Lynn Webster speaks

[lobelsteve]

http://www.painmedicinenews.com//Vi...d=244&i=ISSUE:+June+2014&i_id=1066&a_id=27622

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[Jcm800]

hes a good man. never hurt a person...

 

[101N]

http://www.painmedicinenews.com//ViewArticle.aspx?ses=ogst&d=Web Exclusives&d_id=244&i=ISSUE: June 2014&i_id=1066&a_id=27622

Even if he shouldn't.

 

[jettavr6]

Today was one of those days where I wished, for just a few minutes, that the FDA banned all opiates.

 

[jsaul]

I knew a fellow that worked for him for a few years. He started off in research and then went into clinical. He left after 3 years

 

[epidural man]

http://www.painmedicinenews.com//ViewArticle.aspx?ses=ogst&d=Web Exclusives&d_id=244&i=ISSUE: June 2014&i_id=1066&a_id=27622

"but there are countless others whose pain is so severe that opioid therapy is the only option that provides enough relief for them to live functional lives."

Unfortunately, most studies, when the patients are blinded to treatment, don't find opioids helpful at all. Isn't that interesting? When blinded, they show no difference than placebo, but when the studies are open label, they show tremendous benefit.

I find that strange.

"That dilemma is only worsened when one realizes how close the link is between chronic pain and suicide."

The answer to suffering is not at the mu receptor unfortunately.

"should be reserved for a subset of the patient population who truly need them."

I can never tell who that is. I can't imagine anybody can. Studies have clearly shown that even the best of us...when trying to predict who isn't misusing opioids...are wrong about 50% of the time (based on urine screening).

"More people than we realize live with chronic pain every day. When I practiced medicine, I heard the cry for help from patients too often, many of whom just wanted someone to believe that their pain was real. Hopefully, society soon will start to believe that we need a better way before the chronic pain and drug overdose epidemic claims one more life."

I have no idea what this means. If you truly believe lots have chronic pain, does that mean you should have a low threshold to try opioids? Is that what he is trying to say? What is his point? So we all accept and believe patients when they tell us they have chronic pain. Okay. Now what? How does that change anything? Someone smarter than me please explain this point to me. This was his concluding paragraph. This was the big sum up. This was suppose to be the poetic lines that brought the whole literal piece home. And I don't get it.

 

[Aether2000]

Cochrane did an analysis on 15 RCTs with opioids and found that in 13 out of 15 trials, the opioids did show clinical improvement.

The use of opioids for chronic pain currently is because we have few other viable long term options for the treatment of chronic pain. The risk/benefit ratio is higher with opioids than with other treatments but can be mitigated through control by the physician.
In some ways chronic pain treatment is like that of treating cancer with chemotherapy....there are cocktails that are more lethal than others but these risks are weighed by the physician and patient. The fact that without such cocktails, cancer patients will die and chronic pain patients may not die, is lost on chronic pain patients who live in excruciating life changing pain everyday. They want relief. The lethal cocktails provided as treatment for chronic pain were handed out injudiciously by doctors rather than weighing risks/benefits, and now law enforcement/tort attorneys/medical boards/and attorney generals are forcing doctors to prescribe less lethal cocktails to society. This is a just and warranted effort on their part, and is not simply cruelty to chronic pain patients. But pushed to the extreme, there will be more chronic pain patient deaths from suicide, much more rapid embracement of SSD by patients who have no alternative, and a whole society that may reel against the medical profession due to a perceived lack of compassion. Nurses have compassion and doctors don't will be the message, and patients will flock to NPs that will prescribe hydrocodone whereas their opioid-phobic physicians will not. Effectively, pain patients will become stratified into those that respond to injections, provided injections are still covered by insurance, and those that don't want injections who will see non-physicians. Until the NPs begin doing injections routinely. Certainly this is one possible outcome that will be embraced by those physicians that despise opioids however, are there enough patients that will subscribe to the needle only therapy to keep physicians employed especially given the increasing scrutiny of insurers over injections (that have their own risk/benefit ratios that appear to be increasing according to the feds)? Is there a possibility the pendulum will swing so far as to bring further scrutiny on the pain profession's other side- needles and investigational procedure cash practices?

