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Thread: Study: Don't Avoid Opioids to Treat Back Pain

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    Study: Don't Avoid Opioids to Treat Back Pain

    Study: Don't Avoid Opioids to Treat Back Pain
    Thu Oct 3,11:51 PM ET
    By Holly VanScoy
    HealthScoutNews Reporter

    THURSDAY, Oct. 3 (HealthScoutNews) -- Doctors and pharmacists tend to avoid prescribing them, patients are afraid of becoming addicted to them, and government officials are concerned about their abuse. It's little wonder that opioids have acquired something of an unsavory reputation in medicine.



    But is it all deserved?

    A new study suggests it's a mistake to ignore the potential value of these powerful pain relievers for chronic conditions, including musculoskeletal pain and lower back pain.

    There's evidence that opioids such as morphine, oxycodone, and fentanyl can help and should be the treatment of choice for some patients, says Dr. J.D. Bartleson, a Mayo Clinic neurologist and lead author of the study. It appears in the latest issue of the journal Pain Medicine.

    "The prejudice against the use of analgesic opioids is unfortunate," Bartleson explains. "Especially since it results in their being underutilized in situations where they can contribute to improving patient outcomes. Opioids can provide significant relief for patients experiencing severe pain. I believe physicians and patients should be considering them more often than they presently do, including use in the management of chronic, nonmalignant pain."

    Bartleson bases his conclusion on extensive analysis of all studies of opioid use in the treatment of chronic lower back pain. Despite longstanding controversies over opioid misuse and potential dependence, Bartleson found there is a place for their carefully considered and closely monitored use in treating this persistent, debilitating condition. In particular, he says, opioid use may provide a better alternative than back surgery and other pain medications for many patients whose lower back pain is persistent.

    "Fewer than half of all back surgeries are successful in relieving chronic back pain," Bartleson says. "Other medicines for pain -- including aspirin and acetaminophen -- can cause permanent adverse effects. Opioids have been demonstrated to provide pain relief, without long-term side effects."

    John Giglio, executive director of the American Pain Foundation, concurs. He adds the recent controversy over the opioid OxyContin has further muddied the waters over the benefits of this entire class of prescription medications.

    "There is mounting evidence that physicians are being deterred from using opioid drugs for patients in pain, not only because of the bad publicity about certain ones of these medications, but also because they are concerned they will be investigated by the U.S. Drug Enforcement Agency if they prescribe them," Giglio says. "Even where there is no arrest, no indictment, no evidence of physician or pharmacist wrongdoing, an investigation sends a strong negative ripple through the medical community."

    Giglio says chronic back pain is only one of the conditions for which negative publicity has overshadowed opioids' legitimate and proven medical benefit. Even in the treatment of serious malignant conditions, doctors and patients tend to shy away from the powerful drugs.

    "In a recent survey of cancer specialists in California, for example, only about 60 percent of the oncologists reported being certified to prescribe opioids," Giglio says. "Of these, only 40 percent had ever done so -- which means that only one in four physicians specializing in cancer treatment in California are presently using the most powerful painkillers available in their practice."

    Giglio and Bartleson agree that additional, longer-term and better-designed studies are needed to study how opioids can be best used in medical care.

    Although Bartleson now counts himself among believers in opioids' benefits in the treatment of chronic back pain, he doesn't advocate their use for every back pain patient. "Opioids definitely have a role to play," Bartleson says. "But a physician has to make sure that whatever treatment is pursued is the best for the individual patient. Opioids aren't for everyone."

    Bartleson adds that, more than anything else, his study points out the need for additional well-designed studies on treating back pain, including the role opioids can legitimately play in such treatment.

