4-20 and the curse on medical cannabis

Cannabis has  been with mankind for twelve thousand years and used in many ways from fiber(not the dietary kind) ,medicine, soporific and most recently, whipping boy.

Despite multiple peer-reviewed papers documenting the potential use of cannabis in medicine most of main stream medicine remains opposed or ill-informed and about cannabis and seem content to remain so.

How is it scientifically educated individuals have become so reluctant to take a look at the scientific evidence when it comes to cannabis?

Well here is my take on the issue. Today is Adolph Hitler’s birthday as well as my devoted and long-suffering bride. However, and far more significantly, today is 4-20, National Pot Day in case you were on Mars and missed it! There are lots of tales about the origin of 4-20, including it being a police radio code for ‘marihuana smoking in progress. The one I prefer is that it was the time 4:20PM when a certain group of arts students got together to have a joint after classes were over for the day.

However the day got it’s moniker, it has become quite a big deal amongst the recreational pot users who are inclined towards public disobedience.

Marc Emery, the newly freed Prince of Pot was  given airtime on CTV today from Vancouver where Pot Day is almost a provincial holiday.  He indicated he was planning to pass out several hundred joints to the disobedient who will be out in large numbers to smoke pot, wave signs and just make a nuisance of themselves for the not so disobedient who just want to go about their business.

Now the term civil disobedience when it comes to Pot Day in Vancouver is about a disobedient as goose hunting in Kindersley, Saskatchewan since cannabis smoking is almost a legal requirement to live in British Columbia.

Let me get to the point. Recreational cannabis is ILLEGAL in Canada. Whether BC cares or not is irrelevant. That is my real problem.

In our practise of chronic pain cannabis is used legally, yet illegal everywhere else, to alleviate chronic pain in patients who have failed other care or who choose not to take opioids for pain and other modalities have failed.

What has been our experience? It is not generally more effective then standard therapies yet carries somewhat less overall risk. It is used most commonly for conditions with painful arthropathy (the other joints) and neuropathy(pain related to damaged nerves). Opioid use is lower in cannabis patients. The majority of them are gainfully employed. We used mandatory urine drug testing in all our pain patients and we do not see more illicit drug use in the cannabis patients. You could not pick them out as a group on the street. Many of these patients  are referred to out clinic by doctors who are unwilling  to prescribe  cannabis. Please remember this is the experience of our clinic and not any kind of peer reviewed research on our patients.

So the why is 4-20 the curse on medical cannabis?

In my estimation the reason for the lack of support for medicinal use of cannabis is simply because it is illegal. Once legalised, cannabis will have it’s fair chance to prove it’s value without being seen as an evil illegal gateway drug used  by young rebels and aging hippies who never grew up. Most College regulatory bodies for doctors have little or no support for cannabis. How can anyone blame these bodies when the stuff is illegal? In the case of America cannabis is considered right up there with heroin as a scourge.

So I see 4-20, Pot Day, the celebration of illegal recreational use as a curse on my practise. In Canada the Harper Government has forced doctors into being the gatekeepers for medical cannabis while hypocritically refusing to do the right thing and make it legal.

Chronic pain-is it better to ignore or validate?

Chronic pain is almost always caused by non-fatal conditions that are stable. Most chronic pain patients are not dying from their disease. In chronic pain the pain is the disease and not the back, the shoulder, the neck or wherever the pain is felt. If not for the pain, most chronic non-cancer pain patients are capable of normal activity including work of a physically demanding  nature.

Sadly, because of lack of education in pain, there are many pain patients who have been told not to lift, not to bend, not to exercise and they assume it is because they will harm themselves. In fact, most chronic pain patients will gain benefit, not harm, from normal physical activity.

Where did all this fear come from? Mostly, it is from the inferences drawn from acute pain where the experience(pain) can be close to the actual health of the tissue and is actually protective and the pain will go away when the tissue heals.

If the back pain we experience is no longer an indication of back health and we continue to protect the back we will eventually become crippled by the pain and unable to  function normally despite the back being quite stable.

