By Mark Pew, Senior VP, Preferred Medical
This week I want to share two interesting articles about two different topics. The first article is about how alternative treatments can be just as effective as prescription opioid use. The second article is about our brain’s cognitive biases. As is becoming increasingly known and accepted, the human brain is the most important tool in finding the most successful approach to managing pain.
(See link for full article)
by Jennifer Crystal
Every few months, Jennifer Crystal devotes a column to answering your questions. Here she answers some questions she recently received. Do you have a question for Jennifer? If so, email her at.
Did your pain move sometimes? My worst pain is near some scar tissue.
Yes! One of the defining features of Lyme pain is that it’s migratory. This distinguishes it from, say, the pain of Rheumatoid Arthritis (RA), which is more symmetrical (both knees instead of just one), and which doesn’t tend to move around like Lyme pain. While RA affects most of the joints, Lyme can affect one, two, or many.
I felt pain mostly in my forearms and shins, but also sometimes in my back, neck, and head. Sometimes my fingers ached so much I couldn’t type, and other days they felt okay. Now that I’m in remission, I know when I’m having a Lyme flare-up because my forearms and shins start to ache. When I’m overtired or I’ve over-exerted myself, I always get a headache on the left side of my head. (This is due to babesia, which eats oxygen in the red blood cells. When I over-exert myself, I don’t get enough oxygen to that side of my brain, causing inflammation and subsequent pain).
Moreover, Lyme loves to hide in scar tissue, so it makes perfect sense that’s where you’re having the worst pain. I had the anterior cruciate ligament of my left knee repaired before I was aware I had Lyme, and it took much longer for that knee to heal than it should have; this is likely because there was Lyme bacteria in the scar tissue. I’ve also had multiple eye surgeries, and my doctor suspects scar tissue over my left eye is why my headaches often start there.
Is the word “cured” ever used with tick-borne illness?
Yes and no. It depends which illness you have, how long you’ve had it, how quickly you got treatment, and how well you’ve responded to treatment. If Lyme is caught early and treated adequately with two to four weeks of antibiotics—and if it is not complicated by co-infections—it can conceivably be cured. However, even in those cases, some 20% of patients still experience ongoing symptoms called Post Treatment Lyme Disease Syndrome (PTLDS), and they can require additional treatment.
My own Lyme is in remission, not cured because I went eight years undiagnosed. By then the bacteria had crossed the blood-brain barrier. Once it’s in the central nervous system, it becomes very difficult to fully eradicate it. I’m probably 80% restored to full health, a percentage that has continually improved (with brief periods of flare-up).
There are others who have had PTLDS who claim to have been cured, but some of these have subsequently relapsed. It really depends on each individual case.
I was originally diagnosed with the co-infection Ehrlichia, and that is now considered to be cured. I no longer test positive for it or show specific symptoms. The co-infection that still gives me the most trouble is babesia. I was not surprised to hear doctors at this year’s ILADS conference say that babesia can be treated to an extent—symptoms can be alleviated and held at bay for a while—but that it often rebounds. Currently, babesia has no cure.
But don’t despair. Researchers are getting closer to using that coveted word “cure” every day. See my “Highlights From ILADS 2019” post that provides information on new drugs like Dapsone and Disulfiram, the latter of which has some patients, as Dr. Kenneth Liegner stated, “enjoying enduring remission,” that is, feeling well for six months or longer. It’s too early to use the word “cure” decisively.
Do you think I’m going down the right path, being treated for tick-borne disease?
I know it can be confusing when so many doctors give you different diagnoses and treatment options. You don’t know who or what to believe, and that is scary. Even two different LLMDs might give you two different protocols (and that’s because they each have a personal opinion on what might work best for you, since there is no single set protocol for treating tick-borne disease).
If you trust the LLMD who has made a clinical diagnosis of Lyme with or without co-infections, and your symptoms corroborate those infections, and/or your blood work confirms those infections, then yes, I absolutely think you are going down the right path. Remember that having Lyme is not a choice.
Once you begin treatment, you’ll know for sure if you’re on the right path. If you do have Lyme, you’ll likely have a Herxheimer reaction (when the antibiotics kill off the Lyme bacteria at a rate faster than your body can eliminate them, making you feel worse before you feel better). That could be a good indication that you should stay the course.
The real question is, do you feel like you are going down the right path? No one knows your body better than you do. You know you are sick. You know what your symptoms are. You know they are not all in your head. If you’ve seen an LLMD and feel in your gut that the doctor is right for you, then trust that feeling, and don’t worry what anyone else says.
