Colorado Pain Patients Feel Stigmatized by Guidelines

[drusso]

http://www.denverpost.com/2016/12/06/chronic-pain-colorado-opioid-prescriptions/

The comments are interesting:

"So, what might an improvement look like? The answer is reasonable clinical practice "safe harbors" for physicians who choose to treat these patients. And these "safe harbors" should be designed by real pain management physicians and not by the DEA, prohibitionists, Scientologists, or 12 step fanatics. Establish the safe harbors, codify them, and re-visit them periodically when improvements can be made. Use semi-formal, peer-to-peer, compensated review of these practices, including site visits and chart reviews, by pain management physicians who share an interest in avoiding witch trials. But, the current practice of demonizing these patients and their physicians is just inhumane."

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[VA Hopeful Dr]

Multiple pain patches daily for CF chronic pancreaticis? That seems unwise.

 

[nvrsumr]

Thoracic outlet syndrome.

 

[Timeoutofmind]

http://www.denverpost.com/2016/12/06/chronic-pain-colorado-opioid-prescriptions/

The comments are interesting:

"So, what might an improvement look like? The answer is reasonable clinical practice "safe harbors" for physicians who choose to treat these patients. And these "safe harbors" should be designed by real pain management physicians and not by the DEA, prohibitionists, Scientologists, or 12 step fanatics. Establish the safe harbors, codify them, and re-visit them periodically when improvements can be made. Use semi-formal, peer-to-peer, compensated review of these practices, including site visits and chart reviews, by pain management physicians who share an interest in avoiding witch trials. But, the current practice of demonizing these patients and their physicians is just inhumane."

Ummm...or just wean people and offer suboxone to those who can't wean?

Really raises the big question though...

Do we all agree that there is much evidence that COT is not effective in CNP?

It's so weird, despite the fact that this seems done and established EBM-wise...apparently many other clinicians disagree? Are they just ignorant of the literature?

 

[drusso]

Ummm...or just wean people and offer suboxone to those who can't wean?

Really raises the big question though...

Do we all agree that there is much evidence that COT is not effective in CNP?

It's so weird, despite the fact that this seems done and established EBM-wise...apparently many other clinicians disagree? Are they just ignorant of the literature?

I suppose it depends upon if you believe COT is a scientific issue or not. Is plastic surgery a scientific issue? Relatedly, it also depends upon if you believe chronic pain is a medical problem or a character flaw. We don't argue about treating ugly with plastic surgery, but do argue about treating chronic pain with opioids. I suppose that the ugly people could just accept themselves for who they are...but then what would all the plastic surgeons do? There's not enough burn victims to keep them all busy...the outcomes for both cosmetic surgery and COT are subjective (and in the eye of the beholder).

 

[Timeoutofmind]

It depends upon if you believe COT is a scientific issue or not. Is plastic surgery a scientific issue? Relatedly, it also depends upon if you believe chronic pain is a medical problem or a character flaw. We don't argue about treating ugly with plastic surgery, but do argue about treating chronic pain with opioids. I suppose that the ugly people could just accept themselves for who they are...but then what would all the plastic surgeons do? There's not enough burn victims to keep them all busy...

If people wanna be altered CNS wise for whatever reason...we can talk about that and what that means for doctors and politicians. I'm not discussing that. Big topic.

But that's not what I raised. Regardless of what chronic pain is or why it occurs...isn't it basically a scientific fact that if u put these people on opioids...their pain does not improve?

 

[drusso]

If people wanna be altered CNS wise for whatever reason...we can talk about that and what that means for doctors and politicians. I'm not discussing that. Big topic.

But that's not what I raised. Regardless of what chronic pain is or why it occurs...isn't it basically a scientific fact that if u put these people on opioids...their pain does not improve?

I guess you'd have to ask them to find out if their pain improved or not.

 

[Timeoutofmind]

I guess you'd have to ask them to find out if their pain improved or not.

so it's your opinion that studies have not been done regarding the effectiveness of COT for CNP? That no one has "asked them"?

Not trying to be facetious in any way here, just truly wondering how people feel about the state of the evidence.

 

[bedrock]

My patients over 60 yrs, taking 1-3 norco a day to stay functional would certainly argue that opioids help them. I would as well.

The flip side is non-terminal patients on moderate-high doses of ER and IR opioids 24 hrs a day/ 7 days a week. I'm doubt opioids or those doses are really helping most of them.

