“Opioid painkillers cause chronic pain” stories leave physician reader in agony
When writing in 1953 of the structure of deoxyribonucleic acid (DNA), Watson and Crick concluded: “It has not escaped our notice that the specific pairing that we have postulated immediately suggests a possible copying mechanism for the genetic material.”
Words like “postulated,” “suggests,” and “possible” seem quaint in 2016. Instead, we have researchers and their accomplices in the news media who trumpet “game-changing” “breakthroughs” on daily basis – often with the flimsiest of scientific support.
The latest example: opioids causing pain
Consider the headlines generated this week by a study which documented a phenomenon known as opioid-induced hyperalgesia. This is the idea that opioid medication, instead of calming pain, might actually make pain worse.
Denver Post: CU Boulder study: Narcotic painkillers cause chronic pain
FOX News: Opioids may prolong chronic pain, study suggests
Forbes: Prescription painkillers may worsen and lengthen chronic pain
Much has been made of opioid-induced hyperalgesia. Whether it is clinically important for patients with chronic pain on standard opioid medication is unclear. Even the most recent reviews of this phenomenon are unable to determine its prevalence (see here and here), and studies have generally been experimental in nature or with unusual administration of opioids (for example, the drugs have been administered intrathecally; that is, via direct injection close to the spinal cord).
A closer look at the study
As it so happens, the new Proceedings of the National Academy of Sciences study being reported on also involved intrathecal administration of medication.
Not only that, but the study also involved rats who had sutures tied around their sciatic nerves.
The sciatic nerve was tied and the animals were left in pain for 10 days. Then, the researchers administered morphine directly to spinal cords of these rodents for 5 days.
Their conclusion? “That morphine increased the vigor and speed of hindpaw withdrawal to the von Frey filaments in SD rats was supported by increased startle (converted to force; N) to a 0.2-mA shock.”
In other words, the rats that received the morphine showed increased sensitivity to a plastic “hair” and an electric shock.
Use of rat models to help elucidate human disease is nothing new. But use of rats to claim that the study’s “implications for people taking opioids like morphine, oxycodone and methadone are great, since we show the short-term decision to take such opioids can have devastating consequences of making pain worse and longer lasting” is nothing short of ridiculous and harmful.
A PR news release drives the narrative
That sensational quote, originating in the University of Colorado Boulder news release, was subsequently picked up by the Denver Post and a variety of other outlets that covered the story. While most of this coverage did acknowledge (in the body text of the story) that the study involved rodents, few stories pushed back against the researchers’ attempts to draw a straight line from this animal study to humans. Readers drew the same straight line: Of the over 300 reader comments on the Denver Post article alone, almost all are about humans, not rats.
Science magazine was one of those rare outlets that provided the perspective of an independent expert, who offered the following indispensable context:
The finding certainly shouldn’t be the basis for withholding opioids from people in pain, says Catherine Cahill, a neuroscientist at the University of California, Irvine. These drugs also work to block the emotional component of pain in the brain, she notes—a form of relief this study doesn’t account for. And opioids might not prolong pain in humans the way they did in these rats, she says, because the dosing of morphine and its quick cessation likely caused repeated withdrawal that can increase stress and inflammation. Humans usually don’t experience the same withdrawal because they take sustained-release formulations and taper off opioids gradually.
What’s more, none of the coverage that I saw tried to put this 5-day rat study into any appropriate historical perspective. Opium-derived products have been used to relieve pain since ancient times. Opium was one of the only medications not consigned to the bottom of the sea by Oliver Wendell Holmes in 1860. Morphine has been on the World Health Organization’s list of essential medicines since its inception. Yet opioids are not available to 5 billion people with consequent unmitigated pain and suffering. The American Geriatrics Society has determined opioids to be a potentially “indispensable” treatment for selected patients. British geriatric guidelines are similar. While advocating their judicious use, Canadian guidelines note that “opioids can be an effective treatment for chronic non-cancer pain (CNCP) and should be considered.”
