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When Doctors Ignore Evidence, Pain Patients Suffer

Pain medications have been approved because their effectiveness is greater than any harm they may cause.
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When we seek out medical treatment, we expect that what the doctor recommends will be based on evidence and that what is done for us will not make us worse (iatrogenic consequences.) Treatments like blood letting and drilling holes in the skull are no longer performed.

When it comes to treating chronic pain, however, doctors no longer use proper evidence and are creating iatrogenic problems thanks to the new rules on pain medication use influenced by a small group of physicians who call themselves Physicians for Responsible Opioid Prescribing (PROP.) In a recent interview, United States internist Thomas Kline said that the US Food and Drug Administration (FDA) called them the lunatic fringe of medicine and he referred to their Canadian member, David Juurlink, as a zealot. Juurlink was one of the key members who developed the much criticized McMaster opioid prescribing guidelines.

To paraphrase Gertrude Stein, pain by any other name is still pain, and yet medicine today makes a distinction between the pain of cancer and the pain of non-cancer. Hence, we have the McMaster Guidelines on the use of opioids for non-cancer pain. Charles Argoff, a neurologist in Albany, NY, argued that there is no distinction. He suggests that we treat people "who need our help in such a way that addresses their true needs, and not a false dichotomy that it is time to end."

Pain medications have been approved by the FDA in the U.S., Health Canada and the European Medicines Agency because they are effective and that effectiveness is greater than any harm they may cause. They have been around and used for many years but are now suddenly considered bad by many.

PROP petitioned the FDA in an attempt to have them change the rules around opioid prescribing and most of what they requested was rejected. PROP wanted the FDA to distinguish between cancer and non-cancer pain, which they refused to do. The FDA pointedout that PROP did not provide any scientific evidence to differentiate cancer pain from non-cancer pain. Further, they are not aware of any physiological or pharmacologic basis to make that distinction. Note that the McMaster guidelines refer to non cancer pain.

While the FDA agrees that there are adverse events possible with the long term use of opioids (and that is the case with all medications), they stated that there is no causal relationship demonstrated and that more studies are needed.

PROP also requested that the FDA establish a maximum daily dose of 100 mg to prevent increased risks of death, emergency room visits and fractures. After study, the FDA determined that there is no evidence to support any maximum dose. McMaster, however, recommends a maximum dose of 90 mg and tapering of patients who are on higher doses. That tapering is often forced which addiction specialist, Sally Satel, called malpractice.

PROP also asked that treatment be allowed to last for only 90 days which the FDA also opposed.

Despite the fact that the FDA found no evidence to substantiate the arguments by PROP that pain should be arbitrarily divided into cancer and non-cancer categories, that the harms caused by this class of medicines are not substantiated in research, Canada has adopted these ideas in the McMaster Guidelines as has the U.S. in the Centre for Disease Control Guidelines. The U.S. Guidelines are as much criticized as are the Canadian ones.

The result is that the pain that many face is not being properly addressed by doctors and people are resorting to suicide as a result. This is where iatrogenic comes into play. Pain patients who contact me because of my writing on the topic tell me how their overall health is impacted: their diabetes and lupus gets worse. Then I read an article that explained that untreated chronic pain is a medical emergency and that it makes everything else worse.

Alex DeLuca points out that, "Unrelieved pain can be accurately thought of as the 'universal complicator' which worsens all co-existing medical or psychiatric problems." Another physician in the above article pointed out that, "The overall deleterious effect of chronic pain on an individual's existence and outlook is so overwhelming that it cannot be overstated. The risk of death by suicide is more than doubled in chronic pain patients, relative to national rates."

This paper goes on to say that medication is the mainstay to pain treatment and these opioids have fewer side effects than many of the new drugs coming to market with a risk of addiction of less than 5 per cent.

That mainstay treatment of opioid pain medication has been successfully attacked with little or no evidence to back it up. As a result, we are allowing our treatment for people with chronic pain to be dictated by ideology rather than sound medical evidence. The result is misery, increased pain and suicides.

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