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Posts Tagged ‘Pain’

Medical Marijuana & The Justice Department

Perhaps someone in the Justice Department read our article Drug Prohibition Is A Failure. Perhaps a bit of pragmatism is at work since as more states establish laws permitting the use of marijuana for medical purposes the Justice Department has to use increasingly limited resources without the help and cooperation of local law enforcement agencies.

“It will not be a priority to use federal resources to prosecute patients with serious illnesses or their caregivers who are complying with state laws on medical marijuana,” Attorney General Eric H. Holder Jr. said in a statement accompanying the memo. “But we will not tolerate drug traffickers who hide behind claims of compliance with state law to mask activities that are clearly illegal.”

The Attorney General seems to still be confused on an important fact born out by this unfolding drama:

In emphasizing that it would continue to pursue those who use the concept of medical marijuana as a ruse, the department said, “Marijuana distribution in the United States remains the single largest source of revenue for the Mexican cartels.” Going after the makers and sellers of illegal drugs, including marijuana, will remain a “core priority.”

It is a fact that the single greatest destructive force on the profits from the sale of marijuana lining the pockets of Mexican drug cartels are the mom and pop operation now in business in 14 states. If something as simple as decriminalization for medical purposes can have such a profound impact on such a reliable source of profit for murderously violent criminal gangs, it stands to reason that full nationwide legalization of would eliminate marijuana as a source of income entirely.

Current small operation in states with medical marijuana laws have increased the nationwide supply of marijuana which is both high quality and cheap. Since the overall scale of operations is still small, Mexican drug cartels take advantage of breaks in crop cycles when supplies are low to flood the market with their product. Such lulls would not exist if marijuana was grown in a large scale corporate fashion, the way we do with other crops, like wheat and corn.

There is another factor at work here. Many states are now facing tremendous amounts of debt coming due at a time when the economy is depressed and tax receipts are at an all time low. Although prohibition has proven to be a failure, full legalization has not yet happened because states have had a perverse incentive to continue fighting this futile war. Congress allocates money to the states based on their efforts in combating illegal drug use. If those funds were to dry up because of the bad economy, states desperate for revenue may do the one thing they have been fighting so hard against – legalize it and tax it.

Here is a list of the states which have laws permitting marijuana for medical purposes:

  1. Alaska
  2. California
  3. Colorado
  4. Hawaii
  5. Maine
  6. Maryland
  7. Michigan
  8. Montana
  9. Nevada
  10. New Mexico
  11. Oregon
  12. Rhode Island
  13. Vermont
  14. Washington

This story is far from over. A memorandum is a suggestion, nothing more, and prosecutors ultimately have discretion over which cases they choose to take on. Prosecutorial misconduct along with laws which make everyone a felon is the real problem. Someone should write a book about it or something.

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It is a well known phenomenon that when people are in pain, the hustlers and quacks come crawling out from under their rocks to take advantage of the situation. They take advantage of the associative principle, which is that if Y happens after X it is plausible that X caused Y. Since many sufferers of arthritis have pain that comes and goes, a non-scientist may credit the copper bracelet or magnetic wrist wrap with having played a role in reducing the pain in their aching joints.

We refuse to link to any web sites promoting such nonsense, but a quick Google search can turn up many examples of sites selling those items. Some of them babble at length with pages and pages of pseudoscience interwoven with endorsements from satisfied customers.

Here is what they do not tell you: there is no scientific basis for making the claim that a copper bracelet or magnetic wrist strap can cure arthritis or even relieve the pain temporarily. A theoretical framework does not even exist to explain how such a phenomenon can work.

If you have not already done so, we recommend reading The Power of Imagination for a good background on placebos and the placebo effect.

Stewart Richmond, a Research Fellow in the Department of Health Sciences at the University of York led a randomized, placebo controlled study on the effects copper bracelets and magnetic wrist straps have on pain management.

The trial involved 45 people aged 50 or over, who were all diagnosed as suffering from osteoarthritis. Each participant wore four devices in a random order over a 16-week period – two wrist straps with differing levels of magnetism, a demagnetised wrist strap and a copper bracelet.

We guarantee none of the web sites selling this nonsense make any reference to the results of the study:

“This is the first randomised controlled trial to indicate that copper bracelets are ineffective for relieving arthritis pain.”“It appears that any perceived benefit obtained from wearing a magnetic or copper bracelet can be attributed to psychological placebo effects. People tend to buy them when they are in a lot of pain, then when the pain eases off over time they attribute this to the device. However, our findings suggest that such devices have no real advantage over placebo wrist straps that are not magnetic and do not contain copper.

