Opiates not recommended for IBS

[lobelsteve]

http://www.empr.com/pain-management...lizing-treatment-approaches/article/388263/3/

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Members don't see this ad.

 

[emd123]

GI doc where I'm at write opiates for nothing GI related, so I tend to follow that, unless in extreme exceptions

 

[ampaphb]

Opioid therapy is inappropriate in all functional somatic syndromes: temporomandibular disorders, irritable bowel syndrome, fibromyalgia syndrome, chronic fatigue syndrome, multiple chemical sensitivity, and chronic pelvic pain (interstitial cystitis, etc). http://catdir.loc.gov/catdir/samples/cam032/98024733.pdf

 

[101N]

And chronic HA/migraine & chronic axial back/neck pain in working aged adults with normal anatomy.

 

[ampaphb]

And chronic HA/migraine & chronic axial back/neck pain in working aged adults with normal anatomy.

After you rule out facet pathology

 

[101N]

It's just me but, I no longer believe in the concept of painful normal anatomy.

 

[lobelsteve]

It's just me but, I no longer believe in the concept of painful normal anatomy.

Normal. But doc, my MRI says I have 2 bulge discs....

Age appropriate normal.

 

[ampaphb]

It's just me but, I no longer believe in the concept of painful normal anatomy.

Then by all means, enlighten me - which radiological or NM study has good correlation with and predicts which patients will get good relief from MBB's or Z-joint injections? Or do you no longer believe in the concept of painful facet joints?

http://www.ncbi.nlm.nih.gov/pubmed/24029387

http://www.ncbi.nlm.nih.gov/pubmed/12435989

http://www.ncbi.nlm.nih.gov/pubmed/23159979

 

[101N]

Then by all means, enlighten me - which radiological or NM study has good correlation with and predicts which patients will get good relief from MBB's or Z-joint injections? Or do you no longer believe in the concept of painful facet joints?

http://www.ncbi.nlm.nih.gov/pubmed/24029387

http://www.ncbi.nlm.nih.gov/pubmed/12435989

http://www.ncbi.nlm.nih.gov/pubmed/23159979

We've been down this road before. I don't buy painful facet arthropathy
in young people. Old people yes, but even then I don't think RFA is
very effective in large part because the anterior column structures
are bigger contributers to total pain.

 

[emd123]

You guys are missing the point. Whether or not pain exists without positive imaging or a positive diagnostic test is irrelevant. It may be there or may not. There's no way to know. The key factor is: In such theoretical painful conditions which are said to exist without any diagnostic proof, there is also no way to rule out such conditions in malingerers.

That's a hugely important distinction. For example, I'm completely willing to accept that someone that walks into my office with the diagnosis of fibromyalgia has pain. But the fact that there is absolutely no objective way to rule the disease out, is critical. If you're going to use opiates for such conditions, that leaves us as physicians, vulnerable to every single person on planet Earth, that can just walk into our offices and say, "I hurt everywhere," and say "ouch," everywhere you touch them and therefore get an opiate, potentially with no pain and pathology at all. That essentially hands the prescription pen right over to the patient, and this I why we're are where we're at.

At least having a requirement that there must be something objective to match the pain, whether it be a significant MRI finding, a positive EMG, a scar on a body part, response to a diagnostic injection or at least something other than the patient saying, "I hurt need opiate", weeds out a very large portion of potential malingerers.

Back when the false, mythical, fantasy-belief that "addiction and malingering are rare" and was prevalent, that may have been concordant. But now that reality has set back in, and drug abuse has declared itself to be as prevalent as has always been evident, we cannot go forward on a wink and a promise by a patient alone.

 

[ampaphb]

Normal. But doc, my MRI says I have 2 bulge discs....

Age appropriate normal.

So bulging discs in the elderly, which have been found to typically represent the presence of complex degeneration with annular fragmentation, do not hurt?

 

[ampaphb]

You guys are missing the point. Whether or not pain exists without positive imaging or a positive diagnostic test is irrelevant. It may be there or may not. There's no way to know. The key factor is: In such theoretical painful conditions which are said to exist without any diagnostic proof, there is also no way to rule out such conditions in malingerers.

That is simply false. Facet based pain responds to MBBs or Intra-articular facet joint injections. Malingerers do not get better.

 

[ampaphb]

We've been down this road before. I don't buy painful facet arthropathy
in young people. Old people yes, but even then I don't think RFA is
very effective in large part because the anterior column structures
are bigger contributers to total pain.

