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The Opioid Use Hiding Behind the Alleged Superiority of “Nonopioid” Chronic Pain Treatment
The SPACE randomized clinical trial, which 234 veterans with chronic back or knee pain completed, has been touted as demonstrating that opioids are superfluous to chronic pain management. According to JAMA’s summary of the trial,
In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.
and not only did those in the “nonopioid” group experience fewer side effects, but
the use of opioid vs nonopioid medication therapy did not result in significantly better pain-related function over 12 months (3.4 vs 3.3 points on an 11-point scale at 12 months, respectively).
Overall, “nonopioid” treatment appears to win. Omitted from JAMA’s summary of the SPACE trial, though, is the interesting nugget that one of the medications “changed, added, or adjusted” within the “nonopioid” group was tramadol, an opioid. The treatment regimen for the “nonopioid” group can be read off the right-hand column of this graphic helpfully provided by F Perry Wilson of MedPage Today:
Admittedly, tramadol is considered an unusually mild opioid – or was considered unusually mild until recently, when it was scheduled as just another dangerous drug. Furthermore, only 13 of the patients in the “non-opioid based” group received tramadol, meaning most did not. Wilson reports,
Now, I know what you’re thinking. Isn’t tramadol an opioid? I asked lead author Dr. Erin Krebs that very question. She reminded me that this trial started in 2010: “This was before all the concerns about opioid overdose and addiction and back then a big concern was is it ethical to deprive patients of opioids if they fail all these non-opioid medications.”
It wasn’t until August 2014 that tramadol became an “officially dangerous” schedule-IV drug, after having been completely unscheduled for nearly 20 years. So the SPACE trial began back in those halcyon days when tramadol was considered “the safe opioid,” and that, along with basic compassion, appears to be the SPACE trial’s excuse for including tramadol users in the “nonopioid” category.
Indeed, tramadol isn’t just an opioid. It’s also an SNRI, a type of antidepressant, which may help explain tramadol’s formerly-mild reputation: antidepressants also help people cope with chronic pain. As the graphic above shows, stage 2 of “non-opioid based” treatment includes nortriptyline and amitriptyline, both tricyclic antidepressants, presumably for the same reason. A patient receiving tramadol isn’t just getting his opioid receptors tickled; he also benefits from accumulating serotonin and norepinephrine, both of which can improve a chronic sufferer’s mood and function without the opioid “rush.” For someone interested in using opioids as conservatively as possible – stretching small amounts of opioid-receptor tickling into the largest-possible therapeutic benefit – tramadol might seem like a wonder drug.
For many patients, tramadol was that wonder drug, and its scheduling as a controlled substance has proved a burden. As one patient regularly prescribed tramadol back when it was unscheduled puts it,
Fortunately, feeling like a scumbag addict is a great motivator for staying away from opioids, despite the fact that they do take away 100 percent of my pain and allow me to physically function through an average day. Politicians say you’re just weak. [Prospective] employers see you as a potential pill-popping train wreck. Co-workers and subordinates look at you like you’re Dr. House. Friends and family will compare your pain to theirs and blow it off. (“Your back hurts? That’s nothing. I lost three fingers working at the guillotine factory. You don’t see me suckin’ down pain pills”) I simply have to measure the physical pain against the psychological/emotional pain and realize that the latter is greater. Problem solved.
“I simply have to measure the physical pain against the psychological/emotional pain and realize that the latter is greater.” Arguably, that’s a description of tramadol’s scheduling working exactly as it should, deterring law-abiding patients from relief unless their pain is great enough to be worse than the added social stigma and inconvenience.
JAMA must be perfectly well aware that tramadol is an opioid, one which became scheduled before the end of the SPACE trial period. There’s no excuse for JAMA’s summary describing a treatment including tramadol in its final stage as “nonopioid.” SPACE’s “nonopioid” treatment would be better described as “conservative use of a mild opioid as a last resort” treatment, which is exactly how many people supporting opioid usage for chronic pain believe opioids should be used: sparingly, as one of many treatments when less-aggressive management has failed.
Obviously, those who have access to the full text of the SPACE study can read the whole thing and discover for themselves that “nonopioid,” in context, doesn’t really mean “nonopioid.” Science journalists know, though, that many readers only read their summaries of studies, or at best, the study abstracts, rather than the studies themselves, since time and access are scarce. I don’t have access to the full text of the SPACE study, but if we assume that, of the roughly 240 veterans who completed the study, half, or about 120, were in the “nonopioid” group, and we know that of those, 13 received tramadol, then about 10% of “nonopioid” subjects received an opioid. That doesn’t, by itself, prove that roughly 10% of chronic pain patients would benefit from opioid use, but if at most 10% of the roughly 100 million chronic-pain sufferers in the US, or about 10 million people, may benefit from conservative use of opioids, then claims that the SPACE study proves opioids have no place in chronic-pain management are greatly exaggerated.
Published in Healthcare
Try Aleve. It works better than than tylenol for many people with arthritis. It’s generic name is naproxen sodium. It is also okay to take tylenol with aleve. (But the risk with tylenol is that it can affect your kidneys, if you take it continually.)