 

[Ducttape]

The least attractive option is by far the "best" - that the vast majority of patients get what our forefathers and their forefathers did - focus on functionality, quality of life, realize that pain is a part of the human existence, and not buy into those practitioners that advertise cures for chronic pain via injections , opioids, surgery or otherwise.

 

[101N]

"The answer to suffering is not at the mu receptor unfortunately."

Bingo. There is an unexplained epidemic of suffering in the US that some are trying to treat with opioids. This
suffering presents as unexplained musculoskeletal pain, disproportionate to objective exam or lab/imaging findings,
in primary care offices across the US. 88% of all opioids in the US are prescribed for chronic MSK complaints, not cancer
or acute pain. This experiment - treating non-cancer pain akin to palliative care - has been a miserable failure in the US.
But, Webster is incapable of admitting it or apologizing for his significant part in it.

That said, injections are just as ineffective in treating suffering as opioids.

 

[Aether2000]

So, we are slowly coming to the conclusion that just as many other specialties (with the exception of rheumatology for RA and psoriatic arthritis), we lack the tools as pain physicians to adequately treat most chronic pain. It will be interesting to observe the specialty evolve from this point onward....into acute pain? experimental medicine? supplements?

 

[Ducttape]

http://summaries.cochrane.org/CD004959/opioids-for-the-treatment-of-chronic-low-back-pain

In general, people that received opioids reported more pain relief and had less difficulty performing their daily activities in the short-term than those who received a placebo. However, there is little data about the benefits of opioids based on objective measures of physical functioning. We have no information from randomized controlled trials supporting the efficacy and safety of opioids used for more than four months. Furthermore, the current literature does not support that opioids are more effective than other groups of analgesics for LBP such as anti-inflammatories or antidepressants

apparently, this is the best conclusion a biased group of studies can come up with...

Most of the trials followed the patients during three months and were supported by the pharmaceutical industry.

http://summaries.cochrane.org/CD006146/opioids-for-neuropathic-pain

Short-term studies produced mixed results, with just over half indicating that opioids might be better than a placebo. While intermediate-term studies all indicated that opioids were better than placebo, most studies were small, most were short, and none used methods known to be unbiased. All these features are likely to make effects of opioids look better in clinical trials than they are in clinical practice. We cannot say whether opioids are better than placebo for neuropathic pain over the long term. Side effects such as constipation, nausea, dizziness, and drowsiness were common, but not life-threatening.

(note: short term studies - <1 day. intermediate-term - 6-12 weeks.)

 

[hyperalgesia]

So, we are slowly coming to the conclusion that just as many other specialties (with the exception of rheumatology for RA and psoriatic arthritis), we lack the tools as pain physicians to adequately treat most chronic pain. It will be interesting to observe the specialty evolve from this point onward....into acute pain? experimental medicine? supplements?

You must not be aware of the NEWEST mu super-agonistically-antagonist slow release fomulation, which is delivered by LASER. It is shown by a Medtronic-sponsored study to be 1% more effective than placebo (which involves slapping the patient in the face).
In other words, just another day in American healthcare...

 

[Aether2000]

Lol....good to be on the cutting edge...

 

[epidural man]

Cochrane did an analysis on 15 RCTs with opioids and found that in 13 out of 15 trials, the opioids did show clinical improvement.

The use of opioids for chronic pain currently is because we have few other viable long term options for the treatment of chronic pain. The risk/benefit ratio is higher with opioids than with other treatments but can be mitigated through control by the physician.
In some ways chronic pain treatment is like that of treating cancer with chemotherapy....there are cocktails that are more lethal than others but these risks are weighed by the physician and patient. The fact that without such cocktails, cancer patients will die and chronic pain patients may not die, is lost on chronic pain patients who live in excruciating life changing pain everyday. They want relief. The lethal cocktails provided as treatment for chronic pain were handed out injudiciously by doctors rather than weighing risks/benefits, and now law enforcement/tort attorneys/medical boards/and attorney generals are forcing doctors to prescribe less lethal cocktails to society. This is a just and warranted effort on their part, and is not simply cruelty to chronic pain patients. But pushed to the extreme, there will be more chronic pain patient deaths from suicide, much more rapid embracement of SSD by patients who have no alternative, and a whole society that may reel against the medical profession due to a perceived lack of compassion. Nurses have compassion and doctors don't will be the message, and patients will flock to NPs that will prescribe hydrocodone whereas their opioid-phobic physicians will not. Effectively, pain patients will become stratified into those that respond to injections, provided injections are still covered by insurance, and those that don't want injections who will see non-physicians. Until the NPs begin doing injections routinely. Certainly this is one possible outcome that will be embraced by those physicians that despise opioids however, are there enough patients that will subscribe to the needle only therapy to keep physicians employed especially given the increasing scrutiny of insurers over injections (that have their own risk/benefit ratios that appear to be increasing according to the feds)? Is there a possibility the pendulum will swing so far as to bring further scrutiny on the pain profession's other side- needles and investigational procedure cash practices?

