Abandoned Practices for Chronic Pain???

[drusso]

A lawyer asked me a couple thought-provoking questions:

Lawyer: "Doctor, is there a professional consensus on the use of opioids for chronic pain?"

Me: "No."

Lawyer: "Doctor, has the field of pain management abandoned using opioids for treating chronic pain?"

Me: "No."

So, it got me thinking. What have we abandoned? How will we ever know that there is a consensus about the appropriate use of a modality based upon evidence?

Everything (chiro, acupuncture, opioids, PT, psych, etc) despite contradictory/inconsistent evidence still remains on the table for treating chronic pain...

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[DrCommonSense]

A lawyer asked me a couple thought-provoking questions:

Lawyer: "Doctor, is there a professional consensus on the use of opioids for chronic pain?"

Me: "No."

Lawyer: "Doctor, has the field of pain management abandoned using opioids for treating chronic pain?"

Me: "No."

So, it got me thinking. What have we abandoned? How will we ever know that there is a consensus about the appropriate use of a modality based upon evidence?

Everything (chiro, acupuncture, opioids, PT, psych, etc) despite contradictory/inconsistent evidence still remains on the table for treating chronic pain...

Kind've reminds me of cardiologists and stents:

https://nypost.com/2017/11/02/heart-stents-dont-actually-help-chest-pain/

For chronic anginal pain, stents appear to be used as the go to modality for 100s of thousands of patients per year.

Seems like stim has better evidence for anginal pain over stents.

Same as almost every area of medicine that is procedurally based.

 

[DrCommonSense]

A lawyer asked me a couple thought-provoking questions:

Lawyer: "Doctor, is there a professional consensus on the use of opioids for chronic pain?"

Me: "No."

Lawyer: "Doctor, has the field of pain management abandoned using opioids for treating chronic pain?"

Me: "No."

So, it got me thinking. What have we abandoned? How will we ever know that there is a consensus about the appropriate use of a modality based upon evidence?

Everything (chiro, acupuncture, opioids, PT, psych, etc) despite contradictory/inconsistent evidence still remains on the table for treating chronic pain...

IDET comes to mind as something that was abandoned.

 

[DrCommonSense]

A lawyer asked me a couple thought-provoking questions:

Lawyer: "Doctor, is there a professional consensus on the use of opioids for chronic pain?"

Me: "No."

Lawyer: "Doctor, has the field of pain management abandoned using opioids for treating chronic pain?"

Me: "No."

So, it got me thinking. What have we abandoned? How will we ever know that there is a consensus about the appropriate use of a modality based upon evidence?

Everything (chiro, acupuncture, opioids, PT, psych, etc) despite contradictory/inconsistent evidence still remains on the table for treating chronic pain...

Also, this is a common problem in all of medicine from CV treatment to cancer treatment:

https://web.archive.org/web/2017031...cle/when-evidence-says-no-but-doctors-say-yes

Should we use Beta Blockers despite RCTs confirming they do nothing to benefit patients
Should we use stents despite no evidence of benefit in terms of morality or pain control?
Are the guidelines for lower BP logical considering most RCTs don't support mortality benefit lowering BP further?

Does Lyrica work? Do statins work?

Should we do prostate surgeries considering no mortality benefit was found on a population level 10 years out after being diagnosed with prostate CA?

Should we continue to do mammograms and how often?

Stuff is infinitely complicated.

 

[DrCommonSense]

A lawyer asked me a couple thought-provoking questions:

Lawyer: "Doctor, is there a professional consensus on the use of opioids for chronic pain?"

Me: "No."

Lawyer: "Doctor, has the field of pain management abandoned using opioids for treating chronic pain?"

Me: "No."

So, it got me thinking. What have we abandoned? How will we ever know that there is a consensus about the appropriate use of a modality based upon evidence?

Everything (chiro, acupuncture, opioids, PT, psych, etc) despite contradictory/inconsistent evidence still remains on the table for treating chronic pain...

Thousands of heart patients get stents that may do more harm than good

"
This study speaks to a much bigger problem with medical evidence
The study represents the best available evidence on the impact of stenting for pain in stable angina patients — and could eventually avert unnecessary, costly procedures in the future. But the study is also important for what it says about the quality of medical evidence doctors often rely on to make decisions.

“This is a great example of a device that got on the market without ever having a high-quality trial behind it,” Redberg says. “For 40 years, we have been doing this procedure without any evidence that it’s better than a sham procedure.”

