Sunday, 7 May 2017

Opioids For Chronic Pain: The Discussion

Today's post from (see link below) is quite long and somewhat unwieldy but is nevertheless important for those nerve damage patients who are struggling with both their own feelings and those of society, regarding their use of opioids to control their pain. It explores patients' results and attitudes towards alternatives (such as acupuncture and chiropractic) but it's greatest value lies in the fact that it's a discussion involving many views and will hopefully in turn, stimulate discussion as a result. Many people feel increasingly isolated because they have little alternative but to use opioids to control their pain - the stigma and widening restrictions on access to their drugs means they are being doubly punished, basically for being sick enough to need these drugs. It's a necessary discussion...let's hope we're not just preaching to the choir here!

Patient perspectives on opioids and alternative treatments
Mar 2017 – free full-text PMC article

The objective of this study was to identify the practical issues patients and providers face when accessing alternatives to opioids, and how multiple parties view these issues.

We identified four themes around opioid use:

(1) attitudes toward use of opioids to manage chronic pain;
(2) the limited alternative options for chronic pain management;
(3) the potential of A/C (acupuncture and chiropractic) care as a tool to help manage pain; and
(4) the complex system around chronic pain management.

Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options.

Most of the participants’ perceived A/C care as helpful for short term pain relief.

We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment

These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making A/C ((acupuncture and chiropractic)) care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers

Among CAM treatments for CMP, acupuncture and chiropractic (A/C) care are the most highly accepted by physician groups even though such treatments are only modestly efficacious.

Nevertheless, the potential for adverse outcomes is low and the treatment could facilitate self-care lifestyle changes considered instrumental to improve longer-term functioning for patients with CMP

While much of the current literature has focused on the problems associated with opioid medications, a growing body of work is examining how to mitigate risks of adverse outcomes and increase the potential effectiveness of other pain therapies.

Despite this literature, little has been written about the practical issues providers and patients face when trying to access alternatives to opioids for managing chronic pain and how both patients and their various providers view these issues

The goal of our analysis was to inform current debates about chronic opioid use for pain management and to describe the barriers providers face in changing therapeutic practice and CMP patients face in using such practices and co-managing their needs.

A/C – acupuncture and chiropractic care,
PCPs primary care provider, Pts – patients,
QOL – quality of life,
Tx – treatment,
HMO – health maintenance organization
Options for chronic pain treatment are limited

Across participant groups, however, respondents reported that despite efforts to discourage and more closely manage opioid use, medications (particularly opioids) were frequently the only option available and respondents from all groups were not satisfied with how they were managed.

One of the challenges PCPs reported was that while they can refer to pain management, physiatry, and other specialists to help manage complex cases, many CMP patients may already be taking substantial doses of opioids by the time such referrals are placed.

PCPs also noted that barriers to other treatment options (including wait times to get into specialty clinics, and patients’ financial constraints), coupled with patients’ desire for quick pain relief

“We don’t have very much to offer. […] We don’t have medicines that are really satisfying to give [patients] to help. And, you know, there’s limits on the type of therapy we can put them through. […] Really, all we end up having to offer them is chronic narcotic therapy”

Patients may be unwilling to manage self-care or reduce pain medication.

This makes perfect sense because the pain arises from a pathophysiologic process – a purely physical/mechanical issue in the case of EDS.

Most PCPs expressed negative attitudes towards opioids for CMP treatment.

PCPs said they would prescribe medications to help patients manage pain, but they stressed the need for patients to participate, engage, and assume responsibility during treatment.

PCPs felt that opioid medication was an ineffective, long-term solution that fostered patients’ passivity and reluctance to do anything but take medications for pain management.

PCPs aren’t the ones suffering pain, so their personal feelings about opioids should be irrelevant to their job as doctors.

Patient-driven action was described as the most important aspect of successful pain relief

PCPs continually pointed to patients’ beliefs in the effectiveness of opioids to reduce pain and the unwillingness of patients to actively manage their condition through lifestyle change as impediments to reducing opioid medications use.

… because people who are suffering from pain know opioids work and other meds or therapies often don’t.

Chronic pain patients will logically select the option that’s most effective and they are the ones who experience the disappointing lack of pain relief from all the other therapies.

Very often it’s very difficult to find something that works for them. And they end up, I’m hurting, I’m hurting, I’m hurting so much. And they end up wanting to slide into opioids.

In this same article, this prejudiced statement is contradicted many times.

No pain patients that I know “want to slide into opioids” and this accusation is very offensive.

The reason we don’t want to use other methods is that they don’t work for us.

PCPs described unrealistic patient expectations for zero pain, which if used to guide prescribing only led to increasingly powerful medications and doses being prescribed.

Some providers referenced a subset of patients who were particularly manipulative and worked very hard to obtain opioid prescriptions. These individuals were characterized as having psychological and dependency issues and using medications inappropriately.

While PCPs generalized about patients being drug seeking, patients’ attitudes toward opioids were much more complex, conflicted, and conditional.