“Although their use is generally harmless, people with osteoarthritis should be especially cautious about spending large sums of money on magnet therapy. Magnets removed from disused speakers are much cheaper, but you would first have to believe that they could work.”

We consider swindling old and sick people out of a big chunk of their hard earned money to be a cause of harm. This may be complete quackery but it is also big business.

Magnet therapy is a rapidly growing industry, with annual worldwide sales of therapeutic devices incorporating permanent magnets worth up to $4 billion US.

Conclusion: Copper bracelets and magnetic wrist straps do not work for relieving pain.

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The Power Of Imagination

The placebo effect is well recognized in medical research and is taken into account in legitimate studies.

For the uninitiated, here is a brief rundown of placebos and the placebo effect:

A placebo is a sham medical intervention. In one common placebo procedure, a patient is given an inert sugar pill, told that it may improve his/her condition, but not told that it is in fact inert. Such an intervention may cause the patient to believe the treatment will change his/her condition; and this belief does indeed sometimes have a therapeutic effect, causing the patient’s condition to improve. This phenomenon is known as the placebo effect.

When an inert substance makes a patient better, that effect is called the placebo effect. The phenomenon is related to the perception and expectation which the patient has; if the substance is viewed as helpful, it can heal, but if it is viewed as harmful, it can cause negative effects, which is known as the nocebo effect. Placebo effects are a scientific mystery.

A distinguishing characteristic of legitimate scientific research is having  control group to gauge how much of any positive effect shown is real and how much can be ascribed to the placebo effect.

The study was conducted by researchers at the University of North Carolina at Chapel Hill and Duke University Medical Center.

For this study, 34 children ages 6 to 15 years old who had been diagnosed with functional abdominal pain by a physician were recruited to participate by pediatric gastroenterologists at UNC Hospitals and Duke University Medical Center. All received standard medical care and 19 were randomized to receive eight weeks of guided imagery treatment. A total of 29 children finished the study; 15 in the guided imagery plus medical treatment group and 14 in the medical treatment alone group.

Randomization also lends credibility to any study’s results since it removes a potential source bias and accusations of stacking the deck to achieve preselected results.

When we then heard that children were able to reduce abdominal pain by up to half through the power of their imagination we were skeptical but not entirely disbelieving. Other studies have shown similar results:

Prior studies have found that behavioral therapy and guided imagery (a treatment method similar to self-hypnosis) are effective, when combined with regular medical care, to reduce pain and improve quality of life. But for many children behavioral therapy is not available because it is costly, takes a lot of time and requires a highly trained therapist.

This study was different because the guided imagery material was prepared for the children to use on their own, independently of therapists.

The guided imagery sessions, developed jointly by van Tilburg, co-investigator Olafur Palsson, Psy.D. and Marsha Turner, the study coordinator, were recorded on CDs and given to children in the study to use at home.

The treatment consisted of a series of four biweekly, 20-minute sessions and shorter 10-minute daily sessions. In session one, for example, the CD directs children to imagine floating on a cloud and relaxing progressively. The session then gives them therapeutic suggestions and imagery for reducing discomfort, such as letting a special shiny object melt into their hand and then placing their hand on their belly, spreading warmth and light from the hand inside the tummy to make a protective barrier inside that prevents anything from irritating the belly.

The results are incredible:

In the group that used guided imagery, the children reported that the CDs were easy and enjoyable to use. In that group, 73.3 percent reported that their abdominal pain was reduced by half or more by the end of the treatment course. Only 26.7 percent in the standard medical care only group achieved the same level of improvement. This increased to 58.3 percent when guided imagery treatment was offered later to the standard medical care only group. In both groups combined, these benefits persisted for six months in 62.5 percent of the children.

The study concluded that guided imagery treatment plus medical care was superior to standard medical care alone for the treatment of functional abdominal pain, and that treatment effects were sustained over a long period.

Video games can have powerful and positive effect in developing and strengthening a child’s mind. Of course, there are plenty of other things to do which can develop a child’s imagination in that mystical land referred to as “not in front of the TV”.

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As with many scientific discoveries, there is an interesting back story here.

The story begins with a biologist, Robert Silverman of the Cleveland Clinic Foundation in Ohio, investigating if prostate cancer is caused by a virus.

Actually, the story begins a bit earlier than that. Scientists have known that viruses can cause cancer since the early 20th century.