Right now, medical devices are less rigorously regulated than drugs: Only 1 percent of medical devices get FDA approval with high-quality clinical trials behind them. Even in these cases, devices typically reach the market based on data from a single small, short-term trial, Redberg wrote in a 2014 editorial in the New England Journal of Medicine, where she called for a sham control study of stents. "

Lets not even get started on the corruption and politics behind the FDA approval process either.

 

[Timeoutofmind]

A lawyer asked me a couple thought-provoking questions:

Lawyer: "Doctor, is there a professional consensus on the use of opioids for chronic pain?"

Me: "No."

Lawyer: "Doctor, has the field of pain management abandoned using opioids for treating chronic pain?"

Me: "No."

So, it got me thinking. What have we abandoned? How will we ever know that there is a consensus about the appropriate use of a modality based upon evidence?

Everything (chiro, acupuncture, opioids, PT, psych, etc) despite contradictory/inconsistent evidence still remains on the table for treating chronic pain...

what was the context of those questions?

 

[drusso]

what was the context of those questions?

Medical malpractice.

 

[lobelsteve]

PENS, IDET, Coblati.on, chymopapain, disktrode.

 

[drusso]

PENS, IDET, Coblati.on, chymopapain, disktrode.

You're right: Not much chymopapin getting done these days, but there are still folks doing IDET, PENS, etc for cash.

 

[willabeast]

The problem is simple - medicine is not a science. Even the goals are problematic.

 

[BobBarker]

What about sarapin?
A drug rep told me her horse got some injected in his foot and it seemed to help.

 

[DrCommonSense]

The problem is simple - medicine is not a science. Even the goals are problematic.

The problem with medicine is that for anything procedurally oriented throughout basically every field there is contradictory evidence with financial bias.

Do stents work for >95% of patients who get them? According to the COURAGE study over 10 years and recent LANCET study, there is no benefit even for angina.

Do Beta Blockers work? Depends on which year we talk about it? Should we give them perioperatively?

Everything in Orthopedic surgery is contradictory with far more evidence proving little to no benefit than evidence for benefit (arthroscopic surgery, rotator cuff surgeries, TKR/THR in obese/diabetic/neuropathic patients, etc) in the good majority of patients it has been used for.

Do prostatectomies help reduce mortality over the long term for prostate CA patients? The largest study of its kind over 10 years showed no benefit over watching yet urologists are convinced that it benefits patients.

Do any back surgeries help more than short term outside of severe myelopathic patients?

Dont even get started on the big pharma sponsored studies or device company sponsored studies.

Almost nothing in medicine is truly "evidence based"

Outside of antibiotics for bacterial infections, some antivirals and some trauma surgery, there is little "evidence" basis for most of medicine by "level one" evidence over long time horizons.

 

[DrCommonSense]

Also for anyone that takes the FDA regulatory process is "evidence based" rather than just blatant regulatory capture by big pharma, you are kidding yourself:

http://www.healthaffairs.org/do/10.1377/hblog20150706.049097/full/

 

[emd123]

Along the lines of stupid things lawyers have asked us during depositions: Once during a deposition, I asked the attorney to repeat/rephrase the question a few times. I guess he got kind of irritated with me, because I was using it as a stalling technique to get more time to think about my answers and he asked, "Dr EMD, are you on drugs? Are you on drugs!?"

I swear to God, it was hilarious. The attorneys were all freaking out, screaming, "Object! Object!" from all different angles. When they all calmed down, I was like, "No."

Lol.

 

[drusso]

What about sarapin?
A drug rep told me her horse got some injected in his foot and it seemed to help.

I think that Sarapin is still around...

SARAPIN

Truly, I think that so far the only therapy Pain Medicine has abandoned is Chymopapin...

 

[unchockey21]

Anyone still using methylene blue?

 

[drpainfree]

I don't know if I share this on the forum here. One time I heard of this analogy about evidence-medicine: no one has ever proven wearing a parachute saves life when jumping out of air plane. But no one would not try to do so without one.

Sometimes medicine is common sense. Sometimes it's so complicated there's no "evidence" to support anything we do in medicine.

 

[lobelsteve]

Here you go.

 

[unchockey21]

Here you go.

Obviously sponsored by the big parachute industry.

 

[drusso]

Here you go.

What do the "hired guns" at Evicore think about this study?

 

[Blitz2006]

The problem with medicine is that for anything procedurally oriented throughout basically every field there is contradictory evidence with financial bias.

Do stents work for >95% of patients who get them? According to the COURAGE study over 10 years and recent LANCET study, there is no benefit even for angina.

Do Beta Blockers work? Depends on which year we talk about it? Should we give them perioperatively?

Everything in Orthopedic surgery is contradictory with far more evidence proving little to no benefit than evidence for benefit (arthroscopic surgery, rotator cuff surgeries, TKR/THR in obese/diabetic/neuropathic patients, etc) in the good majority of patients it has been used for.

