Dr Steve Feinberg pointed me to two studies conducted by the Agency for Healthcare Research and Quality on chronic pain, both systematic reviews [reviews of published studies of a specific topic]. One focused on opioid treatments for chronic pain, the other on non-opioid pharmacologic treatment.
The non-opioid research reviewed 190 studies, of which 185 were RCTs. Researchers concluded:
improvement in pain and function was small with specific anticonvulsants, moderate with specific antidepressants in diabetic peripheral neuropathy/post-herpetic neuralgia and fibromyalgia, and small with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis and inflammatory arthritis.
The takeaways include there are some benefits from some drugs, often dependent on the patient’s medical condition.
The opioid treatment for chronic pain study was based on a review of 162 studies; “115 randomized controlled trials (RCTs) [the gold standard of clinical research], 40 observational studies, and 7 studies of predictive accuracy.”
Note that for research purposes, chronic pain is described as pain that lasts more than 3 to 6 months.
There was more credible research available to assess short-term outcomes vs longer-term outcomes; there was no RCT comparing opioids to placebo for medium or longer-term periods.
Takeaways included (and these are direct quotes):
- There were no differences between opioids and nonopioid medications in pain, function, or other short-term outcomes
- Opioids were associated with small benefits versus placebo in short-term pain, function, and sleep quality.
- There was a small dose-dependent effect on pain, and effects were attenuated [reduced] at longer (3 to 6 month) versus shorter (1 to 3 month) followup.
Most concerning, “there is evidence of increased risk of serious harms that appear to be dose dependent” [the higher the dose, the greater the risk].
This crossed my desk the day before a good friend’s brother died of an apparent opioid overdose, adding a painful exclamation mark to the study’s conclusion.
Extensive research in Australia focused on long-term opioid use in patients with chronic non-cancer pain found that:
Despite limited evidence of efficacy, there has been a considerable increase in the long-term prescribing of opioids for chronic non-cancer pain in several countries
Here’s the thing; the research we do have clearly demonstrates the risk of opioids is high, and the benefits are limited. However, there isn’t near enough research on the efficacy of long-term usage of opioids for chronic pain.
Anecdotal evidence indicates some patients can do well on opioids for extended periods.
That said, the evidence we do have suggests that overall, efficacy may be limited at best, and the risks are high. Fortunately more research on opioid efficacy and risks and chronic pain has already been funded.
What we cannot do is force patients off opioids; this is dangerous and unethical.
What does this mean for you?
Opioids have their place – but be very careful, especially when use is long-term. Life is precious.
Joe thank you as always for bringing serious issues to light. From the data you highlighted above it is obvious that except in end of life situations, relying solely on medicinal interventions for pain management is not best practice. The HHS document, “Pain Management Best Practices Inter-Agency Task Force”, which was chartered in response to the 2016 Comprehensive Addiction & Recovery Act, and is available here: https://www.hhs.gov/ash/advisory-committees/pain/index.html outlines the FIVE treatment treatment approaches to pain management. It recommends a patient centered approach which considers and integrates five different approaches including: restorative therapies (physical and occupational therapy), interventional procedures, behavioral health approaches, complimentary and integrated health, in additional to medicinal therapies. The document recommends a risk benefit approach based on individual patient characteristics. This is a nice resource to understand part of the problem we face as a society with regards to pain management and addiction as well as where we are with regards current best practices and suggested areas of research towards finding a solution. Like so many societal issues it appears we look for simple answers to difficult problems and oversimplifying our approach leads to unintentional and potentially devastating consequences. I am sorry for your friend’s lose. We need to continue to move this issue forward to get people the care and relief they need and deserve and prevent the ever so prevalent tragedy of addiction and life loss.
David – thanks for the information and link – we agree.
be well – Joe
I commented on the issue of OPIATES for pain medicine in chronic pain. I also commented on OPIOIDS that drug addicts mainly mellenials. have been using in the form of HEROIN illicit drugs. In fact we are CURRENTLY viewing what using drugs can do to your heart while agitated. GEORGE FLOYD demise. While his death is a tragedy and touches on so many issues in this country FAILED WAR ON DRUGS should be top of the list. Pain has been undertreated and has forced many to use street drugs that are highly addictive and powerful. Chronic pain patients not only live functional lives but PROSPER by running businesses and their families.Forcing an individual into early retirement ending in poverty due to undertreated pain is CRIMINAL INHUMANE AND HUMAN RIGHTS ABUSE. More people will die due to undertreatment of the patient and the denial of health care due to a stigma and fear of surveillance. I can only hope your organization has a small voice. GOD HAVE MERCY ON YOUR SOULS for your repeated lies to further your agenda. What substance did your friend die from HEROIN alcohol pressed pills. PAIN MEDICATION DOES NOT KILL PATIENTS. Illicit drugs do!
Hello Ms Hansen – and thank you for your comment.
I do not know how you can conclude that pain medication does not kill patients. That is demonstrably false as has been proven and stated literally thousands of times. Here is a quote from a recent MMWR “The prescription opioid-involved death rate decreased 4.5% from 4.4/100,000 in 2013 to 4.2 in 2019.”
I also do not why you wish “god to have mercy on my soul”; or where I have “lied”, or what causes you to speak about me with such vitriol and anger. Perhaps you have not read much of what I have written, or more unfortunately have ignored it. If you would kindly point to where I have lied, I would much appreciate it.
I will insist that commenters not make verifiably false statements Mr Floyd’s cause of death. The coroner and other credible experts have stated clearly that but for the pressure on his neck by Officer Chauvin, Mr Floyd would not have died.
Ms Hansen, I sincerely wish you well.
Joe