Anatomical changes correlated with chronic pain

https://edsinfo.wordpress.com/2020/02/06/anatomical-changes-correlated-with-chronic-pain/#comments

Anatomical changes correlated with chronic pain in forensic medicine – Free full-text /PMC6197126/ –  Jun 2017

This article from the NIH has a good summary of physical changes that come about due to chronic pain, not just psychological “problems”, but numerous physical harms resulting from unrelieved pain.

This study was performed to determine the relationships between chronic pain and anatomic changes that may occur in the body.Autopsies were performed on fatalities that required death investigation in Linn County, IA, or adjacent and nearby areas.

Certain causes of death may also have been related to chronic pain. The heart, lungs, liver, spleen and kidneys were significantly heavier in persons with chronic pain; emphysema and pleural and abdominal adhesions were more common in persons with chronic pain.  

Diabetes, hypertension and depression were more common in persons with chronic pain.

There appear to have been diffuse changes in the body related to chronic pain. These changes may have been mediated by a number of systemic mechanisms that are involved with chronic pain, including cardiovascular activity, the immune system, the neuroendocrine system and others.

Results

Based on medical records and scene investigations, 54 persons had been diagnosed with chronic pain ante-mortem, and 320 had no known chronic pain.

The demographic data are summarized inTable 1.

The types of chronic pain encountered are listed in Table 2.

Systemic or widespread pain was the most common type, such as neuropathic pain, fibromyalgia, multiple sites of arthralgia or pain from disseminated carcinoma; musculoskeletal or site-specific pain followed, particularly chronic low back pain.

Table 1.
Subject data (case number).

Subject	Parameter/classify	Chronic (N = 54)	Control (N = 320)	Significance
Age (years old)	Mean ± SD	50 ± 13	44 ± 18	P = 0.020 4
Range	29–82	13–88	–
Sex	Men	34	224	–
Women	20	96	–
Race	Caucasian	52	269	P = 0.018 3
Other	2	51	–
Height (inches)	Mean ± SD	68 ± 4	69 ± 4	–
Range	60–75	55–77	–
Weight (pounds)	Mean ± SD	194 ± 66	180 ± 48	–
Range	101–422	55–375	–
Body mass index (BMI)	Mean ± SD	29.0 ± 9.0	26.9 ± 6.6	–
Range	15.8–52.7	10.2–57.1	–
Social	Caffeine	14	63	–
Tobacco	1	23	–
Alcohol	9	96	–
Marijuana	3	48	–
Medical	Diabetes	10	21	P = 0.006 2
Hypertension	18	52	P = 0.004 0
Psychiatric	Depression	28	60	P < 0.000 1
Bipolar affective disorder	3	8	–
Schizophrenia	0	5	–
Substance abuse	13	42	P = 0.005 2

Table 2.
Sites of chronic pain (N = 54).

Sites	Number
Systemic	20
Back	14
Abdomen	5
Neuropathic	6
Other musculoskeletal	5
Chest	2
Headache	2
Total	54

Death from natural causes was significantly more common among persons with chronic pain (chronic pain n = 28, control n = 109; P = 0.014 6).

The Cox analysis of survival showed no differences based on sex, race, height, weight and BMI.

Based on clinical factors (P = 0.000 4), systemic hypertension was significantly correlated (P = 0.000 8) with early mortality, while chronic pain, narcotic use, depression and diabetes mellitus did not appear to contribute significantly as covariates to overall survival.

This is good news: “narcotic use did not appear to contribute significantly”.

The Cox analysis using organ weights as the hazard is reported in Table 3. Chronic pain was identified as a significant covariate in heart weight

Chronic pain was also identified as a significant covariate in spleen weight, along with Caucasian race and increased body weight.

Anatomic findings from autopsy are summarized in Table 4.

All of the visceral organs were significantly heavier in the chronic pain group compared to the controls.

Table 4.
Anatomic findings.

