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Prince did not die from pain pills — he died from chronic pain

Prince did not die from pain pills — he died from chronic pain

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The media can’t seem to get its stories about Prince right. As the news feed overflows with stories with the word “Prince” and “addiction” in them, very few of them feature the word “chronic pain.” Multiple reports mention that Prince had suffered from years with pain in his hips due to injuries racked up during his performances. His body wracked with pain, Prince relied on opiate pain medications to provide him some relief. And yet, even today, the stately New York Times features a long article about Prince seeking “help” with an “addiction.”

Prince was not addicted to pain medication. Prince had a medical condition — chronic pain — which is criminally under-treated. It is also a medical problem that is more likely to be reacted to with stigma and condescension, even challenges about the patient’s moral character, or, if male, masculinity. Pain is still the condition that we treat by telling its sufferers to just “suck it up,” or “maintain a stiff upper lip,” or to stop acting like a “wuss.” And yet, when someone dies from complications of the disease — for that is what chronic pain is — we react with shock and pity and anger that the person died from a drug overdose. Some outlets make money off our confusion about overdose and medications and our fascination with drugs.

As early as 2009, reports surfaced that Prince was in chronic, debilitating pain. His friends reported that he was taking pain medication to try to control the constant, excruciating pain from damaged hips. The supposed conflict between Prince’ conversion to the Jehovah’s Witnesses and his ability to accept a blood transfusion — should the need arise during hip replacement surgery — was bandied about by the vultures who pose as gossip reporters. The idea that Prince would forego surgery in order to serve his faith contributed to the undercurrent that Prince was “weird.” Nevertheless, at least some news outlets report that Prince did have the double hip replacement surgery in 2010.

But it’s not just about how the media doesn’t understand how chronic pain works. They are also ignoring the realities of the impact of race upon the practice of medicine.

Into the mix must surely be added the element of race. Prince was a black man. Strong racial disparities in how doctors and other medical staff respond to pain in the emergency room has been documented. For example, a recent study published in one of the most prestigious pediatrics journals studied the treatment of appendicitis, a condition that is often initially suspected after a “chandelier test.” In medical slang, if a doctor places her hand on the pain point in the lower abdomen affected by the pain of an inflamed appendix, the patient will try to jump up into the metaphoric chandelier on the ceiling above their head.

And yet, even here, black kids cannot get a break. 

“Our findings suggest that there are racial disparities in opioid administration to children with appendicitis,” wrote one of the lead researchers, Dr. Monika Goyal.

“Our findings suggest that although clinicians may recognize pain equally across racial groups, they may be reacting to the pain differently by treating black patients with nonopioid analgesia, such as ibuprofen and acetaminophen, while treating white patients with opioid analgesia for similar pain.”

Similar studies have documented that African Americans’ chest pain is less likely to be diagnosed correctly as a heart attack. Other studies have attempted to measure whether African Americans have a “lower pain threshold.” Similar studies about why women’s pain is not taken seriously in emergency rooms have also been produced.

Surgeries can fail to repair the issues that trigger intense pain. And they fail often. In medical conditions in which pain has been long-standing, scientific evidence suggests that the brain’s pain receptors “short out.” After a while, regardless of even whether the painful part of the body has been removed — as in amputations — the brain’s pain receptors continue to process signals that the body is under attack. Phantom limbs can cause severe pain. It does not make the pain fake. It is the brain that feels pain. And the brain can continue to experience pain even after surgery has been performed.

And yet, despite the evidence that Prince was being given Percocet for documented pain, the media narrative has shifted to a story in which Prince died of an overdose. An overdose is a self-inflicted wound. It’s a moral judgment. That’s how we react to it. “He was such a talented actor. Why overdose?” Or, “She had such a powerful voice. But she was a demon for drugs.” That story allows us to distance ourselves, to see it as the fault of a weak personality, an “addictive” personality. It’s part of the mythos we create around talented folks. The idea that the truly gifted are also the ones in the worse psychological pain, and their psychological “weaknesses” make them ripe for drug addiction.

Prince is being pushed toward that precipice over which we have pushed Amy Winehouse, Whitney Houston, Philip Seymour Hoffman, Michael Jackson and every other artist who has died from drugs in the past century — especially those who succumbed to heroin. But heroin and pain medication are not the same thing. Undoubtedly, some will gain fame for their discussions of the “abuse” of pain medication.

Chronic pain management requires, in most cases, the taking of strong, often-opiate based medications. ANY patient who takes these drugs on a daily basis will become “physically dependent” in a short time. Physical dependence is not addiction. Diabetics are physically dependent on insulin, and yet we do not call insulin an addictive drug. Without it, diabetics would die. Stopping pain medication that has been used for chronic pain can kill you if it’s done abruptly. Under a doctor’s care, a change in pain medication is handled on a strict schedule in which the body is weaned off one drug in order to either start a new medication, or to determine whether the body is reacting in a different way to the condition causing the pain.

I am not Prince. And yet, I know chronic pain from the inside. And I know how it is treated by cynical doctors who suspect that everyone is just trying to score.

My own experiences in hospital emergency rooms have involved being willing to go through several treatment options before being given the IV opiate medication that I need when I have a cluster headache. Cluster headaches are nicknamed “suicide headaches” by doctors, for good reason. The pain of cluster headaches has caused me to hallucinate, to have trouble breathing, and, of course, to wish for death. And yet, in the midst of a cluster headache, or its cousin, migraine, I have been interrogated by emergency room physicians who want to get me to admit that I am faking my symptoms while on a “drug-seeking” mission.

Prior to moving to the state of Florida in January, I had spent 23 years living in New York state. For the past nine years, I have suffered with migraines and clusters. During that time, I have been hospitalized for more than 24-hours seven separate times. I have had every diagnostic test available that might reveal why my head hurts so much. I have tried nearly every prophylactic treatment available. I have changed my diet. I avoid “triggers” that may cause a headache. I exercise, try to eat right, and wear prescription eyeglasses to make certain that it’s not eyestrain that make my migraines feel as if someone has inserted a bottle opener under my orbital bone and is trying to pry it out.

In New York, after all other treatments had failed, I was prescribed opiates. Yet, when I moved to Florida—which in a moral panic about its reputation as a state where it was easy to score drugs—has passed laws that make it near impossible for a family doctor to prescribe strong pain medications. Instead, I had to wait nearly two months to get in to see a specialist—in my case, a neurologist, who prescribes what I need. Triptans, the most common and effective way to treat migraine pain, are also expensive. My insurance company limits my triptans so that I can only use one of my pills for every three headaches I experience. Opiates are cheap. Guess which one my insurance company prefers to pay for?

Before the media narrative of the tortured genius who abused drugs takes over the story, there needs to be a pushback. Chronic pain patients should step forward and speak of their own experiences of living with the condition, and the constant barriers that are being thrown up to treatment. The latest obsession with white kids using heroin is stigmatizing those with chronic pain.

Chronic pain kills. It killed Prince. It’s time to talk about it.



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Retirement Planner: Recent Social Security Claiming Changes

What do the Recent Social Security Claiming Changes Mean for Me?

The Bipartisan Budget Act of 2015 (Public Law 114-74; November 2, 2015), made some changes to Social Security’s laws about claiming retirement and spousal benefits. Section 831 of the law (entitled “Closure of Unintended Loopholes”) made several changes to the Social Security Act and closed two complex loopholes that were used primarily by married couples. This fact sheet explains what is changing and how it might affect you.

Determining when to start your Social Security benefits is a complex and personal decision. We encourage you to research your options before you apply for benefits. You may also contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) to speak with a representative about your retirement options.

Timing of Multiple Benefits (also called “Deemed Filing”)

What was the loophole? The law provides incentives to delay claiming retirement benefits: monthly benefits grow larger for each month you delay receiving retirement benefits between full retirement age (currently 66) and 70. The loophole allowed some married individuals to start receiving spousal benefits at full retirement age, while letting their own retirement benefit grow by delaying it.

How is the law changing? Under existing law, if you are eligible for benefits both as a retired worker and as a spouse (or divorced spouse) in the first month you want your benefits to begin and are not yet full retirement age, you must apply for both benefits. You will receive the higher of the two benefits. This requirement is called “deemed filing” because when you apply for one benefit you are “deemed” to have also applied for the other.

Under the new law deemed filing is extended to apply to those at full retirement age and beyond. In addition, deemed filing may occur in any month after becoming entitled to retirement benefits. For example, if you begin receiving your retirement benefit and only later become eligible for a spousal benefit (or vice versa), you will be “deemed” to have applied for the second benefit as soon as you are eligible for it. Your monthly payment will be the higher of the two benefit amounts.

What is the rationale for this change? Historically, spousal benefits were designed to be paid only to the extent they exceeded any benefit the spouse earned based on his or her own work record. This change in the law preserves the fairness of the incentives to delay, but it means that you cannot receive one type of benefit while at the same time earning a bonus for delaying the other benefit.

Who will be affected? If you turn 62 on or after January 2, 2016, and will be eligible for benefits both as a retired worker and as a spouse (or divorced spouse), then the new law applies to you. Deemed filing applies to retirement benefits, not to survivor’s benefits. So, if you are a widow or widower, you may start your survivor benefit independently of your retirement benefit if you restrict the scope of your application. There are also some exceptions to deemed filing. For example, deemed filing does not apply if you receive spouse's benefits and are also entitled to disability, or if you are receiving spousal benefits because you are caring for the retired worker’s child. If you have questions about your specific situation, contact Social Security.

How and when is Social Security implementing this change? We have already implemented this change with specific instructions to our field office employees because the law applies to those who attain age 62 on January 2, 2016 or later. We are continuing to update our website and materials.

Example 1: Maria turns age 62 after January 1, 2016 and her husband, Joe, is 65. They have each worked enough years to earn a retirement benefit. In March of 2020, Maria has reached her full retirement age and files for benefits. Maria is eligible for a spousal benefit on Joe’s record. Maria must file for both benefits. She can no longer file only for the spousal benefit and delay filing for her own retirement. She will receive a combination of the two benefits that equals the higher amount.
Example 2: Jennie is a 62-year-old widow. She is eligible for retirement benefits based on her work history, and she is also eligible for survivor benefits based on her deceased husband’s record. She starts her survivor benefit this year, restricts the scope of her application to widow’s benefits, and does not start her own retirement benefit, allowing it to grow. At age 70, she starts her own increased retirement benefit, which she will receive for the rest of her life. The new law does not affect her because deemed filing does not apply to widow(er)s. Jennie will receive the higher of the two benefits.

Voluntary Suspension of Benefits (also called “File and Suspend”)

What was the loophole? As described above, retirement benefits grow for each month you delay claiming, between full retirement age (currently 66) and 70. A loophole allowed a worker at full retirement age or older to apply for retirement benefits and then voluntarily suspend payment of those retirement benefits, which allowed a spousal benefit to be paid to his or her spouse while the worker was not collecting retirement benefits. The worker would then restart his or her retirement benefits later, for example at age 70, with an increase for every month retirement benefits were suspended.

How is the law changing? Under the new law, you can still voluntarily suspend benefit payments at your full retirement age (currently 66) in order to earn higher benefits for delaying. But during a voluntary suspension, other benefits payable on your record, such as benefits to your spouse, are also suspended. And, if you have suspended your benefits, you cannot continue receiving other benefits (such as spousal benefits) on another person’s record.

There are some exceptions. If you are a divorced spouse, you can continue receiving a divorced spousal benefit even if your ex-spouse voluntarily suspends his or her retirement benefit.

What is the rationale for this change? There is less rationale for paying dependents if the primary worker has not retired or is not receiving payment from Social Security. It also preserves the fairness of the incentives to delay, so that couples cannot simultaneously receive a benefit and get a bonus for delaying.

Who will be affected? The new law applies to individuals who request a suspension on or after April 30, 2016, which is 180 days after the new law was enacted. Remember, you must have reached your full retirement age (currently 66) in order to request a suspension.

In some situations, we will honor requests received before April 30, 2016, that we are unable to process until after April 30, 2016. For example, there could be a situation where you are already full retirement age, and you contact us to apply for benefits before April 30, 2016, expressing your intent to apply for, and suspend, your benefits. If we cannot take your application until June 2016, we will honor the request for voluntary suspension that we received before April 30, 2016.

If you voluntarily suspended benefits prior to April 30, 2016, you may remain in voluntary suspense status, and the new law will not affect you. Also, if you submit your request before April 30, 2016 and your spouse or children become entitled to benefits either before or after that date, they will not be affected by the new rules and will continue to receive payment.

How and when is Social Security implementing this change? We have developed instructions for our field office employees so they can answer questions before this change takes effect for suspension requests that are submitted on or after April 30, 2016.

Example: Thomas will turn 66 in 2016, and Maria will turn 62. Thomas starts his retirement benefit at his full retirement age, 66, in June 2016, and Maria starts her spousal benefit based on his record. Thomas immediately suspends his benefit. In past years, that would have meant that Maria could continue receiving spousal benefits while Thomas could restart his own benefit at age 70 and receive an increase for each month he waited. Now, because Thomas reached his full retirement age and requested the suspension after April 30, 2016, he is subject to the new law. He can still choose to voluntarily suspend his benefit after his full retirement age, but if he does suspend his benefits, Maria’s spousal benefit will also be suspended.

For more information about these changes, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

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Fibromyalgia now considered as a lifelong central nervous system disorder

Fibromyalgia is the second most common rheumatic disorder behind osteoarthritis and, though still widely misunderstood, is now considered to be a lifelong central nervous system disorder, which is responsible for amplified pain that shoots through the body in those who suffer from it. Daniel Clauw, M.D., professor of anesthesiology, University of Michigan, analyzed the neurological basis for fibromyalgia in a plenary session address today at the American Pain Society Annual Scientific Meeting.

“Fibromyalgia can be thought of both as a discreet disease and also as a final common pathway of pain centralization and chronification. Most people with this condition have lifelong histories of chronic pain throughout their bodies,” said Clauw. “The condition can be hard to diagnose if one isn’t familiar with classic symptoms because there isn’t a single cause and no outward signs.”

Clauw explained that fibromyalgia pain comes more from the brain and spinal cord than from areas of the body in which someone may experience peripheral pain. The condition is believed to be associated with disturbances in how the brain processes pain and other sensory information. He said physicians should suspect fibromyalgia in patients with multifocal (mostly musculoskeletal) pain that is not fully explained by injury or inflammation.

“Because pain pathways throughout the body are amplified in fibromyalgia patients, pain can occur anywhere, so chronic headaches, visceral pain and sensory hyper-responsiveness are common in people with this painful condition,” said Clauw.

“This does not imply that peripheral nociceptive input does not contribute to pain experienced by fibromyalgia patients, but they do feel more pain than normally would be expected from the degree of peripheral input. Persons with fibromyalgia and other pain states characterized by sensitization will experience pain from what those without the condition would describe as touch,” Clauw added.

Due to the central nervous system origins of fibromyalgia pain, Clauw said treatments with opioids or other narcotic analgesics usually are not effective because they do not reduce the activity of neurotransmitters in the brain. “These drugs have never been shown to be effective in fibromyalgia patients, and there is evidence that opioids might even worsen fibromyalgia and other centralized pain states,” he said.

Clauw advises clinicians to integrate pharmacological treatments, such as gabapentinoids, trycyclics and serotonoin reuptake inhibitors, with nonpharmacological approaches like cognitive behavioral therapy, exercise and stress reduction.

“Sometimes the magnitude of treatment response for simple and inexpensive non-drug therapies exceeds that for pharmaceuticals,” said Clauw. “The greatest benefit is improved function, which should be the main treatment goal for any chronic pain condition. The majority of patients with fibromyalgia can see improvement in their symptoms and lead normal lives with the right medications and extensive use of non-drug therapies.”

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3 reasons the new CDC opioid medication guidelines hurt patients

Last week, the U.S. Centers for Disease Control and Prevention (CDC) released a new set of guidelines for doctors intended to reduce the “addiction risk” of prescription painkillers such as Vicodin, Percocet, and other opioids. Coming on the heels of a years-long freakout in the U.S.—or, as addiction journalist Maia Salavitz calls it, “America’s prescription painkiller panic”—regarding abuse of prescription painkillers and addiction to those same drugs, the CDC’s new recommendations are not particularly surprising. But to people with chronic pain who use opioids responsibly, these recommendations are particularly fraught for many reasons.

1) The timeline is off

The CDC’s document acknowledges that the development of these recommendations did not take studies on opioid treatment that lasted for more than a year, and intended to treat chronic pain, into consideration. The plural of anecdote is not “data,” of course, but leaving out the experiences of people in chronic pain who have had success with long-term opiate therapy in reducing pain—and, crucially, improving their quality of life—seems like a misstep. Hard data on opioid use lasting longer than a year for chronic pain may also be difficult to come by, since very few studies have been completed on that issue. But apparently for the CDC, the absence of much evidence in favor of opiate therapy for chronic pain is just fine, especially when it lines up with their recommendations.

2) The recommendations seem like yet another exercise in throwing pain patients under the metaphorical bus, while collapsing addiction issues into pain management issues even though they are completely different.

As Salavitz has written, “There’s little evidence that such policing prevents addiction or does anything else beyond inconveniencing and stigmatizing pain patients […] The stigma of addiction is what’s behind the curtain here […] When the situation is considered rationally, our outsized fear of addiction has little to do with the reality of chronic pain. Instead, it’s about the way we see addicts: gun-toting robbers of Oxy from pharmacies and other scummy, lying, sociopathic criminals—people we don’t want to be around or become.”

