02/25/18 Beth Darnall

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This week, we discuss pain and pain treatment with Professor Beth Darnall, PhD, a pain psychologist, clinical scientist, and clinical professor at Stanford University. Plus, the March For Our Lives #MarchForOurLives is March 24 in cities and towns across the United States.

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FEBRUARY 25, 2018


DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century Of Lies. I'm your host Doug McVay, editor of DrugWarFacts.org.

This week, we discuss pain and pain treatment with Professor Beth Darnall, a pain psychologist, clinical scientist, and clinical professor at Stanford University.

But first, on February 21, in front of the White House, this happened.

STUDENT PROTESTERS: We are out here today because we are sick and tired of politicians prioritizing their NRA donations over student lives!

We are sick and tired of prayers and condolences because that doesn't initiate action! It is time to send more than just condolences. It is time to send a message from all of us! It is time to send the importance of peace and love, and get rid of this hate that has infiltrated our heads and our country!

They think we're just here to leave school and not go because we just have nothing better to do. They are wrong. We're here to show democracy this is what democracy looks like!

This is what democracy looks like!
Tell me what democracy looks like!
This is what democracy looks like!
Tell me what democracy looks like!
This is what democracy looks like!
Tell me what democracy looks like!
This is what democracy looks like!
Tell me what democracy looks like!
This is what democracy looks like!
Tell me what democracy looks like!
This is what democracy looks like!
Tell me what democracy looks like!
This is what democracy looks like!

We can't do this every day, but you can call, you can email, you can write a letter to your Congressman, every day, every day, you can write letters every single day until they change these laws, until they pass regulations, because we will never leave.

How many more?
How many more?
How many more?
How many more?
How many more?
How many more?
How many more?

We have a voice!
We have a voice!
We have a voice!
We have a voice!
We have a voice!

Be proud of yourselves! Never let anybody tell you that you, and your voice, doesn't matter, that you can't make a difference, because you're making a difference!

Hey hey, ho ho, the NRA has got to go!
Hey hey, ho ho, the NRA has got to go!
Hey hey, ho ho, the NRA has got to go!
Hey hey, ho ho, the NRA has got to go!
Hey hey, ho ho, the NRA has got to go!

DOUG MCVAY: Those are high school students who were protesting in front of the White House on Wednesday, February 21. They were calling on Congress and the administration to take the problem of gun violence seriously.

The February 14 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, a Twenty-First century Saint Valentine’s Day Massacre, has spurred a nationwide movement of young people who are demanding that elected officials take action. They are tired of excuses, they are tired of the same old rhetoric, and they are tired of politicians dancing to a tune played by the National Rifle Association and the far right.

On March 24, young people will be leading demonstrations and protests in Washington, DC, and in cities and towns across the United States. You can find out more, and give them your support, by going to the website MarchForOurLives.com. You can also find them on facebook at Facebook.com/MarchForOurLives.

Now, that conversation with Professor Darnall.

BETH DARNALL, PHD: Hi, I am Doctor Beth Darnall. I'm a clinical professor at Stanford University, in the department of anesthesiology, peri-operative, and pain medicine, and I am a pain scientist and pain psychologist.

DOUG MCVAY: Doctor Darnall, you recently had a research letter published in the Journal of the American Medical Association Neurology on pain and helping patients to taper down from their opioid use. Could you tell me, tell us about your study, what you found?

BETH DARNALL, PHD: Yeah, so, I think most people have heard that there has been a trend towards over-reliance, or over-prescribing, long-term opioids to treat chronic pain, and this is fraught with complications because there's a lot of health risks included with opioids, particularly at high doses. And we've been hearing about some of the unintentional overdose deaths caused by opioids.

As a consequence of this, there is great interest in both reducing opioid use for chronic pain, treating pain with lower risk treatment strategies, and also helping the 6.8 percent of the US population that is now taking long-term opioids, helping them reduce their use of the medication.

And so what we put forward was one of the first studies to describe how we may do this effectively for patients who are just living in the community, you know, everyday people who are taking long-term opioids for chronic pain who are looking for a way to reduce their use without having an increased pain.

A lot of people may have the interest of going into inpatient programs to reduce their opioid use, but these are costly, and very few people have access to these inpatient programs, so we need outpatient solutions, and that's what we describe in our report.

