I have more than one condition that limits what I can take for pain. I do not want to take opioids but I also do not want to hurt. My doctor recently told me that some study said that pain meds only stopped the pain in patients' minds. Who gives a fruitcake where it stops the pain if it stops? I never heard anything so stupid before. Of course he offers no solutions. I also resent people who abuse drugs so that those of us who need them can't get them and even more so the politicians who make them so hard to get because of some crises that does not effect me. This is especially aggravating when I run into people who can get them when they need them, the privileged somebodies in the world. If I say anymore I am going to get very ugly so I will stop. Let it suffice to say that anyone who perpetuates these lies and leaves patients in pain deserves to experience excruciating pain on a daily basis for the rest of your life, you deserve it.
1
Having had knee replacement surgery recently, I am very familiar
with opioids and their bad side effects.Why then do doctors
only prescribe opioids for severe pain? I must admit that I am skeptical about this study for that reason. I wasn't told that
I had a choice of pain medicines,I was prescribed oopioids
So why is this done?
I had my gallbladder removed without a big cut. I was walking around in the hospital and not complaining of pain. Yet they gave me a prescription for opioids when I left. I didn't fill it because I had no pain. But I could have filled it for $10 and probably sold the pills.
1
"Because people know that opioids exist, it’s hard to get them into a trial where they might take less powerful pain medications, like acetaminophen or ibuprofen. "
Most adults already know whether acetaminophen and ibuprofen are effective in reducing their own pain. They are available OTC, and are the first things most people try for chronic pain. Studies that look at large numbers of patients may reveal the potential for effectiveness, but they say nothing about how well a pain medication will work for an individual patient.
That is one of the things that is wrong with current chronic pain management -- at least in my own experience. So-called specialists have read a study or two -- or more likely the results of a study or two -- and then apply the results to every individual patient. Common sense may not be able to tell us who will or won't be helped, but it will tell us that some won't be, yet they are still required to ignore what may have proved effective for them in the past and accept the new conventional wisdom that opioids are no better than acetaminophen for chronic pain.
In my state, the chronic pain opioid prescribing guidelines are designed to reduce overdoses and deaths, not treat chronic pain.
"It’s also hard to do the long-term studies we need, because patients often want to try other options if the first one doesn’t work."
If it doesn't work, why continue to take it? Good study; bad medicine.
1
In this article Mr. Carrol explains how most healthcare studies are completed in the laboratory. They are done in a controlled environment, in optimal conditions. If successful, scientists can show that a treatment will work in these conditions, thus proving the treatments efficacy. Mr. Carrol argues that these studies are not effective and we actually need to do studies in the real world, under real settings. These studies are called pragmatic trials, and he believes they can prove a certain treatments effectiveness rather than efficacy.
This article leads the reader to believe that pragmatic studies should often replace studies completed in a laboratory setting. While I agree that pragmatic studies are extremely beneficial and can lead to real life results, this article fails to examine the difficulties that arise when conducting a true pragmatic trial. In 2016 the New England Journal of Medicine examined Pragmatic Studies in an article titled “The Changing Face of Clinical Trials: Pragmatic Trials”. This article identified a few key challenges to Pragmatic Trials.
One of the biggest struggles of Pragmatic Studies is the time and effort required to recruit study participants. Finding the ideal patients is difficult enough, and then it is still necessary to recruit them to join the study. NEJM discovered that less than a 10% response rate to screening is common. It also appears that this rate is continually declining as well.
2
In most trials, there is commonly a random group whom is blinded to the ongoing actions of the study and investigators. However, in true Pragmatic trials, the random group is generally not blinded. In the Pragmatic trial referenced throughout Mr. Carrol’s article, it is not stated if the group who was not administered opioids was blinded or not. It is necessary for patients in studies such as these to be blinded for it to truly be effective.
Mr. Carrol does indeed mention throughout the article that there are difficulties that arise with Pragmatic Trials. He mentions that indeed because of these difficulties, most Pragmatic Trials are not completely Pragmatic, but rather they are somewhere on the continuum of trials. Mr. Carrol casually mentions these difficulties, and then moves on to expound upon the benefits of Pragmatic Trials. I believe that this article needs to more fully examine the difficulties that will arise when doing Pragmatic Trials, and not casually push them to the side.
1
In the US, when we have a crisis we generally overreact. In the 90s doctors were undertreating chronic pain. So, they dramatically increased the prescriptions for opioids.
Move forward to the opioid overdose crisis. Once again, the US has a crisis so it overreacts. Now, acetaminophen and ibuprofen are routinely being pushed by pain management doctors as being at least as effective and often more effective in treating chronic pain than opioids. Along the way the individual patient has disappeared. In Washington State, the guidelines for prescribing opioids for chronic pain have little to do with treating pain and everything to do with reducing overdoses and deaths. The goal is to reduce every patient to a level of opioid ingestion that makes overdosing extremely unlikely. If, at that level, the patient suffers from inadequately treated pain, that's just too bad. After all, there is always acetaminophen or ibuprofen. Nevermind that patients with cardiovascular disease can't take ibuprofen or naprosyn.
What we don't see is the breakdown of overdoses and deaths. What percentage are chronic pain patients taking their meds as prescribed? What percentage are people carelessly combining opioids with alcohol or benzodiazepines, for example? And what percentage are people who were denied opioids by their doctors and have turned to street drugs out of desperation?
Most people I know say that acetaminophen does nothing for them. I find it may help with minor headaches. Patients with
6
We are exhorted in our post-op-care instructions, especially for orthopedic surgeries requiring subsequent physical therapy, to "stay ahead of the pain" because it's easier to maintain a steady 2 or 3 on a scale of 0-10 than to try to bring it down from a 6, 7, or worse. Yet even 5 years ago it was far easier to do that, and to wean off opioids gradually and fully. Nowadays, the same meds require us to repeatedly visit our physicians to get paper prescriptions, which are limited to perhaps a week's worth or less. For those who can't (or shouldn't) drive yet, to have to make those repeat visits to doctor & pharmacy far more often, it is truly a hardship that seriously hinders recovery--how can we rehab our injuries and function if our pain is inadequately controlled?
It is manifestly unfair to punish pain patients because others depend on the euphoria and end up addicted to not just opioids but opiates, with tragic results. Do we keep people from buying matches & candles because house fires happen? Do we severely restrict driving and auto sales because of traffic deaths?
4
Study needed ?
Surely you jest.
Anyone with basic common sense and some basic biology classes knew many years ago that there were too many people receiving too many pain pills for too many things.
When a child , I would tell my mother that a bruise still hurt if ice cream was involved as treatment.
Now we have created a backlash against those that have real pain and are being denied by a medical professionals that once again, want to be with the "in" crowd of their field. One extreme to another.
2
Not a great explanation of pragmatic trials, of which there are a great many varieties. Moreover, they are not necessarily any more expensive, depending on the design (e.g., a factorial trial may be more efficient). Pragmatic trials can tell a lot about implementation and like traditional RCTs, they can be used to look at moderators or subgroups if sufficient power is present. The limitation of RCTs is that they are good for a limited range of comparisons and the construction of control conditions often has little to do with practical or other reality, but guys like you have been enshrining them for far too long as a gold standard.
2
At least opioids can be tested. The Veterans Administration is not even permitted to do clinical trials on medical marijuana!
4
Tramadol is indeed an opioid and can be highly addictive. Many states have now recognized this and have reclassified Tramadol into a more restrictive prescribing classification.
4
@Trish you are so right
1
@Trish Tramadol did nothing for me. I may as well have been taking nothing for all the good it did. I have my doubts on the efficacy of this drug.
I know there are over the counter drugs that have the same effect for me like Tylenol and Ibuprofen are both useless and worthless for me as neither of those work for me.
As a person who often has severe chronic pain, it is sad that there is often no relief for me or others even worse off than me. This war on drugs is particularly harmful to those with Migraines, Cancer, Fibromyalgia, Rheumatoid Arthritis, and other painful diseases and conditions for which OTC drugs do not work in any meaningful way.
2
@Trish Yes Tramadol certainly is an opioid.I am rather surprised that this was not clarified in the article.
Ok gang, let's bottom line it, imo, what history has taught us.
Promoting or banning a dangerous drug almost always ends up in failure.
We promoted hard core drugs like LSD, coke etc. in the 1960-70s (although they were technically illegal) and there were countless deaths, drugs wars, crime etc.
We did a similar thing with opioids now with a similar result.
Now trying go get an opioid pill legally is all but impossible. It in effect has a de facto legal ban which opens up the black market and crime.
Safer drugs should have the least regulation and dangerous drugs should have the most regulation.
Outright bans never work. The most dangerous drugs should have the strictest regs. on them.
4
LSD is not a “hardcore drug”, and was not even made illegal until late in the 60s (1968). LSD has very low toxicity, and there have been no fatalities from overdoses. Nor is there any evidence of long term harm physical or mental from its use, although it is true that people can have a “bad trip”, and in very rare cases do themselves or others harm as a result. Harm to the self or others is, on the other hand, relatively common with many other drugs, both legal and illegal. Please stop the baseless fearmongering about psychedelic drugs like LSD.
1
The only thing this study proved is that patients who weren't deemed to need opiates/opioids by their own doctors got a correct medical assessment in the first place. If anything, this suggests we're moving in the right direction with opioid prescriptions: they're being withheld from patients who do not really need them. It doesn't speak at all to the condition of patients who do require these drugs.
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As a pain medicine and addiction medicine specialist who has prescribed opioids when they are appropriate and who now teaches a remedial live nationwide prescribing course, I am fully aware that there are people who benefit from opioids, and others who do not, as well as those who misuse the medications. But I regret that Mr Carroll used this particular study from which to draw conclusions about the lack of value of opioids for chronic back pain and for osteoarthritis-related knee and hip pain. The SPACE trial is highly flawed in its methodology. For one thing, as Katt above commented, the study did not include patients whose doctors had previously believed they might benefit. Even worse, the printed study did not list the actual opioid doses these patients received; you have to get online to find this. It turns out that the mean opioid dose the opioid group received was about 21 mg of morphine or morphine equivalents [ME] per day, which is a very small dose for many patients with chronic pain.[eTable 8 reports that for patients treated with opioids, the mean daily opioid dose at 3 months was 21 mg ME, at 6 months 23 mg ME, at 9 months 21 mg ME, and at 12 months 21 mgME] So it's not surprising that a large proportion of them did not experience significant pain relief -- they just weren't getting enough medication! A meaningful study would be one that gives those patients doses that are actually often effective. Jennifer Schneider M.D., Ph.D.
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Dr. Schneider,
You overlook two important facts:
1. There are no studies proving that opioids are beneficial for chronic pain at any dosage. It's ironic that we need to prove other medications are effective for it but don't require this for opioids.
2. When it comes to the management of chronic pain, the most important thing is improvement of functioning. It doesn't matter how much the pain is improved if there are no objective signs of improvement of functioning then the patient really isn't benefit. This one of the problems with all the studies on medical marijuana for pain; they only look at self-report of reduction in pain but don't seek to determine its impact on functioning.
Steve, As Dr. Alford in an editorial in New England Journal of Medicine (2016;374:301-303) cogently wrote, "Groups lobbying against prescribing opioids for chronic pain remind us that the effectiveness of long-term therapy has been inadequately studied. I believe this is a case of ABSENCE OF EVIDENCE rather than EVIDENCE OF ABSENCE." The point is, efficacy studies are done primarily by drug companies, and it seems it hasn't been worth it for them to fund long-term studies. So the absence of studies does NOT mean opioids don't work, just that high-quality studies haven't been done. What we have now is the clinical experience of physicians like myself who have followed patients for years on opioids and have observed how they've benefited in function. In the live remedial prescribing course that I've been teaching for years to prescribers who've been disciplined by their various state medical licensing boards regarding their prescribing, I repeatedly emphasize the importance of focusing on FUNCTION. Jennifer Schneider M.D., Ph.D.
A lot of the people commenting about how opioids are the one and only thing that helps them with their chronic pain may be suffering from addiction and afraid to admit it to themselves.
The strongly defensive tone taken towards opioids is suggestive of addiction.
3
No. This is exactly the terrifying thing here: anyone whose pain cannot be managed by Tylenol and deep breathing is now being treated as a criminal trying to steal drugs. Patients are treated with this kind of cruelty and contempt when they don’t fit your one-size-fits-all box.
12
These sounds rather insular. You can have all the studies and debates you want. But why is it no one asks the simple question: what about the rest of the world? (Whataboutism, so?)
They too have hip replacements, knee surgeries, molar extractions, fractures, falls and so on. Why do they not have the same issues with painkillers? In fact, in one medical seminar in Asia, a doctor commented that Asians don't like to take painkillers. Interesting because it reflected personal experience. I just had 3 molars extracted and was given three types of medication for pain. I took none of them.
With all the whining over so many things (eg China cheats, EU unfair, gays ill-treated, Trump idiotic, foreign meddling, etc), have Americans gone to the stage where they can't take pain?
3
@Andrew Ton Americans can't handle pain as effectively because of all of the sugar in our diets. The sugar causes added inflammation, which requires heavier painkillers. I take gabapentin for joint pain and was able to reduce my dose from 900 mg daily to 300 mg daily after I eliminated sugar from my diet. The crazy thing is that there is research from the American Diabetes Association published in 1984 that shows that both sugar and opioids have the same affects on blood sugar and that naloxone is beneficial for insulin resistance in the same way that it helps people suffering from overdoses. http://care.diabetesjournals.org/content/7/1/92
Sugar is our society's gateway drug to opioids and is the reason many of us need them in the first place.
1
I have been taking oxycodone for eleven years. I have degeneration of both the c-spine and l-spine; at times these conditions cause considerable pain.
I have GERD, so aspirin, COX-1 and COX-2 medications (such as ibuprofen) are contraindicated. Acetaminophen (paracetamol for you Brits) doesn’t help, and can cause liver damage.
I have yet to become addicted—I make sure to never abuse my medications; I average less than one 5 mg. oxycodone per day—I only take it when I absolutely need it—days go by with no use. Tramadol made me feel suicidal due to its SSRI-like effect (I called it truamadol), so I can’t take that, either.
The epidemic of opiate abusers have made my life more difficult. Regulations now require that I must see my doctor every month.
Pragmatic trials are an excellent idea, but where does that leave me when the data shows that I can live without the medications that I absolutely need. Samuel Clemens said it best, though the origin of the quote is obscure: “There are three kinds of lies: lies, damned lies, and statistics.”
Data never tells the whole story.
6
"Let’s take chronic pain as an example. Those who suffer from it want relief, and they want it now"
What an appallingly caviler attitude towards pain sufferers. And from a doctor, this is even more appalling. I wonder if the author -- or any family member, has ever experienced terrible pain, which lasts and lasts and/or seems as if it will never end? It's so easy to tell other people to suffer!
11
Pain control?
Stop prescribing addictive drugs.
Pharmaceutical companies, stop manufacturing.
Doctors, stop prescribing.
Public shaming of both parties is essential. Analogous to tobacco growers, cigarette manufacturers.
The VA needs to get behind this, and all others.
What if the whole opioid hysteria was just an attempt to keep the prisons full now that pot is being legalized? Nicotine kills more than 3 times as many people as opioids, with no medical benefits at all. I guess it all boils down to who your lobbyist is.
I now live in Sydney, Australia where the protocols for pain treatment are very different. My daughter recently underwent major surgery. In the aftermath, they prescribed a combination of opioid, Endone, and Panadol, for just three or four days post operation, then Panadol only until the pain subsided. The Endone makes you very nauseous, so our daughter elected to stop taking it the second day after the surgery, opting instead to deal with more pain but a drug with few side effects. I recall an OpEd in this paper some months ago about practices in France, which are similar. It seems to me that a large part of the problem is the expectation that you can, and should, make pain disappear, if possible. Perhaps we need to change expectations in the US as well as trial other drugs.
3
The study design is meant to reflect actual patterns of patient treatment in a clinic and judge how well they respond.
There's a *major* flaw with the study design. Patients aren't *immediately* offered chronic doses of opiates.
All of the "non-opioid" therapies are tried first and then *only* if the patient's quality of life is continuing to decline are they escalated to opiates.
You don't get on morphine without having tried *every* non-opioid intervention this study evaluates along with 20 others it didn't.
This study is trying to illustrate that opiates are no more effective than non-opioid therapies... in the target population.
They didn't actually look at the target population. The target population is the patients with unrelenting pain that *didn't* respond to other therapies.
An *actually* pragmatic study design would filter these patients through the entire range of escalating therapies. The ones who succeeded with non-opioid therapy would be released from the study... and those that didn't would continue.
In the end you would compare the efficacy of drugs' effects in the same patients (not across). For the patients escalated to fentanyl was it more effective than the tylenol they started with?
The question isn't whether opiates are a good idea for everyone.
It's whether they work for the most severe chronic pain that *does not* respond to other therapy. The target population isn't people with a "sore back", it's people who are ready to commit suicide.