In 1909 Peyton Rous discovered that a virus could cause sarcomas in chickens. For discovering the Rous Sarcoma Virus, Dr. Rous was awarded the Nobel Prize in 1966. This discovery led directly to the discovery of cellular oncogenes (genes that cause cancer) by Bishop and Varmus, which also was rewarded with a Nobel Prize.

Subsequently, numerous other human cancers have been associated with viral infections. The most important of these is Burkitt’s lymphoma. Burkitt’s lymphoma comes in three varieties: one form is endemic to sub-Saharan Africa and is most likely caused in large part by infection with a virus called Epstein-Barr Virus (EBV, which also causes mono), one form is sporadic (as opposed to endemic), and one form is associated with immunodeficiencies such as AIDS. The endemic form of Burkitt’s lymphoma typically causes a large, painful jaw mass, while the sporadic form more commonly involved the intestines. Interestingly, another name for EBV is Human Herpesvirus-4 (HHV-4). EBV, or HHV-4, also causes nasopharyngeal carcinoma in southeast Asia (and elsewhere). It is clear that there is a real connection between viruses and cancer.

Now back to Robert Silverman, who discovered a new retrovirus called XMRV.

The retrovirus was very similar to MLV, a group of viruses that can cause cancer and neurological and immunological diseases in mice. Silverman found XMRV in a subset of prostate tumours, and more recent research found a stronger correlation between XMRV and aggressive prostate tumours.

We should pause for a moment and explain the difference between a virus and a retrovirus. A virus is a very simple organism – basically a protein shell containing a little DNA. Viruses need to find hosts because they lack the tools to multiply on their own.

Cells also contain DNA, but cells (especially those of complex organisms such as humans) have ridiculous amounts of DNA. Most of the instructions in DNA used by cells on a daily basis are for creating proteins. Since mistakes are most likely to occur proportionally to how often DNA is copied, a system using RNA minimizes copying by only duplicating the specific section of DNA needed to build a specific protein. RNA is slightly different than DNA on a molecular level, so cellular machinery can respond to it but not to DNA. A cell which needs a particular protein manufactured goes through the following (simplified) steps:

  1. A portion of DNA is translated into RNA.
  2. RNA is sent to the endoplasmic reticulum.
  3. The specified protein is built.

A standard virus hijacks the cell’s machinery by inserting DNA, which gets translated into RNA, which is then made into the specified protein; only in that case the protein is the virus.

Retroviruses are more insidious. They contain RNA rather than DNA. When a retrovirus attacks a cell, the RNA gets translated into DNA, which then gets incorporated into the cell’s own genome. Rather than hijacking the cellular machinery for their own nefarious plans, they Borg the cell. From then on, every time the cell multiplies it is bringing the virus along with it. Our genome is littered with scars from ancient battles with retroviruses which may have fundamentally shaped us into what we are today.

Alright, enough with the interruptions already.

Judy Mikovits of the Whittemore Peterson Institute for Neuro-Immune Disease in Reno, Nevada, asked Silverman to see if there was a connection to chronic fatigue syndrome.

Mikovits asked Silverman to analyze the blood samples of 101 CFS patients and 218 healthy controls. The authors detected XMRV DNA in the immune cells of 67% of the CFS patients but in only 3.7% of healthy controls. The authors also showed that the virus was able to spread from infected immune cells to cultured prostate cancer cells and that the virus’s DNA sequence was more than 99% similar to the sequence of the virus associated with prostate cancer. The findings were published in Science.

So far, although the results are encouraging, there has only been one pilot study completed. The magic which makes science work is verification and duplication of results.

William Reeves, principal investigator for the Centers for Disease Control and Prevention (CDC)’s CFS public health research programme, says the findings are “unexpected and surprising” and that it is “almost unheard of to find an association of this magnitude between an infectious agent and a well-defined chronic disease, much less an illness like CFS”.

But Reeves is cautious. “Until the work is independently verified, the report represents a single pilot study,” he says. According to Reeves, the CDC is already trying to replicate these findings. He also notes that CFS is a heterogeneous disease and likely arises from a combination of many factors.

The Wall Street Journal has a heartbreaking example of the suffering caused by CFS:

Ms. Whittemore-Goad says she was a regular school girl, playing sports and involved in school activities, until the age of 10, when she became ill with a monolike virus that she couldn’t shake. She said doctors first told her parents that the illness was psychological, that she had school phobia and was under stress from her parents. “We kept searching for an answer,” says Ms. Whittemore-Goad, who says lymph nodes in her groin were so painful that her brothers and sisters used to have to carry her upstairs. She was diagnosed at age 12 with chronic-fatigue syndrome.