DOUG MCVAY: And, you mentioned, people who wanted to. These were all people who, on their own volition, wanted to reduce their use of opioids, it wasn't a question of a doctor saying, hey, we think you're using too much. These are -- these patients had a -- were personally motivated to reduce their use, right?

BETH DARNALL, PHD: It's a little bit of a hybrid approach. It was definitely a voluntary study, so people needed to want to volunteer to reduce their use. But their doctor approached them and said, you know, we think that this will be better for you. We know that taking opioids long-term has some health risks. We also know that we can help you reduce your use without increasing your pain, if we do it the right way. I am proposing to partner with you to do it in the right way. Are you interested in trying this?

And, so what we found was that when we approached all of the patients in a pain clinic, with this formula, we found that over half of the patients, close to 70 percent of the patients, were interested in trying this. And what that suggests to us is that a lot of patients are looking for solutions, but they just haven't been offered them. And so that's what we aimed to put forward.

DOUG MCVAY: And, so, how did it go? What kind of response did you have? How was retention, and how successful?

BETH DARNALL, PHD: Yeah, so, 107 patients were offered a patient-centered, voluntary opioid reduction program. Of those, 68 patients actually engaged in the taper, meaning that they completed a baseline survey, they entered our study. Of those 68 who entered our society, 51 completed the four month program, and so we had a 25 percent dropout rate, which really is quite low. It's about what you'd see for a non-opioid study.

Of those 51 patients who went through the entire program, we had -- we showed great engagement. We found that on average patients were able to effectively reduce their opioid dose, essentially by half, and these are patients who were taking high dose and very high dose opioids, all the way up to over a thousand milligrams morphine equivalent daily.

These are patients who are on very high dose opioids. Some patients tapered completely off their opioids in four months, but the -- you know, I'm reporting the median reduction, which was, you know, roughly in half.

So what we were able to show, most importantly, is that patients can effectively reduce their opioid dose on an outpatient basis if it's done in a patient-centered way, without increases in pain. This is really important, because the number one patient fear about reducing opioids is that they're going to have an increase in pain. And what we're showing is that there is a way to do this, where you can reduce patient risk, without increasing their pain.

And this is vitally important information for both prescribers and patients to hear. We are now testing these patient-centered methods in a very large study in almost 900 patients taking long-term opioids. This clinical trial launches in July in four western states. So while this JAMA publication put forward the preliminary evidence, we aim to answer these questions more definitively in this larger study.

DOUG MCVAY: I know that some of my listeners will be quite interested in knowing the answer to this one: how extensive were people -- how many of your research subjects were users of medical marijuana -- medical cannabis, sorry -- during your test?

BETH DARNALL, PHD: You know, if I recall correctly, 17 came into the study using marijuana, you know, whether for medical or other purposes, but we just quantified marijuana. And one of the things that we were interested in understanding, the study was conducted in Colorado, and I hypothesized that people may taper down off their opioids, but they'd be more likely to transition to marijuana.

We actually didn't find that. We did find that people who were using marijuana at baseline were more willing to engage in the taper program, but our numbers were kind of small, yo know, there were only those 17 people who dropped out of the study, and fewer of the 17 were using marijuana relative to those who stayed in the program. So I think, you know, the caveat is, our numbers are small, this is not definitive, but I think the one take-home is that we didn't -- we didn't see that marijuana use increased over -- as people reduced their opioid use.

DOUG MCVAY: And that's -- and that's a remarkably small number of pain patients who were using, especially considering that's in Colorado, not only legal for medical use, but legal for adult use, I mean, even if people didn't want to go to a physician to get a recommendation, you know, people self-medicate because of sleep, because of stress, anxiety, because of -- as well as pain, all of -- and sleep disturbance and anxiety go hand in hand with pain conditions a lot, so that's -- I mean, I find that, you know, I find that astounding.

BETH DARNALL, PHD: Well, you know, but in truth, if you consider that 51 people went through our entire program, and of those 51, thirty percent were using marijuana, you know, that's pretty accurate for what we see among people taking -- who have chronic pain, you know, that's a -- it's a fair number of people, thirty percent. So just to put that in perspective.

DOUG MCVAY: Now, I -- let's step back for a moment and talk about -- let's talk about pain for a moment. This is a -- well, I mean, we have our attorney general saying that people should just suck it up and take a couple of Bufferin.