    What To Do

    Learn more about policies governing opioid use in the United States from the Pain Policy Study Group at the University of Wisconsin. The American Pain Foundation advocates for those who hurt.


    http://story.news.yahoo.com/news?tmp...reat_back_pain

    ==============================
    "It was once written "To thine own self be true". But how do we know who we really are? Every man must confront the monster within himself, if he is ever to find peace without. .." Outer Limits(Monster)



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    Opioids Should be Considered for Relief of Chronic Lower Back Pain

    Opioids Should be Considered for Relief of Chronic Lower Back Pain
    Library: MED
    Keywords: OPIOIDS BACK PAIN
    Description: Opioid analgesics (opioids), powerful pain relievers whose use has been hotly debated in the medical community, should be prescribed for some patients with chronic lower back pain, according to the Mayo Clinic. (Pain Medicine, Sep-2002)



    EMBARGOED: Hold for release until Thursday, Oct. 3, 2002, 12:01 a.m. EDT
    Pain Medicine

    ROCHESTER, Minn. -- Opioid analgesics (opioids), powerful pain relievers whose use has been hotly debated in the medical community, should be prescribed for some patients with chronic lower back pain, according to a Mayo Clinic article published in the September 2002 issue of Pain Medicine, http://www.blackwellscience.com/journals/pain. After reviewing all available studies of opioid use for this condition, the author recommends that physicians and their patients at least consider opioids for the treatment of chronic, nonmalignant pain, including musculoskeletal pain and chronic lower back pain, before a patient undergoes surgery.

    "Although this is somewhat controversial in that the majority of physicians still have prejudices against the use of opioid analgesics for chronic pain, there is a place for their carefully considered and closely monitored use in patients with low back pain," says J. D. Bartleson, M.D., Mayo Clinic neurologist and lead author of the paper.

    Opioids are pain relievers derived from or resembling those derived from the opium plant. Well-known examples of this class of medications include morphine, oxycodone and fentanyl. The use of opioids is complicated for patients and physicians due to controversy over misuse and potential drug dependence.

    "Opioids are some of the most underused drugs around because of the possibility of abuse," says Mike Joyner, M.D., Mayo Clinic anesthesiologist. "Opioids are wonderful drugs, but because of the abuse problem and moral overlay, it's hard to get a straight answer. This is because of irresponsible use by a limited number of people."

    "Opioids can be a "lifesaver' for patients with severe pain," continues Dr. Joyner. "For people with chronic pain, opioids can be like letting them out of jail."

    Dr. Bartleson's article reports a dearth of randomized, controlled trials of opioid analgesic therapy for chronic lower back pain, the most common chronic pain syndrome in the United States. The available data from all studies of chronic lower back pain patients, however, indicate that opioids are useful for pain relief.

    Though their effectiveness in pain relief has not been widely questioned, the prescription of these medications for patients who do not have cancer has remained contentious in the medical community.

    This study addresses some of the following major objections that have been raised related to using opioids for pain relief:

    * Risk of side effects: In published studies on opioid analgesics, opioids are associated with some moderate side effects, but not with long-term adverse effects.

    * Development of tolerance and need to increase dosage over time: Available studies indicate that opioid dosage remains fairly stable over time and benefit is maintained; however, many of the published studies are of relatively short duration.

    * Risk of drug dependence and withdrawal if the drug is stopped or dosage reduced: Existing studies indicate a low risk of drug dependence and withdrawal.

    Additionally, the studies point to a preference for longer-acting versus shorter-acting opioids for persistent lower back pain relief, and they indicate a vital need to carefully select which patients to treat with opioids and closely monitor patient progress.

    Even the author of the paper indicates that while his research has convinced him that opioids have a place in pain medicine, he takes a cautious approach with his own patients.

    "Although I am now a "believer,' I still don't treat many patients with opioids," says Dr. Bartleson.

    Both Dr. Bartleson and Dr. Joyner call for additional objective evidence regarding opioids for chronic lower back pain in the form of controlled, blinded, long-duration studies of specific opioids.

    "This study highlights the need for well-done studies on the treatment of back pain," says Dr. Joyner. "The cost of back pain to our society -- in numbers of days of missed work, etcetera -- is huge."

    TECHNICAL INFORMATION
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    ==============================
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    Opiod Medications a Good Bet for Shingles-Related Pain

    Opiod Medications a Good Bet for Shingles-Related Pain
    Library: MED
    Keywords: SHINGLES OPIATES PAIN CHICKEN POX NEURALGIA
    Description: Despite worries over side effects, morphine and other opiates appear to be effective in treating shingles-related nerve pain in older adults, a study at Johns Hopkins suggests. (Neurology, 8-Oct-2002)



    October 3, 2002

    Johns Hopkins Medical Institutions' news releases are available on an EMBARGOED basis on Newswise at http://www.newswise.com and from the Office of Communications and Public Affairs' direct e-mail news release service. To enroll, call 410-955-4288 or send e-mail to bsimpkins@jhmi.edu.