Organs	Parameter/classify	Chronic (N = 54)	Control (N = 320)	Significance
Brain	Weight (grams)	1 340 ± 167	1 362 ± 156	–
	Cerebral oedema	11	61	–
Heart	All (non-surgical), weight (grams)	426 ± 87	389 ± 118	P = 0.032 4
	Normotension, weight (grams)	401 ± 81	366 ± 100	P = 0.046 4
	Hypertension, weight (grams)	476 ± 78	505 ± 135	–
	Cardiac hypertrophy	35	89	P < 0.000 1
	Atherosclerotic cardiovascular disease (ASCVD)	26	148	–
	Myocardial infarction (MI)	3	9	–
Pleural cavities	Adhesions	11	13	P = 0.000 1
Lung, right	All, weight (grams)	639 ± 193	569 ± 230	P = 0.036 3
	Pneumonia(−), weight (grams)	641 ± 201	555 ± 213	P = 0.012 1
	Pneumonia(+), weight (grams)	630 ± 156	848 ± 352	–
Lung, left	All, weight (grams)	557 ± 220	492 ± 197	P = 0.028 3
	Pneumonia(−), weight (grams)	568 ± 235	484 ± 189	P = 0.007 9
	Pneumonia(+), weight (grams)	501 ± 116	639 ± 283	–
	Pneumonia	9	14	P < 0.002 5
	Emphysema	21	82	P = 0.044 6
Abdomen	Adhesions	7	6	P = 0.000 7
Appendix	Present	35	250	P = 0.000 6
Liver	Weight (grams)	2 026 ± 568	1 769 ± 544	P = 0.001 9
	Weight range (grams)	1 200–3550	700–3910	–
	Steatosis	27	135	–
	Cirrhosis	4	14	–
	Hepatitis	13	62	–
Gallbladder	Present	38	283	P = 0.000 2
Spleen	Weight (grams)	245 ± 112	186 ± 107	P = 0.000 3
Kidney	All, weight (grams)	339 ± 78	310 ± 94	P = 0.037 3
	Normotension, weight (grams)	335 ± 76	301 ± 90	P = 0.033 9
	Hypertension, weight (grams)	346 ± 84	356 ± 99

 

Discussion

This study investigates whether a documented experience of ante-mortem chronic pain may have been related to anatomic changes in the body that could be observed at autopsy.

The task can seem daunting, since chronic pain does not have a single clinical signature.

It has a number of causes and presentations, although they share a common experience of persistent distress that impairs one’s experience of life, activities of daily living, work and relationships.

Yet, in opioid studies, such persistent and impairing distress is completely discounted.

It is important to consider that chronic pain is a very diverse condition arising from many aetiologies, so to consider them as a single diagnosis would be inappropriate.

Yet all opioid studies assume that all chronic pain is alike. This seems li,e a gross scientific and logical error that would completely corrupt any such study and make it meaningless.

This study furthermore appears to find that the body may undergo changes that may be correlated with chronic pain.

While many organs had interacting covariates in their size at the time of death, the heart and spleen were specifically correlated with chronic pain at the time of death, and all of the other visceral organs in persons with chronic pain weighed more than controls as independent variables.

Systemic changes may suggest systemic mechanisms that cause the visceral organs to enlarge, such as those mediated by the

• central nervous system [2,7,8,15,17,18,20–26],
• peripheral nervous system [23],
• neuroendocrine system,
• endogenous opioids and cytokines [2,20,21,23,25,26,28],
• the circulatory system including blood pressure [8,10],
• serum factors [21,35–39], and
• the immune system [2,20,21,23,25,26,28].

Under the direction of these interacting systems, chronic pain may induce stress that leads to reactive enlargement of the organs.

For example, systemic mechanisms that could enlarge the organs may include fluid redistribution to the interstitial space due to endocrine stimulation; immune cells may evoke inflammatory reactions; the central nervous system may stimulate sympathetic reactions; and others.

The significant incidence of pneumonia in persons with chronic pain could be related to decreased mobility in persons who experience ongoing pain, or the higher incidence of emphysema that was found in the pain group.

Adhesions were more common in the pleural and abdominal cavities of the pain group, suggesting systemic inflammation. Conversely, there was no increased incidence of cerebral oedema, atherosclerotic cardiovascular disease, myocardial infarction, steatosis cirrhosis or hepatitis.