Recently, I heard a speaker from Toronto(a pain doctor) emphatically state that if we validate the pain(to me that means to agree that the patient has pain) we are legitimising their disability. This is one of the great debates in pain medicine.  If the patient has no actual physical disability and the pain is the problem, why not just pretend it is not there-just do not validate the pain?

Can we make the pain better just by telling the patient it is not real? Pain is an experience that resides in the conscious brain. Is the patient disabled because she believes the pain means she is crippled or likely to become so if she works?

Are we making patients worse by agreeing they have pain? How could we even study this issue and would it be ethical? Patient satisfaction is increasingly being used as an index of quality of care. Is there an educational tool that allows us to understand that although their pain is real and severe that it doesn’t mean their back(neck,head,shoulder) is ruined and they will soon be a cripple if they use it normally? Patient who are engaged in their treatment are more likely to improve. Can this engagement be increased with high quality pain teaching? The brain is not a computer and it has no compartments. Can education about the meaning of pain actually reduce fear of movement and actually reduce pain and disability.

Pain is intended to protect us from, during and after injury. In chronic pain this is not so. In chronic pain the pain actually makes us worse in so many ways. Are there techniques we can use to restructure our brain so it can recognise the difference and improve chronic pain? We can train the brain to recognise different wine varietals, can we not train the brain to be less attentive to pain that is not helping?

If we are convinced(and I am) that the pain is real in chronic non-cancer pain and yet is not an indication of real tissue threat, does that mean it is a mistake to validate the pain?

Are there patients who are so mentally disordered or so devious that we can never make them accept the concept that they have real pain without real tissue damage and they can  return to normal work and function? Of course, but the numbers are very small. If research could  tell us that education can reduce pain disability reliably and significantly in chronic non-cancer would we be less reluctant to acknowledge(validation) that patients are truly having pain?

We need much more research in this area.  Could education and brain rewiring techniques work as well as surgery, drugs and injections in some patients? There are some studies that indicate that increasing patient satisfaction may worsen, not improve outcome in some patients. Is this because a less educated patient may not  engage in optimal care? Is patient directed care a bad idea or is it a poorly educated patient directing care that is a bad idea?

Try to answer these questions and I feel we will have better pain care that is better accepted by patients without imperious and insensitive caregiver or resorting to the path of least resistance.

Thank you

Mind over matter-not a crazy concept?

Most of us have multiple personalities when this topic comes up. If we are talking about bending spoons , moving coins or killing goats in the movies(The Men Who Stare at Goats) most of us are pretty skeptical.

However, when we see someone suffering from chronic pain with no obvious pathology(trauma, tumour, infection, deformity or the like) we are often tempted to think, “Why don’t they just get over it and stop making such a fuss”. Many pain patients report feeling judged in this manner often and being very resentful.

Of course, some of this relates to a widely held misconception that chronic pain is imaginary and pain is only real if you can identify a site where the body is being injured or at least very close to being injured. It is also generally understood that humans can imagine many ,so the concept of imaginary reality is quite established in most of us. We can imagine cats and dogs and palm trees and being on holidays. We are also aware that we can stop this imaginary reality anytime and move on with our tasks.

So, if chronic pain is imaginary, why can’t we just imagine it to go away or are chronic pain patients somehow built in such a way that they can only extinguish pleasant memories? That seems a bit of a stretch for me.

If we could extinguish pain by some kind of active mental exercise that would be excellent if it were easily learned and especially helpful in chronic pain where the body is not in imminent danger or injured.

Studies of CBT(cognitive behavioural therapy-one of these mental exercises) have shown only a small effect(but better than none, of course) on pain and suffering.

Can thought actually move matter(if so then maybe changing a mere experience like pain might be possible, even if difficult)? Of course. When you think(mind) about standing up you can actually convert mind into matter-the act of moving yourself to standing up. Silly as it sound we convert mind into matter millions of times and never realise how magical it really is!

