Cochrane Reviews of Non-Opioid Pain Therapies

Again I found a lot of useful information about this topic from the user “Seshet” in the long-running and up-to-the-minute “Opioid Information Thread” from the Inspire.com support forums. I’ve excerpted his summary of reviews of non-opioid therapies:

I’ve been collecting Cochrane reviews for years. They are very handy for understanding the general consensus about a particular treatment option for a specific condition.

But they are not necessarily current because Cochrane produces reviews of reviews and not cutting-edge original research. So it’s possible that there are new or experimental therapies that may be helpful for a particular disorder, and Cochrane simply won’t have anything about them.  

Also, Cochrane is reporting on average outcomes, that is to say what generally happens to most people. Some people may still benefit, and even if that benefit it small, it may still be worth going for.

And Cochrane doesn’t generally look at complex treatment regimens as might be seen in medically complicated people with disorders such as lupus, MS, or EDS (in other words, the stuff that we here tend to have). These disorders are often rare enough that there just aren’t any large-scale reviews or meta-analyses, and they typically are managed by specialists who don’t publish much.

Despite these limitations, Cochrane is as close to a gold standard as we have.

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Cochrane has four reviews of acupuncture for various chronic painful conditions.

Acupuncture for Carpal Tunnel Syndrome

(https://www.cochrane.org/CD011215/NEUROMUSC_acupuncture-and-related-treatments-symptoms-carpal-tunnel-syndrome) “Acupuncture and laser acupuncture may have little or no effect in the short term on symptoms of CTS in comparison with placebo or sham acupuncture. It is uncertain whether acupuncture and related interventions are more or less effective in relieving symptoms of CTS than corticosteroid nerve blocks, oral corticosteroids, vitamin B12, ibuprofen, splints, or when added to NSAIDs plus vitamins, as the certainty of any conclusions from the evidence is low or very low and most evidence is short term.”

Acupuncture and Dry-needling for Low Back Pain

(https://www.cochrane.org/CD001351/BACK_acupuncture-and-dry-needling-for-low -back-pain): “The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only.”

Acupuncture for Hip Osteoarthritis

(http://www.cochrane.org/CD013010/MUSKEL_acupuncture-hip-osteoarthritis): “Acupuncture probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis. Due to the small sample size in the studies, the confidence intervals include both the possibility of moderate benefits and the possibility of no effect of acupuncture.”

Acupuncture for Neuropathic Pain

(http://www.cochrane.org/CD012057/SYMPT_acupuncture-neuropathic-pain-adults): “Due to the limited data available, there is insufficient evidence to support or refute the use of acupuncture for neuropathic pain in general, or for any specific neuropathic pain condition when compared with sham acupuncture or other active therapies.”

Basically, acupuncture isn’t supported by evidence.

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Cochrane has lots of reviews of cannabis for chronic painful conditions. Here are four of them:

Cannabis Products for Crohn’s Disease

(https://www.cochrane.org/CD012853/IBD_cannabis-and-cannabis-oil-treatment-crohns-disease) “The effects of cannabis and cannabis oil on Crohn’s disease are uncertain. No firm conclusions regarding the benefits and harms (e.g. side effects) of cannabis and cannabis oil in adults with Crohn’s disease can be drawn.”

Cannabis Products for Fibromyalgia Pain

(http://www.cochrane.org/CD011694/SYMPT_cannabis-products-people-fibromyalgi a): “Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low-quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low-quality evidence).”

Cannabis Products for Adults with Chronic Neuropathic Pain

(http://www.cochrane.org/CD012182/SYMPT_cannabis-products-adults-chronic-neuropathic-pain): “The potential benefits of cannabis-based medicine (herbal cannabis, plant-derived or synthetic THC, THC/CBD oromucosal spray) in chronic neuropathic pain might be outweighed by their potential harms.”

Cannabis Products for Ulcerative Colitis

(https://www.cochrane.org/CD012954/IBD_cannabis-and-cannabis-oil-treatment-ulcerative-colitis) “The effects of cannabis and cannabidiol on UC are uncertain, thus no firm conclusions regarding the efficacy and safety of cannabis or cannabidiol in adults with active UC can be drawn. There is no evidence for cannabis or cannabinoid use for maintenance of remission in UC.”

In sum, the evidence doesn’t support cannabis for some conditions. When cannabis does seem to help, it’s often with a lot of side effects.

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Cochrane has looked at lots of modalities for treating neuropathic pain.

Amitriptyline for Neuropathic Pain

(http://www.cochrane.org/CD008242/SYMPT_amitriptyline-neuropathic-pain-adult s): “The most important message is that amitriptyline probably does give really good pain relief to some people with neuropathic pain, but only a minority of them; amitriptyline will not work for most people.”

Buprenorphine for Neuropathic Pain in Adults

(https://www.cochrane.org/CD011603/SYMPT_buprenorphine-neuropathic-pain-adul ts): “There was insufficient evidence to support or refute the suggestion that buprenorphine has any efficacy in any neuropathic pain condition.”

Duloxetine for Painful Neuropathy

(http://www.cochrane.org/CD007115/NEUROMUSC_duloxetine-treating-painful-neur opathy-chronic-pain-or-fibromyalgia): ““There is adequate amounts of moderate quality evidence from eight studies performed by the manufacturers of duloxetine that doses of 60 mg and 120 mg daily are efficacious for treating pain in diabetic peripheral neuropathy but lower daily doses are not. Further trials are not required. In fibromyalgia, there is lower quality evidence that duloxetine is effective at similar doses to those used in diabetic peripheral neuropathy and with a similar magnitude of effect.”