A 2008 study cited by Salavitz showed that only 3.26% of chronic pain patients with no previous drug/alcohol problems became addicted to opiate medication when opiates were used as part of treatment for chronic pain; over 96% of patients whose medication use was tracked in that study did not become addicted.

Certainly, those struggling with opiate addiction should have access to comprehensive drug treatment and rehabilitation options, but collapsing the issue of opiate addiction with the issues that people with chronic pain face serves no one. It can also mean, in practice, that people with chronic pain who rely on opiates to control their pain are treated like potential addicts—subject to unending suspicion from medical professionals, random drug tests, and pill counts, in addition to the pressure to act “compliant” at all times.

It is a real possibility that were the CDC recommendations to be adopted by doctors’ offices and pain clinics around the U.S., such measures of control would only increase for pain patients. Just take a look at recommendation number six, for example:

When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

A lot of people with chronic pain—and I include myself in this category—don’t know exactly how long acute pain “flares” are going to last, particularly when they’re in the middle of one. Extrapolating from this CDC guideline, a person who has three days’ worth of medication but whose flare lasts longer than three days would have to a) go to their doctor’s office when they are in extreme pain or b) “tough [the flare] out” after they’ve run out of medication. Neither option is great, but since chronic pain has been linked to changes in the brain over time, forcing a patient to “tough it out” if three days’ supply is not enough seems not only unhealthy (especially if the patient experiences withdrawal symptoms), but needlessly cruel for their long-term well being.

3) Chronic pain is an energy suck, and the guidelines could make it more so for some patients

Is there any acknowledgement in the CDC guidelines that being in chronic pain is a full-time state for people with it? Unsurprisingly, no—and this is the crucial piece that the CDC authors seem to be missing (or disregarding) with these new recommendations. Having to go to the doctor’s office and then the pharmacy once per week—or perhaps more, if one only gets three days’ supply of a medication at a time—is a more-time and energy-consuming activity for people with chronic pain than for people without it.

Disability activist and Disability Visibility Project founder Alice Wong (@sfdirewolf on Twitter) compiled a Storify of tweets by people with chronic pain regarding the new CDC opiate guidelines, and some of the participants in the conversation following the release of the CDC guidelines speak to this point. (In the interest of full disclosure, a few of my tweets are included in Wong’s Storify.) A person who uses up most of her available energy one day per month to obtain a controlled substance medication—and who can’t get out of bed in the morning without that medication—will not be served well by new regulations that require her to get a new prescription for that substance and then get refills once a week or more.

Of course, the reasons enumerated here as to why the CDC’s “suggested” guidelines will do more harm than good for pain patients are not the only reasons to be skeptical of the recommendations; even more tightly controlled opiate prescription will not stop the diversion of opiate pain medications to drug dealers, nor to addicts. A “no narcotics for chronic pain” policy, if widely adopted by medical professionals around the United States, could very well result in more people with chronic pain turning to street drugs, thereby feeding the very epidemic that the failed War on Drugs—and the CDC’s recommendations—have claimed to be fighting for the good of the public.

With this latest crackdown on the so-called “overprescription” of opiate medications, people with chronic pain who use these medications for legitimate reasons could be forced to further bear the brunt of an epidemic that they had no hand in creating, as will the medical professionals who are only trying to help by prescribing pain medications responsibly. The World Health Organization has called access to pain relief a “human right”; unfortunately, with the release of these recommendations, the CDC has shown just how far the United States has left to go in advancing that right for people disabled by chronic pain conditions.

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CRPS rank higher on pain scales than childbirth, cancer, amputation

Imagine pain in an arm or leg so intense that the sufferer would rather undergo an amputation than put up with it any longer. For those with complex regional pain syndrome (CRPS), this is not just a hypothetical nightmare—it is reality. According to the National Institute of Neurological Disorders and Stroke (NINDS), CRPS is a chronic condition most often affecting one limb (arm, leg, hand or foot), usually after an injury or trauma to that limb. The main complaint is pain that is way out of proportion to the severity of the initial injury. The cause of the condition isn't clearly understood, according to NINDS. It can manifest as visual swelling, redness and other abnormalities in a limb.

CRPS is widely considered to be the single worst source of pain—ranking higher on pain scales than childbirth, cancer and amputation. Yet the condition is rare and can be difficult to recognize. As a result, patients with CRPS—predominantly women, with an average age of 40, according to the National Institutes of Health—can search for an average of approximately four years before being properly diagnosed with the condition, according to a study published in the Scandinavian Journal of Pain. This long wait, compounded by the pain, can severely impact their daily living and quality of life. Although reports of those experiencing the symptoms of this condition have existed as long ago as the Civil War, according to a study published in The BMJ, no medication has yet been approved.

Randall Kaye, M.D. is the Chief Medical Officer at Axsome Therapeutics, Inc., a clinical-stage biopharmaceutical company currently enrolling patients at sites across the U.S., Canada, the U.K. and Australia in a clinical study, called CREATE-1, to evaluate its experimental medication AXS-02 for the treatment of chronic pain caused by CRPS. In this quest, Axsome is motivated by the many stories from CRPS patients, describing how difficult it can be to live with CRPS. Thought not yet approved, AXS-02 has been granted Fast Track and Orphan Drug Designation by the U.S. Food and Drug Administration and Orphan Medicinal Product Designation.

AXS-02 (disodium zoledronate tetrahydrate) is an oral, non-opioid, potentially first-in-class pain therapeutic being developed for the treatment of chronic pain caused by CRPS. The compound has multiple mechanisms of action to address chronic pain: it inhibits bone-resorbing osteoclasts, downregulates acid-sensing ion channels, reduces pro-inflammatory cytokine production and is anti-angiogenic.

As a result of his efforts at Axsome Therapeutics, Dr. Kaye is especially able to appreciate the need for novel approaches to CRPS and to oversee efforts to advance the state of care.


National Institute of Neurological Disorders and Stroke

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Anterior Cervical Discectomy & Fusion (ACDF)


Anterior cervical discectomy and fusion (ACDF) is a surgery to remove a herniated or degenerative disc in the neck area of the spine. The incision is made in the front of the spine through the throat area. After the disc is removed, a bone graft is inserted to fuse together the bones above and below the disc space. Your doctor may recommend a discectomy if physical therapy or medications fail to relieve your neck or arm pain caused by pressure on the spinal nerves. Patients typically go home the same day; recovery time takes 4 weeks.

top view of vertebraFigure 1, top. (top view of vertebra) Degenerative disc disease causes the discs (purple) to dry out. Tears in the disc annulus can allow the gel-filled nucleus material to escape and compress the spinal cord causing numbness and weakness. Bone spurs may develop which can lead to a narrowing of the nerve root canal (foraminal stenosis). The pinched spinal nerve becomes swollen and painful.

What is an anterior cervical discectomy & fusion (ACDF)?

Discectomy literally means "cutting out the disc." A discectomy can be performed anywhere along the spine from the neck (cervical) to the low back (lumbar). The surgeon reaches the damaged disc from the front (anterior) of the spine through the throat area. By moving aside the neck muscles, trachea, and esophagus, the disc and bony vertebrae are exposed. Surgery from the front of the neck is more accessible than from the back (posterior) because the disc can be reached without disturbing the spinal cord, spinal nerves, and the strong neck muscles. Depending on your particular symptoms, one disc (single-level) or more (multi-level) may be removed.

After the disc is removed, the space between the bony vertebrae is empty. To prevent the vertebrae from collapsing and rubbing together, a spacer bone graft is inserted to fill the open disc space. The graft serves as a bridge between the two vertebrae to create a spinal fusion. The bone graft and vertebrae are fixed in place with metal plates and screws. Following surgery the body begins its natural healing process and new bone cells grow around the graft. After 3 to 6 months, the bone graft should join the two vertebrae and form one solid piece of bone. The instrumentation and fusion work together, similar to reinforced concrete.

Bone grafts come from many sources. Each type has advantages and disadvantages.

  • Autograft bone comes from you. The surgeon takes your own bone cells from the hip (iliac crest). This graft has a higher rate of fusion because it has bone-growing cells and proteins. The disadvantage is the pain in your hipbone after surgery. Harvesting a bone graft from your hip is done at the same time as the spine surgery. The harvested bone is about a half inch thick – the entire thickness of bone is not removed, just the top half layer.
  • Allograft bone comes from a donor (cadaver). Bone-bank bone is collected from people who have agreed to donate their organs after they die. This graft does not have bone-growing cells or proteins, yet it is readily available and eliminates the need to harvest bone from your hip. Allograft is shaped like a doughnut and the center is packed with shavings of living bone tissue taken from your spine during surgery.
  • Bone graft substitute comes from man-made plastic, ceramic, or bioresorbable compounds. Often called cages, this graft material is packed with shavings of living bone tissue taken from your spine during surgery.

After fusion you may notice some range of motion loss, but this varies according to neck mobility before surgery and the number of levels fused. If only one level is fused, you may have similar or even better range of motion than before surgery. If more than two levels are fused, you may notice limits in turning your head and looking up and down. Motion-preserving artificial disc replacements have emerged as an alternative to fusion. Similar to knee replacement, the artificial disc is inserted into the damaged joint space and preserves motion, whereas fusion eliminates motion. Outcomes for artificial disc compared to ACDF are similar, but long-term results of motion preservation and adjacent level disease are not yet proven. Talk with your surgeon about whether ACDF or artificial disc replacement is most appropriate for you.

Who is a candidate?

You may be a candidate for discectomy if you have:

  • diagnostic tests (MRI, CT, myelogram) show that you have a herniated or degenerative disc
  • significant weakness in your hand or arm
  • arm pain worse than neck pain
  • symptoms that have not improved with physical therapy or medication

ACDF may be helpful in treating the following conditions:

  • Bulging and herniated disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall (annulus). Irritation and swelling occurs when this material squeezes out and painfully presses on a nerve.
  • Degenerative disc disease: As discs naturally wear out, bone spurs form and the facet joints inflame. The discs dry out and shrink, losing their flexibility and cushioning properties. The disc spaces get smaller. These changes lead to canal stenosis or disc herniation (Fig. 1).

The surgical decision

Most herniated discs heal after a few months of nonsurgical treatment. Your doctor may recommend treatment options, but only you can decide whether surgery is right for you. Be sure to consider all the risks and benefits before making your decision. Only 10% of people with herniated disc problems have enough pain after 6 weeks of conservative treatment to consider surgery.

Your surgeon will also discuss the risks and benefits of different types of bone graft material. Autograft is the gold standard for rapid healing and fusion, but the hip incision can be painful and at times lead to complications. Allograft (bone-bank) is more commonly used and has proven to be as effective for routine 1 and 2 level fusions in non-smokers.

Who performs the procedure?

A neurosurgeon or an orthopedic surgeon can perform spine surgery. Many spine surgeons have specialized training in complex spine surgery. Ask your surgeon about their training, especially if your case is complex or you’ve had more than one spinal surgery.

What happens before surgery?

You may be scheduled for presurgical tests (e.g., blood test, electrocardiogram, chest X-ray) several days before surgery. In the doctor’s office, you will sign consent and other forms so that the surgeon knows your medical history (allergies, medicines/vitamins, bleeding history, anesthesia reactions, previous surgeries). Discuss all medications (prescription, over-the-counter, and herbal supplements) you are taking with your health care provider. Some medications need to be continued or stopped the day of surgery.

Stop taking all non-steroidal anti-inflammatory medicines (Naprosyn, Advil, Motrin, Nuprin, Aleve, etc.) and blood thinners (Coumadin, Plavix, etc.) 1 to 2 weeks before surgery as directed by the doctor. Additionally, stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems. No food or drink is permitted past midnight the night before surgery.

The most important thing you can do to ensure the success of your spinal surgery is quit smoking. This includes cigarettes, cigars, pipes, chewing tobacco, and smokeless tobacco (snuff, dip). Nicotine prevents bone growth and puts you at higher risk for a failed fusion. Patients who smoked had failed fusions in up to 40% of cases, compared to only 8% among non-smokers [1]. Smoking also decreases your blood circulation, resulting in slower wound healing and an increased risk of infection. Talk with your doctor about ways to help you quit smoking: nicotine replacements, pills without nicotine (Wellbutrin, Chantix), and tobacco counseling programs.

Morning of surgery

  • Shower using antibacterial soap. Dress in freshly washed, loose-fitting clothing.
  • Wear flat-heeled shoes with closed backs.
  • If you have instructions to take regular medication the morning of surgery, do so with small sips of water.
  • Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
  • Leave all valuables and jewelry at home (including wedding bands).
  • Bring a list of medications (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken.
  • Bring a list of allergies to medication or foods.

Arrive at the hospital 2 hours before (surgery center 1 hour before) your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks. An intravenous (IV) line will be placed in your arm.

What happens during surgery?

There are seven steps to the procedure. The operation generally takes 1 to 3 hours.

Step 1: prepare the patient 
You will lie on your back on the operative table and be given anesthesia. Once asleep, your neck area is cleansed and prepped. If a fusion is planned and your own bone will be used, the hip area is also prepped to obtain a bone graft. If a donor bone will be used, the hip incision is unnecessary.

Step 2: make an incision 
A 2-inch skin incision is made on the right or left side of your neck (Fig. 2). The surgeon makes a tunnel to the spine by moving aside muscles in your neck and retracting the trachea, esophagus, and arteries. Finally, the muscles that support the front of the spine are lifted and held aside so the surgeon can clearly see the bony vertebrae and discs.

Neck incisionFigure 2. A 2-inch skin incision is made on the side of your neck.

Step 3: locate the damaged disc
With the aid of a fluoroscope (a special X-ray), the surgeon passes a thin needle into the disc to locate the affected vertebra and disc. The vertebrae bones above and below the damaged disc are spread apart with a special retractor.

Step 4: remove the disc 
The outer wall of the disc is cut (Fig. 3). The surgeon removes about 2/3 of your disc using small grasping tools, and then looks through a surgical microscope to remove the rest of the disc. The ligament that runs behind the vertebrae is removed to reach the spinal canal. Any disc material pressing on the spinal nerves is removed.

disc annulus is cut openFigure 3. The muscles are retracted to expose the vertebra. The disc annulus is cut open and the disc material is removed with grasping tools.

Step 5: decompress the nerve
Bone spurs that press on your nerve root are removed. The foramen, through which the spinal nerve exits, is enlarged with a drill (Fig. 4). This procedure, called a foraminotomy, gives your nerves more room to exit the spinal canal.

disc annulus and nucleus are removedFigure 4. (top view) The disc annulus and nucleus are removed to decompress the spinal cord and nerve root. Bone spurs are removed and the spinal foramen is enlarged to free the nerve.

Step 6. prepare a bone graft fusion
Using a drill, the open disc space is prepared on the top and bottom by removing the outer cortical layer of bone to expose the blood-rich cancellous bone inside. This “bed” will hold the bone graft material that you and your surgeon selected:

    • Bone graft from your hip. A skin and muscle incision is made over the crest of your hipbone. Next, a chisel is used to cut through the hard outer layer (cortical bone) to the inner layer (cancellous bone). The inner layer contains the bone-growing cells and proteins. The bone graft is then shaped and placed into the “bed” between the vertebrae (Fig. 5).

  • Bone bank or fusion cage. A cadaver bone graft or bioplastic cage is filled with the leftover bone shavings containing bone-growing cells and proteins. The graft is then tapped into the shelf space.
A bone graft (blue) is shaped and inserted into the shelf space between the vertebraeFigure 5. (side view) A bone graft is shaped and inserted into the shelf space between the vertebrae.

The bone graft is often reinforced with a metal plate screwed into the vertebrae to provide stability during fusion. An x-ray is taken to verify the position of the graft, plate, and screws (Fig. 6).

fig 6a - polyetheretherketone (PEEK) cage  fig 6b - between the vertebraeFigure 6. X-ray and illustration showing a metal plate and four screws used to hold the bone graft between the vertebrae while fusion occurs.
Fig 7. Spine Artificial disc replacement
Figure 7. Artificial disc replacement preserves motion of the spine segment.

Alternative option: artificial disc replacement (Fig. 7). Instead of a bone graft or fusion cage, an artificial disc device is inserted into the empty disc space. In select patients, it may be beneficial to preserve motion. Talk to your doctor – not all insurance companies will pay for this new technology and out-of-pocket expenses may be incurred.

Step 7. close the incision The spreader retractors are removed. The muscle and skin incisions are sutured together. Steri-Strips or biologic glue is placed across the incision.

What happens after surgery?

You will awaken in the postoperative recovery area, called the PACU. Blood pressure, heart rate, and respiration will be monitored. Any pain will be addressed. Once awake, you will be moved to a regular room where you’ll increase your activity level (sitting in a chair, walking). Patients who have had bone graft taken from their hip may feel more discomfort in their hip than neck incision. Most patients having a 1 or 2 level ACDF are sent home the same day. However, if you have difficulty breathing or unstable blood pressure, you may need to stay overnight.

Discharge instructions


  • After surgery, pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). As their regular use can cause constipation, drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) can be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).
  • Hoarseness, sore throat, or difficulty swallowing may occur in some patients and should not be cause for alarm. These symptoms usually resolve in 1 to 4 weeks.


