Thursday, December 20, 2018

Opioids Don't Work Well for Chronic Pain

I am hardly an expert in opioid abuse. Nevertheless, I am happy to report research on the topic. The last time I wrote about the topic, a few days ago, commenters suggested that there really wasn’t much of a crisis, and besides, how can anyone possibly complain about offering painkilling medication to people in pain.

So, consider this post to be reportage. The first statistics were presented by Andrew Sullivan last  February:

We consume 99 percent of the world’s hydrocodone and 81 percent of its oxycodone. We use an estimated 30 times more opioids than is medically necessary for a population our size.

As for the number of prescriptions, Sullivan reports:

Between 2007 and 2012, for example, 780 million hydrocodone and oxycodone pills were delivered to West Virginia, a state with a mere 1.8 million residents. In one town, population 2,900, more than 20 million opioid prescriptions were processed in the past decade. Nationwide, between 1999 and 2011, oxycodone prescriptions increased sixfold. National per capita consumption of oxycodone went from around 10 milligrams in 1995 to almost 250 milligrams by 2012.

But, just in case you do not trust Sullivan, the Daily Mail reports on a study published in the Journal of the American Medical Association. It concludes that opioids do not really work very well for chronic pain that is unrelated to cancer.

I report the Daily Mail summary:

Opioids, which have gripped America and are prescribed for an array of reasons, don't actually work well for chronic pain, according to a new study.

Opioids are principally prescribed for treating pain associated with cancer but they're also handed out for back pain, headaches, and after surgeries.

They're also turning out to be one of the biggest killers in America as 70,000 people died of drug overdose in 2017 and a majority of those deaths involved opioids like fentanyl.

Underscore the last statistic, 70,000 dead a year.

As for the study, conducted by Jason Busse, it was published this week:

A study conducted by Jason Busse of McMaster University in Ontario and his colleagues sought to test just how well opioids work to treat chronic pain unrelated to cancer and found the drug barely helped patients in need.

'The benefits of opioids for managing chronic pain tend to be quite modest,' Busse and co-workers wrote in the report published on Tuesday in the Journal of the American Association.

The study found that other drugs and treatments such as physical therapy or ice work better for non-cancer pain, according to researchers.  

However, a common problem in the medical field is when opioids fail to control pain, doctors simply up the dosage, which can lead to dependence and addiction, according to NBC.  

Ah, ha… note well. When opioids do not control pain, physicians increase the dosage, which causes dependence and addiction.

The Daily Mail continues:

The effects of opioids on chronic pain are uncertain, whereas the harms found to be associated with prescription opioids include diversion, addiction, overdose, and death,' the report adds.

In the study, opioids gave only slight improvements in pain. It offered also no improvements in emotional functioning.  

'Compared with placebo, opioids were associated with small improvements in pain, physical functioning, and sleep quality; unimportant improvements in social functioning; and no improvements in emotional functioning or role functioning,' according to the report.

In fact, opioids were associated with increased side-effects like vomiting.

'Compared with placebo, opioids were associated with increased vomiting, drowsiness, constipation, dizziness, nausea, dry mouth, and pruritus (itching),' the report adds.

What's more - prescription opioids were found to have similar pain-relief benefits as non-opioid treatments including nonsteroidal anti-inflammatory drugs, according to Live Science.   

The report is more important than ever because in 2016 some 50million adults in the U.S. were prescribed opioid medications for their chronic non-cancer pain.  The widespread use of the drug has led to an epidemic of addiction.

Note the last statistic: 50,000,000 adults were prescribed opioids in 2016. Please do not tell me that this is a good thing.

The Daily Mail concludes:

'The findings reported by Busse (and colleagues) illustrate that most patients who are prescribed opioids for the treatment of chronic non-cancer pain will not benefit from those drugs,' Dr. Michael Ashburn and Dr. Lee Fleisher of the University of Pennsylvania said on the report.

'However, when opioids fail to provide pain relief, a common response by clinicians may be dose escalation rather than reconsidering use of the drug,' he added.

The reports says that doctors do not realize they may not be truly helping patients when prescribing the drug.

'What most physicians do not recognize is that 92 percent of people who misuse opioids do so by taking prescription opioids, and that 75 percent of individuals who use heroin report that they started misusing opioids through the misuse of prescription opioids,' the report says.  