Why can’t we do this with pain? Evolution has made it very difficult because pain, like suffocation is a highly evolved system to protect our DNA from harm so it can be passed on successfully to the next generation and further the survival of our species(well more precisely our species specific DNA). Allowing us to easily choose to stop the pain would be bad for the species as it would make us much more prone to risk ourselves(our DNA).

Acute pain can totally immobilise an animal and prevent it from being able to escape when injured. That is bad for the species specific DNA as far as survival is concerned.

Last June, while participating with my staff in an extreme obstacle race, I fell from a log(don’t say it, I know it ‘s easy) and rotated, landing on my right shoulder and the right side of my head on the caliche in the ravine. The immediate pain was intense and forced me to lay perfectly still to the chagrin of my team who were mortified. Within a few seconds, the pain was gone and by the time the team and the paramedic got into the ravine I said I was fine, just a bit shaken and a lot  embarrassed!

Just as if the sabre-toothed cat was still chasing me I became able to move and over the next 45 minutes finished the ‘race’ picked up my attendance prize(I am not an athlete!) and got in the back seat ( my wife who had seen my fall was unconvinced at my protestation of wellness). We stopped in Taber(about an hour later) for lunch and by then I needed help to get out of the car being unable to move my right arm. Lunch was good since I am in my right mind(left-handed). By the time we got to Medicine Hat anything but minor upper body movement was painful beyond description. My chiropractor BFF came over and diagnosed a separated AC joint and possible shoulder damage. In fairness to him he really couldn’t examine me because of the pain at virtually any movement and I could only take shallow breaths. He sent me for x-rays the next day. The initial xray requisition was for the shoulder revealing the AC joint damage but it wasn’t until my chiro asked the rads to have a closer look that they spotted the displaced fracture of the second rib! It is difficult to imagine the amount of energy it takes to break a rib as well hidden(and in my case as well padded) as the second rib. For the next three weeks I slept in a recliner because it was impossible to sit from lying down. I developed a fracture blister over my back and a year later the scar of the fracture blister is all that remains. In all my years of practise I have never seen a second rib fracture.

For years I have taught students and patients about the brain’s ability to suppress acute pain in an emergency and now that I have experienced it I am witness to one of nature’s most powerful miracles. More importantly the brain did this without me actually doing anything-I really wasn’t aware I was injured!

It is now clear to me in more than just an academic sense that pain can be totally independent of the health of the body.

What an amazing thing if we could we could re-activate that internal pain control system in chronic pain. Sadly, that has not been possible yet.

What if it were possible to reroute brain circuits to reduce the experience of pain even if we are unable to repair the damaged nerves which are responsible for the  sending the signals.? Recently, a psychiatrist colleague, Dr. Stein, who is an expert in treating chronic non cancer widespread pain, like fibromyalgia, introduce me to the to the clinical and research work of  Dr. Michael Moskowitz. He is involved in an evolving paradigm whereby the brain can be encouraged to create new pathways that allow us to experience less or even no pain in situations where the chronic pain had overwhelmed the patient’s consciousness. Shortly thereafter, I read a book by Dr. Norman Doidge called The Brain that Changes Itself wherein Dr. Moskowitz’ work figures prominently. I recommend it to furhte understand the paradigm shifting concepts in brain-body medicine.

Thank you.

I do not prescribe opioids

I do not prescribe opioids excluding special circumstances.

The title certainly does not apply to me personally and the second should apply to all pain doctors and should also apply to everything we do.

This article has started enigmatically for a good reason. The rather concise title of this document and the first line actually were produced by the same pain doctor. Of course you are right they are mutually exclusive. The two statements represent a metaphorical ‘Heisenberg Uncertainty Principle’.

It has become politically and medically unpopular to advocate the use of opioids in chronic non cancer pain. This concept of virulent opiophobia will be most likely expressed in a group of doctors gathered together to discuss the conquering of pain via surgery, invasive nerve injections or destruction, behavior modification and addiction.