  • If you had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing.
  • Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse.
  • Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon.
  • Avoid sitting for long periods of time.
  • Avoid bending your head forward or backward.
  • Do not lift anything heavier than 5 pounds (e.g., gallon of milk).
  • Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer.
  • Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise.


  • You may need help with daily activities (e.g., dressing, bathing), but most patients are able to care for themselves right away.
  • Gradually return to your normal activities. Walking is encouraged; start with a short distance and gradually increase to 1 to 2 miles daily. A physical therapy program may be recommended.
  • If applicable, know how to wear a cervical collar before leaving the hospital. Wear it when walking or riding in a car.

Bathing/Incision Care

  • You may shower 1 to 4 days after surgery. Follow your surgeon’s specific instructions. No tub baths, hot tubs, or swimming pools until your health care provider says it’s safe to do so.
  • If you have staples or stitches when you go home, they will need to be removed. Ask your surgeon or call the office to find out when.

When to Call Your Doctor

  • If your temperature exceeds 101° F, or if the incision begins to separate or show signs of infection, such as redness, swelling, pain, or drainage.
  • If your swallowing problems interfere with your ability to breathe or drink water.

Recovery and prevention

Schedule a follow-up appointment with your surgeon for 2 weeks after surgery. Recovery time generally lasts 4 to 6 weeks. X-rays may be taken after several weeks to verify that fusion is occurring. The surgeon will decide when to release you back to work at your follow-up visit.

A cervical collar or brace is sometimes worn during recovery to provide support and limit motion while your neck heals or fuses (see Braces & Orthotics). Your doctor may prescribe neck stretches and exercises orphysical therapy once your neck has healed.

If you had a bone graft taken from your hip, you may experience pain, soreness, and stiffness at the incision. Get up frequently (every 20 minutes) and move around or walk. Don’t sit or lie down for long periods of time.

Recurrences of neck pain are common. The key to avoiding recurrence is prevention:

  • Proper lifting techniques
  • Good posture during sitting, standing, moving, and sleeping
  • Appropriate exercise program
  • An ergonomic work area
  • Healthy weight and lean body mass
  • A positive attitude and relaxation techniques (e.g., stress management)
  • No smoking

What are the results?

Anterior cervical discectomy is successful in relieving arm pain in 92 to 100% of patients [3]. However, arm weakness and numbness may persist for weeks to months. Neck pain is relieved in 73 to 83% of patients [3]. In general, people with arm pain benefit more from ACDF than those with neck pain. Aim to keep a positive attitude and diligently perform your physical therapy exercises.

Achieving a spinal fusion varies depending on the technique used and your general health (smoker). In a study that compared three techniques: ACD, ACDF, and ACDF with plates and screws, the outcomes were [3]:

  • 67% of people who underwent ACD (no bone graft) achieved fusion naturally. However, ACD alone results in an abnormal forward curving of the spine (kyphosis) compared with the other techniques.
  • 93% of people who underwent ACDF with bone graft placement achieved fusion.
  • 100% of people who underwent ACDF with bone graft placement and plates and screws achieved fusion.

What are the risks?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots (deep vein thrombosis), and reactions to anesthesia. If spinal fusion is done at the same time as a discectomy, there is a greater risk of complications. Specific complications related to ACDF may include:

  • Hoarseness and swallowing difficulties. In some cases, temporary hoarseness can occur. The recurrent laryngeal nerve, which controls the vocal cords, is affected during surgery. It may take several months for this nerve to recover. In rare cases (less than 1/250) hoarseness and swallowing problems may persist and need further treatment with an ear, nose and throat specialist.
  • Vertebrae failing to fuse. There are many reasons why bones do not fuse together. Common ones include smoking, osteoporosis, obesity, and malnutrition. Smoking is by far the greatest factor that can prevent fusion. Nicotine is a toxin that inhibits bone-growing cells. If you continue to smoke after your spinal surgery, you could undermine the fusion process.
  • Hardware fracture. Metal screws and plates used to stabilize the spine are called “hardware.” The hardware may move or break before the bones are completely fused. If this occurs, a second surgery may be needed to fix or replace the hardware.
  • Bone graft migration.< In rare cases (1 to 2%), the bone graft can move from the correct position between the vertebrae soon after surgery. This is more likely to occur if hardware (plates and screws) is not used or if multiple vertebral levels are fused. If this occurs, a second surgery may be necessary.
  • Transitional syndrome. Fusion of a spine segment causes extra stress and load to be transferred to the discs and bones above or below the fusion. The added wear and tear can eventually degenerate the adjacent level and cause pain.
  • Nerve damage or persistent pain. Any spine surgery comes with the risk of damaging the nerves or spinal cord. Damage can cause numbness or even paralysis. However, the most common cause of persistent pain is nerve damage from the disc herniation itself. Some disc herniations may permanently damage a nerve making it unresponsive to surgery. Like furniture on the carpet, the compressed nerve doesn't spring back. In these cases, spinal cord stimulation or other treatments may provide relief.

Sources & links

If you have more questions, please contact the Mayfield Clinic at 800-325-7787 or 513-221-1100.


  1. Bose B: Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers. J Spinal Disord 14:3-9, 2001.
  2. Hilibrand AS, et al.: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 83-A:668-73, 2001.
  3. Xie JC, Hurlbert RJ. Discectomy versus discectomy with fusion versus discectomy with fusion and instrumentation: a prospective randomized study. Neurosurgery 61:107-16, 2007.



allograft: a portion of living tissue taken from one person (the donor) and implanted in another (the recipient) for the purpose of fusing two tissues together.

autograft (autologous): a portion of living tissue taken from a part of ones own body and transferred to another for the purpose of fusing two tissues together.

bone graft: bone harvested from ones self (autograft) or from another (allograft) for the purpose of fusing or repairing a defect.

discectomy: a type of surgery in which herniated disc material is removed so that it no longer irritates and compresses the nerve root.

foraminotomy: surgical enlargement of the intervertebral foramen through which the spinal nerves pass from the spinal cord to the body.

fusion: to join together two separate bones into one to provide stability.

interbody cage: a device made of titanium, carbon-fiber, or polyetheretherketone (PEEK) that is placed in the disc space between two vertebrae.

updated > 7.2013
reviewed by > Robert Bohinski, MD, Mayfield Clinic / University of Cincinnati Department of Neurosurgery, Cincinnati, Ohio

Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic & Spine Institute. We comply with the HONcode standard for trustworthy health information. This information is not intended to replace the medical advice of your health care provider.

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Opioid-Maintained Patients Who Require Surgery

When your patient requires surgery, many worry about pain management. Here are tips from an intractable pain clinic.

A practical, common problem in pain management is how to handle a patient already maintained on opioids and about to undergo surgery. During this time, anxiety may run high among the patient, their family, and the surgeon—the fear being, is the patient going to get adequate pain relief during and after the surgery.

Unfortunately, chronic pain patients with osteoarthritis, certain neuropathies, and trauma are more likely to need surgery than patients without chronic pain. Dental surgery is probably the most common procedure performed, followed by knee, hip, and shoulder joint surgery.

Postoperative pain management key for patients with chronic pain who are undergoing surgery.

Seven of my own patients required surgery in the last 2 months, which inspired this article, including: dental extraction, cholecystectomy, tongue biopsy for carcinoma, oophorectomy, and cancer surgery for kidney, lung, and esophageal malignancies.

Each of these patients required preoperative preparation and coordination with the surgical team. The American Pain Society recently released new guidelines for the perioperative and postoperative pain management. The guidelines recommend that clinicians should counsel patients to continue regularly prescribed opioids during the preoperative period, unless there is a plan to taper or discontinue opioids.1

Pre-Surgery Preparation

During preparation for surgery, a major problem clinicians may encounter is when the surgeon believes that the patient should reduce or even should stop their opioid medication before surgery. This is a dangerous and clinically unnecessary belief and based on the false assumption that surgery may go better in an opioid-free state.

Unfortunately, an opioid-maintained pain patient who attempts to significantly lower or cease their opioid dosage just prior to surgery will throw their autonomic nervous, endocrine, and immunologic systems into a dysfunctional state. Multiple physiologic abnormalities will result, including hypertension, tachycardia, leukocytosis, hypercortisolemia, and opioid withdrawal symptoms.

These physiologic abnormalities may increase the risks of infection and poor recovery. In addition, analgesia during surgery and after surgery may be difficult to achieve if the patient enters surgery in a pain flare and/or in a state of opioid withdrawal.

Opioids are effective pain management tools that can be used during the preoperative, intraoperative, and postoperative period. However, opioid use is also associated with postoperative nausea, vomiting, pruritus, urinary retention, and respiratory depression. For patients who are on chronic opioid therapy prior to surgery, there are certain evidence-based approaches to provide adequate analgesia in the postoperative period.1 These include:

  • Ensuring patients continue to take their regulalry prescribed opioids prior to surgery, unless there is a plan to taper or discontinue opioids
  • Utilizing intravenous patient-controlled analgesia (PCA) for systemic analgesia when the parenteral route is needed
  • Considering the amount of opioid the patient takes preoperatively and adjusting the postoperative doses of opioids accordingly to prevent inadequate pain management from “usual or standard” postoperative opioid doses.

My firm recommendation is that pain patients should remain on their regular opioid regimen up until the day and time of surgery. In addition, they should resume their regular opioid regimen as soon after surgery as possible.

Non-Opioid Preparations

Every pain patient and their family should be educated to maximize their general health before surgery. They may not be aware that both pain and opioids may suppress and impair their immunologic and endocrine systems, which must function maximally to have a successful surgery and avoid such complications as bleeding, infections, or poor healing.1,2

I emphasize to patients and families that:

  • Proper sleep, diet, and exercise (as appropriate) is necessary in the month prior to elective surgery
  • Dosage of all their medications including opioids should remain stable in the 30 days prior to surgery
  • High protein, anti-inflammatory diet (Table 1), and dietary supplements that include vitamins B12 and D are highly recommended.

Surgeons usually recommend stopping vitamin E several days before surgery because of an increased risk of bleeding. If the patient is a poor or irregular eater, I recommend protein powders or bars, as well as a general dietary supplement such as brewer’s yeast, alfalfa, algae, or soy.

Pain Relief During Surgery

Every surgeon and anesthesiologist has their favorite analgesic medications they use during surgery and in the immediate post-operative period. After a review of the evidence, the APS formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacologic and nonpharmacologic modalities, organizational policies, and transition to outpatient care.

As part of the perioperative pain management planning, I recommend a conversation with the surgeon and/or anesthesiologist prior to surgery. Have the patient’s precise opioid regimen on hand when you converse with the surgeon or anesthesiologist. They will want to know the 24-hour opioid intake.

To me, the main points that the primary care physician needs to relay to the surgeon are that there is no medical reason to taper opioids before surgery, that the patient needs to be maintained on their usual opioids (just like continuing their diabetic, antihypertensive, and other medications), and give intravenous equivalents of their usual dose if the patient is nil per os (NPO) for a while.

The surgical team will then decide which opioid and which route of administration they will use during surgery and in the immediate post-operative period.

Post-Operative Pain Plan

The surgical team and pain practitioner must be prepared to recommend or administer multiple strategies for analgesia in the 1 to 10 day period following surgery. No one strategy will work for every patient.

For postoperative pain, the chronic pain patient likely will need more than the usual dose that opioid-naïve patients normally receive. The postoperative medications can be the same as what the patient was getting prior to surgery (or IV equivalent if NPO), and often in somewhat higher doses. Also, if the patient is likely to be NPO for more than a couple of days, an alternative to IV dosing is a fentanyl patch.

Here are some principles to follow in post-operative pain care:

  • The patient’s regular opioid regimen should be reinstituted as soon as possible.
  • Resumption of the patient’s regular pain regimen will usually depend, to a great extent, as to when the patient can take oral fluids and food.
  • In those patients who cannot ingest oral medication, an injectable or other non-oral route of administration (patient-controlled analgesia) is necessary. My favorite post-operative opioids are injectable hydromorphone, meperidine, or morphine.
  • Once oral medication can be taken, a short-acting opioid can be used.
  • For knee, hip, shoulder, and back surgery, the patient can usually take oral medication quickly after surgery.

The key point in post-operative pain management is not relying only on opioids in the patients’ regular maintenance regimen. Patients may become tolerant to their maintenance regimen, therefore post-operative pain relief may require a combination of agents not regularly used by the patient. One example, is the use of a non-opioid drug, such as ibuprofen, which may be sufficient in some minor surgeries, such as dental extraction and biopsies.

I have found that surgeons and anesthesiologists have 2 routine questions:

  • What are my recommendations for post-operative pain relief?
  • Will I resume routine pain care after the immediate post-operative period?

The answer to the second question must be that the pain practitioner will resume pain care as soon as the patient is able to leave the hospital or surgical facility. Surgeons must operate with the comfort of knowing that pain care will be available post-surgery.

As noted, chronic pain patients maintained on opioids often need a higher opioid dose than a patient who is opioid-naïve. This should not be considered analgesic resistance—if the patient has been taking 100 mg per day morphine, the patient is not likely to get adequate analgesia with a 1 to 2 mg IV or a lower oral dose. This may even include their usual long-acting opioid as well as their short-acting, breakthrough opioids.

The tip-off is when the patient and/or family complain that no analgesia is forth-coming even from an injectable opioid or an opioid given by PCA. The solution to this problem may be to simply change opioids or raise dosage.

Hypothalamic-pituitary-adrenal suppression may occur with both chronic pain and opioid maintenance.3,4 The stress of surgery may be enough to put the HPA axis into a hazardous insufficiency state. Adequate serum levels of glucocorticoids are necessary for analgesia. Besides poor analgesia response, the patient may develop hypotension and tachycardia.

When adrenal insufficiency is suspected, an emergency serum cortisol level should be obtained. An injection of a corticosteroid such as methylprednisolone or hydrocortisone can be diagnostic if the patient obtains analgesia afterwards. In addition to cortisol, serum levels of testosterone and possibly other hormones may drop and require supplementation in the post-operative period.


Chronic pain patients who are maintained on an opioid regimen require a variety of surgical interventions. In preparation for surgery, the patient should be kept at a stable opioid dosage. Reduction or cessation of opioids is ill-advised as any drop in opioid dosage may cause opioid withdrawal symptoms, emergence of suppressed pain, and dysfunction of the immune and endocrine systems that may increase surgical risks.

Pain control in the post-surgical period may require a short-acting opioid. Long-acting opioids are not recommended or labeled for use in the immediate post-operative period.5 Oral opioids are preferred in the postoperative period. However, since the patient may be unable to take oral fluids or medications in the immediate post-operative period, non-oral opioids may have to be administered. The patient should resume their regular opioid maintenance regimen as soon after surgery as possible.


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CDC Guidelines Instruct Pain Doctors Not to Test for THC

The Centers for Disease Control and Prevention, in long-awaited guidelines on prescribing opioid medications for pain, gives tepid endorsement for the use of urine testing before and during opioid therapy for pain, despite its statements that, “Urine drug tests do not provide accurate information about how much or what dose of opioids or other drugs a patient took,” and "The clinical evidence review did not find studies evaluating the effectiveness of urine drug screening for risk mitigation during opioid prescribing for pain.”

"Urine drug testing results can be subject to misinterpretation and might sometimes be associated with practices that might harm patients (e.g., stigmatization, inappropriate termination from care),” the guidelines state. Indeed, Cal NORML regularly hears from patientswho are terminated from pain management medications because of their use of medical marijuana.

"Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear,” the CDC states. "For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC)”...Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety."

"We applaud the CDC's reasoned approach to the use of urine testing and its drawbacks when used on pain patients," said Ellen Komp, Deputy Director of California NORML. "Considering that opioid overdose deaths are significantly lower in states with medical marijuana programs,we are sorry the agency apparently didn't read the letter Elizabeth Warren recently sent to its chief calling for marijuana legalization as a means of dealing with the problem of opiate overdose."

Also from the guidelines:

"Experts agreed that prior to starting opioids for chronic pain and periodically during opioid therapy, clinicians should use urine drug testing to assess for prescribed opioids as well as other controlled substances and illicit drugs that increase risk for overdose when combined with opioids, including nonprescribed opioids, benzodiazepines, and heroin [notice THC is not included.]” The use of "a relatively inexpensive immunoassay panel for commonly prescribed opioids and illicit drugs” was acknowledged but its drawbacks were noted (does not detect synthetic opioids (e.g., fentanyl or methadone) and might not detect semisynthetic opioids (e.g., oxycodone). These panels are often where THC is detected.

"Most experts agreed that urine drug testing at least annually for all patients was reasonable. Some experts noted that this interval might be too long in some cases and too short in others, and that the follow-up interval should be left to the discretion of the clinician. Previous guidelines have recommended more frequent urine drug testing in patients thought to be at higher risk for substance use disorder. However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder."

"Some clinics obtain a urine specimen at every visit, but only send it for testing on a random schedule. Experts noted that in addition to direct costs of urine drug testing, which often are not covered fully by insurance and can be a burden for patients, clinician time is needed to interpret, confirm, and communicate results.”

Read the CDC Guidelines.

Called "the nation's top federal health agency," CDC sought the input of experts to assist in reviewing the evidence and providing perspective on how CDC used the evidence to develop the draft recommendations.

