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Effectiveness of Opioids for Chronic Pain

Long Term Opioid Therapy Reconsidered Effectiveness for Chronic Pain Treatment of chronic pain with opioid has
increased dramatically in recent years Evidence to support this practice is lacking. Myth: Opioids have been proven safe and effective
for chronic non-cancer pain. Mark D Sullivan, MD PhD, Professor, University
of Washington: We really don’t know from controlled trials
what people are getting after a year of opioid therapy. I mean, ah the trials are about twelve
weeks and uh… whether we have a persistence of benefits from twelve weeks to a year or
a deterioration we just don’t know. Fact: Evidence of long-term benefit is lacking.
Most studies are less than 16 weeks. Andrew Kolodny: In your opinion, for most
patients with chronic non-cancer pain who receive long-term treatment with opioids,
how to most people fare? Alex Cahana, MD FIPP, Chief, Pain Medicine,
University of Washington Medical Center: I can tell you that after almost three years,
where we’ve been measuring systematically thousands of patients that we see uh… at
our center, I would say that the vast majority, nine out of ten are doing worse when we escalate
doses of prescription opioids for non malignant chronic pain, in the, I would say in regards
to pain, mood and function. So, it just doesn’t work in the cohort of
patients that we see Gilbert J. Fanciullo, MD MS, Director, Section
of Pain Medicine, Dartmouth Hitchcock Medical Center: I mean I certainly have my patients
you know my patient who has an acoustic neuroma that
involves the facial nerve and has severe uh… neuralgia in her face and I and I know she
benefits from the use of methadone uh… to help relieve her pain but my innumerable patients
with axial low back pain who are in their thirties and forties
who are being treated with opioids either by myself or by others uh… I’m clearly not
sure that they’re benefitting from the use of opioids at all Mark Sullivan: Pain intensity reductions tend
to be about thirty percent at twelve weeks on average which means from a six out of ten
to a four out of ten. So it’s not zero and it’s not even two, for most patients. And
improvements in function are less consistent and less significant. UhÉ quite a bit smaller
and in fact a lot of the controlled trials monitor things like lumbar flexion and grip
strength rather than overall function or role function, which is of course the most interesting
and important aspect to function Gilbert Fanciullo: I don’t think there’s any
question that there has to be some improvement in function otherwise I don’t think we should
be treating people with opioids. If what we have a patient that walks in the door and
says my pain is a nine out of ten constantly and all I do is lie on the
couch all day and I put them on a hundred milligrams of morphine and see
them you know six months later and I say how are you doing? And they say I’m doing much
better, my pain as a nine out of ten but these drugs are really helping and and how are you
spending your day? Well I’m still spending most of my day on the couch. Then
I don’t think that that’s a patient that should be treated with opioids and we really don’t
have to go much further than that. If there’s not a measurable decrease in pain
and a measurable increase in function then the patient probably is not benefiting from
the use of these drugs. Mark Sullivan: We had years of experience
of tapering patients off of opioid therapy in our structured pain program uh… where
it was quite successful. We would taper people over a period of about two weeks. But we were
seeing them everyday and providing a lot of support
during the taper period and uh… it was certainly impressive that patients who were very inactive
and on high doses medication would emerge from under the cloud of opioid therapy. And
often times we would get amazed assessments from their spouses. About, oh this is the
person I married. They’re back. uh… so i think that there’s at least the possibility,
we don’t know this, we’d like to study it in fact, uh… that people look and feel a
lot better off of opioid therapy. Gilbert Fanciullo: And when I speak to my
patients, I talk to them about addiction uh… constipation, sedation, sexual
dysfunction, hypogonadism, increased risk of fractures, increased risk of osteoporosis,
increase risk, possibly, of certain types of tumors, increase rise, possibly, of certain
types of infections. So these are not benign drugs. These are drugs that have a litany
of side effects and complications and if there’s no measurable measurable benefit then then
weshouldn’t be subjecting our patients to the side effects that these drugs can cause. Alex Cahana: But then we start to really ask
ourselves, from a scientific perspective, almost saying, you know in twenty years they
are going to say “what were the thinking of when they were
giving opioids for chronic non-malignant pain? Didn’t they know that it has adverse effects
on the modulation system or in the descending noxious inhibitory control?” So um… I think
that some scientific humility should now come in to place
and a a better intellectual framework to work with in. Gilbert Fanciullo: Doctors, for the most part,
are really good people, they really care about their patients, they’re
trying to help people and this is a situation where they’re not
sure if they’re actually helping and that’s a very big problem for doctors. Brought to you by Physicians for Responsible
Opioid Prescribing. www.responsibleopioidprescribing.org

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