The anatomic changes with the corresponding clinical or demographic correlations found in this study suggest that differences in the body are possibly correlated with chronic pain in many ways, such as

• organ enlargement,
• pneumonia,
• depression and
• increased likelihood of abdominal surgery such as cholecystectomy and appendectomy

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How It Feels to Be Force Tapered Off Pain Medication for Chronic Illness

https://themighty.com/2020/01/force-tapered-off-pain-medication-chronic-illness/

It’s that time of the month again.

I’m headed to my pain management doctor (more like my PO or parole officer) for a monthly checkup and prescription refill.

It’s the same every month…I sit in an over crowded office for over an hour, after my actual appointment time. I’m called back by the nurse to a room where I am asked to leave all my belongings. I’m given a cup with my name, DOB and date on it to pee in. I go into the bathroom, clean “down there” with a sanitary wipe, open the cup, start peeing, catch the pee in the cup (sometimes I accidentally pee on my hand, gross!) close it up, wipe myself and place the cup within the little box in the wall.

I open the bathroom door to let the nurse know I’m finished. She comes in to look everything over, flushes the toilet and lets me know I can wash my hands. I’ve never been arrested or gone to jail, but I certainly feel like I have now. It’s like I’m visiting my parole officer monthly, instead of my doctor.

I go back to the room where the nurse originally had me leave all my belongings, and now I wait. My doctor comes in and doesn’t make eye contact with me any longer, goes straight to her computer and asks how I’ve been and if there’s any new symptoms or health issues since last visit. I tell her “my quality of life is slowly going down the drain since she started to force taper me off pain medication.”

I must have struck a nerve because she finally looks me in the eyes and states “it is not her fault and her hands are tied due to the CDC guidelines” and “there’s nothing she can do about it.”

I think about letting her know, I’m in on her little secret. No one is forcing doctors to taper their patients living with rare and painful diseases. Doctors have bought into the “Fear of Addiction” media, the US government, the Drug Enforcement Administration (DEA) and the Centers for Disease Control and Prevention (CDC) has sold us all on.

Instead, I smile and shake my head yes. Yes, I know she’s afraid that the DEA will barge into her office, take all her patient files and threaten jail time. Yes, I know she’s afraid to lose her career she’s worked so hard for. Yes, I know about the kickbacks doctors (maybe not her) receive now, if they lower their patients under a certain percentage off their pain medications. Yes, I know that she is no longer my doctor, the government now controls what medications I receive, how much I receive and how often I receive it.

My doctor stares at her computer monitor and asks me again, “do I have any new symptoms or health issues.”

I tell her it takes me longer to get going in the mornings. One of my major health issues is complex regional pain syndrome (CRPS) in my arms, upper body and head. My hands usually swell three times larger than normal every morning.

I let her know that my neck pain is getting harder to keep under control. I’ve broken it two times in two different car accidents, which led to five neck surgeries.

She tells me that my pain levels will go up as she tapers me, and then will start to lower once I’m completely tapered and my body adjusts to having no pain medication. She must be kidding?! I understand withdrawal. I’ve tapered myself several times off pain medication when preparing for ketamine infusions. My pain always did go up as I tapered, but it definitely didn’t “go down” or “go away” after my body adjusted to no pain medication in my system. Maybe she doesn’t believe the several diagnoses is accompanied with pain. Maybe she doesn’t believe I’m actually in that much pain?

She lets me know that I should prepare myself with the reality that she will completely taper me off all pain medications in the next few months.

I don’t say anything. I fight with myself on how to respond. I would love to give her a piece of my mind, but I know that will do nothing except give her a reason to dismiss me as her patient, immediately giving me a one way ticket out of the little care I still receive and probably red flagged for life on my medical records.

I decide to be the good and docile patient. I ask her if there’s any other medications or alternative therapies I can try? She smiles a little. She starts going through the different groups of medications I can try: gabapentin, different anti-depressants used for pain, blocks I can get in my neck, ketamine infusions, NSAID’s…I stopped listening at this point. I’ve tried what she’s suggesting at some point in my 25 year career as a patient.