In this particular case it was a doctor’s group dedicated to the treatment of pain by injection and burning of the offending nerves. In his address to the audience, the title statement was made during his opening remarks and was met with a lot of seemingly grateful smiles and nods. Clearly he struck a resonant chord suggesting there were a considerable number present who took his remarks at face value-the total prohibition of opioids in chronic non cancer pain.

This mantra is spreading its dark countenance over North America following the upsurge of ‘hillbilly heroin’ as Oxycontin became widely known. Fifty years ago opioids(painkillers derived from opium poppies and synthetic chemical which work the same way) were rarely used for chronic pain. By the 1980’s it became clear that patients dying of cancer could be relieved of much of their pain with morphine and similar drugs. A public outcry and the consensus opinion of hundreds of nurses, doctors and clergy around the world treating the dying convinced the World Health Organisation to release the WHO Ladder for the use of opioids in cancer pain in 1986.

For palliative care patients the result has been almost miraculous. What happened next was horrendous yet largely well-meaning. These same opioids began to be widely recommended for the millions suffering chronic noncancer pain, based on their success in palliative care and research showing their safety and low addiction risk in acute pain and operating rooms. It was also true that some drug companies exploited this opportunity to market opioids to doctors treating noncancer and nonacute pain.

Opioid use, misuse and harm has skyrocketed and now the ‘genie’ has to be put back in the bottle. The same press that pushed for wider availability of opioids has now tossed doctors and pharmaceuticals under the bus and the only press for opioids is doom and gloom. Addiction and opioid related deaths have supposedly reached ‘epidemic’ proportions of a biblical scale.

The rise of a politically popular lobby of opioid prohibitionists has made rational discussion of opioids almost an impossibility. Such phrases as ” I do not prescribe opioids” have almost become campaign slogans like, “I will give up my gun when  they pry it out of my cold dead fingers” for the fanatical right. As was said in the movie ‘Paul’, “You just can’t talk to those people”.

When speaking to a group of interventional pain docs with little interest or experience with opioids making such a dogmatic statement is likely to be well received-and it was.

Sadly, there are many North Americans living productive lives with chronic pain on stable effective doses of opioids. You do not hear about them and you will not. There is neither the political will or the funding to gather the evidence. Chronic pain patients are a silent lot and there are no huge organisations like the American Cancer Society to fly the pain patient flag.

Should we be bludgeoned back to the dark ages of opioid prohibition we will have lost a valuable tool that has and can benefit many chronic pain sufferers. In chronic non cancer pain opioids have been shown to be at least as effective in selective patients as less maligned drugs(gabapentin, pregabalin, duloxetine).

The less maligned drugs are generally not used to get high and rarely addictive. This gives them the benefit of not being seen as ‘forbidden fruit’.

Now back to the first line of the piece.

I do not prescribe opioids excluding special circumstances. In patients with chronic pain the statement can and should apply to all medical(drugs) surgical and injection-based treatments. Most patients requires none of these.

That said let me come to my point. We need to be intellectually honest. You see, the title of the piece was made to a select group of doctors and the first line is on the same doctor’s homepage at the university where he works and is soliciting new patients.

It all seems so much like the  recent election in Israel where on the eve of election facing defeat Netanyahu repudiated a two state solution, courting the right only to step directly backwards the next day with defeat off the table. Many  Canadians will remember the same feat of intellectual duality that Pierre Elliot Trudeau used to end Joe Clark’s Prime Ministerial hopes.

One either prescribes opioids or not. Every patient and treatment should be individualized not ‘dogmatised’.

Kratom-what you should know

A few months back as one of my patients was leaving the office, she handed me an envelope to look at when I had a minute. It did not contain a ‘mysterious white powder, but instead a small package containing kratom and a warning that it was not intended for human consumption.

Today I was doing an epidural steroid injection on a patient with radiculopathy, who also suffers from migraines and fibromyalgia. As I was slowly advancing the Tuohy needle with pressure on the plunger of the loss-of resistance syringe, seeking the epidural space, she said,” Doc did you hear there is a cure for fibromyalgia?”