5
In 1979 I had a laparotomy (open abdominal surgery) where my incision was 12 inches long. After 3 days in the hospital, where they were giving me morphine shots every 4-6 hours for the first 2 days they stopped on the third day and sent me home with no pain medication. The pain was excruciating. I needed at least a week before I could walk to the bathroom without my parent's assistance. I was a strong teenager back then and I could have used about a week's worth of Percocet (14 pills) or whatever they were prescribing back then. I only had plain aspirin, Motrin and Aleve were only available by prescription in 1979. My mother later called our GP and he prescribed some Motrin by prescription a few days later after having to deal with excruciating pain. Years later, doctors started giving out opioids in large quantities between the late 90's -2000's. Example, we went to the ER because my husband hurt his ribs and wanted to get an x-ray. The doctor offered him a prescription for some Percocet or other opioid which he did not accept because there was only bruising, no broken bones. Now with the opioid epidemic we have swung back to where we were in the 70's. Doctors are reluctant to prescribe even small amounts of opioids after major surgeries. I read online that they are now offering Motrin after major surgeries such as mastectomies. The last time I had Percocet was after a laprascopic surgery in 2011. It was major surgery and I was given an appropriate amount (about 10 pills).
4
I've got a better question than the authors opening title.
What if doctors, pharmacists, and the drugmakers did their jobs and monitored patients and when their patients were getting hundreds of pills months after surgery they weened them off. The same can be done for serious chronic pain.
Stop making people pay for the mistakes that you made, but cutting off everyone.
Our medical care is starting to look like it's run by the Keystone Cops.
2
Hey everyone, stop assuming that your threshold for pain is the same as everyone else's. I had four teeth pulled at once by an oral surgeon as a teen. He gave me a bottle of codeine and said to use if if ibuprofen/ tylenol did not work. For whatever reason, I had practically no pain and didn't even have to use ibuprofen/ tylenol. However, as an adult now who takes care of patients, I don't assume that just because I didn't need pain meds, my patients don't either.
16
What if studies showed that the opioid crisis was mostly fueled by fentanyl from China? What if studies showed that studies on prescription opioid use did less than Portugal's strategy of decriminalizing drug use to stem drug deaths?
6
In the early 90's I landed in the ER after an accident gave me a nice 4-in slice above my knee. The attending MD said "only a few" muscle fibers were affected but she wanted to do a dye-injection test into the joint to make sure the knee capsule wasn't compromised. I wanted to decline but was told "better safe than sorry", so I agreed to it. As a result of the pressure caused by the injection, I was in agony almost immediately and for over 24 hrs; it was way worse than the injury, and all they offered me was ibuprofen, when they could have at least given me a 36 hr Rx of an opioid. I'll never forget the pain, and never forgive their insensitivity. A little common sense in prescribing would go a long way.
12
@Mary Ann
Dr’s (and other prescribers) are afraid, must be Very afraid of(?).... liability issues or government (DEA!).
I share your annoyance.
Most comments written here seem to be working hard at justifying the need for opiates for all levels of pain management. Of course, there are many variables at work, but the one absolute is that they are addicting. Yes, we have a problem with deaths related to alcohol and smoking, but clearly that doesn't justify not addressing this one that may cause drug seeking behavior, if one cannot get a script. For short term, acute pain, opiates are the right choice, but for longer term, chronic pain there needs to be an attempt to find other methods, and there are quite a few. The numbers of opioid drugs that were distributed to many small community pharmacies in amounts that were so far beyond what was required was like having pushers in place.This didn't happen without the efforts of those seeking the almighty dollar.
5
@Diane B Patients who take opioid analgesics as prescribed do not always -- I dare say they rarely -- become "addicted." Are they dependent on their medication for their quality of life? Yes. So are diabetics, but we don't call them insulin addicts, do we? All patients should receive appropriate medication to treat their conditions regardless of how society may feel about opioids or any other safe, effective medication.
11
Yes, they are addicted. Try telling them that they need to wean off their pain meds. They will scream, cry and beg. I work for a former pain management family practice practitioner. Long term opioid patients need to be followed by pain management specialists. For most patients, opiates should only be used for short term, acute pain.
2
@Sandi
Do you ever wonder if they are screaming, crying, and begging for help because they actually have a decent quality of life with opiates?
"Perhaps" they aren't crying because they are "addicted" but they are crying because you are destroying their lives.
How would you expect a well educated type-1 diabetic patient to behave if you took them off their insulin? Do you think they would be okay with it? Thanking you for "saving" them from the insulin they were "dependent" upon?
1
Everyone can become physically dependent on opioids, if they take them regularly for a period of time, say 5 to 7 days. A stronger opioid i.e., fentanyl, a higher dose, or a longer period of treatment will likely lead to greater physical dependence. Many of the physical symptoms of opioid withdrawal are similar to a severe case of the flu: diarrhea, upset stomach, chills, sweats, gooseflesh, runny nose, tearing, and bone or joint aches. Anxiety, restlessness, tremor, yawning, and increased pulse are also common.
However, people with the flu do not break into pharmacies to get flu meds. However addicts will do many illegal and dishonest things to maintain their drug supply. Addiction is more than just physical dependence. It has the added ingredient of an overwhelming craving for opioids beyond the dose needed for pain. In addiction, the entire personality can be subverted by a cluster of drug seeking behaviors.
Purely physical dependence can often be managed by gradual dose reduction on an outpatient basis. But addiction requires detoxification in a controlled environment, and even that does not remove the long term craving for opioids that causes addiction to be a frequently relapsing disease. The best long term management strategies seem to be maintenance with methadone (a long acting opioid) or various buprenorphine containing drugs. Only some people will become addicts if treated for pain with opioids. Sadly, doctors can't tell who they are in advance.
1
@MikeMav
Studies in European countries show pretty clearly that addicted patients have the best results being maintained on full agonist opioids .. morphine or even heroin.
Likewise once they are on a stable dose ... find happiness and stability ... weaning them off like any other patient becomes not only feasible but something *most* CHOOSE to do.
@MikeMav
I find it interesting that you don’t deal with psychological aspects of addiction. My belief is that an individual may be weaned from drugs physically—if there is no pain—but if they are addicted psychologically, they will relapse.
@MikeMavSounds like a problem best left to insurance companies.
First, in a world not run by and for corporations, drug companies would have nothing to do with paying for research. It's like having every parent test their own kid; how ridiculous.
I don't understand even caring about bacterial contamination of urine; how is that efficacy? I would have thought antimicrobials on catheters (in-dwelling?) would be to prevent urinary tract infections due to colonization of the cath; I'll agree that's the effect desired.
I don't understand how previous generations, before docs were taught by drug companies to relieve all human suffering with narcs, were not screaming in pain.
I've had a few broken bones recently; the rib fracture really hurt. Lidocaine patches worked great. My wrist fracture and then a hip fracture didn't need anything but a few motrin type meds. I told a nurse about that and he said he also broke a leg that didn't need narcs for pain relief.
But then how effective are narcs for chronic pain? Some chronic patients just need more and more. Maybe it's something else involved in the problem called pain.
I had sciatica for about 3 weeks, it didn't resolve so I used those left over lidocaine patches. Perfect. Then I told my daughter, the acupuncturist. She applied her needles, the first treatment relieved about 75% of the pain, without those lidocaine patches. The next week, I got a second treatment and the sciatic nerve is relaxed and happy. So am I.
Narcotics, sugar and tobacco: they sure work on lining some pockets.
3
@citizen vox
Previous generations did have opium. The opium poppy is one of the oldest known domestic plants, dating back at least 3,500 years in the Middle East, and cultivated all across Eurasia. It was regarded as a blessing, not a curse, and no religion bans it. Opium was a regular article of trade and commerce until the beginning of the 20th century. It doesn't seem to have destroyed civilization.
3
@citizen vox
Read "The Hacking of the American Mind" by Robert Lustig.
Your right on the money about Narcotics, sugar and tobacco. These are huge profit centers for the corporations and all three destroy the health of millions. Big Pharma spends billions to develop new drugs to treat self induced diseases caused by corporate greed. Our corporately owned government looks the other way to allow the corporations to feast on the lives of uneducated and clueless people duped by the FDA. It's actually a criminal corporate mentality that poisons our nation daily.
Sure, doctors need to rein in how they prescribe opioids (and they are). Sure, drug companies need to quit rewarding high prescribers (and they are). Statistics are useful for generalizations but we must also think about the individual patients with severe chronic pain, who have tried everything in the non-opioid list as well as cognitive behavioral therapy and meditation. Where I live, many primary care providers, fearing litigation, have stopped prescribing opioids, referring patients to the pain clinic which is not accepting any new patients for medication management.The patient with chronic severe pain is left to seek relief in cannabis, street drugs, or suicide. This is not melodramatic, just the way it is.
19
The "opioid epidemic" is largely an issue of either entirely illegal substances or illegally obtained medications. Few people with legitimate pain become addicted. There is a difference between physical dependence (a normal effect of many drugs including widely prescribed antidepressants) and addicition where people misuse a drug for pleasure. Focusing on people who need medication for pain will do nothing to tackle illegal drug use and addiction. Furthermore, there seems to be a complete disregard for the dangers of the alternative medications. NSAIDs like advil cause tens of thousands of deaths per year in the US due to bleeding and stroke. Too much Tylenol can destroy the liver. Many of the prescription alternatives have very serious side effects. When properly taken opioid pain medications are often MUCH safer. If you have to take 4,000 mg of regular acetaminophen (tylenol) every day for some relief you run a sizeable risk of liver damage but you can likely manage quite well with a modest dose of Norco that has only a small amount of acetaminophen. Are we all meant to lay down and die so people can ignore the real and difficult problem of illegal drug use? My choices at the moment are Norco, a surgery to remove part of my spine that could leave me paralyzed and make my pain worse, or death. Which would you choose?
16
As a person who has endured 17 surgeries (more than half were to help correct congenital deformities, knees and neurological/cervical spine), after the knee reconstructions I needed opiates for a short period. I was in my early teens then. With no problems, I successfully titrated down to nothing. When I hit my thirties, my cervical spine needed reconstruction. After the first (of six), I toughed it out as best I could after being released from the hospital and titrated down on the post-surgical opiods. I went two years in horrid pain, migraines all the time, etc. Two years trying to never "get hooked" to opioids. After a suicide attempt, I realized I needed to listen to my doctor and try something stronger. That was 2001. I've been on different opiates, varying combinations, etc., over the years. I am a life-time pain management person, I have come to accept ... it took me many years to get here (in part due to shaming from some in the medical industry and family, part my own upbringing).
One of my fears--and it is a deadly one for me; I can't live/function without the palliative care I receive--is enough physicians will be bullied into not prescribing these types of medications due to red tape, so much so that I and others wouldn't be able to access these life-giving treatments. I take as few pills as possible; I eat to live. I'm close to running out of space, but know that there are folks for whom opiates are a last resort. Thank you.
24
Pain management is best handled as a medical problem. Doctors do not prescribe drugs randomly,and people with chronic pain need all the help we can give them. When my daughter had cancer the last thing I worried about was that she would become addicted to her pain medication. Opioid addiction is a medical problem and putting people in prison,almost always the addict, is not going to solve it. If you are concerned about the "opioid epidemic";then you must be out of your mind about rate of death from tobacco products. Over 400,000 deaths a year attributed to tobacco use. All drugs pale in comparison to the damage done by alcohol in our society.
13
Every doctor should know this. Still I shudder, because neither I nor anyone in my family gets any pain relief from the common aspirin or Tylenol-some genetic thing-and that combined with my low pain threshold means that inevitably some day I will be screaming in pain while some angry nurse lectures me about faking. Already when I tell a nurse that aspirin and Tylenol don’t do anything, they recoil and look at me like I’m a drug addict. Or worse, that I might cause extra paperwork. Controlling opioid prescriptions is great; hysteria and fear of prescribing them is not.
20
i agree with previous comments that we are in a period of shaming people who legitimately need and receive opioid pain medication. The "epidemic" is regional. The distribution of pain is not regional. The obvious conclusion is that in certain regions, doctors are overprescribing. fix that problem instead of making me survive hip replacement with acetaminophen. Anyone who has tried gabapentin (I deliberately omit the brand name) knows it is next to useless, and it was once the great white hope of pain medication. Professor Carroll seems biased in favor of a result that his proposed test might not support.
15
@ralph Your doctors prescribed gabapenton for hip surgery pain? Oh, gawd, no wonder you were in such agony. Gabapenton is for neurological issues. And, yes, this article seems biased. Spend a week in any palliative care clinic (hospital-based ones are usually best, but we go we with what we can) will shine some light on the issue.
3
@ralph
Congrats You survived. Ice packs post replacement most helpful. BTW a friend did endure knee replacement pain using Tylenol: the opioid made her sick!!
A thoughtful and important contribution to the discussion - not only about pain control, but other medical interventions.
"Evidence based" sounds rigorous and conclusive. But such "evidence" is rarely gathered in a context exactly like the individual patient. Each patient absorbs and metabolizes every medication somewhat differently. Furthermore the medication effect will be somewhat different for each patient. Selecting treatment for both benefit and reduced harm seem desirable. The health system and patients can benefit from greater individualization.
2
Here is the problem: Studies deal in statistical analysis. Patients are individuals. Statistics say nothing about any given individual. What all this really boils down to is a physician's decision about what they think is best for their patient. I know physicians like to rely on studies, but the fact is no study can determine for a physician what their judgement call should be. No one will ever convince me that opiates are not the best treatment for pain. But, treatment of pain is not the only consideration a physician has to make. They have to know their patient. Are they really in sufficient pain to prescribe an opiate or is their patient just playing them to get the drug. That is a judgement call a physician has to make. And there is no way around that.
4
Opioids aren't usually needed? Who knew? Oh, other than the big-pharma companies that have been pumping the pills out by the hundreds of billions. Cha-ching.
5
The under-treatment of pain is a national scandal. Chronic pain patients are being shamed, acute pain patients are being told an ibuprofen is enough for a leg fracture.
It is only a fool, like this so- called "professor of pediatrics", who writes more like a child than a scientist, who ignorantly blathers about "pain" and knows essentially nothing about it himself.
Opiods are the gold standard, the best, or let us put it in high words for professor Carroll ( deliberate small letters) ..... The Most Efficacious. Period!
All this nonsense about other treatment has been brought about by an addicted society, an alcoholic society, a nicotine drugged society. Everyone is looking to get high. The timorous and gutless physicians are being pushed around by a bunch of ignorant politicians, lawyer-types who never graduated college with a shred of science, nor chemistry, nor pharmacology. I saw not one future lawyer, nor politician, nor "liberal arts" student taking the hard science courses needed to understand basic medicine. Never mind Pain Relief Aaron. It is not your specialty; but hey, thanks for explaining what is real testing and what isn't for the rhubarbs out there. NY Times, are you printing just anything these days? Why give this quack a forum to sell his products, books, and vapid opinion.
19
England gave China the Opium War. Now China gives us the opiate war.
4
Tramadol is a synthetic opioid analgesic that acts in the central nervous system by binding to the opioid receptors that morphine and other opioids bind to. It carries similar risks of tolerance, dependence, and misuse in people with substance addiction. The belief that it is not an opioid is widely held, but is inaccurate. That uncorrected inaccuracy in this piece undermines its credibility. William S. Grass, M.D.
19
what if a study showed that people have known about this addiction for a very very long time? and what if the study showed that people need to speak up and say no or tear up their prescription, or their child's prescription? Do not blame the medical profession or the pharmacy industry. HEY ADDICTS: stop using others for your addiction!!!! written by a definite left, thinking and not naive person!!!
1
I had 4 joint replacements and got addicted to opiates and self-detoxed after every operation. It was hell. Hip replacements now are done so you don't need opiates for more than a few days but when I had my first, it hurt like hell, for weeks. The doctor prescribed oxy a hundred at a time with many refills. The second hip was a cake walk but I still got hooked, though the doctor was much more stingy on the prescriptions. The knees were impossible without opiates and the pain went on for months. I went to a pain specialist which is basically a doctor that supplies addicts. He said I was his only patient who ever wanted to quit, which I did, by myself at home. He had zero experience with withdrawal or detox, just left it up to me and it was hell. Too bad that opiates have been around for 30000 years and we have nothing really better for acute pain.
It’s really too bad your detoxes were so hellish. I relate the following not in the spirit of competition or shaming but simply to suggest that detoxing under a knowledgeable doctor’s active management might help ameliorate the worst of the experience. That said I would also note that we’re all different.
Anyway, I’ve been through opiate detox six times in about 35 years of chronic pain but always under the supervision of whatever physician was overseeing my opiate regime at the time. It could be difficult but has never been hellish. Ended up going back on opiates in each case because, via dedicated trial and error, we never found anything that worked better. This growing tendency to lump all pain patients together is anathema to good medical care, which always boils down in the end to the individual patient.
6
@hormel
Actually, it's too bad that doctors that write 100 pills at a time for post op pain aren't all in jail.
@hormel What you describe is not addiction but physical dependence which is a side effect of many drugs and can be managed by slowly tapering off. It should only feel that bad if you taper off too fast.
I had a hip replacement last year. I left the hospital with 48 hydrocodone pills. I still have 47 of them. I got through my recovery with basic Tylenol and a lot of ice packs. I think that often, we are led to believe that the pain is guaranteed to be severe enough to warrant the prescriptions that are given to us, without actually assessing our own level of discomfort at the onset.
7
I just got a tooth extracted. They wrote a script for Norco and after I pressed them on it said it was an Opioid. I said I'm gonna take Tylenol thanks. I also told them I was gonna smoke a big fat joint (seriously) as a joke but added that marijuana has been shown to interrupt pain receptors in your brain. Also, pain has been shown to be about the anxiety around "anticipation of pain" rather than the pain itself many times - which pot helps with.