I let her know I will research everything she suggested and next month we can go over these new options. She hands me my prescription and leaves with a “have a great day.”

I leave my appointment feeling helpless, hopeless and scared. How is it that as a United States citizen I am now treated as “junkie,” a criminal and a drug seeker? I’ve always taken my medications as prescribed. I don’t take illegal or street drugs. I’ve always been a great patient, following my doctors instructions and willing to try new medications and therapies when asked too.

Living with health issues for over 25 years, I’ve tried most medications and “alternative therapies.” I’ve always been realistic and careful when taking my pain medications. Pain medication will never take the pain away completely. It takes the edge off just enough to sleep and function throughout the day.

I’ve learned to use a combination of medications, therapies, diet and exercise in order to achieve the best quality of life. Taking away pain medication from patients living with constant and high levels of pain is barbaric and wrong!

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https://www.medicarerights.org/about-us

Another chronic pain senior citizen shared this with me… and indicated that they can be of great assistance for those on Medicare and having trouble getting appropriate services/care.

I am going to post a link to this post on the resources tab on my blog

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Moody, pharmacy chains tangle in opioid lawsuit

https://www.news4jax.com/news/2020/02/06/moody-pharmacy-chains-tangle-in-opioid-lawsuit/

TALLAHASSEE, Fla. – Castigating the tactic as a “publicity stunt,” Attorney General Ashley Moody is asking a judge to reject an effort by the nation’s two largest pharmacy chains to add 500 unidentified physicians to the state’s lawsuit against the pharmaceutical industry over the opioid epidemic.

CVS Pharmacy Inc. and Walgreen Co. filed what is called a third-party complaint against 500 “John and Jane Doe” doctors, alleging that the prescribing physicians — and not the drug stores — are to blame for faulty prescriptions.

The state’s lawsuit against the chains “is nothing more than unsupported speculation” that pharmacists “filled prescriptions for opioid medications that they should not have filled” despite the state’s “inability to support its claim with even one instance of an improperly filled prescription,” the pharmacies argued in the third-party complaint filed Jan. 22. By looking at The Law Offices Of Michael H. Pham Avvo Profile, it is better to get a consultation about this issue first with them. Then, they would study the case properly and will suggest some measures to clear this case and would eventually get it done with the order obtained at the court of law.

“But pharmacists do not write prescriptions and do not decide for doctors which medications are appropriate to treat their patients,” the chains’ lawyers wrote. “While pharmacists are highly trained and licensed professionals, they did not attend medical school and are not trained as physicians. They do not examine or diagnose patients. They do not write prescriptions.”

Pharmacists, “with limited exceptions,” are “bound to respect a prescribing doctor’s professional medical judgment about which medications are appropriate to treat a particular patient under the doctor’s care,” the companies argued.

The pharmacy chains deny they are “liable in any respect.”

But responding Wednesday to the third-party complaint, lawyers representing the state accused CVS and Walgreens of having “launched a publicity stunt attempting to deflect attention from their role in causing the opioid epidemic plaguing Florida.”

“CVS and Walgreens’ gambit is factually unsupported because both pharmacies have records concerning the prescriptions that the pharmacies dispensed, including the names of the doctors who wrote the prescriptions,” the state’s lawyers wrote.

The attorney general’s office filed the lawsuit in 2018 to try to recoup millions of dollars the state has spent because of the opioid epidemic. The lawsuit was filed against manufacturers, distributors and sellers of opioids and included a series of allegations, including misrepresentation about opioid use and filling suspicious orders for drugs. The state later added CVS and Walgreens to the lengthy list of defendants in the case.

In the third-party complaint, CVS and Walgreens lawyers wrote that if the chains can be held liable for filling prescriptions, “ultimate responsibility must rest with those who wrote the prescriptions: the prescriber defendants themselves.”

The chains will amend their complaint to identify the doctors “if plaintiff (the state) ever identifies the specific prescriptions it claims should not have been filled,” they wrote.

The state’s attorneys, however, wrote that the pharmacies have records of prescriptions, including the names of the doctors who wrote the prescriptions, but they failed to identify “a single prescriber.”