UPDATE 2/26 PM: This response was received from CDC spokesperson Courtney Lenard:

It is prudent for clinicians to restrict use of any medical test to situations when results of the test would be helpful in decisions about patient management. This is particularly important when testing or test results might have unintended negative consequences for patients. Some experts noted that in some cases, positive THC results might have legal or other consequences for patients but might not inform patient care decisions. While CDC is not stating that urine tests for THC should never be used, the guideline recommends that clinicians should only test for substances (including THC) if the clinician knows how he or she would use the results to inform patient management.

Regarding the statement “However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder.”: this statement refers to the difficulty in risk-stratifying patients for urine drug testing, given that most other available tools would not allow clinicians to accurately predict which patients are at low enough risk for substance use disorder that urine drug testing would not be needed.



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Docs Who Get Company Cash Prescribe More Brand-Name Meds

The more money doctors receive from drug and medical device companies, the more brand-name drugs they tend to prescribe, a new ProPublica analysis shows. Even a meal can make a difference.
Prescription drugs line a cabinet in this March 25, 2011 photo. (Photo by Eric Hunsaker via Flikr)(Photo/Eric Hunsaker via Flikr)

Doctors have long disputed that the payments they receive from pharmaceutical companies have any relationship to how they prescribe drugs.

There’s been little evidence to settle the matter — until now.

A ProPublica analysis has found for the first time that doctors who receive payments from the medical industry do indeed tend to prescribe drugs differently than their colleagues who don’t. And the more money they receive, on average, the more brand-name medications they prescribe.

We matched records on payments from pharmaceutical and medical device makers in 2014 with corresponding data on doctors’ medication choices in Medicare’s prescription drug program.

Doctors who got money from drug and device makers—even just a meal– prescribed a higher percentage of brand-name drugs overall than doctors who didn’t, our analysis showed. Indeed, doctors who received industry payments were two to three times as likely to prescribe brand-name drugs at exceptionally high rates as others in their specialty.

Doctors who received more than $5,000 from companies in 2014 typically had the highest brand-name prescribing percentages. Among internists who received no payments, for example, the average brand-name prescribing rate was about 20 percent, compared to about 30 percent for those who received more than $5,000.

ProPublica’s analysis doesn’t prove industry payments sway doctors to prescribe particular drugs, or even a particular company’s drugs. Rather, it shows that payments are associated with an approach to prescribing that, writ large, benefits drug companies’ bottom line.

“It again confirms the prevailing wisdom … that there is a relationship between payments and brand-name prescribing,” said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who provided guidance on early versions of ProPublica’s analysis. “This feeds into the ongoing conversation about the propriety of these sorts of relationships. Hopefully we’re getting past the point where people will say, ‘Oh, there’s no evidence that these relationships change physicians’ prescribing practices.’”

Numerous studies show that generics, which must meet rigid Food and Drug Administration standards, work as well as name brands for most patients. Brand-name drugs typically cost more than generics and are more heavily advertised. Although some medications do not have exact generic versions, there usually is a similar one in the same category. In addition, when it comes to patient satisfaction, there isn’t much differencebetween brands and generics, according to data collected by the website Iodine, which is building a repository of user reviews on drugs.

There’s wide variation from state to state when it comes to the proportion of prescribers who take industry money, our analysis found. The rate in Nevada, Alabama, Kentucky and South Carolina was twice as high as in Vermont, Minnesota, Wisconsin and Maine.

But overall, payments are widespread. Nationwide, nearly nine in 10 cardiologists who wrote at least 1,000 prescriptions for Medicare patients received payments from a drug or device company in 2014, while seven in 10 internists and family practitioners did.

Dr. Walid Gellad, an associate professor of medicine at the University of Pittsburgh and co-director of its Center for Pharmaceutical Policy and Prescribing, who also reviewed our analysis, said the pervasiveness of payments is noteworthy. “You can debate if these payments are good or bad, or neither, but what isn’t debatable is that they permeate the profession.”

The results make sense, said Dr. Richard Baron, president and chief executive of the American Board of Internal Medicine. Doctors nowadays almost have to go out of their way to avoid taking payments from companies, according to Baron. And those who do probably have greater skepticism about the value of brand-name medications. Conversely, doctors have to work to cultivate deep ties with companies—those worth more than $5,000 a year — and such doctors probably have a greater receptiveness to brand-name drugs, he said.

“You have the people who are going out of their way to avoid this and you’ve got people who are, I’ll say, pretty committed and engaged to creating relationships with pharma,” Baron said. “If you are out there advocating for something, you are more likely to believe in it yourself and not to disbelieve it.”

Physicians consider many factors when choosing which medications to prescribe. Some treat patients for whom few generics are available. A case in point is doctors who care for patients with HIV/AIDS. Others specialize in patients with complicated conditions who have tried generic drugs without success.

Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, the industry trade group, said in a statement that many factors affect doctors’ prescribing decisions. A 2011 surveycommissioned by the industry found that more than nine in 10 physicians felt that a “great deal of their prescribing was influenced by their clinical knowledge and experience,” Campbell said in a written statement.

“Working together, biopharmaceutical companies and physicians can improve patient care, make better use of today’s medicines and foster the development of tomorrow’s cures,” she wrote. “Physicians provide real-world insights and valuable feedback and advice to inform companies about their medicines to improve patient care.”

Several doctors who received large payments from industry and had above-average prescribing rates of brand-name drugs said they are acting in patients’ best interest.

“I do prefer certain drugs over the others based on the quality of the medication and also the benefits that the patients are going to get,” said Dr. Amer Syed of Jersey City, N.J., who received more than $66,800 from companies in 2014 and whose brand-name prescribing rate was more than twice the mean of his peers in internal medicine. “My whole vision of practice is to keep the patients out of the hospital.”

Dr. Felix Tarm, of Wichita, Kansas, likewise prescribed more than twice the rate of brand-name drugs than internal medicine doctors nationally. Tarm, who is in his 70s, said he’s on the verge of retiring and doesn’t draw a salary from his medical practice, instead subsidizing it with the money he receives from drug companies. He said he doesn’t own a pharmacy, a laboratory or an X-ray machine, all ways in which other doctors increase their incomes.

“I generally prescribe on the basis of what I think is the best drug,” said Tarm, who received $11,700 in payments in 2014. “If the doctor is susceptible to being bought out by a pharmaceutical company, he can just as easily be bought out by other factors.”

A third doctor, psychiatrist Alexander Pinkusovich of Brooklyn also prescribed a much higher proportion of brand-name drugs than his peers in 2014 while receiving more than $53,400 from drug companies. He threatened to call the district attorney if a reporter called again. “Why are you doing a fishing expedition?” he asked. “You know that I didn’t do anything illegal, so good luck.”

ProPublica has been tracking drug company payments to doctors since 2010 through a project known asDollars for Docs. Our first lookup tool included only seven companies, most of which were required to report their payments publicly as a condition of legal settlements. The tool now covers every drug and device company, thanks to the Physician Payment Sunshine Act, a part of the 2010 Affordable Care Act. The law required all drug and device companies to publicly report their payments. The first reports became public in 2014, covering the last five months of 2013; 2014 payments were released last year.

The payments in our analysis include promotional speaking, consulting, business travel, meals, royalties and gifts, among others. We did not include research payments, although those are reported in the government’s database of industry spending, which it calls Open Payments.

Separately, ProPublica has tracked patterns in Medicare’s prescription drug program, known as Part D, which covers more than 39 million people. Medicare pays for at least one in four prescriptions dispensed in the country.


Most Doctors Take Money From Drug, Device Companies

Nationally, about three quarters of doctors across five common medical specialties received at least one payment from a company in 2014. In Nevada, that number was over 90 percent. In Vermont, it was less than 24 percent.

This analysis matches the two datasets, looking at doctors in five large medical specialties: family medicine, internal medicine, cardiology, psychiatry and ophthalmology. We only looked at doctors who wrote at least 1,000 prescriptions in Medicare Part D.

Sen. Charles Grassley, R-Iowa, who pushed for the Physician Payment Sunshine Act, said in a statement that “it’s gratifying to see” ProPublica’s analysis.

“Since brand name drugs generally cost more than generic drugs, what doctors prescribe has major effects on Medicare and other payers in the health care system,” he said. “I look forward to more data, more analysis, and to hearing from doctors about what influences their decision to prescribe brand name drugs versus generic drugs.”

Dr. David W. Parke II, chief executive of the American Academy of Ophthalmology, suggested that many payments made to ophthalmologists don’t relate to drugs they prescribe in Medicare Part D, and instead may be related to drugs administered in doctors’ offices or devices and implants used in eye procedures. As a result, he said, it may be unfair to presume that industry payments are associated with prescribing in Part D.

Still, he said, ProPublica’s analysis points to areas that specialty societies may want to look at. “In some cases, there are very appropriate and clinically valid reasons” for doctors who are outliers in their prescribing. “For others, education may very easily result in prescribing change leading to substantive savings for patients, employers and society.”

Dr. Kim Allan Williams Sr., president of the American College of Cardiology, said he believes relationships between companies and doctors are circular. The more physicians learn about a new drug’s “differentiating characteristics,” he said, the more likely they are to prescribe it. And the more they prescribe it, the more likely they are to be selected as speakers and consultants for the company.

“That dovetails with improving your practice, and yes, you are getting paid to do it,” he said.

Williams said new drugs are, at least in part, responsible for a significant decrease in cardiovascular mortality in the past three decades.

“If you’re not making strides in this highly competitive area, if you don’t have a product that’s better, it’s not going to fly,” he said. “So the fact that there’s this high relationship in cardiology [between doctors and companies] may in fact be driving the progress that we’re making.”

© Copyright 2016 Pro Publica Inc.

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Canadians Push Back Against Opioid Pressure from U.S. Lawmakers

Canadians Push Back Against Opioid Pressure from U.S. Lawmakers

The Canadian government has issued a typically Canadian response — polite but firm —to American lawmakers calling for Prime Minister Justin Trudeau’s administration to crack down on the flow of Canadian painkillers into the United States.

U.S. House and Senate members, citing a nationwide prescription drug abuse crisis, penned a letter last week calling for Canada to move more quickly to limit the availability of non-abuse deterrent opioids, including oxycodone pain relievers, manufactured north of the border.

In response, the Canadian health ministry has cautioned against overstating Canada’s role in the opioid crisis in the United States, where drug overdoses have surpassed motor vehicles and firearms as the No. 1 cause of accidental death.

“While abuse and use of opioids is certainly an important public health issue in Canada and the USA, diversion of illegal products to the USA does not appear to be a major contributor to the issue,” Sean Upton, Health Canada’s senior media relations officer told InsideSources.

Citing a study recently published in the Canadian Medical Association Journal, Upton wrote in an emailed statement that there is “no evidence of any increase in dispensing of the generic non-tamper-resistant formulations near the Canada-USA border.”

That conclusion seems to contradict some of the arguments posited by the bipartisan congressional group that asked the Trudeau administration in a March 7 letter to move more quickly to tighten Canadian regulations on how opioids are manufactured and prescribed — especially Canadian drugs that, under present rules, are not “abuse deterrent.”

“It is concerning to us that … Canada still permits the manufacture and sale of non-abuse deterrent formulations of oxycodone pain relievers, and these drugs continue to find their way across the border to every region and almost every state in the United States,” the lawmakers wrote to Canadian Minister of Health Dr. Jane Philpott, a Trudeau appointee.

“We respectfully urge you to consider accelerating the timetable for the removal of non-abuse deterrent formulations of oxycodone pain relievers from the Canadian marketplace.”

New Hampshire Sens. Kelly Ayotte, a Republican, and Jeanne Shaheen, a Democrat; Sen. Richard Burr, R-N.C.; and Sen. Steve Daines, R-Mont., signed the letter, as did House Republicans Frank Guinta of New Hampshire, North Dakota’s Kevin Cramer, Michigan’s Bill Huizenga and New York’s Elise Stefanik, along with House Democrats Peter Welch of Vermont, New Hampshire’s Ann McLane Kuster, Washington’s Suzan DelBene and New York’s Brian Higgins.

Asked if the Canadian government, had a response to the March 7 letter, Upton wrote that there is “no evidence of disproportionate diversion or abuse” of Canada’s generic controlled-release oxycodone products.

“Health Canada takes the issue of prescription drug abuse very seriously,” he wrote, saying the department is working to address prescription drug abuse by:

  • Educating consumers
  • Increasing inspections to minimize diversion of prescription drugs from pharmacies
  • Improving surveillance data on prescription drug abuse
  • Working with partners to enhance prevention and treatment services.

“This strategy includes a series of actions to specifically limit any potential diversion of non-tamper-resistant controlled-release oxycodone pain relievers,” Upton wrote.

The American lawmakers’ entreaty came just days before Trudeau made his first official state visit to the White House since taking office in Toronto in November.

Trudeau’s meetings with the Obama administration were dominated by talks on trade and the fight against global terrorism, but with overdoses skyrocketing across the country, the opioid crisis has become a political, health and crime priority in border states like New Hampshire.

The Senate last week overwhelmingly approved, 94 to 1, a bill to combat the opioid and heroin abuse epidemic. The Comprehensive Addiction and Recovery Act, which focuses efforts on prevention, treatment and recovery programs, now goes to the U.S. House.

The measure was considered a critically important victory for the bill’s top two Republican sponsors, Ayotte and Sen. Rob Portman of Ohio, as both face tough re-election fights in November.


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A Broken Compensation System Is Leaving the Most Vulnerable Workers in Pain


A new report reveals the gradual erosion of employer liability requirements that have left workers alone to shoulder the costs of workplace injury.


In the toughest industries, the cardinal rule of prevention, “safety first,” often gets papered over by an unspoken law of the workplace: the most dangerous jobs are done by those who can’t afford safety. The hidden cost of the extra risks they bear quietly—the broken bones, severed thumbs and stained lungs—place an underlying drag on the most vulnerable segments of the economy. An analysis by the Occupational Safety and Health Administration (OSHA) shows the toll society pays for employers’ and regulators’ malign neglect.Changes in state-based workers’ compensation insurance programs have made it increasingly difficult for injured workers to receive the full benefits…to which they are entitled.… This cost-shift has forced injured workers, their families and taxpayers to subsidize the vast majority of the lost income and medical care costs generated by these conditions.

The double injustice of paying for the physical suffering imposed by your employer is no accident; it’s calculated cruelty. The Workers’ Compensation system has been gradually eroded to limit employer liability, while disenfranchised, precarious workers often have little choice but to accept an inadequate award or none at all.

Guadalupe González struggled just to force her employer to recognize her injury, after she twisted her ankle badly while working her custodial job with the multinational contractor Sodexo in 2011. Though she had been injured on a cleaning shift while traversing the campus at Lasell College in Massachusetts and eventually needed surgery, she recalls, “The manager denied it, as well as the insurance company.… The manager was just saying that I was always complaining about something, and that’s how he tried to get out of it.”

González had to “complain” for months just to recover part of her lost income, but many injured workers have no one even to complain to. The rise of “outsourced” labor—temp work, independent contracting and other contingent jobs—and the misclassification of blue-collar workers as “independent contractors” has placed countless workers in an unregulated zone, cut off from benefits and full legal recourse against managers who aren’t officially employers.

With about “three million serious occupational injuries and illnesses” recorded annually, official estimates put “the cost of fatal and non-fatal work injuries at $198 billion” in 2012. Meanwhile countless injuries go unreported, and the impacts are often hidden and chronic, resulting in long-term sickness and death not attributed directly to work (try suing a company over cancer linked to decades-old asbestos exposures). Past workplace exposures to hazardous materials lead to an estimated 50,000 deaths each year.

Workers’ Compensation generally covers just one-fifth of occupational injury costs. Workers, their families and the public pay the rest: roughly 50 percent is paid out of pocket, private insurance covers 13 percent and underfunded welfare and care programs that make up the “safety net” absorb the remainder of the burden of unsafe jobs.

To handle the cost of injury efficiently, the Workers’ Compensation system was designed to offer a “no fault” insurance system to cover medical care and lost wages outside the courts. But the program’s regulations, which vary by state, have become increasingly byzantine and exclusionary, leaving many with heavily damaged bodies and little to no recompense. About 40 percent of eligible workers never even apply for Workers’ Compensation. One study cited in the report showed that “one-third of workers with employer recorded carpal-tunnel syndrome had not received workers’ compensation.” And lest you think their injuries simply weren’t serious enough, zero benefits went to the same proportion of workers with amputations. A study of workers in New Mexico shows that even those with benefits lost some 15 percent of projected income in the ten years following an injury, or about $30,000.

This cost-shifting trend means that employers are not only less financially responsible for safety but are also losing incentive to protect it. Developers may find it less “cost effective,” for example, to pay to provide adequate protective gear at construction sites. Because Workers’ Compensation rules assign higher premiums to employers with worse safety records, OSHA reports that employers are perversely incentivized to avoid liability by “assigning workers employed by a staffing agency to the most dangerous tasks…to avoid higher premiums.”Corporations have for years steadily chipped away at safety liabilities.According to ProPublica: “Since 2003, legislators in 33 states have passed workers’ comp laws that reduce benefits or make it more difficult for those with certain injuries and diseases to qualify for them. Florida has cut benefits to its most severely disabled workers by 65 percent since 1994.”

