Corrupt report: “Opioid painkillers cause chronic pain”

“Opioid painkillers cause chronic pain” stories leave physician reader in agony – HealthNewsReview.org –  by Stephen Martin, MD, EdM, – June 2016

we have researchers and their accomplices in the news media who trumpet “game-changing” “breakthroughs” on daily basis – often with the flimsiest of scientific support.

The latest example: opioids causing pain

Consider the headlines generated this week by a study which documented a phenomenon known as opioid-induced hyperalgesia. This is the idea that opioid medication, instead of calming pain, might actually make pain worse.  

Much has been made of opioid-induced hyperalgesia. 

Whether it is clinically important for patients with chronic pain on standard opioid medication is unclear. Even the most recent reviews of this phenomenon are unable to determine its prevalence (see here and here), and studies have generally been experimental in nature or with unusual administration of opioids (for example, the drugs have been administered intrathecally; that is, via direct injection close to the spinal cord).

A closer look at the study

  • As it so happens, the new Proceedings of the National Academy of Sciences study being reported on also involved intrathecal administration of medication.
  • Not only that, but the study also involved rats who had sutures tied around their sciatic nerves.
  • The sciatic nerve was tied and the animals were left in pain for 10 days. Then, the researchers administered morphine directly to spinal cords of these rodents for 5 days.

Use of rat models to help elucidate human disease is nothing new. But use of rats to claim that the study’s

“implications for people taking opioids like morphine, oxycodone and methadone are great, since we show the short-term decision to take such opioids can have devastating consequences of making pain worse and longer lasting”

is nothing short of ridiculous and harmful.

A PR news release drives the narrative

That sensational quote, originating in the University of Colorado Boulder news release, was subsequently picked up by the Denver Post and a variety of other outlets that covered the story.

While most of this coverage did acknowledge (in the body text of the story) that the study involved rodents, few stories pushed back against the researchers’ attempts to draw a straight line from this animal study to humans.

Science magazine was one of those rare outlets that provided the perspective of an independent expert, who offered the following indispensable context:

The finding certainly shouldn’t be the basis for withholding opioids from people in pain, says Catherine Cahill, a neuroscientist at the University of California, Irvine.

These drugs also work to block the emotional component of pain in the brain, she notes—a form of relief this study doesn’t account for.

And opioids might not prolong pain in humans the way they did in these rats, she says, because the dosing of morphine and its quick cessation likely caused repeated withdrawal that can increase stress and inflammation. Humans usually don’t experience the same withdrawal because they take sustained-release formulations and taper off opioids gradually.”

What’s more, none of the coverage that I saw tried to put this 5-day rat study into any appropriate historical perspective.

Opium-derived products have been used to relieve pain since ancient times.

Consider the CDC context

This rat study and the related coverage aren’t taking place in a vacuum. They’re taking place amid the CDC’s recent recommendations for the use of opioids in chronic pain — guidelines that excluded a Cochrane review showing effectiveness.

The CDC took the acknowledged limited study in this area and interpreted it as evidence only of harm.

Can harms happen with chronic opioid use? Yes.

Can benefits also happen? Yes.

By not acknowledging this dual truth, the CDC recommendations – and especially the rhetoric that has surrounded them (e.g. “prescription opioids are just as addictive as heroin”) – risk creating more heat than light.

This is in contrast to the National Institutes of Health 2014 report “Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain.” The report found that:

Patients, providers, and advocates all agree that

there is a subset of patients for whom opioids are an effective treatment method for their chronic pain, and that

limiting or denying access to opioids for these patients can be harmful.

Biased media reports on opioids also affect patients. Stories that focus on opioid misuse and fatalities related to opioid overdose may increase anxiety and fear among some stable, treated patients that their medications could be tapered or discontinued to “prevent addiction.”

The CDC guidelines also excluded acute pain. I’m not sure how 10 days of sudden unrelieved pain is considered by a rat, but it sounds acute to me.

Here we see in miniature the flaws of basic science and public health policy alike in their promulgation of questionable “evidence.”  

A rat study headlined “Narcotic painkillers cause chronic pain” – that  doesn’t mention the rat subjects – is the latest example of the pendulum being pulled back so far it is straining credulity as well as contributing to people’s suffering.

The next time a patient of mine becomes a rat, has its sciatic nerve constricted with sutures, and asks for 5 days of morphine near its spinal cord 10 days later, maybe I’ll take another look at this study.

In the meantime, I’ll tell my patients to ignore the unbalanced news coverage that the research spawned.