The pharmacies’ “tactic” is legally groundless “because Florida law treats such John and Jane Doe filings as a nullity,” the state’s lawyers wrote, adding “such a filing does not commence a legal action against any party.”

Retail pharmacies “are the last line of defense between dangerous opioids and the public,” the state argued, accusing Walgreens and CVS of failing to fulfill their obligations to adequately review prescriptions and ensure they were “effective, valid, and issued by a practitioner for a legitimate medical purpose” as required by law. If in Festus attorneys defending against drug charges issues are available in case of a problem.

Both pharmacy chains were the target of enforcement actions related to the opioid epidemic, the state argued.

CVS “paid millions of dollars to resolve allegations of malfeasance” at one of its stores in Sanford, and Walgreens “paid millions of dollars in connection with diversion and record-keeping problems” at its Jupiter distribution center and six retail stores, Moody’s lawyers pointed out.

A Walgreens in Pasco County “sold 2.2 million tablets in Hudson alone in one year,” the state added. The lawsuit is filed in the 6th judicial district, which encompasses Pasco and Pinellas counties.

The state asked the judge to strike or sever the third-party complaint, saying the John and Jane Doe pleadings were not proper and that any attempt to litigate the third-party claims along with the state’s complaint “would be unduly cumbersome for the parties and the court.”

In the third-party complaint, the pharmacy chains said the state has not sued health-care practitioners who wrote the opioid prescriptions. Over 60 percent of the opioids dispensed in Florida did not come from the chains, they argued.

“But in a misguided hunt for deep pockets without regard to actual fault or legal liability, plaintiff has elected not to sue any of these other parties,” the pharmacies’ lawyers wrote.

The pharmacies also denied the state’s allegations that a vast number of Florida doctors wrote an excessive volume of opioid prescriptions without legitimate medical purposes.

“Perhaps unsurprisingly, the state’s lengthy amended complaint against the Florida pharmacy chains fails to identify even one prescription that was supposedly filled improperly by any pharmacist for any of the Florida pharmacy chains. Not one,” the chains said.

Pharmacists who work for the drug store chains “are among the best, most caring, and most conscientious in the business,” their lawyers argued. One can follow the link here and get a good legal expert who can stand by you and help you with your case.

“They care just as deeply about their communities as anyone else and could not take more seriously the responsibility of dispensing of controlled substances, including prescription opioid medications. At the same time, they are committed to serving the legitimate needs of patients across the community who must have access to such medications, as prescribed by their doctors for conditions that can range from pain in terminal cancer patients to severe pain after surgery to disabling chronic conditions,” they added.

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https://www.pbs.org/video/the-poison-squad-5sf93j/

‘The Poison Squad’ tells the story of government chemist Dr. Harvey Wiley who, determined to banish these dangerous substances from dinner tables, took on the powerful food manufacturers and their allies.

I stumbled on to this PBS show and Dr Wiley’s crusade to get the establishment of the FDA. His story starts in the late 19th century and this documentary shows how BIG CORPORATIONS had many/most of Congress in their pocket and Congress resisted taking correcting action against those corporations who was using all sorts of “bad preservatives” in food and even gets to dealing with the “Caffeine addiction” from Coca Cola products.

Take away is that Congress has not changed much over the 19th-20th-21st centuries … lobbyists and $$$ rule the day !

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Neurologist found guilty in $150M fraud scheme alongside 3 other physicians

https://www.beckersspine.com/spine/item/48190-neurologist-found-guilty-in-150m-fraud-scheme-alongside-3-other-physicians.html

A federal jury convicted neurologist Mohammed Zahoor, MD, and three other physicians of participating in a $150 million healthcare fraud scheme, the Department of Justice announced Feb. 4.

The four-week trial also culminated in convictions for Michigan pulmonologist Tariq Omar, MD, and emergency medicine specialists Spilios Pappas, MD, and Joseph Betro, DO, of Ohio and Michigan, respectively.

