Avoid opioids for chronic back/knee/hip pain

[Pluripotent]

Nope, not Prevention. Here are a couple of cites:

From the site of the National Kidney Foundation: Pain Medicines (Analgesics) | The National Kidney Foundation


Experts Warn Against Long-Term Use of Common Pain Pills - The New York Times

I don't remember where I first learned about the side effects of long-term use of NSAIDS, because it was 15 years ago when I looked into it, but I'm pretty sure it was not Prevention. You are an n of 1 - don't think that establishes the truth for everyone.



See my reply to Rip and quotes I included there.



Oxycontin is one, oxycodone (the quick-release formula -- oxycontin is the long-acting one), morphine and ms-contin (which is morphine in a slow-release form), fentanyl skin patches, etc. The docs here probably know others. Or you could find out from rxlist.com by searching for "analgesics." There are many, and you don't HAVE to accept the combination pills. (None of them are "commonly" prescribed any more, but maybe the crackdown is going farther than it should, is what I'm saying.)

Never used acetaminophen & ibuprofen together, but I can tell you acetaminophen does nothing for me. To say that using those two together is powerful for pain relief does not contradict the idea that using them for years is bad for your liver and/or kidneys, so I don't get how you began with "there is so much wrong with this post." Do you know anyone who had surgery without any narcotic analgesia? Would you want to have surgery with nothing but acetaminophen and ibuprofen? I think you'll find the consensus among doctors is that narcotics are the most effective pain relievers we have, if you'd care to do some research. In fact, I just saw that statement while looking for some quotes for my repsonse to Rip's comment -- but I'm not going to go back and look for that statement again. I'll leave you to it.



Well, you've "met" a bunch of us now, through this forum.
Sadly, those of us who do lift barbells get discouraged from training by our doctors. If you know a weightlifting doc in Phoenix, tell me who s/he is.

Medications that are effective are dangerous. That's how it works. Medications that are "safe" are generally not effective. This is why the caduceus is a staff with a snake around it (or the Rod of Asclepius, if we're being precise). The physician uses the venom of the snake to heal. The greek word pharmakon means poison. You can use ibuprofen and acetaminophen responsibly, knowing their danger, and they can be helpful. It isn't the length of time but the dose that makes the poison. And since acetaminophen and the NSAIDS are completely eliminated in a brief time (half life measured in hours), you can use them chronically and not kill your liver or kidneys, unless you are taking unreasonable doses (unlike, say, amiodarone, which has a 1/2 life measured in months). Personally, I think the danger of opioids used long term make them a poor choice for chronic pain, only to be used in extreme circumstances. Not that they don't have their place. For acute pain, I am much more favorable towards them, although the difficulty is that for many people, once you start them, patient's tend to not want to go off them again, so there's that. For reasonable people who are just going to use them for post surgical pain and then stop, perhaps not even finish the bottle, they're great. But I often see people on them from a surgery that happened years ago and they keep asking for refills. And now they passed legislation that says you have to have dedicated office visits with a one month follow up for any dose change and three months otherwise, and the patient's have to sign a pain contract. This is why these people are all being referred to pain clinics now. No one can deal with this in their clinics anymore.

[Will Morris]

I routinely see people have surgery and be sent home with Tylenol and ibuprofen for post-operative pain control. I see it most frequently in individuals I treat who have had abdominal surgery, though several orthopaedic surgeons I work with reserve opiate pain medications for post-operative pain control in those with surgeries involving significant bony involvement. Further, the typical narcotic pain control course after surgery is limited to no more than 7 days.

MS-Contin, Fentanyl skin patches, morphine are not commonly prescribed for chronic pain. These are most commonly prescribed for patients with severe pain from metastatic disease.

If you have end stage esophageal cancer, or metastic disease in your spine, Tylenol won't do anything for you. If you have fibromyalgia, chronic pain syndrome, complex regional pain syndrome, myofascial pain syndrome, trigeminal neuralgia, or cluster headaches, this would be a completely different conversation.

[msupples]

Nope, not Prevention. Here are a couple of cites:

...

Well, you've "met" a bunch of us now, through this forum.
Sadly, those of us who do lift barbells get discouraged from training by our doctors. If you know a weightlifting doc in Phoenix, tell me who s/he is.

The big question here is: exactly what type of chronic pain are you trying to treat?

That will dictate which analgesics are best suited. Spoiler alert: it's almost never opioids.

[Jonathon Sullivan]

Another one, as reported in sciencedaily:

Study Shows Long-term Use Of NSAIDs Causes Severe Intestinal Damage -- ScienceDaily

Did you notice anything missing from this press report? Actually, several things?