For workers, low pay and high risk go hand in hand: the poverty wages prevalent in unsafe jobs lead to more working hours, and “long work days lead to worker fatigue and increase the risk of both work-related and non-work-related injuries, as well as of motor vehicle crashes.” Moreover, the risk inherent in being an undocumented immigrant can lead workers to avoid reporting injuries for fear of exposure to law enforcement.

Despite improvements in risk reduction over time, OSHA notes, some industries are growing relatively more dangerous on a global scale: “the work fatality rate in the United Kingdom is about one-third the rate of the United States and the rate in construction is about one-quarter the U.S. rate. While the rates in both countries are decreasing, the difference between the rates has grown substantially since the 1990s.”

Though González managed to win compensation, it ultimately covered just 60 percent of her original income of about $10.80 an hour. And all that took months of legal wrangling, working with advocates at Massachusetts Coalition For Occupational Safety And Health. Pressured to return to work, she ended up hurting her back when she stumbled on a stairwell. Though the second injury was caused by the first, she recalls, “the insurance company was just insisting that I was just making this up and that maybe I just deliberately fell on my back.”

Now in physical therapy and struggling to support her household, González says she’s unsure when she’ll return to work, and the company has lost its contract with the campus—so she might have to start all over in any case. For workers like her, the road to recovery keeps going in circles.




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What Will Happen to My Disability Benefits When I Turn 65?

The first thing to realize with Social Security Disability (SSD) benefits and retirement is that “full retirement age” is not always 65. In fact, 65 is only considered the age of retirement for those born in 1937 or earlier, so chances are that you will be among those who hit full retirement age at a later date. In any event, you will still want to know how your SSD benefits will be affected by hitting what is considered retirement age by the Social Security Administration (SSA) for someone in your age demographic.

When is Full Retirement Age for Me?

Over the years, the SSA has periodically adjusted the age of full retirement. There are several designations of full retirement age according to the SSA and each is defined by your date of birth. The breakdown is as follows:

Date of Birth Full Retirement Age
1937 or before 65
1938 65 +2 months
1939 65 +4 months
1940 65 +6 months
1941 65 +8 months
1942 65 +10 months
1943 to 1954 66
1955 66 +2 months
1956 66 +4 months
1957 66 +6 months
1958 66 +8 months
1959 66 +10 months
1960 or after 67


For the majority of current SSD beneficiaries, the age of full retirement is 67, which means you may have at least a couple more years before you need to be concerned with how hitting retirement age will affect your benefits; however, it’s good to understand the process in advance so there are no surprises when you do reach 67.

What Happens with My SSD When I Hit Full Retirement Age?

There are two major changes that take affect when you reach full retirement age. The first is that your benefits will no longer be paid through SSD. Instead, you will transition to the SSA’s “Old Age” or retirement program instead. Your benefits will not be interrupted with this transition and the benefit payment will be processed as usual. It will simply come in from a different Social Security fund rather than SSD, but you won’t even notice the difference.

The second change that comes with reaching full retirement age is that your benefits are no longer subject earning limits that were in place with your SSD benefits. In other words, you can increase your earnings from a part time job or other income source without losing dollars in your monthly benefit check.

Will Full Retirement Age Change My Benefit Amount?

Standard full retirement benefits from the SSA are calculated on what a worker contributed to the Social Security system over the course of their employment. Disability benefits are as well, so the amount of your monthly benefit payment is not affected by the transition from SSD to retirement benefits.

What’s Required for Me to Make the Transition?

SSD beneficiaries don’t have to do anything when they hit the age of full retirement. The SSA automatically transitions your benefits to the retirement fund without requiring you to complete new applications or other forms.

What about SSD and Early Retirement?

The SSA does currently allow people to apply for and begin receiving early retirement benefits at the age of 62; however, if you are disabled and have been receiving SSD benefits, then hitting early retirement age is not applicable for you. Instead, you would simply continue to receive SSD benefit until you reach the age of full retirement, at which time you would be transitioned from SSD to retirement benefits automatically by the SSA.

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Who Gets the Most in Disability Pay? 8 Key Social Security Facts

Who Gets the Most in Disability Pay? 8 Key Social Security Facts

The Social Security Disability Insurance program dodged a bullet late last year when Congress approved a temporary patch to keep the program from running low on cash.

With as many as 11 million Americans facing a 19 percent reduction in their disability insurance benefits, Congress and the White House agreed to shift funding from the much larger Social Security retirement account to keep the program going with full benefits through 2022.


However, the long-term prognosis for the $150 billion annual disability insurance trust fund is cloudy for now. And before lawmakers agree to extend it again, there is likely to be a tough reexamination of the program to find ways to reduce costs, crack down on fraud and move more people off the roles and back to work.

“I think with any program like this there are always going to be challenges to it in terms of people questioning whether it should exist at all,” Jonathan Schwabish, a senior research associate with the Urban Institute and an expert on disability insurance, said in an interview Thursday. “On the other side there are people questioning whether it provides the support that people who are disabled need.”

The program was designed to assist the physically and mentally disabled and their families, although over the years it has been expanded to provide assistance to more people with physical problems, especially women. While the program frequently has come under criticism for being overly generous, benefits average $1,165 per month, or roughly $14,000 a year.

Both the Social Security retirement trust fund and the companion disability insurance program are on shaky financial ground in the long term and their funding will have to be addressed by Congress in the coming years to avert a crisis. The retirement fund itself is anticipated to run out of cash by 2035, according to a trustees’ report. And there may be increased pressure on the retirement program as a result of Congress shifting funds from it to the disability program.

However, in many ways, the disability insurance program will be much harder to fix, according to Schwabish, because of the wide range of disabilities that are covered and the types of judgments that are made to allow people into the program or to remove them. Congress ordered a number of pilot projects to experiment with ways to wean more beneficiaries off the program, but past efforts at this have been generally unsuccessful.

The percentage of disabled workers as a share of all workers has more than tripled since 1970, according to Schwabish. The disability insurance program provided benefits to nearly 9 million disabled workers in 2013, nearly six times the 1.5 million disabled workers who received benefits in 1970.

Schwabish and the Urban Institute this week published an important primer on the disability insurance program, including how it operates and who it benefits. Here are some of the highlights:

  • The share of workers receiving disability has more than tripled from 1.6 percent in 1970 to 5.5 percent in 2013. There are many reasons for this increase, including the rapid aging of the population, declining employment prospects during the recession and new, more liberal eligibility criteria.

  • The state-by-state distribution of people receiving disability insurance varies greatly.  For instance, Maine and New Hampshire have the highest rates of mental illness in the country. Southern states like Mississippi, Alabama and West Virginia have the highest rates of circulatory disease.  

  • Southerners are most likely to receive disability benefits. West Virginia had the highest rate of residents receiving disability in 2014 at 8.9 percent. That was followed by Alabama at 8.5 percent, Arkansas and Kentucky both at 8.4 percent, and Mississippi at 7.9 percent.

  • Musculoskeletal disorders are among the most common problem. People receiving disability for disorders of the muscles, nerves, tendons, joints, cartilage, neck and lower back increased by an extraordinary 65 percent between 1996 and 2014.

  • The number of people joining the program each year per 1,000 people has remained relatively flat since 1991. The “incident rate” of being placed in the program has ranged overall between 4.7 and 6.4 per 1,000 disability-insured Americans, depending on the state of the economy.

  • More than half of women and a third of men receive DI benefits below $1,000 per month.As women’s rates of labor-force participation and earnings approach those of men, women’s DI benefits should begin to approach those of men.

  • DI benefits disproportionately go to low-income people. In 2010, slightly less than half of DI beneficiaries ages 31 to 49 fell into the bottom income quintile.

  • Few people leave DI. Once disabled people have been accepted into the program, they rarely leave it unless they retire and begin drawing Social Security retirement benefits or they die. The number of people who are removed from DI per 1,000 existing beneficiaries went from 174 in 1970 to just 76 in 2003. Since then, the number of beneficiaries per 1,000 removed every year rose slightly, to 87.
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Injured workers wait — and wait — for benefits

Some wait years for help as backlog in Social Security disability system grows.

Daniel Boda, partner at Mitchell + Pencheff, Fraley, Catalano & Boda Law Firm. SUBMITTED

By Chris Stewart

Staff Writer

More than a million Americans — including 40,000 Ohioans — are caught in the federal government’s biggest traffic jam: the line of people appealing denied Social Security disability claims.

The system is overwhelmed with cases that grow by the minute.

Claims of waste and abuse are rampant. So are the tales of real suffering.

Some people die before their cases are heard. Others with serious physical or mental disabilities are are left to live in squalid conditions or, in some cases, on the streets.

There’s “no question” the wait times are too long, said Daniel Boda, a partner at Mitchell + Pencheff, Fraley, Catalano & Boda Law Firm, which has an office in Springfield.

Boda represents about 75 clients each year in Social Security disability cases.

Many claimants already wait half a year or more for an initial determination of their eligibility, Boda said. Then the clock starts ticking again if a denied claimant requests a hearing with a judge.

“Given time between a denial and filing for the next level of appeal, you may be six or seven months into it before you even file for a hearing,” he said. “Then on top of that it’s about 16-18 months now.”

That long wait typically ends in a small government conference room with a 45 to 60-minute hearing in front of a judge. Also in the room are a court reporter, a vocational expert and the claimant’s attorney. Sometimes a neutral medical expert is present, but rarely, Boda said.

He said some of his clients have spouses with jobs and are able to weather the wait while others get to the point of homelessness. He said a couple of his clients have died waiting.

“It actually surprises me I haven’t had more,” said Boda, who has been practicing 40 years.

Backlog grows

The Social Security Administration started falling behind on processing appeals when Gerald Ford was president in the 1970s. By 2007, with the backlog up to 743,800 cases, a plan was launched to greatly reduce processing times, which had ballooned to 512 days.

The 38 initiatives in the plan included hiring more administrative law judges and increasing efficiency through automation and improved business processes.

A goal was set of reducing the number of pending cases to 466,000 by the end of the 2013 fiscal year.

Instead, the backlog went in the other direction, even as processing times improved slightly. Last September, the Office of the Inspector General reported: “As of March 2015, SSA had over 1 million claims awaiting a decision.”

It was the highest number ever recorded within the Social Security Administration and the biggest backlog in the federal government.

By the end of January, the queue had grown even longer with 1,103,830 Americans waiting to have their day in front of a Social Security Administration judge.

‘Disaster for due process’

Not every claimant is found deserving of disability benefits. Historically, fewer than a quarter of disability claims are approved on the initial application, which leads each year to hundreds of thousands of Americans entering a four-stage appeals process that applicants find excruciatingly slow and judges who hear the cases say is antiquated.

“This is a disaster for due process. This is disaster for the American people,” Judge D. Randall Frye said while testifying in front of federal lawmakers in 2010. Frye was then president of the Association of Administration Law Judges.

Part of the reason for the bottleneck is the sheer number of people seeking disability each year, which has risen by 66 percent to 2.5 million over the past 15 years.

Experts attribute the increase to population growth, aging Baby Boomers, the increase of women in the workforce and a rise in the age for full Social Security retirement from 65-66.

Frye said the resources needed to handle the increased case load did not keep pace. As a result, he testified, judges were pressured to cut corners, which meant not reviewing all the evidence on individual cases.

“We are terribly concerned,” he told a joint House-Senate congressional committee. “There is a finite number that judges can do and do accurately.”

Doug Nguyen, a Social Security Administration spokesman, said the biggest reasons for the backlog are the lack of resources to handle the workload and the crush of hearing requests.

Nguyen said the administration hopes to have up to 1,900 administrative law judges seated by 2018, an increase of about 200 over the 1,697 that are in place now.

“The American public deserves timely, high quality hearing and appeal decisions,” he said. “Currently the wait for a hearing decision on a disability benefit is too long. Resolving this public service challenge is one of our highest priorities.”

Huge money at stake

Claimants who are approved draw payments from the Disability Insurance Trust Fund, which is supported by all workers and their employers. Each pays in 6.2 percent of the first $118,500 in earnings. Self-employed individuals pay 12.4 percent which can be offset by income tax provisions, according to the Social Security administration. A separate trust fund covers retired workers, dependents and survivors.

The amount of money at stake is mind-blowing. Each case approved can cost the trust fund $300,000 over a lifetime.

Cases that crawl through the appeals process are often complex and labor-intensive, requiring multiple sources of information. And that’s part of the problem, those involved in the system say.

“We don’t have the experts — the medical experts that we need. We don’t have lawyers working for us to assist us. We’re kind of in a do-it-yourself operation,” said Judge Linda Stagno, a ranking official with the Association of Administrative Law Judges. “We’ve given the agency many, many suggestions on how to tighten up the process.”

Stagno said some of those recommendations include tightening procedural rules, adding clerical staff and highly-trained paralegals with a medical background, and bringing in medical experts to assist on complicated cases.

“We are not doctors but we have to make medical judgments,” Stagno said. “Some of the law is 30 and 40 years old; it hasn’t changed over time.”

Judge Marilyn Zahm, the association’s president, said each case is a very labor intensive process that requires judges to weigh the evidence and determine the extent of physical or mental functional limitations involved with each claimant and provide a detailed written decision required by federal courts.

“Every case is somebody’s life and you do want to do a careful, thorough job in making a determination,” Zahm said. “They sometimes have as many as five to 10 impairments. You need to make findings on all of them.”

Zahm said the size of the case files has exploded in recent years, particularly as new regulations have been added. As a result, up to 30 percent of the files now contain more than 1,000 pages of medical evidence, she said.

“Do you have any idea how long it takes to review 1,000 pages of medical evidence?” said Zahm. “We are the only adjudicatory body that I’m aware of that allows such loose requirements for representatives.”

A work analysis study commissioned by the Association of Administrative Law Judges in 2014 found it would take a judge more than seven hours to process and render a legally sufficient decision on a case containing 652 pages, the national average for that year.

But with an expected quota of at least 500 dispositions a year, a judge would have available only 2.5 hours per case, the study found.

As one fix, the association recommended removing the reconsideration phase, which it says prolongs a claimant’s wait, wastes government resources and results in a different decision in only about 2 percent of the cases.

“That does not serve the American people,” Frye said in his 2010 testimony. “It is not fair to make them wait nine more months for a reconsideration level when they could get to a hearing more quickly.”

Antiquated job listings

Ultimately, judges must decide if the claimant before them can hold any kind of job, and that process too is flawed.

The federal guidebook judges are instructed to use is the decades-old Dictionary of Occupational Titles first published in 1938 and updated last in 1991.

The dictionary includes jobs like four-horse hitch driver and gas-station attendant, but the words online or Internet aren’t found in the nearly 30,000 listings. Likewise, the judges and vocational experts can find Sousaphone maker, station telegrapher and phone book deliverer in the antiquated reference book, but no jobs dealing with smart phones.

“There’s not one computer-related job in the Dictionary of Occupational Titles that we use,” Stagno said.

The administration has started testing a new Occupational Information System to replace the Dictionary of Occupational Titles but it is not yet operational.

A number of other reforms have launched, including establishing five regional hearing centers that do teleconferencing to speed the process for hearing claims.

Social Security Administration Commissioner Carolyn W. Colvin also rolled out a plan in January called CARES that is intended to address the growing wait times and number of pending hearings. The plan calls for additional funding to hire more administrative judges to reduce the wait time for a hearing to 270 days by 2020.

“High quality decisions are at the heart of our initiatives to reduce wait times and better serve the American public,” Nguyen said.

Still waiting

Rainey Cowgill of Middletown once played linebacker in high school and spent most of his adult life working in concrete construction. But chest pain sent him to the emergency room in December 2013, and the next day he underwent triple bypass surgery.

His doctor told him his days of physical labor were over.

No one told him what a difficult time he would have getting disability benefits.

Cowgill’s first application for Social Security disability benefits was denied. A second review also was turned down. Last April he filed an appeal to have his case heard by an administrative law judge. He finally heard last week — more than two years after he fell ill — that a date in front of a judge has been scheduled for May.

He has no idea when, or even if, he’ll get benefits.

“I feel helpless. I can’t work,” he said. “I’ve got no income coming in.

“Some days I just sit here and cry because I don’t know what to do. I’m sick of worrying about how I’m going to make it from one day to the next.”

Applying for Social Security disability in Ohio

• Complete application online at, select “Apply online for disability benefits.”


• Contact Ohio’s Rehabilitation Services Commission, Division of Disability Determination toll-free at 1-800-772-1213. If you are deaf or hard of hearing, you can call us at TTY 1-800-325-0778.

• Call or visit your local Social Security office.

Stages of a Social Security disability claim appeal

If a claim is denied, claimants can take steps to appeal.

• Reconsideration

Claimants have 60 days to file. The review is by the same state office that handled the the initial request, but is reviewed by another examiner.

• Hearing by an administrative law judge

If the decision is denied during reconsideration, the claimant can appeal and appear in front of an administrative law judge with representation. The hearings are held via teleconference or at an office typically within 75 miles of a claimant’s home.

• Review by the Appeals Council

A claimant may further appeal a decision to an appeals council located in Falls Church, Va. The Appeals Council may choose not to review the administrative law judge’s decision, rule one way or another on the case, or return the case to another administrative law judge.

• Federal Court review

A claimant not satisfied with the Appeals Council decision may file a lawsuit in federal district court.

By the numbers

1,103,830: Backlog of Social Security disability claims.