I’ll also follow universal precautions in prescribing opioids, listen carefully to my patients and their context, work to find the best approach for mitigating their pain, limit side effects and untoward outcomes, respond effectively should they occur, and practice with a compassion not shown to these rats.

Author: Stephen Martin, MD, EdM, is an Associate Professor of Family Medicine and Community Health at the University of Massachusetts Medical School.
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3 thoughts on “Corrupt report: “Opioid painkillers cause chronic pain”

  1. Richard A. Lawhern, Ph.D.

    When this article was first published, I offered the following comment. This is even more pertinent today.

    As a non-physician patient advocate, author, and webmaster for peer-to-peer chronic pain communities, I have talked with thousands of patients during the past 20 years. Of those, a minority were prescribed opioid medication, generally in combination with other drugs (notably anti-seizure and tri-cyclic antidepressants used off-label for pain). Opioids are almost always a last-resort alternative after multiple therapies have been attempted and failed.

    In all of this time, I have heard of a few patients who built so much tolerance to an opioid that they had to be tapered off from very high doses and then tapered up on different meds. One or two were forced to enter narcotic detox. But I have never encountered a clear indication of hyperalgesia confirmed by a medical doctor.

    I have also heard from literally hundreds of people who have successfully used opioids for five to ten years or more at stable doses. In many cases, opioids are the only therapy that gives them even marginal quality of life. However these people are invisible in the medical literature; their long term experience has never been studied, and was not reflected in the proceedings of the CDC Consultants’ Group that drafted the recent changes to medical guidelines for the prescription of opioids for adult non-cancer chronic pain patients.

    In the support work I do with chronic pain patients, I almost daily hear from one or more people who are being forced to taper off opioids by doctors who are suddenly gun-shy of DEA prosecution if they continue prescribing at doses above 50 MMED (Morphine Milligram Equivalents per Day — itself a highly problematic if not mythological unit of comparison). In some cases, patients have been summarily discharged by pain management specialists, without referral for either pain management or withdrawal management from their meds. I know of at least one death from side effects of withdrawal, and I have seen indications of more coming in a potential wave of suicides or street drug overdoses in people who have been plunged into despair and can no longer find effective pain relief from medical providers.

    The CDC voluntary guidelines are neither voluntary nor guidelines. They are becoming a defacto mandatory restrictive treatment standard due to fears of DEA prosecution. And they are directly responsible for plunging thousands of patients into agony. The CDC needs to be bludgeoned into retracting these guidelines for major re-writing by a new consultants’ group — this one to include multiple Board Certified pain management physicians who actually and routinely see patients (unlike the group that produced the present one-size-fits all nonsense).

    Failing the voluntary withdrawal of the CDC guidelines, it may be necessary to file a class action lawsuit against the people who served on its consultants group, and their overseers on permanent staff with CDC. Grounds can include medical negligence, denial of care, and possibly facilitating desertion of patients in desperate need of pain relief.

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  2. Kathy C

    The World of Alternate Facts has invaded medicine. The Facts really don’t matter anymore. I found this Article on the use of Rats in Scientific Studies. It is really clear that there is an Attack on Patients. The problem is that many gullible people believe this kind of nonsense.

    http://www.realclearscience.com/blog/2016/01/why_many_mice_studies_are_meaningless.html

    Here is another Article on the Dangers of Antidepressants the Drug they claimed “Cure” Chronic Pain. We are down the rabbit hole. The Pharma Industry made it difficult if not impossible to track any of this.
    “Reports both anecdotal and clinical have included side-effects such as constant pain, an altered sense of smell, taste or hearing, visual problems, burning hands and feet; food or drug intolerances and akathisia (the medical term for a deep inner restlessness). When a patient begins tapering down their dosage, these effects are generally ascribed to the drug leaving their system; if it is long after withdrawal is supposed to be over, however, patients are often disbelieved (according to the drug companies, withdrawal should take just two weeks for most people, though they acknowledge that for some it can be months).”

    https://www.theguardian.com/society/2017/may/06/dont-know-who-am-antidepressant-long-term-use?utm_source=pocket&utm_medium=email&utm_campaign=pockethits

    This is some scary stuff.

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    1. Zyp Czyk Post author

      That last link poses a scary question – when we stop taking antidepressants, are the illmfeelongs that result from the original depression or from withdrawal symptoms?

      Still, these meds have saved me from suicidal depression and anxiety.

      I don’t know why so many people think they are “happy pills” – they must be getting a completely different effect than I do. I sure wish they made me as happy as some people claim!

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