As it turns out, I didn't even need the Tylenol! This article is spot on. Big Pharma literally caused a societal epidemic.
4
@Ignatius J. Reilly You're not supposed to smoke (or even use a drinking straw) after a tooth extraction. The suction could dislodge the clot in the space and cause dry socket. On the other hand if you feel you must smoke you should keep a piece of gauze packed tightly in the hole where the tooth was extracted from.
I have found that the pain from the toothache was usually worse before the extraction than after. I've only had one molar extracted though and it had a root canal in it so no root.
This strikes me a carelessly written article. For one thing, tramadol IS an opiate! This is a hugely important point. The highest level on the "non-opiate" arm is in fact an opiate. So what on earth does this study show?
Also, both ibuprofen, and, even more so, nortriptyline, have some very serious side effects of their own, which seem to go completely unmentioned in this article. Nortriptyline can in fact be fatal. Why is this not mentioned?
Opiates are sometimes overprescribed, yes. But the large majority of patients receiving appropriately prescribed ones do fine with them, and do not risk addiction. As with alcohol, marijuana, etc , those prone to dependency, for whatever reason, may have problems. But that shouldn't lead to banning the use of badly needed pain medicines for all. With alcohol, we already tried Prohibition , didn't we? It was a disaster.
18
Why are you discussing comparing one drug with another? There is an alternative approach for chronic pain - and post operative pain and healing in general. A small US company in Maryland has the Actipatch - for $30 you get a 720 hour "loop" that provides sensation free PEMF treatment that a) treats the nerves back into health and also readjusts cells so they heal faster. Proven technology (PEMF used by NASA and for 80 years in hospitals but now miniaturized). Should be the first option so as not to get started on pills. www.actipatch.com . FDA Cleared for specific treatments and applied for general pain. NHS cleared for general pain prescription coverage.
1
@Dave What an ad for an unproven device. Believe me, if there were effective methods, doctors WOULD be using them, depsite the promotion of doctors all being on the take. A very big insult to the true, caring physician.
How do cells get 'readjusted' so they heal faster. Sounds like some pyramid scheme woo woo.
2
I've read studies which show that patients using drugs for pain don't generally become addicted to them afterwards.
Similarly, American soldiers who had taken heroin in the Vietnam War were mostly not addicted when they returned home.
People in pain are addicted to ending it; once it's ended, they are no longer addicted. So it's best to give them what they need regardless of addictiveness.
9
@Ambrose No, addiction is a biological process, regardless of your degree of pain. The belief in your statements were actually what started the out of control dispensing of opiates by the medical community. As a young nurse opiates were dispensed with much greater concern about the addiction that would evolve with ongoing use. the working theory was that acute short term pain can be managed with opiates, but chronic pain needed a different approach.
1
Interesting points indeed, and pertinent. Could you cite some reliable sources of your information (which I’m soliciting sincerely, not snarkily)?
@Michael Evans-Layng
My source is Daniel Shapiro, "Addiction and Drug Policy." Social Ethics (7th Ed). McGraw Hill, 2007.
The insane war on pot, based on a hundred years of lies, wrongly jailed or criminalized millions of Americans. It is the single most glaring miscarriage of justice since slavery.
Now, with the opiate crisis, we are seeing a similar, stupid, reactions. People who need pain killers, will pay the price by being forced to live in excruciating, but totally unnecessary, pain.
The other day, the New York Times reported that - "From 1999 to 2016, annual cirrhosis deaths increased by 65 percent, to 34,174, according to a study published in the journal BMJ. The largest increases were related to alcoholic cirrhosis among people ages 25 to 34 years old."
https://www.nytimes.com/2018/07/18/health/cirrhosis-liver-cancer.html
A 65% increase in cirrhosis deaths from alcohol, a legal drug. And this a very expensive problem to deal with, as are most of the myriad of health and social problems caused by alcohol, a legal drug. Yet we accept this as "normal". People on opiates usually work and keep jobs - drunks do not. For many, the only way they CAN work is with opiates. We need to seriously rethink the whole drug issue.
10
Opioids actually do work for some people. The relentless attack against them end up punishing those patients who no longer can obtain them without significant difficulties. The spectrum has shifted way too far in the wrong direction. Reasonable physicians should be able to prescribe them without fear of regulatory interference.
26
@Ron Klein This is where we were before the opioid crisis. There was a pervasive (and certainly at least partly true) worry that we were undertreating real pain, that people benefited from opioids, which lead to the explosion of opioid prescriptions, made stronger and more pervasive by Purdue Pharma and other pharmaceutical companies looking to make profit. Before that point, it was hard for people who needed pain meds to get it. Then it became far too easy for anyone to get it, and here we are. Opioids are not meant to be used in the long-term, except in palliative and oncological care, and for short-term use for acute pain like after surgery. Evidence does not support that people with chronic pain do better with opioids than other methods for pain reduction, such as meditation. And we might need to recognize that we can't obliterate all pain reasonably. It is sad, but the answer is not making these drugs easy to get.
4
@ck Do you have chronic pain? What treatment would you recommend for a patient when other medications, cognitive-behavioral strategies and meditating do not relieve excruciating pain? The kind of pain that makes life seem absolutely intolerable? The answer is not making these drugs easy to get but it is supporting providers who use them when nothing else works.
1
@ck
The root of irony is that the people least in the know are the ones making the most wordy demands for regulation and change. I won't give examples b/c everyone has his examples.
One thing that happens is that people refer to studies, statistics and extraneous situations. These applications defer the human results that case study provides. Mostly, we would prefer the machine to make the mistake.
Last year I developed the dreaded problem of chronic sciatic nerve pain. Walking for any length of time without severe pain was impossible. Grocery shopping a challenge. The problem did not resolve with physical therapy. Six months after the pain started it was still not resolved and I became worried about pain management, concerned about pending surgery.
Because my physician is smart, is a member of a medical group that does not prescribe opioids (or very reluctantly), and because I did not ask for them - I don't want them - my physician was very proactive in using all other available modalities in both controlling the pain and assessing the source of the pain (injections, non-opioid pain medications, nerve studies, etc) . A year later, I can hike, bike, grocery shop without leaning on the cart.
The problem still exists and some day I may have to have surgery. But for now, I have minimal pain and no opioids in my cabinet.
7
@Lan I have lumbar spinal stenosis and went for those shots and they did absolutely nothing to cure my problem. In fact I had an unexpected "period" after being menopausal for about 3 years and had to go to the doctor for this issue to get it checked out. Turns out that Kenalog 40 (the steroid used in epidural steroid injections) can cause abnormal bleeding. So I will no longer be getting those shots. I am also afraid to get surgery because I might end up with much worse pain. I don't take opioids either though.
1
There are many other options besides opiates for chronic pain. One major issue is that patients don't receive individualized assessments and treatment plans. One method works for one patient but not another. Each case is different based on history and goals for quality of life. The opioid epidemic happened partially because of standardized care; simply prescribing painkillers for pain rather than identifying other courses of treatment. Now, the opposite is occurring; regulations are taking away painkillers but some patients actually do need them. We need to move away from one-size-fits-all treatment in order to change the system and make a difference.
6
Several years ago while visiting another city I suffered a serious fracture and required two surgeries. As a result I was in the hospital twice and then in care facilities.
Along the way I was scripted for OXY several times. I took 3 pills for the 2 surgeries. What I was prescribed was locked up for me until I left each facility.
By my count I had over 100 pills. I took Tylenol for the pain and that was sufficient after each surgery and one or two OXYs. Mind you, neither surgery was real serious but I received a pain blocker and a lot of anesthesia.
My point is that I was over prescribed. If I were a different sort of person I could have sold the pills or taken them.
If two tylenol twice a day was enough, why over prescribe an addictive drug.
Some people get dependent easily. This is why there is an epidemic. Some rational thinking needs to prevail on usage and application.
9
I just had open abdominal surgery to remove uterine fibroids. I spoke to my doctors and anesthesiologist before they performed the surgery and told them that I wanted to use opioids minimally. I know I have a high tolerance of pain as I’ve been living with excruciating period pain for a decade. More importantly I have many extended family members who are hopelessly addicted to opioids. It wasn’t that I was afraid that I’d become addicted, it was that I wanted to prove it was possible to recover without opioids even if it meant being in a little pain. Even after I had spoken to all those in attendance to me they still snuck some fentanyl into me as I was coming out of the anesthesia. I was vulnerable and not on my protest game. I must have missed someone in my care group. Even so, they had previously told me I’d be groggy all day after the surgery and I was not. I definitely had some pain, but good ole Ibuprofen and Acetaminophen were my best buds. They sent me home with those and some Tramadol should I need it. They gave me 20 doses of Tramadol. I did use it twice on the first nights so I could sleep, but I haven’t since. I’m on the 4th day of recovery and I’m starting to improve. I wish they had other tricks up their sleeves than the highly addictive opioids.
5
Absolutely but I hate health insurers even more than the pharmas. I had pinched nerves in my lower back that unfortunately required two surgeries over two years to repair enough to be functional. The ONLY drug that worked for the unbearable pain I had were opiods. I did not get hooked and stopped them immediately after surgery. Japan and many countries barely permit such drugs, and maybe that's a good thing. But if the insurer let my medical team do what they knew they had to do, full surgery on three areas would have been done in that first month and saved me three years of pain and risk of addiction.
3
Um, Tramadol breaks down to an opioid precursor, can cause seizures in large doses and has been shown to be an ineffective pain reliever. Opioids are over prescribed, and certainly much over prescribed for postoperative pain, but some people have no pain relief from these other drugs, or have developed complications such as GI bleeding or renal impairment that prevents their use.
6
@Linda. Tramadol IS an opioid. Carroll's error on such a simple point should cause one to doubt his other statements... including his interpretation of experimental results.
6
The medical establishment will do anything to convince patients they don’t need opioids. Recently I had a serious surgery and was not adequately medicated because the hospital’s policy was to reduce opioid use whenever possible. Each day I was in the hospital, suffering terribly, I got a lecture delivered along with meds about addiction. I have had several surgeries and I know that opioids work very well. And I have never become an addict.
18
Taking opioids can lead to dependence. Dependence is not the same as addiction. Addiction is an active process of maladaptive learning. Dependence is where discontinuing a drug will cause withdrawal symptoms. This also happens with anti-depressants, anti-psychotic, anti-hypertensives, and a whole host of other classes of drugs, but because they're not narcotics, this gets labeled as "discontinuation syndrome", even though they are, to a large extent, functionally equivalent.
No one becomes instantly addicted to a drug. There are always pre-existing factors (childhood trauma, poor or lack of coping strategies for stress, feelings of social disconnection, etc.) that lead to addiction, which is when a person repeatedly engages in a behavior despite negative consequences that they have difficulty stopping.
Dependence (and withdrawal) can be a part of addiction, but dependence on its own isn't addiction. This article (and much of the clinical community) doesn't seem to get this very important distinction.
12
I had minor surgery at Kaiser on the side of my face to remove a pre-cancerous area. After the surgery they wrote me a prescription for an opiate pain medication. I didn't take it and didn't need it. They should have suggested that I start on an over the counter medication and told me to call if I needed something stronger, rather than the other way around.
9
It's wonderful to see the medical profession finally acknowledging that there are better alternatives to relieve pain than opioids. But why in the world does this article say that the arm of the study prescribing non-opioids included tramadol? Tramadol is considered to be an opioid and has addictive qualities. Toradol is a similar-sounding non-opioid alternative.
7
I've been prescribed opioids a half dozen times over the last decade or so and doubt I've ever needed them. After a minor surgery I weaned myself off them in just a couple days, but I could have done it faster and it's likely I would have been fine with just OTCs. For more minor things, stitches or dental repairs I either haven't taken any of the pills or haven't even filled the prescription. I've seen family members addicted so I tread carefully.
1
@fletc3her Forty years ago I had my wisdom teeth out. I took 2 or 3 of my prescribed opioids, then switched to aspirin [like I said, it was 40 years ago.] The pain relief was a good or better. But from reading the other comments, it seems clear that for a lot of people, opioids are necessary. I hope the medical profession tries to figure out how to decide who needs opioids, and who, like you and me, doesn't.
4
All of these anecdotal posts regarding pain after surgery, both minor and major, where opioids should never be used, just make me shake my head. Before opioids became the norm, patients were required to stay in the hospital under supervised care until their bodies recovered enough to tolerate the ride home. 30 years ago I spent a week in the hospital after major surgery and 8 weeks off of work. Even after that, it took months to return to full-function without a flare-up. The pain-relief options at that time were limited to tylenol with codeine which was usually given for a maximum of 7-10 days. Without pain your body has no way of knowing when and how much to rest, and how much it has healed. That said, there is a huge difference between post-op surgical pain and severe uncontrolled nerve pain. Having experienced both, I can testify to that. My opinion is that those who have never experienced it have no business second-guessing a doctor's prescription. There are very easy lab tests to see if a patient is taking their own medicine, so I don't buy this whole argument that opioids somehow turn pain-sufferers into street addicts, or that patients are selling their prescriptions. It's very easy to armchair-guess the reasons why street addicts die, but prescribing opioids to chronic pain suffererers isn't one of them.
35
@Gloria I had open abdominal surgery in 1979 to remove a large ovarian cyst and they sent me home on the third day without any opioid painkillers. I don't know if the insurance company made me leave after only 3 days. I was in the hospital for 3 days before the surgery having tests done in the hospital. Those were in the days before MRI's and other high tech medical tests. They should have kept me longer imo.
1
@Gloria
I often wonder if people were able to rest and take time off to heal after back injuries that appear minor at the time, something those in jobs that are hard on the back are rarely able to do, would we have so many people in chronic back pain and on disablity at relatively young ages. People work through pain in our culture, something which impairs healing, raises inflammation, and can lead to chronic conditions.
My husband was able to get through two serious sciatica attacks using marijuana cookies and a vaporizer pen. He never filled the Vicodin prescriptions his GP and back doctor wrote for him. And he's fine now. Eats one cookie a day and it hasn't come back. They need to test pot in these trials too.
12
I've had chronic low back pain for years and two fused vertebrae in my back. I've tried all the non-drug therapies: Physical therapy, acupuncture, chiropractic, CBT, and meditation. None gave me enough pain relief to have a decent quality of life and to continue to work. Tylenol did nothing for me and high doses of NSAIDS gave me gastritis. Nortriptyline gave me chronic insomnia and put out me out of work while I took it. Lyrica and low doses of Tramadol are the only things that allow me to stay functional. Still, I'm treated like all the drug seekers and pill sellers. If the government wants all of us off any type of opiods why isn't it funding research into non-addictive pain medications? I guess it's easier to beat up on chronic pain suffers and just hope we die off.
33
@trucklt - There are few things more debilitating than back pain.
You mentioned physical therapy but what about a regular exercise program, particularly yoga or pilates? I know from experience how effective these things are but they don't get enough attention.
Hang in there.
6
@trucklt You are lucky, Tramadol isn't really a problem, since it's a very low level opiate. It's over the counter in most countries.
2
This article has an incredibly misleading title. Opioids are better at treating pain than other substitutes, period. Of course it’s difficult to conduct a truly randomized control test because no one in serious pain wants to take just Advil. The benefit that no one gets addicted to opioids in the latter group is offset by the immense pain they had to endure.
The same argument could be made for opiods vs. no pain medication at all. Stop trying to make misleading arguments for the statistically illiterate.
26
If only patients were treated that way in real life. If you are on Medicare you might get a 15 minute appt with a doctor followed up by a prescription. All the other razzle dazzle would never happen unless you are a politician or in a study.
5
@Maggie I just had major surgery 2 months ago and my follow up appointment lasted approximately 8 minutes. The doctor also was talking about himself for the first minute. I really couldn't believe how little time he spent. I have great health insurance too, I'm not on Medicaid or Medicare. I would have been thrilled to have him spend 15 minutes on my appointment. We actually timed the appointment. It was way too short. I wasn't given any opioids either, they told me to alternate tylenol with motrin. I don't work at the moment so I spent a week lying on the couch while on my laptop to avoid moving too much. It hurt less when I was lying down.
1
I had painful oral surgery and the surgeon prescribed Oxy. Didn't alleviate the pain did quite the opposite in fact in spades. It heightened the pain and brought me to tears. I took two extra strength Tylenol and within 30 minutes the pain subsided so much so that I was able to sleep. Got rid of the remaining pills and told the surgeon if ever I need surgery again not to prescribe these pills. They are poison. And any doctor that continues to write a scrip knowing full well the damage they cause ought to lose their licenses. Don't they read JAMA? Don't they watch the news or dare I say read a paper?
4
Research shows that those with elevated depressive symptoms, trait anxiety, catastrophic thinking and perceived disability are characterized by a deficit in endogenous opioid function. This, in turn, predicts an enhanced responsiveness to opioid analgesic medication. Greater positive affect is associated with comparatively more potent endogenous opioid function and less opioid analgesia. Burns JW, Bruehl S, France CR, et al. Psychological factors predict opioid analgesia through endogenous opioid function. Pain. 2017;158(3):391-399.
