Medical Director of the Fibromyalgia and Fatigue Centers.

Brain fog is a classic part of chronic fatigue syndrome and fibromyalgia, presenting as:
  1. Horrible short-term memory,
  2. Difficulty with word finding and word substitution (e.g., substituting the word "fork" for "knife"), and
  3. Occasional disorientation — Approximately 30 percent of those with CFS or fibromyalgia have episodic disorientation lasting around 30-60 seconds. This often occurs when driving or even turning down a supermarket aisle. It can feel scary, but is not dangerous. Though you may not know where you are (or are going) people seem able to drive or walk safely till it passes. This can also manifest as briefly not recognizing common objects or names (even of children).
In some cases, brain fog is mild.  For some, however, it can be severe and quite scary — especially in professionals who otherwise function at a very high level. Though standard testing will often not pick up the problem, in these cases the brain fog can make it difficult or even impossible to continue one's job.  It may even leave you concerned that you are developing Alzheimer's. But you're not. CFS brain fog is when you keep forgetting where you left your keys — Alzheimer's is when you forget how to use your keys!

Clearing the Fog
Poor energy production in the brain with associated alterations in blood flow, as well as alterations in neurotransmitters (brain chemicals like serotonin, dopamine or adrenaline), blood pressure, or blood sugar can all contribute to brain fog.

The good news? Brain fog responds very well to treatment with the SHINE Protocol. Let's look at the key issues and treatments.
  1. Sleep — Getting eight hours of sleep a night is critical, but make sure your sleep, pain or other medications are not the cause of your feeling foggy the next day.  Add natural treatments at bedtime such as melatonin, calcium and magnesium. These are less likely to cause brain fog and will lower the amount of medications needed.
  2. In men, optimize testosterone; and in women, estrogen and progesterone. If you get irritable when hungry, optimize adrenal support, as recurrent low blood sugar also can trigger brain fog.
  3. If you have nasal congestion or sinusitis or irritable bowel syndrome (gas, bloating, diarrhea or constipation) you likely have Candida/yeast overgrowth, and this can leave you very foggy. If so, look into taking the medication Diflucan while avoiding sugar.   Probiotic pearls and anti-yeast herbals can also help.
  4. Optimize your nutritional support with a good multi-vitamin supplement and take ribose — in a study of 257 CFS/FMS patients, a daily intake of ribose not only increased energy an average of 61 percent, but also improved mental clarity an average 30 percent and overall well being 37 percent.  Also ask your physician about B12 injections. If you have dry eyes, dry mouth or depression, increase your consumption of fish oil through supplementation or by having 3-4 servings of tuna or salmon each week.
  5. Stay hydrated. If your mouth or lips are dry, you're dehydrated. It's amazing how the mind can clear significantly after simply drinking a glass of cool water. Getting fresh air and sunshine (in moderation — don't burn) can also help.
  6. So called "energy drinks" loaded with caffeine and sugar are loan sharks.  Avoid them. Instead, drink 1-2 cups of tea (made from real tea bags or leaves — not the powdered/bottled stuff loaded with sugar). This is often enough to jump start your brain in a healthy way without crashing you later, and the antioxidants in 1-2 cups of tea a day help your CFS and overall health as well. 
Like CFS/fibromyalgia pain, brain fog responds well to treatment. The problem is largely that most physicians are simply not trained in these illnesses. Most of these treatments can be done on your own, and you can ask your physician to assist with those requiring a prescription. If they refuse, get a consultation with a Fibromyalgia and Fatigue Center (FFC) physician. 

With a little knowledge, you can get your brain back!

Another Study Showing CFS-Related Brain Fog Not "All In Your Head"
Meanwhile, the "you're crazy, it's all in your mind" school of thought on CFS continues to recede into ancient history. There were those who attributed the brain fog (and all of CFS) to depression — which was, well, crazy! Here is another new study showing that the brain fog of CFS and depression are not  related.