493 days: Average processing time per claim.

2.5 million: Number of people who applied for disability last year.

1,697: Number of administrative law judges hearing appeals.

63: Percentage of cases that are denied for medical or technical reasons.

Source: Social Security Administration

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I Am Getting Social Security Disability Benefits and Want to Work. How Do I Get Started?

The cover of the Social Security Administration's 2016 Red Book

By Guest Blogger Marsha V. Robinson-Vaden, Office of Research, Demonstration, and Employment Support, Social Security Administration

If you are getting disability benefits and want to work, we have good news for you! Social Security’s work incentives and Ticket to Work programs can help you get started.

Special rules make it possible for people receiving Social Security disability benefits (SSDI) or Supplemental Security Income (SSI) to work and still receive monthly payments. And, if you cannot continue to work because of your medical condition, your benefits can start again – you may not even have to file a new application.

Work incentives include:

  • Continued cash benefits for a period of time while you work;
  • Continued Medicare or Medicaid while you work; and
  • Help with education, training and rehabilitation to start a new line of work.


The rules for Social Security disability and SSI are different. However, we describe the rules under each program in ourRed Book (Publication No. 64-030) – A Guide to Work Incentives. Also, Social Security recognizes the importance of supporting youth in their efforts to navigate the path toward adult life. In this year’s edition of the Red Book, we included resources to assist youth with this transition. We provide general information to assist youth and the parents, providers, or representatives of a youth receiving SSI or Social Security disability to locate national and community supports and resources.

Whether you are receiving Social Security disability or SSI benefits, it is important to let the Social Security Administration know promptly when you start or stop working, or if any other change occurs that could affect your benefits.

The Ticket to Work program may also be able to help you. You can receive vocational rehabilitation, training, job referrals and other employment support services free of charge. You will not undergo medical reviews while you are using the Ticket and making timely progress pursuing your return to work plan. Find help in your are by visiting the Ticket to Work website at

When you are ready to explore your work options, we have a national call center where you can talk directly with us about work, benefits or our work incentive programs.  Just call 1-866-968-7842, Monday through Friday, between 8 a.m. and 8 p.m. EST. If you are deaf or hard of hearing, you may call our TTY number, 1-866-833-2967. Or you can call our toll-free number and ask for a free copy of the publication, Your Ticket to Work(Publication No. 05-10061).

For more information about the ways we can help you return to work and our work incentives programs, please read the Red Book


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Doubts Raised About Chemical Stew in Fragrances Used in Consumer Products

iStock Photo

iStock Photo

For Joyce Miller, one sniff of scented laundry detergent can trigger an asthma attack.

“What happens is I feel like someone is standing on my chest,” says the 57-year-old professor of library science in upstate New York. “It’s almost like a choking feeling – pressure and choking. And then the coughing starts,” she said.

Miller is among the many Americans sensitive to “fragrance,” the cryptic ingredient added to thousands of products, from cleaning supplies to toiletries. The term encompasses thousands of combinations of chemicals that give consumer goods their pleasant odors. But specific chemicals in any given product rarely are disclosed to consumers.

For decades, fragrance makers have insisted on treating their recipes as trade secrets, even as complaints about negative health effects have become more common. A 2009 study, for example, found that more than a quarter of Americans were irritated by the smell of scented products on other people while 19 percent experienced headaches or breathing difficulties from air fresheners.

The industry, with estimated global sales of $40 billion per year, says that it ensures the safety of fragrances through a rigorous system of self-regulation administered by its trade group, the International Fragrance Association. But a tiny women’s advocacy organization in Missoula, Mont., recently outlined what it says are troubling flaws in the industry’s science as well as scores of toxic chemicals used in its mixtures.

The industry association’s North American branch declined to speak to FairWarning about the findings. Chemical giant BASF, an association member, also declined comment. Calls to four other members  Phoenix Aromas & Essential Oils, Premier Specialties, Flavor & Fragrance Specialties Inc., and Bedoukian Research – were not returned.

“There’s a real kind of state of ignorance on the part of scientists, on the part of researchers, on the part of consumers, on what is in fragrance and how safe fragrances are for your health,” said Alexandra Scranton, the director of science and research at Women’s Voices for the Earth, a nonprofit seeking to eliminate toxic chemicals that predominately affect women. “We were trying to pick apart the claim that the industry is making that they are ensuring the safety of fragrance.”

Questions about the safety of fragrances are not new. A 2005 California law, the California Safe Cosmetics Act, requires cosmetics manufacturers to report any products that contain ingredients known or suspected to cause cancer, birth defects or reproductive harm. The data is posted on a website at However,  the public database does not list ingredients identified as trade secrets, including fragrances. The program also has met with complaints from experts that some cosmetics firms failed to report their ingredients.

At the federal level, the U.S. Food and Drug Administration and the Consumer Products Safety Commission have limited oversight of fragrances. The FDA, which has authority over cosmetics and cosmetic ingredients, doesn’t require cosmetics makers to prove their products or ingredients are safe before putting them on the market. It’s up to the agency to prove harm before a product can be pulled from the shelves. The FDA also requires cosmetics to list their ingredients, but allows a trade secret exemption for chemicals deemed to be fragrance or flavor.

Meanwhile, the Consumer Product Safety Commission has authority over other scented products, such as laundry detergents and air fresheners. The commission, however, does not have an active program to screen fragrances.

“Government has failed to provide a real regulator,” which is a problem, said Scott Faber, vice president of government affairs for the Environmental Working Group, based in Washington, D.C. “There are plenty of examples of where counting on the good graces of industry has wound up being a mistake,” he said.

In 2008, Women’s Voices began pressing the industry to reveal the specific ingredients. Two years later, the International Fragrance Association posted on its website a list of some 3,000 chemicals used by its members.

Late last year, Women’s Voices published a review of those chemicals, finding that a large number of them appear on official lists of hazardous chemicals, or are banned or restricted in consumer products. For example, a comprehensive classification of chemical hazards adopted by the United Nations tags 1,175 chemicals on the fragrance list with the word “warning” and labels another 190 fragrance chemicals as a “danger,” according to Women’s Voices.

The International Agency for Research on Cancer, part of the World Health Organization, classifies seven fragrance chemicals as possible carcinogens in humans, the organization said. Fifteen chemicals on the fragrance association’s list are barred from use in cosmetics in the European Union, Women’s Voices said.

Joyce Miller, who is among those highly sensitive to fragrance chemicals. One sniff of a scented laundry detergent and “I feel like someone is standing on my chest.”

Joyce Miller, who is among those highly sensitive to fragrance chemicals. One sniff of a scented laundry detergent and “I feel like someone is standing on my chest.”

Scranton, who authored the Women’s Voices study, is careful to note that the industry’s list gives no indication of how much these chemicals are used, making it difficult to know if consumers are in actual danger. “When I see styrene (a possible carcinogen) on the list of chemicals in fragrance, that’s a red flag,” she said. “Is it only used very, very rarely, in very small amounts? Possibly, and maybe it’s not as much of a problem. Is it used in every fragrance that you come across? Then it’s going to be a problem.”

In a brief paper available on its website, the fragrance association touts the industry’s ability, through self regulation, to ensure “the highest levels of safety of fragranced products.” It says the industry can adapt to new scientific findings “more quickly and efficiently through self-regulation as opposed to diverse legislation in different countries on different continents.”

The industry association works with its research arm, the Research Institute for Fragrance Materials, to produce standards that it says are based on science. Women’s Voices, however, says there are several shortcomings in the system.

For one, the group maintains that the vast majority of scientific studies exploring fragrance safety are produced by fragrance houses themselves, or the industry’s research institute. Rarely are these studies published or even peer reviewed, the organization says. No one is independently reviewing laboratory practices or levels of significance, or ensuring “that the results of these studies have not been manipulated,” Women’s Voices says.

Over the last year, the European Commission Scientific Committee on Consumer Safety reviewed studies by the research institute and repeatedly noted failings in the institute’s methods, including incomplete data and invalid protocols.

Women’s Voices also says that an independent expert panel that reviews the industry’s research bases its safety opinions on information curated by the fragrance industry itself. The expert panel meets in secret and no transcripts or meeting minutes are publicly available, Women’s Voices said.

“The Research Institute for Fragrance Materials is like a black box,” said Janet Nudelman, the director of program and policy for the Breast Cancer Fund and the director of the Campaign for Safe Cosmetics. “They attempt to assure the public that they have the safety of fragrance chemicals under control, that they’re looking at all of the safety data regarding fragrance chemicals. But none of their safety studies are publicly available.”

The industry has either banned or restricted the use of 186 substances in fragrance products. But Women’s Voices says the industry does little to ensure that its standards are actually being followed.

The fragrance industry has not commented directly on Women’s Voices’ research, but a few days after the organization released its report in November, the research institute put out a statement saying “the industry is committed to addressing consumers’ interests through a continuous health and environmental safety review.”

The industry, however, remains opposed to greater transparency of its ingredients. In California, the industry association has opposed Assembly Bill 708, by Assemblyman Reggie Jones-Sawyer, a Los Angeles Democrat, which would require cleaning products to disclose their ingredients on their product labels. In a letter, the industry said it was worried about counterfeiters.

“It would be very helpful if companies could list on labels the chemicals that they use for their fragrances,” said Miller, the professor from the Glens Falls area of New York who suffers from fragrance sensitivity. “Fragrance is not just some pretty concept. It actually can be a fairly nasty combination of chemicals,” she said.

CORRECTION: An earlier version of this story erroneously identified Assemblyman Reggie Jones-Sawyer as Reggie Sawyer-Jones.


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Fibromyalgia In-Depth Report

Fibromyalgia In-Depth Report


Fibromyalgia is a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and fatigue. Fibromyalgia is also known as fibrositis or fibromyositis.


Pain. The primary symptom of fibromyalgia is pain. The pain can be in one place or all over the body. The exact locations of the pain are called tender points. Fibromyalgia pain is often described as:

  • Tender point pain that occurs in local areas, usually in the neck and shoulders. The pain then spreads out from these areas. The actual pain starts at the muscles. The joints are not affected. There are no lumps or nodes associated with these pain points, and no signs of inflammation (swelling). People diagnosed with fibromyalgia feel pain in at least 11 of 18 specific tender points.
  • Widespread stiffness, burning, and aching pain. The pain also "radiates," or spreads, to nearby areas. Most patients report feeling some pain all the time. Many describe it as "exhausting." The pain can vary depending on the time of day, changes in the weather, physical activity, and the presence of stressful situations. The pain is often more intense after sleep is disturbed.

Fatigue and Sleep Disturbances. Another major fibromyalgia complaint is fatigue. Some patients report that their fatigue is more distressing than their pain. Sleep disturbances, particularly restless legs syndrome, are also very common. Fatigue and sleep disturbances are almost universal in patients with fibromyalgia. Some experts believe that if these symptoms are not present, the condition may not be fibromyalgia.

Depression and Mood. Up to a third of fibromyalgia patients have depression. Disturbances in mood and concentration are also very common. These conditions often go undiagnosed.

Other Symptoms. The following symptoms may also be present:

  • Digestive problems, including irritable bowel syndrome with gas, and alternating diarrhea and constipation
  • Dizziness
  • Painful menstrual periods
  • Tension or migraine headaches
  • Tingling or numbness in the hands and feet
  • Urinary frequency caused by bladder spasms

Symptoms in Children. In general, children with fibromyalgia most often have sleep disorders and widespread pain.


In the most common type of fibromyalgia, the causes are not known. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may trigger the disorder, but no one trigger has proven to be a cause of primary fibromyalgia.

Many experts believe that fibromyalgia is not a disease, but is rather a chronic pain condition brought on by several abnormal body responses to stress. Areas in the brain that are responsible for the sensation of pain react differently in fibromyalgia patients than the same areas in healthy people.

People with fibromyalgia have been found to have decreased activity in opioid receptors in parts of the brain that affect mood and the emotional aspect of pain. This reduced response might explain why fibromyalgia patients are likely to have depression, and are less responsive to opioid painkillers, researchers say.


Sleep disturbances are common in fibromyalgia. Patients with the condition have a higher-than-average rate of a sleep disorder called periodic limb movement disorder (PLMD). Patients with PLMD involuntarily contract their leg muscles every 20 - 40 seconds during sleep, which may occasionally wake them up.

Some researchers believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first. Researchers continue to investigate the link between fibromyalgia and sleep.

  • In one study, healthy volunteers reported fibromyalgia-like pain after their deep sleep had been disrupted. Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and lower tolerance to pain. Patients with fibromyalgia have increased rates of cyclic alternating sleep pattern (CAP), which may produce serious sleep problems and have been strongly linked to symptom severity. Previous studies have also suggested that CAP may be related to PLMD.
  • Sleep disorders that cause breathing problems are common in women with fibromyalgia.
  • Other biological measures of troubled sleep, such as levels of the hormone melatonin (which helps regulate circadian rhythms and the sleep-wake cycle) appear to be normal in most people with fibromyalgia.


Many abnormalities of hormonal, metabolic, and brain chemical activity have been described in studies of fibromyalgia patients. Changes appear to occur in several brain chemicals, although no regular pattern has emerged that fits most patients. Since there has been no clear cause-and-effect relationship established, it may be that fibromyalgia is a result of the effects of pain and stress on the central nervous system, which lead to changes in brain circuitry, rather than a brain disorder itself.

Serotonin. Of particular interest to researchers is serotonin, an important nervous system chemical messenger found in the brain, gut, and other areas of the body. Serotonin plays important roles in creating feelings of well-being, adjusting pain levels, and promoting deep sleep. Serotonin abnormalities have been linked to many disorders, including depression, migraines, and irritable bowel syndrome. Lower serotonin levels have also been noted in some patients with fibromyalgia.

Stress Hormones. Researchers have also found abnormalities in the hormone system known as the hypothalamus-pituitary-adrenal gland (HAP) axis. The HAP axis controls important functions, including sleep, stress response, and depression. Changes in the HAP axis appear to produce lower levels of the stress hormones norepinephrine and cortisol. (By contrast, levels of stress hormones in depression are higher than normal.) Lower levels of stress hormones lead to impaired responses to psychological or physical stresses. (Examples of physical stress include infection or exercise.)

Low IGF-1 Levels. Some studies have reported low levels of insulin-like growth factor-1 (IGF-1) in about a third of fibromyalgia patients. IGF-1 is a hormone that promotes bone and muscle growth. Low levels of growth hormone may lead to impaired thinking, lack of energy, muscle weakness, and intolerance to cold. Studies suggest that changes in growth hormone likely stem from the hypothalamus in the brain. While researchers have not found a link between IGF-1 levels and fibromyalgia, growth hormone levels in the blood may be a marker of the disorder.

Abnormal Pain Perception and Substance P. Some studies have suggested that people with fibromyalgia may perceive pain differently than healthy people. Fibromyalgia may involve too much activity in the parts of the central nervous system that process pain (the nociceptive system). Brain scans of fibromyalgia patients have found abnormalities in pain processing centers. For example, researchers have detected up to three times the normal level of substance P (a chemical messenger associated with increased pain perception) in the cerebrospinal fluid of fibromyalgia patients.

Using brain scans, researchers have also discovered an abnormal increase in blood flow (called "brain perfusion") in an area of the brain that discriminates the intensity of pain, and a decrease in blood flow in areas thought to be involved in the emotional response to pain. These abnormalities were unrelated to the patients' depression and anxiety levels, further reinforcing the idea that fibromyalgia is a real disorder, rather than just a side effect of depression.

Some fibromyalgia patients may be oversensitive to external stimulation, and overly anxious about the sensation of pain. This increase in awareness is called generalized hypervigilance.

A conflict between sensory perception and nervous system processing might occur in people with fibromyalgia. Fibromyalgia patients have been found to have greater awareness of, or less tolerance for, movement problems (such as tremor) that don't match with their expected sensory feedback. This mismatch in sensory signals might enhance the perception of pain. Fibromyalgia patients also seem to be more sensitive to sounds.


Fibromyalgia has symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia, however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an inflammatory response in fibromyalgia.


Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:

  • They could make individuals susceptible to fibromyalgia.
  • They may play some role in triggering the onset of the condition.
  • They may perpetuate, or be responsible for, the condition.

Studies have reported higher numbers of severe emotional and physical abuse in patients with fibromyalgia compared with the general population. Most often, the abusers are family members or partners. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients. PTSD, an anxiety disorder, is a reaction to a specific traumatic event. Some evidence indicates that PTSD actually results in changes to the brain, possibly from long-term overexposure to stress hormones.


Some research has found muscle abnormalities in fibromyalgia patients. These problems can be classified as the following:

  • Biochemical abnormalities: Fibromyalgia patients may have lower levels of the muscle-cell chemicals phosphocreatine and adenosine triphosphate (ATP). Such chemicals regulate the level of calcium in muscle cells. Calcium is an important component in the muscles' ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells, and the muscle remains contracted.
  • Functional abnormalities: The pain and stress of the disease itself may harm muscle function.
  • Structural and blood flow abnormalities: Some researchers have seen overly thickened capillaries (tiny blood vessels) in the muscles of fibromyalgia patients. The abnormal capillaries could produce lower levels of compounds essential for muscle function, as well as reduce the flow of oxygen-rich blood to the muscles.

To date, none of these abnormalities has a clearly defined relationship with fibromyalgia.

