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- Page navigation anchor for RE: Rethinking "doing well" on chronic opioid therapyRE: Rethinking "doing well" on chronic opioid therapy
Dear Dr. Juurlink
Thank you for your articles article regarding the use of opioids in managing chronic pain. This is an area that has been confused by inadequate research, and the influence of drug companies driven by enormous profits. Harms harms of opioids have become widespread. Rather than a pendulum of opioid favour/disfavour, we need a rational practice.
In 2006 the CMAJ published and article titled: Opioids for chronic non-cancer pain: a meta-analysis of effectiveness and side effects. It gave guidelines on "safe" opioid prescribing for chronic pain. I believed these were problematic, and wrote a response titled "Fundamental problem with opioid trials for chronic pain". I believe it supports your current article.
We do need to think broadly and logically about the EBM we use make important decisions, especially regarding practices that impact a large segment of the population.
Best Wishes
Dr. Tushar Mehta MD CCFPReferences
1) Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006;174(11):1589-94
2) Fundamental problem with opioid trials for chronic pain
CMAJ April 24, 2007 176 (9) 1307-1308; DOI: https://doi.org/10.1503/cmaj.1060140
http://www.cmaj.ca/content/176/9/1307.3Competing Interests: None declared. - Page navigation anchor for RE: Some patients with chronic pain need low-dose opioid therapyRE: Some patients with chronic pain need low-dose opioid therapy
One thing that makes sure that chronic pain will persist is that it is much easier to prescribe painkillers including narcotics and marijuana than to examine the patient to find a cause for their pain. In my office, every day, I see between one and three people with severe low back pain, who have had x-rays, CT scans and MRIs to their lumbar spine, which show a variety of pathologies, most of which are asymptomatic. Unfortunately, no one has examined their sacroiliac joints, where I have found that most severe low back pain originates.
Many physicians are so reliant on medical imaging, that they no longer use their hands to make a diagnosis, and, unfortunately, it is very difficult to diagnose a sprained sacroiliac joint using medical imaging. I just reviewed 180 charts of patients with low-back pain, and only 16 of them presented with pain coming from their lumbar spine. In all the others, the main pain generators were the sacroiliac joints. I know that without a doubt, as correcting the alignment of sprained sacroiliac joints resulted in immediate, complete pain relief in 50% of those treated, and partial pain relief in a further 30%. The findings from this UBC ethics–sanctioned chart review will be presented as a poster at the Canadian pain Society meeting in May 2018.
https://www.youtube.com/watch?v=NXNS6PNKRPo
Neuropathic pain can also be diagnosed through palpation along the course of the...
Show MoreCompeting Interests: None declared. - Page navigation anchor for Some patients with chronic pain need low-dose opioid therapy for survival and quality of lifeSome patients with chronic pain need low-dose opioid therapy for survival and quality of life
Whatever the underlying science or dynamics of "opioid dependance" we have to accept there is a core group of patients with chronic pain who attribute low dose opioid therapy for "survival and some quality of life". Chronic pain syndrome is a not so apparent evil that destroys the life of many who at some point were the hardest workers, putting in long hours, OT etc with hardly any sick leave and taxing the health care system the least and now find shunned by the same system as "opioid seekers". Not withstanding the research studies with an overflow of theories let us never forget Dr. Juurlink's opening sentence that "the relief of suffering is the fundamental objective of medical practice."
Competing Interests: None declared. - Page navigation anchor for RE: Opioids for Chronic PainRE: Opioids for Chronic Pain
Chronic pain patients are suffering from considerable anxiety and increased pain as their doctors are lowering their use of opioids against their will. This has all come about because of the concern that opioid deaths among illicit drug users are increasing. As a consequence, McMaster University revised the prescribing guidelines for opioids at the request of Health Canada and significantly reduced the maximum daily recommended dose.
Early on in the discussions on opioid use, Dr B. Elliot Cole, writing in MD Magazine,[1] wondered why “If an individual patient has no problems associated with the use of 120, 180, or 240 mg of morphine equivalent on a daily basis, why do we need to reduce that dose? If an individual patient is functioning well with opioid therapy after 90 days, and there is no better treatment available, why would we stop treatment and inflict worsening pain?”
One of the key players in the McMaster guidelines is Dr David Juurlink who was one of the four members of the steering committee. In his paper, Rethinking “doing well” on chronic opioid therapy, Dr Juurlink begins by stating that there is little evidence that opioids helps with chronic pain. However, a 2010 Cochrane Review[2] with 4893 participants found that there was significant reductions in pain. It also found that opioid addiction was rare. This study was not cited in the Guidelines. The Lancet[3] just released a review on the poor use of opioids for pain and said that many worldwid...
Show MoreCompeting Interests: None declared.