Here is some info on it. https://www.everydayhealth.com/drugs/naproxen
Also a long time ago, when I was a mere babe of 40, I complained to a co-worker that I was already getting arthritis. She asked if I ate pork. I did. She said, “Stop eating pork for six months and see if that helps.” Within a month of no longer having pork chops or roast pork, my arthritis was gone. I still have pork in the form of decently cured bacon or sausage, though that is limited a bit since I try to keep sodium down. Cured meats dont’t seem to affect me. There is a reason major religions advise against pork. I find it only takes one pork chop for me to have arthritis crop up again.
Maybe that’s part of it Midge. But I see a lot of similarity between the attitude of anti-gun nuts toward guns and the attitude of anti-drug nuts (yes, I used the word) toward drugs. Neither group seems particularly “analytical” to me. Rather, they seem to be wrapped up in an almost religious fervor against the (inanimate) object of their hatred. To the extent that they see people at all they can only see them as victims of gun violence / opioid overdoses, and they completely lose sight of the much larger number of living human beings who need these tools to deal with real problems. To my mind, a doctor who would want to prohibit something as mild as marijuana to a cancer patient is about on the level of a school administrator who expels a fifth grader for chewing his pop tart into the shape of a gun. They are both off the rails.
I agree, Larry, that distrusting ordinary people to use these very powerful tools in constructive ways has a lot to do with it.
Actually, I alternate Aleve and Tylenol, and usually only when I hit the golf course, twice a week or so; my wife takes those three mile walks without me, mostly. I’ve gotten into lap swimming, which is great. I rarely eat pork roast or chops.
I had wondered about that.
According to Statista, hydrocodone consumption is trending down since 2012.
Kilograms, miligrams per capita, or if you wanted to get fancy, morphine-equivalent doses, are all more sensible measures of consumption than # of prescriptions written, for exactly the reasons you state. It’s natural that, the more prescribers are pressured to offer shorter-term prescriptions, the more prescriptions they will write.
I love prednisone too! But I only use it a couple times a year for skin problems. Fortunately my lupus is well controlled with plaquenil.
And if foreign sourced, fair trade.
We tried that with my as-yet-unknown-inflammatory/auto-immune hell. I tried it for almost a year with no real noticeable effects.
Sometimes there is really no replacement for a well-used opioid.
Yeah, not sure about curing cancer… I’ve heard of CBD oil being good for anxiety, but I doubt it’s actually curing cancer.
I don’t know that I said every patient coming in with pain was drug seeking. If you come in as a trauma, you’re going to be in pain and I will medicate you accordingly. However, there are a lot of people who come in with migraines and tell us that the only thing that works for them is Dilaudid….that’s made up.
Yep, we’re all different. I am so sorry about your dilemma – I only had one year of hell 25 years ago and I remember like it was yesterday.
I was literally just doing my pain management continuing ed stuff when I decided to cruise on over here (which I don’t get to do much these days). Midge’s post pretty much summarizes what I was just reading- opioids are ineffective at treating chronic pain. Much like applying heat to an injured muscle or joint, in the short term opioids works, but in the long term they actually have a paradoxical effect- they make the pain worse. Daily narcotic use alters your mu pain receptors and causes hyperalgesia. In a sense, you could liken it to a drug induced fibromyalgia where, with legit fibromyalgia, the body is hypersensitive to stimuli and it creates a pain response to something that would not normally induce pain. Continued opioid use does the same thing. That’s why drug addicts will just about cut you if you have to dose them with Narcan, because it reverses all their mu receptors that have been up regulated.
As to whether Ultram (Tramadol) is an opioid- it technically is, but it was moved up in the schedule somewhat recently. There have been times when it wasn’t considered a controlled substance and didn’t have to be counted whenever you went to pull it from the med dispenser. It is now considered a control, but we like to give it to the elderly especially since it has a much kinder side effect profile than most other narcotics. As to why a drug is or isn’t used, y’all have to remember a lot of this is physician/institution preference. You’ll find providers at one hospital prefer one cocktail for sedation, rapid sequence intubation, or pain management. I worked in one hospital that never used Fentanyl in the ED, but we use it in the hospital I currently work in. A lot of it is just hospital “culture.” Because providers don’t often prescribe Ultram isn’t an indictment against Ultram. I almost never give it now, but use to give it all the time in my last job.
Even so, it’s considered normal to resort to applying heat at least occasionally if you’re dealing with many types of chronic pain. Many forms of temporary temporary relief become part of the arsenal of chronic pain management. As the advice goes,
If occasional use of strategies, including drugs, which temporarily make the offending part feel more safe, protected, and stabilized (irrespective of whether they “really are”), work because of the change in sensation, then, well, using them 24/7 is just the new normal, no longer a change in sensation. On the other hand, regular, but intermittent, use, would still provide a change of sensation.
With all due respect, that’s not such a good analogy: There is no good evidence that ice helps healing. It does reduce the levels of proinflammatory signaling chemicals produced by acutely injured tissues… but that’s not necessarily a good thing, and done long term it impairs healing. Inflammation is part of tissue repair, and if you knock it down too much you slow the healing.