Over the years, doctors have treated her symptoms, like intense headaches and severe pain, but the illness persists. She has had her gallbladder, spleen, and appendix removed because they became infected. She tried an experimental drug that she says gave her relief for years, but she then started experiencing side effects and had to stop taking it. Recently the illness has become worse; she began suffering seizures and can no longer drive.

Go read the whole thing.

If this virus is the cause of CFS, diagnosis and detection can be done with a simple blood test. Antiretroviral therapies designed in the fight against HIV are under investigation as a potential cure. The story is not yet over but we remain hopeful that this breakthrough represents the real deal for sufferers of CFS.

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There are a number of doctors who prescribe a high volume of commonly abused pain medications, sometimes to clients who turn around and sell the pills on the street. It is the responsibility of the Drug Enforcement Agency to stop flagrantly illegal behavior. Clinics run by such doctors are called “pill mills”.

People seek pain relief for all sorts of conditions and as individuals may have different levels of pain tolerance. Someone who is on a particular medication for awhile may need to have the dosage increased because their body gets used to it. Certain medications may also cause chemical dependency.

Judging how much pain medication a patient needs is a fundamental part of a physician’s job, and that decision should be free from interference by the government. Unfortunately, should someone at the DEA decide that you, as a doctor, are prescribing too much medication to a patient, you will face arrest, fines, loss of license, and imprisonment. The overzealous attitude of those in government are creating the conditions today in which patients suffering from chronic pain are routinely under medicated.

The problem is not limited to the DEA. Local prosecutors working for the Department of Justice are the ones actively pursuing these cases, even though it doesn’t make any sense. Harry A. Silverglate writes in Forbes about a particularly egregious case:

The current contretemps in Wichita has its roots in 2002 when Sean Greenwood, who for more than a decade suffered from a rare but debilitating connective tissue disorder, finally found a remedy. William Hurwitz, a Virginia doctor, prescribed the high doses of pain relief medicine necessary for Greenwood to be able to function day-to-day.

Shortly thereafter, Dr. Hurwitz was arrested and shut down by federal agents. Greenwood couldn’t find any other doctor willing to risk the wrath of the DEA, so he suffered for 3 years before dying. High blood pressure, caused by years of untreated pain, was likely a strong factor in his untimely death.

Improprieties galore marked the prosecution of Dr. Hurwitz. Before his trial in federal court in Virginia in 2004, the DEA published a “Frequently Asked Questions” (FAQ) pamphlet for prescription pain medications. In a remarkable admission, the DEA wrote that confusion over dependence and addiction “can lead to inappropriate targeting of practitioners and patients for investigation and prosecution.” Yet on the eve trial, the DEA, realizing that Hurwitz could rely on this government-published pamphlet to defend his treatment methods, withdrew the FAQ from its Web site. Winning the case proved more important than facilitating sound medical practice. Hurwitz was convicted.

Sadly, Dr. Hurwitz is not alone, and his case is not nearly the most egregious.

The litany of abusive prosecutorial tactics could fill a volume. A “win-at-all-costs” mentality dominates federal prosecutors and drug agents involved in these cases. After a Miami Beach doctor was acquitted of 141 counts of illegally prescribing pain medication in March 2009, federal district court Judge Alan Gold rebuked the prosecution for introducing government informants–former patients of the doctor who were cooperating to avoid their own prosecution–as impartial witnesses at trial.

Greenwood’s wife, Siobhan Reynolds, decided to do something about a situation she saw as outrageous.

In 2003 she founded the Pain Relief Network (PRN), a group of activists, doctors and patients who oppose the federal government’s tyranny over pain relief specialists.

Somehow, the arrogant fools in power decided that having a concerned citizen shed light on their abusive practices is a bad thing to be stopped.

Now, the PRN’s campaign to raise public awareness of pain-doctor prosecutions has made Reynolds herself the target of drug warriors. Prosecutors in Wichita have asked a federal grand jury to decide whether Reynolds engaged in “obstruction of justice” for her role in seeking to create public awareness, and to otherwise assist the defense, in an ongoing prosecution of Kansas pain relief providers. The feds’ message is clear: In the pursuit of pain doctors, private citizen-activists–not just physicians–will be targeted.