I'm thrilled you don't "buy" it. Now can you cite some literature to justify your beliefs?
http://www.painphysicianjournal.com/2008/january/2008;11;67-75.pdf (note figure 1 on page 72)

Also, does that mean you accept the need for MBBs in the face of "normal anatomy" in the elderly?

 

[101N]

Here is the study that you need,but don't have,to support your conviction: DblB-RTC with 2 arms, Duel MBBs, one arm bup/lido and the other NS. 60 pts each arm, cLBP age 18-55. Primary outcome measure is pain relief - 0-10 scale - over 6 hrs. Exclusion criteria : no prior back surgery.

Guarantee these results would piss many IPM docs off, but get published in NEJM.

 

[emd123]

That is simply false. Facet based pain responds to MBBs or Intra-articular facet joint injections. Malingerers do not get better.

Diagnostic MBBs or facet injections would fall into the category of "diagnostic injections" I referenced. See bolded below, from my previous post.

You guys are missing the point. Whether or not pain exists without positive imaging or a positive diagnostic test is irrelevant. It may be there or may not. There's no way to know. The key factor is: In such theoretical painful conditions which are said to exist without any diagnostic proof, there is also no way to rule out such conditions in malingerers.

That's a hugely important distinction. For example, I'm completely willing to accept that someone that walks into my office with the diagnosis of fibromyalgia has pain. But the fact that there is absolutely no objective way to rule the disease out, is critical. If you're going to use opiates for such conditions, that leaves us as physicians, vulnerable to every single person on planet Earth, that can just walk into our offices and say, "I hurt everywhere," and say "ouch," everywhere you touch them and therefore get an opiate, potentially with no pain and pathology at all. That essentially hands the prescription pen right over to the patient, and this I why we're are where we're at.

At least having a requirement that there must be something objective to match the pain, whether it be a significant MRI finding, a positive EMG, a scar on a body part, response to a diagnostic injection or at least something other than the patient saying, "I hurt need opiate", weeds out a very large portion of potential malingerers.

Back when the false, mythical, fantasy-belief that "addiction and malingering are rare" and was prevalent, that may have been concordant. But now that reality has set back in, and drug abuse has declared itself to be as prevalent as has always been evident, we cannot go forward on a wink and a promise by a patient alone.

 

[ampaphb]

Here is the study that you need,but don't have,to support you conviction: DblB-RTC with 2 arms, Duel MBBs, one arm bup/lido and the other NS. 60 pts each arm, cLBP age 18-55. Primary outcome measure is pain relief - 0-10 scale - over 6 hrs. Exclusion criteria : no prior back surgery.

Guarantee these results would piss many IPM docs off, but get published in NEJM.

So I take it the answer is no, you don't have any literature to support your clinical impression.

http://www.ncbi.nlm.nih.gov/pubmed/7702395

Just so I'm clear, since according to you, IPM doesn't work, medication management doesn't work, and PT doesn't work. So why bother? On are you from the Richard Deyo nihilistic school of thought?

 

[ampaphb]

Diagnostic MBBs or facet injections would fall into the category of "diagnostic injections" I referenced. See bolded below, from my previous post.

Minor problem - diagnostic injections are inherently SUBJECTIVE.

 

[101N]

Here is the study that you need,but don't have,to support you conviction: RTC with 2 arms, Dbl blind, duel MBBs, CLBP age 18-55, one arm bup/lido and the other NS. 60 pts each arm. Exclusion criteria : no prior bAck surgery.

Guarantee this pisses many IPM docs off and is published in NEJM.

So I take it the answer is no, you don't have any literature to support your clinical impression.

http://www.ncbi.nlm.nih.gov/pubmed/7702395

Just so I'm clear, since according to you, IPM doesn't work, medication management doesn't work, and PT doesn't work. So why bother? On are you from the Richard Deyo nihilistic school of thought?

Getting back to the specifics you brought up here: cLBP in working-aged adults, with normal anatomy.

1. Chronic opioids don't improve function, pain, or RTW status in any measurable way
a.Opioids compared to placebo or other treatments for chronic low-back pain Luis
Enrique Chaparro,*, Andrea D Furlan, Amol Deshpande3, Angela Mailis-Gagnon, Steven
Atlas, Dennis C Turk Editorial Group: Cochrane Back Group Published Online: 27 AUG
2013
b.Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales
KH, Kosten TR, Fiellin DA.Ann Intern Med. 2007 Jan 16;146(2):116-27. Review.
c. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Kalso E, Edwards JE, Moore RA, McQuay HJ. Pain. 2004 Dec;112(3):372-80. Review.
d. The Effectiveness and Risks of Long-term Opioid Treatment of Chronic
Pain: http://effectivehealthcare.ahrq.gov...nic-pain-opioid-treatment-protocol-131219.pdf

