Sunday, March 27, 2016

Chronic Pain: NPS and the CDC Guidelines Trending on Social Media

Chronic pain topics trending on social media have increased with the release of the National Pain Strategy (NPS) and the CDC Guidelines for Prescribing Opioids. Having submitted comments on both drafts, I felt it was time to express my personal opinions. There are vast differences between the two, even though the “CDC Guidelines” are specifically mentioned at the conclusion of the NPS report.

CDC Opioid Checklist: The good, the bad, and the ugly 

Overall, the checklist is not difficult to understand and physicians will be more likely to use it. Where I do not comment, assume it to mean I don’t see any reason to mention it.

Good Stuff:

·        “For primary care providers treating adults.” - Primary care physicians need guidelines by government agencies so they do not fear retaliation by the DEA. Not all patients living with persistent pain require supervision by a pain specialist; in fact, there aren’t enough pain physicians to meet the needs of over 100 million Americans living with chronic pain.
·        “Known risk factors” – Important assessment.
·        Prescription drug monitoring program”  (eleven states do not have a PDMP) – You can read what I think about medication safety on my website. PDMPs are good for identifying signs of drug diversion or abuse, which protects responsible people, but will physicians who treat patients with conditions that cause chronic pain, i.e., pain physicians or rheumatologists be singled out? And, how will this affect patient care in states without a PDMP?
·        “Behavioral treatment” – This piece is often difficult for physicians to discuss with their patient’s, and vice versa. However, there is evidence that shows our behavioral response to pain makes a difference in our ability to cope with the fall of of living with chronic pain, and how we respond to it mentally and emotionally can affect our pain intensity. (This does not mean it treats the pain source directly, however.)
·         “Schedule initial reassessment within 1– 4 weeks.” – This should be done any time a new medication is started, including non-opioids that affect the central nervous system.
·        “Assessing pain and function using PEG scale” – This one gets a mixed review. Relieving pain, decreasing the intensity to improve quality of life is the reason we seek pain care. However, quality of life should be assessed according to what that means for each individual patient. For instance, a diseased spine or joint is not going to function better despite pain relief. Q1 is difficult because it relates to an acute pain scale, which is not helpful for assessing chronic pain, especially in a person with more than one pain condition. Q2 reverts back to my comments on changing behaviors. Enjoyment of life is not affected by opioids, it is affected by developing healthy coping skills as is the truth for any chronic illness. Enjoyment of life fluctuates for everyone.  Q3 Improving endurance, i.e. activity, cannot be achieved without therapies that are often capped by Medicare and is not based on patient outcome. And, easing pain will not necessarily result in increased activity. Overall, asking a patient to make their own assessments is important, but placing an arbitrary number (30% improvement) is punitive. Many factors, life situations, can cause the numbers to fluctuate. One cannot assume status quo for chronic pain anymore than they can assume blood sugars will remain constant in treatment of diabetes.

Bad Stuff

·        “Benefits of long-term opioid therapy for chronic pain not well supported by evidence.” – Describe evidence? Anecdotal reports from physicians who specialize in pain medicine are evidence (but they were not represented in the “Core Group” of experts). If they are referring to research, there is no evidence to suggest opioids don’t work for long-term pain care.
·        “Schedule reassessment at regular intervals (≤ 3 months)” – This guideline is not appropriate for patients who do not need advanced pain care. Patients who have been on the same opioid dose for years do not require such close observation. Many patients, particularly the elderly, do not have the ability to see the doctor this frequently, nor is the physician available. To put an absolute time interval (without cause) puts an unnecessary burden on the physician, patient, and insurance, including Medicare, and drives up healthcare costs. This is a total disregard for common sense.
·        “Urine drug screens.” I am not against them when there are signs of abuse. (Perhaps the checklist should include assessment of those behaviors.) However, using drug screens to assess risk without probable cause is offensive for several reasons: they are accusatory (guiltily until proven innocent), they are humiliating, they are not consistently accurate, and they are not always covered by insurance, which is discriminatory against folks who can’t pay. Innocent people are being tortured by inaccurate results, while drug testing companies are making a killing, sometimes literally.

The Ugly

·        “NON-OPIOID THERAPIES Use alone or combined with opioids, as indicated:” – Suggesting long-term use of NSAIDs is not safe, and there is evidence to suggest this. Antidepressantsare not without consequences; they have many drug-to-drug interactions and can lead to suicidal thoughts, they are not always a safer choice. Anticonvulsantsare also abused because of euphoric effects and can have serious side effects like antidepressants. Non-opioid treatments should be considered, but the effects of alternate drugs should not be undermined.
·        “Calculate opioid dosage morphine milligram equivalent (MME).” Every patient is different. It is common sense to taper any drug or treatment to effect, but this particular issue could put a prescribing physician at risk of litigation.  (See Dr. Fudin's opinions.)