And one from a medical journal, which could be used as a starting point for further research for those interested -- focused on people over age 60:

Recognizing the Risks of Chronic Nonsteroidal Anti-Inflammatory Drug Use in Older Adults

And before we even get out of the abstract, we encounter this:

Preferred analgesics in older adults that may have a lower risk of these adverse drug reactions include acetaminophen, a nonacetylated salicylate (eg, salsalate), a short half-life NSAID (eg, ibuprofen), or low-dose opioid/opioid-like agents in combination with acetaminophen (in appropriate patients).

And so, to summarize:

There's a risk to using any medicine.

NSAIDs are incredibly useful, inexpensive and effective medicines in chronic and acute pain, but can and do cause some harm in some people after prolonged or inappropriate use. They should be used rationally, and with care, and both their efficacy and side effects should be monitored, particularly in vulnerable populations. No kidding.

Opioids are incredibly useful and effective medicines in acute pain and appropriate for limited use in some chronic pain scenarios. But they are powerfully addictive, subject to illegal diversion and recreational abuse, and--oh yeah!--they can make you stop breathing, which as a physician I find to be just a little more troublesome than intraluminal epithelial erosions.

So, as often happens in the real world and clinical practice, we have a choice. And given that choice, and based on available data, clinical experience, and the catastrophic results of our twenty-plus year experiment with liberal prescription of oral narcotic compounds for chronic pain, I think we can make a pretty good argument: We should use NSAIDs, acetaminophen, and sometimes opiates for acute pain, and avoid opiates for chronic pain except in fairly narrow circumstances (cancer, certain neurodegenerative conditions, etc, where I have always said give 'em more, give 'em more, give 'em more. But that's a minority of cases.).

Finally, it's interesting that you find the literature you cite to be compelling and dispositive...but not the 2018 JAMA paper that launched this thread, which says pretty much what the rest of us are saying and which those of us in clinical practice have known for some time.

Chronic opiate use for most chronic pain, especially musculoskeletal pain, is inappropriate.

PS: I missed the data showing how acetaminophen at recommended doses makes the liver go away. Because if it did, I'd be on my 12th liver transplant by now.

[Amy-in-PHX]

Why does the tylenol bottle say that if your pain lasts more than ten days you must stop using the drug and see your doctor, if there is no danger from chronic use?

I am well aware that all meds have risks. My original point was that opioids are both more effective and have a more benign side effect profile than NSAIDS. And I think people with chronic severe pain should not be deprived of opioids in a misguided attempt to protect other people, who choose to abuse drugs. Why should one person's medical care be curtailed by another person's behavior?

I have not yet read the 2018 study that launched the thread, because as I stated originally, its text was not available to me. I was very clear in my first post that I had not read that study. I will read it when I have time to do so. I am skeptical of it, because its conclusion that opioids are no more effective for pain than NSAIDs makes no sense.

People may be limited to NSAIDs and tylenol for post-op pain these days, but I was talking about analgesia during the actual surgery, itself, above. No surgeon cuts on a person unless there's really effective pain control meds going on -- they don't just tell you to pop a couple Advil and lay down on the table. I figure that is, at least in part, because the opioids are more effective.

[David Kirkham]

NSAIDs are incredibly useful, inexpensive and effective medicines in chronic and acute pain, but can and do cause some harm in some people after prolonged or inappropriate use. They should be used rationally, and with care, and both their efficacy and side effects should be monitored, particularly in vulnerable populations. No kidding.

Opioids are incredibly useful and effective medicines in acute pain and appropriate for limited use in some chronic pain scenarios. But they are powerfully addictive, subject to illegal diversion and recreational abuse, and--oh yeah!--they can make you stop breathing, which as a physician I find to be just a little more troublesome than intraluminal epithelial erosions.

So, as often happens in the real world and clinical practice, we have a choice. And given that choice, and based on available data, clinical experience, and the catastrophic results of our twenty-plus year experiment with liberal prescription of oral narcotic compounds for chronic pain, I think we can make a pretty good argument: We should use NSAIDs, acetaminophen, and sometimes opiates for acute pain, and avoid opiates for chronic pain except in fairly narrow circumstances (cancer, certain neurodegenerative conditions, etc, where I have always said give 'em more, give 'em more, give 'em more. But that's a minority of cases.).

Chronic opiate use for most chronic pain, especially musculoskeletal pain, is inappropriate.

I find this entire discussion fascinating. A special thanks to everyone who has participated--especially the docs. Again, I am quite sympathetic to anyone who is in chronic, serious pain. It just plain sucks. It takes over your life. It's horrible.

I'll just throw this in. I have a customer who is the head of a very large ER department in a major city. We got into this whole opioid discussion one day and I commented, "I was very surprised in the hospital when, right after the birth of one of our children, the hospital gave my wife 800 mg pills of ibuprofen for pain. Why not an opiate?" My customer replied, "There is very little pain I can't control with an appropriate dose of ibuprofen and I see a lot of bad stuff. It is my main, go-to medicine of choice. It is cheap, safe, and incredibly effective."

