Avoid opioids for chronic back/knee/hip pain

[thras]

Hey Rip,

Have you seen this yet? Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE... - PubMed - NCBI

It's nice to see a big study backing up advice that I've seen here on the boards a few times from various SSCs/MDs: Take NSAIDs/acetaminophen for back/knee/hip pain, not opioids.

The study's population was people with "moderate to severe" chronic pain. So not people with minor injuries. Looking at the results, opioids seem like a good way to keep your chronic pain around forever.

[Mark Rippetoe]

What you have seen on these boards is the advice to take squats and deadlifts for chronic pain. Acute pain is another matter entirely. Doctors have created this problem, so let them fix it.

[Pluripotent]

When I was in medical school, they told us that bad doctors were not taking patient's pain seriously. When I was a resident, they told us that bad doctors were killing people by overprescribing opioids. Meanwhile, the actual evidence is most opioid overdoses are not from prescribed opioids. Politicians like to blame doctors because it gets them off the hook for their bad policies. The public also likes to blame doctors because they're rich and fuck those guys. Meanwhile, there's an opioid epidemic that no one is taking seriously.

[Mark Rippetoe]

Are most opioids used in overdose deaths sourced from pharmacy burglaries/robberies?

[Pluripotent]

Are most opioids used in overdose deaths sourced from pharmacy burglaries/robberies?

I think it comes from a lot of places. Physicians do tend to prescribe lots of pills. My wife just got 30 pills for something that she maybe needed 5, maybe. The pharmacy said they had to fill the whole prescription or none of it. But it only cost $6, which is crazy. I try not to give enough to kill anyone if they take them all at once, which tends to piss the patients off. And I just assume half or more of what I prescribe is being sold. The overdose deaths are increasingly from heroin or synthetic fentanyl that is produced on the black market.

[Mark Rippetoe]

I keep a few hydrocodone at home for cough medication, but they have absolutely no analgesic effect on me, so I'd make a shitty addict anyway. At any rate, most physicians are lazy bastards, just trudging through the day, doing what they've been trained to do, never attempting to rethink anything, and never doing anything that could be called into question even though all of it should be called into question. You know this better than we do.

[Pluripotent]

I keep a few hydrocodone at home for cough medication, but they have absolutely no analgesic effect on me, so I'd make a shitty addict anyway. At any rate, most physicians are lazy bastards, just trudging through the day, doing what they've been trained to do, never attempting to rethink anything, and never doing anything that could be called into question even though all of it should be called into question. You know this better than we do.

I think a lot of it is bad incentives. In medicine, you are taught from medical school on to keep your head down and go along to get along. Doctors are not particularly brave. I know I got into the most trouble by saying what I thought rather than just saying nothing. I spent three whole rotations with an attending just praying that she would not tell me to do something that I couldn't do, and she could make some spectacularly bad decisions, which I then would have to implement. She had already done it twice and each time it was a big deal, and I thought I was going to get kicked out or something if I was put into another situation like that, because the other attendings were on her side. But incentives matter, even if you don't want them to. With opioids, they made pain the 5th vital sign and hired a bunch of nurses trained to be "pain ambassadors" who would go around to every room in the hospital to make sure that every patient had their pain "well controlled." Now they got rid of the pain ambassadors, but the nurses still do this and patients are trained very well to rate their pain on a meaningless 1-10 scale (what's the difference between a 7 and an 8, really?) Every time I try to ask a nurse or a patient what type of pain the patient is having, I get a number. It's maddening. (No, WHERE is the pain?) I can even ask, "Is it mild, moderate or severe?" And I get a number. So I just translate: 1-7 is mild, 7-8 is moderate, 9- infinity is severe (many people, when asked to give a number between one and ten will say 11, because they're off the fucking charts man!) Now the patient satisfaction scores are quickly becoming all that matters, and your pay is going to be based on it, which is like the pain ambassador on steroids. Patients get pissed when you don't give them narcotics, and some patients are only happy when they are barely awake. So what's going to happen? Those doctors who are not willing to drug their patients into oblivion will be replaced by doctors who will. Of course, we have been assured that this is not going to be the case...

I had a bad back spasm once in medical school and went to the ER because I couldn't get up off the floor, they gave me narcotics, but I didn't finish the bottle (although my anatomy professor called me into her office to quiz me about it, trying to determine if I was an addict or not). I had back pain most of my adult life and it didn't stop until I started doing Starting Strength. So far I have not met another back pain patient who is willing to do that to get rid of their back pain. So I don't know what the answer is. Patients will not do what they need to do, this will undoubtedly mean that they will have recurrent or constant back pain and will likely need medication or even implanted pain pumps or TENS units because they won't do anything else about it. Of course this is the doctors fault, because "nobody can figure it out." (Granted, in this case, no one but me is telling them to lift, so probably no one else can figure it out.)

[Pluripotent]

I had some other thoughts on this issue. I think the use of opioids for chronic pain, which is a bigger problem for men than for women is a sign of nihilism. Nihilism is not just a philosophical idea, not even primarily a philosophical idea. How do you know if you are a nihilist? Are you participating in self sabotage? People who engage in nihilistic behavior are essentially destroying themselves. This includes all the drug and alcohol addictions, smoking and even less obvious behavior, such as fragility from the lack of physical training. Essentially, I think people engage in nihilist behavior when they lack clear goals for the future, either because they are unable to make goals, or because they have no hope that they could ever achieve goals even if they did make them. The problem affects men and women, but currently more men, because men are being inundated with the idea that masculinity is somehow "toxic" and they are being told that their contributions are not wanted. Most of the time this is implicit rather than explicit, although it is becoming increasingly explicit. And so men retreat into activities that can only be described as slow suicide (or they just do it outright). People need to make goals. The act of making goals for the future is the best antidote for nihilism because it is its opposite. And, assuming that those goals aren't also nihilistic (such as to shoot up a high school or concert), then the goals themselves are going to be incompatible with the self destructive behavior. You cannot get to a 315 lbs squat for 3 sets of 5 and smoke or do drugs (or at least it's very unlikely and it would be much better if you didn't). Making goals forces people to decide between self destruction and self improvement. So if we could just get people to lift...

[Kyle Martin]

People need to make goals. The act of making goals for the future is the best antidote for nihilism because it is its opposite.... Making goals forces people to decide between self destruction and self improvement. So if we could just get people to lift...

This is some important stuff. It makes me sad that I have no idea how to get other people to understand it.

[Jonathon Sullivan]

When I was in medical school, they told us that bad doctors were not taking patient's pain seriously. When I was a resident, they told us that bad doctors were killing people by overprescribing opioids. Meanwhile, the actual evidence is most opioid overdoses are not from prescribed opioids. Politicians like to blame doctors because it gets them off the hook for their bad policies. The public also likes to blame doctors because they're rich and fuck those guys. Meanwhile, there's an opioid epidemic that no one is taking seriously.

Plenty of blame to go around here: policy makers, doctors, drug companies and, yes, many of the fatalities as well.