Trying to control my excitement I finished the injection without puncturing the dura and then asked her to fill me in.

She had been on/in a couple of FM chat rooms where the ‘cure’ was being described. Lo and behold it was the same mysterious ground plant material that had been secreted in that envelope months earlier, which had somehow disappeared into the trash leaving the kratom research I had planned, undone.

So, I spent a few hours scouring the world-wide interweb trying to find out a bit about kratom and whether I would be recommending the cure to my FM patients.

The answer is ‘NO’ at least not for quite a while.

Kraton is a plant from southeast Asia where, as in many parts of the world, chewing plants and making tea from them is pretty common.. It seems it is used for many things including pain, fatigue and even sexual boredom and has now entered the north American unofficial unsanctioned recreational and therapeutic pharmacopeia without the FDA’s approval although it is apparently not illegal yet as it is in some countries.

Like many plants the number of chemicals in kratom is quite spectacular and clearly our ancestors were as adventurous as north American youth and tried many plants seeking wisdom healing and sometimes revenge.

Kratom has two particularly interesting chemicals, mitragynine and 7-hydroxymitragynine. The latter is the more potent and acts like morphine(and blocked by morphine antagonist naloxone) and additionally activates the kappa opioid subtype possible explaining why respiratory depression is not seen much as we see with morphine. This helps understand why kratom has found a niche in the underground pain and addiction world where it is reportedly used to treat pain and opioid addiction. Presumably that would be for folks without a drug plan.

Kratom also contains chemicals said to produce the effects of serotonin and noradrenalin, both of which are employed widely in conventional medicine for pain and depression.

We have been using duloxetine(a drug which increases both serotonin and noradrenalin) to treat FM and others kind of pain for some years now.

Equally interesting is the idea of having in kratom combined morphine-like activity and duloxetine-like activity. In 1977 Grunenthal in Germany introduced just such a drug, tramadol and more recently tapentadol which have some similarity to the reports of kratom pharmacology.

In chronic pain it is believed that a receptor for the excitatory chemical NMDA contributes to the pain. Drugs which block this receptor have been found useful in some pain states in some patients. Dextromethorphan and ketamine are two such drugs. At least one of the chemicals in kraton blocks the NMDA receptor to some extent.

Wow! This sounds to good to be true. It likely is.

Kratom is potentially addicting and has a withdrawl or abstinence syndrome. Perhaps more important for the unsuspecting it is uncontrolled and therefore you have no idea what else may be in the little capsule. In Sweden there was a reportedly potent brand of kraton called, of all things, Krypton. Deaths occurred(at least 9). Krypton turned  out to have been spiced up with O-desmethyltramadol, the active metabolite of tramadol which is much more potent  than the parent drug. Potency of course can also contribute to lethality.

A recent rash of deaths in in Canada from counterfeit oxycodone 80mg tablets where the oxycodone was replaced by fentanyl and caffeine should tell us not to rely on the underground pharmacy.

Although it is clear there may be some possible benefits in actual kratom, I will not be suggesting my  FM patients even think about thinking about kratom. In a world where street marihuana is laced with cocaine, heroin, ecstasy, strychnine and heaven knows what else and the  world -wide interweb is a lawless frontier only an idiot would try to purchase kratom.

As important is the whole issue of FM itself. This can be a very serious disease with accompanying problems like mental health and addiction that could be worsened by kratom. Chat room on the web are not monitored for  mental health and morality.

When kratom is  standardised and licensed then subjected to good studies in FM(anecdotally that seems quite reasonable)  I will be in a position to even consider its merits.

The best paper I have found on the subject is written by Dr. Walter Prozialeck and colleagues and published in The Journal of the American Osteopathic Association, December, 2012.