Do prostatectomies help reduce mortality over the long term for prostate CA patients? The largest study of its kind over 10 years showed no benefit over watching yet urologists are convinced that it benefits patients.

Do any back surgeries help more than short term outside of severe myelopathic patients?

Dont even get started on the big pharma sponsored studies or device company sponsored studies.

Almost nothing in medicine is truly "evidence based"

Outside of antibiotics for bacterial infections, some antivirals and some trauma surgery, there is little "evidence" basis for most of medicine by "level one" evidence over long time horizons.

Sure, because the healthcare system is a profit-based system.

Look at this study comparing fusion surgery vs. CBT + exercise for chronic lower back pain:

Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. - PubMed - NCBI

No difference in outcomes between the 2 interventions. But guess which intervention brings hospital more money?

 

[DrCommonSense]

Sure, because the healthcare system is a profit-based system.

Look at this study comparing fusion surgery vs. CBT + exercise for chronic lower back pain:

Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. - PubMed - NCBI

No difference in outcomes between the 2 interventions. But guess which intervention brings hospital more money?

Considering almost nothing in Orthopedics has level one evidence except AGAINST most elective procedures (lancet just had a recent shoulder article that was in another thread), Back Surgery, Cardiac Stents for >98% of patients, Ablation for A fib vs medications, Prostate CA surgeries vs watching, most big pharma products, we would have a big problem in medicine if we eliminated all of this stuff in terms of medical economics.

Most big pharma, device companies, hospitals, etc would go out of business if we enacted those standards across the board.

Salaries for physicians would collapse as well.

 

[Blitz2006]

Considering almost nothing in Orthopedics has level one evidence except AGAINST most elective procedures (lancet just had a recent shoulder article that was in another thread), Back Surgery, Cardiac Stents for >98% of patients, Ablation for A fib vs medications, Prostate CA surgeries vs watching, most big pharma products, we would have a big problem in medicine if we eliminated all of this stuff in terms of medical economics.

Most big pharma, device companies, hospitals, etc would go out of business if we enacted those standards across the board.

Salaries for physicians would collapse as well.

I agree with you, but the system needs to change in order to enact these standards.

The NHS in the UK has decided to cut down on Da Vinci Robotic surgery:

'Useless' surgical masks and robots could be scrapped to help save NHS £150 million a year

Why?

"The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’"

Humans still make better surgeons than robots, study shows


And also:

"The researchers, who studied 1,500 paper into the benefits of procedures, found that surgeons were overusing endoscopes - tiny cameras which can fit into small areas of the body.
They estimated that unnecessary endoscopic procedures are currently costing the NHS nearly £42 million a year.
Switching to a better method of gallstone removal called an index cholecystectomy, which prevents complications, could also save £72 million a year, including £13 million in readmissions. Ditching enemas before colorectal surgery could also save almost £100,000 a year."


So there are ways to enact these standards...we have the evidence. The question is, will we?

 

[DrCommonSense]

I agree with you, but the system needs to change in order to enact these standards.

The NHS in the UK has decided to cut down on Da Vinci Robotic surgery:

'Useless' surgical masks and robots could be scrapped to help save NHS £150 million a year

Why?

"The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’"

Humans still make better surgeons than robots, study shows


And also:

"The researchers, who studied 1,500 paper into the benefits of procedures, found that surgeons were overusing endoscopes - tiny cameras which can fit into small areas of the body.
They estimated that unnecessary endoscopic procedures are currently costing the NHS nearly £42 million a year.
Switching to a better method of gallstone removal called an index cholecystectomy, which prevents complications, could also save £72 million a year, including £13 million in readmissions. Ditching enemas before colorectal surgery could also save almost £100,000 a year."


So there are ways to enact these standards...we have the evidence. The question is, will we?

Still only saves peanuts in terms of overall costs in the US system.

The biggest cost drivers in American medicine are Big Pharma overcharging, Device companies overcharging, SOS differentials for the big hospitals vs ASCs/Office and end of life care.

We also had HUGE increases in administrative costs in the US far in excess of the physicians.

Also the decisions about "what to cut" is VERY political considering the dearth of evidence for almost ANYTHING in procedural medicine.

Do we cut out stents for stable CAD? Do we cut out fusion surgeries? Do we cut out most ortho procedures?

It becomes political at that point where everyone tries to cut the other guy's stuff due to "lack of evidence" while fighting for their procedures that have equal "lack of evidence".

Also, if we go with "value" medicine rather than fee for procedures, how do we determine the salaries of future doctors?