Opinions expressed by contributors are their own.
Jennifer Crystal is a writer and educator in Boston. Her memoir One Tick Stopped the Clock is forthcoming. Contact her at email@example.com.
The precise chronological origin of acupuncture as a medical procedure is unknown, but it’s thought to date back to as many as 3,000 years ago, in ancient China. Today it’s popular all around the world as a natural treatment for a variety of disorders and discomforts.
In its ancient form, the process, which involves inserting thin needles into specific areas of musculature, was based on the idea that energy imbalances in the body were the root cause of illness. While that may be true in the broadest sense, modern practitioners tend to think of acupuncture as less of a mystical intervention and more as a way of subtly stimulating the body’s nervous system….(go to link for full article)
According to the article, acupuncture can help the following:
The article also points out that according to a meta-analysis acupuncture is a good treatment for chronic pain-related insomnia, an issue many Lyme/MSIDS patients struggle with.
National Institutes of Health researchers found that a single, low-dose ketamine infusion was relatively free of side effects for patients with treatment-resistant depression. Elia Acevedo-Diaz, M.D., Carlos Zarate, M.D., and colleagues at the NIH’s National Institute of Mental Health (NIMH) report their findings in the Journal of Affective Disorders.
Studies have shown that a single, subanesthetic-dose (a lower dose than would cause anesthesia) ketamine infusion can often rapidly relieve depressive symptoms within hours in people who have not responded to conventional antidepressants, which typically take weeks or months to work. However, widespread off-label use of intravenous subanesthetic-dose ketamine for treatment-resistant depression has raised concerns about side effects, especially given its history as a drug of abuse.
“The most common short-term side effect was feeling strange or loopy,” said Acevedo-Diaz, of the Section on the Neurobiology and Treatment of Mood Disorders, part of the NIMH Intramural Research Program (IRP) in Bethesda, Maryland. “Most side effects peaked within an hour of ketamine administration and were gone within two hours. We did not see any serious, drug-related adverse events or increased ketamine cravings with a single-administration.”
The researchers compiled data on side effects from 163 patients with major depressive disorder or bipolar disorder and 25 healthy controls who participated in one of five placebo-controlled clinical trials conducted at the NIH Clinical Center over 13 years. While past studies have been based mostly on passive monitoring, the NIMH IRP assessment involved active and structured surveillance of emerging side effects in an inpatient setting and used both a standard rating scale and clinician interviews. In addition to dissociative (disconnected, unreal) symptoms, the NIMH IRP assessment examined other potential side effects – including headaches, dizziness, and sleepiness. The study did not address the side effects associated with repeated infusions or long-term use.
Out of 120 possible side effects evaluated, 34 were found to be significantly associated with the treatment. Eight occurred in at least half of the participants: feeling strange, weird, or bizarre; feeling spacey; feeling woozy/loopy; dissociation; floating; visual distortions; difficulty speaking; and numbness. None persisted for more than four hours. No drug-related serious adverse events, cravings, propensity for recreational use, or significant cognitive or memory deficits were seen during a three-month follow-up.
Credit: NIMH.To overcome the limitations associated with side effects and intravenous delivery, ongoing research efforts seek to develop a more practical rapid-acting antidepressant that works in the brain similarly to ketamine. These NIMH researchers, in collaboration with the National Institute on Aging, and the National Center for Advancing Translational Science, are planning a clinical trial of a ketamine metabolite that showed promise as a potentially more specific-acting treatment in pre-clinical studies. Meanwhile, the U.S. Food and Drug Administration earlier this year approved an intranasal form of ketamine called esketamine, which can be administered to adults with treatment-resistant depression in a certified doctor’s office or clinic.
Jules Asher – NIH/NIMH
The image is credited to NIMH.
Original Research: Closed access
“Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression.”. Acevedo-Diaz EE, Cavanaugh GW, Greenstein D, Kraus C, Kadriu B, Zarate CA Jr, Park LT.
Journal of Affective Disorders doi:10.1016/j.jad.2019.11.028.
Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression.
Concerns about ketamine for treating depression include abuse potential and the occurrence of psychotomimetic effects. This study sought to comprehensively assess side effects (SEs) associated with a single subanesthetic-dose intravenous ketamine infusion. A secondary aim was to examine the relationship between Clinician-Administered Dissociative States Scale (CADSS) scores and dissociative symptoms reported on a comprehensive, clinician-administered SE questionnaire.