Chronic pain, UFOs, and Rodney Dangerfield

In 2013 Research! America commissioned Zogby to conduct a poll on issues surrounding chronic pain, drug abuse, addiction and doctor prescribing. It is well-known that the numbers of chronic pain patients exceeds the total of cancer, heart disease and diabetes combined. Of the over one thousand people who took this poll the numbers were reversed and only 18 percent rated chronic pain as a significant health problem, yet the percentages of participants voting for cancer, heart disease  and diabetes were  59%. 52% and 52% respectively.

The famous, much missed late comedian and actor, Rodney Dangerfield  was famous for not getting any respect, or so he insisted. It would appear he had a lot in common with chronic pain patients-no respect.

On the surface, it seems simple that the real reason is because chronic pain cannot be observed or proven with any ease. Cancer, heart disease and diabetes mellitus are quite easy to diagnose and validate, but not so with chronic pain.

Interestingly, in the Zogby poll it appears that the people who were asked seemed to understand this concept although they were way off mark in guessing the significance of chronic pain. A full 60% of the study participants actually opined that the general public and doctors are dismissive of chronic pain patients, a conclusion often reached by chronic pain patients themselves.

I have been attempting to help chronic pain patients for 25 years and one thing is clear. A person, healthcare professional or not, requires either personal experience or a serious understanding of the way the nervous system works in order to be reliably convinced that the vast majority of pain patients are reporting legitimate suffering. The vernacular is loaded with potentially negatively words such as non-organic pain, pain behavior, supratentorial pain, Waddell’s signs and psychological overlay which are familiar to most pain patients who are well aware that when it is suggested the pain is all in their heads it is not a neurophysiology reference.

The attitudes towards chronic pain would support a rather unscientific approach to pain by most North Americans. This is reinforced by a widespread assault on science in general. Evidence is seen in the anti-vaxxer movement as well as widespread support for homeopathy. A surprising number of Canadians and Americans express the belief that evolution is fiction, man and dinosaurs co-existed and the age of the earth can be calculated using the Old Testament of the Bible’s Genesis.

The UFO literature seem to support the lack of science education hypothesis. Although only 5% of Americans claim to have seen an unexplained flying phenomenon more than 50% feel they are real and more than 60% feel there is a conspiracy to keep the truth from the public. Given this evidence I am not sure whether the public is in any way equipped scientifically to even recognize the truth.

An amazing number of Canadians and Americans actually quite strongly feel a cancer cure exists and has been suppressed by big pharma. In May of 2014, Oliver released results of just such studies. Nearly 1400 Americans were randomly surveyed.  12% believe the CIA started the AIDs epidemic and 37% actually believed that the Federal Drug Administration is suppressing cures for cancer and other diseases and the pressure comes from big pharma.

This kind of widespread ignorance-based opinion that is not only wrong and indicated a lack of a high quality fact-based education but it is likely harming our society and hindering progress with medical and problems.

Chronic pain patients are suffering from this lack of informed education. How can we make progress when there is widespread ignorance of the existence, causes and management of chronic pain? It is difficult to see  how chronic pain research and care can move forward in a society that is so swayed by conspiracy theories, religious fundamentalism and strong uneducated opinion.

Despite widespread opinion to the contrary, chronic pain is real, has real causes, is not a synonymous with mental weakness or drug addiction. the educational level must change before the dialogue will change. It is time to get some respect for chronic pain patients.

“greenies”, counterfeit oxycodone, fentanyl and death by ignorance

Here we go again! Another round of deaths here in Alberta related to opioids. Just one more trial for the legitimate chronic pain patient and those of us who persist in being willing to prescribe opioid trials to seek those who benefit from opioids and willing to be vigilant to detect side-effects, abuse and diversion in those patients. In our clinic the absolute numbers of opioid patients who benefit significantly exceeds those who do not.

In a normal year we discharge three to five patients for selling  their medication or using illegal drugs with their prescribed opioids. As long as the demand for illegal mind-altering drugs and human beings exist in large numbers this will remain  an issue.

Ignorance(to not know) is probably not as much of a problem as stupidity(to know and still do) but ignorance is wide spread. The recent epidemic of deaths from fake oxycodone 80mg tablets(sometimes called ‘greenies’ on the street) is a case in point. Most of these patients were found with high level of fentanyl in the blood at autopsy(that should be a hint of a poor outcome!). What is going on here?