Consider the CDC context
This rat study and the related coverage aren’t taking place in a vacuum. They’re taking place amid the CDC’s recent recommendations for the use of opioids in chronic pain — guidelines that excluded a Cochrane review showing effectiveness. The CDC took the acknowledged limited study in this area and interpreted it as evidence only of harm. Can harms happen with chronic opioid use? Yes. Can benefits also happen? Yes. By not acknowledging this dual truth, the CDC recommendations – and especially the rhetoric that has surrounded them (e.g. “prescription opioids are just as addictive as heroin”) – risk creating more heat than light.
This is in contrast to the National Institutes of Health 2014 report “Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain.” The report found that:
Patients, providers, and advocates all agree that there is a subset of patients for whom opioids are an effective treatment method for their chronic pain, and that limiting or denying access to opioids for these patients can be harmful.
… Biased media reports on opioids also affect patients. Stories that focus on opioid misuse and fatalities related to opioid overdose may increase anxiety and fear among some stable, treated patients that their medications could be tapered or discontinued to “prevent addiction.”
The CDC guidelines also excluded acute pain. I’m not sure how 10 days of sudden unrelieved pain is considered by a rat, but it sounds acute to me.
Here we see in miniature the flaws of basic science and public health policy alike in their promulgation of questionable “evidence.” A rat study headlined “Narcotic painkillers cause chronic pain” – that doesn’t mention the rat subjects – is the latest example of the pendulum being pulled back so far it is straining credulity as well as contributing to people’s suffering.
The next time a patient of mine becomes a rat, has its sciatic nerve constricted with sutures, and asks for 5 days of morphine near its spinal cord 10 days later, maybe I’ll take another look at this study. In the meantime, I’ll tell my patients to ignore the unbalanced news coverage that the research spawned. I’ll also follow universal precautions in prescribing opioids, listen carefully to my patients and their context, work to find the best approach for mitigating their pain, limit side effects and untoward outcomes, respond effectively should they occur, and practice with a compassion not shown to these rats.
Filed under: General Problems
I have taken this opportunity to share my heartbreaking story in hopes these witch hunting Opiate ill informed skeptics will read and understand that I would have no life without Medically prescribed Opiates by a physicians care and strictly monitored monthly urine and blood test. Please remember that An Opinion Before A Thorough Investigation Is The Epitome Of Ignorance! And that a little more compassion from the Medical Field and its representatives could have saved my beautiful Stepdaughters life. Let me say this! A person who has a addictive personality will abuse anything that helps them feel better. I have taken Oxycontin for 14 years , I have had 25 major surgery’s in 14 years. I have so much physical pain I can not even get out of bed with out Medically Prescribed Pain meds and when I run out I run out and just lay in bed praying the Lord relieve me of this horrible condition and I pray God that pain med skeptics never go through what I go through everyday of my life when the only thing you have to do is threaten what help I get, Shame on them! There will always be drug abuse and as the so called war on drugs has failed all this will! All that these witch hunters are doing is stoking and aiding the Illegal Heroin Dealers business to knew heights in the Black Market of Heroin while trying to deprive folks as me to this horrible movement! My Stepdaughter committed suicide 6 years ago because of being treated like a drug addict by some of her family and doctors when all along she suffered from Lupus and Fibromyalgia which I believe was brought on by a deadly car crash at her age of 18 , she told me between that which I was being put through and what they were putting her through she was not going to live her life in such a hell brought on by people like these Opiate Ill-Informed Skeptics that are on a witch hunt to out law Opiates and pain meds that give us some sort of a life . I will send you a last picture of me and my precious Stepdaughter a year before she committed suicide so you can see a face on our story. As a retired Police officer and worked indirectly close to the DEA, some of these people do not have a clue how thrilled they are making the illegal Heroin trade and think of my Late Stepdaughter as they continue on with this 2017 Version of the ( 1940s Propaganda Film named (REEFER MADNESS )movement to outlaw opiates! Just like the slaughter of children at Sandy Hook Elementary School if there would have just been gun laws , my God they were Gun Laws , the guns that murdered all those 20 children were all registered and owned by a school teacher! You fight Drug Addiction in Elementary education by teaching all children the dangers of Booze and Tobacco which if these witch hunters want for us to know the real truth but they do not. I miss my Stepdaughter so much and some of us will continue on the fight to protect our right to feel better and function without fear of these witch hunters trying to convince us to commit suicide . And they are doughtily wanting us Chronic Pain Sufferers to do exactly that as horrifying as it sounds to do exactly THAT!( SUICIDE)!