The National Pain Strategy (NPS)

“National Pain Strategy outlines actions for improving pain care in America
Plan seeks to reduce the burden and prevalence of pain and 
to improve the treatment of pain”

There are many things I agree with, some that I can tolerate, and others that I felt needed attention. The NPS did have representation by advocates during its draft, and we have all been waiting for it to be released. And, so it has been. You can see and overview and download the National Pain Strategy here.   

“The Strategy provides opportunities for reducing the need for and over-reliance on prescription opioid medications;” this statement disturbs me. I believe the only way we can reduce the need for pain relief is to find a cure for scleroderma, complex regional pain syndrome, the effects of aging on the body, arthritis, fibromyalgia, EDS, myofascial pain syndrome, the centralization of pain, etc. Relieving pain is instinctive to all animals, including humans.

Not including all the stakeholders in the drafting of the CDC guidelines has many advocates and advocacy groups incensed, and rightly so. Public notice of the guidelines was made public for only 3 days. Only after being caught, did they allow our voice. But, despite pleas made by people far better equipped and knowledgeable (and unlike me, able to retain what they read), the CDC published them anyway. The total disregard for our government process - by, with, and for the people - is deplorable.

The CDC guidelines could have been done much better and would have been better received if our voices had been heard. And, it bothers me that the NPS overview ends with this statement, The goals of the National Pain Strategy can be achieved through a broad effort in which better pain care is provided, along with safer prescribing practices, such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain. I doubt many of those who helped draft the NPS were aware of these guidelines being drafted when they participated in the drafting of the NPS. Some of those same people are among those who tried to hold the CDC accountable for their lack of transparency. (Read about it in The Guardian.) The CDC Opioid Prescribing Guidelines are not all bad, but they are written with a discriminatory tone, which is counter-productive to the Institute of Medicine’s report, Relieving Pain in America, available from my website here.

To me, it is more of the same and that’s really is a shame. Persistent untreated pain has biological consequences that are seldom considered, and certainly not here. A great opportunity has been squandered by lack of corroboration, something I value.

You can read my comments to the NPS and the CDC guidelines:

Other blogs of interest:

~ • ~ • ~ • ~ • ~ • ~

"Adversity is only an obstacle if we fail to see opportunity."  
Celeste Cooper, RN
Author—Patient—Health Central Chronic Pain Pro Advocate

Celeste’s Website:

Learn more about what you can do to help your body function to its potential in the books you can find here on Celeste's  blog. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others.

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.  

Monday, March 14, 2016

A Message of Hope from My Guest, Clarissa Shepherd

 “There is no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something better tomorrow.” 

~Orison Swett Marden, 1850 - 1924

Did you know that March is “Brain Awareness” month? We know the brain is a very complex organ, many people, with many disorders could have many things to say to raise awareness. Being one with a fibro-migrainus brain, I also know how important a message of hope can be for anyone who shares this journey with us. I am truly blessed to be able to share with you a message of hope written for you by my friend, Clarissa Shepherd, the, leader of the Facebook Group, Fellow Travelers

Get ready to face illness with courage, a sense of renewal and hope.

Renewing in Hope by Clarissa Shepherd

For those of us who face chronic illness each day, thinking positive is not an easy task. It's not as if we dwell on the negative, yet it finds us. We not only deal with daily pain and many other symptoms – we also deal with all of life's difficulties. I feel we do a magnificent job surviving a long list of daunting symptoms. Following is what you mean to me.

Learning to live within your limitations is not a negative thing; it’s a way to rearrange your life so you can live to your fullest potential. Finding new ways of doing daily tasks is a very creative thing. I find it amazing that you manage so well. You find new ways of healing, new ways of coping, new ways to entertain yourself, new talents that you didn't know you had.

Your journey may be very difficult. It may be very long and tiresome, yet you do it with such grace. A grace like I've never seen before. You're learning a new way to live, a new way of thinking, and ways of doing it soulfully. You've learned how to rethink what being productive means to you now, and you acknowledge that everyone's yardstick for measuring what’s productive isn't the same, and that's OK. You're still alive and moving ever forward as you learn to maneuver this new way of life. You've accepted the challenge and looked it right in the face. I call you—courageous.