Risk Factors

About 5 million Americans have fibromyalgia. The condition affects women more often than men.

Some evidence suggests that several factors may make people more susceptible to fibromyalgia. These risk factors include:

  • Being female
  • Coming from a very stressful culture or environment
  • Having a psychological vulnerability to stress
  • Having had difficult experiences in childhood


Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during menopause.


The disorder usually occurs in people ages 20 - 60 years, though it can occur at any time. Some studies have noted peaks at around age 35. Others note that fibromyalgia is most common in middle-aged women. In one study, cases of fibromyalgia increased with age, and reached a frequency of more than 7% among people in their 60s and 70s.

Juvenile Primary Fibromyalgia. This type of fibromyalgia appears in adolescents, typically after age 13, with a peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. Symptoms are similar to adult fibromyalgia, but outcomes may be better in young people.


Studies report a higher incidence of fibromyalgia among family members. It is not clear whether genetic or psychological factors, or both, are involved. Studies have found that:

  • About a third of children whose mothers have fibromyalgia also develop the disorder.
  • About two-thirds of parents who had children with fibromyalgia report some sort of chronic pain. About 10% of them have fibromyalgia.


There is no obvious, objective method for diagnosing fibromyalgia. The criteria used for studying fibromyalgia are very helpful, particularly if the patient does not have an accompanying disorder, such as depression or arthritis, that could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. Fibromyalgia should be suspected in any person who has muscle and joint pain with no identifiable cause.


In 1990, the American College of Rheumatology (ACR) set the following criteria for classifying fibromyalgia:

A. Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:

  • Both sides of the body
  • Above and below the waist
  • Along the length of the spine

B. Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on a tender point is very localized and intensely painful (not just tender). Tender points are located in the following areas:

  • The left or right side of the back of the neck, directly below the hairline
  • The left or right side of the front of the neck, above the collarbone (clavicle)
  • The left or right side of the chest, right below the collarbone
  • The left or right side of the upper back, near where the neck and shoulder join
  • The left or right side of the spine in the upper back between the shoulder blades (scapula)
  • The inside of either arm where it bends at the elbow
  • The left or right side of the lower back, right below the waist
  • Either side of the buttocks below the hip bones
  • Either kneecap

Other Factors. The ACR classification provides a guideline, but doctors will also use a patient's medical history and other symptoms to reach a diagnosis. Fibromyalgia is often diagnosed when other diseases have been excluded. Long-term symptoms that may indicate fibromyalgia include:

  • Fatigue
  • Headache
  • Morning stiffness
  • Numbness or tingling in the hands and feet
  • Sleep disturbance


A doctor should always take a careful personal and family medical history, which includes a psychological profile and history of any factors that might indicate other conditions, such as:

  • Infectious diseases
  • Muscle weakness
  • Physical injuries
  • Rashes
  • Recent weight change
  • Sexual, physical, or substance or alcohol abuse

Patients should report any drugs they take, including vitamins and over-the-counter or herbal medications.


Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the doctor press firmly on all potential tender spots. These spots must be painful when pressed, not simply tender. In addition, for a doctor to reach a diagnosis of fibromyalgia, these tender sites should normally not show signs of inflammation (redness, swelling, or heat in the joints and soft tissue). The tender points may also change in location and sensitivity over time. A doctor may then recheck tender points that do not respond the first time in patients who have other significant symptoms.

Detection of Other Causes of Symptoms. A health care provider will also examine the nails, skin, mucus membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.


No blood, urine, or other laboratory tests can definitively diagnose fibromyalgia. If such tests show abnormal results, the doctor should look for other disorders. Tests for specific diseases depend on family histories and other symptoms, and may include:

  • Blood count
  • Sedimentation rate
  • Tests of certain antibodies
  • Thyroid and liver function tests

The doctor may suggest follow-up psychological profile testing, if laboratory results do not indicate a specific disease.

Conditions With Similar Symptoms

Between 10% and 30% of all doctor's office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and widespread muscle pain. Because no laboratory test can confirm fibromyalgia, doctors will usually first test for similar conditions. A diagnosis of many of the disorders below may not always rule out fibromyalgia, because it can accompany other common conditions.

Several conditions may overlap or coexist with fibromyalgia, and have similar symptoms. It is not clear whether these conditions cause fibromyalgia, are risk factors for the disorder, have causes in common with fibromyalgia, or have no relationship at all with it.

Chronic Fatigue Syndrome. There is a significant overlap between fibromyalgia and chronic fatigue syndrome (CFS). As with fibromyalgia, the cause of CFS is unknown. A doctor can diagnose either disorder based only on symptoms reported by the patient. The two disorders share most of the same symptoms. They are also treated almost identically. The main differences are:

  • Pain with tender points is the primary symptom in fibromyalgia. Some patients with CFS exhibit similar tender pressure points; however, their muscle pain is less prominent.
  • Fatigue is the main symptom in CFS. It is severe, is not caused by excessive work or exercise, and is not relieved by rest or sleep.

Some doctors believe that fibromyalgia is simply an extreme type of chronic fatigue syndrome. Physical evidence, however, indicates that the two disorders are distinct, and each has its own treatments.

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points, as opposed to tender points, and typically there is no widespread, generalized pain. Trigger-point pain occurs in tight muscles, and when the doctor presses on these points, the patient may experience a muscle twitch. Unlike tender points, trigger points are often small lumps, about the size of a pencil eraser.

Major Depression. The link between psychological disorders and fibromyalgia is very strong. Studies report that 50 - 70% of fibromyalgia patients have a lifetime history of depression. However, only 18 - 36% of fibromyalgia patients have major depression.

Some studies have found that people who have both psychological disorders and fibromyalgia are more likely to seek medical help, compared with patients who simply have symptoms of fibromyalgia. If this is the case, study results may be biased, finding a higher-than-actual association between depression and fibromyalgia.

Depressed feelings in people with fibromyalgia can be normal responses to the pain and fatigue caused by this syndrome. Such emotions, however, are temporary and related to the condition. They are not considered to be a depression disorder. Unlike ordinary periods of sadness, an episode of major depression can last many months.

Symptoms of major depression include the following:

  • Depressed mood every day
  • Feeling worthless or inappropriately guilty
  • Inability to concentrate or make decisions
  • Insomnia or excessive sleeping
  • Low energy every day
  • Restlessness or a sense of being slowed down
  • Significant weight gain or loss (of 10% or more of an individual's typical body weight)
  • Suicidal thoughts

If several of the above symptoms are present, and none of the physical symptoms (particularly the tender points) of fibromyalgia exist, the condition is most likely major depression.

Chronic Headache. Chronic primary headaches, such as migraines, are common in fibromyalgia patients. Some experts believe that migraine headaches and fibromyalgia may even share common defects in the systems that regulate certain chemical messengers in the brain, including serotonin and epinephrine (adrenaline). Low levels of magnesium have also been noted in patients with both fibromyalgia and migraines. Chronic migraine sufferers who do not benefit from usual therapies may also have fibromyalgia.

Multiple Chemical Sensitivity. Multiple chemical sensitivity (MCS) is a term that describes conditions in which certain chemicals cause symptoms similar to CFS or fibromyalgia. As with CFS and fibromyalgia, some experts are uncertain whether MCS is a medical problem or psychologically based condition. Because everyone is exposed to many chemicals on a daily basis, it is very difficult to determine whether chemicals are responsible for specific symptoms.

Experts have come up with criteria to help recognize MCS:

  • Symptoms can be produced by exposure to the chemical at levels lower than the person previously or usually tolerated.
  • Symptoms can be triggered by multiple substances that are chemically unrelated.
  • Symptoms involve multiple organ systems.
  • The condition is chronic.
  • The symptoms always happen with repeated exposure to a chemical. (These are often common chemicals found in popular products, such as perfumes, fabric softeners, and air fresheners.)
  • The symptoms improve when the chemical is removed.

Restless Legs Syndrome. About 15% of people with fibromyalgia have restless legs syndrome. Restless legs syndrome is an unsettling and poorly understood movement disorder that is sometimes described as a sense of unease and weariness in the lower leg that is aggravated by rest and relieved by movement.

Disorders Affected by the Sympathetic (also called Autonomic) Nervous System. Other conditions that commonly accompany fibromyalgia include:

  • Chest pain and heart palpitations
  • Mitral valve prolapse
  • Sudden drop in blood pressure


Certain stress-related disorders commonly occur with fibromyalgia, and have overlapping symptoms. In fact, some experts believe these disorders so often interact that they may all be part of one general condition.

  • Chemicals and environmental toxins -- exposure to various chemicals and environmental toxins such as solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other symptoms of fibromyalgia.
  • Irritable bowel syndrome
  • Osteoarthritis -- a common form of arthritis that can coexist with fibromyalgia. The two conditions may be confused, particularly in elderly people. However, osteoarthritis causes joint pain, not widespread or generalized pain.
  • Temporomandibular joint disorders

Some tests may be positive for one or more of these diseases. However, fibromyalgia should not be ruled out if the results are uncertain, these conditions have already been treated successfully, or the patient meets the criteria for fibromyalgia.

Multiple sclerosis. This condition may have symptoms similar to those of fibromyalgia. Magnetic resonance imaging (MRI) scans often detect patches of tissue in the brain that confirm multiple sclerosis (MS). MRI findings combined with other tests and clinical findings usually make this diagnosis fairly certain. However, some patients may have symptoms that suggest MS, but tests cannot confirm the diagnosis. Some of these patients may have symptoms similar to those of fibromyalgia.

Autoimmune diseases. Rheumatoid arthritis, systemic lupus erythrematosis, and Sjogren syndrome are usually easy to diagnose, but they may develop slowly and be difficult to diagnose at first. Even if a doctor determines that a patient is most likely to have fibromyalgia, the doctor should keep track of any changes in symptoms over time in case the patient actually has one of these other illnesses.

Lyme Disease. Lyme disease is a bacterial disease transmitted by ticks. Health care providers can usually diagnose early Lyme disease correctly, but a delayed response or recurrence of this disorder may be mistaken for fibromyalgia. Some experts believe that 15 - 50% of patients referred to clinics for Lyme disease actually have fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the organism that causes this disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease with prolonged courses of antibiotics, the drugs may have serious side effects.

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. Constant fatigue is also a symptom of drug and alcohol dependency or abuse. Health care providers should consider medications as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness. It generally occurs in older women. Tender points are also present with this disorder, although they almost always occur in the hip and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue. A higher-than-normal erythrocyte sedimentation rate (ESR) can help diagnose polymyalgia rheumatica. Elevated ESR, however, also occurs with other conditions. Polymyalgia rheumatica usually responds dramatically to low doses of a steroid medication such as prednisone. Because polymyalgia rheumatica is sometimes associated with a rare condition called temporal arteritis, which may cause blindness if not treated, an accurate diagnosis is important.


Fibromyalgia can be mild or disabling, and the emotional toll can be substantial. People with fibromyalgia experience greater psychological distress and a greater impact on quality of life than those with other conditions, such as chronic low back pain. About half of all patients have difficulty with routine daily activities, or are unable to perform them. An estimated 30 - 40% of patients have had to quit work or change jobs. Patients with either CFS or fibromyalgia are more likely to lose jobs, possessions, and support from friends and family than are people suffering from other conditions that cause fatigue.


The pain, emotional consequences, or sleep disturbances that come with fibromyalgia may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine.


Outlook in Adults. Some studies show that fibromyalgia symptoms remain stable over the long term, while others report a better outlook, with 25 - 35% of patients reporting improvement in pain symptoms over time. Studies suggest that regular exercise improves the outlook. Those with a significant life crisis, or who are on disability, have a poorer outcome, as determined by improvements in the patients' ability to work, their own feelings about their condition, pain sensation, and levels of disturbed sleep, fatigue, and depression. Although the disease is lifelong, it does not get worse and is not fatal.

Outlook in Children. Children with fibromyalgia tend to have a better outlook than adults with the disorder. Several studies have reported that more than half of children with fibromyalgia recover in 2 - 3 years.


Fibromyalgia is a mysterious condition. Its causes are still largely unknown, as is how it inflicts damage. No strong evidence indicates that any single treatment (or combination of treatments) has any significant effect for most patients.

However, in 2007 the U.S. Food and Drug Administration approved pregabalin (Lyrica) as the first drug treatment for fibromyalgia after a study showed the medicine reduced fibromyalgia pain in 63% of patients. A year later, the FDA approved the drug duloxetine (Cymbalta) for fibromyalgia. Cymbalta has been shown to reduce fibromyalgia pain by more than 30%.

Many patients with fibromyalgia are treated first with medication; however, the American Pain Society Fibromyalgia Panel recommends a combined approach using cognitive-behavioral therapy, education, medication, and exercise. Treatment usually involves not only relieving symptoms, but also changing a patient's attitude about the disease. Treatment should also teach patients behaviors that help them cope.

Treatments usually involve trial and error:

  • Patients may start with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral therapy.
  • If these methods fail to improve symptoms, an antidepressant or muscle relaxant may be added to the treatment. Doctors usually prescribe these drugs because they may improve pain tolerance.
  • Patient education and programs that encourage coping skills are an important part of any treatment plan.

A combination of non-drug therapies appears to work just as well as drug therapy in improving pain, depression, and disability. This combination includes exercise, stress management, massage, and diet.


Patients must have realistic expectations about the long-term outlook of their condition, and their own individual abilities. It is important to understand that fibromyalgia can be managed, and patients can live a full life. The following tips may be helpful when starting a treatment program for fibromyalgia:

  • The goal of therapy is to relieve symptoms, not cure them.
  • Treatment must be tailored to each patient, and a combination approach is often needed.
  • Patients must begin all treatments with the attitude that these treatments are trial-and-error. There is no clear treatment solution. Patients and doctors need to work together to make the best choices for individual symptoms and concerns.
  • Treatments are long-lasting, in some cases life-long, and patients should not be discouraged by the return of symptoms (relapses).
  • Enlisting family members, partners, and close friends, particularly to help with exercise and stretching programs, can be helpful.
  • Becoming involved with support groups also benefits many patients. Support groups may also help family members, particularly parents of children with fibromyalgia. One study noted that the severity of the disorder increased in children whose parents were less able to cope with their pain.

The definition of improvement is personal. For example, some patients are pleased with only a 10% reduction in pain and other symptoms.

Lifestyle Changes

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients must expect to take part in a long-term exercise program. Physical activity prevents muscle wasting, increases well-being, and, over time, reduces fatigue and pain. Many studies have also demonstrated that exercise can improve physical and emotional function, as well as reduce symptoms, including pain.

Programs often combine aerobic, strength-training, and flexibility exercises with self-management education. Some studies have shown improvements lasting for up to 9 months after the exercise program ends.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you slowly increase the amount of your physical activity.

In general, graded exercise involves:

  • A very gradual program of activity, beginning with mild exercise and building in intensity over time.
  • Stretching exercises before working out. A daily stretching routine can help relax tense muscles and prevent soreness.
  • Walking, swimming, and using equipment such as treadmills or stationary bikes. Swimming and water therapy are good because they don't require putting weight on the joints.

Patients who try difficult exercises too early actually experience an increase in pain, and are likely to become discouraged and quit.

Every patient must be prepared for relapses and setbacks, but they should not get discouraged. Patients who do not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen fatigue from poor posture and positioning, and help condition weak muscles.


Sleep is essential, particularly because sleep disruptions worsen pain. Many patients with fibromyalgia have trouble getting a restful and healing night's sleep. Those who are unable to sleep consistently have little improvement in symptoms. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep habits can add to sleep problems. Tips for good sleep habits include:

  • Avoid caffeine or alcohol 4 - 6 hours before bedtime.
  • Avoid drinking fluids right before bedtime so that you do not have to wake up to urinate.
  • Avoid exercising 6 hours before bedtime.
  • Avoid large meals before bedtime. A light snack, however, may help you sleep.
  • Avoid naps, especially in the evening or late afternoon.
  • Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on weekends and during vacations.
  • If you are unable to fall asleep after 15 or 20 minutes, go into another room and start a quiet activity. Return to bed when you feel sleepy.
  • Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well ventilated.
  • Use the bed only for sleep and sexual relations.


Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole grains, fresh fruits, and vegetables. Although everyone should be careful about calories from fats, some are healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold-water fish. You can also purchase these oils as supplements called EPA-DHA or omega 3.

Vegetarian or Vegan Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds. The actual benefit of various vegetarian diets remains unproven.


Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. Evidence shows that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. Several relaxation and stress-reduction techniques may be helpful in managing chronic pain, including:

  • Biofeedback
  • Deep breathing exercises
  • Hypnosis
  • Massage therapy
  • Meditation
  • Muscle relaxation techniques

Biofeedback. Evidence from controlled trials does not suggest that biofeedback techniques are very helpful for fibromyalgia patients. During a biofeedback session, electric leads are taped to a subject's head. The person is encouraged to relax using any method that works. Brain waves are measured and an audio signal sounds when alpha waves are detected. Alpha waves are brain waves that occur with a state of deep relaxation. By repeating the process, people using biofeedback connect the sound with the relaxed state, and learn to relax on their own.