The under line real truth is THESE witch hunters would rather us Chronic Pain sufferers commit suicide are and DRINK all the BOOZE we can drink! The Federals legalized it ( ALCOHOL) knowing its a more deadly drug than Strychnine. And just because the DEA has miserably failed with their witch hunt type movement on drugs why do they so desperately launch all this propaganda to compare us that have legitimate Chronic Pain try to compare us with Heroin Addicts? And attempt to deprive us sick people of our Constitutional Rights to be Happy in that pursuit of with Professional Physicians care and monitoring of Opiate Pain Medications taking Legally Prescribed medications that give us relief of this horrible malady of Chronic Pain ! May God have mercy on their miserable souls they that seek to destroy us Chronic Pain Sufferers only and little hope of temporary relief of this horrible sickness.
When they choose to ,”cherry pick,” the info ,,it proved to me,,,it was about there PERSONAL BELIEVES about viewing our MEDICINE AS SOME DEMON DRUG,, for those who choose to believe our MEDICINE is a demon drug,,,they will believe only 1 side,,the problem is,,these 1 side -ers,,our in position of power,,,thus it proves THEY HAVE ABUSED THAT POWER,, to harm people,,,it reallly is a basic humane human decision to not want human beings to suffer,,,I CAN’T WATCH IT AND STAND BY AND DO NOTHING,,,,I JUST CAN’T,,,,, i have never been one to be able to watch a animal suffer,,,,,let alone a human being,,,,,,,,these people who choose to be 1 sided,,,can,,,,they can stand by and watch us die and suffer,,,,there demented in my opinion,,,there,”’off””,,, BUT WHEN U GET PSYCHOPATHS IN A POSITION OF POWER,,,,,THERE DEADLY,,,OBVIOUSLY!!!!!!!! our suffering is caused by bigotry,arrogance,ignorance and prejudice..I heard Kasik say,,,get into othere people business,,,,,well NO,, this is a free country for adults,,,and should remain that way..The very 1st Continental congress coin of this nations,,,had imprinted on it,”’mind your own business,”to remind the founding fathers to do just that!!!!!my medical decision is not my government decision,,this is where this is all headed,,,maryw
The cover-up, lies, and ignorant “broken record syndrome” seems to be changing by the day.
I have never returned, complained, or incurred multiple doctor visits, from medically necessary medications, until they “reappeared” from the “shortages”, post- Health Care Reform Act.
Today is the first-time I read a statement from the FDA, [listed on the bottom of an 8 page very abnormal blood-test report], as for giving the reason why the heavy metal request wasn’t preformed, as being “unnecessary”
Ironically, at the suggestion of my PCP, [including specific symptoms and observations related to my medication-reactions]; he ordered a heavy metal analysis.
The tests came-back hi- positive for three: Cadmium, Trioxide, and Cephalon. After intense study, and research, I found-out that not one, but two of my medications had synthetic Arsenic, as well as Cadmium. .
I was not offered chelation therapy; the use of heavy metals shouldn’t have been inside these medications at all. Heavy metals toxicity can become a chronic-illness itself, if not identified, and treated in a timely manor. They are cancerous; extremely painful, and easily become a chronic-illness of themselves.
Because the FDA prevented a test approved by Medicare by calling it unnecessary, my health and ability to function are a direct result from these toxic and useless heavy metals, carelessly added to medically necessary medications, and for which have no known purpose.