For years the medical community has turned to opioids such as oxycodone and hydrocodone to treat patients for severe, chronic back, knee or hip pain, particularly when other medications have failed. But a new study published in March 2018 in the Journal of the American Medical Association (JAMA) suggests opioids may actually be no better than non-narcotic alternatives. At least that is what many of the national newspapers reported.
But has the media gotten it right?
Allow me to explain.
This latest study consisted of 240 patients who sought medical treatment at VA clinics from 2013 to 2015. All patients reported moderate to severe pain in their back, knee or hip. All patients had previously tried to treat the pain on their own.
Patients were divided into 2 groups (opioid vs. non-opioid) and treated for 12 months. The first group received modest doses of opioids such as morphine, oxycodone or a combination of hydrocodone with acetaminophen. The second group was treated with acetaminophen or an NSAID (such as ibuprofen). Treatment over the 12 months was adjusted and escalated as necessary.
The results? Both treatment groups experienced a decrease in pain, with a slight advantage to the non-opioid group with respect to pain intensity. That slight advantage to the non-opioid group is what got the most attention, resulting in headlines that declared that NSAIDs (like ibuprofen) were the clear winner.
But before patients who are currently on chronic opioids for pain decide to ditch them for OTC acetaminophen and the like, several things about the study should be pointed out.
First, it should be noted that standards of care today would almost never recommend opioids for patients who (as in this study) had only self-treated for pain. We ordinarily recommend various non-drug interventions, then move on to a consistent regimen of anti-inflammatory agents, both OTC and prescription strength. This could include muscle relaxants and trials of several NSAIDs or topical agents. Most patients can expect some relief from this approach. But this study put some patients directly on opioids. That is unusual at best.
Second, it should be remembered that the “escalation” medications available to the NSAID patients in the study were arguably very strong and, in some cases, quite expensive. Lidocaine patches and Lyrica® and tramadol are all powerful drugs which patients had access too if their pain was significant. Therefore, it is not totally fair to say the study simply compared “ibuprofen” and “oxycodone.”
Finally, the study looked at a very limited patient population with a specific type of chronic pain. Many news articles appeared to miss this. Instead, they made sweeping statements like seen in Newsweek which read “Opioids don’t treat chronic pain any better than ibuprofen.” The Chicago Tribune made a similar statement saying “Opioids no better than common painkillers for treating chronic pain.” These statements go well beyond anything proved by this small study.
As a pharmacist I’m as concerned as anyone about our excessive utilization of opioids in this country. We need more treatment options for addicted patients who want help. But I’m also afraid we have all become targets for a lot of inaccurate propaganda about opioids as well. The number of deaths has been sometimes exaggerated. The role of opioids in these deaths have been highlighted, to the exclusion of other mitigating contributors such as alcohol or illicit drugs. The overwhelming majority of patients using opiates for real pain do not misuse, divert or overdose on these drugs.
Churchill said that “a lie gets halfway around the world before the truth has a chance to get its pants on.” Sometimes even well-intentioned journalists miss the mark. And while ibuprofen is safe and effective for some patients, many others still need the additional relief available from conservatively prescribed opioids.