While working at several Tri-County Group medical clinics in Michigan and Ohio from 2008-16, Drs. Zahoor, Omar, Pappas and Betro allegedly required patients to receive expensive, medically unnecessary services such as facet joint injections and urinary drug screens in order to obtain prescriptions for opioids, benzodiazepines and other narcotics.

Patients who told the physicians they didn’t “want, need or benefit from” the expensive, unnecessary injections were denied prescriptions until they agreed to have them.

The defendants prescribed over 6.6 million doses of opioids and regularly offered patients 30 milligrams of oxycodone, a dosage only deemed suitable for terminally ill cancer patients. Some of their patients suffered from legitimate pain, and others were drug dealers or opioid addicts. In certain cases, the unnecessary shots made patients’ pain worse or led to adverse conditions, including open holes in the back.

In an “assembly line” type operation, the four physicians would see dozens of patients during shifts ranging from two to four hours, prosecutors said. The defendants were paid up to $3,500 an hour by falsely representing medical necessity and exaggerating time spent with patients on Medicare claims.

The physicians were also involved in a scheme to send urine tests for every patient to National Laboratories, a business owned by a co-conspirator, in exchange for tens of thousands of dollars in illegal kickbacks.

The physicians’ sentencing hearings are scheduled for July. Each was found guilty of one count of healthcare fraud and one count of conspiracy to commit healthcare fraud and wire fraud. Previously, 17 other defendants, including eight physicians, pleaded guilty in connection with the case.

Doctor would not give individuals their pain medication … unless they capitulated in having an epidural

So here we have two examples – one of the DOJ going after “needle jockeys” and the other getting sued for refusing to give oral opiates to pts unless they submitted to on going ESI’s.

The first case, whatever valid chronic pain pts there was in the practice are once again “tossed to the curb” and will most likely be shunned by other prescribers because they were a pt at that “dirty practice” that got taken down by the feds.

The second, I have not heard anything about any resolution, but it could have been settled with a confidentiality agreement and it may have just “faded away” never to be heard from again.

I have been saying for several years … that the potential solution to the problems that the chronic painers have in getting adequate pain management will be based on actions taken in our court system over the next few years.

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Conway states in the video about 17+ minutes into it: pain pt when they need opiates – THEY WILL BE THERE !

Is it time for those in the chronic pain community to start tweeting white house, conway and trump when chronic pain pts are DENIED THEIR MEDICALLY NECESSARY OPIATES.

Include a link to the video in your tweet  https://www.wtxl.com/news/national/kellyanne-conway-to-provide-update-on-white-house-effort-to-fight-opioid-abuse

we all know that there is no longer enough opiate production to provide adequate pain management for the vast majority of chronic pain pts.

Of course Conway is another ATTORNEY and part of the same DOJ/DEA “industry”.  There is a old attorney saying… “… when the law is on your side argue the law.. when the facts in on your side, argue the facts … if neither the law nor the facts is on your side … deny…deny…deny…”

It would appear the Conway is using the THIRD OPTION in defending the administrations position… deny… deny… deny that any chronic pain pts are being harmed by the administration’s policies

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I have recently seen a lot of discussion about states that are considering or others that have pass STATE LAW that is suppose to help chronic pain pts get better/adequate pain management.  Encourage prescribers to be more liberal in prescribing opiates and other controlled meds that are needed by pts that are medically dealing with subjective diseases ( pain, anxiety, depression, ADD/ADHD, mental health issues ).

I am not aware of the authority of any state to establish boundaries for any federal agency – especially DOJ/DEA – enter the state and forced to observe/adhere to state laws.

I wish someone would point out to me where a STATE LAW could supersede the DEA’s authority under the Control Substance Act.

In fact, the DEA has been granted – or took – the authority to both be able to establish new interpretations/regulations of existing laws and then proceed to enforce those same regulations.  It is almost like the DEA can create “designer regulations” to meet their specific wants to enforce.

All one has to do is look at California who made MJ legal some 20 yrs ago and the DEA still -at times – raids MJ clinics and MJ growing patches.

The DEA might even take it as a challenge to the states that pass some sort of new legislation that encourages better pain management and just raid more practices to just prove who is really in charge.

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