2. IPM doesn't improve function, pain, or RTW status in any measurable way
a.Spine (Phila Pa 1976). 2009 May 1;34(10):1066-77. doi: 10.1097/BRS.0b013e3181a1390d.
Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.
Chou R1, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM;American Pain Society Low Back Pain Guideline Panel.
In patients with persistent nonradicular low back pain,
facet joint corticosteroid injection, prolotherapy, and in-
tradiscal corticosteroid injection are not recommended
(strong recommendation, moderate-quality evidence).
There is insufficient evidence to adequately evaluate ben-
efits of local injections, botulinum toxin injection, epi-
dural steroid injection, intradiscal electrothermal ther-
apy (IDET), therapeutic medial branch block,
radiofrequency denervation, sacroiliac joint steroid in-
jection, or intrathecal therapy with opioids or other med-
ications for nonradicular low back pain.
facet joint corticosteroid injection, prolotherapy, and in-
tradiscal corticosteroid injection are not recommended
(strong recommendation, moderate-quality evidence).
There is insufficient evidence to adequately evaluate ben-
efits of local injections, botulinum toxin injection, epi-
dural steroid injection, intradiscal electrothermal ther-
apy (IDET), therapeutic medial branch block,
radiofrequency denervation, sacroiliac joint steroid in-
jection, or intrathecal therapy with opioids or other med-
ications for nonradicular low back pain.

3. PT doesn't improve function, pain, or RTW status in any measurable way.
a. Eur Spine J. Jan 2011; 20(1): 19–39. Published online Jul 18, 2010. doi: 10.1007/s00586-010-1518-3 PMCID: PMC3036018
A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain
Marienke van Middelkoop,

1 Sidney M. Rubinstein,2 Ton Kuijpers,3 Arianne P. Verhagen,1 Raymond Ostelo,4 Bart W. Koes,1 and Maurits W. van Tulder5

4. Multidiscipinary care including CBT/Mindfulness/Acceptance, etc may have a small beneficial effect in a subset of patients.
a. Cochrane Database Syst Rev. 2014 Sep 2;9:CD000963. doi: 10.1002/14651858.CD000963.pub3. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Kamper SJ1, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW.

So why pay for all this stuff?

 

[ampaphb]

Since none of your studies reference IPM, by all means, cite articles that are specific to RF (since MBBs are a precursor procedure to RF) not improving function

At no point did I ever suggest that these patients' anatomy was normal. What I I did say was these patients did not have any positive imaging or nuclear medicine findings. However, those who then undergo diagnostic facet joint injections or medial branch blocks which are deemed to be positive clearly have facet joints that are pain generators. That is in no way normal anatomy.

Also, I note you still have not answered my question - which radiological or nuclear medicine study has good correlation with and predicts which patients will get good relief from MBB's or Z-joint injections? Or do you no longer believe in the concept of painful facet joints?

 

[101N]

I'm intentionally arguing about the reliability of MBBs as the "gold-standard diagnostic tool" to identify the "source" of LBP in working aged adults. There are no RTCs of this technique. If the test for the purported disease isn't valid, the disease itself isn't valid, and therefore the treatment - RFA - isn't valid.

The pyrite standard: the Midas touch in the diagnosis of axil pain syndromes. The Spine Journal 7 (2007) 27–31
Eugene J. Carragee, MDa, Stanford University School of Medicine, 800 Pasteur Drive, #R171, Stanford, CA 94305, USA b
Department of Neurology, University of California, Irvine, and Department of Epidemiology, School of Public Health, Scott Haldeman, MD, DC, PhDb , Eric Hurwitz, MDc a
University of California, Los Angeles, 1125 East 17th Street, Suite 127, Santa Ana, CA 92701, USA c
Department of Public Health Sciences, John A. Burns School of Medicine,
University of Hawaii at Manoa, 1960 East-West Road, Biomed. D-104H, Honolulu, HI 96822, USA

 

[jonnylingo]

So bulging discs in the elderly, which have been found to typically represent the presence of complex degeneration with annular fragmentation, do not hurt?

Disc bulging, as well as herniation, and degeneration, and annular fissures often don't hurt. Studies above done on asymptomatic individuals.

 

[DOctorJay]

is that a Tim Maus slide?

 

[emd123]

So I take it the answer is no, you don't have any literature to support your clinical impression.

http://www.ncbi.nlm.nih.gov/pubmed/7702395

Just so I'm clear, since according to you, IPM doesn't work, medication management doesn't work, and PT doesn't work. So why bother? On are you from the Richard Deyo nihilistic school of thought?