Well, technically it is quite simple. Oxycontin was replaced by Oxyneo because it cannot be easily crushed and snorted or crushed, filtered and injected. The technique is the way illegal users can get the fastest and most aggressive ‘high’. When drugs are snorted or injected they enter the blood without being changed by the liver and the time it takes for the drug to get from the mouth to the stomach and intestine for absorption is eliminated as well. So we have a group of people who know how to perform this piece of moronic magic. This is the first part of the perfect storm.

The second part goes way back to 1960 when Paul Janssen created fentanyl, a derivative of meperidine(Demerol), revolutionising the use of opioids in anesthesia. Demerol, like fentanyl is best given by injection(poorly absorbed in the gut) but has toxic breakdown products and in large doses is toxic to the heart. Fentanyl became rapidly the  commonest drug of the opioid class used in anesthesia and the drug of choice for open heart surgery anesthesia.

The third part happened more recently. Fentanyl was a good pain drug but could not be given by mouth because it was not well-absorbed when swallowed and was also destroyed by the liver. If you held it in your mouth or nose it would be absorbed much better but that wasn’t very useful for chronic pain patients. Things changed when a research company in California in the 1990’s figured out the technology to put fentanyl in  a patch delivery system that would get the drug into the blood through the skin, bypassing the liver metabolism and creating stable blood levels for three days from one patch. This created a useful product for patients with cancer pain and patients whose guts were not working well. As the shift occurred where doctors were encouraged to try opioids for chronic non cancer pain fentanyl patches became widely used and widely known. The original patches were called Duragesic by their manufacturer. These patches made it very difficult for illegal extraction of the fentanyl and very little absorption if the patch is swallowed. Much higher blood levels could be achieved by chewing the patch, but this is extremely dangerous because there is more than enough fentanyl in a patch to kill from overdose. Later, when the original patent expired, generic companies began making patches and sadly some of them are quite easy from which to extract the fentanyl for illegal purposes.

Fast forward to today. The illegal drug community is well aware Oxycontin pills can be crushed and snorted or injected. They are also aware that Oxyneo(the replacement for Oxycontin) is almost impossible to crush, snort and inject(ingenious methods have been proposed on the internet, however). The Canadian Government has, in a very questionable decision, allowed generic drug companies to produce the old crushable formulation. Of course a prescription is required.

Enterpreneurs who prey on the stupid, illegal and ignorant have devised a brilliant plan. They put fentanyl in a pill that looks like Oxycontin 80mg(the ‘greenie’) and sell it on the street. The enterpreneurs knew these morons would snort or inject the drug so it would work(fentanyl when swallowed does very little). What the unsuspecting morons did not understand was how potent fentanyl is compared to oxycodone-if your body is not used to huge dose opioid doses, the result is a guick overdose death and that is precisely what we are seeing today!

Personally, I feel anyone who dies from an overdose of an illegal counterfeit pill should qualify for a Darwin Award.

Foy you math lovers. 10 milligrams of fentanyl injected  intravenously  is about the same same as 500 to 1000 milligrams of morphine. Just ten milligrams of fentanyl in a fake Oxycontin 80mg(a ‘greenie’) would kill all but a very few even seasoned addicts with high tolerance and everyone else!

This new product may remove more than a few by death by ignorance.

The evolution of pain-what we don’t know really hurts!

The longer we treat pain the more questions keep coming up. After many years of seeing patients with no serious tissue damage or damage that has healed quite well, and suffering from disabling pain demands attempted explanation. It is our view that these patients have normal brains and are not mentally ill.

So are they imagining this pain? That is unlikely, since pain is almost as unpleasant as suffocation and to imagine either would be potentially harmful at most and at least highly unpleasant. If we really could imagine pain, as soon as it started to bother us we would put it out of our mind immediately. We cannot do that. Yes, I agree there are some very special individuals that seem able to shut out pain (shamans and yogis) but most mere mortals cannot. We know there are forms of brain training (ACT, CBT, guided imagery to name some) can reduce the angst associated with pain but the pain usually persists.