We have -- before we were, before we started the interview, I was telling you a story about a speech that I had to -- a presentation I had to do before a group of HR reps many years ago, during a medical marijuana dispensary initiative, and I got a really, you know, pretty decent response from most of them, but one in particular was just angrily dismissive of the whole idea of pain as something that needed to be treated. Whining malingerers, I think, was the kindest thing that that gentleman had to say.

But pain is a real condition, right?

BETH DARNALL, PHD: Oh, absolutely. Pain is -- all pain is real. This is the first message that I always deliver. All pain is real, and what's interesting about pain is that no matter where we feel it, in our body, it's all processed in our central nervous system, the brain and the spinal cord. And for that reason, because pain is processed in our central nervous system, it's highly influenced by a lot of different factors.

Pain is processed in regions of the brain that are very much associated with the emotional experience. Pain is highly influenced by our attention, by our focus, by our cognitive processes. In fact, pain is highly influenced by our psychology, and by our mindset.

And this is actually recognized in the definition of pain. We tend to think of pain as being a purely negative sensory experience, you know, something that we just feel in our body, but in fact, the definition of pain is that it's a negative sensory and emotional experience. So psychology is built into the definition of pain.

And you really and truly can't separate the two. And that doesn't mean that pain is any less real. It just acknowledges that we have an opportunity to focus on some of these psychological aspects: our attention, our thoughts, the emotional aspects. We can focus on some of those pieces to help dial the pain down. It doesn't mean that the pain is any less real.

Unfortunately, a lot of people living with pain may have heard at some point that their pain isn't real, or it's all in their heads, and nothing could be further from the truth. All pain is real, and there's an opportunity for us to equip individuals with certain skills and information that they can use to help reduce their own suffering.

DOUG MCVAY: Again, we're speaking with Professor Beth Darnall, a pain psychologist and researcher. Her recent research letter now is going to be a large-scale research project. Nine hundred or so individuals, you said?

BETH DARNALL, PHD: Yes. Yeah, so, in total, 865 patients who are taking long-term opioids for chronic pain will be enrolled in our voluntary opioid reduction program. We aim to help them first reduce their opioid use, and also treat pain better. We're going to be giving them various classes that can -- where they learn information that they can use to simply better self-manage pain.

But we're also going to be studying -- we're going to be following about 400 additional patients who simply are remaining on opioids long-term. We don't have a lot of data that -- to inform how people do when they're taking opioids long-term. So we want to characterize that as well. So in total, it will be between 1,200 and 1,300 patients that we characterize over the course of the three and a half year study.

DOUG MCVAY: Now, you said in four western states, so presumably you'll still be taking note of medical marijuana, or just regular marijuana use. That's not a disqualifier, obviously, for the --

BETH DARNALL, PHD: Oh, absolutely not. No, no, there -- you can be taking any other types of medications, and still be in the project. We will be characterizing marijuana use, of course. We're very interested in that. The only exclusionary criteria, other than not being able to provide informed consent, is if somebody is -- has substance use disorder. In that case, we want to steer them towards appropriate treatment.

DOUG MCVAY: And then presumably if they are in treatment for that, then that's -- that takes them out of the equation as well.

BETH DARNALL, PHD: Yeah, correct.

DOUG MCVAY: Obviously if they're in treatment they've been diagnosed. Okeh, that was a dumb question. Sorry about that. Doctor Darnall, how did we get to this point? What led us to this, these levels of use and these levels of concern, and these levels of untreated pain. What brought us here?

BETH DARNALL, PHD: So, there's a -- my response to that question is that it's -- the reasons are multifactorial. A lot of different factors combined to get us to this point, where we see this over-prescribing, with a lack of focus on the alternatives that are lower risk for people, but I will say that one of the main issues has been a lack of pain education in medical schools.

And, this is highly problematic. Physicians are trained very well to solve quick problems, to treat infections, to write a prescription that addresses the quick symptoms, but they're not well equipped to manage chronic conditions, especially chronic pain, which necessarily involves more of a rehabilitative approach, and one that necessarily involves pain's psychosocial dimensions, because pain is truly involved in psychosocial aspects.

So for that reason, we have been overly enthusiastic about prescribing opioids when they don't correlate, on average, with people being able to restore function and get back to doing the things they love. Now, I want to be really careful, because I freely acknowledge that opioids are effective for some people, and prescribing rights should be preserved for those people who strictly need them, but they have been the minority of patients who have been prescribed opioids long-term.

So, given that, the CDC, the DEA, the FDA, all of these federal agencies, started to realize that there was something of a crisis and needed to put prescribing limits in place. Unfortunately, these prescribing limits at the federal and state level were put in place without doctors having the training to do this in the right way, and without having alternatives in place for patients.