Also, those with greater distressed mood, unfortunately, are more at risk of opioid misuse. Arteta A, Cobos B, Hu Y, et al. Evaluation of how depression and anxiety mediate the relationship between pain catastrophizing and prescription opioid misuse in a chronic pain population. Pain Med. 2016;17(2):295-303.
In addition, deficits in emotional regulation and reward processing has been shown to be associated with prescription opioid use and misuse. Garland EL, Bryan CJ, Nakamura Y. Deficits in autonomie indices of emotion regulation and reward processing associated with prescription opioid use and misuse. Psychopharmacology. 2017;234(4):621-629.
2
Something tells me the people behind this do not suffer from a condition that causes chronic pain.
28
@mja Amen!
6
Yeah, but WHO decides? No doctor knows how much pain you have. I've had 4 surgeries, in the last 9 years. In two of them, I didn't, initially, get the pain relief I needed. Thought I would die from the pain. In the other 2, I didn't really need it, at all. Did fine with OTC pain relief. I am personally sick of being discriminated against because of those who abuse a medicine I need. I am not a criminal, and I don't require supervision from the government. As usual, Congress, and legislatures, pay no attention to the real culprits, because the politicians take money from the real criminals. They do not care about you, the patient.
28
@ChesBay
For a country that brags about its freedoms as much as we do, there's precious little of that for chronic pain sufferers. To me, freedom from pain is as much a fundamental human right as freedom of speech, because when you're in pain, you can't do much talking.
Has anyone considered that pain is usually a byproduct of violence and that we are arguably the most violent country on earth? That we incarcerate more people than any other country and that guns proliferate? Perhaps not all of the "opioid crisis" is the result of "over medication" but that our government sets an example by its constant use of violence as a matter routine foreign policy? We invade a lot of countries. We break a lot of bodies. Has there ever been a time when this country wasn't at war? The westward expansion was one continuous war. A violent society requires pain relief.
2
I refuse opiods every time they're offered to me. Pre-op protocols usually assume patients need to be sedated first to lessen anxiety. Not with me. Enter an emergency room with severe pain from an accident and the first thing the attending physician wants to do is "ease the pain" with opiods. They'll even come into the examination room with hypodermic and pills all ready, in spite of my not having requested any relief. I always refuse. "Oh no you don't! Are those opiods? Get them out of here! I will not have them in my body!" And guess what? The emergency room accounting dept will actually charge you for the medications (?) that are prepared (without the patient's consent) but not administered (because the patient refuses them.)
We should all learn to manage our pain with the Lamaze Method of breathing through natural childbirth. No painkillers needed..... Been through 2 births, hernia and two eye surgeries, two colonoscopies, and three broken bones without opiods. Attending anesthesiologists are useless around me and are never needed.
Deal with your pain. It won't kill you, so long as you know it really isn't killing you.....as in, "No, you have not punctured a lung or an artery...."
5
@ultimateliberal - Lamaze has definitely seen me through some rough times, that and an OTC pain killer have gotten me through a number of medical procedures.
3
I would be curious to know how you talked doctors into performing those surgeries without anaesthesia.
5
That's the problem - chronic pain can and does kill. After a while, you would rather die than live with that amount of pain... because you can't live with it. You can't think. You can't speak. You can't remember anything. If you have never experienced that amount and type of pain, you do not know what you are talking about.
I suffer from severe knee arthritis. I cannot afford to have my knees replaced. I take an nsaid in the morning, go to work , and suffer all day- barely able to get up from my desk. I go home, take my 1/2 minimum dose OxyContin, and within 1/2 an hour I can mow my lawn, walk the dog, do the laundry, all of these pain free. I have followed the same routine/dosage for over a year. It makes my live livable. I am not giving it up.
21
@Maggie Figure out how to get your knees replaced and live your life. I know, easier said than done but get the top level insurance with the smallest deductible and have your knees done in the same calendar year. It will cost you about $3000 out of pocket. Don't accept living with pain, beg, borrow, GoFundMe or however you can so you can get on with your life.
2
This article fuzzes up the logical distinction between different types of experiments. All the trials described are in fact randomized clinical trials, which is the key to inferring causality against a background of systematic confounding effects. What the spectrum describes is range of treatment types for the trials. These can include extremely well-defined treatments, allowing any causality demonstrated to be narrowly assigned. At the other end they can include broader families of treatments (e.g. aiming for BP of 120 vs. aiming for BP of 140). As the article states, these all have a role.
The opposite of an RCT, however, is not an RCT with more broadly defined treatment categories but rather an observational study, in which it's very difficult to match the groups of people who got the different treatments.
6
I had an ski accident in Italy 3 years ago. German hospital. Two spiral fractures to my pub ic bone. Excruciatingly painful. Could not move, flat on my back in a hospital. No internet, no cell phone. I passed out from the pain in the hospital. They gave me opioids for 3 days, then took me off (and I could feel that!) and gave me what later learned was ibuprofen. They didn't send me home until I could get myself up and around on crutches a bit - this took two weeks. Then I took a 3 hour taxi to Munich, and got on a 9 hour, two-leg flight home, on ibuprofen. I had no problem. It was fine, I could control the pain.
I didn't know what it was they gave me, I can't read German. I just knew it worked and I took it up to the max you can take in a day. When I got home I was stunned. Ibuprofen. 500ms a capsule. Nothing else. I was able to take this for several months and had no problem stopping.
It works. I'm not a hero or insensitive to pain.
8
@joyce Patients with kidney disease cannot take ibuprofen or other NSAIDS, so your suggestion isn't a good one for them.
2
A couple of years ago I had a cycling accident in Germany, after X-Rays and all the other tests I was sent on my way with crutches and ibuprofen because apparently in Germany they are averse to prescribing stronger pain medications. All I can say is that I was in agony and the ibuprofen was as useful as talcum powder.
So now we live in the pendulum swing of over reaction where people who need pain alleviating medications can't get them because their healthcare providers don't want the hassle. WE live in a society where the majority suffers the consequences of the abuse by the few. Its no way to provide healthcare, period.
31
Just because a writer has the best of intentions doesn't make his statements true or his arguments valid. NSAIDs like Ibuprofen are often the most dangerous possible drugs for those in pain, rendering people injured or dead (but not dependent!). Drugs like Tylenol often have no efficacy at all in treating major pain. For the vast majority of individuals (90% or more) in substantial, chronic pain, addiction to opioids is not an issue-- it just doesn't happen very often: they're too busy managing their pain. Let's focus our efforts on those whose lives are damaged by addiction, rather than killing with kindness those who are not. One size does not fit all-- it destroys lives.
38
@P. Siegel - I couldn't agree more. Your comment about Tylenol reminds me of the retort of a nurse after I had some out-patient surgery a few years ago. She reminded me that the only thing I could take for pain was acetaminophen (due to risk of post-operative bleeding). I replied that, unfortunately, that did not work for me as a pain reducer and she replied, "that's why they advertise." I loved it.
8
@P. Siegelave a friend who died at 42 from an overdose of Tylenol. Yes, that's right, Tylenol!
12
@P. Siegel Agreed! And millions of people can't take them because they have a history of GI disease or are on anti-coagulants. It's great when people can manage their severe or chronic pain without opioids, but just because a few patients can do so doesn't mean everyone can.
We just passed the 200th anniversary of the first marketing of morphine as an analgesic. What other drug was first used in 1817 - the year Jane Austen died and James Monroe became President of the US - and is not only still used but is still the gold standard among drugs of its kind?
Morphine and its relatives are still at the top of the pain relief pyramid because they work. When they're overused, you get more addicts, but the current overreaction was predictable and sad.
I predict that in 20 years or so, articles will appear warning doctors that they're under-treating pain. Again.
9
Interesting that post-op in places like South America or Europe, the pain meds dispensed to patients is usually something akin to strong Tylenol. No opioids at all. And people seem to manage and recover. It seems that routinely prescribing opioids in the first place may be a big part of the problem.
1
@Julz Traveler
Post-op is a finite period of time, not a chronic pain situation. It is precisely the very best time to use a small prescription of an opioid. Just the mental benefit of an absence/lessening of pain from the surgery is bound to help recovery.
10
@Julz Traveler What is "something akin to strong Tylenol"? There is no such thing. There's just acetaminophen (Tylenol). Extra-strength Tylenol is just a higher dose of the drug. Acetaminophen is notorious for causing liver damage after overdose or even just long-term high-dose use.
I'm dubious that post-op pain is managed with just Tylenol anywhere. Are you sure you don't mean what is often called Tylenol #3 or #4? These are just ordinary acetaminophen with codeine added. Codeine is an opiate.
13
All medications have side effects,interact with other medications and affect pre existing conditions.
NSAIDs are available over the counter and are taken without supervision or control.They are a major cause of gastrointestinal bleeding,interact with drugs used to treat hypertension and affect renal function.
Judicious use of opioids are safer in the elderly who are in chronic pain and who are on multiple medications particularly anti coagulant and anti platelet drugs (to prevent the blood from clotting) with heart and renal disease .
Pain sensation is entirely subjective and only the sufferer can quantify their tolerance.It may not be possible to be totally pain free in chronic conitions
20
There is an opioid-prescribing hysteria in this country. Tramadol is an opioid-like medication which can cause dependence/tolerance; it's "scheduled" just like Norco, Tylenol #3, etc. In addition, when it's put into the electronic medical record, there are numerous red flags for possible drug interactions which do not appear with Norco. Please: acetaminophen is worthless for pain. Works for fever, but that's about it. Ibuprofen, naproxyn and other NSAIDs work well for some people but can have serious side-effects and I always feel uncomfortable advising patients to use them for chronic pain problems. So what are we left with? Rxs which cause weight gain and profound sedation.
In my experience, many of the patients I see requesting scheduled medications are not addicts--they're selling them on the street to supplement their income. They obtain the Rxs at taxpayer expense and have created a cottage industry. So most of the time, in order to protect my license which is scrutinized by the DEA and the California Dept. of Justice, I just say no to any scheduled drugs for chronic use. I will Rx small amounts for obvious short-term acute pain, but that's all. And the State of California is requiring this year that I look up a prescription history on every patient I give a scheduled Rx. This is tremendously time-consuming and the data base I'm forced to use is tremendously inaccurate.
My expectation: this hysteria will eventually fade. New hysterias will emerge.
15
"What if a Study Showed Opioids Weren’t Usually Needed?", says a person with no life altering chronic pain (or one rich enough to pay whatever it takes).
37
Regardless of if one views opioids as either either indispensable or not to treat pain there must be agreement that they are dangerous. The danger being if they are not used properly. Proper use must include monitoring to assure that safe limits are not exceeded and more damage is done that exceeds the benefits that these drugs provide.
Illegal and criminal use of these substances is a law enforcement problem but how many cases of addiction and death result from lack of sufficient monitoring of unnecessary, excessive and/or prolonged use causing the epidemic now in progress?
3
According to an article I read in Science a year ago or so, both opioids and nsaids begin to cause to nervous system to compensate for their presence after only 3 days. If this is true neither will be effective for chronic pain, except as a placebo and both likely create increased pain upon withdrawal or reduction of the meds. Something better is needed for chronic pain.
2
The mistake here with regards to chronic pain is that CP is a symptom, not a defined disease. If you do a pragmatic trial dealing with a symptom, you have no way to know how the nature of underlying problem affects the outcomes. I'm shocked that an actual professor would fail to understand that. If you have a forest with 20 different tree species suffering defoliation and you run a pragmatic trial with two different drugs, you may find one to be more effective because of the relative tree populations rather than some true effectiveness. When you add in the Hawthorne effect, pragmatic trials have limited use. When trials like this are made public there is a rush to control opiods based on clearly fallacious reasoning. It's entirely possible that opioids are prescribed too broadly but it's also important to be careful not to use the blunt instrument of public policy to cause these people even more pain for no gain.
Imagine a trial to treat "fever". One group gets anti-biotics. Another group gets aspirin. The aspirin wins because most fever is viral and can['t be fixed with antibiotics. So, now you recommend pulling anti-biotics off the market because aspirin is so much more effectlve. Maybe this example with make the logic problem here a bit clearer. I hope so.
29
@Ross Salinger, I see your logic, but your example is something of a straw man. The pragmatic trial that is the focus of this article compares two different treatments for pain, not one for pain and one for the underlying cause.
12
In this trial they treated many different conditions with two different regimes. This does not "prove" that you can treat patients "just as well" with non-opioid analytics because you don't have a clue about what condition you were actually treating. All you know is that in the absence of any additional diagnosis you can treat some forms of chronic pain without opioids. That just not the same as the doctor is claiming. This new "information" is now informing public policy and the logic is just wrong. I'm sorry if I missed your point.
@Ross Salinger These are great illustrations; thanks very much.
Had total replacement left hip 10 yrs ago. After surgery, was given morphine pump for a day while hospitalized for 6 days. Left with 100 Vicodin. Still have 95 Vicodin left, I preferred Ibuprofen for the couple of days required rather than that fuzzy brain that came with the Vicodin.
Had my right hip replaced June 18. Learned this time it would be different. No morphine drip. My ortho practice had changed their ways. They used my current favorite pain relief...ICE PACKS, in conjunction with acetaminophen in my IV. Left the hospital before lunch the next day. The practice offered me 80 pills of some opioid. When I said I don't need them, they offered me 40 pills. Said I really should take them "in case" because it could take up to 2 days to get them later. I told them I would sell them on the street if they insisted. I left with NO opioids and have not been sorry.
Monday was my 5 week anniversary. I drove to town by myself yesterday. Back to almost full practice of Tai Chi. Still using ice packs and rest and physical therapy. Moving makes everything feel better. Really glad this practice has at least begun to address the opioid crisis.
27
@jack
Thank you for your comment. It is very timely for me because I will be having left hip replacement surgery in 4 days. One of the things that I am most nervous about is the possible side effects associated with the prescribed opioid (hydrocodone). It is very helpful to learn that ice packs and acetaminophen offered you the pain relief that you needed. I don't know what medication will be in my IV, but I plan on following the ice pack/acetaminophen treatment after surgery. Thank you again.
5
@Julie, I'm sure that Jack is well-intentioned, but we should all be cautious about using one or two people's experiences as "advice." Pain is very subjective and the reaction to drugs is also incredibly variable. Many who take pain meds have no side effects at all and the vast majority of those who take prescribed opiods never become addicted. If YOU know that you react badly to a particular drug, tell your surgeon, but I'd be very hesitant to refuse pain medication you might need just based on an unfounded fear of addiction and one NYT commenter. No one will make you swallow them, but better safe than sorry. What happens if you are in tremendous pain and need those pills, but refused the prescription?
2
@Julie
Full disclosure..I'm Jack's wife. I learned before 1st replacement to acknowledge pain w/o responding to it. Have practiced Tai Chi 15 yrs now. Cured my migraines 50 yrs ago using relaxation techniques. Had 7 out of 10 Hydrocodone left from tooth extraction "in case" but had found them less effective than Ibuprofen. Exercise every AM. 74 yrs now. Good luck with your hip.
Most of the comments here are thoughtful and well-informed. They, and comment sections like it, are one of the principal reasons I continue to subscribe. If only this carried over to the political articles....
14
I did my first medical study from ages 13 to 15. I used lab rabbits so the population was exactly the same -- no outliers and no need for use of the pi variable and level confidence. I studied liver disease by providing different diets to each study group. I won a NSF grant to start Columbia Medical School. My next studies, done at Yale, involved breast cancer treatment -- the Halstead vs. Criles' debate. Halstead was a misogynist; Criles did actual studies based on stage, age, prior treatment. I then checked post-op breast cancer treatment from 1960 to 1969 using hospital records; 600 hospitals had to be broken down using the pi variable. Current medical studies reject outliers: people who used a competitive drug, people with diseases (as the only surviving offspring of a WWII atomic vet., I have a messed up system). But I used to be on opiates which ended four years ago when NYS passed an opiate registry; besides, RF and nerve block are 'surgery' and 'cost' much more than a scrip. The NY Marijuana Program was a failure; paying street price in cash and receiving a generic 20:1 THC when there are 200 varieties and I know one handles nerve inflammation and micro-spasms. But I am not accepted for clinical trials because I have so many diseases and would be an outlier.Studies can just assign a pi variable and level of confidence covering outliers -- the ones most in need and, if conquered, would be applied to further, general studies.
4
Annual deaths related to prescription drugs: 32,000.
Annual deaths related to alcohol: 85,000.
Annual deaths related to Marijuana: 0.
22
@George Orwell
I won't quibble with your numbers but psychoactive drugs have different impacts for each person. Fully developed adults (persons over age 28) with no history of significant mental health concerns are at very low risk for developing problems related to using marijuana.
However, please take care to notice that diagnosis of bipolar disorder and severe psychiatric illnesses like schizophrenia are up over 100% in Colorado, Oregon, and Washington among young adults with psychiatrists recognizing that "recreational" use of marijuana is a significant contributing factor. Persons with family histories of bipolar or psychotic disorders or experience with significant anxiety or depression as teens should defer using marijuana until they are safely into adulthood to reduce the risk of triggering psychiatric problems.
5
The problem with many of these studies on marijuana and the brain is that researchers tend get their scary dramatic results when they fail to control for alcohol use by participants.
People do not appreciate just how damaging alcohol can be in the brain. Some of this damage scientists have discovered through the technique of WRONGLY blaming marijuana, by failing to control for alcohol in studies on marijuana.