Agree. What's he suggest we do, nothing? Just shutter our doors and close down? Just focus on the one treatment that might work but we can't use (comprehensive long term intensive psych/rehab)?

 

[Ducttape]

jonny, nice slide, but i fail to see how evidence of a radiologic finding on an asymptomatic patient correlates to a symptom in another patient. especially since the symptom is so subjective as pain.

for example, the rate of clinical hypothyroidism is 0.3%, the incidence rate of biochemical hypothyroidism is 4.6%. ie 6% of all patients with biochemical hypothyroidism have clinical symptoms. does that mean that biochemical markers are useless? why bother checking TSH?

and to 101N... one of the organizations you tout has this to say about COT:

Further, we are concerned that implementation of these labeling changes which would dictate indications, dosing and duration of opioid treatment will not accomplish the intended goals, but instead have unintended negative consequences for patients including but not limited to untreated pain and loss of access to individualized care. It is clear that there are sub-populations of patients with chronic pain for whom the risk-benefitbalance is better for opioids (sometimes beyond the limits proposed by the PROP physicians) than for other available treatments; for some patients, opioids are clinically appropriate for treatment of moderate pain, or at doses higher than 100mg morphine equivalents per day, or for longer than 90 days or a combination of these.

its kind of interesting that its board is primarily made of PhD and PharmD, and not MD, but oh well.

 

[jonnylingo]

jonny, nice slide, but i fail to see how evidence of a radiologic finding on an asymptomatic patient correlates to a symptom in another patient. especially since the symptom is so subjective as pain.

I use this info to educate patients that MRIs are riddled with findings, and it's mainly helpful when symptoms/history correlate with imaging. When they don't, it's anybody's guess. Sure MBB can be helpful, but how often do we see positive response to MBB, then failed RF?

 

[jonnylingo]

is that a Tim Maus slide?

Indeed.

 

[pmrmd]

It's just me but, I no longer believe in the concept of painful normal anatomy.

Have you ever been in an MVA as a youngster? These people have normal appearing facet joints but a painful capsulitis that does not tend to show on MRI.

 

[Pacman27]

Indeed.

Jonny can you post that whole article or presentation.

That slide speaks volume and is of critical importance when patients come in stating they have been told they need surgery because of an MRI finding.

I put patients at ease everyday when I tell them its a normal part of aging.


Dont treat MRI's, treat patients

 

[jesspt]

Since none of your studies reference IPM, by all means, cite articles that are specific to RF (since MBBs are a precursor procedure to RF) not improving function

At no point did I ever suggest that these patients' anatomy was normal. What I I did say was these patients did not have any positive imaging or nuclear medicine findings. However, those who then undergo diagnostic facet joint injections or medial branch blocks which are deemed to be positive clearly have facet joints that are pain generators. That is in no way normal anatomy.

Also, I note you still have not answered my question - which radiological or nuclear medicine study has good correlation with and predicts which patients will get good relief from MBB's or Z-joint injections? Or do you no longer believe in the concept of painful facet joints?

Why does the anatomy have to be "abnormal" to create a pain experience for the patient? Doesn't the huge volume of abnormal anatomy in the asymptomatic population cast significant doubt on this typie of certainty? If not, I would think the large number of people with cLBP that don't seem to respond to any intervention would also cast some serious doubt.

 

[101N]

Because from the patient's perspective opioids/time off work/disability/etc are popular and desirable. And from the IPM doctor's perspective injections typically reimburse well and are desirable for them. This creates perfect storm for abuse.

One of the best predictors of 'chronicity' for axial back pain in working-aged adults with normally aligned spines is psychosocial distress/catastrophizing. Other good predictors - in our world - are desire for opioids/time off work/
pending litigation/disability applications/etc. It' easier to take a patient's c/o pain at face value if you are not the person expected to write the Rx for opioids, or the endorsement for disability/time off work/support for the PIP, etc.

A smart doc once said:
"Patients lie to doctors all the time for drugs, certificates, or referrals. Tears, demands, threats, complaints, anger, hostility, and defensiveness are the indicators of manipulation and lying. Patients from all backgrounds lie, though sometimes in different ways: aggression is aggression however passively and politely expressed. Women and men are both capable of aggression, manipulation, and dishonesty; most fabrications of illness in children are perpetrated by mothers.2 This isn’t cynicism but realism."

 

[bedrock]

101N,

I fear you are jaded by your particular practice. You consistently describe the most f--ked up patient population I have heard of. I would shoot myself if I had your job. BTW, This isn't a dig at you.

