1/Well, look what just dropped at JAMA, a great trial of opioids vs stepped therapy for chronic joint/back pain:
Bottom line: making opioids step 2 after ibuprofen for most adults with chronic back pain is dumb so stop it but were you really doing that? jamanetwork.com/journals/jama/…
Bottom line: making opioids step 2 after ibuprofen for most adults with chronic back pain is dumb so stop it but were you really doing that? jamanetwork.com/journals/jama/…
2/People want quick takes, and this fine study is likely to be used like a cudgel to suggest lessons it does not show, so my take is here:
3/Who was in this study? 240 middle aged volunteers with standard chronic hip/back pain who had low levels of psychological distress compared to some of our clinics
4/These folks had mod-severe pain and just taking NSAID/APAP hadn't worked. Here are the 2 step scales available (slide from Dr. Krebs at @SocietyGIM )
5/Both trial arms started with -average of truly "moderate" pain related function (BPI) and improved nicely, like 35%, over a year. Simple pain score slightly BETTER in non-opioid arm (p<.05)
6/Pain severity & psychological symptoms at baseline were lower than voluntary trial participants in a fibromyalgia trial, and this is not a study for that condition or for patients with more severe conditions with or without psych. morbidity
7/In terms of care, saying "no opioids" is not a treatment strategy. But if docs are still (still?) offering opioids to standard arthritis patients every time they say "my tylenol didn't work" this is a plausible time to stop if you haven't already.
8/If any clinician, Board, or journalist twists this to say that patients currently stable ON opioids should be forced OFF or forcibly tapered, that's not evidence-based & risky: healthaffairs.org/action/showDoP…
9/Instead of arguing a pill, lets focus on the patient, and think about the complex psycho-physical chain of events in chronic pain that is often far more debilitating than the folks in the SPACE trial. That reframe should change our care discussion.
10/I'd love to take care of more patients like those in SPACE trial. But I'm receiving patients harmed, for years, by lack of early sensible pain, rehabilitation & psych. care, with harm from procedures by surgeons & interventionists & polypharmacy @BethDarnall @DavidJuurlink
11/With these folks we need to stop the "opioids win/lose" discussion. Lets demand that insurers,CMS, Canadian government authorities& experts help us build a REAL care approach, and PAY for it.
12/A final point published by Dr. Doug Chang & I about a similar trial of yoga for low back pain. These trials do not measure & cannot report on the specific spine pathologies that might ideally require different treatment plans. Unmeasured variation in both trial arms.