Meditation. Meditation, used for many years in Eastern cultures, is now widely accepted in this country as an effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who practice on a continued and regular basis. The practiced meditator can achieve the following physical benefits:

  • Reduced heart rate, blood pressure, adrenaline levels, and skin temperature while meditating.
  • Improved well-being.
  • Better sleep -- some research has reported an increase in melatonin levels in experienced meditators. Melatonin is important in regulating the sleep-wake cycle.
  • Less pain, possibly from reductions in levels of cortisol, a stress hormone.

An important goal for both religious and therapeutic meditation practices is to quiet the mind -- essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy.

People who try meditation for the first time should understand that it can be difficult to quiet the mind, and they should not be discouraged by a lack of immediate results. Some experts recommend meditating for no longer than 20 minutes in the morning after awakening and then again in the early evening before dinner. Even once a day is helpful. Do not meditate before going to bed, because it causes some people to wake up in the middle of the night, alert and unable to return to sleep.

Hypnosis. In one small, short-term controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows the heart and relaxes the body. In one study, patients who were given 30-minute massage sessions twice a week experienced lower stress and anxiety and less pain after 5 weeks compared to a group receiving an alternative therapy called transcutaneous electrical stimulation (TENS).


Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Although some studies have reported a benefit from these treatments, there is not enough evidence to recommend them. In one analysis, evidence was weakest on the advantages of so-called manipulative ("hands-on") approaches, such as chiropractic treatments.

Acupuncture. Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small studies suggest that it offers some benefit, especially to people who cannot take medicines because of their side effects. Acupuncture also seems to help relieve pain when added to treatment with tricyclic antidepressants and exercise, and the improvements last for a few months after treatment ends. Other studies have not found enough evidence to support the use of acupuncture for fibromyalgia.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. While some studies have reported pain relief and improved sleep with osteopathic manipulation, larger controlled studies are needed to clearly identify whether manipulation is an effective treatment. Osteopathic techniques may include manipulation of the spine or muscle tissue release. There is always a very small risk for adverse effects from any of these techniques. For example, in rare cases manipulation of the neck has caused stroke or damage to the large blood vessels in the neck.

Hydrotherapy and Similar Treatments. Hydrotherapy, also called balneotherapy, involves soaking in water, such as hot tubs, pools, or baths, to help relieve pain. One study found that exercising in a warm swimming pool was a cost-effective therapy that improves quality of life in women with fibromyalgia.

Warmth itself might provide some relief. According to another small study, Waon therapy -- a type of treatment in which patients first sit in a dry sauna and then are placed in a warm room and wrapped in blankets -- significantly reduced pain in fibromyalgia patients.

Herbal or Natural Remedies. Some alternative remedies are being investigated for fibromyalgia:

  • Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia, but trials studying so far it have not been well designed.
  • S-adenosylmethionine (SAMe) is a natural substance that has antidepressant, anti-inflammatory, and analgesic properties. It has shown some benefit in controlled studies.

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. Consult a doctor before using any untested products or dietary supplements. Also discuss with your doctor the potential interactions between the supplements and any medications you take.


Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the U.S. Food and Drug Administration to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even deadly side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Behavioral Therapy

Studies show that fibromyalgia patients feel better when they deal with the consequences of their disorder on their lives. Cognitive-behavioral therapy (CBT) enhances a patient's belief in their own abilities and helps them develop methods for dealing with stressful situations. CBT, also called cognitive therapy, is known to be an effective method for dealing with chronic pain from arthritic conditions. Evidence also suggests that cognitive-behavioral therapy can help some patients with fibromyalgia.

Although the effects of CBT and other non-medication treatments for fibromyalgia do not always last over the long-term, they may help certain groups of people, particularly those with a high level of psychological stress.

CBT may be particularly useful for addressing insomnia, one of the hallmark symptoms of fibromyalgia. In studies, patients who received CBT for insomnia woke up 50% less often at night, and had fewer symptoms of insomnia and improved mood.

The Goals of CBT. The primary goals of CBT are to change any unclear or mistaken ideas and self-defeating behaviors. Using specific tasks and self-observation, patients learn to think of pain as something other than a negative factor that controls their life. Over time, the idea that they are helpless goes away and they learn that they can manage the pain.

Cognitive therapy is particularly helpful for defining and setting limits, which is extremely important for these patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, pushing themselves too far until they collapse. This collapse reverses the way they view themselves, and they then think of themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route. Patients learn to prioritize their responsibilities and drop some of the less important tasks or delegate them to others. Learning these coping skills can eventually lead to a more manageable life. Patients learn to view themselves and others with a more flexible attitude.

The Procedure. Cognitive therapy usually does not last long. It typically consists of 6 - 20 one-hour sessions. Patients also receive homework, which usually includes keeping a diary and trying tasks they have avoided in the past because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

  • Keep a Diary. Patients are usually asked to keep a diary, a key part of cognitive therapy. The diary serves as a general guide for setting limits and planning activities. Patients use the diary to track any stress factors, such as a job or a relationship that may be improving or worsening the pain.
  • Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs. For example, "I'm not good enough to control this disease, so I'm a total failure" becomes the coping statement, "Where is the evidence that I can control this disease?"
  • Set Limits. Limits are designed to keep both mental and physical stress within manageable levels, so that patients do not become discouraged by getting in over their heads. For example, tasks are broken down into incremental steps, and patients focus on one step at a time.
  • Seek out Pleasurable Activities. Patients list a number of enjoyable low-energy activities that they can conveniently schedule.
  • Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.

Patients should learn to accept that relapses occur, and that over-coping and accomplishing too much too soon can often cause a relapse. Patients should respect these relapses and back off. They should not consider them a sign of failure.

Research also shows that patient education can be effective in treating fibromyalgia, especially when combined with CBT, exercise, and other therapies. Educational programs can take the form of group discussions, lectures, or printed materials, although there isn't any clear evidence on which type of education works best.


Cognitive therapy may be expensive and not covered by insurance. Other effective approaches that are free or less costly include support groups or group psychotherapy. In one study, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results are not typical in all centers. Therapeutic success varies widely depending on the skill of the therapist.


In 2007 the Food and Drug Administration approved Pregabalin (Lyrica) as the first drug specifically for the treatment of fibromyalgia. Other drugs used to treat fibromyalgia are antidepressants or muscle relaxants. The goal has been to improve sleep and pain tolerance. Medications from other drug classes (such as sleeping aids and pain relievers) may also be prescribed. Patients receive drug treatments in combination with exercise, patient education, and behavioral therapies.


Pregabalin is an anti-epileptic. Also called anti-seizure drugs and anti-convulsants, these medicines affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing.

Pregabalin was approved in 2004 to treat nerve pain and diabetic peripheral neuropathy. Research is indicating it may improve sleep quality, fatigue symptoms, and fibromyalgia pain. One study found that three different doses of pregabalin -- 300 mg, 450 mg, and 600 mg -- were all effective at improving pain and sleep, and all were well tolerated by patients. The most common side effects include mild-to-moderate dizziness and sleepiness. Pregabalin can impair motor function and cause problems with concentration and attention. Patients should talk to their doctor about whether pregabalin may affect their ability to drive.

Studies have shown that another anti-convulsant, gabapentin (Neurontin), which is approved for the treatment of postherpetic neuralgia, affects pain transmission pathways and may relieve pain associated with fibromyalgia. Patients who took gabapentin also reported that they slept better and were less tired.


The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants were the first drugs to be well-studied for fibromyalgia. They cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally, only small doses of tricyclic antidepressants are needed to relieve fibromyalgia. Therefore, although tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include:

  • Blurred vision
  • Difficulty urinating
  • Dizziness
  • Drowsiness
  • Dry mouth
  • Heart rhythm disturbances
  • Sexual dysfunction
  • Weight gain

As with all medications, tricyclic antidepressants must be taken as directed. An overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including a delay or loss of orgasm and low sex drive.

Serotonin-Norepinephrine Reuptake Inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and serotonin. These drugs appear to have more consistent benefits for fibromyalgia pain than SSRIs.

SNRIs include:

  • Duloxetine (Cymbalta) has been approved by the FDA for treating fibromyalgia. In studies, it reduced fibromyalgia pain by more than 30%. The most common side effects with this medication are nausea, dry mouth, constipation, decreased appetite, sleepiness, increased sweating, and agitation. It may also increase the risk of hemorrhage in patients taking NSAIDs, aspirin, or blood thinners.
  • Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure. There have also been reports of problems with the electrical system of the heart in people taking this drug. These side effects may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
  • Milnacipran (Ixel) is under investigation and is not yet approved in the United States. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. Milnacipran appears to improve fibromyalgia pain and other symptoms, including fatigue, poor sleep, and depression.


Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It helps relieve fibromyalgia symptoms. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects, including drowsiness, dry mouth, and dizziness.


Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep in patients with insomnia.


Pain relief is of major concern for patients with fibromyalgia. Pain relievers for fibromyalgia include:

  • Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
  • For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, because the pain is not caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil).
  • Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful for relieving painful areas in other disorders. It may also have some value for fibromyalgia patients.
  • Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Such patients should use narcotics only if they cannot find relief with other, less potent treatments. Patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids, such as oxycodone (Roxicodone) or morphine sulfate (Duramorph), for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids, and then should evaluate those patients periodically for continuing pain relief, side effects, and signs of dependence.
  • Pramipexole, a drug used to treat Parkinson's disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia. Pramipexole stimulates the production of dopamine, a chemical messenger in the brain.
  • The atypical antipsychotic drug olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine and other antipsychotics cause unpleasant and potentially serious side effects.


Tropisetron. Tropisetron (Navoban) is a drug used to reduce vomiting during chemotherapy. European studies suggest that it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Fatigue and dizziness are the most common side effects.

Nabilone. A synthetic drug derived from marijuana may be another effective addition to fibromyalgia treatment, according to early studies. In one study, nabilone (Cesamet), which is also used to treat severe nausea and vomiting in chemotherapy patients, significantly relieved fibromyalgia pain compared to placebo. There are some challenges to using nabilone for fibromyalgia, however. First, it is a controlled substance that can become addictive, and researchers say it is so expensive that it would be cost-prohibitive to use for a chronic disease such as fibromyalgia.



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CDC’s proposed guidelines on opioids create uproar

Critics, including Myra Christopher of the Center for Practical Bioethics, say plan ignores needs of pain patients

Supporters are frustrated by delay in guidelines

The bioethics center is among seven nonprofit organizations investigated by the U.S. Senate Finance Committee for their ties to opioid manufacturers.

Kolodny called Christopher “one of the most prominent spokesmen of the opioid lobby.”

Christopher is unapologetic about her advocacy.

“I’ve been labeled everything in the universe, but it doesn’t matter to me,” she said. “I’m not financially motivated. … What I care about is that we make decisions based on good data and that we don’t harm populations that have nothing to do with this problem.”

Kolodny, she said, “is a true believer. I have a lot of respect for Andrew Kolodny. He’s just wrong.

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“I know of many, many chronic-pain patients who are dependent on opioids but who aren’t addicted.”

Taking on the CDC is important because doctors, hospitals and insurance companies probably will adopt whatever it recommends, Christopher said.

She said guidelines should be coming from professional organizations such as the American Medical Association, rather than from a government agency.

Many health care organizations and medical societies have been offering such guidance, often recommending that non-addicting drugs and other pain therapies be tried before opioids.

Before Temple University Hospital in Philadelphia established guidelines for prescribing to emergency room patients with certain minor pain complaints, 52.7 percent were receiving opioids. After the guidelines went into effect: 29.8 percent.

Christopher took no issue with opioid critics who say the drugs have been overused and misused.

“We have done a really lousy job of using these medications,” she said. Opioids are effective for only about half the patients who receive them; pain management should include other kinds of care, such as counseling, chiropractic, acupuncture, she said.

“I don’t want to sound like I’m pushing opioids. I’m not,” she said. “But to deny (opioids to) people in pain because there’s an addiction problem is cruel and wrongheaded.”



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In an effort to prevent and deter crimes that put the lives and the health of workers at risk, the Departments of Justice and Labor announced today a plan to more effectively prosecute such crimes. Under the new plan, the Justice Department’s Environment and Natural Resources Division and the U.S. Attorneys' Offices will work with the Department of Labor’s Occupational Safety and Health Administration (OSHA), Mine Safety and Health Administration (MSHA), and Wage and Hour Division (WHD) to investigate and prosecute worker endangerment violations.

Starting last year, the Departments of Justice and Labor began meetings to explore a joint effort to increase the frequency and effectiveness of criminal prosecutions of worker endangerment violations. This culminated in a decision to consolidate the authorities to pursue worker safety statutes within the Department’s Environment and Natural Resource Division’s Environmental Crimes Section. In a memo sent today to all 93 U.S. Attorneys across the country, Deputy Attorney General Yates urged federal prosecutors to work with the Environmental Crimes Section in pursuing worker endangerment violations. The worker safety statutes generally provide for only misdemeanor penalties. However, prosecutors have now been encouraged to consider utilizing Title 18 and environmental offenses, which often occur in conjunction with worker safety crimes, to enhance penalties and increase deterrence.  Statutes included in this plan are the Occupational Safety and Health Act (OSH Act), the Migrant and Seasonal Agricultural Worker Protection Act (MSPA), and the Mine Safety and Health Act (MINE Act).

In addition to prosecuting environmental crimes, the Environment and Natural Resources Division has also been strengthening its efforts to pursue civil cases that involve worker safety violations under statutes such as the Clean Air Act, Clean Water Act, Resource Conservation and Recovery Act, and the Toxic Substances Control Act. Violations of a number of provisions under these statutes can have a direct impact on workers tasked with handling dangerous chemicals and other materials, cleaning up spills and responding to hazardous releases. 

Related Documents:

Memorandum from the Deputy Attorney General to United States Attorneys Regarding Prosecutions of Worker Safety Violations, December 17, 2015

Memorandum of Understanding between the U.S. Departments of Labor and Justice on Criminal Prosecutions of Worker Safety Laws



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People Prescribed Opioids Are Not Automatically 'Junkies'

  • Kate Mitchell
  • Blogger, writer, grad student and advocate for people with arthritis
To say that I am upset about the response to one of the Superbowl ads is an understatement. You probably saw it and side eyed it because we can all agree that no one wants to see Superbowl advertisements for medications used for stomach and digestive problems. I'm with you on that one. I'm talking about the black-and-white ad for people with OIC, opioid induced constipation. The problem was how people responded to that ad. For example, Bill Maher tweeted, "Was that really an ad for junkies who can't sh@#? America, I luv ya but I just can't keep up".
I get that this was supposed to be funny. And I'll agree that it is definitely ironic that politicians keep talking about the opioid epidemic while the FDC approves a drug for OIC. But here's the thing - there is a difference between people who are prescribed opioids and people who are junkies. There is a difference between people who are on opioids for very real health issues and addicts. (And his treatment of addicts here is a whole other issue, one that should be addressed, but this is not the time.)
It's time to talk about how people prescribed opioids for chronic pain are not automatically junkies.
The only thing I'm addicted to is coffee. Let's start with that. I am not addicted to my pain medication. When I am in less pain overall -- as in my when main treatment for my autoimmune arthritis has kicked in -- I don't take as much. The only thing I need from my opiate is pain relief, and if I can get that from other things, I don't take it. What things? In addition to my pain medication, I use ice, a heating pad, an NSAID like Advil, yoga, chiropractic care, higher steroid dose, etc. I do everything I possibly can to reduce my pain, and just because that can involve an opiate does not mean that I am an addict.
And another thing - I don't want to take my pain medication, but it is without a doubt the only reason why I haven't been to the ER since May 2014. Also, I really don't enjoy spending my time rolling on the floor sobbing from pain. And I have a rather high pain tolerance; I keep burning my fingers in my toaster due to short bread problems and that's a 3/10 for me. My pain tolerance is high and I'm still in excruciating pain on a regular basis because, you know, I live with a highly active autoimmune disease attacking my body. I don't want to take my pain medication, but it's so much better than the alternative.
My opiates are not my main pain-management treatment. Not by a long shot. I'm switching to Stelara injections from Rituxan infusions, and I also take the maximum amount of NSAID (anti-inflammatory) you can in a day. Actually, I take 3 medications daily for my arthritis pain, 3 daily for my fibromyalgia pain, plus 1 weekly for my arthritis. On top of that, I do yoga and walk every day, I use a heating pad for my fibromyalgia as needed, I see a chiropractor every week, and I do physical therapy exercises from my knee surgery every day. Oh, and I've also changed my diet. So my pain medication is NOT my primary source of pain relief, but it is the one thing I can take that immediately makes a large difference in my pain. And you want to shame me for that, for something I can't control when I'm trying my best to feel better?
Let's look at some statistics in case my personal experience is not enough for you. A study in the American Journal of Psychiatry found that 78% of people addicted to opiates were not prescribed the drug for any medical reason. A study by the Partnership for Drug-Free Kids found that 9 in 10 chronic pain patients tried a non-opiate based treatment before relying on opiates. Oh, and my favorite statistic? 96 percent of chronic pain patients on opioids do not become addicted. That's right. Ninety-six percent.
Here's the issue at the heart of the misunderstanding: 100 million Americans are affected by chronic pain, more than those with heart disease, cancer, and diabetes combined. We are the ones suffering the most from people making light of our struggles. We are the ones being treated like addicts while our bodies attack us. We are the ones suffering. Would you say that someone living with cancer was drug seeking and looking for opiates to get high, not for pain relief? Why would that be okay to someone living with chronic pain?
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
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