We did discuss the terrible problem of addiction and he said, "You have to really be obviously hurting--like a bone sticking out--before I reach for the opioids." (I don't know if that was just his frustration speaking--but clearly there is a major problem). He says patients get mad and give him bad reviews, but the hospital can't really do much about it because he is the Department Head, about to retire, and the hospital is ground zero in a very bad neighborhood where no one else wants the job. He says people ask him "all day, every day" for pain pills.

Contrast that to another customer who is the head of the ER in another major hospital, "The stupid legislature has mandated that we control pain. Patients come in here and threaten to give us a bad review if we don't pass out pills...so we pass them out. We are creating addicts right and left to not get written up and have our jobs threatened. It makes me sick. This isn't why I went into medicine."

Clearly we have a problem. One of the reasons I am so interested in this is I have the ear of many legislators in our state. We discuss this very topic ALL THE TIME. It is taking up a disproportionate amount of their time, money, and energy.

[Mark Rippetoe]

Why does the tylenol bottle say that if your pain lasts more than ten days you must stop using the drug and see your doctor, if there is no danger from chronic use?

Because the FDA makes them say that. Most adults take Tylenol when they need it for pain, if it works for them, without running that decision by the FDA. As a result, most adults have learned that acetaminophen will not kill you unless to want it to.

I am well aware that all meds have risks. My original point was that opioids are both more effective and have a more benign side effect profile than NSAIDS. And I think people with chronic severe pain should not be deprived of opioids in a misguided attempt to protect other people, who choose to abuse drugs. Why should one person's medical care be curtailed by another person's behavior?

The doctors think you're wrong, Amy. And you know me -- I don't suck the cocks of doctors. But in this case, if these guys with lots of experience with NSAIDs, opioids, and their use in both acute and chronic pain cases tell you that opioids are a problem in some cases and that NSAIDs are safer, well-tolerated, cheaper, much more widely available, and keep the DEA out of their offices, maybe in this case you should try harder to understand their position.

I have not yet read the 2018 study that launched the thread, because as I stated originally, its text was not available to me. I was very clear in my first post that I had not read that study. I will read it when I have time to do so. I am skeptical of it, because its conclusion that opioids are no more effective for pain than NSAIDs makes no sense.

People may be limited to NSAIDs and Tylenol for post-op pain these days, but I was talking about analgesia during the actual surgery, itself, above. No surgeon cuts on a person unless there's really effective pain control meds going on -- they don't just tell you to pop a couple Advil and lay down on the table. I figure that is, at least in part, because the opioids are more effective.

You really don't know a lot about anesthesia. The anesthetist uses a combination of several drugs to produce analgesia, paralysis, and amnesia that are tailored for the individual patient depending on medical history, the case on the table, and the experience of the anesthetist. Hint: they don't always use opioids.

[Will Morris]

People may be limited to NSAIDs and tylenol for post-op pain these days, but I was talking about analgesia during the actual surgery, itself, above. No surgeon cuts on a person unless there's really effective pain control meds going on -- they don't just tell you to pop a couple Advil and lay down on the table. I figure that is, at least in part, because the opioids are more effective.

Generally speaking, no surgeon performs a surgical procedure without general anesthesia, conscious sedation, or a regional or epidural nerve block. Yes, that is true. But, do you recognize that the medications given to people prior to surgery either effectively render the central nervous system incapacitated, or render the sensory and motor of that particular area completely non-functioning? This is an entirely different conversation than the idea that opioids for chronic pain are useful. Generally speaking, again not speaking of metastatic disease or other neurodegenerative conditions, chronic pain is best treated with an interdisciplinary approach, involving behavioral health, activity, and early release from opioid treatment. Opiates for chronic low back pain, fibromyalgia, chronic pain syndrome, myofascial pain syndrome, lupus, etc are all worse than useless in the long term. Musculoskeletal pain from an acute trauma (ruptured ACL, dislocated ankle, etc) has some utility in the first couple days, much like the first few days after surgery, but they should not be used for long term. As Pluripotent said, I routinely have people come into my clinic who have been on percocet for 5 years after a routine ankle surgery.

Opioids themselves only alter someone's perception of pain. There is no mechanism to achieve long term changes to the person's pain experience using opioids, and again, they are highly addictive, interact very poorly with other drugs and alcohol, and have a high possibility of misuse. The reason why this is such a hot topic of discussion is because pain creates very strong emotional reactions. Simply believing you, or others, have a right to near useless drugs to combat your unique pain experience does not negate the fact that they are much more dangerous than the routine pain control regimens now espoused by the medical community.

Again, if you had a condition like metastatic disease, bony mets, trigeminal neuralgia, cluster headaches, etc. This is an entirely different conversation.