As I said, I have no qualifications to judge painkillers. But these studies seem clear.


whitney said...

Almost a decade ago I had a terrible car accident and was in a wheelchair for about six months and a bunch of other things and took a lot of Oxycodone. I was concerned about getting addicted to it because I have what you would call an 'addictive personality'. I got to say I don't get it. I never understood the appeal. It worked okay on the pain but with horrible side effects. But I was actively curious why people liked it so much and in a couple occasions abused it just to see and I got nothing. It made me sleepy and a little nauseous. And the constipation is no joke. I never could watch House the same way.

trigger warning said...

Personal observation, FWIW...

In grad school, I did something to my shoulder (playing too much squash and tennis) that was exquisitely painful and lasted several months. I was prescribed an opioid. To my surprise, I still felt the pain, I just didn't care. The drug treated the affect, but not the pain. Hm.

Then in the 90's, I had some minor periodontal surgery to prep for a crown replacement. My periodontist lied - it was one of the most, if not the most, painful medical procedures I've ever experienced. I was prescribed an opioid and ibuprofen, and told to use one or the other. I started with what I thought would be the "good stuff"; i.e., the opioid. The opioid helped, but I was still in serious pain. Figured what the hell, I'll try the ibo. Ahhhhhhhh. Joy. Give me a NSAID any day.

Sam L. said...

I was sent home from a hospital after surgery with a vial of oxycodone. The next day, and ever since, I have been pain-free. I took the vial to the police station, and left them there.

jfmoris said...

My sister got ovarian cancer and got misdiagnosed as 'seeking pain killers'. By the time she finally got diagnosed the cancer was too advanced, and she died. I've looked up the symptoms of malingering that doctors use and I think she may have said and done some things that got her classified as a drug seeker. A faker would have learned better, and had a lot of free time and medicaid to seek until they found a doctor who'd give them what they want.

My main experience with social security disability was running a small motel where I'd rent by the week during the winter. I got to where I'd refuse weekly rates to anybody who said the words "social security". It's like a govt training program to become a drug addicted scammer - you get into it by lying to doctors and then have to augment your income by scammming. The reason I didn't like renting to them was all the claims about their ssi checks not coming, and I think the reason they ended up paying motel rates was because they pulled that BS on too many landlords and roommates.

Govt programs inherently favor scammers and ruin things for those truly in need. Here's a pharmacist's blog where he has a lot to say about the huge waste caused by this idiocy.

Kansas Scout said...

There is NO effective alternative to opiods for pain relief for signifcant pain. My wife has had three terrible bouts of severe back pain. The last time was hell for her because the so called pain Dr refused to prescribe an effective dose. Only after two trips to the ER for demerol injections was the Pain Dr. finally starting to prescribe higher doses. People with chronic pain need opiods period. The overdose hysteria is hurting the hurting. This hysteria sweeps the nation about every ten years. It fades away as people recover their minds and ditch the hysteria and return to giving people relief. I've become beyond angry over all this. Watching your wife suffer horribly is not something you want to experience.

trigger warning said...

You make a good point about the sweeps of public hysteria, KS. It's the nature of feedback and regulated processes. A thermostat doesn't keep a house at 72°. It lets the temp fall to 71° or so, switches on the heat until 73° or so is reached, then starts all over. Financial regulation, health care regulation, criminal justice regulation, etc. all follow the same pattern. When there's a response lag in the system - as there always is with government regulation - it just makes things more erratic.

Problem with the current "crisis" is the death rate. As I've noted here before, enough pills were shipped to three rural counties in my native state, WV, to supply every resident of the state for years. Nine million doses were shipped to a single pharmacy over a two year period. State population is somewhere around 1.5 million, IIRC. Sumthin's busted in that system, needs fixin'.

DocVinny said...

I really wish people who public the results of "studies" would differentiate fentanyl, the pharmaceutical made in controlled environment and accurately dosed - in micrograms - with the stuff coming in mixed into heroin to give it more kick. Very different, and for people with severe chronic pain fentanyl can be an excellent choice.

I once had a heated discussion with a pain management doctor colleague, who are a dinner we were at together stated that here is no legitimate use for opiates for long term pain. He now has a staff nurse practitioner who writes for the opiates for the people in his practice with long term pain.

The big push in our area is to get everybody off opiates and on cannabinoids. Brilliant.