Data from 188 participants were pooled from four placebo-controlled, crossover ketamine trials and one open-label study (n=163 with either treatment-resistant major depressive disorder or bipolar disorder and 25 healthy controls). SEs were actively solicited in a standardized fashion and monitored over the time-course of each study. Statistical analyses assessed the effect of drug (ketamine, placebo) on SEs and measured the relationship between CADSS total score and SEs contemporaneously endorsed during structured interviews.
Forty-four of 120 SEs occurred in at least 5% of participants over all trials. Thirty-three of these 44 SEs were significantly associated with active drug administration (versus placebo). The most common SE was feeling strange/weird/loopy. Most SEs peaked within an hour of ketamine administration and resolved completely by two hours post-infusion. No serious drug-related adverse events or increased ketamine craving/abuse post-administration were observed. A positive correlation was found between dissociative SEs and total CADSS score.
The post-hoc nature of the analysis; the limited generalizability of a single subanesthetic-dose ketamine infusion; and the lack of formal measures to assess ketamine’s cognitive, urological, or addictive potential.
No long-lasting significant SEs occurred over the approximately three-month follow-up period.
It’s also been shown to limit borrelia in vitro: https://madisonarealymesupportgroup.com/2018/03/10/ketamine-limits-bb-in-vitro/
And its’s been shown to relieve chronic pain, improve quality of life, reduce depression and suicidal ideation, and reduce opioid consumption: https://madisonarealymesupportgroup.com/2017/09/14/iv-ketamine-in-ptls/
In a recent study, a team of Mayo Clinic researchers examined the effectiveness of spinal stimulation for pain control, compared to medical therapy or multiple surgeries for patients with long-term spine or limb pain.
They found spinal stimulation was significantly more likely to reduce pain than medication for patients with intractable pain. Their findings were published in Mayo Clinic Proceedings.
“Intractable pain, or refractory pain is pain that occurs when multiple evidence‐based treatments have been tried and the patient has not reached treatment goals,” says study first author Tim Lamer, M.D., an anesthesiologist, pain management, and spine care specialist at Mayo Clinic. “Typically this means they have not achieved satisfactory pain reduction and/or functional improvement.”
According to the National Institutes of Health, “almost 11 million U.S. adults have ‘High Impact Chronic Pain,’ that is, pain that has lasted 3 months or longer and is accompanied by at least one major activity restriction, such as being unable to work outside the home, go to school, or do household chores.”
Because back and/or limb problems are the commonest pain complaints, Dr. Lamer says it made sense to try and determine the most effective ways to help patients.
In this meta-analysis (analysis of a collection of relevant studies), the team study used a random-effects model to compare any type of spinal stimulation to medical therapy. They also compared newer stimulation technologies such as high frequency spinal cord stimulation and dorsal root ganglion stimulation to conventional spinal stimulation.
“This kind of research (random-effects) incorporates uncertainties due to differences between the settings of the studies, like patient or provider characteristics,” says senior author M. Hassan Murad, M.D., a preventive medicine physician and health services researcher at Mayo Clinic. “It’s a common tool in meta-analyses.”
After conducting a search of peer-reviewed publications, they found 17 manuscripts, from 12 clinical trials comparing medical therapy or repeated surgeries to either conventional or new spinal stimulation for pain control.
The researchers also employed the indirect comparison technique. “If studies compare treatments A vs B, and B vs C, we can indirectly compare A and C,” explains Dr. Murad.
“Because we found no studies comparing new spinal stimulation technologies to medical therapy, we needed to indirectly compare them.”
Although there are some limitations, Dr. Murad says this kind of research can help lead to the best possible outcomes for patients.
“The estimates we provide should be used to support shared-decision making,” he says. “Other factors, such as patient’s values and preferences, feasibility and accessibility of treatment also need to be considered when making treatment decisions.”
Publishing the meta-analysis in and of itself may prove to be helpful for patients, as it calls attention to the option of spinal stimulation for pain control.
“Many non-pain specialists are not generally aware of spinal cord stimulation,” says Dr. Lamer, “and how effective it can be for properly selected patients with difficult to manage chronic pain.”
He says that this includes patients with complex spinal pain syndromes, painful neuropathies including diabetic neuropathy, and post-traumatic pain syndromes such as complex regional pain syndrome.
“Patients who are not responding to conventional conservative measures such as medications and physical therapy should be referred to a qualified interventional pain specialist to be evaluated for spinal cord stimulation candidacy.”
Dr. Murad leads knowledge synthesis research like this meta-analysis, in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. He also is the director of the Evidence-based Practice Center.