 

[drusso]

so it's your opinion that studies have not been done regarding the effectiveness of COT for CNP? That no one has "asked them"?

Not trying to be facetious in any way here, just truly wondering how people feel about the state of the evidence.

Well, *ALL* the evidence supporting the CDC opioid prescribing guidelines, except for buprenorphine for OUD, was based upon weak (level 3) or weakest (level 4) evidence.

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

 

[Ducttape]

Yet all the evidence supporting COT for CNP is, well, not there at all.

If one is using COT with no EBM, relying only on subjective measures that carry no validity, does that qualify as GIGO treatment?

And if one believes that the CDC is based on GIGO science...
I'm sorry, but imho, GIGO science is preferable to lore and some else's opinion.


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[Timeoutofmind]

I have not been very clear.

Here are two statements:

1. There is not scientific evidence to support the efficacy of COT for CNP
2. Scientific evidence exists refuting the efficacy of COT for CNP

I think everyone agrees with #1.

My questions if what is your opinion about #2. And what do you think is generally the opinion of most physicians?

 

[DrCommonSense]

Yet all the evidence supporting COT for CNP is, well, not there at all.

If one is using COT with no EBM, relying only on subjective measures that carry no validity, does that qualify as GIGO treatment?

And if one believes that the CDC is based on GIGO science...
I'm sorry, but imho, GIGO science is preferable to lore and some else's opinion.


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Well by that logic:

1) All antidepressants rely on "subjective" measures of depression and have basically no EBM for evidence to decrease suicidal ideation. In fact, most evidence points towards increased suicidal ideation with this class of medications.

2) Lyrica depends on subjective information about treatment of neuropathic pain.

I can make the same argument for many ortho and neurosurgical procedures as well.

Very difficult to define "EBM" for this stuff.

 

[Ducttape]

but, unlike COT, there is some EBM for antidepressants.

please present the EBM for COT...

(don't you think that if there was any malleable evidence for COT, that Purdue or Jansen or Mylan etc would have released it and sent out thousands DVDs broadcasting these results?)

 

[DrCommonSense]

but, unlike COT, there is some EBM for antidepressants.

please present the EBM for COT...

(don't you think that if there was any malleable evidence for COT, that Purdue or Jansen or Mylan etc would have released it and sent out thousands DVDs broadcasting these results?)

Please offer any evidence for long term usage of antidepressants.

http://www.newsweek.com/why-antidepressants-are-no-better-placebos-71111

Meta-analysis shows there is no benefit for literally bringing together all the antidepressant trials:

http://peh-med.biomedcentral.com/articles/10.1186/1747-5341-3-14

Show me anything that refutes this.

 

[bedrock]

Please offer any evidence for long term usage of antidepressants.

http://www.newsweek.com/why-antidepressants-are-no-better-placebos-71111

Meta-analysis shows there is no benefit for literally bringing together all the antidepressant trials:

http://peh-med.biomedcentral.com/articles/10.1186/1747-5341-3-14

Show me anything that refutes this.

I don't have any articles to cite at the moment, but I agree that antidepressants are overused for people who just need coping skills. I think if you stratified depression studies for the severe cases of depression you find there is statistical value to using antidepressants for severe depression, but I agree that SSRIs are used way too much and for too long by most PCPs for mild to severe depression which is just life. These PCPs are likely looking for a 3 minute way to get out of the room.

 

[DrCommonSense]

I don't have any articles to cite at the moment, but I agree that antidepressants are overused for people who just need coping skills. I think if you stratified depression studies for the severe cases of depression you find there is statistical value to using antidepressants for severe depression, but I agree that SSRIs are used way too much and for too long by most PCPs for mild to severe depression which is just life. These PCPs are likely looking for a 3 minute way to get out of the room.

Again, there is about as much evidence for long term depression studies and antidepressants as there is for COT for chronic pain.

In fact, I would say the evidence for antidepressants are potentially worse considering newer studies confirm these drugs actually INCREASE risk for suicide.

Also, what the hell is "fibromyalgia"?

That seems to be a disease we just diagnose based upon vague symptoms without any imaging/blood testing/objective data.

Yet we seem to literally spend BILLIONS of dollars per year on "treatments" that include Pfizer's number 1 selling drug Lyrica for this "disease". For some reason, we have money to pay for that though right?

Where are the studies that show spending billions per year on "Fibro" actually improve functionality or people continuing to work in the real world?