Gabapentin for Chronic Neuropathic Pain

(http://www.cochrane.org/CD007938/SYMPT_gabapentin-chronic-neuropathic-pain- adults): “Gabapentin at doses of 1800 mg to 3600 mg daily (1200 mg to 3600 mg gabapentin encarbil) can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is very limited.” Cochrane also notes that “Over half of those treated with gabapentin will not have worthwhile pain relief but may experience adverse events.”

TENS for Neuropathic Pain

(http://www.cochrane.org/CD011976/SYMPT_transcutaneous-electrical-nerve-stimulation-tens-neuropathic-pain): “For adults with neuropathic pain, it is impossible to confidently state whether TENS is effective in relieving pain when compared to sham TENS.”

I included buprenorphine here even though it’s an opioid. But that doesn’t help. Neuropathic pain sucks, and most things don’t do much to help with it.

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Cochrane has looked extensively at treatments for chronic low back pain. Here are summaries for many of the oft-touted modalities.

Behavioral Treatments for Chronic Low Back Pain

(https://www.cochrane.org/CD002014/BACK_behavioural-treatment-for-chronic-lo w-back-pain): “In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms.” (Note: This review is from 2010, so does not include recent work.)

Chiropractic interventions for low-back pain

(https://www.cochrane.org/CD005427/BACK_combined-chiropractic-interventions- for-low-back-pain) “Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.”

Massage for Low Back Pain

(https://www.cochrane.org/CD001929/BACK_massage-low-back-pain): “We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up.”

Multidisciplinary Treatment for Back Pain

(https://www.cochrane.org/CD000963/BACK_multidisciplinary-treatment-for-back -pain): “There was moderate quality evidence that multidisciplinary treatment results in larger improvements in pain and daily function than usual care or treatments aimed only at physical factors. The difference was not very large, about 1 point on a 10 point scale for pain, but this may be important for people whose symptoms have not responded to other treatments.”

Prolotherapy for Chronic Low-Back Pain

(http://www.cochrane.org/CD004059/BACK_prolotherapy-injections-for-chronic-l ow-back-pain): “There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low-back pain. When used alone, prolotherapy is not an effective treatment for chronic low-back pain. When combined with spinal manipulation, exercise, and other co-interventions, prolotherapy may improve chronic low-back pain and disability. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions.”

Spinal Manipulative Therapy for Chronic Low-Back Pain

(https://www.cochrane.org/CD008112/BACK_spinal-manipulative-therapy-for-chro nic-low-back-pain) “High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.”

Yoga for Non-specific Low Back Pain

(http://www.cochrane.org/CD010671/BACK_yoga-treatment-chronic-non-specific-l ow-back-pain): “There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months.”

Basically, most of these things offer modest benefits at best. And most of them do no better than just doing obvious things at home like trying some light exercise, a heating pad or ice pack, or just patiently waiting for the slow improvements time brings.

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Cochrane has also looked at treatment options for fibromyalgia. There are lots of options.

Cannabis Products for Fibromyalgia Pain

(http://www.cochrane.org/CD011694/SYMPT_cannabis-products-people-fibromyalgi a): “Nabilone did not convincingly relieve fibromyalgia symptoms (pain, sleep, fatigue) better than placebo or amitriptyline (very low-quality evidence). Compared with placebo and amitriptyline, more people experienced side effects and left the study due to side effects (very low-quality evidence).”

Clonazepam for Neuropathic Pain and Fibromyalgia in Adults

(https://www.cochrane.org/CD009486/SYMPT_clonazepam-neuropathic-pain-and-fibromyalgia-adults) “This review uncovered no evidence of sufficient quality to support the use of clonazepam in chronic neuropathic pain or fibromyalgia.”

Mirtazapine for Fibromyalgia

(https://www.cochrane.org/CD012708/SYMPT_mirtazapine-treating-fibromyalgia-adults): “Mirtazapine at 15 mg to 45 mg daily is unlikely to substantially reduce pain in people with fibromyalgia. Mirtazapine can cause drowsiness, weight gain, and liver damage. A small number of people may experience some improvement (moderate pain relief, better sleep) without side effects from mirtazapine, but that cannot be predicted. The off-label use of mirtazapine can be considered if established treatment options have failed.”

Pregabalin for Fibromyalgia

(https://www.cochrane.org/CD011790/SYMPT_pregabalin-treating-fibromyalgia-pain-adults): “We found high-quality evidence that pregabalin at daily doses of 300 to 600 mg produces a large fall in pain in about 1 in 10 people with moderate or severe pain from fibromyalgia. Pain reduction comes with improvements in other symptoms, in quality of life, and inability to function.”

The one option among Cochrane reviews that has strong evidence is pregabalin (Lyrica), but it only works for some people.

Lyrica seems to be a situation where any sort of “average effectiveness” is misleading because, for actual patients, it really is all or nothing.

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I’ve posted two previous summaries of Cochrane reviews regarding pain treatments:

  1. Cochrane Reviews: Pharmacological Treatments for Pain – a detailed list of 47 different medication treatments for various pain syndromes (Nov 2014)
  2. Analysis of Non-Opioid Pain Mgmt Tx from Cochrane Reviews – list of scientific evaluation of various non-opioid pain management treatments that are highly recommended by our government these days (as of June 2018)

1 thought on “Cochrane Reviews of Non-Opioid Pain Therapies

  1. canarensis

    Lordy, how i wish it was possible to force every zealot on the Oregon task farce not only to read this, but to assimilate & act upon it. And I also wish for a Powerball winning ticket and a pretty silver unicorn to ride around town instead of my 20 year old Hyundai. And universal peace among nations, and for Congress to behave intelligently.

    Liked by 1 person

    Reply

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