    On a POST-EMBARGOED basis find them at http://www.hopkinsmedicine.org

    ************************************************
    EMBARGOED FOR RELEASE UNTIL TUESDAY, OCTOBER 8, 2002
    ************************************************** *

    OPIOID MEDICATIONS A GOOD BET FOR SHINGLES-RELATED PAIN

    Despite worries over side effects, morphine and other opiates appear to be effective in treating shingles-related nerve pain in older adults, a study at Johns Hopkins suggests.

    Caused by the same herpes zoster virus that causes chicken pox, shingles and its bouts of painful rashes on the body, limbs and face yield severe nerve pain at the sites of the healed rash.

    Fearful that opiates would create dependency or mental disturbance in the elderly, physicians have been reluctant to prescribe the painkillers for the treatment of such persistent pain. But reporting in the Oct. 8 issue of Neurology, a team of Hopkins pain researchers demonstrate that in 76 seniors, opiates provided relief for the nerve pain, called postherpetic neuralgia (PHN), without any of these side effects.

    "By comparing opiates to antidepressants head to head, our study suggests that opiates effectively relieve pain and are preferred by a greater proportion of patients," says anesthesiologist Srinivasa N. Raja, M.D., lead author of the study and director of pain research at Hopkins. "This adds further evidence that opiates are a good alternative for patients not responding to other types of pain medications."

    Raja and colleagues studied the PHN patients from 1995 to 1999. The patients' average age was 71; 45 percent were male. All had PHN for at least three months following the shingles rash. Fifty-seven had increased sensitivity to touch, eight had increased sensitivity to cold and 14 had increased sensitivity to heat.

    Researchers evaluated each patient's neurologic and mental health. In a series of three eight-week periods, each patient took either an opiate, an antidepressant or a placebo.

    A pharmacist prepared the medications in identical gel capsules and mailed them straight to the participants' homes, so neither they nor the researchers knew in which order the medications would be taken. Patients started with one pill a day at bedtime and gradually increased until they experienced maximum pain relief or ill side effects. Researchers then followed up with each patient twice a week through telephone surveys.

    Forty-four of the 76 patients completed all three parts of the study. Thirty-eight percent reported pain relief with opioids, compared to 32 percent who had relief from antidepressants and 11 percent with relief from placebo. More patients said they preferred the opiate (54 percent) to the antidepressant (30 percent). Some patients dropped out during the opiate portion of the study because of bad side effects or because their family members expressed concern they would become dependent on the medications.

    The most common side effects were constipation, nausea, dizziness, drowsiness, loss of appetite and dry mouth. These were more common from opiates than the other medications.

    The study was funded by the National Institutes of Health. Co-authors were J.A. Haythornthwaite, Ph.D.; M. Pappagallo, M.D.; M.R. Clark, M.D.; T.G. Travison, Ph.D.; S. Sabeen, M.D.; R.M. Royall, Ph.D.; and M.B. Max, M.D.

    Raja is a paid consultant to Purdue Pharma L.P. This relationship, which did not exist at the time the study was completed, is being managed by The Johns Hopkins University in accordance with its conflict-of-interest policies.

    -- JHMI --

    Raja, S.N. et al, "Opioids versus antidepressants in postherpetic neuralgia: A randomized, placebo-controlled trial," Neurology, Vol. 59: pages 1015-1022.

    Related Web site:

    Facial neuralgia resources
    http://facial-neuralgia.org/conditions/postherp.html

    Media Contact: Karen Blum 410-955-1534

    ==============================
    "Events in our past seem to slip further away with time. But what happens when they circle back and meet us head on....in the present? Before we allow ourselves to be consumed by our regrets, we should remember the mistakes we make in life are not so important as the lessons we draw from them.." Outer Limits(Last supper)



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