You can even increase the swelling by icing too much: it will cause the blood vessels to dilate (this is known as the Hunting effect.) Because the lymphatic and venous return from the area are insufficient to keep the swelling down, it gets worse. Not only that, too much cold for too long makes the lymphatics leakier.
If there’s a lot of local swelling and inflammation from the injury, brief applications of ice (and maybe using NSAIDs) in the first 1-3 days may make sense, and there is practical experience to say that this works. The caveat is that what makes sense in a pitcher’s postgame sore elbow or a linebackers twisted ankle doesn’t make sense in a coder’s carpal tunnel syndrome or a pain syndrome associated with the adhesions that start developing within hours of immobilizing a part of the body.
After the first 1-3 days, it’s heat. And motion.
1-3 days is an interesting refrain, isn’t it? “Opioids for 1-3 days after trauma or surgery,” “Ice for the first 1-days,” “NSAIDs for the first 1-3 days” may have more clinical benefit than risk, and after that the adverse consequences start increasing.
I think there are several other factors, in addition to the many mentioned in this thread, contributing to the rise in the prescription of opioids over the last two decades.
Hospitals, particularly outpatient surgical departments, are releasing people who are pretty sick and in great pain. In the old days, people were under hospital care a lot longer. Now, as soon as the hospital can detach the IV, out the patient goes.
The result of these policies that send people home so soon after major heart surgery or the same day after outpatient surgery has been more unused leftover painkillers in home medicine cabinets. Understandably so: the doctors want the patients to be able to self-medicate. They kindly and compassionately try to give a prescription that will help the patient in the doctor’s absence. Sometimes it’s more than the patient actually needs ultimately. It’s impossible for the doctors to know exactly.
Another factor is our understanding of the healing process and how it relates to the patient’s mobility and exercise. The biggest complication for major surgery used to be pneumonia. It became clear to hospitals that the pneumonia was growing in the fluid accumulating at the bottom of the immobile patient’s lungs. In addition to the weakened immunity from the surgery itself and the germ-ridden hospital environment, the patient’s lack of exercise allowed the fluid to pool in the lungs. The way to fix that was to get the patient on his or her feet as quickly as possible. The only way for nurses to accomplish that feat–getting the patient out of bed the day after surgery–was to dull the surgical pain as much as possible. Again, painkillers solved a real problem. And those painkillers saved lives.
Same thing happened with orthopedic surgeries of all kinds. The key to healing was getting the patient in motion. The only way to do that was to dull the pain. Painkillers, again, saved lives.
The existence of painkillers even helped patients decide to have the life-saving surgery in the first place. I say that with complete confidence because a patient who is suffering from hip pain is not moving as much as his or her heart and lungs need. Over time, the person gets sicker and sicker just from lack of exercise. If we can treat the hip pain, we can get the patient back to the golf course. The only way the patient will let us operate is if we can assure him or her that we will prescribe the painkillers he or she needs after surgery.
Given the new mandates to avoid prescribing painkillers, what I predict will happen over time is that people will avoid these life-saving surgeries because they will be afraid of being abandoned in their pain. Particularly because of the press coverage being given to the new rules for avoiding prescribing the opioids, people are, right now, making a mental note not to have surgery.
Over a surprisingly short time. Insulin resistance sets in in a few days (who knows, it may be compensatory to help slow muscle wasting or some other problem,) fibrosis in the muscles and connective tissues begins in less than a day of immobilization. That’s just the tip of the iceberg.
I’m sure.
I broke my ankle once, and I was in a cast for almost eight weeks. The doctor took the cast off and I excitedly tried to stand on that foot. I fell flat on my face. :)
Painkillers are as integral to modern medicine as anesthesia.
No question about it.
Ondansetron (orally disintegrating tablets) was prescribed to myself by the emergency room physician because I asked whether there was anything I could get to manage pain induced nausea. With the nausea, I was unable to even take my Percocet (except in tiny slivers) leftover from a previous prescription for knee injury pain, when I was having near-intractable pain from an as-yet undiagnosed kidney stone. It turns out this medicine was developed for people in chemotherapy.
Just keep in mind that there is a difference in how we treat acute pain, and that includes acute in chronic pain. Opioids may absolutely be indicated for acute and acute in chronic pain; however, the treatment for chronic pain is not a oxy free for all. The things that contribute to chronic pain are much more nuanced than just “I hurt therefore I need oxy.” And I’m not saying that in cancer patients we shouldn’t be more liberal with our treatment. However, my patient yesterday who was 21 with periorbital cellulitis that was improving after some IV antibiotics did not need oxycodone for her eye as much as she overacted while I was in the room and then quieted down and played in her phone as soon as I walked out. There’s a lot of nuance to treating patients.
My point was actually that applying heat (and ice) can be helpful for a little bit but if overused can actually make things worse, just as you said. Opioids are the same way. They can be helpful for a short period of time, but when used for long periods of time they actually make your pain worse.