“I just need like Vicodin, or a pain med, on occasion. And I don’t like taking it. And I told my doctor that, that I wanted so I could sleep through the night. And now he, well, I’ll give you 10, but it’s got to last. Like he treats me like a drug addict. [PT 1-X]

If you’re going to be able to walk, and you take one pain pill so you can walk and live life, you’re going to do it, even though you may not like it. [PT 2–5]”

The immediacy of pain and the functional constraints that pain imposed on patients’ lives could lead them to use medications for a quick remedy, particularly if opioid medications had provided temporary relief in the past. At the same time, side effects of opioid medication (e.g., drowsiness, general unease) sometimes interfered with, rather than supported, functioning and quality of life.

For other patients, opioids did not work for them. The variability of expectations of patients for pain relief and descriptions of compatibility between a person’s body and treatment type were reflected in the difficulty PCPs and A/C practitioners had identifying effective treatment for individual patients.

Patients also discussed the stigma attached to using opioid pain medication. They expressed frustration and discomfort with being treated suspiciously by their PCPs, such as when being restricted to a certain number of pills per month.

Many who disclosed that they used opioids were quick to add qualifying statements regarding how they self-limited their use, used only as a response to genuine need (e.g. sleep problems), and never were “buzzed” by their usage.

While many patients defended their opioid usage, they also expressed concerns about dependence.

Indeed, across participant groups, long-term opioid use was construed as highly problematic.

This contradicts the earlier statement that patients “wanted to slide into opioids”.

“Usually, after about six months, we progress to providing them with some narcotic pain relief […] even though you tell [patients] it’s a one-way street, even though you tell them it’s kind of the road to perdition, sort of, they feel stuck and they feel like they have to do something to feel better.”

We feel stuck – when pain is limiting your life, making it difficult to work, take care of children, go to school, or even keep up with errands, it becomes more and more important to get some relief just so you can function.

Patients, like PCPs, expressed negative attitudes toward medications and some explicitly stated they wished to no longer have to take them.

Again, this contradicts the earlier statement that patients “wanted to slide into opioids”.

Why don’t other scientists/researchers challenge these obvious logical inconsistencies? It’s because of the unstated, unproven, and fallacious assumption that opioids are evil.

Despite this desire, tapering patients off medications (whether or not they had been used appropriately) was described as very difficult

It’s dfficult because nothing else provides pain relief as effectively.

While patients described sequencing therapies for pain treatment (e.g., first trying physical therapy, then pain classes, then A/C care), PCPs often expressed frustrations with lack of timely patient access to the necessary system resources and with ultimate patient outcomes.

Patients also cited the lack of access to other perceived effective therapies or to a structured process for tapering their dosages.

While PCPs often described patients’ resistance to moving off opioids, this resistance might have less to do with problematic attachment to medications or passive orientations to their role in treatment and more with resistance to experiencing debilitating pain.

As one patient explained:
“We don’t want to take a pill. We want relief.

“When [patients] can stop taking so much medication and have an experience of success with the acupuncture, a number of them are quite elated. Like less Vicodin, you know. [AC 43]”

Across groups, while participants described a range of positive experiences with acupuncture, it took time for patients to experience relief, if there was any relief at all. From all groups we heard acupuncture appraised in terms of time:

“I’ll have somebody with chronic pain on a ton of narcotics, VERY excited about their first couple of sessions [of acupuncture] and then they just sort of stop going back. And I’m like, well, you know, why did you stop going back? It seemed like it was…Well, it just stopped working. So the bloom is off the rose, kind of thing.”

The temporariness of the effects and the possible need for follow-up acupuncture sessions often resulted in mixed or uncertain reports of the modality’s effectiveness. All groups believed that acupuncture was a relatively benign therapy that often helped patients experience short-term (at least) pain relief

All groups commented about situations when acupuncture was not a complete solution to CMP.

“The only thing that ever really helped me was the morphine that I’m on now. I mean, enough, you know, to function. […] The acupuncture, if I’d have done it longer maybe, but we couldn’t afford to keep doing it.”

“people want to do other things, and so they’ll use [acupuncture] with the hope of having to use fewer pain medications. But it never completely replaces them.”

“There is an occasional dramatic benefit, but more often transient benefit, and more often no benefit. Patients say, ‘Yeah, I feel better for a day doc, but there was no overall improvement from week to week.’

Comments relating to chiropractic care were also mixed but addressed a slightly different set of issues. Many described the positive ways chiropractic care could impact chronic pain:

As with the experiences described for acupuncture, the patients, PCPs, and chiropractors mentioned the difficulties they encountered maintaining effects. Chiropractors emphasized a successive treatment plan that tapered in frequency.

Periodic maintenance visits served, in part, to help correct for existing lifestyle or other complicating factors (e.g., non-ergonomic work environment, obesity) that could erode the benefits experienced early in treatment.

And who will pay for these life-long “periodic” visits?