An attorney for the government should know better than to try and squash op-ed pieces. Even if it were Reynolds opinion that everyone in the United States should get cases of whatever pain pills they desire for no particular reason, it is still her 1st Amendment protected right to express her opinion.

In Kansas, it appears that zealous prosecutors are targeting not only the doctors, but also their public advocates. When Reynolds wrote op-eds in local newspapers and granted interviews to other media outlets, Assistant U.S. Attorney Tanya Treadway attempted to impose a gag order on her public advocacy. The district judge correctly denied this extraordinary request.

Having learned nothing up until this point, Treadway is still going in for the kill with a new subpoena.

“Obstruction of justice” is the subpoena’s listed offense being investigated, but some of the requested records could, in no possible way, prove such a crime. The prosecutor has demanded copies of an ominous-sounding “movie,” which, in reality, is a PRN-produced documentary showing the plight of pain physicians. Also requested were records relating to a billboard Reynolds paid to have erected over a busy Wichita highway. It read: “Dr. Schneider never killed anyone.” Suddenly, a rather ordinary exercise in free speech and political activism became evidence of an obstruction of justice.

On Sept. 3, a federal judge will decide whether to enforce this subpoena, which Reynolds’ lawyers have sought to invalidate on free speech and other grounds. The citizen’s liberty to loudly and publicly oppose the drug warriors’ long-running reign of terror on the medical profession and its patients should not be in question. Rather, the question should be how the federal government has managed to accumulate the power to punish doctors who, in good faith, are attempting to alleviate excruciating pain in their patients.

Harvey A. Silverglate is the author of Three Felonies A Day: How The Feds Target The Innocent. Glenn Reynolds writes about it here:

Some years ago I started on a project entitled Due Process When Everything Is A Crime. The gist was that since criminal law has expanded to the point where everyone is some sort of a felon, the real action is in the area of prosecutorial discretion — in choosing whom to prosecute from among this population-wide mass of the guilty — where, in fact, due process basically doesn’t apply. That suggests that maybe there should be some due-process limits on decisions to prosecute. I never got to it (my scholarly rangetop has so many back burners it must be a half-mile deep) but the issue continues to deserve attention.

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The MC1R (melanocortin-1 receptor) gene produces melanin in humans. A variant of this gene present in redheads may be responsible for an increased sensitivity to pain. Non-redheads may carry this variant nor is it 100% guaranteed that a redhead will have it.

Many people will encounter anesthesia for the first time in their everyday lives at the dentist’s office. Administering too much anesthesia can have serious consequences so dentists are hesitant to go above recommended guidelines. Someone with a heightened pain sensitivity will likely never want to set foot in a dental office again after single procedure requiring anesthesia. Postponing dental care will likely make the problem worse and cause even more pain down the road.

“Redheads are sensitive to pain,” said Dr. Daniel Sessler, an Outcomes Research Department chair at The Cleveland Clinic, in Cleveland, Ohio, who is one of the authors.

“They require more generalized anesthesia, localized anesthesia. The conventional doses fail. They have bad experiences at the dentist and because of the bad experiences, they could avoid dental care.”

Sessler, an anesthesiologist, began studying redheads’ sensitivity to pain after hearing chatter from colleagues.

“The persistent rumor in the anesthesia community was that redheads were difficult to anesthetize,” Sessler said. “They didn’t go under, had a lot of pain, didn’t respond well to anesthesia. Urban legends usually don’t start studies, but it was such an intriguing observation.”

This led to two studies. In 2004, research showed that people with red hair need 20 percent more general anesthesia than blonds and brunettes.

A 2005 study indicated that redheads are more sensitive to thermal pain and are more resistant to the effects of local anesthesia.

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A new study by The George Institute for International Health has found Tai Chi to have positive health benefits for musculoskeletal pain. The results of the first comprehensive analysis of Tai Chi suggest that it produces positive effects for improving pain and disability among arthritis sufferers.

Arthritis is a painful inflammation of the joints, and comes in a variety of painful flavors. The common theme, if you haven’t been paying attention, is pain. Tai Chi exercises apparently are allowing some people suffering from arthritis to enjoy an improved quality of life, to the extent that The George Institute for International Health is working on similar research involving the use of exercise to relieve lower back pain.

“This research should reassure people with musculoskeletal conditions such as arthritis to seek exercise to relieve the pain. The fact that Tai Chi is inexpensive, convenient, enjoyable and conveys other psychological and social benefits supports the use this type of intervention for pain conditions”, added Ms Amanda Hall, The George Institute.

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