This is what happened with the scary news that smoking pot could make holes in the white matter of a teenager's brain.
It turned out, after four years of arguing and redoing the experiment but controlling for alcohol, that these holes in the brain are caused by alcohol use and have zero to do with marijuana. Scientists have settled the issue and now they agree, it's alcohol making those holes. So they discovered something new about alcohol, through the path of wrongly bkaming marijuana.
So before you go believing any study on pot and the brain, check whether the researchers controlled for alcohol use by participants. If they didn't take this precaution, then you're probably seeing the effects of alcohol, not marijuana.
This has been confusing and misleading the public for decades, and it really needs to stop.
2
@George Orwell--It's preposterous to say there are zero deaths attributed to Marijuana. If you drive after ingesting MJ and get into an accident (like maybe causing a fatal wreck) you bet that death is going to be related to Marijuana.
2
I recently had my gall bladder out and was prescribed opiates for the pain, your typical Oxycotin. I was in considerable pain for several times following my surgery but after the second day I just couldn't take the drugs and switched to Tylenol.
The opiates had SUCH a dramatic effect on my cognitive ability to function normally that I felt I couldn't take them anymore. I questioned my ability to make informed decisions and asked my wife to take point on caring for our 1 year old son since I didn't feel fully in control of my body. It was a terrifying and enlightening experience into the world of pain treatment.
Next time I'm opting for CBD/medical marijuana if it's an option - I never want to feel like those Oxy's made me ever again in my life.
10
Agree. After my shoulder surgery in Sweden last year I was given OxyContin for the pain. I took the pills for about 3 days and then switched to wine and weed. That worked much better for me.
1
@Nick People have wildly divergent reactions to opioids, or they perceive that they do. I hate taking opioids for the same reason you do, they make me feel useless and stupid, and they interfere with my sleep cycle, but one person's useless and stupid is apparently another person's euphoria.
10
@Nick - I live in Seattle where we treat cannabis as serious medicine. I use it for epilepsy. I have many friends who use it for chronic pain (as in multiple car wrecks).
It can be great for chronic pain management but some people do not like the feeling they have on medical marijuana. Depending on which strain a person gets, the plant has a wide range of effects on the human body. If I go into a store, I have about 150 strains to choose from. There are some that make me spend the evening thinking that KellyAnne Conway is listening to me through my microwave:) And they are not very effective against seizures. Other strains seem like a gift from God. Any bona-fide medical-mj dispensary could give good advice but the best advice would be from another patient like yourself who could help you avoid nights with KellyAnne:)
If a patient is capable and law permitting, they should grow their own to ensure high quality and be affordable.
5
Hmmmm all this thought and work to NOT address the REAL issue for the vast majority of pain patients: NO access to real medical care THAT is the cause of our opioid problem. I know I've been involved personally for 15 yrs and was given massive amounts of pain killers because the states STILL refuse along with our federal gov't access to public health care therefor our doctors are commanded to ONLY TREAT SYMPTOMS not the cause which is the perfect setting for addiction. By only treating the symptoms the actual cause keeps getting worse and worse so the patient needs more pills all because we are the ONLY nation who hates it's own people so much that the gov't has villainized those who wish we had public health care. This has gone on since the 50's when Reagan put out his album against "socialized" medicine. You can have all the pragmatic trials you want they won't do any good with our current health care system which is now not only the most expensive in the world by far but the most useless. Our system is the third leading cause of death just under cancer and the number one cause of bankruptcy and the powers that be think this is a wonderful system.
13
There has been an enormous increase in alcohol related deaths in this country, especially among younger adults. Alcohol is the poor man's daily sedative. It is the only pain relief they can get.
19
In the middle east tramadol is generally the highest level of pain relief an outpatient can get (and even then only from a special hospital pharmacy for controlled substances). Not incidentally, it's also one of the most abused medications in that region. Opioid or not, hard to understand how this medication was used as a control.
6
@Drummond Not sure this is relevant, but I was given Tramadol for cracked ribs and it's the only thing that works. I can still feel the pain through the medicated haze, but I can relax a little.
Ibuprofen didn't cut it.
I don't like the high. I thought I would, but it's an annoyance.
9
I take Tramadol for joint pain related to a genetic condition. I don't like the "high" either, so I only take it when the pain is completely unbearable and I can't function without a pill. Ibuprofen did not work and I already have connective tissue disease--I need my liver and kidneys functioning, thank you very much.
As for the "abuse" factor, not everyone becomes an addict. I have my RX filled so infrequently that any refills usually run out on the time limit given on the bottle and I have to request new refills. Yes, that's how sparingly I use it--and I resent it when people (usually those not in chronic pain) say yadda, yadda, it's "addictive." Not for me, thank you--it's been a lifesaver when I had no other choice and had to function in my daily life--either that or kill myself. So, yeah, people can just stuff it about the addiction nonsense.
Pay attention to your own health care needs, and leave those of us who need that level of pain control alone.
1
@Drummond
Tramadol requires breakdown in the liver to a metabolite to produce another compound that might cause an opioid high. Not everyone has the same ability to break down tramadol in the manner, though many people with Mediterranean or middle eastern backgrounds seem to derive greater effects from it, including pain relief.
Tramadol was not scheduled by the FDA until roughly 2015 or so. It had been around in the US since the 1990s. It was never widely prescribed by doctors, or widely sought after by patients. This only started to change when overdose deaths from oxycontin and percocet started to skyrocket. The LD50 of tramadol is very high, meaning that it is extremely difficult to take enough of it to cause respiratory depression and death. This stands in stark contrast to other drugs like dilaudid, morphine, oxycodone etc that we typically discuss in this context.
If you speak to anyone who works in addiction medicine in the US, or who did pre-2015, they would likely tell you not only that they had never seen anyone with a primary addiction to tramadol, but that they were not aware of any need to treat typical opiate withdrawal symptoms relating to stopping tramadol, ie diarrhea, nausea, insomnia, restlessness etc. What's more, tramadol was considered a permissible medication with which to treat patients who were in recovery from other addictions if they needed medication for pain.
2
I have a elderly doctor friend that suffered a broken back a few years ago. While never stingy with opioid prescriptions, he agreed with me that medical students should somehow be subjected to severe pain before receiving their medical licenses.
Even at a advanced age he said he never realized how bad the pain from his injury could be until it happened to him. He stated that it is often too easy to dismiss the severity of what someone else is experiencing.
59
@Paulie, as I recently told my own pain specialist doc--"You think the opiod overdose deaths are high? Take away the meds from the vast majority of us who need them in order to reduce our pain enough to be able to walk and function and you will see suicide rates the likes of which our country has never seen." The ratio of those who take opiods and are fine to those who abuse them is very high, but the latter seem to get all the attention. It's time for those of us on the functioning side of the equation to speak out.
13
The take away here is that it is very important to support government funded medical research. Not all research is beneficial to the business market. Many medical issues, such as the development of new antibiotics or non-medication based pain management, have no market force to stimulate research funding. Yet they offer us HUGE potential benefits. Extending and maintaining GOOD funding to the CDC, NIH, as well as university and hospital based researchers is vital to our national health and well being.
13
@kathleen Another area that needs government research is finding new uses for old drugs with expired patents. No manufacturer wants to do additional research to find new uses for a drug that will never be on patent.
7
There are tests that my pain management doctor does which determine my “addiction profile” and which drugs I could (genetically) have a higher chance of abusing. This gave him room to prescribe pain medications for me, based on my genetic profile. Why isn’t this done more in all clinical settings? It would surely help doctors make better prescribing decisions and give the patient a better understanding of their own physiology.
8
For one thing, tests like that are still fiarlu expensive, and for another, while genetics play a role in developing physical dependence, there are a lot of other factors in the development of addiction. Social and mental health, for example, appear to have a large impact on drug abuse, and doctors don’t always have an easy time evaluating those, especially if their patients aren’t being honest with them. Minimizing the use of addictive drugs overall is a cheaper, safer alternative to putting too much faith in genetics.
4
The medical profession went an incorrect direction about 20 years ago. First, they decided that all pain could be eliminated. Second, they decided to promise this to patients. Third, they didn't realize that people feel pain to different levels.
Physicians should begin telling patients that they would have pain after operations, but that the pain would be tolerable. And they need to give very small amounts of opioids. Like 1 day's supply. After a rotator cuff operation, I was in great pain for 1 day. After that, the pain diminished, and I stopped the opioids. I took ibuprofen for 3 days. I felt pain, but it was not that difficult.
16
After breaking an arm about 8 years ago, I was given a 1 week supply of an opioid. It worked well on the pain AND seemed to soothe every other worry I had. I can easily see why most people who try this medication will want more. It's easy to fake pain in the doctors office to obtain longer prescriptions. Some doctors reportedly even give a 30 day prescription for sore throats associated with bronchitis and the like.
I sensed after 1 week the opioid could very easily become addictive and relied on over the counter pain killers after that. When the opioid epidemic became national news 3-4 years ago, I wasn't shocked. I understood how appealing this drug could be to someone who is generally unhappy in life, who is unemployed or underemployed and who doesn't have a sense of hopefulness about their life.
My 1 week experience explains the opioid crisis to me directly. I happen to be enjoying a life that has been happy with occasional dashes of very good luck, so I have a strong incentive to protect myself against addiction of any kind.
If my life was a sad misery every day, opioids would look far more attractive regardless of the consequences.
30
@Andy
You need a lot of losers for one Powerball. That's how our predatory form of capitalism works. Places with lots of opioid abuse are economic deserts - victims of the government picking winners and losers in trade agreements; places also where work injuries tend to be common (W. Va.) along with inadequate health care or safety net. Pain has one corollary emotion, and that is anger. I'd rather have a mob of dozed-out, unemployed workers than a horde of enraged, underserved, ex-coal miners with black lung disease and nothing to lose, angry at authority, our social contract, our Puritanical admonitions, and willing to take matters into their own hands.
4
Well, this is basically an argument for the evidence-based evaluation of medical procedures and therapies originally part of Obamacare.
It's pointless to niggle about efficacy or effectiveness when the end point is sufficient tracking data for all patients on all medical interventions. This is the second most important potential benefit of single payer health care.
There's a difference between an outcome study of knee implants, where one kind of hardware design or appliance manufacturer can be revealed to fail more often, and an outcome study of different kinds of drugs, where human bodies simply respond differently. There's a difference between evaluating the tools of medicine as tools, and evaluating how important it is to consider patient genetic, health or lifestyle variation in the application of the tools. The long term cost and benefit of therapies are also poorly evaluated in efficacy studies.
The significant differences between males and females, or whites and blacks, both in the incidence of diseases and the appropriate therapies for them, is a well known and still unresolved complication.
9
I just had surgery a few weeks ago. I was given a very strong, but short duration intravenous pain medication. It killed the pain, but wore off after 30 minutes and if used long-term, would be addictive.
I had to wean myself off this medication after a few days and change to a very mild painkiller mixed with Tylenol. It gave me some relief, but I still felt some pain.
In my mind, pain can sometimes be a good thing. It lets you know where you are in your recovery and doesn't always cloud your judgement, like opioids do.
When it came time for me to stop using my limited pain medication, I turned to a small amount of non-psychoactive, cannabis derived CBD tincture to lessen the pain and inflammation and was astonished at the relief it gave me.
Not for one moment will I doubt the severity of the opioid crisis, nor will I disparage any person legitimately in pain and needing to use these medications, but I will take issue with the utter lack of research into the positive uses for naturally derived cannabis products.
I shudder to think of my recovery without the use of this CBD tincture and the benefits it provided. Its value can't be overstated.
13
I recently developed an auto-immune disorder which was acutely quite painful. I am a physician. This necessitated some narcotic relief at night so that I could sleep. a 5/325 did it. I am an anesthesiologist who has also undergone total joint replacement. I am aghast at how hard it has become to adequately treat acute pain in the current, neo-puritanical environment. Thanks to Hcapps and lax chronic prescribing practices, patients with acute pain are now going under-treated. This, in large part, is because narcotics are easy and cheap; insurers will not pay for the extended patient interactions required to help people cope with and mitigate their chronic pain. No doubt there were too many oral narcotics prescriptions being written with consequent morbidity/mortality. I suspect that the true cause of this crisis is the pervasive hopelessness that is hollowing out our society, but that's just one citizen's opinion,,, All the rest of the jawboning is just making excuses for the corporate medical machine; what we quietly call the "wealth care system"... Physicians are now tightly locked into a "double agency" rock-and-a-hard-place corner; they can serve their patients or answer to the politicians and regulators. One size does not fit all.
47
@Mitch Keamy. Good point. I am 68 and have had a very active life with lots of broken bones, torn ligaments and other trauma that resulted in acute short term pain. For me and my injuries and surgeries, narcotics were useful for a few days but not longer. I worry that the current climate around opioids will end up harming people who do not abuse them and benefit from them to manage short term pain.
7
@Mitch Keamy
Please actually look at the research.
Europe has somehow managed to not develop major opiate use issues despite the fact that they prescribe *more* medication to their patients with chronic, intractable pain.
The difference is they hardly ever prescribe the sort of opiates we do in the context of *acute* pain. Codeine is OTC, but 99% of cases in the ER aren't given even that.
To give you some more context... the sort of *chronic* pain I experience from my spinal cord injury makes the pain I experienced from a gallbladder crisis look like a stubbed toe.
I completely blew the doctor's minds when I was sitting there calmly asking for them to give me an opiate with the gallbladder thing. They told me patients tend to scream ... non stop.
I told them it was painful but my neck hurt a whole lot more.
I think maybe it's easy to dismiss or something because I should be "used" to it ... "suck it up" ... and move on with my life.
The pain I have "chronically" though is far far worse than 99% of "acute" pain.
Acute pain isn't worse it's just happening in someone completely inexperienced with serious pain and no tolerance for it. They scream and beg and cry more than a chronic pain patient, so you *think* it's worse.
Trust me it's not.
in 2012 i had a c-section after 40 hours of unmedicated induced labor. I was given a PCA and IV push ketorolac. after 36 hours i was off all the IV pain meds, and asking for ibuprofen. The nursing staff couldn't understand how I could possibly be "pain free" after a day and a half... They kept insisting I needed PO oxycodone etc. Finally I asked that they call the doc... who came and said "well, give her ibuprofen". So when I was discharged on POD 4, i hadn't had narcotics in almost 3 days... yet i was handed a script for 30 oxycodone... never took one. It would be prudent to fit the treatment to the needs of the patient, rather than some template.
26
Doctors have used opoiods for thousands of years, and for good reason. Anti-inflammatory analgesics are fine for inflammation but do little to relieve nerve pain caused from a crushed disk or many other problems. Opioids block nerve pain and more importantly help take a patient's mind off the pain, a critical role that reduces blood pressure. I fear more people will die prematurely from stroke and heart attack as opioids are restricted and patients are told simply deal with the pain, take an Advil and high blood pressure medication, rather than getting appropriate care that central to medical ethics.
38
30+ years ago: "you want a Tylenol#3? are you an addict?"
20 years ago:
Doctors shot at USC emergency room by patient seeking pain medications.
Bergman v. Chin: Doctor sued for undertreatment of pain.
Pain is the 5th vital sign.
Patients with chronic pain "can't become addicted to opioids"
Now:
Families suing doctors for writing for opioids
If you write for opioids you are a bad doctor.
Prescribers need to check the state database to see if patients are double or triple dipping on their controlled meds.
At the end of the day, most of us want to help you with your pain. We are doing our best to help you with what we currently know. I agree that many patients probably don't or didn't need opioids (cf 80 y.o. opioid naïve patient who received 30 days' of dilaudid after a minor surgical procedure). Unfortunately, the study Dr. Carroll sites is inherently flawed and unlikely to drive the discussion meaningfully forward.
19
Opioids are needed, for companies to make money. It's an addictive product that cures nothing and requires more and more to do the same. The real question is my mind is, are doctors stupid, ignorant or corrupt? Are they mentally unable to understand what they are doing when they prescribe opioids? Are they unaware of what the consequences are? Or maybe it simply doesn't matter to them as long as they maintain a good relationship with their dealers?
1
Tramadol is an opioid....
10
Tramadol also causes a lot of confusion for elders and sedation
2
@MomT ...and is the only thing that works for my smashed ribs. Ibuprofen was as effective as whistling in the wind.
Fortunately for me, I don't have to drive. I immediately figured out what activities I'm klutzy at and stopped doing them. My partner picks up the slack.
7
I had surgery on my shoulder.
The Dr. prescribed Tramadol. I had never heard of this drug and had been oblivious to the opioid crisis (I mean, I knew about it, but it was not personal knowledge).
I loved the drug! I took more. He prescribed more. I was up to 8 pills A DAY for three weeks.
Then, the insane itching began.
So I looked up more about Tramadol and realized I had better get off (I still had not made a direct connection between Tramadol and opioid crisis (I am a prof. of mathematical physics and enjoy my shell).
For five nights, I slept on the couch (the surgical sling kept me out of bed). I got up, walked around and made horrible faces. I flung my arms around. I slapped myself. Horrible, sinister, murderous thoughts entered my head (I cannot talk about those thoughts).
I do not drink, I do not smoke and do not do drugs. I work out 10 hours a week. I am healthy. So I had no idea/experience (despite my age -- call it naive) what cold-turkey really meant.