By contrast, patients and PCPs frequently focused on shorter duration effects

“I think that the benefits from chiropractic are extremely transient. Right? And I’m not really sure…I haven’t had any chiropractic training […] But I don’t think I’ve seen any studies that shows lasting benefit from it. I think the manipulations they do feel as good as cracking any joint. You may get some reflex muscle relaxation, and it’s extremely transient.”

While all groups discussed the transience of pain relief for some patients, that evaluation differed based on whether relief was expected to be long lasting.

As with the discussions of acupuncture, when expectations and experience were at odds, this could raise concerns about the quality and efficacy of the received treatment.

Unlike with acupuncture, patients and PCPs were more concerned about the quality of chiropractic care patients received, the potential risks posed by adjustments, and the importance of finding the right practitioner.

As with acupuncture, however, chiropractic alone was not adequate for pain management.

“I’ve had a lot of people say it seemed to help, for awhile. But, most often it doesn’t seem to really create any long-lasting benefit for them. I mean, for people that are clearly on a path of going from injured to getting better, they seem to do a little better through time.”

Managing chronic pain involves multiple contexts, resources, concerns, expectations, and costs and benefits, across time.

Many patients expressed dissatisfaction with the lack of alternatives offered for pain management and frequently discussed how they used over-the-counter and prescription medications to cope with pain and to function in everyday life (even if in a limited fashion). The patients also noted fears of becoming addicted or being perceived as addicted to opioid medications.

Both patients and PCPs reported that a patient’s desire for non-pharmacological options could help encourage referral to A/C practitioners. As one patient described:

“There are patients who really hate drugs. They hate the concept of taking any kind of medication. And so they’re more likely to be open to [acupuncture], and to value it more just for the sole reason that it doesn’t involve taking a medication.”

Yet again, this contradicts the earlier statement that patients “wanted to slide into opioids”.

Almost all PCPs stated that A/C care was not a first-line treatment, so they often would not make referrals to A/C care until the patient had already tried (and failed) several other lines of treatment.

The complicated nature of the patients they were seeing, limitations on the number of A/C visits allowed under the referral, and lack of coverage for maintenance therapy created challenges to the outcomes that might be realized.


Patients weigh the benefits and harms of treatment routes in light of their daily lives

How else would they “weigh the benefits and harms of treatment”?

Interview and focus group data uncovered widespread dissatisfaction with opioids among PCPs, patients, and A/C providers

This shows that patients in general are not drug seeking, but use opioids only because nothing else works for them, physically or financially.

Yet again, this contradicts the earlier statement that patients “wanted to slide into opioids”.

While prescribing opioids is increasingly viewed as at odds with best practices for chronic pain management, there remains a lack of feasible alternatives.

But this doesn’t stop them from withdrawing the treatment that’s working: opioids.

This discrepancy contributes to discontent across parties, over the course of multiple clinical encounters, and throughout the long course of individuals’ experiences with chronic pain.

Our findings also showed that patients and providers were not always satisfied with the overall effectiveness of A/C treatment.

These findings may also point to a need to better educate both patients and providers about results they can expect in terms of sequencing, time frames, and impacts from A/C treatment, and to a need to tailor treatment benefit structures to these realities

Randomized trials suggest that A/C care provides the greatest short-term benefits while the long-term sustainability without continuing treatment is less clear.

Unfortunately, for many patients chronic pain is truly chronic.

Patients indicated that while they were concerned about and resistant to initiating opioids due to possible side effects, addiction, and stigma, many had experienced opioids as the only thing that could reduce their pain. Thus, they wanted opioids when experiencing an acute flare and desiring relief and in the absence of other positive treatment experiences.

Yet again, this contradicts the earlier statement that patients “wanted to slide into opioids”.


Our data pointed to the complexity of chronic pain management, particularly given the typical duration of ongoing pain management needs

Finding the best long-term treatment strategies will likely vary depending on the unique patient’s condition, treatment trajectory, expectations, lifestyle, individual values, benefits coverage, and availability of services.

While experiences and perceptions of acupuncture and chiropractic care differed along several dimensions, improving access to them would offer providers and patients more options in addressing this complex problem.

The article repeats over and over that acupncture/chiropractic treatment does not work for patients, so why are they suggesting better access?

Each patient is unique and the persistent theme of the importance of timing in our data point to the complexity of treating individual patients.

But they are not treating “individual patients” – they are treating the “average patient” as established by universal guideliens.

Finding the best treatment for an individual may depend on his or her
where he or she is in his treatment trajectory, and
the expectations,
individual values,
benefits coverage, and
availability of services.

Moreover, patients typically come in to see their physicians when they are in pain.

This almost implies that patients should see their doctors when they are NOT in pain. That would certainly make it easier for the doctor!

There is no one best approach, and deciding on which therapies to use and when will depend on many factors in the context of chronic pain management.

Universal guidelines completely deny this reality.

I’ve only annotated some parts of this article and it is definitely worth a complete read: Provider and patient perspectives on opioids and alternative treatments for managing chronic pain

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