Arthroscopic Subacromial Decompression No Better than Placebo

[drusso]

"The new research was massive, involving 32 hospitals, 51 surgeons, and more than three hundred patients in the UK. The patients were randomized to either surgical decompression, arthroscopy only (placebo surgery where nothing was done), or no treatment. The results? The surgery groups did slightly better, but those differences weren’t clinically important."

"The findings send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions. Hopefully, these findings from a well respected shoulder research group will change daily practice. The costs of surgery are high, and although the low occurrence of complications might suggest that the surgery is benign,10 there is no indication for surgery without possible gain. Therefore, the focus on the cure for these patients should be on developing effective conservative treatment programmes based on exercise and probably combined with tape, manual therapy, extracorporeal shockwave lithotripsy, or laser treatment."

Will a large, prospective RCT of chronic opioid therapy compared to placebo show similar results for chronic pain??

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[DrCommonSense]

"The new research was massive, involving 32 hospitals, 51 surgeons, and more than three hundred patients in the UK. The patients were randomized to either surgical decompression, arthroscopy only (placebo surgery where nothing was done), or no treatment. The results? The surgery groups did slightly better, but those differences weren’t clinically important."

"The findings send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions. Hopefully, these findings from a well respected shoulder research group will change daily practice. The costs of surgery are high, and although the low occurrence of complications might suggest that the surgery is benign,10 there is no indication for surgery without possible gain. Therefore, the focus on the cure for these patients should be on developing effective conservative treatment programmes based on exercise and probably combined with tape, manual therapy, extracorporeal shockwave lithotripsy, or laser treatment."

Will a large, prospective RCT of chronic opioid therapy compared to placebo show similar results for chronic pain??

Seems like nothing can beat sham in almost every part of medicine.

Just this last month stents were also shown to be no better than medication for anginal pain as well.


As to the last question: Buprenorphine transdermal system for opioid therapy in patients with chronic low back pain Butrans already ran a study up to 6 months out that proved to be better than placebo for low back pain

 

[Ducttape]

yes... i do like butrans...

but that article has 5 out of 9 authors associated with Purdue or Astellas Pharma and it was paid for by a grant from Purdue Pharma, Canada...

 

[pmrmd]

Ortho surgeries aside from arthroplasties and ACL reconstruction are questionable to me.

 

[skiz knot]

Ortho surgeries aside from arthroplasties and ACL reconstruction are questionable to me.

Way to back up your argument with data, chief.

 

[DrCommonSense]

yes... i do like butrans...

but that article has 5 out of 9 authors associated with Purdue or Astellas Pharma and it was paid for by a grant from Purdue Pharma, Canada...

So are all big pharma studies of ANY drug that has been published in NEJM, JAMA, Lancet, etc.

Butrans is just playing the same game as everyone else.

The statin guidelines were made by the ACC which were composed of mostly consultants for Pfizer, Merck, etc.

The BP guidelines was the same way.

Or how about the neurologist guidelines for "neuropathic pain" using Lyrica as a class one drug over all the others despite higher costs?

Or the Cancer guidelines?

Name ANY area that the research isn't done by the consultants for big pharma

 

[DrCommonSense]

Way to back up your argument with data, chief.

There is no data in support of any of those surgeries or there is data against anything arthroscopic as the boys at NEJM, JAMA and Lancet have been attacking all of them aggressively for the last few years.

 

[nvrsumr]

Acl in nonathlete is very questionable. There are several scandanavian studies showing no difference vs non-operative care

 

[Ducttape]

So are all big pharma studies of ANY drug that has been published in NEJM, JAMA, Lancet, etc.

Butrans is just playing the same game as everyone else.

The statin guidelines were made by the ACC which were composed of mostly consultants for Pfizer, Merck, etc.

The BP guidelines was the same way.

Or how about the neurologist guidelines for "neuropathic pain" using Lyrica as a class one drug over all the others despite higher costs?

Or the Cancer guidelines?

Name ANY area that the research isn't done by the consultants for big pharma

exactly, but thats why you have to read each individual article and see which are paid by Big Pharma and really take those results in to consideration. an article like what you quoted - written 7 years ago, paid for by the company that produces the drug - doesnt really pass my muster.

 

[DrCommonSense]

exactly, but thats why you have to read each individual article and see which are paid by Big Pharma and really take those results in to consideration. an article like what you quoted - written 7 years ago, paid for by the company that produces the drug - doesnt really pass my muster.

Cool in theory but you wouldn't be able to prescribe any medications based on evidence by that logic.

How can you prescribe any Cymbalta, Celebrex, Lyrica, etc without using industry sponsored evidence as justification?

When they obtain FDA approval for these drugs, they use industry sponsored research as well (usually for very short intervals)

 

[Ducttape]

you research studies and find ones with the least amount of industry bias.
for example:

Randomized, Double-blind, Placebo-controlled Phase III Trial of Duloxetine Monotherapy in Japanese Patients With Chronic Low Back Pain
(yes Eli Lilly did contribute but from what i can gather the authors did not have financial conflict).

this one on buprenorphine looks decent.
A randomized, placebo-controlled study of the impact of the 7-day buprenorphine transdermal system on health-related quality of life in opioid-naïv... - PubMed - NCBI

obviously, we do the best we can with what we have. there may even be conflicts that we cant find out. and there will be research with results so blatant that bias may need to be taken in to consideration in and of itself.

fyi, all these studies that you are quoting also suffer from bias, yet you clearly take their results that most interventions are no better than placebo at face value and trumpet those results on multiple threads without any consideration for bias. you cant have it both ways - saying that

 

[Blitz2006]

you research studies and find ones with the least amount of industry bias.
for example:

Randomized, Double-blind, Placebo-controlled Phase III Trial of Duloxetine Monotherapy in Japanese Patients With Chronic Low Back Pain
(yes Eli Lilly did contribute but from what i can gather the authors did not have financial conflict).

this one on buprenorphine looks decent.
A randomized, placebo-controlled study of the impact of the 7-day buprenorphine transdermal system on health-related quality of life in opioid-naïv... - PubMed - NCBI

obviously, we do the best we can with what we have. there may even be conflicts that we cant find out. and there will be research with results so blatant that bias may need to be taken in to consideration in and of itself.

fyi, all these studies that you are quoting also suffer from bias, yet you clearly take their results that most interventions are no better than placebo at face value and trumpet those results on multiple threads without any consideration for bias. you cant have it both ways - saying that

But is there any reason to choose butrans over fentanyl, with regards strictly to analgesia?

Comparison between Transdermal Buprenorphine and Transdermal Fentanyl for Postoperative Pain Relief after Major Abdominal Surgeries

 

[Ducttape]

i wouldnt use butrans for postop pain. you do want something short acting and "immediate" and adjustable, dont you?

id prefer PCA...

 

[Blitz2006]

i wouldnt use butrans for postop pain. you do want something short acting and "immediate" and adjustable, dont you?

id prefer PCA...

Oh I agree. I just posted that study to focus on the pros vs. cons of Fentanyl vs. Butrans. Just so happened to be a post-op study.

But I was wondering what your opinion is on butrans vs. fentanyl for chronic pain in general?

 

[Ducttape]

Butrans is more appropriate than fentanyl. Patches can still be abused and there is a “resale value” for used patches - addicts buy them and chew/smoke them to decrease withdrawal symptoms.


MED is also lower. The max “CDC appropriate” fentanyl dose is 37.5 mcg/hr...