I'm not sure why anyone would believe anything that came out of Cochrane since meta-analysis tell very sly lies.

However, since you mentioned it, all those RCT's are for short term opioid use. No one argues that opioids don't help in short trials.

 

[epidural man]

Cochrane did an analysis on 15 RCTs with opioids and found that in 13 out of 15 trials, the opioids did show clinical improvement.

The use of opioids for chronic pain currently is because we have few other viable long term options for the treatment of chronic pain. The risk/benefit ratio is higher with opioids than with other treatments but can be mitigated through control by the physician.
In some ways chronic pain treatment is like that of treating cancer with chemotherapy....there are cocktails that are more lethal than others but these risks are weighed by the physician and patient. The fact that without such cocktails, cancer patients will die and chronic pain patients may not die, is lost on chronic pain patients who live in excruciating life changing pain everyday. They want relief. The lethal cocktails provided as treatment for chronic pain were handed out injudiciously by doctors rather than weighing risks/benefits, and now law enforcement/tort attorneys/medical boards/and attorney generals are forcing doctors to prescribe less lethal cocktails to society. This is a just and warranted effort on their part, and is not simply cruelty to chronic pain patients. But pushed to the extreme, there will be more chronic pain patient deaths from suicide, much more rapid embracement of SSD by patients who have no alternative, and a whole society that may reel against the medical profession due to a perceived lack of compassion. Nurses have compassion and doctors don't will be the message, and patients will flock to NPs that will prescribe hydrocodone whereas their opioid-phobic physicians will not. Effectively, pain patients will become stratified into those that respond to injections, provided injections are still covered by insurance, and those that don't want injections who will see non-physicians. Until the NPs begin doing injections routinely. Certainly this is one possible outcome that will be embraced by those physicians that despise opioids however, are there enough patients that will subscribe to the needle only therapy to keep physicians employed especially given the increasing scrutiny of insurers over injections (that have their own risk/benefit ratios that appear to be increasing according to the feds)? Is there a possibility the pendulum will swing so far as to bring further scrutiny on the pain profession's other side- needles and investigational procedure cash practices?

Also, please understand that I am not arguing against the use of opioids. If you have horrible, intense pain from opthalmic herpes neuralgia, and a dose of oxycodone helps significantly - sign me up to be the guy to give it to you! Absolutely.

But if you have piriformis syndrome, or you have a "blackened disc" and can't forward flex past 20 deg because it hurts just SOOO BAD, and you can't work? Absolutely not. And in addition, I will speak out against you (in court, in peer review, etc) in any way I can. The problem is - chronic pain A does not equal chronic pain B.

Does that mean that all my patients that have some arthritis in their back aren't on opioids? No, I have some. I didn't start them, and I work to stop them - but I do have some.

 

[Aether2000]

The trouble with the French Revolution is that those deciding whose necks were to meet the sharp blade of madame Guillotine later were viewed as conspirators and counter-revolutionaries by the standards of others, and they then became the victims of the blood lust.
Those that espouse some arbitrary practice of medicine based on their own experience rather than a thorough understanding of EBM and testify in court against others based on their arbitrary practice model as a standard of care may find their own standards to be far too liberal for others. This is especially true with opioids for chronic pain. Even treating one patient long term with opioids will be viewed by some as hypocrisy and substandard care by some. The blade is very sharp and can be used by governments, prosecutors in criminal proceedings, plaintiff's attorneys in secondary wrongful death suits, against any physicians prescribing opioids long or short term. The behavior of the medical community in adopting a measured but firm response to the opioid overprescribing in this country vs uniform condemnation of any opioid prescribing for more than 2 months will set the stage for the tort and prosecutorial law for many years.