Most of us here on the forum see many patients everyday that we can really help. A few daily head cases as well, which most of us will send to psych, back to PCP, or to a university. For some reason you continue to see all these mentally unwell patients and prescribe them opioids, that would never get a return appt with me or many others on this forum.

Because I don't waste time on nutjobs, I treat people that generally get better or can at least make a significant improvement.
That includes some patients with relatively normal facets on MRI, who respond very well to RF.
Younger patients who had an MVA, jarring physical trauma, or have an autoimmune process, often do very well with RF, but not if they're just narc-seeking whack jobs, as those tend to move to Oregon.....

My point really, is just that head cases don't get better with anything that we can offer, and they carry a higher risk of misusing their meds, so they don't get opioids from me. And in contrast, non-head cases do respond to treatment, including interventional procedures, most of the time.

 

[DOctorJay]

Jonny can you post that whole article or presentation.

That slide speaks volume and is of critical importance when patients come in stating they have been told they need surgery because of an MRI finding.

I put patients at ease everyday when I tell them its a normal part of aging.


Dont treat MRI's, treat patients

PM me your email address for the ppt

 

[jonnylingo]

View attachment 187939
Disc bulging, as well as herniation, and degeneration, and annular fissures often don't hurt. Studies above done on asymptomatic individuals.

Charles Aprill's, at the ISIS meeting in Chicago in October, said he avoids the term "disc degeneration" and uses "aging disc" when reviewing MRIs with patients.

 

[ampaphb]

View attachment 187939
Disc bulging, as well as herniation, and degeneration, and annular fissures often don't hurt. Studies above done on asymptomatic individuals.

What u say is true. They hurt, depnding to the study, between 25 and 50% of the time. Steve impiled that a degenerative or aging disc was "normal for age", and thus, by implication, never hurt.

Then again, Steve also believes he is never wrong, so take that for what it's worth.

 

[ampaphb]

I use this info to educate patients that MRIs are riddled with findings, and it's mainly helpful when symptoms/history correlate with imaging. When they don't, it's anybody's guess. Sure MBB can be helpful, but how often do we see positive response to MBB, then failed RF?

10% of the time, when done according to the Dreyfuss double block paradigm

 

[ampaphb]

Because from the patient's perspective opioids/time off work/disability/etc are popular and desirable. And from the IPM doctor's perspective injections typically reimburse well and are desirable for them. This creates perfect storm for abuse.

One of the best predictors of 'chronicity' for axial back pain in working-aged adults with normally aligned spines is psychosocial distress/catastrophizing. Other good predictors - in our world - are desire for opioids/time off work/
pending litigation/disability applications/etc. It' easier to take a patient's c/o pain at face value if you are not the person expected to write the Rx for opioids, or the endorsement for disability/time off work/support for the PIP, etc.

A smart doc once said:
"Patients lie to doctors all the time for drugs, certificates, or referrals. Tears, demands, threats, complaints, anger, hostility, and defensiveness are the indicators of manipulation and lying. Patients from all backgrounds lie, though sometimes in different ways: aggression is aggression however passively and politely expressed. Women and men are both capable of aggression, manipulation, and dishonesty; most fabrications of illness in children are perpetrated by mothers.2 This isn’t cynicism but realism."

When a patient with axial low back pain improves, whether it be for a few hours or a few days, s/p mbb, and then improves again after confirmatory blocks, they are no longer playing you. Patients, in general, are not smart enough to know when to improve, or how long that improvement is reasonable.

 

[lobelsteve]

What u say is true. They hurt, depnding to the study, between 25 and 50% of the time. Steve impled that a degenerative or aging disc was "normal for age", and thus, by implication, never hurt.

I never said they couldnt hurt. They just shouldn't hurt.

 

[ampaphb]

I never said they couldnt hurt. They just shouldn't hurt.

Because ... you say so? Or is there something more than just the great and powerful Lobel's opinion to justify that viewpoint?

 

[lobelsteve]

Because ... you say so? Or is there something more than just the great and powerful Lobel's opinion to justify that viewpoint?

http://forums.studentdoctor.net/threads/opiates-not-recommended-for-ibs.1112900/#post-16013229

 

[ampaphb]

Circular arguement. Makes no claim what should and shouldn't hurt. Identifies that some do, some don't. In no way validates your policy of benign neglect for the ones that are in pain.

 

[lobelsteve]

Circular arguement. Makes no claim what should and shouldn't hurt. Identifies that some do, some don't. In no way validates your policy of benign neglect for the ones that are in pain.

You can assume it hurts. Ill assume you have no studied or supported treatment.