[Jonathon Sullivan]

Why does the tylenol bottle say that if your pain lasts more than ten days you must stop using the drug and see your doctor, if there is no danger from chronic use?

Because Lawyers.

Also, because the people who are selling you the acetaminophen don't know why you have pain. Maybe you've been taking tylenol for what will turn out to be a silent heart attack or, I dunno, dead bowel. Sumpin' bad. Suboptimal, yo. Mebbe time to see a doctor, yo.

Look, the toxicology of acetaminophen is very, very well understood, right down to the kinetics...right down to the level of the frippin' electrons. The natural history of acetaminophen toxicity is completely described, its consequences very well understood, and the indicated therapy for this poisoning is known by heart by virtually every med school graduate. Let me ask you a question: do you think doctors use tylenol so much, for their patients and themselves, because they like to live dangerously? I can tell you in my sleep what's happening in the liver when I take tylenol. I've cared for dozens and dozens of tylenol overdoses (all intentional). I've seen death from tylenol induced hepatotoxicity, and it's ugly. And yet I take tylenol all the time, at least several times a week, year in and year out.

Do you think I'm just stupid?

I am well aware that all meds have risks. My original point was that opioids are both more effective and have a more benign side effect profile than NSAIDS.

The OP study, which methods and results you have yet to substantively rebut, says otherwise. Also, NSAIDs are not addictive and can't make you stop breathing. So I rather tend not to agree.

And I think people with chronic severe pain should not be deprived of opioids in a misguided attempt to protect other people, who choose to abuse drugs.

We don't avoid them primarily to protect others (although that is not, as you seem to imply, an insubstantial consideration). We avoid them because they are therapeutically inappropriate, have a treacherous benefit/risk profile, and, as noted in the OP study (and others) are no more effective for chronic musculoskeletal (read: back and joint) pain that non-narcotic options.

Why should one person's medical care be curtailed by another person's behavior?

If by "behavior" you mean "non-superior response to therapy, failure to address the underlying cause of pain, addiction, and death," well, I can give you a host of reasons.

I have not yet read the 2018 study that launched the thread, because as I stated originally, its text was not available to me. I was very clear in my first post that I had not read that study. I will read it when I have time to do so. I am skeptical of it, because its conclusion that opioids are no more effective for pain than NSAIDs makes no sense.

No more effective for chronic pain, Amy. This distinction is critical. I don't administer NSAIDs or tylenol as primary analgesia for an acute abdomen or a broken femur (although I find that tylenol + ibuprofen is often completely adequate for acute headache, tooth abscess or a broken finger). But for chronic OA, back pain, fibromyalgia, tendonitis, and other common causes of chronic pain, long-term management with opioids is grossly inappropriate from virtually every relevant clinical or public health perspective.

You are correct to be skeptical about the paper, but as you chase it down bear in mind that it reaches a completely boring consensus conclusion that has already been encompassed by other research and the experience of clinicians everywhere. The burden of proof lies with any contention that opiates are appropriate for chronic pain management. We, as a nation, did the experiment, and it failed.

People may be limited to NSAIDs and tylenol for post-op pain these days, but I was talking about analgesia during the actual surgery, itself, above. No surgeon cuts on a person unless there's really effective pain control meds going on -- they don't just tell you to pop a couple Advil and lay down on the table.

I figure that is, at least in part, because the opioids are more effective.

The analgesic effect of opiates is clearly superior to just about everything else, yes. Do you understand that this fact alone is not and cannot be discriminatory in the selection of an appropriate analgesic for different clinical circumstances? No surgeon opens a belly or a chest without general or regional anesthesia, which are superior to even opiates. And yet we do not use these agents for chronic or even acute pain. Potency of a drug is far from the only indicating criterion.

[Pluripotent]

Where did this idea come from that opioids are somehow more benign than Tylenol or nsaids? Some of the side effects have been discussed already, but one of the major reasons they are inappropriate for chronic pain is tolerance. You need more and more of them for less and less effect. Then there's the fact that chronic use actually increases pain sensitivity, something called hyperalgesia of chronic narcotic overuse, which means that when you try to taper people off of them, they are going to hurt more, and there is no way around it. If they are ever going to be off the opioids again, they are going to have to go through a period of increased pain before they get there, something that chronic pain patients in particular really don't want to do. And then there's the constipation. At high doses, your bowels just stop. I've had multiple patients present with turds the size of their damn head, but they don't want their narcotics reduced. One girl and her mother (because it's difficult to get into this position without an enabler) begged me for surgery rather than reducing narcotics from 100s of milligrams 2x/day plus PRN. I ended up reducing narcotics by half and gave her relistor and she pooped a baby. But they were still both pissed at me for daring to reduce narcotics and she left AMA after I saved her from surgery.