Yesterday’s news was filled with the proclamation “opioids are not effective for non-cancer chronic pain”. Apparently there’s a new JAMA (Journal of the American Medical Association) meta-study that has found there is a statistically significant improvement of opioids over placebo…but that benefit is small.
The media has jumped on the headline and is reporting it ad-nauseum. More proof that the ‘opioid epidemic’ is the fault of chronic pain patients and irresponsible doctors. And obviously the way to solve the crisis is to just stop prescribing opioids for chronic pain, right?
If you have no idea about chronic pain, you might actually believe that rot.
But if you read the actual study, things become a little less clear.
Firstly, what is a meta-analysis? The study authors have basically analysed the results of 96 previous other studies on chronic pain and opioids and consolidated the results. The combined study included more than 26,000 patients. In each study the participants were given an opioid, or a non-opioid pain medication or a placebo and were followed for at least a month.
The study looked at clinical trials that involved several different kinds of pain: neuropathic pain (nerve pain – 25 trials), nociceptive pain (pain from active inflammation and/or tissue damage – 32 trials), central sensitisation pain (pain persisting after the initial injury has healed – 33 trials) and ‘mixed types of pain’ (whatever that is – 8 trials).
On average, it was found that 12% more patients prescribed opioids reported pain relief, 8% had more had improvements in physical function and 6% reported improvements in sleep quality. The conclusion was for “patients with chronic noncancer pain, the use of opioids compared with placebo was associated with significantly less pain and significantly improved physical functioning, but the magnitude of the association was small.”
The media then reported that opioids do not work for chronic pain. Bit of a leap.
Let’s break it down further. It has already been well established that opioids often aren’t the best choice for neuropathic pain and central sensitisation pain. I’d like to see what the results were purely for the patients with nociceptive pain, for which opioids have been shown to be effective. Pain like arthritis pain, pain from EDS or joint hypermobility.
Talk to people who have severe arthritis, or severe EDS, they’ll almost universally tell you that opioids help with pain. And they do so far better than non-opioid options. But of course, that’s purely anecdotal.
Only one third of the study participants had the kind of pain that opioids are indicated for (after the failure of other treatments). Clearly including the other kinds of pain statistically reduced the number of people reporting benefit.
The study also compared opioids and nsaids, and the results showed that opioids were superior, although again, the benefits were modest. The media reported this result as opioids provided no more relief than nsaids. This is also misleading.
Additionally, the authors state that the quality of those studies used was low to moderate.
So is this meaningful at all? I would say no.
In fact, I would say its harmful. Many people just read the headline (including GPs who are time poor) without examining, or possibly even understanding the study itself. And these people walk away with the impression that opioids are bad and that no one should be taking them.
And patients like me, who get significant pain relief from opioid medications are vilified, treated like addicts, and have their pain and illness questioned, undertreated and dismissed.
When doctors believe the headlines, it gets significantly harder to have opioid medications prescribed. Some patients have had their opioid medications taken away on the basis of ‘low to moderate quality’ studies such as this. Chronic pain patients get desperate. Some buy street drugs. Some suffer. Some commit suicide.
Opioids are not appropriate for everyone, but they are appropriate and effective for some. The study states that a doctor must treat eight patients before one finds *significant* benefit from opioids. If you remove the people with neuropathic pain and central sensitisation pain (going on averages) its more like one in three. Isn’t that worth trying?
The hysteria over addiction prevents doctors from wanting to try. The truth about addiction is that less than 1% of pain patients become addicted to opioids. The risk is negligible. But media beat ups like this don’t address addiction statistics and ultimately just make it much harder for an already suffering population to get help.
Most medications are trialled, to see if the patient benefits. Opioids are no different. Monitoring and follow up are essential, but so too they are with anti-depressants, gabapentinoids, anti-hypertensives…virtually ALL medications. Why are opioids being singled out?
Because it makes a good story. It presents a nice, easy-to- package villain for the masses to get outraged over.
But what we’re really left with is a population of people who are in significant pain, who are suffering. And for whomno alternatives are offered. “Opioids are bad” is the message, without even attempting to offer other possibilities.
In the absence of anything better, at least opioids help some people. Pain is complicated, and so are the treatments. Opioids are one option in a toolbox of options. Rare is the person who takes opioids in isolation and doesn’t also utilise physiotherapy, simple analgesics, heat and cold, exercise and rest. And while opioids won’t help everyone, they will help some. And they need to remain one option in a toolbox of options, no matter what the media report.