Consequently, there has been this movement to drastically reduce opioid prescribing, and with -- it has been traumatizing to patients who have been taking opioids long-term, and then find themselves suddenly being told, okeh, we're going to reduce this. Forced tapers do not work well, and this is why our study is unique, because what we are putting forward is the radical idea that it is incredibly important to partner with your patient in a compassionate way, work with them, engender their trust, develop a slow plan to help them reduce their use, one that addresses their fears and their concerns.

It's vitally important that patients feel trust, and that they feel safe, and secure. Otherwise, we will be amplifying their fears, and this will undermine their ability to successfully reduce their opioids. This authoritative environment around their opioids, you know, laws and regulation and dictating what will happen has been flowing from agencies to the doctors down to the patients, and that approach doesn't work well, so we are putting forward a different approach that necessarily integrates the patient as the most important person in the equation. We have to help them succeed.

DOUG MCVAY: I'm curious, will you also be looking at -- as I said, sleep disturbance and anxiety go hand in hand with chronic pain. Are you also going to be looking at the use of anti-depressants, the use of sleep medications, or is that outside the scope?

BETH DARNALL, PHD: Yeah, we are -- we're reporting use of all medications. We are specifically focusing on reducing, actively reducing, opioid use, but we will be tracking all medication use over the course of the study.

DOUG MCVAY: Terrific. And, well, let's see. Are you currently recruiting, or have you already recruited the patients for your study?

BETH DARNALL, PHD: Now, the -- right now we're staging all of our systems, and our clinical trial goes live in four states on -- in the first week of July.

DOUG MCVAY: Wow. Well, I wish you all the luck in the world, and I want -- I hope to speak with you when you've got results. This is interesting work.

BETH DARNALL, PHD: That sounds great, Doug, I really appreciate the opportunity to speak, and if you or any of your listeners want to learn more, they can visit my website at BethDarnall.com.

DOUG MCVAY: Excellent. And, any closing thoughts for the listeners, and for the benefit of folks, Beth Darnall, that would be spelled BethDarnall.com.

BETH DARNALL, PHD: Yes, that's correct. And, even if they misspell it, chances are they'll get redirected to my site, so, that's just fine.

I would just encourage listeners to visit my website or any other resources where you can learn more about pain psychology, and how pain psychology can help you learn how to better manage, better control pain non-pharmacologically.

DOUG MCVAY: Terrific. Professor Darnall -- Doctor Darnall, thank you so much for your time. This is fascinating. I greatly appreciate it.

BETH DARNALL, PHD: I appreciate it, Doug, thank you for the opportunity.

DOUG MCVAY: That was my interview with Professor Beth Darnall, a pain psychologist, clinical scientist, and clinical professor at Stanford University.

You’re listening to Century of Lies, a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I’m your host Doug McVay, editor of DrugWarFacts.org.

Earlier this month, on February 14, at a Florida high school, seventeen people were shot and killed by one person with an assault rifle. At a protest at the White House on February 21, students read off the names of those who died.

Scott Beigel.
Martin Anguiano.
Nicholas Dworet.
Aaron Feis.
Jaime Guttenberg.
Chris Hixon.
Luke Hoyer.
Cara Loughran.
Gina Montalto.
Joaquin Oliver.
Alaina Petty.
Meadow Pollack.
Helena Ramsay.
Alex Schachter.
Carmen Schentrup.
Peter Wang.

DOUG MCVAY: On March 24, young people will be leading demonstrations and protests in Washington, DC, and in cities and towns across the United States. You can find out more, and give them your support, by going to the website MarchForOurLives.com. You can also find them on facebook at Facebook.com/MarchForOurLives.

We close this week’s show with the words of Mario Savio, a leader of the Berkeley Free Speech Movement, speaking in 1964 in front of Sproul Hall at the University of California – Berkeley.

MARIO SAVIO: There's a time when the operation of the machine becomes so odious, makes you so sick at heart, that you can't take part, you can't even passively take part. And you've got to put your bodies upon the gears and upon the wheels, upon the levers, upon all the apparatus, and you've got to make it stop! And you've got to indicate to the people who run it, to the people who own it, that unless you're free, the machine will be prevented from working at all!

DOUG MCVAY: For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.

Dean Becker Wants YOU to Call the Drug Czar