 

[epidural man]

vs uniform condemnation of any opioid prescribing for more than 2 months will set the stage for the tort and prosecutorial law for many years.

Well that is certainly true. Luckily, I don't know a single person who advocates uniform condemnation of any chronic use of opioids. Certainly no one on this forum seems to be advocating that.

 

[emd123]

The trouble with the French Revolution is that those deciding whose necks were to meet the sharp blade of madame Guillotine later were viewed as conspirators and counter-revolutionaries by the standards of others, and they then became the victims of the blood lust.
Those that espouse some arbitrary practice of medicine based on their own experience rather than a thorough understanding of EBM and testify in court against others based on their arbitrary practice model as a standard of care may find their own standards to be far too liberal for others. This is especially true with opioids for chronic pain. Even treating one patient long term with opioids will be viewed by some as hypocrisy and substandard care by some. The blade is very sharp and can be used by governments, prosecutors in criminal proceedings, plaintiff's attorneys in secondary wrongful death suits, against any physicians prescribing opioids long or short term. The behavior of the medical community in adopting a measured but firm response to the opioid overprescribing in this country vs uniform condemnation of any opioid prescribing for more than 2 months will set the stage for the tort and prosecutorial law for many years.

I agree. "Think before you throw stones in your glass house."

Although the drug class (opioids) is problematic as hell, and I hate prescribing them, I do believe there a certain people who benefit from chronic opioids (usually low-moderate dose), and certain doctors who do everything in their power to properly prescribe and monitor them. We can't lose site of that and let the pendulum swing too far to to the other side where we're "burning witches." At some point, some responsibility has to fall on the so called "patients" who make it a full time job, to lie, cheat and manipulate for drugs they fully intend to abuse.

 

[Aether2000]

If we adopt the mantra that opioids are not indicated for chronic pain because of the lack of studies to support such usage and the risks of accelerated usage/substance abuse/overdose etc, then this is taken to mean all opioids, not just low dose. My concern is that prosecutors and medical boards will not be able to make any differentiation in low vs high dose for chronic pain if we as physicians publically and in educational meetings espouse views that chronic pain patients should not receive opioids for chronic pain. I am not saying this is incorrect....perhaps they shouldn't, but if we don't place some restraint on our rhetoric and offer a balanced view, doctors that continue to prescribe only low dose opioids will find themselves in the crosshairs of regulatory bodies and lawyers.

 

[knoxdoc]

I agree with many of the statements above - don't rely on the intepretation of a Cochrane Review. I would encourage all of you to pull each of the "high quality" articles individually and review them for yourselves. The data is comical - opioids provide modest relief, at best, for pain (just like NSAIDS, etc), but the lackeys who conducted the studies for Endo and other companies go out of their way to make conclusions in favor of the opioids that are complete bull$hit. I wish docs would actually read these studies.

 

[Aether2000]

There are very few treatments in chronic pain that offer much more than modest relief long term...

 

[Pacman27]

There are very few treatments in chronic pain that offer much more than modest relief long term...

Aquatic therapy
Weight Loss
Better Sleep
Fix the Depression
Stop Smoking
Most importantly winning the lottery


IMO there is a role for opioids in chronic pain, but a very limited role in the majority of our patients. The unfortunate reality is to discuss all of the above to deaf ears takes way more time and effort, then just writing a script. I wish I could tailor my practice to be highly selective, but then I would be out of a job...

 

[Ducttape]

There are very few treatments in chronic pain that offer much more than modest relief long term...

agreed, but again, we are probably - and the typical pain patient - is remained fixated on "relief".

the patients who do the best are those that realize that chronic pain is, er, chronic, and functionality and quality of life can be independent of pain levels. that should remain the impetus towards pain management. convince patients that having a high quality highly functional life, one that a person can be proud of years from now, when all is said and done, should be espoused more. Opioids dont provide that.

 

[emd123]

There are very few treatments in chronic pain that offer much more than modest relief long term...

As is typical of most "chronic" conditions, ie, hypertension, diabetes, obesity, allergy, mental illness, auto-immune conditions, renal disease. That's why we are needed, for ongoing treatments, etc. (Obviously you know that, but sometimes it's worth stating the obvious, for the people that don't get it.)