One week later, I was off.
NEVER EVER AGAIN will I even LOOK at Tramadol.
23
Apparently Dr. Carroll is unaware that tramadol does contain an opioid. In fact, it is a combination medication combining a serotonin-norepinephrine reuptake inhibitor (SNRI) similar in action to nortriptyline with an opioid. Unfortunately, many physicians with limited knowledge of analgesics commonly make this mistake. It is especially problematic because of the opioid, tramadol can be abused and people can become addicted to it.
As to the study, we have known for years that opioids are not the most efficacious analgesic medications for many forms of chronic pain including chronic back and arthritis pain. That we have to keep proving the same thing over and over again just because of patients' and doctors' misconceptions and ignorance is foolish.
13
Patients with musculoskeletal conditions are ALREADY suffering more pain - and have been for severl years - due to the panicked reactions of some states to limit the use of these life-style saving medications.
People drive too fast and carelessly, and do stupid tricke to impress their friends; but have you seen cares forced to go slower, or laws limiting the height of biuildings and/or mountains to keep people from killing themselves in stunts?
Only with opioid abusers choosing to recklessly end their lives are we seeing innocent patients aused more pain because of the mistakes of others.
Solve addiction however you will, big-government types, but don't force the innocent - generally older - people to suffer while you figure it out.
19
Here’s my suggestion. Only doctors, researchers that have chronic pain should be allowed to carry out these torture trials. See how they function for hours, days, on acetaminophen that doesn’t work. Keep asking them to describe their pain level from 1-10. Make them beg for relief via young, peppy staff members in waiting rooms. I’m guessing by the time they publish any results, they’ll be in jail for trying to score something, anything, on the streets. Put that in your “real world” trials.
64
@Jo Williams
Not only that I think prescribing doctors need to have personal experience with these drugs to really properly prescribe them.
The *only* pain management doctor I've ever had that possessed enough understanding of tolerance, addiction, and the psychopharmacology to effectively prescribe these drugs just so happened to be a chronic pain patient himself ... taking morphine.
The rest of them fail to understand the logarithmic curve of tolerance .... and how it tends to plateau. You usually end up failing to get properly titrated up after tolerance develops ... *creating* a pseudo "addiction" as the patient struggles to manage an insufficient amount of medication to treat their disorder.
Most doctors really lack the basic understanding of psycho-pharmacology to prescribe *any* psychoactive drugs ... let alone manage a patient on opiates.
Imagine being on 1-hour of sleep for two weeks ... waking up screaming ... vomiting ... and in relentless pain... Yet you *know* the CURE is sitting in your bedside table. The problem is taking what you need will result in a label of "addict" from your doctor and you being denied *any* medication.... if you even try and broach the issue of insufficient dosage.
People are really failing to understand the necessity of these drugs and the impact they have on patients with chronic pain.
I've had more than one doctor try and tell me my disability from a SPINAL CORD injury was really all because of the opiates.
2
As long as there is cannabis, opioids are not really necessary. Great for pain of all kinds, depression, and anxiety. Not addictive and you can't overdose. And it's 100% organic. Time to look at what Mother Nature has to offer and stop big pharma from killing us.
4
@Mr. Slater
Cannabis is highly overestimated as a painkiller and a tranquillizer. So are its side effects.
When you have a very severe – read: torture painful – polyneuropathy, cannabis has no effect. It does not even calm you down, thus enabling you to get some sleep when the pain is worst. My severe polyneuropathy is a sequela to an extremely severe (life threatening) MCS, and the MCS is due to dramatic mould and chemical circumstances in our previous Danish house. Strong opioids DO help. However I develop anaphylactic shock when getting opioids and other painkillers. Therefore at first I found cannabis a fantastic idea. Due to my neurological damage (3 concussions, lime disease and FSME), however, my brain and mind behave strangely in addition to the next to zero effect of cannabis: I get hallucinations, not unpleasant ones at all, but nonetheless hallucinations.
And finally: not all cannabis on the market is organic. On the contrary. Only if you cultivate it yourself, of course.
5
@Mr. Slater More research is necessary, but so far, cannabis is not coming out as a drug of choice for chronic pain under emerging research.
https://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(18)30110-5.pdf
6
@Mr. Slater
Not true for me, although I do take cannabis when the low dose opioid rx does not lessen the times of excruciating pain. Wish cannabis alone was effective as it is legal in my state.
Opioids are needed for people in legitimate pain. The stress of pain can have a serious impact on mental and physical recovery.
So people are suppose to suffer because junkies lie and claim they got addicted due to painkillers? We could take every opioid off the market and junkies will still get high off something and find another excuse for their addiction.
Here's a fact and you don't need a study to learn it. Addicts lie.
40
@Hellen
"We could take every opioid off the market and junkies will still get high off something and find another excuse for their addiction."
And in fact, this is what has happened with people switching to fentanyl and other synthetic fentanyl analogues that they purchase illicitly, and are much more likely to kill them.
11
How many lives have opioids saved? How many people would otherwise be alive if they were not used?
8
Being and geriatrician, I see a different portion of patients who often have not been given anything for their pain or they’re given Tylenol or Advil. If Tylenol or gabapentin it works that is definitely the best choice, as well as using physical therapy and keeping active. Sometimes CBD can help, or salon pause patches. However for severe bone on bone pain often a small amount of Norco can give incredible relief.
10
@Elizabeth
being a geriatrician, you should know the patches are called Salonpas ... and (according to my wife) they really work.
If it is difficult to get subjects for a pain study (I wonder why) I suggest the author volunteer. It’s so easy to claim a aspirin is enough to treat severe or chronic pain when it’s not you that’s in pain.
23
We need to keep in mind that people enjoy getting high. As a child I enjoyed codeine cough medicine, which my mother would give me on a rare winter day. It was a side-benefit to getting sick. That's the way I look at prescriptions for post-op pain. What's the point in professional help for pain treatment when you can get it off the shelf at Walmart?
@James
My experience of taking a very low dose opioid s for otherwise intractable pain is that I get no high, or anything close. Severe pain uses up the opioid so there is none left over for a high to o ccur. I remarked to my doc that I didn't understand why people experience them as a pathway to high.
3
I know someone who has struggled with opioid use for years. The struggle is between the perceived need and the risk of abuse. I'm no doctor, but I believe this person's actual pain is less than claimed based on observing their daily function. However, this person has become psychologically dependent on the opioids, albeit not addicted. The fear that real pain will come back keeps them wanting the opioids within reach. They have been comforted too long to break away.
2
Be careful trusting the results of any study that claims to confirm what the researchers desperately want to be true. Considering the addiction problems with opioids, many advocates would like to find them an unnecessary evil. But the danger of opioids isn't that their ineffectiveness, it's their powerful effects, which patients need and others desperately want.
10
The study abstract points out that the opiod group did not differ statistically meaningfully from the non opiod group on the primary study measure, which dealt with ability to function. On a secondary measure, the opiod takers reported they were in greater pain than the non opiod takers. Why should strong pain killers increase pain? A possible explanation is the opiod group had greater pain, before the study began. This could easily be tested if a pre-study measure of pain were taken. Normally, random assignment prevents key pre-study differences, but not always. And, generally, such an important detail is part of the study abstract (e.g., pre-study differences on self-reported pain levels were not significant.) Unfortunately, the study abstract says nothing about ruling out that the opiod group started out the study with higher levels of pain; of course, this outcome would vitiate the story that opiods do not work. There is more to this story, and those repoing it should dig a bit more, trying to explain a counter-intuitive result of strong pain killers (opiods), seemingly increasing pain levels.
1
As several comments claim that abuse of opioids prescribed for pain is rare, I wish to point out that a Federal government report issued two years ago found that 25% of patients who take opioids for chronic pain end up abusing them.
And I should point out that this was not previously unknown as the first prospective study (i.e., a study that followed patients going forward) published over 25 years ago reported the same thing.
5
@Steve,
Can you post a link to these?
5
@Steve,
Would still like to see the studies you are referring to when you have a chance. One factors that accounts for the much larger numbers reported in some studies are the differences in what they actually measure and how they define. For example a study that says "x percent of patients were dependent on opioids one year postop." will likely report more cases than one that says "y patients developed addiction (OUD) postop because dependence is a broader term than addiction/OUD.
Unless specified otherwise...
1. dependence usually refers to physical dependence.
2. No way to know
a) % surgical error
b) % taking opioid for reason unrelated to procedure
c) % developing known complications from procedure
who develop chronic pain.
"Association is not equal to causation."
A second confounder is the recently revised definition for misuse that's employed in the NSDUH, which is far more broad than the one previously used. Virtually everyone alive misuses medication to some extent if you look at this definition.
3
Our correspondent has clarified many complex and competing variables in play over the effectiveness and efficacy of these analgesic medications. However we too often overestimate the altruism of the pharmaceutical industry when it comes to marketing medications. What's the word I'm searching for? Oh yes, profitability. We are examining a class of drugs that are inexpensive to manufacture, effectve in managing pain and easy to convince physicians to prescribe. What could possibly go wrong?
3
At the very least, doctors should not be prescribing opioids BEFORE a patient complains of pain. I was part of an online support group prior to getting a certain surgery, and most of us in that group received Oxycontin in advance. We were told we "probably" would not need it but that it would be good to have "just in case." I was astounded at how many people in the group chose to take - not so much because they felt great pain but because they were afraid that without the pills, the pain would suddenly come out of nowhere and be unbearable. It was clearly all in their head. I was one of the few who refused to take it. When the pain came, extra strength Tylenol was good enough.
13
As OxyContin takes several days to attain maximum effect, it would be worthless for both postoperative pain and to be taken as you were instructed. Whomever was prescribing it doesn't seem to know what he or she was doing.
4
@wbelm
When was this? OxyContin is NOT a postop med because it is long-acting and takes longer to work-no good at as far as pain relief OR safety goes after surgery. The ONLY reason I can imagine taking it BEFORE pain would be because the person (erroneously) prescribing it knew it would take time to have an effect. I was a registered nurse prior to being in a wheelchair and I can promise you that prescribing Oxycontin in this manner was RARE years ago-unheard of today.
Could it have been oxycodone you were given? Pain medication DOES work best if taken before pain gets severe. If a procedure is very short (5-10 mins) and known to be pretty painful immediately afterwards, some doctors WILL have a patient take the pill just before because it generally takes 15-30 minutes to work. During this time, pain would be increasing, a larger overall dose would be needed, or an IV opioid might be needed. Oral medication lasts longer and has less of peak so the side effects are typically less and the dosing interval is longer.
14
Isn't oxycodone the generic name of Oxycontin? It was definitely an oxy. The year was 2012 for a two hour long surgery. The prescription was filled immediately post surgery to have "just in case".
2
Because I have taken prescription strength Ibuprofen, I know that the OTC brands are limited to advising maximum dose levels that are well below what a doctor would prescribe. For people in pain who would like to use OTC analgesics, I suggest you take a look at the prescription strength labeling to determine what you would be prescribed were you to receive that drug per doctor's prescription. NSAIDs have side effects to, so I wouldn't go long without visiting a doctor for pain, but it's clear for whatever reason that our system is oh so careful to the point of paranoia about prescribing too high a dose of NSAIDs, or ensuring that Methodone and Suboxone are never abused, is completely heedless when it comes to opioids. It's insane.
Agreed. When I had surgery, I took 3 Advil when needed. That extra one made a difference. I did not overdose.
1
First, of all it is important to point out that an estimated 16,000 people in the U.S. die from use of NSAIDs primarily due to gastrointestinal bleeds and this can occur at therapeutic doses. Even acetaminophen (Tylenol) can also be deadly due to liver toxicity.
As to opioids, things have changed with regard to prescribing. Hydrocodone combined with acetaminophen is the most commonly prescribed opioids. A couple of years ago the DEA put it in a more restrictive category which limits how many and how many refills doctors can prescribed at one time.
9
@Steve Yes, agreed, NSAIDs have side effects too and I would definitely seek a physician's care for anything that is chronic, but look at it this way: 16,000 people die every year using one of the most common classes of drugs that is freely available OTC -- compared to 60,000 who died from opioid overdoses. Even if only half or 1/3 of those are related to prescription opioids, that gives you an idea of the relative dangers between the types of drugs.
I had a tiny, and I mean tiny, basal cell carcinoma removed from my arm. The doctor gave me a 30 DAY SUPPLY of Oxycodone. I expressed some doubt about the need for this and the doctor explained that I would later experience "deep pain" from the site.
The site did hurt a little bit later that day, but far far less than, for example, wearing high heels. I threw the pills, but came to understand exactly why we have an opioid crisis. Note - that the I never asked for the pills and even expressed doubt about needing them, but the doctor prescribed them anyway.
31
@DWS
Doctors prescribe more pills than you might need because they do not want to be bothered after hours or on weekends. It's a "just-in-case" prescription. There is no law against not filling a prescription and throwing it away after the surgery.
4
@DWS
The important point is that you did not need them. Not the case for those with severe chronic pain. In your circcircumstances, I would have done the same.
Overprescribing does still occur, but infrequently in my state due to severe political measures and the legitimate fear of good docs of having their licence to practice revoked.
The DEA revoked one local doc's licence in a highly publicized raid and office shutdown. My good and responsible doc mentioned that all local docs recognized this as a shot across the bow and reacted accordingly.
What I see is that the majority of "opiod" fatal ODs are caused by heroin and much stronger street drugs. This doesn't lessen the horror of these deaths, but strangling the availability of responsible prescribing and use of low dose opioids does nothing to stem the tsunami of street obtained drug deaths.
Which the media, including the NYT, never fails to alarmingly label as the opioid crisis rather than the actual crisis of illegal street drugs.
1
@DWS Interesting comment. It suggests that there's something not quite right with your doctor. I had a lumpectomy performed for a somewhat substantial tumor in day surgery and was sent home with barely a two-day supply of opioids; and less than that after the procedure to install a chemotherapy port. Those small doses were more than adequate, and I was grateful to the doctors who were willing to effectively relieve my short-term, but acute discomfort.
Having just been through a period where I was under prescribed opioids for a couple of months I suspect that's not the problem.
The more relevant issue is the placebo effect as it relates to how one feels one might “need” substances when they don't have physical pain.
And yet an even more relevant issue is the cycle of social panics that occur periodically and the mechanistic view panic purveyors have of the general population. There's way too much quackery in this field.
6
@Mumon We went through this a century ago, with alcohol prohibition. There's no question that the "Great Experiment" was a dismal failure that gave us organized crime. We're seeing the same thing today, with drug cartels making billions in profits off illegal fentanyl and heroin.
That same fentanyl and heroin is killing Americans, not illegal prescription opioids, which have become nearly impossible to find. The DEA catches less than 2% of the imports. The "war on drugs" was lost before it began -- sadly, it's become a war on people, including some of the most vulnerable: chronic pain patients with crippling disabilities and severe pain.
10
I was talking to a pharmacist about rose oil I wanted to use in a flower syrup I make from lavander and the subject came up about American health care (or should I say lack of) and being that I'm an American who hasn't taken an aspirin in 30 years or any pills for that matter, we were talking about the opioid crisis there.
She informed me that Austria doesn't prescribe ANY opioids here for pain control. I've been through 2 colonoscopy exams and both times I had to fill out information about what prescription drugs or any kind of medication I take, how much and when. I turned my information in and the nurses came back (twice) and told me I didn't fill in the information they needed to have. I told them I haven't taken an aspirin in 30 years and take nothing at all. No pills and nothing of any kind. They did not believe me. They never had that happen before with someone my age. I know I've been blessed in life, truly blessed.
I do suffer, though, with a constant pain in my heart daily. It's called TRUMP "dis-ease" and its severe and incurable. No opioid in the world can kill the pain I feel daily (I know their are other Americans who suffer along with me). I don't drink either. But November seems like years and years from now and I just might start!
10
@C T - Did you write "none" in the space for meds? If not, that's probably why the nurses kept coming back.
A lot of people of all ages take no medications.
1
"What if a Study Showed Opioids Weren’t Usually Needed? "
Wouldn't massive pharma ignore it, discredit it, or pay for a study with opposing results which would, at least, muddy the waters?
9
Incorrect or misleading dosing protocols for NSAIDS may be part of the problem.
I was prescribed Tramadol when I fractured five bones in my foot and sprained my ankle. I took it very sparingly and briefly over the first couple of days and only when I felt the pain was unbearable.
Then I tried taking the maximum one-time dose of aspirin--three 325-mg tablets at once--and they worked wonderfully. Spreading the dosage out was not helpful. FYI taking vitamin C tablets or capsules with aspirin greatly reduces the risk of stomach bleeding.
And that's a helpful strategy for migraines too. But only if I've the wit to take that dosage at the first sign of a headache, when the pain is dull and unfocused. That won't stop the headache but will greatly lessen its force and duration.
Common sense is required for successful navigation of life. If you don't fill that prescription for opioids, or take a minimum dose only when genuinely required, you won't get addicted. Self-restraint is a valuable skill.
4
@SCA
That approach is very dangerous - numerous studies (Fine 2011 among others) have shown the danger of improperly treating pain - it is important that chronic pain is managed with the objective of minimizing or avoiding its associated long-term sequelae.
Consult Dr. Google and use self-diagnosing at your own risk - if a treatable pain becomes a life-long chronic pain then you might regret DIY ethos.