You are a vital human being. This illness is not of your own making, and it does not define you. It just is. You show your strength and courage with each breath you take, every obstacle you overcome, and every new way you learn to cope. You are fearless, even in your pain.

Now I want you to take this truth into each day. Allow it to cover your entire being. There will be those in your life that don't, or won't, understand what you face each day. Chronic illness has taught me this…

Some people will fill you up,
Others will drain you of energy better spent,
So, choose wisely.

The reality is you are wonderful—just as you are. Your bravery is unparalleled, because you live it in solitude. Believe in yourself, as you renew in hope. Just as the season's change, so does your strength. Hope, courage, and renewal define you. They are in you, beside you, in front of you. Know this, and let the beacon, your bright light, guide you, hold you, and sustain you. You are brave. I applaud the person you are.

~ ~ ~

I am constantly encouraged by Clarissa and her generous spirit. Following is perhaps one of my favorite affirmations from her, which is included in one of our books.

"Be kind to yourself.

Respect who you are.

Walk in the light of your fearlessness."

~ • ~ • ~ • ~ • ~ • ~

"Adversity is only an obstacle if we fail to see opportunity."  
Celeste Cooper, RN
Author—Patient—Health Central Chronic Pain ProAdvocate

Celeste’s Website:

Wednesday, March 2, 2016

A Spring Lesson on Mindfulness: Dealing with Pain and Illness

It comes as no surprise that when we are sedentary, our mind shifts without provocation. And for those of us who live with persistent pain and illness, its source sticks out like a thumb that was just smashed with a huge hammer, red and swollen, throbbing, and begging for attention. But unlike a sore thumb, chronic pain and illness does not heal with time. Want to or not, we must acknowledge it. Through acknowledgement, we learn to accept it. And, when we learn not to scream, ridicule, or judge pain, fatigue or chronic illness, we do better. 

“But only a person in the depths 
of despair neglected to look beyond winter to the spring that inevitably followed, bringing back color and life and hope.”
~Mary Balogh

Biofeedback gives us hard evidence that our mind does have an effect on our body. This mindfulness boosts our defenses against the myriad of problems living with chronic pain and illness can bring to our door. So, what can we do to calm down the brain when it wants to take on a mind of its own? We can learn to be mindful. 

Our pain or other illness is not the villain here; it is the result of a bad character insulting our body. It doesn’t want to exist anymore than we want to experience it. So, being hard on it isn’t helpful, it won’t make it go away, and it won’t make us feel better.

In your journal, or in this book, write down what you think you MUST do. Now, go back and decide what it really is that you NEED to do. I suspect you will find the Must Do's that keep getting pushed to the bottom of your inbox resolve on their own. If you are having trouble giving up the driving force of stress inducing thoughts, pick up a good CD on mindfulness. There is a difference in living a packed life and living a full life.

Ten Lessons from Pain:
  1. Acceptance of what is.
  2. Compassion for the less fortunate.
  3. Change is not a bad word.
  4. Humility is a virtue.
  5. Strength in not surrendering to stressors.
Can I make a list of my own ten lessons on pain?

[The above is an excerpt from: Broken Body Wounded Spirit: Balancing the See-Saw of Chronic Pain, SPRING DEVOTIONS, Day Seventy-five]


Remember, there will be times when no matter what we do to negate it, pain will demand its just courseDuring these periods, we should be particularly aware so our mind-body interaction can heal. Whatever means you use to become mindful, whether it be prayer, meditation, structured action, silent retreat, creative visualization, T'ai Chi, just do it! Procrastination is not our friend. 

You can find other topics, tips and exercises in our books (Jeff Miller, PhD, coauthor), and more. Take a few minutes to go through the table of contents for Spring Devotions.

 "We are all subject to the slings and arrows of outrageous fortune; they are around us, in a space we do not control. This book is a gentle, yet forceful reminder that the best defenses against them reside within- in a space we do control, welling up from resources we can learn to cultivate. Hope here is equally soft and irresistible, much like Spring itself."
 ~Dr. David L. Katz, MD, MPH, FACPM, FACP, Director,Yale University Prevention Research Center

Read what our other reviewers had to say about Broken Body, Wounded Spirit: Balancing the See-Saw of Chronic Pain, SPRING DEVOTIONS.

~ • ~ • ~ • ~ • ~ • ~

"Adversity is only an obstacle if we fail to see opportunity."  
Celeste Cooper, RN

Celeste’s Website:

Learn more about what you can do to help your body function to its potential in the books you can find here on Celeste's  blog. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others. 

Celeste’s other books can also be found at Author Central. 

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.  

Celeste's Website

Celeste's Website
Click on the picture