Study: The role of depression in cognitive impairment in patients with chronic fatigue syndrome
In the test, 57 women with CFS were evaluated for cognitive function using neuropsychological tests that measure mental acuity in areas such as ability to pay attention, to count forward and backward, auditory-verbal learning skills, executive functions, and psychomotor skills.

Participants were divided into two groups, with one group including those CFS patients who suffered depression (based on clinical assessment to determine scores on the Hospital Anxiety and Depression Scale) and the other including those CFS patients who were not determined to be depressed.

The results showed no difference between the two groups in their levels of cognitive deficit in performing attention and executive functions. Researchers therefore concluded that there was no link between depression and the cognitive impairments exhibited by patients with CFS.

The role of depression in cognitive impairment in patients with chronic fatigue syndrome. Santamarina-Pérez P, Freniche V, Eiroa-Orosa FJ, Llobet G, Sáez N, Alegre J, Jacas C. 2011 Mar 12;136(6):239-243. Epub 2010 Dec 9.

Is marijuana effective for pain management?

There is a lot of anecdotal evidence that marijuana can relieve pain.  I have not tried this, but have heard from friends that it works for them.  I want to start adding some information on scientific studies on the issue, if I can find them.  Here is one that does not sound very promising.

Marijuana and Pain Management

By: Bill McCarberg, M.D.

Millions of people in the United States suffer from chronic pain, and much of that suffering cannot be relieved adequately by existing treatments. Patients are in desperate need of new pain management approaches. Cannabinoid medicines appear very promising, although the subject often is obscured by controversy, prejudice, and confusion in part because cannabinoids have some relation to the cannabis plant – also known by the slang term marijuana.

What scientific reasons do doctors have to think that cannabinoids actually work? Do they provide genuine symptom improvement, or do patients become intoxicated and merely think that their symptoms are reduced?

Basic research conducted over the past 20 years provides us with many answers. In the early 1990s, researchers identified the cannabinoid receptor system. This system is found in some of the most primitive animal forms on earth – it is also the most widespread receptor system in the human body.

The cannabinoid receptor system has two types of receptors:

  • CB1 receptors are found primarily in the brain, spinal cord, and periphery.
  • CB2 receptors are on the immune tissues.
Specific molecules (called endocannabinoids) are produced by the body that interact with these CB1 and CB2 receptors, much like endorphins interact with the body's opioid receptor system. These findings initiated a new era of scientific interest and research in cannabinoids.

Numerous studies have now established that cannabinoids help lessen pain and affect a wide range of symptoms and bodily functions. Such research has also demonstrated that cannabinoids may work together with opioids to enhance their effectiveness and reduce tolerance.

This body of research has allowed cannabinoids to be informally classified into three types:

  • endocannabinoids (produced by the body)
  • phytocannabinoids (produced by the cannabis plant)
  • synthetic cannabinoids (produced in the laboratory)
Each type is being studied aggressively, but because endocannabinoids are quickly metabolized and probably cannot be patented, they have not yet been researched in humans.

What progress is being made toward developing cannabinoids as prescription pain relievers? Some cannabinoids are unstable and many are insoluble in water, which makes them difficult to research and turn into modern medicines. Patients react very differently to cannabinoids. Data from recent clinical trials are encouraging, but somewhat mixed. Looking closely at the results suggests that composition and delivery route (i.e., how a medicine is administered) are extremely important to the viability of cannabinoid medicines.

The Delivery Route

When taken orally, cannabinoids are not very well absorbed and often have unpredictable effects. Patients often become sedated or have intoxication-like symptoms when tetrahydrocannabinol (THC – the primary psychoactive cannabinoid in cannabis) is metabolized by the liver. A small number of studies with Marinol (synthetic THC in sesame oil in a gelatin capsule) and Cesamet (synthetic THC analogue) have shown some effectiveness in pain relief, but optimal doses that relieve pain often cannot be achieved because of unpleasant psychologic side effects.