2
Sorry, been taking vitamin C does not decrease the bleeding risk from aspirin. Please be careful.
2
The issue is not the effectiveness of opioids. Rather, it is the overprescribing of opioids by doctors instead of other pain medications.
Time and again I hear experiences from friends where doctors immediately prescribe opioids. You can argue the merits of the study all you want but the reality is opioid use is encouraged by Big Pharma and carried forward by the medical profession.
Maybe if Big Pharma would stop looking solely at the bottom line and doctors would prescribe opioids judiciously we would not be in the crisis we are in today.
11
I totally agree. I've been prescribed opioids several times throughout my life for pain that I chose to manage (successfully) with OTCs. The issue is not whether they work when needed, it's how often are they truly necessary.
5
The media has a strange sense of priority. Little does the media appreciate the effect that the constant drumbeat of "epidemic" has on patients who abide by the rules and require palliative care. The pendulum has swung 180 degrees. Now, it is very difficult if not impossible for patients in need of relief from pain to obtain medication. This, in turn, has caused a tremendous upsurge in heroin use, and the epidemic in suicides is partially as a result of people preferring to end their life rather than suffer.
What drug kills three times as many as Americans as opiods, but nary a word from the media brains- alcohol. Never a story on the devastating consequences of booze.
And the media does not understand why the public has lost confidence.
31
@f: I am one of those chronic pain patients who abides by the rules and has tried every conceivable option over the last several decades to manage my condition. We are in a class being punished for the abuses of others. I use opiates in rotation with NSAIDs and other therapies and this has proven effective for me to retain enough function to continue working and having some semblance of a life. I started out with non-drug alternatives of every kind. When my illness advanced and those no longer worked, I switched to NSAIDs for my severe and disabling inflammation. When I could no longer tolerate those in dosing sufficient to manage my pain, I tried a biologic, from which I had debilitating side effects that persist to this day. For me, opiates are an essential part of my regimen, but I use them carefully both to help me function and to supplement the few NSAIDs I can still take. NSAIDs carry far more risk from long-term use that opiates, a fact that is often ignored in these articles. Biologics can work wonders but those drugs also carry considerable risks. Pain patients should have access to the medications they need as well as the information on how to use them wisely. As far as I can determine, punishing us for the abuses of others is doing nothing to stem the epidemic, neither are articles that over-generalize the plight of people who are just trying to get through the day without debilitating pain.
25
@Eric
Thanks for taking the time to write the response I was planning. I've been dealing with debilitating chronic pain for over 15 years, using NSAIDS until I had very negative side effects. An article that recommends NSAIDS for long term chronic pain is hard to take seriously in light of the published risks. I have used various non-pharmacological approaches-most of them unreimbursed by insurance and costly. They remain an adjunct to pharmaceuticals for me, but are not enough on their own to allow daily functioning. The idea that this country can solve "the opiod epidemic" by across the board refusal to prescribe is a politician's pipe dream. Meanwhile, law-abiding pain patients suffer. Each month I don't know if I will be able to find a pharmacy that has enough of my medication on hand to fill my prescription. Is this the answer?
7
@f
I concur. A very solid comment. The only addendum I would include is not only does alcohol kill more individuals who drink, but also over 10,000 innocent people who are killed due to drunk drivers each year.
2
I had week long debilitating migraines ( in bed in the dark, with excruciating headaches for years.) I tried every kind of migraine medication prescription available and also Tylenol with codeine. Headaches were still bad, and then suffered from side affects of being depressed and fuzzy thinking.
My cure after being fed up that nothing was working - Aspirin. Not Tylenol or ibuprofen. Excedrin migraine 3 with coffee.
I call it my miracle drug.
5
@EverydayPeople. Be careful of rebound headaches. Headaches that occur when daily use of short acting analgesics such as excedrin wear off and require another dose. So in other words while excedrin helped you for one episode, it may become a problem with frequent and repetitive use
1
Really, the comments are well worth reading. All sides on this issue have something to say that is worth listening to.
For myself, I think a lot of this is about abuse and addiction and the people who fall prey to addiction. Which can be very sad indeed. I'm not trying to pass judgment here, so what if we simply say that some people are closer to that dangerous edge than others? It's most likely not their fault. And some people take some pride (Misguided, perhaps?) in terms of their ability to withstand pain. Pain exists for a reason. And some people simply do not feel the pain so deeply? Maybe it is bravery? But bravery would be feeling the pain and still managing.
But the bottom line seems to be that such powerful pain relief is over-prescribed. There is an opioid epidemic. I have been told I do not have a great sensitivity to pain, but the other side of that is that bad things can happen if you don't react properly/promptly to pain.
4
I was told I had a great tolerance to pain when I was young. When I was older, in addition to other health issues, I developed fibromyalgia. it does change your perspective, especially when few drugs work to relieve your pain.
8
@Richard
I realized, after writing this comment, that I had not addressed a critical issue, which made some difference. And that is the idea of chronic pain, meaning, as seems to be expressed in this main article, pain that seems to have gone on, and lasted, a long time, and doesn't show signs of going away any time soon.
That would be discouraging, to say the least. But still, I think the issues remain somewhat similar, and, worse, the pain medication does little (if anything) to actually solve the underlying cause of the pain. At one point, many years ago now, I had some joint/bone surgery, which was just very painful, before the surgery and after I woke up. Yes, I indeed toughed it out to some extent, and I enjoyed the morphine pump a bit. But I was pretty certain that the pain would end. True, it was replaced by re-hab pain for a while. But all of that is still different from facing a pain that doesn't seem to have an end.
Meanwhile, many of the over the counter pain relief medicines work well enough, or as advertised, for short term (One week max?) relief. But they are simply not designed for long term use. But my current understanding is that much long term (chronic) pain seems to be very difficult to explain, in terms of causation. and so we head back to how well an individual can deal with pain and, better, rehab or behavior modification work to avoid the pain.
My initial reaction is to be reminded of "confirmation bias". A secondary reaction: I sense a danger of "blaming the victim".
This kind of study, however, does seem to fit right in with current social trends, heavy on both these pitfalls (or opportunities, depending on one's point of view).
9
At my age, pain of some sort is constant now (arthritis and wear and tear) but I have known some pain most of my life. Unless it is severe, I mentally learned to live with it and an occasional ibuprofen when I truly hurt something. My problem with any use of opioids that were prescribed after appendix surgery and knee surgery in my 60's is my mental state. The night terrors and horrible dreams left me soaking wet in sweat with no sleep at all and I stopped taking them after just two days. Thanks but no thanks.
4
As a scientist involved with development of novel medicines:
If the primary objective of trials is to determine efficacy – including better / worse than current standard regimen, different dosing etc. – trials must be blinded and include proper controls, otherwise the outcome is heavily 'contaminated' by bias of patients and investigators, and placebo response. Obviously, sufficient statistical powering and use of validated outcome measures.
This is the absolute basic principle of almost any efficacy study, preclinical or clinical, in medical disciplines.
There are trials which are not double-blind placebo-controlled and yield meaningful outcomes, but these are typically for specific aims:
- Observational studies characterizing a patient population
- Trials testing novel clinical measures (like certain imaging techniques, EEG, or rating scales)
There are also special circumstances, e.g. when treating life-threatening conditions or when drugs such as cancer chemotherapies hold unacceptable risks for healthy volunteers, which justify to minimize the placebo-control group. These studies are for the most part though still blinded.
I am not trying to specifically argue for or against opioids for pain control, I am trying to emphasis that blinded, controlled studies are key to being able trusting their outcome. With unblinded, open-label type studies we have seen it time and time again that one can produce the results that the investigators or sponsors want.
24
@LL I came to the comments section to make exactly this point. And, as you well know, medicines cannot be approved in the first place without two adequate and well-controlled trials, which usually means the described placebo-controlled trial (there are exceptions for diseases like cancer, in which it would be unethical not to treat with standard of care). The "real-world" trials described do not meet the approval standard, which is in place for good reason.
I spent many years doing "real world" studies. They have their place and their purpose, but as you point out they can be manipulated, and they also risk turning a collection of anecdotes (multiple, different regimens lumped together) into a "treatment" recommendation that really gives very little insight.
5
Leaving aside the dubiousness of the study - Dr. Lawhern in the comments addresses that - I want to tell a personal experience.
I watched my mother suffer the last few years of her short life because the doctors then - in the 1990s - were, like now, afraid of treating pain. The pain was excruciating. Imagine a cramp on your foot or leg, the strong kind you get that is sudden and intense. Then imagine that all over your body. Then imagine it not stopping but going on and on for hours, days, weeks, with no rest. She hallucinated and vomited with the pain. She died at age 56.
Now imagine offering her some Tylenol and telling her you dont' want to offer her anything stronger because you're 'worried' about her getting addicted.
This is what Carroll means when he says 'patient expectations' are what drives drug prescriptions--& implies we should simply manage expectations and Tylenol will be fine.
No. It won't. It's horrifically cruel to act as though that would work. You'd know this if you ever suffered real pain or knew a loved one who did. The only people who can talk about Tylenol with a straight face for severe pain are either those who have no idea what real pain are, or people who are worried about getting sued.
Yes, opioids can be abused. So let's treat the abusers. Drug abusers have their own issues. To punish those who are using the meds for their actual purpose, to make them suffer because, basically, others are suffering, is a mockery of medicine.
114
I believe this study was looking at outcomes for non-malignant chronic pain. Your description of your mother's experience is likely to have been at the extreme end of a malignant pain continuum, and if she were dying, there would not be a clinical concern about addiction. Opioids have an important role to play in managing distressing symptoms at end of life.
The dilemma for prescriber's is how to interpret the evidence of managing those with chronic pain syndromes. Prescribers have always known that opioids were generally not doing a good job of managing this kind of pain. Results of opioid studies were always equivocal, and a certain percentage of patients were going to get into dependency and addiction issues that were not easy to prevent or predict.
This study confirms my experience managing all kinds of pain in my clinical palliative care practice. Chronic, non malignant pain should be aggressively managed sans opioids whenever possible, and every conceivable non -opioid intervention including mind-body work, acupuncture, PT, exercise, weight loss, etc should be deployed before the prescription pad comes out.
10
@ach
Great idea to include weight loss as an intervention. My observation has been that people will do ANYTHING to get better with the exception of changing their diet and seriously loosing weight. Ending the stress on bones and joints might be the cure.
3
Your story reminds me of that famous Yogi Berra quote that a restaurant was so popular that nobody ever went there anymore.
Based on what you say, we have tens of millions of prescriptions for opioids each year yet nobody is prescribed them. Perhaps you can explain how that is possible.
I use generic Tylenol with codeine for one issue: severe headaches that leave me so nauseous and dizzy and in pain that all I can do is try to sleep to get them to go away. Since I changed my diet decades ago I rarely get these headaches but when they occur nothing touches them but the Tylenol with codeine. These headaches are debilitating.
I cannot take the anti-inflammatories because I'm allergic to aspirin and there is a cross sensitivity there. So when I have other aches and pains I take acetominophen with great caution.
Perhaps one of the reasons people need so much in the way of pain killers is because our society doesn't allow enough time to get over injuries or take the time necessary to recover from surgery. Our wealth care system shoves people out of the hospital and provides very little follow up care in the home which is where most patients go after a stay. Then there is the lack of personal attention in the hospital that can keep pain at a distance.
We all have known severe pain. Usually it goes away without medication and without us becoming addicted. But today's health care system focuses on paperwork and covering certain points, not paying attention to what the patients need. The worst thing that can happen to a person in pain is to be left alone with it or to feel that it won't ever end.
50
@hen3ry There is a new migraine medication on the market which works through antibodies. It is a once monthly injection. My son just got this injection last week for his intractable migraines. He also has triptan medications. These drugs cost over $1,200 a month. He is still on our insurance policy luckily. We are looking into what to do when he ages out of our coverage.
This professor of pediatrics just informed us how to deal better with the "opioid epidemic"....yeah, lost of addicted 3 year olds out there.
I am a chronic pain patient. I do not now use any opioids but have in the past: opioids prescribed to me by board certified pain management doctors, who knew me for me and year and actually accepted that I was in chronic pain. Now I take ibuprofen and acetaminophen
as the author of the article seems to advocate (or the study he reports on does.) Do any of the people involved in the study even have or truly understand pain or the difference in effect between a real pain medication (almost always an opioid) and those over the counter pills (which when used for severe/ chronic pain are incredibly dangerous and damaging to the kidneys and liver)?
A good point: "Contrary to the impression left by most press coverage of the issue, opioid-related deaths do not usually involve drug-naive patients who accidentally get hooked while being treated for pain. Instead, they usually involve people with histories of substance abuse and psychological problems who use multiple drugs, not just opioids." from: https://reason.com/archives/2018/03/08/americas-war-on-pain-pills-is
My understanding is that people with genuine pain, whether its back pain, knee pain, burn pain, cancer, do NOT tend to become addicted. Their bodies use the opioids to control the pain and seldom become addicted in the way that the media and government tell us they do.
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@RLiss Precisely. I was prescribed an opioid immediately after knee replacement surgery. I took it when needed, which meant spacing the doses farther apart as my pain called for it less often.
Wound up with several pills to spare. I'm hanging onto them just in case by the time TKR #2 happens this fall, my orthopod falls prey to the anti-opioid hysteria and won't prescribe them. Knee replacement pain can be agonizing while it lasts.
25
Using anti inflammatories for chronic pain can kill you. Read the labels folks--they will ex pain about stomach bleeding and why usage must be limited and Acetaminophen causes severe liver damage with extended use. So those remedies are incompatible with chronic pain which requires extended use to be effective.
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I have long lobbied for just pure opiates and was thrilled when a company was going to offer it without Tylenol. The idea was dropped cause the company wanted or make it one big dose.
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@Betty
To paraphrase the 1950's slogan: Better dead than addicted! People who think tylenol will work on severe pain have never been in severe pain.
11
Contrary to popular belief, people who are on opioids for chronic pain are NOT addicted to those medications. And, what do you with people who have tried every other intervention known to humankind (medications and adjunctive treatments) and their condition remains unresolved? People think that you just walk into an office and say you have pain and practitioners just hand out opioids Willy Nilly. In the real world, opioids are an option of last resort. If you are going to a decent pain clinic, you are rigorously tested on a monthly basis. There are records from the State that keep track of every prescription of pain medications that you fill, so you cannot have multiple prescribers. Clinicians are continually working to keep the patient at the lowest dosage possible. So, safeguards against misuse do exist.
Personally, I am totally fed up with the hubris of some people who diss what is a viable and very effective treatment for many patients. The conclusions in this article about people doing better off of opioids are wishful thinking on your part. If you want to tackle the opioid ‘epidemic,’ then study people who abuse opioids, along with other all of the other substances they abuse. Opioid use is a medical issue, not a moral one. Leave legitimate pain patients alone!
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According to a Federal government report, an estimated 24% of patients who take opioids for chronic pain end up abusing them. If you don't believe its studies, please cite the ones upon which you make your contention.
As to Doctors not handing out prescriptions for opioids so easily, that is something that is a very recent development.
@banannamom
I had one doctor who insisted that opioids CAUSED pain. Needless to say he is no longer my doctor.
@banannamom Alleluia and thank you! The self-congratulations of some of the commenters here who can navigate a week of tooth pain or the stiffness of aching joints with aspirin or anti-inflammatory ibuprofen hardly qualifies them for the moral high ground they seem to be staking out.
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A professor of pediatrics is telling us internists and family docs how pragmatic trials work for “adults?”
Adults are infinitely more challenging that dealing with children. A patient with chronic pain comes in with baggage of having seen three neurologists, an orthopedic surgeon, two or three psych consults and told “Nothing found! Learn to live it.”
Live with unrelenting pain!
Now let’s talk about clinical trials.What the good doctor leaves out, what pharmaceutical companies leave out are the patients that are refused as candidates for the study.
Age-too young or too old. Other med problems can “interfere” with results of meds and therapy. Patient has been diagnosed with Borderline Personality Disorder, Major Depressive Disorder, or Multiple Sclerosis-no way they get in the study.
I know! Because I have patients who plead to get into a study, then they’re told NO--you don’t fit our criteria.
Also the doctor doesn’t talk about the patients they drop from the study. I went back and read up on the early studies of Lyrica--the magic drug for fibromyalgia and diabetic neuropathy (pain in feet). 2% had suicidal ACTION.Not ideation where they THOUGHT of suicide, but actual attempts--getting plastic bags and duct tape-suffocation, buying rope to hang oneself, etc. Patient had NEVER considered suicide before.Patients removed from study! I wrote up a 17 page FDA “adverse reaction report” on these findings and NOW it’s on TV and magazine ads.
Every patient is different.
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Opioids have proven to be a very effective means of controlling pain for decades particularly the less “ addictive “ 5 or 10mg varieties. It’s not the opioids is the people using them and the medical professionals cashing in on other things like physical therapy, and other pain management “tools” owned by the same Wall Street entities as physician groups hospitals and the buildings themselves. In fact low dosage generic hydrocodone is very cheap as well as effective, the operative words being generic and cheap, the docs and the pharmaceutical companies don’t make the big bucks they do if a “ therapist” or pain management specialist is involved. The idiots dying of drug overdoses, first of all are dying largely from heroin or cocaine or combinations thereof, not low dosage pain pills that until “ reclassified “ weren’t even considered a narcotic. It’s the money honey always and forever in America’s obscenely expensive healthcare system. The same people killing themselves by overdose, were that not available would be and are doing it with alcohol, cigarettes, guns, food or religion. All drugs should be legal to take the profit motive out of it and people should assume responsibility for their own actions. Of all things cigarettes should be illegal, second hand smoke kills, you don’t directly die from someone next to you popping a pill.
