Follow-up on Chronic Pain Management

Susan Perry at MinnPost today has an interview with the lead author on the chronic pain study I mentioned a few days ago. Here are the key points I took from the interview. (Emphasis added.)

The news articles (and my write-up) were vague on what medications were used in the non-opioid treatment group. Tylenol and NSAIDs were mentioned. Dr. Erin Krebs says that gives the wrong impression:

It's been reported that we compared opioids to Tylenol, and that is not at all what we did. What we did was to take a variety of different medications and carefully adjust those medications to try to find the best treatment option for each patient. In the opioid arm we used opioid medications. In the nonopioid arm we used a whole bunch of different prescription and nonprescription pain medications. We had a pharmacist follow up with patients monthly to check in on how they responded to each medication change. They then switched medications, adjusted the dose and made changes according to how they responded. So it was really a pretty intensive kind of management approach on both sides. I would hate for people to get the message that Tylenol works better than opioids. That's not true. In fact almost all the patients in the study had already tried over-the-counter medicines and not gotten good relief.

The findings were also a bit more complicated than reported. They definitely still showed that opioids, on balance, are not the best treatment, but this is the detail:

We asked a number of questions along the lines of how much did pain interfere with your walking, with your activity, with your work, with your sleep, with your mood?... And on that scale there was no difference between the two groups. Our second most important outcome was pain intensity, you know, how bad is the pain itself? And on that scale the nonopioid group actually improved more than the opioid group. The third thing was about side effects. We used a checklist of common medication side effects, and we simply counted them up and compared the number between groups. The opioid group had about twice as many side effects as the nonopioid group, even though we tried really hard to manage side effects in the study.

The study was only of chronic pain in the knee, hip and lower back, including osteoarthritis. It was not about acute pain from surgery or injury.

Dr. Krebs said the core take-away message of the study is this:

Even if you've tried some nonopioid medications, like over-the-counter medicines, and they haven't worked for you, opioids are not going to work better. So we really should not, in most cases, go to opioids even if nonopioid medications don't work. The better approach would be to continue to try different nonopioid medication options, and also to remember, just for context, that the core treatments for these pain conditions are not medications at all [but] things like exercise, rehabilitation therapy and other treatments. Those are what are strongly recommended for the management of both back pain and arthritis pain. Medications in general are really just helping people get through the day and take the edge off so that they can participate in those more important core therapies.

Let's see if this study has an effect on prescribing practices. I hope so.