Inhaling cannabinoids, especially THC, also may cause problems for many patients. Blood levels rise suddenly and then drop off sharply. This rapid on-off effect may produce significant intoxication, particularly in patients who are new to cannabinoids. This may pose the risk of abuse potential. Smoking cannabis produces this effect, which is the very reason that recreational users prefer the inhaled route. Patients, however, generally wish to avoid psychologic effects, and it is unclear how difficult it might be to find a dosing pattern that enables them to have pain control without side effects.

A new product, called Sativex, was approved by Health Canada in June 2005 for marketing as an adjunctive medicine for central neuropathic pain in multiple sclerosis. Adjunctive therapy means taking two or more medications to help control pain.

Sativex has a different delivery system – an oromucosal/sublingual spray absorbed by the lining of the mouth – that, according to the manufacturer, generally allows patients to gradually work up to a stable dose at which they obtain therapeutic pain relief without unwanted psychologic effects.

In the United States, Sativex is being studied in large randomized trials in cancer pain that has not been adequately relieved by opioids. Three early and six pivotal controlled studies in the United Kingdom demonstrated positive results treating chronic pain of various origins including neurologic pain, various symptoms of multiple sclerosis, rheumatoid arthritis, and cancer pain. Initial results show improvement in pain for more than one year despite lack of effectiveness of the opioids. Common adverse effects of Savitex have included complaints of bad taste, stinging, dry mouth, dizziness, nausea or fatigue.

Additional research also may uncover other ways of avoiding the problems associated with oral or inhaled delivery. Ajulemic acid, a synthetic cannabinoid, binds to both the CB1 and CB2 receptors, and has shown benefit in a small neuropathic pain trial. It may have reduced psychologic effects and is being studied for the treatment of interstitial cystitis.

The Interplay of Cannabinoids

The use of herbal cannabis – usually smoked – has received considerable media attention since California and Arizona passed "medical marijuana" initiatives in 1996. Despite numerous anecdotal reports of effectiveness, very few controlled studies have been published in the pain area. Little is known about the number of patients who actually experience some degree of benefit or side effects.

Furthermore, herbal cannabis is neither standardized nor monitored for quality. The cannabinoid content can vary a great deal, and cannabis sold at dispensaries may be contaminated with pesticides or mold. Dosing is uncertain, depending on the preparation or method of use. So-called "vaporizers" do not eliminate all the contaminants. Without clinical trial data and an assurance of product quality, physicians lack the information necessary to assist patients in making informed therapeutic decisions. Both the FDA and Institute of Medicine have stated that there is no future for herbal cannabis as a prescription medicine.

Nevertheless, there may be some truth to the idea that there is pain relief potential in phytocannabinoids (plant-based cannabinoids) and that such potential may be affected by the interaction of THC with other botanical components, particularly with other cannabinoids. Modern strains of cannabis have been bred to maximize the THC at the expense of all other cannabinoids, most of which do not have psychologic effects. Some of those cannabinoids, such as cannabidiol (CBD), have been demonstrated to have important therapeutic value, particularly on pain and inflammation.

Concluding Thoughts

The possibilities for cannabinoid medicines are very promising, and much exciting research is proceeding at a rapid pace. As new FDA-approved cannabinoid products become available, physicians and patients will have a solid scientific foundation from which to assess their appropriateness. Hopefully, robust scientific data will soon allow cannabinoids to take their place – along with opiates and other pain relievers – in the modern medical supply for treating chronic pain.

Bill H. McCarberg, MD, is founder of the Chronic Pain Management Program for Kaiser Permanente, San Diego, and assistant clinical professor in the Department of Family Practice at the University of California, San Diego, School of Medicine. He has served on the board of directors of the American Pain Society and currently is co-president of the Western Pain Society and a National Pain Foundation Advisor.

Biological link between pain and fatigue