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@Ted
Opioids have benefited humans for thousands of years, not just decades.
The government, the media, the moralists began attacking them a decade or so ago.
They make them so hard to get for people who truly need them, that MANY people turn to heroin or illicit drugs instead, for pain relief.
Judgmental people telling people in true pain that they are bad, lazy, weak and so on do NOT help anyone.
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@Ted
There is a commercial going around Southern Oregon (our news channels here in Northern California) that begin with a mother stating her son became "addicted" to pain pills when given them for a torn ACL, then voila he died of a heroin overdose. Nothing about what happened in between. Had they relied on tylenol for pain relief she probably would have sued the doctor for ineffective pain control. I am sorry her son died, but it wasn't from getting effective pain relief from a very painful condition!
10
I live in Italy and three years ago broke my forearm in four places, needing surgery and permanent plates. After surgery I was offered aspirin to handle the pain. I took it twice and was fine after that.
There is no opioid epidemic here.
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@Julia
You may have a high pain tolerance, I don't know, but you are being very judgmental in your statement. People are very different, and how they interpret and deal with acute pain (what you describe and very, very different from chronic pain or terminal pain, as seen in cancer for instance) doesn't mean everyone else will react the same. Or that you are better than anyone else for using only two aspirin.
14
@RLiss - Yes, she's better than everyone else - she lives in Italy, don't you see? And there's NO OPIOID epidemic there! Things are perfect .... in her world. If only everyone were as perfect as her. (Alas) ;-)
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@Julia
No opioid epidemic in Italy? You sure about that?
http://www.lastampa.it/2017/07/17/esteri/heroin-addiction-resurfaces-in-...
1
Ignoring the pain study quoted, Dr. Carroll has pointed out the value of pragmatic trial designs. These often answer questions about efficacy and safety of drugs after approval, in the real world situation with patients who might not have been eligible for the registration trials. Drug manufacturers are rarely the sponsors of these pragmatic trials for many reasons. A key one is the lack of recognition by the FDA of the statistical validity of the results. To be included on the drug's label, and therefore to be communicated by the manufacturer to doctors and patients, the study results must be as statistically rigorous as the original registration trial. This is difficult to achieve in real world pragmatic trials because of the mix of patients and mix of severity and features of the disease.The information may be extremely useful to clinicians, but unless the FDA broadens the type of data that can be shared by the manufacturers, our access to pragmatic trials and real world data will remain limited.
8
Non-opioid pain relievers work, but their dangerous side effects make them unsuitable for managing chronic pain. Overuse of NSAIDs and Acetaminophen can lead to extreme digestive problems, liver failure and for some NSAIDs heart failure.
Yes, opioids also have potentially dangerous side effects through addiction, but less than 20% experience addiction/abuse problems. As long as potential addiction/abuse is properly managed by the physician and patient, opioids are far safer alternatives to using NSAIDs and Acetaminophen to manage chronic pain.
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@Ytnok
You're right, the rates of abuse and addiction vary widely. Varying definitions of abuse, misuse, and dependence (i.e. studies that measure physical dependence and consider physical dependence in itself a negative outcome) account for some of this variation. Most studies actually have findings far less 20 percent.
Cheadle, Gallagher, and O’Brien (2017) found that less than “5 percent of their study population revealed any evidence of substance use disorder”. Minozzi and colleagues (2013) concluded “opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence.”. As for addiction rates in acute pain, Arpeet et al (2017) retrospectively reviewed charts of 675,527 patients undergoing urological procedures and found 0.09% were diagnosed with opioid dependence or experienced an overdose.
References
Arpeet, S., Blackwell, R., Kuo, P., Gupta, G. (2017). Rates and Risk Factors for Opioid Dependence and Overdose after Urological Surgery. Journal of Urology (198)5: 1130-6.
Cheadle, M. & Gallagher (2017). Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain. Pain Medicine;0: 1–10. [E Pub].
Minozzi, S., Amato, L., Davoli, M. (2013). Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction,108(4):688-98.
14
You're right, the rates of abuse and addiction vary widely. Differing definitions of abuse, misuse, and dependence (i.e. studies that measure physical dependence, but don't differentiate patients functioning well on prescribed opioids versus those who are not-physical dependence itselfs considered a negative outcome) account for some of this variation. Most studies actually have findings far below 20 percent. Cheadle, Gallagher, and O’Brien (2017) found that less than “5 percent of their study population revealed any evidence of substance use disorder”. Minozzi and colleagues (2013) concluded “opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence”. In acute pain, Arpeet et al (2017) retrospectively reviewed charts of 675,527 patients undergoing urological procedures and found 0.09% were diagnosed with opioid dependence or experienced an overdose.
References
Arpeet, S., Blackwell, R., Kuo, P., Gupta, G. (2017). Rates and Risk Factors for Opioid Dependence and Overdose after Urological Surgery. Journal of Urology (198)5:1130-6.
Cheadle, M. & Gallagher (2017). Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain. Pain Medicine;0: 1–10. [Epub]
Minozzi, S., Amato, L., Davoli, M. (2013). Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction,108(4):688-98.
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@Anne Fuqua
I think the point of the article is that non opioids and opioids have similar efficacies. The studies you list above are all about effectiveness, which is a different concept.
Pragmatic trials can be incredibly useful and fill a much needed void in areas where it can be difficult to perform a randomized controlled trial, or RCT, often known as the gold standard in research. My views are very similar to what Dr. Lawhern (with whom I'm acquainted) has voiced. I don't feel the Krebs study is a good example of a pragmatic trial. As Dr. Lawhern said, there are serious flaws in the design of this study.
1. The non-opioid arm contains an opioid - tramadol.
2. Most patients with these conditions DO NOT typically
require chronic opioid therapy. It only makes sense
that non-opioids would compare favorably in a
population like this who typically don't require
opioids.
3. Maximal doses of non-opioids are compared against
very minimal opioid doses at longer dosing intervals
than would be effective for most patients.
44
You needed a "study" to show that pain meds are over used. When you are asked about your satisfaction pain management is a priority, and with our wimpy population they think any pain is too much.
3
@vulcanalex"
very judgmental and confusing (apparently ) morality with this issue which is far more complex.
4
Does one really need a study to determine whether addiction to opioids results from doctors prescribing opioids? Opioids can be toxic killers, they are reason infections like HCV, HIV and others transmitted by IV drug users sharing contaminated syringes, they can be hard to get rid of from one's system.
Pain is often due to inflammation or injury at least in such cases anti-inflammatory treatment may suffice to alleviate pain.
When laproscopic surgery was done on me, my request was to let me suffer the pain without any opioids after anesthesia had worn out. So they gave me an analgesic and I tried not to think about the pain by getting out of the uncomfortable bed and watching TV while sitting on the sofa. It was one of the longest nights of my life but I was discharged without ever craving for pain killers. No pain no gain.
2
@Girish Kotwal:
once again an apparently well meaning person is confusing ACUTE pain with CHRONIC (day in and day out for years, decades) and the type of pain caused by burns, cancer etc.
12
@Girish Kotwal
"It was one of the longest nights of my life but I was discharged without ever craving for pain killers. No pain no gain."
One night, no matter how agonizing is not chronic pain.
For the last 9 years, due to several diagnosed and documented conditions for which there is no intervention or therapy that minimizes the level of pain I have been prescribed low dose opioids. Even with this rx, I am able to leave my house only for doc appointments and that only due to friends kind enough to drive me, due to the pain and the physical disability that drastically limits my functionality. For personal reasons, suicide is not an option for me but without the low dose opioid rx, I am not sure I could take the relentless severe pain.
I am an expert in finding joy in my days. Friends stop by almost daily, if I'm in good enough shape to chat for a few minutes. When pain allows I am a readaholic. I work to up my mental and spiritual game, my imagination has become a saving gift. I am fortunate indeed to have this grace in my life, and I have it only due to the low dose opioid rx.
8
@Girish Kotwal: YOU are not EVERYONE. Because YOU did not feel much pain after a laproscopic surgery does not mean OTHER PEOPLE have no pain.
1
It is regrettable that Aaron E Carroll chose to use the Krebs study as his example of pragmatic trials. The Krebs study was deeply flawed by its attempt to assess the relative effectiveness of opioid therapy versus non-opioid therapy in a class of pain disorders where opioids are rarely used in practice. The study design erroneously designated Tramadol -- an atypical opioid analgesic - as a non-opioid. Moreover, Carroll reveals his own bias when discussing the reasons why double-blind opioid trials are rarely conducted. Those reasons have almost nothing to do with patient expectations. Reality is that large numbers of patients who have previously used opioid analgesics will lapse into breakthrough pain when tapered off them. And for large numbers of patients with serious pain, nothing but opioids actually works.
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@Richard A Lawhern PhD I wished that CDC, Dr. Carroll and others would be more straightforward and honest about the evidence behind the government's recent policy to cut back on opioid use. No doubt there are people who abuse opioid medications and need help. However, when the recent changes came about, I went to the CDC's website and read the full report, not just the brief summaries, graphics, or other communication pieces. What I found was that the CDC itself rated the evidence behind their policies as low quality or sparse yet when one reads the short pieces, they seem to make the recommendations seem much more solid/ far-reaching than they are. In particular, recommendations were made about chronic use yet very few trials had a duration beyond 1 year. "Chronic" pain often lasts years if not decades so 1 year hardly cuts it. This is very shoddy work: I have worked on guideline committees and have seen the brief/ public-oriented communications that come out. Most of the time, they are accurate but other times, I really question how good communications teams are at capturing the reality of what was discussed. In the case of opioids, I felt like governmental policy was dictated more by politics than science.
An important followup to pre-approval clinical trials (Phase I, II and III) are the Phase IV studies that are conducted after the product is approved. These studies are "real world" in that they are conducted under actual drug use conditions including manufacturing of the drug at large scale volumes. And of course, the drug is given to a much wider range of people, including off-label use which, while controversial, is legal. Phase IV is where drug effectiveness can be better verified as long as big pharma does not find ways to hide inconvenient truths.
7
Lower back pain and hip and knee pain are poor choices for testing the effectiveness of opioids. They usually get better on their own and can be managed with analgesics in the meantime. Such studies are irrelevant for more serious types of pain, including chronic pain from more serious permanent injuries, cancer and other conditions.
I agree that dentists, endodontists and oral surgeons prescribe way to much hydrocodone but complaining about that is just attacking a straw man. Opioids have their place. The problem is irresponsible use, not their existence.
33
@Tom Sure they have their place, in the hospital and with those with serious issues, not every little thing.
@vulcanalex I don’t know exactly what you mean by “every little thing”. I take opioids due to to injuries from a car accident. Prior to going that route I did all of the usual things (naproxen gabapentin, acetaminophen, even a pain clinic) with no effect. I eventually had to go the opioid route and it’s been somewhat effective. Of course, due to the “opioid crisis” my doctor is afraid to prescribe a reasonable amount, but at least I get four hours of relief.
I worked with drugs for a long time. First it was LSD and good heroin, then it was cocaine and crack, then meth, and now opioids that was the worst thing ever. The only thing different with opioids is the population demographics.
@Tom Actually they are great choices because it proves these common ailments don't always need management with potent narcotics. No one is saying narcotics should be banned entirely, but that they shouldn't necessarily be a first line drug just because someone has pain.
3
The study cited here only included musculoskeletal pain. Some kinds of musculoskeletal pain are already well-known to respond best to non-opioid treatment. There are (to my knowledge) no studies (pragmatic or otherwise) on patients like me, in lifelong opioid therapy with a pain specialist for severe intractable pain caused by rare autoimmune disease.
That's because it's unethical to give someone like me placebo for 20 years, not because we're somehow manipulating our way into treatment we don't need. Many (if not most) of us went through literally every non-opioid therapy that exists, before we were referred to lifelong pain management.
This is not just a side point that "purists will argue correctly," it's the lives of real people. I hope the NYT might consider, in future publications, allowing more than one sentence for rare disease patients who are, necessarily, left out of the research we hear so much about in the news.
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@Reese Tyrell
Yes. And I would be over the moon with joy if any other treatment, non-hysteria inducing rx or otc pain relief worked. Because my life would be so much easier.
3
I know a recovering addict who was afraid to get his wisdom teeth pulled because he heard the doc involved would prescribe opioids for the related pain; and he knew he would take them. His drug counselor recommended he turn down the opioids specifically, prior to the extractions; and try a combination of acetaminophen and ice packs. This worked. He remains clean and sober (this happened 18 years ago). This is an example of simple alternatives which are skipped over for the supposed benefit of opioids. Like many addictive substances, if there is a benefit it is completely at the front end. The heavy price follows later. Non-opioid alternatives, like ice, over the counter medications, physical thereapy, relation and hypnotherapy, acupuncture and CBD salves, need to be considered as viable alternatives for routine and time-limited pain management.
9
@Frank Or just tolerate the pain, humans used to do that a lot.
1
@Frank, the old doctors' advice still holds, "Take two aspirin and I'll see you in the morning".
Aspirin is very cheep and effective for adults if taken with 12 oz. of fluid.
1
@vulcanalex And humans with any sense figured out long ago that "tolerating" severe pain when relief is available is a doggone stupid thing to do.
6
But pain isn't really objectively measurable, is it? One person's chronic, unbearable pain is another annoying twinge.
That being said, I find it very, very hard to believe that aspirin is more effective for chronic pain than opioids.
18
@bebopluvr there are many more non-narcotic pain relievers than aspirin. Some surgeons are even managing aftercare pain without any narcotic use. We've been told for decades that narcotics are our best options but it really is not always the case.
4
Dr. Carroll has put his finger on one of the cornerstones of expensive and with opioids dangerous medical care. I graduated from Med School in 1975 and retired last year. I have noticed that money in Medicine has grown exponentially, both in volume and influence. Then, objective medicine was replacing doctor judgement medicine and controlled trials were considered the standard. We found out that coronary disease was caused by atherosclerosis and clots. So anti-coagulation and routing out the clots worked well and anti-lipids worked. Antibiotics had of course been found to be effective and by 1990 antibiotic studies abounded. The double-blinded controlled trial could sift out effect vs no effect, and the age of statistical inference blessed medicine with effective treatments. But after 2000, trials were a way to cement University jobs and most studies were funded by Pharmaceutical Co's. Sales and profit became more a driver and negative studies were buried. Today there is paltry antibiotic research, but lots of pain studies for clever opioid delivery systems. This is true for my field of Lung medicine. For COPD there are 3 effective drugs and now about 100 ways of delivering them, each more expensive than the previous while studies support marginal benefits. Epipen and Daraprim represent obvious gouging. Pharma compains about research costs but it spends more on advertising.
I thank Dr. Carroll for this report, it should make us think about the cost/benefit of medical care.
54
My wife and I have both had opioids prescribed by dentists after extractions or driling for implants. Both of us tried one pill, found no benefit, and didn't use the remainder of a weeks supply. If this practice is common it is no wonder that
opioids are everywhere. We also have a friend who was prescibed an opiod for chronic back pain, became addicted and had the greatest difficulty n weaning himself off the drug, long after his back pain had gone. Too many medications are being prescribed for the presumed wish of the patient.
4
Interesting contrast: you and your wife discovered that opioids didn't have any effect; and your friend found them so effective, he couldn't stop. Which one is it?
5
I was having hip pain last year, initially intense at times. It eased very slowly, and my doctor prescribed three different drugs over a month or so. The last turned out to be an opioid, which I learned only after I filled the prescription and never took. I told her she should have told me, and I would have saved my money.
5
@Diane
She should have told you (and you could have asked, right up to the point that you paid for the prescription). Still, you report intense pain and that two non-opioids did not help. So it appears that your doctor wasn't pushing opioids on you; rather, she tried the other stuff first and when they didn't work she gave you the opioids. Of course, we don't know your diagnosis, but if it was bursitis or arthritis, I would have expected that you would be given physical therapy and/or a cortisone shot before the opioid.
Which leads back to the point. Because opioids are addictive, they should be a last resort. There are decent options. For those who can tolerate them, NSAIDS are good, although when the data come in on their effect on the heart I think they'll be used more sparingly than they are now. PT is good, expensive and time-consuming. Tylenol can help, but is hard on the liver. For some people, tramadol is the answer, but it's weird stuff. At the end of the day, if you are really hurting, you'll end up with an opioid. I'm all for trying other things first, but I am not for people living in pain because of a national hysteria. The 1950s ended a long time ago. Managed addiction may well be the right choice if unremitting pain is the only alternative.
Carroll fails to mention that successful completion of randomized control trials are required by the US Food and Drug Administration and similar agencies in other countries in order to market drugs. The concept of a "pragmatic trial" is new to these regulatory agencies.
5
Nothing will stop the opioid epidemic, just as nothing will stop the gun violence epidemic, because both are driven by the need to increase profits. As Edward Abbye described our economic system, "Growth for the sake of growth is the ideology of a cancer cell." And cancer cells don't care if they kill.
29