By Marvin Ross
Since the highly flawed CDC guideline on opioid prescribing was introduced, followed by the “copycat” Canadian guideline, pain patients have lost rational treatment for their pain. Each patient is an individual and should be treated as such by his/her physicians. What works for one person may not work for another and finding the best treatment is often a trial and error process involving switching treatment modalities and titrating dosages. Unfortunately, since the advent of these guidelines and the opposition to using opiates, newly diagnosed pain patients have been forced into predetermined boxes, or, if previously treated successfully with opiate medicine, forced to forgo that treatment.
Examples abound. I fractured a knee cap recently and was told by the ER doc to take NSAIDs. Before the flawed guideline, I would have been given a script for Tylenol 3, but she told me that it would cause constipation and stronger pain drugs would cause me to fall down. Constipation is a very manageable side effect and causing me to fall down would be quite remote. These were poor excuses not to prescribe; plain and simple. Fortunately for me I did have Tylenol 3 left over from a tooth extraction.
We also see reports of how NSAIDs are sufficient for post-surgical pain. The fine print of course, is that the surgeries these studies report on are often laparoscopic which typically involve minimal pain. Try an NSAID for post-surgical bypass where the sternum is cracked open and the incision is lengthy and see how that works out. How about a mastectomy without opiates for recovery?
The research being done is often biased and conducted by those who start out with an attitude that NSAIDs and other non-opioid prescribing are good medicine for all that ails you. A case in point is a study that appeared in the Journal of American Medical Association by Jason Busse, a chiropractor and editor of the Canadian guideline. Busse found that in 42 high quality studies of opiates versus placebo, opiates resulted in reduced pain. However, he then reports that moderate quality data from 9 random controlled trials found no difference between NSAIDs and opiate pain medicine. This was the message picked up by the media and we were all told that NSAIDs are equal to opiates despite the fact that the studies were not high quality – which he admitted in the report.
Stephen Nadeau, a neurologist at the VA Medical Center in Gainesville, Florida, told the Pain
News Network that:
“Because the study designs in all but a handful of studies did not remotely emulate clinical practice, it cannot be inferred that the results of this analysis are applicable to management of the general population of patients requiring opioid management of moderate to severe chronic non-malignant pain.”
The Pain News Network expressed that opiate critics were quick to focus on the Busse study as proof that opiates should rarely be prescribed for pain. Recently, we see a new study that did not involve researchers with biases and has entirely different results. This report was prepared for The Agency for Healthcare Research and Quality (AHRQ) by the Pacific Northwest Evidence-based Practice Center (EPC) at Oregon Health & Science University using objective researchers. This new study concluded that evidence was:
“too limited to draw conclusions” on long-term use of non-opioid drugs, and “no treatment achieved a large improvement in pain or function.” They also cautioned that “careful consideration of patient characteristics is needed in selecting non-opioid drug treatments” because of the risk of side effects. This evaluation involved 200 studies of which 25 were of good quality.
When it came to the medications used for neuropathic pain, their results were markedly different from the conclusions presented by the CDC. Neuropathic pain is often treated with the anti-epilepsy gabapentinoid class of drugs. The EPC researchers found that:
“Large increases in risk of adverse events were seen with pregabalin (Lyrica: blurred vision, cognitive effects, dizziness, peripheral edema, sedation, and weight gain), gabapentin (Neurontin: blurred vision, cognitive effects, sedation, weight gain), and also cannabis (nausea, dizziness)….Dose reductions reduced the risk of some adverse events with SNRI antidepressants. In the short term small increases in risk of major coronary events and moderate increases in serious gastrointestinal events (both short and long term) were found with NSAIDs.”
The takeaway message from this research is that pain patients deserve to be treated with whatever works for them at effective doses and not medications which are pre-determined by flawed reports and can have devastating side effects. One-size-does-not-fit-all yet prescribers are being forced into a situation where they offer not what their patients require, but what is dictated by the misguided agenda of the day.