First we need to try to understand why pain is so powerful and so insistent that it be felt. The answer is millions of years old. Up until about 200 million years or so ago, organisms responded to harmful events and physical threats by reflexively pulling away using the sensors, nerves, and muscles endowed from billions of years of plodding evolution. The organisms that were the best at this got to pass their genes on in the process of natural selection and the next generation got a tiny bit better at staying out of harm’s way.

Two hundred millions of years ago the earliest mammals got a neocortex, a new addition to the old brain. It was capable of doing more than responding. The neocortex could feel. It had consciousness. Consciousness provided a greater range of behavioural responses and hence gave them a selective advantage – meaning their genes had a leg up on the competition.

Since damaging stimuli needed to be avoided, the sensation we now call pain evolved to be highly unpleasant and as close as biologically possible to the actual events (cut, burn, break, etcetera). Pain experience gave mammals many advantages. Mammals could learn and avoid injury (pain). Mammals could teach their offspring to avoid injury (pain). Pain could also allow wounded individuals to protect the wounds until healed when the pain would go away.

Mammals, and eventually us, needed pain to get where we are and as such the mechanisms within our nervous system are robust and likely redundant (more that one way to experience pain). Our brain knows that pain is good for survival!

Evolution probably also created a spectacularly powerful way to block pain immediately following injury. It is frequently stated that there is no biologic value to stopping pain in the dying prey mammal. What is missed in that assumption is actually quite simple. Many more animals are wounded than killed in predator-prey interactions. If pain were allowed to immobilize the animal they would all become lunch. At the same time if pain were not highly unpleasant animals would have far less motivation to flee or flight. Intense stimuli from severe damage have developed the capacity to temporarily stop the pain and allow the injured animal to flee, go to ground and heal. The better this was the more mammals could live to breed again.

We refer to this as ‘shock analgesia’ and it is powerful. Last summer I fell during a race and fractured my second rib (if you know much about trauma the significance of a fracture first or second rib will be clear). I got up and finished the race unaware of the seriousness of the injury. I spent the next two weeks virtually unable to rise from my bed. Had I fallen being pursued by a sabre-tooth tiger I would have been able to continue fleeing!

This pain control system is exploited by pain medications like duloxetine, tramadol and tapentadol.

So then, ‘why pain?’ when there has been healing in some people? I feel the answer is simple but the solution difficult. Pain becomes conscious when a specific pattern of signals reaches this neocortex (the new part of the mammal brain). After trauma and disease tiny nerves leading to the brain often do not heal perfectly. The neocortex is there to protect us so our genes get reproduced and it relies on nerve signalling. This is a powerful system. After injury nerves will send imperfect signals because of damage. The wily, protective brain seeing an abnormal signal may remember the initial injury or simply decide it is pain and yet there is no new injury of disease. If fact it may do this even when the limb is not even there-so called phantom pain.

The wily brain, of course keeps telling us (consciousness) our back, neck, ankle, shoulder, whatever is injured when in fact it is not or at least it is healed as much as it is going to heal. If this is the reason we have pain and we get an operation to ‘correct, the back, neck, ankle, shoulder ,whatever it will fail and we will be upset with the surgeon.

When you see your doctor with this kind of pain you are often told there isn’t anything wrong with you. If you injure your back and six months later you still have pain your back is not likely ruined even though those unhealed nerves are still telling your wily protective brain something very different.

Most patients with chronic non cancer pain are really in this group- real, not imaginary, pain but no real ongoing injury. Pain converted from protector to tormentor. Jekyll to Hyde. Pain of no biologic or survival value. This is hard pain to treat but if your doctor looks hard and cannot find a treatable cause and enough time has passed after the injury to allow healing you will have a better outcome when you understand this and learn to see the pain in this way. You are not a malingerer.